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seemed to me to sum up, perhaps better than any other form of words, what the President of the Royal Society of Medicine had in mind when he wrote to me a year ago. Moral and Spiritual Aspects I make what small contribution I can today out It was in December last year that I was first of the conviction that much hard thinking remains approached by Sir Gordon Wolstenholme as to the be done on this subject, and that we shall only possibility of my giving the Edwin Stevens Lecture work our way towards positive and helpful printhis year. Let me say at once how high a privilege I ciples in so far as practitioners in various departconsider this to be, though I accept the honour ments of life and learning join their skills and with a considerable measure of diffidence due in marry their experiences in the give and take of part to the distinction of the audience which I open discussion. I speak as one who, unlike those address and in part to the immense difficulty of the who have spoken before me this evening, has no scientific or legal expertise, but as one who, in a subject which I have been given. Since I was rash enough to accept the invitation, ministry as priest and bishop extending well over I have myself been a victim in the hands of the forty years, has often come close to those who are doctors - for me a rare experience and, as I dis- dying and is deeply concerned that the act of dying covered somewhat to my surprise, an enriching should be as good an act as preparation and skill one. I will not succumb to the temptation, often and love can make it. I speak as a Christian, with yielded to by men of advancing years, to go into all the bearing that Christian belief and practice detail as to the nature of my complaint. Nothing have on our subject. But I am convinced that the could be less interesting. It was a matter of minor major part of what I shall say has relevance for surgery, and I was out of the hospital some ten those who do not hold the Christian faith, or only days after entering it. What I do feel constrained to partially do so, and much of it for those who say is this: I wrote to my daughter, who is a cannot even subscribe to that view of death which gynxcologist serving in Pakistan, and I said to my is summed up in the words (from the preface of the wife, who is the daughter of a surgeon, 'I raise my Mass of the Dead) Vita mutatur, non tollitur, 'Life is changed, not taken away', by the incident of hat to the medical profession'. Trying to analyse what it was that made a death. It might be of help if, at the outset, I said a word slightly painful experience so enriching a one, I recognize, of course, that there is an element of about the limits to the doctor's responsibility to vanity in all of us and it is pleasant to be made a keep his patient alive, and what Christian moralists fuss of. I recognize, further, that even in a com- have to say on the subject. I refer first to some paratively minor piece of surgery there is a com- words contained in the Papal Allocution of Pope bination of skills the operation of which gives great Pius XII to a congress of anesthetists which met in confidence to the man on whose behalf they are November 1957, and I quote from the booklet used. But I think the main reason which converted 'Decisions about Life and Death: A Problem in the bane of this experience into the blessing that it Modern Medicine' (Board for Social Responsiundoubtedly has become was the skilled bility of the Church of England 1965, pp 52-53): friendship - and I use adjective and noun 'The Pope was considering inter alia certain moral advisedly - shown by the two doctors mainly in- questions that may arise through the use of artificial respiration in cases of cerebral lesion. A patient has been volved. I preface my lecture with these words, partly plunged into unconsciousness by central paralysis, artiso as to maintain his because I welcome the opportunity of paying a tiny ficial respiration has been applied several days of but after and circulation, breathing tribute to a great profession and partly because I treatment there is no sign or prospect of any improveshall have occasion to revert to them, in a very ment in his condition. In such circumstances may the different context, later on. apparatus that is maintaining the circulation be removed, The subject which has been assigned to me is one or ought it to be kept in operation until the circulation of very great difficulty and complexity, and only a stops in spite of it? 'The answer given in the allocution was based on the fool would approach it without the utmost diffidence. Those who have spoken before me this distinction, already drawn by Roman Catholic moralists, evening have touched on some of the related between "ordinary" and "extraordinary" medical or surgical procedures. "Ordinary" in this context does not problems within their own particular spheres of mean what a medical man would regard as "normal" learning. The title of this lecture was suggested by treatment: it means whatever a patient can obtain and the title of a report (1975) of a working party set up undergo without thereby imposing an excessive burden of the of Responsibility the Board Social by on himself or others. Thus "extraordinary" treatment Church of England which formed the subject of a has been defined as "whatever here and now is very costly debate in its General Synod in February 1976. I or very unusual or very painful or very difficult or very have given this title to this lecture because it dangerous, or if the good effects that can be expected
The Most Rev and Right Hon Donald Coggan DD, Archbishop of Canterbury
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from its use are not proportionate to the difficulty and inconvenience that are entailed". 'The point of the distinction is this. As a general rule a sick man is bound, as are those who have the care of him, to employ the appropriate available means of preserving his life and restoring his health. But there are obviously limits to this obligation. He is not bound to incur, or impose upon his family, an impoverishing expense; nor is he bound to submit to treatment which would cause him great distress and of which the benefits are problematical. In other words his strict obligation extends only to the "ordinary" means of preserving life and restoring health, and not to the "extraordinary" as defined above. He may accept "extraordinary" treatment if he thinks fit; but he is not bound to do so, unless he has some special obligation to stay alive. As for those who have the care of the patient, the doctor has neither right nor duty to insist on "extraordinary" treatment against the patient's will, nor is he bound to apply such treatment in cases where the patient cannot be consulted; and the patient's family is in much the same position.'
Though there are obvious difficulties in the outworking of the principles enunciated in this allocution, there are marked similarities between them and the attitude reflected by the Anglican canon lawyer, Chancellor E Garth Moore, when dealing with another aspect of the same problem, namely the legitimacy of action taken by a doctor which may lead to the shortening of the patient's life. The useful ethical distinction between a principal intention, or moral object, which is good, and indirect consequences, may throw light on the nature of the decision facing the doctor who wishes to give a pain-killing drug to a patient. Garth Moore writes: 'It would seem reasonably certain that the giving of a pain-killing drug to a patient in extremis can be justified, not only by the theologian's law of double effect, but also by the Common Law doctrine of necessity, even where one of the effects of the drug is the probable shortening of the patient's life. This is because the evil averted, namely the agony of the patient, is greater than the evil performed, namely an act leading to the probable shortening of his life...' (Board for Social Responsibility of the Church of England 1965, p 50). The first two Conclusions of the signatories of the report 'On Dying Well' (to which allusion has already been made) also show marked similarity to the general conclusions both of Pope Pius XII and of Chancellor Garth Moore. They read: '1. In its narrow current sense, euthanasia implies killing, and it is misleading to extend it to cover decisions not to preserve life by artificial means when it would be better for the patient to be allowed to die. Such decisions, coupled with a determination to give the patient as good a death as possible, may be quite legitimate. '2. Nor should it be used to cover the giving of drugs for the relief of pain and other distress in cases where there is a risk that they may marginally shorten the patient's life. This too we think legitimate' (Board for Social Responsibility of the Church of England 1975, p 61).
