CASE REPORT | https://doi.org/10.5005/jp-journals-10028-1437 |
Euthanasia: A Debate—For and Against
1Department of Psychiatry, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
2,3Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Corresponding Author: Aseem Mehra, Department of Psychiatry, Post- graduate Institute of Medical Education and Research, Chandigarh, India, Phone: +91 7087002714, e-mail: aseemmehra86@gmail.com
How to cite this article Kumar A, Mehra A, Avasthi A. Euthanasia: A Debate—For and Against. J Postgrad Med Edu Res 2021;55(2):91–96.
Source of support: Nil
Conflict of interest: None
ABSTRACT
The debate on euthanasia once again re-embark on the recent legalization of passive euthanasia by the Supreme Court of India, with that India has joined leagues of counties where euthanasia is legal in some, or the other form. On one side, the Supreme Court decision brought a ray of hope to some while some have expressed their apprehensions. This is important to understand what has changed over the period, how the dynamics of forces working around euthanasia, some in favor or opposition, has changed over the period, so passive euthanasia has become a possibility now. This review is an attempt to revisit this controversial yet important concept of euthanasia in the current context.
Keywords: Euthanasia, Euthanasia-debate, Passive-euthanasia..
INTRODUCTION
The concept of “good death” seems to be originated with civilization. Debate on euthanasia seems to be older than the term “euthanasia” itself, perhaps the topic remains controversial since civilization start or humans developed moral sense. A wishful death has been documented in ancient Hindu sculptures, is a concept used in the field of medicine which means easy or gentle death, and is defined as the deliberate speeding up of the death of an individual suffering from a terminal illness like cancer.1 The term euthanasia originated in Greece and meant a good death.2 There are different definitions or laws to define the term euthanasia. The medical definition is “the act or practice of causing or permitting the death of hopelessly sick or injured individuals in a relatively painless way for reasons of mercy”.3 The British House of Lords Select Committee on Medical Ethics defines euthanasia as “a deliberate intervention undertaken with the express intention of ending a life, to relieve intractable suffering”.4 In the Netherlands and Belgium, euthanasia as “termination of life by a doctor at the request of a patient”.5 The Dutch law, however, does not use the term “euthanasia” but includes it under the broader definition of “assisted suicide and termination of life on request”.6 Still, there is not enough to find a clear societal consensus on death with dignity and without suffering, and how do we go about achieving this?
The advances in scientific knowledge and medical technology have enhanced enthusiasm among the general public for human potential and providing unprecedented ability actually to manipulate life and death.4,7,8 However, many of these advances have posed new ethical challenges, current euthanasia and physician-assisted suicide (PAS) debate is a result of these medico-technological advances leading to a heated debate involving issues related to legal, moral, philosophical, religious, sociocultural, and end-of-life decisions.9,10 Currently, euthanasia is legally permitted in the Netherlands, Luxembourg, Switzerland, Belgium, and some other countries, including some states of the USA.11–15 Canada has introduced a federal law allowing medical aid in dying.16 Victoria has become the first state in Australia to legalize voluntary euthanasia from mid-2019.17
Considering India, recently in a historic judgment, the Supreme Court of India legalized passive euthanasia. The apex court remarked in the judgment that the Constitution of India values liberty, dignity, autonomy, and privacy.18
Historical Perspective: Birth of the Idea of a Good Death
The term “euthanasia” originated in the early 17th Century from the Greek words eu means “well” and Thanatos means “death”. Euthanasia was practiced in Ancient Greece and Rome: e.g., hemlock was employed as a means of hastening death on the island of Kea, a technique also employed in Marseilles. Euthanasia was supported by Socrates, Plato, and Seneca the Elder in the ancient world. However, Hippocrates appears to have spoken against the practice, writing “I will not prescribe a deadly drug to please someone, nor give advice that may cause his death”.19–21 Euthanasia conceptualized under the framework of “good death” which could be traced back to the medieval era when historian Suetonius described the death of Emperor Augustus as euthanasia.22
Euthanasia was first used in the medical context by Francis Bacon in the 17th century to refer to an easy and painless death. However, he did not approve of the administration of poison by physicians to hasten death.23,24 The medical historian, Karl Friedrich Heinrich Marx, drew on Bacon’s philosophical ideas. As per him, a doctor had a moral duty to ease the suffering of death through encouragement, support, and mitigation using medication.25,26 Hippocrates too prohibited the use of any poison to the diseased in his oath. In 1865, Francis Galton, cousin of Charles Darwin, proposed the concept of Eugenics which involves applying principles of genetics and heredity to improve the human race.27 In 1870, S. D. Williams, a non-physician, proposed that chloroform be used to intentionally end the lives of patients22(1). In the late 19th century (mid of the 1890s) Ingersoll and Adler argued for voluntary euthanasia of adults suffering from terminal ailments.28
