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‘Euthanasia: Right to Die with Dignity’

Kalaivani annadurai.

Department of Community Medicine, Shri Sathya Sai Medical College and Research Institute, Kancheepuram district, Tamil Nadu, India

Raja Danasekaran

Geetha mani.

Dear Editor,

The concept of Euthanasia has been a controversial topic since its inception. The word ‘Euthanasia’ is derived from Greek, ‘Eu’ meaning ‘good’ and ‘thanatos’ meaning ‘death’, put together it means ‘good death’. Euthanasia is defined as the hastening of death of a patient to prevent further sufferings. Active euthanasia refers to the physician deliberate act, usually the administration of lethal drugs, to end an incurably or terminally ill patient’s life. Passive euthanasia refers to withholding or withdrawing treatment which is necessary for maintaining life. There are three types of active euthanasia, in relation to giving consent for euthanasia, namely voluntary euthanasia – at patient request, nonvoluntary – without patient consent, involuntary euthanasia – patient is not in a position to give consent. [ 1 ]

Other terminology like assisted suicide and physician-assisted suicide are not synonyms of euthanasia. [ 1 ] Do not resuscitate (DNR) order means the attending doctor is not required to resuscitate a patient if their heart stops and is designed to prevent unnecessary suffering. Even though DNR is considered as passive euthanasia, it is practiced in most part of the world without much legal issues. [ 2 ]

Common conditions which make patients to seek euthanasia are terminally ill cancer patients, acquired immune deficiency syndrome (AIDS) and other terminally ill conditions where there is no active treatment. Factors which are responsible for decision making are classified into physical and psychological factors. Physical conditions that affect the quality of life in these patients are unbearable pain, nausea and vomiting, difficulty in swallowing, paralysis, incontinence, and breathlessness. Psychological factors include depression, feeling a burden, fearing loss of control or dignity, or dislike of being dependent. [ 2 ] But some argues that suicidal ideation and inadequate palliative care might also be the underlying reasons for seeking euthanasia. [ 3 ]

Passive euthanasia is generally accepted worldwide. Active involuntary euthanasia is illegal in almost all countries. Practicing active voluntary euthanasia is illegal and considered as criminal homicide in most of the countries and will faces punishment up to imprisonment for 14 years. While active involuntary euthanasia is legal in countries such as Netherland, Belgium, and Luxembourg, assisted suicide is legal in Switzerland and the United States of Oregon, Washington, and Montana. [ 4 ]

Previously there was an age restriction for euthanasia in Belgium, but recently the country has passed a bill in the parliament which lifts ban on all age restriction on euthanasia. In Belgium alone, there are 1400 cases of euthanasia practiced. The concept of death tourism or euthanasia tourism is slowly increasing in which patients who want to seek euthanasia or other assisted suicide services will travel to countries where it is legalized to avail those services. Switzerland is known for death tourism, where every year patients primarily from British, German, and French travel there to end their lives. [ 5 ] In Netherland, euthanasia accounts for 2% of all deaths. [ 6 ]

Many activists against euthanasia feel that legalizing euthanasia will leads to ‘slippery slope’ phenomenon which leads on to more number of nonvoluntary euthanasia. To conclude, strict standard guidelines should be formulated to practice euthanasia in countries where it is legalized, regulation of death tourism and other practices like mandatory reporting of all cases of euthanasia, consultation with psychiatrist, obtaining second opinion, improved hospice care have to be followed for standardization of euthanasia.

Euthanasia*

Feb 07, 2012

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Euthanasia*. Philosophy 2803 Lecture VIII March 26, 2002 * This replaces the lecture originally labelled lecture VIII. Euthanasia. A broad range of activities are sometimes classified as euthanasia Withholding or withdrawing treatment Actively ending someone’s life

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Presentation Transcript

Euthanasia* Philosophy 2803 Lecture VIII March 26, 2002 * This replaces the lecture originally labelled lecture VIII

Euthanasia • A broad range of activities are sometimes classified as euthanasia • Withholding or withdrawing treatment • Actively ending someone’s life • Providing someone with the means to end his/her life • What all of them have in common is that they involve situations in which: • it is somehow deemed better that the person we are concerned with dies than that he or she lives and • some course of action or inaction is undertaken with the understanding that it will bring about the death of the person

Is Euthanasia Ever Morally OK? • If we give the term a broad reading, most people will answer ‘yes’. • E.g., Suppose Tom has terminal cancer and that all conventional treatments have failed. • Left untreated, he will die in a few days. • However, there is an experimental drug that has shown some promise in treating cancers like his, but that also has some very unpleasant side effects. • Few would argue that it is immoral if Tom’s doctors accept his wish to refuse this treatment.

