Euthanasia and the Ethics of a Doctor's Decisions

An Argument Against Assisted Dying

Ole Hartling

• Publisher: Bloomsbury Academic
• Year: 2021
• ISBN:
  9781350186248
• Edition: 1
• Topic: Philosophy
• Subtopic: Ethics & Moral Philosophy

Why do so many doctors have profound misgivings about the push to legalise euthanasia and assisted suicide? Ole Hartling uses his background as a physician, university professor and former chairman of the Danish Council of Ethics to introduce new elements into what can often be understood as an all too simple debate. Alive to the case that assisted dying can be driven by an unattainable yearning for control, Hartling concentrates on two fundamental questions: whether the answer to suffering is to remove the sufferer, and whether self-determination in dying and death is an illusion. He draws on his own experience as a medical doctor to personalize the ethical arguments, share patients' narratives and make references to medical literature. Here is a sceptical stance towards euthanasia, one that is respectful to those who hold different opinions and well-informed about the details and nuances of different euthanasia practices. Written from a Scandinavian perspective, where respect for autonomy and high quality palliative care go hand in hand, Hartling's is a nuanced, valuable contribution to the arguments that surround a question doctors have faced since the birth of medicine. He shows us how the intentions of doing something good can sometimes lead to even greater dilemmas, opening us up to those situations where an inclination to end suffering by ending life is deeply conflicting both for the clinician and for any fellow human being.

1

The obviousness of the question

While on an emergency call-out, I met a patient, Robert, who told me about his difficult but changeable situation. He also said he had written about it in a letter to some friends. From what the patient related, the letter might have sounded like this:

Dear Friends!

Thank you for your lovely Christmas missive. It’s good to hear you’re doing well over there. I had been meaning to reply for a very long time, but the only thing I managed to write was ‘Dear Friends’.

The days passed, however, and I could not find the energy to write. As you know, for a long time now I have been in pain, from virtually the whole of my body. It had been getting worse and worse. I realized it was my prostate cancer flaring up. At one point I was completely desperate and afraid, almost panicky and endlessly tired, because I couldn’t sleep either. Six weeks ago I was admitted as an emergency. I asked the doctor straight out whether they could put an end to my misery. I had spoken to the children; they could see no alternative either. I was willing to sign anything, anything at all, I said. I would take responsibility myself, of course. She said there was no question of that, giving me a ‘lethal injection’. I told her how illogical that was. After all, under any other circumstances I’m allowed to make up my own mind – for example, whether I want medication, a blood transfusion and so on; and at the time I could have refused the operation. I think I also said the medical profession let people down when it came to the crunch. She admitted that it might be illogical. ‘But we can’t. It’s not legal.’ She added that she and the other doctors would do whatever they could to help me.

Actually, they have all but eliminated my pain. You probably can’t quite imagine it, but it’s miraculous when I compare it with the way I was. I’m pleased my request was not granted. I am not well, I do know that. My situation is certainly not without its dangers, but I take one day at a time and no longer think about leaving the land of the living.

In a country with a law on active euthanasia, Robert would undoubtedly meet the criteria for being granted active euthanasia. In that country you might find the draft, among the papers left behind, of a letter headed merely: ‘Dear Friends, …’.

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Some school pupils emailed me:

Hello!

Our project assignment this week is about active/passive euthanasia, and we would like to know your opinion about active and passive euthanasia, for instance:

Which is ethically more correct: To let a person suffer and refuse to help them to die because you believe that suffering is part of life – or, conversely, to help that person eliminate the suffering and end their life in accordance with their wishes?

Why do you think passive euthanasia is legal and active euthanasia is illegal?

Do you think it’s OK not to grant a person their wish to die?

Animals are put down if they are suffering what we assume to be unbearable suffering – so how come humans don’t have the same right?

Do we remove patients’ self-determination by not giving them the right to choose their own death?

Why do you think most doctors and politicians are against euthanasia when the majority of the population are in favour? (State your reasons)

When the suffering becomes unbearable for a patient, is it not our duty to relieve that individual of their suffering?

Two other pupils were more succinct, asking, ‘Is it murder or mercy to perform active euthanasia?’ and adding, ‘We don’t need to hand this in until Friday, but please feel free to reply by Wednesday at the latest,’ showing me that the pupils have a straightforward and somewhat crude expectation that even complex ethical issues can be addressed and handled with rapidity.

I think the array of questions also shows that the pupils’ view on the face of it is that euthanasia must be the right thing: to allow patients, rightly, to be able to have their life ended if they are experiencing great suffering, if their condition is hopeless and if it is their own wish.

Many people are preoccupied with the subject, and that applies to young people too. I have often been contacted by school pupils of all levels and by trainee journalists, asking me questions about euthanasia when they are writing an assignment; or by journalists following up a case in the media and just wanting to ask me whether introducing euthanasia would not be the right thing to do.

In their assignment or article, they intend to describe the status quo and find out when a law on assisted dying might be passed, and why I think it hasn’t happened yet. The reasoning behind introducing such a law appears straightforward: Suffering must be relieved, and the patient’s own will must be respected, because the individual must be the most obvious person to determine whether life is worth living.

