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Euthanasia

by Lorenzo Cantoni

 

1. Notion 

Euthanasia is a term which has long lost its connection with the greek ethymon of good death, and it is often used in current debate with quite different meanings. A distinction is frequently made between active – or positive, or also direct – and passive – or positive, or indirect – euthanasia; the former meaning occurs when a physician, or someone else in authority, acts directly to cause the patient’s death, the latter when there is an abstension from interventions that may keep the subject alive. A further distinction is made between voluntary euthanasia – when explicitly required by the patient – and involuntary euthanasia, when the patient’s will cannot be expressed, as the subject is incapacitated.

Euthanasia is sometimes opposed to disthanasia or to life-sustaining treatment, meaning the resort to medical interventions to prolong life which are irrespective of the patient’s dignity. Conceptually and factually near to euthanasia, though distinct, is the medically assisted suicide, through which death is a direct consequence of a suicidal action by the patient, with the advice and help of a psycian. It is clearly a range of meanings far by being homogeneous and definite, and then deeply influenced by the adopted theoretical perspective.

A complete and precise definition – usually quoted even by those authors who don’t agree with the related ethical assessments – can be found in the Declaration on Euthanasia "Iura et bona", issued by the Congregation for the Doctrine of the Faith on May 5, 1980, at number 6: By euthanasia is understood an action or an omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated. Euthanasia’s terms of reference, therefore, are to be found in the intention of will and in the methods used

 

2. Suffering, pain treatment and euthanasia

One of the defining characters of euthanasia is therefore its aim to reduce suffering. Sometimes, it is believed that the request for an euthanasic intervention or assisted suicide by patients is directly proportional to the seriousness of their disease, and to their suffering. Actually, this is an undue oversimplification. For instance, according to the report titled When Death Is Sought: Assisted Suicide and Euthanasia in the Medical Context – published in 1994 by the State of New York – "studies indicate that for many patients with severe pain, disfigurement, or disability, the vast majority do not desire suicide. In one study of terminally ill patients, of those who expressed a wish to die, all met diagnostic criteria for major depression.".

The experience of the Hospices – medical centers whose primary goal is the humanization of the care provided to the terminally ill patients and pain treatment through the so-called palliative care – is a further challenge to the apparently obvious connection between suffering and desire to die: "Patients with uncontrolled pain – as reads the quoted report – may see death as the only escape from the pain they are experiencing. However, pain is usually not an independent risk factor. The significant variable in the relationship between pain and suicide is the interaction between pain and feelings of hopelessness and depression.".

 

3. Legal and juridical aspects of euthanasia

Although the English Parliament debated a proposal of legalization in 1936, euthanasia never found a separate status in any legislation until a very recent time, except for the German National Socialist law. It is always traced back to other existing cases: in Italy, for instance, it amounts to the crime of murder of the consenting – provided for by the criminal code, article 579 – and of incitement or help to suicide, article 580.

Within this juridical context, both the decriminalization of euthanasia in the Kingdom of the Netherlands – in 1994 – and its legalization in the Northern Territory of the Australian Federation – in 1995 – took place, with yet quite unforeseeable consequences.

In the Kingdom of the Netherlands, the decriminalization of euthanasia was introduced through an amendment of the Coroner’s Code, article 10; starting from June 1994, the amendment decreed the non-liability to punishment for the psycians who helped patiens to die but are able to demonstrate they satisfied some conditions. The euthanasic action has to be documented by a written record demonstrating that the patient was affected by a terminal disease, that there were unbearable sufferings and that the patient requested it repeatedly. Such conditions must be then confirmed by a colleague of the declarant. The report has also to include the clinical record of the patient and the tools utilized for the euthanasia and then notified to a coroner.

Since the Dutch criminal code still provides for the crimes of murder of a consenting person, article 293, and of incitement or help to suicide, article 294, the Dutch legislator had to resort to article 40 – providing for the privilege of necessity – to decriminalize euthanasia. The patient’s request is therefore considered a "necessity" that makes the psycian practicing euthanasia non-prosecutable. Actually, such a position introduces in the legal system a sharp discrimination between healthy life –which has to be protected – and ill life, whose protection is no more obligatory

In June 1995, the "Rights of the Terminally Ill Act", legalizing euthanasia, became effective in the Northern Territory of the Australian Federation. Such a law gives the conscious and major patient the chance to request for euthanasia when terminally ill or with untreatable pain. Unlike the Dutch one, the Australian law claims the existence of a "right to die", considering euthanasia an action in defence of the person. Thus, it is accepted the possibility that even other people may sign a request for euthanasia on behalf of the incapacitated patient and in the presence of witnesses. Moreover, the law doesn’t provide for any specific punishment against psycians giving euthanasia without the necessary requisites.

 

4. Elements for an ethic evaluation

Compared to suicide, euthanasia shows a new factor: the intervention of another person, almost always a psycian or an health worker, intended as an help to relieve pain by putting an end to the patient’s life.

As a a matter of fact, this is anything but an obvious answer to the question: is homicide an appropriate help to the suffering? Or, in other words, is there a duty of the psycian – or whoever’s – to kill a person who asked him to? Or, again, is anyone – psycian, judge, relative – given the right to decide whether an innocent life is worth to be lived or not?