This is in keeping with the point made by the Bishop of Truro in introducing the debate on the Report, when he said: 'The demands that a patient in extremis should not be subjected to troublesome treatment which cannot restore him to health and that doctors may use drugs to control pain even at the risk of shortening life do not involve voluntary euthanasia at all and are not in question' (General Synod of the Church of England 1976). In the light of these references, I need hardly emphasize that the view, held by many, that Christians believe that life must be artifically prolonged under all circumstances is not true. You will recall the case of the American girl, Karen Quinlan, which was widely reported in the press last year. I am informed that it was the doctors, not the priest, who gave the advice which led to the prolongation of her life. Probably all of us would agree in deploring the events which so fearfully prolonged the life - if life it can be called - of General Franco. A similar case of malpractice is described in a letter quoted by Hugh Trowell (1973, p 29) in his important and sensitive book 'The Unfinished Debate on Euthanasia'. He rightly describes the letter as 'terrible'. Lord Edmund-Davies has already quoted Arthur Hugh Clough's words: 'Thou shalt not kill, but need'st not strive Officiously to keep alive."i However great the difficulties in law of working out the implications of these oft-quoted lines, there would seem to be a wide consensus of Christian opinion in favour of the principles contained in
them. There is another matter, closely related to the one which we have just been considering, which must cause anxiety, and at times perhaps agony, to a doctor who has to weigh up his responsibility in making a choice. I refer to the choice between, on the one hand, making the most advanced techniques available to a few, and, on the other hand, improving the level of services available to many, and especially to those who have in the past been inadequately cared for. The resources of the national exchequer are not limitless (in the year 1975/76 the nation spent £4564 million on health and welfare, including local authority costs), and the prolongation of the life of one aged patient may in fact entail the deprivation of aid to others and even the shortening of their lives. Nor are beds in ' These lines of Arthur Hugh Clough are from 'The Latest Decalogue'. They are frequently quoted, with some solemnity, in books and papers on euthanasia and kindred subjects. The author would, I think, have been amused, for Clough's 'Decalogue' is satirical, one might almost say cynical. See, for example, the last of his 'commandments': 'Thou shalt not covet, but tradition Approves all forms of competition.'
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hospitals limitless; and the extension of the life of a terminal patient may necessarily involve the suffering or even death of those who, if speedily admitted to hospital treatment, might have many years of useful life ahead of them. I realize that here I am treading on exceedingly dangerous ground. I am fully aware of the great dangers of legalized euthanasia. I bear in mind a passage in Sir Norman Anderson's recent book 'Issues of Life and Death' in which he writes that, if voluntary euthanasia were to be made legal, '. . . there would soon be a demand for further concessions. It would not be long before the argument would be heard that paralysed, incontinent or semi-comatose elderly persons would certainly sign the suitable form if only they were to have a sufficiently lucid interval; so why should not their relatives do for them what they would wish to do for themselves? "That agreed" - to quote a recent article by R F R Gardner- "within a month someone would say 'But to expect relatives to make this decision is to impose an impossible emotional burden; let us authorize an official to do this without distressing them'. Naturally parallel arguments would be advanced for the congenitally damaged neonates. It would then be suggested that the problem of approval for the euthanasia of the conscious but incapacitated aged would be even more distressing, and therefore it would be vital to relieve relatives of any involvement in this and have it arranged by some distant office"' (Anderson 1976).
Of all this I am vividly aware - one has not lived through the days of the Nazis without memories which are not easily blotted out.' But the awareness of these appalling abuses must not blind us to the realities of a situation the severity of which will not diminish but rather increase as the percentage of old people rises and, quite possibly, the extent of Government financial aid reaches a figure beyond which it cannot go. The doctor has a responsibility - an accountability - to the patient and the patient's family under his immediate care. But he has also a responsibility to the other patients in the long waiting queue. He has a further responsibility - to the Government, or, to put it more personally but none the less accurately, to his fellow tax-payers who provide the resources to keep the National Health Service going. The question arises as to whether some kind of consensus -I had almost said some kind of ethic - can emerge on the distribution of resources as between one part of the Health Service and another. A free-for-all could be disastrous. (I understand that the DHSS has this year issued a Discussion Document on Priorities in the Health and Personal Social Services). In this connexion, my attention has been drawn to a recent lecture by Dr David Millard of the ' See also J A Baker (1970, this subject
pp
85ff), for a sensitive discussion of
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Oxford University Department of Social and Administrative Studies. It was given in July this year to the Hospital Chaplains' Fellowship in Oxford. He writes: 'The life-time of the National Health Service has seen a burgeoning of such bodies as the National Association for the Welfare of Children in Hospital, the association to do with patients' rights to free visiting and indeed to staying in hospital with their sick children, the Patients' Association, of a more political role for MIND (formerly the NAMH), among many others. They seem to have grown up partly, at least, in response to a lack of accountability on the part of doctors for the wider implications of their work.'
He continues: 'The administrative re-organization of the NHS of 1974 seems to me to be another form of response to this situation - by increasing the power of the administration there has been introduced a greater requirement of accountability of the medical profession. We are seeing, I suggest, a considerable national experiment in the relationship between the professions and the public, in the replacement of accountability through the forces of the market by other forms of social control more consistent with citizenship principles. Some doctors would like to keep its accountability within the profession - accountability to peers, or in terms of some form of medical audit. Now this is splendid, but it is not, in my view, enough. Neither, however, is it enough to make the professionals accountable simply to bureaucrats in medical administration, for bureaucracies themselves can be the opponents of the common good -especially when they become too large. So ultimately accountability needs to be to the recipients of the service - to the community on whose behalf the service exists. And the healthy way of managing our national medical service should maximize the participation of the consumer in the choices which are made about that service.'
