Current Ethical Issues Surrounding Suicide and Euthanasia
Gonzalo Herranz. department on Bioethics, University of Navarra
lecture in the Series of Lectures on Bioethics
Giorgio La Pira Cultural Center
Trieste, March 22, 1990
1. The obligation to provide medical attend on to a person who has attempted suicide
2. Doctors in the Fight Against the Suicide Epidemic
II. Medical Ethics and Euthanasia
1. On the Need to Use Clear Words and Keep Ideas Clear
2. The Need to Closely Monitor the Situation in the Netherlands
III. The Consequences of a Diminishing Respect for Human Life
Acknowledgments and remarks for the occasion.
I suppose that here in Italy, just as in Spain, the “ topic ” of death with dignity—that which, paradoxically, some call “dying with dignity”—is frequently present in the press, on television, and in conversations. Here and there, pressure groups are active in promoting the decriminalization of euthanasia and the “ financial aid ” of voluntary suicide. And in our pluralistic and tolerant society, this activism stirs up very mixed feelings.
We physicians are directly affected by the pro-euthanasia ideology and its claim that we must collaborate in the technically correct execution of deliberate death. The “ status ” that this could create is fraught with ominous signs for the future of medicine and society as a whole. However—every cloud has a silver lining—the infiltration of the euthanasia ideology into society compels us to reflect on it and will serve as a stimulus—such is the fate of all heresies—to strengthen and enrich traditional deontological doctrine.
In this paper, I will attempt to summarize some aspects of the medical ethics of suicide and euthanasia that I consider significant.
In the face of suicide, what are the physician's deontological obligations? Basically, two. The first is to care for the victim of an attempt at self-destruction. The other is to contribute to the prevention of suicide, to fight against this endemic evil in our society.
1. The obligation to provide medical attend on to a person who has attempted suicide
Extremists of ethical autonomism claim that everyone—including doctors—must respect, until the very end, the act of suicide committed by someone who freely and consciously decides to do so and carries it out so eloquently. They are convinced that every autonomous person has the right to commit suicide. And that, if carrying out that decision does not affect the interests of others, no one is authorized to interfere with their action—neither to prevent it nor, once it has begun, to stop it from proceeding.
Medical ethics, however, do not permit a physician to assist in suicide, nor do they permit neutrality or passivity in the face of it. Such an approach would be entirely foreign to the ethos of medicine. “I will never give poison to anyone, even if asked, nor will I suggest that anyone take it,” states the Hippocratic Oath once and for all.
First and foremost, a physician cannot cooperate with a lucidly calculated and planned suicide. An act of this nature is result of an ideology—one entirely foreign to the medical ethos—that holds that a person may freely dispose of his or her own life and is graduate to choose the place, manner, and time of taking one’s own life. A physician who were asked financial aid to carry out such a cold-blooded suicide could not, as a physician, cooperate in an act in which there is no status of illness requiring his or her specific professional intervention. A physician provides care for two basic reasons: to sustain life and to alleviate suffering. But suicide is neither a medical solution to any human problem nor a humanitarian solution to any medical problem.
This unconditional refusal to cooperate with physician-assisted suicide takes very specific and direct forms. Suppose a patient, who is contemplating the possibility of ending his or her life, wishes to discuss the matter with a physician, and that physician appears inclined to assist him or her in this purpose. This would result in a tremendous status : the patient would legitimately come to believe that his or her physician places very little value on his or her life, which would be deeply distressing and would radically erode his or her trust in the physician. A doctor can never accept even the remotest possibility of assisting in suicide. Such a refusal must be unequivocal and instinctive, for such assistance seriously undermines an essential element of the doctor-patient relationship: the patient’s trusting conviction that their doctor will devote themselves fully and exclusively to caring for their life and health, and will never harm or abandon them.
Even advocates of extreme, libertarian autonomy must acknowledge that a terminally ill patient cannot act with full deliberation and autonomy. A terminally ill patient is often so limited in their ability to make decisions that they typically follow their doctor’s advice. If the doctor were to advise suicide, the patient would often be unable to reject that suggestion—not because he is truly tired of living or because life is an unbearable burden to him, but because he believes that others—including his doctor—are tired of him and that he is an unbearable burden to them.
