Defining euthanasia

On Tuesday, June 22, 2010, the Tasmanian Attorney-General, Lara Giddings, announced she was to develop voluntary euthanasia legislation. The announcement was made despite the defeat of a similar bill introduced into parliament last year by Greens leader, Nick McKim. The basis for the decision to introduce similar legislation is that the majority of the Tasmanian public are said to be in favour of the legislation. Further, Lara Giddings points out that MPs who voted against McKim’s bill in November last year were opposed to the form the bill had taken, rather than the principles behind the bill.

The statement that the majority of Tasmanians support euthanasia is based on findings cited in the Joint Standing Committee on Community Development’s Report on the Dying with Dignity Bill 2009 (the Report). Those findings were that “80%” of respondents to a national poll and “78%” of respondents to a Tasmanian poll were in support of “voluntary euthanasia”. In one of the polls, the respondents were asked:

Thinking about voluntary euthanasia where a doctor complies with the wishes of a dying patient to have his or her life ended; are you in favour or against a change in the law that would allow doctors to comply with the wishes of a dying patient to end his or her life?

However, the findings are flawed. For the Report also concedes that “it is unclear whether respondents considered the withdrawal of, non-commencement of, or refusal of futile treatments as voluntary euthanasia” (at 13). It is not possible to tell, from the way the questions were framed, whether the respondents were merely reiterating their support for withholding and withdrawal of life-sustaining measures from a competent but terminally ill patient who requests it, or whether they really were in favour of legalising the administration of a lethal substance to end a person’s life. It is therefore not safe to rely on the findings as a gauge of community support.

The Report itself fails adequately to distinguish the proposed reforms from what is currently lawful. For example, Part 1 of the Report defines “euthanasia” merely as “painless death”, and “voluntary euthanasia” as “euthanasia practised at the wish of a person with a terminal illness”. “Active voluntary euthanasia” is defined as “where medical intervention takes place, at the patient’s request, in order to end the patient’s life” and “passive voluntary euthanasia” is defined to mean “where medical treatment or life support is withdrawn or withheld from a patient, at the patient’s request, in order to end a patient’s life”.

These definitions are inadequate because they all can include withholding and withdrawing life-sustaining measures, and so anyone reading the Report may mistakenly think that the debate concerns whether this should be legalised. Accordingly, consideration must first be given to clarifying the issues for debate and consulting with the community once again.

There has been much debate about whether a meaningful, or morally relevant, distinction can be drawn between withholding and withdrawal of life-sustaining measures and the administration of a lethal substance. Resolution of this issue will determine how the term “euthanasia” itself should be applied. Many philosophers and legal academics, including Peter Singer and Helga Kuhse, have doubted whether the distinction is of any moral relevance. Further, even if a distinction could be defended, there are additional worries about whether it can apply to withdrawal which, unlike withholding, requires positive steps to bring about the patient’s death, making it more analogous to the provision of a lethal substance.

My purpose here is to provide some clarification of the distinction between withholding or withdrawing life-sustaining measures and administering a lethal substance, so that people, including members of parliament, can make an informed judgement. My aim is not, however, to advocate acceptance or rejection of any proposed law. This article is not the place to review the extensive literature on the topic. Rather, my aim is to clarify what the term “voluntary euthanasia” should really be understood to include, with a view to clarifying the kinds of question that should be put to respondents in future polls.

What is the distinction between euthanasia and withholding life-sustaining measures?

What is it, exactly, that we have so far objected to in allowing doctors to administer a lethal substance? The objection is normally said to be that killing is wrong. Why, then, is administering a lethal substance assumed to be killing, but withholding life-sustaining measures is not?

The first step to understanding the difference is to look at the circumstances in which the two different courses of conduct are proposed.

In cases where the administration of a lethal substance is concerned, the patient, although dying, is not normally dependent on life-sustaining measures. If they were, the question of whether to administer the substance would not arise, for doctors could simply engage in the lawful conduct of withholding or withdrawing the measures instead. The cases where the provision of a lethal substance is at issue are always cases where, without such intervention, the patient would live on and, as a consequence, suffer intolerably (assuming all palliative care options, including pain relief, have been exhausted). The question in such a case, then, is whether to cut short a life that, without intervention, would continue.

In cases of withholding, the converse is the case. In withholding, the question is whether we should intervene to prolong the patient’s life instead, by providing life-sustaining measures. In this case, without intervention, the patient will die. Intervention is required, not to cut short a patient’s life, but rather to prolong it.

