The Ethical Dilemmas of Euthanasia - CASE

Discussion of euthanasia often elicits strong emotion, which is not surprising as it involves life and death issues. For over 2000 years it has been a prohibited medical practice. But now?

Euthanasia is legal in the Netherlands, Belgium and Luxembourg. Physician Assisted Suicide (PAS) is legal in Oregon and Washington State in the US. There are serious discussions going on in Montana, Singapore and Spain. In The UK, over 100 Brits have died under the arrangements in Switzerland, and the government is developing guidelines for prosecution of those who assist in such suicides. The Swiss authorities are having a similar debate themselves, with the final outcome far from clear.

In Australia legislation concerning end-of-life issues has been dealt with on a state basis. In 1995 the Northern Territory passed legislation allowing euthanasia, but it was overturned by the Federal Parliament in 1997. Last year a bill was tabled in the Federal Senate trying to reactivate it. Recently bills have been debated in Victoria, Tasmania and South Australia. Legislation for euthanasia has been twice considered and rejected by the NSW parliament. It just keeps coming back.

Why are we having this debate in Western countries at a time when we have more medical cures than ever before in human history? What is going on?

In this paper I will first discuss the definitions of the terms of the debate. I will then consider arguments for and against euthanasia, before giving a Christian perspective.

Definitions
In the euthanasia debate, inadequate definitions have been a real barrier in attempts to find clear community consensus. It is no secret that many euthanasia advocates have muddied the waters by bracketing euthanasia with other accepted end-of-life practices in order to increase public support. We need to keep our definitions clear so we all know what we’re talking about.
The word euthanasia is taken from Greek eu thanos, meaning ‘good death’. However, this is not particularly helpful as both sides claim the advantage of bringing about a good death, and indeed, the question of what constitutes a good death is at the heart of the euthanasia debate. We would all like to see people in our communities dying with dignity and without suffering. The question is, how do we go about achieving this?

I define euthanasia as: ‘An act where a doctor intentionally ends the life of a person, by the administration of drugs, at that person’s voluntary and competent request, for reasons of compassion’. I prefer to keep the definition narrow, so we can evaluate each end of life scenario individually.

The terms active/ passive, and voluntary/involuntary should be avoided when referring to euthanasia, as they are ambiguous and confusing. For example, there is no such thing as involuntary euthanasia. It is a contradiction of terms. If someone is killed without their consent, even in a medical setting, it is not euthanasia, it is murder. I will discuss the active/passive distinction in a moment.

I define Physician Assisted Suicide (PAS) as: ‘The situation where a doctor intentionally helps a person to commit suicide by providing drugs for self-administration, at that person’s voluntary and competent request’. In PAS the doctor is distanced from the act but morally it is no different from euthanasia as the motive, intention and outcome are the same. As they are similar in moral terms, I will use euthanasia and PAS interchangeably in this paper.

To understand the debate we also need to be clear on what euthanasia is not. Euthanasia needs to be distinguished from the withdrawal of treatment, and management of symptoms at the end of life.

In discussions of legislation for euthanasia and PAS, the focus population has always been those who do not have long to live. When a patient is in the terminal stages of their illness, a time may come when treatments aimed at cure either no longer work (they are futile) or the burden of side-effects such as nausea and vomiting may be so overwhelming that they cancel out any benefit of treatment. At this stage the treatment may be not prolonging life so much as prolonging the process of dying. At this time a decision may be made to stop, or not to start, such a treatment. The decision is made carefully in full consultation with the patient and their family and it is not euthanasia because the intention is not to kill the patient, but to allow the underlying disease to take its course. Full supportive care will remain in place so the patient is kept comfortable.

Another situation which if often confused with euthanasia is adequate symptom control in the terminally ill. In all areas of care we seek direction from the patient as to where we should place our efforts. Very occasionally in the terminal stages of disease the distressing nature of a patient’s symptoms may require the careful sedation of the patient. The most common indication would be delirium or extreme agitation. Once again this will be done carefully in consultation with the patient and their family and we will seek to preserve the dignity of the patient. The doses are titrated to allow regular awakening so that the patient and their loved ones can communicate. It is not euthanasia because the intention is not to kill the patient, but to alleviate their distressing symptoms.

