Examining Euthanasia: Medical Ethics Considerations

Euthanasia discussion is one of the most common medical ethics topics for the essay as it is highly relevant to medical professionals and students, especially given the recent legalisation of “Voluntary Assisted Dying” in Victoria. The Australian Medical Association (AMA) defines euthanasia as “the act of deliberately ending the life of a patient for the purpose of ending intolerable pain and/or suffering” and physician assisted suicide “where the assistance of the doctor is intentionally directed at enabling an individual to end his or her own life”. The key distinction, then, is the physician directly participating in ending the patient’s life in euthanasia, compared to providing the meadns for the patient to end their own life in physician assisted suicide.

In the discussion of euthanasia, it is sometimes divided into two categories: “passive” euthanasia, in which is a withdrawal of treatment to allow the patient to die, and “active” euthanasia, where there is direct action intended to end the patient’s life. However, there are arguments that there is no ethical justification for such a distinction. The “double effect” principle refers to an action that has both good and bad effects being morally acceptable if the action is good in itself, the intention is solely to produce the good effect, the good effect is not achieved through the bad effect, and there is sufficient reason to permit the bad effect.

The AMA currently opposes “interventions that have as their primary intention the ending of a person’s life” but is not against discontinuing treatments that are “of no medical benefit” to a dying patient. The AMA therefore has a distinct stance against “active” euthanasia and physician assisted suicide, but their statement reagarding treatments of “no medical benefit” leaves room for interpretation; an argument can be that prolonging a patient’s life may be of “no medical benefit” if their quality of life is impaired to an extreme extent. Hence the AMA seems to not take a strong stance on “passive” euthanasia.nThe AMA also recognises differing views of medical professionals and of broader society,nand that the law regarding the issue is ultimately a matter for society and government.

Euthanasia Legislation

Euthanasia is currently illegal in Australia except in Victoria. In Victoria, the Voluntary Assisted Dying (VAD) Act 2017 came into effect on June 19 2019 and allows Victorians who meet strict eligibility criteria to request access to voluntary assisted dying. This is an example of physician assisted suicide. Doctors may conscientiously object to VAD and have no obligation to participate or to refer patients to a physician who does participate. In order to be eligible for VAD, a patient must be aged 18 years or more, have decision-making capacity, and be diagnosed with a disease, illness or medical condition that is incurable, advanced, progressive, is causing suffering to the person that cannot be relieved in a manner that the person considers tolerable, and is expected to cause death within weeks or months, not exceeding 6 months. In contrast, euthanasia was decriminalised in the Netherlands in the 2001 Termination of Life on Request and Assisted Suicide Act, and contributed 3.9% of all deaths there in 2015. With the new Victorian legislation, there are practical implications for Australian doctors. All doctors should not initiate a conversation about euthanasia. For those practicing outside Victoria, an understanding of the current illegality of euthanasia in their state or territory, and that Victorian VAD requires residing in Victoria for at least 12 months, is key for advising patients and families when discussing end-of-life. For Victorian doctors, it is important to carefully introspect and decide whether to participate in VAD: only fellows in specialty colleges and vocationally registered GPs may participate, but other doctors should also think about whether they are prepared to refer patients. Specialists and vocationally registered GPs who decide to participate in VAD will need to undergo a training course.

Is Euthanasia Acceptable?

From a medical ethics point of view, the discussion of euthanasia should be informed by the basic principles of benificence, non-maleficence, justice, and autonomy. The primary arguments in advocating for euthanasia are based on benificence and autonomy: proponents contend that it can alleviate the suffering associated with a gradual, irredeemable, and painful death, and that individuals have the right to choose when and how they die. In contrast, opponents of euthanasia are concerned that euthanasia constitutes maleficence, in that directly acting to cause death is unethical, and violates the sanctity of life. James Rachels’s 1975 article “Active and Passive Euthanasia” was crucial in influencing the modern conversation around euthanasia. Rachels argues that “active” euthanasia is ethically equivalent to “passive” euthanasia, exploring the similar situations of premeditated murder of a baby, and planning the murder only to watch the victim accidentally fall into a bath and drown. The crucial argument is that knowingly allowing someone to die through inaction is no different to directly causing their death through an action; in fact inaction itself is a kind of action. Hence, there should be no distinction between “active” and “passive” euthanasia.

Peter Singer is a key contemporary proponents of euthanasia, and uses utilitarianism, focusing on the result of an action rather than the action itself, in his argument. He proposes that if the reason against killing is the goods contained in life, then when the patient is no longer capable of possessing those goods, or that the goods will be outweighed by the bad things that will happen, then it is not immoral to end the patient’s life, since the overall impact is not negative. He also argues that if a human’s desire to continue living is a reason against killing, then a desire to die must be a reason in favour of killing. He agrees that beyond the fundamental ethical debate there are significant difficulties in ensuring any decision truly is voluntary, but argues that these can be controlled by careful regulation such as in the Netherlands.