By the 1920s, eugenics became an influential social and political movement29(2). In 1902, an Indiana physician by the name of Dr Harry Sharp urged the passage of mandatory sterilization laws. In 1907, Indiana became the first state to pass a eugenics-based sterilization law.29 At the same time, discussion of euthanasia formally entered in a legislative forum with the introduction of a bill in support of euthanasia which was ultimately defeated.30 In January 1936, King George V was given a fatal dose of morphine and cocaine to hasten his death, by his physician, Lord Dawson.31
The Holocaust and Nazi medical atrocities had a tremendous negative impact on the movement of euthanasia.30,32 Euthanasia was justified as a way to divert money being spent on the ill and disabled to other more important societal needs29(2). Under the infamous “T-4” Program, calculated 250,000 people were murdered; mass Jewish genocide took place, although, later on, it was revoked under public pressure. After World War II, euthanasia lost its public support although voluntary euthanasia survived. Western societies began to look to scientific and technological solutions to problems previously seen as religious, moral, or even political in character, and death became medicalized, and moral and religious questions were reframed.8 Life supportive modalities like cardiopulmonary resuscitation, mechanical respirator, and intensive care units revolutionized care and prolonged life. Physician-assisted suicide looked at the technological solution of the euthanasia dilemma.33 The paradigm had shifted, the stage had been set, the medicalization of euthanasia started winning the legal battle, right to die movement set in motion, what could be seen as re-emergence of euthanasia.8
Euthanasia: Various Dimensions
Euthanasia originally meant the condition of a good, gentle, and easy death.34 The noun euthanasia has changed into the transitive verb “to euthanize”. Latin manuscript (in 1826) referred to medical euthanasia as “the skillful alleviation of suffering”, and physician was expected to provide conditions that would facilitate a gentle death. But, “least of all should be permitted, prompted either by other people’s request or his sense of mercy, to end the patient’s pitiful condition by purposefully and deliberately hastening death”.34 Over the decades, many terms have been evolved like “a good death”, “death with dignity”, “planned death”, and “assisted death”, or “aid in dying”. The use of such broad language in the euthanasia debate could be highly deceptive. Euthanasia encompasses various dimensions, as depicted in Table 1.28,35,36
Ethical and Moral Aspects of Euthanasia
Euthanasia is primarily considered an ethical and moral dilemma. Hippocratic Oath, a primary ethical benchmark for all physicians, clearly condemned euthanasia-like practices by stating that I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice. I will neither give a deadly drug to anybody if asked for it nor will I make a suggestion to this effect. Similarly, I will not give a woman an abortive remedy. In purity and in holiness, I will guard my life and my art.37 Hippocratic Oath is perhaps the most significant safeguard against euthanasia based on the central idea “do no harm”. World Medical Association considered euthanasia unethical even at the patient’s own request or at the request of close relatives.38 Medical Council of India (MCI) too considered euthanasia as unethical conduct. However, on specific occasions, the question of withdrawing supporting devices shall be decided only by a team of doctors and not merely by the treating physician alone.39
| Term | Competency | Consent | Physician’s role | Patient’s intention |
|---|---|---|---|---|
| Voluntary active euthanasia | Yes | Yes | To end life | To die |
| Involuntary active euthanasia | Yes | No | To end life | Not known |
| Non-voluntary active euthanasia | No | No | To end life | Not capable |
| Passive euthanasia* | Yes | Yes | Not to save | To die |
| Indirect euthanasia | Yes | Yes | To relieve pain | To relieve pain |
| Physician-assisted suicide | Yes | Yes | To tell the way | To die |
* Passive euthanasia has been legalized in India
The counter-argument of legendry Hippocratic Oath is based on the interpretation that the basic idea of the oath is to “do not harm”. It all comes down to what constitutes “harm”. When a patient is in intense pain or suffering severe mental anguish, our society could be doing more harm by keeping them alive than allowing them to die.40 Physician-assisted suicide came up as a solution which argued to be following the primacy of personal autonomy, promoting human dignity, and may represent a deeply humanizing act.
Religious Aspects of Euthanasia
Christianity had a profound effect on views associated with euthanasia and explicitly left no gray area and condemned suicide; there was no mention of the term euthanasia.30
Judaism also considered murder to cause death, even if the person was already dying. Similarly, robust opposition was seen in other religions like Islam, Buddhism, and Hinduism.
