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Why Euthanasia Should Be Legal: Analysis of Arguments and Counterarguments

• Categories: Assisted Suicide Euthanasia Right to Die

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Introduction, why euthanasia should be legal, works cited, counterarguments.

• Corder, Mike. “Dutch Euthanasia Center Sees 22% Rise in Requests in 2019.” WAVY.com, 7 Feb. 2020, www.wavy.com/news/health/dutch-euthanasia-center-sees-22-rise-in-requests-in-2019/. Accessed 10 March 2020.
• Davis, Jacky. “Kevin Davis Deserved Choice.” Dignity in Dying, www.dignityindying.org.uk/story/kevin-davis/. Accessed 13 March 2020.
• De La Torre, Esther B. The Right to Assisted Suicide , www.lonestar.edu/rightto-assist-suicide.htm. Accessed 19 March 2020.
• “Euthanasia Laws - Information on the Law about Euthanasia.” Information on the Law about Euthanasia - Suicide, Life, Act, and Mercy - JRank Articles, law.jrank.org/pages/11858/Euthanasia.html. Accessed 10 March 2020.

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• Published: 15 January 2014

Should assisted dying be legalised?

• Thomas D G Frost 1 ,
• Devan Sinha 2 &
• Barnabas J Gilbert 3  

Philosophy, Ethics, and Humanities in Medicine volume  9 , Article number:  3 ( 2014 ) Cite this article

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When an individual facing intractable pain is given an estimate of a few months to live, does hastening death become a viable and legitimate alternative for willing patients? Has the time come for physicians to do away with the traditional notion of healthcare as maintaining or improving physical and mental health, and instead accept their own limitations by facilitating death when requested? The Universities of Oxford and Cambridge held the 2013 Varsity Medical Debate on the motion “This House Would Legalise Assisted Dying”. This article summarises the key arguments developed over the course of the debate. We will explore how assisted dying can affect both the patient and doctor; the nature of consent and limits of autonomy; the effects on society; the viability of a proposed model; and, perhaps most importantly, the potential need for the practice within our current medico-legal framework.

Introduction

Over the past two centuries, the United Kingdom has experienced rapid population growth associated with a substantial decline in mortality from acute infectious diseases and poor nutrition [ 1 ]. As the average life expectancy has increased, so too have the rates of debilitating chronic illness – particularly coronary artery disease and cancers [ 2 ]. These diseases require years of treatment instead of the mere days to weeks that medicine once operated within [ 2 ]. Although healthcare systems have sought to adapt to such changes, aiming to prevent and treat such disease wherever possible, debate has arisen regarding those patients in the latter stages of chronic, incurable, terminal conditions [ 3 , 4 ]. Moreover, there is increasing recognition that the patient must be at the centre of health care decision-making, such that outcomes must be tailored to their individual needs and views. By extension, assisted dying might seem a logical step to help achieve these goals within the realm of end-of-life decision making [ 5 ]. Several jurisdictions, notably Oregon (1997) and the Netherlands (2001) have already legalised assisted dying in some form. These factors have contributed to ongoing legislative discussions within Parliaments for almost a decade, with current opinion polling suggesting a majority of medical practitioners and the public in favour of physician-assisted suicide [ 6 ].

Viability of assisted dying in practice

In the UK, a model for assisted dying has been developed from the legal structure found within the Assisted Dying Bill introduced by Lord Falconer in the House of Lords in 2013 [ 7 ]. Assisted dying could only be considered under circumstances in which a patient of legal age is diagnosed with a progressive disease that is irreversible by treatment and is “reasonably expected to die within six months” [ 7 ]. Registered medical practitioners would make such decisions for patients with terminal illnesses. Addressing the technicalities of ‘assisted dying’ requires distinction between ‘physician-assisted suicide’ (offering patients medical actions or cessation of actions by which they can end their own life) and ‘euthanasia’ (whereby the medical practitioner actively induces death). In light of the strong hostility of the medical profession towards active euthanasia, this proposed model, as with previous attempts to legalise assisted dying, permitted only the former [ 8 – 10 ].

However, there is concern that such distinction may be unrealistic in practice because medical practitioners could find themselves with a patient who had failed to successfully end their own life and was subsequently left in a state of greater suffering. Were such a patient no longer able to give consent, a heavy burden would then be placed on the physician regarding how to proceed. Moreover, the practice of physician-assisted suicide might be deemed discriminatory, for example by giving only patients with good mobility control over their own method of death.

The Assisted Dying Bill 2013 included the provision that any terminal prognosis must be confirmed and attested by a second registered practitioner. The strictness of such criteria has parallels to a similar double-physician requirement when procuring a legal abortion under the 1967 Abortion Act. The stated aims of the provision in both cases are as follows: first, to check the accuracy of the prognosis upon which the decision was being made; second, to ensure that the situation meets the required criteria; and third, to check that such a decision was taken by the patient after full consideration of all available options [ 11 , 12 ]. By having a second independent doctor, the legislation ensures that all three checks are met without prejudice or mistake.

Problematic for any protocol for assisted dying is the fact that estimates of life expectancy in terminal prognoses are erroneous in 80.3% of cases [ 13 ]. Furthermore, the accuracy of such prognoses deteriorates with increased length of clinical predicted survival. Forecasts of survival times are based largely on past clinical experience, and the inherent variability between patients makes this more of an art than a science. This brings to concern both the accuracy of any prognosis meeting the six-month threshold and the validity of requests for assisted dying based partly or wholly on predicted survival times. Whilst the majority of errors in life expectancy forecasts are a matter of over-optimism and hence would not affect either of those two concerns, many cases remain unaccounted for. Overly pessimistic forecasts occur in 17.3% of prognoses; hence we must decide whether the one in six patients making a decision based on an inaccurate prognosis is too high a cost to justify the use of this system. Patients requesting an assisted death often cite future expectations of dependency, loss of dignity, or pain [ 14 ]. If the hypothetical point at which the progression of their illness means they would consider life to be not worth living is not, as informed, mere weeks away but in fact many more months, then this information would have resulted in a different decision outcome and potentiated unnecessary loss of life.

Whilst the presence of a second doctor would be expected to mitigate such forecasting errors, the anchoring bias of the initial prediction may be enough to similarly reduce the accuracy of the second estimate. It is prudent to question the true independence of a second medical practitioner, and whether this second consultation could become more of a formality, as has now become the case with abortion [ 15 ].

Another challenge for an assisted dying system would be to recognise whether patients requesting death were legally competent to make that decision. Consider that any request for suicide from a patient with clinical depression is generally categorised as a manifestation of that mental disorder, thereby lacking capacity. It is arguably impossible to separate out the natural reactions to terminal illness and clinical depression. Indeed, there is evidence that major depressive disorders afflict between 25% and 77% of patients with terminal illness [ 16 , 17 ]. Any protocol for assisted dying must first determine what qualifies as a ‘fit mental state’ for a terminal patient.

The need for assisted dying

It could be argued that a doctor’s fundamental duty is to alleviate forms of suffering in the best interests of the patient. The avoidance of physical pain, as an obvious manifestation of suffering, might explain why assisted dying would be both necessary and within the duties of a doctor to provide. The evolving principle in common law known as the ‘Doctrine of Double Effect’ offers a solution to this problem [ 18 ]. This legal judgement stated that “[a doctor] is entitled to do all that is proper and necessary to relieve pain even if the measures he takes may incidentally shorten life”. This entails that a protocol already exists for patients searching for an escape from chronic pain. Furthermore, numerous retrospective studies have revealed very little correlation between opioid dose and mean survival times: one study of over 700 opioid-treated patients found that the variation in survival time from high-dose opioid treatment is less than 10% [ 19 – 21 ]. It can therefore be said that pain alone, if appropriately managed, should never be cause for considering assisted dying as an alternative.

By contrast, the ‘Doctrine of Double Effect’ might be seen as a subjective interpretation that has been applied unequally due to a lack of specialist training or knowledge [ 22 ]. Despite this, the principle can be easily understood and poor awareness can be remedied by improvements in medical education and standardisation of protocols. Moreover, should we choose to accept arguments for assisted dying that are based upon inadequate administration of pain medication, we set a precedent for conceding shortcomings in palliative care and other end-of-life treatments. Offering hastened death could become an alternative to actively seeking to improve such failings.

Whilst much has been made of the ‘pain argument’ here, the call for assisted dying is rarely this simple. Many patients also suffer a loss of dignity, often due to their lack of mobility – the inability to relieve oneself without help is a potent example. Beyond this are additional fears of further debilitation and the emotional costs of dealing with chronic illness, both for the patient and for their relatives and friends. A study of terminal patients in Oregon showed that these were the most significant reasons behind requests for assisted suicide, the next commonest reason being the perception of themselves as a ‘burden’ [ 14 ]. Clearly, we could seek to provide balanced, compassionate medical care for these patients, and still fail to address these points.

Developments in healthcare and technology may reduce this emotional burden, but remain an imperfect solution.

Rights of patients and limitations of their autonomy

J.S. Mill’s pithy dictum describes autonomy as follows: “over himself, over his own body and mind, the individual is sovereign” [ 23 ]. Not only has the sanctity of bodily autonomy profoundly influenced the development of liberal democracies, it has also provoked a holistic shift in making our healthcare systems more patient-centred – “care that meets and responds to patients’ wants, needs and preferences and where patients are autonomous and able to decide for themselves” [ 5 ]. The ethical principle of controlling the fate of one’s own body is inherently relevant to the debate on assisted dying. It is difficult to reconcile that citizens may have the right to do almost anything to and with their own bodies– from participating in extreme sports to having elective plastic surgery – yet a terminal patient cannot choose to avoid experiencing additional months of discomfort or loss of dignity in their final months of life.

Expectation of individual liberty has been codified in law. The right to bodily autonomy has been interpreted to be included under Article 8 - the right to privacy - of the European Convention on Human Rights (ECHR) and subsequently the Human Rights Act (HRA) [ 24 , 25 ]. Moreover, the ECHR underpins the right of individuals to ‘inherent dignity’ [ 26 ]. Hence, if an individual feels that dignity is unattainable due to the progression of a terminal illness, then taking recourse though assisted dying ought to be a legitimate option.

Conversely, there are two notable oversights in this interpretation of a right to assisted dying as an extension of the principles of bodily autonomy:

First, it would be wrong to view individual liberty as absolute. The HRA allows for exceptions to Article 8 on grounds of ‘health or morals’ [ 25 ]. The principle of autonomy is not inviolable. Governments have limited such privileges for the protection of individuals and society, for example by criminalizing the use of recreational drugs or the selling of one’s own organs. The preservation of life by denying assisted dying could fall within this category.

Second, the right of autonomy is not necessarily intrinsic to human beings but, as Kant argued, is dependent on our ‘rational nature’ [ 27 ]. This concept sees autonomy as an exercise of ‘evaluative choice’ [ 27 ], requiring rationality on the part of individuals to appreciate the nature of options and their consequences. To achieve true autonomy, there must be sufficient information to make those rational decisions; this is the basis of informed consent and why it is a fundamental duty of a doctor to offer a patient an informed series of treatment options [ 28 ]. The logistical issue is that doctors are unable to advise patients regarding the point at which their situation becomes less preferable to being dead. No doctor (or individual) has any knowledge or experience of what ‘death’ may be like. Hence, in this case, the idea of exercising true autonomy through informed consent might be considered meaningless.

Legalising assisted dying by attempting to establish an absolute right to bodily autonomy may undermine other individual and group rights. Vulnerable patients may feel pressured into assisted dying because of social, emotional, or financial strains placed on family and/or friends. This is exemplified by the trend showing that the proportion of patients stating ‘relief of burden’ on others as the reason for requesting assisted dying has risen from 17% to 25% in Oregon since legalisation [ 29 ]. One could even consider the risk of assisted dying becoming an expected choice rather than a free one. Thus, assisted dying may erode the elemental right to life of terminal patients as the value of their life becomes tied to relative costs to society and to those around them.

Moreover, by creating one class of individuals for whom life is expendable, that particular view may be extended by society to all groups possessing such attributes (e.g. the permanently disabled). There would be a definite risk to the rights of these vulnerable groups in the form of society being less willing to provide for their health and social care.

It is often raised that the limited legalisation of assisted dying would inevitably become extended in scope, but this is not necessarily a flaw. Even if the right to determine the manner of death were later extended to a wider group of people, posterity may reflect positively on such a change, just as extending the franchise to women ultimately led to legislation demanding equal pay.

Effect on health professionals and their role

‘To act in the best interest of the patient’ is often cited as a central duty of the doctor [ 28 ]. This concept of ‘best interest’ guiding the doctor’s action has seen the development of two important ethical principles: beneficence and non-maleficence. Beneficence mandates that the actions of the doctor must be aimed to bring about benefit (clinical improvement) for the patient, usually measured in terms of reduced morbidity or mortality; non-maleficence requires that the doctor not carry out treatment that is likely to cause overall harm the patient [ 30 ]. These traditional ethical imperatives on a doctor both conflict with intentionally hastening the death of a patient, and a resolution of this tension would require redefining what constitutes ‘acting in the best interest’.

A further dimension is the potential reluctance of health professionals to engage in a practice that contravenes their own ethical beliefs, particularly as this would affect doctors who never entered training in the knowledge that assisting patients to die would be an expected duty. This is certainly no argument against the introduction of assisted dying; indeed, a recent survey of a cohort of NHS doctors found that 46% would seriously consider requests from patients to undertake steps to hasten death [ 31 ]. It merely expresses the point that any early model would have to account for the fact that an initial 54% of the doctors in the NHS would be required to advise qualifying patients of assisted dying as a legitimate option, despite disagreeing with it in principle.

