I have recently been participating in an Australian web forum for current and prospective Australian medical students known as "Paging Dr." The following article is mostly derived from a number of posts that I wrote on that forum.
I am gratified to see that euthanasia has come back into the social agenda, in the Sydney newspaper press in any case. On Australia Day (26 January 2007), The Sydney Morning Herald published a wonderfully human story on Dr John Ellison, a Sydney medical doctor dying from myeloma who travelled to Switzerland to "end his life with dignity"(1). He sought the assistance of a Swiss charity "Dignitas" who assist patients with suicide. About Dignitas (from the BBC)(2):
Do people have a right to death?
Firstly, consider the fundamental question, for the moment outside the boundaries of law and ethics: "do people have a right to choose the option of death?"
If the answer is in the negative, then obviously euthanasia cannot be condoned by any means.
However, I believe, that in some settings, the answer is clearly in the affirmative. It helps to consider a scenario; a captain who "falls onto a grenade" to save his men has clearly chosen to sacrifice himself for a particular (and noble) reason. In fact, he is considered heroic. I can think of any number of other scenarios but it is clear that there is no blanket ban for a person choosing to die.
Indeed, if we consider this from a civil liberties point of view, then surely if we have a right to chose the way we live, the logical conclusion is that we can chose to die given that the endpoint of life is universally death.
"In some settings"
Establishing that someone has a right to choose death, however, does not mean that as a society must accept that choice unconditionally. Death by its nature is irreversible and the tenacity for the will to live is so strong that in most settings we would consider the voluntary act to extinguish life to be contrary to the human condition. We, for example, almost always consider a victim of suicide to be a tragedy and would aim to prevent it if possible. Mosts survivors of attempted suicide retrospectively view those events of their life as extreme low points.
In what settings then would euthanasia be considered acceptable?
Let us first describe an unambiguous case. A person with terminal metastatic cancer with extreme pain who has an expected lifespan measured in hours to days. By giving a sufficiently high dose of analgesic to control symptoms, a hastened death would be likely. I think that most people would consider the ethical duty to treat the distressing symptoms to overwhelm the ethical duty to not harm the patient (indeed, what further harm can be done?)
I think it is important to recognise this case. The reason being is that this is clinical reality and it happens every day across the globe and has been the case for centuries. It is important to note at this stage that many people do not consider this to be "euthanasia" as the argument is that the aim of the active treatment is to treat symptoms rather than to hasten death. Nevertheless, I feel that this may be a case of intellectual sophistry as we are still knowingly hastening death.
The "real" public debate on euthanasia
The above scenario is not really debated except as a point of grounding. That is not the "real" debate on euthanasia. When someone is on the "cusp" of death for the most part the debate is rendered irrelevant.
The real debate is for someone like Dr John Elliot as described in the above article. I quote verbatim(1):
The criteria for allowing euthanasia
If we accept then that (i) people have a fundamental right to chose death in some settings, and (ii) there is at least one unambiguous scenario where euthanasia is considered a clinical norm, what then follows as the criteria we use to "allow" people to choose death?
1. "Personal choice and competence"
Although this is needed, it is clearly not enough. Many people with depression who attempt suicide also "choose" their actions but we rightly (i) try to prevent suicides and (ii) try to resuscitate people who have had a suicide.
So thus, we must establish that people who make this "personal choice" are competent to do so. This is not a trivial thing to do. It is essentially a contradiction to ask whether someone who wants to suicide is in the "right mind" to choose it.
An analogy: someone who is hypomanic often feels fantastic when they are unwell. If they are an intelligent hypomanic, then they can make the most convincing arguments against treatment. how it is their "choice" to remain this way. Indeed, "people with hypomania are generally perceived as being energetic, euphoric, overflowing with new ideas, and sometimes highly confident and charismatic."(3) This of course all falls down then either they are treated or the hypomania stops. When they are well, they have the insight to their illness, which is why for the most part, we still treat people with mild bipolar disorder.
Establishing whether someone is in the "right mind" to chose death is not an easy thing as the experience of suicidal thoughts are that they go away when the underlying affective disorder or social situation improves.
Thus, not only must it be the personal choice of the person, but it must be established that they are completely free from all mental illness; something that I believe to be difficult to establish in someone with a terminal malignancy.
2. Delegation of responsibility
Following on from personal choice and competence comes the question whether the responsibility of the choice can be delegated to others; for example, the family, the treating doctor, a carer/guarding, a public guardian, or even some form of advanced directive. This is highly relevant considering that many terminal illnesses may lead to a decline in cognitive function.
