Ten Reasons Why Voluntary Euthanasia Should Not Be Legalised

Professor David E. Richmond MB ChB MHPEd. MD FRACP FRCP(Lond.) (See biographical details at the end of this article)

Executive Summary
The proposed legislation to legalise voluntary euthanasia should be rejected because:
  • It is not reasonable to introduce radical legislation on the basis of the perceived needs of a tiny proportion of the population.
  • It is not compassionate to elevate the rights of a small minority over the rights of the majority.
  • It would not be consistent with the nation's stance on capital punishment.
  • Its practice could not be confined within "strict guidelines" as its proponents assert.
  • It introduces a conflict of interest for medical practitioners who will be expected to execute it, and will change the ethos of the health system from preserving life to providing death.
  • The philosophical stance that allows euthanasia to be contemplated at all is flawed and dangerous.
  • It is the wrong solution for the majority of people who might request it.
  • It has the potential to reduce interest in and funding for palliative care and the hospice movement.
  • It does not guarantee a "good death".
  • Legalising euthanasia gives too much power to the medical profession.

1.It is not reasonable to introduce radical legislation on the basis of the perceived needs of a tiny proportion of the population.

The proponents of euthanasia have a problem. On the one hand, they want to avoid any suggestion at this stage that the practice could become widespread. So their arguments in favour of legalising euthanasia (or for that matter, turning a blind eye on its practice as happened in Holland for many years), are based on the tiny proportion of people who have faced or are facing difficult end-of-life problems.

On the other hand, they need to frighten the majority into thinking that intractable problems at the end of life are common, hence their coverage of these cases is emotionally charged.

The fact is that only a tiny minority of people face problems at the end of life that conventional treatments have difficulty in coping with: the vast majority of us will die comfortably. As the legal aphorism has it: hard cases make bad law.

2.It is not compassionate to elevate the rights of a small minority over the rights of the majority.

Given that the majority of people die in the absence of major distress, the question arises: how would legalising euthanasia affect that majority, especially those with
disabilities, those who are old (a rapidly increasing proportion of our population), and those who are not in full control of their mental faculties?

The answer is to be found in reports and reflections on the outcome of years of practising euthanasia in Holland. They show that it would impact adversely on Society's regard for the elderly, disabled and handicapped.

"The society which embraces euthanasia even under the strictest rules sends a subtle message to its most vulnerable members: ?We don't mind getting rid of you' " wrote Dr. Richard Fenigsen a Dutch cardiologist in a paper on euthanasia in that country[1]. For example, he reported that at a time when the Dutch Parliament was considering the legalising of euthanasia, a group of handicapped adults wrote to the Parliamentary Committee for Health Care and Justice in the following terms:

"We feel our lives threatened...We realise that we cost the community a lot...Many people think we are useless...Often we notice that we are being talked into desiring death...We will find it extremely dangerous and frightening if the new medical legislation includes euthanasia."

This letter highlights some important issues. There are, as any social worker or family doctor will know, many families that exert pressures on their elderly or disabled kinsfolk to make decisions that are not in their best interests. Elderly and disabled people often compromise their autonomy on the grounds that they do not wish to be a nuisance.

If euthanasia is legalised, additional pressures will inevitably surface and we too will have the spectacle of elderly and disabled people being "talked into desiring death". A report by the Dutch Attorney General into the use of euthanasia in Holland, published in 1991, identified that 33% of those who requested euthanasia did so on grounds which included being dependent on others.

At least one recent case of euthanasia performed by a close family member in this country appears to have come about because that person could no longer cope with the victim's needs, yet had not requested help. In how many other cases is the real reason that another's life is terminated by a family member, the fact that that member could not handle the situation? It is not compassionate of any society to put not only the welfare, but the lives of its older and disabled citizens under greater pressure.


3. It would not be consistent with the nation's stance on capital punishment.

When New Zealand abolished capital punishment, the key reason for doing so was the realisation that despite the best efforts of the law enforcement agencies and the legal system, a small number of innocent people had been executed. The country took the view that even though the numbers were small, any wrongful execution of an innocent person was abhorrent to the majority of us.

The proposed Death with Dignity legislation offers people with "terminal and/or incurable ill(ness)" the option of requesting assistance from a medically qualified person to voluntarily end their life. The Bill does not define "terminal or incurable illness". It does require a second opinion as to the nature and prognosis of the person's illness.

It is well recognised that the diagnosis of an incurable illness and whether or not it is terminal, and if so, how imminent death is, all separately carry a certain, often large, probability for error. The annals of medicine abound with incorrect diagnoses and erroneous predictions of death. In my own years of practice, I can recall four examples of people diagnosed with terminal cancer by highly qualified teams of medical specialists, who, in the fullness of time proved not to have that disease.

