As medical science advances, and our ability to keep people alive improves, we increasingly find people reaching the last stages of their life, or surviving in conditions that would have proved fatal in the past. However, in many of these cases, people are going through physical and emotional suffering that can cause their lives to become very difficult. In an attempt to relieve this suffering, some people seek euthanasia. This can provide people with a controlled way to end their lives, ensuring their last moments are dignified and peaceful, and allowing them to escape the suffering they were forced to endure. While some advocate for this practice, others say that it is immoral, and suggest an increased focus on palliative care to support those facing these problems. Exploration of this issue finds that ultimately, while there appears to be an increasing role for euthanasia in the modern world, the definitive determination of euthanasia’s place in society will require much more research and discussion of the core issues which it raises.
Introduction
Euthanasia is defined as “the act of deliberately ending a person's life to relieve suffering”. People seek euthanasia as it provides a solution to problems that many views as insurmountable; more specifically to deal with “unbearable” suffering that may arise in life, and or death. While euthanasia deals with this suffering, it is an extreme solution, and one which raises many issues: is euthanasia the optimal way to deal with the issues that people are facing? Is it a moral course of action? Is it compatible with the culture of modern-day society? Ultimately the place of euthanasia in healthcare comes down to the answers to these questions.
Is Euthanasia a Solution to Poor Quality of Life?
One of the primary reasons individuals seek euthanasia is because they feel they are experiencing poor quality of life. In the throes of serious illness or in the final stages of life there are lots of factors that can cause an individual’s quality of life to decline. Many people’s suffering comes from a physical deterioration associated with their condition. This can manifest itself as pain, a loss of normal abilities, or as other symptoms (such as breathlessness, nausea, or fatigue). Suffering can also come from losing purpose in life, which can come from a loss of dignity, an increased dependency on others, and loneliness. This is not an exhaustive assessment of the reasons people perceive themselves to have a reduced quality of life. However, the key point is that this perception exists and that many people also believe there is no chance of their situation improving. This leaves people with a sense of hopelessness, which is often a driving factor in the decision to seek euthanasia.
While euthanasia can therefore offer a solution to the relief of suffering in this situation, it may be more appropriate to try and address the suffering itself. Through palliative care, the wants and needs of an individual can be identified, and a care plan can be put into place to work towards these. This can involve working towards the relief of physical suffering, as well as bringing meaning back to an individual’s life by helping them live in the way that they want to. Through this approach, it could be possible to improve the quality of peoples’ lives in situations where they thought that to be impossible, which is a preferable approach to relieve suffering than euthanasia is. This is supported by studies showing that patients’ wishes to seek euthanasia changed when they had appropriate pain management.
However, a systematic review conducted by the BMJ found that the evidence on the benefits provided by palliative care was either inconclusive or suggested only modest benefits. Furthermore, the treatment provided in palliative care can cause its own issues, and another study found that some people found the side effects intolerable. It should therefore be recognized that while palliative care offers an alternative way to deal with suffering and improve the quality of peoples’ lives, it will not necessarily relieve all of the problems faced by those who seek euthanasia.
Does Euthanasia Offer the Best Quality of Death?
Another reason people seek euthanasia is to have a good quality of death. The idea of a good quality of death can mean different things to different people. For some, it refers to a desire to control the circumstances of their death, and in one qualitative study a terminally ill patient is quoted as saying “We should all have the right to choose when we die and how we die”. There are numerous reasons people may wish to have this control; qualitative research has revealed that many people do not wish to be a burden on their family as they become increasingly dependent, while others simply wanted to be able to spend their last moments with their loved ones while they were still themselves, rather than reaching a stage where they would be physically and cognitively impaired. For many individuals, the good quality of death refers to death free of pain. Through discussions with those who are terminally ill, it was found that a large motivation for seeking euthanasia was to avoid a painful death.
Again it is important to consider the ability of palliative care to achieve a good death as an alternative to euthanasia. As a patient approaches their last moments the role of palliative care is to provide a peaceful, pain-free death. Research shows that pain management towards the end of life can be effective at controlling pain, with relatives of cancer patients reporting that pain toward the end of life was completely controlled. In cases where physical symptoms do not respond to treatment, continuous sedation can be employed. This involves reducing the patient’s level of consciousness continuously until the time of death. This can be used as a last resort to control a patient’s symptoms in the last days of their life.