Now someone might object: are we not cutting short a life if we don’t intervene to prolong it? But there is a difference between bringing forward a death that would otherwise have occurred later, and refusing to defer death. If we allow a patient to die from their underlying medical condition, that is, from natural causes, we allow them to die when nature so chooses, rather than when we choose. In that sense, we are not “cutting short” their life at all, but are simply refusing to prolong it. In euthanasia - the administration of a lethal substance - we override nature by bringing death about sooner than it would otherwise occur naturally. This is the reason why withholding, unlike euthanasia, is not regarded as killing.

Is the distinction morally relevant?

But is this distinction nonetheless morally relevant? Does talk of allowing someone to die “when nature chooses” make of nature some kind of moral agent and does it not have a kind of religious overtone, replacing “God” with “nature”? Some critics think so, but the point is that it is not necessary to interpret such talk in that way at all. Talk of nature’s dominion or allowing nature to take its course is merely a façon de parler, a way of distinguishing between allowing things to happen and making them happen.

But it does not follow from this that the distinction being drawn might not have moral significance. It would be reasonable for someone to believe that it is wrong to interfere with the natural course of things, without that person being committed to any religious world view. Such a position can be adopted by people who are not religious and who hold no metaphysical beliefs at all. A person might reasonably consider life itself to be “sacred”. The fact that the word “sacred” may originally have had its home in religious discourse no more means that we must be religious if we use the word, than does the fact that the word “gift” is used to talk of someone who is talented mean that we must believe in a God who “gave” the person their “gift”.

A different objection might be that we already intervene in nature in countless ways, so why should we single out intervening in nature to accelerate someone’s death as any different? But in response, we should note that in all those cases, we intervene in order to prolong life, not to shorten it. Advances in technology and medication are there because we value life and seek to prolong it as long as possible, and the provision of life-sustaining measures is an example of precisely this kind of intervention.

In a sense, it is because we value the gift of life that we seek to preserve it whenever we can. Whereas, again, where a lethal injection is concerned, the kind of intervention being contemplated is not for the prolongation of life, but rather for the purpose of cutting short the patient’s life. And it is reasonable - I do not judge whether it is correct - to see this as one step too many, as a step which expresses a Promethean will to master and control our ultimate fate, rather than surrender oneself to it.

None of this detracts from debate about whether this respect for the natural order of things should be allowed to prevail over the intolerable suffering someone may be made to endure if we do not change the law. On the contrary, this is precisely the kind of debate that we should have. My point is that we need to be clear on the differences between the two courses of conduct first and only then can we be in a position to make an assessment about whether intolerable suffering should outweigh the moral considerations I have just been outlining.

Is withdrawal different from withholding?

Does the fact that measures might be provided and later withdrawn change this analysis? Is not “switching off” an artificial ventilator a lot more like providing a lethal injection? No. The same analysis applies to withdrawal as applies to withholding. The moment of intervention takes place when the measures are provided, and the patient’s life is being prolonged. When a decision is then made to stop providing those measures, the decision is to allow nature finally to take its course.

This still differs from euthanasia because, in the case of euthanasia, the patient’s life is being cut short prematurely. So in withdrawal we are, as it were, restoring to nature her dominion after having taken it away by providing the life-sustaining measures. Whereas in euthanasia, we are overriding nature and taking control of our ultimate fate ourselves.

It follows that it is misleading to continue to call withholding and withdrawing life-sustaining measures a kind of euthanasia, or “passive euthanasia”. The use of the term is liable to bleach out these important differences and respondents of polls are liable to misunderstand what they are being asked. Accordingly, their responses to the poll are likely to be unreliable.

I want to conclude with a suggestion about how a question designed to elicit an accurate portrait of community views might be worded. It will need to be done in two stages, to ensure that the respondent actually understands the difference between the two different courses of conduct (withholding and euthanasia):

1. The law currently allows a terminally ill patient to refuse life-sustaining measures like a blood transfusion and other life-support, but not to ask a doctor to give them a lethal injection or to give them a lethal substance so they can end their own life. Why do you think we’ve so far been reluctant to take this extra step?
2. Do you think that a terminally ill patient who isn’t dependent on any life-sustaining measures, but who is suffering intolerably, should actually be allowed to request a lethal injection or be allowed to request a lethal substance so that they can take it themselves and end their own life?

Both questions are necessary because, if the respondent doesn’t actually turn their mind to the differences between the two courses of conduct, they might mistakenly think that there is no basis for a different legal position in respect of each one. On something so important, it is vital that every effort is made to ensure that a respondent is aware of what they are being invited to comment on and, ultimately, vote for.