Some people would call this practice of symptom control passive euthanasia because of a myth in the community that use of morphine shortens the life of the patient. They argue that if we already practice that type of euthanasia, there is no reason not to practice the other type of euthanasia, using lethal injection, which they call active euthanasia. You see the problem.

But it is all based on a myth, that morphine shortens the life of the patient. This myth causes lots of problems for palliative care workers. It’s been around for years, and we don’t seem to be able to squash it. It makes people scared to use what is an excellent treatment for pain. Let me state clearly that research has shown that morphine in therapeutic doses does not shorten life. Indeed, not only does it not shorten life, it may in fact prolong it. A study in 2005 showed increased survival of patients in a Newcastle hospice on high doses of morphine.[i]

Stopping futile and burdensome treatment and maintaining adequate symptom control are good medical practices at the end of life and should be encouraged in clinically appropriate situations. When the public has a better understanding of end-of-life care it reduces the call for euthanasia because there is less suffering experienced along with an increased sense of control for the patient.

Arguments for euthanasia
Euthanasia is a compassionate response to the suffering of the terminally ill which is perceived (often wrongly) to be otherwise unrelievable.
2.Euthanasia is an expression of autonomy – that a competent individual should have the right to make self-governing choices, especially in the face of increasing support for euthanasia in public opinion polls.
Legalisation is called for as a way to regulate the alleged existing practice of euthanasia in order to provide protections for patients and doctors under the law.

Arguments against euthanasia
Sanctity of human life forbids it.
Euthanasia is unnecessary due to the availability of palliative care to relieve suffering in the terminally ill.
There are negative social consequences of legalising euthanasia.
There is danger of abuse due to the slippery slope which is created with the legalisation of euthanasia.

Let me unpack these for you.

Responding to suffering
It is true that many people experience pain and suffering when they are dying, and this has led to a situation where too many of us have seen someone die badly. Perhaps they were in pain, treated without dignity, or experiencing spiritual turmoil. Maybe this is your experience.

This should not happen, but it still does and is an important factor in the call for the legalisation of euthanasia. It has been the experience of many people campaigning most strongly for the cause. We must do better.

I don’t know how many dying patients I have cared for as a palliative care doctor, but I imagine it must be in the thousands. I would like to assure you that at the end of your life, you will not be faced with just two options – pain and suffering on the one hand, or euthanasia on the other. There is another option, which explains why euthanasia is increasingly unnecessary: palliative care.

Palliative care is specialised care for dying people, which aims to maximise quality of life, and assist families and carers during and after the death. Its intention is to liberate patients from the discomfort of their symptoms, and neither hastens nor defers death. An old slogan for palliative care was ‘we will help you live until you die’.

Currently, only a fraction of those people who would benefit from palliative care, receive it. Why is this?

The main reason is that, although churches established the first hospices in the 19th century, the modern palliative care movement is relatively new. While students now receive training in pain control, there are many doctors in the community who are not aware of what can be done. The discovery that different types of pain respond to different treatments has revolutionised care of the dying.

Furthermore, there are certain demographic characteristics which reduce access to palliative care in the community - low income, non-urban location, acute care settings and nursing homes, ethnic or indigenous background, very old or very young age, and non-cancer diagnosis.[ii]

The World Health Organisation has developed a pain relief ladder which enables up to 90% patients to be pain-free using a basic approach which all doctors can learn.[iii] Specialist centres can achieve even higher rates of success. Not everyone needs to see a specialist or visit a hospice, but all dying patients would benefit from palliative care in some form.

Interestingly, one response to the brief legalisation of euthanasia in Australia was an increased injection of funds into palliative care services by the federal government. Since then, the argument for euthanasia on grounds of unrelieved suffering of dying patients has become much less prominent. Palliative care in Australia is improving all the time, but we should not be complacent: the most common reason why palliative care services cannot help dying patients is because they are referred too late or not at all. As the European Association for Palliative Care states in their position statement on euthanasia, our challenge is ‘to transform our care of the suffering and the dying, not to legalise an act which would all too easily substitute for the palliative competence, compassion and community that human beings need during the most difficult moments of their lives’.[iv]

We also need to recognise that suffering is not merely a medical problem but an existential problem which extends beyond physical pain. It is influenced by psychological, cultural and spiritual factors. The physical symptoms can be dealt with but the suffering may well remain.

