Alternatives to Euthanasia

Hospices and hospice home-care support are seen as viable alternatives to euthanasia for the terminally ill. Those who want to die but do not have a terminal illness, are usually lonely or depressed.
  • The greatest fear held by the dying is not physical pain, but the fear of being abandoned either by family, society, or both.
  • The World Health Organisation (WHO) recommends that governments devote specific attention to cancer pain relief and palliative care before considering laws allowing euthanasia.
  • Most patients who request suicide change their minds once satisfactory pain control is established.
  • Non-psychiatric physicians are not reliably able to diagnose depression let alone to determine whether the depression is impairing judgment.
  • Psychological distress, particularly depression, is a major risk factor for suicide and for requests to hasten death.
  • "People use the principle of autonomy as a justification for voluntary euthanasia."
The real alternative to euthanasia and assisted suicide (EAS) is to provide loving, competent care for the dying or disabled person.

For the relatively healthy individual who supports the legalising of euthanasia, the reason is fear that they, themselves, might want it sometime in the future: fear of cancer and other debilitating diseases or disabilities; fear of becoming a burden to one's family; fear of surviving without really living; and, perhaps most of all, fear of severe, uncontrolled pain.

Opponents of EAS believe that the development of modern methods of palliative care makes the legalisation of euthanasia unnecessary. This addresses one of the greatest fears that humans have namely the fear of pain. It does not, however, address all the issues.

Those experienced in Hospice care say that the greatest fear of the dying is not physical pain, but the fear of being abandoned either by family, society, or both.
"Once a patient feels welcome and not a burden to others, once his pain is controlled and other symptoms have been at least reduced to manageable proportions, then the cry for euthanasia disappears. It is not that the question of euthanasia is right or wrong, desirable or repugnant, practical or unworkable. It is just that it is irrelevant.

Proper care is the alternative to it and can be made universally available as soon as there is adequate instruction of medical students in a teaching hospital. If we fail in this duty to care, let us not turn to the politicians asking them to extricate us from this mess." 1
For those who have no family and/or few friends to be with them, loneliness can be a key factor in wanting to die. Hospice provides the answer and many lonely, elderly or dying people have found friendship when they least expected it.

Professional hospice - palliative - care can be given either at home or in special facilities for the dying. Its purpose is to ease the psychological pain of loneliness and the physical pain of dying that many people suffer near the end of their lives.

Better pain and symptom management
In 1990, a World Health Organization (WHO) Expert Committee found that the greatest improvements in quality of life for cancer patients and their families would result from implementation of existing knowledge about pain and symptom management.

The committee concluded that "...with the development of modern methods of palliative care, legalisation of euthanasia is unnecessary. Now that a practical alternative to death in pain exists, there should be concentrated efforts to implement programs of palliative care, rather than yielding to pressure for legal euthanasia." 2

The WHO Expert Committee recommended that governments devote specific attention to cancer pain relief and palliative care before considering laws allowing euthanasia.
Unfortunately, "not enough health professionals, patients, families, and government policymakers understand that the proper use of existing drugs and neurosurgical, anesthetic, and psychological approaches can relieve pain and make life worth living.

Some people may believe that suicide is the only way to avoid a painful death. Severe, chronic pain can result in helplessness and hopelessness - two mental states that can lead to suicide.

Controlling pain can help ease these mental states and change the belief that a premature death - a painless "final exit" is the solution."

For example, patients at Memorial Sloan-Kettering Cancer Center who had requested suicide dismissed this as an alternative once satisfactory pain control was established." 3, 4
Killing the pain, not the patient
"Euthanasia will always be an issue because people who've had a bad experience will see it as the only option," said Dr Richard Hillier, chairman of the Association for Palliative Care in the UK.

"These people will have seen a friend or relative receive sub-standard care - they will have seen them die appallingly probably. The vast majority of them will have been nowhere near a palliative care unit.

