TRA CIELO E TERRA



EUTHANASIA: DO PEOPLE HAVE A RIGHT TO DIE?

What is Euthanasia?

Euthanasia is the termination of a very sick person's life in order to relieve them of their suffering.

A person who undergoes euthanasia usually has an incurable condition. But there are other instances where some people want their life to be ended. In many cases, it is carried out at the person's request but there are times when they may be too ill and the decision is made by relatives, medics or, in some instances, the courts.

The term is derived from the Greek word euthanatos which means easy death.

The issue has been at the centre of very heated debates for many years and is surrounded by religious, ethical and practical considerations.

The ethics of euthanasia

Euthanasia raises a number of agonising moral dilemmas:

-- is it ever right to end the life of a terminally ill patient who is undergoing severe pain and suffering?

-- under what circumstances can euthanasia be justifiable, if at all?

-- is there a moral difference between killing someone and letting them die?

At the heart of these arguments are the different ideas that people have about the meaning and value of human existence.

Should human beings have the right to decide on issues of life and death?

There are also a number of arguments based on practical issues. Some people think that euthanasia shouldn't be allowed, even if it was morally right, because it could be abused and used as a cover for murder.

Killing or letting die

Euthanasia can be carried out either by taking actions, including giving a lethal injection, or by not doing what is necessary to keep a person alive (such as failing to keep their feeding tube going).

'Extraordinary' medical care

It is not euthanasia if a patient dies as a result of refusing extraordinary or burdensome medical treatment.

Euthanasia and pain relief

It's not euthanasia to give a drug in order to reduce pain, even though the drug causes the patient to die sooner. This is because the doctor's intention was to relieve the pain, not to kill the patient. This argument is sometimes known as the Doctrine of Double Effect.

The doctrine of double effect

This doctrine says that if doing something morally good has a morally bad side-effect it's ethically OK to do it providing the bad side-effect wasn't intended. This is true even if you foresaw that the bad effect would probably happen.

The principle is used to justify the case where a doctor gives drugs to a patient to relieve distressing symptoms even though he knows doing this may shorten the patient's life.

This is because the doctor is not aiming directly at killing the patient - the bad result of the patient's death is a side-effect of the good result of reducing the patient's pain.

Many doctors use this doctrine to justify the use of high doses of drugs such as morphine for the purpose of relieving suffering in terminally-ill patients even though they know the drugs are likely to cause the patient to die sooner.

Factors involved in the doctrine of double effect

-- The good result must be achieved independently of the bad one: For the doctrine to apply, the bad result must not be the means of achieving the good one. So if the only way the drug relieves the patient's pain is by killing him, the doctrine of double effect doesn't apply.

-- The action must be proportional to the cause: If I give a patient a dose of drugs so large that it is certain to kill them, and that is also far greater than the dose needed to control their pain, I can't use the Doctrine of Double Effect to say that what I did was right.

-- The action must be appropriate (a): I also have to give the patient the right medicine. If I give the patient a fatal dose of pain-killing drugs, it's no use saying that my intention was to relieve their symptoms of vomiting if the drug doesn't have any effect on vomiting.

-- The action must be appropriate (b): I also have to give the patient the right medicine for their symptoms. If I give the patient a fatal dose of pain-killing drugs, it's no use saying that my intention was to relieve their symptoms of pain if the patient wasn't suffering from pain but from breathlessness.

-- The patient must be in a terminal condition: If I give the patient a fatal dose of pain-killing drugs and they would have recovered from their disease or injury if I hadn't given them the drugs, it's no use saying that my intention was to relieve their pain. And that applies even if there was no other way of controlling their pain.

Problems with the doctrine of double effect

Some philosophers think this argument is too clever for its own good.

--We are responsible for all the anticipated consequences of our actions: If we can foresee the two effects of our action we have to take the moral responsibility for both effects - we can't get out of trouble by deciding to intend only the effect that suits us.

--Intention is irrelevant: Some people take the view that it's sloppy morality to decide the rightness or wrongness of an act by looking at the intention of the doctor. They think that some acts are objectively right or wrong, and that the intention of the person who does them is irrelevant. But most legal systems regard the intention of a person as a vital element in deciding whether they have committed a crime, and how serious a crime, in cases of causing death.

--Death is not always bad - so double effect is irrelevant: Other philosophers say that the Doctrine of Double Effect assumes that we think that death is always bad. They say that if continued life holds nothing for the patient but the negative things of pain and suffering, then death is a good thing, and we don't need to use the doctrine of double effect.

--Double effect can produce an unexpected moral result: If you do think that a quicker death is better than a slower one then the Doctrine of Double Effect shows that a doctor who intended to kill the patient is morally superior to a doctor who merely intended to relieve pain.

