Social History of Medicine Vol. 28, No. 1 pp. 155–171
‘Roy Porter Student Prize Essay, 2012’
Easing the Passing: R v Adams and Terminal Care
in Postwar Britain
Caitlin Mahar*
Summary. This article examines the 1957 trial for murder of Dr John Bodkin Adams in the context of
medical care of the dying in postwar Britain. R v Adams is significant because it is understood to have
rendered lawful the medical administration of pain-relieving drugs to the dying even when it is
known they will hasten death. I argue the legal sanction of this practice in the 1950s reflected
and reinforced the rising authority and faith invested in physicians as specialists in terminal care. Specifically, the case highlights the role of the administration of potent narcotics in the establishment of care of
the dying as a branch of medicine requiring specialised knowledge and skills. Finally, I argue that by
drawing attention to a medical intervention intent on eliminating pain, the Adams case enables exploration of an aspect of the medicalisation of dying in the twentieth century that is rarely examined.
Keywords: history of dying; palliative care; R v Adams; postwar Britain; medico-legal history; pain
On the morning of 18 March 1957, John Bodkin Adams, a successful and prosperous
middle-aged general practitioner from the picturesque English seaside town of Eastbourne,
appeared in London’s Old Bailey charged with murdering an elderly patient, Mrs Edith Alice
Morrell, with doses of heroin and morphine in the hope of pecuniary gain. So began a long
and sensational trial: it ran for three weeks and, as one reporter put it, kept ‘the eyes of the
whole newspaper-reading world focused in fascination’ until Dr Adams’ acquittal on 9 April.1
The Adams case has disappeared from the headlines, but it lives on in a less sensational
manner in medico-legal literature dealing with end-of-life matters. Here it is understood
to have rendered lawful the administration of pain-relieving drugs to the dying even
when it is known they will accelerate death.2 Legal sanction of this practice is traced back
*PhD Candidate, School of Historical and Philosophical Studies, Faculty of Arts, The University of Melbourne, Parkville,
VIC 3010, Australia. Email: [email protected]
Caitlin Mahar is a doctoral candidate in the School of Historical and Philosophical Studies at the University of Melbourne. She has degrees from The University of Melbourne and Monash University. Her dissertation explores the
history of euthanasia in the context of changing conceptions of dying and suffering.
‘Not Guilty’, Time, 22 April 1957, 69, 33. In his annual
survey, Famous Criminal Cases, Robert Furneaux
described the trial, at the time the longest in English
history, as ‘one of the greatest murder trials of all
time’. See Kieran Dolin, ‘The Case of Dr. John Bodkin
Adams: A “Notable” Trial and its Narratives’, Yearbook
of Research in English and American Literature (Law and
Literature), 2002, 18, 145–65, 149–50.
2
For a succinct overview of the legal position on this practice, see Richard Ashcroft, ‘Death Policy in the United
Kingdom’, in Robert H. Blank and Janna C. Merrick,
1
eds, End-of-Life Decision Making (Cambridge, MA:
MIT Press, 2005), 197–218, 205–6. On the medical position and contemporary palliative care practice, see
British Medical Association Ethics Department,
Medical Ethics Today: The BMA’s Handbook of Ethics
and Law, 3rd edn (Chichester, West Sussex: WileyBlackwell, 2012), 434–9. While there is no doubt hastening death in the context of modern palliative care
is considered lawful, it should be noted that there is considerable debate in contemporary medical circles
regarding the extent to which this does, or needs to,
© The Author 2014. Published by Oxford University Press on behalf of the Society for the Social History of Medicine.
doi:10.1093/shm/hku067
Advance Access published 12 September 2014
156
Caitlin Mahar
to a passage of Justice, later Lord, Devlin’s directions to the jury in R v Adams.3 Devlin directed
that a doctor was entitled to relieve the pain and suffering of a dying patient even if the measures he took precipitated death.
Most scholarly discussion of this case has taken place in medico-legal and bioethical
circles. Here scholars have sought to explain Devlin’s directions to the jury in terms of
ethical and/or legal principles that obscure the historical context of the case.4 Meanwhile,
other commentators appear unaware or uninterested in the novelty of Devlin’s direction
and its implications for end-of-life care. Instead, they are engaged in what Kieran Dolin
has described as an ‘historical contest over Adams’s guilt or innocence’; a debate over
whether Adams was in fact a doctor who got away with serial murder.5 In the most sympathetic of these, by journalist Percy Hoskins, Adams emerges as the victim, albeit a roguish and
avaricious one, of a scurrilous trial-by-newspaper.6 Pamela Cullen, the first writer to be
granted official access to the police files, sees him as a more sinister figure.7 She argues
that Dr Adams was a murderer who probably had more victims than Dr Harold Shipman, Britain’s most prolific serial killer.8
This article approaches the Adams case from a different historical perspective, examining
the case and trial in the context of a history of dying. It follows legal historian A. W. Simpson’s
suggestion that Devlin’s comments to the jury might best be seen as a deferral to ‘current
conventions in medical treatment’, bearing in mind that ‘practices in the care of the dying
differ over time and between cultures’.9 My argument is also informed by Shai Lavi’s
work on the history of dying in the United States, which has highlighted life-shortening palliative care and its legal sanction as historical (and not simply medico-legal or ethical) phenomena. Lavi points to these developments as indicative of the medicalisation of dying.
The rise of this form of care reflects the transformation of dying from an experience governed
by religion to one increasingly governed by modern medicine and the law. This is inextricably
entwined with changing cultural conceptions of the ‘good death’—in particular the modern
understanding that to die well one should be free of pain and suffering.10
occur. See, for example, Rob George and Claud
Regnard, ‘Lethal Opioids or Dangerous Prescribers?’,
Palliative Medicine, 2007, 21, 77–80.
3
Unreported, see Henry Palmer, ‘Dr Adams’ Trial for
Murder’, Criminal Law Review, 1957, 1, 365–77.
4
A critical and circumspect overview of the way scholars
in these fields have (implicitly or explicitly) sought to
explain R v. Adams can be found in Margaret Otlowski,
Voluntary Euthanasia and the Common Law (Oxford:
Clarendon Press, 1997), 172–6. See also, for example,
Glanville Williams, The Sanctity of Life and the Criminal
Law ((London: Faber & Faber, 1958), 289–90; Cicely
Saunders, ‘In Britain: Fewer Conflicts of Conscience’,
The Hastings Center Report, 1995, 25, 44–5; David
Price, ‘Euthanasia, Pain Relief and Double Effect’,
Legal Studies, 1997, 17, 323–42, 327–9; Ashcroft,
‘Death Policy’, 205. The legal, medical and ethical implications of the sanctioning of life-shortening palliative
care, which are subject to voluminous contemporary
scholarly debate, are beyond the scope of this essay.
5
Dolin provides a useful summary of many of these commentaries. See Kieran Dolin, ‘The Case of Dr. John
Bodkin Adams’, 145–66.
6
Percy Hoskins, Two Men Were Acquitted Today: The
Trial and Acquittal of Doctor John Bodkin Adams
(London: Secker & Warburg, 1984).
7
Due to remain closed until 2033, these were opened in
2003 at Cullen’s request. See Pamela Cullen, A Stranger
in Blood: The Case Files on Dr John Bodkin Adams
(London: Elliott & Thompson, 2004).
