- Toby Levy
Do Medical Ethics Support Euthanasia?
Euthanasia is the deliberate ending of someone’s life with the intention to end suffering. The word euthanasia itself stems from the Greek for ‘good death’. Euthanasia is a complex issue, and can be passive, where treatments are withheld or doses of painkilling drugs raised (with the intention of easing pain even if life is shortened), or more controversially be active, where a doctor gives a patient a lethal dose of a drug that ends their life. This differs from physician-assisted suicide where a doctor helps a patient to commit suicide by prescribing them a drug but doesn’t actually administer it. Palliative care is a common form of end-of-life care where a dying patient is given treatment to relieve their suffering and allow them a comfortable death. This is separate from passive euthanasia, as the patient is already dying and their life is not shortened as a result. Euthanasia itself can be voluntary or non-voluntary depending on whether the patient has the capacity to make the decision or not. In cases of non-voluntary euthanasia, a close family member may make the decision, or a doctor may decide that passive euthanasia is the best course of action. Active euthanasia is currently legal in 7 countries, with the Netherlands and Belgium being the first to legalise it in 2002, and Spain and New Zealand joining the list only this year. The legality of passive euthanasia is more complicated and less straightforward. For example, in the US, passive euthanasia is legal in all states as it is considered to be letting someone die rather than a form of killing. In the UK, although both active and passive euthanasia is illegal, doctors can remove life support without legal repercussions. In this essay, I will be considering both active and passive euthanasia, in both voluntary and non-voluntary scenarios.
Medical ethics are a set of values for doctors to consider when making decisions in relation to the care of a patient. The 4 pillars of medical ethics are non-maleficence, autonomy, beneficence, and justice. In short these refer to: the duty to do no harm, respect for the patient’s right to self-determination, the duty to do good, and treating patients with equality and fairness, respectively. Medical ethics have their root in the Hippocratic Oath, the first set of guidelines for doctors, written in the 5th century BCE, which notoriously instructs doctors to ‘do no harm’. In this essay, I will consider euthanasia in relation to each pillar of medical ethics and also briefly relate to other theories outside of medical ethics such as deontology and consequentialism.
A simplistic conclusion to the question ‘Does euthanasia contravene the principle of non-maleficence?’, would be to say that yes, euthanasia involves deliberately causing the death of a patient and therefore is not an appropriate action from a doctor in any situation. The Hippocratic Oath states: ‘neither will I administer a poison to anybody when asked to do so’, which seems to outlaw both voluntary and non-voluntary active euthanasia as they involve administering drugs to patients in high enough doses to kill them, which renders them as essentially poison. However, this argument relies on an outdated code of ethics that doesn’t represent our modern world, and the assumption that euthanasia causes harm to the patient. It is therefore necessary to ask ourselves what we mean by harm. When someone is harmed, we would expect that they are experiencing either emotional or physical pain. The most commonly used drugs for euthanasia are barbiturates, which slow down the activity of the brain and nervous system, eventually leading to death. This class of drugs can be used as anaesthesia in smaller doses. These drugs are safe and effective in causing a painless and swift death.8 Therefore, one could argue that euthanasia does not harm the patient.
On the other hand, death could also be considered a form of harm in itself and therefore, causing death in any way would be against the principle of non-maleficence. Religious views such as the Sanctity of Life would deem euthanasia as unethical, and this may affect some doctors’ willingness to partake in euthanasia, but this isn’t really valid in the wider context of medical ethics. Furthermore, many branches of deontological ethics would argue that killing is immoral no matter the outcome and therefore euthanasia is immoral. The problem with this is that these inflexible rules do not distinguish between murder and relieving someone’s suffering. Consequentialist philosophy could be used to argue that if the outcome of euthanasia is removing suffering from a patient, then it is morally right. We tend to see death in a very negative way but it is, after all, a natural process. Perhaps if society viewed death with less fear and more acceptance, then the idea of euthanasia wouldn’t seem as extreme. It is also a question of the role of the doctor. Are doctors supposed to simply prevent patients from dying, or to provide them with the best possible quality of life? If the former, then euthanasia is not supported by non-maleficence, however, I believe the latter is the ideal answer and, combined with other evidence already mentioned, suggests that euthanasia and non-maleficence can be compatible.