The Sulmasy test - Daniel P. Sulmasy has put forward a way for a doctor to check what their intention really is. The doctor should ask himself, "If the patient were not to die after my actions, would I feel that I had failed to accomplish what I had set out to do?"

Mercy killing

Very often people call euthanasia 'mercy killing', perhaps thinking of it for someone who is terminally ill and suffering prolonged, unbearable pain.

Why people want euthanasia

Most people think unbearable pain is the main reason people seek euthanasia, but some surveys in the USA and the Netherlands showed that less than a third of requests for euthanasia were because of severe pain. Terminally ill people can have their quality of life severely damaged by physical conditions such as incontinence, nausea and vomiting, breathlessness, paralysis and difficulty in swallowing. Psychological factors that cause people to think of euthanasia include depression, fearing loss of control or dignity, feeling a burden, or dislike of being dependent.



Overview of pro-euthanasia arguments

Arguments in favour of euthanasia can be broken down into a few main categories:

Arguments based on rights

-- People have an explicit right to die

-- A separate right to die is not necessary, because our other human rights imply the right to die

-- Death is a private matter and if there is no harm to others, the state and other people have no right to interfere (a libertarian argument)

Practical arguments

-- It is possible to regulate euthanasia

-- Death is a private matter and if there is no harm to others, the state and other people have no right to interfere (a libertarian argument)

-- Allowing people to die may free up scarce health resources (this is a possible argument, but no authority has seriously proposed it)

-- Euthanasia happens anyway (a utilitarian or consequentialist argument)

Philosophical arguments

-- Euthanasia satisfies the criterion that moral rules must be universalisable

-- Euthanasia happens anyway (a utilitarian or consequentialist argument)

-- Is death a bad thing?

Arguments about death itself

--Is death a bad thing?

Regulating euthanasia

Those in favour of euthanasia think that there is no reason why euthanasia can't be controlled by proper regulation, but they acknowledge that some problems will remain.

For example, it will be difficult to deal with people who want to implement euthanasia for selfish reasons or pressurise vulnerable patients into dying.

This is little different from the position with any crime. The law prohibits theft, but that doesn't stop bad people stealing things.

People have the right to die

Human beings have the right to die when and how they want to

In...cases where there are no dependants who might exert pressure one way or the other, the right of the individual to choose should be paramount. So long as the patient is lucid, and his or her intent is clear beyond doubt, there need be no further questions. - The Independent, March 2002

Many people think that each person has the right to control his or her body and life and so should be able to determine at what time, in what way and by whose hand he or she will die.

Behind this lies the idea that human beings should be as free as possible - and that unnecessary restraints on human rights are a bad thing.

And behind that lies the idea that human beings are independent biological entities, with the right to take and carry out decisions about themselves, providing the greater good of society doesn't prohibit this. Allied to this is a firm belief that death is the end.

Religious objections

Religious opponents disagree because they believe that the right to decide when a person dies belongs to God.

Secular objections

Secular opponents argue that whatever rights we have are limited by our obligations. The decision to die by euthanasia will affect other people - our family and friends, and healthcare professionals - and we must balance the consequences for them (guilt, grief, anger) against our rights.

We should also take account of our obligations to society, and balance our individual right to die against any bad consequences that it might have for the community in general.

These bad consequences might be practical - such as making involuntary euthanasia easier and so putting vulnerable people at risk.

There is also a political and philosophical objection that says that our individual right to autonomy against the state must be balanced against the need to make the sanctity of life an important, intrinsic, abstract value of the state.

Secular philosophers put forward a number of technical arguments, mostly based on the duty to preserve life because it has value in itself, or the importance of regarding all human beings as ends rather than means.

Other human rights imply a right to die

Without creating (or acknowledging) a specific right to die, it is possible to argue that other human rights ought to be taken to include this right.

The right to life includes the right to die

-- The right to life is not a right simply to exist

-- The right to life is a right to life with a minimum quality and value

-- Death is the opposite of life, but the process of dying is part of life

-- Dying is one of the most important events in human life

-- Dying can be good or bad

-- People have the right to try and make the events in their lives as good as possible

-- So they have the right to try to make their dying as good as possible

-- If the dying process is unpleasant, people should have the right to shorten it, and thus reduce the unpleasantness

-- People also have obligations - to their friends and family, to their doctors and nurses, to society in general

-- These obligations limit their rights

-- These obligations do not outweigh a person's right to refuse medical treatment that they do not want

-- But they do prevent a patient having any right to be killed

-- But even if there is a right to die, that doesn't mean that doctors have a duty to kill, so no doctor can be forced to help the patient who wants euthanasia.

The right not to be killed

The right to life gives a person the right not to be killed if they don't want to be.

Those in favour of euthanasia will argue that respect for this right not to be killed is sufficient to protect against misuse of euthanasia, as any doctor who kills a patient who doesn't want to die has violated that person's rights.

