Eric Liddell Centre, 15 Morningside Road, Edinburgh EH10 4DP, Tel: 0131 447 6394 or 0774 298 4459
Advocates of assisted suicide have suggested that assisted suicide would enable persons who become terminally ill and find themselves in an unbearable situation, to not have to suffer a slow, drawn-out death.
In response to this the SCHB notes that:
Suffering can be adequately alleviated in all but the most extreme cases with up to 95% of patients having their pain and/or symptoms effectively relieved when treated by healthcare professionals with the relevant expertise [1]. Experience shows that once people are comfortable and their fears concerning suffering have been addressed, they often change their minds about wanting to end their lives. Similarly, patients with an illness such as motor neurone disease (a serious progressive neurological disorder) are often afraid of choking to death. But studies from the most experienced hospice units have demonstrated that, with appropriate palliative care, this virtually never happens. Thus, few patients request assisted suicide when their physical, emotional and spiritual needs are properly catered for.
Even in the extremely rare cases where suffering does not respond to treatment there is the possibility of using artificial transient sedation to keep them asleep in order to address the intolerable physical and/or mental distress. Thus, there is absolutely no reason for anyone to die in pain.
Advocates of assisted suicide have suggested that individuals should be able to determine their own dignity and quality of life. For example, it has been proposed that persons who fear that they will lose their dignity during the final stages of a terminal illness should be able to 'die with dignity' before these stages occur.
In response to this the SCHB notes that:
It is wrong to suggest that any person can ever lose his or her human dignity. Indeed, even though human dignity is a belief and not a scientific concept, it is something that everyone should always accept is found in everyone to an equal extent. This is in accordance with the United Nations’ Universal Declaration of Human Rights.
Furthermore, persons who consider that their lives are no longer worth living or believe that they have lost their ‘dignity’ are discriminating against themselves and, indirectly, indicating that the lives of persons in the same or in worse medical situations than themselves are also not worth living and should be ended.
With assisted suicide, as opposed to suicide, another person must also believe that it would be preferable for a person wishing to die not to continue living. In other words, assisted suicide, is a reflection of the unacceptable belief by a person that another person has lost his or her dignity and that his or her life is not worth living and should be ended.
Once quality of life becomes the yardstick by which the value of human life is judged, the protection offered to the most vulnerable members of society is weakened.
Advocates of assisted suicide have suggested that a person’s fear of disability and dependency should enable him or her to die while he or she is still autonomous and that assisted suicide would enable self-determination to exist. In other words, they propose that individuals have the right to make decisions concerning their own life and death situations in accordance with their own values and beliefs. These should not be imposed by a court, a doctor or a family member. It is a question of freedom and equality in the face of death.
Thus, the advocates of assisted suicide have suggested that nobody has the right to impose on the terminally-ill and the dying the obligation to live out their lives where they themselves have persistently expressed the wish to die.
In response to this the SCHB notes that:
The development of complete and total autonomy for a person does not enable human dignity to exist. Indeed, the very concept of human dignity is dependent on persons having a relationship with one another. Human society should never encourage anyone to believe that a person can lose his or her human dignity.
Though the requests for euthanasia are often motivated by fear of loss of autonomy, legalising voluntary euthanasia would actually undermine autonomy. It would give doctors power that could be too easily abused, and a responsibility that they should not be entitled to have. Historical precedent in the Netherlands demonstrates that progression to involuntary euthanasia requires only four accelerating factors: favourable public opinion, a handful of willing doctors, economic pressure and no convictions for those involved. If legislation allowing euthanasia comes into effect, and political and economic interests are brought to bear, the generated momentum could prove overwhelming.
Advocates of assisted suicide have suggested that, at present, it appears to be extensively practised in secret and that it is this reality that carries the greatest potential for abuse. They indicate that the pressures that can influence end-of-life decisions will be more pernicious if exercised in the dark and that the gap between law and practice must be reconciled if respect for the rule of law is to be maintained.
In response to this the SCHB notes that:
Having the option of assisted suicide is dangerous since it may be considered by many elderly and other vulnerable people who feel that they are a burden to family, carers and society or that their care may be eating up some of the inheritance which they wanted to pass on. A risk then exists that these vulnerable people may believe that a right to die is actually a duty to die!
