EUTHANASIA
Whether or not euthanasia and assisted suicide should be legalized is one of the most hotly debated legal and ethical issues. Most AIDS community groups have supported legalization, arguing that terminally ill persons have a right to choose to end their life at the time they themselves choose. Previous issues of the Newsletter have dealt extensively with arguments in favour of legalizing euthanasia and have printed some of the position statements adopted by Canadian AIDS-community groups. In the HIV/AIDS movement, arguments against legalization are seldom made. The following article offers a variety of such arguments, and will hopefully stimulate much-needed discussion, which we will reproduce in future issues of the Newsletter.[1]
Legalizing Euthanasia
Proponents of legalizing assisted suicide and euthanasia often defend their case by mixing two types of argument. One is based on social policy; the other is related to individuals – their liberty, dignity, pain and suffering.
Some of these arguments are, in my view, flawed, and are inadequate to justify the legalization of assisted suicide and euthanasia. Legalization could have grave consequences, especially for those who deserve support and protection because of their vulnerability. Although AIDS advocacy groups frequently argue in favour of euthanasia and assisted suicide, I am concerned that people living with HIV/AIDS could be seriously harmed by the legalization of mercy killing.
The "New Realism"
The social-policy argument reflects a form of "new realism" that has been invoked successfully in discussions of HIV/AIDS. Thus, Ogden argues in a previous issue of this Newsletter[2] that the euthanasia prohibition forces people to commit acts of euthanasia or assisted suicide in appalling "conditions akin to those of back-street abortions." It could be expressed this way:
• the prohibition forces people to commit "backstreet" acts of euthanasia;
• therefore, it should be abolished.
In other words, because euthanasia is actually practised, it should be legalized so that control can be exercised on the manner by which people are put to death.
This "realistic" approach is not new. It has been a key element in the campaign to control the spread of HIV/AIDS. Lifting many of the taboos on sexuality was necessary to inform people about how they could prevent transmission of the virus. Needle-exchange programs and the distribution of bleach are also clear acknowledgments of previously hidden practices. Against those who opposed bleach and needle distribution, it was argued that the advantages of preventing the spread of HIV/AIDS outweigh any objection to drug use.
Does this argument make sense in the context of euthanasia? As an ethical argument, it is not solid. It is a well-established ethical principle that the end does not justify the means. Although avoiding back-street acts of euthanasia is a valuable goal, it is dangerous to argue that euthanasia should therefore be legalized. Needle distribution can be justified, but not just because its goal is valuable. It is more justifiable than allowing euthanasia, because using drugs is not the same as killing a person or asking others for assistance in suicide. For example, the suffering and death of young girls during back-street surgical removals of the clitoris is not a reason to legalize the practice and allow physicians to perform it in "ideal circumstances." A practice can be unacceptable, independent of its goal. This can be due to the revolting character of the act, but can also be due to the social consequences of legalization.
Pain and Pain Relief
Is it true that the euthanasia prohibition is the cause of back-street killings? Euthanasia is necessary, it is claimed, because many patients are in agony and pain and are forced into life-prolonging treatments. But people are not forced to undergo treatment. It is perfectly legitimate in Canada to refuse treatment even if this clearly hastens death. It is also legitimate to refuse food and liquids. Euthanasia is not the only method of relieving pain; adequate relief is possible for most patients, including those in the terminal phase of illness. However terrible the idea of starving to death might be, those who choose to refuse food and liquids can be kept comfortable without major problems. For the approximately five percent of patients who do not respond to traditional pain-relief treatment, total sedation can be practised.
This does not mean that pain relief is always provided. Health-care professionals frequently do not provide adequate pain relief from an unfounded and often absurd fear of drug addiction. The solution is not to legalize euthanasia but to educate people, including health-care professionals, about treatment refusal and pain relief. This alone would solve many problems of suffering patients. The Special Senate Committee on Euthanasia and Assisted Suicide, which rejected legalization, recommended making palliative care a priority and improving pain-control training for all health-care professionals.[3]
Loss of Dignity
Proponents of euthanasia argue that the measures discussed above do not mitigate the loss of dignity that dying patients might experience. Why, they ask, should society have to impose a way of dying? Both arguments are based on the idea that legalizing euthanasia is a neutral policy that allows people to choose their way of dying. Consent, in this view, would be an adequate safeguard. As I argue elsewhere, though, legalizing euthanasia does more than offer a free choice.[4]
Words such as "dignity" and "dehumanization" are not neutral, objective terms. "Dignity" refers essentially to the way others perceive us. If we feel "undignified," it is because we are so in the eyes of others around us. What constitutes dignity is culturally determined. For example, dependence on others is considered "undignified" in a society that values independence and self-determination. However, we are all confronted with loss of autonomy. We are dependent as children, and count on others when we can no longer work and take care of our own. This need not be experienced as degrading – unless it is assumed that we lose our dignity when we are physically dependent or economically useless; the latter can be fostered by a legal system.
The Message Behind Legalization
Legalizing euthanasia sends a message: when physical and mental impairment undermine autonomy, dignity is indeed lost and life is no longer worth living. Societal approval of death as a solution to dependence and loss of autonomy might, in the long run, have a serious impact on the way people perceive themselves. Laws are not neutral statements of facts; they express specific values. They also re-establish, reinforce and slowly change values. Allowing physicians to ask patients if they want to terminate their life is not tantamount to offering a choice. It shows that the lives of patients have already lost value.
A Burden to Society?
