Euthanasia
by Dr. Charles C. Crichton
General Practitioner, Portree, Isle of Skye
In the preparation of this paper, I have appreciated the support and encouragement of my minister, Rev. William Macleod, and the Skye and Uist Presbytery. I also acknowledge the valuable work of Drs Eric Mackay <1> and Murdoch Murchison <2> in previous papers on euthanasia, and the theme of Professor MacDonald's moderatorial address <3>.
The subject of euthanasia covers vast areas of philosophy, theology, and medicine, and consideration of it can be quite overwhelming, both intellectually and emotionally. I am no philosopher nor theologian. My qualification to speak on this subject is simply that I am a Christian with medical experience and I appreciate the privilege of being able to share some very basic considerations with you. I am a physician with two roles (i) as a principal in a general medical practice, and (ii) as a community hospital doctor. My colleagues and I are privileged to see people with a wide range of medical problems, and we regularly have to apply the practice of palliative medicine, both in the patients' homes and in our hospital in Portree, Isle of Skye. I trust that undergirding my practice of medicine is my Christian faith which gives me supreme reasons for dispensing optimal care to those who are dying and who are dependent on others.
Now let me briefly outline my presentation. I will consider
1 working definitions of common terms
2 resume of important trends worldwide
3 the apparent case for euthanasia
4 the foundation principles in society which have led to the case for euthanasia
5 the contrasting Christian foundation principles
6 the consequent Christian ethics and therefore the case against euthanasia
7 a summary of basic principles and a suggested statement of practice
I will not recount a list of anecdotes - these may illustrate points well but do not teach basic principles, and for every Christian anecdote, the euthanasia lobby have anecdotes of their own.
(i) Definitions of terms are helpful.
Much confusion prevails in the literature as non-Christians and Christians have different views about such emotive words. However, there is general acceptance in Scotland of both the 1994 House of Lords Select Committee Report on Medical Ethics <4> and the Church of Scotland book of 1995 entitled Euthanasia <5>. These two are in reasonable agreement and offer useful definitions as follows:
Euthanasia or 'active euthanasia' - deliberate intervention undertaken with the express intention of ending a life to relieve intractable suffering (i.e. terminal, painful, or distressing illness). The original Greek roots eu thanatos mean dying well or good death, a general concept that the Christian could support; sadly the received definition nowadays is rather different. Euthanasia may be voluntary or involuntary (vide infra);
Withdrawal of treatment, or not initiating treatment, or a treatment - limiting decision - these are terms appropriate to situations where treatment is proving ineffective in achieving recovery and should rightly be stopped, or not even started. It is the expression of good clinical judgement. It is not passive euthanasia; it is an aspect of good medical practice.
Double effect - the administration of pain-killers or other drugs (e.g. sedatives) necessary for the relief of a patient's severe distress, but in the knowledge that a probable consequence is the shortening of a patient's life. Again, this is the expression of good clinical judgement; it is not passive euthanasia;
Passive euthanasia - the deliberate shortening of a life through an omission to act;
Voluntary euthanasia - a patient's death is brought about at their specific request. This category is at the centre of attempts to legalise euthanasia and these also include the contentious role of advance directives;
Non-voluntary euthanasia - the ending of the life of a person who does not apparently have the capacity to know or to express their wishes regarding continued existence (e.g. infants, severe brain damage, dementia, persistent vegetative state);
Involuntary euthanasia - the ending of the life of a person who is competent to request or consent to the act, but does not do so. The motive may be to terminate suffering, but this act is tantamount to murder;
Physician-assisted suicide - a competent patient has expressed a desire to end their life, but requires help to perform the act; the physician provides the means for ending the life (usually drugs) but does not participate in the event;
Competent - able to understand the information about one's condition, and the risks and benefits of treatment; incompetent therefore implies one who is unable, temporarily or permanently, to make decisions about their medical care;
Advance directive (living will) - a document drawn up while the person is competent which defines the wishes of that person about medical treatment or non-treatment in the event of being unwell, and unable to express their desires i.e. becoming incompetent. Strictly speaking, these are not a request for euthanasia;
Palliative care (W.H.O. definition <6>) - "recognises that care or long-term control is not possible, is concerned with quality of life, and whose primary aim is the highest possible measure of patient comfort."
