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Euthanasia: The “good death”!
Surg Neurol
423
1991;36:423-5
Euthanasia: The "Good Death"! Edward C. Benzel, M.D., F.A.C.S. Division of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
A dissertation recently presented in this journal discussed euthanasia with regard to its religious and ethical ramifications [5]. Among the subjects discussed were concepts and issues such as the reverence for human life, the atheistic/agnostic perspective, the religious perspective, and the background that determines the individual's ethical beliefs and aids him/her in formulating attitudes regarding issues such as euthanasia. However, the true issues surrounding the concept of euthanasia were evaded and, thus, further thrust into a state of confusion and misconception. If most people consider life to be good and special, how can one interpret the taking of such a life to be "good" (euthanasia taken literally means "good death")? Some believe there is no "good death" and that "a human life should not be destroyed, regardless of how fragile or futile it seems" [5]. Alexander [ 1] has addressed the broad and far-reaching aspects of the term euthanasia. In his dissertation, he pointed out that ambiguity may often be involved with medical ethics issues, such as euthanasia, and that decision-making processes require the need for the individualization of each response. A separation of fact from fiction is, therefore, mandatory. To clarify the issues involved with euthanasia, an attempt will be made herein to establish the true facts and issues, and to separate these from myth and inappropriate emotion. To some, life is mystical. Sorensen [5] suggested that there is a mystical nature to life [5]. "The essence of life" and "the 'spark' which is present in life but absent in death" are phrases that emphasize, to a significant extent, our lack of understanding of the p h e n o m e n o n we call life. Through scientific investigation we have narrowed the schism that exists between the unknown (which is often viewed as mysterious) and the known. We have been able, for example, to define life's point of termination, and we have characterized it scientifically and legally by a constellation of parameters called brain death criteria. Although these criteria vary somewhat from Address reprint requests to: Edward C. Benzel, M.D., F.A.C.S., Division of Neurosurgery, University o f N e w Mexico School of Medicine, Albuquerque, N e w Mexico 8 7131. ~'~)1991 by Elsevier Science Publishing Co., Inc.
country to country, state to state, institution to institution, and physician to physician, they are relatively uniform and consistent. In spite of this, the terms brain death, vegetative state, and irreversible coma have at times been used interchangeably. The lay public and many physicians remain confused regarding the definitions o f these clinical states [9]; this is unfortunate and disconcerting. This "ignorance" compounds the public's lack of understanding of the complex issues involved with the termination of life, issues such as euthanasia, brain death determination, and organ procurement. These definitions must be clearly established in the minds of physicians before we can expect the lay public to sort out the pertinent issues and make legitimate rational decisions. Euthanasia (in the context utilized here), simply stated, is the act of permitting a hopelessly ill individual to die at his or her (or family or loved one's) request. Although there have been many arguments pro and con regarding euthanasia, the true issue of concern is the right of the individual: Does he or she have the right to request that life-sustaining treatment be stopped, and if so, under what circumstances? The word euthanasia is, perhaps, inappropriate terminology. To some, it implies the act of "putting to sleep," as one might do for an ailing pet. Some think it can be performed without the consent of the individual, which adds to its negative connotation. Euthanasia has been divided into active and passive components, the active being akin to the putting to sleep situation and it is emphasized, with the individual's consent (or the consent of his or her legal guardian). The difficulty most often encountered with active euthanasia is its lack of clear separation from the term "murder." The public's fear of random and reckless active euthanasia needs to be respected. The definition of euthanasia used here is that of passive euthanasia, the act of permitting the death of a hopelessly ill individual at the individual's (or family or loved one's) request. This is a passive process in which the physician does not actively cause the individual to die. Many ethicists are concerned about the terminology involved with euthanasia: they believe there should be no separation between the active and passive compo0090-3019/91/$3.50
424
Surg Neurol 1991;36:423-5
nents. Perhaps the term euthanasia should not be used at all because of its negative implications. What is being addressed here is not "murder," "killing," or euthanasia per se but an attempt to define more clearly the rights of the individual. If the individual does, indeed, have the right to choose his or her own medical therapy, then the withholding or withdrawal of a therapy upon the request of the patient is simply complying with the patient's wishes. Perhaps it should not be considered as euthanasia, but simply the act of respecting the rights of the individual. However, we are stuck with the existing terminology. What we can do to minimize confusion is to deemphasize the concept of euthanasia and emphasize the issue of individual rights. Perhaps we should also deemphasize the use of the words active and passive as they pertain to this situation. The context in which the term euthanasia is applied is significant. If applied to a person who has