Euthanasia and Assisted Suicide: A Physician's and Ethicist's Perspectives.

Alex Schadenberg, Executive Director of the Euthanasia Prevention Coalition summarizes the peer reviewed journal article titled: Euthanasia and assisted suicide: a physician’s and ethicist’s perspectives by Dr Margaret Somerville and Dr J Donald Boudreau that was published by Medicolegal and Bioethics on July 17, 2014. 

Dr Margaret Somerville

Margaret Somerville is a member of the Faculty of Law, Faculty of Medicine, and Centre for Medicine, Ethics and Law, McGill University, Montréal, QC, Canada.

Link to Margaret Somerville's recent talk in Adelaide Australia.

J Donald Boudreau is a member of the Faculty of Medicine, Department of Medicine, McGill University, Montréal, QC, Canada.

The article: Euthanasia and assisted suicide: a physician’s and ethicist’s perspectives  provides a thorough understanding of what constitutes euthanasia and assisted suicide, and it effectively explains why acts of killing should not be legalized or practiced by medical professionals.

Dr Donald Boudreau

The article sets its goals in the following manner:

We define euthanasia and assisted suicide, reveal common misconceptions in this regard, and expose euphemisms that, regrettably, often serve to confuse and deceive. We review the main arguments advanced by proponents and opponents of legalizing euthanasia. The philosophical assumptions guiding our perspectives are laid out. We consider the impact of legalization on patients and their families, physicians (as individuals and a collectivity), hospitals, the law and society at large.

The article defines euthanasia and assisted suicide in the following manner:

We recommend the one used by the Canadian Senate in its 1995 report: (Euthanasia) “The deliberate act undertaken by one person with the intention of ending the life of another person in order to relieve that person’s suffering.” 

Terms such as ‘active’ and ‘passive’ euthanasia should be banished from our vocabulary. An action either is or is not euthanasia and these qualifying adjectives only serve to confuse. When a patient has given informed consent to a lethal injection the term “voluntary euthanasia” is often used; when they have not done so, it’s characterized as “involuntary euthanasia”. 

Assisted suicide has the same goal as euthanasia ― causing the death of a person. The distinction resides in how that end is achieved. In physician-assisted suicide, a physician, at the request of a competent patient, prescribes a lethal quantity of 'medication' intending that the patient will use the chemicals to commit suicide. 

In short, in assisted suicide the person takes the death-inducing product; in euthanasia, another individual administers it.

In the article, Somerville and Boudreau use the term euthanasia to represent euthanasia or assisted suicide unless the situation clearly requires the use of one term or the other.

Somerville and Boudreau then examine terminal and palliative sedation. Very few articles handle these contentious issues with the clarity of this article:

A lethal injection can be classified as “fast euthanasia”. 

Deeply sedating the patient and withholding food and fluids, with the primary intention of causing death, is “slow euthanasia”. The use of “deep sedation” at the end of life has become a more common practice in the last decade and has been the focus of controversy and conflict, especially because of its probable abuse.

They article then further defines the practice of sedation based on its circumstance.

“Palliative sedation,” which is rarely indicated as an appropriate medical treatment for dying people, is used when it is the only reasonable way to control pain and suffering, and is given with that intention. It is not euthanasia.

“Terminal sedation” refers to a situation in which the patient’s death is not imminent and the patient is sedated with the primary intention of precipitating their death. This is euthanasia.

The term “palliative terminal sedation” confounds these two ethically and legally different situations.

The article then examines the circumstances when deep sedation is euthanasia.

Euthanasia advocates have been arguing that we cannot distinguish the intention with which these interventions are undertaken and, therefore, this distinction is unworkable. But the circumstances in which such an intervention is used and its precise nature allow us to do so. For instance, if a patient’s symptoms can be controlled without sedation yet they are sedated, and especially if the patient is not otherwise dying and food and fluids are withheld with the intention of causing death, this is clearly euthanasia.

This section of the article concludes by stating that the withdrawal of artificial hydration and nutrition continues to be a very contentious issue especially when a person is not competent and not capable of deciding for themselves.

After thoroughly defining euthanasia, Somerville and Boudreau put forward their key perspective.