Furthermore, doctors who agree ethically with this practice may find themselves facing conflicts of interest. It is expensive to treat chronically ill patients, particularly in the final months of life [ 32 ]. Moreover, it would be difficult for commissioners to ignore the fact that the sustained treatment of one individual could deprive many others from access to surgery or access to novel drugs. Such an argument does not suggest that doctors or any other hospital staff would treat this practice without appropriate respect or care; rather it acknowledges the need for appropriate rationing of care and questions the intentions of service providers. The perception of an ulterior motive could negatively impact patient trust. One survey showed that a reasonable minority of patients (27%) – and particularly particularly the elderly – believe that legalising assisted dying would lessen their trust in their personal physician [ 33 ]. The costs of weakened trust in the doctor-patient relationship could far outweigh the benefits of assisted dying, particularly given the importance of trust when treating a chronic patient for an extended period of time.

There is no doubt that assisted dying would empower some patients to maximise control over the timing and manner of their own death. Such expression of autonomy would surely solidify moves towards a patient-centred approach to healthcare. However, the capacity for such consensual requests remains in doubt. Clinically, the patient’s state of mind and the reliability of diagnostic predictions are of issue; philosophically, the idea of informed consent for death is contradictory. The implications for patients, physicians and society have been weighed extensively within this article. The central tenet throughout has been the balancing of an individual’s right to escape a circumstance that they find intolerable, alongside the consequential changes to their other rights, and the rights and responsibilities of third parties. Ultimately, the challenge is for us as a society to decide where this balance lies.

About the debate

The Varsity Medical Debate was started in 2008 with the aim of allowing students, professors and members of the polis, to engage in discussion about ethics and policy within healthcare. Utilising the age-old rivalry between the two Universities, the debate encourages medical students from both Oxford and Cambridge to consider and articulate the arguments behind topics that will feature heavily in their future careers.

The debate was judged on the logic, coherence, and evidence in arguments, as well as flair in presentation. Although the debaters may not have necessarily agreed with their allocated side, the debate format required them to acknowledge a particular school of thought and present the key arguments behind it. Oxford, who opposed the motion, was awarded the victory in the debate; however, this does not mean that the judges believe that position ought to become public policy.

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Acknowledgements

For Cambridge University: Hilmi Bayri (Trinity), Alistair Bolger (Jesus), Casey Swerner (St Johns).

For Oxford University: Devan Sinha (Brasenose), Thomas Frost (Lincoln), Collis Tahzib (Lincoln).

Martin Farrell (Cambridge).

Baroness Finlay: Professor of Palliative Care Medicine and former President of the Royal Society of Medicine.

Dr. Roger Armour: Vascular Surgeon and Inventor of the Lens Free Ophthalmoscope.

Mr. Robert Preston: Director of Living and Dying Well.

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Frost, T.D.G., Sinha, D. & Gilbert, B.J. Should assisted dying be legalised?. Philos Ethics Humanit Med 9 , 3 (2014). https://doi.org/10.1186/1747-5341-9-3

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Intelligence Squared U.S.

Debate: should physician-assisted suicide be legal.

Bioethicist Peter Singer argues that, under certain circumstances, people should have the right to die at a time of their choosing. Samuel La Hoz/Intelligence Squared U.S. hide caption

Bioethicist Peter Singer argues that, under certain circumstances, people should have the right to die at a time of their choosing.

Since Oregon legalized physician-assisted suicide for the terminally ill in 1997, more than 700 people have taken their lives with prescribed medication — including Brittany Maynard, a 29-year-old with an incurable brain tumor, who ended her life earlier this month.

Advocates of assisted-suicide laws believe that mentally competent people who are suffering and have no chance of long-term survival, should have the right to die if and when they choose. If people are have the right to refuse life-saving treatments, they argue, they should also have the freedom to choose to end their own lives.

Opponents say that such laws devalue human life. Medical prognoses are often inaccurate, they note — meaning people who have been told they will soon die sometimes live for many months or even years longer. They also argue that seriously ill people often suffer from undiagnosed depression or other mental illnesses that can impair their ability to make an informed decision.

At the latest event from Intelligence Squared U.S. , two teams addressed these questions while debating the motion, "Legalize Assisted Suicide."

Before the debate, the audience at the Kaufman Music Center in New York was 65 percent in favor of the motion and 10 percent against, with 25 percent undecided. After the debate, 67 percent favored the motion, with 22 percent against, making the team arguing against the motion the winner of this debate.

Those debating:

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FOR THE MOTION

Peter Singer is a philosopher and author, best known for his work in ethics. He is the Ira W. DeCamp Professor of Bioethics in the University Center for Human Values at Princeton University, a position that he now combines with the part-time position of Laureate Professor at the University of Melbourne. Some of his more recent books include The Point of View of the Universe and The Life You Can Save: Acting Now to End World Poverty . In 2014 the Gottlieb Duttweiler Institute ranked him third on its list of Global Thought Leaders, and Time has ranked him among the world's 100 most influential people. An Australian, in 2012 he was made a Companion to the Order of Australia, his country's highest civilian honor.

Andrew Solomon is a writer, lecturer and a professor of clinical psychology at Columbia University. Solomon's newest book, Far From the Tree: Parents, Children, and the Search for Identity , won the National Book Critics Circle award for nonfiction and was chosen as one of the New York Times "Ten Best Books" of 2012. Solomon's previous book, The Noonday Demon: An Atlas of Depression won the National Book Award for nonfiction and was a finalist for the Pulitzer Prize. He is a director of the University of Michigan Depression Center and Columbia Psychiatry; a member of the board of visitors of Columbia University Medical Center; serves on the national advisory board of the Depression Center at the University of Michigan, and on the advisory board of the Depression and Bipolar Support Alliance. In 2011, he was appointed special advisor on Lesbian, Gay, Bisexual, and Transgender Mental Health at the Yale School of Psychiatry.

Dr. Daniel Sulmasy, with debate partner Ilora Finlay, argues that policies legalizing physician-assisted suicide are unethical. Samuel LaHoz/Intelligence Squared U.S. hide caption

Dr. Daniel Sulmasy, with debate partner Ilora Finlay, argues that policies legalizing physician-assisted suicide are unethical.

AGAINST THE MOTION

Baroness Ilora Finlay , a leading palliative care physician, is president of the British Medical Association, president of the Chartered Society of Physiotherapy, and is a past president of the Royal Society of Medicine. She has led the Palliative Care Strategy Implementation Board in Wales since 2008, and chaired the Welsh Medical and Dental Academic Advisory Board since 2012. Finlay was a general practitioner in inner-city Glasgow before returning to Cardiff to work full-time in care of the terminally ill. She works at the Velindre Cancer Centre, covering South East Wales when clinically on call. Finlay started the Marie Curie Hospice in Wales and since 2008 has responsibility on behalf of Welsh Government for strategic oversight of all hospice and palliative care services in Wales. Since 2001, Finlay has been an Independent Crossbench Peer in the House of Lords.

Dr. Daniel Sulmasy is the Kilbride-Clinton Professor of Medicine and Ethics in the Department of Medicine and Divinity School at the University of Chicago, where he serves as associate director of the MacLean Center for Clinical Medical Ethics and as director of the Program on Medicine and Religion. Sulmasy was appointed to the Presidential Commission for the Study of Bioethical Issues by President Obama in 2010. His research interests encompass both theoretical and empirical investigations of the ethics of end-of-life decision-making, ethics education and spirituality in medicine. He is the author or editor of six books, including Safe Passage: A Global Spiritual Sourcebook for Care at the End of Life . He also serves as editor-in-chief of the journal, Theoretical Medicine and Bioethics .

• physician-assisted suicide

Should Physician-Assisted Suicide or Euthanasia be Legalized in the United States? A Medically Informed Perspective.

There is a pressing debate in the United States concerning the implied physicians' obligation to do no harm and the status of legalizing physician-assisted suicide (PAS). Key issues that underpin the debate are important to consider. These include: (1) foundational medical beginnings; (2) euthanasia's historical and legal background context; and (3) the key arguments held by those for and against legalization of PAS. This paper reviews the major claims made by proponents for the legalization of PAS and the associated complexities and concerns that help underscore the importance of conscience freedoms. Relief of suffering, respect for patient autonomy, and public policy arguments are discussed in these contexts. We argue here that the emphasis by healthcare providers should be on high quality and compassionate care for those at the end of life's journey who are questioning whether to prematurely end their lives. If medicine loses its chief focus on the quality of caring-even when a cure is not possible-it betrays its objective and purpose. In this backdrop, legalization of PAS harms not only healthcare professionals, but also the medical profession's mission itself. Medicine's foundation is grounded in the concept of never intentionally to inflict harm. Inflicting death by any means is not professional or proper, and is not trustworthy medicine.

Duke Scholars

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Article Contents

The implication of a medicalized dying process, the historical case against physicians assisting suicide, the medical cloak, collaborators in euthanasia, healing and euthanasia, recent developments, is euthanasia medical treatment, acknowledgements.

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Euthanasia is not medical treatment

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J. Donald Boudreau, Margaret A. Somerville, Euthanasia is not medical treatment, British Medical Bulletin , Volume 106, Issue 1, June 2013, Pages 45–66, https://doi.org/10.1093/bmb/ldt010

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The public assumes that if euthanasia and assisted suicide were to be legalized they would be carried out by physicians.

In furthering critical analysis, we supplement the discourse in the ethics and palliative care literature with that from medical education and evolving jurisprudence.

Both proponents and opponents agree that the values of respect for human life and for individuals' autonomy are relevant to the debate.

Advocates of euthanasia and assisted suicide give priority to the right to personal autonomy and avoid discussions of harmful impacts of these practices on medicine, law and society. Opponents give priority to respect for life and identify such harmful effects. These both require euthanasia to remain legally prohibited.

Proposals are emerging that if society legalizes euthanasia it should not be mandated to physicians.

The impact of characterizing euthanasia as ‘medical treatment’ on physicians' professional identity and on the institutions of medicine and law should be examined in jurisdictions where assisted suicide and euthanasia have been de-criminalized.

….tha'll nivver feel it, tha'll be out of existence i' two minutes

James Billington

Physician-assisted suicide (PAS) and euthanasia are among the most contentious issues faced by the medical profession. Numerous scholars have argued in favor of 1 or against 2 ‘assisted death’, as these interventions are euphemistically called. These debates generally take it for granted that the person carrying out euthanasia will be a physician. That assumption has been questioned, most recently, by two ethicists from the Harvard Medical School who propose a limited role for physicians in assisted dying. 3 We discuss their proposal shortly. The possibility of deleting the physician from the equation has certainly not been salient in professional discourse.

In this article we will examine factors, highlighting historical contexts and the influence of language, which have helped campaigners who aim to sanitize ‘assisted dying’ by associating it with medicine. We broach the issue of whether euthanasia can be considered medical treatment by focusing on the irreconcilability of euthanasia with medicine's mandate to heal.

In the remainder of this text, we use the word euthanasia to include PAS, unless the contrary is indicated. We do so in accordance with the fact that both procedures raise the same ethical and legal considerations with respect to many of the issues discussed in this article. In PAS and euthanasia, physicians and society are complicit in helping persons to commit suicide or giving them a lethal injection, respectively. Moreover, whether or not a society will alter its laws to allow ‘medically induced death’ is a binary decision.

Are medical doctors, by being responsible for the prolongation of the dying process, blameworthy for the existence of conditions that elicit a desire for hastened death? The profession has indeed created circumstances, through overly aggressive technical interventions, whereby persons' illness narratives have included chapters with alienating, depersonalizing and dehumanizing plots and characters. The following trajectory of a hypothetical patient with amyotrophic lateral sclerosis is all too common: first, non-invasive nocturnal ventilation enters the scenario; next, a wheelchair; then a Dobhof feeding tube, promptly replaced by a jejunostomy; innumerable venous punctures and catheterizations; intervening urinary tract infections; recurrent aspiration pneumonias, followed by invasive ventilation, eventually necessitating a tracheostomy; accompanied by unremitting despondency; and finally, progressive somnolence and terminal sepsis. Too many patients find themselves in a sickroom in such a state, one of spent physical resources and suspended hope or even total despair. Some would add that this metaphoric dwelling is also inhabited by a crushed spirituality.

Pro-euthanasia advocates sometimes present such scenarios to support their views that the profession is, in some measure, responsible for the condition in which a patient may conceive of no escape or redress other than self-willed death. A comment such as, ‘I'd rather die than slog on with deformity, disfigurement and disability', is not infrequently heard and, when expressed, often denounces a sequence of medical interventions rather than the original illness. In dire situations, one of the few avenues that can seem to offer a sense of comfort is that of personal control. Control, usually packaged in a discursive frame of politico-judicial personal autonomy, can be manifest as a desire to manage the ultimate mode of exit from life, that is, for patients to select the method, place and hour of their death. Moreover, some may want this stance to be legitimized by societal approval and even see it as a heroic act and as furthering a common cause, by promoting shared values and ideologies. 4

It would, however, be an overstatement to attribute all changes in the nature of death to the health professions. Improvements in general socioeconomic conditions have decreased the incidence of death from catastrophic accidents, trauma and obstetrical mishaps and have lessened the impact of previously deadly infectious diseases. Undeniably, the shift in prevalence from acute and preventable conditions to chronic degenerative diseases, as well as many cancers, is a consequence of a prolongation of life resulting from improvements in public health, universal literacy and preventive interventions. Nonetheless, there is a kernel of truth in the notion, expressed in commentaries dating from Hellenistic to modern times, that physicians have invented ‘lingering’ death. 5 We believe that some of the profession's approaches in responding to illness in modern society may have fueled the clamour for radical solutions such as euthanasia.

