INTRODUCTION.
One of the principal questions in contemporary medical ethics that bleeds into societal morality is the question of euthanasia. Should modern medicine do all it can to save a patient, or should quality of life issues enter into the question? What is the moral balance between preserving life and preventing a once vital human from remaining comatose, sometimes for years? Should religious beliefs prevent medical professionals from helping to ease the pain and suffering of prolonged treatment in a terminally ill patient?
1> RECENT DEVELOPMENTS.
The Supreme Court of India on Monday rejected a petition for mercy killing, but ruled that passive euthanasia was permissible under certain circumstances. The case centered around Aruna Shanbaug, a former nurse who was raped and strangled at work 37 years ago and has been in Mumbai's King Edward Memorial Hospital in a blind and vegetative state ever since. Pinki Virani, a journalist and friend, petitioned the court [Hindustan Times report] to stop hospital staff from force feeding Shanbaug and allow her to die. The court stated that, while there is no statutory provision to support active euthanasia, where an individual dies by lethal injection, passive euthanasia through a withdrawal of life support would be permissible with approval by the high court after receiving requests from the government and close family members of the individual and getting the opinions of three respected doctors. The court determined that Virani was not as close to Shanbaug as hospital staff and rejected her petition.
2> COMA
Coma is a prolonged period of unconsciousness. Unconsciousness is the lack of appreciation of (or reaction to) a stimulus. Coma differs from sleep in that one cannot be aroused from a coma.
Coma involves two different concepts:
1.) Reactivity: Reactivity refers to the innate (or inborn) functions of the brain, i.e., the telereceptors (eyes and ears), the nociceptors (responses to pain), the arousal reaction (wakefulness) and the orienting response (turning one's head toward the source of sound or movement). We could also refer to these as reflexive movements.
2.) Perceptivity: Perceptivity refers to the responses of the nervous system to stimuli, which have been learned or acquired, i.e., language, communication skills, individual methods of movement such as gestures, etc. Perceptivity also refers to less complex learned or acquired reactions such as flinching when threatened. We can also think of these as conscious movements.
A person in a coma does not exhibit reactivity or perceptivity. He/she can not be aroused by calling his/her name or in response to pain.
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New Evidence That Coma Patients Feel Pain
Their is increasing research which shows that individuals in a comatose state who were previously thought to be incapable of feeling pain, are in fact aware of pain and require pain medication.
Coma is a poor term to describe the various states of unconsciousness. Better terms have been developed which classify patients in three stages, Coma, Vegetative State and the Minimally Conscious State. However, it is important to know that their are frequent errors made in the diagnosis of a patient's particular stage of consciousness and studies have shown that upwards of 41 percent of patients diagnosed as being in a vegetative state are actually in a minimally conscious state.
A new study evaluating brain scans of patients in various stages of coma has found that many of these individuals in both the vegetative state and the minimally conscious state are able to perceive and react to pain. This study is strong evidence that these individuals previously thought to be "brain dead" are capable of awareness and require pain medication.
The full study is in the October issue of the Lancet Neurology journal.
3> MEDICAL ETHICS & EUTHANASIA
One popular account of medical ethics, makes appeal to "the four principles":
1. non-maleficence (to avoid harm)
2. beneficence (to do good)
3. autonomy (the right to act freely) and
4. justice (acting fairly towards the patient).
Leaving aside the obvious shortcomings of such an abbreviated approach to medical ethics, we can nevertheless see how euthanasia by neglect violates all four principles:
1. Euthanasia by neglect is maleficent: it causes harm by killing a patient through a very long drawn out process of starvation and dehydration, a process which is uncomfortable and painful for the patient.
2. Euthanasia by neglect cannot be beneficent: A doctor is ethically and legally obliged to act in a patient's best interests. Intentionally killing the patient by neglect of reasonable care can never be in the patient's best interests.
3. Euthanasia by neglect extinguishes the autonomy of patients and diminishes the autonomy of doctors. Autonomy is not an absolute the exercise of which trumps all other considerations.. The patient must exercise his or her right to autonomy in a responsible and ethically sound manner. Both ethics and the law say that, just as we cannot sell ourselves into slavery, we cannot consent to be murdered. This is because the right to life, like the right to liberty, is inalienable. The obligation to respect the right to life extends to respecting one's own life. It is unethical to intentionally deprive oneself of life. Making euthanasia by neglect available to patients would lead to pressure on doctors and nurses to assist suicide and intentionally kill their patients by neglect. The effect of this is to significantly diminish their autonomy to practice their professional arts ethically, and according to their consciences and the Hippocratic Oath. Legalizing assisted suicide and intentional killing by neglect of reasonable care turns a class of private citizens into public killers. It changes doctors and nurses from being healers and carers into poisoners and killers.
4. Euthanasia by neglect violates justice, the requirement to treat all patients impartially and to be fair when allocating health care resources. The possibility of euthanasia by neglect would lead to pressure (real or perceived) on the elderly and the chronically ill to cease being a burden on society, on the health service, and on their relatives. Legalizing euthanasia by neglect reduces the patient from being an individual to whom the doctor has a professional obligation, into a utile, a unit in a utilitarian system of healthcare rationing, with an implied duty to die if they became too difficult or time-consuming or expensive to treat.
4> IN USA.
