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Euthanasia: Why the right to die remains a debate across the world

Euthanasia is sensitive and complex issue that has been debated across the world for centuries. Various factors come into play when discussing the topic including safeguards in legislation, morality and the precedent it may set

The euthanasia debate has captured the world's attention (Indian Express)

Earlier this month, a man became the first person in Colombia to be euthanised without the prerequisite of suffering from a terminal illness. Victor Escobar’s decision to die has reignited the debate over euthanasia and its application under the laws of different countries

Euthanasia, which comes from the Greek words meaning “a good death”, refers to the practice under which an individual intentionally ends their life. Euthanasia falls under the category of assisted dying, which also includes assisted suicide. The difference between euthanasia and assisted suicide is contingent on the person who commits the act. Euthanasia is when an individual ends another person’s life painlessly whereas under assisted suicide a physician assists a patient in ending their life usually by lethal injection. Euthanasia can be further categorised as active or passive. Passive euthanasia is far more common and usually entails withholding lifesaving interventions with the consent of the patient or someone on their behalf. Active euthanasia is legal in only a handful of countries and necessitates deliberately using substances or forces to end the life of another person.    

Richard Huxtable, the author of Euthanasia, Ethics and the Law (2007), who spoke with indianexpress.com, stresses that intent matters. “There will be many everyday situations in which treatment is not started or is stopped that do not involve euthanasia – because, for example, the intention is simply to remove something that is not working or unduly burdensome, given the patient’s condition,” Huxtable says. 

Under the laws of every country that has legalised assisted dying, in order for the act to be distinct from murder or manslaughter, it must be committed with the express intent of relieving someone from unbearable suffering, usually with a prerequisite of the person in question with a terminal prognosis.

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History of the euthanasia movement

Euthanasia was practiced in both ancient Greece and Rome, wherein hemlock was employed as a means of hastening death. The term itself was used for the first time by philosopher Francis Bacon and expanded upon later by Karl Marx. Suicide and euthanasia become acceptable practice during the Age of Enlightenment in Europe and countries like Japan where suicide was used as a means to preserve a person’s honour and therefore not considered to be a sin.

In Dying with Dignity (2015), Giza Lopes writes that in the mid-19th century, doctors regularly used morphine or chloroform to induce the death of patients who were terminally ill with no hope for recovery. The first attempt to legalise euthanasia took place in the United States in 1906, but the campaign was ultimately unsuccessful. In 1935, the movement regained steam in England with the formation of the Voluntary Euthanasia Legalisation Society. In fact, although the practice wasn’t legally condoned, it was employed frequently by physicians of the time. In 1936, King George V of England was given a fatal dose of morphine and cocaine to hasten his death, although this event was kept secret for another 50 years. 

In one of the more controversial examples of historic euthanasia, in 1939, Nazi Germany conducted the mass killing of mentally and physically impaired people and more than 300,000 died in the process. Later, during World War Two, British and American soldiers kept lethal pills on themselves to be used if they were captured or compromised. In a landmark announcement in 1957, the Vatican proclaimed that passive euthanasia was permissible under the church’s doctrine. This led to an increasing number of countries legalising either passive or active euthanasia over a period of time.

Countries where assisted dying is legal (Indian Express)

Today, a handful of countries have legalised assisted dying in its various forms. In Switzerland, where assisted suicide is legal, around 1.5 per cent of Swiss deaths are the result of the practice. People also travel to Switzerland for assisted suicide, with statistics from 2018 indicating that around 221 people visited the country for it. Both euthanasia and assisted suicide are legal in the Netherlands, Luxembourg, and Belgium in cases where someone is experiencing unbearable suffering with no chance of improvement. There is no requirement to be terminally ill and the law even allows for people with mental illness to undergo the practice. In March 2021, Spain made it legal for people to end their lives in some circumstances and the same year, Canada expanded its law on assisted dying.

Colombia is the first, and so far, only, Latin American country to decriminalise euthanasia. Several states in Australia also allow euthanasia with similar legislation enacted in New Zealand. A number of states in America allow assisted dying with Oregon and Washington being the two most prominent. In India, passive euthanasia was legalised by the Supreme Court in 2018, as long as a person has a “living will” that specifies what actions should be taken if they are unable to make their own medical decisions in the future. If the person does not have a living will, their relatives are allowed to petition the high courts for permission to allow passive euthanasia.

Bioethics

The moral debate surrounding assisted dying falls under the realm of bioethics. Polling is inconclusive on the subject with cultural norms and legal directives playing a huge role in how the practice is perceived. In a poll of 1,500 physicians conducted in the Netherlands in 2015, over 90 per cent of respondents supported the liberal Dutch approach to euthanasia. In a similar poll conducted in Mumbai, 75 per cent of physicians argued that patients should be allowed to end their own lives but only in the case of a terminal illness. Revealingly, in a study conducted by Asch, 17 per cent of doctors and nurses reported having received at least one request for physician-assisted suicide, with 11 per cent admitting having granted such a request. YouGov and Gallup polling in the UK and the US respectively, showed that between 73 and 50 per cent of people supported physician-assisted suicide even in cases where the patient is not suffering from a terminal illness. Polling further indicates that the practice is becoming more acceptable over time.