Definitions are tedious, but useful. We may disagree about the detailed semantics but they are necessary tools to help us understand the unnerving developments of these last few years.
(ii) What is the worldwide situation in this present year? <7>
In the U.K. , the House of Lords Select Committee on Medical Ethics of 1994 pronounced that "there should be no change in the law to permit euthanasia" <4> and this is the current received position in law and endorsed by the BMA conference two months ago. Christian lobbying of the House of Lords committee had the enormously beneficial effect of turning a majority in favour of euthanasia into a unanimous vote against it.<7> But fierce pressure is sustained - (i) by the media capitalising on medical mismanagement of patients with terminal disease, (ii) by a few lay and medical personnel practising euthanasia in thankfully very small numbers and daring the law to address them, <8> (iii) by leading thinkers who espouse apparently benign motives, <9> (iv) and in a negative sense, by the churches not being alert to developments and failing to speak unequivocally against euthanasia.
In Australia, in Northern Territory, voluntary euthanasia was voted into law on 1st July 1996, <10> and the ghastly scenario took place on 22nd September 1996 when a patient with prostatic cancer ended his life by answering three questions on a laptop computer, then pressing the space bar which activated a pre-set intravenous infusion of drugs arranged by his doctor (physician-assisted suicide). We give thanks that this law was made illegal by the vote of the Australian Senate on 29th March this year (but only by 38 to 33) <11> - we now witness the bizarre irony of the Australian government being sued by someone with terminal illness who had travelled to Northern Territory ("euthanasia tourism") in order to commit physician-assisted suicide. The basis of the claim is the "emotional distress" caused by the revoking of the Northern Territory law. Remember Australia.
In the U.S.A., Oregon state has permitted euthanasia since 1994, although it has been held in abeyance by legal challenge, and New York and Washington states intended to follow suit - but thankfully in June this year the U.S. Supreme Court rules that there is no constitutional right to physician-assisted suicide. <12 > However, the ghoulish work of Dr Jack Kevorkian continues in Michigan because the courts have failed to convict him - the law has effectively been overturned and public acceptance may be the critical factor <7>.
In Holland in 1990, 3% of all deaths were due to euthanasia <13> i.e., 3000 people died in this way and 1000 of these were by involuntary euthanasia; <14> in February this year the rules were further relaxed to reduce the risk of doctors being criminalised.<15> Some Dutch patients are now complaining about poor access to euthanasia, and so the "slippery slope" argument is endorsed.<16> It is noteworthy that a visit to observe the situation in Holland helped to influence the House of Lords Committee to reject euthanasia. The Times of 27.8.97 reported that no other European country was eager to follow the Dutch model. What bitter and exquisite irony that Dutch doctors during World War II absolutely refused to co-operate with the German euthanasia programme, with costly personal consequences, <14>,<17> but today lead the world in the practice of euthanasia and are not ashamed to be so identified.<18>,<19>
(iii) The apparent case for euthanasia.
In considering euthanasia and the brief review of the situation in these countries, it is of vital importance to look at the reasons for society's interest, especially Western society/first world in this matter. About 70% of us at some point will be faced with a critical life-saving decision regarding ourselves or our families.<20> It may therefore seem quite appealing to agree with those who advocate the following simple advice:
1 Death is a normal process, therefore 'ending it all' is simply advancing the normal course 'probably just a little ahead of time';
2 Each person has the right to exercise self-determination or autonomy, therefore one can decide to end one's life. This is a reflection of our human-ness and is seen as total freedom. The euthanasia lobby therefore exalts individual freedom above a corporate commitment to the goodness of life - it indeed asks with Cain, and in the spirit of his asking, 'Am I my brother's keeper?';
3 Pain and suffering, both physical and psychological, are extremely unpleasant and the fear of such a prospect should persuade us to agree to end life sooner rather than later;
4 The indignity of illness, that is, dependence on others, loss of bowel and bladder control, loss of brain function, and so on, surely we should be allowed to state in advance that we would rather die than suffer such indignities;
5 The burden of dependence, and the cost to society - resources are limited, and could be directed to the more active medical care of those who will be able to return to good health, therefore get rid of the burden.
