Euthanasia is an act that seeks to cause the death of a sick person. The social and medical challenge consists in seeking to control pain and to relieve suffering.
The recent legalization of euthanasia in Holland has prompted some political parties to call for the legalization of euthanasia in Spain. With this document, the Associació Catalana d’Estudis Bioètics (ACEB) wishes to contribute to the important social debate some fundamental reflections on a matter as delicate as the decriminalization of actions against human life.
1- What is Euthanasia?
The World Health Organization (WHO) defines euthanasia as that “action of the physician that deliberately causes the death of the patient.”
This definition highlights the intention of the medical act, that is, the will to voluntarily cause the death of another. Euthanasia can be carried out by direct action: administering a lethal injection to the sick person, or by indirect action: not providing the basic support for his survival. In both cases, the purpose is the same: to end a sick life.
This action upon the sick person, with the intention of taking his life, was called, is called, and should continue to be called homicide. The patient’s information and knowledge about his illness and his free and voluntary demand to put an end to his life — so-called assisted suicide — does not change the fact that it is a homicide, since what is proposed enters into grave conflict with the guiding principles of Law and of Medicine down to our own days.
2- The current debate
Euthanasia is an act that seeks to cause the death of a sick person, and it entails grave family, social, medical, ethical, and political consequences. Its decriminalization will modify at its very root the relationship between the generations and the professionals of medicine. The Remmelink Report on the practice of euthanasia in Holland brings to light 1,000 deaths by involuntary euthanasia (without consent) in 1990. These 1,000 euthanized patients become 1,000 most powerful reasons to oppose active euthanasia. Likewise, in the cases in which euthanasia is requested by the sick person, there is a grave ethical problem, because it is a social and professional defeat in the face of the problem of illness and of death. Extreme cases and personal autonomy, always invoked by the advocates of euthanasia for its decriminalization, must not generate socially unjust laws, which pit individual desire against the State’s inescapable duty to protect the physical life of every citizen.
Human suffering must be eliminated, but not the human being who suffers.
Three complex questions are present in the debate on euthanasia: democratic consensus, the dignity of the human person, and personal autonomy.
Consensus:
Consensus makes the legislative principle the sole source of truth and of good, and leaves human life at the mercy of the number of votes cast in a Parliament. The laws on abortion, human cloning, extracorporeal fertilization, and embryonic experimentation are the consequence of the application of the principle of majorities.
Human rights are not granted by the number of votes obtained, nor by society, nor by political parties, although these must always recognize and defend them. Neither are they based on social consensus, since rights are possessed by each person, by virtue of being a person. Parliamentary votes do not modify the reality of man, nor the truth about the treatment that is due to him.
The dignity of human life. No life lacks value.
The fact of being born and the fact of dying are nothing more than facts, and only facts, adorned naturally with all the importance one wishes. Precisely for that reason they cannot be held to be worthy or unworthy according to the circumstances in which they occur, by the simple and elementary evidence that the human being always, in every case and situation, is exceptionally worthy, whether he is being born, living, or dying. To say otherwise is to go directly against what singles us out and holds us together as a society.
To legalize euthanasia is a declaration of social, political, and medical defeat before the sick person, one that will not put an end to the perplexities of life, nor of death, nor to the doubts of conscience of physicians, of patients, and of relatives.
Personal autonomy.
“The right to die is not regulated constitutionally; there does not exist in the Constitution the availability of one’s own life as such.” If this absolute right over life existed, other rights would exist, such as the possibility of selling your own organs or voluntarily accepting slavery.
Personal autonomy is not an absolute. One cannot will freedom only for oneself, since there is no human being without others. Our personal freedom always remains connected to responsibility for all those who surround us and the whole of humanity. Democratic coexistence obliges us to submit to and accept taxes, norms, and laws that are at no moment questioned as limits to personal freedom. Why do we not wish to discover a social good in the legal protection of life in its finitude? What culture will we leave to our children if we transmit to them that the sick do not deserve the protection of all?
3- How do we want to die?
We all want a good death, without their artificially prolonging our agony, nor applying to us a technology or means disproportionate to the illness.