The answer to this is fraught with dilemma. There are practical considerations but at the same time, there are obvious inherent conflicts of interest:
For a person with a terminal illness, there are many stakeholders apart from the ill person who would benefit from a hastened death. Where there is a legislated pathway, there would also be a huge potential for abuse, unless, it was strictly regulated.
3. "Terminal condition"
Must there be a "terminal condition" for a patient to choose euthanasia? This is a hard question. One must consider people with multiple sclerosis, motor neurone disease and degenerative neuromuscular diseases. In themselves they are not "terminal" in the way malignancies are.
In the follow on from this question is the time frame. Too short a time frame and it would exclude just about everyone. Too long a time frame and there will be a subset of patients who may not have had a terminal illness at all.
For example, let's say that an inclusion criteria is that your expected lifespan must be less than 6 months. A small percentage of these patients may live for years if they are not euthanised ("life expectancy" is firstly a grouped average and secondly is more art than science).
Thus, if we use "presence of a terminal condition" as an inclusion criteria, it necesitates a time frame and the time frame chosen will be purely arbitrary.
4. Quality of life
Must the patient have an expected deterioration in their quality of life? The answer would appear to be "yes", but, the devil is in the details. How much reduction?
Furthermore, can this even be competently determined on an a priori basis?
For example, requiring a colostomy bag may be the worst thing that a particular person can imagine. The reality of a colostomy bag, however, may be much less onerous. On the other hand, managing a colostomy may actually be a terrible imposition on that person if they had to do it.
Thus if we accept that we must take quality of life into account, we must not only gauge whether the expected reduction is real, but also whether the person has realistic expectations. Clearly, euthanasia should not have a place as a method of treating a person's fears of the future.
5. Other problems - refusal of standand therapy
If we permit euthanasia, could a patient be included if they refuse standard therapy?
Examples:
A person has an operable colon cancer but it would involve a colectomy (i.e., colostomy bag) with chemotherapy. They refuse treatment (clearly within a persons right to choose) but wants euthanasia (so not to have to experience cancer death).
A more subtle example:
A person has metastatic melanoma (i.e., inoperable) but targeted radiotherapy and chemotherapy / immunotherapy could lead to significant improvement in both quality and quantity of life. They refuse treatment (again clearly within their right) but wants euthanasia (so not to have to experience cancer death).
The significance of these questions is that they are realistic. Most patients in fact do have options other than euthanasia; treatment modalities that would either improve their symptom control and/or improve their lifespan.
Practical implications of legalised euthanasia
The point of the above discussed criteria is to highlight that if euthanasia were permitted, it would by necessity be rigidly regulated, and that any inclusion and exclusion criteria arbitrary and at some level, inconsistent. Many people who may "benefit" from euthanasia will still not have access to it. Some people who are euthanised will on retrospectively analysis be considered to have been a bad decision.
To a certain level, clinics like Dignitas as described in the Sydney Morning Herald article work because they are a rare and limited service and their clients are highly self-selected motivated individuals.
For a widely available and accessible service (which would be the implication of "legalised" euthanasia) a lot of money will need to go into the regulatory framework. From an economic point of view, one must consider whether the manpower, intellectual investment and money would be better spent elsewhere (e.g., palliative care).
"Passive" and "active" euthanasia - consideration of ethics
"Active" euthanasia is when "the medical professionals, or another person, deliberately does something that causes the patient to die"(4).
For the most part, "active" euthanasia is illegal in both Australia and worldwide (with a few exceptions).
"Passive" euthanasia occurs when "the patient dies because the medical professionals either don't do something necessary to keep the patient alive, or when they stop doing something that is keeping the patient alive". Activities that would fit this definition is legal and in many places part of standard therapy. It is considered a practical necessity.
However, is there actually an ethical difference between the two?
Some people argue that there isn't. Giving someone a lethal cocktail to hasten death is an active process on the part of the health professional. Withdrawal of active therapy is also an active process. Even withholding therapy (e.g., not giving further blood transfusions) is at a cognitive level an active management choice.
Thus, it can be argued that given we accept withdrawal of therapy as a valid medical decision, and that there is no ethical distinction between this and so called "active euthanasia", the logical conclusion is that euthanasia should not only be legal but performed were clinically appropriate.
There is a lot of appeal to this argument but I believe that it suffers from a flaw.
If you believe that this makes a difference then it means that "passive" euthanasia cannot be lumped in the same class as "active" euthanasia.