From a severely practical point of view, the main problem with which we are dealing, namely dying well, points to several urgent needs. One is the multiplication of such institutions as St Christopher's Hospice, over which Dr Cicely Saunders presides with such distinction. Such institutions help to reverse the unfortunate trend of recent years to institutionalize medical care and dying. There is great need to enable those at home to offer the care that they can give and wish to give. These are institutions specially designed for terminal cases, where technical skills are married to deep but non-sentimental compassion, and where arrangements are such that there is time for a loving relationship to be built up between patient and doctor and between patient and nurse. I have used two words here of great importance - relationship and time. You cannot have the one without the other. And there's the rub. One of the main disadvantages of the National Health Service as it now operates is that so often a
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relationship of any depth and intimacy fails to exist religion and pastoral psychology. He is one of a between patient and doctor. The patient is passed growing number of priests and psychologists who from one doctor to another in such a way that little want more and better help for the dying. In a book confidence of the one in the other has any oppor- (Berger 1974) entitled 'The Last Achievement' tunity of development. Nor is this the fault of the (first published in Holland in 1973 and in England doctor. He is not callous. On the contrary, he longs in 1974), he shares with his readers some of his for the development of such a relationship in thoughts on dying well. He is - rightly, as I think depth. But this system makes this well-nigh im- distressed at the conspiracy of silence which so possible. If this is tragic in the case of ordinary often surrounds death, a silence which isolates the patients, it is doubly tragic when the life of the person who is dying and who, just because of his patient is nearing its close. Even when the patient condition, needs the consolation of understanding has relatives and friends, and when conditions are companionship. He writes of priests who are ill at such that visits can be long and frequent, the need ease and uncertain in the presence of death, of for a close relationship between doctor and pa- nurses who, almost without realizing it, delay on tient, or nurse and patient, is paramount. When the their way to the dying person's bed. This kind of patient has no relatives or friends - and there are thing results in putting the dying person in many such cases in Britain today - and when emotional isolation, or in treating him as though conditions for visiting are difficult, the need is all he were a child unable to take responsibility on an the greater. But how can this exist in the big adult level. He thus finds himself in loose touch institutions for the aged and the dying which are to with people who do not communicate with him be found in many of our large cities? naturally and who, because of their lack of ease in As the percentage of aged in the population the presence of impending death, fail to fulful their increases, pressure will have to be brought to bear share of total responsibility. on the Government not only for homes for the Dr Berger, as a priest and a psychologist, of aged - these have increased in number in recent course recognizes to the full the part to be played years - but for hospitals for terminal cases where by the professional in the help of the sick person. the organization is small enough to allow of the But he argues that much of the work for the dying establishment and deepening of the trustful re- man should be done by the 'layman' and that it is lationship which I now have in mind.' But there the task of the professional (the doctor, the priest can be no doubt that this will involve very heavy and so on) to help the ordinary members of the expenditure. And the expenditure will not only be family to help one another, and so to help the on bricks and mortar. It will extend also to the patient to come to terms with his own death and to training of young doctors and nurses specifically die it with dignity. for the manning of these small institutions; and for We have largely overcome the conspiracy of this a very special kind of expertise, and, one may silence which surrounded the subject of sex a few add, of character will be called for. In this task decades ago. Some would think we have so overthere should be the closest cooperation between come it that we have become obsessed by the local priests or clergymen and doctors and nurses. subject until a lovely thing has become a boring Hence the need for careful training for the or- thing. Now there is a conspiracy of silence about dinand in the care of the dying, so that, wherever death. Literature would seem to suggest that the one of these small specialist institutions for the Victorians were more open about it than we are dying is set up, there should be a little team - sometimes to the point of morbidness. But this can doctor, nurse and priest- who will between them be said for them - that they did not dress it up, use provide a little network of intimate caring for the euphemisms when referring to it, or think it dying man or woman. necessary to indulge in the kind of excesses to Much is being done in groups linked to the which morticians on the other side of the Atlantic Society for the Study of Medical Ethics. There are and elsewhere go. Is there not a need for those of us such medical groups in twenty-one British medical whose work brings us frequently into contact with schools, and great attention is being given to death so to come to terms with it ourselves that we teaching about death and clinical practice for the cooperate in breaking up the conspiracy of silence dying. But much - very much - waits to be done. and helping more people to speak of it naturally Dr Willem Berger is a Roman Catholic priest and react to it constructively? born in Holland in 1919. He lectures at the The question to tell or not to tell is undoubtedly a University of Nijmegen on applied psychology of difficult one, and there is no one clear answer in all cases. I can well conceive cases where to tell would be to depress and to extinguish cooperation be1 There is a list of Hospices in the United Kingdom and of Marie tween patient and doctor: the patient would, like Curie Memorial Foundation Homes and Centres in 'Care of the the sick Hezekiah (Isaiah 38, 1-3), simply turn his Dying' by Cicely Saunders (1976). This is a valuable collection of essays by an acknowledged expert face to the wall and give up. But I suspect that in
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more cases than we generally recognize the patient knows when he is terminally ill, and immense relief would come to him if he knew that those around him were not sharing in a kind of play-acting to the effect that he was soon going to get better. How often does a dying patient find himself an unwilling participant in a kind of charade - a charade kindly meant, I have no doubt - but one from which he would gladly be free, if he might find himself upheld by the skill ofexperts and the love of friends who would speak naturally with him of the coming event. As it is, relatives and friends find themselves in the position so well described by Hugh Trowell (1973, p 90): 'They must start the task of mourning, but this they must hide as far as possible from the loved one, for often he has as yet not realized his fate. This introduces an element of constraint into all their talk. They meet but cannot talk; they talk but cannot meet' [italics mine].
Elisabeth Kiibler-Ross, whose book 'On Death and Dying' is written against a background of research far more extensive than that of most other writers on this and kindred subjects, puts this matter with real insight: 'I believe the question should not be stated, "Do I tell my patient?" but should be rephrased as, "How do I share this knowledge with my patient?" The physician should first examine his own attitude towards malignancy and death so that he is able to talk about such grave matters without undue anxiety. He should listen for cues from the patient which enable him to elicit the patient's willingness to face the reality. The more people in the patient's environment who know the diagnosis of a malignancy, the sooner the patient himself will realize the true state of affairs anyway, since few people are actors enough to maintain a believable mask of cheerfulness over a long period of time. Most if not all of the patients know anyway. They sense it by the changed attention, by the new and different approach that people take to them, by the lowering of voices or avoidance of rounds, by a tearful face of a relative or an ominous, smiling member of the family who cannot hide their true feelings. They will pretend not to know when the doctor or relative is unable to talk about their true condition, and they will welcome someone who is willing to talk about it but allows them to keep their defences as long as they have the need for them' (Kubler-Ross 1969, pp 36-37).
One of the most sensitive articles I have read on this matter is a paper by J Michael Wilson (1975) of the Department of Theology, University of Birmingham, entitled 'Communicating with the Dying'. I feel this particularly strongly in the case of husband and wife who over a long period of years have shared every decision, every major event and every intimacy of life. Why, except in the most exceptional circumstances, should the last great event be un-shared? Why should there be the whisperings behind closed doors, and not, rather,
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the openness of a healthy sharing? And if those concerned believe in the resurrection to life eternal, then why deprive them of the joy of shared anticipation? A friend of mine who recently retired from a splendid career as a surgeon, a man of fine skill and deep compassion, recently shared with me some of his strongest convictions. I reread them after I had written what I have just said, and I venture to quote in part what he wrote to me: 'Some very elderly patients have no will to live, are tired of life and have no fear of death. We must let them die in peace and even quickly with our own medical skill. Those who are terrified of dying need spiritual help. Those who are frightened of pain must be relieved. However, even the old and sick and weary tend to cling to life. 'Surely in all this we must have and give our patients hope, never tell them lies even if we don't always tell them the full truth, or do so only in stages. 'Everyone must see and feel that we care, never lose confidence in their doctor or nurse, never feel they are neglected or that full medical resources are not available for them. 'I have had far more letters from patients expressing thanks for my kindness, my caring, my consideration, than ever for my medical skill or surgical expertise. 'Today in the great State medicine of the NHS it is often the relatives or loving friends that are neglected rather than the patients. In intensive care units or postoperative recovery areas we may keep them out for reasons of sterility, but I'm sure we don't keep them fully informed or consult them enough about our reasons for and methods of prolongation of life.'
