Euthanasia.

Euthanasia

In this lecture… General overview A right to die?
Arguments for voluntary euthanasia Arguments against voluntary euthanasia The slippery-slope argument Non-voluntary and involuntary euthanasia Active vs. Passive euthanasia Physician-assisted suicide End-of-life care

General overview In earlier periods of human history, physicians could do little to stave off death. Today, improvements in public sanitation, the development of immunization, antibiotics, and other breakthroughs in modern medicine have combined to lengthen the human lifespan, particularly in the developed world.

General overview In the developed world, with its sophisticated healthcare systems, the majority of the population dies at comparatively advanced ages of degenerative diseases – cancer, stroke, heart disease, etc. – with characteristically long downhill courses, marked by a terminal phase of dying.

General overview The developments in medical technology and treatments, which prolong and sustain life, mean that more patients stay alive for longer. However, the extension of life is often associated with severe pain as well as intense and burdensome treatments for terminally ill patients.

General overview At the same time, there has been progress in the legal acknowledgement of patients’ rights. In many developed nations, patients have the right to refuse unwanted treatment or to discontinue it once it has been started.

General overview Euthanasia is the termination of a patient’s life in order to relieve him or her of suffering. The following are some related terms and definitions: Voluntary euthanasia – death is brought about or hastened at the patient’s request.

General overview Non-voluntary euthanasia – euthanasia conducted where the explicit consent of the individual concerned is unavailable. Involuntary euthanasia – euthanasia performed on a person who is able to provide informed consent, but does not, either because he or she does not choose to die, or because he or she was not asked.

General overview Active euthanasia – hastening death by the use of drugs or other means, with a doctor’s direct assistance. Passive euthanasia – hastening death by withholding or withdrawing life-sustaining treatment. Physician-assisted suicide – the practice of a doctor providing the means for a patient to end his or her own life.

General overview Can life become so burdensome, so filled with pain and suffering, that it loses all meaning and value? Should life be preserved at the cost of continuous suffering when modern medicine makes this possible?

General overview An accident or illness may bring people to an extreme of pain, disability, distress or dependency, so that continued living becomes intolerable. If there is no reasonable prospect of substantial improvement, perhaps hastening the end of life is the only way to relieve suffering.

General overview While most people think that unbearable pain is the main reason people seek euthanasia, surveys in the USA and the Netherlands showed that less than a third of requests for euthanasia were because of severe pain.

General overview Terminally ill patients can have their quality of life severely damaged by physical conditions such as incontinence, nausea and vomiting, breathlessness, paralysis and difficulty in swallowing.

General overview Psychological factors that cause people to seek assistance in dying include depression, fearing loss of control or dignity, feeling a burden, or dislike of being dependent.

A right to die? Most countries that put a value on individual liberty allow competent adults to refuse medical treatment even if such treatment is life-saving. Besides, people have the right to die in the sense that they can choose to commit suicide – attempted suicide has been decriminalized nearly everywhere in the world.

A right to die? Supporters of the right to die argue that each person has the right to control his or her life and so should be able to determine at what time, in what way and by whose hand he or she will die. In other words, the notion of ‘autonomy’ entails the right or freedom to make end-of-life decisions for oneself.

A right to die? Some people, however, invoke the right to life (or the ‘sanctity of life’ principle) to justify banning suicide and euthanasia. According to this view, if we have the right to life, we owe ourselves the duty to keep ourselves alive under any circumstances.

A right to die? Kantians, in particular, believe that persons must be treated as ends in themselves and never merely as means. Suicide, in Kant’s view, uses oneself merely as a means (by giving up one’s own life) to avoid pain and suffering. For Kant, treating oneself as a mere means debases one’s humanity.

A right to die? Do you think that the terminally ill should have the right to die? Do you think that individuals who have no hope of recovery should have the right to decide how and when to end their lives?

A right to die? It can be argued that the right to die is an integral part of our right to control our own lives. However, euthanasia is not a completely autonomous act or personal decision in that it requires the assistance of another person.

A right to die? We may have a right to do whatever we like, including ending our own lives, as long as our action does not harm others. However, even if we have a right to die, it does not mean that doctors have a duty to kill us (or help us commit suicide) – no doctors should be forced to help patients who want euthanasia.

A right to die? Apart from that, end-of-life decisions will affect other people such as one’s family and friends, and therefore a balance may have to be struck between exercising one’s freedom and the consequences of one’s decision for others.

