The euthanasia argument – in detail
Euthanasia is the act of deliberately ending a person’s life to relieve suffering.
For example, a doctor who gives a patient with terminal cancer an overdose of muscle relaxants to end their life would be considered to have carried out euthanasia. Assisted suicide is the act of deliberately assisting or encouraging another person to kill themselves. If a relative of a person with a terminal illness were to obtain powerful sedatives, knowing that the person intended to take an overdose of sedatives to kill themselves, they may be considered to be assisting suicide. The euthanasia argument is over wether this should be classed as murder or not.
Both active euthanasia and assisted suicide are illegal under English law. Depending on the circumstances, euthanasia is regarded as either manslaughter or murder and is punishable by law, with a maximum penalty of up to life imprisonment. Assisted suicide is illegal under the terms of the Suicide Act (1961) and is punishable by up to 14 years’ imprisonment. Attempting to kill yourself is not a criminal act in itself.
Types of euthanasia
Euthanasia can be classified in different ways, including:
- active euthanasia – where a person deliberately intervenes to end someone’s life – for example, by injecting them with a large dose of sedatives
- passive euthanasia – where a person causes death by withholding or withdrawing treatment that is necessary to maintain life, such as withholding antibiotics from someone with pneumonia
Euthanasia can also be classified as:
- voluntary euthanasia – where a person makes a conscious decision to die and asks for help to do this
- non-voluntary euthanasia – where a person is unable to give their consent (for example, because they are in a coma or are severely brain damaged) and another person takes the decision on their behalf, often because the ill person previously expressed a wish for their life to be ended in such circumstances
- involuntary euthanasia – where a person is killed against their expressed wishes
Depending on the circumstances, voluntary and non-voluntary euthanasia could be regarded as either voluntary manslaughter (where someone kills another person, but circumstances can partly justify their actions) or murder. Involuntary euthanasia is almost always regarded as murder. There are arguments used by both supporters and opponents of euthanasia and assisted suicide.
End of life care
If you are approaching the end of life, you have a right to good palliative care – to control pain and other symptoms – as well as psychological, social and spiritual support. You’re also entitled to have a say in the treatments you receive at this stage. For example, under English law, all adults have the right to refuse medical treatment, as long as they have sufficient capacity (the ability to use and understand information to make a decision). If you know that your capacity to consent may be affected in the future, you can arrange a legally binding advance decision (previously known as an advance directive). An advance decision sets out the procedures and treatments that you consent to and those that you do not consent to. This means that the healthcare professionals treating you cannot perform certain procedures or treatments against your wishes.
Active euthanasia is currently only legal in Belgium, Holland and Luxembourg. Under the laws in these countries, a person’s life can be deliberately ended by their doctor or other healthcare professional. The person is usually given an overdose of muscle relaxants or sedatives. This causes a coma and then death.
However, euthanasia is only legal if the following three criteria are met:
- The person has made an active and voluntary request to end their life.
- It is thought that they have sufficient mental capacity to make an informed decision regarding their care.
- It is agreed that the person is suffering unbearably and there is no prospect for an improvement in their condition.
Capacity is the ability to use and understand information to make a decision. In some countries, the law is less clear, with some forms of assisted suicide and passive euthanasia legal, but active euthanasia illegal. For example, some types of assisted suicide and passive euthanasia are legal in Switzerland, Germany, Mexico and five American states.
Euthanasia, also known as assisted suicide, physician-assisted suicide (dying), doctor-assisted dying (suicide), and more loosely termed mercy killing means to take a deliberate action with the express intention of ending a life to relieve intractable (persistent, unstoppable) suffering. Some interpret euthanasia as the practice of ending a life in a painless manner. Many disagree with this interpretation because it needs to include a reference to intractable suffering. In the majority of countries euthanasia or assisted suicide is against the law. According to the NHS, UK, it is illegal to help somebody kill themselves, regardless of circumstances. Assisted suicide or voluntary euthanasia carries a maximum sentence of 14 years in prison in the UK. In the USA the law varies in some states.
There are two main classifications of euthanasia:
- Voluntary euthanasia – this is euthanasia conducted with consent. Since 2009 voluntary euthanasia has been legal in Belgium, Luxembourg, The Netherlands, Switzerland, and the states of Oregon (USA) and Washington (USA).