It is made worse by the fact that we, as a society, have lost touch with the spiritual concerns surrounding death. Dying forces us to face the big issues of life – What does it all mean? What are we doing here? Western society is struggling to answer these questions. We are youth-obsessed and death-denying, and don’t know how to die properly anymore. We’re uncomfortable discussing it and we have lost our traditions in the West. I think we could be trained to die by example, but few of us have seen examples. Most members of the public have never seen a corpse and many people have long ignored the spiritual dimension when they face the mystery of death. They’re unprepared, and it can be scary.

Furthermore, we are immersed in a culture of comfort where we are more likely to reach for the quick fix than the stiff upper lip. Christians understand the benefits of suffering, such as the opportunity to grow in perseverance, character and hope (Rom 5:3-4), but the wider community does not share this understanding. It may be that what people are requesting in the call for legalised euthanasia is not so much a right to die, as the opportunity to avoid the process of dying itself.
In our community the fear of dying is promoted by numerous accounts of pain and misery experienced as life draws to a close. There seems to be a desire in some people to go from a state of health, straight to a state of being dead, without having to ‘die’ at all. In a society which has lost touch with the meaning of suffering, there is also, understandably, a loss of the willingness to endure it.
Medicine and protection of life
One aspect of the euthanasia debate that is often ignored is that it expects doctors to perform euthanasia. I was asked recently whether the doctor uses a sterilised needle when performing euthanasia. This encapsulates how antithetical euthanasia is to the way medicine is currently practised. There seems to be an attempt to confer medical legitimation on the ending of life, but what will happen to doctor- patient relationships if patients can’t trust their doctor to always be a protector of life? Will patients forgo medical care because of fear of euthanasia?
Euthanasia violates codes of medical ethics which have existed since antiquity. The Hippocratic Oath, taken by doctors on graduation since the 5th century BC, specifically prohibits doctors from helping their patients die. Medical and palliative care associations all over the world are strongly opposed to the legalisation of euthanasia.
Dying as part of life
If we accept dying as a part of life we should all embrace, is there anything good about the dying process?
When a person is dying, he and his family find themselves in a crisis situation. All the joys and regrets of the past, the demands of the present and fears for the future will be brought together. Help may be needed to deal with things like guilt, depression and family discord, but in this time of crisis, there is the possibility of resolving old family problems and finding reconciliations which greatly strengthen the family group. The time between diagnosis of a terminal condition and death is often a time of great personal growth. I have seen this time and time again. When relatives think back on the last days of their loved one, how much better to remember a time of peace and reconciliation than one of anguish which is violently cut short. Those at the coal face know very well that patients can and do choose the moment of death as a natural act if good care is available.
Legalising euthanasia
Arguments supporting euthanasia laws presuppose a world of ideal hospitals, doctors, nurses and families. But we don’t live in an ideal world. We live in a fallen world where humans make mistakes and have selfish motives. For this reason, legalisation of euthanasia holds a number of risks.
We cannot be sure that euthanasia, once legalised and socially accepted would remain voluntary. Vulnerable and burdensome patients may be subtly pressured to request termination of their lives, even though they don’t really want to. Consider the difficulty of having a relative in hospital long term, the stress of daily visits – finding a parking space! And sadly, the prospect of inheritance brings out the worst in a lot of people. These patients aren’t stupid. They know what a burden they can be on others. Legal euthanasia introduces a factor which should not be present in the environment of a sick person.
With euthanasia legalised, would we remain a caring society ready, in times of financial constraint, to continue to invest money and resources into attempts to improve the care of the terminally ill? Palliative care is expensive and becoming more so as patients survive longer and develop more complex problems. It is a very labour intensive discipline. Public opinion can be influenced once a law is changed. Is this what we want? I believe western medicine has progressed as far as it has because we do value all human lives and continue to seek cures for the diseases which afflict us.
