Sami Fulton
Biology Senior Seminar
November 28, 2007
The voluntary ending of a patient’s life is such a controversial debate that it will not be resolved because there are many interpretations of the role physicians and nurses play as well as the right of the patient to live a quality life.
Introduction
Imagine lying in a hospital bed in an excruciating amount of pain; the pain medicine the doctors keep adding to the IV aren’t working any more. Diagnosed with cancer ten months ago, there seems to be no hope of pulling through; this visit showed that the cancer has spread into vital organs and the doctor’s prognosis is grim. Some days you wish the suffering would be ended by just a little more Morphine. In this situation, what is the legal obligation of the doctors and/or nurses? The voluntary ending of a patient’s life is such a controversial debate that it will not be resolved because there are many interpretations of the role physicians and nurses play as well as the right of the patient to live a quality life.
First, in order to understand the terms regarding the end of life that will be used in this paper, some must be defined. Voluntary euthanasia involves a doctor intentionally prematurely ending the life of a patient by the patient’s request (Varelius, 2006), meaning both giving a lethal dose of a pain medicine (and other such activities) as well as withholding “life-prolonging” treatment. What is not covered in this term is physician-assisted suicide. Physician assisted suicide (PAS) occurs when the doctor prescribes a lethal medicine (usually an injection) and the patient administers it him-/herself (Ersek, 2005). This method relieves the doctor of the feeling of directly killing the patient. It is important to note here that in both of these situations (voluntary euthanasia and PAS) the decision to terminate life is being made by a patient who is mentally competent enough to determine the course of action in relation to their deaths, not solely by the doctor deciding it is time for a patient to pass on.
A few other expressions that need to be defined are life, death, and quality of life. The first two are seem fairly simple; according to Webster’s Collegiate Dictionary, life is “the quality that distinguishes a vital and functional being from a dead body” and death is “a permanent cessation of all vital functions” (Mish, ed., 1997). At first, these terms seem simple, but if one is in a coma for years, are they a “vital and functional being”? Quality of life, however, is something that is defined differently for each person. In general it means how well someone is living. Some people would base this on material possessions, emotional health, or even physical health. It is in these gray areas where this debate can occur.
Two Modes of Thinking about Voluntary Euthanasia and Their Arguments
There are at least two sides to any debate and this one is no different. Depending on the person one talks to, voluntary euthanasia is either a form of murder, a humane act, or somewhere in between. Since voluntary euthanasia involves withholding what could be life-saving treatment, it is logical to see how that could be thought of as murder. On the other hand, looking at the vast amounts of physical pain someone is in and how much a patient is suffering is cause enough for a person to think that euthanasia is the right decision. It is allowing the person to die with a little bit of dignity and not as much suffering; it is far more humane than forcing them to undergo pain until their death.
There are many sources that have components of this polarized debate (DuBose, 1999; Seay, 2005; Magnusson, 2006; Dickinson, 2005), but most of the main arguments are published succinctly in a book by Margaret Battin called Ending Life (2005). In this work, Battin proposes five key arguments of this debate, which will be discussed below. The arguments for voluntary euthanasia will first be presented; then the arguments against it will follow. One point of view that is very common is the idea of a “right to autonomy”. This comes mainly in Western culture in which citizens are given many rights, one being the right to decide what happens with their life. Embedded in this right, is an idea that since citizens are capable (and even encouraged) to determine their course of life events, they should be able to determine their course of death as well. Opponents to this argument suggest that there is nothing that is truly autonomous due to social factors and other circumstances beyond an individual’s control. Another argument against the “right to autonomy” viewpoint is that since a patient didn’t choose to have the specific terminal illness he or she does, he/she could possibly be in a depressive mood or could have some other psychological situation which complicates the ability to make an informed decision about the end of one’s life.
The second viewpoint coming from Battin (2005) is that relief from pain and suffering is a worthy enough reason to aid in the termination of the sufferer’s life. Many terminal illnesses cause a variety of complications that are painful. If an illness is terminal, it may seem impractical to spend the time and monetary cost of treatment on managing the pain and other hurdles associated with any such disease. People opposed to this view would argue that there are many affordable methods to employ in managing pain, and emphasize the idea that you cannot put a monetary value on life. This is argument is one in which the quality of life comes into play because who is to say that one who is suffering with a lot pain is not having a good quality of life. This is something that is going to vary based on each person’s idea of a quality of life. Another opposition to this view is that the dying process has much to offer in the way of spiritual and emotional growth, as well as giving a person time to think about such events as the afterlife; they would say that doctors shouldn’t try to skip out on this process due to its teaching abilities.
