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ss triple helix - spring 2005,  Euthanasia - arguments from autonomy

Euthanasia - arguments from autonomy

‘Respect for autonomy’ is an increasingly common argument for legalising euthanasia. But a law allowing even voluntary euthanasia would paradoxically undermine rather than support autonomy. Most requests for euthanasia represent a cry for help arising from desperation rather than a serious desire to be killed, but even ‘respecting’ deliberated requests would inevitably put in danger others who felt pressure, whether real or imagined, to seek early death. Doctors and other health professionals who had a conscientious objection to the practice would almost certainly be excluded from certain specialties. Furthermore experience in the Netherlands has demonstrated that when voluntary euthanasia is made legal, involuntary euthanasia inevitably follows.

There are concerns that the Mental Capacity Bill might let euthanasia in by the back door. [1] Intense interest also surrounds the Report of the House of Lord’s Select Committee considering Lord Joffe’s Assisted Dying for the Terminally Ill Bill, [2] which if ever enacted would allow ‘front door’ physician assisted suicide with lethal injection back-up for patients incapable of swallowing medication.

Three arguments for euthanasia

Now is the time for all Triple Helix readers to have at their fingertips the arguments for and against legalising euthanasia. There are essentially three arguments for:

  • We want it - the autonomy argument
  • We need it - the compassion argument
  • We can control it - the public policy argument

A previous Lords’ Select Committee reported on euthanasia in 1994, and unanimously recommended no change in the law. Its Chairman, neurologist Lord Walton of Detchant, later described in Parliament their fear that any such legislation would lead to ‘pressure, whether real or imagined, to request early death’. [3] The debate in the 1990s centred on the compassion case, but because of cultural changes and palliative care’s success, has moved to arguments based on autonomy.

The word means ‘self-determination’ and the language now is 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.

The theological case

The biblical case against euthanasia can be stated concisely. No Scripture can be found in favour and the sixth commandment [4] ‘You shall not murder’ applies. This prohibits the intentional killing of the legally innocent [5] but most practising doctors meet situations where they ask, however momentarily, ‘Why does God say that?’

Christians should generally support autonomy because it reflects the unique value of each human being made ‘in the image of God’. [6] However, autonomy is not absolute. Four arguments against the autonomy case for euthanasia follow, which are derived from respect for autonomy. There are brief reflections only on the compassion and public policy arguments. These secular answers go some way towards helping us understand the ‘No’ an infinitely wise and loving God has given us, and interestingly similar points have recently been made by a self-declared atheist! [7]

We want it

- the autonomy argument

1) Following patient autonomy to the hilt impacts others

Where a patient’s autonomy is followed so far that they receive a prescription for lethal medication or are dispatched by injection, the doctor’s autonomy is compromised. ‘So what? Lord Joffe’s Bill has a conscience clause. Objectors need not be involved.’ But the conscience clause in the 1967 Abortion Act has only worked partially, [8] and abortion has kept doctors away from obstetrics and gynaecology and from general practice.

While abortion can be avoided as a doctor and still leave considerable career choice, there is no branch of medicine where one can entirely avoid issues of death and dying. What effect might enactment of such legislation have on recruitment and retention of medical staff? Further, the abortion conscience clause has only had limited application to colleagues in some health disciplines and none at all to other members of the team. What impact therefore might euthanasia legislation have throughout the National Health Service on staffing, which is already critical? And as the award winning pro-euthanasia Spanish film Mar Adentro (The Sea Inside) makes so clear, the autonomy of family, friends and others close to the patient is inevitably affected, often with serious long term consequences.

2) Most requests mean something else

Those working with the dying know 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; or spiritual - wanting answers to‘Why me?’ and ‘Why now?’ Osler’s old adage counsels ‘No treatment without a diagnosis’. If doctors bother to make a real diagnosis and then treat that, requests for euthanasia usually go away. Therefore to prescribe euthanasia, even with the proposed safeguards, would far more often undermine autonomy than underline it.

3) But some requests are deliberated! Why can’t they have euthanasia?

Why with controls can’t there be a law to accommodate exceptional cases? The answer follows the previous one. For all the reasons hinted at there, and bearing in mind that prognosis is always uncertain, to change the law to allow euthanasia for this small minority within a minority would mean it was performed far more often when it was ‘wrong’ than when some would see it as ‘right’. To protect that majority, the minority forego a right they don’t actually have anyway.

This sounds utilitarian but that is how coexistence has to be in complex societies. For example, we all accept limitations on our road traffic ‘freedoms’ in order to protect vulnerable others, while John Donne’s famous words ‘no man is an island’ evoke the issues of community and relationships always present in the euthanasia debate. Respect for the right of autonomy has to be balanced with the responsibilities that recognise restrictions.

4) ‘Voluntary’ leads to involuntary

If we change the law to allow voluntary euthanasia for those who are suffering and have the capacity to ask for it, surely we should similarly provide euthanasia on compassion grounds for that patient who is suffering at least as much but has no capacity to request it? This logical slippery slope will follow if society ever gives doctors the power to decide that any patient’s life is not worth living.

The progression from voluntary to non-voluntary euthanasia (patient lacks capacity) or involuntary euthanasia (competent patient is not consulted) is well documented in the Netherlands. The Remmelink Report [9] 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 is not respect for patient autonomy but doctor paternalism of the very worst kind.

We need it

- the compassion argument

This stands or falls on the answer to the question: Do we have to kill the patient to kill the symptoms? Palliative care has answered ‘No’, though the harder symptoms to deal with (and those more likely to lead to requests for euthanasia) are not positive physical ones but negative ones of loss - the things patients can’t do any more. The challenge to healthcare now becomes restoring a sense of dignity and bringing meaning and hope in the face of suffering.

We can control it

– the public policy argument

As the Dutch statistics confirm, we cannot. We never could control it, when the key witness is dead.

Conclusion

Nobody has a ‘right’ to be killed by a doctor, Britain does not need euthanasia, and no society could ever control it. All three arguments are found wanting. Let us take action to prevent the acceptability, practice and legalisation of euthanasia. Let us get on with the task of working for that genuinely ‘gentle and easy death’ all our patients deserve.

References
  1. Treloar A. The Mental Capacity Bill - gateway to euthanasia? Triple Helix 2004; 29:6-7
  2. www.cmf.org.uk/index/_joffe_bill.htm
  3. Walton. Hansard. 1994; May 9:1345. Quoted in Maughan T. Euthanasia. CMF File 2003; 22
  4. Exodus 20:13, Deuteronomy 5:17
  5. Saunders P. Euthanasia. Nucleus 2000; 11-23 (April)
  6. Genesis 1:26-27
  7. Yuill K. Ten myths about assisted suicide - the flaws in the arguments for ending lives.
  8. Members’ Attitudes to Abortion - a survey of reported views and practice. CMF 1994
  9. Remmelink Report. A translated summary appeared in Lancet, 1991; 338:669-74
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