The Mental Capacity Bill - legalising euthanasia by neglect
The Mental Capacity Bill, introduced into Parliament by the Government on 18 June, will legalise euthanasia by neglect
Patients with conditions like dementia, stroke or brain injury are most at risk. They may be killed by withholding their basic medical care or even food and fluids, if the Bill goes through. Euthanasia by neglect means deliberately killing patients by withholding or withdrawing reasonable medical treatment or basic care (such as food and fluids given by tube). The worldwide euthanasia movement has declared that the legalisation of euthanasia by neglect is one of its key goals in its campaign to legalise euthanasia by lethal injection.
Any alleged benefits of the Bill pale in comparison with the evils it legalises. The Government claims that the Bill gives people a greater say in how they will be treated if they have a disease or accident that prevents them from making decisions about their lives. In reality, the Bill:
will mean thousands of patients dying for want of ordinary treatment. 'Treatment' under the Bill is defined as "includ[ing] a diagnostic or other procedure" (section 60). This would include tube-feeding, giving sedatives or pain-killers, and possibly spoon-feeding and turning patients to prevent bedsores. (Food and fluids delivered by tube is not "life-support" or "medical treatment" but basic care.)
creates government-appointed "independent consultees" who will have power to tell NHS doctors not to give life-saving treatment to incapacitated patients (sections 34-39).
would make advance decisions ("living wills") legally binding, including those with a suicidal intent (sections 24-29) - a long-standing objective of the Voluntary Euthanasia Society and the worldwide euthanasia movement.
undermines doctors' common-law duty to protect the life and health of patients - doctors who insist on treating patients properly could be charged with criminal offences (explanatory notes to section 26).
undermine patient's clinical best interests - i.e. health - by prioritising subjective, non-clinical considerations such as "wishes and feelings" (section 4)
The present government says it is against euthanasia. But it makes a qualification. While it claims to oppose the idea of active euthanasia - such as lethal injections - it supports changing the law to allow euthanasia 'by neglect'.
5> Medical Capacity Bill -Contd
Four key facts about the Mental Capacity Bill
1. Leading experts oppose the Bill because it means legalised killing
Leading human rights lawyer Richard Gordon QC has concluded that the draft Bill was incompatible with the European Convention on Human Rights. "The obvious scope for treating vulnerable persons contrary to their best interests in [the Bill] and in a way which deprives them of life is considerable." Dr. Jacqueline Laing, D.Phil (Oxon.), senior lecturer in law at London Metropolitan University has concluded that the revised Bill "entrenches involuntary 'slow euthanasia' - a sanitised form of homicide - in hospitals".
Dr. Philip Howard, a senior lecturer in medicine in London and consultant physician, has predicted that conscientious doctors and nurses will be criminalised or forced to leave their profession if they continue present practices that save the lives of suicidal patients.
Dr John Fleming, director of the Southern Cross Bioethics Institute and a foundation member of UNESCO's International Bioethics Committee, has predicted that a demand for euthanasia by lethal injection would be created by the horror of the long, drawn-out deaths by dehydration permitted under the Bill.
2. The euthanasia lobby supports the Bill
The Voluntary Euthanasia Society (VES) welcomed the draft Bill, so it is not only opponents of euthanasia who believe that it promotes euthanasia. It is no coincidence that "living wills" - a key part of the Bill called "advance decisions" - were invented by the euthanasia movement in the late 1960s; the VES is the UK's leading promoter of "living wills". The Bill would make advance decisions legally-binding, including suicidal ones. The worldwide euthanasia movement has declared that the legalisation of euthanasia by neglect is one of its key goals in its campaign to legalise euthanasia by lethal injection: "If we can get people to accept the removal of all treatment and care--especially the removal of food and fluids--they will see what a painful way this is to die and then, in the patient's best interests, they will accept the lethal injection" (Dr Helgha Kuhse, then president of the World Federation of Right-to-Die Societies, 1984)
The joint parliamentary committee which endorsed the draft Bill last year also endorsed the notion of a "right to die". The committee was stacked with the government supporters as well as members with close ties or official links with organisations supporting the Bill.
Among the Bill's supporters, many support a "right to die", in particular Patient Concern, led by senior Voluntary Euthanasia Society veteran activist Roger Goss.
3. The "safeguards"in the Bill will be ineffective
The Bill as presented is substantially more dangerous than the draft version. Promised so-called "safeguards" made to the Bill will be ineffective: "[The draft bill] not only lacks sufficient safeguards to prevent harm or abuse to patients, it is difficult to see what safeguards might be of any use" (Dr John Fleming). They will be flouted, just as the "safeguards" in the Abortion Act which are routinely flouted, allowing abortion on demand.
4. Disability rights groups oppose the Bill
Several organisations representing people with learning disabilities opposed the draft Bill:
"Values into Action believes that the draft Mental Incapacity Bill...far from protecting vulnerable people actually substantially increases their vulnerability...";
"Changing Perspectives have concerns that the Mental Incapacity Bill will violate the fundamental rights of people without perceived capacity"
"People First do not like this Bill because it will take away our independence and break our human rights.... If the draft Mental Incapacity Bill becomes law it will be a very big step backwards for people with learning difficulties' rights."
First published by Deepankar Choudhury on Mar 10, 2011
