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June 2009

Ethical objections to euthanasia

By David Richmond

Contrary to what its advocates would have us believe, euthanasia is a complex ethical, social and theological issue. New Zealanders tend to hear only arguments in favour of euthanasia because they are more prevalent in the media. Advocates for the practice have no difficulty getting their views canvassed by the media, especially when a tragic case occurs in which someone suffers a difficult death. The community must have access to all points of view, especially if more moves are made to legalise the practice.

Euthanasia refers to killing those who are incurably ill and in great pain or distress, to spare them further suffering. A distinction is made between active euthanasia, in which something is administered to hasten or bring about death, and passive euthanasia, or withdrawing some life-prolonging measure to allow death to occur.

It is also important to distinguish 1) voluntary euthanasia, where procedures take place with the knowledge and consent of the patient; 2) involuntary euthanasia, where the procedure takes place without the patient’s knowledge or consent though he or she would have been capable of giving consent; 3) non-voluntary euthanasia, where the procedure takes place without the patients’ knowledge or consent because they are not capable of understanding the issues involved; 4) Physician-assisted suicide [PAS] where the doctor provides the suicidal person the means to kill themselves but does not participate in the act.

In Holland, voluntary active euthanasia (VAE) was legalised in 2001, although it had been practiced with impunity by doctors since 1973. Belgium legalised VAE in 2005. The US state of Oregon legalised PAS in1998 as did Washington state in 2008.

Those who advocate euthanasia justify it on several ethical grounds:

1) The respect for autonomy, i.e., individuals should have the power to determine the time and manner of their death.

2) Compassion, i.e., preventing intractable suffering. In the past, the emphasis was on preventing pain during dying but this should no longer be relevant because of advances in pain relief. Now the emphasis is on avoiding ‘suffering’, often interpreted to include depression and loss of dignity in dying.

3) Lack of a moral difference between ‘killing’ and ‘letting die’. If a doctor decides a person’s life should not be prolonged, is there a moral difference between administering a fatal injection to kill the patient, and withdrawing life-support systems to allow them to die of the disease or injury?

4) Beneficence or the concept that the quality of some lives is so poor, the individual would be better off dead.

Is there a right to die? The right to determine the time, place and manner of one’s death is an important lynchpin of the arguments of euthanasia advocates. For them, the basis of human dignity lies in self-determination.

The ‘right to die’ is variously interpreted as a right to refuse treatment, a right to control one’s own dying, a right to be killed or become dead, or a right to assistance with death.

As commonly expressed, the ‘right to die’ has no limits. It implies that anyone, no matter what their state of health, someone can demand death. In the past this was a serious objection to euthanasia but no longer. In Holland and Belgium doctors advocate that people be allowed to request euthanasia on the grounds of psychological discomfort, and many do. Thus the availability of euthanasia can distort commonly held concepts of morality and the duties of doctors. It justifies charges of a ‘slippery slope’.

Does ‘compassion’ include an obligation to kill someone who is suffering? Proponents say there is an obligation to relieve ‘meaningless’ suffering. Where that cannot be achieved by therapy, there is a duty to provide ‘mercy killing’ as an act of beneficence. The hardest cases to resolve in this category may relate not to pain but to other forms of suffering such as paralysis and a lack of purpose in life.

There is a huge challenge to the community, especially to the Christian community, to remember the importance of being with people who are suffering. Many who advocate euthanasia, especially for a loved one, are motivated much more by their own difficulty in handling the situation than by the actual discomfort the sick person is experiencing. They really want to relieve themselves rather than the sufferer.

Is there a moral distinction between killing and letting die?

There may be situations where it is morally acceptable to withdraw treatment where it is futile to continue it, even if this allows the person to die. But it is not morally acceptable to directly take a person’s life. In the first case, the pre-existing condition is the cause of death. In the second, the cause of death is the lethal substance administered.

In the first case, the intention is not to cause death but to relieve suffering. The doctor does not know if the patient will die and indeed, patients have been known to recover. In the second, it is to relieve suffering by killing the patient. In the first case, the doctor recognises and accepts medical limitations to reverse the dying process; in the second, the intervention is aimed at death. These two motivations are morally different.

Is there such a thing as a ‘life not worth living’? Utilitarian ethicists who support the liberalisation of euthanasia argue on the basis of the value of human life and the quality of life. Only a sentient being, one who can value their own existence, is regarded as a person.

Joseph Fletcher, a prominent utilitarian philosopher, argued that because non-sentient human beings are non-persons, they may be destroyed without moral qualm. Such lines of thinking are not new. This philosophy spawned the holocaust in Germany in the 1930s and 40s.

In 1890s the German Adolf Jost enunciated the concepts of a ‘right to die’ and ‘human worthlessness’. His ideas were taken up by others, who maintained there were people whose lives were ‘not worthy to be lived’.

These included the terminally ill, those in coma and psychiatric patients. They emphasised the high financial cost to the German State in their continuing treatment. An official euthanasia programme began in Germany in 1933 and became compulsory in 1939. Some 275,000 persons in nursing homes, hospitals and asylums were killed in this programme before World War II. Out of that came the holocaust.

Advocates of euthanasia are desperate to avoid any link with what happened in Nazi Germany. The point is that the modern day pro-euthanasia movement is grounded in exactly the same philosophy. It involves a high level group taking end of life decision on behalf of others, and an economic motivation hidden in it.

Dr David Richmond, MD is professor emeritus, University of Auckland and founder and chairman of the HOPE Foundation for Research on Ageing.