Euthanasia and physician-assisted death (PAD) are complex issues. Both processes facilitate a peaceful death as an alternative to suffering in terminal disease. Cultural, religious and social considerations meet personal choice under dire circumstances. Practice is currently illegal under UK law.
Cases are emotionally charged and cause media frenzy. Legalisation is a subject of growing global interest with recent changes in Canada sparking international debate. In this article I hope to clear misconceptions, elucidate arguments for and against these processes and discuss possible ways forward. The subject matter is infinitely complex, so consider this work an introduction.
Euthanasia vs PAD
Euthanasia and PAD are different. Euthanasia is physician-delivered death, usually with medication. In PAD the doctor provides the environment or method and the patient self-administers. This is the difference between pulling the trigger and lending the gun. The subtleties of these terms are more extensive so forgive my simplification. The two methods carry some different moral and legal contentions, but arguments around both can be made using similar approaches.
Arguments for or against can be simplified as 'ethical' or 'pragmatic.' Ethical arguments revolve around concepts such as quality of life, freedom of choice, state control of health provision, abuse and tolerance of pain. These are issues of 'what is right'. Pragmatic arguments centre on legislation, function and societal repercussions associated with a change in practice. Multiple factors such as religion and cultural belief also factor. These are issues of 'what is realistic'.
The arguments in favour of euthanasia
Arguments for euthanasia emphasise a number of points which together create a logical narrative. A 'right to life' might be inferred as a right to choose its end. Autonomy over decisions is personal and not to be dictated by state or others. Freedom of choice supersedes legal or social concern as long as no one else is harmed. Quality of life is judged by the patient alone. Painless death may be preferable to tortured existence. These decisions are personal and should be facilitated by state healthcare as matter of best interest if applicable.
Passive forms of euthanasia and PAD may already exist in withdrawal of care and the use 'double-effect' medications (ie those that primarily treat discomfort but may hasten death through other means, such as painkillers given in end-stage cancer treatment.) Tight legislation will improve overall patient experience and prevent suffering. It is worth noting that withdrawal of care and palliative care pathways are not considered euthanasia and PAD, but aspects of their practice are transferrable to argument. Withdrawal of care and palliation are legally practised and deserve their own discussion.
The arguments against
The counter arguments to euthanasia and PAD are equally strong. Religious beliefs about the sanctity of life are confluent globally and grossly reject suicide in any form. There is justified concern that legalised processes would lead to a 'slippery slope' where the motivation for euthanasia or PAD may be financial, either from the family, legal or medical entities. The less scrupulous may see profit in the earlier death of wealthy relatives.
Facilitation of euthanasia/PAD may discourage research in problem areas and remove the pressure for diagnosis and treatment, reducing healthcare quality for all. It may also be seen as a way of saving money for starved healthcare agencies, a real concern in wavering economies. One may see a future where healthcare provision is limited to age and disease severity. Could euthanasia be seen as a cost saving?
Further arguments between medical ethicists include the core duties of physicians, often understood as the Hippocratic Oath. 'First, do no harm' (non-maleficence) may prohibit any action leading to patient death, even if death is considered in best interests (beneficence.) Withdrawal of care in dire circumstance is seen as ethical, but the extension of this judgement further requires debate. The rapid growth and improvement in care provides growing alternatives to death even in severe disease, and that choice to pursue terminal action is a 'failure.' The inherent public expectation for heroic measures makes this argument especially strong.
We can see that these processes inspire careful thought. Simple answers are near impossible due to the complexity of pragmatic and ethical issues considered. Patient autonomy, quality of life and reality of disease progression are just the first pages in a complex narrative of moral, cultural, economic and religious drama. It is likely that as the age of the population increases, and with it patient empowerment, this subject that will begin to dominate news further.
Summing up: my view
I am conflicted but err on the side of patient choice. We have no right in dictating another's life or death. A person's right to choose their death is an extension of their autonomy. Help in the face of intolerable pain may be ethically justified but would require extraordinary consideration. It may just be a matter of time before we consider 'how' and not 'if' legalised euthanasia or PAD is practised. Getting ahead of the curve may be beneficial for all.
A state funded and legislated system may be the only safe option. Such change would require a progressive and brave society to place such trust in the hands of its people and public servants. Such a society would set an example of the tolerance and value of personal expression and empowerment. Religious and cultural expectations would have to be considered in all cases. Laws would need to change, and perhaps this is overdue in this rapidly evolving world. This has already happened in Switzerland.
Applicants would have to prove futility of treatment and rational intent, which would require medical and psychiatric review. Anonymity would be key for practitioners due to the potential religious and cultural backlash. State legislation would prevent abuse and runaway privatisation which would likely undermine ethical rationale. Ethics committees would provide a fair and balanced analysis to reduce risk of mistakes. It is only in these circumstances that I would agree with assisted death and euthanasia.
Ben is a young NHS doctor in the Southwest. His interests include neurology, health communication, and medical ethics. He is also an avid advocate of compassionate care and quality improvement, running a project in the Southwest around medical humanities. Please follow and support: Dr Janaway on Facebook Dr Janaway on Twitter
The opinions expressed in this article are the author's alone and do not reflect those of the NHS or associated agencies. All facts are based on the best available evidence. The author is happy to receive questions. There are no conflicts of interest and due consideration has been given to the consequence of conclusion or interpretation.