Euthanasia and assisted suicide

Euthanasia is the act of deliberately ending a life to relieve suffering.

For example, a doctor who gave a patient with terminal cancer an overdose of muscle relaxants to end their life would be considered to have committed euthanasia.

Assisted suicide is the act of deliberately providing assistance or encouragement to another person who commits, or attempts to commit, suicide.

For example, if a relative of a person with a terminal illness used an internet site to obtain powerful sedatives, knowing that the person intended to take an overdose of sedatives to kill themselves, they would be assisting suicide.

Legal position

Both euthanasia and assisted suicide are illegal under Irish law.

Depending on the circumstances (see below), euthanasia is regarded as either manslaughter or murder and is punishable by up to life imprisonment. 

Assisted suicide is illegal. Attempting to commit suicide in itself is not a criminal act. 

Assisted suicide (AS)

Assisted suicide is the act of deliberately assisting or encouraging another person to kill themselves (1).

Euthanasia

Euthanasia is “the act of deliberately ending a life to relieve suffering”  (1).

Palliative Sedation

This is where a person who is expected to die within a period of hours or days and is experiencing extreme physical or psychological suffering, for which there is either no effective treatment or all alternative measures have been ineffective, is sedated using sedative medications with the sole intention of relieving intractable distress.

Under the European Association for Palliative Care (EAPC) 2009 Framework on the use of sedation in palliative care (2), therapeutic (or palliative) sedation in the context of palliative medicine is:

“the monitored use of medications intended to induce a state of decreased or absent awareness (unconsciousness) in order to relieve the burden of otherwise intractable suffering in a manner that is ethically acceptable to the patient, family and healthcare providers.”

1       NHS Choices. Euthanasia and Assisted Suicide [Internet]. UK; Updated: 2016 June 29. Available from: http://www.nhs.uk/Conditions/Euthanasiaandassistedsuicide/Pages/Introduction.aspx

 2       Cherny NI, Radbruch L. The Board of EAPC: European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care. Palliat Med. 2009, 23: 581-593.

Legal position in other countries

Active euthanasia is currently only legal in Belgium, Holland and Luxemburg. Under the terms of these countries’ laws, a person’s life may be deliberately ended by their doctor or other health professional.

The person is usually given an overdose of muscle relaxants or sedatives, which cause a coma and then death.

However, euthanasia is only legal:

  • if that person has made an active and voluntary request to end their life, and
  • it is thought they have sufficient mental capacity to make an informed decision regarding their care, and
  • it is agreed that the person is suffering unbearably and there is no prospect for an improvement in their condition

Capacity is the ability to use and understand information to make a decision.

There are a number of countries where the law is less clear, and some forms of assisted suicide and passive euthanasia are legal but active euthanasia is illegal.

For example, some types of assisted suicide and passive euthanasia are legal in Switzerland, Germany, Mexico and the American state of Oregon. 

Below are some of the main arguments used by both supporters and opponents of euthanasia and assisted suicide.

None of these arguments necessarily represent the opinions or policies of the HSE or the Department of Health.

Arguments for euthanasia and assisted suicide

There are several main types of argument used to support the practices of euthanasia and assisted suicide:

  • an ethical argument: according to the widely accepted ethical principle of respect for autonomy (freedom of choice), people should have the right to control their own body and life (as long as they do not abuse any other person's rights), and the state should not create laws that prevent citizens being able to choose when and how they die
  • a pragmatic argument: euthanasia, especially passive euthanasia, is already a widespread practice (allegedly), just not one that people are willing to confess to, so surely it is better to properly regulate euthanasia

The pragmatic argument is discussed in more depth below.

Pragmatic argument

The pragmatic argument states that many of the practices used in end-of-life care are essentially a type of euthanasia in all but name.

For example, there is the practice of making a 'Do Not Attempt Resuscitation' (DNAR) order, where a person has requested that they do not receive treatment if their heart stops beating or they stop breathing.

Critics have argued that DNAR is essentially a type of passive euthanasia as a person is being denied treatment that could potentially save their life.

Another controversial practice is known as palliative sedation. This is when a person experiencing extreme suffering, for which there is no effective treatment, is put to sleep using sedative medication. For example, palliative sedation is often used to treat burns victims who are expected to die.

While palliative sedation is not directly carried out for the purpose of ending lives, many of the sedatives used carry a risk of shortening a person's lifespan. So it could be argued that palliative sedation is a type of active euthanasia.