"We have to respect the freedom of the patient", the supporters of euthanasia often repeat, thus acceding to the so-called "aporia of the slave": can one freely renounce to freedom and to the fundamental requisite of its exertion, namely life? The ill demands rather for pain relief, and that is the psycian’s responsibility; his duty is to keep close to the patient and to alleviate his physical and spiritual suffering, and not to have power of life and death over him. Such a limit was quite clear in the Oath of Hippocrates of Chios (about 460-377 B.C.) stating:"I will give no deadly medicine to any one if asked, nor suggest any such counsel"; the same commitment in defence of life and against death was reasserted also in the Code of Medical Deontology – adopted by the Italian Medical Association (Federazione Nazionale degli Ordini dei Medici Chirurghi e degli Odontoiatri) in June 24, 1995 – article 35: " The psycian, even if requested by the patient, should not use use any treatment aiming to reduce his psychical or physical integrity, hastening or causing his death".

The premise to accept the justness – and the legality as well – of euthanasia is the assertion of an omnipotent and irresponsible right of man to dispose of his own life, and to ask for its suppression when it is "worthless". But once claimed that "worthless" life can be suppressed, who’s going to have the right and the burden to estabilish when life is so then? In fact, why only the ill, the elderly or the severely ill should "benefit" by the right to euthanasia?

Before proceeding to an ethical analysis, it is worth to mention two possible and important consequences of a legalization, otherwise of a spreading of the euthanasic practice. The first is a diminishing of the attention to pain treatment: once the option for euthanasia is possible, the effort to riduce pain would most likely decrease, especially as regards the socially and economically weaker people, towards whom the resort to euthanasia would be the most "obvious" and economic solution; furthermore, the second predictable effect of the possibility to choose euthanasia would be a sort of shifting of the burden of proof of every human life’s dignity and value. In other words the patient should unceasingly explain his choice to not request for euthanasia to his relatives and to the medical staff.

The close and inseparable connection between suicide and euthanasia shows already some premises of a culture of euthanasia, especially in the incapacity to give a sense to pain and death, and in the concept of human person as owner of an unlimited power on life and death. This is precisely the depth where we find an insurmountable opposition to the religious position, considering life as a gift from God, a value of which man is beneficiary and responsible, but not proprietor.

This way, the teaching of the Catholic Church – that has long intervened in the debate on euthanasia with sharpness and firmness – can be easily understood. It is possible to go over the main topics of such a teaching by reading a passage of the encyclical letter Evangelium Vitae on the value and inviolability of human life of March 25, 1995, by Pope John Paul II, at number 66: "Even when not motivated by a selfish refusal to be burdened with the life of someone who is suffering, euthanasia must be called a false mercy, and indeed a disturbing ‘perversion’ of mercy. True ‘compassion’ leads to sharing another’s pain; it does not kill the person whose suffering we cannot bear.[...]

"The choice of euthanasia becomes more serious when it takes the form of a murder committed by others on a person who has in no way requested it and who has never consented to it. The height of arbitrariness and injustice is reached when certain people, such as phsycians or legislators, arrogate to themselves the power to decide who ought to live and who ought to die.[...]

"Thus the life of the person who is weak is put into the hands of the one who is strong; in society the sense of justice is lost, and mutual trust, the basis of every authentic interpersonal relationship, is undermined at its root".


Update (July 2001)

In 1996, the year following its approval, the law of Northern Territory of the Australian Federation legalizing euthanasia has been cancelled.

On april 11st 2001, the Dutch Senate approved the Law on Euthanasia and Assisted Suicide. This law, approved by the Chamber of Deputies on Nov. 2000, officialized the factual impunity enjoyed till then by physicians who ended the life of seriously ill or terminal patients by administrating lethal doses of medicines or by stopping the ordinary treatments necessary to life. The only condition is the observance of some rules - basically the same already provided for in 1994 - beside some specifications about minors - the legal age limit to choose euthanasia is 16, while a parent's or a fiduciary guardian's consent is requested from 12 to 16 years and for mentally disabled persons - and the acknowledgement of the Living Will, when the patient cannot express his will. Thus, the practice of euthanasia is no more under control of the judiciary and is exclusively delegated to physicians, as any other treatment.


Update (January 2003)

On May 28th 2002, a law on voluntary euthanasia has been approved in Belgium. This law – which came into force on September 23rd 2002 – sanctions the impunity for physicians performing euthanasia on full age patients – or competent under age patients – who require it freely, consciously and repeatedly, in presence of a “serious and incurable” disease, which causes presumably unbearable and constant suffering.

The text points out that such sufferings can be either physical or psychological, so extending in an indefinite way the application limits of this law. Moreover, the euthanasia request has to be written. If unconscious, the patient’s written living will has a legal value, for a period of five years.

Although the physician has to inform the patient about palliative care support, s/he has simply to execute the patient’s will – through means that are not specified – and to write a report to be judged by an examining commission, which has to assess its mere procedural correctness.


Deepenings: see by the author and Giovanna Fravolini – Thanatos ed eutanasia, Cristianità 249, Jan. 1996, pages 5-14, and Analisi dei risvolti giuridici, sociali ed etici connessi alle recenti esperienze legislative in materia di eutanasia, Rassegna dell’Arma dei Carabinieri 2, Apr.-Jun. 1996, pages 26-40; elements for a correct ethic evaluation in Elio Sgreccia, Manuale di bioetica I. Fondamenti ed etica biomedica, ed.2, Vita e Pensiero, Milano 1994, pages 631-681. On death and the care of the dying person: edited by E. Sgreccia, Antonio G. Spagnolo, Maria Luisa Di Pietro, L’assistenza al morente. Aspetti socio-culturali, medico-assistenziali e pastorali, Vita e Pensiero, Milano 1994. About the position of the Caholic Church see also: Pontifical Council for Pastoral Assistance to Health Care Workers, The Charter for Health Care Workers, ed. 4 Vatican City, 1995, at numbers 119-124; L. Cantoni, La "Carta degli Operatori Sanitari". Una presentazione, Cristianità 239, March 1995, pages 6-10.