January 1988 IX/5
EUTHANASIA: ON THE HORIZON?
"Movement to legalize euthanasia could succeed in 1988?" This is the lead headline in a recent newsletter on medical ethics. (1) For centuries, physicians and others in health care have been dedicated to protecting and preserving life. If the effort to have euthanasia accepted succeeds, physicians and others in health care would be expected to cause death. Participation in euthanasia would not only pervert the purpose of health care, it would also destroy all trust and confidence on the part of patients. With this potential damage in mind, a closer look at euthanasia and the factors disposing people to accept it is in order.
The term euthanasia comes from Greek words which mean "good death." In common parlance, euthanasia implies that a stronger person causes the death of a weaker, suffering or debilitated person. From an ethical perspective the elements involved in euthanasia are the intention of the person acting (the agent) and the effect of this intention. The effect of the intention to perform euthanasia may be achieved by placing an act or by withholding an act. Examples of euthanasia accomplished through placing an act would be injecting poison into a sick person's system or smothering a suffering person with a pillow. But euthanasia may also be accomplished by withholding a life-prolonging action; for example, by withholding food from a debilitated patient when there are medical indications the person may recover from his illness.
To signify the difference between euthanasia which is accomplished through an act, and euthanasia which is accomplished by omitting an act, a distinction is often made between active and passive euthanasia. The impression is conveyed that while active euthanasia is ethically unacceptable, passive euthanasia is acceptable because it does not require a positive action which brings about death. From an ethical perspective the distinction between active and passive euthanasia is meaningless. If the intention of the agent is to cause the death of a patient, then an unethical effect results whether by means of placing an action or withholding an action.
If euthanasia is unethical, must the life of every suffering and comatose person be prolonged as long as possible? By no means. If a person has a fatal pathology, an ethical decision must be made whether to circumvent or alleviate the fatal pathology. The decision concerning the use of therapy should be made by the patient if he or she is competent, by a proxy if the patient is incompetent; the physician and other health care professionals supplying the necessary information for an informed decision on the part of the patient or proxy. The criteria for withholding or discontinuing therapy when a fatal pathology is present are twofold: whether the therapy is effective for prolonging life, and whether the therapy would cause excessive burden in relation to the anticipated benefit. If one or the other criteria applies, then the therapy need not be utilized or, if already begun, may be discontinued. In such circumstances, the intention of the agent is not to cause the patient's death. Rather, if the therapy is deemed ineffective to prolong life, then the intention of the agent is simply to avoid doing something useless or futile; always an ethical imperative. If the therapy is deemed excessively burdensome in relation to the benefit for the patient, then the intention of the person removing or withholding therapy is to remove a burden from the patient. Clearly, when effectiveness of therapy is being evaluated, the physician will have more responsibilities than when burden and benefit are being evaluated?
The distinction between euthanasia and "allowing a patient to die" is often misunderstood. Some people maintain that this distinction splits hairs. But in reality, there is a great difference between the two actions. First of all, the intention of the two actions are entirely different. Secondly, in euthanasia, the intention brings about death by prompting the performance or withholding of an act. Allowing a person to die when there is no ethical obligation to prolong life does not cause death directly. Rather, the person dies because of the fatal pathology which has not been circumvented or alleviated. In both cases death ensues: in euthanasia it is directly intended by the agent; in "allowing to die," it is the unwanted side effect of a good ethical action.
Why is there a growing trend toward accepting euthanasia in our society? Briefly, let us mention some of the more prominent reasons:
1. Ronald Cranford, MD, a leading expert in the case of comatose patients, maintains that the practices of the medical profession are fueling the drive toward euthanasia. (3) The customs of medical care lead physicians to utilize all life-support systems without asking the proper ethical questions: Is the therapy effective for prolonging life? Does the therapy in question cause an excessive burden for the patient?
2. Another cause of the trend toward euthanasia is the practice of prolonging physiological function when it has been determined medically that cognitive-affective function cannot be restored. Specifically, health care professionals must question when the therapy to prolong life is truly effective. In the face of medical and hospital opposition, the courts of several states have maintained that life-sustaining mechanisms are not ethically nor legally required if only physiological function can be sustained.
3. When considering excessive burden, many people will recognize only physiological burden (physical pain and suffering) as a reason for removing life-support therapy. But psychological, social, and spiritual burden should be considered as well. Considering the social burden to the patient requires that the burden to the family must be considered as well.
4. Another attitude leading people to promote euthanasia is the desire to be "in control of one's life." However, as David Peretz points out: The desire to be in complete control of one's life is irrational and unhealthy; we are not masters of our fate in regard to many important events in our lives." (4)
The foregoing seem to be more prominent reasons for the trend in our society to accept euthanasia as an acceptable method of terminating life. It seems that each factor results from an inaccurate ethical evaluation either of the purpose of life or the purpose of medical care.
Kevin O'Rourke, OP
1. Medical Ethics Advisor. Dec. 1987.
2. Medical Ethics Advisor. loc.cit.
3. Brody and Tomilson. NEJM, vol. 318, p.43.
4. Hastings Center Report. 11(1981) p.40. loc.cit.
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