8
Cullen, A Stranger in Blood, 592–5, 636–49. Convicted in
2000 of murdering fifteen of his elderly patients, a public
inquiry concluded Shipman had killed at least 215
patients over 24 years. See also, Herbert G. Kinnell,
‘Serial Homicide by Doctors: Shipman in Perspective’,
British Medical Journal, 2000, 321, 1594–7, 1596.
9
A. W. Brian Simpson, review of Easing the Passing: The
Trial of Dr John Bodkin Adams, by Patrick Devlin,
Michigan Law Review, 1986, 84, 807–18, 817.
10
Shai J. Lavi, The Modern Art of Dying: A History of
Euthanasia in the United States (Princeton: Princeton
University Press, 2005), esp. ch. 5.
R v Adams and Terminal Care in Postwar Britain
157
The analysis that follows draws on medical literature and the police files and trial transcript
of the Adams case to offer a close reading of R v Adams in the context of medical care for the
dying in postwar Britain.11 I argue that the medical evidence presented during the course of
the Adams trial and Devlin’s unprecedented sanctioning of life-shortening terminal care
should be understood as reflecting and reinforcing the rising authority and faith invested
in physicians as scientific specialists in dying and its care, or ‘treatment’. In particular the
case highlights the role of the administration of potent narcotics in the establishment of
care for the dying as an exclusive medical activity requiring specialist knowledge and
skills. This nascent specialisation is evident in the pivotal role medical experts played in the
trial of Dr Adams. Specifically, it is evident in medical accounts of the care of the dying
that were bound to arcane technical language and techniques that appeared beyond the
assessment or judgment of the court.
This recasting of R v Adams builds on two bodies of scholarship. First, it engages with work
on the history of the relationship between medicine and the law.12 As Catherine Crawford
observes, influenced by Foucault, much modern scholarship in this area has illuminated the
way ‘“juridical power” (that of a sovereign) has, during the past few centuries, been overtaken in significance by “biopower” (the power of the norm), a process that has tended to
enhance the power and importance of medicine’.13 A substantial body of literature has
explored aspects of this shifting balance of power through the changing conception, role
and importance of medical experts and expertise in the Anglo-American legal enterprise.14
This is an evolution often examined in relation to the spectacular rise of forensic medicine
and science in the nineteenth and twentieth centuries—a development heralded by the
emergence of, and courts’ increasing dependence on, expert medical witnesses in two
areas that began to appear ‘most difficult for the non-expert to penetrate: insanity and
poisoning’.15
This work demonstrates that the increasing value and authority accorded to expert medical testimony in the English courtroom corresponds with dramatic improvements in the
efficacy of medical science and technology but also with processes of professionalization,
11
Records of the Metropolitan Police Office (Scotland
Yard), The National Archives, Kew, (henceforth
MEPO). Two book-length accounts of the trial by witnesses—a contemporaneous account by a novelist/
journalist attending the trial and a memoir by the presiding judge—also offer valuable insights into the
trial’s machinations. See: Sybille Bedford, The Best
We Can Do: An Account of the Trial of John Bodkin
Adams (Harmondsworth, UK: Penguin Book, 1961);
Patrick Devlin, Easing the Passing: The Trial of Dr
John Bodkin Adams (London: Bodley Head, 1985).
12
For a recent discussion in the British context, see
Imogen Goold and Catherine Kelly, eds, Lawyers’
Medicine: The Legislature, the Courts and Medical
Practice, 1760–2000 (Oxford: Hart Publishing, 2009).
For pan-European discussion, see Michael Clark and
Catherine Crawford, eds, Legal Medicine in History
(Cambridge: Cambridge University Press, 1994).
13
Catherine Crawford, ‘Medicine and the Law’, in
W. F. Bynum and Roy Porter, eds, Companion
Encyclopedia to the History of Medicine (Routledge:
London, 1993), 1619–40, 1619.
14
Recent key texts examining this aspect of the history of
medico-legal interaction include: Tal Golan, Laws of
Men and Laws of Nature: The History of Scientific
and Expert Testimony in England and America (Cambridge, MA: Harvard University Press, 2004); Joel
Peter Eigan, Witnessing Insanity: Madness and
Mad-doctors in the English Court (New Haven: Yale
University Press, 1995); Ian Burney, Bodies of Evidence:
Medicine and the Politics of the English Inquest,
1830–1926 (Baltimore: John Hopkins University
Press, 2000); Ian Burney, Poison, Detection and the
Victorian Imagination (Manchester: Manchester
University Press, 2006); Katherine Watson, Forensic
Medicine in Western Society: A History (London:
Routledge, 2011).
15
Watson, Forensic Medicine, 70.
158
Caitlin Mahar
specialisation and medicalisation through which, writes Ian Burney, ‘social understandings
and responses to such basic human experiences as pain, illness and death’ were ‘displaced
by arrangements that produce and legitimate a narrower set of expert interventions’.16 As
Joel Eigen points out, the very public nature of the courtroom provides historians with a particularly fruitful arena in which to examine wider acceptance of these emerging expert
medical interventions, for here the budding medical expert has to assert their opinion not
just before colleagues but the lay (and legal) public.17
Through the figure of the expert witness, R v Adams offers a rich as well as rare opportunity to study the expansion of medical expertise and authority into the realm of dying. In
an era when the medical management of those close to death was rarely publically discussed, even within medical circles, physicians were required to testify as to the ethics
and practice of terminal care in the midst of a sensational trial. The evident lay and legal
deference to this medical testimony is indicative and constitutive of the extent to which
dying was becoming an area of expert medical intervention by the 1950s. The following
analysis draws attention to the enormous discretion thus afforded the medical profession
at the deathbed, where the decision of whether, and in what circumstances, hastening
death with pain-killers was justifiable was devolved to individual practitioners. In this
way it seeks to underline the historical contingency of an aspect of contemporary
medical ethics, reminding that ‘like “nature,” the “ethical” is what society and culture attribute to it at any particular historical moment’.18 R v Adams offers insight into the way
modern notions of what might constitute ethical medical care of the terminally ill have
evolved and, thus, this analysis also aims to contribute to the literature on the history of
dying.
As Julie-Marie Strange observes, while in the wake of Philippe Ariès’s seminal scholarship
death has become a major area of academic inquiry, investigation into the history of attitudes and practices specifically surrounding dying, as opposed to death and its aftermath
(funeral rites, grief and mourning), is relatively new.19 This is particularly true of the early
to mid-twentieth century where research into dying and its care remains limited, due at
16
Burney, Bodies of Evidence, 10. By way of contrast,
earlier notions of ‘medical’ expertise in the English
courtroom were not tied exclusively to professional
credentials, encompassing, for example, all-female
juries summoned as experts in cases that involved
pregnancy, childbirth and sexual assault. See Golan,
Laws of Men and Laws of Nature, 18–22; Crawford,
‘Medicine and the Law’, 1628.
17
Joel Peter Eigen, ‘Not their Fathers’ Sons: The Changing Trajectory of Psychiatric Testimony, 1760–1900’,
in Goold and Kelly, Lawyers’ Medicine, 79–98, 82. Of
course, as Eigen and others have shown, the rise of
the modern expert witness has not been without
tension and controversy. Particularly in the nineteenth
century, while medical expertise became an increasingly
indispensable part of the legal process, the spectacle of
experts contradicting each other on the witness stand
roused great scepticism about scientists and their
method. See also, for example, Golan, Laws of Men.