The problem is that if euthanasia had been legal, and if these people had requested it before time and the progress of events proved the diagnosis to be incorrect, an "innocent life" would have been lost, and, the error not discovered until the coroner's post-mortem (if such were ever held ?see section 4 below).

Such a scenario did in fact occur in the case of Nancy Crick an Australian patient of Dr. Philip Nitschke's who killed herself whilst surrounded by advocates of euthanasia, on the basis of a diagnosis of bowel cancer. An autopsy revealed no evidence of cancer.[2] Incidentally, it is noteworthy that Dr. Nitschke's enthusiasm for euthanasia was not at all dampened by this tragic event.


4. Its practice could not be confined within "strict guidelines" as its proponents assert.

The 1991 report by the Dutch Attorney General on the status of euthanasia in that country (where the practice was long tolerated although ostensibly illegal) disclosed that in 1990, up to 38% of all deaths in the Netherlands involved some sort of life-terminating procedure. Of these, more than 20 000 cases involved the administration of a drug with the intention of accelerating death.

The report estimated that some 5500 cases of "involuntary" euthanasia (i.e. the withdrawal of treatment or the administration of drug overdoses without consent to patients who, although judged to be competent to make their own decision were not consulted) had occurred. It also revealed a large number of cases of non-voluntary euthanasia, i.e. cases where the patient was judged to be legally incompetent to make a request for the termination of life.

Under Dutch law at the time, both involuntary and non-voluntary euthanasia were illegal. One can only conclude that despite its attempts to do so over more than 25 years, Holland has been unable to put measures in place that would ensure that its regulations governing euthanasia are adhered to. Why is that? Because doctors who provide it, do not report it.

The authors of the report freely admitted that the true number of cases of physician assisted death was greater than the figures indicate because "the physician often declares that the patient died a natural death". They do this to avoid the bureaucratic procedures that are supposed to follow the reporting of a death by euthanasia. That such circumvention of legal requirements is relatively easy is exemplified by the fact that in the U.K., a general practitioner, Dr. Harold Shipman, murdered over 200 of his patients and was brought to justice only when he attempted to alter the will of one of them.

The proponents of euthanasia quote evidence that indicates that a small number of medical practitioners already perform covert euthanasia in Australia and New Zealand. If the evidence is correct, these practitioners are already adept at hiding their tracks. Why would anyone think that the prospect of reporting such deaths to the coroner with the attendant possibility that a post-mortem examination might prove the diagnosis wrong, would be an attractive option to them? All that legalising the situation will do is to increase the likelihood that medical practitioners will feel free to covertly euthanase more people.

Moreover, the situation in Holland has demonstrated that there is more than one "slippery slope" in that people diagnosed with depression, a curable disorder in the vast majority, may now request and receive, euthanasia. An example of slippery slopes closer to home may be found in the abortion law reform. What was touted as a solution to a few hundred problem pregnancies each year has ballooned out into a major industry in the health system with many thousands of foetuses being aborted each year.


5. It introduces a conflict of interest for medical practitioners who will be allowed to execute it.

From the earliest times, medical practice has focussed on the preservation and enhancement of life and health. The Hippocratic Oath that most medical graduates give allegiance to in one form or other, includes a commitment to eschew administering any harmful substance to a patient with the intent of terminating that person's life.

Twentieth century codes of ethics, such as the Nuremberg Code, that health services and practitioners subscribe to, are without exception concerned with the protection of human life from political movements that might endanger it.

Late 20th. Century codes of ethics have largely focussed on protecting people from medical research that might harm them. The need for such codes has come about because of a recognition that the mushrooming of medical research, in itself a great boon to humankind, has greatly increased the chances that medical researchers will have conflicts of interest that deter them from recognising harmful elements to their research. Hence, all research involving humans, is closely vetted in advance by research ethics committees.

Now it is proposed to introduce yet another conflict of interest for medical practitioners via the legalisation of euthanasia. There is evidence from experience in Holland that "difficult" patients, and patients with complex medical conditions are in special danger of involuntary euthanasia at the hands of some medical practitioners.

This was certainly the case in Nazi Germany. Dr. Hallervorden, a German pathologist, when asked about the way people were selected for the Nazi euthanasia programme, told Dr. Leo Alexander, a consultant psychiatrist to the Nuremberg War Crimes Tribunal that the "physicians ....were either too busy or did not care, and they delegated the selection to the nurses and attendants....

Whoever looked sick or was otherwise a problem was put on a list and transported to the killing centre....The worst thing about this business was that it produced a certain brutalisation of the nursing personnel. They got to simply picking out those they did not like...."[3] Do we as a nation actually want to put patients in the position of being advised about euthanasia by health professionals who may have a personal antipathy toward them?

