The Voluntary Euthanasia Society wants to allow people “with a severe illness from which no relief is known” to be lawfully killed” if they wish. One US euthanasia campaigner has suggested people could be killed on the basis of their previous instructions, even if they now want to live.(www. globalchange.com
Chapter Three
Laws and Legalisation
Laws are there to protect the innocent, and many believe that the innocent would be at risk if voluntary euthanasia is legalised and practised here in the UK. People may begin to feel that they ought to request euthanasia in order to spare others the burden of caring. Also it is possible that ‘murder disguised as euthanasia could readily stimulate an act of mercy’. (Harris 1985).
Legalisation of euthanasia is usually championed by those who have witnessed a loved one die in unpleasant circumstances, often without the benefits of optimal palliative care that leads to demands for a ‘right to die’. Calls for voluntary euthanasia have not been encouraged either by the failure of doctors to provide adequate symptom control, or by their insistence on providing inappropriate interventions which neither lengthen life nor improve its quality. This has provoked a distrust of doctors by patients who feel that they are being neglected or exploited. The natural reaction therefore becomes seeking to make doctors more accountable.
According to a ruling on 4th September 1996, Doctors in Scotland who withdrew treatment from permanently vegetative patients with the court’s permission did not face prosecution for killing them. In England, eight persistent vegetative state (PAVES) patients, including Tony Bland, England’s first right to die patient, died after the courts sanctioned the removal of feeding tubes. Doctors were assured informally that they would not risk prosecution if they obtained a second opinion from a consultant and discussed the matter with the patient’s relatives.
History has shown clearly that once voluntary euthanasia is legal, involuntary euthanasia follows. The British House of Lords recently recommended no change to the law on euthanasia after an extensive enquiry and in view of increasing public interest in euthanasia. In the light of Tony Bland and other cases, the House of Lords set up a Select Committee on Medical Ethics to look seriously into this issue in 1993. The submission was taken from a variety of parties and persons, which included the Department of Health, The British Medical Association, the Home Office and the Royal College of Nursing who all argued against any change in the law. Although the issue was undecided, the committee ruled that there should be no change in the law and concluded with the following statement.
‘We conclude that it was virtually impossible to ensure that all acts of euthanasia were truly voluntary and that any liberalisation of the law in the UK 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.’ (www.cmf.org.uk/ethics/twelve.htm).
In Australia, Kevin Andrews introduced The Euthanasia Law Bill 1996 into the House of Representatives on 9 September 1996 as a Private Member’s Bill. The aim of the bill was to take away the power of the legislative assemblies of the Northern Territory, the Australian Capital Territory and Norfolk Island and to make laws which permit or have the effect of permitting the form of intentional killing of another called euthanasia (which includes mercy killing) or the assisting of a person to terminate his or her life. The bill may also impact on the Territories’ powers to pass other kinds of laws that include “refusal of medical treatment”. (www.euthanasia.com).
In Netherlands, article 293 and 294 of the Dutch Criminal Code treats voluntary euthanasia and doctor assisted suicide as criminal offences, although in practice, prosecutions are rare if doctors adhere to a criteria of due care. Doctors when ending a life must be convinced that the patient’s request was voluntary, well considered and lasting. They have to be convinced that the patient was facing unbearable suffering, consult at least one other independent physician who has examined the patient and formed a judgement on the above and then reach a firm conclusion with the patient that there was no reasonable alternative solution. Finally they can terminate the life in a medically appropriate fashion.
Diane Pretty, 42, on August 2001, made the first legal challenge to Britain’s law on euthanasia. Diane, who can hardly move or speak and has to be fed through a tube, is challenging the decision of the director of public prosecutions to prosecute her husband if he helps her to commit suicide. Richard Lamerton, a spokesman of one of the campaigners against legalising euthanasia added, “Once you have killed somebody they have no rights and no choice. It would leave the door open to all sorts of dubious decisions and abuse and would mean that people with progressive illness no longer had the protection of the law and could be put under all sorts of pressure to agree to take their own lives” (Catholic World News 2001).
