Euthanasia and the right to choose

© Gina Rydland published: 03.11.2008

"The euthanasia debate requires us to confront the most basic of human concerns- the mortality of self and loved ones - and to balance the interest in preserving human life against the desire to die peacefully and with dignity ... This controversy may touch more people more profoundly than any other issue the court will face in the forseeable future." - Ninth Circuit Court judge Stephen Reinhardt. 1996 decision on the right-to-die-case: Compassion in dying et al. v. State of Washington.

Imagine, yourself or a loved one suffering from an incurable degenerative or disabling condition, terminal or non-terminal, requesting help to end life. A situation we all hope to never experience, but many of us will have to face. Personal references to belief systems, and life experience might guide us in the process leading to the final decision making of ending or prolonging life. What feels right for one person, might seem unacceptable to another.

Today most Western countries and states in U.S. accept a DNR order [1]. Competent adults are allowed to refuse medical treatment also which sustains life. Surrogates [2] can also refuse such treatment on behalf of incompetent, but formerly competent adults. Other forms of euthanasia however is not legalized in most of the worlds countries [3] leaving those requesting it forced to follow the view of those who oppose euthanasia.

In the U.S. the first attempt to legalize voluntary euthanasia [4] performed by physicians was a bill introduced to the Ohio legislature in 1906 [5]. The votes were against the bill, 78 to 22. Another attempt to legalize euthanasia was made in Great Britain in 1936. A bill was introduced into the Parliament, but the House of Lords voted it down by 35 to 14 [6]. It would take a few decades before bills passed (e.g. California, U.S.-1976) and the right-to-die movement started to expand (1980s) [7].

Arguments held by the opposition is that a legalization could lead to forced euthanasia of vulnerable members of our society, like the poor, disabled, elderly and chronically ill. Many also believe that no individual´s rights outweighs the states duty to protect life. They say euthanasia is against the physicians duty not to harm a patient.

The right-to-die movement on the other hand see it as a human right for every individual to decide when and how to die, when suffering from a non curable condition. They ask; is keeping a ill person with no possibilities for treatment or relief, alive against his/her will to be considered as an expression for protection of life, compassion and respect for the patient? And is this a human and non-harmful act by a physician? [8]

In the Netherlands the Termination of Life on Request and Assisted Suicide Act was put into effect 01.04.2002 [9]. It gives empirical evidence to be studied by other countries.

The differences in world countries health care systems and culture might be a challenge. The Netherlands provide health care for all their citizens, but U.S. does not since millions of Americans lack private health insurance and consequently have limited or no access to health service. Legalizing euthanasia and securing the individuals right to have choices rooted in reality, rests upon the societies ability and will to make these options economically available to all citizens.

An illegal practice of euthanasia exist in today's system of health service [10]. Doctors provide the means to, or perform euthanasia, both for competent persons who request it and for incompetent patients who are suffering from incurable diseases, terminal or non terminal. The opening for abuse that the opposition claim will become a fact if euthanasia is legalized, already exist. Legalizing euthanasia and having it in a controlled form better secures the patient if the conditions of a strict law is met.

Passive euthanasia [11] is widely used and legal in many countries. Is it more human and morally correct to let people die from starvation and thirst because refusing medication and nutrition is the only option the patient or surrogate has to end a patients life? Or would active euthanasia be a more human choice? [12]

Many in the opposition, including physicians claim that today's offer of pain relief available to the patient is sufficient, hence there is no need for euthanasia. A Norwegian state report, series 2:96 concluded that pain relief treatment is underdeveloped. The medical establishment in Norway finally had to admit being unable to provide patients with sufficient pain relief causing unnecessary suffering and a unworthy situation for the patient. A larger part of the medical establishment is in desperate need of a change of attitude in regards to respecting a persons autonomy [13], which is alfa and omega in the question of euthanasia. Hopefully those responsible for the education strategy will mature and improvements made. The fact that physicians admit the shortcoming of pain relief is signaling more openness and willingness to listen to the patients needs.

