Introduction

The topic of euthanasia is one that is shrouded with much ethical debate and ambiguity. Various types of euthanasia are recognised, with active voluntary euthanasia, assisted suicide and physicianassisted suicide eliciting the most controversy. [1] Broadly speaking, these terms are used to describe the termination of a person’s life to end their suffering, usually through the administration of drugs. Euthanasia is currently illegal in all Australian states, refl ecting the status quo of most countries, although, there are a handful of countries and states where acts of euthanasia are legally permitted under certain conditions.

Advocates of euthanasia argue that people have a right to make their own decisions regarding death, and that euthanasia is intended to alleviate pain and suffering, hence being ascribed the term “mercy killing.” They hold the view that active euthanasia is not morally worse than the withdrawal or withholding of medical treatment, and erroneously describe this practice as “passive euthanasia.” Such views are contested by opponents of euthanasia who raise the argument of the sanctity of human life and that euthanasia is equal to murder, and moreover, abuses autonomy and human rights. Furthermore, it is said that good palliative care can provide relief from suffering to patients and unlike euthanasia, should be the answer in modern medicine. This article will define several terms relating to euthanasia in order to frame the key arguments used by proponents and opponents of euthanasia. It will also outline the legal situation of euthanasia in Australia and countries abroad.

Defining euthanasia

The term “euthanasia” is derived from Greek, literally meaning “good death”. [1] Taken in its common usage however, euthanasia refers to the termination of a person’s life, to end their suffering, usually from an incurable or terminal condition. [1] It is for this reason that euthanasia was also coined the name “mercy killing”.

Various types of euthanasia are recognised. Active euthanasia refers to the deliberate act, usually through the intentional administration of lethal drugs, to end an incurably or terminally ill patient’s life. [2] On the other hand, supporters of euthanasia use another term, “passive euthanasia” to describe the deliberate withholding or withdrawal of life-prolonging medical treatment resulting in the patient’s death. [2] Unsurprisingly, the term “passive euthanasia” has been described as a misnomer. In Australia and most countries around the world, this practice is not considered as euthanasia at all. Indeed, according to Bartels and Otlowski [2] withholding or withdrawing life-prolonging treatment, either at the request of the patient or when it is considered to be in the best interests of the patient, “has become an established part of medical practice and is relatively uncontroversial.”

Acts of euthanasia are further categorised as “voluntary”, “involuntary” and “non-voluntary.” Voluntary euthanasia refers to euthanasia performed at the request of the patient. [1] Involuntary euthanasia is the term used to describe the situation where euthanasia is performed when the patient does not request it, with the intent of relieving their suffering – which, in effect, amounts to murder. [3] Non-voluntary euthanasia relates to a situation where euthanasia is performed when the patient is incapable of consenting. [1] The term that is relevant to the euthanasia debate is “active voluntary euthanasia”, which collectively refers to the deliberate act to end an incurable or terminally ill patient’s life, usually through the administration of lethal drugs at his or her request. The main difference between active voluntary euthanasia and assisted suicide is that in assisted suicide and physician-assisted suicide, the patient performs the killing act. [2] Assisted suicide is when a person intentionally assists a patient, at their request, to terminate his or her life. [2] Physician-assisted suicide refers to a situation where a physician intentionally assists a patient, at their request, to end his or her life, for example, by the provision of information and drugs. [3]

Another concept that is linked to end-of-life decisions and should be differentiated from euthanasia is the doctrine of double effect. The doctrine of double effect excuses the death of the patient that may result, as a secondary effect, from an action taken with the primary intention of alleviating pain. [4] Supporters of euthanasia may describe this as indirect euthanasia, but again, this term should be discarded when considering the euthanasia debate. [3]

Legal situation of active voluntary euthanasia and assisted suicide

In Australia, active voluntary euthanasia, assisted suicide and physician-assisted suicide are illegal (see Table 1). [1] In general, across all Australian states and territories, any deliberate act resulting in the death of another person is defined as murder. [2] The prohibition of euthanasia and assisted suicide is established in the criminal legislation of each Australian state, as well as the common law in the common law states of New South Wales, South Australia and Victoria. [2]