We all want to be treated effectively for pain, to have the necessary help, and not to be abandoned by the physician and the health-care team when the illness is incurable.
We all want to be adequately informed about the illness, the prognosis, and the treatments that medicine has available, to have the data explained to us in comprehensible language, and to participate in the decisions about what is going to be done to us.
We all want to receive respectful treatment; that in the hospital we may be accompanied by family and friends with no other restrictions than those necessary for the good course of the illness and the good functioning of the hospital.
How do we want to die?
Without pain.
Being able to refuse treatments that artificially prolong life.
Informed about the illness and the treatment possibilities, in comprehensible words.
Being able to decide about what is going to be done to us and to refuse treatments that artificially prolong the agony.
Always treated with respect and affection by the health-care professionals.
Accompanied by family and friends.
4- The Role of the Physician
The medical act is based on a relationship of trust in which the patient entrusts to the physician the care of his health, a fundamental aspect of his life, of himself. In the relationship between the two there can be no place for the pact of an intentional death. Euthanasia will mean the end of the trust placed for millennia in a profession that has always committed itself never to cause death intentionally under any circumstance.
Euthanasia will dehumanize medicine. Only from absolute respect is it possible to conclude that all human lives are worthy, that none is dispensable or unworthy of being lived.
Euthanasia will halt the progress of medicine. Physicians will gradually become indifferent toward certain types of illness; there will be no reasons to investigate the pathogenic mechanisms of senility, of cerebral degeneration, of terminal-stage cancer, of biochemical or morphological malformations, etc.
The solution lies in giving integral care to the one who is soon going to die, treating both his physical sufferings and his psychological, social, and spiritual sufferings.
This is the foundation of Palliative Medicine, which, from the perspective of the absolute respect due to every person and in the face of the therapeutic limits of medicine itself, proceeds to control the symptoms of the illness, especially the presence of pain, accompanying the sick person until death.
What is terminal sedation?
“Terminal sedation is understood to be the deliberate administration of drugs to produce a sufficiently deep and foreseeably irreversible diminishment of consciousness in a patient whose death is expected to be near, with the intention of relieving a physical and/or psychological suffering unattainable by other means and with the explicit, implicit, or delegated consent of the patient.” Resorting to implicit or delegated consent when the patient is able to know the information deprives the dying person of his right to face the final act of his life: his own death. The family and the physician supplant and strip the sick person of the knowledge of this decision.
True respect for the rights of the patient requires making him a participant in the decisions about his care, even though these may have to involve unpleasant information.
Terminal sedation is ethically correct when:
The aim of the sedation is to mitigate suffering;
The administration of the treatment seeks solely to mitigate suffering and not the intentional causing of death.
There is no alternative treatment that achieves the same principal effects without the side effect, which would be the shortening of life. Then the action is correct and ethically acceptable.
Terminal sedation is correct only when it seeks to mitigate the suffering of the sick person and not when the purpose is to hasten his death. In this case it is active euthanasia.
Consequences of the decriminalization of euthanasia
The difficult circumstances that some illnesses or an unpleasant family experience provoke can be the cause of a personal position in favor of euthanasia. But extreme cases do not generate socially just laws, because of the difficulties they themselves entail. Extreme cases are used and presented as unsolvable, so that if today we accept killing a patient intentionally as the solution to a problem, tomorrow we will be able to find a hundred problems for which killing is the solution.
Euthanasia does not solve the problems of the sick person; rather, it destroys the person who has the problems.
An antecedent of what has been set forth can be considered in the consequences of the decriminalization of abortion under the three assumptions or exceptions to the norm in the abortion law of 1985: for rape, for fetal or congenital malformations, and for the danger to the physical or psychological health of the mother. The danger to the psychological health of the mother has become a catch-all into which everything fits, since 97.83% of the reasons take shelter under this assumption. Today no one any longer speaks of the right to life of the unborn, and abortion has become a habitual medico-social practice without any legal control whatsoever in the cases contemplated by the law.
There is talk of the absolute control of the euthanistic act once it is decriminalized, but the evidence is very different, for the physician, if euthanasia is decriminalized, will have impunity to kill without anyone finding out.
