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Euthanasia -Ethical and Legal Perspectives

Article · October 2013

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DYPJHS Volume 1 Issue 1 : 7-10 Oct-Dec. 2013
D Y Patil Journal of Health Sciences
REVIEW
Euthanasia - Ethical and Legal Perspectives
Amit Patil
Abstract
Euthanasia being a controversial issue has become a matter of ethical
concern for physicians who are dealing with patients suffering from
terminal illness like advanced cancer, patients in persistent
vegetative state etc. On one hand we have patient's right of autonomy
and self determination while on the other hand rests the code of
medical ethics which is the main guiding principle for medical
profession. The proponents of euthanasia feel that every individual,
by virtue of right of autonomy, is entitled to choose his quality of life
as well as death. While the critics argue that the request of euthanasia
made by a terminally ill patient is devoid of autonomy and is not done
in sound and rational mind. The concept of "sacredness of life"
vehemently proposed by different religions worldwide clearly
opposes the right of self killing. Amid such scenario there lacks clear
opinion on this matter and hence it has remained a debatable issue
since long time. The present article deals with the concept and
meaning of euthanasia, its perspective from ethical and religious
point of view, its legal sanctity in India and other countries. The
article also highlights some arguments put forth by opponents and
proponents of euthanasia.
Key words: Euthanasia, physician assisted suicide, religious,
ethical and legal perspectives.
Introduction
The topic of euthanasia is one that is associated with much
controversy and ambiguity amongst common public, legal
and medical professionals. The term euthanasia is derived
from Greek words "eu" and "thanatos" meaning good death.
Taken in its common usage however, euthanasia refers to the
termination of person's life, to end their suffering usually from
an incurable or terminal condition.[1] Thus euthanasia means
easy death or mercy killing. In other words, "euthanasia is the
termination of the life of the terminally ill patients at their
request or in their interest". [2] This issue of terminating the life
of a person who is suffering from incurable and painful
disease, on his request and in his interest has raised moral and
ethical questions, such as: does the person have the right to
request termination of his life (autonomy)? Whether such act
is beneficial to him in alleviating his severe pain
(beneficence)? Whether such act can be justified? Is it right for
*Corresponding author: Amit Patil, E-mail : dramp1976@gmail.com
Department of Forensic Medicine and Toxicology Padmashree Dr. D Y Patil
Medical College, Padmashree Dr. D Y Patil University,
Navi Mumbai - 400 706.
7
ISSN 2347-3665
medical health care provider who are under moral and ethical
obligation of not to harm his patients (Hippocratic Oath), to
end the life of such terminally ill patient?
Types of Euthanasia
Active or positive euthanasia - It refers to the deliberate
merciful act, usually through the intentional administration of
lethal drugs, to end an incurably terminally ill patient's life. It
is an act of commission.[1]
Passive euthanasia (letting die or aid in dying) - It implies
deliberate withholding or withdrawal of life prolonging
medical treatment resulting in the patient's death.[3] It is an act
of omission such as failure to resuscitate a terminally ill
patient, not giving life extending drugs or not carrying out life
extending operation, disconnecting feeding tube etc. "Letting
Die" means to give way to an ongoing inner organic process of
disintegration, without supporting or substituting vital
functions. Therefore the extubation or removal from a
ventilator of an incurably ill patient, though constitutes
physical act leading to death, it is not killing in its proper
meaning. The extubation does not produce the effect of death;
it only influences the time of its occurrence.[4]
Unsurprisingly, the term passive euthanasia has been
described as a misnomer. In Australia and most countries
around the world, this practice is not considered as euthanasia
at all. According to Bartels and Otlowski[1] withholding or
withdrawing life prolonging treatment, either at the request of
the patient or when it is considered to be in the best interest of
the patient, "has become an established part of medical
practice and is relatively non controversial". Even the House
of Lords Select Committee on Medical Ethics describes ''the
term passive euthanasia'' as ''misleading''.[5]
Voluntary Euthanasia refers to euthanasia performed at the
request of patient.
