Euthanasia: Who Needs It?

Issues: 

Do people really want doctors to help them end their lives in times of pain and illness? To listen to the media or read the press, you certainly would think so. Advocates of euthanasia argue that if people are given a choice between dying in agonizing pain or undergoing euthanasia/physician assisted suicide (PAS), the preferred choice would be euthanasia/PAS. Indeed, few people would choose to die in agony, except possibly Jesus, as the recent movie The Passion of the Christ has so graphically re-enacted.

However, the presentation of only these two extreme alternatives is deeply biased. Agonizing pain and euthanasia/PAS are not the only ways people die. A wide range of choices and experiences exist between these extremes including adequate treatment of pain and other bothersome symptoms (so-called "palliative care"), hospice care at home or in a medical facility, and even sedation to the point of complete anesthesia and unconsciousness (known as "terminal sedation"). Questions, like this one, frequently are meant to be misleading. One choice is set up to be so unpalatable (i.e., dying in agony) that it makes the other option (euthanasia/PAS) seem acceptable in comparison. However, when considered separately, a physician’s assistance in death would be judged unacceptable. Fear of the dreaded alternative may motivate a respondent to make an immoral choice. Posing questions in this way is an old trick that is easily anticipated when only polar alternatives are presented.

Regardless of whether euthanasia/PAS is desired by most people or even viewed as moral, it has been legalized in the Netherlands, Belgium, and the U.S. State of Oregon. The irony of the Netherlands being the first nation to legalize the practice is lost on many who are unfamiliar with the history of medical practice in that nation. In the Nazi era, 98% of Dutch physicians refused to conform or participate when ordered by the Germans to become members of its Nazi-led, anti-Semitic medical society and thereby lost their authority to practice medicine. Now it is their medical heirs who are the leading the world in the acceptance and practice of PAS!

Many predicted abuses of PAS have come to pass and are increasingly well documented. These include physicians failing to follow one or more of the mandated regulations for administering PAS. The requirements are that (1) the patient is in "unbearable suffering," (2) no other effective alternative treatment is available, (3) two physicians agree that PAS is indicated, (4) the patient requesting PAS is competent, not depressed, and not pressured by others, and (5) that all cases of PAS are reported to the authorities. Most alarmingly, some physicians have decided to administer PAS when neither the patient nor family has requested it.

However, recent trends indicate a shift in the practice. A recent survey of 1,500 physicians in the Netherlands by a professor at Nijmegen University reported that euthanasia/PAS is waning in their country. Due to improvements in palliative care and pain relief, it is increasingly rare for Dutch physicians to see medical indications for euthanasia or PAS. This should not be a surprise. Over 2,000 years ago, Hippocrates recognized the importance of ensuring that physicians gave exclusive attention to patients’ needs and did not participate in harming them in any way. Attending to patients’ needs certainly does not include helping to kill them.

This "Hippocratic" form of medicine initially was a minority practice at a time when both medical and spiritual care were often under a single individual, such as a shaman, who might bless or curse a person seeking assistance. Hippocratic medicine was entered into by swearing an oath that proscribed, among other things, giving poison to a patient (a form of PAS). This oath has, of course, become known as the Hippocratic Oath, and though originally sworn to Greek deities, has been adopted in a slightly modified form by Jewish, Christian, and Muslim medical practitioners. Though increasingly watered down to conform to current societal mores, the Hippocratic Oath is foundational to Western medicine. It recognizes what Dr. William Osler later more succinctly put into words: "The secret of caring for the patient is caring for the patient." Studies have shown that it is not euthanasia/PAS that patients want, but optimum pain relief, end of life care, and the assurance that their physician will not abandon them.

The push for legalized euthanasia/PAS is, to a great extent, the result of a failure of medical training and practice. Only recently have the relief of pain, optimum palliative care, and the availability of hospice services become a high priorities. Medical societies, such as the American Medical Association, are working to ensure that all physicians are trained adequately in pain relief and end of life care. Bemoaning past failures to provide this type of care will do little to help our current patients. Even the most active proponents increasingly recognize that the legalization of euthanasia and PAS is more reflective of a failure than a solution. One can only hope that the increasing rejection of physician participation in euthanasia and PAS will spread and initiate a recognition of and return to the wisdom of Hippocratic values in patient care.