People undertaking an ethical analysis belong in one or other of two main “camps” ― principle based (or deontological) ethics or utilitarian ethics. We belong to the first group. We believe that there exists a universal morality and that, at the very least, there is significant inter-cultural agreement on core concepts of ethics.

Edmund Pellegrino

The authors make it clear that a religious perspective is not necessary to believe in a universal morality. The authors continue:

…we categorically reject moral relativism, the utilitarian view that what is right or wrong depends just on weighing whether benefits outweigh risks and harms, and, in particular, that this is only a matter of personal judgment. Some things ought never to be done to patients by their physicians. 

In relation to euthanasia, physician-philosopher Edmund Pellegrino states it well: “Physicians must never kill. Nothing is more fundamental or uncompromising.” We strongly agree and this central tenet informs our entire line of argument.

The article then examines the terminology in the euthanasia debate.

The “right to die” terminology is used in the euthanasia debate to propose there is a right to have death inflicted. 

Where there is a right, there is an obligation, therefore, were a “right to die” to exist, a logical consequence would be that some other person or agent would have a duty to inflict death (especially if the requisitioner were physically incapable of accomplishing the act themselves).

The authors establish a difference between a “right to die” and a “right to be allowed to die.”

The claim to a “right to die” must be distinguished from a “right to be allowed to die”, for instance, by refusing life-support treatment. The right to permit the dying process to unfold unimpeded flows from and is a consequence of persons’ exercise of their right to inviolability, the right not to be touched without their informed consent. It does not establish any “right to die” in the sense of a “right to be killed”.

The article then examines the question of whether assisting a suicide is the same as suicide.

Importantly, the decriminalization of suicide does not establish any right to die by suicide. Furthermore, if there were such a right, we would have a duty not to treat people who attempt suicide. ...if there were a right to choose suicide it would mean that we have correlative obligations ...not to prevent people making that choice. ...Psychiatrists who fail to take reasonable care that their patients do not commit suicide ...when a reasonably careful psychiatrist would not have failed to do so, can be liable for medical malpractice, unprofessional conduct, and, even, in extreme cases, criminal negligence. 

…Suicide is a solitary act carried out by an individual (usually in despair). PAS is a social act in which medical personnel licensed and compensated by society are involved in the termination of the life of a person. It asks not that we attempt to preserve life, the normal role of medicine and the state, but that we accept and act communally upon a person’s judgment that his or her life is unworthy of continuance.

The article then moves on to the question of autonomy.

Advocates of euthanasia rely heavily on giving priority to the value of respect for individuals’ rights to autonomy and self-determination. Respect for autonomy is the first requirement listed in the principlism approach to biomedical ethics ― the “Georgetown mantra” ― which strongly influenced the early development of applied ethics in the 1980’s. 

The way in which respect for autonomy is implemented in practice and in law is through the doctrine of informed consent. Among many requirements it demands that the patient be fully informed of all risks, harms, benefits and potential benefits of the proposed procedure and its reasonable alternatives. Consequently, to obtain legally valid informed consent to euthanasia, the patient must be offered fully adequate palliative care. As well, the patient must be legally and factually mentally competent and their consent must be voluntary ― free of coercion, duress or undue influence. We question whether these conditions can be fulfilled, at least with respect to many terminally ill patients.

The authors then examine the question of autonomy as to how decisions affect other people.

…we do not live as solitary individuals, but in a web of relationships that influence our decisions and these must be taken into account when assessing the validity of our decisions in terms of their being a valid exercise of our autonomy. This means the role that respect for autonomy should play in relation to the decision whether to legalize euthanasia must be examined, not only from the perspective of the patient, but also that of the patient’s relations.

The article continues by examining autonomy as to how it affects health care professionals.

Even if euthanasia could be justified at the level of an individual person who wants it (a stance with which we do not agree) the harm it would do to the institutions of medicine and law and to important societal values, not just in the present but in the future when euthanasia might become the norm, means that it cannot be justified.

The article moves on to the principle of respect for human life.

Respect for human life must be maintained at two levels: respect for each individual human life and respect for human life, in general. Even if it were correct, as pro-euthanasia advocates argue, that when a competent adult person gives informed consent to euthanasia there is no breach of respect for human life at the level of the individual, there is still a breach of respect for human life, in general. If euthanasia is involved, how one person dies affects more than just that person; it affects how we all will die.