Other arguments invoked to support the legalization of euthanasia reveal growing pressure on all those who have become dependent because of age or mental and physical disability. Financial cost, not to mention the emotional cost of seeing beloved ones "without dignity," are often mentioned in support of euthanasia. Cuts in the health-care system result in less support for the sick and their relatives. This increases social pressure, making it more and more difficult to accept the idea that disability and dependence do not deprive life of value. Again, the solution is not to encourage people to choose to be killed, but to increase their psychological, medical and financial support. People should not believe that they are a burden to those around them. On the contrary, they should believe that they are owed respect and support. One British study, reported in the British Medical Journal, should ring an alarm bell. It reveals that relatives (except spouses), friends, neighbours and health-care officials are keener on euthanasia than patients.[5] It was also concluded that, rather than being in pain, fear of being dependent and being a burden to relatives was most likely to be the reason for requesting euthanasia.
The "Value of Life"
Obviously, there are situations in which "the value of life" can seem trivial. If one is close to death, many would argue, one hour, one day or even one month does not matter if staying alive means enduring physical and mental decline, or involves a nearly vegetative existence that causes suffering to loved ones. There is no valid argument against this feeling, which depends on personal beliefs. Does it mean that in the name of liberty, we must give legal approval to killing or assisted suicide? Liberty is necessarily restricted by merely living in society. There will always be reasonable limits to the exercise of liberty.
Consequences of Legalization: The Slippery Slope
Before allowing individuals to request the assistance of others to kill themselves, we should consider the potential consequences. Slippery-slope arguments must be placed in this context. Legalizing euthanasia and assisted suicide could be the first step on that slope. I have mentioned the influence this might have on our perception of what constitutes a valuable life. We might all be forced to acknowledge that dependence and physical decline diminish human dignity.
As the New York State Task Force on Life and the Law suggested, "[o]nce assisted suicide and euthanasia are integrated into medical practice, the criteria now proposed as safeguards will prove elastic and unstable."[6] In its report on assisted suicide and euthanasia, it indicated that safeguards such as "consent," "terminal illness" and "unbearable pain or suffering" are likely to be challenged and gradually transgressed. For example, if the relief of suffering is an important aim, it seems unreasonable to limit it to those who are able to consent. "Once euthanasia becomes an accepted 'therapy,'" the New York Task Force warned, "the expansion to include those who are incapable of consenting would be a logical, if not inevitable progression."[7] Then, too, "unbearable pain and suffering" are inherently subjective terms and are unlikely to remain limited to physical suffering. Finally, what does "terminal illness" mean? How certain are medical diagnoses? Many people survive their diagnosis by many months or years.
The difficulty in keeping euthanasia within limits, once it is accepted as an exceptional procedure, is already clear in the Netherlands. There, physicians are not prosecuted for euthanasia or assisted suicide where guidelines are respected. They can perform euthanasia on explicit request if patients are forced to endure unbearable physical and/or mental suffering without any prospect of improvement. But studies indicate that between 0.8 and 1.6 percent of all deaths in the Netherlands involve cases of termination of life without patients' consent.[8] The New York Task Force calculated that, if the same were to occur in the US, this would amount to 16,000 cases of involuntary euthanasia a year. Moreover, the Dutch Supreme Court held in the 1994 Chabot case that euthanasia or assisted suicide are available options for people suffering from depression. Chabot, a psychiatrist, gave a depressed woman, who was not his patient, lethal medication after having seen her over a period of one month. The Supreme Court judged that he should have asked the opinion of a second physician but accepted the idea that euthanasia or assisted suicide may be performed on patients who are "suffering unbearably" from depression. The Dutch policy, so often praised as a model, shows that the danger of a slippery slope is real.
Conclusion
Is everything then going smoothly under the Canadian system? Clearly not. "Back-street killings" are a concern. The suffering of patients is not helped by locking up the physicians and relatives who assist them in dying. Laws cannot predict all possible situations, but they should not treat all killings alike. It should be possible to be more lenient toward those who act in despair or out of mercy.[9] But this does not mean that we should give legal approval to killing. When we refuse to collaborate in suicide, we must, though, reassure people that they are not a burden to us and that we will relieve their suffering. It implies appropriate pain relief, palliative care, and adequate support of relatives and friends. This should not be forgotten when decisions about the future of health care are made.
- Trudo Lemmens
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ENDNOTES
[1] See the articles by R Ogden in issues 1 and 2, the British Columbia Persons with AIDS Society Position Statement on Euthanasia in issue 1, and the Position Statement on Assisted Suicide of the AIDS Committee of Toronto in issue 4.
[2] R Ogden. The Uncloseting of AIDS-Related Euthanasia. Canadian HIV/AIDS Policy & Law Newsletter, vol 1, no 1 (October 1994) at 14-15.
[3] Of Life and Death: Report of the Special Committee on Euthanasia and Assisted Suicide. Senate of Canada, 1995.
[4] T Lemmens. Euthanasia and the Good Life. Perspectives in Biology and Medicine 1995 (forthcoming).
[5] L Dillner. Relatives Keener on Euthanasia than Patients. British Medical Journal 1994; 309(29 October):1107.
[6] The New York State Task Force on Life and the Law. When Death is Sought: Assisted Suicide and Euthanasia in the Medical Context. New York: The Task Force, 1994, at 132.
[7] Ibid. at 133.
[8] Ibid. at 134.
[9] See Of Life and Death, Report of the Special Committee on Euthanasia and Assisted Suicide, supra note 3.