Another risk is that doctors may not be able to resist the extension of euthanasia to those who don’t, or can’t, consent to termination of their lives. Proponents of euthanasia will tell you that legal guidelines will prevent this happening. However, the Dutch Government’s Remmelink Report in 1991[v] found that around one in three euthanasia deaths were without patient knowledge or consent (around 1000 each year). Government reviews showed similar results in 1995[vi] and again more recently,[vii] despite the fact that there are stringent guidelines in place in Holland. One argument put forward to support euthanasia suggests that we need to regulate what is already taking place illegally. If those doctors performing euthanasia now are unwilling to obey the law, why do we think we could trust them to do so after it is changed?
Lastly, if euthanasia were legalised, would we avoid the intolerable abuses that other civilised countries have slipped into before us? We say the holocaust could never happen again, but in the Nuremburg trials after WWII it was established that the extermination programmes of the Nazis had their origins in the promotion of mercy killing by German doctors in the 1920s[viii]. Once you accept that some lives are not worth living, what will happen?
In the Netherlands, euthanasia was legalised in 2002 after 20 years of widespread practice under legal guidelines. By the time the law had passed, the courts had already legitimized the death of patients who were not terminally ill.[ix] The Dutch are currently debating the need to allow the elderly to be euthanased when they are ‘tired of life’.[x] And early in 2005 a Dutch hospital published their guidelines on how to kill disabled newborns.[xi] Are these the values we want to pass onto our children?
We ignore the lessons of the Netherlands at our peril. The discrimination, racism and triumph of expediency over justice in our society should warn us against naïve enthusiasm about proposals to decriminalise euthanasia.
Autonomy
Now I would like to look at what I think is the strongest argument for euthanasia – that of autonomy, the principle of self-determination, expressed here as the right of the individual to choose the timing and manner of their own death.
It is undeniable that after we have done all we can in palliative care and made sure the patient is mentally competent, there will be a small number of patients who still suffer and who request euthanasia. It is unlikely to be because of pain. There is little good research into why people actually request euthanasia, but the studies that have been done show the most common reasons are not related to physical factors but to psychosocial and existential factors—things like the fear of death and loss of control, fear of becoming a burden and of loss of dignity, fear of the future.[xii] Patient desires are known to fluctuate over time,[xiii] but whatever the reason, euthanasia is what these patients want. What are we to do with this small group of people who rationally request that their lives be terminated after all our attempts to care for them are still not enough?
There are a few things you need to check. Suicidal thoughts are a symptom of depression. The first step when a patient is requesting euthanasia is to assess—and where appropriate treat—the patient for depression. Research shows that sometimes when patients expressed their fears at the end of life it was misinterpreted by healthcare providers as a request for euthanasia when it was really intended to be a cry for help.[xiv]
The incidence of depression in cancer patients has been measured as high as 45%.[xv] There are reports that 1 in 6 of patients who requested a lethal prescription in Oregon 2004-2006 were clinically depressed but not referred for counselling, (as the law requires).[xvi] In any other group, a request for death would alert a doctor for urgent psychiatric review: why is this group of patients being treated differently?
Another thing to check is whether the patient aware of the rights they already have in terms of refusing life-prolonging treatment. I find many patients are not aware that this is an ethical and legal option. No mentally competent patient has to undergo futile, burdensome or life-prolonging treatment if they don’t want to. It can be hard as a doctor to accept this decision, but knowledge of the right to refuse treatment would ease many of the concerns felt by those who fear being kept alive by artificial means against their wishes.
Finally, if the suffering the patients wish to avoid is due to metaphysical or spiritual concerns, then it is not only patient autonomy, but also the social, psychological, religious and cultural concerns that need to be addressed.
