To Be or Not to Be: Euthanasia Today
Is euthanasia ever justified? Is there a difference between “euthanasia” and “physician-assisted suicide”? With health-care costs under a virtual electron microscope, are special populations (the oldest old, the chronically ill, the mentally ill, and others) at risk of being targeted by unethical practices in the name of saving money? There are no simple answers, and no black-and-white responses, to these questions. However, this paper will attempt to present a reasoned view of when euthanasia and physician-assisted suicide can be considered reasonable options.
Define the Terms
Firstly, it is important to distinguish between the two terms. “Euthanasia is defined broadly as ‘the mercy killing of the hopelessly ill, injured, or incapacitated’” (Pozgar, 2010, p. 102). Furthermore, there are “active” and “passive” forms—the first being the “intentional commission of an act” (p. 103), the second being “allowing the terminally ill patient to die a natural death” by removing or withholding treatment (p. 103). Beyond this, there are “voluntary” and “involuntary” categories; the former occurs when the patient himself decides that death is the right option for him. The latter happens when someone who is not the patient—a guardian, for example—makes the decision for him (p. 104).
Physician-assisted suicide is clearly voluntary and active, using the above definitions. No one but the terminally ill patient can make this decision, and she must be competent in a legal sense. She must also have been given as complete a set of information regarding the possibilities of treatment and probabilities of various outcomes as can be given under her circumstances, in order to make the most informed decision possible for herself.
Who Should Choose?
Are euthanasia and physician-assisted suicide (hereafter PAS) ever justified? Under very specific circumstances, the moral and ethical answer must be yes. For someone in a persistent vegetative state (PVS) following an automobile accident, for example, there is little point in prolonging life and avoiding death. Keeping such a patient alive by medical treatments, which feeding tubes constitute, serves little purpose for the patient herself. She cannot know whether it is day or night, raining or sunny, or who is sitting by her bedside reading to her. Family members of such patients need to be informed of the likelihood of their recovery—next to none, often—and to carefully weigh the scales of their own interests (“we can’t say goodbye”) against the realities of the situation. The harsh truth is, the resources being expended on such a patient could be going toward another who will benefit far more greatly than she (Morris & Dracup, 2008), leading to what is termed “moral distress” for the staff. If the patient has an advance directive (AD), it needs to be followed, regardless of the family’s wishes. The patient’s rights trump theirs.
Without the guidance of an AD, decisions are much more difficult to make for everyone concerned—staff, family, friends. Circumstances such as this call for input from the facility’s health ethics committee. This input cannot be considered “the final answer,” but must be carefully weighed against personal convictions of the deciding individual (spouse, parent, sibling). Absent any legal guardian or proxy, the ethics committee could well find itself making the decision for the patient. Pozgar provides a summary of the guiding principles used by the Kentucky Supreme Court in Woods v. Commonwealth (2004): “’If there is no guardian,’ but the family, physicians, and ethics committee all agree with the surrogate, there is no need to appoint a guardian. ‘If there is a guardian’ and all parties agree, there is no need for judicial approval (in order to remove life support). ‘If there is disagreement,’ the parties may petition the courts” (p. 147).
What About Grandma?
As regards special populations—elderly, poor, minority, female, infant, disabled—the same caveats should be applied. No group should be considered “lesser” in terms of their rights or privileges concerning requests for euthanasia or PAS. The same kinds of questions need to be asked, regardless of the patient’s age and financial situation. The answers may well not be the same, but the same issues need to be considered. In the case of an infant, clearly the patient is incompetent and cannot self-determine the request; the parents (or guardian, if the parents are unable for some reason) must make the decision alongside the physician and ethics committee. If an elderly woman has an AD, that takes precedence over anyone else’s desires. If she does not, and she is competent in a legal sense, she can and should be allowed to make her own determination. The only circumstance under which finances should come into the picture is when the patient herself desires not to bankrupt her family by demanding she be kept functional by extraordinary measures, if death were otherwise the most likely outcome. That is not a decision for anyone else to make.
Specific, Not General
Carrie Scotto (2006) opines: “Healthcare professionalsand their patients have merely mistaken the question. It isnot a question of life and death; it is a question of the lifeand death of a particular person. Decisions about what typeof care a person receives should be based on the context ofthe situation; they involve a unique individual who has a particularhealthcare problem” (p. 452). In response to Scotto, Lisa Day says: “. . . (E)very individual’s perspective and values come from somewhere,and . . . the culture in which we are immersed plays a significantrole in that development. By shaping the broader social perspectiveon dying in a way that favors hastening death and excludes questionsabout its goodness, we risk establishing this point of viewas the background to all further discussion and, ultimately,as a social value that will be adopted—unexamined—byindividuals” (p. 452).
Awareness of this risk/benefit analysis is mandatory when considering the decision for euthanasia or PAS. Rather than adopting general guidelines that could well lead to the “slippery slope” argument, every case must be considered on its own merit, by the patient (if s/he is capable and competent) or his/her guardian, the medical staff, and the ethics committee of the facility where care is provided. The “goodness” of dying is always relative, and must be treated as such. Patients are not geese and ganders; what is good for one is not necessarily good for another.
A Vanguard of Two
PAS remains illegal in all but two states as of this writing. Only Oregon and Washington provide legal access to PAS. Montana’s legislature is considering the issue. Wisconsin, the author’s state of residence, has expressly forbidden PAS as recently as August, 2009 (Baklinski, 2009) when the state medical society “rejected a proposal tabled within its ethics committee to remain neutral on legalizing assisted suicide.” The society believes that acceptance of PAS leads to a state of pressuring the elderly and disabled to choose death over life, particularly for financial reasons, be they cost-containment or family pressures. It is the author’s contention that this need not become the case, so long as ethics and morals remain intact during the decision-making process. As stated earlier in this paper, no group of people deserves to be considered “lesser” for purposes of medical treatment. Situations exist where choosing to accept death, rather than avoid it, is the best decision for the patient—and the patient should have that right.
In the EndUltimately, the decision for euthanasia or PAS is between the patient and her Maker. Her family should be consulted during the decision-making process, to be sure, as should her medical team. If they feel it necessary, the family and/or the team (and the patient, perhaps) should consult with the ethics committee for professional input outside the physician’s sphere. Legislation must be carefully worded, so as to avoid the sweeping generalizations that so many fear will lead to mass killings of the elderly, the disabled, or the mentally ill. As Scotto said, “It is not a question of life and death. It is a question of the life or death of a particular person.” Case by case is, at present, the best way to continue the slow process of accepting the patient’s right to choose to stop avoiding death by extraordinary means.
Baklinski, T. (2009) “Wisconsin medical society rejects resolution supporting physician-assisted suicide.” Retrieved October 10, 2009 from http://www.lifesitenews.com. http://www.lifesitenews.com/ldn/2009/aug/09081703.html
Euthanasia. (n.d.). Retrieved October 9, 2009, from ProCon.org: http://euthanasia.procon.org
Morris, P., & Dracup, K. (2008). "Time for a tool to measure moral distress?" American Journal of Critical Care , 17, 398-401. Retrieved October 9, 2009 from PubMed database. PMID: 18775992
Pozgar, G. (2010). Legal and ethical issues for health professionals. Sudbury, MA: Jones and Bartlett Publishers.
Scotto, C. (2006) "Context is key when considering end-of-life treatment options." American Journal of Critical Care, 15; 452. Retrieved October 9, 2009 from PubMed database. PMID: 16926365