Euthanasia

Previously in this section, we have looked at medical futility ¹ and refusal of treatment. ² This Five-Minute Focus deals with the related subject of euthanasia but will be confined to definitional and ethical aspects and will not cover the law in detail as it suffices to say that under current law, it is a criminal offence to cause a patient's death by actively intervening with the sole intention of killing the patient.

Defining euthanasia

The word euthanasia derives from the Greek eu + thanatos meaning ‘good’ ‘death’, but while it might be said that the aim of euthanasia is to provide a good death, such a definition fails to make sense of the ethical controversy that euthanasia provokes: it seems unlikely that anyone would be opposed to a good death. Another commonly used definition is ‘a gentle and easy death’, which some consider as an improvement over ‘a good death’ because there are many deaths that might be described as good, but that would not be seen as appropriate in a medical setting, such as that of a soldier who throws himself on an activated hand grenade to protect those around him. Having said this, a person who has led a life characterized by autonomy and self-determination might not prioritize peacefulness and gentleness valuing instead an end that is efficient and effective and thereby also potentially shocking and sudden.

Euthanasia is distinguished from suicide by the involvement of other parties in the ending of the life. It is also distinguished from assisted suicide by the nature of that involvement. In euthanasia, the other party directly brings about the death of the person, in assisted suicide the other party provides necessary assistance be it in the form of drugs or some type of physical support, but the person wishing to die performs the final act.

English law draws no distinction between active euthanasia and murder, yet we debate the moral permissibility of euthanasia in a way that we do not in the case of a murder. The significant difference seems to be that the person performing euthanasia is well motivated: they sincerely believe that they are acting in the best interests of the person who dies as a result (because that person is in some important sense ‘better off dead’), whereas a murder is committed without regard for the interests of the victim.

A more complete definition of euthanasia could therefore be: euthanasia occurs when one person intentionally brings about the death of another, using the most appropriate means available in that particular situation, motivated solely by the belief that dying is in the best interests of the person whose death is caused.

The necessary elements of euthanasia are, then:

that another party or parties cause the death (through action or inaction);

that death is intended;

that the only motive is to serve the best interests of the person who dies.

This means that we are able to distinguish euthanasia from other occasions where death occurs in a medical setting. For instance, if a treatment is withheld or withdrawn because it is in short supply and it is thought that it will give more benefit to another patient, this is not euthanasia because what motivates this action is not the best interests of this patient but a balancing of this patient's interests against those of some other patient (or the need to make a decision about how best to use scarce resources). Similarly, it is not euthanasia if treatment is withdrawn or withheld because it will not achieve its physiological objective (‘physiological’ futility ¹ ) because death is neither caused nor intended – rather it would have happened whatever one did. More controversially, it is argued – using the doctrine of double effect – that administering a potentially lethal dose of analgesia is not euthanasia if the intention was not to kill the patient but to relieve their pain, even though it was foreseen that death would result. Such an action is not euthanasia because the necessary intention to directly cause death is absent.

Varieties of euthanasia

Active and passive euthanasia

Commentators commonly distinguish between active and passive euthanasia, although the value of the distinction has been challenged.

Active euthanasia is said to have occurred when the person intending the death took some positive action to ensure this outcome – such as administering a lethal dose of medication.

Passive euthanasia occurs when an action that could have prevented death is not taken (e.g. antibiotics are not given) or an intervention that is keeping death at bay is withdrawn (e.g. artificial ventilation).

It is sometimes argued that, because we are not as culpable for our inactions as we are for our actions (the acts/omissions distinction), a case of passive euthanasia could be permissible even if active euthanasia is ruled out.

Clearly, this is not a move that is likely to be accepted by consequentialists. James Rachels, for instance, argues that the distinction is morally bogus because the morally relevant issue is not the fact of whether someone acted or omitted to act but rather that the intention, motivation and outcome are identical. ³ He goes on to claim that if one believes that passive euthanasia is permissible, then, one ought to be prepared to perform active euthanasia because the latter is more likely to result in an effective and appropriate death (i.e. better fits the motive). On the other hand, one could argue that if the two are morally equivalent, where one opposes active euthanasia, one ought also to oppose passive euthanasia. One would then be committed to condemning the withholding or withdrawing of any treatment that may prolong life if the withdrawal is motivated by the belief that the patient would be better off dead.

As the British Medical Association points out, ⁴ life-prolonging treatment may be withdrawn or withheld not because it is believed that the patient would be better off dead, but because it is believed that the treatment does not serve their interests. Here, a distinction is being drawn between considering that the patient's life is valuable and a belief that the treatment is not valuable. One difficulty with this distinction, which is intended to distance the act of withholding/withdrawing life-prolonging therapy from euthanasia, is that decisions about the value of an intervention may unavoidably depend upon one's views about the quality of a patient's life, and this in turn may hang upon one's views about what makes a life not worth living. ⁵

Voluntary, non-voluntary and involuntary euthanasia

Another common distinction that is drawn when discussing euthanasia is the distinction between voluntary, non-voluntary and involuntary euthanasia.