Some hasten to say that they themselves are supporters of a law on assisted dying; or they say they are certainly inclined to advocate it but would like to hear from anyone who opposes it first. I explain my opposition, but am often met with disbelief to start with: ‘So, do you think people should suffer? Should we not be allowed to control both our life and our death ourselves?’ I reply that I don’t advocate suffering, and I do advocate respect for the right of self-determination and free will. Saying that should be superfluous, since most people agree with both, as it is generally taken entirely for granted as the starting point for such a discussion. But I go on to say that such a law may spell misfortune for patients and doctors, and for the doctor–patient relationship; and maybe for our culture too. And after the conversation the questioners sometimes say the whole thing was probably not as simple as they first thought.

Something has then been achieved; their absolute certainty has been given a slight nudge, a little doubt has been sown. That’s why I always go out of my way to reply to school pupils and journalists. Yet at times it is like punching a feather pillow – a transient indentation is made, but the whole soft mass will re-form and level out again. Not long after, someone else follows, again articulating the thought that euthanasia has to be the humane answer to suffering. On the face of it, the thought appears to be so obvious as to seem to brook no contradiction.

But when something seems so right that no one even spots there might be any objection to it, there may be good reason to examine it more closely. And if you do that, you cannot help but discover that it is more complicated than meets the eye. In the euthanasia issue, you need to check the tenability of the assertion that making it legal to relieve people of their life will alleviate more suffering than it causes. Even if the field is carefully regulated, one of the first things to arise will be doubt as to whether it will ever be possible to draft a law so robust that it affords protection for the most vulnerable. As the general practitioner Iona Heath wrote in 2012:

Most of the discussion of and support for assisted dying revolves around exceptional individuals who are intelligent, articulate, and facing the prospect of suffering and who clearly understand their situation and predicament. Not infrequently, the debate about legalizing active euthanasia is conducted by people who are good at articulating their reluctance to end up in situations of unbearable suffering and helplessness. Yet legislation has to protect everyone including those who struggle to express or even fully understand what is happening to them.

Anyone who dismisses a dilemma or has failed to grasp it can settle a matter with the no-nonsense phrase: ‘Opinion cannot be split on that’, whereas someone else would say that that is precisely the case. The word dilemma originally means ‘two opinions’, and on this issue we are dealing with a genuine dilemma. The proviso is to want what is good – it is not a dilemma per se, because it is the starting point. In ethical matters the dilemma always consists of working out how to achieve the good.

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A word here on the terminology used in the current debate about end-of-life. I return to this issue and the use of euphemisms in Chapter 10. In his book Euthanasia (in the ‘All That Matters’ series from Hodder & Stoughton), Richard Huxtable, professor of Medical Ethics & Law at the University of Bristol, also grapples with terms and definitions (Huxtable 2013). He states that ‘euthanasia’ should be used for the intentional ending of a life of suffering. He mentions that a distinction might be drawn between ‘active’ and ‘passive’ euthanasia: ‘Giving a lethal injection would count as “active”, while some would say that denying (or removing) life-supporting treatment amounts to “passive” euthanasia.’

Euthanasia is divided into ‘voluntary’ (the person agrees to it), ‘involuntary’ (the person opposes the act) and ‘non-voluntary’, when the person lacks the ability to agree or object (a baby or a demented patient, say) – a matter of competence.

‘Assisted dying’ conveys a concept of voluntary euthanasia where the assistant is a medical doctor, whereas ‘mercy killing’ (or ‘compassionate killing’) suggests that the performer of the deed is any person, for example, a loved one.

‘Assisted suicide’ denotes that the final act is performed by the suffering individual being assisted by another person. If that person is a doctor, the term could be ‘physician-assisted suicide’.

It is regularly stated that physician-assisted suicide is ethically more acceptable than euthanasia in as much as the end-of-life medication is self-administered by the patient. Thus, it does not require the physician to actively kill the patient. The doctor prescribes the medication, but it is not his or her final responsibility that it is taken. It is like handing a loaded gun to a suicidal person – it is for this person to pull the trigger – a final expression of autonomy (compare the device constructed by the Australian general practitioner Philip Nitschke, p. 26). The contention is also that this somehow exonerates the doctor.

The Oregon Death with Dignity Act from 1997 that legalized physician-assisted suicide has been described as a more attractive and safer alternative to euthanasia, first and foremost because it gives the impression that the dying is a result of the patient’s own free will. It is, however, the physician who decides whether the patient’s request for assisted suicide can be granted, and as will appear in the following chapters the pressure on a suffering patient may still exist. Dutch jurisdiction from the first days when euthanasia was debated in the 1980s has looked upon euthanasia and assisted dying as two aspects of the same matter, or two sides of the same coin, and the Dutch Termination of life on request and assisted suicide Act (2002) regulates assisted suicide in the same way as euthanasia (Nys 2017). Likewise, the World Medical Association (WMA) deems both euthanasia and assisted suicide as unethical (cf. p. 116).

Oregon’s Death with Dignity Act only covers the time until the lethal medication is prescribed; thus, there are no measures to secure that the patient in fact takes the remedy consciously or voluntarily. This involves some risk (Hendin and Kamisar 2009). In the majority of cases there is no information about how much time has elapsed until the death took place. Reported complications (seizures, difficulties with ingestion, regurgitation, regaining consciousness) are few, as no data exists in 105 out of 168 cases (Oregon Public Health Division 2019). This means that the process of death cannot be evaluated; hence it is difficult to determine whether the death was dignified as the name of the law implies.

It is also increasingly realized that a self-administered oral drug can be ineffective in bringing about a rapid and easy death. Therefore, a change to the law has been proposed so that patients that request assisted suicide should be given the possibility of receiving a lethal injection (House Bill 2217 2017). This underscores that it may be difficu...