Euthanasia

Terminal Cases

Motor Neurone Disease is a neurological muscle wasting disease. There is no known cause and no known cure. The disease takes 3-4 years to run its course. During this time the victim suffers increasing disability often becoming quadriplegic. Throughout the process the victim’s mental capacities remain unimpaired. Much can be done to manage and treat the pain and symptoms but the disease remains fatal.

Muscular Dystrophy is a muscle wasting disease caused by the absence of proteins which feed the muscles. It is caused by a defective gene. There is no known cure. During this time the victim suffers increasing disability often becoming quadriplegic. Throughout the process the victim’s mental capacities remain unimpaired. Few victims survive beyond 30. Much can be done to manage and treat the pain and symptoms but the disease remains fatal.

Cystic Fibrois is a genetic disease where the body produces a thick mucus which clogs the lungs and can cause life threatening lung infections. It is incurable. Sufferers do not live much beyond their mid thirties. The symptoms can be relieved through drugs and therapy but in time the patient will succumb to the disease mainly as a result of respiratory problems but other organs can be affected too. During the latter stages of the disease the patient retains all mental capacities.

Alzheimer’s Disease comprises a variety of conditions where the structure and chemistry of the brain become damaged over a period of time. Symptoms include loss of memory, confusion and problems with speech and understanding. There are many causes of Alzheimer’s but on the whole they seem to be related to lifestyle, age and genes. The later stages of Alzheimer’s see the sufferer have increasing problems communicating and are dependent on others for even the simplest of tasks. In time the problem can become so severe that sufferers are unable to even identify illness in themselves. There is no cure and the disease is degenerative. Initially patients can be distressed by the symptoms but with lessening awareness the distress decreases. It affects the elderly and is life shortening. Sufferers usually die from an unrelated condition.

PVS is persistent vegetative state. Patients in PVS have lost the higher powers of the brain but retain lower functions. This means that patients can breathe on their own and their circulation is intact. They appear to be normal and respond to external stimuli; eyes open and emotions like laughing and crying occur but these are spontaneous. Patients do not speak or respond to any commands. Recovery, if there is any, depends on the location and extent of the damage. Some regain a degree of awareness after PVS others can remain in this state for years, even decades requiring increasing care as time progresses. The most common cause of death for PVS patients in pneumonia.

Brain Death is defined as the irreversible loss of all brain functions. This can be tested in three main ways: absence of electrical activity in the brain, absence of blood flow to the brain, absence of all functions of the brain e.g. no movement, no response to stimulation, no breathing, no brain reflexes. Causes usually include oxygen loss to the brain (drowning, choking, drug overdose), blood loss to the brain, head injuries, aneurisms and brain tumours. The heart and lungs can often still function with the use of respiratory and circulation equipment but only with these pieces of

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equipment. There is no recovery from brain death. Patients are unable to experience physical or psychological pain. Palliative Care is care of the dying. Life is important and dying is part of a normal process. Palliative care does not hurry or delay death but provides relief from pain and suffering taking care of the physical, psychological and spiritual needs of the patient and his family. It gives the patient and their loved ones a chance to spend quality time together, with as much distress removed as possible.

Principles of a Good Death A number of ethical, age concern and religious groups have tried to suggest the key elements of dying a good death. There is no agreement on what constitutes a good death. In 1999 Age Concern of London produced this list. It is no way a medical or ethical definition of a good death but the principles do give food for thought;

to know when death is coming, and to understand what can be expected to be able to retain control of what happens to be afforded dignity and privacy to have control over pain relief and other symptom control to have choice and control over where death occurs (at home or elsewhere) to have access to information and expertise of whatever kind is necessary to have access to any spiritual or emotional support required to have access to hospice care in any location, not only in hospital to have control over who is present and who shares the end to be able to issue advance directives which ensure wishes are respected to have time to say goodbye, and control over other aspects of timing to be able to leave when it is time to go, and not to have life prolonged pointlessly

Then we have the approach of sixties pop musician-turned-poet Roger McGough where he has a rather more dramatic end planned for himself;

Let Me Die a Young Man's Death By Roger McGough

Let me die a young man's death not a clean and in between the sheets holy water death not a famous-last-words peaceful out of breath death

When I'm 73 and in constant good humour may I be mown down at dawn by a bright red sports car on my way home from an all night party

Or when I'm 91 with silver hair and sitting in a barber's chair may rival gangsters with ham-fisted tommy guns burst in and give me a short back and insides

Or when I'm 104 and banned from the Cavern may my mistress catching me in bed with her daughter and fearing for her son cut me up into little pieces and throw away every piece but one Let me die a young man's death not a free from sin tiptoe in candle wax and waning death not a

curtains drawn by angels borne 'what a nice way to go' death

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The Facts Definitions

Active or Direct Euthanaia In active euthanasia a person directly and deliberately causes the patient's death. Example: the patient is given drugs which will kill him. The person giving the drugs is fully aware of what they are doing and fully aware of the consequences of their action.

Passive Euthanasia In passive euthanasia a person does not directly take the life of the patient, instead they allow the patient to die. Example: A patient arrives in hospital having had a massive stroke. The brain damage is very extensive and the prognosis very poor. The doctor does nothing to save the patient, she just lets nature take its course. The doctor is aware that by doing ‘nothing’ the patient will die. Withdrawing and withholding treatment are both forms of passive euthanasia.

Voluntary Euthanasia Voluntary euthanasia is when the patient asks to have their life ended. Example: A dying patient asks for treatment to be withheld or withdrawn or asks for drugs which will effectively given them an overdose and end their life.

Involuntary Euthanasia Non-voluntary euthanasia is when an individual is unable to make a decision about their condition and some appropriate person makes that decision for them. Example: a brain damaged infant is desperately ill and its parents take the decision to switch off the life support machine. There is another version of this type of euthanasia where a person wants to live but is given euthanasia anyway…this is often called murder!

Indirect Euthanasia This method of euthanasia is related to the principle of double effect. This is where action is taken by medical staff to relieve the pain of the patient a side effect of which is hastening the death of the patient. Example: The pain killing drugs a cancer patient is receiving are no longer effective at the present dosage. The dosage requires to be increased but the result of the increase is that the patient will die sooner rather than later. The medical staff give the drugs with the main intention of relieving the pain. The patient dies as a result of the overdose.

Assisted Suicide This usually refers to cases where the person who is going to die needs help to kill themselves and asks for it. It may be something as simple as getting drugs for the person and putting those drugs within their reach.

The Law in the UK

Euthanasia is illegal in the UK. Until 1961 suicide was a criminal offence- a bizarre law- punishable by death! In any case it was decriminalized in 1961. However the Suicide Act of 1961 forbade anyone from helping another to end their life. The law as it stands at present stipulates that any person who helps another person to die can be charged. In England, Wales and Northern Ireland the charge is usually manslaughter whilst in Scotland it is culpable homicide. Both

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offences are not as serious as murder but are technically a form of murder where offenders can receive up to fourteen years in prison. The Act allows the Director of Public Prosecutions to decide whether or not to go ahead with the case of this kind of unlawful killing and the sentences handed down on both sides of the border are very often influenced by the desperately harrowing circumstances of the victim and their family. Sentences are almost always non custodial and it is not unusual for cases to be dismissed. The law applies equally to everyone including medical staff.

In 2005 Wendolyn Markcrow received a 2 year suspended sentence after suffocating her 36 year old Downs’ Syndrome son as a result of finding his care impossible against her own background of depression. In September 2005 Donald Mawditt suffocated his wife of 50 years who had been suffering a terminal illness. He was given a conditional discharge. Andrew Wragg was cleared of killing his 10 year old terminally ill son in December 2005. He was given a two year suspended jail sentence. In all cases the defendants pled guilty to manslaughter on the grounds of diminished responsibility. These cases are fairly typical of how courts deal with mercy killings.