It is interesting that in this letter the writer stresses not only the combination of compassion and skill but also the need to care for the relatives of the patients, thus indirectly underlying the need which I have already stressed for the multiplication of small units to which terminal patients can be sent and where visiting facilities are greater than they can be in the wards of our large hospitals. Incidentally, and relevant to this last point, those of us who have travelled in the Far East have often noted how well the patient is cared for by his relatives who surround him (even though at the same time we have been horrified at the lack of cleanliness which their presence often entails). There is a loneliness about dying in our Western society which is not healthy. There is much we could learn, for example, from Africa. The Archbishop of Central Africa, Donald S Arden (1976), writing of the distinction made by the African between natural death at full age and the accidental death of the young, says of the former: 'The death of the old is quite different, and the domestic theology of the living-dead draws on a wisdom that the West has lost. In Swaziland I spent a night with the medical assistant of a government clinic, who was also the leader of a little Christian congregation. Another
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guest was his father, a gentle, happy man in his late sixties, who lived eighty miles away. On my next monthly round I was shocked to be told by my friend that his father had just died at the family home. I expressed surprise, since he had seemed to be in excellent health, and asked of what he had died. "Nothing, it was just his time. We are four children in the family, so he came to stay with each of us for a week and talk and play with all his grandchildren, and to say good-bye. He reached home last week, and now he has gone. It is good." It is indeed good, and better than our complex way of prolonging life in order to launch ourselves on disputations about the rightness of shortening it again to its natural span.'
The Christian will see in this African approach to the dead an adumbration of the doctrine of the communion of saints, springing as that does from his conviction that Christ is Lord of the living and the dead. Ladislaus Boros (1965), in his book 'The Moment of Truth', speaks of dying as the event which gives 'man the opportunity of posing his first completely personal act'. How important, then, that he should prepare, seriously and intelligently, for this great act, the more so if he believes it to be the return of his life to the God who gave it to him. But 'completely personal' though that act undoubtedly is, it should not be completely lonely. Even Jesus, forsaken by God as He felt Himself to be, had His Mother and young John by Him as the end drew near. The gist of what we have been saying is that a man as he comes to die should have around him not only -not even primarily - the apparatus of modern technical medicine designed to extend his life a trifle or to ease his physical suffering, but also the unhurried companionship of people who are not frightened by the fact of death and are prepared to go with the man concerned as far as they may to the point of his departure. Sigmund Freud maintained that the two central questions of life were: how do you deal with your sexuality? and how do you deal with your death? If a fraction of the care were given to the second question that is given to the first, life would be robbed of much of its fear and death itself would gain a measure of the dignity which belongs to it. That is where - to revert to the matter to which I alluded at the beginning of this lecture - both skill and friendship are called for. Given the skill alone, however brilliant and sophisticated that skill may be, there can only be a clinical chill about the dying. Given friendship alone, however warm that friendship may be, there will be needless suffering and discomfort. Given both, you have the main ingredients which go to the helping of a man to die with dignity. Given a living faith, there can be added an element of triumph, for death is then viewed not as a terminus but as a junction. Incipit vita nova.
I have forborne in this lecture to ask you to follow me in detail down the path of discussion as to the rightness or wrongness of euthanasia, as that word is usually understood. Suffice it to say two things: First, I have little doubt that most of you have debated this with yourselves over many a long year and reached certain conclusions. Secondly, I have myself been influenced and largely persuaded by such books as Hugh Trowell's 'The Unfinished Debate on Euthanasia', Sir Norman Anderson's 'Issues of Life and Death' and Professor G R Dunstan's 'The Artifice of Ethics' (Dunstan 1974). The warnings given in those books, to mention no others, seem to me to be so weighty as to make the case very strong indeed for leaving the issues much as they now are in the hands of the doctors. And I note, not only in books such as these but also in the debate on Baroness Wootton's recent (and abortive) Incurable Patients Bill (February 1976) in the House of Lords, that it is, generally speaking, the doctors themselves who as much as anybody else even more than others -resist the idea of any legislation which would define the limits within which euthanasia could be put into effect by doctors or nurses in hospitals or homes. Rather, I have sought to show that there is a large measure of agreement among Christians of widely differing traditions as to the wrongness of prolonging the life of all those with terminal illnesses, just for the sake of doing so. Rather, leaving the duty of caring appropriately for their dying patients to the wisdom and skill of doctors and nurses who are in consultation with ministers of religion and with the relatives of the patients concerned, we should eschew the pursuit of legislation and let experience and wisdom decide. Further, I have pleaded for such consultation between doctors and their colleagues, between representatives of the National Health Service, and between recipients of the service, as would lead towards some kind of consensus, or ethic, on the distribution of the resources provided by the taxpayer. Again, I have urged the multiplication not only of such institutions as St Christopher's Hospice but also the provision of those conditions where a close relationship between the doctor and the terminally sick patient can be achieved. I have stressed the importance of the most careful training of doctors, nurses, clergy and others in the understanding of what it means to care for the dying; and I have underlined the point made by Dr Kubler-Ross that the right approach to our patients should be the sharing, on the part of as many as is reasonably possible, of the knowledge of the terminal nature of the illness of the patient concerned. The 'completely personal' act of a dying man does not mean the total loneliness of that man.