A right to die? There is also the justifiable fear that some elderly patients might be pressured by family members or health care providers, or by the example of other terminally ill patients, to choose euthanasia.

A right to die? For the elderly, the sick and the disabled, the right to die may become a ‘duty to die’. These people may think of themselves as an unwelcome burden on others. If euthanasia has become a widely accepted option, they may feel under pressure to ask for it.

Arguments for voluntary euthanasia
There are two main arguments for voluntary euthanasia: respect for patient autonomy the argument from compassion

‘Autonomy’ or ‘self-determination’ refers to people’s right to making important decisions about their lives for themselves according to their own values or conceptions of a good life, and the right to be left free to act on those decisions.

In exercising autonomy or self-determination, people take responsibility for their lives. Since dying is a part of life, choices about the manner of their dying and the timing of their deaths are, for many people, part of what is involved in taking responsibility for their lives.

Proponents of euthanasia argue that as long as a patient is free and autonomous, he or she should have a right to self-determination in end-of-life decisions. They believe that individuals should have the right to control the circumstances of their own deaths and to determine how much suffering is too much.

Patient autonomy includes the right to full information concerning the nature and development of the terminal illness. Any decision about how to die must be made on the basis of ‘informed consent’.

Generally speaking, informed consent exists when patients can understand what they are agreeing to and voluntarily choose it. Patients should be informed of their diagnosis, their prognosis, their options in responding to their condition and all other relevant information.

Counterargument [1]: For a decision about death to be voluntary, the individual must give explicit consent. Patients in an indefinite coma or persistent vegetative state are not candidates for euthanasia.

Counterargument [2]: Euthanasia cannot be justifiably administered in cases of serious dementia or clinical depression. Clearly, if a patient is depressed or suffering from a mental disturbance, therapy and counseling – not euthanasia – should be recommended.

Counterargument [3]: We can never be absolutely sure that we have voluntary and informed consent. The pain and drugs may prevent patients from making a fully rational decision.

Another argument for euthanasia is based upon compassion, mercy and beneficence. In cases of intractable suffering and inevitable death, a spirit of mercy and compassion is supposed to be the correct response to a patient’s desire to die.

On this view, life is devoid of quality and meaning to patients subject to severe and unremitting physical or mental suffering. These patients should have the option of a quick and painless relief.

Doctors, as the argument goes, have a duty to do everything within their power to relieve that suffering, even to the point of hastening death if there are no realistic alternatives acceptable to the patients.

Counterargument: Suffering is almost always relievable without killing the patient. Thanks to techniques of pain management and better palliative care, it is possible to treat virtually all pain and to relieve all suffering.

Arguments against voluntary euthanasia
There are 3 main arguments against voluntary euthanasia: the argument from the intrinsic wrongness of killing the argument from the integrity of the medical profession the argument from potential abuse (i.e. the slippery-slope argument)

One objection to euthanasia invokes the ‘sanctity of life’ principle which claims that all killing is morally wrong. Human life is sacred and intrinsically valuable because it is a gift from God. Deliberately shortening life is against God’s will. Only God should determine the time of death.

The deliberate taking of human life should be prohibited except in self-defense or the legitimate defense of others. ‘Thou shalt not kill’ and ‘Man should not play God’ are typical objections to euthanasia based on religious faith.

Counterargument [1]: In a free, democratic society, the government should respect the right of its citizens to choose their own religious values and therefore should not use the law to enforce the religious views held by some people on others who do not share those views.

Counterargument [2]: For those who believe that all matters of life and death must be decided by God, to use medicine to keep a sick person from dying is playing God. If playing God simply means doing what will affect the chances of life and death, then a lot of responsible social action does exactly that (e.g. giving aid to starving children).

Counterargument [3]: The trouble with the sanctity of life principle is that it implies that every human being should be kept alive as long as possible, and that is a proposition few thoughtful people would accept. Most would agree, for example, that it is pointless to keep alive patients in an irreversible coma or a persistent vegetative state.

Another objection to euthanasia is that there is always the possibility of an incorrect diagnosis or spontaneous remission. Besides, allowing euthanasia may undermine the commitment of doctors and nurses to saving lives and discourage the search for new cures and treatments.

There is also the worry that allowing doctors to abandon their duty to preserve human life could damage the doctor-patient relationship. Patients could become distrustful of their doctors’ efforts and intentions, thinking that their doctors would rather ‘kill them off’ than take care of them.