Diane Pretty took a different approach to the law before passing away in 2002. She suffered from motor neurone disease and wanted someone to end her life because she was so crippled she could not do it herself. She lost her case twice in the UK and also lost it in the European Court of Human Rights. She argued, amongst other things, that Article 3 of the European Convention on Human Rights established the right of individuals not to receive inhuman and degrading treatment. Keeping her alive in her present condition represented a violation of that right. She lost the case and died naturally in a hospice two months later.

In 1997 the Doctor Assisted Dying Bill was presented in the House of Commons looking for permission for doctors to end the life of terminally ill patients. The bill was heavily defeated. Almost 3:1 against but there was a recognition that public attitudes seemed to be turning in favour of euthanasia.

In England and Wales the “Assisted Dying for the Terminally Ill Bill” was introduced in 2005 but the General Election of 2005 meant that it could not be taken through parliament. The bill states that it would "enable a competent adult who is suffering unbearably as a result of a terminal illness to receive medical assistance to die at his/her own considered and persistent request". The bill was introduced by Lord Joffe in the House of Lords and never made it to the House of Commons where laws are made. Therefore the bill at present is a dead duck. It has to be introduced again by someone in order that it can be debated and a decision made as to whether or not it should be law.

The position is much the same in Scotland. There is talk about proposing a bill to permit physician assisted suicide and there’s various bits of lobbying going on but as yet we have still to see concrete proposals. If there is to be a law on voluntary euthanasia on either side of the border then two things are likely: the first is that the bill will be brought in as a private members’ bill meaning that no political party need be seen to be promoting euthanasia and secondly that MPs and MSPs will be allowed a free vote meaning that their party will not tell them how to vote on the issue.

One of the leading lawyers in the UK is Scottish lawyer Lord Mackay of Clashfern. He gave a clear summary of the Law in October 2005 in the House of Lords, “The position may be summed up as follows: the law does not forbid suicide, although those institutions that have in their care persons with suicidal tendencies, such as prisons or hospitals, must take reasonable care to prevent them

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giving effect to those tendencies. However, the law forbids helping someone to take his or her own life and ending someone's life at his or her request, although the law is not implemented in such a way as to visit the maximum sentence on anyone who acts in that way. Every case that comes to notice is considered on its merits by the police and by the Director of Public Prosecutions to assess whether a crime has been committed, and, if so, whether the circumstances justify a prosecution. If a prosecution is successful, the court must consider whether a custodial sentence or some other sentence is called for. That flexibility in our law was recognised recently and commended by the European Court of Human Rights.”

Problems with the Law - depends a lot on the viewpoint of euthanasia (f= supported by those in favour of euthanaia; a= supported by those against euthanasia)

It is vague. It neither denies nor permits euthanasia. (f/a) Each case is taken on its own merits- problems of consistency. (f) It is abused- people take a chance with it. (f/a) It allows euthanasia by the back door. (a) It does not protect the right to life of the dying. (a) It allows people to take the law and morality into their own hands. (f/a) People are given euthanasia so it does not deter them from using it. (f/a) It forces euthanasia underground. (f) Prolongs the agony of the dying. (f) Fails to take account of high quality palliative care. (a) Does not recognise the right of God to decide (a)

Benefits of the Law

Each case is dealt with on its own merits. (f) Responsibility lies with the courts not with the individual or medical staff. (f) It sets clear precedents. (f) It does not make it easy to give euthanasia. (a) It does not place medical or political organisations in a difficult position- the courts decide. (f/a) It works- it is a halfway house between legalisation and an outright ban.(neither)

The Law in Holland

Euthanasia is legal in three places in the world. It is legal in Holland, Belgium and the state of Oregon in the US (in spite of government opposition). It is also carried out in Switzerland but their approach is unusual and difficult to fully understand. It is basically that euthanasia is illegal but assisted suicide even by non medical people is acceptable providing it is done for the right reasons. The approach causes considerable controversy in Switzerland although the Swiss are generally in favour of it.

The Swiss, Belgians and Oregonians (if that is what they are called) are not our concern. The only one we are required to know about is the Dutch approach. Since 1973 the Dutch government had been aware the euthanasia was being practiced by medical staff. During the next 25 years the practice became more widespread and more accepted by the public and politicians alike. By 2001

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the Dutch parliament comfortably passed the Termination of Life on Request and Assisted Suicide (Review Procedures) Act which became law on April 1, 2002. The law basically made legal what had been common practice for about 20 years.

The law is as follows: Euthanasia must be performed in accordance with 'careful medical practice', that is, the previously listed

official guidelines are to continue to be observed.

All cases will be discussed by a regional review committee, made up of a lawyer, a doctor, an ethicist and others.

Euthanasia and assisted suicide will not be a crime if carried out by a doctor who has followed the guidelines, and reported it to a local medical examiner.

The local medical examiner has to satisfy himself that procedures have been carried out properly and then sends a report to the regional committee and the prosecutor.

Children between 12 and 16 must normally have their parents' consent before they may request euthanasia. In exceptional cases a doctor may agree to a child's request even without parental consent.

Requests by children aged 16 -17 do not require parental consent, but parents should be involved in decision making.

Patients who are able may request euthanasia through an advance directive which can be used if the patient later becomes unable to make a request for euthanasia.

The patient's suffering must be unbearable with no prospect of improvement. The patient's request for euthanasia must be voluntary and persist over time (The request can

not be granted when under the influence of others, psychological illness or drugs) The patient must be fully aware of his/her condition, prospects and options. There must be consultation with at least one other independent doctor who needs to confirm

the conditions mentioned above- the independent doctor must have no previous knowledge of the patient.

The death must be carried out in a medically proper fashion. It is preferred that the patient takes the fatal medication themselves but often this is not possible. Medication usually involves a drug that makes the patient unconscious followed by a drug that stops the heart. The drugs are taken intravenously or orally and the doctor must be present throughout the procedure.

If these conditions are not met then the doctor will be subject to prosecution. It is possible for non-Dutch nationals to receive euthanasia. It is strongly discouraged but ‘euthanasia tourism’ remains an issue. In 2003 just over 1% of deaths in Holland were through requests for euthanasia. The bulk of them were for cancer patients and the most of the patients opted to die at home. It is very likely that these figures are artificially low because many deaths from euthanasia will not have been recorded or reported. Interestingly enough the Dutch government has palliative care as an entitlement in their National Health Service unlike the UK where there is a dependence on charitable organisations to provide palliative care.

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The Dutch government’s statement on this matter is as follows: “Interest in palliative care grew in the 1990s. After 1995 the provision of palliative care in the Netherlands underwent rapid change and the range of care services for terminally ill patients expanded substantially. In the Netherlands, palliative care is part of regular health care. The approach of the Dutch government is that palliative care should be provided as much as possible by generalists (general practitioners, nurses and care workers). This is in line with the needs and wishes of terminally ill patients. In the Netherlands, 60% of people with non-acute disorders die at home.” Criticisms of the Dutch Euthanasia Law

It does not prevent illegal euthanasia. (f/a) It denies people the right to life. (a) It devalues life (a) Euthanasia can still go unreported (f/a) Violates the principle that government’s duty is to protect lives of innocent (a) It permits involuntary euthanasia in some cases (f/a) It goes against the fundamental purpose of a doctor as a healer (a) It has created a beaurocracy of death with its committees and reports (f/a) Increases pressure on doctors from families and patients. (a) Increases pressures on patients to request euthanasia. (a) Changes the patient-doctor relationship. (a) Euthanasia for minors is too early, overestimates maturity. (a) Advance Directive risks uninformed changes of mind. (a) Can mental illness really be described as unbearable suffering requiring euthanasia?(a) Doctors against euthanasia are under pressure to go against their consciences(a) A tiny percentage of Dutch people request it so why have it?(a) The final medical procedures can go wrong.(f/a) Bad motives for euthanasia cannot ever be eliminated. (a) 66% of requests are turned down thus patient doesn’t really have the right to choose, it is up

to others. (f/a)

Positive Reactions to Dutch Euthanasia Laws It reduces incidences of underground euthanasia. (f) It is compassionate. (f) It allows people to die with dignity at a time of their choosing.(f) It has safeguards against abuse through its procedures.(f) It is policy to ensure that those thinking about euthanasia are fully informed.(f) It gives people a choice. (f) Better to have laws about euthanasia than none at all.(f) Protects the vulnerable from pressure- gives them the right to get advice.(f/a) Palliative care is given equal importance in the law. (f/a) Doctors and nurses can never be disciplined or prosecuted for not carrying out euthanasia.