Edwin Stevens Lecture
Along such lines as these we may move forward - forward to a day when death will be regarded not as a sordid end but rather as an act of dignity on the part of a man 'dying well'; an act worthy of someone made in the image of God; an act which, it is true, ends one phase of his manhood, but which ushers in that new phase for which indeed he was created, the phase when - so the Christian believes- the vision of God, dimly seen here, is fulfilled in the bliss of life eternal. REFERENCES Anderson N (1976) Issues of Life and Death. Hodder & Stoughton, London; p 102 Arden D S (1976) Anglican Theological Review, Supplementary Series, June, p 24 Baker J A (1970) The Foolishness of God. Darton, Longman & Todd, London
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Berger W (1974) The Last Achievement. Grail (England) Publications, Pinner, Middlesex Board for Social Responsibility of the Church of England (1965) Decisions about Life and Death: A Problem in Modern Medicine. Church Information Office, London (1975) On Dying Well. Report of a Working Party. Church Information Office, London Boros L (1965) The Moment of Truth. Burns & Oates, London Dunstan J R (1974) The Artifice of Ethics (Moorhouse Lectures). SCM Press, London General Synod of the Church of England (1976) Report ojfProceedings 7, 506 Kubler-Ross E (1969) On Death and Dying. Macmillan, New York Saunders C (1976) Care of the Dying. Nursing Tinmes, London Trowell H (1973) The Unfinished Debate on Euthanasia. SCM Press, London Wilson J M (1975) Journal of Medical Ethics 1, 18
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seemed to me to sum up, perhaps better than any other form of words, what the President of the Royal Society of Medicine had in mind when he wrote to me a year ago. Moral and Spiritual Aspects I make what small contribution I can today out It was in December last year that I was first of the conviction that much hard thinking remains approached by Sir Gordon Wolstenholme as to the be done on this subject, and that we shall only possibility of my giving the Edwin Stevens Lecture work our way towards positive and helpful printhis year. Let me say at once how high a privilege I ciples in so far as practitioners in various departconsider this to be, though I accept the honour ments of life and learning join their skills and with a considerable measure of diffidence due in marry their experiences in the give and take of part to the distinction of the audience which I open discussion. I speak as one who, unlike those address and in part to the immense difficulty of the who have spoken before me this evening, has no scientific or legal expertise, but as one who, in a subject which I have been given. Since I was rash enough to accept the invitation, ministry as priest and bishop extending well over I have myself been a victim in the hands of the forty years, has often come close to those who are doctors - for me a rare experience and, as I dis- dying and is deeply concerned that the act of dying covered somewhat to my surprise, an enriching should be as good an act as preparation and skill one. I will not succumb to the temptation, often and love can make it. I speak as a Christian, with yielded to by men of advancing years, to go into all the bearing that Christian belief and practice detail as to the nature of my complaint. Nothing have on our subject. But I am convinced that the could be less interesting. It was a matter of minor major part of what I shall say has relevance for surgery, and I was out of the hospital some ten those who do not hold the Christian faith, or only days after entering it. What I do feel constrained to partially do so, and much of it for those who say is this: I wrote to my daughter, who is a cannot even subscribe to that view of death which gynxcologist serving in Pakistan, and I said to my is summed up in the words (from the preface of the wife, who is the daughter of a surgeon, 'I raise my Mass of the Dead) Vita mutatur, non tollitur, 'Life is changed, not taken away', by the incident of hat to the medical profession'. Trying to analyse what it was that made a death. It might be of help if, at the outset, I said a word slightly painful experience so enriching a one, I recognize, of course, that there is an element of about the limits to the doctor's responsibility to vanity in all of us and it is pleasant to be made a keep his patient alive, and what Christian moralists fuss of. I recognize, further, that even in a com- have to say on the subject. I refer first to some paratively minor piece of surgery there is a com- words contained in the Papal Allocution of Pope bination of skills the operation of which gives great Pius XII to a congress of anesthetists which met in confidence to the man on whose behalf they are November 1957, and I quote from the booklet used. But I think the main reason which converted 'Decisions about Life and Death: A Problem in the bane of this experience into the blessing that it Modern Medicine' (Board for Social Responsiundoubtedly has become was the skilled bility of the Church of England 1965, pp 52-53): friendship - and I use adjective and noun 'The Pope was considering inter alia certain moral advisedly - shown by the two doctors mainly in- questions that may arise through the use of artificial respiration in cases of cerebral lesion. A patient has been volved. I preface my lecture with these words, partly plunged into unconsciousness by central paralysis, artiso as to maintain his because I welcome the opportunity of paying a tiny ficial respiration has been applied several days of but after and circulation, breathing tribute to a great profession and partly because I treatment there is no sign or prospect of any improveshall have occasion to revert to them, in a very ment in his condition. In such circumstances may the different context, later on. apparatus that is maintaining the circulation be removed, The subject which has been assigned to me is one or ought it to be kept in operation until the circulation of very great difficulty and complexity, and only a stops in spite of it? 'The answer given in the allocution was based on the fool would approach it without the utmost diffidence. Those who have spoken before me this distinction, already drawn by Roman Catholic moralists, evening have touched on some of the related between "ordinary" and "extraordinary" medical or surgical procedures. "Ordinary" in this context does not problems within their own particular spheres of mean what a medical man would regard as "normal" learning. The title of this lecture was suggested by treatment: it means whatever a patient can obtain and the title of a report (1975) of a working party set up undergo without thereby imposing an excessive burden of the of Responsibility the Board Social by on himself or others. Thus "extraordinary" treatment Church of England which formed the subject of a has been defined as "whatever here and now is very costly debate in its General Synod in February 1976. I or very unusual or very painful or very difficult or very have given this title to this lecture because it dangerous, or if the good effects that can be expected
The Most Rev and Right Hon Donald Coggan DD, Archbishop of Canterbury
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from its use are not proportionate to the difficulty and inconvenience that are entailed". 'The point of the distinction is this. As a general rule a sick man is bound, as are those who have the care of him, to employ the appropriate available means of preserving his life and restoring his health. But there are obviously limits to this obligation. He is not bound to incur, or impose upon his family, an impoverishing expense; nor is he bound to submit to treatment which would cause him great distress and of which the benefits are problematical. In other words his strict obligation extends only to the "ordinary" means of preserving life and restoring health, and not to the "extraordinary" as defined above. He may accept "extraordinary" treatment if he thinks fit; but he is not bound to do so, unless he has some special obligation to stay alive. As for those who have the care of the patient, the doctor has neither right nor duty to insist on "extraordinary" treatment against the patient's will, nor is he bound to apply such treatment in cases where the patient cannot be consulted; and the patient's family is in much the same position.'
Though there are obvious difficulties in the outworking of the principles enunciated in this allocution, there are marked similarities between them and the attitude reflected by the Anglican canon lawyer, Chancellor E Garth Moore, when dealing with another aspect of the same problem, namely the legitimacy of action taken by a doctor which may lead to the shortening of the patient's life. The useful ethical distinction between a principal intention, or moral object, which is good, and indirect consequences, may throw light on the nature of the decision facing the doctor who wishes to give a pain-killing drug to a patient. Garth Moore writes: 'It would seem reasonably certain that the giving of a pain-killing drug to a patient in extremis can be justified, not only by the theologian's law of double effect, but also by the Common Law doctrine of necessity, even where one of the effects of the drug is the probable shortening of the patient's life. This is because the evil averted, namely the agony of the patient, is greater than the evil performed, namely an act leading to the probable shortening of his life...' (Board for Social Responsibility of the Church of England 1965, p 50). The first two Conclusions of the signatories of the report 'On Dying Well' (to which allusion has already been made) also show marked similarity to the general conclusions both of Pope Pius XII and of Chancellor Garth Moore. They read: '1. In its narrow current sense, euthanasia implies killing, and it is misleading to extend it to cover decisions not to preserve life by artificial means when it would be better for the patient to be allowed to die. Such decisions, coupled with a determination to give the patient as good a death as possible, may be quite legitimate. '2. Nor should it be used to cover the giving of drugs for the relief of pain and other distress in cases where there is a risk that they may marginally shorten the patient's life. This too we think legitimate' (Board for Social Responsibility of the Church of England 1975, p 61).
