Can Euthanasia be part of "Good-Doctoring?'

- Sahin Aksoy M.D., Ph.D.
Harran University, Faculty of Medicine,
Department of Medical Ethics and Medical History,
Dekanlik Binasi, 63200 Sanliurfa, Turkey
Email: saksoy@doruk.net.tr

Eubios Journal of Asian and International Bioethics 10 (2000), 152-4.
Abstract

Euthanasia is a popular subject that health care professionals, lawyers and theologians has dealt with for a long time. While it was an extreme and exceptional case to support and argue in favour of euthanasia among health care professionals and lay public, it becomes more and more common to see supporters of this act especially among health care professionals.

In this article euthanasia is examined from different perspectives, and tried to draw a conclusion that may be helpful to clarify our thinking on this issue. Throughout the article, the concept of "ownership' and the popular bioethical principal "right to autonomy' are also explored. It is mainly concluded that since the euthanasia is the termination of a human life, and violates the internal morality of medicine, it cannot be considered as a part of "good-doctoring' before it is questioned and debated very closely by the concerned public, as well as health care professionals, lawyers, theologians and politicians.

Key Words: Euthanasia, ownership, autonomy, good-doctoring.

Euthanasia is one of the most widely discussed issues among health care professionals as well as ordinary people. While supporting and practising euthanasia was an exceptional and extreme view in the beginning it became to be perceived as a "matter of choice' during the course of the time. Although it did find ground to itself in "materialistic' and "utilitarian' societies before, it turns to be a possible option for the individuals in "more traditional' societies. [1]

There are different definitions of euthanasia, each putting the emphasis on different parts of the concept. The word itself is derived from a compound of two Greek words- eu" and "thanatos- meaning literally a good death. It is generally understood today as the intentional putting to death by artificial means of persons with incurable or painful disease. [2] The decision to end a person's life may involve direct interventions (active euthanasia) or withholding of life-prolonging measures (passive euthanasia). If the decision reflects the person's own consciously and expressly declared wishes, it is called voluntary euthanasia. Where the person does not know about the decision and has not expressly approved it in advance it is called non-voluntary euthanasia. Another type of euthanasia, namely involuntary euthanasia, occurs whenever such a decision is implemented against the express wishes of the individual. [3]

There have been individuals and groups who are for or against euthanasia. Those who argue in favour of the practice usually presuppose a person's absolute ownership of his or her body and life: as people are entitled to dispose as they choose of the things they own, the analogy is that they may also choose the circumstances most appropriate for them to "dispose' of "their' life. This is one of the rationales behind voluntary euthanasia.

However, the ownership (or property right) of humans over their bodies is not a property right in the usual sense of the term. Munzer defines various types of "ownership', "property right' etc. and concludes: "Most body rights are personal rather than property rights; examples are rights not to be murdered, not to be searched without a warrant or just cause, not to be compelled to testify against oneself, not to be libelled or slandered, to speak freely, and to exclude others from sexual or other physical contacts". [4] However, he says: "Some body rights are property rights whether weak, such as the right to donate an organ upon death, or strong, such as the right of publicity or the right to sell blood or semen; but these weak and strong property rights are neither so numerous nor so central as to establish that persons "own' themselves". [5] Evidently, it is not very easy to propose or prohibit euthanasia by using the "property rights' argument. (Perhaps we can summarise the issue by saying that the language of "property rights' is appropriate only in the context of commercial/contractual transactions. If it ever was, it is no longer thought proper to speak of buying or selling human beings outright; we only speak nowadays of buying or selling an individual's time or skills.)

Voluntary euthanasia has been likened to suicide in many respects. Therefore almost all religious traditions reject it; they reject the idea of terminating one's life, and declare it to be one of the greatest misdeeds. [6] According to this understanding, our lives and our bodies are given by God. We are stewards and not owners of our lives, hence to contrive the ending of our own lives or to harm our bodies knowingly is a sign of disrespect to the "real owner'.

