快猫短视频

LAST December Alayne Buckley, a 61-year-old former receptionist from Wakefield in the north of England, told 快猫短视频 about the dilemma she was facing. Buckley had been diagnosed with motor neuron disease, also called amyotrophic lateral sclerosis, a progressive paralysing condition that is almost always fatal.

By Christmas, Buckley needed a ventilator to help her breathe, and she was spending most of her time sitting in a chair, or occasionally shuffling short distances using a Zimmer frame. She knew that within a few months she would most likely be completely paralysed and unable to communicate, while still being able to see, hear and feel pain.

Buckley wanted to die before reaching this 鈥済lass coffin鈥� stage, as she called it. So she faced a choice: either she could switch off her ventilator and suffocate to death, or she could travel to Switzerland, where a doctor could legally mix up a lethal cocktail for her to drink.

Suffocation is not a pleasant way to die. But the trip to Switzerland would also throw up problems. In the UK it is illegal for anyone to aid a suicide, so she would have to make the journey on her own. But her mobility was dwindling fast. 鈥淭he ridiculous thing is that I will have to go while I鈥檓 still able to move, which may be before I鈥檓 ready to die,鈥� she said.

Euthanasia and similar end-of-life issues are rarely out of the news these days. A succession of patients keep making headlines in the UK as they fight for what they see as their right to a dignified death. And the US has recently witnessed an unedifying public battle over the removal of a feeding tube from Terry Schiavo, the 41-year-old woman from Florida, who suffered brain damage after a heart attack in 1990 and died at the end of March. It seems that rather than helping people at the end of their lives, some advances in medical technology have made dying a more prolonged and undignified business.

But there are signs that around the world the tide of public opinion is turning in favour of what is sometimes called mercy killing. Switzerland is not the only country where assisting dying is legal: in the past decade, the Netherlands, Belgium and the US state of Oregon have legalised the act in some form. And there are campaigns to follow in their footsteps elsewhere, including the UK, other US states and South Australia.

In Britain a proposed right-to-die law won tentative support this month from a parliamentary committee. The Assisted Dying for the Terminally Ill Bill would enable a dying adult who was suffering unbearably to receive medical assistance to die. After considering the experiences of other countries, the committee recommended that the bill should be further debated in parliament. 鈥淚 believe the problems and the suffering caused by the present laws will become increasingly difficult for parliament to ignore,鈥� says Joel Joffe, the House of Lords member who is championing the bill.

Assisted dying is not a particularly modern controversy. When taking the Hippocratic oath, a pledge dating from 400 BC, trainee doctors had to swear to 鈥済ive no deadly medicine to any one鈥�. This was despite the relatively permissive attitude to suicide in ancient Greece. The Bible is not generally seen as frowning on suicide, with Christian disapproval of the act dating from about the 4th century, after St Augustine interpreted 鈥渢hou shalt not kill鈥� as condemning suicide as well as murder.

Switzerland has the longest history of allowing assisted suicide 鈥� although not euthanasia (see 鈥淭erminology鈥�). A law dating from 1942 states that it is only illegal to help someone to commit suicide 鈥渨ith a selfish motive鈥�, which is widely interpreted to mean that disinterested helpers are safe from prosecution. Because Switzerland is the only place in the world that allows such help for non-residents, sick people from all over Europe and occasionally the US have trekked there to receive help in dying.

Assisted dying seems to be most prevalent in the liberal Netherlands, where the courts have tolerated both assisted suicide and euthanasia since the early 1970s. They were specifically legalised only in 2002, however, after lobbying by the Royal Dutch Medical Association, which argued that doctors needed legal protection.

In the US, doctor-assisted suicide has been mooted in several states, including California and Michigan, but it is only in Oregon that this act has been legalised, since 1997. The federal government has made several attempts to overturn this law, but so far it has been unsuccessful. And in 2002 Belgium legalised euthanasia by doctors, but not assisted suicide.

In the rest of the world, however, it remains illegal for anyone 鈥� doctor, nurse, friend or relative 鈥� to help someone commit suicide or carry out euthanasia, no matter how ill the patient. The law generally distinguishes between 鈥渁ctive鈥� euthanasia, when a doctor administers a lethal drug, and what is sometimes called passive euthanasia, when a life-saving treatment is rejected or withdrawn. Such treatment withdrawal is completely legal, although sometimes a patient鈥檚 relatives disagree with the decisions of medical staff 鈥� or with each other, as in Schiavo鈥檚 case.

So what kind of circumstances might lead someone to try to hasten their own death? According to Exit, a Swiss organisation that helps in around 100 suicides a year, about 70 per cent have cancer. Other common conditions are heart disease, AIDS and neurological disorders such as motor neuron disease. Patients seek relief from symptoms such as unremitting severe pain, breathing difficulties such as choking and suffocating, and nausea and vomiting.

Get-out clause

Drugs can relieve some symptoms, of course, but most strong painkillers have unpleasant side effects, points out Michael Irwin, a retired general practitioner and former chairman of the UK鈥檚 Voluntary Euthanasia Society. For example, at high doses, opioids such as morphine can cause nausea, vomiting, severe constipation and sedation to the point of unconsciousness.

High doses of opioids can also hasten death, because they depress activity in the brain鈥檚 respiratory centre, slowing down the breathing rate. In many countries doctors may legally give a dose of painkillers high enough to accelerate death, as long as their primary goal is pain relief. This get-out clause is sometimes called the doctrine of double effect.

Estimates of the proportion of terminally ill patients whose pain cannot be relieved range from 3 to 7 per cent. 鈥淭he 5 per cent or so who remain with severe pain can only be helped by being placed in a coma, not just made sleepy,鈥� says Irwin.