The following examples make manifest the insecurity of the sick:
La Vanguardia (6/01/2001) published the following news item: “Family doctor and serial killer.” A meticulous report by the University of Leicester determines that “probably 297 patients of Harold Shipman, known as ‘Doctor Death,’ did not die of natural causes.” Shipman, an Englishman, father of four children and a general practitioner, is already serving a life sentence for having murdered fifteen of his patients. In his file one reads that he killed predominantly middle-aged women, between 50 and 65 years old, administering to them overdoses of drugs such as heroin, which he obtained with his medical license by making it appear that they were to relieve his patients’ pain. The relatives of some of the victims continue to press the British prosecutor’s office to find out whether their loved ones were murdered. Dr. Shipman was discovered for tampering with the will of Kathllen Grundy, which the family reported.
EL País (23/06/2000) published the case of an English nurse investigated for the death of 18 minors. The doubts arose from a mother’s letter complaining about the treatment received by her son, now deceased. Being well versed in the palliative care applied to incurable cases, her visits to the various homes were not supervised with the same rigor as the tasks of the rest of her colleagues. The authorities of Runwell Hospital, in the county of Essex, suspended her without pay. The news item did not cite the nurse’s name.
In Brazil, ABC (11/05/99) published “funeral homes investigated over the new ‘angel of death.’” The nursing assistant Edson Izidoro, suspected of having killed 131 patients in serious condition, confessed to having received a commission from the funeral homes and to having acted for money.
La Razón (12/01/99) published “A Dutch physician denounces before the Council of Europe 900 cases of euthanasia without consulting the patient.” The denunciation was made by Doctor Henk Ten Have at the meeting of the Parliamentary Assembly of the Council of Europe that took place the day before.
Amnesty International (AI), Diario Médico (3/11/98) reported, declared that physicians who intervene in the execution of a convict by means of a lethal injection incur a practice contrary to professional ethics, even if the country’s legislation protects them. Doctor James Welsh has affirmed that when the use of the lethal injection was introduced “it was presented as a system that notably humanized executions. However, in practice, there is a record of a high number of cases in which it has failed and has caused a painful death.”
El Mundo published (7/01/99) “The British police investigate 50 deaths by euthanasia.” Several hospitals have been accused of having withdrawn the intravenous drip from their patients, while they were sedated, and of causing their death by dehydration. Doctor Gillian Craig said in this regard: “On some occasions, to sedate a patient and dehydrate him is equivalent to euthanasia. Water and food constitute a basic necessity and cannot be considered a treatment that physicians may grant or withdraw at their whim.”
ABC (8/08/2000) published “In Denmark the terminally ill will not be attended to in order to save costs.” The pact agreed between physicians and politicians scandalizes society.
What will happen if it is decriminalized?
The decriminalization of euthanasia will bring about a progressive ethical decadence. Gonzalo Herranz describes in four phases the situations through which we will pass in the event that it is decriminalized:
Euthanasia will be presented as a treatment that can be applied only in certain extreme clinical situations, subjected to a strict control of the law.
After a few years, the repetition of cases will gradually deprive euthanasia of its exceptional character. Habituation will occur, with the idea that it is an intervention not lacking in advantages, and even an acceptable therapy. Euthanasia will deceitfully win the battle against palliative care by being more painless, quick, aesthetic, and economical, becoming for the sick person a demandable right to a gentle death, for the relatives a more comfortable way out, for some physicians a simple recourse that saves time and effort, and for the health-care administrators an intervention of optimal cost/efficiency ratio.
For those professionals who accept voluntary euthanasia, involuntary euthanasia will become, for reasons of moral coherence, an inescapable obligation. This phase entails involuntary euthanasia. The physician reasons that the life of certain patients capable of deciding is so lacking in quality, has so high a cost, that they are not worthy of being lived. It is very easy to expropriate from the patient his freedom to choose to go on living.
This concept will be generalized to other sick people, and euthanasia will replace medicine.
