This post is from a contribution I made on the Richard Dawkins forum to a discussion about euthanasia. Because of the time and effort I took to write it, I’ve decided to add it to my own blog too.
Being an ex-Catholic I am well aware of the Catholic “theological” explanations against euthanasia. In practice however modern Catholic philosophers rely on other arguments against euthanasia which, although I am no longer a believer in the Catholic religion or God, I still find compelling in my personal humanist opposition to euthanasia.
For instance Luke Gormally (Euthanasia and Clinical Practice) and Jack Keown (Euthanasia and the Law) are both academics at the British lay Catholic bioethical think-tank “The Linacre Centre”, which made a comprehensive and influential presentation to the British House of Lords for an enquiry prompted by the case of David Bland, a young man left in a permanent vegetative state following the football stadium tragedy. Their work is almost entirely devoid of religious reference, but relies on secular public-policy reasoning against euthanasia.
It seems to be a topic that arouses tremendous passion among proponents as well as opponents, but at the level of public opinion polls and talk back radio the issue is reduced to extremely simplistic slogans, sound bites, part-truths and rhetoric. I am a doctor so the issue is extremely important to my work. And I think it deserves careful reflection and analysis. So read on if you are prepared to take some time and think about it in such public policy terms, and not only in personal emotional experience and anecdotes. You might see how, though atheist, I also can avidly hold a position opposed to euthanasia. Indeed, whenever thorough public consultation and comprehensive examination of the legislative consequences has been undertaken (for instance by the House of Lords, by the New York Task Force, by the Australian Federal Government) lawmakers have tended to see the matter too fraught with potential for abuse, and to change too fundamentally the role of doctors in society, to allow legislative process that enshrines euthanasia.
To begin an exposition of my own opposition, I would suggest that civilized society maintains laws and restricts liberties of citizens to facilitate social harmony and to protect the weak and vulnerable. I argue that allowing even voluntary euthanasia damages important social institutions, gives unprecedented powers to a group not adequately constrained in their exercise of it, as well as removes protection from people arguably at their weakest and most vulnerable.
We think it a feature of civilized society that we would rather bear the risk of 99 guilty criminals set free than a single innocent person jailed. We consider it more civilized when a society removes from its statutes the option of judicial killing, because it removes the risk of injustice that people might be executed when innocent, or executed even partially owing to prejudice among jurors, or executed out of pressure from populist politicians (each of these travesties has and still occurs in the USA, which in its maintenance of the death penalty is I believe less civilized than those societies that have abolished it).
In short, civilized society errs on the side of vulnerability, because we recognize how easy it is for individuals with power to err. Civilized society also errs on the side of realism – recognizing that human weakness, passion, and corruptibility have a history of undermining even the most idealistic institutions or most carefully framed laws.
I am a general practitioner and it is my privilege to be able to spend half my practice looking after the sick elderly in nursing and retirement homes, and severely disabled children and young adults in group care homes. So I probably have more opportunity to confront the type of scenario you describe than most people – with the exception perhaps of specialist palliative care doctors and nurses.
I also live in Australia – not a notably religious country (indeed singled out for condemnation by Pope Benedict recently for our secularism), and in our Northern Territory for a brief time in 1996-97 there was legislation allowing voluntary euthanasia in controlled circumstances. The legislation was essentially drafted by members of the Voluntary Euthanasia Society, so it was very careful in providing “checks” and “safeguards”. And I am well acquainted with the arguments for and against legalized voluntary euthanasia, on account of being involved in the major public debate that was had in this country prior to the Australian Federal Government overturning the laws.
Despite the casual way in which Richard Dawkins claims in “The God Delusion” that he would be prepared to have a doctor end his life, in reality not many people do look on having their life removed like having an appendix removed – not even atheists! Last year I was involved in caring for an elderly gentleman who moved into my practice area and who was a card-carrying member of the Voluntary Euthanasia Society. He showed me his living will and advance directive when we first met – pro forma documents from the society which he had completed and signed some years before his current illness, and we discussed this well before he entered the terminal phase. I told him I would offer every care and would undertake to try and control every distressing symptom as needed, and reassured him that I would not undertake resuscitation in the event of cardiac arrest.
However I informed him I would not administer a deliberately lethal dose of medication because I was not a vet but a medical doctor, and that it was my professional vocation to serve the living, and that my commitment to the advancement of the health and well-being of the community would be fatally undermined if I agreed to bring on the death of people in suffering and distress. He respected that and we grew very close over the coming months.
