'...not just the premier
Christian bioethics institute in Britain,
but one of the finest in the
world, Christian or secular'
Most Rev. Anthony Fisher O.P., Auxiliary Bishop of Sydney
Unpacking the Debate
It is always helpful, when discussing euthanasia,
to begin by looking at the meaning of the term, as definitions vary widely.
The definition I will use reflects the way the word is often used in the
bioethics literature, though as we shall see, the word is used in a more
narrow sense in the Netherlands. By euthanasia, I mean the intentional shortening
of life, by act or omission, on the grounds that it is not worth living.
On this definition, euthanasia can be voluntary or non-voluntary, active
or passive, depending on the method used and on whether the patient has
consented. Note that it is not euthanasia if life is shortened as
a side-effect of trying to achieve some other goal. It is not euthanasia
to give high doses of painkillers with the aim of alleviating pain, if we
only foresee, and do not intend, that the patient will die sooner as a result.(1)
Nor is it euthanasia to refrain from giving (for example) some burdensome
treatment, if we only foresee, and do not intend, that the patient will
die sooner as a result. Only if our aim (2) is to shorten life, by
act or by omission, can one speak of euthanasia.
In the Netherlands the term `euthanasia' is
normally used to refer solely to voluntary euthanasia. Moreover,
use of the term is often further restricted to voluntary active euthanasia.
Partly for this reason, there has been a lot of controversy over empirical
data from the van der Maas Survey (3) and a subsequent survey by van der
Maas and van der Wal.(4) Doctors in the Netherlands were asked what their
intentions were in making medical decisions concerning the end of life.
The way the figures were added up by the authors of the Surveys tends to
minimize the incidence both of voluntary euthanasia - euthanasia
in the Dutch sense - and of non-voluntary euthanasia. If, however,
we count all the cases of euthanasia in the broad sense, including non-voluntary
euthanasia and euthanasia by omission, we get a much higher total for euthanasia
and doctor-assisted suicide.
Counting all those cases in which doctors acted,
or refrained from acting, with the `explicit purpose' of shortening life,(5)
the original van der Maas Survey gives us a figure of 9,050 cases in 1990,
of which 5,450 - more than half - were without the explicit request of the
patient.(6) Non-voluntary euthanasia was thus more common than voluntary
euthanasia in 1990, notwithstanding guidelines laid down by the courts,
the Royal Dutch Medical Association and the Ministry of Health, to the effect
that euthanasia must be voluntary. Nor was the requirement that euthanasia
be voluntary the only guideline being breached. Other requirements, such
as that the patient be suffering intolerably, that euthanasia be a last
resort and that euthanasia be reported, were also being freely disregarded,
on the admission of doctors themselves.
Apart from a few procedural changes, such as
an increase in reporting, there was no improvement in the situation five
years after 1990. The van der Maas and van der Wal Survey dealing with the
year 1995 found an increase both in voluntary euthanasia and in requests
for euthanasia.(7) There was a slight decrease in life-terminating
acts without the patient's request, as these were counted in the Survey.
However, the Survey did not include in this category 1,537 cases where palliative
drugs were given with the explicit intention of hastening death, and without
the patient's request. If these cases had been included, an increase would
have been seen in the incidence of non-voluntary life-termination.(8) There
was certainly a marked increase in euthanasia by omission,(9) which in a
large majority of cases took place without the patient's request. The Survey
also recorded both passive and active euthanasia of newborn babies - clearly
without the request of the babies whose lives were so curtailed. It would
therefore be rash indeed to claim that euthanasia in the Netherlands is
wholly or largely voluntary - or, indeed, that it is otherwise proceeding
according to plan.
The slippery slope
The Dutch experience is, in fact, a powerful
example of what can be called the `practical' slippery slope: of what can
happen in practice when voluntary euthanasia is accepted by the courts and
by the medical profession. However, it is also worth exploring what can
be called the `theoretical' slippery slope: the theoretical reasons why,
in particular, non-voluntary euthanasia might be accepted, once voluntary
euthanasia has been accepted. To explore these reasons, we will need to
return to the definition of euthanasia with which we began.
Euthanasia was defined as the intentional shortening
of life, by act or omission, on the grounds that it is not worth living.
It may be objected that the doctor who performs euthanasia need not make
a judgement on the value of the life of the patient who is killed. The doctor
may simply ascertain that the patient has requested euthanasia, and perform
it simply on the basis that this is what the patient wants.
