‘…Craving death, but lacking the means to die’: perspectives in favour of voluntary euthanasia from a medic to be
Dory-Anthony Ghanem
After writing, the British Medical Association published the largest ever survey of its members on support for ‘physician-assisted dying’, revealing an overall support of queried members for legal changes to current prohibitive euthanasia legislation, in favour of broadening the scope of patient-choice about death. The results can be found here: https://www.bma.org.uk/advice-and-support/ethics/end-of-life/physician-assisted-dying-survey
In 2012, 51-year-old Tony Nicklinson applied to the UK’s High Court for assurance that it would be lawful for a doctor to end his life. He had locked-in syndrome, a pseudocoma with near complete body paralysis, and was unable to die unassisted as such. The courts rejected his appeals and six days after the ruling he died from the ‘old man’s friend’, pneumonia.
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Etymologically, ‘euthanasia’ is derived from the ancient Greek words for ‘good death’, eu and thanatos respectively. Euthanasia can be classified in relation to the nature of the act, and the conviction (or lack thereof) of the patient in question1. The main object of discussion here will be voluntary euthanasia, whereby the patient, with mental capacity, makes clear their intention to be euthanised, expressing their intent either directly to their physician or via proxy. Voluntary euthanasia might be active or passive. Active refers to those instances where the physician brings about death by administering a drug or by performing an action that terminates life. Passive euthanasia is when death is brought about by the withholding of drugs or by the ceasing of activities needed to sustain life, for example turning off a life support machine (1). Physician-assisted suicide is informally considered a subset of active euthanasia, although here the physician would be merely facilitating the patient’s suicide by providing the patient with the means to end their life independently.
This essay will assume a critical synoptic perspective on the history of philosophical discussion of voluntary active euthanasia from the outlook of a medical student in the 21st century. The issue of euthanasia is one that has potential to redefine what the role of a doctor is, and affect how doctors and doctors-to-be will practice. I will assess the morality of euthanasia, and my support for its legalisation, in terms of autonomy. Autonomy is an essential marker of our humanity and defines our identity, it is our ability to have and make choices in any given circumstance. We must, though rarely consider, the autonomy of both the patient, and the second agent of euthanasia, the doctor. The morality of euthanasia should be considered as its permissibility, in the appropriate circumstances of terminal illness or incurable pain, as the best course of action for a patient’s wellbeing, thus respecting the physician’s commitment to the duty of care, and the suffering patient’s concrete autonomy. It should also reflect whether euthanasia can really offer a ‘good death’: a death with dignity, organisation and composure, in circumstances that have not obstructed the physician’s right, indeed duty, of care. We have already met the ‘old man’s friend’, Pneumonia. This is a phrase that became commonly adopted after Sir William Osler, in 1892, recognised the tendency of pneumonia to transition the elderly patient into a reduced state of consciousness, leading to a near-painless death. Could this have been an early indication of what a good death meant?
The Hellenistic schools of the Stoics and Epicureans suggested standards for a good and moral death. The Stoics proposed that suicide was morally permissible, given life was less desirable than its absence, an absence which we could consider as ultimate nothingness. In some instances, suicide was even encouraged as an escape from having to commit a dishonourable act. The Epicureans contrasted the Stoics, hesitant in too quickly sanctioning suicide as a moral act, they suggested rather that the taking of one’s life was often an admission of defeat, even in the most disagreeable of circumstances (2). Epicurus’ fourth principle doctrine of the tetrapharmakos, or four-part-remedy, suggests that “evil is easy to endure”. (3) He specifies that extreme pain is seldom unremitting, and as such, we should not fall victim to it, especially not so far as to take our own lives. Acute pain might be short and harsh, but it will not last long. Chronic pain, although long-lasting, is dull and understated. Endure the pain to recognise your threshold and develop a tolerance for pain to become accustomed to it. This will make for a more fulfilled life, and attainment of eudaimonia, or flourishing (4).
