Euthanasia- assisted suicide or a dignified release from a painful and traumatic life? The debate is certainly not new. Euthanasia was legalized in Germany a long time ago and the Netherlands followed suit about 20 years ago. Whether it was for the better or for worse, needs to be analyzed objectively albeit with compassion as it concerns the one thing that human beings cherish more than anything else in the world- life. Our case in question involves a 78 year old woman, Mildred D, who suffers from diabetes and heart disease and a stroke has left her semi comatose and paralyzed.
The nutrition she receives from a naso-gastric tube is the only thing that has sustained her. Her condition deteriorates day by day but the process of death seems to be a long and tortuous one. There is almost no hope of her survival and even less of her returning to consciousness. Mildred had previously conveyed to her family that in a condition like this, she would not want to be kept alive. In accordance with her wishes, her family wishes to stop the nutrition but the doctor finds it unethical. The ethical issues that confront both the physician and the near ones in a crisis like this are many.
Would it be morally and ethically justified to stop the nutrition and speed up death? Also to be decided is that whether the family or for that matter any one except the patient, has the right to make this decision for the patient? Should the fact that she earlier indicated that she would prefer death to life like this, be considered reason enough to end her life artificially? It is only when we search for answers to such questions, shall we be able to come to a rational decision about what needs to be done or not done for terminally ill patients with little hope for survival or resuscitation.
The two obvious choices in the above situation are – a) to induce death with as much dignity as possible, and b) to let Mildred reach her end naturally and not attempt to lend nature a hand. Both choices find their supporters and dissenters. It is a moral and ethical dilemma and a legal one as well because the Canadian Law is not exactly crystal clear as to what it calls assisted suicide and what it considers manslaughter. Supporters of assisted suicide say that people with terminal illnesses without any hope of recovery or people with disabilities should be allowed to put a dignified end to their traumatic life.
Suicide is already legal in Canada and thus the case for assisted suicide has to be treated similarly. The argument put forward is that a person who is unable to put an end to his life due to illness, weakness or disability should not be deprived of the right to die a dignified death and should be allowed to ask for help in termination of their unbearable lives. This will give them more control and autonomy. Also the resources that are being used in keeping these people alive against their wishes can be delegated to those who wish to stay alive. On the other hand, we have voices in complete disagreement of euthanasia.
People on this side of the river believe that euthanasia is nothing more than an elimination of people with illness or disability. Euthanasia will be something that will be misused to no end and most people with disabilities will have these choices coerced on them. They recount the terrible times of the Nazi rule in Germany wherein an uncountable number of people were killed after euthanasia was legalized, for no rhyme or reason whatsoever. Legally in Canada any form of euthanasia is not permitted. Active euthanasia (where the physician administers a lethal medication) is illegal whether it is voluntary or non voluntary.
Passive euthanasia (where a physician withholds/withdraws treatment with an intention to end life) is acceptable when the patient expresses a clear and explicit request. Nancy B. , a bright young girl, paralyzed neck down, moved a petition to the court to remove the ventilator that sustained her and let her die a dignified death. The court, brushing aside Section 14 of Canadian Criminal Code, decided that Nancy was under no compulsion to live. The real dilemma comes into picture when the patient is incompetent to ask for life ending help. This is the condition which concerns us in our study of Mildred’s case.
Being semi comatose, Mildred is not in a condition to convey that she would like help in ending her life in a dignified manner. In such cases, we look upon Advanced Directives, which provide for times when a person is no longer in a position to make decisions for him/her. First alternative is to transfer a power to attorney by the patient to another person. This is called Proxy Directive. That person will then have the right to make such decisions in the patients’ best interests. Another alternative, often called Instructional Directive, is a living will.
The weight age given to the living will must obviously be decided by considering several factors such as the time when the will was signed, the physical, cognitive and psychological state of the patient at the time of writing the will and the patient’s awareness about the situation he/she could be in the time to come. A living will, however, does not have any legal force in Canada, that is, it neither protects the physician administering euthanasia from legal action, nor does it expose the physician to legal liability if the physician decides to ignore it. Legalization of living wills is again a debatable issue as it has two sides to it.