Opponents of euthanasia may disagree, and argue that allowing euthanasia will greatly increase the risk of people who want to live being killed. The danger of violating the right to life is so great that we should ban euthanasia even if it means violating the right to die.

The rights to privacy and freedom of belief include a right to die

This is the idea that the rights to privacy and freedom of belief give a person the right to decide how and when to die.

The European Convention on Human Rights gives a person the right to die

-- Not according to Britain's highest court.

-- It concluded that the right to life did not give any right to self-determination over life and death, since the provisions of the convention were aimed at protecting and preserving life.

English law already acknowledges that people have the right to die

This argument is based on the fact that the Suicide Act (1961) made it legal for people to take their own lives.

Opponents of euthanasia may disagree:

-- The Suicide Act doesn't necessarily acknowledge a right to die;

-- it could simply acknowledge that you can't punish someone for succeeding at suicide

-- and that it's inappropriate to punish someone so distressed that they want to take their own life.

Euthanasia opponents further point out that there is a moral difference between decriminalising something, often for practical reasons like those mentioned above, and encouraging it.

They can quite reasonably argue that the purpose of the Suicide Act is not to allow euthanasia, and support this argument by pointing out that the Act makes it a crime to help someone commit suicide. This is true, but that provision is really there to make it impossible to escape a murder charge by dressing the crime up as an assisted suicide.

Libertarian argument

This is a variation of the individual rights argument.

-- If an action promotes the best interests of everyone concerned and violates no one's rights then that action is morally acceptable

-- In some cases, euthanasia promotes the best interests of everyone involved and violates no one's rights

-- It is therefore morally acceptable

Objections to this argument

Opponents attack the libertarian argument specifically by claiming that there are no cases that fit the conditions above:

-- people sometimes think things are in their best interests that are not morally acceptable (the arguments that euthanasia is intrinsically wrong fit in here)

-- people are sometimes wrong about what's in their best interests

-- people may not realise that committing euthanasia may harm other people

-- euthanasia may deprive both the person who dies and others of benefits

-- euthanasia is not a private act - we cannot ignore any bad effects it may have on society in general

Medical resources

Euthanasia may be necessary for the fair distribution of health resources

This argument has not been put forward publicly or seriously by any government or health authority. It is included here for completeness.

In most countries there is a shortage of health resources.

As a result, some people who are ill and could be cured are not able to get speedy access to the facilities they need for treatment.

At the same time health resources are being used on people who cannot be cured, and who, for their own reasons, would prefer not to continue living.

Allowing such people to commit euthanasia would not only let them have what they want, it would free valuable resources to treat people who want to live.

Abuse of this would be prevented by only allowing the person who wanted to die to intitiate the process, and by regulations that rigorously prevented abuse.

Objections to this argument

This proposal is an entirely pragmatic one; it says that we should allow euthanasia because it will allow more people to be happy. Such arguments will not convince anyone who believes that euthanasia is wrong in principle.

Others will object because they believe that such a proposal is wide-open to abuse, and would ultimately lead to involuntary euthanasia because of shortage of health resources.

In the end, they fear, people will be expected to commit euthanasia as soon as they become an unreasonable burden on society.

Moral rules must be universalisable

One of the commonly accepted principles in ethics, put forward by Immanuel Kant, is that only those ethical principles that could be accepted as a universal rule (i.e. one that applied to everybody) should be accepted.

So you should only do something if you're willing for anybody to do exactly the same thing in exactly similar circumstances, regardless of who they are.

The justification for this rule is hard to find - many people think it's just an obvious truth (philosophers call such truths self-evident). You find variations of this idea in many faiths; for example "do unto others as you would have them do unto you".

To put it more formally: A rule is universalisable if it can consistently be willed as a law that everyone ought to obey. The only rules which are morally good are those which can be universalised.

The person in favour of euthanasia argues that giving everybody the right to have a good death through euthanasia is acceptable as a universal principle, and that euthanasia is therefore morally acceptable.

This alone does not justify euthanasia

This is sound, but is not a full justification.

If a person wants to be allowed to commit euthanasia, it would clearly be inconsistent for them to say that they didn't think it should be allowed for other people.

But the principle of universalisability doesn't actually provide any positive justification for anything - genuine moral rules must be universalisable, but universalisability is not enough to say that a rule is a satisfactory moral rule.

Universalisability is therefore only a necessary condition, not a sufficient condition for a rule to be a morally good rule.

So, other than showing that one pre-condition is met, universalisibility doesn't advance the case for euthanasia at all.

How similar can situations be?

Every case is different in some respect, so anyone who is inclined to argue about it can argue about whether the particular differences are sufficent to make this case an exception to the rule.

Universal exceptions to universal rules

Oddly enough, the law of universalisability allows for there to be exceptions - as long as the exceptions are themselves universalisable. So you could have a universal rule allowing voluntary euthanasia and universalise an exception for people who were less than 18 years old.

