right to die

Should terminally ill patients have a right to die?

A version of this article was printed in Humanism Ireland, Sep-Oct, Vol. 142 (2013)

Suppose you have just discovered you are suffering from multiple sclerosis, a disease of the nervous system. This condition, you learn, is progressive and, in time, you’ll become fully paralysed; most likely, as a result, you’ll be entirely dependent on the care of others. Worse still, you realise you’ll no longer be able to look after yourself and will not be capable of swallowing the food somebody else placed in your mouth. To avoid dying from hunger, you’ll have to be fed through a tube inserted into your stomach.

Fortunately for most, the chances of suffering from multiple sclerosis are rare. This is not the case, however, for 59-year-old Marie Fleming who is terminally ill with the condition. Although it has no impairing on her cognitive facility, she suffers frequently from severe and at times intolerable pain. She has fought a long legal campaign to challenge Ireland’s ban on assisted suicide. She claims the ban—in her situation, as a severely disabled person unable to end her own life unassisted—unjustly breaches her autonomy rights under the Constitution and the European Convention on Human Rights. In other words, the ban is discriminatory, Fleming argues, because an able-bodied person may take his own life lawfully, but she cannot be lawfully assisted to do the same.

Nevertheless, the court said that nothing in its judgment should be taken as implying that it would not be open to the State to legislate in order to deal with a case like that of Marie Fleming. After the hearing, Tom Curran, Fleming’s partner of 18 years, informed reporters of her disappointment, yet remains willing to help her die, despite what the law says.

In light of this case, does a person, we may ask, have a moral and legal right to be helped bring about the end of their life?  Should Marie Fleming have the right to be assisted in dying? The ancient Greeks and Romans certainly did not believe that life had to be continued at any cost, and there was tolerance of suicide in instances where no solace could be offered to the patient, or where he didn't wish to continue living. The philosopher Seneca, for instance, thought it was more desirable to prefer one’s own death than to carry on living with demised capacities. Many historians agree that Judaism and Christianity greatly contributed to the general view than human life is sacred and must not be deliberately ended. More recently, the Vatican’s “Declaration of Euthanasia” (1980) made this clear by stating that “nothing and no one can in any way permit the killing of an innocent human being, whether a fetus or an embryo, an old person, or one suffering from an incurable disease, or a person who is dying.”

This was the accepted view for all Western societies for several centuries, but it’s no longer universally held. This is possibly due to the fact that secular societies are less likely to unquestionably accept religious doctrine values, and on account of technological advances over the past few decades, which means that life can now be prolonged to a stage that some may find counterproductive and inutile. It is more common now to believe that when threatened by incurable illness and suffering, the legal provision of assisted suicide and voluntary euthanasia should be made.  At present the legal practice of assisted suicide exist in Switzerland and four states in the USA; assisted suicide and euthanasia is presently legal in Belgium, Luxembourg, and the Netherlands.  Both practices are not permitted in most countries in the world.

So what are the ethical arguments against euthanasia? Some might be tempted to appeal to religious doctrine, but even believers should agree that in a pluralist society—where church and state are separate—they should not be sufficient for making laws on assisted suicide or voluntary euthanasia.  Notwithstanding this, we might say than it’s always morally wrong to kill a person, irrespective of the circumstances.  To randomly kill someone in a hospital bed would be considered wrong because it intentionally ends the life of that person; perhaps, for the same reason, we could say that assisted suicide and euthanasia would also intentionally bring an end to life. Both instances, then, are morally alike, and hence wrong.

But are the cases morally identical?  No, I claim, because the reason that is averse to assisted suicide cannot be put forward without specifying important details of the case. What’s morally significant here is that one case is voluntary and the other isn't.  Like most areas of life, we usually consider voluntary acts, where full consent is given, as morally acceptable, and we normally view acts that are coercive, in opposition to one’s request, as morally adverse.  In this way, involuntary euthanasia occurs if performed on one who hasn't requested such an action; but it’s considered voluntary euthanasia, on the other hand, when carried out at the request of the patient, for the patient’s interest.  In short, there’s an obvious moral violation in the former case, but not in the latter.