(f/a) 66% of requests are turned down so it is not automatic.(f/a) Euthanasia laws allow it to be regulated.(f/a) Takes moral burden off doctors.(f/a)

The Guidelines of the British Medical Association (BMA)

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Most doctors are members of the BMA. It does not have any role in certifying doctors but many doctors look to the BMA for advice on a huge range of professional and medical issues. The responsibility for registering doctors and monitoring professional standards lies with the General Medical Council (GMC). In terms of euthanasia the BMA opposed legalisation until June 2005. It changed its position from one of opposition to one of neutrality at its annual conference. However in changing its position to one of neutrality the BMA conference made the following points:

Assisted dying is an issue for parliament and society as a whole. They will not oppose changes to the law but will press for strong safeguards of medical staff

if they do change. Vulnerable patients must be protected. There must always be the alternative of high quality palliative care. There must be safeguards for doctors and patients who do not wish to practice euthanasia.

The BMA also have guidelines on what to do in particular situations. Where a patient is unable to make decisions for themselves e.g. severe brain damage and they have made it known in writing or otherwise that they wish to be kept alive then doctors should always honour that wish. If the patient values life to that extent then this must be respected. For patients in PVS the BMA recommends that no decision be taken before they have been in that condition for a year because diagnosis and prognosis in PVS are both difficult and not infallible i.e. mistakes can and have been made. If there is any doubt whatsoever then the BMA advises against ending the patient’s life. Both of these situations involve the withholding or withdrawal of treatment and the BMA believes that no medical professional should be expected to act in a way which offends their moral conscience nor should they be penalized in any way for refusing to carry out a treatment which they find morally unacceptable.

Where patients who are aware of the consequences of refusal of treatment refuse that treatment the BMA advises doctors to discuss the situation with them sensitively and seek alternatives to the proposed refusal. Ultimately though the patient’s wishes have to be respected so if they choose to die by refusal of treatment then doctors must grant that wish.

Withdrawal of treatment is a form of euthanasia and this occurs regularly. The BMA’s position on this is that it is acceptable to withdraw hydration and nutrition from a patient if the patient has suffered severe permanent and irreversible brain damage. If the treatment provides no benefit to the patient then withdrawal or withholding of treatment is acceptable. The BMA insists though that there should be no general rule, decisions should be made on a case-by-case basis. Any decision like this should be supported by legal advice.

The BMA is opposed to physician assisted suicide even if it becomes part of a euthanasia law. It believes it would have an adverse effect on patient-doctor relationships. As one US lawyer put it "I never want to have to wonder whether the physician coming into my hospital room is wearing the white coat of the healer ... or the black hood of the executioner. Trust between patient and physician is simply too important and too fragile to be subjected to the unnecessary strain." If the ‘suicide’ involves withdrawal of treatment then that is acceptable but to take direct steps to assist a

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patient in committing suicide is out of the question. Overall the BMA is opposed to any change in the law which permits physician-assisted suicide.

Where a patient has made an advance directive either in writing or orally in relation to refusal or authorisation treatment, future desires and intentions or a firm decision about life and death the BMA recommends that these are respected. These statements carry more moral weight than they do legal weight. The key issue here is patient choice and the courts tend to have upheld cases where patients have left some form of advance directive although verbal ones are harder to uphold.

The BMA recognizes that there are both benefits and drawbacks of having advance directives and for that reason is prepared to say that they are useful and where possible they will be honoured.

Another type of withdrawing or withholding treatment is a DNR order. DNRs are Do Not Resuscitate orders. A DNR order on a patient's file means that a doctor is not required to resuscitate a patient if their heart stops and is designed to prevent unnecessary suffering. The BMA’s position on this is that a decision is taken in close consultation with the patient or family. DNR is usually employed when if a patient's condition is such that resuscitation probably will not work, the patient has said they do not want resuscitated, there is an advance directive about it or if it would not be in the patient’s interests and the quality of life would be very poor. Technically it is a form of passive euthanasia

The BMA’s approach is one of considerable caution in all ending of life issues. Aside from the moral issues affecting patients and external groups the BMA has to balance the interests of the patient against the clinical judgements of the doctor and of the ethical position of both the profession as a whole and individual doctors.

The Arguments and The Responses

The requirement of the course is that you should know one view of euthanasia independent of religion and two views from within one religion. For our purposes this means that we will consider the views of the Voluntary Euthanasia Society and also ProLife (just so that you get a balance of non religious views). We will also consider the views of the Roman Catholic Church and Reformed Churches. In general it can be said that the RC Church opposes all forms of euthanasia; active, passive, voluntary or involuntary. The same can be said of the more traditional and conservative Reformed Churches. However there are reformed churches who have more relaxed views of euthanasia considering that passive indirect euthanasia is an acceptable form of it but that voluntary, active or direct euthanasia in any shape or form is forbidden.

The arguments are best divided into three categories: religious, ethical and practical and this is the approach that will be taken in these notes.

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The Arguments Against Euthanasia Religious Arguments

It is against the will of God

One of the key religious arguments is that euthanasia is forbidden by God. Every human being is a special creation by God. Not only that, everything in our lives has a purpose so if we are suffering a terminal illness God has a purpose in that, To end a person’s life is to prevent God from carrying out that purpose. The Roman Catholic declaration on euthanasia in 1980 stated, “It is necessary to state firmly once more that nothing and no one can in any way permit the killing of an innocent human being, whether a fo etus or an embryo, an infant or an adult, an old person, or one suffering from an incurable disease, or a person who is dying. Furthermore, no one is permitted to ask for this act of killing, either for himself or herself or for another person entrusted to his or her care… For it is a question of the violation of the divine law, an offence against the dignity of the human person, a crime against life, and an attack on humanity.” The statement covers more than just euthanasia but the last couple of lines reinforce the idea that the RC Church is citing DCT to support this view. God has said the taking an innocent life is wrong under any circumstances. This is further reinforced by the RC catechism which states, “Whatever its motives and means, direct euthanasia consists in putting an end to the lives of handicapped, sick, or dying persons. It is morally unacceptable.” Reference could also be made to the 10 commandments which forbid murder. Murder is against God’s will. Euthanasia is murder therefore it is against God’s will. The RC Church will not tolerate the deliberate killing of a being who has been made in God’s image. This is a view that is supported by almost all Reformed or Protestant churches: there should be no direct or deliberate killing of a dying patient nor should a patient request that a doctor ends his or her life.

Human Life is Sacred

Christians believe that human life has an intrinsic value. It is believed that we have a God-given value and that for this reason every human life is sacred. Life must be respected no matter what condition it is in. Our life has a value no matter what state we are in. We must therefore respect and recognize that our lives are sacred. To do that we must not end our lives because we are suffering- our life has value whether or not we are suffering. It is a gift from God and therefore not ours to do with what we will. The deliberate destruction of human life be it your own or that of another person cannot be permitted except in self defence or the defence of others. This is a view that is held by almost all mainstream Christians.

Suffering Has a Value

Suffering is an issue for all religions. It is a fact of human life and it is a fact that in many terminal illnesses suffering is involved. We refer back to Christian beliefs about purpose. A general belief is that suffering has purpose and it has a divine purpose at that. Not only that, suffering brings out qualities in people that might otherwise not be known.

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In 1980 the RC Church said of this issue, “According to Christian teaching, however, suffering, especially suffering during the last moments of life, has a special place in God's saving plan; it is in fact a sharing in Christ's passion [sufferings] and a union with the redeeming sacrifice which He offered in obedience to the Father's will.” In effect therefore the RC Church is saying that just as Christ accepted his suffering so too should we accept our suffering. Palliative care is something that the Church supports because again through the shared experience of suffering God’s purpose can be worked out. Pope John Paul II said in 1984, “Down through the centuries and generations it has been seen that in suffering there is concealed a particular power that draws a person interiorly close to Christ, a special grace.” Once again, an emphasis on the special qualities that suffering draws out of individuals.