But given that some people do still request euthanasia, how do we proceed?
The public debate is about whether we should change the law to allow euthanasia, not about whether euthanasia is right or wrong for individual cases. Euthanasia is going to be ethically appropriate for some individuals whose morality recognizes autonomy as a priority. If you think that this world is all there is and living has become unbearable, the choice to end it all makes sense.
So from the community perspective there is a tension here – between those people who rationally request euthanasia and the vulnerable people who would be at risk of being killed against their will, as is happening now in the Netherlands. Autonomy – the right of the individual to determine the timing and manner of their own death – versus security – the right to protection and security as expressed in the values of the larger society. How are we to resolve this? Is there a right to die that the government should support?
While as Christians we would say our bodies are not our own, legally, a man is free to end his life when he chooses. But that does not mean he has a right to do so, and he certainly does not have the right to compel someone else to kill him.
Many people say that when they are facing death they would want to be able to request euthanasia. A news poll from October last year commissioned by a Euthanasia support group found 85% of Australians in favour of euthanasia[xvii] (though I have questions about what exactly was asked and how well defined the questions were). Even if we accept that large numbers of people would like the option to request euthanasia though, the proportion of people actually requesting it when facing death is very different. A study done in Sydney has shown that only 2.8% of patients in a palliative care service requested euthanasia when first seen. After palliative care commenced, this number was reduced to less than 1% of those referred.[xviii] I am not surprised by these low numbers – in my experience, those facing death are more likely to want more time, not less.
We do need to respect autonomy, but as one of many relevant factors, not as a preeminent stand-alone factor. People are more than autonomous entities. The argument from autonomy is based on a view of human beings which is too shallow, and devoid of the inevitable social context.
Moreover, in practice, some will lose autonomy whichever legal path is chosen: if euthanasia is legalised, precedent shows that legally unprotected persons too often have their autonomy to choose life undermined; if it remains illegal, Persons genuinely desiring euthanasia lose their autonomy to choose death. Either the right of the vulnerable to protection, or the right of the sufferer to end their suffering is compromised. Surely it is the responsibility of our society to care for those who cannot care for themselves.
In view of the very small number of people demanding autonomy, I believe that we must err on the side of justice and the responsibility of our society to care for those who cannot care for themselves. Those demanding euthanasia will not have what they want and that is terrible for them, but we must protect the frail and vulnerable who want to live. This is the conclusion of government-sponsored enquiries in England, Canada, the USA and Australia.[xix]
Proponents of euthanasia bills will reject this reasoning. They keep saying that it only affects patients and their carers, but this is just not true. It can’t be. Legalisation of euthanasia must affect society as a whole because in legalising euthanasia we are changing one of the most basic tenets of our society. That is, that we do not kill each other, even for reasons of mercy and compassion.
Christian ethical response
Ethical choices involve motivation, action and consequences. So far the arguments we have looked at for and against euthanasia judge right and wrong on the basis of the consequences believed to ensue if euthanasia were legalised. Christians have another moral compass: the Bible. The Bible teaches that in ethical decision-making, motivations, actions and consequences all matter.[xx]
The most common motivation for those on both sides of the euthanasia debate is compassion for those who suffer. Motivation prompts us to act but does not inform the content of our actions, so common motivation may lead to different actions. Euthanasia is an inappropriate response for Christians because there are some actions we must never do, whatever the motivation or consequences. The Bible is very clear on euthanasia: the intentional killing of an innocent human being is wrong (Ex 20:16).