Not legalizing euthanasia has led to several cases where people have died by their own hand or with help from family and friends [14]. E.g. British journalist Derek Humphry, march, 1975, helped his wife, Jean, terminally ill with cancer, to commit suicide with drugs obtained from a doctor for the purpose. Cases have been tried in court and people have been prosecuted like in the Postma case in the Netherlands [15]. Tragic events and death without dignity could have been avoided if a euthanasia law giving people the right to choose was put into effect.

Responsible authorities and citizens should develop a free health care system of high quality. In the home for the elderly, the means to give the patients the opportunity to fulfill their choice must be made available. Staffs knowledge on palliative care and euthanasia upgraded. Establishing special units and hospices for palliative care or/and euthanasia is crucial to provide citizens with the professional help and care they need.

A document stating the wishes of the patient in various case scenarios and designating a surrogate if the person becomes incompetent, should be a part of that individuals health record and put into system for all citizens. This to ensure that the physician, family or friends are able to make the best decision possible.

Providing strict laws and routines, giving people the options creates the balance needed to avoid possible abuse of euthanasia and gives those in need of it a dignified way to end their life.

Court cases around the world show the complexity of the euthanasia issue, e.g. the Quinlan case in New Jersey [16]. The debate needs to be brought out to the public. The patient her/himself, family, health care personnel, lawmakers and government representatives should work in a joint effort to secure the right of the individual regardless of their choice and point of view. There are no contradictions in securing those who oppose euthanasia and those who want it legalized. What should be the core issue is every humans right to decide over their own life when suffering from an incurable degenerative or disabling condition, terminal or non-terminal, resulting in unbearable physical/mental pain and severely lowered quality of life.

"Those who believe strongly that death must come without physician assistance are free to follow that creed, be they doctors or patients. They are not free, however, to force their views, their religious convictions, or their philosophies on all the other members of a democratic society, and to compel those whose values differs with theirs to die painful, protracted, and agonizing deaths." - Ninth Circuit Court judge Stephen Reinhardt.

[1] Do-not-resuscitate order (DNR order): An order on a patient's medical chart, usually signed by a physician after consultation with the patient and/or family. Health care personnel are not to attempt to revive the patient if the patient's heartbeat or breathing stops. A DNR order is a form of advanced health care directive. Some states but not all allow DNR orders to be honored in non-hospital settings. In Norway DNR order is put into system.

[2] Surrogate is a person (close family, friend, physician) designated to decide on behalf of a never competent person. Or incompetent, but formerly competent adult who left prior instructions to do so in form of a living will or other advanced directives. Courts may appoint surrogates to act for never-competent people or formerly competent people whose previous wishes are not known.

[3] Physician-assisted suicide is legal or openly practiced e.g.: Switzerland, Oregon- USA, Belgium and the Netherlands.

[4] Volunteer euthanasia: Killing a person at the persons request to avoid or stop the suffering caused by a terminal or incurable disease or injury.

[5] The bill proposed that (according to a contemporary newspaper): "When an adult of sound mind has been fatally hurt and is so ill that recovery is impossible or is suffering extreme physical pain without hope of relief, his physician, if not a relative and if not interested in any way in the person´s state, may ask his patient in the presence of three witnesses if he or she is ready to die......Three other physicians are to be consulted." When the patient wanted to die and if three three doctors agreed about the patient´s condition, the physician could provide a painless death.

[6] The British Voluntary Euthanasia Society (formed in 1935) promoted the bill drafted (1931) by health officer for the city of Leicester, C. Killick Millard. The society had members like H.G. Wells, Georg Bernard Shaw and Bertrand Russel.

[7] The bill Natural Death Act signed by Governor Jerry Brown, came into law, 30.10.1976. It allowed the refusal of life-prolonging medical treatment only if the patient was terminally ill.

"This bill gives recognition to the human right that people have to let their life come to its natural conclusion ."

