Jacqueline A. Laing

There is currently a dearth of bioethical literature presenting what might be called a more traditional approach to medicine and health care. Life and Death in Healthcare Ethics promises a reasoned and clear alternative. It considers ethical concerns raised by reproduction and death and dying. The issues considered include euthanasia and withdrawal of treatment, the persistent vegetative state, abortion, cloning and in vitro fertilization. Given its clarity and simplicity the book is likely to be read eagerly by students from a range of different disciplines. For those who want a basic text to introduce them to life and death issues in bioethics, this is a most welcome contribution.

John Harris criticises the European Parliament’s ‘waft in the direction of human rights and human dignity’ and rejects its suggestion that ‘human cloning violates the principle of equality since “it permits a eugenic and racist selection of the human race”’. He argues that, by parity of reasoning, so too do ‘pre-natal and pre-implantation screening, not to mention egg donation, sperm donation, surrogacy, abortion and human preference in choice of partner’. Conflating the techniques mentioned (ie, human cloning, egg donation, etc) with human preference in choice of a partner, he holds that reproductive liberty must be the operative principle in determining what ought to be prohibited by law in the realm of human reproduction. This article challenges his two problematic assumptions.

A useful case against voluntary euthanasia. This short article summarises at least ten reasons why voluntary euthanasia should not be legalised.On the subject of voluntary euthanasia she argues that institutionalizing medically assisted death - erodes respect for human life, underestimates human capacity for error and vice and is intrinsically discriminatory. She argues that it plays into the hands of illicit interests and trades on an improper understanding of human autonomy. She warns against dismissing “the army of corporate, financial, medical and political interests that there are in controlling death, euthanasia’s corrosive effects on public and professional attitudes, and the discrimination implicit in its implementation.”

The recent revelation that the rolling out of the Liverpool Care Pathway as the NHS National End of Life Care strategy in 2008 had been financially incentivised and implemented with astonishing compliance emerged as a thought-provoking development. Many of us have been warning for years of the financial, political and research interests that there are in institutionalising sedation-and-dehydration regimes, and then, inevitably, medical homicide. Freedom of Information Act requests exposed the millions of pounds that have been paid for the implementation of this national end-of-life care strategy. Much more interestingly, it showed that some hospital trusts had been paid these funds for ensuring that up to two thirds of all deaths were Pathway deaths. Given that the very livelihood of health professionals was being judged against the new Commissioning for Quality Innovation (CQUIN) ’Gold Standards Framework’, professional observance of the pathway was predictable. The revelation of management targets, despite the best efforts of the regime’s proponents to play them down, radically alters the debate. Unlike education or housing targets, these ones are potentially homicidal.

The article discusses questions on the significance of blood relatedness in the context of identity arguments about artificial reproduction (AR). Kinship, origins, and biological connections are significant to human beings. The author explains that family relationships bear on the identity of human beings. Moreover, she emphasizes that once these principles are neglected, it is possible to create people in ways that threaten significant human bonds and alienate people who are naturally related spelling loss, confusion and grief for them.

Law, we are told, is a system of rules, created by men to govern human behaviour. Students of law, introduced to legal systems, become familiar with varied sources of law – legislative, judicial and executive in character. There are undoubtedly prescriptive human rules that govern men set up by public authorities that are advertised as being for the common good. These appear as visible, socially constructed systems in different jurisdictions and even as international systems across jurisdictions. But is this all there is to law? Is law merely a human construct subject to flux, different according to time and place? Or must law, in its fullest sense, be seen as an activity that needs to be interpreted aright, binds the human conscience and is answerable to certain universal and timeless demands? Is there any natural moral law common to all men, universal and timeless?

A consideration of monotheism. The term ordinarily suggests belief in one God and derives from the Greek monos meaning “one” and theos meaning “god.” In the Abrahamic religions, Judaism, Christianity, and Islam, the one god is regarded as supreme lord and creator of the universe, almighty, all-knowing, and all-good. Traditionally, Christianity has taught that God revealed himself to our first parents, Adam and Eve, as the one true God in Genesis. The Old Testament reveals a jealous God who forbids the worship of strange and multifarious gods. God's chosen people, the Jews, are destined to prepare the way for the coming of the universal religion available not just to a privileged few.

