Euthanasia and physician assisted suicide: do the moral arguments differ?
A discussion paper from the BMA’s Medical Ethics Department
Euthanasia
The BMA has clear policy opposing euthanasia. It accepts that, legally and ethically, patients can refuse life-prolonging treatment and that interventions designed to keep patients comfortable and pain-free may reduce their lifespan. Nevertheless, it has opposed proposals for changing the law to allow interventions, such as a lethal injection, whose sole purpose is to end life.
The BMA's position is based on two main strands of argument. The moral arguments that killing is intrinsically wrong, alien to the ethos of medicine and potentially diminishes societies that permit it as a solution for social problems are reinforced, in the BMA's published view, by practical concerns. Prominent among these is the view that toleration of euthanasia would irrevocably change the context of health care for everyone but especially for the most vulnerable. Patient autonomy, in the BMA's view, is an important principle but one which must be balanced in proportion with other moral precepts, such as the doctor's duty to avoid harm in its widest sense.
BMA publications partly base their arguments on fears that, were euthanasia to be legalised, the goals and context of medical treatment would change.
Pressures including those within the NHS where resources are limited, those within society where the inarticulate tend to be marginalised and those arising from emotional, psychological and financial tensions in personal relationships, are likely to impinge on the choices made by people who become ill or disabled. Endorsing some individuals' choice to die would impact on society's views generally, potentially altering perceptions of the weak, the chronically ill and the mentally impaired. While some people readily accept that legalising euthanasia would oblige all sick people to view their options in a radically different way (and perhaps influence some to die prematurely to benefit family or heirs), the BMA considers that the opportunities for manipulation and abuse in such a situation would be unacceptable. It maintains that the arguments concerning "beneficence" or "autonomy" sometimes used to justify changing the law, may appear theoretically convincing but fail to reflect the real flaws and weaknesses inherent in our society and in any system of health care.
Once established as an option, the BMA also considers that it would be difficult to restrict euthanasia to those who ask for it.
A study of death certificates in Holland, for example, judged that 0.8% of all deaths each year involved doctors terminating a patient's life without an explicit request although the Dutch regulations prohibit this. In 1993, it was estimated that about 270 deaths occurred annually this way in Holland.Go to reference 4 It has been argued, however, that these do not genuinely constitute abusive practice since many of the patients were too close to death to communicate and their generally supportive attitude to euthanasia was previously known to the doctor. The acknowledged contravention of the permissive Dutch rules may nevertheless be seen as a cause for concern.
Doctors have a duty to avoid harming people. Some people argue that premature death is not a "harm" for the patient who seeks it. The BMA, however, considers that establishing it as a "right" for those who demand it will inevitably raise questions about why such a "right" should be denied to others such as the senile or mentally ill, for whom it may constitute a harm.
Not all doctors or ethicists believe that these arguments are well founded. Some see the Dutch situation as a model of success. Although the Dutch regulations are not universally observed, only relatively minor evidence of abuse has emerged despite intense national and international scrutiny. More recent indicators also show positive improvements in Dutch adherence to the rules. Some argue that the clandestine use of euthanasia outwith the law, as in the UK, is a greater cause for concern. A comparative study from Monash University, for example, purported to show higher rates of non-voluntary euthanasia in Australia, a country with prohibitive laws at the time of the survey, than in Holland which allows the open practice of voluntary euthanasia Go to reference 5.
While some commentators identify "autonomy" arguments and the patient's desire to remain in control as providing a strong argument for euthanasia, surveys show that doctors (if they believe euthanasia justifiable at all) see it in terms of the duty to relieve suffering (ie "beneficence"). Difficult to contest are the arguments put forward about the duty of medical beneficence when patients encounter apparently intractable pain or distress at the end of life.
In response to these, the BMA has pointed out that emotive arguments about pain are often, unfortunately, overplayed in the public consciousness. It acknowledges, however, that for a small minority of terminally ill patients, symptom control represents a significant and as yet unresolved problem. Doctors faced with such a situation have obligations to explore all possible sources of specialised expertise. Even for this group of patients, however, the BMA currently maintains that the societal price for changing the law would be unacceptably great and would contravene the principle of justice in reducing protection for the majority of vulnerable people. The BMA has supported the conclusion of the House of Lords that:
"Ultimately we do not believe that the arguments are sufficient reason to weaken society's prohibition of intentional killing. That prohibition is the cornerstone of law and of social relationships. It protects each one of us impartially, embodying the belief that we all are equal. We do not want that protection to be diminished. We acknowledge that there are individual cases in which euthanasia may be seen by some to be appropriate. But individual cases cannot reasonably establish the foundations of a policy which would have such serious and widespread repercussions. Dying is not only a personal or individual affair. 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 interests of the individual cannot be separated from the interests of society as a whole".
References
4 Life terminating acts without explicit request of patient, Pijnenborg L, Van der Maas P, van Delden J, Looman CWN, Lancet 1993;341:1196-99. Another study found 0.7 deaths were without explicit consent. New England Journal of Medicine 1996; 335:1699-705 as 1 above.
5 Report by Singer P and Kuhse H published in Medical Journal of Australia, February 1997.