What Matters Morally? • The question thus becomes: under what conditions is euthanasia morally acceptable? • Discussion of this issue often turns on the type of euthanasia involved: • Active vs. Passive Euthanasia • Voluntary vs. Non-voluntary Euthanasia • Assisted Suicide

Active vs. Passive Euthanasia • Active - roughly, involveskilling a patient • E.g., administering a fatal dose of morphine to a terminally ill cancer patient • This is often what people have in mind when they simply speak of euthanasia • Be careful to distinguish killing from murdering (‘wrongful killing’) – not all killings are murders • Passive - roughly, involves letting a patient die • E.g., failing to revive a patient who has signed a DNR order

Two Kinds of Passive Euthanasia • (i) Withholding of Treatment e.g., not performing a needed surgery or not administering a needed drug • (ii) Cessation of Treatment e.g., turning off a respirator • Question:  While i above seems clearly passive, why is cessation of treatment passive? • Rachels: "what is the cessation of treatment ... if it is not 'the intentional termination of the life of one human being by another'?" (375) • Answers to this question tend to rest on claims about ‘naturalness’

Voluntary vs. Non-voluntary Euthanasia • Voluntary - killing or letting die a competent person who has expressed a desire for this (usually over a sustained period of time). • Non-voluntary - killing or letting die when the patient is unable to express such a desire • Note: there is a difference between involuntary and non-voluntary • Involuntary euthanasia is not a seriously considered possibility

Assisted Suicide • Not actually euthanasia, since the 'patient' ultimately kills himself or herself. • The line between the two can, however, become very thin. • e.g., Dr. Jack Kevorkian's 'Mercitron'   • Many of the same issues arise in considering assisted suicide as in considering euthanasia, • e.g., the Sue Rodriguez case (pp. 366-372)

The Law • Very roughly, the following summarizes the Canadian legal situation re. euthanasia • voluntary passive euthanasia = legal • in fact, required • voluntary active euthanasia = illegal • although see ‘The Doctrine of Double Effect’ • non-voluntary passive euthanasia = legal • under appropriate proxy decision • non-voluntary active euthanasia = illegal • although again see ‘The Doctrine of Double Effect’ • assisted suicide = illegal • see the Sue Rodriguez case (pp. 366-372)

Voluntary Passive Euthanasia • As noted, this is the least controversial form of euthanasia • It is now a well established principle that a competent patient has a right to refuse treatment, including lifesaving treatment • But why? • The short answer: because of the central role of informed consent – no consent, no treatment

A Longer Answer: The Autonomy/ Dignity Argument for VPE • P1:  A weakened, dying patient has lost control over her life in a significant way. • P2:  Allowing the patient control over how her life ends provides a way of preserving her autonomy and her dignity (as far as is possible). • P3:  Dignity and autonomy are very important values. • C:  In order to preserve the patient's dignity and autonomy, a terminally ill patient should be allowed to choose when treatment will be withheld or withdrawn.

Two Questions about the Autonomy/Dignity Argument • Does this argument apply only to terminally ill patients?  If autonomy is so important then why shouldn't the patient's wishes be respected even if she is not terminally ill? • E.g., The anorexic patient who refuses force-feeding • A rational, healthy patient who simply wants to be allowed to starve himself to death. • Because of the stress placed on informed consent, issues of competence are often raised. • Those who think a request for cessation of treatment will be easily agreed to are often mistaken, particularly when the family or medical staff don’t agree

Two Questions about the Autonomy/Dignity Argument • Does this argument also support assisted suicide or active euthanasia? • A common response:  ‘No.  There is a morally significant difference between killing and letting die.  While autonomy provides a ground for allowing the person to die.  It provides no grounds for active killing.’ • The American Medical Association (1973):  While "[t]he cessation of the employment of extraordinary means to prolong the life of the body ... is the decision of the patient and/or his immediate family," "mercy killing ... is contrary to that for which the medical profession stands." (372) • James Rachels challenges this view.  He claims the distinction between killing and letting die is morally irrelevant. (372-376)

Rachels on Active vs. Passive Euthanasia • "once the initial decision not to prolong his [i.e., a patient with incurable cancer] agony has been made, active euthanasia is actually preferable to passive euthanasia". (373) • Objection: But killing is morally worse than letting die! • Response:  Rachels claims that we have been misled by the fact that most actual cases of killing are morally worse than most actual cases of letting die • Because of this, we have made the mistake of concluding that there is some deep moral difference between killing and letting die.

