Doctor's dilemma of pain or death: Dr Nigel Cox will be sentenced today for the attempted murder of one of his patients, 70-year-old Lillian Boyes. Kathy Marks looks back at his trial

THERE can have been few people in Winchester Crown Court during the past 10 days who did not feel sympathy for Nigel Cox or question whether his case should ever have come to trial.

This was no ordinary criminal trial. The defendant was a caring and dedicated hospital consultant of distinguished reputation. The crime was attempted murder of an elderly patient who was suffering intolerably and wanted to die.

It must have been a difficult case to prosecute. Rarely can so many tributes to a defendant's character, or such understanding of the actions which brought him to court, have been heard from a prosecution barrister.

The facts were never in dispute. Dr Cox administered a lethal dose of potassium chloride - normally given only to boost potassium deficiency - to a woman who five days earlier had signed her own death warrant by deciding to refuse all therapeutic treatment.

Lillian Boyes died within minutes and Dr Cox recorded the injection in her medical notes. Among the staff who saw the entry was the rheumatology ward sister, who informed the hospital authorities.

The situation which confronted Dr Cox on 16 August last year could hardly have been more harrowing.

Mrs Boyes, his patient of 13 years, was terminally ill with what two leading rheumatologists described as the worst case of rheumatoid arthritis they had encountered. In the 18 years before her death, she had been admitted to hospital 20 times.

Mrs Boyes, whose husband died in 1974, was also suffering from internal bleeding, septicaemia and vasculitis, a condition which caused deep body abcesses and gangrenous organs.

Her pain was agonising. Any movement caused intense discomfort and she screamed at the slightest touch. She was severely emaciated; the hospital chaplain, the Rev Richard Clarke, described her arm as no thicker than two of his fingers.

There was an unusually strong bond of affection and respect between doctor and patient. She could not praise him highly enough, while Dr Cox greatly admired the courage of a woman who had displayed a remarkable cheerfulness and resilience until a few weeks before she died.

In the last few days of Mrs Boyes's life, events took a particularly cruel turn. As her pain intensified, she was given massive doses of diamorphine, or heroin, the strongest analgesic in the medical armoury. But, highly unusually, the heroin had little effect.

Mrs Boyes had a few hours, at most, to live. She had told Dr Cox that she wanted to die and her two sons, Patrick and John, a constant presence at her bedside, supported her decision. Dr Cox, who had refused to help her to die but had promised her that she would not suffer, was deeply distressed.

Both the prosecution and the defence strenuously denied that the case was about voluntary euthanasia. It was, they said, about one doctor and one patient who found themselves in a highly unusual situation.

Sydney Kentridge QC, the leading defence counsel, said Dr Cox's actions had been unorthodox and controversial, but his main intention had been to relieve Mrs Boyes's suffering.

Outside the courtroom, however, there is little doubt that the trial was viewed as a test case by many in the euthanasia debate.

There was much discussion during the proceedings of the ethics of medical intervention to shorten the life of terminally ill patients. Neil Butterfield QC, the leading Crown counsel, said that while it was a doctor's duty to minimise suffering, it was unacceptable both to the law and the medical profession to kill a patient to end that suffering.

The dilemma facing doctors in Dr Cox's position was graphically highlighted when two defence witnesses, both leading rheumatologists, were asked what options were open to him when the heroin failed.

Professor David Blake appeared to find the question highly distressing and finally replied that he could not answer it. Dr Alan Dixon said he hoped he would have had the courage to do the same as Dr Cox.

Dr Dixon said that the current legal position placed doctors in a curious predicament: they were permitted to adminster drugs to ease suffering even if death was thereby hastened - this was the case with the diamorphine in the doses which Mrs Boyes was receiving - but not to hasten death in order to ease suffering. It was, he said, 'a razor's edge'.

Two statements were made in court which perhaps summed up the polarities of the debate. Asked about drugs which could alleviate pain but might hasten death, Professor Blake replied: 'There are worse things than death.'

Discussing Dr Cox's dilemma, Mr Butterfield said that there were limits to the skills of the medical profession and added: 'Medicine does fail sometimes, with tragic results to those involved.'

Leading article, page 18

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