However, in practice few doctors would perform
euthanasia just because the patient wants it. If a patient was temporarily
depressed, but was otherwise in reasonable health, we would expect even
a pro-euthanasia doctor to refuse to end a life which he or she would see
as having value. Doctors are not, after all, mere tools to be used by their
patients, but professional people with some responsibility for evaluating
what they are asked to do. A doctor who supports euthanasia will therefore
distinguish between those patients who have reason to want to die,
because their lives are not worth living, and those patients who do not
have reason to want to die, because their lives are worth living,
in the doctor's estimation. While the doctor may defend euthanasia in terms
of the autonomy of the patient, he or she in fact believes that only some
patients - namely, those whose lives are not worth living - should be helped
to exercise autonomy by choosing to be killed.(10)
However, if some human lives are not worth living,
as euthanasia advocates believe, not all these lives not worth living will
have owners who are competent to choose. If a patient's life has no value,
but the patient is mentally disabled and cannot consent to euthanasia, it
is not clear there is anything to stand in the way of our killing the patient,
at least if the relatives give their consent. It is therefore not
surprising that many supporters of voluntary euthanasia also support
(whether openly or discreetly) non-voluntary euthanasia. For if death
is either a benefit, or at least no harm, why should we deny it to those
who cannot request it? The practical slide from voluntary to non-voluntary
euthanasia has in this way a theoretical basis in the notion that some human
lives have no value, and may be ended on those grounds.
Euthanasia in Britain
Belief in this notion is not, of course, confined
to doctors in the Netherlands. In Britain, non-voluntary euthanasia by omission
was, in effect, enshrined in law by the judgement on the Bland case. Tony
Bland was a young man left in a state of permanent unconsciousness after
the Hillsborough football stadium disaster. In judging his case, the Law
Lords accepted what they saw as the view of a body of responsible medical
opinion that life in Tony Bland's condition was in no way a benefit. Three
out of five Law Lords stated (the others not dissenting) that the aim of
withdrawing tube-feeding was to bring about Tony Bland's death. Withdrawal
of feeding, including oral feeding, is now being extended to adults who
are not in a `persistent vegetative state' (PVS) and not in the final stage
of dying. In addition, there are reports from time to time of the sedation
and starvation of newborn babies with disabilities. If a patient's life
is not seen as having value, it is harder to resist that patient's killing
not so much for the patient's sake as for the sake of his or her
relatives. Acceptance of the view that some lives are not worth living paves
the way not merely for non-voluntary euthanasia, but for non-voluntary euthanasia
for the benefit of others, such as parents or society. Thus when the Bland
case was discussed by the media, stress was laid not only on the supposed
worthlessness of Tony Bland's life in PVS, but on the suffering his condition
caused his parents, and the desirability of putting an end to that suffering.
While it is true that to see a family member in PVS can be a cause of real
distress, it is surely remarkable that the suffering of others should be
seen as a reason for ending the life of an innocent human being. One might
also question whether the experience of helping to bring about the death
of their son was really of benefit to Tony Bland's parents, as it was predicted
that it would be.
In a case of serious mental impairment like
that of Tony Bland, it may be claimed not so much that life is not worth
living, but that there is no life - or no `personal' life - involved.
Thus Tony Bland's body was described by one of the judges of his case as
a `shell' from which his spirit had flown. This was despite the fact that
Tony Bland's brainstem was functioning, that he was breathing spontaneously,
his heart was beating, and so on. Here there is a tendency to see the human
person as a separate individual from the living human organism
- a view which many philosophers (and others) reject as incompatible with
our experience of ourselves and each other as bodily beings.(11)
The value of life
While it is sometimes claimed that the soul
or `person' has departed from a patient's living body, it is perhaps more
common to accept that the patient is still alive, but to claim that his
life is not worthwhile. The view that life can have literally no value,
such that it need not and should not be protected, is, however, a radical
departure from the traditional view of human life: radical both in itself
and in its implications when it is used as the basis of law. Someone accused
of killing another human being can say, `I admit I took a human life
- but it was a life with no value.' We should note that this is not
the way in which, for example, killing in self-defence is rightly seen as
justifiable. If I kill a person who is trying to kill me, this is quite
compatible with my recognizing the value of the life of my aggressor, which
I endanger only with reluctance on the grounds that he or she has deliberately
chosen to endanger my own. To kill a person on the grounds that his or her
life has no value is to demonstrate an attitude to human life not
found elsewhere in justifiable homicide.
What, then, is the basis for rejecting killing
on the grounds that life has no value? The basis is the fact that human
beings are in possession of a fundamental human dignity which cannot be
eliminated. We have this dignity in virtue of our nature: in virtue of the
fact that we are human beings, with a nature directed at rational behaviour
even in situations in which we are currently incapable of rational behaviour.