The process has been abetted by those who espouse so-called ‘progressive values’, in what are often referred to as the ‘culture wars’, and who often manifest a pervasive questioning of authority. 6 A desire for unfettered individual decision-making powers—seeing ‘radical autonomy’ as always being the overriding value—and the demotion of established religions as influential voices in the public square are also important factors in the rise in demands to legalize euthanasia. We consider euthanasia a misguided solution to a complex socio-cultural transformation. It is reasonable that the medical profession not deny its contributions to the situation; but, it would be perverse if it allows itself to be co-opted by a perceived need for atonement. It must be vigilant to avoid over-compensating by endorsing society-sanctioned euthanasia.

The profession must not disown its ethical tradition or abandon its basic precepts. The potential harm is not only to individuals, but also to the institutions of medicine and law and the roles they play in society, especially in secular societies, where they are the primary carriers of the value of respect for human life, at the level of both the individual person and society. Ironically, they are more important in this regard now than when religion was the main carrier of the value of respect for life. 4 Therefore, the degrees of freedom, in terms of legitimate actions and behaviours available to physicians confronted with a dying patient are, and must remain, clearly and strictly limited.

The injunction against physician involvement in hastening death has recurred throughout recorded history, the Hippocratic Oath providing the following emblematic statement: ‘I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect’. 7 This unambiguous prohibition has oriented medical practice towards specific ends and means and away from certain others for over 2400 years. Its enduring impact was apparent in early-modern Western society. Euthanasia was discussed by the lawyer Casper Questel in a book entitled ‘De pulvinari morientibus non subtrahendo’. 8 Translated as ‘On the pillow of which the dying should not be deprived’, it described common practices that were thought to hasten death. These popular practices included removing pillows from dying persons so that, with their bodies completely supine, ventilatory capacity would be constricted and death accelerated. Another strategy was to transfer dying persons from their beds to the ground. Perhaps the latter operated through a tacit understanding that the bodily cold thereby induced would bring dying persons closer to their natural demise. Regardless of the underlying pathophysiologic mechanism, it is highly probable that symbolism (for example, facilitating passage of the soul from the shell of the dying body to life eternal) was at play. We note that it was natural death that was sought, not terminating the life of the person.

An intriguing and noteworthy feature of this ancient text is that such practices were popular amongst the general public. They were not acts delegated by society to a particular group and certainly not restricted to medical doctors. Questel was aware of undesirable ramifications if they were practiced by physicians. Physicians risked losing trust should they be discovered to have intentionally shortened the lives of dying patients. Trust is of paramount importance to a successful doctor–patient encounter and is indispensable to the implicit moral contract between the profession and society. 9 Maintaining the trust of individual patients and of society is a sine qua non for the maintenance of professional status. Participating in euthanasia carries the risk of vitiating trustworthiness.

Constraints on physician complicity in euthanasia are to be found throughout history. An 1826 Latin manuscript by a physician, Carl Friedrich Marx, referred to medical euthanasia as the skillful alleviation of suffering. 10 He absolutely forbade physicians from engaging in any attempt at accelerating death, stating : ‘ … and least of all should he be permitted, prompted either by other people's request or his own sense of mercy, to end the patient's pitiful condition by purposefully and deliberately hastening death’. Examples of more recent statements of such prohibitions include the defeat in the House of Lords in 1932 of the ‘Voluntary Euthanasia Bill’ 11 and the Canadian parliament's clear rejection in 2010, by a vote of 228 to 59, of Bill C-384, a private member's bill that would have permitted PAS and euthanasia. 12

Certain jurisdictions, notably the Netherlands and Belgium, have legalized euthanasia. In America, Oregon's ‘Death with Dignity Act’, which permits PAS, came into force in 1997 and Washington state followed suit in 2008. However, on 6 November 2012, Massachusetts voters defeated a ballot that would have allowed assisted suicide, 51–49%. There have been discussions, debates and proposed legislation in many other American states and other countries in the recent past. Generally, these have reaffirmed the ban on medical assistance in killing (whether in the context of end-of-life or, in the USA, physicians' involvement in carrying out capital punishment through lethal injections). The Benelux and a few American states represent the exception to the rule. ‘Do not kill’ has been considered a moral absolute for most physicians for millennia, and remains so for physicians even in jurisdictions where the public has looked favorably on legislative change. That medicine has all to do with healing, and nothing to do with the purposeful ending of life, has been a reverberating imperative throughout history.

The pro-euthanasia lobby derives advantages by aligning itself tightly with medicine and physicians. The history of physician involvement in capital punishment is illustrative of this strategy. Juries in the USA, who had seen horrific footage of convicted murderers being executed in the ‘electric chair’, became reluctant to convict persons accused of capital offences or to vote for a death sentence for felons convicted of a capital offence. Most physicians and the American Medical Association adamantly opposed medicine's involvement in administering capital punishment by lethal injections. Nevertheless, some physicians participated. By virtue of their involvement and in concocting a method of execution that makes a convicted criminal appear serene during final moments, enhanced acceptability was conferred on the procedure. It has been suggested that ‘the law turned to medicine to rescue the death penalty’. 13

It is germane to point out that the word ‘doctor’ is linked etymologically to ‘teacher’. The Oxford English dictionary's definition is: ‘one who gives instruction in some branch of knowledge, or inculcates opinions or principles’. 14 Medical doctors can influence public opinion, much as teachers contribute to the socialization of their pupils. The recruitment of doctors, both as a collectivity and as individuals, to undertake a procedure, can greatly modify the public's view of that procedure.

Language is critically important in not only reflecting, but also creating reality. For example, the field testing conducted prior to the passage of the Oregon Death with Dignity Act demonstrated that when the intervention was described as ‘suicide’ or ‘euthanasia’, popular support declined by 10–12%. 15 The phrase ‘death with dignity’, by avoiding the negative connotations of suicide, was perceived as less alarming. It was able to create a halo of benignity and to generate greater support for and muted opposition to the proposed law. For similar reasons, the euphemism ‘physician assistance in a dignified death’ is reassuring. It would be rare indeed for an individual to wish explicitly for a gruesome death or want to banish a benevolent healer from the sickroom. Research shows that emotions, 16 which we would qualify as ‘examined emotions’, and we would add, moral intuition, are important in making good ethical decisions. Choice of language affects both these human ways of knowing what is morally right and morally wrong. 17

Jill Dierterle, a member of the Department of History and Philosophy at Eastern Michigan University, denigrates the validity and power of words in order to claim that none of the anti-PAS arguments hold merit and concludes that ‘we have no reason not to legalize it’. 18 She turns a blind eye to any potential harm and conveniently overlooks the lacuna in current data-gathering procedures or impact assessments. This stance flies in the face of the golden rule of medicine: primum non nocere. Hence, it is anathema to the vast majority of practicing physicians. Few of us, presented with a new and relatively untested therapeutic instrument, would conclude, ‘we have no reason to doubt its safety; let's forge ahead’. Her nonchalant dismissal borders on the offensive. Note how she handles an important deontological argument against PAS: ‘ … if PAS is wrong, its wrongness cannot be constituted by its conflict with the Hippocratic Oath. After all, the Hippocratic Oath itself is just a bunch of words’. 18 With the phrase ‘just a bunch of words’ Diertele implies that the oath is hollow and meaningless. But ethical precepts and laws are also just a ‘bunch of words’, yet they establish our metaphysical reality—what can be called our metaphysical ecosystem—which, depending on its nature, determines whether or not we have a society in which reasonable people would want to live.

It is critical to the euthanasia debate to consider what role, if any, physicians may, should or must not play. It is not a ‘given’ that, were euthanasia to be legalized, it would be inextricable from the medical mandate. We propose that it is in the best interests of individuals and society to remove the medical cloak from euthanasia in order to lay bare fundamental arguments against it. The stakes are too high to have the veneer of doctoring obscure the essential core of what is involved and its potential harms and risks.

The commentary previously mentioned, ‘Redefining Physicians’ Role in Assisted Dying’, suggests that a non-physician group could be made responsible for the ‘active’ role in euthanasia. 3 The label ‘thanatologist’ has been suggested for such a group. 11 The possibility that a new discipline might emerge raises a set of intriguing questions: What would be the scope of practice of thanatologists? Where would one draw the line between ‘active’ and ‘passive’ roles? Of what might their education consist? We want to make it clear that we believe euthanasia is inherently wrong and, therefore, should never be undertaken, but, it is important to consider what such a proposal could involve if it were put into practice.

It is reasonable to speculate that the training could be offered in a program at a technical level and that the duration of training period would be modest. The act of terminating someone's life is thought to be fairly straightforward—at least, the execution of it is not overly complicated. The experience in the UK of recruiting and training hangmen can provide useful clues. 19 Executioners were trained in the late 19th to mid-20th century with a 5-day course that included lectures, a practical component—‘applicants to pass pinioning in the presence of the Governor’—and ended with a written examination that included simple algebra—the applicant was required to calculate the length of drop (i.e. stretch of the rope) for men of varying weights. Given the complexity of drug-based protocols used in euthanasia, 5 days of instruction would likely be insufficient. A program in the order of 24 weeks, as is the case for cadet training in many police academies, might allow for core objectives to be adequately covered and relevant abilities to be tested and credentialed.

A provocative essay on the topic suggests that lawyers could be trained in euthanasia, practicing a new specialty called legistrothanatry. 20 Although admittedly implausible, the proposal serves to foreground pragmatic issues relevant to the debate. It rests on two fundamental assumptions: (i) that lawyers are trained to interpret laws and regulations accurately, to apply them strictly and to act on the basis of implementing patients' values and (ii) that carrying out the required tasks does not require sophisticated technical expertise. The authors state, ‘Attorneys who wish to provide this service would require only a small amount of additional training’. 20 An appropriate educational blueprint could include the following cognitive base: the physiology of dying, basic pharmacology and an overview of the historical, ethical and legal aspects of natural and requested/assisted death. The toolkit of required skills would likely include: communication, verification of decision-making capacity and informed consent, securing of intravenous access, supplying and/or administering of lethal drugs, management of complications, accurate recognition of death and completion of death certificates. The desired attitudinal substrate would include: personal resolve (that is, stick-with-it-ness), respect for individuals' rights to autonomy and self-determination, and, ideally, a calm demeanour.

Although the tone of the previous discussion may be—and should be—rather ‘chilling’, the substance it addresses has clearly gained a foothold in the current medical literature. A description of procedures for successful euthanasia has been published; one is entitled ‘Euthanasia: medications and medical procedures’. 21 It includes protocols for dealing with terminal dyspnea or agitation in the terminal phase, euthanasia, and the induction of ‘controlled sedation’. Controlled sedation is placed in inverted commas by the author, presumably because he feels that it needs qualification; in his opinion, it represent a hypocritical response to suffering and is undertaken with the aim of muzzling the patient while he dies. We note, but will not discuss here, the ethical issues raised by ‘palliative sedation’, sometimes called ‘terminal sedation’, in which the dying patient is sedated in order to relieve otherwise unrelievable suffering. We suggest that the former term should be used when sedation is the only reasonable, medically indicated, way to relieve the patient's suffering (when it is not euthanasia); the latter term is appropriate when those conditions are not fulfilled and the doctor's intention is to hasten the patient's death (when it is euthanasia).

The epigram to the euthanasia guidelines cited above is fascinating. It states: ‘One summer evening, Mr J-M L, suffering from Charcot's Disease, passed away peacefully after having asked for and obtained the assistance of a physician. Upon leaving the home, the latter did not ponder: ‘What did I do?’ but rather, ‘Did I do it well?’ (Translation by author JDB) 21 This formulation reveals a unique mindset. The affective and moral stance expressed in that quote is closely aligned to a technical perspective, one where the emphasis is on accomplishing tasks with self-efficacy as opposed to one embellished with critical reflection. Meta-reflection is an important aspect of doctoring. What we do and the conversations we routinely engage in forge who we become; they become a habitus. Even the clothing we wear can influence our thought processes. For example, a recent article documents the impacts on cognition of donning a lab coat. 22 If the simple habitual act of wearing a white lab coat can affect thinking and action, one can easily imagine the harmful impacts of regular discussions of euthanasia as they insinuate themselves into the ethos of medical care.

‘The Executioner's Bible’, a story of England's executioners in the 20th century, describes the work of the hangman as a ‘cold, clinical operation’. 19 The epigram we have chosen for our essay, extracted from that textbook, is a quote from James Billington, the UK's Chief Executioner from 1891 to 1901. It is intended to evoke calculated efficiency. The author of ‘Euthanasia: medications and medical procedures’ is similarly categorical, prescriptive and unrestrained by self-doubt. For example, he advises the physician not to propose suicide without medical assistance; to do so is considered incompatible with the role of the physician. He warns the physician against using ‘violent options’ (such as injecting potassium chloride) as this is considered contrary to medical ethics. Leaving aside a disregard for the value of respect for life, the punctilious euthanizer can be seen as behaving with professional dignity and serenity, within a priori defined limits. As the Home Office stated in 1926, when describing the work of hangman William Willis, ‘ … .even an executioner can remain humane and decorous’. 19 Our purpose in making this historical link is not to denigrate advocates of euthanasia. Rather, through this analogy we are endeavoring to focus on the act itself and not just the actor. The latter is often well meaning.

Thanatologists, given the narrow focus of their field of expertise would, over time, almost certainly develop clinical practice guidelines; these might be tailored to different illness categories, for instance, neurodegenerative diseases and the various cancers with poor prognosis. This process seems to be well underway. For example, a recent paper explores euthanasia requests and practices in a highly particularized context, namely, patients in Belgium dying of lung cancer. 23 If euthanasia is accepted as integral to ‘medical care’, this sort of disease-specific focus will surely expand. One can envisage the emergence of guidelines delineating the complementary roles of physicians and thanatologists. Most physicians (we hope) would eschew any involvement in euthanasia and confine themselves to traditional roles such as diagnosing, estimating prognosis and providing supportive care and symptom control, that is, excellent palliative care—which does not include euthanasia, as some advocates argue it should.

