The Irish Times - Friday, April 24, 2009

Moral equivalence is of little use to those dying without dignity

OPINION: BECAUSE OF the refusal to let me speak in Ireland, my arguments for the legalisation of euthanasia have unfortunately been lost in the noise surrounding the non-event writes LEN DOYAL 

This has been especially evident in the press and on the internet where I have been subjected to intense abuse based on erroneous beliefs about my position.

For example, I have never argued, as many have claimed, that involuntary euthanasia should be legalised or that money could be saved by the state through killing vulnerable or elderly people. Nor have I argued that the law should be broken, but rather that it should be changed.

Many of the public debates following the cancellation of my talk compounded misunderstanding rather than clarifying the reality of current medical practice, and exploring some of the confusion in its legal and moral underpinnings. This saddens me.

My views on euthanasia are based only on the search for moral coherence and on compassion for those whom I have been accused of wishing to harm. I hope very much that the important arguments outlined below can now be debated openly in Ireland.

The main aim of my talk was to demonstrate that many doctors are already involved in shortening the lives of patients, in Ireland and elsewhere. This occurs when decisions are made either not to provide or to withdraw life-sustaining treatments to patients who are severely brain damaged and have no actual or potential quality of life. Such individuals – often neonates or adults in intensive care – may still have the potential for suffering but are not in a position to communicate this to those caring for them. Under these circumstances, it will often be decided that continued life-sustaining treatment is not in their best interests.

Doctors, nurses and family members may then take a decision to foreshorten the patient’s life by not sustaining it medically, stopping the provision of ventilator support for example. How long the death of such a patient will then take depends on the type of treatment to be withdrawn and the patient’s clinical condition. For some it may involve a lengthy period of suffering, for themselves and their families.

These actions are not carried out to save money or to rid society of “undesirables”. Rather they are done because the lives of those concerned are deemed to be no longer worth living. Remember, the purpose of life-sustaining treatment is precisely that: to sustain life. If such treatment is deemed to be of no benefit to the patient, it must be because a prior decision has been made that life itself is of no benefit to them and hence life-sustaining treatment is not in their best interest. Indeed, a doctor who did not make such a decision would arguably be in violation of his duty of care. Under these circumstances, what kind of moral sense does it make to force patients to die slowly when they could do so quickly with compassion and care? Why allow any vulnerable patient to suffer a slow death when a quick and painless one could easily be provided were non-voluntary euthanasia to be legalised?

When doctors medically foreshorten life in this way they do so actively and not just passively. This is often denied and their actions are said to have nothing to do with euthanasia. It is argued that they are in fact doing nothing at all – other than “letting nature take its course” or “omitting” to act. Yet the idea that withdrawing ventilator support or other forms of life-sustaining treatment from a patient is not an action is absurd. Switches must be flipped, drips removed. Positive acts such as these that lead to patients dying take place regularly in Irish hospitals. These should not be denied but acknowledged and embraced as humanitarian interventions for some patients.

So how are these actions justified in a society where euthanasia itself is so vehemently opposed by some sections of society?

One important argument used to square this apparent circle is that doctors who withdraw treatment can be deemed to be morally righteous if they do so with the aim of relieving the patient’s suffering rather than taking away their life. It is claimed that the legalisation of euthanasia is wrong because it enables doctors to act with the transparent intention of killing.

This is also a weak argument. Remember that when a decision is made either not to provide or to withdraw life-sustaining treatment, there has already been a prior judgment that the patient’s life is no longer worth living.

So why should the intent to bring about death after such a decision be morally worse than the intent to relieve suffering? In circumstances where the palliative relief of suffering may be unachievable or unavailable, the intent to administer a quick and painless death should be seen as a more morally worthy goal.

If the parents and healthcare team of a 23-week-old severely damaged neonate agreed that life was of no further benefit to the baby, we would presumably be unimpressed by a senior consultant who said that he would not flip the switch because he had become unsure of his own intentions! The best interests of the child should prevail; not the subjective feelings of the doctor.

Doctors should be able to abide by their commitment to minimise suffering. For some patients, this will entail ending life quickly.

So much for the argument in support of the legalisation and regulation of non-voluntary euthanasia. If this argument is correct, the case for voluntary euthanasia directly follows. If doctors are enabled to make these decisions on behalf of severely brain damaged and incompetent patients, why should competent and suffering patients who are terminally ill not be allowed to make the same decisions for themselves?

Despite frequent claims to the contrary, there is no good evidence that the legalisation of euthanasia will lead to widespread and unjustified killing of patients. Contrary to what is often claimed, scholarly research has shown that this has not been the case in Holland for example.

At present, the potential suffering of vulnerable patients who might be frightened by the prospect of euthanasia – however well regulated – is given more weight than the actual suffering of competent and incompetent patients who in too many cases are ending their lives in pain and distress.

What kind of compassion – Christian or otherwise – is that? It seems to me that this exercise of arbitrary prejudice is a violation of even the simplest principles of moral equality, presumably on the grounds of religious beliefs which many of those thus deprived of the right to a quick and easy death may not themselves hold.

Whether or not readers agree with the preceding arguments, I hope that it is now clear that they would have served to promote an interesting debate in Cork. I regret that dogmatism, apparently fuelled by religion, and lack of respect for free speech prevented this. Beware, it could happen again!

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Len Doyal is emeritus professor of medical ethics at Queen Mary College, University of London, and professor of healthcare ethics at the University of East Anglia

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