As one member of the WADA’s Ethics and Health Policy committee clearly points out when discussing a physician’s involvement in assisted suicide, “By definition, treatment intended to cause death does not cure and is therefore fundamentally incompatible with the role a physician must play in the physician-patient relationship.”
Even when suicide might seem like the only possible way out in the face of a desperate status of pain or worthlessness, it would still be a non-solution, since the victim, in addition to destroying his or her own life and dignity, hurts and upsets those around him or her. The notion that a person who commits suicide is acting rightly as long as his or her action does not harm others lacks any empirical basis. That is an unrealistic claim. Suicide triggers concentric circles of pain and feelings of guilt among the victim’s loved ones and even among mere bystanders. In many cases, a completed suicide leaves a deep and very lasting mark of agonizing grief. In others, it disrupts moral convictions regarding self-destruction. Self-destruction is sublimated as a tribute to the victim; it becomes something falsely dignified and honorable, even heroic. It is precisely among this susceptible population that the hero acts as model and as a contagious seed, initiating and spreading a micro-epidemic of mimetic suicides.
The idea of “innocent” suicide is therefore unacceptable. Suicide always causes some harm to others: it always inflicts deep pain on a few; no matter how noble and dignified its motives and execution may be, it entails a localized destruction of humanity and erodes respect for human beings in a subtle yet effective way. All suicide is harmful; for this reason, a physician can never ethically assist in voluntary suicide.
How should a doctor respond to a victim of a suicide attempt? When someone decides to end their life, this in no way nullifies the doctor’s moral obligations toward that person: the self-inflicted injuries automatically make that person a patient whose life must be saved. Failing to intervene in order to respect the suicidal person’s autonomy would indicate a lack of that sincere concern for others that is part of the medical vocation; whereas, on the contrary, intervening to save a life is a fundamentally medical act. That this is the truly deontological attitude is demonstrated by the repeated, overwhelmingly numerous instances of gratitude from the majority of suicidal individuals rescued from death thanks to medical intervention. The physician will always act correctly if he or she interprets suicide as the final and most heart-wrenching cry for help.
At summary: Medical ethics teach that a physician may not, under any circumstances, renounce his role as healer and protector of life. He cannot remain indifferent to any human being who, for whatever reason, is discussion between life and death. A good physician has no way out: he must care for the suicidal person just as he would any other patient in an emergency status , and will do everything in his power to prevent the self-destruction that has begun from being carried out. He will act in this way not only to avoid the criminal risks of refusing aid or failing to provide assistance, but also to fulfill the ethical rule to restore a person’s physical and mental health. If the physician refrained from acting, people would be justified in suspecting that, on some occasions, the physician sample remains indifferent to the fate of those who need his care. Therefore, the physician will fulfill his or her official document duty as a healer clearly and unambiguously, even when faced with a patient who is attempting suicide for the umpteenth time. If there are medical grounds to believe that the patient’s recovery is possible, the physician will administer the necessary resuscitation and intensive care measures.
2. Doctors in the Fight Against the Suicide Epidemic
There is a second important aspect of the medical ethics of suicide: the physician's obligation to reduce the incidence of this social evil.
He will do so first by preventing a relapse into suicidal behavior among the patients he has treated. His work does not end when he brings his patient out of acute status and restores his homeostatic parameters. They must also strive to restore, if not joy, then at least the courage to live. attend Saving a suicidal patient in the acute phase is relatively easy today, thanks to the implementation of highly specialized and technologically advanced intensive care and detoxification. This requires, above all, monitoring the patient’s biochemical and functional parameters. But very often, the suicidal patient awakens feeling vulnerable and extraordinarily alone. As the patient regains awareness of his or her status and of his or her newly regained life, he or she needs help with personal problems and to be welcomed into the community of the living. And this is not easy. It demands a great deal of skill , and energy from the physician.
Medical ethics impose on physicians not only the duty to care for their own patients but also the duty to safeguard the health of the community. In their internship, physicians—regardless of their specialization program —must be able to recognize or intuit the risk of suicide in a timely manner. This risk is distributed, for example, very unevenly across the various medical specialties. Some, such as Oncology and Psychiatry, are particularly vulnerable to this danger. Setting aside free will as a determining cause of suicide, there are medical factors (incurable illness, mood disorders, unbearable pain, feelings of worthlessness, heredity, and personality) and social factors (loneliness, peer influence, life events, the feeling of being despised, cruel treatment, and involuntary confinement) that indicate situations of increased risk of suicide. The physician must be able to identify these factors in a timely manner and take responsibility for intervening. If the physician does not feel capable of doing so, he or she should seek the financial aid of a colleague who can do so with skill. Every suicide among his or her patients is a call to examine the quality of the preventive and curative care provided by the physician and perhaps an opportunity to improve some aspect of it.