Contemporarily, Western medicine considers good death using psychosocial models. The Kübler-Ross Grief Cycle supposes that a person who faces grief, for reasons of imminent death or otherwise, advances through five stages: denial, anger, bargaining, depression and finally, acceptance. If the fifth stage is realised, a person can be considered ready to die a ‘good’ death, that is, a death with dignity and composure (5). Nevertheless, the vast majority of patients will not reach this stage of equanimity, for it is conditional on there being exceptional palliative care, including adequate pain relief. If we consider that 3% of pain cannot be managed without use of intrusive epidural catheters or nerve blocks, this leaves a multitude of patients without the liberty to pursue such a ‘good death’ (6).
Much of the modern and historical conversation on the morality of euthanasia and suicide centres around pain. Pain, a phenomenon of our nociceptive pathways, is a driver of emotion and action. Discussions of euthanasia, therefore, have tended to be largely emotive, impulsive and instinctive. In contrast, we ought to consider the image of a good death, one with autonomy for the patient, noting something more than the mere absence of pain. What constitutes a good death is one with choice, for, again, it is our choices that define us. However problematic, the ability to choose one’s death, in the circumstances of otherwise total incapacitation and absence of choice, becomes one’s remaining, and therefore defining, liberty. Sophocles, in Electra, concluded that ‘… death is not the most odious thing; it is rather craving death, but lacking the means to die.’ (7)
Autonomy in life and death
Traditionally recognised as the one great certainty, we have solemnly anticipated death throughout our history. We have an urge to reproduce, and fear pain and danger. This finitude of our time, that comes as a consequence of death, is what gives meaning to our decisions, indeed to the mere fact we can make decisions. We can neither go back nor pursue a path untravelled. Erikson’s eight-stages of psychosocial development highlight this by concluding with the choice, in our late adulthood, between ego integrity and despair. A person nearing the end of their life recalls their achievements and considers whether they can die with integrity and dignity, or despair and regret (8). Ego integrity according to Erikson is, ‘a post-narcissistic love of the human [Freudian] ego—as an experience which conveys some world order and spiritual sense, no matter how dearly paid for…’ (9). Success in doing so leads to so-called “wisdom”, and acceptance of death. These terms are not solid, but it is provocative to consider such models. We can consider integrity as tied to our personal identity, derived from, and thus giving each of us, accountability and autonomy over our decisions. As such, we should strive for a life of integrity, up until our final moments, even if previously unconsidered.
A 2006 study queried terminally ill patients in the UK on their positions on and motivations surrounding euthanasia and concluded that the majority of those in the sample were pro-legalisation, often citing the main reason for this was fear of loss of dignity on their deathbeds (10). Proponents of euthanasia posit that it might bring choice back into the process of dying, permitting a death with dignity, and maintaining integrity. In our final stages, should we fall into despair, one, for our lack of choice and, two, for lack of comfort on our death beds? In cases of incurable suffering and tribulation, should we resolve to die in opposition to having to relish, as Epicurus would have it, in our pained existence?
Proponents of voluntary active euthanasia often arrive at their opinion from secular ideas, especially those of individual autonomy and liberty. John Stuart Mill’s Harm Principle serves as an archetypal reasoning in favour of euthanasia and its morality. Surely in our free society, one should have the liberty to do as he pleases with his own life, so long as he does not bring harm upon others? Mill’s philosophy draws largely from Benthamite utilitarianism, that we should maximise pleasure and aspire to ultimate hedonism, although to Mill this is about maximising morally good acts. For him, to do this we must not be obstructed by our deprivation of liberty so as to reach the boundaries of our capacity to do good. As such, we can consider that in times of tribulation and extreme helplessness, which might accordingly incapacitate us, we should be able to exercise any final piece of liberty we might have in choosing to die. At such a stage in our lives we might not have capacity much more than to die, so why not choose to die on one’s own terms and with dignity?