Chapter Four
Issues on Religion, culture, and medical opinion
Religion and politics may be virtually unmentioned in polite company, but death remains the greatest taboo especially in a multi-cultural society where we hold a diverse array of different moral views. Every year, millions of people must face death and its consequences, and accept the one certainty in life - that it will end. (Zinn 1996). The church makes an important distinction between euthanasia and what it calls ‘aggressive medical treatment’ to prolong the life of a terminally ill person. Sometimes a person’s life can be prolonged for a short period by medical treatment and if however, that treatment is both costly and distressing for both the patient and the family, it then can be judged better to allow the patient to die naturally. Different religious groups have different views on assisted suicide or euthanasia and below I will be looking on some of these views. I will also explore on some of the cultures as well as medical opinions towards euthanasia.
The Anglican Church would seem to be sympathetic, but the Roman Catholic Church and the Pope have consistently opposed the direct ending of life. They are set against euthanasia saying that human life is in the hands of God and it is not for us to regulate it. ‘Suffering in the last stages of life is part of God’s saving plan for humanity’ (Ludovic 1996). The Vatican’s 1980 Declaration in Euthanasia says that no one is permitted to ask for the act of killing, nor can any authority legitimately recommend or permit such an action. Pope John Paul approved this.
For the Hinduism, they believe that pain and suffering in terminal illness are the consequences of past actions and how one faces that will help determine the conditions of future lives. Cutting life short by medical intervention therefore interrupts this process, producing negative karma for the patient and the physician.
Islamic Koran forbids suicide or the killing of others except as punishment for adultery, killing unjustly or forsaking Islam. They believe that every human life belongs to God; the creator of life, and no one may end it or ask another to take it. The Church of England encourages its members to think through issues themselves in the light of the Christian faith and in dialogue with the Christian tradition. For many years, it has contributed to thinking about questions of life and death and is on the views that those people who become vulnerable through illness or disability deserve special care and protection. According to the church, the law relating to euthanasia is not simply concerned with public morality in that, a positive choice has to be made by society in favour of protecting the interests of its vulnerable members, even if it means limiting the freedom of others to determine their end.
In the Northern Territory of Australia, the Rights of the Terminally Ill Act 1995 are against the interests of the Aboriginal population. The existence of this legislation offends their customary law and traditional beliefs and rituals surrounding death. It is also likely to deter Aboriginal people in the Northern Territory from using health services because of fears that they will be killed without their consent. The Federal Parliament is therefore urged to intervene to protect the vulnerable groups in Australia.
In African Societies, even the most individualistic societies set very definite limits to the individual’s rights over one’s life in the prohibition of suicide. Within a society, an individual is regarded as amounting to nothing except in the context of the community but once situated in the society, they are regarded as having a value that is in principle. Every individual is seen as unique not just in a logical sense but also in a special sense defined by his or her destiny. The right to make the ultimate decision of life and death will be vested in the community rather than the individual. Accordingly, the societies have an abundance of both ordinary and special procedures forwarding off premature death.
Medical advances in sustaining life have outpaced society’s ability to deal with the profound legal, ethical, and moral aspects of issues surrounding euthanasia. The medical profession and the patient’s family have been allowed to determine the courses of action for a terminally ill patient who has raised society’s awareness and forced it to recognize the ethical and moral implications.
The medical profession is split on the legalisation of voluntary euthanasia and a large majority of doctors (60 per cent) say that they would draw the line at assisting the suicide of patients who were severely mentally disabled but not terminally ill.
Chapter Five
Pro Euthanasia and Anti Euthanasia Issues
Very few people in Britain are at either ends of the debate over euthanasia, asserting either a person’s right to die at will or a prohibition against being able to opt for death regardless of the circumstances. The vast majority falls in between, supporting euthanasia in certain qualified circumstances. For example is a survey carried out in UK which showed that 82% of people would support a law allowing doctors to end the life of someone with a ‘painful incurable disease’, up to 75% who took the view about ten years ago. At the other extreme, only 12% think law should allow euthanasia for someone who is ‘simply tired of living and wishes to die. 51% would legalise euthanasia for a person ‘who is not in much pain nor in danger of death, but becomes permanently and completely dependant on relatives for all their needs’. (British Social Attitudes 1996).
The hospice movement was started in the UK because a lot of people were dying of terminal illness. In thirty years over 200 hospices have opened and 240 hospitals now have specialist nurses. Almost 100,000 people each year are visited by home care teams, over half of all those dying of cancer. There is however arguments raised against euthanasia by the public that legalising euthanasia would put at risk a generation of the elderly, frail and emotionally vulnerable as collective pressure grows to ask for early death. Thus weakening doctor-patient relationship and some patients being fearful that they would be persuaded into agreeing to euthanasia. (British Social Attitudes 1996).
