This essay is going to look at euthanasia. This will include an analysis of the theories and principles which guide healthcare practice and decision making, a discussion of the relevant codes of professional practice and the legislation that may guide practice and decision making. This essay will also include an evaluation of the effects of the ethical issue for the individual concerned, their family, health care workers and for wider society. Ethics are the principles on individual uses, in order to make decisions in life and when applying the values of a given profession. The value base informs the decision making process for the individual, but ethical principles also have to be used. There are different schools of thought regarding the function of professional ethics.
Each school of thought will tackle situations in different ways. Utilitarianism, or consequentialism, was developed by Jeremy Bentham (1748-1832) and John Stuart Mill (1806-1873). A utilitarian will believe that a morally right act has to bring about the greatest happiness for the greatest number of people. Utilitarians equate happiness with good, so a morally right act is one which creates the greatest good for the greatest number of people. Utilitarian philosophy holds that all knowledge comes from experience. It can be seen that utilitarian philosophy, like most ethics, involves making personal judgements, rather than following strict rules in a given situation.
Ethical systems of thought always encounter problems. It is difficult sometimes to define what is good. How can you guarantee that all possible consequences have been considered prior to action being taken? The concept of the greatest good for the greatest number of people is not straightforward.
The idea of creating the greatest happiness for the greatest number of people has to be used as a principle to guide the construction of codes of professional conduct, or for designing laws and systems of social regulation. Utilitarianism does not work very well when it is applied to day-to-day decisions, or day-to-day actions. The first reason for this is that very few people can predict the future and manage to work out what will create future happiness.
The second reason that utilitarian principles do not work very well when applied to acts of behaviour is that most people are very biased in their judgement of happiness. So the idea of greatest happiness may be a helpful principle of social justice, but not a useful way to make moment-by-moment decisions in care work. A deontological view (Immanuel Kant, 1742-1804) argues that the same rules should apply to all people and that knowledge comes from a process of reasoning.
Whether an action is right or wrong will therefore depend on the motives for the action. Kant’s theory is universal, this means that everyone has to follow the same moral rules whatever the situation. Kant believed that it is deemed an essential duty always to tell the truth because he believed that in this way respect for the individual is demonstrated. He also believed that all life should be preserved.
Kantians argue that it is impossible to have a meaningful relationship unless it is based on truth, for example, a patient has free will and, if he asks for a diagnosis, the truth must be told. In this way the doctor has done the right thing by telling the truth to the patient and has therefore demonstrated respect for that individual.
Critics of Kantianism state that the definition of duty can be interpreted in different ways by different people. The essential rule always to tell the truth may place an individual in an impossible situation, for example, being told something in confidence by one person then instructed to tell the truth about the confidence by another. Pure logic and absolute trust seem a good idea at first, but when used as a basis for day-to-day decision making the idea does not lead to acceptable practice on its own. It is not enough simply to be logical or truthful. Communication has to show respect for individual beliefs and identity. The care value base does not suggest that it might be acceptable to lie or mislead clients, but it does suggest that truth and logic are not the sole issues in care work.
Decision making in health and social care cannot depend on simple principles like utilitarianism or logic but nor can decision making be left to the beliefs what individuals have been brought up with, or socialised into. Professional value bases or codes of practice are needed to help worked make decisions. The problem is that decision making is still a difficult task, even when staff understand value basses and codes of practice. Many situations require professional levels of judgement.
David Seedhouse (1988) combines the theories of utilitarianism and Kant’s notion of consistency into one theory. Seedhouse argues that when an ethical decision needs to be taken, care workers should weigh up the facts of the situation, for example, workers collecting all relevant details about client need, legal rights and so on, the extent to which a decision may create a good outcome for everyone, this principle is the same as the idea of utilitarianism, fairness and consistency in any decision that is taken. People have a right to an equal quality of service or treatment. People must not be discriminated against.
This principle is similar in some ways to Kant’s ideas about consistency, and finally, the degree to which the decision empowers vulnerable clients and increases their control over their own life (autonomy). Decisions should not result in ‘control’ of others unless this is definitely in the greater interests of the majority people. The word ‘euthanasia’ originated in Greece and means a good or easy death. Nowadays the word is more often used to describe the deliberate ending of life.
There are six different types of euthanasia which are usually recognised.
