Why Choose Death

The arguments for and against euthanasia will now be considered separately in detail. While discussing the opposing arguments in a ‘pros-and-cons’ approach may give us a sense on which particular side is stronger, it will not give us the overall sense of the argument as a whole. Often the issues considered as essential by proponent of euthanasia is different from the issues considered by the exponent of euthanasia. A ‘pros-and-cons’ emphasis will particularizes the different areas but fragments the whole picture. We shall attempt to discuss the argument for and against euthanasia separately in order to offer a more complete overview.

Fear is a strong emotion. An emotion that will force anyone to consider ending his or her own life must be necessarily strong. The post modern society is a society built on fear – fear of uncertainty, insecurity and hopelessness. Proponent for euthanasia such as Derek Humphry[1] of the Hemlock Society and ethicist such as Peter Singer[2] pick on this fear when they argue for euthanasia.

Medical progress has created an interesting phenomenon – dying in bits and pieces and in stages. One of our fear is that medical technology and treatment methods will prolong our dying, long after it was decided that our condition is terminal and hopeless. Karen Quinlan took seven years to die after the ventilator was removed. Seven years in which she never regain consciousness. Seven years of emotional pain and financial burden on her family. All this could have been avoided by a single lethal injection. We dread to be helpless, to know that our bodies are deteriorating, our organs are failing and we are becoming more dependent. And when we are told by the best medical experts around that there is no hope for recovery, only steady deterioration.

Unless an individual somehow understands suffering due to serious illness as a direct consequence of one’s faithful response to the Gospel, endurance of such suffering cannot be seen as a mandate, either moral or theological, on the basis of scriptural witness. It is not a moral failing to view such suffering as devoid of purpose, and thus without redemptive value. This, coupled with the clear precedent of Jesus’ countless efforts to alleviate suffering through his healing ministry, makes clear that there is no obligation incumbent upon the Christian to endure suffering for its won sake.[3]

It recognise the concept of purposeless, unredemptive suffering, that is, suffering that have no value or meaning. For example, an old lady suffering from terminal cancer of the cervix, in extreme pain, dying alone, forgotten in an obscure nursing home. Assisted suicide provides a way of ending the unredemptive suffering of those who do not elect to undergo it, according to that report.[4]

Another fear is the institutionalisation of dying. Dying has become a cold, clinical process. The overwhelming majority of Americans die in institutional settings, such as nursing homes and hospitals. While some of these offer care, safety and familiar personnel and surroundings, others represent sterile, indifferent and sometimes even hostile and unfriendly environments.[5] It is this inhuman side of medicine that is frightening. Such death is comparable to dying ‘in the cold’; by the roadside, uncared for and unloved, without dignity and no different from an animal. It is also this fear that convince many that the option for euthanasia should be available.

Many terminal events, especially cancers, are accompanied by much pain. As the population ages, the incidence of cancers and degenerative disorders increase. Though pain management in palliative care has improved tremendously in the last few years, it is still not ideal and has its limitations.

Pain management is dependent on the expertise and attitude of the attending physicians and supporting personnel. The attitude and belief system of the attending physician and supporting personnel will influence the way they treat a patient. They may believe that in some way, suffering is good for the soul and may unconsciously not optimise the level of the analgesics. Physicians are trained to cure, to win and they may have trouble accepting a case of terminal illness. Many physicians feel a sense of failure and how they react to their feelings may affect their treatment of their patient. They may be indifferent to the needs of their patients, including their pain and even ignore them totally.

The other important point is that not all physicians are trained in pain management. Physicians who have training in pain management are anesthetists, critical care internist and oncologist. Most general physicians do not have the specialist knowledge for effective pain management. As a result, many patients suffer from inadequate pain control.

The pain may be controlled but the patient may be in a narcotic haze and ‘dopy’. Many people are not willing to exchange their awareness and dignity for control of their pain. There are many who have lived through life without any dependence on narcotics. To them it is insulting that their last days be dependent on such drugs.

Such people, with their fear of inadequate pain management would appreciate the option of euthanasia when they can arrange for a dignified death.

Personal autonomy or self-determination is the cornerstone of this post modern world. We would like full control of our lives. This will include the desire to choose the time and manner of one’s death. Betty Rollins, writing the foreword to Humphry’s book : “Some people want to eke out every second of life – no matter how grim – and that is their right. But others so not. And that should be their right.”[6]

In his book, Tuesdays with Morrie, Mitch Albom described the last few months he spent with his old professor, Morrie Schwartz. Morrie was suffering from amyotrophic lateral sclerosis (ALS), a slow unremitting degenerative disorder. The book started with a man who enjoyed dancing and ended with him incontinent in bed before he died.[7]

This is the fear of many of us. The fear of senility and embarrassing dependency. To get a disease like ALS or Alzheimer’s and deteriorate slowly and there is nothing we can do about it. Better to kill oneself with a lethal overdose than to suffer the indignity of slow deterioration. At least we can choose when to die. When we can no longer serve God or others by remaining alive, it is not wrong to exercise our freedom of choice to bring about our own death or to ask others to do so for us.