People who do not agree with voluntary euthanasia often refer to the 1967 Abortion Act and argue that the numbers of abortions which now take place every year show that the safeguards set out in the Abortion Act have been ignored. They continue to argue that such an example should be taken as a warning of what could happen if helping people who are terminally ill to die is made legal. Another striking argument against voluntary euthanasia is that many believe there is a better alternative. For example Duncan Vere suggests the real solution is not to kill those who are dying but to provide them with intensive pre-terminal care to meet their needs of pain management and death with dignity. ( Donnelan 1995).
The terminally ill are vulnerable and it could be seen as a betrayal of their rights if voluntary euthanasia is legalized because the demand for the care needed to die with dignity exceeds the supply. With more resources, excellence in care of the dying could be extended and the dying process might seem less fearful and euthanasia a negative and less attractive option.
Ironically, voluntary euthanasia legislation makes doctors less accountable, and gives them more power. Patients generally decide in favour of euthanasia on the basis of information given to them by doctors, which include information about their diagnosis, prognosis, and treatments available and anticipated degree of future suffering. Patients rest their confidence to the doctor and do not resist what the doctor suggests is right. However, diagnosis may be mistaken or misjudged or new treatments, which the doctor is unaware of, may have recently been developed or about to be developed. Also the doctor may not be up-to-date in symptom control. For example is the case of Geoffrey Lean who went into a coma after a simple operation that went wrong, and his wife was told that he would never wake up again. Yet he did wake up after only a few weeks.
Once voluntary euthanasia is legalised in a single country or state, people from neighbouring countries will take advantage of it. In this way, no territory can act in isolation. Recently there have been a number of cases here in the UK where people are travelling to Australia and Switzerland for voluntary euthanasia yet they have not been considered as terminally ill or in a vegetative state.
Chapter Six
The Slippery Slope and the Living Will
Legalisation of any sort of voluntary euthanasia would lead to a series of changes in logic and practice resulting in both non-voluntary and involuntary euthanasia. (Saunders 1992). Dutch Government statistics released in 1991 show that such a progression is inevitable. Their figures demonstrated that the sanctioning of voluntary euthanasia has led to both non-voluntary and involuntary euthanasia and so it should not be legalised.
Slippery slope is an argument frequently used against legislation and which holds that it is impossible to set secure limits on voluntary euthanasia. It states that once we have made voluntary euthanasia legal, society will soon allow involuntary euthanasia. This is based on the idea that if the law was to be changed to allow a person to help another to die, we will not be able to control it. The main objection of the slippery slope therefore, is powerful because it plays on our instinctive fear of change, of moving into other territory, of engaging in a venture which, although desirable in it, is portrayed, as too hard to control.
The evidence from other countries of legislating for euthanasia suggests that there are inadequate safeguards for removing potential sources of abuse. The slippery slope argument suggests that once euthanasia is permitted on a small scale, it will become more acceptable, hence the categories of those permitted to use euthanasia will widen. A witness from the House of Lords inquiry suggested that once active termination of life is a matter of choice for the competent people in society, the grounds for excluding non-competent people from such treatment becomes harder to defend. Other possible dangers associated with voluntary euthanasia and which people are concerned about are perhaps whereby a family would use it to hasten the death of any elderly relative for their own gain and against the elderly person’s wishes.
The Government’s law reform advisors have re-launched their campaign for ‘living wills’ which critics say amounts to legalised euthanasia. (The Daily Mail April, 1996). The law favours patients being able to make their own decisions about health care, but the practicality of ensuring this is far from clear. Living wills are an attempt to implement this with respect to refusal of certain medical treatments (such as resuscitation) should certain states of incompetence arise. Such are coma, advanced dementia, persistent vegetative state and such. The instructions of a patient in such cases are invaluable and may be formalized into written document or ‘living will’ as difficult medical decisions may need to be taken when a patient is unable to speak for him or herself.
The first case of a legal challenge to a ‘living will’ is that of Ray Noonkester, a Californian meteorologist who became terminally ill with a degenerative nerve disorder. Ray wrote down specific instructions on how he did not want to be kept alive. Unfortunately, his doctor ignored them and was hence sued for keeping Ray alive for two years.