If you don't believe that it makes a difference (i.e., planned active decision resulting in death in both cases) then it can even be argued that active euthanasia is morally superior as it results in less distress and discomfort for the patient.
I believe that it makes a difference (my personal opinion).
It is the duty of doctors to improve health and prolong life, but not prevent death by all means possible (which is impossible). Death is a part of life and part of being a doctor is to allow people to die. That is, I don't believe that there is any ethical principle against letting people die from "natural" reasons. Quotation from the 19th century poet Arthur Hugh Clough:
There is, however, the ethical principle of non-maleficence - i.e., we should refrain from something that harms a patient. Is providing active euthanasia to a patient who desires death it "harming them"? It can be argued either way.
Thus the conclusion is that "passive euthanasia" is okay but "active euthanasia" may or may not be okay on a medical ethics basis, and, that there is a distinction between the two. This is somewhat the status quo though there are strong differing points of view within bioethics.
Reference articles
"Dignitas was founded in 1998 by Swiss lawyer, Ludwig Minelli, who runs it as a non-profit organisation.The reason why someone from Australia would travel to Switzerland for euthanasia, of course, is that euthanasia is illegal in Australia. There is clearly a demand for euthanasia services. Let us explore some of the issues regarding this contentious subject.
It takes advantage of Switzerland's liberal laws on assisted suicide, which suggest that a person can only be prosecuted if they are acting out of self-interest...
...The law on suicide actually states:
"Whoever lures someone into suicide or provides assistance to commit suicide out of a self-interested motivation will, on completion of the suicide, be punished with up to five years' imprisonment".
Dignitas interprets this to mean that anyone who assists suicide altruistically cannot be punished.
Its specialist staff all work as volunteers to ensure there can be no conflict of interest..."
Do people have a right to death?
Firstly, consider the fundamental question, for the moment outside the boundaries of law and ethics: "do people have a right to choose the option of death?"
If the answer is in the negative, then obviously euthanasia cannot be condoned by any means.
However, I believe, that in some settings, the answer is clearly in the affirmative. It helps to consider a scenario; a captain who "falls onto a grenade" to save his men has clearly chosen to sacrifice himself for a particular (and noble) reason. In fact, he is considered heroic. I can think of any number of other scenarios but it is clear that there is no blanket ban for a person choosing to die.
Indeed, if we consider this from a civil liberties point of view, then surely if we have a right to chose the way we live, the logical conclusion is that we can chose to die given that the endpoint of life is universally death.
"In some settings"
Establishing that someone has a right to choose death, however, does not mean that as a society must accept that choice unconditionally. Death by its nature is irreversible and the tenacity for the will to live is so strong that in most settings we would consider the voluntary act to extinguish life to be contrary to the human condition. We, for example, almost always consider a victim of suicide to be a tragedy and would aim to prevent it if possible. Mosts survivors of attempted suicide retrospectively view those events of their life as extreme low points.
In what settings then would euthanasia be considered acceptable?
Let us first describe an unambiguous case. A person with terminal metastatic cancer with extreme pain who has an expected lifespan measured in hours to days. By giving a sufficiently high dose of analgesic to control symptoms, a hastened death would be likely. I think that most people would consider the ethical duty to treat the distressing symptoms to overwhelm the ethical duty to not harm the patient (indeed, what further harm can be done?)
I think it is important to recognise this case. The reason being is that this is clinical reality and it happens every day across the globe and has been the case for centuries. It is important to note at this stage that many people do not consider this to be "euthanasia" as the argument is that the aim of the active treatment is to treat symptoms rather than to hasten death. Nevertheless, I feel that this may be a case of intellectual sophistry as we are still knowingly hastening death.
The "real" public debate on euthanasia
The above scenario is not really debated except as a point of grounding. That is not the "real" debate on euthanasia. When someone is on the "cusp" of death for the most part the debate is rendered irrelevant.
The real debate is for someone like Dr John Elliot as described in the above article. I quote verbatim(1):
"It is minus 5 degrees outside in Zurich and she knots a white scarf around his neck. As he walks out the door he breathes and says faintly: "I'm free."The real debate on euthanasia is someone who has a terminal illness who prefer death rather than face an expected adverse effect on their quality of life in the near future, and they are otherwise well enough such that they are at minimal risk of dying from natural causes in the short to medium term.
The taxi drives a few blocks to a snowy, suburban street. In the ground-floor flat of a plain, four-storey building they meet a male nurse and a female social worker.