18
Roger Cooter, ‘The Ethical Body’, in Roger Cooter and
John Pickstone, eds, Companion to Medicine in the
Twentieth Century (London: Routledge, 2003),
451–67, 466. For an historical perspective on the
ethics of the deathbed see Lavi, Modern Art of Dying.
19
Julie-Marie Strange, ‘Historical Approaches to Dying’,
in Allan Kellehear, ed., The Study of Dying: From Autonomy to Transformation (Cambridge: Cambridge
University Press, 2009), 123–46, 123–5; Philippe
Ariès, The Hour of Our Death, Helen Weaver (trans),
(New York: Knopf, 1981). Significant recent contributions to the history of dying that address developments
in the early to mid-twentieth century include: Emily
K. Abel, The Inevitable Hour: A History of Caring for
Dying Patients in America (Baltimore: John Hopkins
University Press, 2013); Pat Jalland, Death in War and
Peace: A History of Loss and Grief in England,
1914–1970 (Oxford: Oxford University Press, 2010);
Milton J. Lewis, Medicine and Care of the Dying
(Oxford: Oxford University Press, 2007); Allan Kellehear, A Social History of Dying (Cambridge: Cambridge University Press, 2007); Lavi, Modern Art of
Dying.
R v Adams and Terminal Care in Postwar Britain
159
least in part to a scarcity of relevant sources.20 The inter-and-early postwar years are largely
bereft of the rich religious, fictional, personal and, in the nineteenth century, medical literature that historians such as Pat Jalland and Ralph Houlbrooke have employed to illuminate
the attitudes and practices that shaped dying in England in earlier eras.21 This is also a time
prior to the rise of a professional literature on dying and terminal care (in England associated
with the pioneering work of Cicely Saunders) that historians and sociologists have drawn on
to examine the rise of the modern hospice movement and, more broadly, what Tony Walter
has described as the ‘revival’ of death from the 1960s.22
However, while the picture of terminal care in early twentieth-century Britain remains
sketchy, a broad outline of the history of dying in the modern Western world has become
widely accepted. Most scholarship addressing the subject emphasises that dying, like
many aspects of life, became increasingly medicalised in the twentieth century—a
process often associated with the steady rise in the number of deaths taking place in hospitals from the 1930s.23 Strange notes that much of the relevant literature has focused on the
way that in a climate where medicine had developed unprecedented means to cure the sick,
death was often seen as a medical ‘failure’ in the twentieth century and dying patients were
increasingly either subject to aggressive treatments intended to prolong life, or ignored and
neglected by the medical profession.24 Milton Lewis argues that prior to the 1960s, in
advanced Western societies such as Britain, twentieth-century medicine put the cure of
the body before its care and that too often ‘medicine’s great concern with advancing scientific knowledge’ subordinated ‘the relief of suffering of the dying’.25 Caroline Murphy has
documented how in the twentieth century cancer hospitals (established in the nineteenth
century to care for the sick with little expectation of cure) shifted their focus towards research
and ‘patients admitted for aggressive treatment aimed at cure’ replaced those who were
dying.26 David Clark and Jalland have detailed the way in the postwar years a National
20
Jalland, Death in War and Peace, 184. This is not to
suggest that the historical record in this period is completely silent on the subject. As David Cannadine
pointed out some time ago, while ‘domestic’ death
in this period may be characterised by silence, the
horrific numbers of war dead had obvious and profound effects on individual, national and global attitudes to death. See David Cannadine, ‘War and
Death, Grief and Mourning in Modern Britain’, in
Joachim Whaley, ed., Mirrors of Mortality: Studies in
the Social History of Death (London: Europa, 1981),
187–242.
21
Pat Jalland, Death in the Victorian Family (Oxford:
Oxford University Press, 1996); Ralph Houlbrooke,
Death, Religion and the Family in England,
1480–1750 (Oxford: Oxford University Press, 1998).
22
Tony Walter, The Revival of Death (London: Routledge,
1994); Tony Walter, ‘Modern Death: Taboo or not
Taboo?’ Sociology, 1991, 25, 293–310; On the
history of palliative care see, for example, David
Clark, ‘Originating a Movement: Cicely Saunders and
the Development of St Christopher’s Hospice,
1957–1967’, Mortality, 3, 1998, 43–63; David Clark,
‘“Total Pain”, Disciplinary Power and the Body in the
Work of Cicely Saunders, 1958–1967’, Social Science
& Medicine, 1999, 49,727–36; Milton Lewis, Medicine
and Care of the Dying, 121–58.
23
See, for example, Jalland, Death in War and Peace,
182–3; Roy Porter, The Greatest Benefit to Mankind:
A Medical History of Humanity (New York: Norton,
1999), 692. Emily Abel has recently sought to temper
this thesis of medicialisation. Documenting instances
where the profession in America marginalised and
neglected the terminally ill, particularly the dying
poor, she points out that twentieth-century medicine
has not always sought authority over death and the
dying. See Abel, The Inevitable Hour.
24
Strange, ‘Historical Approaches to Dying’, 124; Ariès,
The Hour of Our Death, 586; Walter, ‘Modern Death’,
302; Porter, The Greatest Benefit to Mankind, 692–3;
Abel, The Inevitable Hour.
25
Lewis, Medicine and Care of the Dying, 8.
26
Caroline C. S. Murphy, ‘From Friedenheim to Hospice:
A Century of Cancer Hospitals’, in Lindsay Granshaw
and Roy Porter, eds, The Hospital in History (London:
Routledge, 1989), 221–41, 230. Similar conclusions
have been drawn in the American context, see Emily
K. Abel, ‘In the Last Stages of Irremediable Disease:
160
Caitlin Mahar
Health Service intent on cure and rehabilitation failed to provide guidance on terminal care
or systematic provision for the dying, condemning the poor and disadvantaged to inadequate, sometimes tragic, living conditions at home or under-resourced and under-staffed
institutions.27
This study aims to further the discussion of the medicalisation of dying in the twentieth
century by exploring an aspect of this history that remains less well examined. The two
major postwar reports into terminal care in the United Kingdom, which provide central historical sources for this period, are, understandably, most concerned to document and detail
the inadequate provision made for the poor and otherwise disadvantaged in the community.28 The Adams case, however, offers a rare glimpse of what dying might have looked
like in the homes of England’s more comfortable classes. And it enables exploration of
quite a different medical discourse on dying in postwar Britain, one that assumed physicians
had a duty to provide care for those in the last stages of life and to relieve the pain associated
with dying. Over a decade ago Clark looked at the emergence in postwar Britain of a medical
discourse on dying that expressed active interest in terminal care and in which can be
glimpsed the foundations of modern palliative medicine.29 More recently he has examined
health professionals’ use of analgesics in institutions for the dying from the 1930s.30 This
paper draws on Clark’s work to explore this aspect of the medicalisation of dying further,
seeking to foreground the evolution and accommodation of a specialist form of medical
treatment for terminal patients that was more intent on eliminating pain than staving-off
death.
Easing the Passing in Postwar Britain
In her study of death in Victorian Britain, Jalland has documented the changing attitudes
towards death and suffering in middle- and upper-class families.31 For much of the nineteenth century the pain associated with dying, like death itself, was a matter of divine
providence and to be faced with faith and fortitude. For relatives and friends attending
the dying, the focus was on the spiritual rather than the physical state of those close to
death, and hope was invested above all in the prospect of salvation rather than the restoration of health or the elimination of pain.