Euthanasia happens anyway

Euthanasia happens - better to make it legal and regulate it properly

Sounds a bit like "murder happens - better to make it legal and regulate it properly".

When you put it like that, the argument sounds very feeble indeed.

But it is one that is used a lot in discussion, and particularly in politics or round the table in the pub or the canteen.

People say things like "we can't control drugs so we'd better legalise them", or "if we don't make abortion legal so that people can have it done in hospital, people will die from backstreet abortions".

What lies behind it is Utilitarianism: the belief that moral rules should be designed to produce the greatest happiness of the greatest number of people.

If you accept this as the basis for your ethical code (and it's the basis of many people's ethics), then the arguments above are perfectly sensible.

If you don't accept this principle, but believe that certain things are wrong regardless of what effect they have on total human happiness, then you will probably regard this argument as cynical and wrong.

A utilitarian argument for euthanasia

From a utilitarian viewpoint, justifying euthanasia is a question of showing that allowing people to have a good death, at a time of their own choosing, will make them happier than the pain from their illness, the loss of dignity and the distress of anticipating a slow, painful death. Someone who wants euthanasia will have already made this comparison for themselves.

But utilitarianism deals with the total human happiness, not just that of the patient, so that even euthanasia opponents who agree with utilitarianism in principle can claim that the negative effects on those around the patient - family, friends and medical staff - would outweigh the benefit to the patient.

It is hard to measure happiness objectively, but one way to test this argument would be to speak to the families and carers of people who had committed assisted suicide.

Opponents can also argue that the net effect on the whole of society will be a decrease in happiness. The only way to approach this would be to look at countries where euthanasia is legal. However, as no two countries are alike, it seems impossible to extricate the happiness or unhappiness resulting from legal assisted suicide, from any happiness or unhappiness from other sources.

Even if you agree with the utilitarian argument, you then have to deal with the arguments that suggest that euthanasia can't be properly regulated.

Is death a bad thing?

Why ask this question?

If death is not a bad thing then many of the objections to euthanasia vanish.

If we put aside the idea that death is always a bad thing, we are able to consider whether death may actually sometimes be a good thing.

This makes it much easier to consider the issue of euthanasia from the viewpoint of someone who wants euthanasia.

Why is death a bad thing?

We tend to regard death as a bad thing for one or more of these reasons:

-- because human life is intrinsically valuable

-- because life and death are God's business with which we shouldn't interfere

-- because most people don't want to die

-- because it violates our autonomy in a drastic way

The first two reasons form key points in the arguments against euthanasia, but only if you accept that they are true.

The last two reasons why death is a bad thing are not absolute; if a person wants to die, then neither of those reasons can be used to say that they would be wrong to undergo euthanasia.

People don't usually want to die

People are usually eager to avoid death because they value being alive, because they have many things they wish to do, and experiences they wish to have.

Obviously, this is not the case with a patient who wishes to die - and proper regulation will weed out people who do not really want to die, but are asking for other reasons.

Violation of autonomy

Another reason why death is seen as a bad thing is that it's the worst possible violation of the the wishes of the person who does not want to die (or, to use philosophical language, a violation of their autonomy).

In the case of someone who does want to die, this objection disappears.

Being dead, versus not having been born

Some people say that being dead is no different from not having been born yet, and nobody makes a fuss about the bad time they had before they were born.

There is a big difference - even though being dead will be no different as an experience from the experience of not having yet been born.

The idea is that death hurts people because it stops them having more of the things that they want, and could have if they continued to live.

Someone who makes a request for euthanasia is likely to have a bad quality of life (or a bad prognosis, even if they are not yet suffering much) and the knowledge that this will only get worse. If that is the case, death will not deprive them of an otherwise pleasant existence.

Of course, most patients will still be leaving behind some things that are good: for example, loved ones and things they enjoy. Asking for death does not necessarily mean that they have nothing to live for: only that the patient has decided that after a certain point, the pain outweighs the good things.



Overview of anti-euthanasia arguments

It's possible to argue about the way we've divided up the arguments, and many arguments could fall into more categories than we've used.