Suffering at the end of life can have other values too. Some Christians view suffering as a test from God and that our reaction to it either as the sufferer or the carer is a measure of our faith and trust in God. This is not a view that is actively promoted by any Church but it is a view that many of those caught in the situation would endorse. Many Christians would prefer not to describe suffering as a test from God. For them the process of dying is a very important part of living. When dying it gives an individual time to take stock of things and come to a greater understanding of their place in the universe and God’s plan for us.

The Slippery Slope

This argument is used by both religious and non religious people. The idea behind this is if you allow the terminally ill to be given euthanasia, what will happen next? Will it be involuntary euthanasia? Will doctors be required? Will a lifespan limit be set? An investigation into euthanasia by a House of Lords Committee in 1993 concluded that, “that it was virtually impossible to ensure that all acts of euthanasia were truly voluntary and that any liberalisation of the law in the United Kingdom could not be abused. We were also concerned that vulnerable people - the elderly, lonely, sick or distressed - would feel pressure, whether real or imagined, to request early death.” It can be quite a persuasive argument:

If we change the law then how do we keep euthanasia under control? It would only be a matter of time before doctors did not ask the permission of patients and

family. People do not fully appreciate the difference between killing with permission and killing

without permission. Healthcare costs may force doctors to recommend euthanasia on economic grounds. Humans make errors so it would be a mistake to place all of our trust in doctors and other

health professionals. Legalising euthanasia makes it easier to commit murder. Murder could take place under the guise of euthanasia.

Both Roman Catholic and Reformed (Protestant) Churches would have no difficulty in accepting the principles put forward in the slippery slope argument. Their view is quite clear on the slippery slope…if you do not step on the slope then you have nowhere to slide.

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The religious arguments against euthanasia can be summed up as:

Life is a gift from God and only God can take it away. Suffering has a purpose and to end a life deliberately is to remove that purpose. Life is sacred. It is valuable no matter what condition an individual is in. We all have a duty to protect the vulnerable- and the vulnerable includes the sick and the dying. To kill a dying person is to reject them as an individual. Our right to make up our own minds should not require an act by another person. Death should come at a time of God’s choosing and not our own.

Ethical Arguments Some of the ethical arguments are not unlike the religious arguments. For example, religious people will claim that life is sacred whilst non religious people would argue that life is valuable. The meanings are different (because one involves God) but the effect is the same. All human beings are to be valued, irrespective of age, sex, race, religion, social status or their potential for achievement. Human life is a good thing and for this reason it can only be taken in self defence or the defence of others.Human life has an intrinsic value. This means that humans are valuable for what they are and not in relation to their physical or mental state nor in relation to our creed, race or colour nor our usefulness to society as a whole. Therefore in whatever state we are in we should not ask or expect to be put out of our misery because our life has a value and that value does not become any less because we are suffering pain.

No Life is Less Worth Living Than Another

Peter Singer, an ethicist, caused a bit of a storm not so long ago when he suggested that the right to life is based upon the ability to plan and anticipate your future. Since the unborn, infants and severely disabled people lack this ability, he says that painless infanticide and euthanasia can be justified in certain special circumstances, for instance in the case of severely disabled infants whose life would cause suffering both to themselves and to their parents. It is a view that has caused widespread concern amongst religious and non religious people alike. It is basically suggesting that some lives are less valuable than others and therefore puts the sick and disabled at risk. Disabled people generally feel that this view devalues themselves as individuals too. The slippery slope can come into play here too because you could make the point that people who are at risk of giving birth to a disabled child should not be allowed to conceive children at all and so it continues to the point of developing a master race yet again. The BBC ethics website gives a good summary of why euthanasia should not be used on the disabled:

All people should have equal rights and opportunities to live good lives Many individuals with disabilities enjoy living Many individuals without disabilities don't enjoy living, and no-one is threatening them The proper approach to people with disabilities is to provide them with appropriate support, not

to kill them The quality of a person's life should not be assessed by other people The quality of life of a person with disabilities should not be assessed without providing proper

support first. Not in the Patient’s Best Interests

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A key issue in the euthanasia debate is the patient’s best interests. The debate is around what the patient’s best interests are and who decides what the patient’s best interests are. The problem is seen at its worst when a patient asks for euthanasia, perhaps even feel obliged to ask for it when it is not in their best interests.

This kind of problem arises in many different cases and has led to concerns that there is no way that there can be any safe way to develop a euthanasia law that will be workable both from the doctors’ and patients’ perspective.

Human error is always a worry in euthanasia- what if the doctor’s diagnosis and prognosis was wrong?

Bad advice- what if the care of the patient was poor and the advice given on other options was poor or incorrect? What if the doctor was unaware of the alternatives to suffering?

Dying is distressing. Few people cope with it well in the beginning which means that the patient’s mental state could be one of confusion, depression, fear and an unrealistic assessment of their position- meaning that they cannot make a good judgement of their options and perhaps also meaning that any request for euthanasia is more of a cry for help than a demand.

The patient will feel vulnerable and will have natural feeling that their life is worthless now that the end is in sight.

The patient may be distressed by the pressure they put on their family, health professionals and health resources.

The patient may have strong feelings about euthanasia during this phase of their illness unaware that the next phase will see many of their present feelings disappear.

There has been research done on the subject and the pattern that has been detected in terminally ill patients is that their state of mind fluctuates. Sometimes the desire for death is strong but other times it is barely present at all. These feelings were very common and because of this we have to add another question to our list under the heading of “Best Interests”…we have what are the best interests and who decides what the best interests are; now we have- when are a patient’s best interests decided?

The Rights of Others Of course euthanasia is not just about the rights of the dying person. There are those involved in his or her care as well and perhaps in the termination of their life. There’s the rights of the family who may feel pressurized into making a decision they do not want to make. The pressures could include medical or economical pressures. There may be disagreements in the family on the best way to deal with their loved one. A recent case in the USA, a husband wanted euthanasia for his brain damaged wife whilst her parents did not- the parents lost the case and the woman was allowed to die. Opponents of euthanasia argue that this case would just be the tip of the iceberg if euthanasia was made legal. There’s the rights of medical staff to consider too. What if they were not keen to practice euthanasia? The BMA insists that if any medical staff have problems of conscience with giving euthanasia then they should not be expected to do it. Problem then is that patients requesting

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euthanasia would have to be sent elsewhere and, the slippery slope again, we would end up having death hospitals and fears that medical staff will just send lost causes to these hospitals. Society itself might well be weakened too. It would be OK to kill people, humans can kill the innocent if it suits them, some lives are not disposable, we should give up in the face of suffering, the worth of an individual can be measured in relation to the chances of recovery and the cost of their treatment. There’s more…why care for the disabled? Why care for the vulnerable? The dying are not as valuable as the living. The elderly are not as valuable as the youngerly. Let’s discriminate against the sick and the vulnerable. In short, society would devalue human life and therefore everyone’s rights would be affected. Pressure on the Vulnerable There are fears that legalizing euthanasia would lead to abuse particularly in relation to the vulnerable in society. Preventing people from using pressure on the vulnerable would be both difficult to prevent and difficult to prove because it can be so subtle. Canada looked into the possibility of euthanasia and received this piece of evidence, "I have seen . . . AIDS patients who have been totally abandoned by their parents, brothers and sisters and by their lovers…in a state of total isolation, cut off from every source of life and affection, they would see death as the only liberation open to them…in those circumstances, subtle pressure could bring people to request immediate, rapid, painless death, when what they want is close and powerful support and love."

Sick people can be very dependent and can often feel that they are a burden on their family. In most cases families do not see it that way. They respond in a Kantian way, treating the care of their loved ones as a duty. Indeed whilst the work is hard they will be happy to carry out caring duties. Nevertheless the sick can pressure themselves into asking for euthanasia…if it is legalized they have this option and may feel even more guilty if they delay or do not take this option.

