Euthanasia

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EUTHANASIA

Strictly speaking, euthanasia is Greek for "good death," but it has come to be applied to cases of an ill or disabled person being helped to die or deliberately killed by another for the ill or disabled person's benefit. It is thus distinguished from murder. Euthanasia is also to be distinguished from mercy killing. Whereas mercy killing normally refers to an act on the part of a friend or relative, euthanasia is typically discussed in relation to health care professionals. A number of further distinctions are drawn between different types of euthanasia: between active and passive euthanasia, and between voluntary, non-voluntary, and involuntary euthanasia. Whereas active euthanasia implies a deliberate act of killing, passive euthanasia means causing death by not doing something: allowing to die by withdrawing or withholding treatment. Not all forms of withdrawing treatment count as euthanasia, as when the treatment is futile or constitutes an "extraordinary" means of maintaining life.

Indeed, advances in medical science and technology have intensified concern for euthanasia because of the increased power to keep persons alive who nevertheless become dependent on various treatments. Examples range from cases of feeding tubes and artificial respiration to kidney dialysis and organ transplants. In all such instances, science and technology sometimes lead to deteriorations in the quality of life or costs that lead patients, those closest to them, and health care givers and policy makers to raise questions about continuation of treatment. Such questions often focus on whether and under what circumstances euthanasia might be a proper alternative.

Voluntary euthanasia is a response to a request on the part of a competent individual who regards death as preferable to continuing to live: The individual in question must be in a position to understand the nature of what he or she is asking and to consent to it. Nonvoluntary euthanasia occurs in cases where the individual is not in a position to make a euthanasia request, such as because of a lack of competence. Competence is context-specific, so it is not necessarily the case that the individual in question is unable to make any decisions at all. As a matter of fact, several of the most-discussed issues in euthanasia do concern cases of such total incompetence, as illustrated by the following.

Non-voluntary cases fall into different types. There are adults who have lost the capacity to make an informed choice—for example, because they are in a coma or persistent vegetative state. For such persons, the living will or advance directive is one way of stating a preference should such an eventuality arise. These are subject to criticism, though, on the grounds that people may be unable to anticipate how their preferences might change over time.

Alternatively, there are those who have not yet developed to the stage at which they have acquired the capacity to state a preference, such as infants. In some cases, newborns who are born with severe medical problems are rejected by their parents, and then decisions have to be made by health care professionals about how to deal with this situation. High profile cases such as the Arthur case in the United Kingdom (see Kuhse and Singer 1985) have dealt with the question of whether it is appropriate to allow such infants to die.

In contrast to non-voluntary euthanasia, involuntary euthanasia refers to ending people's lives against or in spite of their wishes. The distinction between involuntary euthanasia and murder is more difficult to draw than in the case of other types of euthanasia, but there are some possible instances; for example, where someone is critically injured on a battlefield, cannot be saved, and a military doctor who is present, having no morphine, shoots the injured person dead.

Arguments for Euthanasia

There is controversy both about the ethics of euthanasia per se and about the moral distinction between active and passive versions. The moral argument for euthanasia is normally put in terms of voluntary active euthanasia—that is, when persons are terminally ill and no longer have any hope of recovery, are in pain or distress, are considered competent, and ask for someone to end their lives, the argument is that these individuals have a right to die based on respect for their autonomy. Surely, the argument goes, if individuals should have control over anything, they should have it over their own bodies, although it may be argued that there is an inconsistency in using an autonomy argument to bring to an end the conditions of exercise of autonomy, namely bodily life.

Euthanasia can also be argued for on the grounds of beneficence, or on consequentialist grounds (that is, as a means to reduce suffering by removing conditions of the possibility of that suffering persisting). This type of argument can be used to justify non-voluntary euthanasia as well as voluntary euthanasia. Where the individual is unable to express a choice, then the incompetent individual could be denied access to help if autonomy were the only type of argument appealed to; they may be granted help if an argument of beneficence or consequentialism is relied upon. Whether the consequentialist argument could be used to justify involuntary euthanasia is much more contentious.

Arguments Against Euthanasia

The autonomy and beneficence arguments are strong, but may be deployed in a different way on the other side of the debate. If what is regarded as important is autonomy, then the autonomy of persons asked to carry out euthanasia must also be considered. They have to agree that this is a course of action they are prepared to undertake. So the fact that someone of sound mind requests euthanasia does not settle the question if the person who is being asked to perform the action does not agree.