Somerville and Boudreau explain how the concept of respect for human life was inverted by Justice Smith in the Carter euthanasia court decision in Canada. Justice Smith wrote:

[T]he [Criminal Code] legislation [prohibiting assisted suicide] affects her right to life because it may shorten her life. Ms. Taylor’s reduced lifespan would occur if she concludes that she needs to take her own life while she is still physically able to do so, at an earlier date than she would find necessary if she could be assisted.

The authors write:

What is astonishing is the novel, to say the least, way in which Justice Smith constructs a breach of Ms. Taylor’s Charter right to life. In effect, Justice Smith’s reasoning converts the right to life to a right to death by PAS or euthanasia. Justice Smith’s judgment was overturned by a two to one majority in the British Columbia Court of Appeal, …It is now on appeal to the Supreme Court of Canada.

The article then looks at the way the euthanasia lobby is changing the language of the debate.

Proponents of euthanasia often use rhetorical devices to foster agreement with their stance by making it more palatable. …As mentioned previously, ‘suicide’ has been a taboo for many cultures and across time. Some commentators have described concepts such as ‘suicide clusters’, ‘suicidal contagion’ and ‘suicide scripting’; none of these are considered beneficial to society. Consequently, there have been efforts at replacing the terminology of assisted ‘suicide’ with assisted ‘dying’. 

Another strategy to white-wash “death talk” is to figuratively wrap it within the white coat of medicine. Cloaking these acts in medical terms softens them and confers legitimacy. This has spawned a host of euphemisms such as ‘medically assisted death’, ‘medical-aid-in-dying’ and ‘death with dignity’ ― after all, we all want good medical care when we are dying. A strategy, that may escape scrutiny, is to link assisted suicide with physicians, that is, PAS. But, assisted suicide and euthanasia are not necessarily glued to physicians.

The article then examines the argument that there is no difference between euthanasia and withdrawing medical treatment.

The reasoning goes as follows: refusals of treatment that result in a shortening of the patient’s life are ethical and legal; this is tantamount to recognizing a right to die; euthanasia is no different from them and it’s just another way to implement the “right to die”; therefore, if we are to act consistently, that too should be seen as ethical and legal. The further related argument is that euthanasia is simply another form of medical treatment. ...the right to refuse treatment is not based on a right to die; and both the intention of the physician and the causation of death are radically different in those cases as compared with euthanasia.

Somerville and Boudreau then examine the role of the physician.

An absolute barrier to physicians becoming involved with acts that intentionally inflict death is that doing so would be incompatible with their healer role. ...A formulation that may provide a more robust understanding of medicine’s healing mandate is the notion that healing amounts to caring for the whole person. 

Healing is a journey rather than a destination and it is a process more than an epiphany. …Healing is associated with the following perspectives: a sense of connection to self, others and a phenomenal world (that is, a world experienced through the senses); an ability to derive meaning in the context of suffering; a capacity to find peace in the present moment; a non-adversarial connection to the disease process; and, the ability to relinquish the need for control. …a person can be helped on a healing trajectory, even as death approaches. Healing interventions are always possible. One can die healed. Consequently, the phrase, “There is nothing more that I can do for you”, has no place in medicine. 

Healing requires recognizing, listening to and responding to a patient’s story ― especially listening for trauma, shame, suffering, lament, and listening in a way that generates “earned trust” ― “trust me because I will show that you can trust me”.

The authors examine an alternative to euthanasia.

There are two great traditions in medicine: the prolongation of life and the relief of suffering. …Palliative care, the provision of high quality care by individuals who share in this belief and are able to act to address the full range of human suffering is the most important goal with respect to terminally ill patients. It also constitutes an obvious and necessary alternative to euthanasia. 

A specific approach to palliative care, with conceptual anchors in the concept of healing, has recently been described and utilized by Canadian psychiatrist, Harvey Max Chochinov and his colleagues; it is called ‘dignity therapy’. …The therapeutic approach described aims to preserve persons’ inherent dignity, in part by helping them to see that their intimate dependencies can be attended to without their losing self-respect and that they can continue to play meaningful roles.