II. Medical Ethics and Euthanasia
In my opinion, there are two issues surrounding euthanasia that require urgent discussion today. The first is the need to unequivocally define “ terminology ” and, along with it, the concepts we use when discussing euthanasia. The second concerns the need to closely monitor the conduct of professionals who accept euthanasia as a solution to certain medical and social problems, as the Dutch example sample .
1. On the Need to Use Clear Words and Keep Ideas Clear
Pro-euthanasia propaganda seeks to cloud people’s understanding of these concepts and blur the moral boundaries between proper conduct and criminal behavior. We therefore need to have a clear understanding of what euthanasia and “death with dignity”—the terms they use—actually entail, and to form our conscience regarding when withholding medical care from a patient is an injustice and when it is a righteous act; regarding the radical difference between causing death by purpose and refraining from delaying death. We must learn to recognize the limitations of medicine, and that means that an excellent way to respect life is to accept the inevitability of death.
In this era of campaigns and public debates on euthanasia—which are paving the way for the legislative “ discussion ” to decriminalize it—the precise use of concepts and words is both an intellectual and an ethical necessity. Public awareness—and, in particular, that of lawmakers—can be clouded, as happened in the case of abortion, by the magic of misleading language.
I believe it is necessary—to avoid the risk of semantic confusion—that we all set aside the etymological origins and noble connotations of the word “euthanasia” and that, from now on, by “euthanasia” we simply and plainly mean the painless and deliberate killing—usually through medical procedures and for medical reasons—of human beings who seem destined for a life tormented by pain or limited by disability, in order to free them from their suffering and society from a needless burden.
When euthanasia is understood in this way, the deontological distinction between active euthanasia (immediately causing death by administering a lethal agent) and passive euthanasia (causing death through the deliberate withholding of medical care that is due and necessary for healing or survival) loses its moral significance.
Understood in this way, the ethical “ assessment ” of euthanasia is completely disconnected from the emotionally charged and confusing debate surrounding excessive treatment. The latter shares only one feature with euthanasia: that of being a deontological violation, an error in clinical and ethical judgment—albeit one of the opposite nature.
With this understanding of euthanasia, it is easy to recognize and denounce the more or less deliberate deception underlying expressions such as “helping someone die” (which is an ambiguously misleading phrase used to conceal any form of euthanasia), “neonatal selection” (used to describe the infanticide practiced against certain malformed or disabled children by denying them food and treatment); withholding nutrition and fluids (to disguise letting someone die of hunger and thirst); “nursing care only” (to conceal that someone is monitoring the effects of administering massive doses of hypnotics until death occurs); or “dying with dignity” (which, in pro-euthanasia activism, is ceasing to be the justifying formula for killing out of compassion in extreme situations of pain or helplessness, but is instead becoming either the slogan for the utilitarian elimination of paraplegics, the depressed, or elderly people living alone who are beginning to have trouble caring for themselves, or the libertarian demand for the right to be killed painlessly at the place, time, and manner of one’s own choosing).
For us as physicians, lexical and conceptual clarity is evident in the most important ethical texts. The Declaration on Euthanasia, issued by the World Medical association (Madrid, October 1987), begins as follows: “Euthanasia, that is, the deliberate act of ending a patient’s life, whether at the patient’s own request or at the request of family members, is contrary to ethics.” The conclusions of the British Medical Association’s “ group ” ( work ) to review the guidelines of the “ association ” on euthanasia, released last May, state: “The law should not be changed. The deliberate killing of a human being must remain a crime. This rejection of any change to the current law—which would allow doctors to intervene to end a person’s life, (...)—is, above all, an affirmation of the supreme value of the individual, no matter how worthless or hopeless they may feel.”