They sign documents. Dr Elliott, from Rose Bay in Sydney, takes a preparation to prevent vomiting. The nurse, Arthur, mixes a drink containing the barbiturate sodium pentobarbital and water.
As they wait 30 minutes for the anti-emetic to take effect they drink a cognac and chat. Arthur says he is from Davos, in the mountains. Oh, Dr Elliott says. He and Angelika used to go to the nearby village of Clavedel. They had so many happy days there.
With a video tape rolling, for legal purposes, Arthur asks Dr Elliott whether he realises that if he takes the drink he will die. Dr Elliott says he does.
"You can opt out at any time," the nurse says, several times.
"No," says Dr Elliott, an American-born doctor who never practised in Australia.
"I just want to get going. Hurry up."
About 10.10, sitting in a chair, Angelika holding his hand, he drinks. "It's not bitter at all," he says, surprised.
He has another cognac. His wife hugs him for the last time in 34 years of marriage. He starts to look drowsy, then his head nods forward, like any person falling asleep. In 15 minutes he is dead.
Dr Elliott spent the last hour of his life as he spent his last three months, unflinchingly determined to die."
The criteria for allowing euthanasia
If we accept then that (i) people have a fundamental right to chose death in some settings, and (ii) there is at least one unambiguous scenario where euthanasia is considered a clinical norm, what then follows as the criteria we use to "allow" people to choose death?
1. "Personal choice and competence"
Although this is needed, it is clearly not enough. Many people with depression who attempt suicide also "choose" their actions but we rightly (i) try to prevent suicides and (ii) try to resuscitate people who have had a suicide.
So thus, we must establish that people who make this "personal choice" are competent to do so. This is not a trivial thing to do. It is essentially a contradiction to ask whether someone who wants to suicide is in the "right mind" to choose it.
An analogy: someone who is hypomanic often feels fantastic when they are unwell. If they are an intelligent hypomanic, then they can make the most convincing arguments against treatment. how it is their "choice" to remain this way. Indeed, "people with hypomania are generally perceived as being energetic, euphoric, overflowing with new ideas, and sometimes highly confident and charismatic."(3) This of course all falls down then either they are treated or the hypomania stops. When they are well, they have the insight to their illness, which is why for the most part, we still treat people with mild bipolar disorder.
Establishing whether someone is in the "right mind" to chose death is not an easy thing as the experience of suicidal thoughts are that they go away when the underlying affective disorder or social situation improves.
Thus, not only must it be the personal choice of the person, but it must be established that they are completely free from all mental illness; something that I believe to be difficult to establish in someone with a terminal malignancy.
2. Delegation of responsibility
Following on from personal choice and competence comes the question whether the responsibility of the choice can be delegated to others; for example, the family, the treating doctor, a carer/guarding, a public guardian, or even some form of advanced directive. This is highly relevant considering that many terminal illnesses may lead to a decline in cognitive function.
The answer to this is fraught with dilemma. There are practical considerations but at the same time, there are obvious inherent conflicts of interest:
- family (release from burden of care, potential financial payout);
- doctor/health system (release from burden of care / lower health costs);
- a public guardian (the shorter the lifespan of their client, the less work they have to do).
For a person with a terminal illness, there are many stakeholders apart from the ill person who would benefit from a hastened death. Where there is a legislated pathway, there would also be a huge potential for abuse, unless, it was strictly regulated.
3. "Terminal condition"
Must there be a "terminal condition" for a patient to choose euthanasia? This is a hard question. One must consider people with multiple sclerosis, motor neurone disease and degenerative neuromuscular diseases. In themselves they are not "terminal" in the way malignancies are.
In the follow on from this question is the time frame. Too short a time frame and it would exclude just about everyone. Too long a time frame and there will be a subset of patients who may not have had a terminal illness at all.
For example, let's say that an inclusion criteria is that your expected lifespan must be less than 6 months. A small percentage of these patients may live for years if they are not euthanised ("life expectancy" is firstly a grouped average and secondly is more art than science).
Thus, if we use "presence of a terminal condition" as an inclusion criteria, it necesitates a time frame and the time frame chosen will be purely arbitrary.
4. Quality of life
Must the patient have an expected deterioration in their quality of life? The answer would appear to be "yes", but, the devil is in the details. How much reduction?
Furthermore, can this even be competently determined on an a priori basis?
For example, requiring a colostomy bag may be the worst thing that a particular person can imagine. The reality of a colostomy bag, however, may be much less onerous. On the other hand, managing a colostomy may actually be a terrible imposition on that person if they had to do it.