Euthanasia is within and facilitates the patient’s rights to autonomy and self-determination. Allowing the patient to decide the context within which their death occurs could allow them to reach acceptance, in spite of incurable pain and poor care. Control over the context of their passing will give the patient a monition, prompting them to organise their affairs prior to them either being too weak or without capacity to do so, accepting their fate with the peace of mind that their loved ones will be cared for. Often patients feel their pain reflected in their loved ones, which adds to their distress and resistance. This pain has led to 44% to suggesting that they would break the law to help a loved-one die, risking a hefty prison sentence (11).
It might be useful to reflect upon possible alternative fates of some terminally ill patients in the absence of euthanasia. We can assume that a portion of the terminally ill would persist in their pain and another portion would take their own lives instead. 300 of those who take their own lives, on average in the UK, were suffering from a terminal illness. This accounts annually for seven percent of all suicides in the UK (12). Suicide, no matter how privately it is conducted, can reasonably be said to always leave angst and unanswered questions behind. Suicide attempts are often mismanaged, and if they fail (as the majority do, with there being an estimated 140,000 failed suicide attempts to 4300 suicides each year in the UK (13)) they can, in enough instances, make life even more unbearable than prior to the attempt at taking one’s life. Neurological deficits which might incapacitate a person for the rest of their lives are common in failed suicide attempts, including Parkinsonian dyskinesias, and might sometimes lead a patient into a persistent vegetative state. On the contrary, euthanasia is highly medicalised, and directed by stringent medico-legal frameworks. The probability of failure and ensuing trauma is significantly reduced.
Where legal, before being allowed euthanasia a patient must fulfil a list of criteria, including numerous psychiatric assessments. These assessments are often psychologically beneficial, either by prescribing them with drugs to ease the mental torment accompanying their physical disorders, or by allowing them the space and prompt to consider a new perspective on the good life and death. Doctors can help guarantee that these patients are making an assured decision. In cases where all organic and psychological means have been exhausted, the mere choice of euthanasia might act as a back-up plan to fall upon should a patient not be able to continue any longer. Acting as a respite, it reassures a patient that they need not suffer endlessly. It provides a limit to their suffering. Euthanasia might give patients the resolve they need to continue for just a bit longer, in the knowledge that they can push the foot break, rather than tumble into chaos without an emergency stop. Ninety-five percent of those who elect to proceed with active euthanasia in the Netherlands, choose for the doctor to administer the medicine rather than them doing it independently, suggesting people recognise there are benefits to medicalising their death (14). Hugo Claus, a 78-year-old Belgian man who opted for euthanasia, died peacefully, singing with his wife after a cigar and a glass of champagne. Though perhaps romanticised, he left behind no disputes, no unanswered questions and precluded the impact of a sudden passing. The definition of a good death varies between people, and is difficult to define, but what could be near universally agreed upon is that a bad death is one without closure, conducted in isolation and out of fear rather than a pursuit of relief. Suicide has been decriminalised in the UK since the passing of the Suicide Act in 1961. Euthanasia should be, too.
Jacques-Louis David’s 1787 The Death of Socrates depicts Socrates’ punishment for the charges of impiety against the Pantheon, and the corruption of the youth of Athens: poisoning by hemlock. Plato’s Crito makes clear that Socrates had the means to escape justice, privileged with followers who would help assure his safety, and by bribes organised by the affluent Crito of Alopece. The aged Socrates refuses Crito’s proposal, arguing one’s goal should not be to live a long life, but a fulfilled and virtuous one. David represents Socrates’ acceptance through his jutting expression, left arm pointing to the heavens and the right hovering above the chalice, suggesting a certain fervour to meet his unbidden end amongst the disbelief of his students. He departs after declaring, “Crito, we owe a cock to Asclepius, pay it and do not forget (15). Socrates was neither regretful nor did he bemoan his fate. In irony, he acknowledges Asclepius, the god of medicine and health, in a bold display of his unfettered acceptance. He will die with dignity and in pride, concurrently teaching his disciples one final lesson.
