Dr. James Manos (MD)
Conclusion
October 8, 2019
Is euthanasia already practiced worldwide? Is it moral?
Image (public domain): The Death of Socrates, by Jacques-Louis David (1787), depicting Socrates prepared to drink hemlock, following his conviction for corrupting the youth of Athens. Source for the image: a faithful photographic reproduction of a two-dimensional, public domain work of art. Source: Wikipedia. Link: https://en.wikipedia.org/wiki/Euthanasia#/media/File:David_-_The_Death_of_Socrates.jpg
Overview
The right to euthanasia is a matter of controversy. However, it is already practiced in most hospitals worldwide! The kind of euthanasia referred to in this text is non-voluntary or involuntary passive euthanasia. It is often practiced in vulnerable groups such as the elderly, patients with terminal cancer, patients with mental incapability, etc. Regarding euthanasia, the most crucial issue is whether it is under the patient's consent, for instance, signing a will, a do-not-resuscitate order (DNR), or their relatives' consent in case the patient cannot decide. That may be in the case of a coma. It is the responsibility of the medical professional to respect the patient's will.
Resuscitation and DNR
If the patient cannot consent because of physical (such as a coma) and/or mental (such as severe Alzheimer's disease) disability, then consent to a do-not-resuscitate order (DNR) can be obtained from the patient's family or partner. However, medical malpractice may be an issue if patients or their relatives, or partners are not involved in their medical treatment decisions. Ethical matters arise when resuscitation is not for the patient's benefit (for example, if suffering from terminal cancer) or when the incentive of not performing it is to free a bed in the ICU (intensive care unit) and have it available to other patients!
Undoubtedly, the most important thing in medical treatment is that it should be following the patient's best interest. Any medical decision regarding treatment should involve the patient or relatives and/or partner if the patient does not have the physical and/or mental capacity to consent. Unfortunately, many countries have no laws or directives about non-voluntary or involuntary passive euthanasia. In many countries, patients can sign a ‘do not attempt resuscitation’ (DNR) form or have a will in advance. However, a DNR is not the same as euthanasia, as the latter may occur before a deterioration preceding a cardiac arrest.
Ethical issues arise for not performing complete resuscitation or not performing resuscitation at all. This may occur in a patient who deteriorated acutely or during a chronic medical condition. Insufficient resuscitation on a deteriorating patient will cause further deterioration and even death. That is why during the last years, the ALS (Advanced Life Support) guidelines stressed the necessity of cardiac arrest prevention by summoning the emergency medical team (EMT) early to resuscitate a deteriorating patient before he/she ends up in a cardiac arrest. It is doubtful if this is the case for all patients, such as the elderly or those with cancer.
Of course, it is unethical to perform resuscitation on a patient who has signed a DNR paper or if this is accepted by the patient's partner and/or the family if consent cannot be given. However, in any case, legislative acts should exist that should dictate what is legal to do in case of life termination in the form of involuntary or non-voluntary euthanasia or the decision not to resuscitate a moribund patient. The law must consider vegetable states such as severe Alzheimer's disease or intractable coma. Also, international directives from the World Health Organization (WHO) are needed to avoid discrepancies between countries.
However, there are directives worldwide for brain death, although there is still no global consensus regarding the term ''brain death.'' The patient's relatives or spouse are often confused with the term ''brain death'' as they wrongly consider death to occur only after cardiac arrest. They are also confused by published cases of people in a coma who eventually recovered from complicated things. There is an exaggeration about these cases in the media, although they refer to coma, not brain death! Importantly, there is no case of a patient with brain death who has recovered. So reversible causes, including metabolic and vascular, should be sought in the case of a coma. If reversible causes do not exist, then a coma may be irreversible. The term ''brain death'' should be used only after confirmation by expert neurologists, and there is a specific protocol to define it.
Although brain death is definite and irreversible, ethical issues emerge mostly regarding resuscitation. If a doctor does not resuscitate a deteriorating patient entirely or does not resuscitate at all, then it is essential to justify this. There should be a reason not to perform resuscitation, such as the patient's decision against it or their family's or partner's decision in case the patient cannot physically and/or mentally consent.
The most important ethical issue here is the excuse that the prolongation of life is in vain and that the patient will suffer from prolonging his or her life. Then, in this case, resuscitation may not be ethical, for example, on a patient with terminal cancer with metastases. However, something moral may or may not be lawful. This may be due to the lack of legal directives regarding these issues. An extreme case may be when the decision to keep a patient in life lies only at the doctor's discretion, without seeking first the patient's (or his relatives or partner in case the patient cannot decide) consent.