However, in the latter part of the century, fear of death, which had once centred on the
post-mortem horrors of eternal physical punishment, came to focus on the dying process
itself. As fear of hell dimmed, even amongst the devout, there were ‘more accounts of deathbed scenes which described dreadful physical or mental suffering with little or no reference
to spiritual and devotional consolation, and none at all to the state of the soul in the final
hours’.32
American Hospitals and Dying Patients before WW II’,
Bulletin of the History of Medicine, 2011, 85, 29–56.
27
David Clark, ‘Cradled to the Grave? Terminal Care in
the United Kingdom, 1948–67’, Mortality, 1999, 4,
225–47; Jalland, Death in War and Peace, 182–90.
28
H. L. Glyn Hughes, Peace at the Last: A Survey of Terminal Care in the United Kingdom (London: Calouste
Gulbenkian Foundation, 1960); Joint National Cancer
Survey Committee of the Marie Curie Memorial and
the Queen’s Institute of District Nursing, Report on A
National Survey Concerning Patients with Cancer
Nursed at Home (London: Marie Curie Memorial,
1952).
29
Clark, ‘Cradled to the Grave?’.
30
David Clark, ‘The Rise and Demise of the Brompton
Cocktail’, in Marcia Meldrum, ed., Opioids and Pain
Relief: A Historical Perspective, (Seattle: ISAP Press,
2003), 85–98.
31
Jalland, Death in the Victorian Family.
32
Ibid., 53.
R v Adams and Terminal Care in Postwar Britain
161
This increasing anxiety about the physical suffering that might precede death was fostered
in part by the rising prominence of the doctor at the bedside of the dying in middle- and
upper-class families. Once attended by family and clergy, those near the end of their life
became the subjects of medical care and attention, a fact reflected in the emergence of
medical literature on the subject. Victorian doctors such as William Munk advised on the importance of spiritual reflection as well as the physical management of the death chamber
(proper ventilation, bedding, nutrition). These medical practitioners also advocated the cautious use of opiates to treat pain.33 Caution was paramount. Concerned that pain-relief that
precipitated death was illegal, violated the medical duty to preserve life and risked eroding the
trust of patients and families, nineteenth-century physicians warned against the administration of such drugs in any situation where death might be hastened even accidently.34
While in the first half of the following century there is a relative dearth of medical literature
dedicated to detailing appropriate care for the terminally ill, it seems clear physicians did not
desert the deathbed. In a major postwar report on terminal care in the United Kingdom prepared for the Calouste Gulbenkian Foundation, H. L. Hughes noted patients’ ‘touching’ reliance on their family doctor, observing that whether in hospital or at home, the patient
‘always felt better for a daily visit, and he often finds it easier to talk to his doctor than his
relatives or a priest’.35 What is less clear is what medical management of the dying actually
involved. Jalland observes that a lack of contemporaneous documentation means little has
been written ‘about the actual care of the dying’ in England in the immediate postwar
years.36 It is particularly difficult to discern what terminal care consisted of in the significant
proportion of situations where death took place in the privacy of the home and the dying
were attended by their general practitioner and professional nursing staff.37 As Irvine
Loudon and Mark Drury write, ‘we know very little about the care of the dying in general
practice before the 1960s, except that it was shrouded in silence. Few talked about it,
wrote about it, or were taught anything about it as students’.38
Clark has begun to shed light on this period by pointing to the emergence from the 1930s
of a medical discourse that not only cautioned against the heroic prolongation of life, but
also expressed an active interest in terminal care. It is evident in the limited and fragmentary
material that emanated from terminal care homes and associated charities as well as interested clinicians. This is a literature that drew on physicians’ personal experience and observations and lay the foundations for the development, under the auspices of Cicely Saunders,
33
William Munk, Euthanasia: Or, Medical Treatment in
Aid of an Easy Death (London: Longmans, Green,
and Co., 1887); Jalland, Death in the Victorian Family,
77–97.
34
Munk, Euthanasia, 73, 81–2; Editorial, ‘Euthanasia,’,
The Lancet, 1887, 130, 1178; Editorial, ‘Euthanasia’,
The Lancet, 1899, 153, 532.
35
Hughes, Peace at the Last, 54.
36
Jalland, Death in War and Peace, 184.
37
Figures cited in Hughes indicate nearly half of all deaths
in the United Kingdom in 1956 occurred at home.
There are no figures available to ascertain the level of
medical attention received in these instances and it
no doubt varied, depending, amongst other things,
on the financial circumstances of the patient.
However, in addition to visits from the district nurse
and/or private nurses, Hughes indicates daily visits
from the family doctor ‘at the end’ were not uncommon. Hughes, Peace at the Last, 15–16, 34, 53–4.
An earlier survey of cancer patients nursed at home
reported 95 per cent received ‘medical attention’
from their doctor as well district and/or private
nursing care. Joint National Cancer Survey, Report on
A National Survey, 20, 35–6.
38
Irvine Loudon and Mark Drury, ‘Some Aspects of Clinical Care in General Practice’, in Irvine Loudon, John
Horder and Charles Webster, eds, General Practice
under the National Health Service 1948–1997
(London: Clarendon Press, 1998), 92–127, 121.
162
Caitlin Mahar
of the modern palliative care movement in the coming decades—a movement which would
make dying and the relief of associated pain the subject of systematic scientific observation,
research and clinical techniques.39 This published medical commentary on terminal care did
not signal a new interest in the medical management of those at the end of life, so much as a
new type of interest. This is a period that marks a transition in the history of the medicalisation of dying, not its emergence. It is a point where, as Clark observes, terminal care, ‘which
had previously belonged to the realm of medical folklore’ was beginning to be seen as a
branch of medicine that involved—and could be promoted as involving—specialist knowledge and skills.40 These would not begin to be consolidated into a professional literature
until the 1960s, but the assumptions and priorities that underpinned this new medical specialisation are clearly evident in earlier medical writings and practices.
By the postwar years the most prominent aspect of specifically medical care for those
at the end of their life (as opposed to more prosaic nursing and the provision of comfort
and consolation) was the treatment of the pain associated with dying using the powerful
narcotics that had become the exclusive province of medicine. Chief among these was
opium and its derivatives. As Virginia Berridge and others have shown, for much of the
nineteenth century opiates were widely available and used for recreational purposes as
well as self-administered, or prescribed, as remedies for numerous common complaints
(toothache, diarrhoea, chilblains). However, the emergence of medicine and pharmacy as
powerful scientific specialities, coupled with growing medical and lay concerns about the
dangers associated with consumption (addiction and poisoning but also deviance) led to
the increasing regulation and restriction of such drugs in the twentieth century. The introduction of numerous milder forms of pain relief further curtailed the need for opiates and
they were used increasingly conservatively within medicine.41 Marcia Meldrum suggests
that by the 1920s one of the very few situations in which the prolonged medical administration of opiates was considered legitimate was in the context of the care of those deemed in
the last stages of life.42
In a 1948 article discussing care of the dying that appeared in The Practitioner, W. N. Leak
observed that ‘purely medical treatment’ for the dying could ‘almost be written in one
word—morphine’.43 At a meeting of the British Medical Association, Dr Ian Grant counselled that, while morphine should be withheld from terminal patients as long as possible
to avoid problems of tolerance, it could sometimes be administered to ‘curative and
Clark, ‘Cradled to the Grave?’, 225–47; David Clark,
‘Originating a Movement: Cicely Saunders and the Development of St Christopher’s Hospice, 1957–1967’,
Mortality, 1998, 3, 43–63; Clark, ‘The Rise and
Demise of the Brompton Cocktail’, 85–98; Clark,
‘“Total Pain”, Disciplinary Power and the Body in the
Work of Cicely Saunders, 1958–1967’, Social Science
& Medicine, 49, 1999, 727–36.