The family may not be one which accepts the burden willingly and for this reason they may put all kinds of subtle pressure on the sick person to ask for euthanasia. It could be inspired by greed, laziness, resentment, stress and many more things. The increase in abuse of the elderly in recent years has made this a particular concern of anti-euthanasia groups.

Dying is an expensive business. The latter stages of one’s life can be very expensive. Family may have to take time off work (unpaid), medical expenses and treatment could be higher than they were before. Homes may have to be adapted for the dying person and so on. All of this adds up to a lot of money when resources are scarce. For £50 and injection could be given and the life ended. The dying person may feel that euthanasia is the fairest option. Why waste money on expensive treatments when there’s one that would end the need for any treatment- could it be bank managers and accountants who put indirect pressure on the dying here if euthanasia were made legal? Could they refuse a loan or a budget because you need it to care for the dying? Legalising euthanasia opens that door.

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Practical Arguments

At a practical level there are arguments against euthanasia too, some of which we have been over before, so forgive the repetition if you will.

Palliative Care Palliative care is physical, emotional and spiritual care for a dying person if there is no cure. The support extends to family and friends. Done well, palliative care is often enough to prevent a person from asking for euthanasia. Dame Cicely Saunders, founder of the modern hospice movement said, “You matter because you are you. You matter to the last moment of your life and we will do all we can to help you die peacefully, but also to live until you die.” Thus the argument goes that you do not need euthanasia because we are able to offer high quality palliative care for the dying. The World Health Organisation states that palliative care affirms life and regards dying as a normal process; it neither hastens nor postpones death; it provides relief from pain and suffering; it integrates the psychological and spiritual aspects of the patient. It therefore supports palliative care although it is careful not to make any statement about its views on euthanasia.

Those involved in palliative care (mainly in hospices) are trained to deal with the needs of everyone involved with the dying patient. Many of these needs are listed under the ‘Good Death’ list noted earlier in these notes. Palliative care tries to ensure that nobody dies on their own (unless that is their wish). Death is a lonely journey so palliative care provides support for as long as it can. It does not come cheap and the fear is that if euthanasia is made legal then palliative care would be cut back because it is less cost effective. At times though, palliative care is not enough. Sometimes the pain cannot be relieved and death is a better option. Or perhaps the patient does not want to become too dependent and lose their dignity. Maybe the patient wants to die at home and not in a hospice or maybe the patient wants to be fully alert when they die rather than drifting off into a drug induced coma or maybe even all that is sought is palliative care up to a point and then a decision to terminate life no matter what care and pain relief is available.

David Roy, a Canadian bio-ethicist said, “There should be no law or morality that would limit a clinical team or doctor from administering the frequent dosages of pain medication that are necessary to free people's minds from pain that shrivels the spirit and leaves no time for speaking when, at times, there are very few hours or days left for such communication.”- hard to say if this is anti-euthanasia though!

How Do You Regulate Euthanasia?

So you have you new law. Well done, how enlightened! But how do you keep a check on it? How do you know that it is being properly applied? How do you know that it is not being abused? How do you know that the vulnerable are being protected? How do you test people’s motives? The law tells us not to commit murders but they still go on. This law would tell us that voluntary euthanasia is legal, but how would we be sure that we could stop people abusing it? Some might say it is better to have some rules than none but the reply to this is if you don’t have the rule in the first place then you don’t have to worry about it being abused. Better to legislate and regulate some would say-it goes on so we should get control of it- but to make it the law means that you are

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saying it is okay to do it. Legalising drugs will only lead to people taking more; legalizing euthanasia will only lead to more of it- it’s the slippery slope again.

You could, of course, do a full survey of the patient and family’s position to safeguard the vulnerable but the problem with that is that those who do the assessing only ever have a snapshot of the situation. They do not know what it is like on a day to day and hour by hour basis. Just like school inspections- inspectors cannot get into the real nitty-gritty, it’s just a quick snap shot of what they see and then they pass a comment (or two or three). Do we want a decision about a person’s life to be based on a snapshot view of a group of strangers? Many would say, ‘no.’ This approach is expensive and would only add to the cost of the care of the dying draining yet more valuable resources away.

Poor Quality Medical Care

There’s also concern about what effect legalizing euthanasia would have on the care of patients. Doctors and nurses, because they are committed to saving the living, could become less concerned about those patients who are due to receive euthanasia. Research into cures for terminal diseases might be affected if all we are going to do is let these patients die. Likewise, euthanasia might be treated as the new cost-effective way of treating patients. Finally, if euthanasia is the approach to the terminally ill, at a practical level medical staff may not explore ways of providing the best possible palliative care for them.

Playing God

It’s a favourite phrase of anti- euthanasia campaigners- Doctors should not be allowed to play God. The fact is that doctors do this kind of thing all the time although not necessarily involving euthanasia. Legalising euthanasia will give doctors too much power. They have the information and facts to hand on a patients’ prospects and for them alone to make a decision would be wrong. There is the risk that doctors would abuse their power and not go to local committees and the likes (e.g. Holland) for approval. Already some doctors have been caught placing DNRs on elderly patient’s files- an abuse of power, what is to stop them writing ‘euth’ at the top of some one’s file?

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The Arguments For Euthanasia

As a general rule religions are against euthanasia so there will not be a huge amount in here about religious responses. These will be looked at in a bit more detail later on because religions do have ways of permitting euthanasia although they would never call it euthanasia! We will look here at the ethical and practical arguments for euthanasia.

Ethical Arguments

The Right To Die

This is the mantra of pro-euthanasia groups- everyone should have the right to die. The word euthanasia comes from two Greek words which, when combined, mean ‘peaceful’ and ‘easy death.’ Behind the idea of the right to die is the belief that just as we all have rights in life so too should we have rights as we approach our death. Those rights include being able to make the decision about how and when you want to die. Our right to life includes our right to die. We should be able to live our lives with a certain quality and if that quality is not there then we should have the option to end it. Dying is an important part of our lives and just as we are able to make decisions about other important parts of our lives so too should we be able to make decisions about our death when circumstances permit. Therefore we have the right to make our death as pleasant as possible. We should not forget our obligations to medical staff, family and society in general but these should, in no way, limit a person’s right to die the death they want to die. Nobody should be forced to live a life which has become intolerable through illness or loss of dignity. To do that is to remove an individual’s right to be treated with dignity and an individual’s right to be treated with respect and never be subjected to degrading treatment.

The Utilitarian Argument You will recall the ethical view of greatest good for greatest number…well, this argument for euthanasia works on that principle. The idea is that sometimes euthanasia is in the best interests of everyone concerned. Providing that nobody’s rights are compromised it would be acceptable to give euthanasia to someone who requested it because of the number of people who would benefit e.g. the patient’s family, the medical staff and the health service and, probably, the patient himself even although it meant his death.

The Kantian Approach Immanuel Kant argued that an act can be correct if the rule can be universalised. Supporters of euthanasia believe that it can be universalised as a moral act.

In relation to euthanasia the argument runs like this: if a person wants euthanasia it would not make sense for them to argue that for all other people euthanasia is wrong. It would make sense however for them to say that if it is right for them to ask for euthanasia then it is right for everyone to ask for euthanasia. In the same way as someone giving euthanasia if it is right for them to give euthanasia when an individual asks for it then it would be right for them in all circumstances to give requested euthanasia.

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The Quality of Life Life is not just about existing. Life is about having a good quality of life or rather, a quality of life that is acceptable to you. There is no single definition of a good quality of life, it is a very individual thing. Euthanasia should be made legal because for some people the quality of their life will deteriorate to the extent that they are reduced to existence rather than living. Existence means being there for no great purpose. Existence means being forced to continue when there is no hope and no point. Existence means, for most people, that they are unable to make decisions about their future due to their condition. It is at that point that there is no quality of life because to have a quality of life we must at least be capable of making decisions, interacting with others and having the hope of treatment or cure.