Living wills are becoming more widely used in Britain, not only by the elderly and the AIDS sufferers but also by some of the healthy middle-aged too. No specific law has been drafted on the legality of advanced declarations. What we have at the moment is a series of individual cases where the judgements handed down indicate that doctors could be taken to courts if they fail to observe the terms of living wills. Groups such as the Patients Association, the Euthanasia Society and the Terrence Higgins Trust all produce guidance and will forms. Dr. Eva Jacobs, an academic who helped draft the Patients Association guidelines says that ‘A living will is really a matter of trust between you and your doctor.’ (Cunningham 1996).
An example of a Living Will Directive Form is attached in the following page.
Chapter Seven
Ethical dilemmas
Traditional medical ethical codes have never sanctioned euthanasia even on request for compassionate motives. For more than 2,000 years, medical practitioners have used oaths and declarations as a way of committing themselves to particular ethical principles. The Hippocratic Oath states: ‘I will give no deadly medicine to anyone if asked, nor suggest such counsel...’ The International code of Medical Ethics as originally adopted by the World Medical Association in 1949, in response to the Nasi holocaust, declares ‘a doctor must always bear in mind the obligation of preserving human life from the time of conception until death’. (www.cmf.org.uk/ethics/twelve.htm).
As the law stands at present here in the UK, doctors are at grave risk if they practise voluntary euthanasia. They have a deep responsibility to use their professional skills to act in the best interests of their patients and so it is cruel irony that law from carrying out this responsibility for some of their patients prevents them. The principal that a doctor should do no harm is an objection which is in danger of being misleading for if a patient’s desire to act according to his or her own conscience in decisions at the end of life is frustrated, the patient is clearly harmed.
Advances in medical science over the past half-century have given society the ability to prolong human life to an unimagined extent. “Extraordinary” means of sustaining life of a terminally ill patient with little or no chance of recovery is now commonplace in most hospitals. Patients are kept alive with sophisticated machinery and the body and its organs can be sustained for indefinite periods. The prohibitive financial burden placed on a patient’s family and society is another dimension of this issue. Medical equipmentt used in sustaining the patients are sophisticated and expensive. Although human life is to be valued above any financial concerns, the burden placed on society is an issue that cannot be ignored.
One of the most important developments in recent years is the increasing emphasis placed on health care providers to contain costs. In such, euthanasia or assisted suicide could become a means of cost containment. Many British doctors and nurses have concluded that the only way to secure the future of the National Health Service (NHS) is to make more treatments available only to those who can pay privately to them. This leaves out the underclass people who cannot afford such treatment. Savings to governments could become a consideration if medical care was provided rather than assisted suicide, which proves to be more expensive. This also could fill the void from cutbacks for treatments and care with the “treatment” of death.
Emotional, financial and psychological pressures could become overpowering for depressed or dependent people. If the choice of euthanasia or assisted suicide is considered as good as a decision to receive care, some people will feel guilty for not choosing death. The concern about “being a burden” could serve as a powerful force that could influence the decision. In the US, 63% of the deaths reported, fear of being a burden was expressed as a reason for requesting assisted suicide.(www.internationaltaskforce.org/faq.htm)
A number of legal considerations are involved in the issue of euthanasia. The state has the right to become very involved in euthanasia cases and can specify the number of individuals that must agree for euthanasia to be performed and also how frequently someone can sign a euthanasia authorization. Living wills are also part in the legal aspects of euthanasia that will express a patient’s thoughts towards his future medical treatment and allow anyone capable of making decisions to tell the doctor beforehand that they do not wish to be put on life support. (Rachels 1986).
The government on the other hand does not have the right to make people suffer or give one groups of people (doctors) the powers to kill another group of people (their patients). Laws against euthanasia and assisted suicide are in place to prevent abuse and to protect people from unscrupulous doctors and others. They are not, and never have been, intended to make anyone suffer.
Chapter Eight
Issues affecting sick people and the Quality of life
Hospices have made great advances in helping patients and their families deal with the problems of terminal cancer. Legalising euthanasia would remove some of the incentive to be creative in caring when cure is not possible. Societies however, must also recognise the needs of people dying with AIDS, the elderly, and those suffering from progressive illnesses, and must be prepared to pay the proper cost of care. (Saunders 1992).
There are circumstances when our concern for the quality of life should override our desire to prolong it. Individuals must be allowed to judge the quality of their own lives as failure to do so involves a real violation of the Hippocratic tradition. Judgement as to whether the condition of a sufferer is intolerable or not must always be made by the sufferer either at the time or beforehand. Examples of situations where a sufferer might consider life to be hopeless could be loss of personal dignity, serious physical suffering, loss of the power of understanding, either completely (as in coma) or when suffering from dementia.