Conceptual clarification is a fundamental ethical obligation. This was the understanding of Spain’s Central Ethics Commission in its Declaration on Euthanasia, from which I quote the first paragraph: “The terms ‘financial aid tion to death’ or ‘dignified death’ are frequently used in the media. Such expressions are misleading, for although they appear acceptable on the surface, they often conceal attitudes contrary to medical ethics and tend to blur the line that must separate medical h attendance s for the dying from euthanasia. Medical attendance —for the dying—is one of the most important and noble professional duties of a physician, whereas euthanasia is the deliberate destruction of a human life which, even if carried out at the victim’s request or out of compassion on the part of the person performing it, remains a crime that is deeply repugnant to a sincere medical vocation.”
These texts clearly outline the lawful scope of a physician’s practice, as well as the ethical limits on that practice. They also address the unlawfulness of a physician’s actions or omissions. I will attempt to summarize in clear terms the ethical doctrine in force today.
- A physician must never deliberately take a life: any form of euthanasia—whether by action or omission, that is, active or passive, requested by the patient or performed without the patient’s consent—constitutes a serious ethical violation.
- A doctor cannot initiate futile and hopeless treatments. Excessive treatment is an ethical error, a commercial or political distortion of medicine, and an irrational—yet effective—argument that plays into the hands of pro-euthanasia activists.
- Except in cases of obvious incapacity or loss of reason, a physician may not override a patient’s wish not to be treated. The patient has an ethical duty to preserve his or her life and to accept life-saving treatments, provided that such treatments offer a reasonable hope of benefit and can be obtained and administered without serious inconvenience, pain, or expense. The patient has the right to refuse any treatment that does not offer a reasonable hope of benefit and that cannot be obtained or received without great suffering, or without serious expense or inconvenience, even if the costs are covered by public funds or an insurance company.
- The long-standing dilemma of life-shortening treatment has been overcome today. Recent advances in the treatment of pain and terminal illness have eliminated the risk of unduly hastening the death of certain patients.
- Today, the debate over euthanasia no longer centers on the traditional issue of killing out of compassion.
- The focus of the debate on euthanasia has shifted to the issue—raised by libertarian autonomism—of the alleged right to be killed by a doctor at the place, time, and in the manner of one’s choosing. Increasingly, euthanasia will be demanded as a medic financial aid e to voluntary suicide.
That concludes our discussion on the proper use of words and the clarity of concepts.
2. The Need to Closely Monitor the Situation in the Netherlands
The answer to the question of where legal tolerance of euthanasia leads can be found by empirically observing what has been happening in the Netherlands over the past few years. The answer is clear: that tolerance leads to an unexpected brutalization of medicine.
It is not easy to summarize the legal, sociological, religious, and medical-ethical aspects that have contributed to the emergence of euthanasia in the Netherlands. In fact, as a result e of a long history of social conditioning, Dutch society has largely accepted that voluntary euthanasia is ethically unobjectionable and a legitimate expression of individual freedom. But that same society also largely accepts involuntary euthanasia and the withholding of life-saving care when applied to terminally ill patients, individuals with severe disabilities, the elderly, or certain patients without family.
In response to this public sentiment, the government and the judicial system in the Netherlands have de facto accepted the internship of euthanasia and have transferred to physicians—the sole experts on matters of life and death—the responsibility for regulating the conditions under which a physician may administer a painless death, thereby preventing potential abuses. In early 1987, the National Health committee t published its Recommendations for the Practice of Euthanasia, which have received plenary session of the Executive Council support from the Government’s board , the Royal Dutch association of Medicine, and the Dutch Nurses’ Union.
In fact, since 1984—and with the judicial guarantee of impunity—the machinery for the euthanasia of disabled people has been set in motion. Naturally, many doctors and a segment of the population are sta civil service examination s to euthanasia. Every year, there are a few trials against doctors or nurses for having performed euthanasia in violation of the required conditions; but these trials are more of a rhetorical gesture to reassure public opinion than a deterrent to criminal behavior. There is no shortage of articles that tend to show that the phenomenon is perfectly under control and that current guidelines are scrupulously followed. There is no doubt about it: society is being lulled into a false sense of security. But what is really happening?