So the pragmatic argument is that if euthanasia is essentially being performed anyway, society might as well properly legalise and regulate euthanasia.

It should be stressed that the interpretations of DNAR and palliative sedation presented above are extremely controversial and certainly not accepted by most doctors, nurses and palliative care specialists. See Euthanasia - alternatives for responses to these interpretations. 

Arguments against euthanasia and assisted suicide

There are four main types of argument used by people who are opposed to euthanasia and assisted suicide:

  • the religious argument: these practices can never be justified for religious reasons, for example many people believe that only God has the right to end a human life
  • the 'slippery slope' argument: this is based on the concern that legalising euthanasia could lead to significant unintended changes in our healthcare system and society at large that we would later come to regret
  • the medical ethics argument: asking doctors, nurses or any other health professional to carry out acts of euthanasia or assist in a suicide would be a violation of fundamental medical ethics
  • the alternative argument: there is no reason a person should suffer either mentally or physically as there are effective end-of-life treatments available, so euthanasia is not a valid treatment option but instead represents a failure on the part of the doctor involved in a person's care  

Religious argument

The most common religious argument is that human beings are the sacred creation of God, so human life is by extension sacred. This means there are limits to what humans can do with their life, such as ending it.

Only God should choose when a human life ends, so committing an act of euthanasia or assisting in suicide is acting against the will of God and is sinful.

This argument, or variations on it, is shared by the Christian, Jewish and Islamic faiths.

The issue is more complex in Hinduism and Buddhism. A number of scholars from both faiths have argued that euthanasia and assisted suicides are ethically acceptable acts in some circumstances, but these views do not have universal support among Hindus and Buddhists.

'Slippery slope' argument

The slippery slope argument is based on the idea that once a healthcare service, and by extension the government, starts killing its own citizens, a line is crossed that should have never been crossed and a dangerous precedent has been set.

The concern is that a society that allows voluntary euthanasia will then gradually change its attitudes to include non-voluntary and then involuntary euthanasia.

Also, legalised voluntary euthanasia could eventually lead to a wide range of unforeseen consequences, such as the following:

  • Very ill people who need constant care or people with severe disabilities may feel pressured to request euthanasia so they are not a burden to their family.
  • Legalising euthanasia may discourage research into palliative treatments and possibly cures for people with terminal illnesses.
  • Doctors may occasionally be badly mistaken about a patient's diagnosis and outlook and the patient may chose euthanasia as they have been wrongly told they have a terminal condition.

Medical ethics argument

The medical ethics argument states that legalising euthanasia would violate one of the most important medical ethics, which in the words of the International Code of Medical Ethics is: 'A doctor must always bear in mind the obligation of preserving human life from conception'.

Asking doctors to abandon their obligation to preserve human life could fatally damage the doctor-patient relationship. Doctors could become hardened to death and the process of causing death becomes a routine administrative task. This could lead to a lack of compassion when dealing with elderly, disabled or terminally ill patients.

In turn, people with complex health needs or severe disabilities could become distrustful of their doctor's efforts and intentions, thinking their doctor would rather 'kill them off' than take responsibility for a complex and demanding case.

Alternative argument

The alternative argument is that, because of advances in palliative care and mental health treatment, there is no reason any person should ever feel they are suffering intolerably, whether it is physical or mental suffering or both.

According to the argument, if the right care and environment is provided, there is no reason a person cannot have a dignified and painless natural death.

There are a number of alternative approaches and options for people with terminal conditions or those experiencing intolerable suffering. These are described below.

Refusing treatment

Under Irish law, all adults have the right to refuse medical treatment, even if that treatment is required to save their life, as long as they have sufficient capacity (the ability to use and understand information to make a decision).

All adults are presumed to have sufficient capacity to decide on their own medical treatment, unless there is significant evidence to suggest otherwise.

The evidence has to show that:

  • a person's mind or brain is impaired or disturbed
  • the impairment or disturbance means the person is unable to make a decision at the current time

Examples of impairments or disturbances in the mind or brain include:

  • brain damage due to  severe head injury,stroke or dementia
  • mental health conditions such as psychosis (where a person is unable to tell the difference between reality and their imagination)
  • any physical illness causing delirium

If someone makes a decision about treatment that most people would consider to be irrational, it does not constitute a lack of capacity if the person making the decision understands the reality of their situation.

