Euthanasia: Volume I – Ethical and Human Aspects; Volume II – National and European Perspectives

Recommendation 1418 (1999) of the Parliamentary Assembly of the Council of Europe on Protection of the Human Rights and Dignity of the Terminally Ill and the Dying was followed by the reply from the Council of Europe Committee of Ministers and adopted on 30 October 2000, at the 728th meeting of the Ministers' Deputies. Recommendation 1418 contains 9 recommendations in which among others, is stated that as a result of medical technical progress, the quality of life of the dying is often neglected, their loneliness and suffering ignored, as well as that of their families and care-givers. This statement is not congruent with what was stated in Recommendation 779 (1976), viz.: the obligation to respect and to protect the dignity of a terminally ill or dying person by providing an appropriate environment, enabling a human being to die in dignity. In the same recommendation it was also emphasised that human beings both begin and end their lives in weakness and dependency, that their vulnerability needs protection and support. Hence, legislation is needed to avoid exposing the dying to unbearable symptoms, prolonging the dying process against the patient's will, allowing the patient to die alone and neglected, or under the fear of being a social burden, and more. In Recommendation 1418 it was among others advised to provide equitable access to appropriate palliative care for all terminally ill or dying persons, to ensure that relatives are encouraged to accompany them, to provide for ambulant hospice teams and networks, and to ensure that they will receive adequate pain relief. A further recommendation was: to protect the terminally ill or dying person's right to self-determination by taking necessary measures such as not to be treated against one's will, to take into account the patient's expressed wishes and so forth. Finally it was advised to uphold the prohibition against intentionally taking the life of the terminally ill or dying person by among others recognising that the wish to die never constitutes any legal claim to die at the hand of another person and recognising that the wish to die cannot of itself constitute a legal justification to carry out actions intended to bring about death. So far it is a clear statement. The word 'Euthanasia', however, is not mentioned in the reports. The wording however tells you that there is no space for discussion. The focus is on palliative care. The wording, I suspect, aims to avoid a well-balanced discussion on 'Euthanasia' because the standpoints between the assembled countries are so different. Maybe they are right, and time and space are not yet fertile to start with this exchange of opinions, which is so urgently needed for the public-at-large. The booklets not only deal with active interventions to end life, but with assisted suicide and refusal or withdrawal of treatment as well. The first volume contains seven contributions about Euthanasia and Ethics, and six separated reflections from the angle of Euthanasia and Religions. The second volume is mainly focussed on opinions about the question from several EU countries and the United States: Euthanasia in Europe and the United States. Obviously, it is not difficult to predict that in this controversial question many of the opinions put forward are confusing and therefore clashing. A reason for this confusion is that in word and meaning, euthanasia contains a semantic ambiguity in itself: "gentle death" and "deliberately caused death" Hence, in common language, it is often called "mercy killing". Another confusion is the definition of euthanasia. Euthanasia is not the administration of analgesics in progressive doses that may cause earlier death. It is neither the restriction nor non-use of active treatment or resuscitation, nor withdrawal of life support systems (such as artificial respiration). There is hardly any discussion about these three among the assembled countries of the EU. Assisted suicide and by the means of injection of a lethal substance, however, cause divergent opinions in as well as between the countries. A single meaning of euthanasia is: death caused deliberately. The proposed definition in the issue is: "euthanasia is an action or omission with the primary intent of bringing about a patient's death in order to end his or her suffering", in other words, euthanasia is an inflicted, as opposed to a natural, death. When it comes to euthanasia as defined above there are some conflicting opinions between those who advocate that ethical acceptance of euthanasia in certain forms and decriminalisation of voluntary euthanasia under very strict conditions, will put an end to cover-ups, hypocrisy and dishonesty and will bring much needed transparency into relations between doctors, patients and families, which will in turn reduce the risk of abuse; and, on the other hand, those who oppose, who think that this message sets society on a dangerous course. They say that the rule that no one may dispose of human life must be absolute. If not, it would open the door to abuses. In response, the formers state that by virtue of technology, there is the chance to claim dominion over life, from the cradle to the grave. Hence, the desire for mastery over death involves a degree of hubris that virtually invites abuses by those who are absolutely against euthanasia. Dignity is debated extensively in the report of euthanasia and raises another confusing point. Advocates as well as critics of euthanasia invoke dignity: to die with dignity is put forward by the former; the latter, however, bring up the respect for human dignity. In that aspect, there are reasons to reconsider one's point of view, if palliative care is developed in such a way (effective alleviation of pain, adequate help) that most patients will experience what they consider to be a dignified death. To put it simply: is euthanasia murder, or a final care measure? And even though euthanasia is murder, may there be circumstances that make it legitimate? Do not forget that the final stages of our lives are our last opportunities to exercise our freedom. It can be the last chance to meet our personality: mind and soul, so is memorised in that part of the first volume. There is a lot more in these two booklets, but that would lead too far in the context of a review. Anyone who is interested in digging more deeply into this broad field with its many opportunities for discussion, I advise to purchase these booklets full of opinions and backgrounds. I end this review with a quotation of a sentence on page 100, volume 1:"What I would like to see is all doctors, with their mission to serve life, becoming doctors of both life and death, so that death would be part of their lives". I personally completely agree with that statement. However, most of the narrators do not share this, to the contrary: "Pronouncements against active steps to hasten death date back to the Hippocratic Oath and have formed the ethical core for professional opposition to these practices." (Quotation page 109, volume 2) This brings us to the heart of the discussion about 'Euthanasia', and that is precisely what is missing in both the issues: a profound discussion or reflection on what life in itself really signifies or contains. Actually, the heart of the discussion is avoided or ignored by almost every introducer. The main line in the booklets is that life is the body with the beating heart. In this assumption there is no space to integrate death in life, because it would contradict the assumption. But even that is not worded. In my opinion, a subject like euthanasia demands an introduction about this question so that a foundation is built to construct the further walls and corner stones. For example, if you accept that life is the body with a beating heart that serves as a vehicle for the soul, then life would extend beyond death. Then the Hippocratic Oath would also be focussed on the process of death and the care of the afterlife. This view of life would give a total different assessment of 'Euthanasia'. I am afraid that we are still a far cry away from that approach in our Western world!