He was dying of respiratory failure secondary to cardiac disease, and over the course of several months he became progressively worse with constant dyspnoea (the sensation of not having enough air to breath) gradually restricting him from walking up the street, to walking in the home, to not leaving his chair, to having oxygen constantly. He had other symptoms as well – incontinence of faeces, anorexia and cachexia (the wasting of the fat and even muscles caused by metabolic overactivity). He also had pain from osteoarthritis, crush fractures from osteoporosis, and sores that developed at pressure areas. Definitely a classic “candidate” for euthanasia one might have thought. He wanted to stay at home and I visited him there most days. We had home nursing visiting daily also, and his wife was assisted with cleaning, cooking and the like by a community assistance package. Despite all these symptoms we managed without calling on the services of palliative care and he never once asked for it to end. He died peacefully in his sleep surrounded by his family.
In my experience, people ask me about euthanasia when they are frightened, when they are depressed, when they are lonely, but always long before they are dying. In every case it seems to me that it has been a request for reassurance, for comfort, for assistance; a request that I really will do my best for them.
Frequently quoted polls claim about 75% of the Australian population “supports” voluntary euthanasia, but these are clearly not the people who I see at the end of life. I’m sure it is the younger and generally healthy people who constitute the majority of that statistic – people who are not in the situation described but imagine they would want it, because from their current circumstance they can’t imagine being able to bear such suffering.
This seems to me the very biggest problem with any solution like euthanasia. People start to decide for other people what is an adequate level of suffering ought to be, or to decide when someone’s life no longer has adequate meaning. Almost imperceptibly people start to say things like: “She was really suffering, they [the doctors] should have done something to put her out of it”. This comment was made to me when I was a junior hospital doctor by an elderly gentleman about a friend who had recently died, in the context of a recent public debate about the Northern Territory euthanasia laws. He was shocked when I suggested to him that he was actually advocating involuntary euthanasia, since he had decided how much suffering that lady should endure!
But I am talking about voluntary euthanasia here, not “involuntary euthanasia” (which is simply paternalistic murder). Every model of legislation I have seen proposed invariably includes safeguards to prevent depressed and suicidal people using it to kill themselves: for instance restricting it to terminally ill, restricting it to those with a certain maximum prognosis, excluding children from accessing it. These safeguards appear quite reasonable to most ordinary people. The Australian legislation also required the diagnosis be confirmed by two doctors, that the patient be assessed by a psychiatrist and not suffering from depression; it also included a “cooling off period” between the decision and the carrying out of the euthanasia.
During the time that voluntary euthanasia was legal in the Northern Territory, only 7 people from around Australia sought to avail themselves of the opportunity to legally have their lives ended by a medical doctor – all as patients of Dr Phillip Nitschke, who was a longstanding advocate for euthanasia in Australia and who had been involved in unsuccessful attempts to have the legislation passed in several states. The Northern Territory has a population of about 300,000, out of Australia’s 20 millions. It has only a single house of legislative assembly and no upper house of review. The law was introduced as a private member’s bill and was not the result of widespread public consultation. Such a nationally important change to medical practice provoked nationwide debate, including a Senate Inquiry, and was eventually overturned by the power of the Federal Government after a conscience vote of all parties in the national parliament.
Dr Nitschke has remained Australia’s foremost euthanasia and assisted suicide advocate and is apparently consultant to the assisted suicide group EXIT. He publicly maintains there should be no restrictions on adults deciding to commit suicide and having assistance from doctors in doing so, whether they have terminal disease or not. True to this cause in 2002 he was involved in another attempt to bring about legal change in Australia, this time by having 21 members of EXIT “break the law” by being present and assisting at the suicide of another patient. In the publicity surrounding this lady’s very public act of suicide (with an online blog diary and regular newspaper updates over several months) Dr Nitschke and his supporters relied on the appeal to the public sympathy on account of her pain from terminal cancer. However it was discovered at post mortem that she was not suffering from a terminal illness at all, and that she had actually been cured of cancer. Dr Nitschke admitted this had actually been known some months prior to her suicide and that it was a “blunder” not to have let the public know the truth of this because, as he callously complained afterwards, it had “set the cause back decades”.
