Friday, November 19, 2021

What is the Good of Euthanasia? Part IV: What it means to present euthanasia as "medical care"

Gordon Friesen
By Gordon Friesen,
EPC Board Member.

To put it simply: to claim that euthanasia is medical care, is to say that euthanasia is "good" in a way that society can agree upon.

Of course there IS no agreement on the medical status of euthanasia. And this article could easily have been written, as many more worthy articles have been, on the theme of exactly WHY euthanasia is NOT good medicine. Moreover this mere observation (that so many doctors continue to name euthanasia as medically unethical) would seem to fatally challenge the medical pretension, precisely because the kind of objective consensus required, to make such a claim, does not in fact exist.

However, I would like to skip over this argument for the time being, in order to pass directly to a description of the theoretical and practical effects of actually accepting a true medical premise for euthanasia. And the reason why that step has become so unfortunately necessary, is because the practice of euthanasia is, indeed, already universally justified, in Canada, as medical care. Therefore, we will simply assume that euthanasia IS (good) medicine, and show where that (most questionable) assumption has (and will) lead us.

Morals and science: intuitive right and wrong, versus empirical fact

To begin with, the introduction of medical ethics to justify euthanasia is, itself, a sort of intellectual end-run, around the common-language notions of right and wrong. People did not (and do not) agree on the moral status of euthanasia. Substituting medical  authority, however, would seem to promise that the passionate conflict of moral opinion might be overcome by the impersonal proof of science.

Once again : there are powerful arguments as to why there can be no way for scientific evidence to determine primary questions of medical ethics, any more than those of common morality. However, the whole point of an appeal to science is to establish beyond discussion that certain things are either true or false (right or wrong), and this simple trick, of conflating utterly different things (science and morals) has been used, in this case, to create the illusion of a logical, dispassionate, consensus around the medical justification of euthanasia, where in fact no such thing exists. And yet such is the legal and clinical situation, in Canada, as we find it today!

Medical indications, treatment, and repeatability

To the extent that medicine is a science, prescribed treatments are supposed to apply to defined indications in a reliably repeatable manner. In other words, applying pressure on a bleeding wound will (observably) reduce blood loss and contribute to the survival of the patient. Therefore, in the presence of bleeding, pressure is applied.

Moreover, from the moment that euthanasia is considered as medical treatment, some clinical equation of this kind must be available to explain its use: In situation A, euthanasia is applied, reliably producing result B.

Now for euthanasia, the result is absolutely reliable. The person will die. Therefore, in the same way we say that reducing bleeding is desirable in certain clinical conditions, we must also be willing to say that death is desirable in others. Not that death might be desirable. Nor that death is desirable if, and only if, the patient desires it. No! Because the whole point of clinical science is objectivity and observable fact. Thus, by choosing this method of conceptualizing euthanasia, we are agreeing, at the outset, to accept that in certain clinical conditions, the patient SHOULD be dead, and it is the doctor's duty to kill them. 

Prescription and consent

Current best practice in clinical medicine assumes that the doctor, more than anyone else, knows what is medically required. It is the doctor, from his or her depth of knowledge and experience, who will arrive at a proposition of treatment which will then be explained to the patient. The patient has the perfect right to decline any treatment, of course, including euthanasia. However, in order to submit to treatment, the patient need only consent. And that consent can be of the most passive and minimal kind. For in practice, anything less than actual, definite refusal of care is deemed as consent.

And that is not all, for pressure is applied to the wounds of bleeding patients whether they are capable of consent or no. For in the absence of ability to consent, that consent will routinely be assumed, in keeping with established protocols of shared and substituted decision-making authority. Clearly, if euthanasia is justified as medical treatment, prescribed in response to objectively identified conditions, then that which is medically good for capable patients can not possibly be denied to the incapable. And therefore, even if present legal forms lag behind the logical conclusions of our argument, we can confidently expect that all sorts of incapable patients will indeed be euthanized (in fact already are), and that the law will be adjusted accordingly (exactly as Bill C-7 adjusted the voluntary limits of euthanasia by removing the illogical requirement that patients actually be dying before they were offered assistance in doing so). For in perfectly rational terms: just as fairness in euthanasia, by choice, requires that anybody be able to choose to die in this manner, so, also, euthanasia as medical treatment does not require that patients be able to choose at all.

Once again, I am fully aware that many will find these notions abhorrent, as do I. I do, however, feel it is useful to point out that this is indeed the conceptual structure that will be (is being, has already been) built upon the now standard assertion that euthanasia is medical care.

What are the clinical indications for euthanasia as medical treatment?

This, clearly, is where that fatal absurdity, which we simply chose to avoid at the outset (concerning the impossibility of pretending there might be an objective justification for euthanasia), must inevitably raise its ugly head once more. For if euthanasia is a medical treatment prescribed in response to objectively recognizable conditions, then what, exactly, ARE those conditions? To be charitable, let us simply say, that in a situation like our present, where a third of Canadian doctors still believe euthanasia is unethical under any circumstances (whatsoever), there can not possibly be a shared consensus as to which clinical conditions objectively indicate the use of euthanasia. In other words, there can be no clarity at all comparable to that surrounding typical (we might say legitimate) medical treatments, like the earlier bleeding wound example.

And yet, because our lawmakers have already decreed that the medical justification for euthanasia will indeed be employed; and because any medical justification requires that some objective indications for the use of euthanasia must exist: what, we must ask, will these be?

Apparently, since there is no collective agreement, we must rely on the individual wisdom, of the individual doctor, in each particular case.

The duty of the doctor and the prerogative of the patient

It is the duty of the doctor to make the best proposition, of clinical care, of which he is professionally capable. There are criteria for which patients may legally be euthanized, but these are not medical criteria, and most if not all doctors would agree that it would be absurd to claim that all patients fulfilling said criteria should be killed. However, the individual doctor is allowed to prescribe euthanasia for any patient within that group. And legally prescribed euthanasia is deemed to be ethical medical care. Therefore, from the moment that ANY doctor prescribes euthanasia for ANY eligible patient, the medical indications to which he was then responding would henceforth serve as a hallowed precedent for the general application of euthanasia to any similar case (and that, with a particularly significant impact, where patient consent is not an issue, due to incapacity).

The eligible patient, on the other hand, has the virtual right to demand euthanasia, such that, even if a doctor is unwilling, that doctor is bound to find another who is. Therefore, it is simply assumed that, should a patient be eligible, a doctor can, indeed, be found, who will declare the procedure ethical. 

The combination of these two principles moreover -- of a patients unfettered choice, and/or a doctor's unfettered ability to prescribe (within the limits of what are now the most broad and vague criteria possible) -- would suggest that no matter how absurd the idea might still appear (that ALL seriously ill or disabled people SHOULD be killed) this really does appear to be the final definition (of objective medical indication for euthanasia), towards which our present practice will logically lead. 

To resume: real objective medical indications cannot be defined for euthanasia.

Legal criteria, however, can be created at the stroke of a pen! And since treating euthanasia as ethical medical care positively demands objective indications: it would seem inevitable that the fraudulent substitution, of medical ethics for common morality, would also entail the subsequent fraudulent substitution, of arbitrary legal eligibility criteria, for actual medical indications.

Incredibly, the clinical application of these principles will now only depend on the personal discretion (subjective caprice) of each individual doctor.

Patient beware!

Gordon Friesen, Montreal, November 19, 2021     (français)      (english site in development)        (personal philosophical musings)

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