- N.Yasemin Oguz, M.D., Ph.D.
18/16 Farabi Sokak, Cankaya 06680, Ankara, TURKEY
In this paper I want to discuss
euthanasia in the context of the circumstances in Turkey. This
paper was presented in a conference, namely "Euthanasia:
Towards a European Consensus", held by Centre for Bioethics
and Public Policy in Brussels in 1995. As a result of the increasing
attention given to the topic and the articles in EJAIB
(1,2,3), I would like to seek comments from other colleagues and
report on how culture and religion influence the debate in Turkey.
Euthanasia means ending a patient's life according to certain principles and under certain circumstances, where medicine can not cure or provide a life of acceptable quality. I classify it in two different ways based on physicians' action and patients' consent. It can be active or passive according to physicians' actions, and it is important to separate DNR orders and physician-assisted suicide from them; especially in countries like Turkey that are debating the level of technological development and their values. According to patients' consent, it is necessary to emphasize voluntary, non-voluntary and involuntary types of euthanasia (4,5).
Euthanasia has deep historical roots. Before Hippocrates, euthanasia was a routine procedure and physicians assumed that they had the authority to kill patients for whom they gave up the hope of recovery, without asking for their permission (6). They accepted this as a part of their medical practice. Hippocrates regarded this procedure as a hindrance to the establishment of confidentiality between physicians and patients. Probably this is the reason for the words in The Hippocratic Oath, "I will give no deadly medicine to anyone if asked, nor suggest any such counsel." This guarantee which Hippocrates provided by his oath, established the basis of the confidence between physicians and patients for 2500 years.
The effects of the Hippocratic Oath were noticed in Anatolia in the 19th century after modern medical schools had been established. Written sources (7) show that euthanasia continued to be widely used after Hippocrates and was a socially exalted procedure among Galatians who settled in Anatolia in 287 BC and some other civilizations followed them. During this period suicide was also exalted by the society, and had some similarities with the harakiri tradition in Japan. Islamic domination put an end to both the euthanasia practice and its high regard in society in Anatolia. Euthanasia was wiped out of the society's living conscience during the period when Anatolia used to be a part of Islamic civilization. But it has continued to be a part of the social subconscience. The contemporary situation of the concepts of death and euthanasia in Anatolia, which entered a new period after the establishment of modern Turkey, was determined by its culture which was considerably affected by this social subconscience and Islamic belief.
The concept of euthanasia entered the agenda in Turkey in 1975. At the beginning, it was thought to be the problem of the countries where medicine was highly developed. The medical technology in Turkey was not very well-developed to make the euthanasia debate necessary at that time. Life sustaining systems rarely existed, intensive care and health care facilities were in poor conditions and hardly accessible. It has become an important problem in Turkey in the last decade, as the result of technological and medical developments. There are still some problems about the attainment and purchasing of health care facilities, and also about the level of medical care. But especially the developments in life sustaining systems and their efficient usage in daily practice made euthanasia an important subject for society. As physicians, patients, patients' relatives, insurance companies and jurists met the dilemma routinely, and as the mass media began to put it on the agenda more, a lot of discussions have taken place. This is an important pressure which forces the State to form some attitude about euthanasia.
In Turkey there is a great difference between the level of medical technology and the physician-patient relationship regarding the contemporary norms. Paternalistic attitudes are common and this also suits the expectations of society. Physicians rarely inform their patients about their diagnosis and treatment, even when it is not a fatal or hopeless situation. The primary reasons which physicians put forward about this fact are that they had to attend to too many patients and patients' educational level was not adequate (8). Undoubtedly these are important factors, but there are evidences which indicate that they can not be the main ones. Even in private clinics where the number of patients per physician is very low, physicians' preferences regarding the relationship are quite similar to those of their colleagues in general hospitals. I think the main reason is the physicians' identity which is determined by medical education and social status. The physician-patient relationship in Turkey totally leans on the belief that a physician always does the best for their patient and always protects life. This belief established the myth of the "little god" physician.
This view began to change and be corrupted dramatically in the last few years. The most appropriate word which describes the contemporary situation is chaos. Today, many social institutions especially the mass media severely criticize physicians' attitudes in Turkey. Sometimes these criticisms turn out to be unfair attacks on medicine. This is the result of corruption in the myth of "little god" physician, and social disappointment about that. The associations of medical professionals try very hard to avoid any harm to medicine as a social institution while passing through this chaotic period. They try to re-establish confidentiality in physician-patient relationships on a stronger basis like the "informed consent doctrine". The foundation of the associations for specialized doctors of medicine is one of the main positive steps in realizing this purpose.