Counterargument: If euthanasia is restricted to cases in which it is truly voluntary, then no patient should fear getting it unless he or she has voluntarily requested it. Patients’ trust of their physicians could be increased, not eroded, by knowledge that physicians will provide aid in dying only when they ask for it.

The slippery-slope argument
One of the main arguments against legalizing euthanasia is the ‘slippery slope’ argument. Critics of euthanasia claim that legalizing voluntary euthanasia will lead to a slippery slope effect, resulting eventually in non-voluntary or even involuntary euthanasia.

They argue that if we permit voluntary euthanasia, then we will be authorizing doctors and nurses to sometimes kill their patients. Once medical professionals are making decisions about whose life is worth living and whose life is not, then over time our commitment to protecting innocent life will inevitably weaken.

On this view, permitting voluntary euthanasia would weaken society’s prohibition against intentional killing, and thereby undermine the safeguards against ending patients’ lives against their will. In order to prevent this from occurring, we need to resist taking the first step.

Slippery slope arguments have been used by conservatives and traditionalists to oppose all sorts of social change. But is there sufficient evidence for the slippery-slope argument against euthanasia?

Some people think that euthanasia should not be allowed because it could be abused and used as a cover for murdering innocent people. For example, the horrors that characterized the Nazi regime’s attempt to weed out the unfit had given ‘euthanasia’ a bad name.

The Nazi practice of ‘euthanasia’ – the killing about 100,000 disabled people on the grounds that they had ‘lives not worth living’ – has been regarded by some as an example of how the removal of restrictions against killing could result in mass murder.

Counterargument [1]: In Nazi Germany, doctors took the lives of tens of thousands of their fellow citizens on orders from the government. Those unfortunate people were neither terminally ill nor in pain. The murder of those people was thinly disguised as ‘euthanasia’.

Counterargument [2]: The Nazi program of ‘euthanasia’ was neither voluntary nor based on compassion; it was, rather, motivated by the desire to preserve the purity of the German race, and hence was essentially the result of a vicious and racist ideology.

For a relevant contemporary example of legalized euthanasia, many scholars focus their attention on the Netherlands, where the practice of voluntary euthanasia was legalized in 2002.

The most recent studies in the Netherlands found no evidence that legalized euthanasia has had any serious bad social consequences. Researchers conclude that, generally speaking, [1] abuse of the Dutch euthanasia system is rare, and [2] no slippery slope effect has occurred.

Suppose there is evidence that some patients may be at risk of being abused (i.e. have their lives shortened against their will), how should this weigh against the freedom of other patients to make specific end-of-life choices?

Just because a practice can be abused does not entail that it should not be allowed. Knives, cars, and drugs can be abused, but that does not mean they should be outlawed altogether. The abuses envisioned in slippery-slope arguments can be prevented by strict legal guidelines, such as those currently in use in the Netherlands.

The legal guidelines for euthanasia in the Netherlands include, among other things, the following: The patient must face a future of unbearable, interminable suffering. The request to die must be voluntary and well-considered.

The doctor and patient must be convinced that there is no better alternative available. A second medical opinion must be obtained and life must be terminated in a medically appropriate way.

Non-voluntary and involuntary euthanasia
Non-voluntary euthanasia refers to cases in which the decision is not made by the person who is to die. Such cases would include situations where, because of age, mental impairment, or unconsciousness, patients are not able to give informed consent to life-or-death decisions and where others make that decision for them.

In those cases where the patients are unable to communicate their wishes, the medical staff and the patients’ families are faced with a dilemma. For example, this may happen when a patient has entered a persistent vegetative state without having expressed their intentions concerning end-of-life choices.

The family may seek to exercise ‘substituted judgment’ and make a decision for the patient according to what the patient would probably choose or what is in the best interest of the patient. Some hospitals have established ‘ethics committees’ to provide guidance on such matters.

Involuntary euthanasia occurs when patients are killed against their will or without their consent. This kind of euthanasia is almost always considered wrong and is rarely debated.

Most people tend to equate involuntary euthanasia with murder, but is it possible to conceive of cases where the killing would count as being for the benefit of the person who dies?

Active vs. passive euthanasia
In active euthanasia, death is brought about by a physician’s act, for example, when a person is killed by a lethal injection. In passive euthanasia, death is the result of withholding or withdrawal of treatment.

In active euthanasia, the proximate cause of death is the physician’s act. But in passive euthanasia, the proximate cause of death is the patient’s disease or injury, not the physician’s act. Some regard the difference as one between killing as an ‘action’, and letting die as an ‘omission’.

