by David Ellis
Following the conference in Utrecht a year ago, she’d been able to get a video of part of a session which she thought would bring home the message. And she’d had to fax copies of her credentials before they agreed to send the video file.
Emma arrived in the seminar room a few minutes early to setup her laptop and noticed that a video camera had already been set up. The twenty trainees due to attend gradually drifted in from their ward rounds and filled their plates from the banquet provided by the drug rep and helped themselves to pens and post-it pads emblazoned with blatant advertisements for drugs that none of them should really be prescribing.
“Okay. Hello everyone. I’m Emma Jones. I’m a consultant in pain medicine and you’ve probably seen me on the wards.” Emma noticed a few nods but most of the trainees were busy stuffing their mouths.
“I’d like to start the session today by asking you to think about what we do to our patients.”
Emma put up a PowerPoint slide which simply read: ‘PRIMUM NON NOCERE’.
“Can anyone tell me what that means?”
Emma heard silence apart from the sound of mastication.
“Well, your silence, apart from your obvious enjoyment of food, is interesting, because that’s the maxim that all doctors are supposed to sign up to. The words are obviously in Latin and translate as: ‘First, do no harm.’ And it was the Roman physician Galen who came up with that phrase to define the welfare of the patient as coming above everything else.”
“But the reality is that we often do cause harm in our practice even though we don’t intend to; for instance, we cause pain when we take blood or put in a cannula; we cause harmful side effects when we give too many drugs; and in the case of chemotherapy, we almost kill patients in order to rid them of their malignancy.”
“Years ago, when I was in a seminar very much like this one, we were asked to think about harm and when it might be morally right to cause harm to others. So, I’ve got four examples that I’d like you to think about.”
Emma put up a slide which read: ‘Let’s suppose that on occasions someone harms her/himself by self-cutting on her/his arms and that doing so relieves unbearable psychological suffering. Is it morally right for an individual to do that?’
“Can we have a vote on that, please?” Eighteen arms went up in the air fairly simultaneously; two SHOs appeared to abstain and Emma noticed them leaving the room.
“Yes, that’s quite straightforward, really. It’s the principle of autonomy which is the key point here, which means that the individual has the right to determine what happens to him/herself, even if it’s by their own hand.”
"Let’s move on to the second example…”
The second slide read: ‘Let’s suppose that the same person has broken both arms which are now in plaster casts. She/he still wants to harm her/himself in the same way in order to relieve suffering, but is in even more distress because of the broken arms. She/he therefore asks her/his best friend to do the cutting. Is it morally right for the friend to do that?’
“And your vote?” A few hands went up but then came down.
“Yes, it’s very tricky and also complicated legally. I’ll give you a couple of examples: it’s legal in the UK for adults to box and potentially cause brain damage, but it’s illegal for consenting adults to engage in sadomasochistic sex. At the end of the day, it seems to be the degree of damage you cause. So, if the individual and the friend agreed on damage limitation – a scratch or two, for instance – that wouldn’t be ABH and the law would be happy.”
“Moving on to the third example…”
The third slide read: ‘Now, what about if a patient with a terminal illness wants to die and is able to devise and carry out a way of doing that without involving anyone else. Is it morally right for an individual to do that?’
“Votes?” Most of the remaining SHOs put up their hands.
“Yes, good, it’s the principle of autonomy again. Also, remember that the act of suicide was finally decriminalised in the UK in 1962.”
“And finally…”
The fourth slide read: ‘What if a patient with the same terminal illness also wants to die and whilst she/he’s able to devise a way of carrying it out, she/he cannot do this without involving others. Is it morally right for someone else to do that?’
“And your votes on this?” A few brave souls extended their arms ceiling-wise but most kept quiet.
“This is really the nub of what physicians face when contemplating the morals of assisted death. And the law doesn’t know what to do with it. On the one hand, we have terminally ill patients scrabbling around to find enough money to go off to Dignitas in Switzerland to swallow a potion; and on the other, there’s Kevorkian’s machine which delivers death on the press of a button by the patient. Both similar, you might think, but whilst the Dignitas doctor escapes any attention from the law, Kevorkian gets an eight year sentence for second-degree murder.
“But let’s consider how the law makers and moral guardians in England, Scotland, Ireland and Wales might see this. I’d like you to split up into four groups and consider how the different regions of the UK might approach the subject of assisted death.”
They SHOs split into four groups with much rearranging of chairs. After giving them a few minutes, she moved between them, briefly joining the discussion and getting an idea of what the headlines where in each group. So, the Welsh group mentioned “free prescriptions” and “independent NHS”, the Scottish group “Calvinism” and “devolution”, the Irish group “Catholic church” and “anti-abortion”, and the English group “lots of law” and “C of E”.
“What I picked up is that you think Ireland would never entertain assisted death because of Catholicism, Wales and England were somewhere in the middle, with lots of test cases keeping lawyers and courts busy, and you thought Scotland might consider something if devolution went through. Would you all agree with that?”
The SHOs nodded.