The prohibition of euthanasia and assisted suicide in Australia has been the status quo for many years now. However, there was a period when the Northern Territory permitted euthanasia and physician-assisted suicide under the Rights of Terminally Ill Act (1995). The Act came into effect in 1996 and made the Northern Territory the first place in the world to legally permit active voluntary euthanasia and physicianassisted suicide. Under this Act, competent terminally ill adults who were aged 18 or over, were able to request a physician to help them in dying. This Act was short-lived however, after the Federal Government overturned it in 1997 with the Euthanasia Laws Act 1997. [1,2] The Euthanasia Laws Act 1997 denied states the power to legislate to permit euthanasia or assisted suicide. [1] There have been a number of attempts in various Australian states, over the past decade and more recently, to legislate for euthanasia and assisted suicide, but all have failed to date, owing to a majority consensus against euthanasia. [1]

A number of countries and states around the world have permitted euthanasia and/or assisted suicide in some form; however this is often under specific conditions (see Table 2).

Arguments for and against euthanasia

There are many arguments that have been put forward for and against euthanasia. A few of the main arguments for and against euthanasia are outlined below.

For

Rights-based argument

Advocates of euthanasia argue that a patient has the right to make the decision about when and how they should die, based on the principles of autonomy and self-determination. [1, 5] Autonomy is the concept that a patient has the right to make decisions relating to their life so long as it causes no harm to others. [4] They relate the notion of autonomy to the right of an individual to control their own body, and should have the right to make their own decisions concerning how and when they will die. Furthermore, it is argued that as part of our human rights, there is a right to make our own decisions and a right to a dignified death. [1]

Beneficence

It is said that relieving a patient from their pain and suffering by performing euthanasia will do more good than harm. [4] Advocates of euthanasia express the view that the fundamental moral values of society, compassion and mercy, require that no patient be allowed to suffer unbearably, and mercy killing should be permissible. [4]

The difference between active euthanasia and passive euthanasia

Supporters of euthanasia claim that active euthanasia is not morally worse than passive euthanasia – the withdrawal or withholding of medical treatments that result in a patient’s death. In line with this view, it is argued that active euthanasia should be permitted just as passive euthanasia is allowed.

James Rachels [12] is a well-known proponent of euthanasia who advocates this view. He states that there is no moral difference between killing and letting die, as the intention is usually similar based on a utilitarian argument. He illustrates this argument by making use of two hypothetical scenarios. In the first scenario, Smith anticipates an inheritance should anything happen to his six-year-old cousin, and ventures to drown the child while he takes his bath. In a similar scenario, Jones stands to inherit a fortune should anything happen to his six-year-old cousin, and upon intending to drown his cousin, he witnesses his cousin drown on his own by accident and lets him die. Callahan [9] highlights the fact that Rachels uses a hypothetical case where both parties are morally culpable, which fails to support Rachels’ argument.

Another of his arguments is that active euthanasia is more humane than passive euthanasia as it is “a quick and painless” lethal injection whereas the latter can result in “a relatively slow and painful death.” [12]

Opponents of euthanasia argue that there is a clear moral distinction between actively terminating a patient’s life and withdrawing or withholding treatment which ends a patient’s life. Letting a patient die from an incurable disease may be seen as allowing the disease to be the natural cause of death without moral culpability. [5] Life-support treatment merely postpones death and when interventions are withdrawn, the patient’s death is caused by the underlying disease. [5]

Indeed, it is this view that is strongly endorsed by the Australian Medical Association, who are opposed to voluntary active euthanasia and physician-assisted suicide, but does not consider the withdrawal or withholding of treatment that result in a patient’s death as euthanasia or physician-assisted suicide. [1]

Against

The sanctity of life

Central to the argument against euthanasia is society’s view of the sanctity of life, and this can have both a secular and a religious basis. [2] The underlying ethos is that human life must be respected and preserved. [1]

The Christian view sees life as a gif offerrom God, who ought not to be off ended by the taking of that life. [1] Similarly the Islamic faith says that “it is the sole prerogative of God to bestow life and to cause death.” [7] The withholding or withdrawal of treatment is permitted when it is futile, as this is seen as allowing the natural course of death. [7]

Euthanasia as murder

Society views an action which has a primary intention of killing another person as inherently wrong, in spite of the patient’s consent. [8] Callahan [9] describes the practice of active voluntary euthanasia as “consenting adult killing.”

