I think a good death is very similar to undergoing good medical or surgical treatment.
The patient is acquainted with all the available options and, once they are as fully informed as possible, they make a decision – sometime alone but often in consultation with family or friends – about how best to proceed.
Modern lifesaving medical or surgical therapy can be pretty grueling, and all the more so if the patient learns subsequently that the treatment has failed to be curative and there is a need to discuss palliative options.
A counterbalance is required for when the extraordinary achievements of modern medicine fail to achieve the extraordinary. Sometimes under these circumstances a patient may be left worse off after treatment than if they had never embarked on therapy.
In this context, if a dying patient is not given all the options, and in fact is not even “allowed” to discuss certain options, it equates to an approach that in any other area of medicine would be considered unacceptable and unethical.
Assisted dying is available to approximately 150 million people around the world, not because it is being imposed by governments or by the medical profession, but because it is what the people want.
As such there are profound similarities to many other past social issues around the world and in New Zealand, but let’s consider for example the legalization of abortion movement and the decriminalization of homosexuality followed by the marriage law amendments which allowed same sex marriage. These issues triggered intense debate and antagonism, with opponents claiming that the very fabric of society was under threat and human life was being degraded and people (especially minors) could be corrupted and coerced.
We now know that society is a better place as a result of these legislative changes and I know from my experience in medicine that the introduction of assisted dying legislation will also be of benefit; of major practical benefit to a small number of people and of great benefit to society as a whole.
I know this not only from my own experience but also from firstly the evidence published in peer reviewed journals (societal satisfaction and confidence in their medical systems, with no evidence of abuse of the vulnerable, or of the ‘slippery slope’ phenomenon); and secondly the principles espoused by the Declaration of Human Rights (which gives humanity the right to self-autonomy); and finally from rational philosophical arguments.
The 1948 Declaration of Human Rights (principle author Eleanor Roosevelt, wife of the US president) is masterly in its simplicity and foresight and deeply moving when one considers the plight of so many around the world. With respect to some of the ethical/philosophical arguments for and against the killing of humans I have outlined a summary of some of these arguments below.
The fact that many doctors unquestioningly accept the premise that medical involvement in euthanasia is unethical, without subjecting the question to objective critical enquiry, is troubling and frustrating.
Until 1989 FIGO, (the Federation of International Gynaecology and Obstetrics) opposed abortion, as unethical, after which it took the position that all women must have access to professionally performed abortions. It now states that “neither society, nor members of the health care team responsible for counselling women, have the right to impose their religion or cultural convictions regarding abortion on those whose attitudes are different”.
In 2016 the Supreme Court of Canada ruled that Canadians have a constitutional right to end their life when they are terminally or incurably ill and of sound mind. This ruling followed the result of a lower court hearing that had carried out the most thorough judicial review ever conducted of the practice of physician–assisted suicide in other jurisdictions. This review concluded that good legislation could effectively safeguard against abuse.
Philosophical arguments for and against killing
If we take the stance that euthanasia is an ethical issue, then it is appropriate to address some of the possible philosophical arguments that provide the foundations for discussing this question. (Some of the following arguments have been paraphrased from the Australian philosopher and ethicist Peter Singer’s book ‘Practical Ethics’, second edition 2005.)
Two questions should be asked before proceeding:
- Are all the facts available to all parties so that the issue can be discussed philosophically? On the specific issue of euthanasia, all the facts are available, so the argument should not be limited by lack of information.
- Are there conflicting ethical views giving rise to disagreements over what to do? The answer with respect to euthanasia is again yes, therefore reasoning and analysis should be helpful in reaching a conclusion.
The ethical arguments against the killing of human beings are detailed. Regardless of the complexities however, we are all aware that there exist strong ethical arguments against killing.
It may be surprising to some that these same arguments support, perhaps even more strongly, the death of a rational human being who wishes to end their own life if they judge it as no longer of sufficient quality to continue living. If a doctor agrees with this person’s judgement (regarding the quality of their life), then complying with a request to assist in their death is acting in the person’s best interests and is therefore an ethically acceptable action.
Four major ethical arguments against the killing of human beings are listed below and can be also used to argue against the killing of self-conscious beings.
But how do they hold up for providing reasons for the killing of people, if they are rational people who wish to die?
Argument 1 (against)
Since self-conscious beings are capable of fearing their own death, the killing of one of them has worse effect to those who live on.
Argument 1 (for)
Does not object to killing a person who has genuinely consented to be killed, as the action would have no tendency to spread fear or uncertainty; those who do not wish to be killed, do not give consent, and therefore do not have a need to experience fear. In fact, more fear may be generated by witnessing or experiencing drawn out and distressing deaths.
Argument 2 (against)
The thwarting of the victim’s desire to go on living is an important reason against killing them.
Argument 2 (for)
If there is no desire to go on living, then there is no thwarting of this desire.
Argument 3 (against)
A theory of rights says that to have a right, one must have the ability to desire that right, so that to have a right to life one must be able to desire one’s own continued existence.
Argument 3 (for)
Identifies that an essential feature of a right is that one can waive one’s rights if one chooses. For instance, I have a right to privacy, but I can waive that, film every detail of my private life and then invite my neighbours in to watch it. Sufficiently intrigued neighbours accepting my invitation, do not violate my right to privacy, because I’ve waived it. If a doctor ends my life at my request, it is because I have waived my right to life.
Argument 4 (against)
There must be respect for the autonomous decisions of rational beings (in this instance to continue living).
Argument 4 (for)
Indicates that respect for autonomy allows us to make autonomous decisions and to live lives free from coercion or interference (providing we do not harm others by our actions). For those choosing to die, a respect for their autonomy leads others to assist them with their choice.
Doctors exist to help their patients. If there were no patients, there would be no doctors.
In the special case of euthanasia, the ethical arguments for and against killing, appear at least as strong for supporting this practice as against it.
This rather surprising result reflects that as self-conscious beings, we know that we exist over time, and will continue to do so, unless we die. Normally continuation of this existence is fervently desired; when the foreseeable continued existence is dreaded, the desire to die may take the place of the normal desire to live, thus reversing the reasons against killing.
In my view the main reasons for opposition to the introduction of assisted dying legislation are apprehension, lack of knowledge, and religious and cultural beliefs.
The first two can be addressed by those who wish to learn; religious and cultural views must be respected but should not be imposed upon those with different perspectives.
It is time for all of us to look objectively at this issue, and I believe that if we can put aside conservative beliefs, we can enact legislation that will be good for medical practice in this country, and enhance our entire society.
Author: Dr Miles Williams is a cardiologist and general physician in Hawke’s Bay who supports the legalisation of assisted dying.