These are voluntary euthanasia: a competent person makes an informed and free decision to end his/her life, non-voluntary euthanasia: a decision is taken to end a person’s life because s/he is hopelessly or terminally ill; it is non-voluntary because the person cannot be consulted about the decision – s/he may be unconscious, involuntary euthanasia: ending someone’s life either without regard to their wishes, when they are competent to give them, or against their expressed wishes, supposedly in their best interests, assisted suicide: someone supplies the patient with the means – for example, a lethal dose of drugs – to take their own life, active euthanasia: a positive action is taken to end life, for example, administering a lethal injection, and passive euthanasia: involving allowing a patient to die by omitting to act, for example, by withholding (or withdrawing) life-saving treatment such as artificial nutrition or hydration.
According to Tschudin (2003) nurses and doctors often have very different views as to the most appropriate care for patients who are terminally ill. Thus doctors may, for example, prescribe tests and treatments that they consider necessary but which nurses – who are more likely to know the patients wishes – consider inappropriate.
In the past death was a relatively straightforward state to identify and define. Thus when a person’s heart or breathing stopped it was generally accepted that s/he was dead. While this definition remains adequate it is not appropriate when intensive treatment has been used to maintain a person’s vital functions. To deal with such cases a different definition of death was developed, namely brainstem death. Although widely now accepted as the standard for determining death, the concept of brain death has always been controversial (Mason et al. 2002). Brainstem death has not been incorporated into legislation but it has been accepted by the courts.
The most persuasive argument in favour of euthanasia is the principle of autonomy. This principle requires you to respect your patient’s rights to make their own decisions about their care and treatment. For some patients this means the right to choose their own death. Some individuals feel that it is their duty to die because of social and other pressures – that they are, for example, a burden on their family or too costly to society (Tschudin, 2003). Voluntary euthanasia is the easiest to justify on autonomy grounds – because it is based on a patient’s free and informed choice.
Non-voluntary euthanasia on the other hand is harder to justify because then the decision to die is made by someone other than the patient. Unless, the so-called ‘substituted judgement test’ is used. This test is based on what the patient would have wanted, regardless of what others may think is a ‘good’ outcome. As an approach to decision making it can be described as autonomous because it looks at the situation from the patient’s point of view rather than the viewpoint of others (Kennedy and Grubb, 2000).
An argument closely related to autonomy is concerned with maintaining a person’s dignity; in particular the right to die with dignity, for example, some patients may not want to spend their last days, weeks or months attached to drips, tubes and so on.
A more practical argument supporting euthanasia is that it is practiced anyway. Thus, in one of many studies that have been carried out over the last few years – both on attitudes to and the practice of euthanasia – it was revealed that 22 out of 750 doctors admitted to having actively ended the life of a patient on request and a surprising 46% said they believed they should be legally permitted to do so (Mason et al. 2002). Nevertheless very few doctors who have taken part in some form of euthanasia are prosecuted for murder.
One of the most popular arguments against euthanasia is the sanctity of life doctrine. This believes that human life is sacred and taking it is wrong. This is a deontological view. Those who adopt this doctrine insist that, whenever possible, human life should be maintained. This means that generally they are keen to put enormous resources into prolonging a person’s life irrespective of the burden to that person or society.
Another very persuasive objection to euthanasia is the so-called ‘slippery slope’ argument. It is an argument that has many forms, but the main thrust of the argument is the claim that once we begin to kill others who have requested death, we will find ourselves sliding down a slope that leads to killings that no one wants (Singer, 1995). Or to put it another way, our moral standards will drop as we move from voluntary euthanasia to compulsory euthanasia.
Related to the slippery slope argument is the claim that, even if it were possible to draw appropriate boundaries and legalise euthanasia, it would never be possible to provide sufficient safe guards to prevent abuse. There is the very real risk, in short, that vulnerable people would be forced by unscrupulous relatives into making premature decisions they did not really want.
It is sometimes suggested that euthanasia is discriminatory because it implies that some lives are of less value than others and so are not worth prolonging. In other words, euthanasia discriminates against those who are terminally or incurably ill by reinforcing the idea that their lives, unlike others are unimportant. There have been several attempts in recent years to introduce legislation on euthanasia but none has been successful.
It is therefore not surprising that various professional bodies have issued comprehensive guidance on the basic moral principles that should guide practice. These cover withholding and withdrawing treatment as well as cardiopulmonary resuscitation. The most important current guidelines are Royal College of Paediatrics and Child Health (1997), General Medical Council (2002) and British Medical Association (2001a, b).
Although these guidelines vary in emphasis, several key moral principles emerge, in summary these are: treatment of patients should reflect the dignity of every person, irrespective of age, debility, dependence, race, colour or creed; actions must reflect the needs of the patient as well as their values, beliefs and priorities; life has a natural end; prolonging a patient’s life usually, but not always, provides a health benefit to that patient but it is not an appropriate goal of medicine to prolong life at all costs with no regard to its quality or the burdens of treatment; although emotionally it may be easier to withhold treatment than to withdraw it, there is no morally relevant difference between the two actions.