Ethical arguments

-- Euthanasia weakens society's respect for the sanctity of life

-- Accepting euthanasia accepts that some lives (those of the disabled or sick) are worth less than others

-- Voluntary euthanasia is the start of a slippery slope that leads to involuntary euthanasia and the killing of people who are thought undesirable

-- Euthanasia might not be in a person's best interests

-- Euthanasia affects other people's rights, not just those of the patient

Practical arguments

-- Proper palliative care makes euthanasia unnecessary

-- There's no way of properly regulating euthanasia

-- Allowing euthanasia will lead to less good care for the terminally ill

-- Allowing euthanasia undermines the committment of doctors and nurses to saving lives

-- Euthanasia may become a cost-effective way to treat the terminally ill

-- Allowing euthanasia will discourage the search for new cures and treatments for the terminally ill

-- Euthanasia undermines the motivation to provide good care for the dying, and good pain relief

-- Euthanasia gives too much power to doctors

-- Euthanasia exposes vulnerable people to pressure to end their lives

-- Moral pressure on elderly relatives by selfish families

-- Moral pressure to free up medical resources

-- Patients who are abandoned by their families may feel euthanasia is the only solution

Historical arguments

--Voluntary euthanasia is the start of a slippery slope that leads to involuntary euthanasia and the killing of people who are thought undesirable

Religious arguments

-- Euthanasia is against the word and will of God

-- Euthanasia weakens society's respect for the sanctity of life

-- Suffering may have value

-- Voluntary euthanasia is the start of a slippery slope that leads to involuntary euthanasia and the killing of people who are thought undesirable

Against the will of God

Religious people don't argue that we can't kill ourselves, or get others to do it. They know that we can do it because God has given us free will. Their argument is that it would be wrong for us to do so.

They believe that every human being is the creation of God, and that this imposes certain limits on us. Our lives are not only our lives for us to do with as we see fit.

To kill oneself, or to get someone else to do it for us, is to deny God, and to deny God's rights over our lives and his right to choose the length of our lives and the way our lives end.

The value of suffering

Religious people sometimes argue against euthanasia because they see positive value in suffering.

Down through the centuries and generations it has been seen that in suffering there is concealed a particular power that draws a person interiorly close to Christ, a special grace.

Pope John Paul II, Salvifici Doloris, 1984

The religious attitude to suffering

Most religions would say something like this: We should relieve suffering when we can, and be with those who suffer, helping them to bear their suffering, when we can't. We should never deal with the problem of suffering by eliminating those who suffer.

The nature of suffering

Christianity teaches that suffering can have a place in God's plan, in that it allows the sufferer to share in Christ's agony and his redeeming sacrifice. They believe that Christ will be present to share in the suffering of the believer.

Pope John Paul II wrote that "It is suffering, more than anything else, which clears the way for the grace which transforms human souls."

However while the churches acknowledge that some Christians will want to accept some suffering for this reason, most Christians are not so heroic.

So there is nothing wrong in trying to relieve someone's suffering. In fact, Christians believe that it is a good to do so, as long as one does not intentionally cause death.

Dying is good for us

Some people think that dying is just one of the tests that God sets for human beings, and that the way we react to it shows the sort of person we are, and how deep our faith and trust in God is.

Others, while acknowledging that a loving God doesn't set his creations such a horrible test, say that the process of dying is the ultimate opportunity for human beings to develop their souls.

When people are dying they may be able, more than at any time in their life, to concentrate on the important things in life, and to set aside the present-day 'consumer culture', and their own ego and desire to control the world. Curtailing the process of dying would deny them this opportunity.

Eastern religions

Several Eastern religions believe that we live many lives and the quality of each life is set by the way we lived our previous lives.

Those who believe this think that suffering is part of the moral force of the universe, and that by cutting it short a person interferes with their progress towards ultimate liberation.

A non-religious view

Some non-religious people also believe that suffering has value. They think it provides an opportunity to grow in wisdom, character, and compassion.

Suffering is something which draws upon all the resources of a human being and enables them to reach the highest and noblest points of what they really are.

Suffering allows a person to be a good example to others by showing how to behave when things are bad.

M Scott Peck, author of The Road Less Travelled, has written that in a few weeks at the end of life, with pain properly controlled a person might learn “how to negotiate a middle path between control and total passivity, about how to welcome the responsible care of strangers, about how to be dependent once again ... about how to trust and maybe even, out of existential suffering, at least a little bit about how to pray or talk with God.” - M Scott Peck.

The nature of suffering

It isn't easy to define suffering - most of us can decide when we are suffering but what is suffering for one person may not be suffering for another.

It's also impossible to measure suffering in any useful way, and it's particularly hard to come up with any objective idea of what constitutes unbearable suffering, since each individual will react to the same physical and mental conditions in a different way.

Sanctity of life

This argument says that euthanasia is bad because of the sanctity of human life.

There are four main reasons why people think we shouldn't kill human beings:

-- All human beings are to be valued, irrespective of age, sex, race, religion, social status or their potential for achievement

-- Human life is a basic good as opposed to an instrumental good, a good in itself rather than as a means to an end

-- Human life is sacred because it's a gift from God

-- Therefore the deliberate taking of human life should be prohibited except in self-defence or the legitimate defence of others

We are valuable for ourselves

The philosopher Immanuel Kant said that rational human beings should be treated as an end in themselves and not as a means to something else. The fact that we are human has value in itself.