The extent to which principled opponents of euthanasia would be legally ‘excused’ from participating in the steps leading up to fulfilling a patient's request for assisted death is a contentious aspect of the debate. How would the profession balance the requirement for individual physicians to fulfill specific social roles and the need to respect the freedom of conscience of those who, on moral grounds, reject certain options? Physician–philosopher Edmund Pellegrino argues that physicians can refrain from entering into professional relationships that have the potential to erode their moral integrity; he offers strategies to assist the physician in navigating potential conflicts. 24

Psychiatrists and medical ethicists who do not reject euthanasia would be expected to focus on soliciting patient perspectives, exploring options and assessing comprehension, competence and voluntariness—that in making her decision, the patient is free from coercion, duress or undue influence, assuming this is possible. The profession has begun to equip itself with tools to deal with this incipient new clinical reality in jurisdictions which allow euthanasia. Physicians in the USA have been provided with an eight-step algorithm to assist them in discussing assisted suicide with patients who request it. 25 These guidelines were developed immediately after the legalization of PAS in Oregon. It is reasonable to expect that additional decision-making tools will emerge should the practice gain wider societal acceptance. Also, the possible consequences on undergraduate medical education, should it have to include protocols for ending patients' lives, have been explored. 26

Again, we note that the above discussion is included for the sake of comprehensive coverage of the issue of physicians' involvement in euthanasia, were it to be legalized, and whether it could be ethically acceptable ‘medical treatment’ or even ‘therapy’. It is not meant to signal that we see euthanasia as ethically acceptable.

It has been repeatedly found that of all separately identified groups in Western societies, physicians are among the most opposed to involvement in euthanasia. There is substantial indirect evidence to support this claim, even in jurisdictions in which doctor-assisted death is legal. For example, in Oregon, there is a suggestion that some patients have to resort to ‘doctor shopping’ to obtain their lethal medications. The Oregon Public Health Division's annual report for 2011 shows that one physician was responsible for 14 of the requisite prescriptions out of a total of 114 that year. 27 Also, the Netherlands recently approved the launching of mobile euthanasia clinics. A stated reason for this development was that patients' goals in self-determination were being thwarted by physician resistance to providing euthanasia. Not all physicians, including many Dutch colleagues, are on-side with having euthanasia become a medical act.

A questionnaire-based study comparing the opinions of the Dutch general public with that of physicians revealed some marked differences. With respect to the active ending of life for patients with dementia, the level of acceptance was 63% for the public and 6% for physicians. 28 With respect to terminally ill cancer patients, the figures were much higher and less divergent; this may be a consequence of the prolonged experience of euthanasia in cases of terminal illness in the Netherlands. Or, it might be that often survey questions are phrased as, ‘If a person is in terrible pain, should they be given access to euthanasia?’ The respondent must choose between leaving the person in pain and euthanizing them. But this choice is wrongly constructed. The person should be able to choose fully adequate pain management—that is, the ‘death’ of the pain—without having to endorse the intentional infliction of death on the patient. 29 Despite high levels of acceptance by physicians of euthanasia for cancer patients in the Netherlands, recent reports reveal persistent ethical concerns. 30 It is also noteworthy that physicians involved in palliative care, including in Britain, appear to be particularly concerned about legalizing euthanasia. 31

What underlies the medical profession's reluctance to accept euthanasia? There are multiple explanations. Aside from ethical, moral and religious beliefs, one of the most salient and compelling has to do with one's conception of the medical mandate, especially as it relates to healing. Healing is a challenging term to define. Many in our institution (the Faculty of Medicine, McGill University) consider it to be ‘a relational process involving movement towards an experience of integrity and wholeness’. 32 It has been operationally defined as ‘the personal experience of the transcendence of suffering’. 33 A feature of healing important to our thesis is the notion that healing does not require biological integrity. Although it may seem counter intuitive at first glance, it has been pointed out that if a sick person is able to construct new meaning and is able to achieve a greater sense of wholeness, that individual may ‘die healed’. 32 It is undeniably a vastly different concept than curing, although they are not in opposition one to the other. Most physicians accept the healer role as a fundamental and enduring characteristic of the profession. 34 In our undergraduate medical program, this concept is taught using the term ‘physicianship’; it refers to the dual and complementary roles of the physician—the physician as healer and professional. 35 It could be argued that one can remain ‘professional’ even while serving as a collaborator in requested death. On the contrary, many commentators—the American Medical Association is a prime example 36 —believe that it is impossible to do so as a ‘healer’, one who is focused on accompanying the patient on a transformational journey towards personal integrity that transcends the embodied self.

The process of healing in the doctor–patient relationship is poorly understood. We do not have a complete picture of how it is initiated or which clinical skills or abilities are essential in fostering a healing relationship. The literature suggests that healing resides in the quality of interpersonal connections and that it requires a deep respect for the agency of the physician in the therapeutic process. 37 An appreciation of the placebo effect, or in more poetic terms, the ‘doctor as the medicine’, is required. 38 , 39 It is almost certainly linked to the phenomena of transference and counter-transference and it may utilize the power differential for salutary purposes, even if these phenomena operate largely at a covert level.

The patient–doctor relationship is marked by intense ambivalence. Any physician who has initiated a discussion with a patient on the issue of resuscitation or desired level of technical intervention will realize how easily it can be misinterpreted, how quickly it can catalyze existential angst and how thoroughly it can overwhelm hopeful sentiments. Affective turmoil and cognitive dissonance can rapidly ensue. These sorts of cross-purpose exchanges would surely be magnified in the context of discussions regarding euthanasia. Although there may be a productive ‘meeting of the minds’ in any specific doctor–patient dyad, the risks of emotional derailment, self-effacing dependency and irremediable miscommunication should not be minimized. It is inconceivable to us that deep layers of existential suffering would not be activated and exposed by such a discussion. A healing space that can support patients would be unnecessarily deflated. Admittedly, this belief is based on incomplete understandings of the clinical encounter, yet the axiomatic foundation of that encounter is anchored in a 2400-year old tradition. We must consider why we have so jealously guarded that tradition. We could always have abandoned it by accepting euthanasia. Unlike many other current medical–ethical dilemmas, neither death nor euthanasia is a novel issue presented by new technoscience.

Many proponents of euthanasia like to claim that opponents rely on two types of unsound arguments: one based on empirical data and the other anchored in axiology. In the first instance, they allege that the outcomes data available from jurisdictions where euthanasia or assisted suicide has been legalized, suggest that our fears of potential abuse are groundless. They deny that there is a ‘logical’ slippery slope—that the situations in which euthanasia will be available will expand over time—or a ‘practical’ slippery slope—that euthanasia will be used abusively. Pro-euthanasia advocates claim that evolving legislation does not pose a threat to persons with a disability, does not lead to euthanasia without consent, does not invite extension of the practice to vulnerable populations—in short, that it has not become a ‘run-away train’. They usually express satisfaction with individual clinicians' professional restraint and integrity as well as with administrative safe guards. Some suggest that the acceptance of euthanasia results in improvements in traditional palliative care. This belief that it represents a positive force for changing prevailing clinical practices is not based on robust evidence. Moreover, the evidence for the existence of a practical slippery slope is very convincing. This was very recently affirmed by the High Court of Ireland, in a judgment we discuss shortly, in deciding whether prohibiting assisted suicide contravened the Irish Constitution, which it held it did not. 40

A recent dramatic example of the logical slope's gravitational pull is the euthanizing, in December 2012, of 45-year-old twins in Belgium. Deaf since childhood, Marc and Eddy Verbessem were facing the additional disability of blindness. Accepting that they were irremediably suffering, their physician euthanized them. 41 Euthanizing patients with non-terminal conditions, even though it can be legal in Belgium, will surely meet with the disapproval of most physicians. Even within the pro-euthanasia movement, this development may be considered an aberration. Nonetheless, there are increasing numbers of commentators who subscribe to the following philosophy: ‘If a patient is mentally competent and wants to die, his body itself constitutes unwarranted life-support unfairly prolonging his or her mental life’. 42

There are two arguments, both warranting careful scrutiny, frequently advanced in support of physician involvement in euthanasia. The first is that physicians have privileged access to information about their patients' unique perspectives and circumstances, including personal resources and frailties, as well as complex family dynamics. That argument has been undermined by evolving practices. The ‘Oregon Public Health Divisions’ report for 2011 reveals that the median length of the doctor–patient relationship for those who died by PAS was merely 12 weeks (with a range of 1–1379 weeks). 27 It is highly unlikely that a physician would have acquired a sophisticated understanding of a person's values, hopes and fears in the matter of a few weeks. It is even less plausible in the case of the mobile euthanasia units currently being deployed in the Netherlands. The second argument is that physicians are inclined, by temperament and experience, to accompany their patients throughout the illness trajectory, including death. That too is not defensible on the known facts. For example, in Oregon, in the first 3 years of the administration of Oregon's ‘Death with Dignity Act’, physicians were present at approximately half of assisted deaths. By 2005, it was 23%. In 2011, it was a mere 9%. 27 The behaviour of these prescribing physicians is not congruent with the image of physicians represented in that iconic painting by Sir Luke Fildes, bearing the title ‘The Doctor’, and often used to portray empathic witnessing. Pro-euthanasia advocates can come across as rather intrepid in their defense of personal autonomy. Autonomy is the overriding principle that is used to buttress arguments in favor of euthanasia; indeed, it generally runs roughshod over all other considerations. Many pro-euthanasia commentators are disposed to brush off concerns about the impact of accepting ‘radical autonomy’ as always being the overriding value—especially concerns about the risks and harms to vulnerable people and to important shared values, in particular, respect for life at the societal level. A 2012 case in British Columbia manifests all these issues; it involved vulnerable persons, values conflicts and shows the preferencing by the court of the value of individual autonomy in relation to euthanasia. The case originates in a challenge to the Canadian Criminal Code's current prohibition of assisted suicide. 43

Gloria Taylor, a plaintiff in the case, Carter v Canada (Attorney General) 44 , was a person with ALS who requested assisted suicide arguing that as her illness progressed she would be incapable of committing suicide, unaided, due to her physical disability. The judge, Justice Lynn Smith, ruled in the plaintiff's favour on the basis that the prohibition was unconstitutional on the grounds that it contravened both Ms Taylor's constitutional ‘right to life, liberty and security of the person’ (under section 7 of the Canadian Charter of Rights and Freedoms) 45 and her right not to be discriminated against as a physically disabled person (under section 15 of the Charter ); and that the prohibition could not be saved (under section 1 of the Charter ), as a reasonable limit on constitutionally protected rights. Consequently, the judge held that the law prohibiting assistance in suicide was not applicable with respect to preventing Ms Taylor and other people in similar circumstances from having such assistance. The judgment is very long and legally complex and is now on appeal. Read as a whole, it strongly supports legalizing PAS and euthanasia.

In that case, the Canadian court reviewed the available evidence from other jurisdictions with liberalised legislation and concluded that there was no evidence of abuse. This Court also reviewed the same evidence and has drawn exactly the opposite conclusions. The medical literature documents specific examples of abuse which, even if exceptional, are nonetheless deeply disturbing. Moreover, contrary to the views of the Canadian court, there is evidence from this literature that certain groups (such as disabled neonates and disabled or demented elderly persons) are vulnerable to abuse. Above all, the fact that the number of LAWER (‘life-ending acts without explicit request’) cases remains strikingly high in jurisdictions which have liberalised their law on assisted suicide (Switzerland, Netherlands and Belgium) – ranging from 0.4% to over 1% of all deaths in these jurisdictions according to the latest figures – without any obvious official response speaks for itself as to the risks involved’. 40

One can also question Justice Smith's conclusions that PAS is not inherently unethical; that individuals' right to autonomy takes priority over the value of respect for life; that sanctity of life is only a religious value; that there is no relevant ethical or moral difference between refusals of life-support treatment that result in the death of the patient and euthanasia; and, that the availability of legalized PAS is necessary ‘medical treatment’ for some.

Justice Smith's justification for allowing euthanasia is largely based on a selective application of Canadian Charter of Rights and Freedoms jurisprudence 45 and depends upon her being able to distinguish the binding precedent set by the Supreme Court of Canada in the Rodriguez case. 46 The latter held, in a four to three split among the judges, that the Canadian Criminal Code's prohibition on assisted suicide 43 was constitutionally valid.

Invoking the Canadian Charter of Rights and Freedoms , Justice Smith ruled that Ms Taylor's right to life was infringed by the prohibition of assisted suicide because she might conclude that ‘she needs to take her own life while physically able to do so, at an earlier date than she would find necessary if she could be assisted’. 44 We believe that this would strike many as a straw man argument. It is to convert a right to life to a right to assisted suicide, by accepting as a breach of a right to life that a person will commit suicide sooner, if not given access to assisted suicide. But validating assistance in committing suicide hardly upholds a right to life.

Like everybody else, Ms Taylor has a right to refuse treatment even if that means she will die sooner than she otherwise would. Justice Smith accepts the plaintiffs' argument that there is no ethical or moral difference between euthanasia and refusals of life-support treatment that result in death and, therefore, both should be legal. But a right to refuse treatment is based in a right to inviolability—a right not to be touched, including by treatment, without one's informed consent. It is not a right to die or a right to be killed. At most, people have a negative content right to be allowed to die, not any right to positive assistance to achieve that outcome. A person with Ms Taylor's illness trajectory will surely die—even more precipitously if they decline many of the interventions described in the hypothetical patient with ALS we introduced earlier on. (Subsequent to the judgment, Ms Taylor died a natural death from an infection). It is also important to underline that current medical practices enable physicians to attenuate much of the suffering that may accompany the progressive loss of function and well-being in advanced ALS.