Many of us fear being a burden to others. The burden may be financial, emotional, physical or spiritual. Hence we would like to have an option of removing that burden ourselves when the right time and place comes.

‘It costs too much to avoid death today’[8] Heathcare is expensive. Dying is expensive. The Ninth Circuit Federal Court of Appeals in the United States acknowledged that some terminally ill patients may request for a lethal dose of medication in order to protect their family from the expense of a prolonged treatment. The court indicated that, this would not be unrealistic. It was “reluctant to say that, in a society in which the costs of protracted health care can be so exorbitant, it is improper for competent, terminally ill adults to take the economic welfare of their families and loved one into consideration”. (Compassion in Dying v. State of Washington, 1996). The financial burden can be heavy for a reason quality of care.

Many of us fear becoming a physical and emotional burden to our spouses, children or relatives when we become chronically ill, debilitated and dependent. Malaysia is a rapidly developing country. Most young couples do not have the time or the resources to take care of the sick in their household. We hear of parents being shuttled from children to children on a two weeks rotation. This is when they are well. What if they are very ill and dependent but do not need hospitalizations. Would they be made to feel welcome? Would their sense of self worth still be intact? Would they consider euthanasia as an appropriate Christian act of love?

· The sickness itself usually causes both patient and visitor to withdraw from each other.

· The delivery of medical care, especially by high-tech procedures, often places physical barriers between the patient and the care-givers.

· For the patient, the whole process of dying is isolating. He or she quits working, quits social activities, spends less time with hobbies, hasn’t the strength to maintain daily activities with family, and his or her time become continually more consumed with caring for himself or herself than for others.

· Friends find it increasingly more difficult to arrange times to visit the patient, and when they do, he or she is less interested in them. Friends lose interest in visiting. So the patient loses more interest in them and his or her surroundings.[9]

Increasing loneliness is a reality in chronic and terminal illness. In a society that fears loneliness, where there are always noise and people and activity. To be alone is a terrifying experience.

Depression is another emotion we fear. Depression is not the usual ups and downs we feel in our daily life but a persistent feeling of despair. A depressed person has a depressed mood that may last weeks or months, suffering loss of pleasure and interest in things previously enjoyed, feelings of worthlessness and excessive guilt, sluggish and slowed down (with psychomotor retardation) or chronically agitated, fatigued, troubled in thinking and concentrating, with changes in weight and sleep pattern and plagued by recurrent thoughts of death.[10]

Unfortunately Christians do not have a good track record in dealing with depression. In the preface to his book, Why Do Christians Shoot Their Wounded? Dwight Carlson wrote, “ In my experience Christians are intolerant, if not prejudiced, against individuals with emotional difficulties [depression]. Most view such problems as personal sin. Some well-known Christian authors have further fueled the fires of stigma and judgement toward those suffering with emotional illness.”[11]

It is not surprising that the fear of loneliness and depression can drive some to seek for relief through euthanasia.

Many people receive suboptimal care because palliative care facilities do not exist or local physicians lack proper training. If people receive the best care, they will not opt for euthanasia. People are interested in getting rid of their pain – not their lives. The alternatives treatments will be described more fully in the next chapter after we have considered the arguments against euthanasia.

A study of terminally ill patients published in an issue of The American Journal of Psychiatry notes: “The striking feature of [our] results is that all of the patients who either desired premature death or contemplated suicide were judged to be suffering from clinical depressive illness; that is, none of those patients who did not have clinical depression had thoughts of suicide or wished that death will come early” [12]

“Patients who request euthanasia are usually asking in the strongest possible ways they know for mental and physical relief from suffering ……..When that request is made to a caring, sensitive, and knowledgeable physician who can assure them that he or she will remain with them to the end and relieve their suffering, most patients no longer want to die”[13].

After the patient expressed his wish, Pellegrino sought to meet the real needs behind the wish.

First he used the best methods of pain relief and increased the patient’s sense of control by

enabling the patient to self-administer the pain medication. This patient was also feeling guilty,

clinically depressed, and concerned about being a burden to others. Pellegrino treated the

depression, brought in a pastoral counselor to address the guilt, and gathered the patient’s family

to help them see how their response to this man’s illness was aggravating his sense of

unworthiness. Once these needs were met, the patient thanked Pellegrino for not responding to his

earlier request to die. “The most valuable days of my life have been the last days I have spent,” he

Psychiatrist Elisabeth Kubler-Ross outlined 5 stages of the dying process- denial, anger, bargaining, depression and acceptance. In an interview, she commented:

“ Lots of my dying patients say they grow in bounds and leaps, and finish all the unfinished business. [But assisted a suicide is] cheating them of these lessons, like taking a student out of school before final exams. That’s not love, it’s projecting your own unfinished business”. [15] Euthanasia will shortcut the dying process.

