Euthanasia raises profound questions about consent and morality.
First, taking up your distinction between active (lethal needle) and passive (removal of supply that is keeping the patient alive)... I think that this often has more to do with ethical and legal considerations on the part of the practitioner than it does with alleviation of the patient's suffering. It is far easier to convince yourself that you haven't killed someone if you turn off say an air supply than it is if you are actively applying the agent of death. As it's a legal grey area too, there are often considerations of whether it constitutes a criminal activity. Say someone gets hit by a car - are you more responsible for killing them if you are driving the car, or if you are a passerby who failed to shout out and warn them? Is the choice of a passive approach simply a method to alleviate guilt on behalf of the practitioner? If passive means they experience months of intense pain before dying, then how is an instant needle worse?
This does of course also impinge on the issue of consent. Can a doctor ever be 100% certain that the patient who has given consent is of sound mind? What if the patient has both terminal cancer and dementia? It's an ethical minefield.
There was
a case in the Netherlands a couple of years ago, where a dementia patient had said that she wanted to be euthanised, but also wanted to specify when it would take place. She said this in the early stages of the illness, when she was of sound mind. Of course when the time came and she said 'now', the disease had progressed considerably and arguably she was no longer capable of giving consent. The case went to court. How could the doctor know whether or not the woman had changed her mind, if she was judged no longer capable of making that decision?
After being diagnosed with Alzheimer's four years before she died, the patient wrote a statement saying that she wanted to be euthanised before entering a care home - but that she wanted to decide when the time was right.
Before she was taken into care, a doctor decided that assisted suicide should be administered based on her prior statement. This was confirmed by two separate doctors independently and a date was set.
When the day came to end the woman's life, a sedative was put in her coffee and she lost consciousness.
But the woman then woke up and had to be held down by her daughter and husband while the process was finished.
"A crucial question to this case is how long a doctor should continue consulting a patient with dementia, if the patient in an earlier stage already requested euthanasia," prosecution service spokeswoman Sanna van der Harg said.
"We do not doubt the doctor's honest intentions," she said.
"A more intensive discussion with the patient" could have taken place before the decision to end her life, she added.
However, the daughter of the deceased woman thanked the doctor.
"The doctor freed my mother from the mental prison which she ended up in," she said in a statement.
In this case the doctor was cleared of any wrongdoing, but crucially it took a court case to determine that. Is the doctor always right in these situations? Arguably, no. One single case can't be treated as a legal precedent to be followed, because each situation is different and each set of circumstances is different. Berna van Baarsen, a medical ethicist in the Netherlands believes that consent is now being inferred far too easily:
"I have seen the shift," she says. "The problem is that the shift is very difficult to catch. But it is happening. It's happening under your nose, and in the end you realise there has been a shift."
She thinks there is an over-reliance on written declarations, or living wills, which patients who might want euthanasia often give to their doctor in the early stages of a disease.
"You can write down what your fears are. What you don't want to experience. But it is a wish. It is an expression of fear, and as we know, people change.
"In the beginning they say: 'Oh no, I don't want to live in an old people's home.' Or, 'I don't want to be put in a wheelchair,' and it happens. People always find ways to cope. That's a beautiful thing about being human."
So she argues that before helping someone to die, doctors must always check that this is still the patient's wish. And with late-stage dementia patients, this is not always possible.
"If you can't talk to a patient, you don't know what the patient wants," she says.
https://www.bbc.co.uk/news/stories-47047579So that's the question of when consent is given, is that real consent or not? We also have the question of cases when consent
isn't given.
Some doctors are arguing that in certain circumstances euthanasia should be performed
without consent. And this returns us to the active/passive element, too. We have the below from Len Doyal, emeritus professor of medical ethics at the University of London (previous link):
Prof Doyal says withdrawing life-saving treatment from severely incompetent patients - which may involve turning off a ventilator, ending antibiotics or withdrawing a feeding tube - is "believed to be morally appropriate because it constitutes doing nothing. It is disease that does the dirty work, not the clinician. Yet this argument cannot wash away the foreseeable suffering of severely incompetent patients sometimes forced to die avoidably slow and distressing deaths."
He draws a parallel with a father who sees his baby drowning in the bath and fails to do anything to save it. The father foresaw the certainty of the death and did nothing and would therefore be morally considered to have killed the child.
"Clinicians who starve severely incompetent patients to death are not deemed by law to have killed them actively, even if they begin the process by the removal of feeding tubes. The legal fiction that such starvation is not active killing is no more than clumsy judicial camouflage of the euthanasia that is actually occurring."
His concern, he says, is not only with patients who are in a permanent vegetative state and therefore feel nothing at all. "The category of patients that concerns me most are the patients where we are not sure. There is still some brain function, but they will never have any brain awareness or cognitive function, but they seem to be suffering," he told the Guardian. This could, for instance, happen after an accident or a stroke. He does not believe that legalising non-voluntary euthanasia for such patients would lead to more or inappropriate deaths.
And inevitably there has been opposition to this, too. We have the below from Peter Saunders, director of Care Not Killing:
"Doyal is advocating the very worst form of medical paternalism whereby doctors can end the lives of patients after making a judgment that their lives are of no value and claim that they are simply acting in their patients' best interests," he said.
"The clear lesson from the Netherlands, where over 1,000 patients are killed by doctors every year without their consent and where babies with special needs are killed ... is that when voluntary euthanasia is legalised involuntary euthanasia inevitably follows."
So this is in the UK, legally different to the Netherlands, as the Netherlands is different to other jurisdictions. The situation is summed up neatly by the British Medical Council: "We have a neutral position," said a spokeswoman. "We leave it to society to decide."
