Euthanasia Controversy Essay

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Euthanasia


Mark T. Maxwell

Abstract

This paper will define Euthanasia and assisted suicide. Euthanasia is often
confused with and associated with assisted suicide, definitions of the two are
required. Two perspectives shall be presented in this paper. The first
perspective will favor euthanasia or the "right to die," the second perspective
will favor antieuthanasia, or the "right to live". Each perspective shall
endeavor to clarify the legal, moral and ethical ramifications or aspects of
euthanasia.

Thesis Statement

Euthanasia, also mercy killing, is the practice of ending a life so as to
release an individual from an incurable disease or intolerable suffering.
Euthanasia is a merciful means to and end of long-term suffering. Euthanasia is
a relatively new dilemma for the United States and has gained a bad reputation
from negative media hype surrounding assisted suicides. Euthanasia has a
purpose and should be evaluated as humanely filling a void created by our
sometimes inhumane modern society.

Antithesis Statement

Euthanasia is nothing less than cold-blooded killing. Euthanasia cheapens life,
even more so than the very divisive issue of abortion. Euthanasia is morally
and ethically wrong and should be banned in these United States. Modern
medicine has evolved by leaps and bounds recently, euthanasia resets these
medical advances back by years and reduces today's Medical Doctors to
administrators of death.

Euthanasia defined

The term Euthanasia is used generally to refer to an easy or painless
death. Voluntary euthanasia involves a request by the dying patient or that
person's legal representative. Passive or negative euthanasia involves not
doing something to prevent death—that is, allowing someone to die; active or
positive euthanasia involves taking deliberate action to cause a death.
Euthanasia is often mistaken or associated with for assisted suicide, a
distant cousin of euthanasia, in which a person wishes to commit suicide but
feels unable to perform the act alone because of a physical disability or lack
of knowledge about the most effective means. An individual who assists a
suicide victim in accomplishing that goal may or may not be held responsible for
the death, depending on local laws. There is a distinct difference between
euthanasia and assisted suicide. This paper targets euthanasia; pros and cons,
not assisted suicide.

Thesis Argument That Euthanasia Should Be Accepted

Without doubt, modern dying has become fearsome. Doctors now possess
the technologies and the skills to forestall natural death almost indefinitely.
All too often, the terminally ill suffer needless pain and are kept alive
without real hope, as families hold a harrowing deathwatch.
In ancient Greece and Rome it was permissible in some situations to help
others die. For example, the Greek writer Plutarch mentioned that in Sparta,
infanticide was practiced on children who lacked "health and vigor." Both
Socrates and Plato sanctioned forms of euthanasia in certain cases. Voluntary
euthanasia for the elderly was an approved custom in several ancient societies .
Euthanasia has been accepted both legally and morally in various forms
in many societies . "There is no more profoundly personal decision, nor one
which is closer to the heart of personal liberty, than the choice which a
terminally ill person makes to end his or her suffering ...," U.S. District
Judge Barbara Rothstein wrote (R-1). Organizations supporting the legalization
of voluntary euthanasia were established in Great Britain in 1935 and in the
United States in 1938. They have gained some public support, but so far they
have been unable to achieve their goal in either nation. In the last few
decades, Western laws against passive and voluntary euthanasia have slowly been
eased (1).
The proeuthanasia, or "right to die," movement has received considerable
encouragement by the passage of laws in 40 states by 1990, which allow legally
competent individuals to make "living wills." These wills empower and instruct
doctors to withhold life-support systems if the individuals become terminally
ill .
Euthanasia continues to occur in all societies, including those in which
it is held to be immoral and illegal. A medically assisted end to a meaningless
and worthless "void" of an existence is both accepted and condoned by the
medical profession. In a Colorado survey, 60% of physicians stated that they
have cared for patients for whom they believe active euthanasia would be
justifiable, and 59% expressed a willingness to use lethal drugs in such cases
if legal. In a study of 676 San Francisco physicians, 70% believed that
patients with an incurable terminal illness should have the option of active
euthanasia, and 45% would carry out such a request, if legal (35% were opposed).
Nearly 90% of physicians in another study agreed that "sometimes it is
appropriate to give pain medication to relieve suffering, even if it may hasten
a patient's death."(R-2)