There are also some conflicts within the professional code of practice for example, in the Nursing & Midwifery Council Code of Professional Conduct, 3.2 states that ‘you must respect patients’ and clients’ autonomy – their right to decide whether or not to undergo any health care intervention – even where a refusal may result in harm or death to themselves’ but in 3.8 it states that ‘where treatment is necessary to preserve life, you may provide care without patients’ or clients’ consent’.
The principle of respect for autonomy acknowledges that patients have the right to control their own lives and so can decide when and how to die. This means that competent adults have the right to refuse life saving treatment. In this kind of situation the principle of respect for autonomy comes into conflict with other ethical considerations – non maleficence and beneficence.
The law strongly supports the principle respect for autonomy. However, legislation and case law have established beyond doubt that, even though patients may request help to die it is unlawful to assist them. So, for example, if a patient commits suicide by taking an overdose of tablets you have left by the bedside for that purpose, you could be found guilty of assisting suicide (under the Suicide Act 1961).
The principle of the sanctity of life is a fundamental legal principle that is now enshrined in the Human Rights Act 1998 (Article 2), but the principle is not an absolute legal one. Thus, even though the law clearly prohibits taking active steps to terminate life, it does not require every patient to be resuscitated. Note too, that the courts have also recognised that Article 3 of the Human Rights Act 1998 (the prohibition on torture, and cruel and inhuman treatment) encompasses the right to die with dignity. In effect, then, the law recognises what has been called a ‘qualified’ sanctity of life principle (Stauch et al. 2002). It is qualified because according to the law a person’s quality of life might be such that it is not in his/her best interests to prolong it.
The principle of beneficence is often seen as the overriding duty in health care. It means the duty to do good. Non-maleficence requires you not to harm patients intentionally. In treatment decisions at the end of life the dilemma in applying these principles often revolves around what course of action will promote the patient’s best interests. In the past, best interests was almost always equated with postponing death, but prolonging life may not now automatically be the most ethical approach, or to put it another way, in end of life decisions the question of how much harm is caused by the treatment needs to be considered, as does the question of whether death itself is always a harm.
In very broad terms one can say that in relation to patients who are dying or incurably ill the legal duty to act in a patient’s best interest means preventing or retarding a deterioration in their condition, and the relief of pain and suffering. Several options are therefore lawful, these include, withdrawing life-sustaining treatment; withholding life-sustaining treatment; DNAR orders; and given pain killing drugs that may shorten life.
The DNAR order is usually given by a doctor in an attempt to avoid ‘over treatment’ and cardiopulmonary abuses. DNAR orders are controversial for several reasons: subjective judgements - lack of consultation with patients and their families raises the spectre of doctors making ill thought out, hasty decisions about lives they think are not worth living (Montgomery 2003). Age discrimination – evidence strongly suggests that
DNAR orders are issued more often and more freely in older patients irrespective of the diagnosis and prognosis (Mason et al. 2002). This shows an inequality in decision making. Inadequate documentation and communication – failings in formally recording and communicating DNAR orders – verbal orders are often the most common form of communicating DNAR status – mean that there is often confusion among staff about the procedure (Tschudin 2003).
DNAR decisions are made by involving moral judgements and this is confirmed by current guidance issued by the NHS, the British Medical Association and the Royal College of Nursing. Few cases have reached the courts on the legality of DNAR orders. Nevertheless case law has made it clear that a DNAR order that is supported by unanimous professional opinion and the patient’s family will almost always be accepted by the courts as lawful.
There is a vast literature on the distinction between killing and letting die (also know as the acts/omission doctrine). The doctrine maintains that there is a moral difference between actively killing someone and failing to take action (an omission) that may save or preserve that person’s life.
Despite the uncertainty as to whether there is a moral distinction between an act and an omission, the law accepts the distinction unequivocally. In other words, there is no doubt that in law there is a fundamental difference between giving a patient a lethal injection (an act) – which is unlawful – and withdrawing or withholding treatment (an omission) – which is lawful. The leading case that established this legal principle was the famous bland case.
21 year old Anthony Bland had been crushed in the Hillsborough football stadium disaster. For 3 years he had been in PVS but his brain stem was still functioning. In law, therefore, Anthony was alive. He was able to breathe and digest food but could not see, hear, communicate, taste or smell. His bowels were evacuated by enema and a catheter drained his bladder. He was fed through a nasogastric tube and lay in bed with his eyes open and his limbs crooked and taut. He had had repeated infections and had also been operated on for various genitourinary problems. With constant care he could be kept alive for many years but he would never regain consciousness.