Our inherent value doesn't depend on anything else - it doesn't depend on whether we are having a good life that we enjoy, or whether we are making other people's lives better. We exist, so we have value.

Most of us agree with that - though we don't put it in philosopher-speak. We say that we don't think that we should use other people - which is a plain English way of saying that we shouldn't treat other people as a means to our own ends.

We must respect our own value

It applies to us too. We shouldn't treat ourselves as a means to our own ends.

And this means that we shouldn't end our lives just because it seems the most effective way of putting an end to our suffering. To do that is not to respect our inherent worth.

The slippery slope

Many people worry that if voluntary euthanasia were to become legal, it would not be long before involuntary euthanasia would start to happen.

We concluded that it was virtually impossible to ensure that all acts of euthanasia were truly voluntary and that any liberalisation of the law in the United Kingdom could not be abused.

We were also concerned that vulnerable people - the elderly, lonely, sick or distressed - would feel pressure, whether real or imagined, to request early death.

Lord Walton, Chairman, House of Lords Select Committee on Medical Ethics looking into euthanasia, 1993

This is called the slippery slope argument. In general form it says that if we allow something relatively harmless today, we may start a trend that results in something currently unthinkable becoming accepted.

Those who oppose this argument say that properly drafted legislation can draw a firm barrier across the slippery slope.

Various forms of the slippery slope argument

If we change the law and accept voluntary euthanasia, we will not be able to keep it under control.

--Proponents of euthanasia say: Euthanasia would never be legalised without proper regulation and control mechanisms in place

Doctors may soon start killing people without bothering with their permission.

-- Proponents say: There is a huge difference between killing people who ask for death under appropriate circumstances, and killing people without their permission

-- Very few people are so lacking in moral understanding that they would ignore this distinction

-- Very few people are so lacking in intellect that they can't make the distinction above

-- Any doctor who would ignore this distinction probably wouldn't worry about the law anyway

Health care costs will lead to doctors killing patients to save money or free up beds:

-- Proponents say: The main reason some doctors support voluntary euthanasia is because they believe that they should respect their patients' right to be treated as autonomous human beings

-- That is, when doctors are in favour of euthanasia it's because they want to respect the wishes of their patients

-- So doctors are unlikely to kill people without their permission because that contradicts the whole motivation for allowing voluntary euthanasia

-- But cost-conscious doctors are more likely to honour their patients' requests for death

-- A 1998 study found that doctors who are cost-conscious and 'practice resource-conserving medicine' are significantly more likely to write a lethal prescription for terminally-ill patients [Arch. Intern. Med., 5/11/98, p. 974]

-- This suggests that medical costs do influence doctors' opinions in this area of medical ethics

The Nazis engaged in massive programmes of involuntary euthanasia, so we shouldn't place our trust in the good moral sense of doctors.

-- Proponents say: The Nazis are not a useful moral example, because their actions are almost universally regarded as both criminal and morally wrong

-- The Nazis embarked on invountary euthanasia as a deliberate political act - they didn't slip into it from voluntary euthanasia (although at first they did pretend it was for the benefit of the patient)

-- What the Nazis did wasn't euthanasia by even the widest definition, it was the use of murder to get rid of people they disapproved of

-- The universal horror at Nazi euthanasia demonstrates that almost everyone can make the distinction between voluntary and involuntary euthanasia

-- The example of the Nazis has made people more sensitive to the dangers of involuntary euthanasia

Allowing voluntary euthanasia makes it easier to commit murder, since the perpetrators can disguise it as active voluntary euthanasia.

-- Proponents say: The law is able to deal with the possibility of self-defence or suicide being used as disguises for murder. It will thus be able to deal with this case equally well

-- To dress murder up as euthanasia will involve medical co-operation. The need for a conspiracy will make it an unattractive option

Devalues some lives

Some people fear that allowing euthanasia sends the message, "it's better to be dead than sick or disabled".

The subtext is that some lives are not worth living. Not only does this put the sick or disabled at risk, it also downgrades their status as human beings while they are alive.

The disabled person's perspective

Part of the problem is that able-bodied people look at things from their own perspective and see life with a disability as a disaster, filled with suffering and frustration.

Some societies have regarded people with disabilities as inferior, or as a burden on society. Those in favour of eugenics go further, and say that society should prevent 'defective' people from having children. Others go further still and say that those who are a burden on society should be eliminated.

