EUTHANASIA AND ASSISTED SUICIDE: THERE IS AN ALTERNATIVE

Ethics & Medicine,  Summer 2007  by Ledger, Sylvia Dianne

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Abstract

People request euthanasia or assisted suicide if suffering is unrelieved; however, it is argued that patients stop asking to have their lives foreshortened when their symptoms are well controlled. The claim that a suffering individual has a right to die (i.e. receive euthanasia or assisted suicide) is discussed; however, the concept that an individual has a right to die is rejected on the basis that death is an inevitability, not a right. It is argued that the rejection of values, such as the sanctity of life and the intrinsic value of life, and the acceptance of euthanasia and assisted suicide erode the moral and social foundations of society. The practice of euthanasia and assisted suicide in the Netherlands is critically discussed, including: Dutch legislation, the decline in the number of reported cases of euthanasia and evidence of involuntary euthanasia. The doctrine of double effect is considered in relation to the use of opiates, and it is argued that appropriate use of opiates does not foreshorten life; indeed, it may even extend life. Finally, it is observed that rejection of euthanasia and assisted suicide by nurses and doctors results in a duty to relieve patient suffering. Experts in Palliative care need to disseminate specialist knowledge of holistic care and symptom control so that all dying people receive appropriate terminal care.

Introduction

Suffering and the relief of suffering raise many challenges for nurses and doctors, especially when the patient who is suffering requests active voluntary euthanasia or assisted suicide. The following seeks to explore the concept of pain and suffering and discusses issues relating to euthanasia and assisted suicide and alternative ways of relieving suffering.

According to Cassell1 human suffering is "a state of severe distress associated with events that threaten the intactness of the person." It occurs when a person perceives the impending destruction of themselves, and is associated with a loss of hope. It effects the individual's physical, psychological and spiritual well being. Reich2 also recognised the harmful consequences of suffering on a person; however, he argued that suffering was associated with anguish rather than distress. He stated that there was a difference between suffering and experiencing pain. Reich recognised that acute and chronic pain could cause physical, mental or emotional distress. He argued that this distress was not necessarily associated with physical pain, but could be due to mental agony caused by a number of factors including feelings of injustice, powerlessness, victimisation, dependency, shame and fear of obliteration following death.

The account of the suffering experienced by Diane Pretty3 (table 1) and Lillian Boyes4 (table 2) appears to reflect the physical, mental and emotional pain, anguish and agony identified by Cassell5 and Reich.6

Ongoing, unrelieved suffering gives rise to loss of hope and despair. The patient whose symptoms have not/cannot be adequately controlled may ask for euthanasia or assisted suicide to escape their suffering and/or "restore" their dignity.

Unremitting pain is one symptom that causes much suffering, distress and anguish, yet there is on-going evidence that pain control is often poorly managed by nurses and doctors in different areas of care in the UK. Apparently "Pain is the most commonly perceived symptom in adults. In the UK, 40.7% of patients present to their GP with a pain problem, and many are under treated or suffer from incomplete pain relief".8

Shuttleworth9 identified that pain management techniques had advanced tremendously during the last two decades; however, she reported that the Pain in Europe survey (2003) identified that about 800,000 adults in the UK live with chronic unrelieved pain. Nearly one third of these people experience severe pain, and about half experience constant pain. For the sufferer, the cost of living with chronic pain was huge. Shuttleworth reported that 16% of people living with chronic pain said that their pain "was so bad some days that they wanted to die."

From an international perspective, Shuttleworth9 identified that because of poor international pain management, the International Association for the Study of Pain wanted pain relief to be recognised as a human right. On a national level, Wood, a freelance pain adviser, felt that the Department of Health should have included pain management in the Essence of Care.9 This was a lost opportunity to highlight the need for appropriate pain management for those who continue to experience unrelieved pain. This is particularly significant as 86% of nurses reported that they had inadequate knowledge to provide effective pain management for their elderly patients, and 97% of these nurses desired to have more training relating to pain management.10

In relation to pain relief in terminal care, Billings11 claimed that "Almost all pain faced by terminally ill people can be adequately relieved"; however, he stated that "clinical practice continues to be characterised by unrelieved pain, illogical prescribing of analgesics and widespread "opiophobia". It appears that some doctors (and nurses) remain reluctant to prescribe and administer appropriate opiates to relieve the pain and suffering. Harrison12 said that "talking about morphine as a drug that will hasten the death of a patient is unsound and reflects a view that was held when we were very ignorant of the drug, considering it to be highly addictive and dangerous..." Harrison argued that lives can even be extended by appropriate use of opiates "under controlled circumstances".