It will obviously save the physicians administering euthanasia from legal liability but the down side is that its absence may be misinterpreted as the patient’s desire for exhaustive treatment and might result in over treatment. Mildred’s case is however very different. There is an obvious absence of proxy directive. We know for sure that she did not invest in anyone a power of attorney to take decisions for her, particularly of such consequential nature. This decision involves her life and the decision to end her life can be taken only by her, and no one else and this should be morally, ethically and legally acceptable.
If we allow others to make such decisions for terminally ill people who are comatose, we will open a Pandora’s Box and people with disabilities will have death coerced on them. No one, absolutely no one, has the right to make such a decision involving life and death. Mildred had earlier vocalized that she would prefer death to vegetative life. This may be considered an unwritten and unsigned form of a living will since even the written and duly signed version is of little consequence legally. It is in both forms only a moral bondage for those administering treatment and the near and dear ones of the patient.
Still, what remains to be considered is that how long ago she had made this statement. Did she even anticipate that such a time may be just around the corner, when her statement would acquire so much weight that her life would depend on it? The statement may have been made in a fit of depression or a momentary feeling of worthlessness. It might have been one of those statements that people often make believing that such situations will never happen in their lives. Maybe she was misinformed of her state of health or what she may expect in future.
Thus according to much weight to her statement which may have been an offhand remark will be foolhardy. So in the absence of proxy directive and no reliable will, Mildred should be allowed to live her life on earth in peace. The physician is reluctant to administer euthanasia. He probably remembers only too well the prophetic words of the Hippocratic Oath which say “I will give no deadly medicine to anyone if asked, nor suggest such counsel”…. Morally, ethically and legally too, it is advisable to let nature take its own course in this case since nothing in the case gives us the sanction to the contrary.
In cases similar to this, when decision belies the power of human rational thinking, the decisions of such importance are best left to God to decide. He is after all the one who gives life and he alone has the right to take it besides the patient. Moreover legalizing euthanasia in such cases will give undue powers to the doctors and also to the significant people in the life of the patient. Carried away by the temporary suffering, or in few cases even ulterior motives, the relatives and the doctors may decide to terminate life of a patient whose condition was not as worse as it seemed to be.
For instance, in Netherlands, after the legalization of euthanasia, there were 3000 deaths due to euthanasia in 1990 and more than 1000 of these were not voluntary euthanasia. (Remmelink Report, 1990). In order to prevent circumstances like these, when people are killed off without sufficient reason for termination of life, it will be better to let euthanasia remain illegal till we can devise a safe and explicit law which will minimize the misuse of this power.
Legalizing euthanasia in cases like these will have many far reaching social and societal consequences which need to be looked into. Terminally ill patients are always a challenge, a motivation for medical science to extend its reaches in the domain of terminal illnesses and bring these patients back to life. If we start eliminating such patients under the hood of euthanasia, no motivation whatsoever will be left to learn more about such illnesses. The easier way will be to eliminate the ill rather than the illness.
Progress will be made in ktenology (the science of killing), and not in medical science as a savior of mankind. To avoid all this, keep euthanasia tamed and limit it to only very few cases which explicitly call for euthanasia as the only alternative. The choice has to be made by the patient and no one else. As far as the concern for suffering goes, effective pain management has been one of the arenas where modern medical science has made arguably the most progress.
Without getting into its intricacies, it can be understood that unbearable pain is no longer a deterrent to a longer life. As far as disabilities are concerned, it is a matter of observation that most disabled people are able to adapt to their disabilities. One of the most awe inspiring features of the human psyche is the ability to adapt to their condition and lead a good quality life. There are thousands of instances where people seriously disabled in accidents were able to adapt and pick up the grains of their former life and create a new life for themselves.
It is only the able bodied people who dwell into pity for these people and interpret that they lead a low quality life. It is just one of those prejudices. Life, in any form is a beautiful thing, to be cherished and lived to the fullest. Mildred opens our eyes to the many issues involved in end of life decision making. All these issues have to be resolved by careful, thoughtful, compassionate and rational thinking. All aspects of the issues have to be looked into and debated upon. Both sides of the debates listened to and pondered upon. Till then, let Mildred live.