Autonomy, as Socrates' death shows, is essential to how we conceive of ourselves, our identity. Just as Socrates dies teaching his students, we must reach a position where we feel as much passion for what we have accomplished, who we are in life - mother, teacher, doctor, brother, human - as when we were well, regardless of whether we are physically able to continue. It is the intention, and therefore the peace of mind, that matters. Crito is a notable character in the story of Socrates’ end. Aside from other reasons, he objects to Socrates’ death for fear it might portray him as being too pusillanimous to save his companion. Crito is comparable to the second agent in a patient’s death, the doctor, who fears uncertain relationships with society and, most importantly, their patients, should euthanasia be legalised. It is now worth considering the medic’s role in euthanasia.
Autonomy in the duty of care
Patients assume their doctors not only to have procedural competency and a breadth of scientific knowledge, but also implicit emotional traits, such as compassion and empathy. The General Medical Council’s Good Medical Practice outlines the role of the doctor as equally being practitioner, scientist and professional (16). The role a doctor should have in euthanasia has been contested for fear it might jeopardise the patient-doctor relationship, breach the orthodox role of a doctor and science in society and, most gravely, lead to an exploitation of power. This reveals a complex conception of a doctor’s obligations: to the care of their patients, the bond with society that underpins this, and their duty to medicine as science. Too often, the duty and right for a doctor to fully discharge his responsibilities is considered tangential to the ethical question of euthanasia.
Accounting for the doctor’s role as a scientist, many raise the impracticalities that the legalisation of euthanasia would create for natural scientific investigation. Challengers to euthanasia fear what may become of Research and Development funds in a post-euthanasia world. Should euthanasia become a mainstream and accepted alternative to traditional medical care, pharmaceutical and biomedical research will be stalled as a consequence of such profound lack of incentive now that terminally ill patients are left to die. If euthanasia had been legal in the 1920s, would Banting, Best and Macleod have pursued treatment of diabetes, which in those days was often a death sentence, and subsequently discovered insulin?
To this rather cynical argument, one might consider that a large proportion of R&D is subsidised by the Government, as well as by donations from family members of patients with these terrible illnesses. State-funded research, as we can note with the COVID-19 vaccine underway, is essential to medical research, and the private sector could never manage alone. As I mentioned, part of a doctor’s broader role is as a scientist, a commitment to the perpetual pursuit of knowledge for the furtherance of human understanding of the natural world. Scientists and physicians alike have a duty to nature, alongside their duty of care. Research is done not only to improve human life, but also for its own sake. We must not consider that the profit motive exclusively drives research either, for those same scientists who discovered insulin sold the patent for a single dollar.
A different kind of opponent holds hope that advances in medical research might mean that illnesses that are presently incurable, might be curable in the future. They see it as an injustice that a life might be lost, when a treatment might be just on the horizon. It is right that a physician exhausts all possible options with their patient prior to consideration and acquiescence of euthanasia. Acting in the best interests of your patient involves keeping up to date with the latest medical breakthroughs in their disciplines. Doctors are experts in their fields and similarly experts in each of their patients’ unique healthcare needs. We can assure ourselves doctors will always pursue any treatment probable to work, in accordance with evidence-based practice. We should also reflect that the likelihood of a life-saving drug suddenly becoming available after a patient’s passing is highly unlikely. Drugs can take anywhere up to 10-15 years to progress through their clinical trials. If a drug was likely to be ready for licencing soon, a doctor should know this, and will accordingly alter the care of their patient in anticipation of perhaps prescribing this drug. But if we suggest holding a patient nearing the end of their life, in anticipation of a drug that might come in the next few months, if not years, this is quite unacceptable given the doctor’s commitment to rational, concrete amelioration of a patient’s quality of life. Research has also shown that doctors tend to overestimate, rather than underestimate, a terminally ill patient’s life expectancy (17). A patient’s suffering should, therefore, not be needlessly prolonged, especially not if they themselves chose to die. Lucretius’ poem On the Nature of Things posed the symmetry argument: we should not worry about death for fear of missing out on things we might have experienced had we died at a later date, no more than we worry about birth and all the things we might have experienced had we been born earlier. Which treatments might or might not be accessible to us after we have passed should not be a source of fear.