“And that polarisation of opinion and law is replicated throughout the world. Take the 52 states of the USA, for instance: you wouldn’t be prosecuted for assisted suicide in Washington, Oregon and Montana, but you would be in New York, Florida and Alaska, where you’d lose your license and be serving a life sentence. And in Europe, assisted death is legal in the Netherlands and Belgium, but illegal elsewhere.
“Finally, I’d like to show you a video from a conference I attended last year.”
Emma started the clip playback on her laptop. If anything, she found it more impressive than before, taking on the quality of a confessional in front of the much smaller audience, who were clearly transfixed by what they heard and saw.
When the video finished, Emma turned to look at the clock on the wall and said: “And at this precise moment in time – 2:00 p.m. GMT or 3:00 p.m. in the Netherlands – Jonah Haugen finally achieved his aim when he received intravenous injections from a doctor of barbiturate and pancuronium.
“Thank you for listening and I’d be pleased to answer any questions.”
Emma heard silence apart from shuffling and quite a few sniffs.
“I’m sure this has been difficult for you, so please feel free to find me in my office if you want to discuss anything.”
On her way out, she noticed the feedback forms that the SHOs were encouraged to complete. One of the questions read ’Will the seminar alter your clinical practice?’ At this early stage of their career, she really hoped not. And she also noticed that the red light on the video camera had finally gone off.
January 2004, one hour later
Four men in suits sat in a conference room watching a video feed on a large, flat screen TV mounted on a wall:
“And at this precise moment in time – 2:00 p.m. GMT or 3:00 p.m. in the Netherlands – Jonah Haugen finally achieved his aim when he received intravenous injections from a doctor of barbiturate and pancuronium. Thank you for listening and I’d be pleased to answer any questions.”
“An interesting ta
lk, although I suspect it went over their heads,” said the first man.
“Yes, most thought provoking,” said the second.
“Dr Jones is certainly persuasive and not a little impassioned,” said the third.
“Indeed, and a recent bereavement and still single,” said the first.
“And an attractive woman to boot,” said the fourth. “I think the time has come for that gentle nudge. Are we all agreed?”
The other three nodded.
“Excellent,” said the fourth.
January 2004, four days later
Arriving back in her office from the clinic, Emma’s PC pinged to alert her to an e-mail from the Medical Director, Michael Martin, asking her to drop by for a chat. E-mails from Michael were actually few and far between outside the annual appraisal jamboree, so Emma was marginally intrigued to find out what was on his mind. Perhaps he simply needed homes for some gerbils.
“Come on in, Emma, “said Michael. “It's good of you to drop by at such short notice.”
“How was Christmas?” asked Emma.
“Oh, fine, apart from the usual angst with the kids and the pregnant gerbil.” He leant back, put his hands behind his head and then leant forwards, looking thoughtful. “Look, Emma, the thing is that a couple of the female SHOs came to see me and it seems that they were a bit put out by your seminar.
“Oops, sorry, I guess the video probably was a step too far.”
“Actually, I think it was the stuff about self-harming which really got to them; you know, a bit too close to home and that sort of thing.”
“Oh, right, point taken.”
“And about the other, er, death stuff… Well, not to beat about the bush, I’m with you on that but I don’t advertise the fact. In fact, I drowned that bloody gerbil although the kids think it slipped on the ice and fell into the pond.”
They looked at each other for a bit, weighing each other up.
“Don’t you think you might be pushing yourself a bit too much, you know, what with your mother’s death and so on?”
“Perhaps.” Emma sniffed and Martin handed her a tissue.
“It might help if you saw someone to talk, you know…”
“Yes, Martin, you’re right, I’ll think about it.”
They looked at each other again.
“Anyhow, time waits for no man or woman…”
“Yes, thanks, Martin.”
Emma turned to leave.
“Oh, Emma?”
“Yes?”
“Please tread carefully.”
After Emma had closed the door, Michael turned to his PC and wrote an e-mail which simply read ‘Now’, and then he pressed the send button.
He returned to thinking about the bloody gerbil and concluded that he’d better buy a replacement if he wanted to avoid the consequences of the former pet’s premature departure from this world. But this time he decided it would be a male gerbil, and that would remain his little secret.
And the sooner the snow thawed, the sooner the kids could bury their ex-pet, which was currently languishing in the freezer compartment next to the Sunday roast.
January 2004, one hour later
Emma returned to her office, feeling just slightly contrite, and mulling over what Martin had said in his muddly, embarrassed way about what he called ‘death stuff’. On her desk, someone had left a white lily with a card. Emma recognised her secretary’s writing. Bless her cotton socks. Inside there was a brief note and a business card. The note read:
“Dear Emma,
Try Daniel, he’s really nice and helped me a lot when John died.
Sandra x”
The business card read “Daniel Armstrong, Therapist.” No title, no qualifications, just a name and what he did. Emma liked the simplicity. It seemed to be saying “cut the crap”. And the name rang a bell but she couldn’t make the connection.
Taking a leaf out of Martin’s book of impatience, Emma phoned the number on the card.
