Striving Officiously to Keep Alive?
One or two readers seized on remarks I made in a recent posting to recruit me to various views on assisted dying, etc. Mr ‘R’, for instance, wrote (first quoting me) :’ “This, in my view , is because the NHS is a sort of Anti-Death League , which mainly intervenes in people’s bodies with scalpel or drug (or both) when they are already very ill, and is very much influenced by modern society’s unwillingness to accept that death is the natural end of life, which we must all undergo.” Which is exactly what the Liverpool Care Pathway prevents - unnecessary and invasive treatment to people who are dying. Unfortunately, this government as a result of a campaign by your sister paper is removing.’
I think the problem with the ‘care pathway’ is that a scheme with humane, benign intent, in the hands of a rigid, target-driven bureaucracy heavily (and terrifyingly) influenced by incentive payments, became in practice something quite different – hence (for example) the many episodes remarked upon (I think) by Lady Neuberger in which patients were wrongly denied water, a denial which is very close to torture when applied to a conscious person. Something had gone very seriously wrong, and I think the campaign by the Mail on Sunday's sister paper was entirely justified and will result in more kindness in the world, rather than less. This is generally a laudable objective in any moral system.
But I do concede that this business of keeping people alive is very complicated indeed, and I was interested to see one contributor quoting Arthur Hugh Clough’s ‘The Latest Decalogue ‘ Thou shalt not kill, but needst not strive officiously to keep alive’ in *support* of the idea that we might make less effort to keep the serioulsy ill from dying. I’m not at all sure that was what Clough himself (whose ‘Say Not the Struggle Naught Availeth’ is one of my favourite poems) intended us to understand, though he was writing about very different times. By the way, I’d also recommend the same author’s ‘Through a Glass darkly’ as a thoughtful examination of the problems of religious belief.
The whole tone of the ‘Decalogue’ poem (there is more than one version, by the way) is a bitterly sarcastic attack on the dubious morals of his own hypocritical late 19th Century (Interesting question: was that era *worse* than our own because they knew that they were being hypocrites, or *better* than our own because they knew they were being hypocrites?)
One version runs
‘Thou shalt have one God only; who
Would tax himself to worship two?
God's image nowhere shalt thou see,
Save haply in the currency:
Swear not at all; since for thy curse
Thine enemy is not the worse:
At church on Sunday to attend
Will help to keep the world thy friend:
Honour thy parents; that is, all
From whom promotion may befall:
Thou shalt not kill; but needst not strive
Officiously to keep alive:
Adultery it is not fit
Or safe, for women, to commit:
Thou shalt not steal; an empty feat,
When 'tis so lucrative to cheat:
False witness not to bear be strict;
And cautious, ere you contradict.
Thou shalt not covet; but tradition
Sanctions the keenest competition.’
Another version ends with this extra sneer:
‘The sum of all is, thou shalt love,
If any body, God above:
At any rate shall never labour
More than thyself to love thy neighbour.’
So I think we should be careful about using the rather tortured Mr Clough, that High Victorian apostle of doubt and sorrow, as a sort of scriptural warrant for switching off the life support machine. The modern problem of medicine which can keep the body alive long after it would have failed in any other age or civilisation, didn’t exist in Clough’s time, and he wasn’t referring to it.
The old Commandment from the original Decalogue (if you acknowledge any such) stands : ’Thou Shalt Do No Murder’ (Gospel According to St Matthew, 19th chapter, 18th verse, words of Christ himself, Authorised or , for Americans, ‘King James’ Version).
This plainly forbids us from killing an innocent human being. What it permits us to do is open to perpetual debate, as in the limits of Just War, and the activities which can be included in such a war, bot to emntion self-defence, or the defence of another under attack, or just punishment for a heinous act. My contention is (for instance) that the execution of some heinous murderers, by performing a redemptive, just and deterrent purpose, is justified in the constant war that ordered societies fight against lawless, selfish violence. I also think that prohibition against ‘murder’ rather than ‘killing’ leaves us with an alarming latitude.
What if (as happens to a character in William Boyd’s ‘The New Confessions’ ) a soldier is begged by another soldier to shoot him. In this case, the man doing the begging is drowning slowly in a shell-hole, and cannot be rescued, but similar, and worse, events are recorded in many memoirs of war. Shall we be forgiven for helping such people to a swift death? Do the morphine packs carried by soldiers in combat , perhaps, allow them to give an appallingly wounded man a dose from which he is unlikely to wake. Does this happen? I suspect so. Little good would be done by publicising these events. I am myself entirely against bereaved relatives being told that their sons, fathers, brothers or husbands have been killed in the appallingly misnamed incidents of ‘friendly fire’ that are so common in warfare. It does not do to think too much about this, nor about the modern ability to save the lives of soldiers terribly wounded on the battlefield, so allowing them to live on, terribly injured in body and sometimes mind.