In the Netherlands, of the criteria required to be legally euthanised, a patient must be in a state of ‘unbearable suffering’ (18). Of course, since suffering is relative, it is up to the doctor(s) who hold a duty of care to this patient to deduce whether this criterion is satisfied. This leads to qualms related to this logistic of euthanasia, which might indicate the doctor becoming the sole gatekeeper to a person’s life (19). Unless it becomes a social duty to care for oneself and acquire adequate knowledge accordingly, medics will always play an integral part in the stories of our lives, and deaths. As such, the medic’s role, and the impact of euthanasia on their ability to perform their purpose must at all costs be considered. If a doctor cannot in all circumstances follow their duty of care, it follows that they should not be trusted in any circumstances, given the significance of any medical intervention in human life.
I am convinced the conventions of euthanasia do not and will not allow the doctor such importance in committing to such a grave decision. A doctor, acting in their capacity as a professional, would not want such responsibility, and no doctor would conceivably ever get it. A doctor recognises that in cases of deviance from the law or the wishes of the patient, the burden will be placed on them. This acts as a deterrent. Numerous consultations occur between the patient and their numerous doctors. It is not an uncomplicated, one-step process. I would consider that to relegate this decision from doctor to a patient, in its entirety, might be equally as dangerous. Human nature often predisposes us to pursuing short term gain, regardless of any greater long-term benefit. In Treatise of Human Nature David Hume notes, ‘[we] yield to the solicitations of our passions, which always plead in favour of whatever is near and contiguous.’ (20) We should not leave such difficult decisions to patients in extremis. Anxiety and desire for death, and pursuing of proximate comforts, might override a patient’s natural instincts of self-preservation. The anguish of the patient and the empathy of the physician is exclusive only to the room in which the patient lies or the consultation occurs, in a heterotopia of crisis. Any idea that a patient could be coerced into euthanasia is also unlikely. Unanimity between each of the medical professionals and the patient is necessary to prescribe euthanasia. This cooperation increases the probability that the correct decisions are being made, with the major and chief involvement of the patient. The autonomy of the doctor would be hindered - to the detriment of the patient - should the patient alone have total responsibility for their euthanasia.
It is only fair then that in any debate on euthanasia that the opinion of physicians themselves be considered. This, too, constitutes a step away from the emotional, impulsive pain-centred conversations we have historically had on euthanasia. The position on euthanasia in the UK has been contested by organisations such as Dignity in Dying, with the Royal Colleges of Physicians, General Practitioners and Nursing all being neutral (as of writing). The British Medical Association is against the legalisation of both physician-assisted suicide and euthanasia (21). A 2017 Serbian study (22) surveyed healthcare professionals in the A&E department, the paramedic team, and physicians from the departments of surgery, transfusion and cardiology on their views of both active euthanasia, and physician-assisted suicide. The results portrayed a solid majority of healthcare professionals holding active euthanasia to never be morally permissible, at a proportion of 56.8%. Similarly, for physician-assisted suicide, 56.8% again were of the view that it was never morally permissible. However, between the two opinions, those who thought that these acts were sometimes morally permissible, rose from 8% with regards to active euthanasia to 10.2% for physician-assisted suicide.