The slippery slope argument.

A major disagreement between euthanasia advocates and opponents revolves around the existence of slippery slopes. There are two types: the logical slippery slope ― the extension of the circumstances in which euthanasia may be legally used ― and the practical slippery slope – its abuse. The evidence during the last decade demonstrates that neither slope can be avoided. For example, while access to euthanasia in the Netherlands has never required people to be terminally ill, since its introduction it has been extended to include people with mental, but not physical illness, as well as to newborns with disabilities and older children. In Belgium, euthanasia has recently been extended to children, it’s being considered whether to do the same for people with dementia, and organs are being taken from euthanized people for transplantation. The logical and practical slippery slopes are unavoidable because once we cross the clear line that we must not intentionally kill another human being there is no logical stopping point. 

When euthanasia is first legalized, the usual justification for stepping over the “do not kill” line is a conjunctive one comprised of respect for individual autonomy and the relief of suffering. This justification is taken as both necessary and sufficient for euthanasia. But as people and physicians become accustomed to euthanasia, the question arises, “Why not just relief of suffering or respect for autonomy alone?” and they become alternative justifications.

As a lone justification, relief of suffering allows euthanasia of those unable to consent for themselves according to this reasoning: If allowing euthanasia is to do good to those mentally competent people who suffer, denying it to suffering people unable to consent for themselves is wrong; it’s to discriminate against them on the basis of mental handicap. So, suffering people with dementia or the newborns with disabilities should have access to euthanasia.

The article continues:

Once the initial justification for euthanasia is expanded, the question arises, “Why not some other justification, for instance, saving on healthcare costs, especially with an aging population?” Now, in stark contrast to the past when saving healthcare costs through euthanasia was unspeakable, it’s a consideration being raised. 

…familiarity with inflicting death and making euthanasia a medical act make its extension, and probably abuse, much more likely, indeed, we believe inevitable, were it to be legalized. We need to stay firmly behind the clear line that establishes that we must not intentionally kill one another.

There are also unintended consequences to legalizing euthanasia.

Among the most dangerous aspects of legalizing euthanasia are the unintended boomerang effects it will have on the medical profession. …For example, with respect to euthanasia there is really no guarantee that the legal and administrative policies erected today, even if currently they functioned as intended, which is doubtful, will be as effective in a different cultural context decades hence. 

Then there are the insidious changes induced by the force of habit ― the unexamined and autonomic modes of human behavior. …How will the involvement of physicians in inflicting death impact on their thinking, decisions, and day-to-day practice. Given that euthanasia will be routinized and expedient, there is a distinct possibility that death will become trivialized and avenues for dignity-preserving care will remain unexplored. …We have little doubt that the slippery slopes include a language of abandonment, generating medical practices that will vitiate hope and a profession that will struggle to identify a true north on its moral compass.

Somerville and Boudreau conclude the article by stating:

The law prohibits killing another person and physicians take an oath not to inflict death. These imperatives must never be abrogated, which legalizing euthanasia ― accepting the notion of ‘therapeutic homicide’ ― would necessarily do. 

Our analysis and explorations, investigations of both practical and theoretical issues raised by euthanasia, have culminated in a profound belief that euthanasia is harmful to individuals, especially vulnerable people, physicians, the institutions of law and medicine, and society, and that the healing role of physicians and euthanasia are simply not miscible; indeed, they are antithetical.

Dr Somerville and Dr Boudreau have written an important article on the ethics of euthanasia and assisted suicide that should be studied by every medical practitioner and student. 

Somerville and Boudreau have done a thorough analysis of the issues of euthanasia and assisted suicide. They have effectively explained why euthanasia should never be legalized and they have effectively explained how euthanasia negatively affects society as a whole.

The Euthanasia Prevention Coalition urges you to study this journal article. This article will help you explain why society should never permit the killing of its citizens.

More information:

• Dutch ethicist: "Assisted suicide - Don't go there".
• A Jewish perspective on euthanasia, assisted suicide and palliative care.
• British Medical Association re-affirmed its opposition to assisted suicide.
• Quebec: Why can't we say euthanasia.