This is in keeping with the point made by the Bishop of Truro in introducing the debate on the Report, when he said: 'The demands that a patient in extremis should not be subjected to troublesome treatment which cannot restore him to health and that doctors may use drugs to control pain even at the risk of shortening life do not involve voluntary euthanasia at all and are not in question' (General Synod of the Church of England 1976). In the light of these references, I need hardly emphasize that the view, held by many, that Christians believe that life must be artifically prolonged under all circumstances is not true. You will recall the case of the American girl, Karen Quinlan, which was widely reported in the press last year. I am informed that it was the doctors, not the priest, who gave the advice which led to the prolongation of her life. Probably all of us would agree in deploring the events which so fearfully prolonged the life - if life it can be called - of General Franco. A similar case of malpractice is described in a letter quoted by Hugh Trowell (1973, p 29) in his important and sensitive book 'The Unfinished Debate on Euthanasia'. He rightly describes the letter as 'terrible'. Lord Edmund-Davies has already quoted Arthur Hugh Clough's words: 'Thou shalt not kill, but need'st not strive Officiously to keep alive."i However great the difficulties in law of working out the implications of these oft-quoted lines, there would seem to be a wide consensus of Christian opinion in favour of the principles contained in
them. There is another matter, closely related to the one which we have just been considering, which must cause anxiety, and at times perhaps agony, to a doctor who has to weigh up his responsibility in making a choice. I refer to the choice between, on the one hand, making the most advanced techniques available to a few, and, on the other hand, improving the level of services available to many, and especially to those who have in the past been inadequately cared for. The resources of the national exchequer are not limitless (in the year 1975/76 the nation spent £4564 million on health and welfare, including local authority costs), and the prolongation of the life of one aged patient may in fact entail the deprivation of aid to others and even the shortening of their lives. Nor are beds in ' These lines of Arthur Hugh Clough are from 'The Latest Decalogue'. They are frequently quoted, with some solemnity, in books and papers on euthanasia and kindred subjects. The author would, I think, have been amused, for Clough's 'Decalogue' is satirical, one might almost say cynical. See, for example, the last of his 'commandments': 'Thou shalt not covet, but tradition Approves all forms of competition.'
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hospitals limitless; and the extension of the life of a terminal patient may necessarily involve the suffering or even death of those who, if speedily admitted to hospital treatment, might have many years of useful life ahead of them. I realize that here I am treading on exceedingly dangerous ground. I am fully aware of the great dangers of legalized euthanasia. I bear in mind a passage in Sir Norman Anderson's recent book 'Issues of Life and Death' in which he writes that, if voluntary euthanasia were to be made legal, '. . . there would soon be a demand for further concessions. It would not be long before the argument would be heard that paralysed, incontinent or semi-comatose elderly persons would certainly sign the suitable form if only they were to have a sufficiently lucid interval; so why should not their relatives do for them what they would wish to do for themselves? "That agreed" - to quote a recent article by R F R Gardner- "within a month someone would say 'But to expect relatives to make this decision is to impose an impossible emotional burden; let us authorize an official to do this without distressing them'. Naturally parallel arguments would be advanced for the congenitally damaged neonates. It would then be suggested that the problem of approval for the euthanasia of the conscious but incapacitated aged would be even more distressing, and therefore it would be vital to relieve relatives of any involvement in this and have it arranged by some distant office"' (Anderson 1976).
Of all this I am vividly aware - one has not lived through the days of the Nazis without memories which are not easily blotted out.' But the awareness of these appalling abuses must not blind us to the realities of a situation the severity of which will not diminish but rather increase as the percentage of old people rises and, quite possibly, the extent of Government financial aid reaches a figure beyond which it cannot go. The doctor has a responsibility - an accountability - to the patient and the patient's family under his immediate care. But he has also a responsibility to the other patients in the long waiting queue. He has a further responsibility - to the Government, or, to put it more personally but none the less accurately, to his fellow tax-payers who provide the resources to keep the National Health Service going. The question arises as to whether some kind of consensus -I had almost said some kind of ethic - can emerge on the distribution of resources as between one part of the Health Service and another. A free-for-all could be disastrous. (I understand that the DHSS has this year issued a Discussion Document on Priorities in the Health and Personal Social Services). In this connexion, my attention has been drawn to a recent lecture by Dr David Millard of the ' See also J A Baker (1970, this subject
pp
85ff), for a sensitive discussion of
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Oxford University Department of Social and Administrative Studies. It was given in July this year to the Hospital Chaplains' Fellowship in Oxford. He writes: 'The life-time of the National Health Service has seen a burgeoning of such bodies as the National Association for the Welfare of Children in Hospital, the association to do with patients' rights to free visiting and indeed to staying in hospital with their sick children, the Patients' Association, of a more political role for MIND (formerly the NAMH), among many others. They seem to have grown up partly, at least, in response to a lack of accountability on the part of doctors for the wider implications of their work.'
He continues: 'The administrative re-organization of the NHS of 1974 seems to me to be another form of response to this situation - by increasing the power of the administration there has been introduced a greater requirement of accountability of the medical profession. We are seeing, I suggest, a considerable national experiment in the relationship between the professions and the public, in the replacement of accountability through the forces of the market by other forms of social control more consistent with citizenship principles. Some doctors would like to keep its accountability within the profession - accountability to peers, or in terms of some form of medical audit. Now this is splendid, but it is not, in my view, enough. Neither, however, is it enough to make the professionals accountable simply to bureaucrats in medical administration, for bureaucracies themselves can be the opponents of the common good -especially when they become too large. So ultimately accountability needs to be to the recipients of the service - to the community on whose behalf the service exists. And the healthy way of managing our national medical service should maximize the participation of the consumer in the choices which are made about that service.'
