What are euthanasia and assisted suicide?
Euthanasia can be defined as 'the intentional killing by act or omission of a person whose life is felt not to be worth living'. Euthanasia can be:
- Voluntary – where a competent patient requests it
- Involuntary – where a competent patient is not consulted
- Non-voluntary – where the patient is not competent to make the request
Euthanasia is usually carried out by a doctor administering lethal drugs, for example, by injection. Physician-assisted suicide (PAS) is where a doctor prescribes lethal drugs for the patient to take himself. Both euthanasia and assisted suicide are currently illegal in Britain.
What are the main arguments against legalising euthanasia?
The main reasons given for not legalising euthanasia are that it is:
- Unnecessary – because alternative treatments exist
- Dangerous – putting vulnerable people at risk
- Wrong – contrary to all historical codes of ethics
Isn't it cruel to deprive suffering people of an end to their pain?
Requests for euthanasia and assisted suicide are extremely rare when patients' needs, including physical, social, psychological and spiritual needs, are properly met. Therefore we believe that our key priority should be to build on the excellent tradition of palliative care that we have in this country and make palliative care more readily accessible to all who need it. We need to get rid of the postcode lottery of palliative care in this country and promote care rather than killing. The vast majority of people dying in the UK, even from diseases like motor neurone disease (from which 1,000 people die every year, in the main comfortably with good palliative care) do not want euthanasia or assisted suicide. The very small numbers of high profile cases of assisted suicide, which are regularly and repeatedly highlighted in the media, are well-publicised exceptions to the rule. The real question is therefore whether we should change the law for a very small number of people who are strongly determined to end their lives. We believe that to do so would place the lives of a much larger number of vulnerable people in danger and mean that pressure, whether real or imagined, is felt by sick, disabled and elderly people to request early death.
Aren't doctors already prescribing medicine knowing that it will result in the death of the patient (eg cancer patients)? - what is the difference between this and euthanasia/PAS?
Very rarely, when strong narcotics like morphine are given to patients who are terminally ill, they may have the secondary effect of shortening life - although with good palliative care this occurs in less than one case in a thousand. This is known as the principle of 'double effect' - when an action has two effects - one good and one bad. The good effect of relieving the pain is intended. The bad effect of shortening life is foreseen but not intended. If a patient dies as a result of double effect that is both ethical and legal. However, if pain is being appropriately treated with narcotics double effect seldom if ever occurs because the toxic dose (which kills the patient) is virtually always higher than the therapeutic dose (which relieves pain). It is virtually always possible therefore for a skilled palliative care physician to kill the pain without killing the patient. On very rare occasions very close to death it may be necessary to sedate a patient to relieve the pain adequately, but even here it is almost invariably the disease which kills rather than the treatment.
What is the difference between withholding a treatment because it is futile and intentionally causing a death through act or omission? Are these not merely semantic differences?
Some people distinguish 'active' euthanasia – administering a lethal injection – from 'passive' euthanasia – withholding or withdrawing treatment. This distinction is unhelpful and confusing because there are a significant number of cases where withholding or withdrawing treatment can be good medical practice. The distinction between euthanasia and good medical practice hinges on the intention with which a treatment is given or withheld. In euthanasia the intention is to kill; in good medical practice it is to maximise the quality of life experienced by the patient.
Some treatments are medically useless in that the suffering that they cause outweighs any benefit they bring. Stopping or not starting a medically useless treatment is not euthanasia, but there is a world of difference between saying that a treatment is useless (and therefore not worth giving) and that a patient's life is useless (and that they are therefore not worth treating). In the same way if a competent patient refuses life-saving medical treatment and dies as a result, that is not euthanasia. Doctors cannot force patients to have treatment against their wills. If a patient who is capable of deciding refuses a life-saving treatment - then the doctor is not performing euthanasia by not forcing it upon them against their will.
If the government won't fund palliative care properly, why should people not choose to end their pain through euthanasia or assisted suicide?
The proper response of a responsible government is to ensure that there is adequate funding to provide palliative care for all who need it. Good palliative care may depend on skilled personnel but it is neither technologically difficult nor expensive to provide. But this question about funding highlights an important danger. If the law is ever changed to allow so called 'assisted dying' it is inevitable that economic pressure will be brought to bear on people, openly or more likely very subtly, to request early death in order to save money for the use of relatives, society or a health service short of the resources it needs. Killing is very cost effective – it does not cost much for an ampoule of barbiturate. That is why we need to promote care, not killing, and hold onto laws which protect vulnerable people.