An example: Holland
According to the new Dutch law, euthanasia will not be a crime if the physician practices it respecting the following requirements: that the patient’s situation be irreversible and the suffering unbearable; that the physician be sure that no one is coercing the patient and that his request to die has been expressed more than once; that the physician ask the opinion of another colleague, who must have seen the patient. All these requirements were already provided for in the legislation of 1993. What is novel about this law is that minors from 12 to 16 years of age can also request euthanasia with their parents’ permission. Those of 16 and 17 years will not need parental consent, but they will need their parents’ participation in the decision process.
P.J. van der Maas and G. van der Wal, professors of Public Health at the Erasmus University of Rotterdam and at the Free University of Amsterdam, carried out a report at the request of the Ministers of Justice and Health to evaluate the application of the legislation. Their conclusions make it possible to compare the current practice of euthanasia with that reflected by another report carried out in 1991 by a commission chaired by the State’s attorney general, Jan Remmelink.
The two studies are based on two separate reports: one based on interviews with physicians and the other on the notification procedure.
The comparison of the Remmelink report of 1990 and that of 1995 makes manifest that, of the total of deaths in Holland:
Deaths by euthanasia have increased from 2,300 cases in 1990 to 3,120 cases in 1995;
Cooperation in suicide has gone from 400 cases to 540 cases;
The practice of euthanasia without explicit consent remains around 1,000 cases.
The explicit requests for euthanasia or assisted suicide grew by 9% since 1990.
The notification procedure does not fulfill its role of a posteriori control. Still, the majority of the cases of euthanasia are not declared as such when the death certificate is drawn up, although the proportion of the declarations has increased from 18% in 1990 to 41% in 1995. With the theoretical threat of incurring criminal liability, it is logical that physicians do not want to report themselves to Justice.
Euthanasias with consent are a great family, social, medical, and political defeat that should move us to reflect on the will to die of these patients who say: “Doctor, I want to die,” which means: “Doctor, I want to live, but will you also be at my disposal when I can bear no more?” The 1,000 cases of euthanasia without explicit consent are a powerful reason not to permit this practice, since we are talking about involuntary homicides.
6- Political reasons for saying no to Euthanasia
The debate on euthanasia lays bare which are the duties of the State, or political duties, and which are personal duties.
The protection of human life is a political duty that cannot be relegated to the particular or private morality of each one. Physical life is a universal good that cannot be threatened by any circumstance.
There exist two differentiated planes:
Juridical-political: it regulates the relations between men — for coexistence in peace, security, and freedom — and protects the common goods in which we all share and in which the physical life of each man is a necessary presupposition for the existence of other goods. It is not a duty of the State to make man good through civil laws, but it is a duty to protect all those who may find themselves deprived of the fundamental right to life, especially in the face of the vulnerability that illness entails.
Moral: it regulates individual acts. The presumed right to assisted suicide is a personal opinion or wish. One thing is the wish we all have to die well, and quite another to decriminalize the intentional act of suppressing a life: homicide.
The right to the protection of the physical life of each person and under any circumstance of illness or of old age is the foundation that protects us from the ethical criteria of others about our own existence, from the way in which others “see me,” and even from the particular morality of the one who does not discover the respect always due to the other, like the physician who practices euthanasia.
7- Some testimonies against decriminalization.
Pablo Salvador Coderch, Professor of Civil Law at the Pompeu Fabra University, writes in an Opinion article, Ministers of death, in La Vanguardia. Friday, February 27, 1998.
“There is nothing resembling a right to death, nor can anyone in his right mind claim that the State recognize for any of its citizens the faculty to demand before a tribunal that an official inject into him a lethal substance.”
“I do not agree (with the message sent by the communications media), a depressing and lethal one: one must help people to live, which is not always easy; in some isolated case, it will be necessary to let die, but killing is too simple a solution. It costs so little that it is within the reach of any incompetent.”
“The judges of the Federal Supreme Court (USA) refused to admit that there is also no need to distinguish between active euthanasia — killing — and passive euthanasia — letting die….. They are right: in life and in law the rule of principle is that it is not the same thing to do something as to abstain from it.”
Camilo José Cela. Nobel Prize in Literature (1989). The Evil Road. ABC.