Compassion Prominent Methodist minister Leslie Weatherhead said, “I sincerely believe that those that come after us will wonder why on earth we kept a human being against his own will, when all the dignity, beauty and meaning of life have vanished: when any gain to anyone was clearly impossible, and when we should have been punished by the state if we had kept an animal alive in similar physical conditions." This is a rare religious statement in favour of euthanasia. The comparison is simple- we put down animals that are suffering as an act of compassion- why can’t we do the same for human beings?

The Will of the People There is a growing public opinion that euthanasia should be legalized. Surveys conducted in various countries show increasing and in some cases overwhelming support for euthanasia. If governments are truly democratic then they should listen to the people and if the people are pressing for a debate or even legalization of euthanasia then the government has a responsibility to take account of their views. To ignore public feeling and to hide behind church pronouncements or legal complexities is simply ducking the issue and not accepting responsibility.

Practical Arguments

Legalisation Means Control Making euthanasia legal means that something that was underground can be controlled and regulated. It takes the pressure of doctors in the heat of the moment when a decision has to be made. They would know that they could not be prosecuted if they acted in the patient’s best interests. The fact is that at present euthanasia goes on so any law would just be formalizing what is there and it would then protect both patients and medical staff. Using the experience of Oregon and Holland a reasonably water tight law could be introduced. There will be abuses, that is inevitable with any law, but the chances of detecting abuse would surely be increased if every case of euthanasia was monitored.

Economic Reasons Public health services all over the world do not have enough resources. Finance has to be carefully managed. Care of the dying is expensive and the duty of health services is to cure the sick. Valuable resources are being diverted away from care of the living to look after those who cannot be cured. Worse still, the money and resources are being used on people who may not want to live so it is a double waste of resources. NB- nobody, government or pro-euthanasia group, has suggested this approach but it is nevertheless a valid argument.

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Pain Relief One of the main arguments for euthanasia is that it puts patients out of their misery. There may come a time when an illness has run its course and when pain management becomes impossible- it is at that time that supporters of euthanasia argue an individual has the right to put an end to their pain through euthanasia. The pain belongs to the individual- not God, not the family, not the hospital nor the law- it belongs to them and it is for the individual to choose whether or not they want the pain to be removed. Legalising euthanasia would allow a person to have that choice. It would allow them the choice not to die in pain.

Removal of the Burden For some patients the burden their illness and disability places on their family is intolerable. They are aware of the strain their condition places on those they love most. They are aware too of the financial burden they place on the health service. Living with this in mind and living when their death is inevitable is as much a burden, for some, as the physical pain they have to endure. For these patients they believe that they should be allowed to choose whether or not they live. For some patients this will not be an issue but for others, because it is an issue it can be an argument for legalizing euthanasia.

Living Wills or Advance Directives Doctors are agreed that where a patient’s wishes are known it is easier to make a decision regarding their future. Pro euthanasia supporters argue that if we have a Living Will then this will be of practical help both for the family and medical staff. Nobody outside the patient has a decision to make; the patient has taken that burden off people. True, people can change their minds but if euthanasia is that much of an issue for them and they have changed their minds then it is likely that the living will would have been withdrawn.

The Responses of Christians

It is very difficult to find any Christian group that advocates voluntary euthanasia. As pointed out before Christians have a belief in life as being sacred and being given by God and this prevents them from supporting euthanasia.

The Roman Catholic Church On May 5, 1980, the Sacred Congregation for the Doctrine of the Faith issued an official "Declaration on Euthanasia," which reaffirmed the Church's prohibition of all forms of physician-assisted suicide and euthanasia. Performing euthanasia on another or allowing it for oneself is called a "violation of the divine law, an offence against the dignity of the human person, a crime against life, and an attack on humanity."

In the most recent version of the Catechism of the Catholic Church (2003), all forms of suicide and euthanasia remain strictly prohibited:

Everyone is responsible for his life before God who has given it to him. It is God who remains the sovereign Master of life. We are obliged to accept life gratefully and preserve it for his honour and the salvation of our souls. We are stewards, not owners, of the life God has entrusted to us. It is not ours to dispose of.

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Suicide contradicts the natural inclination of the human being to preserve and perpetuate his life. It is gravely contrary to the just love of self. It likewise offends love of neighbour because it unjustly breaks the ties of solidarity with family, nation, and other human societies to which we continue to have obligations. Suicide is contrary to love for the living God.

If suicide is committed with the intention of setting an example, especially to the young, it also takes on the gravity of scandal. Voluntary co-operation in suicide is contrary to the moral law. Grave psychological disturbances, anguish, or grave fear of hardship, suffering, or torture can diminish the responsibility of the one committing suicide.

We should not despair of the eternal salvation of persons who have taken their own lives. By ways known to him alone, God can provide the opportunity for salutary repentance. The Church prays for persons who have taken their own lives.

Those whose lives are diminished or weakened deserve special respect. Sick or handicapped persons should be helped to lead lives as normal as possible.

Whatever its motives and means, direct euthanasia consists in putting an end to the lives of handicapped, sick, or dying persons. It is morally unacceptable.

Thus an act or omission which, of itself or by intention, causes death in order to eliminate suffering constitutes a murder gravely contrary to the dignity of the human person and to the respect due to the living God, his Creator. The error of judgment into which one can fall in good faith does not change the nature of this murderous act, which must always be forbidden and excluded.

But then the RC Church seems to permit passive euthanasia: Discontinuing medical procedures that are burdensome, dangerous, extraordinary, or disproportionate

to the expected outcome can be legitimate; it is the refusal of "over-zealous" treatment. Here one does not will to cause death; one's inability to impede it is merely accepted. The decisions should be made by the patient if he is competent and able or, if not, by those legally entitled to act for the patient, whose reasonable will and legitimate interests must always be respected.

Even if death is thought imminent, the ordinary care owed to a sick person cannot be legitimately interrupted. The use of painkillers to alleviate the sufferings of the dying, even at the risk of shortening their days, can be morally in conformity with human dignity if death is not willed as either an end or a means, but only foreseen and tolerated as inevitable. Palliative care is a special form of disinterested charity. As such it should be encouraged.

The above is what we call double effect.

Church of England ‘The Church of England encourages its members to think through issues themselves in the light of the Christian faith and in dialogue with the Christian tradition… In the tragic case of Tony Bland in 1993 the point was made that developments in medical science raised new questions which previous discussions of the law in relation to murder could not have envisaged…The House of Bishops of the Church of England submitted a joint statement with the Roman Catholic Bishops of England and Wales’. ‘God himself has given to humankind the gift of life. As such, it is to be revered and cherished… All human beings are to be valued, irrespective of age, sex, race, religion, social status or their

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potential for achievement. Those who become vulnerable through illness or disability deserve special care and protection. Adherence to this principle provides a fundamental test as to what constitutes a civilised society… A positive choice has to be made by society in favour of protecting the interests of its vulnerable members even if this means limiting the freedom of others to determine their end’. Neither of our Churches insists that a dying or seriously ill person should be kept alive by all possible means for as long as possible. On the other hand we do not believe that the right to personal autonomy is absolute… We do not accept that the right to personal autonomy requires any change in the law in order to allow euthanasia’. [PASSIVE EUTHANASIA] ‘The exercise of personal autonomy necessarily has to be limited in order that human beings may live together in reasonable harmony. Such limitation may have to be defined by law. While at present people may exercise their right to refuse treatment (although this may be overridden in special but strictly limited circumstances), the law forbids a right to die at a time of their own choosing. The consequences which could flow from a change in the law on voluntary euthanasia would outweigh the benefits to be gained from more rigid adherence to the notion of personal autonomy. But in any case we believe… that respect for the life of a vulnerable person is the overriding principle’. ‘The right of personal autonomy cannot demand action on the part of another. Patients cannot and should not be able to demand that doctors collaborate in bringing about their deaths, which is intrinsically illegal or wrong’. ‘It would be difficult to be sure that requests for euthanasia were truly voluntary and settled, even if safeguards were built into the legislation, and not the result either of depression or of undue pressure from other people’ [i.e. terminally ill patients using up scarce resources or are an emotional burden to their family may be pressurised to allow a doctor to end their life]. ‘There is a proper and fundamental ethical distinction which cannot be ignored between that which is intended and that which is foreseen but unintended. For example, the administration of morphine is intended to relieve pain. The consequent shortening of life is foreseen but unintended’. [This is the doctrine of double effect] ‘Doctors do not have an overriding obligation to prolong life by all available means… A pattern of care should never be adopted with the intention, purpose or aim of terminating the life or bringing about the death of a patient… requests for voluntary euthanasia would result in a breakdown of trust between doctors and their patients… Medical personnel [should] remain aware of how advice on pain control may be obtained… Adequate resources [should be] made available for the care of sick and elderly people’ ’ … to deliberately kill a dying person would be to reject them. Our duty is to be with them, to offer appropriate physical, emotional and spiritual help in their anxiety and depression, and to communicate through our presence and care that they are supported by their fellow human beings and the divine presence’.

