Palliative Care vs. Euthanasia

Gonzalo Herranz, department Bioethics, University of Navarra
Presentation at the roundtable: Palliative Care vs. Euthanasia
At the 13th Summer Courses, University of the Basque Country, San Sebastián
Course E.4. Palliative Care: Advances in Medical and Social Treatments
September 3, 1994, 5:00 p.m.

Index

1. Ethics of Palliative Care

2. Palliative Care: A Vaccine Against Euthanasia

Colophon

It falls to me to address this topic the perspective of the professional ethics of doctors and nurses. The topic present many difficulties: when faced with the dilemma of palliative care versus euthanasia, the ethical standards in force among us are unequivocal: by tradition and conviction, they oppose the deliberate termination of life at the end of life and advocate for palliative care. They prohibit euthanasia but require that terminally ill patients be cared for with scientific expertise and dedication. There is, therefore, an ethics of palliative care. I will discuss this briefly below. I will then address the antagonistic relationship between euthanasia and palliative care: the latter is currently presented as the only effective antidote to euthanasia.

1. Ethics of Palliative Care

In fact, there shouldn't be one. A terminally ill patient is just another patient—a human being who cannot be turned away. Since 1948, when the World association adopted its Geneva Declaration¹, all modern codes of conduct for the health professions have included the mandate not to discriminate, by which doctors and nurses are obligated to care application all their patients with the same conscientiousness and application , without distinguishing among them on the basis of birth, race, sex, religion, political opinion, or any other staff social condition or circumstance. By virtue of this rule, all the many manifestations of ethical respect found in general medical ethics are carried over into palliative care.

In light of the activism in recent years in favor of euthanasia, however, there has been a need to propose certain ethical guidelines regarding palliative care, which are worth briefly considering. These include, on the one hand, the Venice Declaration of the World association ². On the other hand, there are the articles dedicated to this topic in the codes of our country’s healthcare professions: the Code of Ethics and Code of Medical Conduct of the Medical Association³, as well as the Code of Ethics and Code of Professional Conduct for Nursing⁴. Also of interest is the Declaration on Euthanasia, which was adopted in 1987 and published by the Central Commission on Professional Ethics⁵.

This is what the relevant paragraphs of the Declaration on Terminal Illness, adopted by the 35th World Medical Assembly in Venice in October 1983, state.

1. A physician’s duty is to cure and alleviate suffering as much as possible, always keeping the best interests of their patients in mind.

2. No exceptions to this principle will be allowed, not even in cases of incurable illness or birth defects.

3. This principle does not preclude the application of the following rules:

3.1. A physician may alleviate a patient’s suffering from a terminal illness if, with the patient’s consent—or, if the patient is unable to express his or her own will, with the consent of the patient’s family—the physician discontinues curative treatment. Such discontinuation of treatment does not relieve the physician of the duty to attend dying patient and to provide the necessary medications to alleviate the terminal phase of the illness.

3.2. The physician shall refrain from using any extraordinary measures that would not be of any benefit to the patient.

Chapter VI of the Code of Medical Ethics and Professional Conduct introduces several concepts that are directly relevant to our topic. In general terms, article .1 states that it is unethical to acknowledge the existence of any period during which human life lacks value. A person’s end-of-life stage, therefore, possesses the same inestimable value as any other phase of human life. More specifically, article .1 condemns euthanasia: A physician shall never intentionally cause the death of a patient—neither on his or her own initiative, nor at the request of the patient or their family, nor for any other reason. Euthanasia, or “mercy killing,” is contrary to medical ethics. Immediately thereafter, article .2 imposes the ethical duty to provide palliative care to the terminally ill patient, while vigorously rejecting obstinacy and futile medical treatment. It states: In the case of an incurable and terminal illness, the physician must limit himself to alleviating the patient’s physical and emotional suffering, maintaining as much as possible the quality of a life that is drawing to a close, and avoiding initiating or continuing therapeutic actions that are hopeless, futile, or obstinate. He shall care for the patient until the end, with the respect that human dignity deserves.

The 1989 Spanish Code of Ethics for Nursing is even more expressive and explicit. article establishes the ethical dignity of palliative care: When caring for a terminally ill patient, the nurse, mindful of the high professional standards of palliative care, will strive to provide, with skill compassion, the care necessary to alleviate the patient’s suffering until the end of their life. The nurse will also provide the family with the financial aid to help them cope with the patient’s death when it can no longer be avoided.