It is clear, moreover, that some doctors develop a special fascination for the art of killing people. Drs Nitschke and Kevorkian are examples of this phenomenon. For example, Dr Nitschke campaigned for the right of Australian woman Martha Bowes to die, ostensibly because of terminal cancer. During the campaign he failed to reveal the vital fact that she was not terminally ill and that surgery might cure her.[4]

This raises the question: if euthanasia is legalised, how will patients know which medical practitioner they can trust to do their best to diagnose correctly and offer curative therapy rather than encourage a morbid interest in dying?


6. The philosophical theory that allows euthanasia to be contemplated at all is flawed and dangerous.

The Voluntary Euthanasia Society and other lay groups advocating legalising the practice do so on the philosophical bases of the autonomy of the individual, the
provision of "death with dignity" and compassion. As noted above, the autonomy of many persons requesting euthanasia is dubious in the extreme, and when a
thorough-going programme is in place, autonomy is not a consideration. In any case, society does not allow the exercise of individual autonomy to the exclusion of all other considerations. It is a relative, not an absolute right.

Historically, the call for ?death with dignity' was justified on the basis of the supposedly high prevalence of intractable pain that terminal patients experience.
However, pain is no longer the problem it once was, as even Dr. Peter Admiraal, one of the most powerful medical advocates for euthanasia in Holland has
admitted.

The philosophical ethicists of the utilitarian school (Singer, Harris, Fletcher) who support the liberalisation of euthanasia do not argue on the basis of issues such as these. They are aware of the need for more subtle arguments that might not only validate voluntary euthanasia but also non-voluntary euthanasia. Their main lines of argument are based on their concepts of the value of human life and the quality of life.

Briefly, in their view, human life per se has no value over any other form of life. Only a sentient being, that is, one who can interact in a meaningful way with the environment is to be regarded as a person. Some would argue that individuals who have the potential to become sentient beings should also be regarded as persons, hence new-borns are persons who should be protected.

However, not all utilitarian philosophers (Peter Singer is one) support such a view.

Whatever one thinks about the philosophical stance of these ethicists, the consequences are chilling. For example, Joseph Fletcher, a prominent utilitarian philosopher, argues that because non-sentient human beings are non-persons, they may be destroyed without moral qualm. Peter Singer follows a similar line of argument. This is then is the true philosophical basis for advancing euthanasia.

If we turn to history, we discover that such lines of thinking are not new. During the 1890's, the German, Adolf Jost, enunciated the concepts of a 'right to die' and human 'worthlessness'. His ideas were taken up and built on by Ernst Haeckel, Karl Binding and above all, Professor Alfred Hoeche. Binding and Hoeche maintained that there were people whose lives were 'not worthy to be lived'.

They were to be found amongst the terminally ill, those in coma and psychiatric patients, especially those residing in hospitals. With regard to this last group, they emphasised the high financial cost to the German State incurred in their continuing treatment. Finally in 1922, Ernst Mann advocated euthanasia not only for the above groups but also for children who were crippled or incurably ill. An officially endorsed euthanasia programme began in Germany in 1933 and became compulsory in 1939.

It is estimated that 275,000 persons who had been in nursing homes, hospitals and asylums were killed in this programme prior to the onset of World War II. Out of that came the holocaust.

Advocates of euthanasia are desperate to avoid any link between what happened in Germany in the 1930's and 1940's with what they are advocating. The point is that the modern day pro-euthanasia movement is grounded in exactly the same philosophy.


7. Euthanasia is the wrong solution for the majority of people who request it.

Requests for euthanasia come from two sources: patients and their relatives. In the presence of death, patients and their relatives are highly vulnerable, anxious people. In my experience in 40 years of medical practice, the majority of requests from patients are not because of intractable symptoms, but because of fear of the unknown. These people require love, physical and psychological support, and careful management of symptoms.

The majority of requests from relatives of patients are because they themselves cannot, or do not want to cope with the experience of watching a loved one pass away. These people need counselling and assistance with supporting their loved one. In my experience, relatives raise the subject even though the patient has not, about as often as the patient raises it without the knowledge of his or her relatives.

This raises uncomfortable questions about the rationale often given by relatives who take it upon themselves to terminate the life of someone near and dear to them. At whom is the so-called act of ?compassion' directed? True compassion is sharing another's pain, not doing away with the person whose suffering we cannot bear.[5]

From time to time people request euthanasia, even though they do not have a terminal illness. I have experience of supporters of voluntary euthanasia who were so adamantly desirous of euthanasia that it interfered with their rehabilitation. In other cases, patients have enquired about euthanasia, having just been given bad news about their illness, even though the prospect of death might be months or years into the future. Such people may well respond favourably to appropriate treatment.

