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Euthanasia – the morning tea version |
 Euthanasia is a complex issue - it is emotive, a source of passionate polarisation, without middle ground and in clinical practice will often take us out of our comfort zone.
This article intends to give a brief overview of some of the broader issues in the euthanasia debate, which hopefully is easily digestible, even over morning tea.
What it is
Etymologically euthanasia comes from ‘eu ‘ meaning good and ‘thanas ‘ meaning death. However, the modern definition is the intentional hastening of a person’s death in order to relieve that person’s suffering. If it is voluntary it is at the person’s request or with their consent. If it is involuntary it is without the person’s request or consent. Physician assisted suicide is when the physician provides the necessary knowledge and means but the act is completed by the person themselves.
In the case of euthanasia, as from diagram 1, the patient dies as the result of a deliberate act and not of their disease.
Passive euthanasia – is there such a thing?
The term ‘passive euthanasia’ is a source of confusion. It is usually taken to mean an omission, rather than an act, which produces the foreseeable death of an individual, eg. not resuscitating a severely handicapped newborn, or in the palliative care setting, not treating a patient’s pneumonia when that patient is in the last few days of life. The issue revolves around whether there is a distinction between ‘killing’ and ‘letting die’.
In diagram 2, and this is usually the palliative care setting, withdrawal of futile treatment means the patient dies of their disease and the death is a timely death, eg. stopping chemotherapy on a patient with advanced progressive disease. Whether the treatment is continued or withdrawn the patient will die as a result of their disease. This is ‘letting die’.
Withdrawing life support, (diagram 3), usually causes the greatest blurring between ‘killing’ and ‘letting die’. If a patient has a life-threatening event, and life-supportive treatment is instigated, then their life is prolonged beyond the point at which death would naturally occur. Therefore, removing the life prolonging treatment would produce a foreseeable death. Is this ‘killing’ or ‘letting die’?
In the palliative care setting this is usually a straightforward matter where withdrawal of life supportive treatment ceases hindering an inevitable process when it is no longer possible to restore health, function, relieve suffering or relieve the dying process. This could be argued quite strongly that it would be allowing the person to die of their disease, ie. a natural death and would be acceptable good medical practice. An example would be if an end stage HIV/AIDS patient requests to withdraw antibiotics and antiretroviral drugs because they feel the burden and side effects of life-prolonging drugs outweigh their benefits.
However, the lines become blurred when there is a possibility of a long life ahead of a person after a life-threatening event, eg. Christopher Reeve and his need for long term ventilation. If he had requested the ventilator to be switched off – is that killing or letting die?
Thus to use the term ‘passive euthanasia’ to mean withdrawing or withholding life-prolonging treatment can lead to confusion. There are times when consentual withdrawing or withholding treatment is legal and good medical practice. However, at the other end of the spectrum, there are times when withholding or withdrawing medical treatment, especially if without consent, is bad medical practice and would probably warrant legal intervention.
Another area where the term ‘passive euthanasia’ is used is with the principle of double effect. This is the administration of a treatment with the intention of relieving symptoms of illness and in the knowledge that this will or may hasten death. An example would be a patient in the last few days of life who becomes agitated, is given sedation at the request of the family, and in doing so may hasten the patient’s demise. The central issue here relies on intent, ie. that the intent of the sedation was to relieve suffering with the accepted risk that the death of the patient may be hastened; the intent was not to hasten death. This is acceptable legally and, to some, ethically. However, the strength of the argument is reliant on the integrity of the intentions of the doctor.
In summary, it is better to avoid the term ‘passive euthanasia’ completely. It is an emotive term and can have different meanings for different people. It usually blurs the discussion, rather than brings clarity.
1. Compassion
Euthanasia may be the only effective means of relieving dying patients from intense suffering in some instances. Even with the best palliative care available there is still a very small percentage of patients who have intense suffering, and persistently request euthanasia.
2. The right to die
The argument is we all have a right to self-determination and therefore should have a right to choose when and how to die.
3. Provides an escape route
If a patient knows that they could have voluntary euthanasia in the future, then that might be sufficient to carry them through tough times, knowing that they have an escape if their situation becomes unbearable.
4. Relieving the burden
Patients may feel a burden to themselves, their families and society and therefore would see it as an honourable thing to withdraw from life, for the greater benefit of others.
The case against euthanasia
1. Sanctity of life
The most common argument, argued on religious grounds is that life is a precious gift and is not ours to dispose of.
2. The thin end of the wedge
If euthanasia was legalised it is sending out the message that if voluntary euthanasia is acceptable then involuntary euthanasia by default is also acceptable and therefore the most vulnerable people in society, eg. the frail, elderly and terminally ill, would become the unwitting victims of involuntary euthanasia.
3. Deny finding meaning in suffering
Many patients diagnosed with a life threatening illness find enormous value, spiritual enlightenment and meaning in their suffering. By offering euthanasia, that uniquely human experience may not be realised.
4. Burden to society
If euthanasia is legalised, will the frail and elderly feel obliged to end their lives as their ‘usefulness’ to society has ended?
In the broadest terms, the euthanasia debate usually boils down to two ultimate questions.
1. Can euthanasia ever be ethically justified?
2. Can legalised euthanasia ever be abuse free?
How to deal with a request for euthanasia
In my clinical experience, patients will often state they “wish things would hurry up” or they “wish it was all over”, but it is quite unusual (less than 5%) to receive persistent requests for euthanasia. If the issue is raised it is usually an expression of how much someone is suffering. In a study in The Lancet (1991) some of the reasons for requesting euthanasia were loss of dignity 57%, pain 46%, (pain as the only symptom 5%), unworthy dying 46%, being dependent on others 33%, tired of life 23%.
Thus, requests for euthanasia are not often about pain and symptom control, and although demand medical competence from the doctor, what is really required is an empathic presence, good communication skills, a supportive role and a knowledge to patients and families that they will not be abandoned. It is also of paramount importance that the patient be assessed and treated for depression, which can be quite difficult to diagnose in the palliative care patient.
In a palliative care setting a request for euthanasia would be seen as a palliative care emergency and I would strongly encourage referral to the Palliative Care Service for ongoing support and management. Fortunately, in my experience, the vast majority of patients and families can be supported through a euthanasia crisis. Support for families after the death will be paramount.
References: (For a full list of references please contact the Palliative Care Service.) Sources: Fiona Randall, R.S. Downie, N Cassem, P Singer, Oxford Textbook Palliative Medicine, H Kuhse, N Lickiss, and Select Committee on Medical Ethics, House of Lords, London, 1994.
Joanne Doran is the NRAHS director of palliative care, based at St Vincent’s Hospital. Ph. 6621 8411. Email: jdoran@nor.com.au Dr Joanne Doran
Joanne Doran is the Northern Rivers Area Health Service director of palliative care, based at St Vincent’s Hospital, Lismore, NSW, Australia.
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