Finally, we have the Declaration on Euthanasia, which the Central Commission on Medical Ethics published in 1987 in response to the concern sparked at that time by pro-euthanasia activism. From this document, I will read the passages most relevant to our issue: (...) attendance for the dying is one of the most important and noble duties of a physician (...) the physician is obligated to fulfill his or her true role of helping and caring for patients as they die through competent treatment of pain and distress. He must strive to ensure the greatest possible physical well-being; he must promote, according to the circumstances, attendance and human comfort for the dying person; he will also provide support to the patient’s loved ones. The physician also dignifies death when he refrains from painful and unjustified treatments and when he discontinues them because they are no longer beneficial.

Thus, the conduct of health care professionals toward the terminally ill patient is defined by the duties not to discriminate against them and to care for them with application restraint. They may not cause the patient’s death, but they must refrain from aggressively treating them with futile therapies. They will never disparage the lives of their patients, but they will learn to respect those lives by accepting the inevitability of death.

There are, therefore, positive professional duties: to alleviate physical and emotional suffering; to maintain, as much as possible, the quality of life as it declines; to be guardians of the dignity of terminally ill or dying patients and of the respect due to them; and to ensure that palliative care is not marginalized from the scientific advances provided by biomedical research.

And there are also negative professional duties: both euthanasia and therapeutic measures that lack reasonableness and sound judgment—which, in seeking a cure that is no longer possible, degrade and dehumanize life at the end of life—are strictly prohibited; such measures may be undertaken out of ignorance, commercial interest, or political reasons.

These are the fundamental principles of palliative care ethics, which we as doctors and nurses must reflect on frequently. From that reflection, we can draw a long list of resolutions or conclusions.

I will limit myself to offering, by way of sample list of research topics research , if addressed in well-designed projects, would help raise the quality of palliative care and lead to the recognition of palliative medicine as a plenary session of the Executive Council specialization program . One sometimes hears unfavorable judgments about the scientific basis of palliative care—for example, that it has not passed the test essay , or that it is the product of a compassionate heart rather than an analytical mind. Therefore, it is imperative to define, in objective and quantifiable terms, the internship and undeniable superiority of emotional compassion over cold detachment, and of openness to the whole person (individual, family, community) over a purely technocratic vision. A vast landscape of research lies ahead, as there are many questions that palliative research must answer:

- the assessment comparison of the effectiveness and efficiency of the various procedures;

-the classification of these into aggressive, symptomatic, and purely palliative measures;

-the expansion of access to specialized palliative care to all potential candidates for such care—that is, to the many terminally ill patients suffering from long-term, painful illnesses—and not just to cancer patients;

-optimizing the cost-benefit ratio of palliative care;

-the development formal and informal methods for teaching the science and general art of palliative care to both students and graduates, since—in keeping with the technocratic mindset prevalent in much of academic medicine—there is a noticeable absence of palliative care in the medical curriculum.

As we can see, research offers a splendid outlook: I need not justify the fact that, since palliative care involves, directly or indirectly, vulnerable individuals, the ethical analysis of projects in this area of research must be given paramount importance.

Let this serve as a brief commentary on the ethical texts on palliative care. Let us now turn to our second point.

2. Palliative Care: A Vaccine Against Euthanasia

Pro-euthanasia activism is also gaining followers among doctors and nurses. Judging by certain sociological surveys, there is a issue of healthcare professionals who accept the idea that it is justified—and even virtuous or morally obligatory—to end certain human lives that are severely lacking in quality. And a few of them are willing to do so, either by administering euthanasia drugs or by withholding nutrition and fluids. If they do not do so, they say, it is because of the legal risks they might face.

What would happen if legislation were enacted that authorized euthanasia and decriminalized internship killing someone due to illness?

My thesis clear: any legislation that permits euthanasia, no matter how strict it may appear to be on paper, leads to a growing brutalization of health care, as it degrades it ethically and impoverishes it scientifically.

Ethical decline is not difficult to foresee. Within the dynamics of legal permissiveness, decriminalizing euthanasia begins by implying that painless killing is an exceptional means of treating certain illnesses—one that is authorized only in extreme and very strictly regulated situations. But before long, inexorably, as a result of habituation and social rationalization, the restrictive rule ends up being interpreted to mean that killing out of compassion is a de facto accepted and frequent therapeutic alternative—and one so effective that doctors cannot morally refuse it. The reason is obvious: euthanasia—a clean, quick, 100 percent efficient, painless, compassionate procedure that is far more economical, aesthetically pleasing, and comfortable, especially for those around the patient, than palliative care—becomes an irresistible temptation for certain patients and their loved ones. And also for some doctors, since the peaceful death of one or another of their patients saves them a great deal of time, stress, and effort—the time and effort they invest in the ultimately futile task of monitoring the case day by day, alleviating symptoms, visiting the patient, and accompanying them through the difficult final moments.