“Hello. Daniel Armstrong here, how can I help?” A nice, gentle sounding voice, Emma thought.
“Oh, hello, Daniel. You won’t know me but I was given your details by a colleague of mine, someone you saw. My name is Emma, Emma Jones, by the way.”
“Yes, Emma, I’d be happy to see you. I’ve actually got a space in my diary for 5:00 p.m. tomorrow. Would that suit?”
“Gosh, I didn’t expect you’d be able to see me so soon, but, yes, that’d be fine. Can I have your address?”
The therapist gave Emma his address, confirmed the details of the appointment and said he looked forward to seeing her tomorrow. He had such a gentle voice. And that bloody bell was still ringing.
January 2004, one day later
Daniel Armstrong was obviously doing well for himself, as his consulting room was in an extremely impressive, Victorian house at the end of a terrace in one of the most expensive streets in Hampstead. Emma climbed the steps, not entirely sure what to expect but basically hoping for the best. His bell push was as simple and unadorned as his card. The door opened and Emma’s jaw dropped in amazement. Standing in the doorway was someone that she recognised immediately from almost twenty-five years ago, still with the same dark wavy hair, soft brown eyes and long eye lashes.
“Dr Jones, I presume?” asked Daniel. “Perhaps I should check first that you’re not going to make me fall down and break my arm.”
“Oh, god, Daniel, I’m just so sorry, I’m so sorry…”
Daniel put his arms around the sobbing Emma and drew her into the house. He sat her down on the sofa in his consulting room.
“Where would you like to start, Emma?”
“Oh, god, Daniel … My mother hated me, I cut myself, I starved myself, I was almost raped, I nearly jumped from a 6 floor car park... and I probably killed a good few people along the way… Oh, god, I’m such a mess.”
“That’s a long list, Emma. Come here…”
Daniel held out his hands and Emma sank against his chest sobbing and repeating, “I’m so sorry, I’m so sorry…”
After a while, Emma turned to him and said, “What about the therapy?”
“Would you like to start now?” asked Daniel.
Emma nodded.
“I should warn you that it might take all night.” added Daniel.
Daniel half carried Emma upstairs to his flat and gently lay her on his bed.
“Emma, you’re so beautiful, I can’t believe that I let you go.”
He gently undressed her and then slowly undressed himself, so that she could take in every hair and every inch of his golden, muscular body. He touched her lips and said “No words, Emma.” The two of them touched, caressed and explored, feeling curves and creases, letting their senses guide their lovemaking. When Daniel finally entered her, it was so smooth and so gentle and so extraordinary that Emma felt a wave of pleasure which seemed to spread to every part of her being. She looked deep into Daniel’s eyes as he came and their combined emotions of pleasure reverberated and swelled into a glorious orgasmic tsunami which was wonderful, endless and beyond anything they’d experienced before.
Afterwards, they lay on the bed, limbs entwined, sated and exhausted and feeling utterly amazed that sex could be like that.
“Christ, Emma, how on earth did you do that?”
“It’s just something I can do with my eyes, Daniel. I’ve always been able to do it.”
“You know, I always wondered why I fell out of the tree; you didn’t push me, did you? And whatever it is you do, it either ought to have a government health warning on the packet or you should patent it.”
“You’re not so bad either, Daniel. Are you sure you’re not really a sex therapist?”
“For you, Emma, I’ll be whatever you want.”
And so they kissed and caressed, surrendering to each other, but this time with eyes kept tight shut; so no tsunami this time but certainly a sizeable wave.
And thus started the most wonderful year for Emma, when she felt as whole a perso
n as she could ever have imagined. Her clinical work was as efficient and dedicated as ever, but now her life revolved around this beautiful man who had come back into her life more by chance than by choice. She blessed her secretary’s cotton socks again and again. Evenings and weekend were taken up with cooking and eating together, enjoying music and theatre and planning holidays. She never realised that life could be so good. And even her anxieties about her ability seemed to fade away.
August 2004
“Emma, there’s a letter for you,” said Daniel. “It’s postmarked ‘Hindhead’, so it must be from your dad.”
“Thanks, Daniel,” said Emma. “That’s strange; he doesn’t usually write unless it’s something important.” She opened the letter and read the contents. “It’s really a letter on behalf of my grandparents. Dad thinks they want to make peace or something like that, and suggests we come down this weekend and go to their place for tea. What do you think?”
“You go down on your own, darling,” said Daniel. “I’m tied up most of the weekend.”
So Emma set off to Hindhead on the Saturday with the aim of having lunch with her father and then going over to her grandparents for tea.
“Dad,” asked Emma, “is there anything I should know before I go round to Grandpa and Grandma?
“You mean whether they’ve got an axe to grind for starting a relationship with Daniel whom they’ve never met?” asked her father.
“I guess something like that,” said Emma. “It just seems unusual for them. The last time I saw them was at Mum’s funeral and they just seemed to look through everyone. In case I get stuck with them, would you mind dropping by about an hour after I’ve arrived so that I can make a swift exit if I have to?”