Dr Paulina Taboada
Profesor Centro de Bioetica
Pontificia Universidad Catolica de Chile
Alameda 340 Correo Central 1
My comments on the empirical data on euthanasia and other end-of-life decisions in The Netherlands recently published by The Lancet(Cf. Onwuteaka-Phillipsen, B. et al.: Euthanasia and other end-of-life decisions in the Netherlands in 1990, 1995, and 2001, The Lancet, published online June 17, 2003: http://www.thelancet.com/) lead me – among other things – to question whether it is conceptually adequate to define euthanasia as "the administration of drugs with the explicit intention of ending the patient’s life on his or her explicit request" as the authors of the article do.
The contemporary debate as well as several of the criticisms to the EAPC Ethics Task Force’s position paper on euthanasia and physician assisted suicide show that our conceptual correlate when talking about euthanasia is far from being settled (Cf. Materstvedt LJ, et al. Euthanasia and physician assisted suicide: a view from an EAPC Ethics Task Force. Palliat Med 2003; 17, 2: 97 – 101. See also the different comments pp. 102-183). And perhaps one of the most crucial points to an understanding of the whole euthanasia debate is the question of what exactly does the concept of euthanasia refer to?
A Dictionary states two meanings of the word euthanasia: "1. The action of inducing the painless death of a person for reasons assumed to be merciful. 2. An easy or painless death." (Cf. Morris W (Ed.): The American Heritage Dictionary of the English Language. Boston: Houghton Mifflin, 1980). On the other hand, the Encyclopedia of Bioethics states (p. 554) that to preserve historical usage, the word "euthanatos" is coined to refer to four meanings: "(1)inducing death for sufferers; (2) ending the lives of the unwanted; (3) caring for dying; and (4) letting people die"(Cf. Warren T (Ed.): Encyclopedia of Bioethics (Rev. Edition). New York: MacMillan, 1995).
The Dutch group as well as the EAPC Ethics Task Force proposed to define euthanasia rather as "a doctor intentionally killing a person by the administration of drugs, at that person’s voluntary and competent request." (Materstvedt LJ, et al. Euthanasia and physician assisted suicide: a view from an EAPC Ethics Task Force. Palliat Med 2003; 17, 2: p. 98). This definition does not include any of the elements of the traditional concept of euthanasia. In fact, it points towards a quite different concept. This "new concept" arbitrarily limits euthanasia exclusively to: 1. a physician’s action, 2. an administration of drugs; 3. a response to a voluntary request. The "new definition" disregards the fact that an act of euthanasia could be committed – in principle- by everyone, by an action or an omission and even against a person’s voluntary request.
Explaining the reasons for choosing such a definition, Materstvedt states that the EAPC Task Force decided to follow the "Dutch way" (Materstvedt LJ. Palliative care on the 'slippery slope' towards euthanasia? Palliat Med 2003; 17: 387-92). This explanation confronts us with the question whether in speaking of euthanasia our concept refers to something real, or whether it rather reflects an individual’s, or a society’s, interpretation of a given fact. A few thoughts on the term ‘concept’ and its relationship to ’definitions’ may help shed light on this point.
A concept is richer, or broader, than a definition. Nordenfelt notes that it is possible to have many definitions corresponding to one concept, or attempting to capture this concept (Cf. Nordenfeldt L: On the Nature of Health. Dordrecht, Reidel, 1987, p. 8). This shows that a concept is more than a linguistic, or propositional entity, while we could consider a definition to be such. But a propositional formulation should succeed in pointing to its object. Perhaps it cannot ’capture’ it completely, but it should at least unequivocally point to it. This is not to discourage the search for definitions, and in particular for a definition of euthanasia. It is only to point out that any definition presupposes understanding - a concept - of that which is to be defined.
Recognizing this dependence of definition on concept again shows the priority of clarifying and refining the concept. At the same time, it rescues definitions from their reductive potential by emphasizing that with every definition there is ‘more’ than what is captured by the definition itself. A concept, on the other hand, could perhaps be characterized as an entity of the understanding, or as the mind’s possession of the thing meant. But the notion of ‘concept’ itself is not an undisputed matter, as any basic course in logic soon makes clear. In a realist understanding, a concept can be a concept of some thing, and through it we grasp the nature or essence of this reality. A nominalistic understanding of concepts, on the other hand, sees concepts as reflective not of reality, but of an individual or collective structuring of the world or of the use of language. The resolution of this dispute depends ultimately on epistemological and ontological investigations. And so, this whole discussion could appear far removed from the concerns raised by the euthanasia debate. But in fact it is not.
If we want to accurately understand for instance the EAPC’s current position on euthanasia and physician assisted suicide, we would need to first clarify the concepts involved. And as we have seen, understanding a concept presupposes already a philosophical standpoint. Nevertheless, the EAPC Ethics Task Force decided to avoid any philosophical or ethical commitment (Materstvedt LJ. Palliative care on the 'slippery slope' towards euthanasia? Palliat Med 2003; 17: 387-92). But such a "method of avoidance" does not seem to be a suitable method for the Task Force’s specific commission. As Vanderpool states (p. 561): "Western pluralism sanctions endless arguing over euthanasia, but the arguments of respective groups readily pass over the others’ heads. Until the discussion deepens to an exchange that deals with the frameworks of meanings that undergird the opposing views, disagreement over induced death is unlikely to end." (Cf. Vanderpool H: Death and Dying: Euthanasia and Sustaining Life. In: Warren T (Ed.): Encyclopedia of Bioethics (Rev. Edition). New York: MacMillan, 1995, pp. 554 – 563).
Dr. Paulina Taboada, MD, PhD
Palliative Care and Bioethics