There appears to be nothing overtly wrong about these reasons - in fact this is surely a caring, concerned, thoughtful society at work ruled by the marvellous principles of beneficence (doing good), non-maleficence (doing no harm), autonomy (self-determination and justice (fairness).<21>
(iv) The underlying reasons for the euthanasia case.
There are deeper, darker currents, and we must not be bewitched by these fine-sounding words and concepts. The heart of the matter is, I suggest, the answer to the simple question: What is man? In today's secularism, he is everything and he is nothing - Protagoras in 485 BC said: 'Man is the measure of all things' <22>; The hero of the so-called Enlightenment, David Hume, in 1760 said: 'Morality is shaped by human nature; there is no rational basis for a belief that there is an external world which may impose on us' <23> (and we are not proud of our famous Scottish philosopher ) Nietzsche, that evil protagonist of nihilism and scepticism, said: 'We are the creators of our values' <24> and how the Third Reich applied them fifty years later! Professor Peter Singer of Melbourne (philosophy) tells us that that which is moral is that which satisfies the most interests and preferences, that is, preference utilitarianism.<25> At the same time as magnifying man, Richard Dawkins tells us that we are simply a collection of interactive chromosomes, a mere blueprint for the future, a biological accident, in a meaningless and silent universe;<26> Peter Singer advises us that we are of the animal kingdom with no specific rights (in particular, human babies may have less right to life than adult monkeys).<27> The New Age movement reassures us that when man dies 'he enters the water and causes no ripple', he is recycled, he merges with God and the universe and so on, i.e. the individual is inconsequential. Thus we conclude that humans are the final moral authority on life and death, and indeed on the deaths of others. Bonhoeffer forecast 'a creative void which blows its anti-God's breath ... Awakens ... all ... to a false semblance of new life ... until it falls in ruins ... for the void spares nothing.<28>' The Times of 30.8.97 spoke of today's adults with no sense of moral universe, no commitments, no beliefs ...a horribly modern void ... functional employable thirty- somethings morally illiterate on great issues. <37> Society is indeed ruled by 'principalities and powers' (Rom. 8:38) and 'the prince of the power of the air'(Eph. 2:2) whose master-stroke is that he is unrecognised. We can summarise the underlying beliefs of today's society with the prophetic and sad irony of Proverbs 14:12. 'There is a way which seemeth right unto a man but the end thereof are the ways of death'. The ways of death indeed.
(v) The contrasting Christian foundation principles.
We do need to take note of the Spirit of the age in order to understand the present growth and development of euthanasia ethics. Are we witnessing the end of the Christian centuries in this country? We must be strong, as the people of God, and confirm that 'there is a more excellent way'. (1 Cor. 12:31)
The Word of God cannot specifically advise on the use of respirators and intra-venous lines that blur the difference between the process of dying and sustaining life, but on the basis of its teaching we ought to carry the day in terms of both principles and consequences. Without embarrassment we assert that in the beginning there is God, infinite, eternal, and unchangeable; but He is also the God of the communicable attributes and He has made man and made him in His own image, His companion, the expression of His purposes, who might glorify Him and enjoy Him for ever, set apart as the steward and head of creation. And despite our present sinful state in all its degradation, God has given us the highest honour by becoming one of us 'being in the form of God ... made Himself of no reputation ... and was made in the likeness of men'. (Phil. 2:6-8) We therefore have absolute dignity because He has made us, made us like Himself and has become one of us 'yet without sin'. Furthermore, we are responsible for each other - Cain understands God's expectation only too well and defied it. The Ten Commandments espouse love for God and neighbour, the Lord Jesus reinforces this with His majestic 'Love one another', and Paul reminds us that 'none of us liveth to himself alone, and none of us dieth to himself alone.' (Rom. 14:7) Therefore, human lives are sacred, have absolute not relative significance and dignity, are inter-dependent, and their disposal is not negotiable. And so, where the situation ethicist of the world speaks of simply doing good, (beneficence), we now speak of compassion and sanctity of life, instead of doing no harm, (maleficence), we speak of value in suffering, for self-determination, (autonomy), we speak of stewardship, society, and the sovereignty of God, for fairness, (justice), we speak of mercy, grace, and eternal hope. <21> Our situation ethics are theocentric - our framework is outside of this world. Consider Micah 6:8 'He hath showed thee, O man, what is good, and what doth the Lord require of thee but to do justly and to love mercy and to walk humbly with thy God.'