It is during the times of a terminal illness that people have a unique opportunity to reflect on the way they have lived their lives, to make amends for wrongs done, to provide for the future security of loved ones and to prepare mentally and spiritually for their own death. Not all make full use of this opportunity, but those involved in hospice work often observe a mending of family relationships and rediscovery of mutual love and responsibility that may not have been evident for years.

It is often through facing the hardship that terminal illness brings, and through learning to accept the practical help of others that human character and maturity develops most fully. Death if properly managed can be the final stage of growth. It can also be a time when words are spoken and strength imparted that will help sustain ‘those left behind’ through the years ahead.[16]

The Christians had always regarded life as a journey. Death is not the end but a gateway to a new, fuller, richer life with God.

Medical research has always been strong when there is a need to find a cure or at least to control a medical condition. When death becomes the treatment or cure as in euthanasia, medical research ceases. Pharmaceutical companies are not going to spent millions of dollars on research on neurodegenerative disorders like Alzheimer’s, ALS, traumatic paralysis and many other medical conditions when there will be no demand for their drugs. When the option to cut short the disease is available, there is not need to spend further on treatments.

Another effect of euthanasia will be that ‘death treatment’ will become more developed. Research will be done to develop more efficient ways to cause death. One notable example is Dr. Karl Brandt, the only public official in modern times to develop an active euthanasia program for a country.

In 1939, Dr. Brandt was asked by Hitler to look into a request by a father to have his deformed and mentally retarded child destroyed. Dr. Brandt approved the request. Later in 1939, Hitler asked Dr. Brandt to initiate a secret euthanasia program aimed at deformed children and the incurably insane. The program was carried out with great efficiency and thousands of mental patients and children were ‘delivered from life’. The program’s scope demanded new medical technologies and led to an invention that proved very efficient : the first gas chamber.[17] This a real danger of the dark side of medical research.[18]

Patient right to autonomy is important but there is no absolute autonomous right to euthanasia. The Lords’ Report[19] includes the words from Romans 14: 7 ‘ For none of us lives to himself alone and none of us dies to himself alone’. As we have seen, theologically and ethically, there is no absolute autonomy.

When we say “ We are Masters of our own lives, Captains of our own soul,” even arguing from an agnostic or atheistic or social science contexts, we are talking about illusions. From the moment we are born to the time we die, we are a product of our environment, our upbringing, our racial makeup, our cultural conditioning, our education and socioeconomic moulding and our sexual orientation. We have never been free. We have always been guided by our own society’s norm. Our society feeds us and protects us. Yet when the going gets tough, we want to get out. The effect of euthanasia on society will be enormous.

No one makes the decision to end his or her life in isolation. The decision will affect others – families and friends left behind, healthcare workers – a whole community and web of relationships.

Unlike suicide, euthanasia is not a private act. For the patient’s autonomy to be

exercised, the doctor’s autonomy must be affected.[20] Daniel Callahan has argued along such a line that permitting euthanasia will be “self-determination run amok”.

[Euthanasia] cannot properly be classified as a private matter of self-determination or as an autonomous act of managing one’s private affairs. Euthanasia is a social decision. It involves the one to be killed, the one doing the killing, and it requires a complying society to make it acceptable. Therefore euthanasia must be assessed in its social dimensions. Precisely for this reason, the appeal to autonomy to justify euthanasia for one individual does not adequately account for the social dimensions of that individual act not the impact that sanctioning euthanasia will have on the common good. Any discussion on euthanasia, then, ought not to be limited to what helps or hinders individual well-being. Rather, it must reach beyond the individual to include the impact that individual acts of euthanasia have on community welfare. Therefore, autonomy must be understood within the limits of the social responsibilities for the common good.[21]

Autonomy is not absolute and must be considered in a social even if not a religious context.

Society has always a duty to protect the weak, the sick and the helpless. Society can only work if all its individual members are willing to submit their autonomy for the greater good. If however the members are not willing to submit, then the society will be destroyed. One good (but unfortunate) example is the allowing of abortion. When individual members of a society decide that a certain life is worthless (in this case the fetus) and works so that they change society’s duty to protect, then the society is in trouble. Once it was accepted that there are a certain life that is worthless, a certain life that is not worth living, the society will withdraw its protection. The allowing of abortion will lead to euthanasia of the deformed infant, the mentally insane, those in persistent vegetative states, the terminally ill and finally the aged, the economic unproductive, the aesthetically ugly and finally the ‘politically unreliable’.