Vulnerable people need to hear that they are valued and loved by the community. They need to know that society is committed first and foremost to their well-being, even if this does involve expenditure of time and money. The manner in which the weakest and most vulnerable people are treated reflects the kind of society we are.
Advocates of assisted suicide have suggested that curing disease and bringing about death are not mutually exclusive roles, the intention in both cases being the relief of suffering. It is further argued that the primary role of the physician is to care for his or her patient, which must therefore entail respecting their autonomous wish to die.
In response to this the SCHB notes that:
Crossing the boundary between acknowledging that death is inevitable and taking active steps to bring about death changes fundamentally the role of the physician, changes the doctor-patient relationship and changes the role of medicine in society. The physician’s role has always been to cure and care for his or her patients, not help to kill them.
Some doctors may also become hardened to death and to causing death and start considering their patients as disposable, particularly when they are old, terminally ill, or disabled. A few may actually feel empower in being able to provoke death. Reciprocally these vulnerable groups of people may start to doubt the intentions of their doctors.
There is good evidence that a desire for death in terminally ill patients can vary with time and is closely associated with clinical depression which can often be addressed. The states of delirium and/or confusion are common in palliative care patients and are sometimes so subtle that they are difficult even for clinicians to recognise. It is impossible to be absolutely confident that a request for a life to be ended does not arise from a disordered state of mind.
Whilst many people are competent to make decisions about their wish for euthanasia, many will not be. This could mean that a decision to end a person’s life could be made by a nominated proxy. The complexities arising from such conditions could lead to a serious abuse of power.
Euthanasia: Comes from the Greek roots eu (well) and thanatos (death), literally ‘to die well’ or ‘a good death’. The term is generally understood as an intervention (an intentional act or omission) to end the life of a person by someone else who believes that it would be preferable for the person to die than to continue living [2]. The key motive is intent. Euthanasia has, as its first objective, to bring about intentionally the death of a person.
Intervention in the health field: Any intentional activity, withholding of activity or the withdrawal of activity in the health field. Interventions include:
Medical treatment: Any positive intentional activity designed to address a specific physical or mental disorder in the best interest of the person. Artificial nutrition and hydration are not generally recognised as treatments.
Basic care: Any positive healthcare activity which is part of the fundamental needs of a person and does not specifically address a physical or mental disorder.
Direct Euthanasia may take the form of:
Active Euthanasia: Generally understood as an active intervention to end the life of a person by someone else, by the use of drugs or other methods [3].
Passive Euthanasia: Euthanasia without active intervention, whereby life sustaining treatment, nutrition and/or hydration are withheld or withdrawn from a patient by someone else with the primary intent of hastening a patient's death. In the UK, these terms are not generally used within the medical profession [4]. Passive euthanasia should be distinguished from the practice whereby medical treatment, nutrition and/or hydration can be withheld or withdrawn in specific circumstances but without having as its primary intent to bring about the death of a person. Passive euthanasia should also be distinguished from passive suicide in which a capable patient decides not to accept or to withdraw from life sustaining treatment, nutrition and/or hydration.
Indirect Euthanasia: Term sometimes mistakenly used to describe the principle of ‘double effect’.
Double effect: In the context of ‘end of life’ circumstances, the principle of double effect may include the administration of drugs to a patient in order to relieve pain, the consequence of which may shorten his or her life though this is not the intent. This procedure is generally considered as ‘good medical practice’ and not as euthanasia.
Voluntary Euthanasia: Emphasises the express intent of the person wanting to die, and distinguishes it from mercy killing or any other form of killing. Voluntary euthanasia is performed by another person and at the autonomous request of an informed and competent patient. Voluntary euthanasia takes place when the request is either given contemporaneously to the action of killing or beforehand if the request still represents the view of the person.
Non-Voluntary Euthanasia (sometimes defined as 'Mercy Killing'): Generally indicates an intervention by a person to end the life of a patient who is, at the time of its performance, incompetent and therefore incapable of assenting to it.
Involuntary Euthanasia: Generally indicates an intervention by a person to end the life of a competent patient who has capacity and which is performed against his or her will. In other words, where the patient is not consulted or where the patient's wish not to have euthanasia is ignored, whether or not it is on the assumption that it is in the person's best interests.
