You’re Looking Very Well

In his book How We Die Sherwin Nuland gives a detailed description of a friend of his with Alzheimer’s and the serious effects it had on his wife. When he passed away she wrote: ‘And when he died, I was glad. I know it sounds terrible to say that, but I was happy when he was relieved of his degrading sickness. I knew he never suffered, and I knew he had no idea what was happening to him, and I was grateful for that.’ A friend told me about her 96-year-old mother and her 92-year-old husband. He was effectively blind and had difficulty going upstairs. Her eyesight was poor but she devoted herself to looking after him. She said he had so changed that he was now quite unlike the person she loved, and his peaceful death would be far the best for both of them. This, thankfully, has now occurred. Death can be a relief. This leads us to consider assisted death, or euthanasia.

Instead of suicide, would not voluntary euthanasia be much preferred? Euthanasia is the intentional ending of life by a painless method for a person’s alleged benefit. It is usually assumed that it has the individual’s agreement, even wish. There are some subtle differences which can have legal implications. Voluntary euthanasia is when death takes place with the patient’s consent, and is different from occasions when the patient has neither requested nor agreed. There is also a distinction between active and passive, the former involving lethal injection, and the latter simple medication or the withdrawal of medication. Assisted suicide is when the patient takes the last step and another person provides the means of bringing about the end of their life. Under current UK law euthanasia is classed as murder, but recently cases of voluntary euthanasia have not been prosecuted. Assisted suicide is legal in Holland, Switzerland and the states of Oregon and Washington in the USA. It is hard to for me to accept the ban on voluntary euthanasia or assisted suicide for the terminally-ill elderly—I cannot accept the reasons that are given.

In ancient Greece and Rome, euthanasia was an everyday reality for many people who preferred voluntary death to endless agony. This widespread acceptance was challenged by the minority of physicians who were part of the Hippocratic School. The ascent of Christianity reinforced the Hippocratic position on euthanasia and culminated in the consistent opposition to euthanasia among physicians. Proposals for euthanasia revived in the nineteenth century with the revolution in the use of anaesthesia. In 1870 Samuel Williams first proposed using anaesthetics and morphine to intentionally end a patient’s life. This led to much discussion within the medical profession, particularly as to how much autonomy should be given to doctors.

The elderly may be exposed to backdoor euthanasia under the Liverpool Care Pathway. With patients deemed to be terminally ill, and if they think the patient is near death, doctors can withdraw fluids and drugs, so the patient, while on continuous sedation is allowed to die peacefully. This seems an attractive procedure but there is some concern about this process, as when under sedation improvement in the patient’s condition cannot be detected, and the doctors involved are not geriatricians. The decision to withdraw treatment is clearly a complex one, but doing so can greatly reduce the suffering of both patient and relatives

Geronticide—involuntary euthanasia—is the modern term to describe the deliberate killing of the elderly because they are old. Julius Caesar is reported to have said that the Romans killed the old who wanted to die, as society was orientated to fighting, and to die of old age was shameful. It was common among some non-industrial societies, and the choice of some agricultural or nomadic communities with inadequate resources was to sacrifice the old. Not infrequently relatives and friends regard these acts as deeds of mercy, and the aged sometimes welcomed and demanded them. Hunter-gatherers are less likely to care for the old when they are less able to gather their own food. Australian Aborigines buried the old in a hole until only the head showed, and let them die. It was a custom among the Dinka tribe in Sudan to give live burial to the old. Bushmen in Africa valued the old for their knowledge and experience, but once they became incompetent they were neglected and could be put on an ox and sent to a remote hut to die. Among the Yaghan indigenous peoples of Tierra del Fuego, the old were cared for but put to death when their condition was considered, by general agreement, hopeless. The same occurred with the Koryak in northern Siberia. In some parts of Japan there was a custom of holding a ceremonial feast every three years, followed by deportation of the old to a sacred mountain to eventually die. Until recently, certain communities expelled old age people from their midst.

John Humphrys, a presenter of the Today programme on BBC radio, cannot forgive himself for not being able to help his father die. He listened to his old father’s cries in the confines of a mental hospital. Would, he wonders, he have done anything wrong if he had helped him die—actually killed him? When interviewed, he compared the rich who wanted to end their life and were able to go to Dignitas in Switzerland with a poor ill old lady who has no one to help her. He points out how terrible someone with severe Alzheimer’s can be for a family. Thousands of people wrote to him when he described his anguish over the death of his father, and he subsequently wrote a book supporting euthanasia. In their book The Welcome Visitor: Living Well, Dying Well, John Humphrys and Sarah Jarvis argue that our attitudes to death and how we handle it need changing as we are living so much longer. We need to plan our death so that there is a minimum of pain and anxiety. We can sign a living will, so that if we have a bad stroke or other very serious illness we will not be revived. Since the book was published, a case before the Law Lords and new prosecution guidelines mean that relatives are less likely to fear prosecution in the future. I believe that euthanasia should be supported and it is unjust that relatives or carers who take a patient to Dignitas in Switzerland to end their lives should be liable to prosecution.

Baroness Mary Warnock, a supporter of euthanasia, believes we have the right to choose to die. This is particularly relevant to the old suffering from serious illnesses, especially if they feel they are a burden on their family. Many oppose this view and claim that one can have a good quality of life even with dementia. Patients with severe dementia may not be able to make rational decisions about death, so there could be a document a patient signs saying that when incontinent, very ill, and unable to even recognise relatives, death is preferred. Martin Amis is very pro-euthanasia: ‘My stepfather died horribly. I think the denial of death is a great curse. It was a lost battle and we all wanted to assist him.’ Many doctors do not support euthanasia, for while they are sympathetic and do not oppose it on ethical grounds, they do not want to be the killers. A majority of the UK public support assisted suicide.

All major religions teach that physical death is not the end, and for many older people and their families it may be important to help the transition from earthly life by performing religious ceremonies and rituals immediately before and after death. Some family members who are, for example, Catholics will insist on all possible treatments to prevent death and are totally against euthanasia. However, in spite of the right-to-life conviction, Catholic bishops have argued that it is necessary to weigh the benefits and burdens of life-saving treatments. Jewish thinking takes a similar view, and says there should not be attempts to prevent death when it is inevitable.

I am attracted to Trollope’s suggestion in his book The Fixed Period (1884), in which a colony near New Zealand need to deal with an ageing population. They decide that anyone over 67 must die and thus be saved from the problems of old age. I once proposed we all should have a gene which ensured painless death when we were 80 and that as everyone knew about this limited lifespan, it could be a great advantage to everyone. I have now increased that age to 85.

Perceived age and looking well, which are widely used by clinicians as a general indication of a patient’s health, are robust biomarkers of ageing that predict survival among those aged 70 and over, and correlate with important functional and medical conditions. So if you are told you are looking well, enjoy it for as long as you can. I find it difficult.

15. Enduring

‘And in the end, it’s not the years in your life that count. It’s the life in your years’

— Abraham Lincoln

In writing this book I have learned a great deal about the serious problems that face many of the old. In addition to the problems involved in how the old are to be cared for, I hadn’t known how many of the old are so poor, and that so many need major help. I also did not know about the extent of discrimination, and why compulsory retirement is bad for so many, or how serious are the problems of of loneliness. I am nevertheless very impressed with how some of the very old cope with their age and enjoy their life. For all these problems charities