- Involuntary euthanasia – euthanasia is conducted without consent. The decision is made by another person because the patient is incapable of doing so himself/herself.
There are two procedural classifications of euthanasia:
- Passive euthanasia – this is when life-sustaining treatments are withheld. The definition of passive euthanasia is often not clear cut. For example, if a doctor prescribes increasing doses of opioid analgesia (strong painkilling medications) which may eventually be toxic for the patient, some may argue whether passive euthanasia is taking place – in most cases, the doctor’s measure is seen as a passive one. Many claim that the term is wrong because euthanasia has not taken place because there is no intention to take life.
- Active euthanasia – lethal substances or forces are used to end the patient’s life. This includes life-ending actions conducted by the patient or somebody else.
Active euthanasia is a much more controversial subject than passive euthanasia. Individuals are torn by religious, moral, ethical and compassionate arguments surrounding the issue. Euthanasia has been a very controversial and emotive topic for a long time. The term assisted suicide has several different interpretations. Perhaps the most widely used and accepted being “the intentional hastening of death by a terminally ill patient with assistance from a doctor, relative, or another person.” Some people will insist that something along the lines of “in order relieve intractable (persistent, unstoppable) suffering” needs to be added to the meaning, while others insist that “terminally ill patient” already includes that meaning.
Active euthanasia is: “A mode of ending life in which the intent is to cause the patient’s death in a single act (also called mercy killing).”
Passive euthanasia is: “A mode of ending life in which a physician is given an option not to prescribe futile treatments for the hopelessly ill patient.”
Options for terminal patients or those with intractable suffering and pain
Patients with a terminal or serious and progressive illness in most developed countries have several options, including:
The World Health Organization (WHO) defines palliative care as – “An approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual”.
One goal of palliative care is for the patients and families to accept dying as a normal process. It seeks to provide relief from pain and uncomfortable symptoms while integrating psychological and spiritual features of patient care. Palliative care strives to offer a support system to help patients live their remaining time as actively as they can and to help families bereave and deal with the illness of a loved one.
Since pain is the most visible sign of distress among patients receiving palliative care, affecting about 70% of cancer patients and 65% of patients dying from non-malignant diseases, opioids are a very common treatment option. These medicines form part of well-established treatment plans for managing pain as well as several other symptoms that patients encounter. Often, opioids are chosen during palliative care in spite of the side effects such as drowsiness, nausea, vomiting, and constipation.
Some type of palliative care is given to about 1.2 million Americans and 45,000 new patients each year in England, Wales, and Northern Ireland. About 90% of these patients have cancer, while the remaining patients have heart disease, stroke, motor neurone disease, or multiple sclerosis. The providers of the palliative care include inpatient care, hospital support services, community care, day care and outpatient care.
In the USA, UK and many other countries, a patient can refuse treatment that is recommended by a doctor or some other health care professional, as long as they have been properly informed and are of sound mind. In the UK, the Mental Health Act 1983 excludes children and people under the age of 18 years.
According to the Department of Health, UK, nobody can give consent on behalf of an incompetent adult, such as one who is in a coma. Nevertheless, doctors take into account the best interests of the patient when deciding on treatment options. A patient’s best interests are based on:
- What the patient wanted when he/she was competent
- The patient’s general state of health
- The patient’s spiritual and religious welfare.
An example in the UK
The doctor may decide the best option for a patient who is declared as clinically brain dead is to switch off the life-support machines; equipment without which the patient will die. The doctor in charge will talk to the patient’s family. However, the final decision is the doctor’s, and strict criteria must be met.
A living will (advance directive)
This is a legally binding document which anybody may draw up in advance if they are concerned that perhaps they will be unable to express their wishes at a later date. In the advance directive the individual states what they want to happen if they become too ill to be able to refuse or consent to medical treatment.
Arguments for and against voluntary euthanasia
We will look at the arguments for and against voluntary euthanasia in turn.
Arguments for voluntary euthanasia
- Choice – freedom of choice is the cornerstone of free market systems and liberal democracies. The patient should be given the option to make their own choice.