Involuntary euthanasia means where euthanasia is
performed when the patient does not request it, with the intent
of relieving their suffering - which, in effect, amounts to
murder.[6] It is practiced against the will of the patient.
Non voluntary euthanasia relates to a situation where it is
performed when the patient is incapable of giving consent.
Such situation may arise when the patient is in a comatose
condition or severely mentally retarded, has suffered severe
head injury with extensive damage to brain etc.
Assisted Suicide or Physician Assisted Suicide (PAS)
Assisted suicide is when a person intentionally provides an
individual with information, guidance and means to take his or
her own life. Physician assisted suicide means, where a
physician intentionally assists a patient, at their request, to end
his life, for example, by the provision of information and
drugs.[6]
Religious and Philosophical perspective
None of the religion advocates and proposes euthanasia.
Islamic jurisprudence, based on convincing interpretation of
the holy Koran, does not recognize a person's right to die
voluntarily. The Islamic arguments against euthanasia can be
summarized in two main reasons
Life is sacred and euthanasia/suicide is not included among
the reasons allowed for killing in Islam. Allah decides how
long each of us will live and two verses support this reason.[7]
The intention to voluntarily kill oneself for selfish motives is
condemned in Hinduism.[8] The Roman Catholics opposes the
right of self killing.[9] Though the religious perspective
opposed euthanasia some of the philosophers like Aristotle,
Plato and Pythagoras favored euthanasia.
Present legal position of Euthanasia in Different Countries
Euthanasia in Netherlands: Active voluntary and physician
assisted suicide are permitted under certain conditions
pursuant to the Termination of Life on Request and Assisted
Suicide (Review Procedures) Act 2002.[3] The Act creates an
exemption from criminal prosecution for physicians who
"have compiled with requirements of due care mentioned in
the Act" as well as reporting the case.[10] Euthanasia may be
performed on adults and in children older than twelve years of
age.[1, 3]
Euthanasia in Belgium: Active voluntary euthanasia is legal
under the Act Concerning Euthanasia which came into effect
in 2002. Euthanasia can only be granted to those whose
suffering involves "a serious and incurable disorder caused by
illness or accident". It imposes an age restriction of eighteen
years of age. This act does not make mention of assisted
suicide or physician assisted suicide.[1, 3]
8
Euthanasia in Switzerland: Euthanasia is illegal, but
assisted suicide is not crime when the motives of the person
assisting are for altruistic reasons and not out of self interest.
However, there is no law that regulates this practice.
Euthanasia in Luxembourg: Euthanasia is legal under the
Palliative Care/Euthanasia Act 2009, where it is regulated
by a living will or advanced directive. Doctors need to consult
with a colleague to assess whether patients are terminally ill
and are suffering from a "grave & incurable condition", and
have repeatedly requested to die.[3]
Euthanasia in Australia: In Australia, active voluntary
euthanasia, assisted suicide and physician assisted suicide
(PAS) are illegal. The prohibition of euthanasia and assisted
suicide is established in the criminal legislation of each
Australian state, as well as the common law in the states of
New South Wales, South Australia and Victoria. There was a
period when the Northern Territory permitted euthanasia and
PAS under the "Rights of Terminally Ill Act (1995)". The act
came into effect in 1996 and made Northern territory the first
place in the world to legally permit active voluntary
euthanasia and PAS. This Act was short lived after the Federal
Government overturned it in 1997 with the "Euthanasia
Laws Act 1997". This Act denied states the power to legislate
to permit euthanasia or assisted suicide.[11]
Euthanasia in UK: Currently in UK, any person found to be
assisting suicide is breaking the law and can be convicted of
assisting suicide or attempting to do so. Although two thirds of
Britons think it should be legalized, a recent "Assisted Dying
for the Terminally Ill Bill" was turned down in the lower
political chamber, the House of Commons, by a 4-1 margin.[4]
Euthanasia in USA: In Oregon, "The Death with Dignity
Act" came into effect in 1997 and in Washington the
Washington "Death with Dignity Act" was passed in 2008.