(vi) Christian ethics, and the case against euthanasia.
The Christian response to secular society's case for euthanasia is therefore robust and unashamed.
1 Ending it all - eliminate suffering by eliminating the sufferer. But relief of suffering belongs in the service of life, rather than in the service of death. It is not part of the doctor's ethos to kill. We acknowledge that God may not relieve suffering as we would like or expect, and His providence can be impossible to understand. But that does not qualify us to join with Job's wife and 'curse God and die.' (Job 2:9) The absence of health and vigour is the sombre, realistic providence of God, and our duty, endorsed by the Saviour, the one who came to comfort, is to comfort and relieve. His own prophetic words endorse this work, 'I was sick and you visited me' (Matt. 25:26) not necessarily cured but cared for, so that the patient does not consider the option of 'ending it all'. The Christian community has the responsibility and the ability to model a better way to deal with dying than to 'end it all'.
2 The individual's right i.e., personal autonomy. By definition, each individual has the right to life; but if we believe that we have the right to choose death then several disturbing consequences follow: (I) we or our relatives might lose the right to stay alive; (ii) others would have the duty to provide the means of death - where is their freedom if they don't want to do this? (iii) groups of like-minded individuals may assert the right to choose death for their own members or the deaths of others - witness the recent American cult with a large number of suicides, or the chilling decisions of Nazi doctors in 1940; the philosophy of Nietzsche come home to roost. In ancient times Seneca said, 'I will chose the death by which I leave life' <30>; Ernest Hemingway said that with suicide we have control of the 'where, when, how' <31>. But freedom does not give me the right to make my own moral law; my rights and freedom must be limited, interactive with the rest of society, and ultimately acknowledging subservience to God and His law. How sad that Hemingway of 'For whom the Bell Tolls' fame should not perceive that 'no man is an island entire of itself.' Intentional killing is prohibited by the law of God - this prohibition is fundamental to individual life and the life of society and is not negotiable.
3 Pain and suffering - as said beforehand, we can eliminate pain and suffering by eliminating the sufferer. Now terminal illness is usually due to diseases which can cause severe pain, very unpleasant loss of function, and very great psychological suffering. There is, very often, depression, loneliness, and fear of this terrible unknown future. There is also the harsh reality of suffering for the relatives and carers, watching a loved one change, disintegrate and die. The reality of life is that people suffer, and we are perplexed by God's providence. But the fact is that in His mercy to all mankind God has provided the means to control pain and reduce suffering - the previously intractable is finding relief, the chronically disabling can be responsive to new rehabilitative measures. Relief of suffering lies in the service of life, not in the service of death. Also, we must be careful to identify the true sufferer - euthanasia may be more compassionate to the hurting family, who cannot cope with the situation, than to the patient, and the question needs to be asked, Who is actually suffering? True care extends to the physical, the psychological, and the social needs of every person involved in each situation, i.e. patients, relatives and carers. The advocate of euthanasia may be compassionate, but is wrong, and misdirected. By outlawing the option of euthanasia, the development of good and better treatment is encouraged, even forced, and this is illustrated by the excellent palliative medicine and hospice care practised in this country, and by which it leads the world. Pain relief, for instance, is more effective now than at any time in recorded history. The euthanasia movement virtually obviates the need to develop such care - rather, Dutch reports speak of the most patient-friendly ways of ending life instead of enhancing what life there is. Our Judaen-Christian medical ethic is 'to cure sometimes, relieve often, comfort always', nothing more, and these purposes are quite achievable.