been diagnosed as brain dead, the point is moot: life-sustaining therapies cannot be removed from a person who is dead. This may seem obvious, but is nevertheless often misconstrued [9]. The issue of euthanasia or the right to die, therefore, only applies to the living. Only those individuals who (or whose families) suffer from the continuation of their own life are the focus of this discussion. These include the terminally ill, those in an irreversible coma, and those whose lives are sustained by life support systems or treatments that (to the individual) prolong an intolerable life. The "right to die" is thought by most to be an individual choice [6,7]; the courts and a presidential commission have confirmed this [4,8]. It is not a moral or religious issue. In fact, Fletcher [3] has outlined five maxims to assist one in making the decision to forego life-sustaining treatment. They incorporate the ethical and legal concerns of five hypothetical situations into guidelines that allow for a rational approach in most circumstances. We cannot take away an individual's right to make decisions regarding his or her own body (regardless of the individual's rationale) if he or she is of sound mind. In this context, a physician cannot force a treatment upon an individual. The type, extent, and timing of medical care is one's choice (within the limits of the physician's recommendations). In these regards, the individual's choice is sanctified, not human life itself. If (1) the right to die is taken away from the individual and placed into the hands of theoretically more learned professionals and (2) these learned professionals opt for ruling in favor of the "sanctity of life" at all costs, chronic care facilities and intensive care units may soon be occupied by an increasing population of chronic, extendedcare patients who are "alive" against their will. More frightening than these ominous possibilities is the
Benzel
thought of financial constraints dictating the need for rationing health care. If chronic care facilities and intensive care units are filled with people who no longer enjoy a meaningful life and/or who only harbor a vegetative existence, we may be forced (for reasons that are neither desirable nor even noble) to decide who should live and who should die based upon financial constraints, rather than upon the wishes and desires of the individual. It should be clear that the rights of the individual supersede any concerns regarding the sanctity of life. This is not to say that life is not important. It does, however, imply that the importance of life is associated closely with the individual's interpretation o f his or her own quality of life. The rights of the individual, especially in countries where freedom and individual rights are a premium, should permeate all aspects of life, from the right to free speech to the right to die. We as physicians cannot force a treatment, such as a surgical procedure, upon a rational individual against his or her will; nor can we play " G o d " and demand the continuation of a medical regimen designed solely to increase the duration o f a life deemed not worth living by a rational patient. We cannot alter our roles as physicians simply because a patient has reached a helpless state. We have to maintain a constant and unalterable course regarding our care of patients, regardless o f the extenuating circumstances and the degree of helplessness of the person whose life and death are in our hands. Indeed, "some articulate and influential medical practitioners in this country" [5] have effectively and solidly posed clear and succinct arguments in favor of euthanasia [8]. Perhaps these arguments address the issue of individual rights more so than that of euthanasia. Individual rights a r e the issue. They a r e the bottom line. If the individual's rights are honored, the controversy over euthanasia will vanish. There will be no "slippery slope." (This point has been addressed by the American Medical Association's Council on Scientific Affairs and Council on Ethical and Judicial Affairs [2].) The term euthanasia as used here implies a "good death." To extend this definition to exclude the concerns and rights o f the individual, however, is treading on dangerous and possibly unethical grounds [1]. Therefore, we must all be careful not to violate the rights of the individual. If we preserve these rights, we will allow our patients to enjoy both a good life and a good death.
References 1. Alexander E. Euthanasia. Surg N e u r o l 1989;31:558-9. 2. Council on Scientific Affairs and Council on Ethical and Judicial Affairs of the American Medical Association. Persistent vegetative state and the decision to withdraw or withhold life support. J A M A 1990;263:426-30.
Euthanasia
3. FletcherJC. Decisions to forego life-sustaining treatment. Virginia Medical 1989;11:462-5. 4. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Deciding to forego life-sustaining treatment. Washington, DC: Government Printing Office 1983;236-9. 5. Sorensen BF. Euthanasia: the "good death"? Surg Neurol 1991;35:74-5. 6. Steinbrook R, Lo B. Artificial feedingwsolid ground, not a slippery slope. N Engl J Med 1988;318:286-90. 7. Wanzer SH, Adelstein SJ, Cranford RE, Federman DD, Hook
Surg Neurol 1991;36:423-5
425
ED, Moertel CG, Safar P, Stone A, Taussig HB, Van Eys J. The physician's responsibility toward hopelessly ill patients. N Engl J Med 1984;310:955-9. 8. Wanzer SH, Federman DD, Adelstein SJ, Cassel CK, Cassem EH,
Cranford RE, Hook EW, Lo B, Moertel CG, Safer P, Stone A, Van Eys J. The physician's responsibility toward hopelessly ill patients: a second look. N Engl J Med 1989;320:844-9. 9. Youngner SJ, Landefeld CS, Coulton CJ, Juknialis BW, Leary M. 'Brain death' and organ retrieval: a cross-sectional survey of knowledge and concepts among health professionals. JAMA 1989; 261:2205-10.