In the next three arguments, Battin (2005) argues against voluntary euthanasia. The first is the simple designation of prematurely ending ones life as murder, thus making it inherently wrong. Proponents of this idea cite the Bible as a resource, saying that it explicitly states that killing is wrong in Exodus 20:13 “You shall not murder,” (NIV). Placing a high value on the life of a person is the main component of this idea. A countering viewpoint states that since killing is readily accepted in most societies in the cases of self-defense, wars and capital punishment, this leaves a possibility that it could be acceptable to end the life of one who is wishing for it to happen sooner than it is.
In Ending Life (Battin 2005), the second oppositional viewpoint is called the “slippery-slope” because it highlights the potential for abuse if voluntary euthanasia is legalized. If doctors are allowed to kill their patients when they are suffering, provided the patient has authorized the doctor to perform the end-of-life treatment, then there is possibility for doctors to say patients have requested to be euthanized when they in fact have not. This could lead to patients having their lives ended prematurely without their consent. Another possible abuse is patients using their terminal illnesses to actually commit suicide when they aren’t in a mentally competent state of mind. Objections to this statement include the argument mentioned above where patients are supposed to have the right to end their lives if they feel it necessary and the fact that there is no proof that this abuse will happen due to the legalization of physician assisted suicide in the Netherlands and Oregon.
A third and final counter viewpoint found in the above mentioned book (Battin 2005) is that allowing voluntary euthanasia will detract from the integrity of physicians’ and nurses’ positions. Most doctors today take the Hippocratic Oath (which will be discussed in more detail below) which distinctly prohibits doctors from killing a patient. Nurses are also bound by an intrinsic set of ideals, usually originating in ethics classes, which also does not include taking the life of a patient. On the other hand, the role of doctors and nurses is to relieve the suffering of patients, and in some cases premature death could account for this relief of suffering. This aspect of the debate will be discussed further due to its ambiguity in many aspects such as what version of the Hippocratic Oath one agrees to and even simply what the role of physicians and nurses is in a hospital situation.
The Role of Physicians and Nurses
The role of physicians and nurses can be debated vigorously, due to the ambiguity in job descriptions and preconceived notions about both of the careers. Some, such as Gary Seay in one of his works, say that the duty of a doctor or nurse is not unconditional (2005). That is, there are exceptions to the rule that they are to never intentionally instigate the death of a patient they are treating. Others argue for the opposing view that doctors and nurses are bound by the Hippocratic Oath and thus should never harm a patient, even if he or she wishes for the doctor to end his or her life.
Seay argues that there are many duties of a physician, the top priority being those duties to the patient which “include confidentiality, avoidance of harm, and respect for autonomy among others,” (2005, p. 519). He reasons through many scenarios depicting the great difficulty in deciphering between which duty is more important in any given situation. For example, which comes as a higher priority, never to kill (avoidance of harm) or to relieve suffering? Also, returning to the five main debates previously stated, where does autonomy play a role in this controversial debate? These are things that Seay says are exceptions to the moral obligations of physicians. He says that duties are not unconditional, but instead must depend on each individual patient’s circumstance. In the words of Magnusson, these choices at the end of a patients life are “Devil’s Choices,” that is there isn’t one answer to the problem that doesn’t come with negative consequences (2006). This having been said, there are others who disagree and think that morality, at least in this aspect, is black and white.
In a compelling collection of essays, the book titled The Case against Assisted Suicide (Foley & Hendin 2002) urges readers to understand why voluntary euthanasia is morally wrong. It advocates the position that doctors are never supposed to do harm to their patients based on the idea that it isn’t what’s best for the patient. For example, in Leon Kass’ essay, he states that if we allow doctors to do something intrinsically wrong (i.e. killing a patient) even if the patient asks for it, would it also be permissible for a medical doctor to have sex with a patient as long as the patient asks for it? Kass says no, and this is the reason that allowing physician assisted suicide is morally wrong. He believes there shouldn’t be exceptions to the rules set forth by the forefathers of the profession.