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David Gushee, a professor of Moral Philosophy summed up the Churches’ problem in Christianity Today (magazine): Let's respond to this question through the eye of the family caring for a sic or dying loved one, because that i the context in which most of us face this agonising issue. We do not like to see loved ones sick, dying, or in pain. It goes against nature, moral training, and Christian faith to sit happily when they suffer.Our first instinct will be to try to find a way to save their lives. We will be supportive of aggressive treatment for as long as our loved one, the rest of the family, and the medical eam hold out hope for a cure. When such hope is no longer realistic and death is imminent and certain, we try to make our loved one as comfortable a possible. There will be little debate that even if the family ends now-futile medical treatment (such a chemotherapy), all reasonable efforts mut be made to alleviate suffering. Beyond hoping for a miracle, all who love the dying person will pray for a peaceful death soon. So far, so good. The question, however, seems to presuppose that this strategy is not good enough when the dying person is in "terrible pain." At that point, it is implied, Christians are hardhearted in not supporting euthanasia. This is a widely held view today. But it is wrong. First we need to define some terms. Most thoughtful bioethicists or physicians accept the legitimacy of withholding or withdrawing medical treatments when they are no longer bringing benefit to an irretrievably dying patient. Nor is there any opposition to aggressive use of painkillers and other form of palliative care. But euthanasia is a different thing when it means (more than simply withdrawing medical treatment) ordering or implementing some act that kills a dying person: whether it is a lethal injection, an overdose of drugs, intentional starvation, or a gunhot to the head. Morally, it matters little if we do the deed ourelves, give our loved one the means to do the deed, or pay the doctor to do it. In any case, we are involved in an act that directly brings about the death of another human being. The quetion is correct in implying that the church, or at least the great majority of its moral thinkers and traditions, opposes euthanasia. This opposition is based ultimately on the commandment "You shall not murder," but is articulated in various other ways, including; the belief that the intentional taking of the life of a peron who poses no threat to the community is a form of murder and is thu intrinsically wrong, even if it i done with good motivesthe fear that the freedom to put to death sick or dying people is a violation of the mandate of the medical profesion and would thus deeply corrupt itthe fear that base motives such a financial gain will interfere with the fmily decision-making process and lead to what is essentially sanctioned family murder of the oldthe fear, based on historical experience, that political leaders will take over the power to kill the infirm and sick and ue it to cut the government's medical expenes or advance some kind of perverse vision of the common goodan intuitive sense that a good and loving family, or a good and loving nation, will find some way to show it compassion to the sick and suffering that does not involve directly taking their lives.

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Fundamentally, Christians oppose euthanasia because it simply does not fit with core Christian theological convictions. God is Creator, not u (Gen. 1:1 ). Human life in his hand (Job 1:21 ). Illness and death are a tragic part of life in a sin-sick world (Gen. 3:19 ), and we must fight them hard—as Jesus fought them hard (Mt. 4:24 ). The time will come when every person's earthly life is over. At that poit, our only hope lie the resurrection promied to those who blong to Jesus Christ (1 Cor. 15:50-56 ). We are called to heal the sick where we can, comfort the dying always, and entrust the dead to God. But we are never called, and we are never for, to hasten the dying across the threshold into eternity.

Finally another Reformed or Protestant Church, the Methodist Church has also come out strongly against euthanasia. Their statement is as follows:

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So what is the Methodist Church's view?

The Methodist Church is strongly opposed to euthanasia.

Why? This opposition is partly based on the practical difficulties that would be faced by doctors and other medical staff. Who would make the decisions? What would the impact be on staff working in the hospital of knowing that euthanasia was administered there? Would relatives be encouraged to be present … as loved ones, as witnesses? These practical problems, and their implications for relationships between professional staff, patients and close relatives are obvious. The medical profession as a whole is opposed to legalising of euthanasia. There is also the difficulty of framing legislation in such a way as to exclude its misuse in the shape of allowing ‘difficult' patients to be done away with, allowing relatives to short circuit the natural life span of a difficult individual.

But isn't it compassionate in some extreme cases?

A firm conviction against euthanasia does not lessen the complex moral problems integral to the final stages of some terminal illnesses. Sometimes, for example, the management of excessive pain may have the outcome of shortening life. On other occasions it may be extremely difficult to ascertain in what sense, if any, a patient may be judged still to be alive (for example, persistent vegetative state).

Should people have the right to decide not to be kept alive 'artificially'?

One of the issues being examined in a current Methodist study is that of ‘living wills'. This is an indication by the author of what would be a legal document that he or she does not wish, should they become ill with no apparent hope of recovery, to be ‘kept alive'. In other words, once that stage is reached, no further treatment would be given except to relieve pain. This is proving to be a more acceptable way forward for some who, while remaining opposed to euthanasia, believe that the manner of the ‘ending of life' is becoming a very difficult issue in our increasingly long-lived society.

What guidance can we get from Bible?

The Christian conviction is that ‘the life of men and women bears the stamp of God who "made man in his own image" (Genesis 1:27). This is the source of our basic dignity and it is the biblical basis for the sanctity of human life.' What God has given, we should not take away. Death is an event marking a transition rather than a terminus. We are called to use all God's gifts responsibly and to find in every situation the way of compassion. This compassion can be shown in energetically developing better methods of care for the dying. The hospice movement has made an invaluable contribution here.

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Pro Life Pro life is a secular group that campaigns against euthanasia and abortion along with a number of other issues. It is widely supported by the churches for its stance on euthanasia. Here is their statement on euthanasia: Our Position The ProLife Alliance is absolutely opposed to any form of euthanasia or assisted suicide. We respect basic human rights at every stage of life, and oppose any changes in existing law which facilitate euthanasia in any form whatsoever. Health professionals are not obliged to give every possible treatment to every patient in every situation just because those treatments exist. It can be perfectly good medical practice to withhold medical treatment if the burden of such treatment outweighs the benefit. There comes a point when the duty to try to save a patient’s life is exhausted and aggressive medical treatment is now inappropriate.

The ProLife Alliance does not oppose the withholding of burdensome medical treatment. What we are opposed to is the intentional killing of the patient, by act or by omission. It should also be noted that we do not agree with the re-classification of food and fluids as medical treatment. This is basic care, which should not be withheld except in extreme situations (for example, at the very end of life, if the patient’s body can no longer process food and fluids). The principle of double effect helps doctors to distinguish between aiming to end life, which is never justified, and merely aiming to give or withhold treatment, while foreseeing this may hasten death. Occasionally medication prescribed with the intention of providing pain relief may shorten the patient’s life as an unintended side-effect. This is not euthanasia, and can be morally justified. Palliative Care We support the life-affirming approach to terminal illness known as palliative care. According to the World Health Organization, palliative care… provides relief from pain and other distressing symptoms; affirms life and regards dying as a normal process; intends neither to hasten nor postpone death; integrates the psychological and spiritual aspects of patient care; offers a support system to help patients live as actively as possible until death; offers a support system to help the family cope during the patient’s illness and in their own

bereavement; uses a team approach to address the needs of patients and their families, including

bereavement counselling, if indicated; will enhance quality of life, and may also positively influence the course of illness; is applicable early in the course of illness, in conjunction with other therapies that are intended

to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing complications.