The judge appears also to accept the argument that legalizing euthanasia enhances palliative care. This goes some way towards treating euthanasia, as some have termed it, ‘the last act of good palliative care’. 47 It is also consistent with the ‘no-difference-between-them approach’ to a spectrum of end-of-life medical interventions. Euthanasia is confused with interventions, such as pain management and rights to refuse treatment, which are ethically and legally acceptable, and an argument is thus set up that, if we are to act consistently, euthanasia must also be ethically and legally acceptable. It is tantamount to legalizing euthanasia through confusion. 48

In the policy, ‘palliative care’ is defined as ‘a qualified medical practitioner, or a person acting under the general supervision of a qualified medical practitioner, administering medication or other treatment to a terminally ill patient with the intention of relieving pain or suffering, even though this may hasten death’. The policy states that that conduct, ‘when provided or administered according to accepted ethical medical standards, is not subject to criminal prosecution’. 44

In other words, the policy's definition of palliative care can be expansively interpreted to place euthanasia in same category as other end-of-life interventions which may hasten death.

For the sake of exploration of the issue, let us assume momentarily that euthanasia is medical treatment. What might flow from this?

Classifying euthanasia as medical treatment would affect the scope of disclosure of information necessary to obtain informed consent. A physician must disclose to the patient all reasonably indicated medical treatments as well as their risks and benefits. It would now have to include euthanasia. Even most pro-euthanasia advocates regard it as unethical for a physician to introduce the possibility of euthanasia. Currently, it is generally accepted that any discussion of it must be initiated by the patient.

It would also mean that to obtain informed consent to euthanasia, all reasonably indicated treatments would need to be offered and they would certainly include all necessary palliative care, in particular, fully adequate pain management. Many of those advocating for euthanasia posit euthanasia and palliative care as alternatives, but informed consent to euthanasia could not be obtained unless good palliative care was available. This is not available to a majority of people who die in Canada; it has been estimated that less than 30% have access to even the most minimal form of palliative care. 49

As well, Canadian psychiatrist Dr Harvey Max Chochinov, who specializes in psychiatric treatment for dying people, has shown that there are significant fluctuations in the will to live, even as death is imminent. 50 The impact of these findings, as well as conditions such as depression, on the possibility of obtaining valid informed consent to euthanasia would need to be fully addressed.

Another crucially important issue is that, if PAS and euthanasia are ‘medical treatment’, then surrogate decision-makers have the authority to consent to them for the patient. Their decisions must be based on either their knowledge of what the patient would have wanted or, if those wishes are unknown, their belief that these interventions are in the ‘best interests’ of the patient. Would mentally incompetent people and those with dementia or disabled newborn babies, as is now the case in the Netherlands under the Groningen protocol, be eligible for ‘therapeutic homicide’? 51

Yet another issue is what would be the indications for euthanasia as medical treatment and who could access it if were legalized? Justice Smith, citing an expert witness for the plaintiffs, refers to ‘the end-of-life population’. 44 This is a term used in the Royal Society of Canada Expert Panel Report on End of Life Decision - Making. 52 In the report, this population is defined as those persons on a continuum beginning with any serious diagnosis or injury. This represents an expansion of a term, ‘end-of-life’, traditionally used for those inevitably in the last days of life, to all people with serious chronic conditions, resulting from illness or injury, that may be fatal in the course of time. And, of course, it is notoriously difficult to predict with any certainty the timing of even obviously terminal illnesses. It is precisely the type of ‘slippery slope’ that we fear emerging from the ‘limited’ exception, as defined by Justice Smith. It will likely culminate in more decisions similar to that taken in the case of the Verbessem brothers in Belgium.

It is also pertinent to point out that Canada continues to fund and promote programs that aim to prevent suicide. If suicide is conferred the status of a right or is held to be acceptable medical treatment it would be difficult to reconcile this situation with the presence of programs that aim to actively thwart it. Some resolve this dilemma by trying to banish the word ‘suicide’ from the debate, in favor of the phrase ‘assisted dying’. Marcia Angell, erstwhile editor of the NEJM and a fervent proponent of PAS, endorses the notion that ‘assisted dying’ can be distinguished from ‘typical suicide’. The latter is described as being undertaken by someone with a normal life expectancy, whereas the former is carried out in someone ‘who is near death from natural causes anyway’. 53 They are going to die anyway, so what does it matter?! We believe that this reasoning is rather disingenuous and that it can result in a dishonouring of that segment remaining in someone's life, whether this is measured in minutes or months, and could deprive them of something as ephemeral as dreams and hopes. It certainly negates the idea of dying as our last great act of living. 54

Finally, a decision classifying euthanasia as medical treatment could have impact far outside the context of issues directly related to death and dying. For example, in Canada, the federal and provincial governments' respective powers are allocated under the Canadian Constitution. The criminal law power belongs to the federal parliament and the power to govern health and social services to the provincial legislatures. If euthanasia was defined as medical treatment, the federal parliament's prohibition of it in the Criminal Code could be invalid by reason of its trespassing on the provincial jurisdiction to govern health and social services. That is one reason that the Quebec College of Physicians and Surgeons, which supports legalizing euthanasia, argues that it is medical treatment. Likewise, the Quebec Legislative Assembly committee, which issued a report, ‘Dying with Dignity’, 55 adopts the same argument. From past experience, we expect that Quebec might challenge the constitutional validity of the Criminal Code prohibition on this basis. However, a legal committee, set up by the Quebec government, has proposed another approach. It has just reported on how Quebec could operationalize giving doctors legal immunity for carrying out euthanasia, including by the Attorney General of Quebec instructing Crown Prosecutors not to prosecute them under the Criminal Code for doing so, provided they comply with certain guidelines. 56 In either case we could see Quebec becoming ‘separate’ from the rest of Canada on this critically important issue.

In pondering medicine's possible involvement in euthanasia, we must foreground those aspects of the medical mandate that are immutable and eternally relevant. We believe these to be the constant nature of ‘illness’, changeless across time, place and culture, and the resultant obligations of the healer. It is important to appreciate how illness affects persons in all spheres of their lives. Patients become intensely vulnerable, impressionable and open to abuse. Pellegrino has summarized the nature of the clinical encounter eloquently as ‘a peculiar constellation of urgency, intimacy, unavoidability, unpredictability and extraordinary vulnerability within which trust must be given’. 57 This vulnerability sets up an intense and enduring obligation of physicians; they must respond to the wounded person with authenticity, compassion and moral agency. The latter demands that physicians harness and deploy their unique influences and persuasive powers in a particular manner. The essential nature of physicianship has evolved over time in a direction that recognizes the extraordinary vulnerability of patients and guards ferociously against their exploitation. In part, this has been achieved by imposing inviolable limits on the physician's terrain of action. Moreover, we believe that, even if one accepted that euthanasia was ethically acceptable—which we do not—it opens up too many doors for abuse.

The medical profession has arrived at a crossroad; it must choose whether to embrace euthanasia as medical treatment, as a logical extension of end-of-life care, or it can reject the redefinition of its healing mandate that this would entail. We believe, that looking back in the future, the euthanasia events of the present time will be seen as a turning point, not only for the profession of medicine, but also for societies. Crossing the line in the sand articulated by Hippocrates, that as a physician ‘I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect’, would result in the ‘doctor as healer’ becoming the ‘doctor as executioner’. In short, healing and euthanizing are simply not miscible and euthanasia can never be considered ‘medical treatment’.

Donald Boudreau was an Arnold P. Gold Foundation Associate Professor of Medicine when this manuscript was written and submitted. He is grateful for the financial support the foundation has provided in the past and requests that readers appreciate the opinions expressed herein are his personal views and not necessarily reflective of the perspectives of the Foundation, its staff, affiliates or benefactors.

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The pros and cons of legalising euthanasia

Help to end suffering for terminal patients could put disabled, elderly and unwell people at risk, opponents warn

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Pro: an end to suffering

Con: losing legal protection, pro: ending 'mercy killings', con: 'slippery slope', pro: shifting opinion, con: religious concerns.

 Demonstrations calling for the decriminalisation of assisted dying are to take place in central London today to coincide with a debate among MPs in Westminster.

The Commons debate – which will not be followed by a vote – was triggered after a petition backed by campaigner Esther Rantzen gained more than 200,000 signatures.

Rantzen, who has stage four lung cancer, revealed last year that she had joined the assisted dying clinic Dignitas, in Switzerland, but that under current UK law her family could be at risk of prosecution if they helped her travel there to end her life.

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"The Great British Bake Off" judge Prue Leith, actor Susan Hampshire and rights campaigner Peter Tatchell are all expected to attend the protests calling for a change in the law. A previous bill in favour of assisted dying was defeated in the Commons by 330 votes to 118 in 2015.

Also known as euthanasia , assisted dying is a controversial issue for legislatures worldwide, with widely cited arguments both for and against a practice that is legal in some countries while totally taboo in others.

It is currently banned in England, Wales, and Northern Ireland – although not a specific criminal offence in Scotland – and carries a maximum prison sentence of 14 years.

Allowing patients to end their suffering is not only morally justified but also essential to upholding the right to personal and bodily autonomy, advocates argue.

A major parliamentary inquiry set up last year to explore whether assisted dying should be legalised in the UK received tens of thousands of submissions from people facing "uncontrollable" pain and "unbearable suffering", which palliative care alone cannot fix,  The Guardian reported.

Paul Lamb, a paralysed former builder from Leeds who died in June 2021, had  lost his legal case to challenge UK laws on assisted dying seven months earlier.

"I cannot understand, in a civilised society like ours, why I should be forced to suffer when millions of people around the world already have the choice I asked for," he said in November 2020.

It is currently a criminal offence under the 1961 Suicide Act to help someone take their own life, punishable by up to 14 years in prison.

Some people believe that legalising euthanasia would put too much power in the hands of doctors, who could abuse their position, or relatives.

Rita Marker, executive director of the International Task Force on Euthanasia and Assisted Suicide in the US, has argued: "Euthanasia and assisted suicide are not about the right to die. They are about the right to kill."

The UK's anti-euthanasia  Care Not Killing alliance said that the law is also in place to protect the vulnerable "from being pressured into ending their lives".

Making her case against any law change, Ilora Finlay, a crossbench peer and palliative care physician, told the parliamentary inquiry that legalising euthanasia in Britain could result in between 5,800 and 58,000 assisted deaths a year, based on extrapolated data from countries where it is already legal. "Such demand would divert an already stretched workforce of NHS clinicians," she said. 

According to  Dignity in Dying , 44% of people would break the law and help a loved one to die, risking 14 years in prison.

In 2022 the Crown Prosecution Service (CPS) said it was considering revising its stance on so-called mercy killings so that defendants are less likely to face criminal charges.

"We are not decriminalising any offence," Max Hill, director of public prosecutions and head of the CPS, told the  i news site, but in offences "born solely out of compassion", justice can sometimes "be achieved by not prosecuting".

Campaigners claim that UK police are also increasingly turning a blind eye to people travelling to other countries to assist loved ones to end their life.

Opponents argue that normalising euthanasia would be a move towards legalised murder.

This "slippery slope is real", said James Mildred of Care (Christian Action Research and Education), which campaigns against assisted suicide. In a 2018 article in  The Economist , Mildred cited "a steady increase year on year in the number of people being killed or helped to commit suicide by their doctors" in countries that have legalised assisted suicide, as the rules are loosened over time.

"Critics say this is happening in Canada," said  New Scientist , "with the criteria for assisted dying having expanded once already and a further change planned for next year." Canada, which introduced Medical Assistance in Dying, or MAID, in 2016, has seen the number of people choosing to end their life rise steadily ever since, with  MAID deaths comprising 4.1% of all deaths in 2022. 

There has been a significant shift in recent years among both the public and professional medical opinion regarding assisted dying for people with a terminal illness.

Polling for  The Guardian last August found 65% of people in the UK believe it should become legal for a doctor to assist an adult of sound mind with less than six months to live to voluntarily end their own life, subject to High Court confirmation.

Dignity in Dying claims this number is even higher, and also that 54% of GPs are supportive or neutral to a law change on assisted dying. 

Many religious people, especially Catholics, believe that life is the ultimate gift and that taking that away is usurping power that belongs to God only. 

In 2020, the Vatican reiterated the Roman Catholic Church's opposition to assisted suicide and euthanasia, describing them as "intrinsically evil" acts "in every situation or circumstance",  The New York Times reported. 

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Essay Service Examples Health Euthanasia

Why Euthanasia Should Be Legal Essay

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Introduction, is euthanasia a solution to poor quality of life, does euthanasia offer the best quality of death, ethical considerations regarding euthanasia, public acceptability of euthanasia, healthcare professionals’ views on euthanasia.

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The Reality of Assisted Dying: Understanding the Issues

• Provides up-to-date data, evidence and reflections from professionals from countries where assisted dying has been legalized;
• Takes a fresh look at the arguments around legalization of assisted dying;
• Shows how a change in the law must take account of all those who will be affected, including families and those who will feel compelled to participate by assisting suicides or performing euthanasia;
• Shows the problems and dangers of embedding assisted dying within healthcare, and explores how alternative socio-legal procedures would improve legitimacy and monitoring for patients and their families.

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The Legalisation of Euthanasia

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Brian Pollard MB BS, FANZCA, Grad Cert Bioeth. Sydney, Australia

The legalisation of euthanasia is a constantly recurring topic for debate, in which the chief themes include the status of good medical and nursing care for the dying, its morality, legal detail and human rights, especially respect for personal autonomy and perhaps privacy, and the role of public opinion. Since there are deep divisions in society on all those issues, it is not surprising that the debate seems to rotate endlessly about them, without any reasonable prospect of consensus. Those for and those against the proposal are both unwilling to yield on what they see as immutable positions of principle.

If progress is to be made, a way needs to be found whereby personal views about the medico-social role of euthanasia can be excluded, while the subject is discussed on neutral grounds, capable of objective examination.

It is apparent now that such a neutral way has been discovered, though perhaps by chance, it has already been used several times and the results of that use have been published. I refer to the reports of the large government-supported committees of inquiry held in recent years, on four different continents, devoted to the consideration of the consequences of legalising euthanasia.