Although no pillar of medical ethics is necessarily more important than the other, autonomy often plays a leading role since patients have the right to decide whether or not to receive treatment. Should this right also extend to dying? Consent is vital in medicine, and doctors shouldn’t act without consent if the patient is able to give it. However, this doesn’t mean that doctors just do what patients tell them. For example, when prescribing drugs, patients can’t just ask for them; the doctor needs to determine whether they will benefit or harm the patient. Therefore, if we determine that euthanasia will not harm the patient then we can say that euthanasia is supported by medical ethics when it will reduce the suffering of the patient and the patient is capable of making a rational, informed decision. The latter could be judged by a panel of doctors to ensure that a fair decision is reached. It would be important for doctors to understand the reasons for patients wanting to undergo euthanasia and present the patients with all their options.
There are several reasons why a patient may want to die and it is important to consider how a doctor might respond in these cases. A patient could be suffering from depression and could feel like their life is worthless and that they would be better off dead. If euthanasia were legal, it would be important for doctors to examine patients for depression as they may not be capable of making a rational decision about ending their life. In this situation, the patient could be referred to a psychiatrist, and if a diagnosis of depression is reached, then it should be recommended for the patient to undergo treatment for this. Doctors would have to respect patients’ rights to refuse treatment, but it would be reasonable for a doctor to refuse to carry out euthanasia if they thought that the patient didn’t have the capacity to make the decision.
Another situation could be an elderly patient who, although they are healthy in the time being, fear the onset of senility and possible dementia. They want to die with dignity before they have wasted away. This is a difficult situation because even if euthanasia isn’t harming the patient, it may not be benefiting them either. Autonomy would support euthanasia in this situation as the patient has made a clear decision to reduce their potential suffering. Furthermore, one could argue that since euthanasia doesn’t cause harm to others, people should have the right to choose to die whether it will benefit themselves or not as they have responsibility for their own life. This would be a difficult case for doctors as their duty here is unclear; respect the wishes of the patient, or protect them from possible harm? Overall, I believe that autonomy supports euthanasia when a patient has suitable mental capacity to decide to die.
A common scenario regarding euthanasia is the terminally ill patient that is in pain and has no hope of recovery. Their quality of life may be extremely low, and they may prefer to die. In this situation it seems that euthanasia would benefit the patient and therefore medical ethics would support it. What if there was a revolutionary treatment that had a 1% chance of completely curing the patient but the other 99% of the time would cause an extremely painful death? Although the most beneficial outcome for a patient would be to receive the treatment and be cured, the action most likely to benefit the patient would still be euthanasia. Non-maleficence is relevant here too since administering the treatment would likely cause harm. What if the odds were reversed? In this situation it may be wise to administer the treatment and hope for the best, but if the patient doesn’t want to take the risk, both beneficence and autonomy would support euthanasia because the patient has made a clear choice in order to relieve their suffering and avoid harm. This situation assumes that the patient can decide, but what if the patient is in a persistent vegetative state? They are alive and appear to be awake but are completely unaware of their surroundings and incapable of communication. Their quality of life is severely reduced and therefore euthanasia is justified. However, they may not be actively suffering. In this case, a better argument, although slightly cynical, would be that they are taking bed space from other patients who could be treated and their quality of life improved. Therefore, if a doctor wants to ensure the best care for and the beneficence of all patients, euthanasia is a justified course of action. Having said that, some would say that this all creates a ‘slippery slope’ where the legalisation of euthanasia in extreme cases eventually leads to euthanasia being used in cases where it is not necessary and may actually be harmful. This would contradict the pillar of beneficence, but it is a hypothetical situation which could be prevented by suitable restrictions and guidelines regarding the use of euthanasia.
An altogether different situation where beneficence would support a doctor using euthanasia, is when an able patient with a terminal illness wishes to die and has stated to the doctor that they are going to commit suicide. In order to prevent the patient from harming themselves using traditional suicide methods such as hanging, poisoning themselves, or jumping from a building, a doctor could end their life painlessly. These suicides methods can not only cause harm, but can also fail and leave the patient seriously injured. In this situation, the risks of refusing to administer euthanasia are greater than any risks of administering it and therefore beneficence would firmly support euthanasia.