As human beings, we have morally significant interests in the `goods' or
benefits appropriate to human beings: goods such as knowledge, friendship,
and, indeed, life itself.(12) Many of our actions are premised on the fact
that these things are good for us and other people: not just good instrumentally,
but good or fulfilling in themselves. Not all human beings have the exercisable
ability (as opposed to the radical capacity) to participate in human goods
other than life. However, life is one human good in which human beings can
always participate, as long as they exist at all. It is never something
bad in itself, or a matter of indifference, that a person is alive. There
is an objective value not simply to a person's enjoyment of human goods
in general, but to his or her presence in the world.
Respect for life
What this value means is not, of course, that
life should be preserved at all costs. Those who believe in the value of
human life have always recognized that there are limits to the duty to preserve
the lives of patients. What steps we must take to preserve a patient's life
will depend on such variable factors as his or her medical condition and
the healthcare resources available. If, for example, the patient has just
a few days or hours to live, we may not be obliged to do anything
to preserve the patient's life, providing we at no stage have the intention
of accelerating his or her death, whether by act or by omission. Similarly,
we are not obliged to provide a competent patient with treatment which he
or she rejects as too burdensome for what it can achieve.
What the value of life does demand is
that we recognize this value at all times, always refusing to attack a human
life on the grounds that it is not worthwhile. We should not, in other words,
buy into the assumption that the lives of some human beings have no value
and may be ended on those grounds. Such an assumption is, as the Dutch experience
shows, extremely harmful to the doctor-patient relationship and to society
at large. It is also highly demoralizing to sick and disabled people, who
receive the message that life with their condition is considered intolerable
by doctors and society.(13) We should not encourage despair on the part
of patients by espousing the view that their lives are not worth living
and may be deliberately curtailed. Instead, we should provide patients with
the kind of support - physical, emotional and spiritual - which affirms
their worth as human beings.
(1) Often, in fact, the use of palliative drugs
is more likely to lengthen than to shorten the patient's life, as the patient
is more rested.
(2) It is worth remembering here that the doctor
may have several different aims in what he or she is doing. If one aim is
to shorten the patient's life, while the other is to end the patient's pain
or that of his or her family, this will still be euthanasia.
(3) Maas PJ van der et al. Euthanasia
and other medical decisions concerning the end of life (English translation).
Amsterdam: Elsevier, 1992.
(4) Wal G van der, Maas PJ van der. Euthanasie
en andere medische beslissingen rond het levenseinde. De praktijk en de
meldingsprocedure. Den Haag: SDU uitgevers, 1996.
(5) This gives us a highly conservative figure
for euthanasia in 1990, since it excludes those cases where the doctor acted,
or refrained from acting, 'partly with the purpose' of shortening life.
In view of this purpose, such cases are also euthanasia (see note 2).
(6) Keown J. The First Survey: The Incidence
of `Euthanasia'. In: Keown J. Euthanasia, Ethics and Public Policy.
Cambridge: Cambridge University Press, 2002.
(7) Keown J. The Second Survey. In: Keown J.
Euthanasia, Ethics and Public Policy. Cambridge: Cambridge University
(8) Hendin, H. The Dutch Experience. Issues
in Law & Medicine 2002; 17: 231.
(9) The situation is, however, complicated by
an explanatory note to the relevant question doctors were asked, which suggested
that an intention to `hasten the end of life' could also be understood as
an intention `not to prolong life'. In fact, the two intentions are by no
means identical: a choice to refrain from life-prolonging treatment could
be made not in order to hasten death, but simply on the grounds that the
treatment was too burdensome.
(10) Watt H. Life and death in healthcare
ethics: A short introduction. London: Routledge, 2000: 31-32.
(11) To say that human persons are essentially
bodily is not to deny they have a spiritual aspect. It is to say, rather,
that the human subject is a living individual, not a ghost. The Christian
tradition, in particular, sees the soul as the source of the life of the
body, and the soul after death as something incomplete, awaiting the body's
(12) Grisez G, Boyle J, Finnis J. Practical
principles, moral truth, and ultimate ends. American Journal of Jurisprudence
1987; 32: 99-151.
(13) Compare this with the message conveyed
to suicidal people who are physically well. These people are assured that
their lives are worthwhile, and that suicide is not the right response to
their current situation. In contrast, if euthanasia is socially accepted,
both suicidal and non-suicidal people with certain conditions will receive
the message that society sees their lives as not worthwhile. On this and
other aspects of euthanasia, see Gormally L. ed. Euthanasia, clinical
practice and the law. London: The Linacre Centre, 1994.