Roman Catholic theologians have reflected on matters of death and dying for centuries. The Sacred Congregation for the Doctrine of the Faiths 1980 declaration on Euthanasia, approved by Pope John Paul II, states: 1) None can make an attempt on the life of an innocent person without opposing God's love for that person, without violating a fundamental right, and therefore without committing a crime of the utmost gravity; 2) Everyone has the duty to lead his or her life in accordance with God's plan. That life is entrusted to the individual as a good that must bear fruit already here on earth, but that finds its full perfection only in eternal life; 3) Intentionally causing one's own death, or suicide, is therefore equally as wrong as murder; such an action on the part of a person is to be considered as rejection of God's sovereignty and loving plan. Therefore euthanasia is a violation of the divine law, an offence against the dignity of the human person, a crime against life, and an attack on humanity. [7]

Among the Protestant denominations that oppose voluntary euthanasia are the Lutherans, Mennonites, Methodists, Presbyterians, Mormons, Jehovah's Witnesses, Episcopalians,Christian Scientists and Baptists. The rationale for rejecting the option of euthanasia or assisted suicide is based generally on the maxim, "only God can give life and only God should take it". [8]

The four branches of Judaism ― Orthodox, Conservative, Reform, and Reconstructionist ― all forbid active euthanasia. The ancient Torah and Talmud did not address euthanasia or assisted suicide. However, in recent years, rabbis have answered questions about death and dying in "responsa " that have come to be considered authoritative. For example, a responsum from the Reform Jewish tradition addressing euthanasia declares: "Human life is more than a biological phenomenon; it is the gracious gift of God, it is the in-breathing of His spirit. Man is more than a minute particle of the great mass known as society: "The spirit of God hath made me," avers Job in the midst of his suffering, "and the breath of the Almighty gives me life" (Job 33:4). Thus, human life, coming from God, is sacred, and must be nurtured with great care. And man is endowed with unique and hidden worth and must be treated with reverence." [9]

Islam also opposes euthanasia. The Qur'an and Sunnah, the authoritative sources of Islamic law, do not speak specifically about euthanasia. However, according to the Qur'an God is the Creator of life. Consequently, persons do not own their lives and have no right to end them or to ask others to do so. [10] The Prophet Muhammad is reported as saying: "None of you should wish to die because a harm befalls him. If he is so determined, let him pray: Oh God, let me live as long as life is good for me, and let me die if death is good for me'". [11] This saying might be interpreted as a permission for euthanasia or deliberate termination of life, if the phrasing of the supplication were "let me kill myself" or "let me be killed" rather than "let me die", which cannot be so interpreted. A contemporary Islamic scholar has argued: "God may deprive an individual of something he or she values, but grant that individual a manifold return that loss in the Hereafter. By means of that loss, God makes you feel your need, your powerlessness, and your poverty in relation to Him. In this way, He makes you turn to Him with a weightier sincerity, a fuller heart, and so makes you worthier of His Blessing and Favour. Thus your apparent loss is in reality a gain" [12] One recent study indicated that the degree of religious observance is a factor that influences the desire for maximal medical intervention. It is argued that fundamental beliefs of the more religious elements of society, regardless of which religion, tend towards an approach in which sanctity of life, rather than quality of life, becomes the prime determinant. [13] Therefore, it is not unusual, among believing people, to come across those who are remarkably contented in spite of circumstances of great hardship, suffering and pain. However, in a pluralistic society, which does not have a sense of common values, one cannot argue against euthanasia on theological grounds. Every individual member of a pluralistic society may not share the same faith commitment. However, there is a general agreement in every society that discussion of values may be made rather in the language of ethics, a language that express right reasons. Therefore, on such philosophical grounds, excellent arguments are supposed to be made that euthanasia cannot be considered as a part of good doctoring and doctors should not involve this practice.

One of the primary things that makes euthanasia unacceptable is the involvement of a second party. Since life is inherently valuable, no one should play a part, directly or indirectly, in terminating a life. Since 1961, it is not illegal in Britain to commit suicide, although it is punishable to help an individual to kill himself. However it is claimed that when the life is objectively meaningless, rather than subjectively, the termination of life and help for it can be justified, and in euthanasia cases lives are generally objectively meaningless. Kohl made the distinction between these two as follows: "A life is subjectively meaningless when an individual earnestly believes he or she cannot possess, can no longer possess, or cannot achieve, any goals. A life is objectively meaningless when any of the aforementioned intersensual and intersubjective conditions exists and is known, or is capable of being known, to be irreversible." [14] In another article, after stating that meaningful life is a precondition for a good life, Kohl said: "An ideally good life is like an ideal meal. What most men desire is a splendid meal with a splendid dessert." [15] So, when the "dessert' is far from splendid, it is good for the person, as well as for those who must take care of that person, to terminate the life. But, as was mentioned in the report by the working party, which reviewed the BMA's guidelines on euthanasia, termination of life requires doctors to examine their ethical convictions rather than their scientific ones. And throughout the many shifts of scientific opinion in medicine, one pervasive feature of medical practice has remained unchanged \ the conviction that human life is of inestimable value and ought to be protected and cherished. [16] But nowadays, as with many other things, these convictions are also under discussion, and tend to be challenged.