Good medical practice: The exercise of maximising the patient’s quality of life and well-being, but never to end life intentionally.
Suicide: Active intervention by which a person ends his or hers own life.
Passive Suicide: Suicide without an active intervention, whereby a person makes a conscious and contemporaneous decision not to accept or to withdraw from life sustaining treatment, nutrition and/or hydration with the aim of hastening his or her own death. Passive suicide recognises the fundamental right of a patient not to accept a medical intervention even if it may save his or her life. This right is recognised in most countries [5].
Assisted Suicide: The act whereby a person aids, abets, counsels or procures a suicide or an attempted suicide of another person.
Physician Assisted Suicide: The act whereby a physician prescribes a lethal medication to a person, but the person administers the dose himself or herself.
Assisted Dying: Term used to cover both Assisted Suicide and Euthanasia.
The key issue in euthanasia is intention since allowing terminally ill patients to die when there is nothing more that can be done to relieve their symptoms or treat their illness has long been part of good medical practice. On the other hand, letting patients die when useful symptom-relief or treatment can be given is negligent.
Some argue that certain forms of pain relief can shorten the lives of patients with terminal disorders and therefore the doctor is actually aiding the patient's death. Under the doctrine of 'double effect' this is deemed ethically acceptable, since the doctor's intended outcome is pain relief and the unfavourable result of shortening life is not the intent. In reality, successful pain relief can extend life as appetite and well-being improve [6].
Euthanasia has had a long history having been practised by the Spartans in antiquity, whereby unhealthy new-borns were left to die on exposed mountains. Recent debates, however, emerged in United States and Britain in response to ideological currents gaining ascendancy in the late 19th and early 20th centuries. This culminated with probably the greatest abuse taking place under the Nazi euthanasia program which was code-named T-4. This referred to Tiergartenstrasse 4, the headquarters of the corresponding administrative system which set-up the T-4 establishments. In these special establishments, nearly 9 000 people were gassed in the first half of 1940. The total number of killings probably exceeded 100 000. More than 3 000 deformed children also fell victim to the T-4 frenzy [7]. The Catholic clergy was a powerful factor which contributed to the suspension of the official euthanasia action in August 1941. Unofficially, however, euthanasia practices continued in Germany until the summer of 1943 [8].
There were a succession of cases during the 1970s and 1980s where defendants who had helped another person to die were prosecuted for manslaughter. Several were allegedly advised to plead not guilty on the grounds of diminished responsibility [9]. In 1992, Dr. Nigel Cox was found guilty of giving a lethal dose to a dying woman whose pain he could not relieve. However, he was neither imprisoned nor dismissed from his hospital job.
In 1994, an all-party committee of the House of Lords unanimously agreed that there should be no change in the law to permit euthanasia. The committee argued that "It would be next to impossible to ensure that all acts of euthanasia were truly voluntary and that any liberalisation of the law was not abused."
The House of Lords committee also rejected the suggestions that a new offence of ‘mercy-killing’ should be created: "To distinguish between murder and mercy-killing would be to cross the line which prohibits any intentional killing, a line which we think it essential to preserve" [10].
However, the committee supported the right of physicians to withdraw medical treatment from patients, particularly those in a persistent vegetative state. Treatment need not be given if it will “add nothing to the patient’s well-being as a person”.
Following a proposal by Lord Joffe to introduce a Patient (Assisted Dying) Bill, in February 2003, a House of Lords Select Committee prepared a report entitled Assisted Dying for the Terminally Ill Bill in April 2005. This report indicated that if an assisted dying bill is considered, it should distinguish clearly between assisted suicide and voluntary euthanasia. This led Lord Joffe to re-introduced a new version of his bill entitled Assisted Dying for the Terminally Ill Bill into the House of Lords on the 9th of November 2005 in a form which would legalise assisted suicide but not euthanasia.
In England and Wales, the term euthanasia is not defined in law and would be regarded as murder. In these countries, murder is a common law offence.
In the medical setting, R v Cox (1992) 12 BMLR 38 confirmed that if a medical professional carried out an action with the intention of ending life, whether or not for compassionate reasons or at the patient’s request, this would constitute murder [11].