People with disabilities don't agree. They say:

-- All people should have equal rights and opportunities to live good lives

-- Many individuals with disabilities enjoy living

-- Many individuals without disabilities don't enjoy living, and no-one is threatening them

-- The proper approach to people with disabilities is to provide them with appropriate support, not to kill them

-- The quality of a person's life should not be assessed by other people

-- The quality of life of a person with disabilities should not be assessed without providing proper support first

Opposition to this argument

Supporters of euthanasia would respond that this argument includes a number of completely misleading suggestions, and refute them:

-- Dying is not the same as never having been born

-- The debate is nothing to do with preventing disabled babies being born, or preventing people with disabilities from becoming parents

-- Nobody is asking for patients to be killed against their wishes - whether or not those patients are disabled

-- The euthanasia procedure is intended for use by patients who are dying, or in a condition that will get worse - most disabilities don't come under that category

-- The normal procedure for euthanasia would have to be initiated at the patient's request

-- Disabled people who are not mentally impaired are just as capable as able-bodied people of deciding what they want

-- Protections will be in place for patients who are mentally impaired, whether through disability or some other reason

-- It is possible that someone who has just become disabled may feel depressed enough to ask for death, which is why any proposed system of euthanasia must include psychological support and assessment before the patient's wish is granted

-- All people should have equal rights and opportunities to live, or to choose not to go on living

Patient's best interests

A serious problem for supporters of euthanasia are the number of cases in which a patient may ask for euthanasia, or feel obliged to ask for it, when it isn't in their best interest. Some examples are listed below:

-- the diagnosis is wrong and the patient is not terminally ill

-- the prognosis (the doctor's prediction as to how the disease will progress) is wrong and the patient is not going to die soon

-- the patient is getting bad medical care and their suffering could be relieved by other means

-- the doctor is unaware of all the non-fatal options that could be offered to the patient

-- the patient's request for euthanasia is actually a 'cry for help', implying that life is not worth living now but could be worth living if various symptoms or fears were managed

-- the patient is depressed and so believes things are much worse than they are

-- the patient is confused and unable to make sensible judgements

-- the patient has an unrealistic fear of the pain and suffering that lies ahead

-- the patient is feeling vulnerable

-- the patient feels that they are a worthless burden on others

-- the patient feels that their sickness is causing unbearable anguish to their family

-- the patient is under pressure from other people to feel that they are a burden

-- the patient is under pressure because of a shortage of resources to care for them

-- the patient requests euthanasia because of a passing phase of their disease, but is likely to feel much better in a while

Supporters of euthanasia say these are good reasons to make sure the euthanasia process will not be rushed, and agree that a well-designed system for euthanasia will have to take all these points into account.

Other people have rights too

Euthanasia is usually viewed from the viewpoint of the person who wants to die, but it affects other people too, and their rights should be considered: family and friends / medical and other carers / other people in a similar situation who may feel pressured by the decision of this patient / society in general

Proper palliative care

Palliative care is physical, emotional and spiritual care for a dying person when cure is not possible. It includes compassion and support for family and friends. Competent palliative care may well be enough to prevent a person feeling any need to contemplate euthanasia.

You matter because you are you. You matter to the last moment of your life and we will do all we can to help you die peacefully, but also to live until you die. - Dame Cicely Saunders, founder of the modern hospice movement

The key to successful palliative care is to treat the patient as a person, not as a set of symptoms, or medical problems. The World Health Organisation states that palliative care affirms life and regards dying as a normal process; it neither hastens nor postpones death; it provides relief from pain and suffering; it integrates the psychological and spiritual aspects of the patient.

Making things better for patient, family and friends

The patient's family and friends will need care too. Palliative care aims to enhance the quality of life for the family as well as the patient.

Effective palliative care gives the patient and their loved ones a chance to spend quality time together, with as much distress removed as possible. They can (if they want to) use this time to bring any unfinished business in their lives to a proper closure and to say their last goodbyes.

Palliative care should aim to make it easier and more attractive for family and friends to visit the dying person. A survey (USA 2001) showed that terminally ill patients actually spent the vast majority of their time on their own, with few visits from medical personnel or family members.

Spiritual care

Spiritual care may be important even for non-religious people. Spiritual care should be interpreted in a very wide sense, since patients and families facing death often want to search for the meaning of their lives in their own way.

Palliative care and euthanasia

Good palliative care is the alternative to euthanasia. If it was available to every patient, it would certainly reduce the desire for death to be brought about sooner.

But providing palliative care can be very hard work, both physically and psychologically. Ending a patient's life by injection is quicker and easier and cheaper. This may tempt people away from palliative care.

Legalising euthanasia may reduce the availability of palliative care

Some fear that the introduction of euthanasia will reduce the availability of palliative care in the community, because health systems will want to choose the most cost effective ways of dealing with dying patients.

Medical decision-makers already face difficult moral dilemmas in choosing between competing demands for their limited funds. So making euthanasia easier could exacerbate the slippery slope, pushing people towards euthanasia who may not otherwise choose it.