In sharp contrast to the usual lack of resolution on debate on this topic, every one of these committees independently reached the same conclusion, namely that legalisation would be unwise and dangerous public policy, because unpreventable abuses could not be eliminated. More astonishingly, when it is difficult to find at random even a small number of people who can agree on almost any aspect of euthanasia, three of these four committees reached this conclusion unanimously, though they all included individuals who held opposing personal views about euthanasia.

The committees and their reports were:

- Select Committee on Medical Ethics, House of Lords, January 1994.(1)

- New York State Task Force on Life and the Law, titled Euthanasia and Assisted Suicide in the Medical Context, May, 1994. (2)

- Senate of Canada, June, 1995, titled Of Life and Death.(3)

- Community Development Committee, parliament of Tasmania, titled The Need or Legislation on Voluntary Euthanasia, 1998.(4)

Of the fourteen members of the House of Lords Committee, it can safely be assumed that some of the Peers were for, and some against, the legalisation of euthanasia when they commenced their deliberations and began to hear evidence. When it visited Holland, the Committee learned there of an alarming number of patient deaths without patient consent, and were openly told by Dutch advocates of euthanasia that effective safeguards against abuse had proved impossible to devise (5).

The Committee of the New York State Task Force had 25 members, including some who thought that euthanasia and assisted suicide were sometimes ethical and compatible with good medical practice. This Committee issued a unanimous report rejecting legalisation, a most valuable compendium of important information.

In early 1997, the Tasmanian parliament established a committee to examine the need for legislation on voluntary euthanasia in that State. When she released the final report of this Committee in 1998, the Chairperson revealed that of its five MP members, four, including herself, had originally been in favour of euthanasia. This Committee unanimously found that 'it would be impossible to frame a law that included all the vital safeguards to protect the vulnerable, weak and disabled' (6).

These reports, taken together, constitute an unexpected and valuable body of expert findings, all pointing in the same direction. Thus, any future proposal for the legalisation of voluntary euthanasia (VE) could reasonably be regarded as incomplete and inadequate unless it displayed familiarity with the arguments contained in those reports, and included effective solutions to the many difficulties they uncovered.

Regarding laws on killing, the House of Lords Report said 'The product of an adequate, legal framework should be public confidence that the law protects life...there can be no more important area in which the law's protection should be complete and transparent than where individual's lives are at stake'.

For a law to be unsafe, it does not have to be shown that it will be abused, merely that it is clearly open to abuse. The more open it is, the greater the likelihood that it will be abused.

A good deal of the reasoning in the reports may be summarised in this extract from the report of the New York State Task Force: 'For purposes of public debate, one can describe cases in which all the recommended safeguards would be satisfied. But positing an 'ideal' or 'good' case is not sufficient for public policy, if it bears little relation to prevalent social and medical practices. No matter how carefully any guidelines are framed, (assisted suicide and) euthanasia will be practised through the prism of social inequality and bias that characterises the services in all segments of our society, including health care. The practices will pose the greatest threats to those who are poor, elderly, members of a minority group or without access to good medical care'.

This paper cannot do justice to the whole of the content of the cited reports which need to be read in full, because they cover an extensive range of subjects. It will include:

- discussion of the essential incompatibility of any euthanasia law with the objectives of sound criminal law

- some discussion of the human rights thought relevant to euthanasia

- the role of public opinion in law making, and

- some of the medical factors that would make any such law unsafe.

Incompatibility of legalised euthanasia with existing criminal law.

Since euthanasia is the intentional taking of innocent human life, it is a form of homicide, and even if it were legalised, it would be legalised homicide. The basic aims of criminal law are to provide equal justice for every citizen and to protect the weak. Additionally, the consent of the victim is by legal tradition no defence to a crime.

Equal. The criminal law of every nation holds that all innocent human life is inviolable, innocent persons being those who pose no threat, or have done no harm, to others. The value placed equally by law on each life is such that its intentional destruction is the greatest of crimes, deserving of the greatest penalty. Euthanasia law would provide the first exception to the prevailing universal protection of innocent life, by creating a category of persons whose lives may be taken intentionally, under certain conditions. It would thus constitute a precedent for repeating the process later to further enlarge the scope of the new principle, where no such precedent had previously existed. The concept of equality before the law would have been abandoned.

Justice. For a law to be just, it should be grounded in sound ethical principle capable of receiving general acceptance; its definitions and provisions should be set out in clear terms so they can be interpreted in the same way by all who read them. This would constitute a particular problem with euthanasia, since many of the phenomena associated with death are difficult to define with such precision; its provisions, particularly those intended to act as safeguards, must be capable of being realised and of being monitored, and it must contain no obvious avenues for abuse. If any of its important elements relied for their observance on opinion rather than fact, that would introduce arbitrariness and would be incompatible with justice.

A patient who requested euthanasia would have concluded that his/her life was no longer worth living, and a doctor who agreed to the request would have reached the same conclusion, by an independent but arbitrary judgment. In the same circumstances, different patients and different doctors would have come to different conclusions, depending on their personal values. Thus, under a euthanasia law that simply accepted these personal choices as grounds for lawful killing, the result would represent a kind of lottery of life, whereby a subjective request was met with a subjective response, and neither would be, or could be, objectively validated. The idea that legally taking life may be made dependent on the untestable choice or opinion of persons is at odds with any mature notion of justice.

Protection of the weak. The lives of individuals or groups who are unable to participate fully in the life of the community are especially protected by the current law, because it allows of no exceptions. These groups include the poor, the aged and the very sick, and those who make heavy demands on the community's time or resources, such as physically or intellectually handicapped, or permanently unconscious, people. Once it had been decided in law that the equal right to life may be waived on account of a low quality of that life, it would seem, to some at least, that individuals in the above categories would be the most logical for the extension of that principle, should other circumstances seem to justify it.

Mutual consent. Voluntary euthanasia involves one person asking and another agreeing to the taking of life. Though, in criminal law, consent is no defence to a breach of any of its provisions, with lawful euthanasia both parties would have acted in defiance of that principle.

It is instructive that the statute laws on killing in the Netherlands are much the same as elsewhere, and that the Dutch have to date preferred to try to justify their expanding euthanasia practices by case law or precedent, not by statute. They have wanted to have euthanasia regarded as an arguable exception to the legal principle that they see as vital to maintain, namely that innocent life should be regarded as inviolable. Most of those who promote lawful euthanasia elsewhere fail to see that the retention of this principle is needed to sustain the credibility and strength of the rest of the criminal law, for a person must at least be alive in order to be subject to its provisions.

Human rights and the law.

As outlined above, any proposal to legalise VE would constitute, not only an attempt to change the present laws, but to overturn them. If the proposal appealed to any human rights for its justification, they would have to be acknowledged natural rights, those derived from considerations of the nature of mankind. That right would also need to be properly defined and understood in the same way by all who discuss it.

Natural rights were originally conceived as the entitlements of citizens that would protect them against injustices. Respect for autonomy can be argued to be a genuine natural right, and as such, it would oblige its acceptance by others. Autonomy is the right of every person to decide freely the course of his/her own life, within the limits set by the competing genuine rights of others, and it will oblige compliance when it respects those rights. That is, autonomy involves both the privilege of choice and the duty to restrain one's choice, when that is required. Difficulties arise in relation to VE when (a) autonomy is not defined or not correctly defined, since clarity is essential when discussing such a contentious and emotional subject, and (b) when it is commonly discussed as though it were no more than a welfare right. Autonomy is now commonly presented as, and often thought to be, merely an individual's expression of preference, which is never claimed to be binding on others.

Welfare rights have a well deserved reputation for being divisive and confronting, because they tend to favour one individual above others. Natural rights, which place equal emphasis on furthering the well-being of both the individual and of society, promote harmony and friendship. The facts that rights are so often incorrectly understood and unequally applied led one observer to comment 'when rights come in, love goes out the door'.

Though any proposal to take innocent life has unarguably high moral content, any suggestion that this merits close examination is apt to be met with accusations of 'religious bigotry' or the like, as though secular morality did not hold similar claims to fundamental importance. However that may be, a common practice now is simply to ignore any discussion of it. When absolute morality is rejected, traditional ways of deciding morality become diluted, without any consistent ethic found to replace them. Questions of right and wrong can then be transformed into questions about individual rights, so that 'What is right?' becomes 'What are the rights?', an entirely different topic.

Autonomy is misunderstood or misrepresented when it is assumed to apply to whatever an individual may happen to want sincerely, or when it is assumed that the significance of the consensual killing of VE is a private matter, with no harmful consequences for others. Both assumptions are wrong. Further, it is widely but incorrectly assumed that choice itself is the essence of autonomy, not what is chosen. Individuals have no entitlement at all to be given what they happen to want--that would be nearer to self-indulgence than self-determination.

Depicting euthanasia as no more than a private matter is dangerously naive, ignoring the fact that euthanasia law would set new and lower standards of respect for human life, because in the eyes of many, making a matter legal signifies it has the approval of authority. VE would then become one of the options that may be put to all vulnerable sick patients, and it would be proper to promote and encourage it. In light of the gross imbalance in power between doctors and their patients, some patients would than be powerfully and unfairly influenced. This would place an unnecessary burden on dying patients when they may already be seriously taxed and confused by so many aspects of their illness.

If the right to request death were a genuine right, it would oblige compliance, though VE supporters are careful always to point out that that is not their aim. A human right cannot be claimed at the same time to be genuine and yet only permitted to be exercised arbitrarily. To be consistent, if the right were genuine, VE should then be available to all who ask, sick or not, at any time, for any or no given reason. The young who now commit suicide in alarming numbers should no longer distress us, but be congratulated for showing how to take control of one's dying, as a matter of right.

Further, to depict VE as no more than an individual patient's wish is to ignore the presence of the person asked, the doctor. This second person is an independent moral agent who must make his/her independent and separate autonomous response, be required to justify it when asked, and take due responsibility for it.

The sum of these deficiencies in the common understanding of autonomy to justify VE means that the argument is distorted. No matter how often or how vehemently it is asserted that an individual's wish binds others to comply, just because that is what he/she sincerely wants, the mere expression of a wish is not autonomy. The wish, and all that may flow from it, must be closely examined within the context of its social and medical setting, and in this paper, some of those factors are discussed.

A different form of distortion, in the opposite direction, is the virtual exclusion from the debate of the right of every innocent person to his/her life, the genuine natural right on which the criminal law is founded. Not only must this right be included, logically it should be first.

The 1948 United Nations‚ Universal Declaration of Human Rights is the most widely acclaimed and accepted statement of human rights. It was compiled at a time when member states of the UN, horrified by their discovery of the then recent extent of the abuse of natural rights, were resolved to ensure that this should never happen again. It describes the right of each person to his/her life as equal, inherent, inviolable, inalienable and deserving of the protection of law. This means that the right is not to be made dependent on its quality at a particular time, there are no exceptions and the right may neither taken away nor given away.

There is an urgent necessity for full consideration of this natural right to be reintroduced whenever the legalisation of euthanasia is being discussed, if the proper role of law in the governance of society is to retained.

The doctrine of personhood is a relatively recently added plank in the platform for VE, and is now receiving broad assent. While it may not directly be connected with human rights, the concept is a denial of the right of every person to his/her life, and is therefore an attack on the ethical basis of law. 'Personhood' claims that the value and dignity of a person, which are the reasons that entitle every individual to be treated with equal justice, are said to depend on the prior development of certain currently usable psychological abilities. This raises questions as to which abilities there must be and how developed they must be. Since there are no standards by which every observer could reach the same conclusions, such questions can be answered only by choosing the criteria that will lead to the conclusion one wants. Thus, this will always be an arbitrary exercise, reliant on the values of the observer, and cannot be just.

If it were asked 'What benefits does this new idea confer on society in order to justify the displacement of the traditional understandings of who may be regarded as a person?', the answer can only be 'None, that do not permit and rely on the taking of the lives of certain individuals who are already unwanted by society, for other reasons, without their knowledge'. Those individuals will be some of the disabled, the senile, the seriously ill and the unconscious, whose lives are at present protected by law, and whose specific human rights are proclaimed in various declarations. When the malignant intention of personhood is realised, with its inherent disregard for both law and rights, its advocates‚ real lack of concern for all human life is exposed, to which is added duplicity when they also purport to appeal to other human rights.

The role of public opinion in law making.

One reason given for wanting the laws on killing changed is that a majority of the community have declared, via opinion polls, that that is what they want.

Opinion polls were developed to test views about political issues, but VE is clearly a moral issue, secular or otherwise. When an issue is as complex in almost every respect as VE is, no valid conclusions can be drawn from polls when the respondents' real understanding of them is both unknown and unknowable. To use such results as an argument to change part of the criminal law would be foolish and dangerous. This would be self evident if it were proposed to change other parts of the law, using the same mechanism.

Morgan opinion polls have been asking the following question in Australia since 1962: 'If a hopelessly ill patient, in great pain, with absolutely no chance of recovering, asks for a lethal dose, so as not to wake again, should the doctor be allowed to give the lethal dose?' The proportion of respondents answering 'yes' has increased from about 50% at first to nearly 80% now. As one commentator noted, it would be hard for an uninformed person to say 'no' without feeling negligent, dogmatic or insensitive.

But when the current ability of good palliative care to relieve the severe pain of terminal illness is known, though it is also known that such care is still not sufficiently available for many, the same question could be more accurately phrased 'If a doctor is so negligent as to leave a terminally ill patient in severe pain, severe enough to drive him/her to ask to be killed, should the doctor be able to compound that negligence by killing the patient, instead of seeking expert help?' The question is really about appropriate standards of medical care, not euthanasia.