From a severely practical point of view, the main problem with which we are dealing, namely dying well, points to several urgent needs. One is the multiplication of such institutions as St Christopher's Hospice, over which Dr Cicely Saunders presides with such distinction. Such institutions help to reverse the unfortunate trend of recent years to institutionalize medical care and dying. There is great need to enable those at home to offer the care that they can give and wish to give. These are institutions specially designed for terminal cases, where technical skills are married to deep but non-sentimental compassion, and where arrangements are such that there is time for a loving relationship to be built up between patient and doctor and between patient and nurse. I have used two words here of great importance - relationship and time. You cannot have the one without the other. And there's the rub. One of the main disadvantages of the National Health Service as it now operates is that so often a
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relationship of any depth and intimacy fails to exist religion and pastoral psychology. He is one of a between patient and doctor. The patient is passed growing number of priests and psychologists who from one doctor to another in such a way that little want more and better help for the dying. In a book confidence of the one in the other has any oppor- (Berger 1974) entitled 'The Last Achievement' tunity of development. Nor is this the fault of the (first published in Holland in 1973 and in England doctor. He is not callous. On the contrary, he longs in 1974), he shares with his readers some of his for the development of such a relationship in thoughts on dying well. He is - rightly, as I think depth. But this system makes this well-nigh im- distressed at the conspiracy of silence which so possible. If this is tragic in the case of ordinary often surrounds death, a silence which isolates the patients, it is doubly tragic when the life of the person who is dying and who, just because of his patient is nearing its close. Even when the patient condition, needs the consolation of understanding has relatives and friends, and when conditions are companionship. He writes of priests who are ill at such that visits can be long and frequent, the need ease and uncertain in the presence of death, of for a close relationship between doctor and pa- nurses who, almost without realizing it, delay on tient, or nurse and patient, is paramount. When the their way to the dying person's bed. This kind of patient has no relatives or friends - and there are thing results in putting the dying person in many such cases in Britain today - and when emotional isolation, or in treating him as though conditions for visiting are difficult, the need is all he were a child unable to take responsibility on an the greater. But how can this exist in the big adult level. He thus finds himself in loose touch institutions for the aged and the dying which are to with people who do not communicate with him be found in many of our large cities? naturally and who, because of their lack of ease in As the percentage of aged in the population the presence of impending death, fail to fulful their increases, pressure will have to be brought to bear share of total responsibility. on the Government not only for homes for the Dr Berger, as a priest and a psychologist, of aged - these have increased in number in recent course recognizes to the full the part to be played years - but for hospitals for terminal cases where by the professional in the help of the sick person. the organization is small enough to allow of the But he argues that much of the work for the dying establishment and deepening of the trustful re- man should be done by the 'layman' and that it is lationship which I now have in mind.' But there the task of the professional (the doctor, the priest can be no doubt that this will involve very heavy and so on) to help the ordinary members of the expenditure. And the expenditure will not only be family to help one another, and so to help the on bricks and mortar. It will extend also to the patient to come to terms with his own death and to training of young doctors and nurses specifically die it with dignity. for the manning of these small institutions; and for We have largely overcome the conspiracy of this a very special kind of expertise, and, one may silence which surrounded the subject of sex a few add, of character will be called for. In this task decades ago. Some would think we have so overthere should be the closest cooperation between come it that we have become obsessed by the local priests or clergymen and doctors and nurses. subject until a lovely thing has become a boring Hence the need for careful training for the or- thing. Now there is a conspiracy of silence about dinand in the care of the dying, so that, wherever death. Literature would seem to suggest that the one of these small specialist institutions for the Victorians were more open about it than we are dying is set up, there should be a little team - sometimes to the point of morbidness. But this can doctor, nurse and priest- who will between them be said for them - that they did not dress it up, use provide a little network of intimate caring for the euphemisms when referring to it, or think it dying man or woman. necessary to indulge in the kind of excesses to Much is being done in groups linked to the which morticians on the other side of the Atlantic Society for the Study of Medical Ethics. There are and elsewhere go. Is there not a need for those of us such medical groups in twenty-one British medical whose work brings us frequently into contact with schools, and great attention is being given to death so to come to terms with it ourselves that we teaching about death and clinical practice for the cooperate in breaking up the conspiracy of silence dying. But much - very much - waits to be done. and helping more people to speak of it naturally Dr Willem Berger is a Roman Catholic priest and react to it constructively? born in Holland in 1919. He lectures at the The question to tell or not to tell is undoubtedly a University of Nijmegen on applied psychology of difficult one, and there is no one clear answer in all cases. I can well conceive cases where to tell would be to depress and to extinguish cooperation be1 There is a list of Hospices in the United Kingdom and of Marie tween patient and doctor: the patient would, like Curie Memorial Foundation Homes and Centres in 'Care of the the sick Hezekiah (Isaiah 38, 1-3), simply turn his Dying' by Cicely Saunders (1976). This is a valuable collection of essays by an acknowledged expert face to the wall and give up. But I suspect that in
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more cases than we generally recognize the patient knows when he is terminally ill, and immense relief would come to him if he knew that those around him were not sharing in a kind of play-acting to the effect that he was soon going to get better. How often does a dying patient find himself an unwilling participant in a kind of charade - a charade kindly meant, I have no doubt - but one from which he would gladly be free, if he might find himself upheld by the skill ofexperts and the love of friends who would speak naturally with him of the coming event. As it is, relatives and friends find themselves in the position so well described by Hugh Trowell (1973, p 90): 'They must start the task of mourning, but this they must hide as far as possible from the loved one, for often he has as yet not realized his fate. This introduces an element of constraint into all their talk. They meet but cannot talk; they talk but cannot meet' [italics mine].
Elisabeth Kiibler-Ross, whose book 'On Death and Dying' is written against a background of research far more extensive than that of most other writers on this and kindred subjects, puts this matter with real insight: 'I believe the question should not be stated, "Do I tell my patient?" but should be rephrased as, "How do I share this knowledge with my patient?" The physician should first examine his own attitude towards malignancy and death so that he is able to talk about such grave matters without undue anxiety. He should listen for cues from the patient which enable him to elicit the patient's willingness to face the reality. The more people in the patient's environment who know the diagnosis of a malignancy, the sooner the patient himself will realize the true state of affairs anyway, since few people are actors enough to maintain a believable mask of cheerfulness over a long period of time. Most if not all of the patients know anyway. They sense it by the changed attention, by the new and different approach that people take to them, by the lowering of voices or avoidance of rounds, by a tearful face of a relative or an ominous, smiling member of the family who cannot hide their true feelings. They will pretend not to know when the doctor or relative is unable to talk about their true condition, and they will welcome someone who is willing to talk about it but allows them to keep their defences as long as they have the need for them' (Kubler-Ross 1969, pp 36-37).
One of the most sensitive articles I have read on this matter is a paper by J Michael Wilson (1975) of the Department of Theology, University of Birmingham, entitled 'Communicating with the Dying'. I feel this particularly strongly in the case of husband and wife who over a long period of years have shared every decision, every major event and every intimacy of life. Why, except in the most exceptional circumstances, should the last great event be un-shared? Why should there be the whisperings behind closed doors, and not, rather,
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the openness of a healthy sharing? And if those concerned believe in the resurrection to life eternal, then why deprive them of the joy of shared anticipation? A friend of mine who recently retired from a splendid career as a surgeon, a man of fine skill and deep compassion, recently shared with me some of his strongest convictions. I reread them after I had written what I have just said, and I venture to quote in part what he wrote to me: 'Some very elderly patients have no will to live, are tired of life and have no fear of death. We must let them die in peace and even quickly with our own medical skill. Those who are terrified of dying need spiritual help. Those who are frightened of pain must be relieved. However, even the old and sick and weary tend to cling to life. 'Surely in all this we must have and give our patients hope, never tell them lies even if we don't always tell them the full truth, or do so only in stages. 'Everyone must see and feel that we care, never lose confidence in their doctor or nurse, never feel they are neglected or that full medical resources are not available for them. 'I have had far more letters from patients expressing thanks for my kindness, my caring, my consideration, than ever for my medical skill or surgical expertise. 'Today in the great State medicine of the NHS it is often the relatives or loving friends that are neglected rather than the patients. In intensive care units or postoperative recovery areas we may keep them out for reasons of sterility, but I'm sure we don't keep them fully informed or consult them enough about our reasons for and methods of prolongation of life.'