In addition, Christians recognise that all humans are made in the image of God and thus have value that is not dependent on our state of health or abilities. It also means that we are creatures, and so our autonomy will operate within the parameters given to us by our creator, God. Our bodies are not our own (1 Cor 6:19-20).
These arguments against euthanasia may seem inadequate in the face of the suffering we have identified as central to the debate. God calls us to be salt and light – salt to preserve the good in the world, light to illuminate the truth as we influence the cultural drift. What does it mean to say no to euthanasia? What do we have to say to those who suffer?
We say that life is a gift from God, and acknowledge that sometimes it takes less courage to die than to continue living. We say that while we do not always understand why suffering occurs, we are willing to walk with them because God in his mercy created us to carry each other’s burdens, and when we are suffering, we are comforted by human presence. This is the challenge for the church: to stay with the dying.
When Job’s friends first saw him, they sat on the ground with him for seven days and seven nights. No-one said a word to him, because they saw how great his suffering was. And as Job learnt, it is only God who can give meaning to our suffering.
The euthanasia debate is an expression of a society that is struggling to find meaning in life, and so finds no meaning in death. It is desperately trying to control death any way it can. But the true answer to our plight as we struggle on in this broken, fallen world is not legalisation of euthanasia but the good news that Jesus came to give us new life, new bodies, better bodies in the world to come (1 Cor 15:44). In the next world there will be no more death or mourning or crying or pain (Rev 21:4). Euthanasia is not the solution to suffering. In the end, the only thing that can wipe our tears from our eyes is the hand of God.
E N D N O T E S
[i] P. D. Good et al., (2005). Effects of opioids and sedatives on survival in an Australian inpatient palliative care population. Intern Med J, Vol.35(9), pp512–517.
[ii] Palliative Care Australia. (2009). EOL, Vol.1(2).
[iii] World Health Organization. (1996). Cancer pain relief (2nd ed.). (Geneva: WHO, 1996).
[iv] F. D. J. Roy & C. H. Rapin et al., (1994). Regarding euthanasia. European Journal of Palliative Care, Vol.1(1), pp1-4.
[v] Medische Beslissingen Rond Het Levenseinde – Rapport van de Commissie Onderzoek Medische Praktijk insake Euthanasie. (The Hague, The Netherlands: Sdu Uitgeverij, 1991).
[vi] H. Jochemsen & J. Keown, ‘Voluntary euthanasia under control? Further empirical evidence from The Netherlands’. Journal of Medical Ethics, Vol. 25(1), 1999, pp16-21.
[vii] A. van der Heide et al., ‘End-of-life practices in the Netherlands under the Euthanasia Act’. The New England Journal of Medicine, Vol.356 (19), 2007, pp1957-65.
[viii] R. J. Lifton, The Nazi Doctors: Medical Killing and the Psychology of Genocide. (New York: Basic Books, 1986).
[ix] Y. Sheldon, Dutch argue that mental torment justifies euthanasia. BMJ, Vol.308, 1994, pp431-432.
[x] Dutch News.nl. 09-02-2010. Tired of life? Group calls for assisted suicide.
[xi] P. Verhagen & P. J. Sauer, The Groningen Protocol — Euthanasia in Severely Ill Newborns. NEJM, Vol.352(10), 2005, pp959-962.
[xii] P. Hudson et al., Desire for hastened death in patients with advanced disease and the evidence base of clinical guildelines: a systematic review. Palliative Medicine, Vol.20, 2006, pp693-701.
[xiii] H. Chochinov et al., Will to live in the terminally ill. Lancet, Vol.354, 1999, pp816–19.
[xiv] Hudson, op. cit. p697.
[xv] S. D. Passik, M. V. McDonald, W. M. Dugan Jr, S. Edgerton & A. J. Roth, Depression in Cancer Patients: Recognition and Treatment. Medscape Psychiatry & Mental Health eJournal, Vol.2(3), 1997.
[xvi] L. Ganzini, E. R. Goy & S. K. Dobscha, Prevalence of depression and anxiety in patients requesting physicians’ aid in dying: cross sectional survey. BMJ, Vol.337, 2008, p1682.
[xvii] News poll (2009) Voluntary Euthanasia Study. Prepared for Dying with Dignity NSW. Available at: http://www.dwdv.org.au/DOCS/Newspollsurvey2009.pdf (accessed March 3, 2010).
[xviii] P. A. Glare, The euthanasia controversy. Decision-making in extreme cases. MJA, Vol.163,1995, p558.
[xix] U K Select Committee on Medical Ethics, House of Lords. (1994). (Unanimous); New York State Task Force on Life and the Law, Euthanasia and Assisted Suicide in the Medical Context, (1994). (Unanimous); Senate of Canada, (1995) Of Life and Death; Community Development Committee, Parliament of Tasmania, The Need for Legislation on Voluntary Euthanasia, (1998). (Unanimous);
Social Development Committee, Parliament of South Australia. Report of the Inquiry into the Voluntary Euthanasia Bill 1996. (1999).
[xx] E.g. Matt 5-7; Rom 3:8.
[17] E.g. Matt 5-7; Rom 3:8.