These acts have remained alive despite challenged in the US
Supreme Court. Both the above acts permit a competent
terminally and hopelessly ill patient to seek lethal drugs from
their doctor. They are required to make two verbal and one
written application which need to be accompanied by a
witness; and obtain consent of two doctors. In terms of
performing the task, it is the patient who takes the lethal drugs
themselves, and the doctor does not administer it. These acts
specifically prohibit euthanasia, which is defined as the
administration of lethal drugs to the patient by a person other
than the patient.[11]
Euthanasia - Indian Perspective
It can be said that in a country like India which is plagued with
innumerable problems like illiteracy, poverty, starvation,
infectious disease, lack of basic medical care and facilities the
issue of euthanasia seems to be little irrelevant. In India,
euthanasia has no legal status. The practice of euthanasia is
still very much considered as a clear act of offence. Section
309 of IPC deals with attempt to commit suicide and Section
306 deals with abetment of suicide - both acts are punishable
offence. Recently there has been a sincere effort to
decriminalize and abolish Sec 309 of IPC, with a view not to
punish the person who has attempted suicide since such acts
are usually done in utter despair mental condition.
The Honorable Supreme Court has clearly indicated that the
"Right to Life" guaranteed by Article 21 of the constitution
does not include the right to die. The court held that Article 21
is a provision guaranteeing protection of life and personal
liberty and by no stretch imagination can extinction of life be
read into it. "Right to life" is a natural right embodied in
Article 21 but suicide is an unnatural termination or extinction
of life and therefore not compatible and inconsistent with the
concept of "Right to Life" and warrants punishment under sec
309 of IPC.
The Medical Council of India, in a meeting of its ethics
committee in Feb 2008 in relation to euthanasia opined:
Practicing euthanasia shall constitute unethical conduct.
However, on specific occasions, the question of withdrawing
supporting devices to sustain cardio-pulmonary function even
after brain death shall be decided by a team of doctors and not
merely by treating physician alone.[12]
In a path-breaking judgement, the Supreme Court on Monday
7th March 2011, allowed "passive euthanasia" of withdrawing
life support to patients in permanently vegetative state (PVS)
but rejected outright active euthanasia of ending life through
administration of lethal substances. The apex court while
framing the guidelines for passive euthanasia asserted that it
would now become the law of the land until Parliament enacts
a suitable legislation to deal with the issue. Refusing mercy
killing of Aruna Shanbaug, lying in a vegetative state for 37
years in a Mumbai hospital, a two- judge bench of justices
Markandeya Katju and Gyan Sudha Mishra, laid a set of tough
guidelines under which passive euthanasia can be legalised
through high court monitored mechanism. The bench also
asked Parliament to delete Sec 309 IPC as it has become
"anachronistic though it has become constitutionally valid".
"A person attempts suicide in depression, and hence he needs
9
help, rather than punishment", Justice Katju writing the
judgement said. The apex court said though there is no
statutory provision for withdrawing life support system from
a person in permanently vegetative state, it was of the view
that "passive euthanasia" could be permissible in certain
cases for which it laid down guidelines and cast the
responsibility on high courts to take decisions on pleas for
mercy killings.[13]
Arguments for and against legalizing Euthanasia
Every patient has a right to decide about his mode of treatment
including when and how they should die based upon the
principles of autonomy and self determination. Autonomy is a
concept granting right to a patient to make decisions relating
to their health and life. A patient's own decision taken after all
consideration cannot be argued and challenged. It is his wish
either to continue his treatment or withdraw it, even though
the outcome may result into his death. It is argued that as a part
of our human rights, there is a right to make our own decisions
and a right to a dignified death.[1]
Beneficence - Advocates of euthanasia expresses the view that
the fundamental moral values of society, compassion and
mercy, require that no patient be allowed to suffer unbearably
and relieving patient from their pain and suffering by
performing euthanasia will do more good than harm.[14]
According to the proponents of PAS, it becomes ethical and
justified when the quality of life of the terminally ill patient
becomes so low that death remains the only justifiable means
to relieve suffering. Lack of any justifiable means of recovery
and the dying patient himself making the choice to end his life
are conditions which make euthanasia more justifiable.[15] In
short, it is the extension of patient's right of autonomy to
determine what treatment to be accepted or refused.
