Behind The Medical Headlines

Euthanasia today

• Dr L Campbell, PhD, University of Edinburgh, Scotland
• Rev K Boyd, Professor of Medical Ethics, University of Edinburgh, Scotland

Summary

Euthanasia is increasingly associated with doctor-assisted death and presents a major ethical and legal challenge. Should a doctor seek to prolong life at all costs or should a doctor assist to end suffering if requested by a patient? Would a system of doctor-assisted death put unacceptable pressure on doctors or make patients feel pressured into ending their lives prematurely? Dr Lorna Campbell and Rev Dr Ken Boyd provide an overview of this emotive ethical area.

Declaration of interests: No conflict of interests declared

‘To please no one will I prescribe a deadly drug, nor give advice which may cause his death.’ These words from the Hippocratic Oath (3rd to 6th centuries BC) date from a time when medical practice was not regulated and suicide might be approved if it was committed for ‘noble’ reasons. The physicians who originally took the Oath are now thought to have been a reforming minority, influenced by religious respect for life, but also anxious to dissociate themselves from those who misused pharmacological knowledge for nefarious purposes. Later, the Oath was adopted by physicians in the Jewish, Christian and Islamic traditions, all of which prohibited suicide because the time of death was for God to decide, and because suffering might be an opportunity for spiritual growth. But compassionate relief of suffering, by medical means where available, was also central to these traditions. In Judaism and Christianity today, drugs may be used to relieve terminal suffering, even if they incidentally hasten death, provided that the intention is to relieve and not to kill.

Against this, a more recent secular view of life and death argues that since modern medical means of prolonging life may also prolong dying, medical means of assisting death should not be denied to a competent terminally ill patient who sincerely wishes this. Many religious authorities agree that there is no duty to prolong life at all costs, and that when the burdens of treatment outweigh its benefits it may be withdrawn. But they remain opposed to active and intentional killing.

The word ‘euthanasia’, hitherto meaning a calm and peaceful death, was first used to advocate physician-assisted suicide in the late 19th century, when developments in pain relief meant not only that suffering could be managed much more effectively, but also that death could be accelerated by administering sufficiently large doses of chloroform. In Britain a voluntary euthanasia movement, around one quarter of whose original members were doctors, was founded in 1935. Before and after the second world war a number of attempts were made to legalise voluntary euthanasia for adult patients suffering from fatal, incurable illness characterised by severe pain. None of these were successful. The Nazi atrocities clearly had an impact on post-war debates on the subject, with concerns being expressed about the possibility of ending vulnerable patients’ lives without their express consent.

During the 1960s, the emergence of the hospice movement provided greatly improved pain relief and care for terminally ill patients, and this, it was argued, rendered calls for legalised euthanasia redundant. The British Medical Association, for example, now states that ‘whilst there are many cases where a doctor should accede to a request not to prolong the patient’s life, a doctor should not actively intervene to end that life’; and it goes on to ‘recognise the vital contribution the hospice movement has made’. Since under 5% of deaths occur in a hospice setting, the official medical view is to seek a transference of hospice practices to hospital wards and patients’ homes.

Euthanasia remains illegal in Britain. But both the Netherlands and Belgium have passed laws permitting doctors to help terminally ill patients to end their lives; and in a recent case the Dutch Supreme Court has ruled that the strict medical guidelines for this do not include simply being ‘tired of living’. Assisted suicide has been legal in Switzerland since 1942, provided that those helping dying patients can show that they are acting from altruistic motives. In the USA, only Oregon has legalised euthanasia, but other states are considering similar changes. The federal government in Australia has reversed a law permitting assisted suicide in the Northern Territories, but the Australian right-to-die lobby remains vocal and powerful.

In Britain, public opinion on legalising euthanasia has been swayed by a number of recent events. In 2002, the European Court of Human Rights rejected the request of Mrs Diane Pretty, a patient in the terminal stages of motor neurone disease, to grant her husband legal immunity if he were to help her to die. The Court ruled that the European Convention on Human Rights did not confer a right to die, and that English law against assisting suicide should be upheld. But in another case occurring at the same time, the English High Court ruled that Ms B, a patient like Mrs Pretty in her forties and paralysed, but unlike Mrs Pretty not terminally ill, should be granted her competent request to have artificial ventilation withdrawn, even though this meant that she would die. These legal rulings were criticised by both advocates and opponents of euthanasia. The advocates argued that the inconsistent outcomes depended on an indefensible distinction between acts and omissions while the opponents argued that since Ms B’s clear intention was to die, the judgement in her case undermined the law’s prohibition of suicide. Mrs Pretty’s case attracted much public sympathy, but this again was tempered by fears about vulnerable patients being killed without their consent. Harold Shipman, an English general practitioner, had recently taken the law into his own hands and murdered a large number of his elderly patients.

British public opinion was again swayed in both directions by two further cases. Sympathy was expressed for Mr Reginald Crew, another patient with motor neurone disease, who in 2003 travelled to Switzerland for assisted suicide. His wife who accompanied him was not subsequently prosecuted because the authorities saw ‘no public interest’ in doing so. But then concerns were expressed when Mr and Mrs Stokes, a couple in their fifties and neither terminally ill, were both assisted to die by the same Swiss organisation. Following Mr Crew’s case, but before that of the Stokes, a survey of 1000 British doctors found that over half agreed that terminally ill patients should be allowed to seek physician-assisted death, but only one third agreed that the law should be changed to facilitate this. These views may seem inconsistent. But that may be because these doctors fear that current arrangements fail patients like Mrs Pretty and Mr Crew, but also feared the alternative - as one doctor told the British Medical Association, ‘We shall start by putting patients away because they are in intolerable pain and have not long to live anyway; and we shall end up by putting them away because it’s Friday night and we want to get away for the weekend’. Euthanasia, in other words, may be a moral question to which no legislative answer, either way, will ever be ethically satisfactory.

References

1. Keown J. Euthanasia Examined. Ethical, Clinical and Legal Perspectives. Cambridge: Cambridge University Press 1995.
2. Boyd K M. Mrs Pretty and Ms B. Journal of Medical Ethics 2002; 28: 211-12.
3. British Medical Association (BMA) website: Ethics
4. BBC News online: who should have the right to die?, 15 April 2003