The UK’s current position is that euthanasia is unlawful and anyone alleged to have undertaken such an intervention is open to a charge of manslaughter. Similarly, medical treatment which is given to a patient with the specific intention to hastening or inducing death, whether at the patient’s wish or not, is considered as being an illegal act. The UK Government has given careful consideration to the issues involved and its position remains that there are no plans to change the current law in this area [12].
In a response before the Scottish Parliament on the 11th of November 2004, the Deputy Minister for Health and Community Care indicated that the Scottish government had "no plans to change the law." [13]
In a response before the Scottish Parliament on the 11th of November 2004, the Deputy Minister for Health and Community Care indicated that "Under Scots law, an act of euthanasia by a third party, including physician-assisted suicide, is regarded as the deliberate killing of another and would be dealt with under the criminal law relating to homicide. The consent of the victim would not be a defence and no degree of compassion on the part of the person who carried out the act would amount to a legal justification. There might be cases in which the circumstances of the offence would make a charge of culpable homicide more appropriate than one of murder, and a court would take all the circumstances of the case into account before sentence was pronounced. However, if the accused was convicted of murder, a sentence of imprisonment would be mandatory." [14]
In addition, it has been noted that the term euthanasia is not defined in Scottish law and would be regarded as murder (a common law offence) [15].
Euthanasia and assisted suicide are devolved matters for the Scottish Parliament under the Scotland Act 1998, Schedule 5 (Reserved Matters), Part II (Specific Reservations), Head J (Health and Medicines).
After a landmark case in 1996, the then Lord Advocate issued a statement that he would not authorise the prosecution of a doctor who - acting in good faith and with the Court of Session's authority -withdrew life-sustaining treatment from a patient with the result that the patient died [16].
European Convention on Human Rights
Two articles of the European Convention on Human Rights (ECHR) protect the right to life, namely:
Article 2.1:
Everyone’s right to life shall be protected by law. No one shall be deprived of his life intentionally save in the execution of a sentence of a court following his conviction of a crime for which this penalty is provided by law.
Article 8:
1. Everyone has the right to respect for his private and family life…..
2. There shall be no interference by a public authority with the exercise of this right except such as is in accordance with the law and is necessary in a democratic society in the interests of national security, public safety or the economic well-being of the country, for the prevention of disorder or crime, for the protection of health or morals, or for the protection of the rights and freedoms of others.
Council of Europe Parliamentary Assembly Recommendation 1418 (1999):
The latest provisions on euthanasia are included in Article 9.c. of the Council of Europe Parliamentary Assembly Recommendation 1418 (1999) which states that:
The Assembly therefore recommends that the Committee of Ministers encourage the member states of the Council of Europe to respect and protect the dignity of terminally ill or dying persons in all respects by upholding the prohibition against intentionally taking the life of terminally ill or dying persons, while:
i. recognising that the right to life, especially with regards to a terminally ill or dying person, is guaranteed by member states, in accordance with Article 2 of the European Convention on Human Rights which states that “no one shall be deprived of his life intentionally”;
ii. recognising that a terminally ill or dying person’s wish to die never constitutes any legal claim to die at the hand of another person;
iii. recognising that a terminally ill or dying person’s wish to die cannot of itself constitute a legal justification to carry out actions intended to bring about death.
In a document covering euthanasia and assisted suicide, prepared by the Council of Europe and published on the 20th of January 2003, containing the replies to a questionnaire from 34 countries of the Council of Europe and the USA, only Belgium and the Netherlands indicated that active euthanasia was permissible in their legislation (though it remains unlawful) [17]. Moreover, the report indicated that both Belgium and the Netherlands did not define passive euthanasia in their legislation.
In the Northern Territories of Australia the ‘Rights of the terminally Ill Act 1995’ was in force between 1st of July 1996 until the 5th March 1997 when the Australian Federal House of Representatives passed an anti-euthanasia Bill. During this time, 7 people officially sought to use the legislation to die.