A doctor's incentive, when determining alone, as mentioned above, may theoretically be, for example, to free a bed in the clinic, especially in the ICU (intensive care unit), and have it available for other emergencies. This scenario is not always in theory, as a decision for admission to an ICU or ITU (intensive therapy unit) considers variables such as age, comorbidity, and prognosis.
Euthanasia
''Euthanasia'' is ending a life to relieve pain and suffering. It can be classified according to whether a person gives informed consent into three types: voluntary, non-voluntary, and involuntary. There is controversy over the non-voluntary (and, by extension, involuntary) termination of a patient's life if it can be regarded as euthanasia, irrespective of intent or circumstances. Voluntary euthanasia is defined as euthanasia conducted with the patient's consent. Active voluntary euthanasia is legal in some countries, including Belgium, Luxembourg, and the Netherlands, while passive voluntary euthanasia is legal throughout the US.
''Assisted suicide'' is the practice in which the patient brings about his/ her death with the assistance of a doctor. Assisted suicide is legal in some countries, including Switzerland, and in some US states, such as California, Oregon, Washington, Montana, and Vermont.
''Non-voluntary euthanasia'' is defined as euthanasia conducted without the patient's consent when this is unavailable, including child euthanasia. Non-voluntary euthanasia is illegal worldwide, with some exceptions in the Netherlands.
''Involuntary euthanasia'' is defined as euthanasia conducted against the patient's will. Voluntary, non-voluntary, and involuntary euthanasia can be divided into ''passive'' or ''active.''
''Passive euthanasia'' is defined as withholding standard treatments, such as antibiotics, necessary for the continuance of life. A typical example is when a patient with cancer decides against chemotherapy or radiotherapy, considering that it is futile, regardless of if it is indeed in vain. This decision may often have a scientific basis, such as in terminal cancer, but in some cases, it may not! I recall an incident of a colleague's father who denied surgery for cancer and eventually died.
''Active euthanasia''' is defined as using lethal substances or forces, such as lethal injection. This may be an anesthetic or sedative that causes respiration arrest or potassium that causes cardiac arrest.
It should be mentioned that many authors consider these above terms misleading and unhelpful! From my perspective, an example of non-voluntary or involuntary passive euthanasia is in case of an emergency of a senior citizen when the paramedics of the ambulance and/or the doctors in the emergency department (ED) are reluctant to perform complete advanced life support (ALS). Instead, they may perform an ''abbreviated,'' incomplete resuscitation and not wait long to pronounce the patient dead.
The same may be true with cancer patients and other vulnerable groups of patients, such as people with Alzheimer's disease or people with mental incapacity. Another example of non-voluntary or involuntary passive euthanasia is the one that relates to inpatients, for example, elderly or patients with a terminal illness or dementia, who, when deteriorate, do not receive (complete) resuscitation.
In some cases of in-hospital cardiac arrest, doctors may only perform an electrocardiogram to ascertain the isoelectric line and pronounce the patient dead without any resuscitation. However, if the patient or his family or partner has not signed a do not resuscitate (DNR) paper in advance, this is not according to the law, even if it is ethical! The keyword is ''consent,'' and the doctors should consider the patient in making decisions. That means that it is not ethical for a decision concerning the life and death of a patient to be made only by the doctor's side as this may be subjective, i.e., biased. Sometimes it may be malicious! For example, cases of malpractice that have led to death or even murders by healthcare professionals have been described in nursing homes and hospices. A recent case in Germany by the male nurse Niels Hogel who killed eighty-five patients, is characteristic.
Another example of controversy is the potential exclusion of groups, such as the elderly, patients with dementia, mental retardation, and cancer patients, from the intensive care unit (ICU) treatment, as the available beds may be reserved for younger patients or patients without a grave prognosis. The most critical issue is when private insurance companies decide which treatment they will pay for. It is said that this was common in the US, especially before Obamacare, when patients who could not afford to pay the hospital expenses were dumped on the street! Obviously, private insurance companies should not interfere with medical decisions. The patient's interest matters, or should matter, first!
Things are more complicated today as new immune therapy with monoclonal antibodies is expensive. Gene therapy is even more financially unbearable to be used in daily clinical practice (other than research). So, the question is to whom these expensive therapies will be reserved. In my opinion, it is immoral to allow insurance companies to participate in a decision to withhold treatment because it is costly. Still, any decision should be exclusively based on a medical basis. For instance, patients with an ominous prognosis in many countries are excluded from therapeutic schemes, including costly chemotherapy and immunotherapy.
Another example of non-voluntary or involuntary passive euthanasia is when a patient, for example, a senior patient or a patient with a debilitating disease, is not transferred by their family or partner in time to the hospital but when it is too late. This practice is prevalent and may also occur in patients nursed in a hospice, nursing home, or institution. The doctors often discourage the family from transferring the patient to the hospital, as any therapy is in vain, at least on the doctors' side.