The House of Lords decided that discontinuing treatment, including ventilation, nutrition and hydration, was an omission. In other words, stopping life support was simply allowing nature to take its course. Health professionals were not therefore – in law anyway – responsible for his death. The case did provide guidelines as to when life saving treatment could lawfully be withdrawn in PVS cases. However, the legality of non treatment decisions in respect of other patients, those not in PVS but who nevertheless have irreversible brain damage – is less clear. It is in these kinds of situations that the distinction between foreseeing and intending death – the so called double effect principle – may be relevant.
The principle of double effect was developed by Catholic theologians in the Middle Ages to determine in what circumstances an action that has both good and bad consequences is morally right. When, in other words, can you do something that is intended to produce a good result but will also have a harmful effect? Prescribing pain relief that, in large doses, shortens the life of a terminally ill patient is often used as an example of double effect. Justification for giving the morphine lies in the fact that, although the patient’s death is foreseen, it is an indirect result of the treatment and unintended. There three main criticisms of the double effect principle.
The main criticism of double effect is that it is simply not possible to distinguish between a consequence that is intended and one that is foreseen, another criticism is that it is no longer appropriate because pain can be ‘controlled’. Finally, the last criticism is that the illusion created by the double effect principle is that we do not intend or expect death. The principle has therefore allowed us ‘not to confront death, not to take part in it and not to understand the issue of dignity’ (Cassell 1996).
The law first recognised the principle of double effect in the 1957 case of Dr Adams, who was accused of deliberately increasing the dose of opiates used as pain relief in order to end the lives of patients who has left him money in their wills. In summarising the legal position the judge said ‘the doctor is entitled to relieve pain and suffering even if the measures he takes may incidentally shorten life’ following this advice the jury acquitted Dr Adams. Inequality in health care is a harsh reality.
This has been shown by more older patients than younger patients being given the DNAR order irrespective of their diagnosis or prognosis. Physician-assisted suicide is contrary to the concept of equality for everyone. Very often the group most targeted by physician-assisted suicide is the disabled community because the ‘quality of life’ of its members is deemed to be ‘poor’ by people outside the community.
This was shown in the Robert Powell case. Robert Powell a disabled person, who was repeatedly refused treatment for various different conditions, said ‘I enjoy life just as much as anybody else does. I can do things that just about anybody else can do. It is a matter of how you perceive ‘quality of life.’ You ask one person about his definition of quality of life and he may give you one opinion, ask a disabled person his opinion of ‘quality of life’ and you'll certainly get another’. Suggesting that people can be ‘helped’ by offering them physician-assisted suicide destroys the very concept of equality and disability rights.
A study was conducted by the Department of Gynaecology, University Medical Centre Utrecht, and by the Research Institute for Psychology and Health (Swarte 2003) to assess how euthanasia in terminally ill cancer patients affects the grief response of bereaved family and friends. The results showed that the bereaved family and friends of cancer patients who died by euthanasia had less traumatic grief symptoms, less current feeling of grief and less post-traumatic stress reactions than the family and friends of patients who died of natural causes.
These differences were independent of other risk factors. The bereaved family and friends of cancer patients who died by euthanasia coped better with respect to grief symptoms and post-traumatic stress reactions than the bereaved of comparable cancer patients who died a natural death. Doctors and hospital staff have the advantage of being used to seeing such things and having clinical detachment, friends and family do not. Advances in medical treatments have enabled us to keep people artificially alive, using respirators and methods of artificial feeding.
Drugs used to try and control diseases can be very expensive; chemotherapy treatments used in the fight against cancer, for example, cost a great deal of money. There comes a point where these treatments are no longer offering therapeutic benefits, and they are merely prolonging the dying process. If the patient were to request euthanasia such treatments would not be given, thus saving a considerable amount of money.
This money could be used to provide resources for people who have a chance of surviving, improving hospital facilities, buying more equipment - it could be used in ways that would save lives. People choosing euthanasia would in fact be helping society. The individual concerned may feel that dying would be the best option, for example, the elderly may feel pressured into requesting euthanasia as they see themselves as being a burden to society or they may have just had enough of the pain and suffering and would not want to go through anymore or for their families to see them go through anymore. In conclusion, euthanasia is a complex issue.
There are many pros and cons towards legalising euthanasia, it would give people greater autonomy over their own lives and give terminally ill people a chance to avoid great pain and emotional distress. However, it begins the degradation of the prohibition of murder, and opens up the possibility of further erosion of the system. The death of a person affects the lives of others, often in ways and to an extent which cannot be foreseen. We believe that the issue of euthanasia is one in which the interest of the individual cannot be separated from the interest of society as a whole. REFERENCES
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