For example, a person may refuse a course of chemotherapy for life-threatening cancer because they would rather not tolerate the side effects of chemotherapy for the sake of a slightly longer life. They understand the reality of their situation and the consequences of their actions and have made a perfectly rational decision.

However, someone with severe (psychotic) depression who refuses treatment because they wrongly believe there is no hope for recovery and they are so worthless they deserve to die would be considered incapable of making a rational decision. This is because they do not understand the reality of their situation.

Advance decisions

If you know that your capacity to consent may be affected in the future - for example, because you may become unconscious - you can pre-arrange a legally binding advance decision (previously known as an advance directive).

An advance decision sets out the procedures and treatments that you consent to, and the procedures and treatments that you do not consent to. This means that the healthcare professionals treating you cannot perform certain procedures or treatments against your wishes.

For an advance decision to be valid, it must be very specific about what you do not want done and under what circumstances. For example, if you want to refuse a certain treatment, even if it means your life is at risk, you must clearly state this.

Cardiopulmonary resuscitation and 'Do Not Attempt Resuscitation' orders

Cardiopulmonary resuscitation (CPR) is a treatment that attempts to restore breathing and blood flow in people who have experienced cardiac arrest (when the heart stops beating) or respiratory arrest (when they stop breathing).

CPR is a relatively intensive type of treatment that can involve chest compressions (pressing hard down on the chest), electrical shocks to stimulate the heart, injections of medication and artificial ventilation of the lungs.

Despite the best efforts of medical staff, CPR does not have a good success rate. If CPR is performed in hospital, only 1 in 5 people survive. If it is performed outside hospital, only 1 in 10 people survive.

Even when CPR is successful, a person can often develop serious and sometimes painful complications such as:

  • fractured ribs
  • damage to the liver and spleen
  • brain damage leading to disability

Also, many people who do survive then require admission and prolonged treatment in an intensive care unit, where they may die anyway.

Due to the low success rate and the corresponding high risk of complications, many people, especially those with terminal illnesses, make it clear to their medical team that they do not want to be treated with CPR in the event of respiratory or cardiac arrest.

This is known as a 'Do Not Attempt Resuscitation' or DNAR order. Once a DNAR order is made, it is placed with your medical records.

If you have a serious illness or you are undergoing surgery that could cause respiratory or cardiac arrest, a member of your medical team should ask you about your wishes regarding CPR, if you have not previously made your wishes known.

A DNAR choice is not permanent and you can change your DNAR status at any time.

Some supporters of euthanasia have argued that DNAR is essentially a form of passive euthanasia, as a person is being denied treatment that could save their life.

The counter argument to this is that the success rate of CPR is often so low and the risks of complications so high that it is not the case that they are being denied a life-saving treatment. Rather, the risks of CPR far outweigh the benefits, so the treatment should not be used as it will have little to no benefit to the individual concerned.

Palliative sedation

Palliative sedation involves giving a person medication to make them unconscious and, therefore, unaware of pain. It is often used in people with terminal illnesses.

Many terminal illnesses can cause distressing and painful symptoms when the person reaches their final stages, such as:

  • muscle spasms
  • bone pain
  • unpleasant and sometimes frightening breathing difficulties
  • upsetting emotions and feelings such as fear, apprehension and distress

Palliative sedation is a way of relieving needless suffering.

While palliative sedation is not intended to end lives, the medication carries a risk of shortening life. This has led some critics to argue that palliative sedation is a type of euthanasia.

A counter argument is known as the 'doctrine of double effect'. This states that a treatment that has harmful side effects is still ethical as long as treatment was in the best interests of the patient and the harmful side effects were not intended. For example, very few people would argue that chemotherapy is unethical, even though it can cause a wide range of harmful side effects.

Withdrawing life-sustaining treatments

There are many different treatments that can be used to sustain life in people with serious or terminal illnesses, such as:

  • nutritional support through a feeding tube
  • dialysis, where a machine takes over the functions of your kidneys
  • ventilators, where a machine takes over your breathing

Eventually, there will come a time when it is clear that the prospects of a person recovering are nil and, in the case of terminal illness, the life-sustaining treatments are only prolonging the dying process.

In such circumstances, the doctors would recommend that the person be sedated (if they are not already sedated) and the treatments withdrawn so they can die peacefully in their sleep.

Content provided by NHS Choices www.nhs.uk and adapted for Ireland by the Health A-Z.

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