The Quietus is Here image

The Quietus is Here

In P.D. James’ brilliant and chilling novel, The Children of Men, the elderly and infirm, a burden on a dying society, are forced to take part in a ‘quietus’ – a choreographed suicide by drowning. It seems the quietus might be upon us.

A decision made by the British Supreme Court in July opens the way for thousands of infirm people to be ushered towards a hidden quietus. Dr Peter Saunders explains,

Patients with permanent vegetative state (PVS) and minimally conscious state (MCS) can now be effectively starved and dehydrated to death if the medical staff and relatives agree that this is in their ‘best interests’.

People with PVS (awake but not aware) and MCS (awake but only intermittently or partially aware) can breathe without ventilators but need to have food and fluids by tube (clinically assisted nutrition and hydration or CANH).

These patients are not imminently dying and with good care can live for many years. Some even regain awareness. But if CANH is withdrawn, then they will die from dehydration and starvation within two or three weeks.

Under the old rules, in order to withdraw CANH from such patients, it was necessary to apply to the Court of Protection. Only about 100 such applications have been made in more than twenty years. Under the new rules, no such application is needed and this opens the way for a quiet culling of thousands of patients.

It is unknown exactly how many patients with PVS and MCS there are in the UK but the figure is likely to be between ten and twenty thousand. These patients represent a considerable financial cost to the health system and it is not hard to imagine that – dressed up in humanitarian claims – withdrawing CANH might increasingly be seen as the right thing to do.

This outcome is made more likely by the fact that there is no requirement to list withdrawal of CANH as a cause of death on the death certificate. Instead, the underlying cause of the PVS/MCS can be given. This means that there will be no record of how many patients are dying as a result of withdrawal of CANH, which is bad policy in terms of data collection and makes abuse far more likely. In Belgium, where euthanasia is legal, withdrawal of CANH is recorded as cause of death so that accurate data is collected. Can it be right that the UK is falling behind even this standard?

This is all the more troubling as new research shows that patients with PVS and MCS are not necessarily as unaware or beyond recovery as is often supposed. In fact, four in ten people who are thought to be unconscious are actually aware and one in five people with severe brain injury from trauma will recover to the point that they can live at home and care for themselves without help. This means that the term permanent vegetative state is inaccurate and should be dropped.

The Supreme Court ruling has not attracted much attention. Indeed, when it was reported it was largely in tones of ‘these people are already effectively dead and this will make it easier for everyone concerned.’ But it is not like that. It is euthanasia by the back door, decided by court rather than Parliament. It is a quietus waiting to happen.


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