The other consideration is that introducing euthanasia into our heathcare system where the costs are high and access uneven, patients, families and physicians will turn to it as a cost effective way to get out of a problem. Euthanasia will certainly save money and free space, physical and emotional for other acute cases.[22] It is indeed a long and slippery road.

[1] Derek Humphry, founder of the Hemlock Society, is a journalist and author who has spent the last twenty years campaigning for lawful physician-assisted dying to be an option for the terminally and hopelessly ill. He started this campaign in 1975 after the death of his first wife, Jean, from bone cancer which had become so painful and distressing that she took her own life with his help.

[2] Peter Singer is the director of the Centre for Human Bioethics at Monash University in Victoria, Australia, and president of the International Society for Bioethics. Among his books are Should the baby Live?, Embryo experimentation and Rethinking Life and Death : The Collapse of Our Traditional Ethics.

[3] Report of the Task Force on Assisted Suicide to the 122^nd Convention of the Episcopal Diocese of Newark, January 27, 1996

[4] Ibid

[5] Committee on Medical Ethics, Episcopal Diocese of Washington, Assisted Suicide and Euthanasia : Christian Moral Perspectives, The Washington report (Harrsburg, PA : Morehouse Publishing, 1997)

[6] Derek Humphry, Final Exit : The Practicalities of Self –deliverance and Assisted Suicide for the Dying ( Eugene, Ore: The Hemlock Society,1991)

[7] Mitch Albom, Tuesdays with Morie (London : Warner Books, 1997). In this book, Mitch Albom describes the slow deterioration of his friend and their conversations. It is notable that in spite of his disease, Morie did not talk about euthanasia nor request for a quick end.

[8] Committee On Medical Ethics, Episcopal Diocese of Washington, D.C. Assisted Suicide and Euthanasia : Christian Moral Perspectives – The Washington Report (Harrisburg, PA : Morehouse Publishing,1997) p.

[9] Kenneth E. Schemmer, Between Life and Death (Wheaton, IL : Vicotr Books, 1988) p. 148

[10] George P. Nichols, Do Real Christian get Depressed? ( Christian Medical & Dental Society website http://www.cmds.org/Ethics/4_4_2c.htm )

[11] Dwright L. Carlson, Why Do Christian Shoot Their Wounded? (Downers Grove, IL : InterVarsity, 1994) p. 9

[12] James H. Brown, Paul Henteleff, Samai Barakat, and Cheryl J. Rowe, “Is It Normal for Terminally Ill Patients to Desire Death?” American Journal of Pschiatry. February 1986. Vol.143, No.2 : 210 [55]

[13] Herbert Hendin, Seduced by Death : Doctors, Patients and the Dutch Cure (New York:Norton,1997)p.204,211; Gary Thomas, “Deadly Compassion,” Christianity Today, June 16, 1997p.17 quoted in Edward J.Larson & Darrel W. Admundsen, A Different Death : Euthanasia & the Christian Tradition (Downers Grove, IL : InterVarsity Press, 1998)p.249

[14] Ibid p. 249

[15] Leslie Miller, “Kuber-Ross, Loving Life, Easing Death,” USA Today, Monday, November 30,1992 Quoted in Burke J. Balch and Randall K. O’Bannon, Why We Shouldn’t Legalise Suicide, Part III : What About the Terminally Ill? (http://www.nrlc.org/euthanasia/asisuid3.html )

[16] Peter Saunders, Twelve Reasons Why Euthanasia Should Not Be Legalised ( Christian Medical fellowship http://www.cmf.org.uk/home.htm )

[17] Gary E. Crum, Dying Well: Death and Life in the ‘90s in Richard D. Land and Louis A. Moore ed, Life at Risk : The Crisis in Medical Ethics (Nashville : Southern Baptist Christian Life Commission, 1995)p.166-167

[18] One of the danger of the Genome Project is that it is possible to identify specific genes belonging to a specific group of people. For example, the gene for sickle cell disease is specific to Africans. Thus it is possible to create a virus that will be specifically destructive to that gene. It can then be released and will cause genocide amongst the Africans, a sort of biological ‘smart bomb’.

[19] Submission from the CHRISTIAN MEDICAL FELLOWSHIP to the SELECT COMMITTEE OF THE HOUSE OF LORDS ON MEDICAL ETHICS ( http://www.cmf.org.uk/home.htm )

[20] Peter Saunders, The Christian case Against Euthanasia ( Christian Medical Fellowship http://www.cmf.org.uk/home.htm )

[21] Daniel Callahan, When Self-Determination Runs Amok,( Hasting Center Report, March-April, 1992) 22:52-55

[22] Richard M. Gula, Euthanasia : Moral and Pastoral Perspectives ( New York : Paulist Press, 1994) p. 19