The distinction between active and passive euthanasia is an important one because some people who reject active euthanasia do accept passive euthanasia as a practice that provides benefits to the dying person without violating ethical standards or religious values.

Opponents to active euthanasia may think that the practice is wrong because they believe that taking a person’s life is morally impermissible under all circumstances. On the other hand, it is generally believed that no one has to take direct responsibility for a person’s death in the case of passive euthanasia.

In contrast to the conventional view, James Rachels argues that there is no morally significant difference between active and passive euthanasia.

Rachels uses the example of Smith and Jones to prove this point. Smith stands to gain a large inheritance if anything should happen to his 6-year-old cousin. One evening while the child is taking his bath, Smith sneaks into the bathroom and drowns the child, and then arranges things so that it will look like an accident.

Jones also stands to gain if anything should happen to his 6-year-old cousin. Like Smith, Jones sneaks in planning to drown the child in his bath. But as he enters the bathroom Jones sees the child slip, hit his head, and fall face-down in the water. Jones watches all this happen without doing anything, and the child drowns all by himself accidentally.

Is Jones’ behavior, Rachels asks, any less reprehensible than Smith’s? If the answer is ‘no’, must we conclude, along with Rachels, that the difference between killing and letting die does not really make a moral difference?

Rachels: “If one simply withholds treatment, it may take the patient longer to die, and so he may suffer more than he would if more direct action were taken and a lethal injection given.”

“…once the initial decision not to prolong his agony has been made, active euthanasia is actually preferable to passive euthanasia, rather than the reverse… the process of being ‘allow to die’ can be relatively slow and painful, whereas being given a lethal injection is relatively quick and painless.”

If death is the inevitable outcome, there is no morally relevant difference between not providing the treatment and taking active steps to end life. Taking active steps to end a patient’s life in a quick and painless manner may be the morally right thing to do because unnecessary suffering can be avoided.

In Rachels’ view, the reason why killing is normally a great wrong is that dying is normally a great harm. But if it is in the best interest of a patient to die now rather than suffer a prolonged and painful dying process, then killing is no longer a wrong.

Physician-assisted suicide
Assisted suicide usually refers to cases where people who want to die need help to kill themselves and ask for it. In physician-assisted suicide, the physician does not directly cause the patient’s death but enables the patient to choose the time and circumstances of his or her own death, usually by prescribing a lethal dose of drugs.

The main difference between physician-assisted suicide and euthanasia lies in who performs the last causal act leading to death. In the case of physician-assisted suicide it is the patient; in the case of euthanasia it is the physician.

Some argue that physician-assisted suicide is preferable to euthanasia because in physician-assisted suicide, the doctor simply provides the means but it is the patients themselves who decide whether to use it to commit suicide. As such, patients can have a higher degree of autonomy in making end-of-life decisions for themselves.

Those who oppose suicide on moral grounds would also oppose physician-assisted suicide. But even those who think that suicide is morally acceptable (under some circumstances) may feel that doctors should not help others commit suicide – doctors, in their view, should be healers, not killers.

Other arguments against physician-assisted suicide may include considerations such as the possibility of discovery of cures, the dangers of mistaken diagnosis, the difficulties of knowing whether the patient asking for it is rational, the potential for abuse, the dangers of patients being coerced by others to choose it, and so on.

Does patient autonomy entails the right to request assistance to end one’s own life? Do you think that doctors have a duty to help patients commit suicide?

End-of-life care We are getting better at providing effective palliative care, and hospice care is more widely available today. Because of advances in palliative care and mental health treatment, there may be no reason that any person should ever feel they are suffering intolerably, whether it is physical or mental suffering or both.

End-of-life care Palliative care is physical, emotional and spiritual care for a dying person when cure is not possible. It provides relief from pain and suffering and thereby offers an alternative to euthanasia. Good palliative or hospice care has the goal of helping the patient to live each day as well as possible.

End-of-life care Advocates of palliative and hospice care emphasize the importance of reducing pain and suffering. Palliative management of suffering is believed to substantially decrease the number of requests for both euthanasia and physician-assisted suicide.

End-of-life care It is generally agreed that palliative and hospice care – including excellent pain and symptom management, as well as psychosocial support for patients and families – should be part of the standard of care for all terminally ill patients.

End-of-life care Given the effectiveness of palliative care in reducing pain and suffering, do you think that improved provision of end-of-life care should be seen as a much better alternative to the legalization of euthanasia and physician-assisted suicide?

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