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Why Euthanasia Is Unacceptable If we were to accept voluntary euthanasia, and the notion that some lives are worthless and that death is a benefit, then why should the mentally incapacitated or the newborn (i.e. those incapable of asking to be killed) be deprived of this “beneficial” treatment? The rationale which justifies voluntary euthanasia also justifies non-voluntary euthanasia. As a result of a legal test case (that of Tony Bland, victim of the Hillsborough disaster), UK law does allow passive euthanasia in some cases. This means that certain people can be purposefully killed even without their consent, as was Tony Bland, whose death was brought about by dehydration and starvation following withdrawal of tube-feeding. The ProLife Alliance rejects the message that support for euthanasia sends to sick, disabled and depressed people: the message that life in their condition is intolerable, the message that even leads some to ask “Do I have a duty to die?” One cannot care for people by killing them. The Euthanasia Mentality Is On a Slippery Slope A real danger of legalising euthanasia, as the Dutch experience has shown, is that it is impossible to prevent the boundaries from being expanded. Initially euthanasia was available for those with terminal illness, then for those with chronic illness, and most recently Groningen University Hospital extended provision to children under 12. Evidence from Holland demonstrates that voluntary euthanasia leads to non-voluntary and even involuntary euthanasia. When the law says that killing is the answer to suffering in some cases it inevitably becomes the answer to suffering (or disability) in other cases. To say that some human lives have no value is dangerous to patients across the board. There is no such thing as a worthless human life: all lives have value, and must be respected. Dignity in Dying (VES) This group used to be called the Voluntary Euthanasia Society but in 2005 it changed its name. It is the leading campaigner in the UK for legalizing euthanasia. Here is its statement: What we do Dignity in Dying is the leading campaigning organisation promoting patient choice at the end of life. We are also the foremost research body on end-of-life issues. We are independent of any political, religious or other organisation. We are supported entirely by voluntary contributions from members of the public. We were set up as the Voluntary Euthanasia Society (VES) in 1935 by a group of clergy, doctors and lawyers. Dignity in Dying was the new name overwhelmingly endorsed by members at their annual meeting in 2005.

Vision Our vision is for everyone to be guaranteed choice and dignity at the end of their life. Palliative care and medical treatment should be patient-led and include a legal right to effective pain relief to help ease suffering. We want end-of-life decision making to be open and honest, and firmly under the control of the patient. We want a full range of choices to be available to terminally ill people including medically assisted dying within strict legal safeguards. Such legal safeguards would also protect the vulnerable and remove the conditions that give rise to unchecked euthanasia and "mercy killings".

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Lobby Dignity in Dying lobbies Government and Parliament to change the law to improve patient choice. We also defend patients legal rights over refusing life-prolonging medical treatment. We also support patients being able to ask for life-prolonging treatment. We worked closely with Lord Joffe on drafting the Assisted Dying for the Terminally Ill Bill which is currently in Parliament.

Empower Every year hundreds of terminally and seriously ill people contact Dignity in Dying for advice and guidance on how to retain control at the end of their lives. We work alongside terminally ill people such as Diane Pretty. We help them get their voices heard. We can help if your medical treatment wishes, such as those contained within a Living Will, are not being respected.

Educate Dignity in Dying educates the legal, medical and nursing professions about Living Wills and other end-of-life decisions. Through research and information work, Dignity in Dying raises the level of debate on end of life decision making both in relation to assisted dying and other end of life decisions like refusal of treatment.

Living Wills As the UK's leading supplier of Living Wills, Dignity in Dying is regularly consulted by the public, NHS trusts, Government bodies and healthcare professionals. A Living Will is a legally binding document which enables you to set out how you wish to be treated should you no longer be able to communicate your wishes to your health care team. The Dignity in Dying Living Will is unusual because it is pro-choice. It enables you to exercise the legal right to refuse treatment. It also enables you to ask for life-prolonging treatment. While such a request is not legally binding, it is good practice for health care professionals to respect this decision. Our Living Will is drafted by top lawyers to ensure its legal standing.

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Key Points UK Law Illegal Treatment can be withdrawn or refused Double effect is legal Goes on all the time Benefits and drawbacks of present law

Dutch Law Legal since 2002 Available for 12+ only Referred to committee Referred to medical examiner Preferred that patients do it themselves Most requests are refused Small percentage officially recorded Benefits and drawbacks

BMA Guidelines Consultation with patients and family Withdrawal and withholding treatment ok after consultation Neutral view on legalization (effectively divided) Nobody should be asked to do anything against their conscience

Arguments For Ethical Arguments The Right To Die The Utilitarian Argument The Kantian Approach The Quality of Life Compassion The Will of the People

Practical Arguments Legalisation Means Control Economic Reasons Pain Relief Removal of the Burden Living Wills or Advance Directives

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Arguments Against

Religious Arguments Life is a gift from God and only God can take it away. Suffering has a purpose and to end a life deliberately is to remove that purpose. Life is sacred. It is valuable no matter what condition an individual is in. We all have a duty to protect the vulnerable- and the vulnerable includes the sick and the

dying. To kill a dying person is to reject them as an individual. Our right to make up our own minds should not require an act by another person. Death should come at a time of God’s choosing and not our own. Slippery slope

Ethical Arguments No Life is Less Worth Living Than Another Not in the Patient’s Best Interests The Rights of Others Pressure on the Vulnerable

Practical Arguments Palliative Care Regulation Poor Quality Medical Care Playing God

Responses

Roman Catholic Church Against (see religious reasons) but they do allow double effect and passive euthanasia but would not

call it that.

Church of England As RC

Methodist Church As RC

Pro Life Non religious group

As religious arguments and other arguments against euthanasia

Dying With Dignity Non religious group As arguments for and Dutch version of the Law

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Exam Approaches

1. There will always be a case study and it will focus on certain issues that arise in euthanasia.

Look up case studies and news articles on the internet and identify the issues that are being raised.

2. Definitions of the different types of euthanasia will also be a regular feature. They will be worth between 2 and 4 marks and could come in a number of guises. Sample questions might be:

What is meant by passive euthanasia? Give two examples of active euthanasia. What are the main differences between active and passive euthanasia? What is involuntary euthanasia? Describe the main features of voluntary euthanasia.

3. You will be expected to know the UK and Dutch laws on euthanasia. Questions again could be worth 3-5 marks although questions on the UK law might be worth less because there is less to say. Sample questions:

What are the key points of the law in Euthanasia in Holland? Describe UK laws on euthanasia. What safeguards for the patient and medical staff are contained in the Dutch euthanasia

laws?

4. You will also need to be aware of BMA guidelines along with the views of one non religious group and two Christian views (though they need not be contrasting). Questions here could be worth more, anything between 4-8 because they are likely to include some AE.

What are the key points of the BMA guidelines on euthanasia? Is it possible for a Christian to support the BMA guidelines on euthanasia? Do you agree that the BMA view on euthanasia is as neutral as they suggest? State the views of one non religious group on euthanasia and assess how acceptable their

views would be to one Christian group. What are the main objections that Christians have to euthanasia? Is it true to say that Christians are against all forms of euthanasia? Refer to two Christian

views.

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5. There will also be questions on the arguments which will consist mainly of identifying what they are, explaining the strengths and weaknesses (for which you more or less do a comparison of strengths and weaknesses), the problems caused by legalizing euthanasia and whether or not religious or secular groups would agree with the arguments. These questions will be very varied and wide open. They should also be pretty straightforward and worth up to 10 marks (at Int2) so you will be writing a piece of fairly extended writing.

What are the main issues in the debate about legalizing euthanasia? How might physician-assisted suicide be justified? Evaluate the religious objections to voluntary euthanasia. Why are there so many concerns over legalizing euthanasia? How convincing are the arguments in favour of euthanasia?

Something to remember is that very often questions with high marks will have some kind of statement followed by a short question. Read the statement carefully and ensure that you pick out exactly what it is looking for.

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