Death and Dying

Editor's Choice
Death and dying

Jane Smith, deputy editor, BMJ

jsmith@bmj.com

The main theme of this week’s issue is death and dying, a subject where the public and the private jostle uncomfortably. This week’s BMJ contains several articles that add to the debate about public policy and throw light on to the nuances of private thoughts and behaviour.

Dutch law on euthanasia requires that the doctor must be convinced that the patient who requests euthanasia has unbearable suffering. In their qualitative study H R W Pasman and colleagues explored what this concept meant for patients whose request for euthanasia was either refused or granted but not carried out, and for their doctors (doi:10.1136/bmj.b4362). They found that doctors had a narrower view of unbearable suffering than patients, tending to concentrate on physical suffering. In some cases doctors thought that the suffering was not unbearable because patients behaved in a way that didn’t seem compatible with unbearable suffering, such as reading books. Patients emphasised psychosocial suffering, such as fear of dependence, not being able to do ordinary things, and deterioration. < P> This difference is illustrated in Alex Paton’s moving account of the death of his wife (doi:10.1136/bmj.b4982): "She wanted to die, and we realised she meant it...a keen plantswoman, she said there was no point in living if she could no longer garden." Yet she was resuscitated in spite of an advance directive, and her family signed her out of hospital against medical advice, to die at home. Paton also argues for care with words, preferring "euthanasia...the bringing about of a gentle and easy death" to "assisted suicide...which continues the myth that euthanasia is a nasty business."

Another article in this week’s issue shows how private acts and thoughts can reach the public stage. Debbie Purdy writes in her patient’s journey about having multiple sclerosis and how she has come to terms with increasing loss of function (doi:10.1136/bmj.b4470). Her main point is the importance of making her "own choices about what constitutes an acceptable quality of life" rather than having others, including professionals, make assumptions about what that is. She says it was this desire that led her to campaign to ensure that "assisted death is part of the support available to patients who are suffering unbearably"—alluding to her very public fight to be allowed to control the manner of her dying. Debbie Purdy hasn’t managed to change English law to allow assisted dying, but as a result of her court cases the House of Lords directed the Director of Public Prosecutions to publish his guidance on the factors that would prompt or argue against prosecution in individual cases.

That guidance was published in September and is now being consulted on. Richard Huxtable and Karen Forbes discuss some of the imponderables in their editorial (doi:10.1136/bmj.b4900), concluding that this guidance has not really clarified things for doctors or made end of life decisions and discussions easier. They fear "stealth lawmaking," where the law slides "from an apparent prohibition to a de facto position of permission."

Yet end of life decisions are already unstraightforward, as the ethical debate led by Stephen Bonner and colleagues illustrates (doi:10.1136/bmj.b4667). They were faced with a woman, unconscious as a result of attempted suicide, who had written an advance directive five years earlier saying she did not want life sustaining medical treatment. Should the directive be followed or should the emergency department staff initiate life saving treatment? Read the article, and its commentaries, to find out what they did, and what others think about it.

Cite this as: BMJ 2009;339:b5044