In other circumstances, doctors trained to make people better are often frustrated by incurable illness. They also have to publish research to get top jobs so there is pressure to try out unproven treatments. Quality of life can therefore disappear under a forest of needles, wires, electronic gadgets and needless operations.
Terminally ill patients adapt to a level of disability that they would not have previously anticipated they could live with. They come to value what little quality of life they have left. As for the elderly people, they may feel a burden to family, carers and to the society that is cost-conscious and may be shorter of resources. They therefore, feel great pressure to request euthanasia ‘freely and voluntarily’.
People who are born with disabilities usually do not see life in negative terms but as a challenge to overcome their disabilities and to do the things they want to do. The world is better off giving disabled people the opportunity to enjoy their lives rather than introducing the possibility that disabled people in general will simply be killed as a matter of routine because it is assumed that their lives are of no value.
A patient with a terminal illness lacks the knowledge and skills to alleviate his own symptoms, and may well be suffering from fear about the culture and anxiety about the effect his illness is having on others. Their decision making may hence be equally affected by confusion, dementia or troublesome symptoms, which could be relieved with appropriate treatment.
Voluntary euthanasia denies a patient the final stage of growth as it is during the time of a terminal illness that people have a unique opportunity to reflect on the way they have lived their lives, to make amends for wrongs done, to provide for the future security of loved ones and to prepare mentally and spiritually for their own death. As death is the final stage of growth, it can also be a time when words are spoken and strength imparted that will help sustain ‘those left behind’ through the years ahead. (Scrutton 1995).
The bland judgement of 1993, legalising removal of the means of life from a patient declared to be in a persistent vegetative state, encouraged the British Association’s Ethics Committee to rule in 1999 that doctors could withdraw food and fluids in the “best interests” of patients who could not speak for themselves, such as newborns, disabled, people with Alzheimer’s disease and those disabled by a stroke. Doctors however must first judge against a set of criteria whether the patient is benefiting from being kept alive.
John Harris (Nursing Times 1995) argues that killing is wrong when it involves depriving someone of something he or she values. Therefore, if a person requests death because his or her life is no longer valuable to him or her, voluntary euthanasia would be unjustified. However, this argument could not support involuntary euthanasia, as only the person deprived of life can decide whether or not its quality is still valuable to him or her.
Summary
In conclusion, while recognising the importance of individual patient autonomy, history has clearly demonstrated that legalised euthanasia poses serious risks to society as a whole. We also need to recognise that requests for voluntary euthanasia are extremely rare in situations where the physician emotional and spiritual needs of terminally ill patients are properly met. Doctors on the other hand have power over their patients, which must not be abused and so if they become killers, patients would become afraid to go into hospital. As from the information gathered, the doctor may be most helpful when asserting the value and the meaning of life, when that has been lost to the patient or those around him or her. Introducing death therefore is a very major change and so to my opinion, legalisation would bring about fear and further anxiety to the already tense situation of serious illness especially to those with disabilities.
I do feel that it is our responsibility to meet the real needs of the terminally ill and not to justify an opinion or to support a position. Each individual is different, and needs a different answer. We need to get alongside people and to respond to the challenge of their specific life-situation with life-affirming responses. Death is no answer to any need.
BIBLIOGRAPHY
British Medical Association (1988).Report of the Working Party to Review the BMA’s Guidance on Euthanasia, London: BMA
Catholic World News 08/12/2001
Cunningham J. (1996). The Telegraph Plc, London
Donnellan Craig (2001) The Euthanasia Issue, Cambridge: The Burlington Press
Donnellan Craig (1995) Abortion and Euthanasia: City Print
Fletcher J. (1985) The Patient’s right to die. London: Peter Owen Pub.
Harris J. (1985) The Value of life. London: Routledge Publishers
Ludovic K. (1996) Nursing Standard. London
Rachels, J. (1986) The End of Life. Oxford: Oxford University Press
Saunders, C.(1992) Care of the Dying. London: Macmillan Publishers
The Daily mail, April 1996
Twycross R. (1993) Bereavement and Grief. London: Edward Arnold Group
Voluntary Euthanasia Society (1989)The Need for Voluntary Euthanasia. London: VES
www.cmf.org.uk/ethics/twelve.htm
www.cwnews.com/browse/2001/08
www.donoharm.org.uk/alert/briefing2002
www.glabalchange.com