423
1991;36:423-5
Euthanasia: The "Good Death"! Edward C. Benzel, M.D., F.A.C.S. Division of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
A dissertation recently presented in this journal discussed euthanasia with regard to its religious and ethical ramifications [5]. Among the subjects discussed were concepts and issues such as the reverence for human life, the atheistic/agnostic perspective, the religious perspective, and the background that determines the individual's ethical beliefs and aids him/her in formulating attitudes regarding issues such as euthanasia. However, the true issues surrounding the concept of euthanasia were evaded and, thus, further thrust into a state of confusion and misconception. If most people consider life to be good and special, how can one interpret the taking of such a life to be "good" (euthanasia taken literally means "good death")? Some believe there is no "good death" and that "a human life should not be destroyed, regardless of how fragile or futile it seems" [5]. Alexander [ 1] has addressed the broad and far-reaching aspects of the term euthanasia. In his dissertation, he pointed out that ambiguity may often be involved with medical ethics issues, such as euthanasia, and that decision-making processes require the need for the individualization of each response. A separation of fact from fiction is, therefore, mandatory. To clarify the issues involved with euthanasia, an attempt will be made herein to establish the true facts and issues, and to separate these from myth and inappropriate emotion. To some, life is mystical. Sorensen [5] suggested that there is a mystical nature to life [5]. "The essence of life" and "the 'spark' which is present in life but absent in death" are phrases that emphasize, to a significant extent, our lack of understanding of the p h e n o m e n o n we call life. Through scientific investigation we have narrowed the schism that exists between the unknown (which is often viewed as mysterious) and the known. We have been able, for example, to define life's point of termination, and we have characterized it scientifically and legally by a constellation of parameters called brain death criteria. Although these criteria vary somewhat from Address reprint requests to: Edward C. Benzel, M.D., F.A.C.S., Division of Neurosurgery, University o f N e w Mexico School of Medicine, Albuquerque, N e w Mexico 8 7131. ~'~)1991 by Elsevier Science Publishing Co., Inc.
country to country, state to state, institution to institution, and physician to physician, they are relatively uniform and consistent. In spite of this, the terms brain death, vegetative state, and irreversible coma have at times been used interchangeably. The lay public and many physicians remain confused regarding the definitions o f these clinical states [9]; this is unfortunate and disconcerting. This "ignorance" compounds the public's lack of understanding of the complex issues involved with the termination of life, issues such as euthanasia, brain death determination, and organ procurement. These definitions must be clearly established in the minds of physicians before we can expect the lay public to sort out the pertinent issues and make legitimate rational decisions. Euthanasia (in the context utilized here), simply stated, is the act of permitting a hopelessly ill individual to die at his or her (or family or loved one's) request. Although there have been many arguments pro and con regarding euthanasia, the true issue of concern is the right of the individual: Does he or she have the right to request that life-sustaining treatment be stopped, and if so, under what circumstances? The word euthanasia is, perhaps, inappropriate terminology. To some, it implies the act of "putting to sleep," as one might do for an ailing pet. Some think it can be performed without the consent of the individual, which adds to its negative connotation. Euthanasia has been divided into active and passive components, the active being akin to the putting to sleep situation and it is emphasized, with the individual's consent (or the consent of his or her legal guardian). The difficulty most often encountered with active euthanasia is its lack of clear separation from the term "murder." The public's fear of random and reckless active euthanasia needs to be respected. The definition of euthanasia used here is that of passive euthanasia, the act of permitting the death of a hopelessly ill individual at the individual's (or family or loved one's) request. This is a passive process in which the physician does not actively cause the individual to die. Many ethicists are concerned about the terminology involved with euthanasia: they believe there should be no separation between the active and passive compo0090-3019/91/$3.50
424
Surg Neurol 1991;36:423-5
nents. Perhaps the term euthanasia should not be used at all because of its negative implications. What is being addressed here is not "murder," "killing," or euthanasia per se but an attempt to define more clearly the rights of the individual. If the individual does, indeed, have the right to choose his or her own medical therapy, then the withholding or withdrawal of a therapy upon the request of the patient is simply complying with the patient's wishes. Perhaps it should not be considered as euthanasia, but simply the act of respecting the rights of the individual. However, we are stuck with the existing terminology. What we can do to minimize confusion is to deemphasize the concept of euthanasia and emphasize the issue of individual rights. Perhaps we should also deemphasize the use of the words active and passive as they pertain to this situation. The context in which the term euthanasia is applied is significant. If applied to a person who has been diagnosed as brain dead, the point is moot: life-sustaining therapies cannot be removed from a person who is dead. This may seem obvious, but is nevertheless often misconstrued [9]. The issue of euthanasia or the right to die, therefore, only applies to the living. Only those individuals who (or whose families) suffer from the continuation of their own life are the focus of this discussion. These include the terminally ill, those in an irreversible coma, and those whose lives are sustained by life support systems or treatments that (to the individual) prolong an intolerable life. The "right to die" is thought by most to be an individual choice [6,7]; the courts and a presidential commission have confirmed this [4,8]. It is not a moral or religious issue. In fact, Fletcher [3] has outlined five maxims to assist one in making the decision to forego life-sustaining treatment. They incorporate the ethical and legal concerns of five hypothetical situations into guidelines that allow for a rational approach in most circumstances. We cannot take away an individual's right to make decisions regarding his or her own body (regardless of the individual's rationale) if he or she is of sound mind. In this context, a physician cannot force a treatment upon an individual. The type, extent, and timing of medical care is one's choice (within the limits of the physician's recommendations). In these regards, the individual's choice is sanctified, not human life itself. If (1) the right to die is taken away from the individual and placed into the hands of theoretically more learned professionals and (2) these learned professionals opt for ruling in favor of the "sanctity of life" at all costs, chronic care facilities and intensive care units may soon be occupied by an increasing population of chronic, extendedcare patients who are "alive" against their will. More frightening than these ominous possibilities is the
Benzel
thought of financial constraints dictating the need for rationing health care. If chronic care facilities and intensive care units are filled with people who no longer enjoy a meaningful life and/or who only harbor a vegetative existence, we may be forced (for reasons that are neither desirable nor even noble) to decide who should live and who should die based upon financial constraints, rather than upon the wishes and desires of the individual. It should be clear that the rights of the individual supersede any concerns regarding the sanctity of life. This is not to say that life is not important. It does, however, imply that the importance of life is associated closely with the individual's interpretation o f his or her own quality of life. The rights of the individual, especially in countries where freedom and individual rights are a premium, should permeate all aspects of life, from the right to free speech to the right to die. We as physicians cannot force a treatment, such as a surgical procedure, upon a rational individual against his or her will; nor can we play " G o d " and demand the continuation of a medical regimen designed solely to increase the duration o f a life deemed not worth living by a rational patient. We cannot alter our roles as physicians simply because a patient has reached a helpless state. We have to maintain a constant and unalterable course regarding our care of patients, regardless o f the extenuating circumstances and the degree of helplessness of the person whose life and death are in our hands. Indeed, "some articulate and influential medical practitioners in this country" [5] have effectively and solidly posed clear and succinct arguments in favor of euthanasia [8]. Perhaps these arguments address the issue of individual rights more so than that of euthanasia. Individual rights a r e the issue. They a r e the bottom line. If the individual's rights are honored, the controversy over euthanasia will vanish. There will be no "slippery slope." (This point has been addressed by the American Medical Association's Council on Scientific Affairs and Council on Ethical and Judicial Affairs [2].) The term euthanasia as used here implies a "good death." To extend this definition to exclude the concerns and rights o f the individual, however, is treading on dangerous and possibly unethical grounds [1]. Therefore, we must all be careful not to violate the rights of the individual. If we preserve these rights, we will allow our patients to enjoy both a good life and a good death.
References 1. Alexander E. Euthanasia. Surg N e u r o l 1989;31:558-9. 2. Council on Scientific Affairs and Council on Ethical and Judicial Affairs of the American Medical Association. Persistent vegetative state and the decision to withdraw or withhold life support. J A M A 1990;263:426-30.
Euthanasia
3. FletcherJC. Decisions to forego life-sustaining treatment. Virginia Medical 1989;11:462-5. 4. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Deciding to forego life-sustaining treatment. Washington, DC: Government Printing Office 1983;236-9. 5. Sorensen BF. Euthanasia: the "good death"? Surg Neurol 1991;35:74-5. 6. Steinbrook R, Lo B. Artificial feedingwsolid ground, not a slippery slope. N Engl J Med 1988;318:286-90. 7. Wanzer SH, Adelstein SJ, Cranford RE, Federman DD, Hook
Surg Neurol 1991;36:423-5
425
ED, Moertel CG, Safar P, Stone A, Taussig HB, Van Eys J. The physician's responsibility toward hopelessly ill patients. N Engl J Med 1984;310:955-9. 8. Wanzer SH, Federman DD, Adelstein SJ, Cassel CK, Cassem EH,
Cranford RE, Hook EW, Lo B, Moertel CG, Safer P, Stone A, Van Eys J. The physician's responsibility toward hopelessly ill patients: a second look. N Engl J Med 1989;320:844-9. 9. Youngner SJ, Landefeld CS, Coulton CJ, Juknialis BW, Leary M. 'Brain death' and organ retrieval: a cross-sectional survey of knowledge and concepts among health professionals. JAMA 1989; 261:2205-10.