4 Indignity - the catchphrase of the euthanasia movement is 'Death with dignity'. The great fear is of loss of function and therefore loss of control, e.g., dementia, stroke, bowel and bladder control - aspects of personal function that are most private; There is also the fear of our reaction in front of others to severe and uncontrollable pain. And ultimately we acknowledge the absolute indignity of death. But (i) God has given us absolute dignity by making us in His own image and becoming one of us, (ii) in His mercy He has allowed us to mitigate the effects of the disorder and chaos of disease, (iii) suffering is not the enemy of dignity, but a bad response to suffering is - suffering in fact may be the cause of the greatest development of human dignity for both patient and carer. Choosing or causing death is a bad response, and is surely 'death with indignity'.
5 Dependence on others - with loss of body function must come the need to have others look after us. Also, the loss of body control will involve costly care packages which reduce the value of one's estate, and invoke the sense of taking up a 'useful bed' and being a burden on society. Nietzsche said that the invalid was a parasite on society and that degenerating life should be suppressed <32> - the advocates of euthanasia are generally horrified to be linked with such a philosophy, but they must be helped to perceive that there is a powerful connection. The Nazi doctors had a horrible term, 'Lebensunwertes Leben' i.e., life not worthy to be lived, and such lives of unacceptable quality were made the target for so-called 'merciful destruction' culminating with attempted genocide.<17> But we are our brother's keepers, 'I was sick and you visited me'. We must carry the burden of those in need with a positive approach, so that they do not feel burdensome. Palliative care will mean dependence on others, but this can be done in a dignified manner with the greatest respect for those in need, despite their loss of privacy and independence. This requires a care system which prioritizes pain relief, and emotional and practical support, to the end of life. But such practice requires pro-active involvement of Christians at every interface - persuading Government, health authorities, hospital administrators, profit-driven nursing homes, and practising, with knowledge, the relieving of symptoms and the comforting of needs - in all situations illustrating the Saviour and being the salt of the earth.
(vii) Summary of basic Christian principles and suggested statement of practice.
The euthanasia lobby is upon us - the church and the individual Christian must be ready to counteract it with the message that contains both foundation principles and consequent positive practice. Otherwise, the law of the land develops in an erratic manner according to the latest court case,33 and hard cases tend to make bad law (note recent medical journal publications about misdiagnosis of the persistent vegetative state).<34> Also, be aware of the advance of the Advance Directive - these have developed with the encouragement of the euthanasia lobby, but there is debatable need for them when society can continue to be confident of a Christian ethos in the caring professions. Consider our foundation Christian principles again; (i) in the beginning there is God, the absolute framework to life the universe and everything, therefore to Him we are answerable; ii) God has made man therefore man is sacred; (iii) man is made in God's image 'with glory and with dignity thou crowned hast his head', therefore has absolute significance; (iv) noting our fallen condition, God has identified with us in our infirmity (but without sin) in Jesus Christ, thus we have absolute dignity which is endorsed by His saving work and our eternal prospect; (v) God has made society i.e., He has made us to be society, we are our brothers' keepers; (vi) therefore life and its disposal are not negotiable. From these principles it is evident that our decision-making is 'God-centred, reality-bound, love-impelled'- (Kilner) <20> Consideration therefore should be given to the following statements of practice (modified from Christian Medical Fellowship advice) as a useful basis for Christian involvement in palliative care:<36>
1 The prime concern of the caring professions must always be to heal, relieve, and comfort, not to decide that someone should not remain alive;
2 human life is accorded the highest value, but it is recognised that it has a natural end, and there is no duty incumbent on any to prolong dying;
3 autonomy is respected and therefore euthanasia in all its forms is rejected;
4 although certain medical treatments may become inappropriate, basic care must always continue, and carers need every encouragement;
5 the deliberate intervention to end life is always wrong. The morality of decisions concerning withholding or withdrawing medical treatment depends o/n the intention;
6 there is no fundamental difference of principle in the approach to competent and incompetent patients, and 'best interest' arguments need rigorous analysis as to whose best interests are being considered.
