Alex Deane: The case against euthanasia

Alexander Deane is a barrister, author and former Chief of Staff to David Cameron.

Because public debate about the “right to die” is always prompted by undeniably tragic high-profile cases, those of us who oppose euthanasia are usually on the back foot.  We let those who favour the legalisation of euthanasia frame the discussion in terms that are very favourable to their position – terms that avoid the reality of an environment in which the deliberate ending of life is part of the medical apparatus.   

The debate about euthanasia isn’t about “letting people die.” It’s about doctors actively taking part in killing them.  To ask if euthanasia should be legalised is therefore not merely to ask whether an in-principle ‘right to die’ exists in moral terms. Proponents of euthanasia are also asking the state to take part, through its laws and its representatives, in the actual act of terminating life. 

The state and society are therefore entitled to a moral stance, and to weigh up the importance of those things that undoubtedly support the case for euthanasia – such as human dignity and relief from suffering – against the importance of preserving life and the clarity of a “bright line” rule on this most fundamental issue.

In order to protect all of us, I believe that the state must say that whilst there is a right to life, there is no right to death. People die.  But the state shouldn’t kill them.  In a euthanasia society, the state is asked to make decisions about whose life should continue, and whose should not – to draw up criteria, perhaps.  As said by the House of Lords: directly or indirectly, the state should never say – should never be able to say – that a person’s life is not worth living:

"The message which society sends to vulnerable and disadvantaged people should not, however obliquely, encourage them to seek death, and instead, should assure them of our care and support in life."

Great dangers might follow any relaxation of the strict rule against medical killing; changing the law encourages more change.  Pro-euthanasia campaigners argue that an absurd contradiction exists under the status quo: individuals able to reach for the pill bottle and swallow can engineer their “exit,” but those who are not able to, cannot: the current law, they say, penalises those who are most impeded.  Ensuring that the latter can die at will as the former can is but a small change, they say.  It equalises the positions of those whose situations are substantially the same but have radically different options due to an unfeeling law, they say.

In a euthanasia environment, with living wills in place as most campaigners recommend, another argument will be advanced along the same lines.  The families of those who had the foresight to sign such a document can ensure their loved one’s undignified suffering in a coma can be ended, they’ll say, whilst the families of those who did not have such foresight cannot.  It’s a small change to allow the latter the same freedom as the former, they’ll say.  It equalises the positions of those whose situations are substantially the same but have radically different options due to an unfeeling law, they’ll say.  And so we would move from a voluntary euthanasia environment to an involuntary euthanasia environment.

It’s for this reason that in February 1994, after lengthy investigation, the House of Lords Medical Select Committee (the membership of which included some previously pro-euthanasia Lords) held unanimously that euthanasia should not be considered in the UK: they stated that 

“creating an exception to the general prohibition on intentional killing would open the way to further erosion, whether by design, by inadvertence or by the human tendency to test the limits of any regulation. These dangers are such that any decriminalisation of voluntary euthanasia would give rise to more, and more grave, problems than those it sought to address.”

This continues to be the Government’s position.

The Medical Profession 

Certainty in medical practice is tremendously important.  The aim of medicine is to help people get better – to preserve life, not end it. That’s why people become doctors. At the heart of medicine lies a pledge called the Hippocratic Oath, which (whilst precise wording varies) says ‘I will give no deadly medicine to anyone, even if asked, nor suggest any such course.’ Euthanasia’s proponents play down its importance, but it doesn’t matter whether doctors actually stand up and swear this oath or not – our understanding of medicine is shaped by it.  That fundamental contract between society and medicine would be broken by euthanasia.

It is true that doctors also have a duty to uphold the dignity of their patients. But the principle of medicine, its fundamental aim, is to heal. If it comes down to life versus dignity, life must win – because that way, doctors are violating the lesser duty, the lesser principle.  If they’re making a mistake, the mistake is lesser in preserving life than the potential mistakes involved in ending it to aid dignity.

On a different note, there’s a reason the BMA recommends maintaining the current anti-euthanasia environment. In a euthanasia environment, as euthanasia cases become more and more common, some doctors who don’t want to perform this procedure for whatever reason will be pressurised to do so. Their careers will suffer as a result. Furthermore, even doctors who are not among those directly concerned, who neither euthanize nor are asked to, are nevertheless affected: doctors have taken up their vocation specifically because of their desire to cure and preserve life. This changes the nature of their profession. It casts the confusion of healer or killer across whole of medicine.

Doctors of faith are put in a terrible position where euthanasia is legal. Even if they don’t have to confront this directly, even if they’re never asked, the profession they belong to is doing something they believe is profoundly wrong. Because it reflects on all doctors, once some doctors start killing their patients.  It erodes doctor-patient trust, and fundamentally changes the doctor-patient relationship.  Patients, especially the elderly, will ask with justification, “need I fear going to the doctor, for he may prescribe death?”

We are often told in response to this that ‘doctors are doing this already’ and that this change merely makes their actions safer for them and the patient.   But are they?   They shouldn’t be. They’re breaking the law, which they are bound to obey just like anyone else. They should be prosecuted. The fact that the law is broken is no justification for changing it.  In truth, this is no argument in favour of euthanasia at all.  Even if it’s true that some doctors really are killing their patients, and in doing are doing what they and all in the case concerned believe to be best, at least the state isn’t currently implicated in that act.

The Impossibility of Certainty

Medicine is always improving. Cures are found, and better techniques are developed. Euthanasia stops the chance of benefiting from new developments and from unexpected improvements, because it ends the life that might have had that benefit.

Furthermore, all medical conditions ebb and flow. Medicine frequently sees remissions that are entirely unexpected. They sometimes come in patients told definitively, certainly, that they have no chance of surviving their condition. 