However, it again must be recognized that palliative care is not a perfect solution. The primary issue is that the methods of controlling pain and other physical symptoms can have adverse effects on the patient. One study found that a concern for some individuals is that the treatment required to control their symptoms would impair their cognition. It, therefore, follows that the solutions offered by palliative care would not be useful for those who wish to remain lucid in their final moments of life. Furthermore, research has identified that while some health care professionals feel there is a clear distinction between continuous sedation and euthanasia, for others it is a blurred line. In particular, one physician is quoted as saying “… initiating a euthanasia or a sedation is the same, ethically speaking.”. As one of the major issues surrounding the use of euthanasia is the ethical problems raised by actively ending a person’s life, it is important to consider that the use of continuous sedation raises the same issues for some individuals, meaning it is not necessarily a viable alternative.
Ethical Considerations Regarding Euthanasia
The ethical dilemmas surrounding euthanasia provide a series of arguments for and against its use. The immediate concern lies in the fact that to actively cause death is in direct contradiction to the principles of beneficence (although this is subject to question in cases of patient suffering) and non-maleficence. However, in cases where an individual is either close to death, or has a life that is deemed as not worth living, this could be considered to be less relevant.
This raises the question of what deems a life as not worth living. Some would argue that all life is worthwhile and that there is, therefore, no justification for taking a life. Others would argue that whether a life is worth living is dependent on the circumstances of the individual, such as in cases of unbearable suffering where there is no hope of improvement. However, cases also exist where an individual may feel this way, but it is not necessarily true; such as when these feelings are due to depression, or when these feelings exist but there is a legitimate chance of an improvement in quality of life. It therefore must be established whether a patient’s view of life as worthwhile can be restored, or whether their view of life as not worthwhile can be trusted before it is established if euthanasia is an appropriate course of action. It should also be realized that it is often difficult for healthcare professionals to make this assessment.
An argument in favor of euthanasia is that the ultimate purpose is the relief of suffering. While playing an active role in the death of an individual can be viewed as causing harm, it can also be argued that in cases of extreme suffering the beneficent act is to relieve it. However, if this suffering can be relieved effectively through other methods, such as those offered by palliative care, some may say that this is the more ethical course of action.
Also in support of euthanasia is the idea of maintaining an individual’s autonomy. In order to maintain freedom of choice, it can be argued that people should be given the chance to control the circumstances of their death. However this is directly contradicted by another idea that death itself leads to the end of autonomy as it removes the ability to make any other decisions, and therefore it is ethical to not perform euthanasia, as this preserves a person’s autonomy. Furthermore, autonomy can only be considered to be valuable when a person has the capacity to make decisions. This poses a particular problem in cases where people are seeking euthanasia because, as previously discussed, patients are often facing circumstances that will impair their ability to make decisions in their best interest, such as suffering depression, or feeling like they are a burden on their family. There is the potential that this problem could be circumvented through the assessment of a patient’s capacity before allowing them to make these decisions, although this can be difficult to accurately determine. However, it is important to recognize that even if someone is deemed as not possessing capacity that they still may be going through unbearable suffering. This raises the question as to whether it is ethical to restrict access to euthanasia to these individuals, and whether there should be alternative methods by which these individuals should be able to gain access to it, such as through advanced directives or the appointment of a health care proxy.
Public Acceptability of Euthanasia
Another important consideration when looking at the viability of euthanasia is the impacts the use of euthanasia would have on society. One very important thing to consider is the effect on the public’s trust in the medical profession. Maintaining this trust is crucial, and is even outlined by the GMC as one of the cornerstones of good practice. If the public fear there is the potential for the use of euthanasia to be abused as an option by physicians this trust could be damaged. On the other hand, legislation surrounding the use of euthanasia could ensure there is appropriate regulation of its use, which would prevent this from being a concern.