Antithesis Argument That Euthanasia Is Unacceptable

With the rise of organized religion, euthanasia became morally and
ethically abhorrent. Christianity, Judaism, and Islam all hold human life
sacred and condemn euthanasia in any form . The American Medical Association
continues to condemn assisted suicide .
Western laws have generally considered the act of helping someone to die
a form of homicide subject to legal sanctions. Even a passive withholding of
help to prevent death has frequently been severely punished .
And the Roman Catholic Church's newly released catechism says:
``Intentional euthanasia, whatever its forms or motives, is murder.'' (R-1).
The Board of Trustees of the American Medical Association recommends
that the American Medical Association reject euthanasia and physician-assisted
suicide as being incompatible with the nature and purposes of the healing arts
(R-2).

"When does the right to die become the obligation to die?" asks the Rev. Richard
McCormick, professor of Christian ethics at Notre Dame University who spoke
recently against assisted suicide at Fort Lauderdale's Holy Cross Hospital.
"Imagine an 85-year-old grandmother" with the option of ordering a suicide dose
from a doctor: ""Do they want me to ask for it now?' Physician-assisted suicide
saves money. ... This is a flight from the challenge of social compassion." (R-
1).

The issue of euthanasia is not a recent one. The Oath of Hippocrates is
said to have originated in approximately the fifth century B.C. and, even then,
it incorporated a specific pledge against physician-assisted suicide when it
said, "I will give no deadly medicine to anyone, even if asked."
What of the innocent bystanders? The family, friends or even foes of
someone that elects to exercise their "right to die"? It is suggested that a
person suffering from an incurable or terminal illness is not complete command
of their mental faculties and thereby incapable of such an extraordinary
decision. Surely a degraded mental capacity rules out realistic thinking with
regard to survivors. How many "innocent bystanders" also pay the price of
euthanasia?

Synthesis For Euthanasia
Euthanasia occurs in all societies, including those in which it is held
to be immoral and illegal . Euthanasia occurs under the guise of secrecy in
societies that secrecy is mandatory. The first priority for the care of
patients facing severe pain as a result of a terminal illness or chronic
condition should be the relief of their pain. Relieving the patient's
psychosocial and other suffering is as important as relieving the patient's pain.

Western laws against passive and voluntary euthanasia have slowly been
eased, although serious moral and legal questions still exist . Some opponents
of euthanasia have feared that the increasing success that doctors have had in
transplanting human organs might lead to abuse of the practice of euthanasia. It
is now generally understood, however, that physicians will not violate the
rights of the dying donor in order to help preserve the life of the organ
recipient .
Even though polls indicate most Americans support the right of sick
people to end their pain through self-inflicted death, euthanasia is one of the
more contentious aspects of the death-with-dignity movement .

"This is really one of the most fundamental abilities that a human being has to
decide if he or she wants to die," says Meyer, who practiced radiology for 40
years (R-1).

Slightly more than half of the physicians surveyed in Washington State
would approve the legalization of physician-assisted suicide and euthanasia
under certain circumstances. A total of 938 physicians completed questionnaires
about their attitudes toward euthanasia and assisted suicide. Physician-
assisted suicide was described as prescribing medication and providing
counseling to patients on overdosing to end their own lives. Euthanasia was
defined as administering an overdose of medication at an ill patient's request.
Forty-two percent of physicians indicated that they found euthanasia ethically
acceptable under some circumstances. Fifty-four percent indicated that they
believed euthanasia should be legal under certain circumstances .
Today, patients are entitled to opt for passive euthanasia; that is, to
make free and informed choices to refuse life support. The controversy over
active euthanasia, however, is likely to remain intense because of opposition
from religious groups and many members of the medical profession .
The medical profession has generally been caught in the middle of the
social controversies that rage over euthanasia. Government and religious groups
as well as the medical profession itself agree that doctors are not required to
use "extraordinary means" to prolong the life of the terminally ill .