It is interesting that in this letter the writer stresses not only the combination of compassion and skill but also the need to care for the relatives of the patients, thus indirectly underlying the need which I have already stressed for the multiplication of small units to which terminal patients can be sent and where visiting facilities are greater than they can be in the wards of our large hospitals. Incidentally, and relevant to this last point, those of us who have travelled in the Far East have often noted how well the patient is cared for by his relatives who surround him (even though at the same time we have been horrified at the lack of cleanliness which their presence often entails). There is a loneliness about dying in our Western society which is not healthy. There is much we could learn, for example, from Africa. The Archbishop of Central Africa, Donald S Arden (1976), writing of the distinction made by the African between natural death at full age and the accidental death of the young, says of the former: 'The death of the old is quite different, and the domestic theology of the living-dead draws on a wisdom that the West has lost. In Swaziland I spent a night with the medical assistant of a government clinic, who was also the leader of a little Christian congregation. Another
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guest was his father, a gentle, happy man in his late sixties, who lived eighty miles away. On my next monthly round I was shocked to be told by my friend that his father had just died at the family home. I expressed surprise, since he had seemed to be in excellent health, and asked of what he had died. "Nothing, it was just his time. We are four children in the family, so he came to stay with each of us for a week and talk and play with all his grandchildren, and to say good-bye. He reached home last week, and now he has gone. It is good." It is indeed good, and better than our complex way of prolonging life in order to launch ourselves on disputations about the rightness of shortening it again to its natural span.'
The Christian will see in this African approach to the dead an adumbration of the doctrine of the communion of saints, springing as that does from his conviction that Christ is Lord of the living and the dead. Ladislaus Boros (1965), in his book 'The Moment of Truth', speaks of dying as the event which gives 'man the opportunity of posing his first completely personal act'. How important, then, that he should prepare, seriously and intelligently, for this great act, the more so if he believes it to be the return of his life to the God who gave it to him. But 'completely personal' though that act undoubtedly is, it should not be completely lonely. Even Jesus, forsaken by God as He felt Himself to be, had His Mother and young John by Him as the end drew near. The gist of what we have been saying is that a man as he comes to die should have around him not only -not even primarily - the apparatus of modern technical medicine designed to extend his life a trifle or to ease his physical suffering, but also the unhurried companionship of people who are not frightened by the fact of death and are prepared to go with the man concerned as far as they may to the point of his departure. Sigmund Freud maintained that the two central questions of life were: how do you deal with your sexuality? and how do you deal with your death? If a fraction of the care were given to the second question that is given to the first, life would be robbed of much of its fear and death itself would gain a measure of the dignity which belongs to it. That is where - to revert to the matter to which I alluded at the beginning of this lecture - both skill and friendship are called for. Given the skill alone, however brilliant and sophisticated that skill may be, there can only be a clinical chill about the dying. Given friendship alone, however warm that friendship may be, there will be needless suffering and discomfort. Given both, you have the main ingredients which go to the helping of a man to die with dignity. Given a living faith, there can be added an element of triumph, for death is then viewed not as a terminus but as a junction. Incipit vita nova.
I have forborne in this lecture to ask you to follow me in detail down the path of discussion as to the rightness or wrongness of euthanasia, as that word is usually understood. Suffice it to say two things: First, I have little doubt that most of you have debated this with yourselves over many a long year and reached certain conclusions. Secondly, I have myself been influenced and largely persuaded by such books as Hugh Trowell's 'The Unfinished Debate on Euthanasia', Sir Norman Anderson's 'Issues of Life and Death' and Professor G R Dunstan's 'The Artifice of Ethics' (Dunstan 1974). The warnings given in those books, to mention no others, seem to me to be so weighty as to make the case very strong indeed for leaving the issues much as they now are in the hands of the doctors. And I note, not only in books such as these but also in the debate on Baroness Wootton's recent (and abortive) Incurable Patients Bill (February 1976) in the House of Lords, that it is, generally speaking, the doctors themselves who as much as anybody else even more than others -resist the idea of any legislation which would define the limits within which euthanasia could be put into effect by doctors or nurses in hospitals or homes. Rather, I have sought to show that there is a large measure of agreement among Christians of widely differing traditions as to the wrongness of prolonging the life of all those with terminal illnesses, just for the sake of doing so. Rather, leaving the duty of caring appropriately for their dying patients to the wisdom and skill of doctors and nurses who are in consultation with ministers of religion and with the relatives of the patients concerned, we should eschew the pursuit of legislation and let experience and wisdom decide. Further, I have pleaded for such consultation between doctors and their colleagues, between representatives of the National Health Service, and between recipients of the service, as would lead towards some kind of consensus, or ethic, on the distribution of the resources provided by the taxpayer. Again, I have urged the multiplication not only of such institutions as St Christopher's Hospice but also the provision of those conditions where a close relationship between the doctor and the terminally sick patient can be achieved. I have stressed the importance of the most careful training of doctors, nurses, clergy and others in the understanding of what it means to care for the dying; and I have underlined the point made by Dr Kubler-Ross that the right approach to our patients should be the sharing, on the part of as many as is reasonably possible, of the knowledge of the terminal nature of the illness of the patient concerned. The 'completely personal' act of a dying man does not mean the total loneliness of that man.
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Along such lines as these we may move forward - forward to a day when death will be regarded not as a sordid end but rather as an act of dignity on the part of a man 'dying well'; an act worthy of someone made in the image of God; an act which, it is true, ends one phase of his manhood, but which ushers in that new phase for which indeed he was created, the phase when - so the Christian believes- the vision of God, dimly seen here, is fulfilled in the bliss of life eternal. REFERENCES Anderson N (1976) Issues of Life and Death. Hodder & Stoughton, London; p 102 Arden D S (1976) Anglican Theological Review, Supplementary Series, June, p 24 Baker J A (1970) The Foolishness of God. Darton, Longman & Todd, London
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Berger W (1974) The Last Achievement. Grail (England) Publications, Pinner, Middlesex Board for Social Responsibility of the Church of England (1965) Decisions about Life and Death: A Problem in Modern Medicine. Church Information Office, London (1975) On Dying Well. Report of a Working Party. Church Information Office, London Boros L (1965) The Moment of Truth. Burns & Oates, London Dunstan J R (1974) The Artifice of Ethics (Moorhouse Lectures). SCM Press, London General Synod of the Church of England (1976) Report ojfProceedings 7, 506 Kubler-Ross E (1969) On Death and Dying. Macmillan, New York Saunders C (1976) Care of the Dying. Nursing Tinmes, London Trowell H (1973) The Unfinished Debate on Euthanasia. SCM Press, London Wilson J M (1975) Journal of Medical Ethics 1, 18