The public acceptability of euthanasia must also be considered. The opinion of the public varies across different societies due to a complex mix of socioeconomic and cultural factors. General trends between countries have established that support for euthanasia is associated with younger ages, secular views, lower social class, and lower levels of education. Considering this, it should be realized that there is no one size fits all policy regarding euthanasia that would work effectively for every society. For example, the place of euthanasia in the UK – where generally there is widespread public support for its implementation – will be different from a country such as Malta – where there is opposition to the concept of euthanasia.
Healthcare Professionals’ Views on Euthanasia
As well as looking at the views of the public, the stance of healthcare professionals on euthanasia should also be taken into consideration, as they are the people who will be carrying it out. A study of the opinion of UK doctors on euthanasia found that in general, they are opposed to its use, with the strongest opposition coming from specialties that are more involved with end-of-life care, such as palliative medicine or care of the elderly. The views of these specialties are of particular importance, as they are the most likely to understand the needs and the views of those who are in the final stages of life, and therefore the most likely to advocate for their best interests.
These findings fall in line with the trends observed in most countries. This lack of support had numerous contributing factors, such as the need for a focus on palliative care or the religious beliefs of the doctors involved that have already been discussed. In particular, a study by D. Clarke et al. found that many geriatricians opposed euthanasia on the grounds that vulnerable patients may feel a duty to die, a view that is likely formed from their experiences in dealing with elderly patients. However, a new theme that emerged was concerned over the role and obligation of doctors in the provision of euthanasia. It was recognized that there should be an opt-out policy for doctors with objections to the practice, and appropriate safeguards surrounding the delivery of euthanasia to protect both patients and doctors.
The perspective of nurses on euthanasia is harder to establish, as there has not been much research in countries where euthanasia is illegal. It was found that while the situation requires more research, general nurses tend to want to act in a way that is most compassionate for the patient, although this is often difficult to determine, and the doubt about what the right course of action left many nurses with negative feelings. It could be argued therefore that euthanasia has a negative effect on the nurses involved with its delivery. However, a study of nurses in Belgium – where euthanasia is legal – found there was strong support for euthanasia. It was suggested that this support was due to an increased ability to aid the relief of suffering within patients. Therefore it could also be argued that euthanasia benefits nurses by enabling them to act compassionately towards patients with untreatable suffering.
Conclusion
In my opinion, euthanasia is an acceptable practice and could be considered the best way to die. I feel that quality of life can degrade to the point where life is no longer worth living and that it is cruel to impose a life of unbearable suffering on a person if they wish to die. While there should be an attempt to improve the quality of life through palliative care, I recognize that it is not guaranteed that this will indefinitely maintain an adequate quality of life and that after palliative care begins to fail the needs of the patient, euthanasia should be considered as an option. I share the concerns of others noted by Hurst SA. and Mauron A. that an endorsement of euthanasia could potentially lead to a reduction in palliative care, as it may be seen as an alternative to it. It is therefore important that if euthanasia is to be available that there are strict guidelines and procedures around its delivery to ensure that other options are explored first. There is evidence to suggest that this is not a concern because Belgium and the Netherlands – two countries in which euthanasia is legalized – have greater palliative care resources than many surrounding countries in which euthanasia is not legal.
In regards to the use of continuous sedation over euthanasia, I believe there to be no difference ethically in the actions being performed. In cases where a patient is undergoing continuous sedation, they are no longer able to live in an autonomous manner, and to say that the patient is still truly alive is a technicality, in that their biological processes continue to function. While ethically these can be considered to be the same, I recognize that the distinction between dying naturally and being actively killed is an important one for some, such as those who are religious, and therefore suggests that both should be able to be requested by patients as an option for end of life care.
The use of euthanasia raises many issues, with many valid points existing on both sides of the argument. By some it is considered to be an act of mercy, allowing someone to die with dignity in order to relieve their suffering where all other options have failed to do so. On the other hand, others view it as an immoral and unnecessary practice, arguing the same effects can be achieved through palliative measures, without the ethical and social implications raised by actively causing a person’s death. More research and discussion will be required to appropriately resolve the issue of euthanasia’s place in modern-day society. As time progresses and medicine continues to improve, more people will find themselves reaching the last stages of life, making this issue increasingly relevant with every passing day.