Cases • (i) A unconscious patient will almost certainly die unless paced on a respirator. His family explain he has expressed a clear desire not to be placed on one. He is treated according to those wishes and dies. • (ii) Case i, but the man is placed on the respirator before his family arrive. After his wishes are explained, he is removed from the respirator and dies. • Are these cases of killing or letting die? • Are these cases morally different?

Cases • (1) A man drowns his young cousin so that he won't have to split an inheritance with him. • (2) Case #1, except, before he can kill him, the cousin slips and falls face down in the bathtub. The man just has to watch his cousin drown. • Are these cases of killing or letting die? • Are these cases morally different?

Cases • (a) In accordance with an ALS patient's wishes the doctors remove her from her respirator. She dies. • (b) A greedy son removes an ALS patient from her respirator because he wants to collect his inheritance. She dies. • Are these cases of killing or letting die? • Are these cases morally different?

Is Rachels Right? • Do the cases make a convincing argument that the difference between active and passive euthanasia is morally irrelevant? • If so, then what is morally relevant?

Non-voluntary Euthanasia • Until relatively recently, NPE & NAE were largely looked upon as morally unacceptable • Two ways in which NPE has become somewhat accepted • By appeal to standards of personhood • When the person is ‘gone’, NPE is generally accepted • E.g., ‘Harvard Brain Death’ = loss of virtually all brain activity including brain stem • By proxy • Under certain conditions, a proxy decision to refuse or suspend treatment is generally accepted even if the person is still arguably there • But recall Re. S.D. from lecture on consent, there are limitations on these decisions

The Case of Karen Quinlan • 1975 - Quinlan goes into a drug induced coma • Suffers anoxia (loss of oxygen to the brain) causing irreversible brain damage • Required a ventilator/respirator to live • Not brain dead, but in a persistent vegetative state (unconscious) • Quinlan’s sister - "If Karen could ever see herself like this, it would be the worst thing in the world for her." • Hospital - '1 in a million' chance of recovery • Family sought to have her removed from the respirator, doctors & hospital refused. • 1976 - N.J. Supreme Court overturns a lower court decision and rules in favour of the Quinlans. • Doctors 'weaned' her off the respirator in a successful attempt to keep her alive. • Died of pneumonia - June 13, 1986

The Case of Nancy Cruzan • June 11, 1983 - Cruzan, 24, suffers anoxia as a result of a car crash, enters a p.v.s. • Kept alive by a feeding tube • Parents sought permission to disconnect their daughter's feeding tube • June, 1990 - U.S. Supreme Court rules that in the absence of 'clear and compelling' evidence of Cruzan’s wishes, it may not be disconnected. • Publicity brings new witnesses (who knew her as Nancy Davis, her married name).  • In a new trial, a lower court rules the 'clear and compelling' standard has now been met. • Dec. 14, 1990 - N.C. is disconnected & subsequently dies • Many commentators thought that the fact that Cruzan required only a feeding tube (not a respirator) made a significant moral difference

Limits on Non-Voluntary Euthanasia • NAE is still very controversial • E.g., the Robert Latimer case • The limits of NPE are also controversial • E.g., Re. S.D. • Robert Wendland (Topic of Groupwork)

A Continuum of Conditions • Coma • Brain activity, but no consciousness or wakefulness. • Persistent Vegetative State (PVS) • Wakefulness, but no awareness • Minimally Conscious State (MCS) • Wakefulness and minimal awareness • Quite Different: Locked-in Syndrome • Full consciousness, but extreme paralysis

Minimally Conscious State • “a condition of severely altered consciousness in which minimal, but definite, behavioral evidence of self or environmental awareness is demonstrated.” • May be temporary or permanent • Criteria (at least one of): • following simple commands • gives yes or no responses, verbally or with gestures • verbalizes intelligibly • demonstrates other purposeful behavior …. in direct relationship to relevant environmental stimuli

Minimally Conscious State • Unlike PVS, those in a MCS can feel pain, etc. • “meaningful, good recovery after 1 year in an MCS is unlikely” • “being nonfunctioning and aware to some degree is worse than being nonfunctioning and unaware” • Ronald Cranford • “MCS is not a diagnosis; it is a value judgment.” • Diane Coleman, president, Not Dead Yet

The Case of Robert Wendland • NPE is now generally accepted when a patient is in a PVS • Recently there have been controversies about whether NPE is appropriate in other sorts of conditions, specifically for patients in a permanent MCS • One way of understanding these controversies is as linked to our conception of personhood – the more restrictive the conception, the greater range of cases in which NPE is accepted

Robert Wendland • Suffered brain damage in a car accident in 1993 • Wendland was supposedly in a permanent Minimally Conscious State (MCS) • Could respond to simple commands. • Wife and children claimed he never recognized them • Mother claimed he would cry and kiss her hand during visits

Robert Wendland • His mother opposed the attempt by his wife to have Wendland’s feeding and hydration tube removed • Wendland died in July 2001 of pneumonia before California Supreme Court could rule • California Supreme Court eventually ruled against his wife

Question • Assuming his wife’s description of Wendland’s condition was accurate, would NPE of Wendland have been morally acceptable? • Why or why not?