40
Clark, ‘Cradled to the Grave?’, 243.
41
Virginia Berridge, The Opium of the People: Opiate Use
and Drug Control Policy in Nineteenth and Early Twentieth Century England (London: Free Association,
1999); Terry M. Parssinen, Secret Passions, Secret Remedies: Narcotic Drugs in British Society, 1820–1930
(Manchester: Manchester University Press, 1983);
39
Howard Padwa, Social Poison: The Culture and Politics
of Opiate Control in Britain and France, 1821–1926
(Baltimore: Johns Hopkins University Press, 2012).
42
Marcia Meldrum, ‘A Capsule of Pain Management’,
Journal of the American Medical Association, 2003,
290, 2470–5, 2471–2. In England the only other situation in which the prolonged use of opiates appears
to have been sanctioned in the period under discussion
was as ‘maintenance’ treatment for addicts. See Virginia Berridge, ‘Drugs and Social Policy: The Establishment of Drug Control in Britain 1900–30’, British
Journal of Addiction, 1984, 79, 17–29.
43
W. N. Leak, ‘The Care of the Dying’, The Practitioner,
1948, 161, 80–7, 85.
R v Adams and Terminal Care in Postwar Britain
163
euphoric effect’. And in cases of desperate misery he advised his colleagues that it should not
be spared, as ‘our first duty is to relieve pain and to induce merciful oblivion’.44 While acknowledging ‘the smoke of battle’ lingered over its use, another medical practitioner
observed that regular injections of heroin, rather than morphine, were most effective ‘for
bringing analgesia and peace of mind to those who have not long to live’.45
Opiates were also administered to the dying orally, often in the form of what one physician
described as ‘that famous Brompton requiem’.46 There was no standard composition of this
mixture but, as formulas or recipes endorsed by clinicians and textbooks at the time indicate,
it almost invariably included morphine or heroin and cocaine mixed with a sweetener (maybe
honey) and alcohol (which might be adjusted to suit the individual taste of the patient). The
doses of opiates recommended by physicians writing on the subject varied and were clearly
intended as guides to be adjusted by individual doctors as they saw fit—presumably based
on the assumption that the doctor at the bedside was best qualified to make judgements as
to what sort of dosage was in the best interests of his patient. Authorities advised, for
example, that Brompton cocktails be given ‘as often as required’ or that in the last stages
of illness the dose of opiates would need to be increased ‘fairly rapidly’ at the discretion
of the doctor.47
The administration of opiates to the dying was not just advocated by individual physicians
but as part of terminal care in the, albeit few, institutions that accommodated the dying in
the first half of the twentieth century. Between the 1930s and 1950s ‘Brompton mixtures’,
which were to become a central component in the work of the modern hospice movement,
were widely prescribed to those deemed terminal in religious and charitable homes as well as
in hospitals.48 Norman Sprott, Medical Superintendent at St Columba’s hospital in London,
advised that these potent analgesic cocktails could be given freely to the dying and described
the effect this way: ‘Large doses of narcotics will sometimes shorten a life—a result for which
the patient might be profoundly thankful—but just as often, by bringing rest and sleep and
comfort, they seem to prolong life, though even then the suffering is greatly lessened.’49
Sprott’s observations, as well as those of the other physicians quoted here, draw attention
to the way powerful narcotics were administered to the dying, but also to the ambiguous
clinical purpose and effect of the medical administration of such drugs. As Clark writes of
the administration of the Brompton to the dying in various institutions: ‘Was it intended
to induce euphoria? Did it potentiate moribundity? Most intriguing of all, was it originally
intended to bring about an “easeful” death or even to hasten death?’50
At the time what might constitute ‘proper’ medical treatment—as opposed to an unjustifiable hastening of death—for the terminally ill was not simply a matter of clinical propriety.
In a very frank and widely circulated lecture, Clifford Hoyle, physician at King’s College Hospital, made it clear that any knowing ‘acceleration of death in the dying’ was illegal—from a
Ian Grant, ‘Care of the Dying’, BMJ, 1957, 2, 1539–40,
1540.
45
C. A. Clarke, ‘Analgesics’, The Practitioner, 1957, 178,
33–42, 38.
46
Ibid.
47
Ibid.; J. S. Richardson and D. Baker, ‘The Management
of Terminal Disease’, in J. S. Richardson (ed.), The Practice of Medicine (London: Churchill, 1956), 1019–22,
1021–2.
44
Clark, ‘The Rise and Demise of the Brompton Cocktail’;
Cicely Saunders, ‘Dying of Cancer’, in David Clark (ed.),
Cicely Saunders: Selected Writings, 1958–2004
(Oxford: Oxford University Press, 2006), 1–11.
49
Norman A. Sprott, ‘Dying of Cancer’, Medical Press,
1949, 121, 187–91, 189.
50
Clark, ‘The Rise and Demise of the Brompton Cocktail’,
96.
48
164
Caitlin Mahar
conventional legal standpoint a doctor who deliberately hastened the death of a terminally ill
patient opened himself/herself to a charge of homicide.51 Yet in Hoyle’s view the physician
attending the deathbed was best placed to decide how far pain-relief for the dying should
go—and in some instances this meant violating the law by hastening the death of a patient.
Moreover, he assured colleagues, ‘the law forbids in theory but ignores in practice’. In practice, he advised, it was tacitly accepted that doctors ‘here, as in other spheres, should be protected from the consequences of steps honestly taken in the interests of patients’.52
There is no suggestion in Hoyle’s article—or, indeed, in any of the medical literature on
care of the dying—that such decisions should be discussed with the patient, the patient’s
family or even colleagues: quite the opposite. ‘If there are occasions when hastening
death seems the most sensible and humane procedure the proper course then becomes a
matter for one’s own conscience,’ instructed Hoyle, ‘the first essential on these occasions
is to keep one’s own counsel’. He went on to suggest that one of the best ways to effect
‘such treatment’ was by administering quickly cumulative doses of morphine.53
It was this ambiguous aspect of terminal care that Justice Devlin unexpectedly found
himself navigating during the trial of Dr Adams in 1957. As he reflected some decades
later, it became clear that he needed to clarify for the jury ‘how far the law allowed the orthodox doctor to go in easing the passing’.54 However, when the Adams story broke in 1956
quite different issues appeared at stake.