The Hippocratic Oath has been mentioned many times in previous arguments, and here it will be delved into in more detail. This oath is recited by many medical school students upon receiving their diploma and certification as a doctor. Originally, the Hippocratic Oath stated that the physician wouldn’t give a drug that could kill the patient, even with his or her urging (NOVA Hippocratic Oath Classical Version 2001). This oath is pretty blatant in its rebuke of harming patients; it seems asinine to argue about this. However, there have been changes made to this oath so the newer one that physicians are swearing to include the phrase “…it may also be within my power to take a life…” (NOVA Hippocratic Oath Modern Version 2001). This certainly gives rise to controversy about which version of the oath one swears to and what the moral implications associated with each are. Some may even ask if physicians are bound by this oath anymore since it has been changed from the original version. Opponents to the theory that the classical version is the way to go would state that the first version includes a section that also makes it clear that a medical doctor should not perform surgery or in any other way use a knife on a patient. There aren’t many people today who are against surgery solely due to the fact that the Hippocratic Oath is against it, but (as has been discussed) there are many that use this argument to refute voluntary euthanasia.
Legal Ramifications and Statistics
Legally, there isn’t much information regarding voluntary euthanasia because it is such a debatable occurrence. It is difficult to tell when a doctor gives a patient a lethal dose of medicine as opposed to the patient naturally dying due to complications of the illness. Thus, voluntary euthanasia isn’t explicitly illegal anywhere in the United States. Physician assisted suicide, however, is illegal in every state except Oregon. There is a difference in strength of opposition based on the wording of the statement between allowing a patient to die and causing a patient to die (Battin 2005). In voluntary euthanasia, the doctor is simply allowing the patient to die with some sort of dignity left. Many people feel better about allowing a patient to die, as occurs in voluntary euthanasia than causing a patient to die as in PAS, which is the basis for existing laws.
Promoters of nationally legalizing PAS suggest that since assisted suicide already happens, from anonymous surveys given to physicians, it would be best to legalize it so those performing it would have some sort of guidelines and regulations to follow (DuBose, 1999). Legalization would also limit the amount of abuse of the practice. If PAS were legalized nation-wide, there would be moral allowances by which physicians and nurses opposed to the rule could plead and thus wouldn’t be obligated to perform the assisted suicide. Such rules are already in place in Oregon making it so opposing nurses and doctors aren’t required to perform something they are morally or ethically against (Battin 2005).
In the United States in 1988, 85% of the deaths of that year occurred in a health care facility and roughly 70% involved the patient’s choice of withholding of life-prolonging treatment (Battin, 2005). This amounts to about 60% of deaths overall in the US being attributed to voluntary suicide. It is also noted that about 1.3 million out of 2 million deaths in critical care units are due to the withdrawal of life support (Battin, 2005). The United States (and many other countries) is considered to be in the fourth stage of epidemiological transition (Battin 2005, p. 47). This means that they have good health care systems and the majority of people dying are dying due to a prolonged terminal illness instead of an acute infection. Since the above statistics are so elevated, it shows how much this topic is an issue in developed countries. If 60% of people are dying due to voluntary euthanasia and it is morally wrong, there is something awry in this country. If however, it is a perfectly legitimate way to reduce the pain and suffering of a patient, then as a whole we need to stop worrying about it and possibly legalize PAS.
Religious Considerations
A belief in a religion that emphasizes a life after death causes many people to behave differently than if they didn’t consider an afterlife. There are many different religious views of euthanasia, all of which bring into account something mentioned above; only a few religious views (Judaism, Methodism, Catholicism, and Islam) will be discussed in this section of paper. Most religions view murder as intrinsically wrong, and have some form of afterlife. This is where the similarities stop and the bifurcations begin.
Judaism sees all forms of euthanasia (active, passive, voluntary and involuntary) as murder, even if the patient wants to die and expresses that feeling. The general consensus in this religion is that no person, no matter how high up on the social ladder, has a right to kill another human being (including oneself). There has been a rabbinical ruling by Rabbi Dorff explicitly listing the ideas of the church, thus making any form of suicide or euthanasia against the church (DuBose, 1999). Because of this stigma, practicing Jews would be unwilling to end their lives due to the teachings of the church.
Methodists of the Christian tradition have a somewhat unique position in that they actually imply that euthanasia used to alleviate suffering may be acceptable, though it shouldn’t be used all the time. This is because there are many ways, such as medicines, to alleviate pain and suffering without ending the life of the patient. The church wrote a book in 1996 called Book of Resolutions of the United Methodist Church (DuBose, 1999) in which these stipulations are stated. It even goes as far as to say that suicide itself is allowed to be a consideration employed to speed up the death process (DuBose, 1999). Most Christian traditions would disagree with this stance on suicide and euthanasia.