I’ve always found it hard to be dogmatic about the hard cases which are frequently given large publicity by the BBC, in its endless campaign for weakening the laws on euthanasia. Have they never heard the old saying that ‘Hard Cases Make Bad Law’, a maxim which seems to me to be invariably true? Why is it that so much of the political and cultural left are so keen on weakening the laws on euthanasia? Why is this campaign so persistent and unending, if it is not intended to have a profound effect? And whose interests will it serve, if the old and ill can more easily be snuffed out without fear of investigation or prosecution?
My view has tended to be that ( as in the Aleck Bourne abortion case of 1938 (discussed here http://hitchensblog.mailonsunday.co.uk/2007/10/safe-legal-and-.html), if people truly think that aiding someone’s death is an act of mercy, they should be ready to stand trial for those beliefs. I think it was right that Dr Bourne was acquitted. I admire Dr Bourne greatly. Yet I also believe, with great reluctance, that what he did was in fact morally wrong. The aborted baby had played no part in the appalling crime ( a gang rape by soldiers) which had impregnated the young woman, actually a girl of 14. The baby could have been adopted. I am well aware of the difficulties of this position, and do not know what Dr Bourne knew about the young woman involved, which led him to conclude with absolute firmness that her life was in danger, the only defence in law to the charge he faced. I strongly suspect that, had I been him I would have done what he did, and I don’t doubt that mercy is available in such dreadful circumstances. For what doth the Lord require of Thee but to do Justly, and to love Mercy, and to walk humbly with thy God? (Micah (not Clarke), 6th chapter, 8th verse). But I think the existence of a firm law is crucial to protect *all* doctors from undue pressure to do things which are much, much more questionable. The abolition of such a law (as happened with the Abortion Act of 1967) has been shown in practice to lead to a general collapse of resolve. Technically, the 1967 Act contains safeguards. In fact, these safeguards are worthless in practice.
I am not interested in the sort of people who will seize immediately on my admission that my position has grave weaknesses. I admit them because they exist, and because moral judgment, in practice, is so often so very difficult, and because we so often fail to get it right. They are not interested in civilised or generous debate, and I am not writing this for them. I expose these weaknesses precisely because the problem is so difficult and often rends the heart. But I think that Dr Bourne’s action was wholly different from that of those doctors who now provide what is in effect abortion on demand, as a form of contraception. And my best witness for that is Dr Bourne himself, who became a founding member of the Society for the Protection of Unborn Children, refused to perform any further abortions for the rest of his life (he was often asked) and wrote, in 1963 : ’ Those who plead for an extensive relaxation of the law [against abortion] have no idea of the very many cases where a woman who, during the first three months, makes a most impassioned appeal for her pregnancy to be 'finished,' later, when the baby is born, is thankful indeed that it was not killed while still an embryo. During my long years in practice I have had many a letter of the deepest gratitude for refusing to accede to an early appeal.’
In the comparable problems of the care of the very old, or the very ill, or very badly injured, for whom life appears not to be worth living, who are in grave pain and distress, what is murder? In my view, I am afraid murder may be involved when the person’s life is ended for the benefit of others. I don’t just mean legacies and property, though these may be involved. I also mean when the person’s life is ended for the convenience of others.
Of course many difficulties are caused by the ‘advance’ of medical science. One example of this common problem is Pneumonia, which used to carry off many old people when they were ready to go, and now doesn’t because of antibiotics and other treatments. But once these treatments are available, isn’t it then a wilful act to withhold them? I think this is why the passage from Clough, about ‘officious striving’ has become so well-known, way out of its true context, in modern times.
Has medicine, in fact, taken a completely wrong turning? Has it become too concerned with combating disease, in the abstract, and too little concerned with preserving the health of the actual person, and with relieving actual pain? I was astonished, during the final illness of an elderly relative some years ago, how reluctant doctors were to allow sufficient pain relief, in one case on the grounds that the person involved, clearly dying, might become ‘addicted’. I began to wonder whether the people I was talking to were entirely sane, but it was probably just bureaucracy at work, as usual, that dreadful inadequate substitute for experience, skill, wisdom, initiative and thought.
The law, it seems to me, must remain in place. Hard cases cannot be used to abolish it. It is precisely when we are most vulnerable that we most need the law’s protection. Those who campaign against the existing law do so, doggedly, repeatedly, determinedly, because they wish to be free to behave differently, and they wish to free everyone else to behave differently too. Will the old be safer if they are so permitted? Of course not. I suspect that many old and ill people are already being quietly shuffled into the next world, as it is.
If the actions involved are genuinely selfless and compassionate, then let those who do them selflessly face the possibility of prosecution. It seems to me that if their arguments are as good as they claim, they will not face any serious risk of conviction.