Today the euthanasia debate still continues academically. While practitioners generally follow the debate closely, because it is very important for them; they prefer not to join it actively, in order to avoid further distrust. Passive euthanasia, especially, is a common practice among Turkish physicians, but they hardly name it. It is hidden or rationalized by practitioners, so the procedure does not have any accepted rules or basis. The physicians' feelings seem to be the only criterion. For instance, discharging an uninformed terminally ill patient from hospital without his consent, mostly according to his relatives wishes is very common and can be regarded as a passive involuntary euthanasia. Prescribing lethal doses of anesthetics is also common. Poor quality of terminal care and its intended reduction is another example for this kind of procedures.
Rapid sociocultural transformation in the society made euthanasia debate difficult. Just a decade ago, 90% of the deaths among patients in Turkey occurred at home. These deaths have existed in a way that hardly allowed any medical interference, so everybody knew what death was. Today more than 40% of the deaths among patients occurs in hospitals. This sudden increase caused a significant conflict in the settled values of the society about death. Death in the hospital is usually an alien condition and it destroys the natural concept of death. Especially for the rural people with low sociocultural level, hospital death is quite a suspicious matter. This suspicion can increase after euthanasia begins to be discussed widely in the society. In my country, the relatives of patients who receive a diagnosis of brain death do not believe that they are dead, and generally refuse organ transplantation or withdrawal of the life sustaining treatment, partly due to lack of trust in physicians.
The mass media has played a very significant positive role in the transformation of Turkish society and has begun to be called as the fourth power by sociologists. However the mass media has hindered the possibility of healthy discussion by causing emotional loading, false beliefs and irrational suspicions. People think that the physicians are going to kill their patients, in what they consider as hopeless situations. The present resistance in the society at large which arose from this misunderstanding is certainly the main hindrance to the euthanasia debate. However, the mass media helps us in seeing one of the most important facts about euthanasia in Turkey, which is the necessity of reaching the limits of contemporary medicine. In Turkey, it is very hard to determine or claim that these limits were reached in Turkey. The reason for this difficulty is that there are many problems in the delivery and purchasing of health care facilities. In my country 60% of the population is not sheltered by any kind of health insurance. The State claims that it provides some kind of social aid in health care, but this is only partial coverage. It does not cover expensive or extraordinary treatments; so it is always a question for a physician, ethicist or judge whether a patient's death wish is really a persistent decision.
One of the most important factors which determines society's attitude towards euthanasia is religion. 90% of the Turkish population are Muslims. As there are various sects and tariqas that cause significant differences, it is important to begin with an overall review of Islamic approach to euthanasia. There are important differences between Islamic countries. The first group contains the countries which are governed by Islamic rules. These countries accept sheria as their legal and administrative code, like Iran and Saudi Arabia. In Iran Shia Muslims and in Saudi Arabia Sunni Muslims as sects of Islam, rule the State. The second group consists of countries which have secularly governed states, but their laws are based on sheria, like Egypt and Algeria. Actually this is the largest group.
Turkey differs from these countries. Although the majority of the population is Muslim, the State is totally secular. Secularism in Turkey includes both the administrative, legislative and all other social systems. Despite a radical Islamic movement, which takes Turkey as its main target, cultural characteristics and historical background in 20th century led to a strong resistance in the society.
Islam's approach to death is quite clear. Allah is the master of life and death. A Muslim is expected to know and accept that there are divine purposes in life's turning to be a painful one and in the delay of desired death. Ending life personally or asking somebody to do it instead, is regarded as an attempt to share Allah's power, so this is assumed to be an unforgivable sin. According to the Koran the wish for death is forbidden (9,10). Suicide is the biggest sin (11). No funeral prayer is made for such people, this means they can never be recipients of Allah's forgiveness. This situation affects the family as well, and causes isolation in society. Murder is a lighter sin. Even if there is no adequate reason found for tolerance, there is a chance for Allah's final forgiveness, because there is no rule which hinders his last prayer.
When Islam's approach to death is examined with regards to the results of euthanasia, it is clear that in countries where sheria is in operation either totally or only legally, practicing euthanasia is impossible. Since Imam-i Gazali, an Islamic commentator (12), Islamic rules have been assumed to have reached perfection, so there could be no additional rules except the interpretation of the existing ones. In Islam, rules about death are very clear that there is no place for interpretation. Islamic rules put every aspect of life in an order and health care issues are one of these aspects. Because of this, medicine in Islamic countries has developed according to these rules. This development has not reached the level of modern medicine yet, so euthanasia is not considered a real problem yet.