The Liverpool Care Pathway is intended as a palliative care regime at the end of life. Even its critics agree that certain of its recommendations may be useful and appropriate. Additionally, critics are aware that there are occasions when death may be a foreseen side effect of perfectly licit palliation whose primary ends are not homicidal at all. It is evident that treatment may be over-expensive, over-burdensome or simply futile. There is no suggestion that critics of the Pathway adhere irrationally to what is known in medical ethics as the error of vitalism, the commitment to excessive, extraordinary or futile treatment, or over-burdensome care at the end of life. However, to ask whether treatment is futile, over-burdensome or over-expensive is very different to the discriminatory question about the futility, burden or expense of a frail and vulnerable patient. The sedation-dehydration aspect of the Pathway attracts much proper opposition. Doctors and families have found that those on the Pathway recovered when they intervened to take the patient off it. Senior medics have stepped forward, in the face of managerial opposition to argue that it is often impossible to know with certainty whether a person is imminently dying. One problem with the Pathway is that where a patient is misdiagnosed as terminal, the combination of morphine and dehydration has a self-fulfilling character and is likely to undermine a patient’s capacity. Persistent dehydration of even fit and healthy sedated patients will kill them. This was the difficulty highlighted by concerned medical professionals many years ago. The independent inquiry ordered in response to Freedom of Information Act requests performed in 2012 demonstrating a staggering increase in the number of people dying on the Pathway once it was financially incentivised needs to ensure certain investigations take place. What is needed, however, is not a whitewash but an independent inquiry with all interests declared and data sets interrogated and collated. These will cover a time-series medical history of each anonymised patient on the Pathway, duration until death, information about interventions provided during the period, monthly raw data from each trust, hospice or care home, medical histories, removals from the Pathway, information about journals that were corrected once a patient recovered, demographic data, location information and an audit trail of all data management.

A critic of utilitarianism, in a paper entitled “Innocence and Consequentialism” Laing argues that Singer cannot without contradicting himself reject baby farming (a thought experiment that involves mass-producing deliberately brain damaged children for live birth for the greater good of organ harvesting) and at the same time hold on to his “personism” a term coined by Jenny Teichman to describe his fluctuating (and Laing says, discriminatory) theory of human moral value. His explanation that baby farming undermines attitudes of care and concern for the very young, can be applied to babies and the unborn (non-persons on his view) and contradicts positions that he adopts elsewhere in his work.

A consideration of the concept of authority. The term authority derives from the Latin 'auctoritas'. Although often regarded as synonymous with 'potestas' or power, authority is more properly considered power legitimately exercised. Whereas Stalin had the power to kill millions of innocents he did not have the authority to do so. Accordingly, it is often said that the supreme authority is God himself who is both omnipotent and all good. On this view God is the source of the eternal law which is observed both in the fullness of the physical universe and also in the moral universe that governs men and angels. Accordingly the book of Proverbs states that “By me kings reign and lawgivers decree just things” (Prov. 8:15).

On the sixtieth anniversary of the Universal Declaration of Human Rights, Laing contends that the practice of eugenics has not disappeared. Conceptually related to the utilitarian and Social Darwinist worldview and historically evolving out of the practice of slavery, it led to some of the most spectacular human rights abuses in human history. The compulsory sterilization of and experimentation on those deemed “undesirable” and “unfit” in many technologically developed states like the US, Scandinavia, and Japan, led inexorably and most systematically to Nazi Germany with the elimination of countless millions of people for their race, class, political views, sexuality, religion or disability. She argues that the new eugenics collapses into the old variety because of its fixation on producing “the better” or even more implausibly, “the best”. It was this very idea that drove much of the injustice of the twentieth century. Ethically questionable strategies were at the time viewed as progressive and socially evolutionary. The new eugenics, she thinks, fares no better and spells disaster for people regarded as deficient in some way. She rejects the idea that autonomous efforts to choose “better” or the “best” children are less problematic for being freely chosen. The fact that one freely chooses to give one’s children away into slavery or medical experimentation or to end one’s life, is no bar to the action’s being part of a eugenic agenda and independently at odds with intergenerational justice and the common good. She points out that misinformation, propaganda and behaviour modification techniques, subliminal or otherwise, are celebrated ways of getting people to act in a way that destroys their own interests. Laing regards eugenics as an ongoing threat to the defenceless in particular, but the ‘deficient’ classes more generally.