Abuse of autonomy and human rights

While autonomy is used by advocates for euthanasia, it also features in the argument against euthanasia. Kant and Mill [3] believe that the principle of autonomy forbids the voluntary ending of the conditions necessary for autonomy, which would occur by ending one’s life.

It has also been argued that patients’ requests for euthanasia are rarely autonomous, as most terminally ill patients may not be of a sound or rational mind. [10]

Callahan [9] argues that the notion of self-determination requires that the right to lead our own lives is conditioned by the good of the community, and therefore we must consider risk of harm to the common good.

In relation to human rights, some critics of euthanasia argue that the act of euthanasia contravenes the “right to life”. The Universal Declaration of Human Rights highlights the importance that, “Everyone has the right to life.” [3] Right to life advocates dismiss claims there is a right to die, which makes suicide virtually justifi able in any case. [8]

The role of palliative care

It is often argued that pain and suffering experienced by patients can be relieved by administering appropriate palliative care, making euthanasia a futile measure. [3] According to Norval and Gwynther [4] “requests for euthanasia are rarely sustained after good palliative care is established.”

The rights of vulnerable patients

If euthanasia were to become an accepted practice, it may give rise to situations that undermine the rights of vulnerable patients. [11] These include coercion of patients receiving costly treatments to accept euthanasia or physician-assisted suicide.

The doctor-patient relationship and the physician’s role

Active voluntary euthanasia and physician-assisted suicide undermine the doctor-patient relationship, destroying the trust and confi dence built in such a relationship. A doctor’s role is to help and save lives, not end them. Casting doctors in the role of administering euthanasia “would undermine and compromise the objectives of the medical profession.” [1]

Conclusion

It can be seen that euthanasia is indeed a contentious issue, with the heart of the debate lying at active voluntary euthanasia and physicianassisted suicide. Its legal status in Australia is that of a criminal off ence, conferring murder or manslaughter charges according to the criminal legislation and/or common law across Australian states. Australia’s prohibition and criminalisation of the practice of euthanasia and assisted suicide refl ects the legal status quo that is present in most other countries around the world. In contrast, there are only a few countries and states that have legalised acts of euthanasia and/or assisted suicide. The many arguments that have been put forward for and against euthanasia, and the handful that have been outlined provide only a glimpse into the ethical debate and controversy surrounding the topic of euthanasia.

Conflicts of interest

None declared.

Correspondence

N Ebrahimi: nargus.e@hotmail.com

References

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[2] Walsh D, Caraceni AT, Fainsinger R, Foley K, Glare P, Goh C, et al. Palliative medicine. 1st ed. Canada: Saunders; 2009. Chapter 22, Euthanasia and physician-assisted suicide; p.110-5.

[3] Goldman L, Schafer AI, editors. Goldman’s Cecil Medicine. 23rd ed. USA: Saunders; 2008. Chapter 2, Bioethics in the practice of medicine; p.4-9.

[4] Norval D, Gwyther E. Ethical decisions in end-of-life care. CME. 2003 May;21(5):267-72.

[5] Kerridge I, Lowe M, Stewart C. Ethics and law for the health professions. 3rd ed. New South Wales: Federation Press; 2009.

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[9] Callahan D. When self-determination runs amok. Hastings Cent Rep. 1992 Mar- Apr;22(2):52-55.

[10] Patterson R, George K. Euthanasia and assisted suicide: A liberal approach versus the traditional moral view. J Law Med. 2005 May;12(4):494-510.

[11] George R J, Finlay IG, Jeff rey D. Legalised euthanasia will violate the rights of vulnerable patients. BMJ. 2005 Sep 24;331(7518):684-5.

[12] Rachels J. Active and passive euthanasia. N Engl J Med. 1975 Jan 9;292(2):78-80.