The Second Chamber of the Dutch Parliment developed and approved the
following substantive and procedural guidelines, or "points" for Dutch
physicians to consider when practicing or administering Euthanasia:

Substantive Guidelines
(a) Euthanasia must be voluntary; the patient's request must be
seriously considered and enduring.
(b) The patient must have adequate information about his or her medical
condition, the prognosis, and alternative methods of treatment
(though it is not required that the patient be terminally ill).
(c) The patient's suffering must be intolerable, in the patient's view,
and must also be irreversible.
(d) There must be no reasonable alternatives for relieving the patient's
suffering that are acceptable to the patient.

Procedural Guidelines
(e) Euthanasia may be performed only by a physician (though a nurse
may assist the physician).
(f) The physician must consult with a second physician whose judgment
can be expected to be independent.
(g) The physician must exercise due care in reviewing and verifying the
patient's condition as well as in performing the euthanasia
procedure itself.
(h) The relatives must be informed unless the patient does not wish
this.
(i) There should be a written record of the case.
(j) The case may not be reported as a natural death. (R-2).

Having choices, including having the legal right for help to die is
what's important in preserving the basic democratic fabric of the United States
of America. The issue of euthanasia is, by it's very nature, a very difficult
and private choice. Euthanasia should remain exactly that; a choice; a choice
that ought not be legislated or restricted by opposing forces or opinions.

(R-1) Assisted suicide: Helping terminally ill, or "quick fix" for
intolerant society? (Originated from Knight-Ridder Newspapers)
by Patty Shillington Knight-Ridder/Tribune News Service June
15 '94 p0615

(R-2) Report of the Board of Trustees of the American Medical
Association. (Transcript) v10 Issues in Law & Medicine Summer
'94 p81-90

(R-3) "Euthanasia," Microsoft (R) Encarta. Copyright (c) 1994
Microsoft Corporation. Copyright (c) 1994 Funk & Wagnall's
Corporation.

(R-4) Report of the Council on Ethical and Judicial Affairs of the
American Medical Association. (Transcript) v10 Issues in Law &
Medicine Summer '94 p91-97

(R-5) The New England Journal of Medicine July 14 '94 p89(6)

(R-6) Death on trial: the case of Dr. Kevorkian obscures critical
issues - and dangers. (Jack Kevorkian) (Cover Story) by Joseph P.
Shapiro il v116 U.S. News & World Report April 25 '94 p31

(R-7) Euthanasia and Medical Decisions Concerning the Ending of Life.
by P.J. van der Maas and J.J.M. Delden


 

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The word euthanasia, originated in Greece means a good death1. Euthanasia encompasses various dimensions, from active (introducing something to cause death) to passive (withholding treatment or supportive measures); voluntary (consent) to involuntary (consent from guardian) and physician assisted (where physician's prescribe the medicine and patient or the third party administers the medication to cause death)2,3. Request for premature ending of life has contributed to the debate about the role of such practices in contemporary health care. This debate cuts across complex and dynamic aspects such as, legal, ethical, human rights, health, religious, economic, spiritual, social and cultural aspects of the civilised society. Here we argue this complex issue from both the supporters and opponents’ perspectives, and also attempts to present the plight of the sufferers and their caregivers. The objective is to discuss the subject of euthanasia from the medical and human rights perspective given the background of the recent Supreme Court judgement3 in this context.

In India abetment of suicide and attempt to suicide are both criminal offences. In 1994, constitutional validity of Indian Penal Code Section (IPC Sec) 309 was challenged in the Supreme Court4. The Supreme Court declared that IPC Sec 309 is unconstitutional, under Article 21 (Right to Life) of the constitution in a landmark judgement4. In 1996, an interesting case of abetment of commission of suicide (IPC Sec 306) came to Supreme Court5. The accused were convicted in the trial court and later the conviction was upheld by the High Court. They appealed to the Supreme Court and contended that ‘right to die’ be included in Article 21 of the Constitution and any person abetting the commission of suicide by anyone is merely assisting in the enforcement of the fundamental right under Article 21; hence their punishment is violation of Article 21. This made the Supreme Court to rethink and to reconsider the decision of right to die. Immediately the matter was referred to a Constitution Bench of the Indian Supreme Court. The Court held that the right to life under Article 21 of the Constitution does not include the right to die5.