It cannot be doubted that most of the community's information and opinions on VE have been obtained from the media which, almost without exception, give an emotionally charged and partial, if not distorted, account. When opinion polls claim to show that most people are in favour of VE, the media, which have created this opinion by their advocacy and lack of balance, then cite these figures as evidence of the need to change the law to allow it! Such behaviour is self-serving and lacking in both truth and justice.

If such issues could really be settled satisfactorily by opinion polls or referenda, parliaments could largely be dispensed with, in favour of endless polling.

Some of the medical reasons why any VE law would be unsafe.

Draft VE laws easily become intellectual constructs within an idealised context, with a false appearance of safety, unless the medical environment in which they will operate is well understood. One of the most tragic medical facts, tragic because it is so remediable, is that, while palliative care is now able to mitigate most of the distresses of dying persons, large numbers of these patients still receive substandard treatment because doctors are uninformed about its practices and/or do not refer their patients to those who are more expert, when they have reached the limit of their own abilities.

The following points are to be found in the cited reports:

1. Necessity for adequate disclosure of medical detail.

Since it would clearly be wrong to allow VE for dying patients with unrelieved symptoms that could be treated by good palliative care, but who had not received such care, information about the quality of their medical care should be an essential requirement before approval could be given for the taking of their lives. No draft euthanasia law in Australia (or elsewhere, as far as the author can discover) has required these facts to be available for scrutiny - it is usual to find only a requirement for medical certificates. These concern opinions, not facts. Thus, the doctor's actions would be unsupervised at the time and could not be reviewed later. Only open, expert scrutiny of a patient's medical care, before euthanasia was carried out, could satisfy the community's need to be assured of a doctor's good judgment and probity.

The community at present properly demands the highest standards of supervision, even when the state has the power to take life. Open hearings, legal representation, avenues of appeal and mechanisms for review are supplied before permitting any legal taking of life, even when deciding the fate of convicted criminals, such as serial killers. In contrast, draft euthanasia bills fail to offer more than token protection for the seriously sick. When examined, their only really effective safeguards are found to be those that protect doctors from civil or criminal action, after euthanasia.

2. Pain and suffering cannot safely be made the basis for taking life because they cannot be measured or compared.

Although palliative care doctors insist that it is not necessary to take life in order to relieve pain, a common reason given by other doctors for wanting VE is to relieve pain. It must be presumed that some doctors take life that could have been relieved by experts, but who are not consulted. Even many advocates of VE now concede that unrelieved pain is probably no longer sufficient justification for taking life. Among the reasons given for euthanasia in the Netherlands, the relief of pain is not prominent.

If pain were a genuine reason to take life, it could not rationally be restricted to the pain of terminal illness, since many other causes of pain are equally distressing.

The mental anguish or suffering associated with life-threatening illness requires different strategies for its management, but it too usually responds to good emotional support. Suffering is evident in a wide range of human conditions, since it is an existential problem, not a medical problem. It has many causes, only some of which are of medical origin, even in those with terminal illness. Most of the causes of suffering are social, requiring understanding of the underlying social, relational and cultural factors.

If suffering were a genuine reason to take life, it could not be restricted to those with terminal illness, since many others causes of suffering are equally distressing. To do so would not only be discriminatory, it would be tragic and a gross abuse to empower doctors to take life for what would commonly be chiefly social reasons.

Neither pain nor suffering can be objectively measured or compared between persons, and so, neither could be subject to the objective standards on which sustainable, just public policy would need to be based. What one person can bear, another finds intolerable. Everything would have come down to the opinion of the patient, based on his/her personal characteristics.

If VE were legalised while the prevailing standards of palliative care were as patchy and unpredictable as they are at present, it would be inevitable that some lives would be taken on account of the medical ignorance of the doctor, even though effective treatment was available. The conclusion is inescapable that such a situation is the probable cause of at least some of the known instances of illegal euthanasia at present, and this would not change, even though the law was changed, in the absence of a widespread correction of the present medical deficiencies in palliative care training and practice.

3. A right to involve another person in one's intentional killing does not exist.

Autonomy has already been discussed, including the point that personal autonomy cannot be extended to others. A right to ask another person to take one's life is not found in any code of ethics or the law or in any statement of human rights. Despite this, such a right is often confidently asserted, even claimed to be 'sovereign' or 'supreme', entirely without warrant. The fact that it is not more often challenged is a reflection of how little is commonly known about rights. Failing its validation by argument, this putative right must continue to be seen for what it is - no more than a wish.

Nor is there a 'right to die', if by that one means a 'right to have one's life taken on request'. There is however a genuine right to die, by which dying persons are entitled to expect that they will be afforded every comfort in their dying, and when it is in their interest to die, not to have their dying unnecessarily impeded.

VE is sometimes said to be permissible as an expression of a claim to privacy, as though it were a matter only of importance between patient and doctor. If a doctor agreed to perform euthanasia, it could only be because he/she had concluded that that life had lost sufficient value - nobody would destroy a life they valued. But if a doctor became comfortable with the idea that it was acceptable for him/her to assign low value to certain patients‚ lives, backed by law, that could be fateful for others of his patients who were in a similar state, but who had not asked to die. He/she would be entitled to interpret any discussion of euthanasia in positive terms, ignoring the evidence that many such discussions are initiated by patients in their desperate need to have their lives affirmed, not rejected. It is well known that to-day's medical systems increasingly depersonalise patients.

3. It would never be certain that a request to be killed was voluntary.

There are no criteria for detecting undue influence on another person, and doctors are no better able to do so than other people. When considering euthanasia in 1982, the Canadian Law Reform Commission observed that coercion would be 'an ever present possibility' (7). The report of the House of Lords declared 'It would be next to impossible to ensure that all acts of euthanasia were truly voluntary, and that any liberalisation of laws would not be abused'. Coercion, particularly if it were subtle, would be very difficult to detect with certainty, and would be impossible if concealment was really wanted.

But would it be likely? After a long inquiry into mental health, a former Australian Human Rights Commissioner said he had discovered that the sick were already 'the most systematically abused, and the most likely to be coerced' (8).

To be seriously ill has been described as being in the 'quintessential state of vulnerability'. Doctors can act coercively even without intending it. Regarding the sexual abuse of patients by doctors, a newspaper editorial claimed 'Even apparent consent is coerced by the power of the professional person in whom the client has placed his or her trust'. The imbalance in power between patient and doctor is far greater than is usually supposed. Just as a doctor's response can forestall suicide, a doctor's ready acceptance of a patient's request to be killed can encourage that outcome, and make the patient feel abandoned.

In such an environment, a patient's request for euthanasia could never be guaranteed to be voluntary.

5. It would never be certain that a request was informed.

Although a draft VE law may require a doctor to inform the patient of the different treatment options, their effects and their likely chances of success, this information will be given in private. Unless an independent, informed observer was present on every occasion, it could never be known whether the information was adequate, correct, unbiased and/or non-coercive. If anyone wished later to check, the only other witness would not be available. Many doctors do not know enough about palliative care-how could they give adequate information about it?

Doctors are often subject to significant stress in dealing with terminally ill patients and their families, arising from frustration at being unable to cure, from uncertainty when faced with difficult problems for which they have not been prepared by their training, and subject to competing and perhaps unfair pressures from distracted patient and family. To suppose that all doctors will behave rationally in these emotionally charged situations is itself irrational, and it would be dangerous to presume it.

6. Even in terminally ill patients, a persistent wish to die is abnormal, while the diagnosis of the underlying psychological disturbance is hard to make and is often missed in those already under medical care.

The true nature of a sustained wish to die, even in the dying, is widely misunderstood, too often being accepted as a natural response to the threat of death. Many persons with terminal illness have suicidal ideation at some time, but never attempt or commit suicide. The great power of fear was revealed in a study that found that more people over 50 committed suicide in the mistaken belief that they had cancer than among those who actually had cancer and committed suicide.

Factors that are consistently found to be strongly associated with a sustained wish to die include: unrelieved severe distress due to pain or other symptoms, previous psychiatric disorder or history of suicide attempt, and the presence of depression or despair. Depression is widely under-diagnosed and under-treated in the elderly, being mistaken for a natural response to aging or dementia. Treatment for depression can remove suicidal ideation in up to 90% of these patients.

The significance of these facts is only half grasped when it is supposed that having a psychiatrist see the patient will provide an effective safeguard. In a recent poll of psychiatrists, only 6% thought they could properly assess mental status in a single consultation. More importantly, only those psychiatrists with training with terminally ill patients will be able to make these diagnoses with confidence in these circumstances.

One experienced Professor of Psychiatry maintains that if these patients were always seen by a psychiatrist with the appropriate training, 'euthanasia would virtually never take place' (9). The scope for abuse in this area would be extraordinary.

Nor are doctors immune to the high emotional content of their patients' situation. A committee of psychiatrists, established in the Netherlands to assist and counsel doctors faced with requests for euthanasia, reported that 'without such consultation, the professionals would often have assisted suicide, even though viable treatment alternatives were available, because of an emotional involvement with the patients'. This caused an American psychiatrist, an expert on suicide, to comment: 'One suspects that those doctors who are most emotionally involved in euthanasia, and most interested in performing it, may be those who whose own needs in the matter should disqualify them' (10).

This important point was emphasised by the comment of a forensic psychiatrist: 'I have, on more occasions than I care to recall, failed professionally to recognise depression because I have been caught up in, and dazzled by, the tragedy of my patient's life. I have accepted their wish for death as a rational and proper desire only to see these desires melt away with their depression when...less involved colleagues treated the process in which the patients were trapped' (11).

7. Progression from voluntary to non-voluntary euthanasia would be simply logical.

Non-voluntary euthanasia (NVE) is discussed more fully in a separate paper, but the core of the message in this title may be simply stated. While VE is regarded by many as a compassionate act, it is assumed that taking life without a patient's expressed wish or consent could only be motivated by some degree of malice. How then could the known incidence of NVE in the Netherlands, United States and Australia be explained, since doctors are not malicious people?

It is because such life taking is seen by its practitioners as an exercise in beneficence. Once taking life on request is regarded as a benefit for that person, it can be thought unfair and discriminatory to withhold that benefit from others who are in a similar plight, just because they cannot ask. That view is logical, if taking life truly supplies a benefit.

No arguments have prevailed to prevent the spread of one practice to the other, and no guarantee could be given that such extension would not occur wherever and whenever VE was introduced. Lawmakers can never guarantee that the law they make will not be modified, perhaps in ways which they could not foresee and would oppose, by subsequent lawmakers. In fact, by making the first exception to the principle of universal protection for innocent human life, they would have created the first precedent for change.

It is sometimes heard that it would be better to have a law to regulate euthanasia practice, even though that law may not be perfect, than to persist with the present position, where euthanasia is practised in secret, without control. That raises several points.

First, there is currently a law to regulate euthanasia-it is the criminal code, which forbids euthanasia as a form of murder, though that law is not commonly invoked. This is because hard evidence is not easy to obtain and the community properly sees a distinction between mercy and malice, even though motive is not taken into account by the law. Thus, euthanasia is presently practised by lawbreakers, who put their own view of their duty above the law, while other practitioners find their duty in the same circumstances fulfilled by different means, such as good palliative care. The former respond to the patient's demands, while the latter look to the demands of the patient's illness.

Second, there is already a proven incidence of secret NVE at the hands of doctors who also carry out VE, because, as stated, they believe it to be compassionate also. Because they include NVE in their concept of duty to certain patients, there could be no guarantee that a law that allowed only VE would not also be disregarded by them. In fact, it would be foolish not to expect it.

Third, given the common finding by inquiries that the lives of other vulnerable sick people could not be protected by any VE law, the House of Lords Committee thought that more lives could be put at risk by such a law than is the case at present. Because abuse would be undetectable, often if not usually, it could then appear to observers that matters had improved, when they had actually deteriorated. To expose the most vulnerable patients to this risk should be seen as unacceptable.

Conclusion.

A number of important factors, hitherto ignored or misunderstood in the debate about the legalisation of VE, have now been revealed in several large studies. They concluded that no such law could be guaranteed to be free of the possibility, if not the likelihood, of abuse, chiefly centred on the lives of other sick persons who did not want their lives taken. An especially dangerous aspect is that such abuse may be easily made undetectable. Thus, impartial observers may believe that a particular law was safe, while many or even every one of its subjects were in fact victims of abuse.

The medical loopholes listed above would alone have justified the common finding of the inquiries, that legalisation would be dangerous. Rather than seek recourse to medical life-taking, all doctors with responsibility for the care of terminally ill patients should accept their duty to deliver this care at the known best standards, as they are legally obliged to do in other branches of medical practice. That means they will familiarise themselves with the principles and practices of palliative care, at the standard required of their peer group, and when for any reason they cannot do that, they will refer their patients to others who can. If they have remaining doubts about the evidence regarding the abuse of euthanasia law, they should acquaint themselves with the contents of the reports listed in this paper, before supporting further attempts to legalise VE.

References.

1. Select Committee on Medical Ethics. House of Lords. January, 1994.

2. When Death Is Sought - Assisted Suicide and Euthanasia in the Medical Context. The New York State Task Force on Life and the Law. May, 1994.

3. Of Life and Death. Report of the Special Senate Committee on Euthanasia and Assisted Suicide. Senate of Canada. June 1995.

4. Report on the Need for Legislation on Voluntary Euthanasia. Community Development Committee, Parliament of Tasmania. June 1998.

5. Gormally L. Why the Select Committee on Medical Ethics of the House of Lords Unanimously Rejected the Legalization of Euthanasia. Proceedings of a Seminar held at St Vincent's Hospital, Sydney. 10 November 1995.

