Euthanasia and physician-assisted suicide not fit for purpose

Euthanasia – from the Greek meaning good death – is the intentional ending of human life in order to relieve intractable suffering. Voluntary medical euthanasia, with the patient’s informed consent, is legal in some countries, as is physician-assisted suicide (PAS), where a physician provides lethal medication that the patient takes himself/herself.

Involuntary euthanasia, without patient consent, is illegal everywhere. Where voluntary euthanasia/PAS is legal, patients must be medically certified as suitable candidates – usually suffering from a terminal illness, in severe distress and close to death.

Whether or not to legalise euthanasia/PAS is a difficult and intense bioethical debate. I believe the principal arguments for euthanasia/PAS are mistaken, although sincerely and compassionately formulated.

Euthanasia/PAS is illegal in Ireland but the Dying with Dignity Bill 2020, sponsored by People Before Profit/Solidarity TD Gino Kenny, sought to legalise PAS here. The Oireachtas decided this Bill was fatally flawed and Kenny plans to introduce an End of Life Choice Bill in 2022.

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Ole Hartling, Danish Council of Ethics member (2000-2007) and nuclear medicine specialist, is opposed to legalising euthanasia/PAS. He summarised his arguments in a book, Euthanasia and the Ethics of a Doctor's Decisions (Bloomsbury Academic, 2021).

Noting 70 per cent to 80 per cent of the general public favour euthanasia in opinion polls, he points out that most people surveyed are healthy and cannot really imagine being crippled, blind, suffering from dementia and dependent on care. They think they would rather die than experience this – but would they? Hartling cites surveys showing that support for euthanasia is much lower amongst very sick people then among healthy people.

Two arguments

Two principal arguments for euthanasia/PAS are patient autonomy (right to choose when and how they die) and avoiding unbearable suffering. Together with beneficience, non-maleficience and justice, autonomy is a universal ethical principle. Autonomy has a strong Anglo-American flavour, is dominant in consumer societies and sits uneasily with cultures such as Latino and indigenous peoples regarding end-of-life decisions.

But, no patient opting for euthanasia/PAS can command full autonomy because physicians are gatekeepers of this decision. The patient’s life quality must be medically assessed as sufficiently low to qualify for euthanasia. Patient autonomy is never independent of other things; a fact insufficiently acknowledged in this debate.

The intent of palliative sedation is relief from suffering, not death, although side-effects of the drugs may hasten death

Hartling argues cogently that euthanasia/PAS is very often an illusory exercise of autonomy. When euthanasia/PAS is available, terminally-ill patients in severe distress feel pressured to make a choice. This has been called “the prison of freedom”. The patient choosing euthanasia/PAS may simply be translating pressures from those around him/her who believe the value of his/her life is not worth preserving and signal this in many ways.

Many patients who “choose” euthanasia/PAS may really be asking the question: “Do you think my life is worth preserving?” The alternative to euthanasia/PAS, voluntary palliative sedation, the intentional administration of sedative drugs to the terminally-ill patient to reduce consciousness and relieve pain, allows a “yes” answer to this question, respecting the inherent value/dignity of human life.

Relief from suffering

The intent of palliative sedation is relief from suffering, not death, although side-effects of the drugs may hasten death. Carers for terminally-ill patients on palliative sedation express satisfaction with outcomes.

Two main arguments against euthanasia/PAS are: legalising euthanasia/PAS initiates a “slippery slope” allowing much more widespread and inappropriate use of this practice than initially intended, and the deliberate killing of another human being is morally wrong.

Slippery-slopearguments are valid (James Mildred, the Economist, August 2018). When euthanasia/PAS is legalised, detailed conditions are appended specifying categories of patients who can avail of the service, and so on.

But experience has shown adherence to these conditions wanes considerably with time. For example, adult euthanasia, introduced in Belgium in 2002, was extended to children in 2014. Twenty four people were euthanised in 2002 but 4,337 cases were reported in 2016, including three children. Belgian euthanasia is not limited to terminal illness and people have been euthanised for depression, gender-identity crisis and anorexia.

Respect for life

Christianity, Islam and Judaism broadly oppose euthanasia/PAS but, because respect for human life is a universal human trait, many non-religious people also oppose euthanasia/PAS. I believe euthanasia/PAS unfortunately corrodes basic respect for life while failing to serve the human needs of distressed terminally-ill patients.

While acknowledging that some cases are extremely difficult to call, I believe everybody should be encouraged and helped to remain living in the human community until natural death, comforted as necessary with palliative medicine.

William Reville is an emeritus professor of biochemistry at UCC