Regarding suicide, the Supreme Court reconsidered its decision on suicide. Abetment of suicide (IPC Sec 306) and attempt to suicide (IPC Sec 309) are two distinct offences, hence Section 306 can survive independent of Section 309. It has also clearly stated that a person attempts suicide in a depression, and hence he needs help, rather than punishment. Therefore, the Supreme Court has recommended to Parliament to consider the feasibility of deleting Section 309 from the Indian Penal Code3.

Arguments against euthanasia

Eliminating the invalid: Euthanasia opposers argue that if we embrace ‘the right to death with dignity’, people with incurable and debilitating illnesses will be disposed from our civilised society. The practice of palliative care counters this view, as palliative care would provide relief from distressing symptoms and pain, and support to the patient as well as the care giver. Palliative care is an active, compassionate and creative care for the dying6.

Constitution of India: ‘Right to life’ is a natural right embodied in Article 21 but suicide is an unnatural termination or extinction of life and, therefore, incompatible and inconsistent with the concept of ‘right to life’. It is the duty of the State to protect life and the physician's duty to provide care and not to harm patients. If euthanasia is legalised, then there is a grave apprehension that the State may refuse to invest in health (working towards Right to life). Legalised euthanasia has led to a severe decline in the quality of care for terminally-ill patients in Holland7. Hence, in a welfare state there should not be any role of euthanasia in any form.

Symptom of mental illness: Attempts to suicide or completed suicide are commonly seen in patients suffering from depression8, schizophrenia9 and substance users10. It is also documented in patients suffering from obsessive compulsive disorder11. Hence, it is essential to assess the mental status of the individual seeking for euthanasia. In classical teaching, attempt to suicide is a psychiatric emergency and it is considered as a desperate call for help or assistance. Several guidelines have been formulated for management of suicidal patients in psychiatry12. Hence, attempted suicide is considered as a sign of mental illness13.

Malafide intention: In the era of declining morality and justice, there is a possibility of misusing euthanasia by family members or relatives for inheriting the property of the patient. The Supreme Court has also raised this issue in the recent judgement3. ‘Mercy killing’ should not lead to ‘killing mercy’ in the hands of the noble medical professionals. Hence, to keep control over the medical professionals, the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002 discusses euthanasia briefly in Chapter 6, Section 6.7 and it is in accordance with the provisions of the Transplantation of Human Organ Act, 199414. There is an urgent need to protect patients and also medical practitioners caring the terminally ill patients from unnecessary lawsuit. Law commission had submitted a report (no-196) to the government on this issue15.

Emphasis on care: Earlier majority of them died before they reached the hospital but now it is converse. Now sciences had advanced to the extent, life can be prolonged but not to that extent of bringing back the dead one. This phenomenon has raised a complex situation. Earlier diseases outcome was discussed in terms of ‘CURE’ but in the contemporary world of diseases such as cancer, Aids, diabetes, hypertension and mental illness are debated in terms best ‘CARE’, since cure is distant. The principle is to add life to years rather than years to life with a good quality palliative care. The intention is to provide care when cure is not possible by low cost methods. The expectation of society is, ‘cure’ from the health professionals, but the role of medical professionals is to provide ‘care’. Hence, euthanasia for no cure illness does not have a logical argument. Whenever, there is no cure, the society and medical professionals become frustrated and the fellow citizen take extreme measures such as suicide, euthanasia or substance use. In such situations, palliative and rehabilitative care comes to the rescue of the patient and the family. At times, doctors do suggest to the family members to have the patient discharged from the hospital wait for death to come, if the family or patient so desires. Various reasons are quoted for such decisions, such as poverty, non-availability of bed, futile intervention, resources can be utilised for other patients where cure is possible and unfortunately majority of our patient's family do accordingly. Many of the terminally ill patients prefer to die at home, with or without any proper terminal health care. The societal perception needs to be altered and also the medical professionals need to focus on care rather in addition to just cure. The motive for many euthanasia requests is unawareness of alternatives. Patients hear from their doctors that ‘nothing can be done anymore’. However, when patients hear that a lot can be done through palliative care, that the symptoms can be controlled, now and in the future, many do not want euthanasia anymore16.