6. Jackson J. Hobart Mercury. 5 June 1998.

7. Working Paper 21, Euthanasia, Assisting Suicide and Cessation of Treatment. Law Reform Commission of Canada. 1982.

8. Burdekin B. Sydney Morning Herald. 21 October 1993.

9. Varghese F. The Australian. 6 June 1995.

10. Hendin H. Seduced by Death: Doctors, Patients and the Dutch Cure. Issues Law Med. 1994. 10; 123-168.

11. Zalcberg JR, Buchanan JD. Clinical Issues in Euthanasia. Med J Aust. 1997. 166: 150-152.

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• Indian J Med Res
• v.136(6); 2012 Dec

Euthanasia: Right to life vs right to die

Suresh bada math.

Department of Psychiatry National Institute of Mental Health & Neuro Sciences (Deemed University) Bangalore 560 029, India

Santosh K. Chaturvedi

The word euthanasia, originated in Greece means a good death 1 . Euthanasia encompasses various dimensions, from active (introducing something to cause death) to passive (withholding treatment or supportive measures); voluntary (consent) to involuntary (consent from guardian) and physician assisted (where physician's prescribe the medicine and patient or the third party administers the medication to cause death) 2 , 3 . Request for premature ending of life has contributed to the debate about the role of such practices in contemporary health care. This debate cuts across complex and dynamic aspects such as, legal, ethical, human rights, health, religious, economic, spiritual, social and cultural aspects of the civilised society. Here we argue this complex issue from both the supporters and opponents’ perspectives, and also attempts to present the plight of the sufferers and their caregivers. The objective is to discuss the subject of euthanasia from the medical and human rights perspective given the background of the recent Supreme Court judgement 3 in this context.

In India abetment of suicide and attempt to suicide are both criminal offences. In 1994, constitutional validity of Indian Penal Code Section (IPC Sec) 309 was challenged in the Supreme Court 4 . The Supreme Court declared that IPC Sec 309 is unconstitutional, under Article 21 (Right to Life) of the constitution in a landmark judgement 4 . In 1996, an interesting case of abetment of commission of suicide (IPC Sec 306) came to Supreme Court 5 . The accused were convicted in the trial court and later the conviction was upheld by the High Court. They appealed to the Supreme Court and contended that ‘right to die’ be included in Article 21 of the Constitution and any person abetting the commission of suicide by anyone is merely assisting in the enforcement of the fundamental right under Article 21; hence their punishment is violation of Article 21. This made the Supreme Court to rethink and to reconsider the decision of right to die. Immediately the matter was referred to a Constitution Bench of the Indian Supreme Court. The Court held that the right to life under Article 21 of the Constitution does not include the right to die 5 .

Regarding suicide, the Supreme Court reconsidered its decision on suicide. Abetment of suicide (IPC Sec 306) and attempt to suicide (IPC Sec 309) are two distinct offences, hence Section 306 can survive independent of Section 309. It has also clearly stated that a person attempts suicide in a depression, and hence he needs help, rather than punishment. Therefore, the Supreme Court has recommended to Parliament to consider the feasibility of deleting Section 309 from the Indian Penal Code 3 .

Arguments against euthanasia

Eliminating the invalid : Euthanasia opposers argue that if we embrace ‘the right to death with dignity’, people with incurable and debilitating illnesses will be disposed from our civilised society. The practice of palliative care counters this view, as palliative care would provide relief from distressing symptoms and pain, and support to the patient as well as the care giver. Palliative care is an active, compassionate and creative care for the dying 6 .

Constitution of India : ‘Right to life’ is a natural right embodied in Article 21 but suicide is an unnatural termination or extinction of life and, therefore, incompatible and inconsistent with the concept of ‘right to life’. It is the duty of the State to protect life and the physician's duty to provide care and not to harm patients. If euthanasia is legalised, then there is a grave apprehension that the State may refuse to invest in health (working towards Right to life). Legalised euthanasia has led to a severe decline in the quality of care for terminally-ill patients in Holland 7 . Hence, in a welfare state there should not be any role of euthanasia in any form.

Symptom of mental illness : Attempts to suicide or completed suicide are commonly seen in patients suffering from depression 8 , schizophrenia 9 and substance users 10 . It is also documented in patients suffering from obsessive compulsive disorder 11 . Hence, it is essential to assess the mental status of the individual seeking for euthanasia. In classical teaching, attempt to suicide is a psychiatric emergency and it is considered as a desperate call for help or assistance. Several guidelines have been formulated for management of suicidal patients in psychiatry 12 . Hence, attempted suicide is considered as a sign of mental illness 13 .

Malafide intention : In the era of declining morality and justice, there is a possibility of misusing euthanasia by family members or relatives for inheriting the property of the patient. The Supreme Court has also raised this issue in the recent judgement 3 . ‘Mercy killing’ should not lead to ‘killing mercy’ in the hands of the noble medical professionals. Hence, to keep control over the medical professionals, the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002 discusses euthanasia briefly in Chapter 6, Section 6.7 and it is in accordance with the provisions of the Transplantation of Human Organ Act, 1994 14 . There is an urgent need to protect patients and also medical practitioners caring the terminally ill patients from unnecessary lawsuit. Law commission had submitted a report (no-196) to the government on this issue 15 .

Emphasis on care : Earlier majority of them died before they reached the hospital but now it is converse. Now sciences had advanced to the extent, life can be prolonged but not to that extent of bringing back the dead one. This phenomenon has raised a complex situation. Earlier diseases outcome was discussed in terms of ‘CURE’ but in the contemporary world of diseases such as cancer, Aids, diabetes, hypertension and mental illness are debated in terms best ‘CARE’, since cure is distant. The principle is to add life to years rather than years to life with a good quality palliative care. The intention is to provide care when cure is not possible by low cost methods. The expectation of society is, ‘cure’ from the health professionals, but the role of medical professionals is to provide ‘care’. Hence, euthanasia for no cure illness does not have a logical argument. Whenever, there is no cure, the society and medical professionals become frustrated and the fellow citizen take extreme measures such as suicide, euthanasia or substance use. In such situations, palliative and rehabilitative care comes to the rescue of the patient and the family. At times, doctors do suggest to the family members to have the patient discharged from the hospital wait for death to come, if the family or patient so desires. Various reasons are quoted for such decisions, such as poverty, non-availability of bed, futile intervention, resources can be utilised for other patients where cure is possible and unfortunately majority of our patient's family do accordingly. Many of the terminally ill patients prefer to die at home, with or without any proper terminal health care. The societal perception needs to be altered and also the medical professionals need to focus on care rather in addition to just cure. The motive for many euthanasia requests is unawareness of alternatives. Patients hear from their doctors that ‘nothing can be done anymore’. However, when patients hear that a lot can be done through palliative care, that the symptoms can be controlled, now and in the future, many do not want euthanasia anymore 16 .

Commercialisation of health care : Passive euthanasia occurs in majority of the hospitals across the county, where poor patients and their family members refuse or withdraw treatment because of the huge cost involved in keeping them alive. If euthanasia is legalised, then commercial health sector will serve death sentence to many disabled and elderly citizens of India for meagre amount of money. This has been highlighted in the Supreme Court Judgement 3 , 17 .

Research has revealed that many terminally ill patients requesting euthanasia, have major depression, and that the desire for death in terminal patients is correlated with the depression 18 . In Indian setting also, strong desire for death was reported by 3 of the 191 advanced cancer patients, and these had severe depression 19 . They need palliative and rehabilitative care. They want to be looked after by enthusiastic, compassionate and humanistic team of health professionals and the complete expenses need to be borne by the State so that ‘Right to life’ becomes a reality and succeeds before ‘Right to death with dignity’. Palliative care actually provides death with dignity and a death considered good by the patient and the care givers.

Counterargument of euthanasia supporters

Caregivers burden : ‘Right-to-die’ supporters argue that people who have an incurable, degenerative, disabling or debilitating condition should be allowed to die in dignity. This argument is further defended for those, who have chronic debilitating illness even though it is not terminal such as severe mental illness. Majority of such petitions are filed by the sufferers or family members or their caretakers. The caregiver's burden is huge and cuts across various domains such as financial, emotional, time, physical, mental and social. Hence, it is uncommon to hear requests from the family members of the person with psychiatric illness to give some poison either to patient or else to them. Coupled with the States inefficiency, apathy and no investment on health is mockery of the ‘Right to life’.

Refusing care : Right to refuse medical treatment is well recognised in law, including medical treatment that sustains or prolongs life. For example, a patient suffering from blood cancer can refuse treatment or deny feeds through nasogastric tube. Recognition of right to refuse treatment gives a way for passive euthanasia. Many do argue that allowing medical termination of pregnancy before 16 wk is also a form of active involuntary euthanasia. This issue of mercy killing of deformed babies has already been in discussion in Holland 20 .

Right to die : Many patients in a persistent vegetative state or else in chronic illness, do not want to be a burden on their family members. Euthanasia can be considered as a way to upheld the ‘Right to life’ by honouring ‘Right to die’ with dignity.

Encouraging the organ transplantation : Euthanasia in terminally ill patients provides an opportunity to advocate for organ donation. This in turn will help many patients with organ failure waiting for transplantation. Not only euthanasia gives ‘Right to die’ for the terminally ill, but also ‘Right to life’ for the organ needy patients.

Constitution of India reads ‘right to life’ is in positive direction of protecting life. Hence, there is an urgent need to fulfil this obligation of ‘Right to life’ by providing ‘food, safe drinking water and health care’. On the contrary, the state does not own the responsibility of promoting, protecting and fulfilling the socio-economic rights such as right to food, right to water, right to education and right to health care, which are basic essential ingredients of right to life. Till date, most of the States has not done anything to support the terminally ill people by providing for hospice care.

If the State takes the responsibility of providing reasonable degree of health care, then majority of the euthanasia supporters will definitely reconsider their argument. We do endorse the Supreme Court Judgement that our contemporary society and public health system is not matured enough to handle this sensitive issue, hence it needs to be withheld. However, this issue needs to be re-examined again after few years depending upon the evolution of the society with regard to providing health care to the disabled and public health sector with regard to providing health care to poor people.

The Supreme Court judgement to withhold decision on this sensitive issue is a first step towards a new era of health care in terminally ill patients. The Judgment laid down is to preserve harmony within a society, when faced with a complex medical, social and legal dilemma. There is a need to enact a legislation to protect terminally ill patients and also medical practitioners caring for them as per the recommendation of Law Commission Report-196 15 . There is also an urgent need to invest in our health care system, so that poor people suffering from ill health can access free health care. Investment in health care is not a charity; ‘Right to Health’ is bestowed under ‘Right to Life’ of our constitution.

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Why active euthanasia and physician assisted suicide should be legalised

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In response to the editorial regarding the legalisation of active euthanasia and physician-assisted suicide,1 I present the following arguments against the legalisation of active euthanasia.

Active euthanasia is unnecessary because alternative treatments exist

It is widely believed that there are only two options for patients with terminal illness: either they die suffering or receive euthanasia. Recent research in palliative medicine has shown that virtually all unpleasant symptoms experienced in terminal illness can be relieved or alleviated by existing techniques.

Requests for active euthanasia are rarely free and active.

A person with terminal illness is vulnerable, lacking the skills and knowledge to alleviate their symptoms. It is very difficult for him to be entirely objective about his own situation. Their capacity for decision-making may equally be affected by confusion, dementia or symptoms, which could be relieved with appropriate treatment. Patients who on admission say "let me die" usually after effective treatment are grateful that their request was not acceded to.

Active euthanasia gives too much power to doctors

Ironically, active 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. If a doctor confidently suggests a certain course of action, it can be difficult for a patient to resist. However, diagnoses may be mistaken and prognoses may be widely misjudged. Active euthanasia gives the medical practitioner power, which in turn can be abused.

Active euthanasia leads inevitably to involuntary euthanasia

When active euthanasia has been previously accepted and legalised, it has led inevitably to inactive euthanasia.

Holland is moving rapidly down the slippery slope with the public conscience changing quickly to accept such action as acceptable. The Royal Dutch Medical Association has recommended that the termination of the lives of patients suffering from dementia is acceptable under certain conditions. Case reports include a woman killed at her own request for reasons of "mental suffering".[2]

Such a progression requires only four accelerating factors: favourable public opinion, willing doctors, economic pressure and a law allowing it. In most Western countries the first three ingredients are present already. When legislation comes into effect and political and economic interests are brought to bear, the generated momentum inevitably follows.

Dr Liz Croton SHO A&E City Hospital NHS Trust, Dudley Rd,Birmingham B18 7QH [email protected]

1. Doyle L, Doyle L. Why active euthanasia and physician assisted suicide should be legalised. BMJ 2001:323;1079-80.

Competing interests: No competing interests

Why Euthanasia Should not be Legalized

A Reflection on the Dutch Experiment

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• Henk Jochemsen 8  

Part of the book series: International Library of Ethics, Law, and the New Medicine ((LIME,volume 12))

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The experience of the Netherlands continues to be cited as illustrative of the euthanasia debate that is going on in many countries. The parliamentary debates on the legalization of euthanasia (November 2000 in the Second Chamber and April 2001 First Chamber) have drawn a lot of international attention. But, before this legalization in the Penal Code this country had adopted a legal regulation of euthanasia and, before and after that, extensive surveys into the practice of euthanasia had been carried out. The fact that the Dutch example is cited both by those who favor the legislation of euthanasia and those who reject it demonstrates that empirical data in themselves do not settle an ethical or juridical issue.

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Euthanasia: Active

The Practice of Euthanasia and Assisted Suicide Meets the Concept of Legalization

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Jochemsen, H. (2001). Why Euthanasia Should not be Legalized. In: Weisstub, D.N., Thomasma, D.C., Gauthier, S., Tomossy, G.F. (eds) Aging: Decisions at the End of Life. International Library of Ethics, Law, and the New Medicine, vol 12. Springer, Dordrecht. https://doi.org/10.1007/978-94-015-9682-4_5

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Judge rejects Trump's second bid to move New York hush money case to federal court

A federal judge on Tuesday denied former President Donald Trump's second and last ditch bid to transfer his New York hush money case to federal court.

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