No certainty exists in medicine, for these two reasons.  But the voice of the ‘expert’ is one of great and misleading allure. Because of the rapidly changing nature of medicine, a doctor or team of doctors may wrongly say – with certainty – that a patient will die.  But patients have a disproportionately high trust of doctors, because of the tremendously esteem in which the profession is held.  In a euthanasia society, that certainty – where in truth things can never be certain – may lead to avoidable death by ill-informed “choice.”  The doctor or doctors might also simply have misdiagnosed, or be incompetent.  Even if he has done neither, he may nevertheless be wrong. 

“It will be the doctor’s values and judgements about pain, disability and dependence that will determine what is recommended and what is done. Since those values will be randomly met, that would be profoundly unjust.”

(from The New York State Task Force on Life and the Law’s “When Death is Sought”) 

Pro-euthanasia advocates avoid this by shunting responsibility onto the patient, who ostensibly wants to choose death – if the individual wants it, they say, and we can guarantee that they are rational, who are we to deny them?   

The truth is that even if the patient is held to be ‘rational,’ if his health is so bad as to warrant the consideration of euthanasia then his condition invariably precludes real judgment.  You are asking people about their view of the future at the worst moment – at their very lowest point, the moment at which their condition is most severe. In Australiain 1996, during a brief period of legality in the Northern Territory, Dr Philip Nitschke was the first doctor in the world to give legal, voluntary euthanasia.  After the law was changed, his supporters campaigned vigorously for a return to euthanasia.  His poster patient June Burns made a tremendously powerful appeal, pleading for death on national TV in 1999, saying she’d rather kill herself than “die like a dog” from cancer.  She went into remission a year later, and (whilst still pro-euthanasia) she is naturally glad that she wasn’t allowed to make that choice, at the moment she was at her worst.

The patient might still be rational, but he is rational in circumstances so extraordinary as to make his choice an impossibly ill-informed one.  He’s not making truly informed choices because medicine doesn’t know with certainty everything that will happen to him in the future. The patient is rational – but he is making this decision only with information available to him, in the circumstance of most pain and suffering, when things look worst.  He thinks that his options are binary – terrible pain, or death – when there may be palliative treatments and better treatments to alleviate suffering and facilitate a rewarding end to life even if death itself is inevitable.  He makes a decision he won’t live to regret.

It is uncertain as to whether there is a point at which there can be an informed and rational choice at all, even for those patients whose plight has been identified with what the medical world believes to be certainty. To stop pain, the patient is often on mindbendingly powerful, drugs.  His “consent” can’t be considered valid in those circumstances. So the patient is taken off the drugs to be asked the choice. He’s in tremendous amounts of pain, and in withdrawal from drugs which are often addictive, so unsurprisingly, when someone asks him if he wants the pain to stop, he says yes.

Supporters of euthanasia attempt to circumvent these problems by supporting “living wills.”  But quality of life is context specific. You or I might say I never want to be trapped in my body, unable to move. But we don’t really know how we will actually feel in that situation.  There are those alive today who communicate through the blinking of an eye, the movement of a finger, and say I want to live. I would not have thought that I would, but I do.  I can enjoy seeing my family around me, my children grow up, my parents smile: this life has its rewards that more than compensate for what I would once have thought unbearable.

Pre-judgement of one’s attitude of quality of life is totally irrelevant until you experience it, and no-one else can make that decision for you.  To say “x condition is too horrible to endure” is to apply objective criteria to conditions that are utterly subjective.

Potential for abuse

All the oft-claimed checks might be in place for the first few high profile euthanasia cases, but in an environment in which euthanasia is an everyday occurrence, where euthanized death is not controversial but banal, the following may occur:

• Families may urge doctors to ‘let their loved ones go’ – nobody should ever be able to hold that sway over the lives of others, but in a euthanasia environment they do.

• Families that stand to gain from the death of the patient may bribe or collude with doctors to agree that this person should die.

• Doctors will face enormous pressure. The need for beds and for precious resources will be apparent. Society will effectively be asking doctors to make value judgements in a system with finite resources – whose life is worth living, whose is not? Presently, they don’t have ability to cut down one life to make space for another – or if they do, by breaking the law, they shouldn’t. Yes, abuse might happen now – but under which system is it more likely?

The point is that in determining public policy, one cannot rely on ideal cases, where all terminally ill patients are treated at the highest standards and all doctors are well informed and competent in terminal care.¹

Euthanasia offers “an easy way out" – which might be thought better than months of treatment.  Said treatment is probably – no, certainly – in the best interests of the patient, who gets to live – but often not in best interests of the family, who don’t want to suffering and the inconvenience of having to watch.

In medicine at the moment, the interests of the patient are the key, no matter what others want.  More than that – they are the sole determinant.  In effect, euthanasia balances the interests of the patient against the interests of others.  The dangers to the patient are obvious.

Euthanasia is sometimes presented as something the conservative should support: that it’s a facet of liberty, a question of control over one’s own body and what happens to it.  Not so.  In a euthanizing environment, if a healthy person, entitled to medical treatment, of sound mind, came to a doctor and said ‘help me die,’ the doctor wouldn’t.  So euthanasia is not actually about the individual’s rights and control over their body.  Bodily autonomy is a red herring in this debate.

Relief is obviously tremendously important: of course, people should not suffer unnecessarily.  Palliative care is getting better and better. Social care at the bedside, anti-depression techniques, pain management – these are all improving and should be pursued with great effort. But we must not legalise euthanasia.

This essay was prompted by a recent trip to Leiden University – the Oxbridge of the  Netherlands – where the topic was debated. Euthanasia has been legal in the Netherlands since 2002.