The Strange Case of Dr Adams
A series of lurid press articles first brought Dr John Bodkin Adams to the attention of the
British public. ‘Seaside Mystery of 13 Rich Women’; ‘Yard Probe Mass Poisoning: 25
Deaths in the Great Mystery of Eastbourne’; ‘Mystery of the 300 Women: Yard Probes Hypnotic Killer Theory,’ screamed the headlines in August 1956.55 These stories were the result
of leaks that a police investigation was underway into the apparently suspicious deaths, as
well as the wills, of hundreds of Adams’ patients. The blaze of hostile publicity continued and
was heightened by the rumour mill in the seaside resort where Dr Adams lived and worked.56
As one commentator insinuated, the case excited national and international attention
because it appeared to have many of the hallmarks of a classic English murder mystery:
this ‘strange case’ was like ‘a macabre story that Agatha Christie might have written’.57
Adams was an Irish-born general practitioner with diplomas in public health and anaesthetics
who became a prosperous doctor in the English coastal town of Eastbourne.58 By the time of his
arrest he had established a lucrative practice attending to many of the wealthy elderly who
Clifford Hoyle, ‘The Care of the Dying’, Post-Graduate
Medical Journal, 1944, 20, 119–23. Based on a lecture
given at Horton Hospital in 1941, this article was first
published in the King’s College Hospital Gazette and
the Brompton Hospital Reports as well as reproduced
in the 1950s. See, for example, Clifford Hoyle, ‘The
Care of the Dying’, in Maurice Davidson (ed.), Medical
Ethics: A Guide to Students and Practitioners (London:
Llyod-Luke, 1957), 130–9.
52
Hoyle, ‘The Care of the Dying’, 123.
53
Ibid.
54
Devlin, Easing the Passing, 124.
51
55
Daily Sketch, 20 August, 1956, 1; Daily Mail, 22 August,
1956, 1; Evening Standard, 22 August, 1956, 1.
See Detective Super. Hebert Hannam to Chief Super.,
report, 16 October 1956, 1, MEPO 2/9784.
57
‘The Strange Case of The Widows of Eastbourne’, The
Australian Women’s Weekly, 6 February 1957, 20–1.
58
The following account draws on Hannam to Chief
Super., report, 16 October 1956, 1–187. For biographical details see also: Percy Hoskins, ‘Adams, John
Bodkin (1899–1983)’, rev. Michael Bevan, Oxford
Dictionary of Biography (Oxford: Oxford University
Press, 2004), <http://www.oxforddnb.com/view/
article/30748> (accessed 22 October 2012).
56
R v Adams and Terminal Care in Postwar Britain
165
retired to that fashionable part of the south coast. At least twenty years before his arrest for
murder—sometime in the 1930s—rumours had begun to spread that Dr Adams subjected
his patients to drugs and sedatives to induce them to alter their wills to include him as legatee
or to obtain powers of attorney and thus gain access to their finances. It was also rumoured
that in some cases, once his purpose had been effected, he had precipitated the death of the
person concerned or allowed them to die without proper medical treatment. According to
the police, solicitors in the town began to shun any business in which Dr Adams was concerned
and, when interviewed, some doctors indicated they regarded his activities as ‘odd’.59
An anonymous tip-off brought Dr Adams to the attention of Eastbourne police. Scotland
Yard was called in on 17 August 1956 and a complex and wide-ranging investigation into
Adams’ activities and the death of numerous patients began.60 In November Adams was
charged with a number of offences including the forging of National Health Service prescriptions and falsely stating on a number of cremation certificates that he had no pecuniary interest in the estates of those deceased. However, these charges were overshadowed when, on
19 December, Adams was arrested and charged with having murdered 81-year-old Edith
Morrell six years earlier.61
During the trial it was agreed that Morrell was a wealthy, autocratic widow who became
an irritable patient after suffering a stroke in 1948 that left her partially paralysed, although
not in significant physical pain. Dr Adams treated her with regular doses of opiates until her
death at home on 13 November 1950. Her body was cremated. The prosecution alleged this
course of drug administration was done in order to secure her dependency on him as he vigorously pursued some legacy under her will and culminated in Dr Adams prescribing and
administering such huge quantities of heroin and morphine that he must have known the
result would be to kill the elderly widow. According to the defence, the drug regime was
medically justified to relieve discomfort, treat insomnia, alleviate restlessness and irritability
and thus, ultimately, ‘ease her passing’.62
The prosecution’s case was weak. At trial there was one case that was six years old, no
body and no permission to use evidence that the police had gathered on the deaths of
other patients attended by Adams.63 Further, although there was convincing evidence
Adams had pursued a legacy under Mrs Morrell’s will, in fact he ultimately received only
an oak chest full of silver tableware. As the defence pointed out, this appeared a paltry
legacy for which to murder an elderly lady who, the physicians agreed, looked likely to die
in a matter of months, even weeks, with no intervention. Indeed, the prosecution failed
to substantiate its case that Adams had murdered Mrs Morrell for money, Adams was acquitted and it was decided to pursue no further murder charges against him.64
59
See Hannam to Chief Super., report, 16 October 1956,
1–2.
60
The police limited their investigation to the years
between 1946 and 1956. Nevertheless, this involved
312 separate investigations and the taking of over
900 witness statements. See Hannam to Chief Super.,
report, 19 August 1957, 1–2, MEPO 2/9784.
61
After his trial for murder, Adams pleaded guilty to
almost all of the more minor charges. For details, see
‘Dr J. B. Adams Fined on 14 Charges’, BMJ, 1957, 2,
303.
62
This summary of the case and arguments is drawn
from, R v. John (Bodkin) Adams, transcript of the shorthand notes of Geo. Walpole & Co., MEPO 2/9790/1–2
(henceforth Trial Transcript).
63
Cullen offers a detailed account of the circumstances
and witness statements related to many of these. See
Cullen, A Stranger in Blood.
64
At committal the prosecution had alleged two further
cases of murder. For a critical account of the prosecution’s handling of the case, see Devlin, Easing the
Passing.
166
Caitlin Mahar
As noted above, there are commentators who consider this to have been a miscarriage of
justice. However, my interest lies elsewhere. One of the complicating factors in a labyrinthine
trial was that the facts of the case and the evidence presented by medical witnesses raised
the question of whether a medical practitioner was ever entitled to adopt a course of treatment which would have the effect of hastening a patient’s death. In this context, the salient
question became not whether Dr Adams had murdered Mrs Morrell for money, but whether
a murder could be said to have been committed at all.
Murder or Medicine?
According to the police, worried that similar charges might follow those of forgery that
Adams was confronted with in November 1956, the doctor arranged a meeting with the
head of the Scotland Yard investigation, Detective Superintendent Hannam.65 There he
expressed his concerns to the detective who informed him that there were some other
charges in the offing: investigations were underway into what appeared to be the unnatural
deaths of some of his wealthy patients. The detective specified that one potential charge
related to the death of Mrs Morrell. According to Hannam, Adams appeared shocked
and responded: ‘Easing the passing of a dying person is not all that wicked. She wanted
to die. That cannot be murder. It is impossible to accuse a doctor.’ A fortnight later, when
Adams was arrested and charged with the murder at his residence, the arresting officers
found his response equally bizarre. Apparently confused and bewildered he reportedly
blurted, ‘Murder?’ paused and continued: Murder? Can you prove it was murder?’ And
then: ‘I did not think you could prove murder. She was dying in any event’.66
The prosecution made much of these statements in court, arguing that they sounded like
the responses of a ‘shaken man who had committed a murder which he thought could not
be proved’.67 The defence did not deny Adams had made the statements. However, counsel
argued that they did not constitute the confession of a guilty man, but the incredulous reaction of an innocent one ‘absolutely stunned by the monstrousness of the charge
brought against him in his professional capacity as a doctor’.68 But from an historical
vantage we might see the doctor’s bizarre statements slightly differently: less as evidence
of his guilt or innocence and more as evidence of a disjuncture between the medical and
legal understandings of the right and proper way to care for the dying. There was virtually
no dispute about the facts of the case. No one (from the above statements we might conclude least of all Adams) denied that, on the doctor’s orders large doses of heroin, morphine
and paraldehyde had been administered to the ailing, 81-year-old widow during the long
illness that preceded her death—or, indeed, that in the last days, Adams prescribed doses
large enough to kill her.69 But did this, as the police and lawyers were trained to understand
it, point to murder? Or, might it be medicine?