We could still say that euthanasia is wrong because one has the intention of participating in the killing of another. In accordance with common sense, it might be argued, it’s always worse to intentionally kill someone than to let him die naturally. The doctrine, in essence, says there is an important moral difference between killing and letting die. The American philosopher James Rachels pointed out—in a well known 1975 paper, published in the New England Journal of Medicine—a number of reasons why this contrast is not sufficient. For example, in a case where a patient is dying from incurable cancer, which cannot be satisfactorily alleviated, and where he doesn't want to go on living since the pain is unbearable—he’s certain to die within a few days anyway—it would be more humane to actively end his life than to prolong it. “[B]eing ‘allowed to die’ can be relatively slow and painful,” according to Rachels, “whereas being given a lethal injection is relatively quick and painless.”

Further, the distinction between killing and letting die, in itself, has no moral relevance. If a doctor, for instance, allows a patient to die for humane reasons she is in the same standing as if she had given the patient a lethal injection for humane reasons. If we say the doctor made the right decision, Rachels argues, the means she used to carry it out here are really not that important. As a matter of fact, if we value the patient’s personal choice, not only is voluntary euthanasia no worse than letting die, it’s probably better.

We could, of course, counter this and say that there really is something significant here: it requires little or no effort to refrain from killing, but it usually requires effort to kill a person. But, as Rachels again points out, it’s not correct to say that allowing the  patient to die, the doctor does nothing; in reality, she lets the patient die: “The decision to let a patient die is subject to moral appraisal in the same way that a decision to kill him would be subject to moral appraisal.” It also seems problematic to say that the doctor who actively ends the life of a patient, with her consent, is any worse from one who administers large dosages of a pain-killing drug (as often happens), that will indirectly result in the patient’s death. The final outcome will be exactly the same in both instances.

Some medical professionals might say that what’s needed is better palliative care. Strong pain relief, they claim, can eliminate the desire for assisted suicide or euthanasia.  For sure, this is true. Palliative care is an essential part of quality medical care and euthanasia can never be a wanted replacement.  Quality palliative care, at the same time, is not an adequate reason for completely ruling out assisted suicide. Some palliative care specialists acknowledge the fact that there are cases where pain and suffering cannot be satisfactorily alleviated, aside from making patients unconscious and keeping them that way until death occurs. We may have to accept that quality terminal care must include the option of voluntary euthanasia. Interestingly, it’s often the case that a terminally ill person, who knows they've the option of help in ending their life, will not in the end request this option; knowing there’s the option to not tolerate superfluous distress in the future can be enough to diminish much existing fear and anxiety.  

Probably the most widely used secular argument against the legislation of voluntary euthanasia is the slippery slope argument. The legalising of assisted suicide or euthanasia, it is often proclaimed, will start a process of erosion, where we’ll soon let vulnerable people, whose family see as an inconvenience, be forced into consenting to be killed-off, followed by a stage where we’ll impel an "end to life" policy on people that are deemed a burden on society. On account of this possibility, perhaps the most responsible attitude in protecting human rights is to have a complete prohibition on assisted suicide and voluntary euthanasia. Yet, when applied to the issue here, what's the evidence to support the slippery slope claim? Studies from over the past 20 years (see here for example) seem to discredit the belief that the open practice of assisted suicide or euthanasia has led to widespread abuse.

Many slippery slope arguments against legalisation seem to rest on assumptions that are generally unfounded, and in some instances are obliquely advanced by their proponents as a rational for preserving the status quo. Legal safeguards, to be sure, need to be established and the notion of the permissibility of voluntary euthanasia ought to be in the patient’s own interest. The social risks and abuse, as the political and legal thinker Joel Feinberg has pointed out, generally overestimates much of the risks and badly underrates the torment and suffering actually felt by the terminally ill.  There may be cases where slippery slope arguments are indeed well founded, but it must be supported with good evidence before it can be seriously contemplated.

A doctor’s duty, I believe, is not always to cure the patient or prolong his life as long as feasibly possible, but to do whatever is in his best interest. We should not assume that prolonging a patient’s life is in his best interest—he may instead want to be assisted in dying, as his life irreversibly deteriorates to a harrowing point. If we really want to respect the interests of autonomous rational beings, then we ought to allow them to decide whether or not their lives are worth living.  Similarly, if we’re interested in decreasing the amount of suffering in society, there are strong grounds for the government to bring in legislation to allow terminally ill patients die a humane and dignified death.