Daniel Callaghan opposes “active” euthanasia on the basis that it is not supported by the key argument of self-determination: he  advances that because euthanasia is carried out by another person, the doctor, then it is not simply a matter of a patient taking their own life, but forfeiting their autonomy to the doctor. (Callaghan, 1992). He also argues against the proposed ethical equivalence between killing and allowing to die, saying culpability and causation are separate, and therefore a patient’s death as a result of a physician stopping treatment because of the futility of continuing it is not the moral responsibility of the doctor. Overall, he argues that the doctor’s responsibility is to relieve suffering, but not to determine when a life is worth living. Another argument euthanasia is that because it is impossible to predict the course of a serious disease with perfect certainty, so a patient who is euthanised may have lived for longer or had better quality of life than anticipated.

Additionally, there is the issue that depression can increase rates of desire for death which makes it difficult to determine whether a depressed patient has the capacity to decide if they should be euthanised; if they were treated, would they change their mind, and if they can not be treated, then is their desire for euthanisation more valid? Apart from the immediate ethical conundrum surrounding the patient, there are numerous issues surrounding any discussion of euthanasia. It has been suggested that euthanasia is a poor solution compared to a well-managed palliative care system, which has the potential to also alleviate pain and suffering while avoiding the physician-caused death of the patient and comparatively prolonging the patient’s life. There is some evidence that physicians who are more experienced in end-of-life management and trained in palliative care are more likely to oppose euthanasia. However, palliative care does not seem to be incompatible with euthanasia; the majority of euthanasia deaths in Belgium appear to involve the opinons of palliative care professoinals, and patients who sought euthanasia were more likely to have received palliative care than other people dying non-suddenly. The impact of euthanasia on patients’ families and friends should be considered: euthanasia can act to alleviate their continued suffering and grief by avoiding a prolonged, painful, and undignified death. However, it also reduces the possibility of creating meaningful moments and memories with the patient during the final days, weeks or months of life that would have been lost if euthanasia was carried out.

There is also the consideration of the emotional impact of euthanasia on the physician who administers or participates in it: physicians have been observed to be profoundly adversely affected by their experiences, feeling shock, powerlessness, and isolation. From a utilitarian and public health perspective it is important to consider the comparative cost of euthanisa and palliative care, since there are always limited funds available, and the aim is providing the maximum benefit to the most people. Euthanasia would reduce the amount of palliative care required and therefore mean more resources are available for other healthcare in the long term. However, this can also be an argument against its legalisation: governments could make euthanasia legal in lieu of providing sufficent support to palliative care systems.

Aside from the fundamental ethical debate, there are social and cultural factors that guide the discussion. For instance, Islam and Christianity are associated with opposition of euthanasia while Buddhists are more likely to support euthanasia. Nationality can also be a factor: for instance, people from the US are more likely to support euthanasia than people from Iran, and there is significantly greater variation in Iranians. Another key factor is personal experience with seeing others die, which makes people more disposed to approve of euthanasia. ​In Australia, support for euthanasia has been growing, and people are more likely to support euthanasia if they are irreligious, and there is also a correlation with political party.

Personal Opinion and Reflection

In my view, euthanisa is ethically acceptable for end-of-life patients, and should be legal but must be tightly regulated, and available alongside a robust and easily accessible palliative care system. Overall, I believe that the value of life depends on the experiences within it, and if we can be reasonably sure that a patient’s life will consist of suffering if they continue, then it is not objectionable to end life early. Though I am concerned that the legalisation of euthanisa may lead to the loss of potential touching, profound moments with family, I believe that mandatory sessions with palliative care physicians for patients during the euthanasia process can acceptably control this problem by giving patients the chance to stop or delay euthanasia if their quality of life can be improved to an acceptable standard through palliative care. Physician assisted suicide should be used over active euthanisation, except in cases where it is impossible, to minimise the impact on physicians.

I found that I was better able to manage researching and writing this assignment than previous ones, in part because of the suggested bioethicists in the task description, but also because I am more experienced in searching and writing. Initially, I had some sense of the ethical dilemma that must surround euthanasia in the sense of weighing up alleiviating the suffering of patients against the problem of a doctor ending a life. However, I had not considered all the implications of euthanasia on other parties, nor all the underlying ethical arguments, and prior to the assingment I had no strong view. It was only through my initial research and by talking to a palliative care doctor that I began to think about euthanasia in comparison to palliative care, and the impact on doctors, families, and the broader healthcare system. Through reading the work of bioethicists I began to appreciate the depth and complexity of applying seemingly basic ethical principles to this issue, and felt more unsure than ever on whether it was acceptable. I was only able to make a judgement by imagining myself or my family suffering from an irredeemable, severe illness. I suspect that as I progress through the world of medicine and have more real interactions with patients in situations like this, my perspective and opinion will change and mature.

References

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