The Doctrine of Double Effect (DDE) • Suppose an action (e.g., giving a terminally ill cancer patient morphine) has some reasonably foreseeable outcome (e.g., quickening the patient’s death) and that it would be unacceptable to perform this action for the purpose of bringing this outcome about. • The DDE claims that it may still be acceptable to perform this action, provided that the action is not performed for the purpose of bringing this outcome about. • E.g., it may still be acceptable to give the patient the morphine provided that it is given in order to control his pain. • The DDE is commonly, if not explicitly, appealed to in practice. In this sense, VAE. & NAE. are quite often practiced.

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• Preferences

Euthanasia and End Of Life Care - PowerPoint PPT Presentation

Euthanasia and End Of Life Care

Euthanasia and end of life care pertaining to various european countries and india. – powerpoint ppt presentation.

• The term euthanasia derived from the Greek word eu and thanatos which means good death or easy death.
• It is also known as Mercy Killing.
• The ancient Greeks viewed illness as a bothersome affliction and allowed sick individuals to seek the approval of the state to commit suicide
• Euthanasia refers to the intentional termination of a persons life, usually but not always at that persons request, and usually in the context of terminal illness and/or incurable suffering.
• The Australian Psychological Society
• While most Greek philosophers supported euthanasia to Aristotle, suicide was an offence against the state.
• In 1516, for instance, Sir Thomas More wrote Utopia in which patients living in an ideal society were encouraged to commit suicide if they were suffering from a terminal illness or experiencing unrelenting pain.
• Hippocratic oath, which was written between 400 and 300 B.C. The oath states To please no one will I prescribe a deadly drug nor give advice which may cause his death.
• According to him, a doctor is to relieve the pain of his patient in one hand and protect and prolong his life on the other hand
• 1930s and early 1940s, the Nazis adoption of the word euthanasia to describe its mass extermination programme .
• In Germany, euthanasia was employed to murder over 100,000 and All the killings were committed without the patients consent and generally without the patient being aware of the impending act.
• The General Assembly of the World Medical Association
• 1) Active or Positive It is an act of Commission. It means a positive merciful act to end useless sufferings and meaningless existence. For example by giving large doses of a drug to hasten death.
• 2) Passive or Negative It is an act of Omission. It means discontinuing or not using extraordinary life sustaining measures to prolong life. For example discontinuing a feeding tube, or not carrying out a life extending operation or not giving life extending drugs etc.
• -------------------------------------------------- -----------------------------------------------
• Reddy KSN. The essentials of Forensic medicine Toxicology, 26th edition. 200741
• 3) Voluntary Euthanasia practiced with the expressed desire and consent of the person concerned.
• 4) Involuntary Euthanasia practiced against the will of the person
• 5) Non- Voluntary Euthanasia practiced in persons who are incapable of making their wishes known .For example in persons with irreversible coma or severely defective infants.
• -------------------------------------------------- ----------------------------------------------
• Doctor provides an individual with the information, guidance, and means to take his or her own life with the intention that they will be used for this purpose
• -------------------------------------------------- -----------------------------------------Murkey P.N. Singh K.S. Euthanasia ( mercy Killing). Review article. - J. Ind. Acad. Forensic Med. Toxicol. Vol-30 no.2, 200892-95
• Jack Kevorkian was a U.S.-based physician who assisted in more than 150 patient suicides.
• Infamous in 1990, when he assisted in the suicide of Janet Adkins, a 45-year-old Alzheimer's patient from Michigan .
• Kevorkian agreed to assist her in a public park, inside his Volkswagen van. Kevorkian attached the IV, and Adkins administered her own painkiller and then the poison.
• The State of Michigan immediately charged Kevorkian with Adkins' murder.
• On March 26, 1999, a jury in Oakland County convicted Jack Kevorkian of second-degree murder and the illegal delivery of a controlled substance and was sentenced to 25 years in prison .
• In 2010, HBO announced that a film about Kevorkian's life, called You Don't Know Jack featuring a film legend Al Pacino as Kevorkian
• He died on June 3, 2011, at the age of 83 .
• Ethical/Moral
• -To respect sufferers autonomy
• -This argument rests on the ideal of being able at all times to exercise as much control over ones own life as is possible.
• To allow individuals to value quality of life over sanctity of life
• To end suffering