"They've got the wrong solution - the answer is not to then go around killing the patient. The answer is to get involved with a very good palliative care unit." 5

Treatable Depression
Studies have also shown that non-psychiatric physicians are not reliably able to diagnose depression let alone to determine whether the depression is impairing judgment. Patients requesting a physician’s assistance in suicide are usually telling us that they desperately need relief from their mental and physical suffering and that without such relief they would rather die.

Although terminally ill and disabled patients often have suicidal thoughts, especially soon after being informed of the serious nature of their condition, these thoughts don't typically last.

When they are treated by a physician who can hear their desperation, understand their ambivalence, treat their depression, and relieve their suffering, their wish to die almost always disappears.

Doctors, lacking clinical knowledge and skills, may not always be able to distinguish between the 'normal' distress, which is inevitable, and more severe psychological distress.
"Psychological distress impairs the patient's capacity for pleasure, meaning, and connection; erodes quality of life; amplifies pain and other symptoms; reduces the patient's ability to do the emotional work of separating and saying good-bye; and causes anguish and worry in family members and friends.

Finally, psychological distress, particularly depression, is a major risk factor for suicide and for requests to hasten death. " 6
Indicators of Depression in Terminally Ill Patients
Psychological symptoms
  • Dysphoria
  • Depressed mood
  • Sadness
  • Tearfulness
  • Lack of pleasure
  • Hopelessness
  • Helplessness
  • Worthlessness
  • Social withdrawal
  • Guilt
  • Suicidal ideation
Other indicators
  • Intractable pain and other symptoms
  • Excessive somatic preoccupation
  • Disproportionate disability
  • Poor cooperation or refusal of treatment
  • Hopelessness, aversion, lack of interest on the part of the clinician
  • Treatment with corticosteroids, interferon, or similar agents
History-related indicators
  • Personal or family history of substance abuse
  • Depression, or bipolar illness
  • Pancreatic cancer
Dr Susan D. Block points out: "Patients with severe depressive symptoms may be too immobilised, hopeless, and dysphoric to effectively engage in psychotherapy; the may first need to receive appropriate antidepressant medication."

EAS opponents propose that, as depressed people are unable to make clear, reasoned decisions while in that state, rather than agree to a request for EAS, a doctor should treat with anti-depressants and ensure that other fears are dealt with.

Disability
Alison Davis of the UK's No Less Human (an activist group for disabled people, their families and carers) said in a submission to the Isle of Man's Voluntary Euthanasia Select Committee, "Vulnerable people deserve better than being told that death is in the best interests of those who suffer. What we need is help to live with dignity, until we die naturally."

Asserting that it is fundamentally wrong to kill vulnerable people, whether or not they have requested death, Davis went on to say:
"People use the principle of autonomy as a justification for voluntary euthanasia. However, such freedom to make decisions entails a responsibility to act ethically, and euthanasia is deeply unethical." The submission states: "Compassion does not mean simply giving people what they want, or say they want, or what others think they ought to want."
Describing cases of people with motor neurone disease who have requested help to end their lives, the submission states: "With proper palliative care, including all necessary hospice support, the choice is between deliberate killing and a peaceful, truly dignified death made as pain free as possible by experts in pain control."

Alison Davis has spina bifida, emphysema and osteoporosis, and uses a wheelchair full time. She suffers considerable pain and was suicidal until friends gave her hope. She writes in the submission: "What has changed is not my medical condition, but my outlook on life."7

References
  1. R. Lamerton,Care of the Dying Priorty Press Ltd., 1973, p. 99 204
  2. World Health Organization. (1990). Cancer pain relief and palliative care: Report of a WHO Expert Committee [Technical Report Series 804]. Geneva, Switzerland
  3. Foley, K.M. (1991). The relationship of pain and symptom management to patient requests for physician-assisted suicide. Journal of Pain and Symptom Management, 6, 289-297
  4. Angarola RT, Joranson DE. Pain and euthanasia: the need for alternatives. APS Bulletin 992;2(2):10,17
  5. Alternatives at death's door
  6. Susan D. Block, MD Assessing and Managing Depression in the Terminally Ill Patient
  7. Isle of Man Euthanasia Submission