Not all doctors believe the answer for these patients is to legalise assisted dying. Nigel Sykes, medical director of St Christopher鈥檚 Hospice in London, argues that pain relief is improving all the time. He points out that in the past 10 years several new opioids have become available, giving patients more chance of finding a drug that suits them. There are also new therapies to combat the side effects of the painkillers, such as anti-nausea medicines. 鈥淲e are gradually whittling away at that group of patients who didn鈥檛 do well on the long-standing drugs,鈥� says Sykes.

But just because drugs are available does not necessarily mean patients receive them. A report published in 2001 by the US Institute of Medicine in Washington DC found that a quarter of cancer patients die in severe pain. There are numerous practical and financial obstacles to patients getting the drugs they need, ranging from inexperienced medical staff to lack of resources. Palliative care, the branch of medicine devoted to helping dying patients, has only recently been recognised as a distinct specialty. Generally things are improving; the number of countries with some form of palliative care service has doubled from 60 in 1994 to roughly twice that today. But even in the US only about a third of academic medical centres have palliative care programmes. Overall, expertise remains patchy. 鈥淭here are definitely places where you would rather not die,鈥� says Timothy Quill, a palliative care specialist at the University of Rochester Medical Center in New York.

鈥淣o longer obsessed by their fear of death, they can spend their energy on living the life that is left to them鈥�

Opponents of assisted dying argue that the priority instead should be to overhaul palliative care services and provide more practical help so the terminally ill do not feel they are a burden. Not only would it be unsafe to introduce euthanasia before good palliative care is available to everyone, says Sykes, 鈥渂ut it would be unsafe to do so before we make all social and nursing care free鈥�.

Experience suggests that the two goals are by no means mutually exclusive. Since 1997 Oregon has seen increased hospice referrals and high attendance of doctors at palliative care conferences. In the Netherlands too, the founding of hospices and the development of palliative care as a separate specialty has only seriously begun in the past three years.

What other insights can be gained from looking at areas where assisted dying is legal? A major fear of opponents is that no matter how tightly it were initially controlled, it would gradually become increasingly common 鈥� the so-called slippery slope argument. 鈥淚n euthanasia there are two choices: you either open the door or leave it shut,鈥� says Peter Hildering, chairman of the Dutch Physicians鈥� League, a group of about 450 mainly Christian doctors who strongly oppose their country鈥檚 law. 鈥淚t is impossible to set this door ajar.鈥�

Some of the most vociferous campaigners against assisted dying are disabled rights groups, who argue that if assisted dying were legalised, the criteria would broaden until disabled people came under pressure to end their lives. Hildering believes that the Netherlands is already sliding down the slippery slope. 鈥淭he discussion has now reached the people who cannot decide for themselves: people suffering from Alzheimer鈥檚 disease, newborns with a defect,鈥� he says.

Slippery slope?

Certainly the official surveys of assisted dying in the Netherlands suggest there are about 1000 cases a year where euthanasia is carried out without a patient鈥檚 explicit request. Dutch doctors say these are mainly cancer patients who are suffering terribly in their final days but are not conscious enough to make the request, or severely disabled newborn babies who seem certain to die.

But the surveys also show that rates of euthanasia and assisted suicide have remained stable at 2.7 per cent of all deaths. And the latest set of figures, from 2003, show doctors are actually getting stricter in their judgements on whether or not patients meet the official criteria for assisted dying (The Lancet, vol 362, p 395). The figures do not seem to support the slippery slope argument.

In Oregon, surveys suggest that so far the law is being used with restraint. Doctor-assisted suicide accounted for only 0.1 per cent of deaths in Oregon in the three years to 2000. 鈥淐ases are relatively rare,鈥� says Quill. 鈥淧eople are using the system as it was intended.鈥�

The findings from Oregon also suggest that not all patients who request assisted suicide go through with it. Almost half of those who get a prescription for the lethal cocktail of barbiturates do not take the 200 millilitres of bitter liquid. Rob Jonquiere, managing director of the Netherlands Right to Die Society, says that tallies with his experiences. To know they have control of their death is an enormous relief for people, he says, and sometimes that is enough. 鈥淣o longer obsessed by their fear of death, they can spend their energy on living the life that is left to them.鈥�

So what is the likelihood that people in other countries will one day be able to receive help in dying? In fact they already do. In the UK, for example, estimates of the proportion of doctors who have helped patients die range from 4 to 12 per cent. According to a 1998 survey of nearly 2000 US doctors, 16 per cent of those who had received a request to hasten death had done so (The New England Journal of Medicine, vol 338, p 1193). Irwin believes that many UK doctors carry out euthanasia while claiming their primary motive is pain relief. 鈥淒octors hide behind the hypocrisy of the double effect,鈥� he says.

The last attempt to legalise assisted dying in the UK was in 1994, when the parliamentary bill was thrown out. Joffe鈥檚 new bill has had a warmer reception. The House of Lords committee that investigated it gathered a huge volume of evidence, visiting the Netherlands, Oregon and Switzerland to gain insights from their experience (). Earlier this month the committee recommended that an amended version of the bill be further debated in parliament.

It is by no means certain to become law, especially as the British Medical Association remains opposed. But several other influential doctors鈥� bodies, such as the Royal College of General Practitioners, have shifted to a position of neutrality on the issue. Supporters of euthanasia have interpreted the Lords鈥� report as a tentative first step on the road to legalising assisted dying.

Whatever the outcome, it is too late to help Alayne Buckley. 快猫短视频 has learned that she died last month. Her family do not wish to discuss the circumstances, although they agreed to the details of her final interview being published in this article.

In future others in Buckley鈥檚 position may not have to face her agonising dilemma. They could instead face other, equally hard choices 鈥� such as who to entrust with their death.