It appears to many that Dr Nitschke puts his commitment to the cause of voluntary euthanasia ahead of the professional duty as a doctor to care for his patient. He probably thought in this case that the needs of the many suffering who would be “helped” by new laws warranted him taking less care dealing with the real person who actually came and sat across from him in his clinic. I think it made him less of a good doctor.
Is this an argument for having even more safeguards? No. I argue that the very fact of having “safeguards” at all means someone else has to make a judgment about the person’s quality of life. What do I mean by this? A doctor has to decide or believe that the patient has no quality of life, or that their life is not worth living, before they will administer a lethal injection/dose of poison. Because doctors, of course, are not going to be compelled to perform euthanasia. And so only those doctors who agree with the patients about their lack of quality of life will kill those patients. Otherwise they will offer them treatment, symptom relief, psychological support, whatever. The lady mentioned above apparently had several doctors who offered her alternative treatments for her symptoms, who said they felt more could be done. But she felt her life was not worth living, regardless, and so evidently did Dr Nitschke. Is that a healthy attitude for a medical practitioner to hold?
If society wants to have euthanasia, it cannot have it administered by the healing profession. The requirement to decide on a patient’s quality of life necessarily changes the dynamic of doctors and their relationship with patients from one of consultant, healer and comforter, to judge and possibly executioner. For unless the doctor were “schizophrenic” in their ability to deal with different patients in different modes – either as a carer or a killer, depending on their stage of life or their particular pathologies – it seems to me that changed dynamic would inevitably carry over to their relationship with all patients.
This line of argument of course only applies to the undesirability of doctors performing euthanasia: that society can’t have both its cake (professional, high-quality, patient-oriented medical care) and eat it too (where the same doctors are also allowed and expected to be killers). But perhaps one can make a case for euthanasia administered by other “professionals” – perhaps vets (who are after all well acquainted with euthanasia for their “patients”).
It is interesting to ponder why people have their animals “put down”. It is not just “to put them out of their misery” as is commonly claimed. Some people pay thousands of dollars to have dogs or cats treated for years with medications, surgery, even organ transplants! Other people just have their animal with the same condition “put to sleep”. Some owners will spend tens of thousands nursing a champion horse back to health, others will have it shot by the vet. Presumably there was the same prospect of misery for the animal, but people’s perceptions of the worth of the animal is different, and that motivates their different choices. I believe the same is true of whether a doctor wants to try and alleviate, or simply put to sleep, a sick patient. And how is the doctor to decide on the worth of the patient’s life? Purely the patient’s own decision or arguments? Shouldn’t the doctor also look at the impact of the ill person on their family? Shouldn’t they bear in mind the impact of the cost of keeping on treating the person – to the family, or in countries like Australia the cost to the national health schemes and the community?
To summarize my arguments, then, it is that human nature is human nature. That doctors, patients, politicians are all motivated by many things and that not all of them are noble or honest. Realists recognize this and strive to frame the laws of our society in such a way that minimize the risk that vulnerable people will fall victim to the ignoble and the dishonest. They also frame laws in a way that limits how those granted power by our society can exercise that power (physical power – for instance police, the military, and of course doctors; judicial power; political power) to protect ordinary citizens from the abuse of those powers; to protect the vulnerable. A legislative framework for voluntary euthanasia administered by doctors would offer to doctors a power that society has seen fit to remove from judges and politicians – the power to end another person’s life. Such a framework would inevitably have to include “safeguards”, but these have the effect of giving the doctor further power, to decide on the worth of another person’s continued existence. These are extremely serious and potentially extremely dangerous powers, and doctors are no more morally incorruptible than judges, juries (though personally I hope we are more morally incorruptible than politicians!). The terrible example of doctors who have been prosecuted for war crimes attests to this tragic reality.
Society is about living harmoniously, not just individually. Therefore individual “rights” are legitimately curtailed and constrained by the implicit common consent of those who live in that society, when the members of that society agree that certain individual liberties could damage the liberties of others or render harm to the mutually beneficial operation of social structures. The cultural edifice of modern scientific medical practice is such a social structure that serves the common good. It is too important to too many members of our society to allow the individual “rights” of certain individuals who have made a particular individual and emotional decision about their life, to disrupt the fundamental dynamic of how all members of the society can expect to interact with that social good. A purported right to suicide or right to decide when to end my life is surely mine only, and does not extend to expecting or requiring someone else to assist that choice, and especially it does not extend to expecting the rest of society to change the orientation of the health professions to align with my very temporary personal situation of emotional need.