Although there is a trend toward legalizing the practice of euthanasia, strong resistance to it persists. [17] Here are some of the traditional arguments against euthanasia. One concern is that, along with the justifiable cases of terminally ill people asking for and receiving a quick, merciful death, there would inevitably be cases in which euthanasia would be clearly wrong. Another is that, a law legalising euthanasia might well be abused, with some person's life being ended, against his or her consent, for a motive other than mercy. We also know that diagnoses and prognoses of a disease can be wrong. For instance, predicting how long someone may live with cancer is very difficult at best. Some whom we expected to die in a few months might live on for years; conversely some might live a much shorter time than we, the caregivers, anticipate. Another valid concern is that the "right to die' may well become a "duty to die'. For instance, frail, disabled elderly people who are financial and emotional burdens on their families may feel some pressure to ask for euthanasia. Finally, even apart from moral and ethical considerations, legalising euthanasia has the potential to weaken and damage the relationship between patients and physicians. [18] The relationship between the patient and the physician within the practice of medicine has been understood traditionally as a covenant or contract with rights on the part of the patient and duties on the part of the physician. The primary duty of the physician in this relationship is, in fact, a negative duty: to do no harm. It also follows from this that the physician has the duty of beneficence. However, in our post-modern era the physician's duty of beneficence has yielded to the patient's right to autonomy. Yet even today a patient's autonomy must have limits, just as the physician's beneficence is limited and can never be absolutized. Limits on autonomy occur for a variety of reasons. A patient's desired action may possibly harm third parties. For instance in the case of voluntary euthanasia (and suicide as well) although the death is person's desire, his or her death may be the worst thing he or she can do to his or her relatives and beloved. It may also be in conflict with the physician's own moral beliefs. It may even violate the internal morality of medicine. A patient's request for euthanasia must be looked upon as an instance where autonomy is limited and is not absolute. It also not to be forgotten that, contradicting the statement made by Oguz, being against the idea of legal acceptance of euthanasia has noting to do with "fundamentalism' in any possible interpretation of the concept. [16]

Bearing in mind that euthanasia is, all said and done, the termination by one means or another of a human life, the justification for it will always be questionable. Thus it cannot be considered as a part of "good-doctoring' until it is questioned and debated very closely by the concerned public, as well as by health care professionals, lawyers, theologians and politicians.

References

1.Oguz, Y. Euthanasia in Turkey: Cultural and Religious Perspective, EJAIB 6 (1996), 170-1.
2.Mason, J.K and McCall Smith, R.A. Law and Medical Ethics, Butterworths, London, 1994:316.
3.Harris, J. The Value of Life, Routledge, London, 1985:82.
4.Munzer, S.R. A Theory of Property, Cambridge University Press, Cambridge, 1990.
5.See reference 4:57.
6.Smoker, B. A "Rejoinder to Religious and Non-Consequentialist Objections'. In: Downing, A.B. and Smoker, B. (eds) Voluntary Euthanasia: Experts Debate the Right to Die, Peter Owen, London, 1986:96-109.
7.Sacred Congregation for the Doctrine of the Faith. Declaration on Euthanasia, Vatican City, 1980.
8.Ramsey, P. Ethics at the Edges of Life, Yale University Press, New Heaven, 1978:145.
9.Bettam, I. Euthanasia. American Reform Responsa, 1950; 60:107―20.
10.An-Nisa 4:29.
11.Buhari, Merd_, Da'avat; 19:30.
12.Gulen, F. Questions-1, Truestar Publications Ltd., London, 1994 p.162.
13.Hammerman, C. "Decision-making in the Critically Ill Neonate: Cultural Background v. Individual Life Experiences'. Journal of Medical Ethics, 1997; 23:164―9.
14.Kohl, M. "Moral Arguments For and Against Maximally Treating the Defective Newborn'. In McMillan, R.C., Engelhardt Jr, H.T. and Spicker, S.F. (eds) Euthanasia and the Newborn, D. Reidel Publication Company, Dordrecht, 1987:233―52.
15.Kohl, M. "Voluntary Ending of Life'. In de Vries, A. and Carmi, A. (eds) The Dying Human, Turtledove Publication, Ramat Gan, 1979:253―62.
16.BMA Report of the Working Party to Review the BMA's Guidance on Euthanasia, London, 1986:18.
17.Willke, J.C. Assisted Suicide and Euthanasia: Past and Present, Hayes Publishing Company, Cincinnati, 1998.
18.Cundiff, D. Euthanasia is not the Answer, Humana Press, New Jersey, 1992.
19.See reference 1:171.

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