With euthanasia decriminalized, the serious issue for doctors, as Leon Kass has pointed out⁶, is that their specific virtues turn against them. Once caught up in the spiral of compassionate death, doctors lose control over compassion, over the prevention of suffering, and over treating everyone equally, so that they are driven by their own professional virtues to apply this supreme therapy with ever-greater zeal: they cannot deny a patient the liberating death that, under similar circumstances, they have already granted to others; nor can they postpone until later what already appears to be the most effective remedy. The concept of terminal illness will continue to broaden; the indications for euthanasia will become increasingly broad and applied at earlier stages.

Anyone who has succumbed to the temptation of a “sweet death” and carried out euthanasia will either regret it with all their might or will no longer be able to stop killing. For if they are ethically consistent with themselves and believe they are doing something good, they will do so in increasingly less dramatic cases, bypassing legal barriers in the name of compassion. For if the law—as seems likely in first-generation euthanasia laws—were to authorize euthanasia or financial aid suicide only for those who freely and voluntarily request it, what reasons could someone who has performed it in accordance with the law on competent and capable patients possibly cite for denying it to someone who is unable to request it, but whose life is, in comparison with others’, more degraded or is a much greater burden on others? Is it certain that, undoubtedly, the mentally ill, those in an irreversible coma, or those in a chronic vegetative state would request it if they had a moment of lucidity⁷. Once euthanasia is authorized, the physician’s virtues turn against him. No matter how careful he is to respect his patients’ autonomy, no matter how much he respects their capacity to choose, if he believes—as a sincere advocate of euthanasia—that some lives are so devoid of quality that they are not worth living, he will conclude that sometimes only one option remains: the death of the extremely vulnerable. If a doctor or nurse were to consider euthanasia a superior remedy to palliative care, they could not help but become the subjective decision-makers for terminally ill patients. Faced with a patient unable to express their will, they reason in their hearts:“It is horrible to live in such conditions of biological or psychological vulnerability. I would not want to live like that. That is no life. It is preferable to die. Therefore, I decide that the best thing for them is a gentle death.” But the utilitarian judges that there are cases in which certain patients’ desire to continue living may be irrational and capricious, since they face a detestable future. They reason as follows:“The lives of certain patients capable of making decisions are devoid of quality; they are not worth living. Insisting on living them is an unjust desire, one that entails an irrational consumption of economic and human resources, which are always scarce: that money and that labor could be put to much better use.” It is very easy to construct a utilitarian argument to deprive the patient of their freedom to choose to continue living.

With each passing day, I become more convinced that palliative care embodies a profound ethical dimension: it is, in and of itself, a branch of medicine that cultivates and enriches the most intimate and fundamental ethical values of our profession. It is, moreover, the antidote that can protect us from the temptation—both frightening and alluring—of euthanasia. A highly effective antidote. The obligation to respect and care for every human life—even the most frail and terminally ill—is a wonderful and inspiring moral force. With it, we must enrich the theory and internship palliative medicine, which will root out from our hospitals the scandalous error of excessive treatment and the cold inhumanity that, disguised as compassion, lurks within euthanasia.

Euthanasia would also undermine the scientific mission of the healthcare professions. In an environment where palliative care and mercy killing for certain patients were considered equally acceptable, research vast areas of pathology would wither away. For if “mercy killing” were offered as the first option to a senile patient or one suffering from Alzheimer’s disease, who would be motivated to study the causes and mechanisms of brain aging or the constellation of factors that lead to dementia? If a patient ravaged by terminal cancer is offered assisted suicide as a valid treatment for their illness, who would be interested in the mechanisms of metastatic spread or the mediators of cachexia? All the mental and moral effort required to investigate truly difficult problems would, in a society tolerant of euthanasia, suffer atrophy from disuse.

I must conclude. The scientific values of medicine are diminished when part of them are absorbed into euthanasia. And human society suffers as well, as it is deprived of death. For with euthanasia, death ceases to be a mystery, to be an uncertain fate: it becomes a mere technical and routine procedure.

Doctors who provide palliative care with compassion and scientific rigor—both in hospitals and in patients’ homes—are making a significant contribution to the ethics of the healthcare professions. For this reason, I would like to thank the organizers for dedicating an entire day of this course to addressing the medical and social aspects of palliative care. Thank you very much.

Colophon

I cannot help but mention here the splendid compendium,*Palliative Care: Recommendations from the Spanish Society of Palliative Care*, which has just been published administrative office the administrative office Technical administrative office of the Ministry of Health and Consumer Affairs and is intended for general practitioners. Reading it is a moral obligation.