In Hinduism, committing suicide is considered a violation of the code of Ahimsa (non-violence) and is therefore as sinful as committing murder. Those who commit suicide become Abhisasta (Man accused of mortal sin), his blood relations (sapinda) shall not perform the funeral rites. In Jainism; santhara, giving up food and water till death is accepted, though it is considered illegal by the Supreme Court of India. Many religious teachers condemned this parallel equation of culturally practiced death, suicide, and euthanasia.41
Philosophical Aspects of Euthanasia
Suicide was widely condemned mostly on religious backgrounds by most of the philosophers of the time like Pythagoras, Pluto, and Aristotle.37 Perhaps Sophocles was first to accept suicide as a cure for miseries of life and suicide was acceptable when we are impeded from pursuing a eudaimonic life.42 Contrary to Stoicism, Cicero rejected suicide; however, in cases of extreme suffering, or favorable suicide would be permissible. Such more and less favorable attitudes to suicide are characteristic of Greek and Roman philosophy for approximately the first two centuries after the death of Christ. Pro-euthanasia philosophy mostly centered on patient’s experiences and rights. They argued that if an individual suffering from a terminal illness and all available life-prolonging measures had been exhausted, then euthanasia is morally permissible.40 The main components of such arguments are:
Autonomy
“Rights to One’s Own Body and Death” The right to life also includes the right to die. People should have the right to shorten the process of death and therefore, reduce the unpleasantness. By refusing a terminally ill patient’s request to die, the state is, in some way, violating that person’s fundamental rights.43
Death is a Private Matter
The state does not tell us how to live our personal lives as long as we live by the law. Death is a somewhat uncomfortable aspect of our lives that we may not want to consider until it is necessary. But, when we are ready to face death, whether it is our own or that of a family member, it should be an entirely private matter. It should be left up to us and our loved ones.40
Dying with Dignity
For many terminally ill patients, it is a matter of concern to die with dignity. They want to be remembered as a person who lived life with pride and died with dignity and not being slowly deteriorated by disease.40 Euthanasia can serve, in Brock’s words, as “psychological insurance” to relieve the anxiety of individuals who worry about having uncontrolled pain and suffering before death.44 The philosophical argument is that allowing euthanasia sends the message, “it’s better to be dead than sick or disabled” not only does this put the sick or disabled at risk, it also downgrades their status as human beings while they are alive. Pain and suffering are to be feared, and euthanasia is the only way to escape suffering.4 Dr Kevorkian, later famous as “Dr Death” euthanized 130 patients to end the suffering of terminally ill patients who wished to die. Arguably, he not only offered his patients a source of relief but also allowed them to keep their dignity.45 Later, Dr Kevorkian got convicted of second-degree murder and spent 8 years in prison.
Legal Aspects for and against Euthanasia
In 2002, the Netherlands became the first country to legalize euthanasia followed by Belgium and Luxembourg. Currently, PAS is legalized in five states of the USA and Canada.11–13,46,47 In India, active euthanasia is illegal and a crime under Section 302 or 304 of the IPC. Physician-assisted suicide is a crime under Section 306 IPC (abetment to suicide), but passive euthanasia has been legalized since March 9, 2018.33 The legalization of passive euthanasia was a landmark judgment in the history of India. The judgment was a result of a criminal writ petition filed on behalf of Aruna Ramchandra Shanbaug in 2009. The Supreme Court laid a provision for caregivers of cognitively incapacitated persons to request for non-voluntary and passive euthanasia to the High Court. Till the legislation from the Parliament is in place, Judgment has cited the powers of article 226 of the constitution. On receipt of any application for passive euthanasia, the High Court would appoint a board of doctors comprising a physician, a psychiatrist, and a neurologist to examine the patient based on which the court would decide on life-supporting treatment.48 On this MCI posited its position by saying that MCI already have clear-cut guidelines on this subject in regulation 6.7 of the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations 2002, which explicitly prohibits doctors from practicing euthanasia. According to the regulation, 6.7 practicing euthanasia shall constitute unethical conduct. However, on a specific occasion, the question of withdrawing supporting devices to sustain cardiopulmonary function even after brain death, shall be decided only by a team of doctors and not merely by the treating physician alone. A team of doctors shall declare withdrawal of the support system. The team shall consist of the doctor in charge of the patient, Chief Medical Officer/Medical Officer in charge of the hospital, and a doctor nominated by the in-charge of the hospital from the hospital staff or following the provisions of the Transplantation of Human Organ Act, 1994.49
Medical Aspects of the Debate
During the renaissance and early modern periods, there was a paradigm shift; the sacred human body became a natural scientific object; for instance, dissecting cadavers became common. By the early modern period, some dared to suggest that perhaps euthanasia was not such a grievous sin after all.30 Physicians throughout Europe and North America started advocating euthanasia openly.30 The human-rights philosophy allied with the rise of technological prowess available through science produced many zealous movements to legitimize medical suicide or euthanasia.32 A shift from the idea of spiritual authority to that of legal authority, six of the thirteen states in the newly-minted U.S.A., no longer mandated legal penalties for those who attempted suicide.30
Physician View on Euthanasia Globally
In a review, studies over 20 years that assess the attitudes of UK doctors concerning active, voluntary euthanasia (AVE) and PAS. In Table 2, listed the physician’s view on euthanasia in the last two decades.