This question became increasingly salient during the trial as it became clear that Adams
was not the only doctor who may have knowingly given a terminal patient drugs that
would hasten death. Medical experts for both the defence and the prosecution indicated
65
Evidence of Detective Super. Hannam, Trial Transcript,
26 March 1957, 1–2.
66
Ibid., 2.
67
Trial Transcript, 8 April 1957, 17.
68
Trial Transcript, 5 April 1957, 39.
69
Playing the memory of the nurses against notebooks
discovered at the last minute, the defence managed
to raise some doubt as to whether all the drugs prescribed had been administered.
R v Adams and Terminal Care in Postwar Britain
167
they believed that in some instances medical practitioners were entitled to administer drugs
that would curtail life. As Devlin noted some time later, this is what Dr Adams’ statements
and defence allusions to easing the passing implied, although, during the trial, Adams’
defence counsel and the medical witness for the defence, no doubt with a keen eye on
the letter of the law, appeared vague on this point.70 The defence simply maintained that
the manner in which Dr Adams ‘eased the passing’ was legitimate medical treatment.71
Neither the defence counsel nor his medical witness, Dr Harman, ever expanded on precisely
what this might involve. But they did not need to. The disjuncture between the medical and
legal perspectives on ‘easing the passing’ became startlingly obvious during the crossexamination of the chief medical witness for the prosecution, Dr Arthur Henry Douthwaite,
a Harley Street specialist, senior physician at Guy’s Hospital and recognised authority on
heroin and morphine.
Douthwaite explained that in his view the type and quantity of drugs given to Mrs Morrell
in the last few days of her life indicated that Adams’ intention was to terminate her life. But,
pressed under cross-examination, it appeared that while he believed this to be medically unjustifiable in the case of Mrs Morrell, who did not appear to have been in significant pain, in
the case of a patient suffering severe physical pain, say in the case of inoperable cancer, it
would be justifiable for a doctor to administer doses of pain-relieving drugs that he knew
would cause death.72 At one point, when pressed for clarification, Douthwaite visibly
startled the bench and counsel by confirming that such doses were indeed ‘intended to
kill’.73 He elaborated: ‘I deliberately said my conclusions were that they [those amounts of
drugs given by doctors] were given to terminate life. I said that deliberately because I
don’t know, it is not my business to know, whether that is synonymous with murder’.74
Defence counsel immediately confirmed the law for the doctor: ‘Murder, Dr Douthwaite,
is killing with intention of killing or terminating life.’ Or was it? Devlin intervened: ‘I think Mr
Lawrence, I am very anxious there should not be introduced into this questions that may be
partly questions of law. I don’t know, it may be a matter of medical practice that if a doctor
gives drugs knowing that they will shorten life but gives them because they are necessary to
relieve pain, he is not committing murder’.75
The trial moved on, but the judge returned to this point six days later during his summation. Here Devlin clarified what he saw as the relationship between the law and lifeshortening terminal care in the following way. First, he pointed out that it did not matter
whether Mrs Morrell’s death was inevitable and her days numbered. If her life was shortened
by weeks or months it was just as much murder as if it was cut short by years. Nor did it matter
whether she was in pain, for the law knows no special defence of preventing severe pain.
However, then he added:
70
Delvin, Easing the Passing, 124.
See, for example, Trial Transcript, 5 April 1957, 39; Trial
Transcript, 8 April, 22–3.
72
Trial Transcript, 1 April 1957, 3–8.
73
Ibid., 5. The observation regarding bench and counsel
is drawn from Bedford, who noted that at this point of
the examination, ‘Bench and counsel look at each
other’. Bedford, The Best We Can Do, 134.
74
Trial Transcript, 1 April 1957, 5. It became clear that the
other medical expert for the prosecution, Dr Ashby,
71
similarly believed that the deliberate medical acceleration of death did not necessarily constitute murder:
While he observed ‘I am certain beyond a shred of
doubt she could not have survived the doses prescribed’, under cross-examination he conceded: ‘I am
not prepared to say whether they [Dr Adams’] were
instructions of a murderous nature’. Trial Transcript,
2 April 1957, 13, 24.
75
Trial Transcript, 1 April 1957, 5.
168
Caitlin Mahar
But this does not mean that a doctor who is aiding the sick and the dying has to calculate
in minutes, or even hours, and perhaps not in days or weeks, the effect upon a patient’s
life of the medicines which he administers or else be in peril of a charge of murder. If the
first purpose of medicine, the restoration of health, can no longer be achieved there is
still much for a doctor to do, and he is entitled to do all that is proper and necessary to
relieve pain and suffering, even if the measures he takes may incidentally shorten life.76
It is easy to imagine the jury were sorely in need of such clarification at this stage of the trial,
for, as Devlin pointed out, even the most basic facts of the Adams case appeared beyond the
grasp of laypeople. It was ‘a most curious situation, perhaps unique in these courts’, the
Judge mused during his summation, ‘that the act of murder has to be proved by expert evidence’.77 He went on to reflect that this was normally something any jury could understand,
but in this case the court—judge and laymen—could not interpret the facts—or ‘data’—
themselves, but were forced to rely on the complex, sometimes conflicting, interpretations
of the medical witnesses. These began with recitals of detailed figures—of the number of
grains of heroin, morphine and various other drugs prescribed for Mrs Morrell and given
to her on particular days, at particular times, in particular combinations. It continued with
debate on the probable effects these drugs would have had on this particular patient
given her age, condition and estimates of the tolerance she had developed, complicated
by broader discussion of how much of a particular drug could and should be given to
whom, when and to what likely effect. It culminated in the confounding (at least for the
lawyers present) revelation that within medical circles it might be considered justifiable to
give those believed to be dying and in pain doses of drugs that shortened their life. But
even here there was complexity. What type of pain justified this course of action? What
level of pain? Was it, as the prosecution medical experts argued, only justifiable in cases
of severe physical suffering, or, as the defence implied, also in cases of discomfort and
mental distress? Or was the definition of pain so subjective, that, as counsel for the
defence contended, it had to be left to the doctor ‘on the spot’ to assess whether the sort
of pain being felt by the patient justified such treatment?78
As a reporter for Time magazine observed, ‘The more the experts talked, the less the
laymen of the jury could be sure of anything’.79 It might have been hoped that the evidence
of medical experts would help illuminate the distinction between a crime scene and a deathbed scene. But the more the medical witnesses spoke, the more inscrutable such distinctions
became. The mysterious nature of the hours of technical testimony was, as the same reporter
noted, compounded by the defence counsel’s skilled cross-examination, which managed—
as was presumably its object—to shroud any sparks of certainty in ‘clouds of doubt’.80 Above
all, the medical evidence suggested that the activities of the doctor at the deathbed were
ultimately beyond the understanding of laypeople or the law. Devlin’s directions to the
jury seemed to confirm this. He explained that there were no questions of ‘legal justification’
or ‘moral justification’ for them to consider in this case for, as he understood it, the word
‘justified’, that they had heard so often during the course of the trial, was ‘used in a
76
Trial Transcript, 8 April 1957, 21.