When palliative care is not enough

Palliative care will not always be an adequate solution:

--Pain: Some doctors estimate that about 5% of patients don't have their pain properly relieved during the terminal phase of their illness, despite good palliative and hospice care

--Dependency: Some patients may prefer death to dependency, because they hate relying on other people for all their bodily functions, and the consequent loss of privacy and dignity

--Lack of home care: Other patients will not wish to have palliative care if that means that they have to die in a hospital and not at home

--Loss of alertness: Some people would prefer to die while they are fully alert and and able to say goodbye to their family; they fear that palliative care would involve a level of pain-killing drugs that would leave them semi-anaesthetised

--Not in the final stages: Other people are grateful for palliative care to a certain point in their disease, but after that would prefer to die rather than live in a state of helplessness and distress, regardless of what is available in terms of pain-killing and comfort.

There should be no law or morality that would limit a clinical team or doctor from administering the frequent dosages of pain medication that are necessary to free people's minds from pain that shrivels the spirit and leaves no time for speaking when, at times, there are very few hours or days left for such communication. - Dr. David Roy, Director of the Centre for Bioethics, Clinical Research Institute of Montreal

Fears about regulation

Euthanasia opponents don't believe that it is possible to create a regulatory system for euthanasia that will prevent the abuse of euthanasia.

It gives doctors too much power

This argument often appears as 'doctors should not be allowed to play God'. Since God arguments are of no interest to people without faith, it's presented here with the God bit removed.

Doctors should not be allowed to decide when people die:

-- Doctors do this all the time

-- Any medical action that extends life changes the time when a person dies and we don't worry about that

-- This is a different sort of decision, because it involves shortening life

-- Doctors take this sort of decision all the time when they make choices about treatment

-- As long as doctors recognise the seriousness of euthanasia and take decisions about it within a properly regulated structure and with proper safeguards, such decisions should be acceptable

-- In most of these cases the decision will not be taken by the doctor, but by the patient. The doctor will provide information to the patient to help them make their decision

-- Since doctors give patients the information on which they will base their decisions about euthanasia, any legalisation of euthanasia, no matter how strictly regulated, puts doctors in an unacceptable position of power.

Doctors have been shown to take these decisions improperly, defying the guidelines of the British Medical Association, the Resuscitation Council (UK), and the Royal College of Nursing:

An Age Concern dossier in 2000 showed that doctors put Do Not Resuscitate orders in place on elderly patients without consulting them or their families

DNRs are Do Not Resuscitate orders. A DNR order on a patient's file means that a doctor is not required to resuscitate a patient if their heart stops and is designed to prevent unnecessary suffering.

The usual circumstances in which it is appropriate not to resuscitate are:

--when it will not restart the heart or breathing

--when there is no benefit to the patient

--when the benefits are outweighed by the burdens

Although DNRs can be regarded as a form of passive euthanasia, they are not controversial unless they are abused, since they are intended to prevent patients suffering pointlessly from the bad effects that resuscitation can cause: broken ribs, other fractures, ruptured spleen, brain damage.

--Do Not Resuscitate orders are more commonly used for older people and, in the United States, for black people, alcohol misusers, non-English speakers, and people infected with Human Immunodeficiency Virus. This suggests that doctors have stereotypes of who is not worth saving

Pressure on the vulnerable

This is another of those arguments that says that euthanasia should not be allowed because it will be abused. The fear is that if euthanasia is allowed, vulnerable people will be put under pressure to end their lives. It would be difficult, and possibly impossible, to stop people using persuasion or coercion to get people to request euthanasia when they don't really want it.

I have seen . . . AIDS patients who have been totally abandoned by their parents, brothers and sisters and by their lovers. In a state of total isolation, cut off from every source of life and affection, they would see death as the only liberation open to them. In those circumstances, subtle pressure could bring people to request immediate, rapid, painless death, when what they want is close and powerful support and love. - evidence to the Canadian Senate Committee on Euthanasia and Assisted Suicide

The pressure of feeling a burden

People who are ill and dependent can often feel worthless and an undue burden on those who love and care for them. They may actually be a burden, but those who love them may be happy to bear that burden. Nonetheless, if euthanasia is available, the sick person may pressure themselves into asking for euthanasia.

Pressure from family and others

Family or others involved with the sick person may regard them as a burden that they don't wish to carry, and may put pressure (which may be very subtle) on the sick person to ask for euthanasia.

Financial pressure

The last few months of a patient's life are often the most expensive in terms of medical and other care. Shortening this period through euthanasia could be seen as a way of relieving pressure on scarce medical resources, or family finances. It's worth noting that cost of the lethal medication required for euthanasia is less than £50, which is much cheaper than continuing treatment for many medical conditions. Some people argue that refusing patients drugs because they are too expensive is a form of euthanasia, and that while this produces public anger at present, legal euthanasia provides a less obvious solution to drug costs. If there was 'ageism' in health services, and certain types of care were denied to those over a certain age, euthanasia could be seen as a logical extension of this practice.



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