Slippery Slope Argument for and against Euthanasia
Euthanasia, in its various forms, continues to polarize debate about medical ethics and has been flooded with slippery slope arguments expressing apprehensions and concerns that could gradually slip down to cruel and inhuman practices. The slippery slope argument is based on the idea that once a healthcare service, and by extension, the government, starts killing its citizens, a line is crossed that should never have been crossed. The concern is that a society that allows voluntary euthanasia will gradually change its attitudes to include non-voluntary and then involuntary euthanasia.58 It was virtually impossible to ensure that all acts of euthanasia were truly voluntary and that any liberalization of the law in the United Kingdom could not be abused. This results in involuntary euthanasia and is regarded as the first step toward the Nazi-style slide into genocide.59 Today the brain dead, tomorrow the mentally handicapped and day after, opponents of government?60 Legalized voluntary euthanasia could eventually lead to a wide range of unforeseen consequences.58 Evidence from the Netherland has shown that informed consent of the patient was frequently ignored in many patients subjected to involuntary euthanasia.59,61 One recent study from the Netherland showed 10% of the doctors deliberately terminate the life of a patient without an explicit request.62 Anti-euthanasia lobby argues that emerging advances at the end of life care or palliative care which is compassionated care of a dying sufficient for peaceful death but pro-euthanasia counter with the argument that pain control is elusive and the loss of control of bodily functions, or mental competence, or the prospect of drawn-out death itself, is of itself unbearable, the denial of autonomous control over their passing is the last indignity.63 The argument counters the slippery slope argument that the moral deterioration cannot be slipped down to out of control as the moral decline has taken place before the murdering begins; the leaders of the regime have nowhere further to slide59 (Table 3).
| Studies | Conclusions |
|---|---|
| Suarez-Almazor et al. 1997 | 60–80%—against euthanasia |
| Willems et al. 2000 | Netherlands physicians–American physicians found euthanasia less often acceptable than the Dutch |
| Parpa et al. 2006 | 42.4% of Greece physicians oppose reviving from cardiac or respiratory arrest |
| Abbas et al. 2008 | Majority of the Indian and Pakistani physician against euthanasia |
| Yun et al. 2011 | <10% of oncologists supported PAS and euthanasia |
| Smets et al. 2011 | (Belgian physicians) 90% in support of euthanasia |
| McCormack et al. 2012 | Majority of the UK doctors appear to oppose AVE and PAS |
| Levy et al. 2013 | Psychiatrists more conservative on PAS than physicians |
| Kane et al. 2017 | 45.8% of physicians agreed that physician-assisted suicide should be allowed in some cases |
| For | Against |
|---|---|
| Autonomy, respect, comfort, and peace belongs to each individual | Sanctity of human life, life is a gift from God, and God has the right to take life |
| Right to die with dignity | Religious prohibition “Thou shalt not kill” |
| Physicians’ responsibility for eliminating suffering and promoting the dignified end of life | In conflict with the basic principles of medical/nursing practice |
| Helps the patient, the patient’s family, and the family’s economy, caregiver burden | Responsibility to protect life |
| The critical illness which cannot be controlled by medical management | Vulnerable populations may be forced to end their lives |
| Encouraging the organ | No right to kill |
| transplantation | Malafide intention |
| Eliminating the invalid | |
| Symptoms of mental illness | |
| Emphasis on care | |
| The commercialization of health care |
CONCLUSION
Worldwide acceptance of euthanasia in some of the other forms and gradual legalization led to a great responsibility on physicians. History has already provided incidents of exploitation of such concepts. Physicians have to be aware and keep enough safeguards while adopting such practices. Euthanasia will remain a major controversy because first euthanasia is illegal and yet, in its passive form, practiced in many hospitals.73,74 Second, medical advances have made it possible to prolong life furthermore artificially; we must all contend with the reality that financial constraints are an essential consideration in modern healthcare provision. Finally, there is an ethical difficulty in interpreting the concept of a patient’s right, or autonomy, vs the rights and duty of a doctor.
KEY MESSAGE
- Euthanasia is a debatable topic since ancestral time.
- Euthanasia is multipronged, has no particular direction or solution.
- The Honorable Supreme Court of India allowed passive euthanasia under the “living will” clause.
- Still, the question of euthanasia is unresolved with many issues pertaining to passive euthanasia are unanswerable like “Who can execute the Advance directive and how?”, What if permission is refused by the medical board?, etc.
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