Dr Paulina Taboada
Profesor Centro de Bioetica
Pontificia Universidad Catolica de Chile
Alameda 340 Correo Central 1
This month, I shall interrupt my reflections on human dignity and devote this article to brief comments on four points of the EAPC Ethics Task Force's Statement on Euthanasia and PAS (cf. Palliative Medicine 2003, 17, 2: 97 - 101). A slightly different version of these comments has been already published in the above-mentioned volume (pp.134 - 135).
First, I agree with the idea that the often-adduced distinctions between 'voluntary', 'non-voluntary' and 'involuntary' euthanasia, as well as the distinction between 'active' and 'passive' euthanasia should be rejected, as they only serve to introduce conceptual confusions in the euthanasia debate. But, in my opinion, the EAPC Task Force's Statement would benefit from a more cogent foundation of this rejection, especially in the case of the distinction between so-called 'active' and 'passive' euthanasia. Arguments in favour of so-called 'passive euthanasia' tend to stress the importance of avoiding a 'medicalization of death'. Nevertheless, to argue that it is morally justified to omit certain medical interventions in order to allow a person to die with dignity is not equivalent to supporting so-called 'passive euthanasia'. Intentionally hastening a person's death by omitting some medical interventions ('passive euthanasia') is conceptually different from omitting disproportionate medical interventions with the intention not to postpone death. Indeed, from a moral point of view, an essential distinction can be made between these two acts. The act of withholding or withdrawing disproportionate treatments (because they are disproportionate) is morally different from the act of omitting proportionate treatments with the 'active' intention to hasten death.
This leads me organically to a second aspect of the EAPC Task Force's Statement that would need further precision, namely the proposition that neither withholding nor withdrawing futile treatments can be considered as euthanasia. Nobody would deny that futile treatments should not be implemented. But to define therapeutic utility/ futility is a difficult task. In fact, this concept has been widely explored in medical literature. I have already referred to this issue in the IAHPC's Ethics Page of July and December 2002, introducing a reflection on the ethical principle of therapeutic proportionality. This principle states the moral obligation to provide patients with those treatments that fulfill a relation of due proportion between the means employed and the end pursued. Medical interventions in situations in which this relation does not hold, are considered 'disproportionate' (previously referred to as 'extraordinary') and regarded as morally non-obligatory. Hence, according to this principle, withholding or withdrawing disproportionate treatments at the end of life is morally not equivalent to so-called 'passive euthanasia'. But we have to keep in mind that this concept of therapeutic proportionality does not exclusively refer to the goal of restoring health. To preserve or enhance a patient's comfort and general well being, and to prevent other diseases or complications of an incurable condition are also desirable goals of medicine, especially in the case of palliative care. And to forgo such measures in particular cases with the intention to hasten a patient's death may be equivalent to so-called 'passive euthanasia' (which I prefer to call 'euthanasia by omission').
There is a third point of the Statement that may be misleading if the text is not read carefully. This is the idea that 'terminal sedation' is not equal to euthanasia. Not infrequently, however, the practice of 'terminal sedation' goes along with so-called 'terminal dehydration'(Cf. Miller F. & Meier D.: Voluntary Death: A Comparison of Terminal Dehydration and Physician Assisted Suicide. Ann Intern Med 1998; 128, 7: 559-562). And the combination of both may be equivalent to euthanasia. An eventual misunderstanding of the EAPC Task Force's position with regard to this relevant point is prevented by stressing the importance of initiating adequate hydration and nutrition in those patients who need to be heavily sedated.
My last point refers to the very concept of euthanasia. Traditionally, the concept of euthanasia has been linked to the idea of an act motivated by the desire to alleviate suffering. In the definition proposed by the EAPC Task Force this idea is completely absent. Even though I do not agree with those suggesting that euthanasia can be justified as an act of compassion, I do think that this reference to the subjective motivation of alleviating suffering provides the grounds for the conceptual distinction between 'plain murder' and euthanasia. Hence, the Statement gives no foundations for this classical distinction.
In spite of the need of some specifications and a more cogent foundation of some of its affirmations, I think that the EAPC's Statement helps shed light on some difficult issues regarding euthanasia and assisted suicide.
Dr. Paulina Taboada, MD, PhD
Palliative Care and Bioethics