7 Advance Directives may have some value as indicators of patients' wishes but should not have the force of law;
8 the Courts should maintain a prohibition on intentional killing;
9 the hospice movement and good palliative medical and nursing care should be given every encouragement.
By doing justly, loving mercy, and walking humbly with our God, pastors, nurses, doctors and all in the caring professions will be better able to make wise decisions, amidst the complexity, ambiguity, and chaos, of life and death - wise decisions that are God-centred, reality-bound, love-impelled.
NOTES
1. Mackay E. Euthanasia 1995
2. Murchison M. Euthanasia. Report to the Committee on Public Questions, Religion and Morals. Free Church of Scotland 1994
3. MacDonald D.M. What is the Church for? The Monthly Record of the Free Church of Scotland 1997; June/July: 123-127
4. House of Lords Session 1993-94. Report of the Select Committee of the House of Lords on Medical Ethics. London: HMSO 1994
5. Church of Scotland. Euthanasia, a Christian Perspective. Church of Scotland Board of Social Responsibility 1995
6. World Health Organisation. Palliative Cancer Care 1989
7. Ferguson A. Euthanasia: An Update. Journal of the CMF January 1997; 43:1
8. Christie B. Man walks free in Scottish euthanasia case. BMJ; 313:961
9. Maclean S. Who judges whether life's worth living? The Express, 22 May 1996
10 Lancet editorial. Managing a comfortable death. The Lancet 1996; 347:1777
11 Zinn C. Australia voluntary euthanasia law is overturned. BMJ 1997; 314:994
12 Churchill L.R. King N.M.P. Physician assisted suicide, euthanasia, or withdrawal of treatment. BMJ 1997; 315:137-8
13 Van der Mass P.J. et al. Euthanasia and other medical conditions concerning the end of life. The Lancet; 338: 669-74
14 Gunning K. An International Perspective: Deliberate Death in Holland, in Death Without Dignity. Rutherford House Books 1990
15 Sheldon T. Dutch Euthanasia rules relaxed. BMJ 1997; 314:325
16 Twycross R.G. Euthanasia: Going Dutch? Journal of the Royal Society of Medicine 1996; 89: 61-63
17 Lifton R.J. The Nazi Doctors. Basic Books 1986
18 Zwart F. A very special day. BMJ 1997; 15: 260
19 Keizer B. Dancing with Mister D. Black Swan 1997
20 Kilner J.F. Life on the Line. Eerdmans 1992
21 Orr R. Decision Making in clinical Ethics, in Bioethics and the Future of Medicine. Paternoster Press 1995
22 Toit du D.A. Anthropology and Bioethics, Ethics and Medicine 1994; 10.2: 35-
23 Broadie A. The Tradition of Scottish Philosophy. Polygon 1990
24 Willam S. Life with Hippocrates: The Vision of Nietzsche. Ethics and Medicine 1996; 12.2: 27-32
25 Appleyard A. Moral Life in this Godless World. The Independent 13 Nov 1995
26 Dawkins R. River of Eden. Phoenix 1996
27 Kuhse M. Singer P. Should the Baby Live? The Problem of Handicapped Infants. Oxford/New York 1985
28 Bonhoeffer D. Ethics. MacMillan, 1965
29 Aly G., Croust P., Pross C. Cleansing the Fatherland. Johns Hopkins UP 1994
30 Hollinger D. Theological Foundations for Death and Dying Issues. Ethics and Medicine 1996; 12.3:60-65
31 Donaldson S. By Force of Will: The Life and Art of Ernest Hemingway. Penguin, 1978
32 Nietzsche F. The Twilight of the Idols/The Antichrist. Penguin,1990
33 Scots Law Report. Law Hospital NHS Trust v Lord Advocate and Another. Scots Law Report, 20 May 1996
34 Andrews et al. Misdiagnosis of the Vegetative State. BMJ 313: 13-16
35 BMA. Advance Statements about Medical Treatment. BMA 1995
36 Submission from the Christian Medical Fellowship to the Select Committee of the House of Lords on Medical Ethics. London 1993
37 Purves L. Speaking up for the weak. The Times, 30 August 1997
OTHER READING
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