Against
Society and various religions believe in the sanctity of life
which must be respected and preserved. The Christian view
sees life as a gift from God, who ought not to be offended by
taking of that life.[1] Similarly the Islamic faith says that "it is
the sole prerogative of God to bestow life and to cause death".
The withholding and withdrawing of treatment is permitted
when it is futile, as this is seen as allowing the natural course of
death.[16]
Euthanasia is considered as intentionally killing of one human
being by another human being which is equivalent to murder
especially active voluntary euthanasia.
Critics of euthanasia argue that the patient's requests for
euthanasia are rarely autonomous as most of them suffering
from terminally ill diseases and may not be in sound or
rational mind while making such decisions. The Universal
Declaration of Human Rights highlights the importance that
"Everyone has the right to life", and euthanasia contravenes
the "right to life".[6] Right to life does not include right to die.
The Role of Palliative care : It is often argued that pain and
suffering experienced by patients can be relieved by
administering appropriate palliative care, making euthanasia
a futile measure. According to Norval and Gwynther[14]
"requests for euthanasia are rarely sustained after good
palliative care is established".
Hippocratic Oath and medical profession : Hippocratic
Oath which guides the medical profession states, "I will
prescribe regimen for the good of my patients according to my
ability and my judgement and never do any harm to anyone. To
please no one will I prescribe a deadly drug, nor give advice
that may cause his death". Thus hastening the death of a
patient by means of PAS is in strict contradiction of the
medical code of ethics. Any attempt to practice euthanasia
will completely erode the trust and confidence built in the
doctor-patient relationship. A doctor's role is to save the life of
a patient and not to terminate it.
Patients from lower socio economic class maybe coerced or
forced to request euthanasia by the family members to curb
financial burden involved in the treatment of such terminally
ill patient.
Conclusion
The issue of euthanasia is still a contentious issue and the heart
of debate is the patient's quality of life and his right of
autonomy. Doctors are at the centre of this ethical dilemma as
ultimately they are going to perform PAS and practicing it
would seriously undermine and jeopardize the objectives of
medical profession. Medical science is progressing, and we
now have better means of controlling the unbearable pain of a
terminally ill patient. Even life of such patients can be
prolonged by artificial means. Though these efforts will
improve the quality of life, these methods may prove very
costly for the patient's family. Also considering the low ethical
levels prevailing in the society one cannot rule out the
possibility of use of such request of passive euthanasia by
unscrupulous relatives for ulterior motives. Though the recent
Supreme Court judgment gave a big boost to the proponents of
euthanasia, there is still a scope of its misuse. Major issues
concerned with it need to be efficiently and effectively
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addressed before it becomes a law. By that time, maybe the
state and the law can play the role of parents patriae as
suggested in the above landmark judgment.
References
1. Bartels L, Otolowski M. A right to die? Euthanasia and the
law in Australia. J Law Med. 2010 Feb; 17(4): 532-555.
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4. PN Murkey, Konsam Suken Singh. Euthanasia (Mercy
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13. No Mercy Killing for Aruna Shanbaug, says Supreme
Court, Monday March 7, 2011.www.zeenews.india.com.
Assessed on 31st Jan 2013.
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care. CME. 2003 May; 21(5):267-272.
15. Quill TE. Death and Dignity: Making Choices and Taking
Charge. New York: WW Norton; 1993:156-157.
16. Bulow HH, Sprung CL, Reinhart K, Prayag S, Du B,
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Intensive Care Med 2008 Mar; 34(3); 423-430.