New Zealand has a strong tradition of terminal and palliative care administered through our hospitals, community support services and the hospice movement. The focus of these compassionate services is to help people die with dignity. There are few supporters of euthanasia in the hospice movement.


8. It has the potential to reduce interest in and funding for palliative care and the hospice movement.

Killing sick people is cheap. Providing palliative and terminal care is a highly skilled, labour intensive enterprise. The major underlying rationale that utilitarian ethicists use to justify euthanasia is the monetary cost to society of nursing and caring for (i.e. showing true compassion to) the sick, disabled and intellectually impaired.

In comparison with much of the remainder of the developed world, at least two of the four jurisdictions that have legalised euthanasia (Holland and the Northern Territories of Australia ) have poorly developed hospice and terminal care facilities.

The New Zealand Health system is struggling financially: there is currently great concern about people with potentially remediable problems being removed from public hospital operating lists because the District Health Boards lack the finance to cope with the waiting lists. Many of these people cannot afford private sector medical assistance.

Under such circumstances, if euthanasia were to be introduced, it would not be logical to continue to make funding available for research and service provision in terminal care. Not only that, but it would also be inevitable that some people - especially older people - with life-restricting disabilities who have been shunted off waiting lists with no assurance of future reinstatement, would seriously consider requesting euthanasia. It would be great for the health budget. Funds could then be channelled into research into the science of killing.


9. Euthanasia does not guarantee a 'good death'.

Research on euthanasia and doctor-assisted suicide in Holland[6] showed that approximately 10% of the former and 30% of the latter forms of attempted ?mercy killings' investigated by the authors were complicated by untoward problems. They included patients who recovered from an induced coma, prolonged waiting for death, vomiting and fits; and technical problems with administering the lethal substance.

Some patients experienced more than one complication. For these people, one could hardly distinguish the experience as death with dignity.


10 Legalising euthanasia gives too much power to the medical profession.

At a time when medical science can do more for patients than at any other time in history, it seems that the public is more demanding, less forgiving and increasingly sceptical about the profession. The Medical Council's Disciplinary Committee and the Health and Disability Commissioner's office are not short of work.

The government is currently introducing new legislation that has as its core rationale the need to make health professionals more accountable. This has come about because fewer health professionals regard medicine as a vocation, and more of them regard it as an occupation not much different from any other. Yet, despite this ethos of public antipathy to the medical profession, we have a proposal to give doctors not less but more power over life and death, by legalising euthanasia.

As Dr. Peter Saunders has written: Voluntary euthanasia makes the doctor the most dangerous (person) in the state.[7] And the argument that because some medical practitioners already indulge in euthanasia is in itself a reason for legalising the practice makes no more sense than an argument justifying legalising paedophilia because some deviants practise it.


Summary.

Legislation allowing voluntary euthanasia should be rejected at the first reading. As history has shown, the dangers inherent in it are in undermining personal autonomy, posing serious risks to the ethos and fabric of society, reducing the likelihood that high quality palliative care will continue to be available, conferring unacceptable power on the medical profession and paving the way for involuntary and non-voluntary euthanasia.


references

[1] Fenigsen R. A case against Dutch euthanasia. Ethics and Medicine 1990: 6: 11 - 18.
[2] Melbourne Herald Sun 27 May 2002
[3] Alexander L. Medical science under dictatorship. New England Journal of Medicine 1949
[4] Melbourne Herald Sun 27 May 2002.
[5] Bryant G. Euthanasia. 1997 Affirm Publications, Auckland, p.17.
[6] Groenwoud J.H., van der Heide a. et al. Clinical problems with the performance of euthanasia and physician-assisted suicide in the Netherlands. New England Journal of Medicine 2000, 342: 551 ? 556.
[7] Saunders, P. J. Submission to the House of Lords Medical Ethics Committee, London, May 1993.

Biographical details.

Professor Emeritus David Richmond is a practising physician in Geriatric Medicine. He was the inaugural Professor of Geriatric Medicine in the University of Auckland, and Assistant Dean in the Auckland Faculty of Medicine.

He is a past president of the New Zealand Society for Geriatrics and was a member of the Prime Ministerial Taskforce on Positive Ageing. He assisted with writing the constitution for the Research Ethics Committee at Auckland Hospital, and chaired that committee for its first three years. He was a founding member of the Health Research Council's Ethics Committee.

He introduced the teaching of clinical ethics to the Auckland School of Medicine, has taught courses in Bioethics and published several papers on aspects of Medical Ethics. He currently chairs the Board of the HOPE Foundation, a charitable trust dedicated to fostering research into ageing and the effects of ageing on society.