Ibid., 72.
78
Trial Transcript, 1 April 1957, 8.
79
‘Not Guilty’, 33.
77
80
Ibid. Geoffrey Lawrence’s cross-examinations in R v
Adams were notably adept. See Henry Palmer, ‘Lessons
of Cross-Examination’, Criminal Law Review, 1957, 1,
773–86.
R v Adams and Terminal Care in Postwar Britain
169
purely medical sense’.81 This was a medical issue, not a legal or a moral one. ‘If the treatment
given by Dr Adams was treatment designed to “promote comfort”, he summarised, ‘if it be
right and proper treatment in the case, the fact—if it be the fact—that it incidentally shortened life does not give any grounds for convicting him of murder’.82
After the Trial
Devlin’s directions to the jury quietly registered what one journalist attending the trial obliquely referred to as ‘one of the undercurrents of the case’.83 The trial and Devlin’s summation were reported in detail and its novelty swiftly noted in legal circles, but the idea that it
was considered legitimate for a doctor to adopt a course of treatment that would hasten a
patient’s death when it was deemed they were in the last stages of life provoked no medical
or legal objections and little public comment, let alone controversy.84
The most sustained medical response to the case did not seem to register the significance
of Devlin’s directions to the jury. The writer of an editorial in the Medical Press was most concerned that the trial had thrown an unwelcome and intrusive spotlight on the sequestered
world of end-of-life medical care. For him the Adams case drew attention to the way officious laymen threatened to circumscribe the discretion of doctors at the bedside and thus
hamper what a physician deemed the best treatment for a dying patient in his care:
Any doctor with normal humanitarian impulses has always felt honour bound to reduce
his patient’s sufferings to the minimum and, in cases where the prognosis was hopeless, has seldom stopped to count the cost as measured in the day-to-day duration of
his patient’s life. Many and many a patient has been ‘“kept under’ at all costs to save
him agony. This will, we imagine, scarcely be the case now, for every one of us will
be looking over his shoulder for the smiler with the knife—somebody making notes
to use against them later.85
But no knives were drawn. The Lancet did note a brief exchange in the Lords that suggested
the trial may have left some others less sanguine about the wide licence physicians appeared
to have when it came to prescribing and administering narcotics to the dying. The Earl of
Craven asked the government if, in the light of the Adams case, it considered it time for a
review of the ‘laws relating to the use of drugs for medical purposes’. But any suggestion
that the case had uncovered medical practices that might require oversight or regulation
was quickly dismissed. Lord Strathclyde replied that the government did not consider it appropriate to further ‘circumscribe the clinical freedom of doctors to treat their patients in accordance with their individual judgement’.86
And there the matter appeared to rest. Popular comment and debate focused not on what
the trial had revealed generally of medical practice at the deathbed, but on whether or not
Adams had got away with murder—a strand of thought evident in the trickle of libellous
comment that preceded the doctor’s death in 1983 as well as the flood of speculation
81
Trial Transcript, 8 April 1957, 24.
Ibid., 23.
83
Bedford, The Best We Can Do, 134.
84
In addition to detailed daily coverage of trial proceedings in The Times, the BMJ published regular reports on
the trial and The Lancet reported aspects of Devlin’s
82
summation. See ‘Acquittal of Dr J. Bodkin Adams:
Judge’s Summing-Up’, BMJ, 1957, 1, 954–55;
‘Shortening-Life’, The Lancet, 1957, 1, 841; For early
legal analysis, see Williams, The Sanctity of Life, 289–90.
85
‘Editorial’, Medical Press, 1957, 237, 363–4.
86
‘Question Time’, The Lancet, 1957, 269, 991.
170
Caitlin Mahar
that followed it.87 The account offered at trial and in the press of Dr Adams’s activities provoked suspicion and criticism, but the same cannot be said of the revelation of the licence
physicians had to administer life-shortening doses of opiates to the dying.
Conclusions
This paper has argued that Devlin’s direction to the jury in R v Adams, and what one legal
scholar has described as the quite ‘remarkable exception to existing criminal law principles’
it represents, is best explained in the context of a history of dying.88 The court’s deference to
expert medical opinion that viewed hastening death with narcotics as justifiable medical
treatment registered the enormous power and authority invested in physicians as experts
in terminal care by the mid-twentieth century. The trial also offers rare insight into evolving
medical attitudes and practices regarding pain-relief for the dying that, even within medical
circles, were rarely the subject of open comment or discussion.
This history of the Adams case has thus sought to broaden discussion of the medicalisation
of dying in twentieth-century Britain. The intensification of this process has often been associated with the steady rise in the proportion of hospital deaths from the 1930s. However, the
Adams case suggests that the medicalisation of dying and its sequestration from laypeople is
not just a result of its physical institutionalisation. It is also a product of the way care of the
dying became the subject of specialist treatment, exemplified by the use of powerful narcotics to treat the pain associated with dying. These were drugs that could only be prescribed by
a physician and demanded increasingly sophisticated pharmacological knowledge and skill
to administer. This was a mode of care that appeared not just beyond the abilities of most
laypeople, but beyond their comprehension.
The development of what has come to be known as palliative care is sometimes seen as a
reaction against the medicalisation of death and a profession that was so intent on developing cures and treatments it had begun to neglect the dying and their pain.89 But this discussion of postwar ‘easing the passing’ has sought to draw attention to a co-existent medical
discourse that prioritised the relief of pain, rather than the preservation of life, underscoring
the continuity between the way physicians managed dying in the nineteenth century
and the practices of doctors in the early twentieth century. This reinforces Clark’s point
that the emergence of modern terminal care in Britain cannot be seen as an ‘anti-medical’
phenomenon. The rise of palliative care and its concern to eliminate the pain and suffering
associated with dying suggests, rather, an extension of medical dominion.90
This is not to imply that the professionialisation of care of the dying should be understood
as a form of conspiratorial medical strategising. It is important to stress, as medical historians
often observe, that the cultural norms and values of a society always underpin the nature of
medical interventions and attitudes and shape the extent to which they are accepted as
beneficial and desirable.91 In this sense the Adams case is part of broader historical contexts
no more than gestured to here. The legal and lay deference to medical practice evident in this
87
During his lifetime Adams accrued substantial libel
damages. See Hoskins, ‘Adams, John Bodkin’.
88
Otlowski, Voluntary Euthanasia and the Common
Law, 176.
89
See, for instance, Lewis, Medicine and Care of the
Dying, 120.
Clark, ‘Cradled to the Grave?’, 242. More broadly, see
Lavi, Modern Art of Dying, esp. ch. 5.
91
For instance: Porter, The Greatest Benefit to Mankind,
691–3; Charles E. Rosenberg, ‘Meanings, Policies and
Medicine: On the Bioethical Enterprise and History’,
Daedalus, 1999, 128, 27–46.
90
R v Adams and Terminal Care in Postwar Britain
171
case suggests that by the 1950s there was not only widespread acceptance that ‘doctor
knew best’ when it came to care of the dying, but a deeply entrenched belief that to die
well one should be free of pain.
Acknowledgements
I am very grateful to Helen MacDonald for her invaluable commentary on drafts of this article
and the anonymous reviewers for their comments and criticisms. I would also like to thank
audiences at the Menzies Centre for Australian Studies, King’s College and the ‘Death Down
Under Conference’ at the University of Sydney for their valuable feedback on different parts
of this paper.