Thus if we accept that we must take quality of life into account, we must not only gauge whether the expected reduction is real, but also whether the person has realistic expectations. Clearly, euthanasia should not have a place as a method of treating a person's fears of the future.
5. Other problems - refusal of standand therapy
If we permit euthanasia, could a patient be included if they refuse standard therapy?
Examples:
A person has an operable colon cancer but it would involve a colectomy (i.e., colostomy bag) with chemotherapy. They refuse treatment (clearly within a persons right to choose) but wants euthanasia (so not to have to experience cancer death).
A more subtle example:
A person has metastatic melanoma (i.e., inoperable) but targeted radiotherapy and chemotherapy / immunotherapy could lead to significant improvement in both quality and quantity of life. They refuse treatment (again clearly within their right) but wants euthanasia (so not to have to experience cancer death).
The significance of these questions is that they are realistic. Most patients in fact do have options other than euthanasia; treatment modalities that would either improve their symptom control and/or improve their lifespan.
Practical implications of legalised euthanasia
The point of the above discussed criteria is to highlight that if euthanasia were permitted, it would by necessity be rigidly regulated, and that any inclusion and exclusion criteria arbitrary and at some level, inconsistent. Many people who may "benefit" from euthanasia will still not have access to it. Some people who are euthanised will on retrospectively analysis be considered to have been a bad decision.
To a certain level, clinics like Dignitas as described in the Sydney Morning Herald article work because they are a rare and limited service and their clients are highly self-selected motivated individuals.
For a widely available and accessible service (which would be the implication of "legalised" euthanasia) a lot of money will need to go into the regulatory framework. From an economic point of view, one must consider whether the manpower, intellectual investment and money would be better spent elsewhere (e.g., palliative care).
"Passive" and "active" euthanasia - consideration of ethics
"Active" euthanasia is when "the medical professionals, or another person, deliberately does something that causes the patient to die"(4).
For the most part, "active" euthanasia is illegal in both Australia and worldwide (with a few exceptions).
"Passive" euthanasia occurs when "the patient dies because the medical professionals either don't do something necessary to keep the patient alive, or when they stop doing something that is keeping the patient alive". Activities that would fit this definition is legal and in many places part of standard therapy. It is considered a practical necessity.
However, is there actually an ethical difference between the two?
Some people argue that there isn't. Giving someone a lethal cocktail to hasten death is an active process on the part of the health professional. Withdrawal of active therapy is also an active process. Even withholding therapy (e.g., not giving further blood transfusions) is at a cognitive level an active management choice.
Thus, it can be argued that given we accept withdrawal of therapy as a valid medical decision, and that there is no ethical distinction between this and so called "active euthanasia", the logical conclusion is that euthanasia should not only be legal but performed were clinically appropriate.
There is a lot of appeal to this argument but I believe that it suffers from a flaw.
- "Active" euthanasia leads to death due to the intervention given by the medical practitioner.
- "Passive" euthanasia leads to death due to the natural history of the disease.
If you believe that this makes a difference then it means that "passive" euthanasia cannot be lumped in the same class as "active" euthanasia.
If you don't believe that it makes a difference (i.e., planned active decision resulting in death in both cases) then it can even be argued that active euthanasia is morally superior as it results in less distress and discomfort for the patient.
I believe that it makes a difference (my personal opinion).
It is the duty of doctors to improve health and prolong life, but not prevent death by all means possible (which is impossible). Death is a part of life and part of being a doctor is to allow people to die. That is, I don't believe that there is any ethical principle against letting people die from "natural" reasons. Quotation from the 19th century poet Arthur Hugh Clough:
"Thou shalt not kill but needst not strive, officiously, to keep alive."
There is, however, the ethical principle of non-maleficence - i.e., we should refrain from something that harms a patient. Is providing active euthanasia to a patient who desires death it "harming them"? It can be argued either way.
Thus the conclusion is that "passive euthanasia" is okay but "active euthanasia" may or may not be okay on a medical ethics basis, and, that there is a distinction between the two. This is somewhat the status quo though there are strong differing points of view within bioethics.
Reference articles
- Button, James. My name is Dr John Elliott and I'm about to die, with my head held high. The Sydney Morning Herald. 26 January 2007. [Link]
- Dignitas: Swiss suicide helpers. BBC News. 20 January 2003. [Link]
- Hypomania. Wikipedia. Accessed 4 February 2007 (last updated 23 January 2007). [Link]
- Active and passive euthanasia. BBC - Religion & Ethics. Accessed 4 February 2007 (Last updated: 20 July 2006). [Link]