There are no official, reliable figures on how many cases of euthanasia occur in the Netherlands, but it is estimated that, when figures from home care and hospital care are combined, euthanasia is performed in 5,000 to 10,000 cases each year. It is said that issue of unreported cases—cases of “cryptanasia”—may account for just as many. A mindset has taken hold among the elderly that it is selfish to want to live while being a burdensome burden on society and that, consequently, they should plan their own euthanasia, as this is a courageous, wise, and progressive act. There are apparently some faint signs of rebellion against this harsh “ status .” The elderly living in nursing homes overwhelmingly (93 percent) oppose active euthanasia, which is supported by 76 percent of the general population. And, although there are many more who carry a living will—their “card de credit para la muerte dulce”—the issue of those who obtain a “declaration of desire to live and to receive medical treatment in the event of illness or accident” is growing, especially among the elderly.
For some doctors, this status constitutes an imminent danger of dehumanization. Consent to euthanasia undermines the trust that must underpin the doctor-patient relationship, an essential part of which is the conviction that the doctor will never abandon his or her patient, nor will he or she ever deliberately inflict harm. Granting the doctor discretionary power over the lives of certain people—many of whom are defenseless—means the breakdown of that fundamental trust. In the Netherlands, there is a growing issue of patients who develop attitudes of fear, suspicion, or distrust toward doctors; who refrain from visiting the doctor’s office or being admitted to the hospital; or who refuse to take their prescribed medications.
An alarming collection of anecdotes about medical brutalization stemming from the social and professional acceptance of euthanasia can be found in an article by Richard Fenigsen, “A Case against Dutch Euthanasia,” published—alongside a diverse collection of programs of study —in a special supplement to the Hastings Center Report, graduate , titled “Compassion, Murder, and Morality: Perspectives on Euthanasia.” Reading it is both chilling and enlightening. Unsurprisingly, a lively exchange exchange of letters to publisher soon followed in the same journal. Among them was the inevitable collective letter signed by numerous distinguished public figures (from politics and the progressive clergy, from libertarian activism and bioethics societies, from academia and the judiciary). Fenigsen has refuted, point by point, with arguments and evidence, each of the objections raised against him. I believe that reading that supplement and the correspondence it sparked is a necessary exercise for responsibly assessing the real and potential risks that the Dutch euthanasia experiment poses to medical internship .
III. The Consequences of a Diminishing Respect for Human Life
Even outside the Netherlands, pro-euthanasia activism is winning over doctors. Judging by certain surveys, the idea that it is justified—and even virtuous or morally obligatory—to end certain human lives is gaining acceptance among doctors everywhere. And, it seems, some of them are willing to do so.
There are many more doctors who take a lukewarm stance on euthanasia. They state that they will refrain from personally participating in the termination of human life, but that they cannot oppose the legalization of euthanasia and the financial aid of voluntary suicide. In fact, they would oppose the medicalization of these actions, which—by their origin and nature—are foreign to medicine and should therefore remain outside the scope of professional practice. And they propose that certified euthanasia practitioners—non-medical euthanasia providers—be authorized to perform this task, since, after all, one does not need to be a medical doctor to administer, via an intravenous injection, a “gentle death” to a patient or capital punishment to a condemned person, nor to advise on the various methods of committing suicide.
This ambivalent attitude—which, on the one hand, refuses to cooperate in the destruction of certain human lives, but, on the other hand, tolerates it—is incompatible with medical ethics: it profoundly distorts the physician’s “ work ,” since it tacitly implies that it is acceptable to turn people’s desires into medical problems, that is, into illnesses requiring treatment, and that some physicians—or at least some paramedics—should be able to fulfill those desires. This lukewarm attitude demonstrates that many physicians consider it acceptable to sever the two basic elements of the profession, separating techn official document y from moral responsibility. Administering an intravenous injection or submit giving a patient some pills appear, from the outside, to be medical acts, even if the syringe is loaded with a lethal dose or the pills contain a deadly poison. Anyone who does not react with moral indignation to the falsification of these gestures implies that, for them, the medical profession is purely a technical endeavor, not an ethical activity.
Any legislation that tolerates euthanasia—no matter how restrictive it may appear on paper—inevitably leads to the ethical and scientific degradation of medicine. For when doctors work in an environment where they know they will face no consequences whether they treat or kill certain patients, their commitment to preserving life as caregivers will gradually erode.