In Euthanasia: An Indian Perspective, authors Vinod Sinha, S. Basu and S. Sarkhel document the moral arguments for and against euthanasia. To summarise, the arguments for assisted dying or the right to die can take several forms. First is that the right to life implies the right to a dignified death. In response to the claim that laws permitting euthanasia can lead to a slippery slope, the authors suggest that proper legislation be enacted to regulate the practice. Finally, they state that from a utilitarian perspective, assisted dying can be useful as it frees up medical resources for other purposes.

Taking this argument a step further, a representative from Dignitas, a right to die organisation in Switzerland, told indianexpress.com that simply knowing one has a way out gives them the “strength and courage to keep on living.” Furthermore, they state that in countries where assisted dying is illegal, many people resort instead to suicide. They write that “research indicates that for each death by suicide, there are up to 50 times more people who attempt or fail” resulting in “dire consequences for the person, family, friends and third persons.”

Alistair Thompson, a representative for the association Care not Killing, vehemently rejects this notion. In conversation with indianexpress.com, he states that data indicates that legalising assisted suicide or euthanasia doesn’t diminish the number of suicides in the general population. Instead, “it normalises death, leading to the suicide contagion effect.” The authors of the Indian study cited before expand upon this idea, writing that vulnerable populations are most at risk, as they may face financial burdens related to medical care that may lead them to opt for assisted dying.

Thompson states that not only do financial considerations come into play, but people also often choose euthanasia in order to cease “being a burden” to their families. Moreover, he states, in Canada, over 1,200 people cited loneliness as the principal reason for assisted dying. When asked about the safeguards preventing the practice from being abused, Thompson states that in his experience, he hasn’t seen any country in which such measures have worked or not been eroded. His argument is supported by data from the Netherlands and Belgium which shows that physicians have often breached the laws around assisted dying, especially when they pertain to psychiatric patients.

Religion is another consideration worth noting. Active euthanasia is explicitly condemned by the Catholic Church and is frowned upon in Islam and Judaism. However, in Hindu texts, the notion of resolving to die through fasting is deemed acceptable. Called prayopavesa, the practice of dying through starvation is permitted when a person has no desire, ambition or responsibilities left or is facing a terminal illness. A similar practice exists in Jainism, termed santhana

Mental illness

When it comes to mental illnesses, the debate around euthanasia or assisted suicide becomes infinitely more complex. A review of euthanasia in Belgium revealed that between 2007 and 2011, 93 people requested it due to unbearable suffering from mental illness. As many as 48 of the requests were approved, 35 were carried out and eight patients either cancelled or delayed euthanasia because they said that simply having the option gave them enough peace of mind to continue. While the numbers are rising, asking for euthanasia due to mental illness is still uncommon. Between 2010 and 2011, more than 2,000 people died by euthanasia in Belgium, with less than 10 per cent of them having terminal illnesses and less than 1 per cent having mental illnesses.

According to Huxtable, “unbearable suffering is notoriously hard to define.” Compounding the problem, unlike motor neurone diseases and cancer, mental illnesses like depression and anxiety don’t show up on a scan or an X-ray. Therefore, when granting assisted dying to a person suffering from mental illnesses, it can be difficult to know when the threshold of unbearable suffering with no hope of improvement is met. Huxtable maintains that suffering is subjective and while some may argue that euthanasia for the mentally ill is risky, others argue that it is “unjust” to deny this option to such patients.

For what it’s worth, in countries where the practice is legal, it is often only granted in the most extreme of cases. Patients have to demonstrate that they have taken every step possible to alleviate their suffering and a psychiatrist must testify that there is no scope for improvement. However, the slippery slope concern persists and some fear that by allowing euthanasia for mentally ill patients, the floodgates may open, leading physically healthy patients to opt for death over treatment.

According to Huxtable, “before making any move to allow assisted dying, it is essential to hear from all the stakeholders”, including disability rights activists and any individuals or groups who may potentially be affected. Most importantly, before implementing or expanding any assisted dying laws, careful consideration must be given to ensure the law makes clear “precisely what is permitted and under what conditions.” Lastly, Huxtable asserts that mechanisms must be in place to “ensure people comply” and states must collect data and monitor the practice to make sure that vulnerable people are not at risk.

Further Reading 

Euthanasia, Ethics and the Law, Richard Huxtable, Routledge, 2007

Dying with Dignity, Giza Lopes, Prager, 2015

In Euthanasia: An Indian Perspective, Vinod Sinha, S. Basu and S. Sarkhel, Indian Journal of Psychiatry, 2012

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