- Quality of life – only the patient is really aware of what it is like to experience intractable (persistent, unstoppable) suffering; even with pain relievers. Those who have not experienced it cannot fully appreciate what effect it has on quality of life. Apart from physical pain, overcoming the emotional pain of losing independence is an additional factor that only the patient comprehends fully.
- Dignity – every individual should be given the ability to die with dignity.
- Witnesses – people who witness the slow death of others are especially convinced that the law should be altered so that assisted death be allowed.
- Drain on resources – in virtually every country there is never enough hospital space. Channelling the resources of highly-skilled staff, equipment, hospital beds and medications towards life-saving treatments makes more sense; especially when these resources are currently spent on terminal patients with intractable suffering who wish to die.
- Public opinion – in nearly all countries a significantly higher proportion of people are for euthanasia than against it. In a democracy, legislation should reflect the will of the people.
- Humane – it is more humane to allow a person with intractable suffering to be allowed to choose to end that suffering.
- Loved ones – it helps shorten the grief and suffering of the patient’s loved ones.
- We already do it – if a loved pet has intractable suffering we put it down. It is seen as an act of kindness. Why should this kindness be denied to humans?
- Prolongation of dying – if the dying process is unpleasant, the patient should have the right to reduce this unpleasantness. In medicine, the prolongation of living may sometimes turn into the prolongation of dying. Put simply – why should be a patient be forced to experience a slow death?
Reasons against voluntary euthanasia
- The doctor’s role – doctors and other health care professionals may have their professional roles compromised.
- Moral religious argument – several religions see euthanasia as a form of murder and morally unacceptable. At best, some see voluntary euthanasia as a form of suicide, which goes against the teachings of many religions. Euthanasia weakens society’s respect for the sanctity of life.
- Competence – euthanasia is only voluntary if the patient is mentally competent – has a lucid understanding of available options and consequences. Determining or defining competence is not straightforward.
- Guilt – there is a risk that patients may feel they are a burden on resources and are psychologically pressured into consenting. They may feel that the burden – financially, emotionally, mentally – on their family is overwhelming. Even if the costs of treatment are provided by the state, there is a risk hospital personnel may have an economic incentive to encourage euthanasia consent.
- Slippery slope – there is a risk that things will start with those who are terminally ill and wish to die because of intractable suffering, and eventually begin to include other patients.
- The patient might recover – the patient might recover against all odds. The diagnosis might be wrong.
- Palliative care – good palliative care makes euthanasia unnecessary.
- How can you regulate it? Euthanasia cannot be properly regulated.
Physicians opinions on euthanasia
Medscape completed a survey of 10,000 American physicians in 2010. When asked “Would you ever consider halting life-sustaining therapy because the family demands it, even if you believed that it was premature?” 16.3% said they would and 54.5% said they would not.
When they were asked “Should physician-assisted suicide be allowed in some cases?” almost 46% said it should and nearly 41% said it should not – the rest responded that “it depends.”
A survey of UK doctors asked whether a person with an incurable and painful disease, from which they will die, should be allowed by law to end their life. Roughly one-third agreed that they should be allowed to choose while almost two-thirds disagreed. They also found that doctors working in palliative care were more likely to be against assisted dying.
Who opts for euthanasia?
A literature review carried out in October 2013 investigated a number of aspects of euthanasia and assisted suicide in countries where it is legal. The following are some of the findings in regards to the underlying illness and demographics:
- In most regions, men opted for assisted suicide more often than women (except in Switzerland)
- The age group most commonly opting for euthanasia was the 60-85-year-olds, followed by 40-59-year-olds
- Most people who chose an assisted death were married, followed by widowed, then divorced
- The disease most commonly found in euthanasia cases was cancer – other diseases included amyotrophic lateral sclerosis (ALS), multiple sclerosis and cardiovascular disease
- The Netherlands reported the highest number of assisted deaths – 3,695 in 2011 (roughly 2.5% of all deaths)
- Overall, in states and countries where euthanasia is legal, between 0.1% and 2.9% of all deaths were assisted.
The euthanasia argument is set to continue indefinitely. In the next few days, I will be posting an article on the History of Euthanasia, be sure to have a read.