There are several alternative approaches and options for people with terminal conditions or those experiencing intolerable suffering.
Under English law, all adults have the right to refuse medical treatment, even if that treatment is required to save their life, as long as they have sufficient capacity (the ability to use and understand information to make a decision).
Under the Mental Capacity Act (2005), all adults are presumed to have sufficient capacity to decide about their own medical treatment, unless there is significant evidence to suggest otherwise. The evidence has to show that:
- a person's mind or brain is impaired or disturbed
- the impairment or disturbance means the person is unable to make a decision at the current time
Examples of impairments or disturbances in the mind or brain include:
- brain damage caused by a severe head injury,stroke or dementia
- mental health conditions, such as psychosis (where a person is unable to tell the difference between reality and their imagination)
- any physical illness that causes delirium (illusions, disorientation or hallucinations)
If a person makes a decision about their treatment that most people would consider irrational, it does not constitute a lack of capacity if the person making the decision understands the reality of their situation.
For example, a person with life-threatening cancer may refuse a course of chemotherapy because they would rather not tolerate the treatment's side effects for the sake of a slightly longer life. They understand the reality of their situation and the consequences of their actions and have made a perfectly rational decision.
However, a person with severe (psychotic) depression who refuses treatment because they wrongly believe that they have no hope of recovering and are so worthless they deserve to die would be considered incapable of making a rational decision. This is because they do not understand the reality of their situation.
Read more about consent to treatment.
If you know that your capacity to consent may be affected in the future - for example, because you may become unconscious, you can arrange a legally binding advance decision (previously known as an advance directive).
An advance decision clearly sets out the treatments and procedures that you consent to and those that you do not consent to. This means that the healthcare professionals who treat you will be unable to carry out certain treatments and procedures that are against your wishes.
For an advance decision to be valid, you must be very specific about what treatments and procedures you do not want and under what circumstances. For example, if you want to refuse a certain treatment, even if it means your life is at risk, you must clearly state this.
As long as the advance decision is valid and applicable, the healthcare professionals treating you must follow it. In other words, it must cover exactly the condition you go on to develop and the treatment decision now at issue. There must also be no doubt about your capacity at the time of drawing up the advance decision.
If there is any doubt about the advance decision, the case can be referred to the Court of Protection, which is the legal body that oversees the Mental Capacity Act (2005).
Read more about advance decisions.
CPR and 'do not attempt CPR' orders
Cardiopulmonary resuscitation (CPR) is a treatment that attempts to restore breathing and blood flow in people who have experienced cardiac arrest (when the heart stops beating) or respiratory arrest (when they stop breathing).
CPR is an intensive treatment that can involve chest compressions (pressing down hard on the chest), electrical shocks to stimulate the heart, injections of medication and artificial ventilation of the lungs.
Despite the best efforts of medical staff, CPR does not have a good success rate, even in patients who are selected as appropriate for CPR.
In hospital, only around 10-20% of people survive after having CPR, and survival rates are even lower in community settings.
Even when CPR is successful, a person can often develop serious and sometimes painful complications such as:
- fractured ribs
- damage to the liver and spleen
- brain damage leading to disability
Also, many people who survive after having CPR need prolonged treatment in an intensive care unit (ICU).
Due to the low success rate of CPR and the corresponding high risk of complications, many people, particularly those with terminal illnesses, make it clear to their medical team that they do not want to have CPR in the event of cardiac or respiratory arrest.
This is known as a 'do not attempt cardiopulmonary resuscitation' or a DNACPR order. Once a DNACPR order is made, it is placed with your medical records.
If you have a serious illness or you are undergoing surgery that could cause respiratory or cardiac arrest, a member of your medical team should ask you about your wishes regarding CPR (if you have not previously made your wishes known).
A DNACPR choice is not permanent and you can change your DNACPR status at any time.
Some supporters of euthanasia have argued that DNACPR is essentially a form of passive euthanasia because it involves a person being denied treatment that could save their life.
The counter-argument to this is that the success rate of CPR is often so low and the risks of complications so high that it is not the case that a person is being denied life-saving treatment.
Palliative sedation is where a person is given medication to make them unconscious and, therefore, unaware of pain. It is often used in cases where a person has a terminal illness.
Many terminal illnesses can cause distressing and painful symptoms when the person reaches the final stages. These can include:
- muscle spasms
- bone pain
- unpleasant and sometimes frightening breathing difficulties
- upsetting emotions and feelings, such as fear, apprehension and distress
Palliative sedation is a way of relieving needless suffering.
Although palliative sedation is not intended to end a person's life, the medication carries a risk of shortening their life. This has led some critics to argue that palliative sedation is a type of euthanasia.
A counter-argument is known as the 'doctrine of double effect'. This states that a treatment that has harmful side effects is still ethical as long as it is in the best interests of the patient and the harmful side effects were not intended.
For example, very few people would argue that chemotherapy is unethical, even though it can cause a wide range of harmful side effects.
Withdrawing life-sustaining treatments
There are many different types of treatment that can be used to sustain life in people with serious or terminal illnesses. For example:
- nutritional support through a feeding tube
dialysis - where a machine takes over the functions of your kidneys
- ventilators - where a machine takes over your breathing
Eventually, there may come a time when it is clear that the prospects of a person recovering are nil and, in the case of terminal illness, the life-sustaining treatments are only prolonging the dying process.
In such circumstances, a doctor may recommend that the treatment is withdrawn so they can die peacefully. In some cases, palliative sedation (medication that relaxes a person and makes them drowsy) may be used while the treatment is withdrawn.