We could come to the conclusion that the majority of healthcare professionals are not in favour of either of these acts, although the reasoning might be more ambiguous. We might recognise this reasoning if we look at the inter-faculty differences of opinion. For those holding that neither of the acts are never moral, the emergency medics always came out with the most unanimous opinion against these acts, followed always by paramedics and finally physicians outside the emergency department. We might put this difference in opinion down to their variety of responsibilities. Doctors in the emergency department have the role of stabilising patients with acute illness, such as those suffering a cardiac arrest. They have an ultimate aim of saving life before it is too late, not taking it. The patient needs to survive in all cases, for you cannot choose to die if you are already dead. These doctors also do not ever follow-up with their patients, rather discharging them after treatment or referring them to a specialist, such as those in the departments of surgery, transfusion or cardiology. These medics who follow up with their patients form a far stronger bond with them, empathising with their strife, worries and anxieties. This might predispose them towards euthanasia. Another reason most medics would be against ideas of active euthanasia, could be to do with public perception. Doctors uphold the patient-doctor bond, for it allows confidence in the medical profession, and grants the patient comfort to open up to their physician. This bond or public relationship might be compromised, if doctors who traditionally saved lives, began to end them. After the patient is gone, it will be the doctor who will have to answer to society; this is not a burden most doctors are willing to carry. UK polling has, however, suggested that 87% of the public believe their bond with their doctors would increase should assisted dying be made legal, if it changes at all (23).
This poll is striking and helps redefine the patient-doctor bond. The reasons for this public opinion lie primarily with trust. Rather than eroding this bond as feared, euthanasia could allow for mutual, unrestricted openness and honesty between patient and doctor. As opposed to travelling abroad alone, afraid of consulting their doctor apprehensive of retribution, legalisation of euthanasia would prompt discussion. The doctor, too, would be better suited to supporting patients in their decisions, without fear of the law, rather than being a barrier to their patients’ autonomy and self-determination. Kantian deontological ethics suggest that we should not use people as a means to an end, because humans have an intrinsic value in themselves as autonomous beings. This rationality correspondingly applies to patients and should be fulfilled by the doctors who would promote discussion with their patients as logical, righteous beings, elevating the patient such that their input is equitable and as deliberated upon as the physician’s. The patient has more liberty in discussion with their doctors, seeing them as not some ominous authority figure, rather a fellow human being who can guide them in their decisions without imposition. Denied the ability to pursue a specific and appropriate diagnosis, whether that be prescribing ibuprofen to performing euthanasia, a doctor is restricted in their autonomy. Radical or dramatic this view may be, it is not without footing. A doctor has the duty of acting in the best interests of their patient according to Good Medical Practice, ‘[a doctor should] work with colleagues to best serve patient’s interests’ (24), and respecting their autonomy while taking into consideration patient input, ‘[a doctor has a duty to] work in partnership with patients.’ (25) A mentally competent patient should, therefore, be able to ask of their doctor to pursue euthanasia, and a doctor, using their medical judgement, should be able to suggest it where apt. A liberal law would restore autonomy for the doctor, allowing them to pursue all avenues in their duty of care for their patients. Any exclusion of the ability to suggest euthanasia would constrict the doctor’s duty of care. It is this capacity that constitutes a doctor’s autonomy.
My arguments in support of voluntary active euthanasia come with recognition that these must be coupled with rigorous and detailed legislation, and that patient consent must be central to any decisions made. I believe euthanasia could provide an escape from suffering and allow patients the same organisation in planning their deaths, as they would in planning their weddings. Every ten days, an adult Briton travels to seek out assistance from Swiss assisted dying charity Dignitas to end their life (26). As a society we assuredly have a duty of care to our most vulnerable. We should legalise euthanasia in order to safeguard against malpractice and truly allow for a death with dignity. 84% of UK adults are of similar opinion to the one I have defended in this essay (27). That said, society should not fall upon euthanasia as the ‘easy way out.’ Our vulnerable were once, and could still be, entirely contributing and fulfilled members of society. We should acknowledge this and move forward in our efforts for promotion of their welfare and maintenance of their independence. We should exhaust all efforts before turning to euthanasia. Society, similarly, should reform its ideas of death, seeing it not as something to be afraid of, rather something to anticipate and plan for. Epicurus’ second principle doctrine of the tetrapharmakos directs us not to fear death, for it can affect us neither when we are alive nor dead. When alive, you are not dead, and when dead, you cease to exist (28).
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