One of the most important considerations for doctors is to act within the law. If doctors were to illicitly use euthanasia, then it could diminish the public’s confidence in the profession. Furthermore, it would be not be practical for a doctor in the UK to break the law and commit active euthanasia, whether it would benefit the patient or not, as they could face legal action and be struck off the GMC register. For the purpose of this section of the essay, let’s assume that laws don’t dictate what doctors can and can’t do and instead they act purely on the grounds of medical ethics. Justice, as a pillar of medical ethics, wants to ensure that all patients are treated equally and fairly. This can be applied to a scenario where a disabled patient wishes to commit suicide but is unable to do it for themselves. If euthanasia is not an option, then this creates an injustice where physically able patients can choose death but disabled patients cannot. If a doctor were to act in the interest of fairness for all patients, then they would have to respect the patient’s wishes and end their life. It could be seen as discrimination if the doctor refuses. In the Netherlands, the concept of tolerance was the leading argument in favour of euthanasia; why not just accept that other people have different views on death? Still, there is the issue of why the patient wishes to die, and it still important to determine whether the patient has the mental capacity to make a rational decision.
When we consider the legal status of euthanasia, we can see that more countries allow passive euthanasia than active euthanasia. Why should this be the case when both actions have the same outcome? Is there really such a difference between withdrawing life-saving treatment and administering life-ending drugs? In terms of medical ethics, I would argue that there is no real difference. The consequences and intentions of the action are identical. Perhaps passive euthanasia is seen as a more moderate and respectable alternative because doctors aren’t directly killing patients with their own hands, but this doesn’t explain why it is any more moral. A distinction could be that active euthanasia allows people that aren’t already suffering and near the end of their life to die, and therefore it is dangerous, but why should we treat them differently from patients that are already dying? Both autonomy and justice would argue that active euthanasia should be available for all, but non-maleficence and beneficence would limit it to only the suffering and dying.
I believe that medical ethics strongly support voluntary euthanasia in cases where the patient is suffering. This is due to a combination of the patient’s right to choose how they are going to die, and the doctor’s duty to relieve the suffering of the patient. I also believe that medical ethics support euthanasia in cases where a patient is in a persistent vegetative state and cannot make the decision themselves. However, I believe that when a patient is not actively suffering then euthanasia is not supported by medical ethics unless they are disabled and unable to commit suicide for themselves. It would therefore be appropriate for doctors to carry out euthanasia in the approved situations if euthanasia were to be legalised. Having said that, as this is such a controversial issue, it wouldn’t be as simple as that. Firstly, any law changes would require considerable support from the public and even greater support from doctors themselves. A survey carried out by the Royal College of Physicians in 2014 showed that only 37.5% of doctors supported a change in the law, up from 26.8% in 2006. Although this is a fairly significant increase, it shows that on the whole doctors are not in favour of euthanasia being legalised. However, it is worth noting that the surveys were only taken by a small portion of doctors and by different sets of doctors. Nevertheless, it would be unwise to legalise euthanasia if only 37.5% of doctors supported this move and only 21.4% said they would definitely be prepared to participate in euthanasia. Furthermore, this essay focused on a restricted view of medical ethics whereas other ethical theories and concerns about abuse of the system or a slippery slope might change the verdict.
Another consideration for doctors outside of the 4 pillars of medical ethics is the perception of the medical profession. Doctors may not want to be seen as executioners as this could harm patients’ trust in them. While not directly linked to euthanasia, there is a similar situation in the United States in regard to the participation of doctors in executions by lethal injection. The American Medical Association has a clear stance against doctors participating in executions, yet a survey in 2000 showed that only 20% of American doctors objected to the involvement of doctors in executions. The reasons for this are similar to the failed suicide argument. If a doctor is present, then the execution is less likely to be botched and harm the patient. It is also similar to a terminally ill patient whereby the patient is going to die but it is up to the doctor to ensure the best possible death. The only difference between them is that one patient is dying for a medical reason and another for a legal reason. It is understandable for doctors to feel uncomfortable taking the life of a patient as they are supposed to be the mystical healers that can cure everything, but as more countries legalise euthanasia, perhaps we will have to learn to accept that taking a life in a painless, merciful manner is part of their duty.