Commercialisation of health care: Passive euthanasia occurs in majority of the hospitals across the county, where poor patients and their family members refuse or withdraw treatment because of the huge cost involved in keeping them alive. If euthanasia is legalised, then commercial health sector will serve death sentence to many disabled and elderly citizens of India for meagre amount of money. This has been highlighted in the Supreme Court Judgement3,17.

Research has revealed that many terminally ill patients requesting euthanasia, have major depression, and that the desire for death in terminal patients is correlated with the depression18. In Indian setting also, strong desire for death was reported by 3 of the 191 advanced cancer patients, and these had severe depression19. They need palliative and rehabilitative care. They want to be looked after by enthusiastic, compassionate and humanistic team of health professionals and the complete expenses need to be borne by the State so that ‘Right to life’ becomes a reality and succeeds before ‘Right to death with dignity’. Palliative care actually provides death with dignity and a death considered good by the patient and the care givers.

Counterargument of euthanasia supporters

Caregivers burden: ‘Right-to-die’ supporters argue that people who have an incurable, degenerative, disabling or debilitating condition should be allowed to die in dignity. This argument is further defended for those, who have chronic debilitating illness even though it is not terminal such as severe mental illness. Majority of such petitions are filed by the sufferers or family members or their caretakers. The caregiver's burden is huge and cuts across various domains such as financial, emotional, time, physical, mental and social. Hence, it is uncommon to hear requests from the family members of the person with psychiatric illness to give some poison either to patient or else to them. Coupled with the States inefficiency, apathy and no investment on health is mockery of the ‘Right to life’.

Refusing care: Right to refuse medical treatment is well recognised in law, including medical treatment that sustains or prolongs life. For example, a patient suffering from blood cancer can refuse treatment or deny feeds through nasogastric tube. Recognition of right to refuse treatment gives a way for passive euthanasia. Many do argue that allowing medical termination of pregnancy before 16 wk is also a form of active involuntary euthanasia. This issue of mercy killing of deformed babies has already been in discussion in Holland20.

Right to die: Many patients in a persistent vegetative state or else in chronic illness, do not want to be a burden on their family members. Euthanasia can be considered as a way to upheld the ‘Right to life’ by honouring ‘Right to die’ with dignity.

Encouraging the organ transplantation: Euthanasia in terminally ill patients provides an opportunity to advocate for organ donation. This in turn will help many patients with organ failure waiting for transplantation. Not only euthanasia gives ‘Right to die’ for the terminally ill, but also ‘Right to life’ for the organ needy patients.

Constitution of India reads ‘right to life’ is in positive direction of protecting life. Hence, there is an urgent need to fulfil this obligation of ‘Right to life’ by providing ‘food, safe drinking water and health care’. On the contrary, the state does not own the responsibility of promoting, protecting and fulfilling the socio-economic rights such as right to food, right to water, right to education and right to health care, which are basic essential ingredients of right to life. Till date, most of the States has not done anything to support the terminally ill people by providing for hospice care.

If the State takes the responsibility of providing reasonable degree of health care, then majority of the euthanasia supporters will definitely reconsider their argument. We do endorse the Supreme Court Judgement that our contemporary society and public health system is not matured enough to handle this sensitive issue, hence it needs to be withheld. However, this issue needs to be re-examined again after few years depending upon the evolution of the society with regard to providing health care to the disabled and public health sector with regard to providing health care to poor people.