• To reduce reliance on life support systems and/or advanced medical knowledge
• To reduce risk of premature suicides
• To reduce the legal jeopardy of those who implement euthanasia
• Changes in professional and public attitudes to euthanasia
• Ethical/moral
• Absolute respect for human life
• Possibility of coercion, loss of autonomy
• Poor decision-making by the sufferer
• Conflicts of interest
• Difficulty of enforcement and monitoring
• Reduction of efforts in diagnosis, treatment, and care
• Adequacy of modern medical and palliative care
• The Canadian law allows a person to refuse medical treatment and the medical profession accepts the living will, but the law does not allow the doctor to actively help someone to kill himself.
• However, amidst the ongoing debates, the Netherlands became the first testing ground for the world since it legalized euthanasia on 28th November 2000.
• Australia also has a voluntary euthanasia law which is statedly working well. In Australia, a computerized injection system is in use to accomplice euthanasia.
• The euthanasia law was adopted in 2001 in Belgium . This law defines conditions for doctors to avoid penal punishment.
• Physician Assisted suicide is legitimized in Switzerland.
• Currently in the UK, any person found to be assisting suicide is breaking the law and can be convicted of assisting suicide or attempting to do so
• Although two-thirds of Britons think it should be legal, a recent 'Assisted Dying for the Terminally- Ill' Bill was turned down in the lower political chamber, the House of Commons
• In USA the practice of euthanasia is a clear offence too theoretically, but in real practice the judgements of different courts during trial of euthanasia cases seem to be liberal.
• Physician Assisted Suicide (PAS) is legal in Oregon and Washington State in the US.
• Like almost in all other countries, euthanasia has no legal status . The practice of euthanasia is a clear act of offence, either a suicide and assistance to commit suicide or a murder.
• The latest judgement of Supreme Court declares that Right to DIE is not included in the Right to LIFE under Article 21 of Indian Constitution.
• Article 21 is a provision guaranteeing protection of life and personal liberty and by no stretch of imagination can imply EXTINCTION OF LIFE.
• Right to life is a natural right embodied in Article 21 but suicide is an unnatural termination or extinction of life and therefore not compatible and inconsistent with the concept of right to life
• In Nov 27 ,1973 , Aruna Ramchandra Shanbaug, aged 24 a nurse at KEM hospital Mumbai was attacked by Sohanlal, a sweepwer working in the same hospital.
• Assaulted in the basement , strangulated with a dog chain resulting in cervical injury and brain stem contusion due to lack of adequate 02 .
• Based on her assessment since 1982, Pinki Virani, a National award winning Journalist, Social activist filed a petition ( criminal ), number 105 , of 2009 in Supreme Court on India , for mercy killing on Behalf of Aruna under article 32 of constitution on India.
• She pleaded Supreme court to have Aruna stopped being fed and let her die peacefully.
• On 24 January 2011, the Supreme Court of India responded by setting up a medical panel to examine her.
• However, it turned down the mercy killing petition on 7 March 2011 but legalized passive euthanasia.
• Assessment of the patient
• Treatment/counselling of the patient as appropriate
• An advocacy role for the patient and/or relatives and/or carers
• educating decision makers, clinical staff, patients and the public in the psychological aspects of euthanasia and what psychologists can offer in the area
• facilitating others professional development in the area
• conducting research in the area and disseminating knowledge
• There exists an inherent tension between respecting individual autonomy and relieving people from unbearable suffering while still protecting the principle of valuing human life remains.
• Any liberalizing of laws in relation to euthanasia needs to achieve respect for individual rights and prevent abuse, without becoming too unwieldy, bureaucratic and time consuming to be practical.
• The decision-making process raises many difficult psychological issues. It is clearly apparent that every case where a patient requests assistance to die should be assessed individually.
• Policy makers should consider these issues seriously and to bring them to the attention of other professionals and policy makers.
• 2. Murkey P.N. Singh K.S. Euthanasia ( mercy Killing). Review article. - J. Ind. Acad. Forensic Med. Toxicol. Vol-30 no.2, 200892-95
• G S Neeley The Right to SelfDirected Death Reconsidering an Ancient Proscription 35 Catholic Law 111 (1995) at 116.
• 4 New York Task Force on Life and the Law When Death is Sought AssistedSuicide and Euthanasia in the Medical Context (May 1994) at 79.
• J Scherer and R Simon Euthanasia and the Right to Die A Comparative View (Rowman Littlefield Publishers, Lanham 1999)

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