What are the main arguments for euthanasia?
There are three main arguments for euthanasia.
- We want it - the autonomy argument
- We need it - the compassion argument
- We can control it - the public policy argument
The debate in the 1990s centred on the compassion argument, but because of cultural changes and palliative care's success, has moved to arguments based on autonomy.
What is autonomy?
Autonomy means 'self-determination' and the language heard now in the euthanasia debate is often that of choice, control, freedoms and rights. The euthanasia lobby's thrust, as evidenced in Lord Joffe's Bill, has moved from euthanasia as a needed response to symptoms to euthanasia as an autonomous choice by those with, for example, degenerative neurological disease.
Shouldn't euthanasia and assisted suicide be a matter of free choice?
Autonomy is important but we have laws because autonomy is not absolute. We all value living in a free society but also recognise that we are not free to do things which threaten the reasonable freedoms of others. Legalising euthanasia would actually undermine people's autonomy for four reasons.
- Most people who ask for euthanasia do not actually want it
- Vulnerable people will feel pressure to request euthanasia
- Euthanasia cannot be controlled
- Euthanasia would change the nature of medicine
On what basis can you say that most people who ask for euthanasia do not actually want it?
Those caring for the dying know that the (relatively few) who currently ask for euthanasia usually have another question behind their question. This may be physical - a distressing symptom needs palliation; psychosocial - they may want an honest discussion with their family; emotional – they may be depressed; or spiritual - wanting answers to 'Why me?' and 'Why now?'. Depression is particularly common in terminally ill patients and leads to suicidal thoughts; and yet in most cases it can be effectively treated. Requests for euthanasia are extremely rare when patients are properly cared for and physical, psychosocial, emotional and spiritual needs are properly met. Our key priority must therefore be to make the highest quality palliative care more widely available. This is true compassion.
Why would vulnerable people feel pressure to request euthanasia?
In 1994 a House of Lords' Select Committee reported on euthanasia, and unanimously recommended no change in the law. Its Chairman, neurologist Lord Walton of Detchant, later described in Parliament their concerns about such legislation: 'We concluded that it was virtually impossible to ensure that all acts of euthanasia were truly voluntary and that any liberalisation of the law in the United Kingdom could not be abused. We were also concerned that vulnerable people - the elderly, lonely, sick or distressed - would feel pressure, whether real or imagined, to request early death.' People who are dying often feel a burden on relatives, carers and a society short of resources. A law allowing euthanasia would place them under huge pressure.
On what basis can you say that euthanasia cannot be controlled?
The progression from voluntary to non-voluntary or involuntary euthanasia is well documented in the Netherlands. The Remmelink Report analysed all 129,000 deaths in the Netherlands in 1990. 3% were by euthanasia. Of that 3%, 1 in 3, 1% of all deaths in the Netherlands in 1990, were euthanasia 'without explicit request'. In a mix of non-voluntary and involuntary euthanasia, Dutch doctors in 1990 killed more than 1,000 patients without their request. This level of euthanasia has continued and now about half of all Dutch euthanasia deaths are not even reported. Furthermore in 2005 Dutch doctors instituted the Groningen protocol enabling the killing of severely disabled children. Legalising euthanasia here would give doctors power they should not be entitled to have and would mean that economic and convenience factors would inevitably start to influence decision-making. Doctors could become the most dangerous people in the state.
How would euthanasia change the shape of medicine?
Legalising PAS and euthanasia would split the medical profession. 75% of doctors in a major poll (Hospital Doctor, 15 May 2003) have already indicated that they will not participate in euthanasia if it is legalised, and a change in the law, as in the case of abortion, will lead to doctors who conscientiously object being excluded from specialties where euthanasia becomes part of the 'full range of services'. Euthanasia legislation would have a devastating effect throughout the National Health Service on already critical levels of staffing, where we are reliant especially on many overseas nurses from Muslim, Christian and other faith backgrounds who are strongly opposed to the practice.
Shouldn't PAS be allowed just for the very difficult cases?