From a consequentialist perspective, it has to be admitted that while in individual cases the best result may appear to be achieved by euthanizing someone whose life has become not worth living, this judgment is fraught with difficulty. In the case of non-voluntary euthanasia, a judgment is made in the absence of a person's own request, when it might well be argued that the benefit of the doubt should count for life. To make the judgment that another person's life is not worth living invites the charge of "playing God."

Partly for this reason, involuntary euthanasia has few supporters: The autonomy argument speaks against it. In the battlefield case it is necessary to assume, if it is to count as involuntary, that the doctor is acting against the express wishes of a soldier, who may be begging for help to save his life. In such a case the doctor may be presumed to make a decision based on the realization that this is not possible.

Apart from the consequences of euthanasia of whatever type for the individual killed, there may be side effects on others. These include worries about hardening the attitudes of those involved in the killing and a gradual lessening in society of respect for life. If euthanasia were widely practiced (as has been the case in some societies), there might be pressure on some people (for example, the elderly and infirm) to agree to request "voluntary" euthanasia. This may be regarded as evidence of a "slippery slope" from voluntary to what could be construed as involuntary euthanasia, because if people feel pressured to consent then their voluntariness is undermined.

In addition, there is the argument based on professional roles. Should health care professionals, who have been trained to cure and to care, use their skills for killing?

The strongest objection to euthanasia, however, derives from the view that killing is wrong in itself, on the grounds of the sanctity of life. If life is sacred, then it is wrong deliberately to take a human life. Of course this principle is very difficult to uphold in all circumstances, although people differ about the nature of potential exceptions such as self-defense, war, and capital punishment. Because of the difficulty of upholding an absolute prohibition on taking the life of another, various distinctions have been proposed, including the active-passive distinction already mentioned, and the doctrine of double effect.

A Moral Distinction Between Active and Passive Euthanasia?

According to the active-passive distinction, there is a moral difference between a deliberate act to end someone's life and allowing them to die. To a certain extent the issues here have increased in complexity with medical knowledge and scientific advance, for example, in the light of greater sophistication of use of drugs to control pain, which may at the same time hasten death. From a consequentialist perspective it has been argued that there is no moral difference between killing and allowing to die, because the ultimate outcome is the same—the person is dead. In fact, when side effects are taken into account, the consequences of allowing to die rather than killing might be worse in terms of distress to all concerned. If what is aimed at is a kind and peaceful death, a quick deliberate act may be more merciful than a long-drawn out "allowing to die."

From the perspective of a deontological tradition, however, the quality of the act is what is important. One case is a deliberate killing. The other allows nature to take its course. In some cases, however, it is clear that more than "allowing nature to take its course" is involved, even where it is claimed that deliberate killing is avoided. It is here that the doctrine of the double effect becomes relevant.

Doctrine of the Double Effect

The doctrine of the double effect presupposes that an action can have two kinds of effect: intended and foreseen. Whereas it is claimed that it is always wrong intentionally to do a bad act, it is sometimes permissible to do an act foreseeing that bad consequences will ensue. As applied to euthanasia, the point would be that while it is always wrong intentionally to kill, it may be permissible to give drugs to relieve pain, even foreseeing that death will be hastened as a result.

While in some cases this doctrine may appear to give intuitively the right result, and while it has indeed influenced medical practice to a considerable extent, it poses several problems. First, how does one know what constitutes the class of bad acts to be absolutely prohibited? There is no agreement that deliberate killing is ruled out in all circumstances. Second, how does one distinguish between an intended and a foreseen consequence, and indeed between an act and its consequences? There need to be some limits to the freedom to describe the action in certain ways, otherwise it could be open to an agent to deny that any undesirable consequences were intended. The British case of Dr. Cox (Rv Cox [1992] 12 BMLR 38) concerned a physician who administered potassium chloride to a patient who was suffering from intractable pain. That drug does not have pain-relieving properties, so it was not open to the doctor to claim that it was given for that purpose. Had he administered morphine, he might have been able to rely on the doctrine of double effect. While philosophers have heavily criticized the doctrine, it has been influential in law.

Conclusion

From a moral point of view the strongest arguments in favor of euthanasia are to benefit an individual, whether to respect their autonomy or to prevent suffering. At the societal level, however, there are serious concerns about abuse of euthanasia for the benefit not of those killed, but of third parties or society especially in the light of issues about scarce health resources and health inequalities and concerns about these as influencing factors. So controversy continues about the practice of voluntary euthanasia according to guidelines such as in the Netherlands, for example. Despite widespread acknowledgement of the benefit to those with intractable suffering, there are also historical precedents of abuse, which lead opponents to argue that one should err on the side of preserving life. These concerns have to be taken into account in considering proposals for legalization.

RUTH CHADWICK