However, delaying treatment is valuable when the prognosis is not grave, or the benefits outweigh the disadvantages. So, sometimes the relatives of a patient with a terminal medical condition such as terminal cancer bring the patient to the hospital's emergency department (ED). Doctors admit the patient for further medical care unless the patient decides against it. This is also true for people with Alzheimer's disease or people with mental incapacity.
But when admission prolongs the patient's suffering, it is ethical for the doctors to advise the patient’s family the next time to avoid transferring him/her to the hospital. But the patient (or their relatives or partner, if unable to decide) will choose this option, not the doctor who may wish to have an available bed soon, for example, in the ICU. However, something moral may or may not be lawful. As mentioned above, this may be due to the lack of legal directives regarding these issues.
When is euthanasia considered medical malpractice?
No law or directive prevents doctors from performing (proper) resuscitation on the elderly or other vulnerable groups of patients, including those with terminal cancer and demented patients, unless they (or their relatives, if unable to decide) fill a do-not-resuscitate order (DNR). In admission, it is essential for patients likely to deteriorate and suffer a cardiac arrest to determine if they will sign a do-not-resuscitate order (DNR). Thus, withholding resuscitation is not considered medical malpractice unless unethical, as the doctor acts in the patient's best interest and consent.
The problem is when prolonging life is unethical, despite the patient's will to do so, and there is a great deal of controversy regarding this issue. For instance, recently, in the UK, a baby suffering a rare neurological disease that depended on ventilator support to breathe died as the state refused to allow its transfer to Italy, where parents waited for a miracle. However, it is apparent in this case that prolonging the baby's life was futile and against its best interests and well-being. The critical issue is quality of life, and it is questionable what quality of life the baby would have if it remained for years on the ventilator. However, I think that although the NHS could refuse therapy in Italy for ethical reasons, the hospital should discharge the baby to go to Rome as it was its parents' will to do this, regardless of the decision of the healthcare system to pay or not the cost. But in the case of private insurance, I doubt that they would even think of it!
The problem is that often lay people do not understand that medicine, regardless of facilities, is the same worldwide and that vain hopes should not be given. So, people should be skeptical when they listen to ''miraculous'' treatments. But that does not mean patients should not take a second medical opinion, especially for severe diseases. That is important because, even in life-threatening diseases such as cancer, many people do not ask for a second opinion but rely on one!
The above incident with the baby shows that things are not black or white and that ethical issues emerge continuously. The most important thing is for all countries to have the appropriate legislation and the medical associations worldwide (the GMC in the UK has the 'good medical practice ''manual'') to issue pertinent medical directives to deal with similar cases. Therefore, a consensus is needed for ethical claims to be subject to statutes passed in legislation so that they do not end up in court!
Things are complicated when the patient is a minor. Then, guardians' consent is needed for deciding the medical treatment. The case in the UK with the baby referred to above is a striking example in which parents decided against the child's good interest and well-being, insisting on going to Italy for a futile ''miraculous'' treatment.
As in this case, if a guardian's decision is not in the child's best interests, then an urgent court decision may be sought. An example is when Jehovah's parents refuse a blood transfusion to their child in case of an emergency, such as an injury or internal organ bleeding. Another example is when a child's guardian refuses to consent to lifesaving surgery. A commoner example involves parents who naively, with zero scientific proof, neglect their child's immunization with the fear of adverse effects. They did this because they read it online or heard a celebrity supporting it. Thus, they expose it to severe diseases such as measles, which has recently become an epidemic in Europe. However, regarding measles mumps and rubella (MMR) combined vaccination, the first report was not anecdotal or from a celebrity but was published in 1998 in the scientific magazine Lancet! However, the official organizations found the study not only biased but unethical as well. Consequently, it was revoked 12 years later!
When is euthanasia legal?
You may read the article at The Complete Guide to Euthanasia in 2023: When is it Legal?
''Quality of life'' and ''consent'' are the keywords that must be considered. The former describes a treatment decision that can be ethical when it is not futile and not at the expense of the patient's quality of life (QoL). The patient or relatives should always seek the latter or, when incapable of consenting, their family or partner. Any treatment decision should involve both sides, the medical professional and the patient. However, before deciding, patients must be fully informed about all the available treatment options, the prognosis, and the consequences of choosing not to be treated. In any case, the palliative care of terminally ill patients should not be neglected. Additionally, a second medical opinion is always better than one, especially for severe diseases such as cancer. Finally, international directives from the World Health Organization (WHO) are needed to avoid discrepancies between countries.
Thanks for reading!