How should the end come?

A POINT OF VIEW

Longer life spans and changing attitudes towards care and hospital treatment mean attitudes towards dying and euthanasia are complicated, writes Katharine Whitehorn.

The Queen no longer sends telegrams to people on their 100th birthday - it's cards these days, and at the present rate it won't be long before she's just about keeping the Post Office in business.

Some of the people who reach that age - or even mere chicks of 80 and 90 - lead vigorous and fulfilling lives. But an awful lot don't, so it's small wonder that the question of how they should live comes up more and more.



Many long terminal illnesses are simply horrific, in spite of good hospices and living wills



Not surprising, either, that Mary Warnock, who had to wrestle with the issues of the start of life, embryos and all that, and Elizabeth Macdonald, a distinguished oncologist at Guy's Hospital in London, have turned their attention to how we should die. The question is how and if life should be brought to an end.

This summer they've been on the stump at literary festivals for their thoughtful and enlightened book Easeful Death, most recently at the Edinburgh Book Festival. There's been more than one bill defeated in Parliament that was designed to make it easier for a really awful life to be ended, but they think that, in spite of the difficulties, our views on human life generally have developed enough for one to succeed now.

It seems certain, anyway, since we can now thwart death in so many ways and live so long, that we're going to have to rethink the end of life the way we have, effectively, re-thought the beginning, what with contraceptives and abortions and IVF.

30-year sabbatical

We're only beginning to realise the implications of us all living so much longer. The Times letters page recently discussed whether Lloyd George's first old age pension in 1908 was or wasn't as generous in real terms as the state pension now, but the massive difference for the government bean-counters is, of course, the sheer length of time the thing has to be paid out.

Until relatively recently, people mostly only lived for a few years after stopping work - now they may easily hang on for another thirty or forty years. In the words of Dr Richard Nicholson, who edited a magazine called Medical Ethics, "a 30-year sabbatical is just not on".

If you're educated and have enough money, if you're obsessed by bridge or golf or grandchildren, if you're allowed to go on working, you may have a good time, at least until your health packs up.


And I suppose if you feel your life is utterly meaningless you can commit suicide - certainly more suicides among the old succeed, compared with the young, for whom it may sometimes be just a cry for help.

But along with the statistics about how long we're all going to live - in a dozen years or so half the population will be over 50 - comes the chilling projection that the very old can look forward to ten years of chronic illness.

Obviously, properly cared for, sick and disabled people can live worthwhile lives. But many long terminal illnesses are simply horrific, in spite of good hospices and "living wills".

Anyone my age has plenty of deaths to brood about. When my mother died, she was staying with friends, who brought her breakfast in bed and found that she had died in her sleep.

When I rang a cousin to tell her, she said: "Oh, how wonderful" - she had been a mental health nurse, and knew only too well the alternatives. I know that one relation of mine starved herself to death, a horrible way to go - so fed up was she with constant intractable pain in spite of really good care - it's a myth that all pain is controllable.

Miserable fragment

When we saw another relative in his nursing home the day before - mercifully, he died - we came away saying "if it was an animal you wouldn't let it go on".

Margaret Forster, in her compelling book Precious Lives discusses two deaths. One was a beloved sister-in-law, dying of cancer, with morphine enough to end her life had she wished, but she didn't and clung on to the last painful moment.

When it came to Margaret Forster's father, a robust, stalwart, highly independent man who had declined over the years to a miserable fragment of himself, she finished the book by saying that history would find it odd that we let him fade away in such a manner - the last words of the book are: "It is odd. It is wrong."


Incredibly telling, to me, is a phrase from the American philosophy Professor Sam Gorovitz whose book on medical ethics called, inevitably, Doctors' Dilemmas tells of a young man who begged the doctors to give his agonised, dying mother more morphine. He was told no, because it might suppress her breathing.

The man accepted this at first, but then came back and said: "Where is it written that the cancer has some right to be the cause of death? That the doctor's job is to keep the patient alive until the tumour can cash in its claim?"

Time was, when doctors were more paternalistic and much less likely to be sued, that a good doctor might quietly help a patient to go. They can still give massive doses of painkiller - if the intention is to relieve pain, not to end a life. It's known as the double effect.

But there are a dozen reasons, and the Harold Shipman case is only one, why they have to be incredibly cautious. Acute pain isn't always the main misery - it can be complete loss of function.

Several European countries have some form of assisted dying; but in spite of the optimism of Warnock and Macdonald I had always thought it wouldn't work here, because we're so inefficient - if we can't even ensure that a miserable old lady gets her disgustingly soiled sheets changed, if a hospital can try to send a very confused elderly woman with dementia back home with no-one to control her heart pills, as Ros Coward recently related in the Guardian, how could we ever be sure we'd get it right about whether a sick person really wanted to go?

Swift death

Warnock and Macdonald have hopes that the time has come for it, even so.

My father had an old pupil who was a marvellous medical missionary and married to another. In retirement they cycled on a two-seater bicycle to raise money for the hospital in South Africa where they had worked. They were finally getting too old for this, but on the day after their Golden Wedding celebrations they set off on the tandem for a last ride round the British Isles - and were knocked over by a lorry and killed outright.

Everyone wrung their hands and said how awful it was - but what could be better than a very swift death, together, without the long agony of one losing the other, of operations and care homes, hearing and sight gradually going wrong, pain only just controlled.

I used to have a sort of Hollywood vision of my deathbed. I would lie on my pillows, pale but brave, and forgive my enemies - on the grounds that nothing would infuriate them more. I know now that I'm more likely to be half senile in hospital, hung about with tubes and drips, confused and hurting.

It may be very difficult to form a law that might give me an easy death, but I just hope they manage it before it's my turn to go.