Voluntary euthanasia occurs when all of the conditions for a valid consent are met: that the patient is competent, fully informed and voluntarily makes a decision to request or agree to euthanasia;

Non-voluntary euthanasia is performed when the patient lacks the capacity to consent (a neonate or patient in a persistent vegetative state, for instance) and, therefore, relies on a best interest argument usually combined with consent of another authorized individual;

Involuntary euthanasia is sometimes used to describe circumstances where the patient is competent but a decision is made to proceed with euthanasia without first going through the process of gaining a valid consent (perhaps the patient was not fully informed, was coerced into agreeing, or was not consulted about the decision). This form of euthanasia is both illegal and the most difficult to justify ethically.

Arguments for and against euthanasia

Patient values and individual autonomy

For some people, direct killing of an innocent human being is considered impermissible under all circumstances because life is intrinsically valuable or possibly even sacred regardless of its quality. On the other hand, many people think that it is up to the individuals to decide for themselves how valuable their own lives are, in which case, if both parties to a euthanasia agree that it is the best course of action no wrong is done by requesting or performing euthanasia. On this argument, no patient should be forced to die before they are ready to and one could add the proviso that no health-care professional should be obliged to participate in a euthanasia with which they disagree. Clearly this kind of argument only supports voluntary euthanasia.

Others would argue that respect for human autonomy entails that we should grant autonomous individuals as much control over their own deaths as possible, even where there is disagreement over the quality-of-life question. However, some would argue that it does not automatically follow that because it is permissible for a person to end their own life they are entitled to receive help in achieving that end. Others would accept that the general duty to relieve suffering could entail assisting a person who has autonomously chosen to die and would characterize a decision not to do so as a form of abandonment.

Balancing the harms and benefits

It could clearly be argued that it is an act of humanitarianism to relieve physical and psychological pain and suffering. The question is whether to refuse to assist a patient when their suffering has become unbearable amounts to harming them and as such, violates the primary obligations of benevolence and non-maleficence. This could entail the acknowledgement of a positive duty to assist in a death when there is no other means to relieve the unbearable suffering (bearing in mind the problems encountered in defining unbearable suffering in this context).

This move assumes that the rightness of actions is determined by the goodness of the consequences, and it also assumes that some forms of unbearable suffering can only be relieved by death, and that a life of unbearable suffering is worse than death. Some people deny that there is suffering that cannot be alleviated (even if these measures include, at the extreme, a period of prolonged unconsciousness prior to death) and they may therefore regard a request for euthanasia as a failure to provide adequate palliative care; ⁶ and, as we have already seen, some people regard life as inherently valuable and therefore reject the view that any life can be worse than death.

Considerations of justice

It is sometimes argued that while many patients can hasten their deaths by refusing different kinds of life-prolonging therapies, this is not true of all of those who want their lives to end sooner rather than later, and it may be regarded as unfair that not everyone is in a position to foreshorten their life by treatment refusal if that is what they want to do. For some, the only option may be to refuse nutrition and hydration and thereby face the uncertain and possibly undesirable death that would ensue.

One could argue that this is an issue of moral luck as opposed to justice and accept that some illnesses provide the opportunity for refusal of treatment and others do not.

The interests of others

Strictly speaking, euthanasia should take no account of the interests of others – e.g. the burdens on a family in caring for a child with special needs or heavily dependent adult – because euthanasia should be motivated solely by the interests of the person who will die.

However, it is not uncommon for arguments against euthanasia to take into account the interests of others in terms of predictions about slippery slopes that could leave other patients vulnerable to unwarranted euthanasia, perhaps because euthanasia becomes a first rather than last resort, or perhaps because we will continually modify our views of a life not worth living to include increasingly less severe forms of suffering.

On the definition of euthanasia offered here, it would be difficult to regard deaths at the bottom of such a slope as euthanasia because they too would lack the appropriate motivation.

It may, however, be worth considering whether there are two potential slippery slopes in play here. The first is that already outlined where human life is increasingly undervalued, but the second is a slide to a position where patients are only allowed to die when every conceivable form of medical intervention has failed.

Summary points

The necessary elements of euthanasia (some of which are shared by other forms of intervention such as physician-assisted suicide) are that an other or others are involved in the death, that death is caused by the action or inaction of these parties, that death is intended, and that the only motive is acting in the best interests of the person who dies;

This precludes as euthanasia the refusal of consent for treatment; rationing decisions; withdrawing/withholding of futile interventions and the relief of pain where death is foreseen but not intended;

Definitional distinctions can be drawn between active/passive voluntary, non-voluntary and involuntary euthanasia;

Active euthanasia is unlawful in the UK;

Withholding or withdrawing life-sustaining treatment is permitted when the burden of treatment outweighs the benefit of treatment to the patient.