In the Netherlands, the ‘Termination of Life on Request and Assisted Suicide (Review Procedures) Act’ came into effect on the 1st of April 2002. The Act incorporates an amendment to Article 293 of the Criminal Code to the effect that although any person who terminates another person’s life at that person’s express and earnest request remains liable to a term of imprisonment or a fine, such an act shall not be an offence if it is committed by a physician who notifies the municipal pathologist of this act in accordance with the relevant legislation and fulfils the stipulated due care criteria, by which the attending physician must:
- be satisfied that the patient has made a voluntary and carefully considered request;
- be satisfied that the patient's suffering is unbearable, and that there is no prospect of improvement (note: it is not a condition that the patient is terminally ill or that the suffering is physical);
- have informed the patient about his or her situation and his or her prospects
- have come to the conclusion, together with the patient, that there is no reasonable alternative in the light of the patient’s situation;
- have consulted at least one other, independent physician, who must have seen the patient and given a written opinion on the due care criteria referred to in the four above indents; and
- have terminated the patient’s life or provided assistance with suicide with due medical care and attention.
Similarly, any person who intentionally incites another to commit suicide, if suicide follows, is normally punishable under Article 294 of the Criminal Code by a term of imprisonment or fine, but commits no offence if the above due care criteria are fulfilled.
The new legislation also includes regulations regarding termination of life on request and assisted suicide involving minors. Children of 16 and 17 can, in principle, make their own decisions. Their parents must, however, be involved in the decision-making process regarding the ending of their life. For children aged 12 to 16, the approval of parents or guardian is required.
Finally, the legislation offers an explicit recognition of the validity of a written declaration of will regarding euthanasia. The presence of a written declaration of will means that the physician can regard such a declaration as being in accordance with the patient's will. The declaration has the same status as a concrete request for euthanasia. Both oral and written requests allow the physician legitimately to accede to the request. However, he or she is not obliged to do so.
In all cases, the physician must report his or her act to the municipal pathologist. The report is then examined by a regional review committee to determine whether it was performed with due care. The judgement of the review committee is then sent to the Public Prosecution Service which uses it as a major factor in deciding whether or not to institute proceedings against the physician in question.
If the committee is of the opinion that the physician has practised due care, the case is closed. If not, the case is brought to the attention of the Public Prosecutor who has the power to launch his or her own investigation if there is a suspicion that a criminal act may have been committed.
Approximately 16 million people live in The Netherlands, of who around 140,000 die every year. Every year, some 9,700 requests for euthanasia are made. About 3,800 of these actually receive euthanasia, of which some 300 are assisted suicides. Euthanasia therefore accounts for around 2.5% and assisted suicide 0.2% of all deaths in The Netherlands. In addition to these, there are about 1,000 deaths a year (0.7% of all deaths) where physicians end a patient's life without an explicit request [19].
Belgian Law on Euthanasia came into force on 23 September 2002. Doctors who practise euthanasia commit no offence if they respect the prescribed conditions and procedures, and have verified that:
- the patient is an adult or a ‘mature’ minor who must be a least 15 years old person [21], possessing legal capacity and aware of what he or she is doing when he or she formulates the request (which must be made in writing);
- the request is made voluntarily, carefully and repeatedly, and is not the result of outside pressure;
- the patient’s medical state is hopeless, and he or she is experiencing constant, unbearable physical or mental suffering, which cannot be relieved and is caused by a serious and incurable injury or pathological condition.
Like in the Netherlands, the law recognises the validity of advanced directives for euthanasia. This enables physicians to practice euthanasia on persons who are no longer capable of expressing their wishes, but who have done so in writing when they still had capacity.
Belgium has also established a system of control, whereby the physician has to declare the act of euthanasia to a Federal Evaluation and Control Commission.
Although no physician is bound to perform euthanasia, a physician who, exercising his or her freedom of conscience, refuses to perform euthanasia, must transfer the patient's medical record to a colleague of the patient's choosing.
The law does not allude to "assisted suicide". Thus it does not specify the method to be used by the physician, even though he or she must describe it in the official form to be forwarded to the Federal Evaluation and Control Commission.