The Mental Incapacity Bill not only paves the way for euthanasia, but invites wholesale abuse and homicide, writes Jacqueline Laing. On 19 October 2004, when the Mental Capacity Bill was at its crucial committee stage, the Law Society issued a statement of ‘strong support’, claiming that it empowers patients and in no way introduces euthanasia. Laing argues that the Bill threatens the incapacitated by granting a raft of new third parties power to require that health professionals withhold ‘treatment’, which, after the controversial decision in Airedale NHS Trust v Bland [1993] AC 789, includes food and fluids delivered both by tube and, in certain cases, by spoon. The Bill further endangers the vulnerable, first, by allowing non-therapeutic research on the non-consenting mentally incapacitated, in breach of the Nuremberg Code and First Declaration of Helsinki, and secondly, by permitting new agents power to undertake on people with learning disabilities certain questionable procedures currently authorised by the High Court, such as non-voluntary sterilisation.

The Mental Capacity Bill endangers the vulnerable by inviting human rights abuse. It is perhaps these grave deficiencies that prompted the warnings of the 23rd Report of the Joint Committee on Human Rights highlighting the failure of the legislation to supply adequate safeguards against Articles 2, 3 and 8 incompatibilities. Further, the fact that it is the mentally incapacitated as a class that are thought ripe for these and other kinds of intervention, highlights the Article 14 discrimination inherent in this and related legislation. The financial, medical and research interests that underpin the legislation highlight how the legilsation endangers the ulnerable. It appears to be both a responsibility shifting exercise. Most alarmingly of all, efforts to permit non-therapeutic research on the non-consenting vulnerable as well as sterilisation and abortion on those who do not consent suggest that the legislation heralds a new era o gross human rights abuse in instutions around the UK.

Helga Kuhse suggested in 1985 at a session of the World Federation of Right to Die Societies in Nice, that once dehydration to death became legal and routine in hospitals, people would, on seeing the horror of it, seek the lethal injection. The strategy of legalising passive euthanasia is itself flawed. Laing argues that the Mental Capacity Bill threatens the vulnerable by inviting breaches of arts 2,3,5,8, and 14 of the European Convention on Human Rights. Most at risk are the disabled and incapacitated. Sections permitting non-therapeutic research and non consensual sterilisation are at odds with the Nuremberg Code. New third party powers to dehydrate the vulnerable permit new systemic human rights abuse of a clinical though not historically unfamiliar variety.

Wars have been entered into as a means of gaining property, taking slaves and dominating and controlling peoples. The pacifist claims that no form of war can ever be justified. By contrast, just war theory holds that it is possible for a war to be morally justified, an idea that underlies much international law, as can be seen in the Geneva Conventions. Teichman introduces us to such thinkers as Aristotle, Cicero, Augustine, Aquinas, Hugo Grotius, John Rawls and Elizabeth Anscombe on the very idea of a just war.

Despite the prevalence of human rights talk in Western jurisprudence, there has never been less belief in or acceptance of, any genuine form of objective morality. Academics reject the reality of moral objectivity and proclaim, as an objective truth, that morality is a mere “socio-historical construct”, illusory because always outweighed by worse consequences, expressions of subjective preference or mere evidence of culturally relative predilections. If morality is not that, then it is thought to be evidence of the power of the ruling elite in an essentially value-free universe. This article examines moral scepticism and moral relativism as a bedrock for human rights laws. It argues that if we are to retain any coherent and meaningful concept of human rights we will have to jettison our moral relativism.