Furthermore, any permissive legislation is inherently expansive. The legal restrictions it contains succumb to the unstoppable force of social demand. In a society that legalizes euthanasia, doctors’ commitment to healing will gradually wane. Sooner or later, a point of habituation—of becoming accustomed to it—will be reached. And then, as society becomes desensitized—as it develops the capacity to metabolize ever-increasing levels of euthanasia—a phenomenon hitherto unthinkable will occur: doctors will gradually become indifferent toward certain types of patients, and care and research will decline in vast areas of pathology. For if, for example, it is possible to rid humanity of “ Geneticsl waste” through low-cost neonatal euthanasia, what interest could basic and applied research have in the diagnosis and treatment of hereditary diseases? If “mercy killing” is applied as the first option for senile patients or those 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? In any case, medicine will increasingly become a form of thanatology.
David Lamb, the astute analyst of the “slippery slope” argument, has pointed out the futility of any attempt to compartmentalize euthanasia, to categorize patients who do not wish to live or who are a burden on society, or to place limits on a physician’s actions, once absolute respect for the life of every human being is abandoned.
It is not difficult to imagine the loss of intellectual and professional values involved in a doctor’s “ withdrawal ” (rejection of the patient’s will) regarding his “ official document ” (responsibility) as a scientific observer and compassionate protector of life. In Fenigsen’s “ article ” (The Medical Ethical Dilemma), cited above, it is “ sample ” (demonstrated) with real-life examples how the ease of inducing death leads to the doctor’s “desinterés” (disinterest) in the intelligent inquiry into the patient’s past, in the “ internship ” (thoroughness) of the clinical examination, and in the rigor of the diagnostic judgment. This lack of interest fosters the development of an intellectually lazy attitude. To accept that euthanasia is the most appropriate treatment that can be given to a patient, to accept that euthanasia is good medicine, is equivalent to enshrining as good internship the pursuit of the path of least resistance; it means renouncing the intellectual and ethical vocation of medicine. All the mental and moral effort of the physician—the sometimes exhausting strain of fulfilling the Hippocratic precept to seek the patient’s well-being—“I will do whatever I know and can to benefit the patient, and I will strive not to cause them harm or injustice”—will suffer atrophy from disuse in the intellect and character of physicians who include euthanasia among their ‘therapeutic’ regimens. Fenigsen states: “To forgo a potentially effective treatment because of euthanasia is a phenomenon that is increasingly crippling the medical profession. Euthanasia is not merely changing medicine or expanding its scope; euthanasia is replacing medicine.”
Medicine suffers a partial eclipse when part of it is absorbed into euthanasia. And humanity suffers as well. Beneath the ceremony of soft music, tears, and tender gestures of farewell—with which the administration of euthanasia is often ritualized—lies a cynical and merciless operation: the expropriation of death. Euthanasia, once it becomes widespread, will be the final solution to the unfathomable mystery of death. Death will no longer be either a problem or a taboo. Post-Christian man will no longer fear it nor suffer final defeat at its hands, for he will subjugate it to his dominion, technicize it, and assign it a manner, place, and time. Death will no longer be a destiny staff, but a simple technical gesture, programmed and executed neatly, without fanfare.
When a doctor performs euthanasia on a patient, he is actually doing two things. One is visible: gently transforming a living person into a corpse. The other is invisible: bringing an end to his own career as a doctor. What a stark contrast to the doctor’s genuine healing attitude!
I would like to conclude my remarks with an anecdote that took place many years ago but continues to point the way forward. Dame Cecily Saunders, the founder of the hospice movement for the care of terminally ill patients, recounts it. “I had exchanged a great deal of correspondence with the former president of the Euthanasia Society of Great Britain, and I took him to visit St. Joseph’s Hospice after I had been working there for a year and a half. When he left, he said to me, ‘I had no idea you were capable of doing this. If all patients died as they do here, I think we would have to dissolve the Society.’ And he added, ‘I would like to come here to die.’” Cecily Saunders adds: “When you’re able to relieve a patient’s pain and make them feel loved—just as they should—then no patient will ask us for euthanasia… It seems to me that euthanasia is like admitting defeat; it’s a completely negative approach. We must work to ensure that no one needs it.”
To work so that no one needs it: that is—and has always been, in the Hippocratic tradition—the ethical framework for euthanasia.
Thank you very much.