Ethical Boundaries of Euthanasia

 

Words by Dr Rika Rijal 

 

A 28-year-old Dutch woman is planning to undergo euthanasia in May 2024 due to severe mental health issues. She was suffering from depressive disorder, autism, and borderline personality disorder. Despite having a loving boyfriend and pets, she feels that her mental illness is untreatable and thus wants to end her life. Even the doctors informed that there were no further treatment options. This aligns with a growing trend in the Netherlands, where euthanasia is legal. More people are choosing to end their suffering from mental health issues rather than endure them.

The procedure is planned to take place at her home. The doctor will administer a sedative, followed by medication to stop her heart. She will be cremated, and her ashes will be scattered in a designated forest spot.

Such a case has sparked debate among many throughout the world. Some believe that this highlights a concerning trend of healthcare professionals readily resorting to euthanasia for mental health problems. Others argue that such a case grants terminally ill patients more control over their final days.

Some psychiatrists share it to be an easy way out in the sense the kind of perception the next generation has developed. They mention that it can be a way of expressing how young people are thinking out their wants: easy money, easy life and quick solutions to issues. And in the above case even her boyfriend supported her decision and would be present during the procedure. So it keeps many in puzzle that what kind of cognition they must be having about euthanasia? 

It has even been debated that it is an antithesis to the mental health act – that is to prevent harm to self & others around the individual. The doctors do involuntary treatment and some countries have laws which allows to that. The choice to take one’s own life in a clear state of mind which is not compromised by illness which impairs judgment & with it the insight will be an extreme clinical rarity.

More people are deciding to end their lives while suffering from mental health problems like depressive or anxiety disorders which are often amplified by economic uncertainty, climate change, social media usage among other issues that has been on the rise in the recent years. Some debate as seeing euthanasia as some sort of acceptable option brought to the table by physicians, by psychiatrists, when previously it was the ultimate last resort. This phenomenon, especially in people with psychiatric diseases and especially in young people with psychiatric disorders, where the healthcare professionals seem to give up on them more easily than before.

The Netherlands was the first country in the world to legalise euthanasia and physician-assisted suicide, introducing preliminary legislation in 1994, followed by a fully-fledged law in 2002. Since then, the number of euthanasia deaths has steadily risen. In 2022, it accounted for 5% of all deaths in the country. This has fuelled criticism from those who believe the law encourages suicide. The patient scheduled for euthanasia herself had addressed these concerns on social media before taking a leave of absence.

Euthanasia had become a public health issue in 1999, with the imprisonment of Dr. Jack Kevorkian, an American Physician for conducting voluntary euthanasia on Thomas Youk, who was in the final stage of ALS. He was charged with second-degree murder, and served eight years in prison. It was claimed that he had exercised euthanasia for at least 130 other patients. Because of such issues, the euthanasia law was adopted in Belgium in 2001 which defines conditions for doctors to avoid penal punishment. 

Since then, changes in the rules and regulations regarding euthanasia have been put forward and the debate is an ongoing one. 

Many arguments have been put forward supporting euthanasia.  Proponents perceive it as an act of humanity toward the terminally ill patient and the only way to alleviate the suffering from long and painful death. When there is lack of any justifiable means of recovery and the dying patient himself making the choice to end his life are conditions which make euthanasia more justifiable. Also that, it is the natural extension of patient’s autonomy and the right to determine what treatments are accepted or refused. When “rational” decision – symptoms and circumstances may not be relieved, even with aggressive palliative care and social services, the decision to hasten one’s death may seem rational. 

The desire to include one’s physician in carrying out a decision to end one’s life can be viewed as an extension of the natural reliance of terminally ill patients on their physicians for help with most aspects of their illness.

While those who are against this often state that euthanasia often contradicts the central tenet of the medical profession- “To please no one will I prescribe a deadly drug, nor give advice that may cause his death.” Thinking in terms of mental health perspective –  suicide should be prevented at all costs – suicidal ideation in terminally ill patients is a manifestation of undiagnosed, untreated mental illness. Improperly managed physical and/or psychiatric symptoms may underlie a patient’s wish for hastened death – inadequate palliative care. Individuals of lower socioeconomic classes or other disenfranchised groups will be “coerced”- because of the social and financial burdens involved in caring for terminally ill family members. Physicians may view euthanasia, perhaps because of their own unrecognized feelings (countertransference), as the appropriate and preferable response to a terminal illness.

Opponents also argue that the legal and medical communities will eventually end up on a “slippery slope,” – ultimately legalized as an acceptable practice for a wider patient population, including non-terminal, non-voluntary patients. They often criticize the “artificial and impractical” demarcation drawn by the court and the religious organizations between active and passive euthanasia.

 

The recent discussion on euthanasia has been fuelled by high-profile cases, legal battles, and shifting public attitudes. In countries, such as Colombia, the Netherlands, Belgium, Luxembourg, Canada, New Zealand, and Spain, as well as in some Australian states  euthanasia is legal under certain conditions. In others, like the United States, it remains a highly contested and often taboo subject. With regards to our neighbouring country India, on 7th March 2018 the Supreme Court legalised passive euthanasia to patients in a permanent vegetative state. However in Nepal, euthanasia is not legalised. A major obstacle is the lack of understanding of the term ‘Euthanasia’, which is often conflated with suicide, and suicide is contrary to almost religious practice here. The Nepal Medical Council Code of Ethics and Professional Conduct-2017 states that:
1. Euthanasia, the act of painless killing of a patient suffering from an incurable and painful disease, is not legalized in Nepal, and hence no medical practitioner should practice it. However, administration of narcotics and sedatives titrated to alleviate pain and distress in a dying patient is not euthanasia, but is palliative care which should be provided and clearly documented in the medical record.
2. If it becomes clear when caring for a terminally ill patient that the treatment isn’t working, and that any treatment that is not palliative in nature is futile, e.g., terminally ill patient admitted in ICU with ventilator support, medical practitioners should discuss the situation empathically with the patient’s family as soon as possible regarding discontinuation of life supportive measures keeping in mind the best interest of the patient. 

There are discussions following practise of Euthanasia in Nepal that if cheap and effective palliative care were easily accessible, most terminally ill patients would avoid pressure to practise euthanasia just because it would be a cheaper option. Medical advancements, such as palliative care and pain management techniques, have further complicated the conversation. While these treatments aim to alleviate suffering and improve quality of life, they may not always provide sufficient relief for patients with terminal illnesses.

As society grapples with these complex issues, it is essential to consider the perspectives of all stakeholders, including patients, families, healthcare professionals, and policymakers. Open dialogue, informed by evidence-based research and ethical principles, is crucial for navigating the ethical boundaries of euthanasia and shaping compassionate end-of-life care policies.

Ultimately, the debate on euthanasia forces us to confront fundamental questions about the value of life, the limits of medical intervention, and the nature of suffering. While there are no easy answers, thoughtful consideration of these issues is essential for promoting dignity, compassion, and respect for all individuals, especially in their final moments.

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