Things are very different in Turkey, not ruled by sheria. Anatolia has a strong and deeply rooted tradition which goes beyond Islamic domination. This tradition has been in accord with Islamic rules in many aspects of life, but there is a significant conflict about death. For example in some Anatolian subcultural groups, though it is not widely practiced today, suicide in some situations is socially respected. For example, in Islam it is the duty of the woman's relatives or society to punish a married woman who committed adultery. In Turkey there is no such procedures. Also suicide is not punished by law in Turkey, but according to sheria it should be.
As a secular State, euthanasia can be accepted legally. This happened for abortion, organ transplantation, genetic technology and in vitro fertilization. The State offered some rights to the people according to certain limitations and standards which are accepted universally (13,14,15). Religious authorities did not approve of some of these procedures, nor totally reject. But society made use of these rights liberally. Euthanasia is considered as one of the subjects of that kind in Turkey. Undoubtedly fundamentalists will react sharply against the idea of legal acceptance of euthanasia, but their effect will be limited by their political power.
Like many countries, Turkish law is established from the principle of the sanctity of life and respect for it. Euthanasia is legally forbidden in Turkey, and is regarded as homicide. As one of the main elements of the crime which is called "bad intention" does not exist in euthanasia, there is a dilemma. There has been no law suit about euthanasia in Turkey, so the jurists' interpretations are not clear. Recently a similar problem existed about the definition of death related to organ transplantation. Jurists passed over this problem by emphasizing the definition of death would be determined and changed according to recent medical knowledge and consensus. As a secular system the Turkish legal system is both rational and open to change after considering the modern requirements.
As a result, it can be claimed that the euthanasia debate in Turkey will stay within the limits of academic societies for a few more years. Symposia like the one held in Izmir in 1994 by the representatives of the Appleton Consensus Project played a triggering role in this debate and sped up the process. That symposium gave us clues about how to reach a conceptual consensus in order to carry on a healthy discussion. Using the classifications about euthanasia as a stand-point is being supported in the discussions, especially in the medical society. One of the reasons is the social value judgments of the Turkish population and the pressure of social dynamics which are partially determined by the radical Islamic movement.
Certainly no legislative or moral arrangements on euthanasia procedure could have existed before the physician-patient relationship was reestablished on a healthy basis. As the relationship depends on "confidence" stemming from Hippocratic contract, it is still a highly paternalistic one, so the society is rather cautious about physicians' "omnipotence". This process does not seem like it will be completed in the near future. But as the transformation of Turkish society appears to be a rapid one, many of the predictions made in the past turned out to be wrong. It is very clear that economical, social and technological developments put a considerable pressure on the State for a legislative arrangement about euthanasia.
Under these conditions, it is important to keep the discussion healthy and alive. Any effort which tends to reach a consensus on this subject will help us in finding a way towards a rational solution for the euthanasia debate in Turkey.
1. Tharien AK. Euthanasia in India.
EJAIB 5 (1995), 33-35.
2. Yali C. The first euthanasia court case in China. EJAIB 6 (1996), 61-62.
3. Kushe H. Voluntary euthanasia: - Australia. EJAIB 5 (1995), 66-69.
4. Singer P. Practical Ethics. 2nd edition. CUP. pp. 127-157; 1981.
5. Nowell-Smith P. In Favour of Voluntary Euthanasia. In: Gillon R. Principles of Health Care Ethics. 2nd edition. NY John Wiley. pp. 753-762; 1995.
6. Ney PG.The universal ethic of mutual benefit. T.Klin.TibbiEtik1994; 2,53-56
7. Lequenne F. Galatlar. (Les Galates). 2nd. edition. Ankara. TTK Pub. 16-27; 1991.(in Turkish)
8. Hayran O. Gürsoy A. Akçay F. Sava_ H. Turkish physicians' attitudes to ethical issues. BME 102 (1994), 16-21.
9. Sahih-i Buhari. (trans. Miras K.) 7th edition. Ankara. Turkish Religious Affairs Publication. Vol. 12. pp.70-71; 1982.(in Turkish)
10. Nisâ sura of Koran. Verse no.29.(in Turkish)
11. Sahih-i Buhari. (trans. Miras K.) 7th edition. Ankara. Turkish Religious Affairs Publication. Vol.4. pp.559-565; 1982.(in Turkish)
12. Karaman H. Islam Hukukunda Içtihat. (Conviction in Islamic Legislation) 1st edition. Ankara. Turkish Religious Affairs Publication. pp.187-188; 1971.(in Turkish)
13. Arda B. Pelin SÞ. Bioethics in Turkey in 1995. EJAIB 5 (1995), 64-65.
14. Arda B. Pelin SÞ. Bioethics in a secular perspective. EJAIB 5: 95-96.
15. Örs Y. Brain-Scarves. EJAIB 5 (1995), 96.