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Questions raised over physician-assisted suicide

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Few issues in medicine have been more controversial in recent years than physician-assisted suicide, with medical experts and the general public unable to come to a consensus that balances the delicate issue of dying with dignity with the interests of the individual and society as a whole. A special session at this year's Euroanaesthesia meeting in Geneva (3-5 June) will see doctors debating this delicate issue.

The European Association for Palliative Care defines physician-assisted suicide as a physician intentionally helping a person to terminate his or her life by providing drugs for self-administration at the person's voluntary and competent request.

Bellerive Hospital, University Hospitals of Geneva, Switzerland, will argue in favour of assisted suicide, highlighting that physician-assisted suicide (PAS) has become an important expectation of some in society. She says: "Consequences of our modern medical system on patients have produced fear that life will be prolonged unnecessarily or will end in unbearable distress. During the final year of life, even individuals who have died by PAS have normally had a large amount of hospital care. Nowadays, death is more likely to be expected than sudden, frequently as a result of a medical decision. In addition, self-determination has reached the dying process. Decisions about time and circumstances of dying are considered to be personal."

Approaches to PAS in Europe are all based on an individual's will and authority of action, not on predicting the future. However, because of the broad range of values and the multicultural context, consensus is unlikely to be reached.

Dr Dieudonné-Rahm says: "The strongest arguments in favour of physician-assisted suicide are respect for autonomy, justice, compassion, honesty, individual liberty and transparency. Autonomy puts emphasis on the individual's feeling of quality and meaning of life from that person's view. For patients not dependant on life supportive measures, forgoing life prolonging treatments is not enough to hasten death. Persons who have died by PAS have argued unremitting suffering, no prospect of recovery, isolation or fearing about being a burden to their family, but had no intention to harm society or relatives. Transparency helps to limit their family's miscommunication and invisible suffering."

She concludes: "To address the question of PAS, frameworks and regulations are needed to help curb pressure on vulnerable people and health care professionals and to avoid the risk of a 'slippery slope' or other kinds of suicides. Considerations of relatives' needs should be addressed."

The 'against' argument will be given by Dr Calum MacKellar, the Director of Research of the Scottish Council on Human Bioethics, Edinburgh, Scotland; Visiting-Lecturer at St Mary's University, London, UK and Fellow with the Centre for Bioethics and Human Dignity at Trinity International University, Chicago, USA.

In his talk "What does dying with dignity mean in assisted suicide?", he will say: "Discussing the topic of assisted suicide, it has become necessary to seek to understand one of the most contested themes being used by both sides of the debate; namely the concept of human dignity."

On the one side, advocates of assisted suicide suggest that individuals should be able to determine their own dignity and quality of life, unrestricted by the moral, religious or cultural beliefs of others. For them, dignity reflects the manner in which individuals may consider themselves according to their personal values, desires and relationships reflecting what is believed to be certain standards of decency. From this perspective, the right to die with dignity reflects a perceived right of persons to be able to die when they believe that their lives no longer have any value, worth or meaning.

However, Dr MacKellar will say: "But another definition of dignity exists – one that has far more implications and goes to the very fabric of civilised society. It is the dignity which sustains the permanent, immeasurable, inviolable and equal value and worth of all members of a society."

From this perspective, Dr MacKellar will argue that legalising assisted suicide would mean that the whole of a society would accept that some individuals can have lives which no longer have any inherent worth and meaning. He says: "It would give the message that the very value and significance of a human life is merely based on subjective choices and decisions and whether a life meets certain quality standards. As a result it would affect everyone in society and not just those contemplating assisted suicide."

Dr MacKellar will emphasise his belief that it is not physical suffering that is the main basis for the real push for assisted suicide. He says: "Instead, it is usually psychological or existential suffering which is beyond the realm of medicine as well as autonomy. I recognise that people with progressive Alzheimer's, Parkinson's, and terrible physical injuries can suffer very deeply. But does suffering take away the inherent value and worth of a human life? The answer can only be 'no'."

He adds: "If the measure of a life is only related to happiness and pleasure, then everyone would have a life with a different value and worth. Civilised society would then be a thing of the past. For it to survive, society must recognise that all lives are seen to be wonderful even if they do experience suffering and even if they are a burden to others."

Dr MacKellar says it is essential that a society in which better palliative care, better pain control and better support for patients is provided. He says: "A society which continues to uphold and protect the important, inherent, and equal dignity as well as value of all human beings – no matter how young or old, able or disabled, sick or healthy, close to or far from death they are – accepting them for who they are and suffering or rejoicing with them in compassion and care."

He concludes: "Many modern societies struggle to understand the concept of inherent human dignity (as mentioned in the UN Declaration of Human Rights). In some countries, such as Belgium and The Netherlands, any debate about the consequences on inherent human dignity did not even take place before euthanasia and assisted suicide were legalised. This is really unfortunate! Indeed, without the concept of inherent human dignity, there is no real value in life nor is there any equality between lives."

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Calum MacKellar
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http://www.euroanaesthesia.org

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