The Supreme Court judgement to withhold decision on this sensitive issue is a first step towards a new era of health care in terminally ill patients. The Judgment laid down is to preserve harmony within a society, when faced with a complex medical, social and legal dilemma. There is a need to enact a legislation to protect terminally ill patients and also medical practitioners caring for them as per the recommendation of Law Commission Report-19615. There is also an urgent need to invest in our health care system, so that poor people suffering from ill health can access free health care. Investment in health care is not a charity; ‘Right to Health’ is bestowed under ‘Right to Life’ of our constitution.

References

1. Lewy G. Assisted suicide in US and Europe. New York: Oxford University Press, Inc; 2011.

2. Dowbiggin I. A merciful end: The euthanasia movement in modern America. New York: Oxford University Press, Inc; 2003.

3. Aruna Ramchandra Shanbaug vs. Union of India & Ors. Writ Petition (Criminal) no. 115 of 2009, Decided on 7 March, 2011. [accessed on August 16, 2011]. Available from: http://www.supremecourtofindia.nic.in/outtoday/wr1152009.pdf .

4. P. Rathinam vs. Union of India, 1994(3) SCC 394

5. Gian Kaur vs. State of Punjab, 1996(2) SCC 648

6. Saunders C. Terminal care in medical oncology. In: Begshawe KD, editor. Medical oncology. Oxford: Blackwell; 1975. pp. 563–76.

7. Caldwell S. Now the Dutch turn against legalised mercy killing. [accessed on August 15, 2011]. Available from: http://www.hospicevolunteerassociation.org/HVANewsletter/0120_Vol6No1_2009Dec9_Now The DutchTurn Against Legalised MercyKilling.pdf .

8. Brådvik L, Mattisson C, Bogren M, Nettelbladt P. Long term suicide risk of depression in the Lundby cohort 1947-1997-severity and gender. Acta Psychiatr Scand. 2008;117:185–91.[PubMed]

9. Campbell C, Fahy T. Suicide and schizophrenia. Psychiatry. 2005;4:65–7.

10. Griffin BA, Harris KM, McCaffrey DF, Morral AR. A prospective investigation of suicide ideation, attempts, and use of mental health service among adolescents in substance abuse treatment. Psychol Addict Behav. 2008;22:524–32.[PMC free article][PubMed]

11. Alonso P. Suicide in patients treated for obsessive-compulsive disorder: A prospective follow-up study. J Affect Disorders. 2010;124:300–8.[PubMed]

12. Bongar BME. Suicide: Guidelines for assessment, management, and treatment. USA: Oxford University Press; 1992.

13. Lonnqvist J. The Oxford textbook of suicidology and suicide prevention. Oxford: Oxford University Press; 2009. Major psychiatric disorders in suicide and suicide attempters; pp. 275–86.

14. The Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations. 2002. [accessed on August 19, 2011]. Available from: http://www.mciindia.org/RulesandRegulations/CodeofMedicalEthicsRegulations2002.aspx . [PubMed]

15. Law Commission report no.196 on medical treatment to terminally ill patients. [accessed on August 19, 2011]. Available from: http://lawcommissionofindia.nie.in/reports/rep196.pdf .

16. Zylicz Z, Finlay IG. Euthanasia and palliative care: reflections from The Netherlands and the UK. J R Soc Med. 1999;92:370–3.[PMC free article][PubMed]

17. Gursahani R. Life and death after Aruna Shanbaug. Indian J Med Ethics. 2011;8:68–9.[PubMed]

18. Chochinov HM, Wilson KG, Enns M. Desire for death in the terminally ill. Am J Psychiatry. 1995;152:1185–91.[PubMed]

19. Gandhi A, Chaturvedi SK, Chandra P. Desire for death in cancer patients - an Indian Study. Presented at the International Congress of the International Psycho OncologySociety, Copenhagen 2004

20. Sheldon T. Dutch legal protection scheme for doctors involved in mercy killing of babies receives first report. BMJ. 2009:339.

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