Euthanasia Special report - BBC - http://news.bbc.co.uk/hi/english/static/in_depth/health/2001/euthanasia/default.stm
Euthanasia (Ethics) - BBC - http://www.bbc.co.uk/religion/ethics/euthanasia/
Euthanasia Files: http://www.euthanasia.com
1. Organisations such as the Hospice Movement reveal that suffering can be adequately alleviated in all but the most extreme cases. See also Pain Control - BBC - http://www.bbc.co.uk/religion/ethics/euthanasia/euth_pain_control.shtml; Using Opioids to Control Pain http://www.painlaw.org/opioids.html
2. http://www.euthanasia.com/definitions.html
3. Replies to the questionnaire for member States relating to euthanasia, Council of Europe, 20 January 2003, http://www.coe.int/T/E/Legal_Affairs/Legal_co-operation/Bioethics/Activities/Euthanasia/Answers%20Euthanasia%20Questionnaire%20E%2015Jan03.asp
4. Ibid.
5. In the case of Airedale NHS v. Bland, Lord Musttill indicated that “If the patient is capable of making a decision whether to permit treatment and decides not to permit it his choice must be obeyed, even if on any objective view it is contrary to his best interests. A doctor has no right to proceed in the face of objection, even if it is plain to all, including the patient, that adverse consequences and even death will or may ensue ...". An example of an application of this judgement is given in the case where a woman paralysed from the neck down was given the right to die - BBC - 2002: http://news.bbc.co.uk/1/hi/health/1887281.stm
6. Euthanasia, CMF, http://www.cmf.org.uk/index.htm?ethics/ethics.htm
7. J.A. Emerson Vermaat, ‘Euthanasia’ in the Third Reich: Lessons for Today?, Ethics & Medicine, 18:1 (2002):21-32.
8. Ibid.
9. Sunday Times 8 October 1996
10. House of Lords: Report of the select Committee on Medical Ethics, HL 21 - I, January 1994.
11. Replies to the questionnaire for member States relating to euthanasia, Council of Europe, 20 January 2003, http://www.coe.int/T/E/Legal_Affairs/Legal_co-operation/Bioethics/Activities/Euthanasia/Answers%20Euthanasia%20Questionnaire%20E%2015Jan03.asp
12. Briefing for the UK Parliamentary Delegation, First Part of the 2004 Session of the Parliamentary Assembly of the Council of Europe.
13. Scottish Parliament Official Report - 11.11.04: http://www.scottish.parliament.uk/business/officialReports/meetingsParliament/or-04/sor1111-02.htm#Col11876
14. Scottish Parliament Official Report - 11.11.04: http://www.scottish.parliament.uk/business/officialReports/meetingsParliament/or-04/sor1111-02.htm#Col11876
15. Replies to the questionnaire for member States relating to euthanasia, Council of Europe, 20 January 2003, http://www.coe.int/T/E/Legal_Affairs/Legal_co-operation/Bioethics/Activities/Euthanasia/Answers%20Euthanasia%20Questionnaire%20E%2015Jan03.asp
16. Scottish Parliament Official Report - 11.11.04: http://www.scottish.parliament.uk/business/officialReports/meetingsParliament/or-04/sor1111-02.htm#Col11876
17. Ministers' Deputies, CM Documents, CM(2003)21 Addendum 2, 12 March 2003, Steering Committee on Bioethics -Report on laws and/or practices of member states with regard to the issues raised by Parliamentary Assembly Recommendation 1418 (1999) on the protection of the human rights and dignity of the terminally ill and the dying. https://wcm.coe.int/rsi/common/renderers/rend_standard.jsp?DocId=29357&SecMode=1&SiteName=cm&Lang=en
18. Parliamentary Assembly, Euthanasia, Doc. 9898, 10 September 2003, Report, Social, Health and Family Affairs Committee
19. House of Lords, Select Committee on Assisted Dying for the Terminally Ill Bill, Assisted Dying for the terminally Ill Bill, Volume I, Report, 2005, paragraph 171; http://www.publications.parliament.uk/pa/ld200405/ldselect/ldasdy/86/8602.htm
20. Parliamentary Assembly, Euthanasia, Doc. 9898, 10 September 2003, Report, Social, Health and Family Affairs Committee
21. However, a new bill permitting euthanasia on children is before the Belgian Parliament: Euthanasia debate in Europe focuses on children - Knight Ridder Newspapers - 14.10.04: http://www.grandforks.com/mld/grandforks/news/world/9890729.htm