It was the first living-will law in the US. Fifty similar bills were introduced in 38 states the following year and they passed in seven. During the next decade 36 states followed California's lead.

[8] Netherlands: Even though euthanasia and assisted suicide was technically against the law (before april, 2002) the legal argument used to permit these acts, was that they took place under the "necessity of duress". Arising from the physicians duty not to let the patient suffer.

[9] 28.11.2000. The lower house of the Dutch parliament voted 104 to 40 to legalize voluntary euthanasia and physician-assisted suicide. The upper house followed 11.04.2001. The Termination of Life on Request and Assisted Suicide Act demands that the patient has made a free, informed, and explicit request to end life and it must be repeated over time. The patient must experience unbearable and unrelievable suffering. The physician must consult another doctor to confirm the diagnosis. After death occurs the physician must report it to the coroner. In contrast to similar laws in other countries the suffering does not need to be caused by an terminal or physical illness.

[10] a) Journal of Medical Ethics. October, 2004: A survey where physicians were allowed to be anonymous, between 4 and 10 percent admitted that they had deliberately helped patients die.

b) 1998: 355 oncologist (cancer specialists) were interviewed. 56 (15.8 percent) admitted having carried out physician-assisted suicide or euthanasia.

Many of these deaths take the form of terminal sedation, also called the "double effect". High doses of narcotics are given to control pain, but the physician know that the dosage will shorten the patients life or end it. "This is the dirty little secret of medicine." - Internist Howard Grossman of the St. Lukes-Roosevelt hospital at Columbia University.

[11] Passive euthanasia: Ceasing or not starting medical treatment that keeps a person alive. (E.g. respirator, food & water through a tube)

[12] Active euthanasia: A physician (or friend, family) causes the death of a sick person without that person´s participation. This can be done voluntary (done at the sick persons request) or involuntary (without the sick person´s concurrent request or permission).

[13] Autonomy: The right of self government and independence.

[14] 26.09.2003. Vincent Humbert, a French man left severely disabled by an automobile accident in 2000, is killed by his mother and doctor after repeatedly, highly publicized request to die. (He had even dictated a book on the subject with movements of one thumb).

2008: Bjørnar Kanli (71) from Arendal, Norway committed suicide in protest against euthanasia not being permitted in Norway. He had cancer and was terminally ill. Before he died he wrote a letter called; "a speech from the grave", which he requested to be printed in the Norwegian newspaper Aftenposten. His letter was printed 26.03. Read the letter

[15] 1973. Physician Geertruida Postma is put on trial in the Netherlands for giving her terminally ill mother a fatal injection at the mothers request. Postma is found guilty but given only a one-month suspended sentence and a years probation. Her case marks the decriminalization of physician-assisted suicide and euthanasia in the Netherlands.

September, 2008. The mother of a paralyzed rugby player who killed himself at a suicide clinic in Switzerland has defended her right to help him end a life 'filled with terror and indignity'. Read article.

[16] 14.04.1975. Karen Ann Quinlan, a 21-year-old New Jersey woman, consumes a mixture of alcohol and drugs at a party and enters what proves to be a vegetative state. 31.07. The parents signed a form requesting her physician, Robert Morse, and St. Clare's hospital to turn off her respirator. Morse and the hospital refuse to comply. 20.10. Lawyer Paul W Armstrong representing the parents of Karen Ann appeal to New Jersey probate court judge Robert Muir, Jr, for legal guardianship for Karen and the right to refuse life-sustaining medical treatment on her behalf.

10.11. Muir rules against the Quinlans, maintaining that the state's interest in preserving life outweighs the family's right to privacy in making medical decisions. "There is no constitutional right to die that can be asserted by a parent for his incompetent adult child."

1976. The Quinlans made an appeal to the New Jersey Supreme Court which unanimously reverses Muir's decision, granting Joseph Quinlan guardianship and permission to turn the respirator off. The court states that the constitutional right to privacy covers this case. This is the first time a state court has applied the right of privacy to a case of "letting die".