The law is a blunt instrument, and there will always be individual cases, usually those that have not been managed well, which raise questions about PAS. But hard cases make bad laws. Any law allowing PAS would threaten the trust necessary for the doctor–patient relationship to function, place pressure on patients to request early death, and introduce a slippery slope to voluntary and involuntary euthanasia. Such legislation would also be impossible to police might well undermine the development of palliative-care services, and could lead to patients being incited to request suicide for economic reasons by family, carers, or society at large.
Why do some people argue that euthanasia is morally wrong?
Many people are convinced by the arguments already given above but go further to argue that euthanasia is fundamentally wrong. Euthanasia is certainly against the Hippocratic Oath ('I will give no deadly medicine to anyone if asked') and in like manner the World Medical Association reaffirmed in 2005 that 'physician assisted suicide, like euthanasia is unethical and must be condemned by the medical profession'. In addition euthanasia runs contrary to the Judeo-Christian ethic on which our laws are based. The belief that euthanasia is fundamentally wrong is also present in Judaism, Islam, Sikhism, Buddhism and Hinduism. Nine UK faith leaders representing the six major world faiths recently wrote every member of both Houses of Parliament opposing any change in the law.
Isn't physician-assisted suicide (PAS) a safer option than euthanasia?
Because of the difficulties in getting voluntary euthanasia (VE) accepted the pro-euthanasia lobby has directed its attention to the seemingly softer target of physician-assisted suicide (PAS). It was calculated by a recent House of Lords Select Committee that a Netherlands-type law (VE and PAS) would lead to 13,000 new deaths per annum in Britain, whereas an Oregon-type law (PAS only) would lead to 650 deaths per annum.
But in fact VE and PAS are ethically equivalent because in both cases the intention of the doctor is to end the life of the patient. There is little practical difference between placing lethal medication in a patient's hand and placing it in a patient's mouth! PAS is simply 'euthanasia one step back'.
Legalising PAS would also bring in euthanasia because of:
- Incapacity
Some patients would be physically incapable of ending their own lives (eg through paralysis) so VE back-up would be required. - Failure rates
Even with a prescription, PAS has a failure rate. Some patients vomit, while others fail to die despite large doses of drugs. In these situations, a doctor will always be required for the coup de grâce. - Incremental extension
Once doctors begin practising PAS there will be those who will 'push the limits' and euthanasia will inevitably follow. When the patient - the 'key witness' - is dead, who is to say whether it was suicide or euthanasia?
How does the medical profession view euthanasia?
Doctors have historically always been opposed to both euthanasia and assisted suicide. The Hippocratic Oath forbids both as do more recent codes of ethics such as the Declaration of Geneva and The International Code of Medical Ethics. The majority of doctors in the UK remain opposed to assisted dying and medical opposition has actually intensified in recent years. The largest most recent surveys show only 22-38% of doctors in favour of a change in the law. This was made very clear to the recent House of Lords Select Committee examining Lord Joffe's Assisted Dying for the Terminally Ill Bill. The opposition to euthanasia is strongest amongst doctors who work most closely with dying patients and are most familiar with treatments available. One of our steering group members is the Association for Palliative Medicine of Great Britain & Ireland, which represents over 800 UK specialists in palliative care. Well over 90% of its members are strongly opposed to euthanasia. The British Medical Association (BMA), the Royal College of Physicians (RCP), the Royal College of General Practitioners (RCGP), the Royal College of Anaesthetists, the Royal College of Surgeons of Edinburgh, The Royal College of Nursing and the British Geriatric Society also remain strongly opposed to euthanasia.
Isn't the public generally in favour of euthanasia?
There has been much recent publicity to the effect that most people are in favour of a change in the law. But most polls of this nature are based on answers to Yes/No or Either/Or questions without any explanatory context and without other options - eg good quality palliative care - being offered. In other words the answer you get depends very much how you ask the question. If you ask people if they would like help to die comfortably, most will say yes. If you ask them if they would like to receive a lethal injection most will say no. Most people have little understanding of the complexities and dangers in changing the law in this way and opinion research consists therefore to a large extent of knee-jerk answers to emotive - and often leading – questions. In addition those most in favour of euthanasia tend to be the 'worried well'. Requests for euthanasia from people who are dying or who are disabled are very rare indeed, provided they are being properly cared for.