“Throughout the world there spreads more and more the idea of the licitness of exterminating whatever may hinder the triumphal march of the victor, and that is dangerous. The retarded, for whatever reason, the fool, the weak, the sick, the old, the black, the pariah, and the loser also have a right to go on living, even if badly. If man is not capable of adjusting his life to justice — and he has been trying too long without succeeding — he will have no choice but to return to charity…….. The energy of the strong must be channeled toward the regeneration of the weak, which will always be possible if one seriously tries to do it.”
“What cannot be admitted is that the gifted should want to make soap out of the underprivileged; a piece of flesh with a human figure, however little it may reason, is still a man and, by the mere fact of being one, is worthy of absolute respect.”
Juan Alberto Belloch, former Minister of Justice (1993-1996), answers the question of the journalist Carla Fibla: What is it that personally makes you show yourself so reluctant regarding the decriminalization of euthanasia?…… “if practicing active and direct euthanasia is decriminalized, in certain cases the risk is that the physician ends up removing or supplanting the will of the patient”…… “One must consider the value of death, whether or not there is an element of pressure on the weakest.” “To fix one injustice we create a greater problem.”
8- International Provisions
The Parliamentary Assembly of the Council of Europe, in its recommendation 1418, approved on June 25, 1999, asked that the access of the terminally ill to palliative care be guaranteed, and it recalls that euthanasia, even voluntary, contravenes article 2 of the European Convention on Human Rights, which affirms that “death may not be intentionally inflicted on anyone.” The 41 deputies exhorted the Governments to maintain “the absolute prohibition of intentionally putting an end to the life of the incurably ill and of the dying.”
A greater knowledge of palliative care in the attention to the terminally ill has caused the support for euthanasia and assisted suicide among the Oncologists of the United States to diminish appreciably. At the end of 1999, the American Medical Association (AMA) decided to support in Congress a law that would prohibit cooperation in suicide throughout the country. Euthanasia has been permitted in Oregon since 1997 and has, on the other hand, been rejected by referendum in Maine.
9- Solutions for the Sick Person
The solution to the sufferings that illness entails must not consist in admitting the killing or the aid to the suicide of sick persons. Killing is never a solution, and even less suicide. The social and medical challenge lies in the development of an effective Palliative Medicine, which admits the suffering condition of the human being and which seeks the control of pain and the relief of suffering.
The true alternative to euthanasia and to therapeutic overzealousness is the humanization of death. To help the sick person to live the last period of life as well as possible. It is fundamental to express support, to improve the treatment and the care, and to maintain the commitment not to abandon him, both on the part of the physician and on the part of the caregivers, the relatives, and also the social environment.
Many cases of requests for euthanasia are due to a “medicine without a heart.” Euthanasia is based on desperation and reflects the attitude of “there is nothing more I can do for you.” One must help people to live, but it is not always easy; it will also be necessary to let die, but killing is too simple a solution. The response to the request for euthanasia is not legalization but rather a better education and health-care and social attention.
Palliative Medicine seeks to respond to any need of the sick when they find themselves in an advanced phase of the illness or in a terminal situation. The extension of the Palliative Care programs is very important in order to be able to better attend to these sick people. Precisely in Spain, the National Plan of Palliative Care that the Ministry of Health, the Insalud, and the representatives of all the autonomous communities are drawing up has as its principal objective to improve the quality of life of patients in a terminal situation.
The solution lies in practicing good medicine, that is, in giving integral care to the one who is soon going to die, treating both the physical sufferings and the psychological, social, and spiritual sufferings of the sick person.
One must be respectful of life and also of death. At the end of life, the treatments that, according to scientific knowledge, are not going to improve the state of the patient should be suspended; and only the painkillers, hydration, nutrition, and the necessary ordinary care should be maintained, until the natural end of life.
Authors:
Rafael Martínez Die. Notary.
Ana Sesé Roca. Journalist.
Xavier Sobrevía Vidal. Physician and priest.
Manuel Sureda González. Oncologist physician.
Isabel Viladomiu Olivé. Psychologist and master in Bioethics and Law.
Source: Encuentra.com
The opinions expressed in the works that are submitted are the exclusive responsibility of their authors.
Colegio de Bioética de Nuevo León, A.C