Coming from a different part of the Christian faith, Catholics have a negative view on voluntary euthanasia. This group goes so far as to have a Declaration on Euthanasia, written in 1980, stating that intentional death (or suicide) is the same as murder and is against God’s will (DuBose, 1999). The Catholics are among the strongest advocates for those who do not want physician assisted suicide (or any other form of euthanasia) to become legalized. This group of people believes that relieving the suffering of a patient is not beneficial in the long run and that no one should tamper with life and death. This view is more common of other Christian traditions as well.
The last individual group of religious believers that will be discussed have the Islamic faith tradition. Muslims believe similarly to the Catholics, that killing of anyone is morally wrong and shouldn’t be done. There are no specific references in religious texts to euthanasia, however, and the Muslims haven’t written as many works on death and dying as the Catholics (DuBose, 1999). Since the Qur’an explicitly states not to take one’s own life, it can be interpreted to mean not taking your own life even in dire circumstances as well as not killing anyone else. This idea helps guide Muslims not to agree with voluntary euthanasia.
One of the key Christian concepts is love. In the gospels, as well as the Old Testament, the Bible states we are to love our neighbor. But what is love? Is it loving to end a life in order to hasten the afterlife for that person and relieve the suffering they have here on earth, or is that simply homicide and should be rebuked? Is it loving to force a patient to survive through many painful days and nights when he or she knows he or she is going to die, solely because it is unlawful to put them out of their misery? These are two perspectives about love and the Biblical interpretation which again show that this debate is irresolvable. There will not be any consensus as to what love is in this situation anytime soon.
Another piece of the puzzle to take into account is the afterlife. If a religious person believes God has ended the life of someone or inflicted them with some sort of terrible terminal illness, then by giving treatment are we being selfish in keeping the person here on earth just a little bit longer? Many people would, after seeing the suffering of their loved ones, vote for the “right to die” meaning they would choose to not have all the treatments to prolong a deteriorating life. This is where voluntary euthanasia comes in. Doctors and nurses must decide at what point their treatment is not helping the patient any longer and is in fact prohibiting them from dying and act at that point. It is only after it gets that far that the doctor or nurse can choose whether or not the circumstances are right for death to be hastened.
Cultural Implications in the Netherlands and Germany
Since the US is full of many different cultural traditions, it is essential to examine at least a few examples of different cultural ideas about voluntary euthanasia. In the Netherlands PAS is legal and goes as far as saying that doctors are allowed to “finish the job” if an attempt at suicide doesn’t work. This may seem strange; however there are quite a few rules that go along with this ideology. Voluntary euthanasia is the only kind of euthanasia allowed. It is unlawful for a physician to kill a patient without the patient’s careful consideration. Other criteria include the extensive trial of anything that could possibly help the patient, the patient must be in a considerable amount of suffering over a long period of time, and the condition must not be treatable, among other things (Battin, 2005). In the Netherlands, about 45% of people die with some sort of aid (Battin, 2005), which is less than in the United States. Even though PAS is legalized in the Netherlands, there are less actual deaths due to physician aid than even in the US where it is illegal to give the patient something to aid them in dying. This shows that even though PAS is legalized, it isn’t being overused.
In German culture, as a result of the historical implications of death enacted in WWII, doctors are never supposed to kill their patients, or even aid in their death. Even though it is written in the law books as illegal, however, physicians are socially allowed to provide assistance in suicide as long as the person is competent enough to decide for themselves. The German language has four words for suicide, one of them having the connotation of being heroic (Battin, 2005), and this one would be used for someone who is using suicide to escape from the peril of a terminal, painful illness.
As noted above, there are many ramifications of cultural ideologies that will differ from culture to culture. Not mentioned in this section are the cultures that have such a different view of death than that of the United States, one that says death or dying is the highest honor one can achieve. Also not mentioned are the cultures that have such an integration of religion and society that it is hard to separate the practical difference. These cultures would have a distinctly different view on voluntary euthanasia, and would be worth looking into if one is a doctor or nurse who is going to have to contemplate this issue further.
Conclusion
In conclusion, the debate of whether or not voluntary euthanasia is morally right will not be resolved any time in the near future. This controversy has many factors, including the interpretation of the roles of nurses and physicians, legal ramifications, religious considerations, and cultural implications. The many facets of this debate have so many little details that are hard to quantify or agree on, making it difficult to ever see this debate resolved. Further complicating the issue, individual considerations must be taken into account in almost every case. What is important is that one makes an informed decision, since this decision could be ending the life of a loved one, or yourself.
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