Abstract
This essay plans to discuss what potential groups of patients could be discriminated against if euthanasia was legalised in the UK. The groups of people the essay focuses on are: those with mental health issues and those with dementia and also the essay will consider the concept of the slippery slope in society and euthanasia and terminal illness. To achieve this the essay will review how legalising euthanasia has affected patients in countries where it has been legalised such as Netherlands. After completing this essay and reviewing the information and evidence available, it is clear that legalising euthanasia is a very controversial area with many patient groups feeling discriminated, specifically people with mental health issues or dementia. I feel that euthanasia should not be legalised in the UK as it could lead to an irreversible change in society causing a change in peoples morals and ideas of what is acceptable in society. Legalising euthanasia could lead to those who are most vulnerable in society being put at risk of involuntary euthanasia.
Introduction
Euthanasia is an act that involves intentionally ending someone’s life to end suffering, this is different from assisted suicide as assisted suicide involves helping someone to kill themselves but the person helping is not involved in actually killing, the patient does this themselves i.e. the person provides the means for death but doesn’t actively kill the person (1).
There are three types of euthanasia which are:
- voluntary (the patient consents for euthanasia),
- non-voluntary (the patient is unable to give consent such as a person in a persistent vegetative state); and
- involuntary (this is cases where euthanasia is performed against a person’s wishes) (2).
Currently in the UK euthanasia is illegal and there debate about whether the UK should follow other countries such as Holland and legalise euthanasia. In 2010 a survey was carried out entitled British Social Attitudes which found 82% of participants thought a doctor should be able to end a patient’s life who had a terminal illness and severe pain if that patient asked the doctor to do so (3,4) this suggests in the UK people may want a change in the law regarding euthanasia. But if the law is to be changed could this result in problems with specific groups of people being discriminated against?
This essay will discuss groups that may face discrimination if the law changed regarding euthanasia in the UK. The essay will discuss the concept of the slippery slope in society. This is the idea that if certain practices become legal such as voluntary euthanasia this leads to acceptance in society of practices that currently are not accepted such as involuntary euthanasia, to avoid slippery slope we must not make any form of euthanasia legal (5). The essay will consider patients with terminal illness, dementia and mental illness relating to euthanasia because as a future doctor these issues will affect day to day decision about patient care and affect how I practice.
The Slippery Slope
People fear legalising euthanasia will lead to a slippery slope in society in other words legalising this would lead to people who are vulnerable or unable to make their own decision being forced into euthanasia (6). The slippery slope idea suggests that making euthanasia legal will result in society accepting ideas that are currently morally unacceptable to the majority of people (5,7). However Margaret Battin concludes in her paper that in the Netherlands where some forms of euthanasia are legal there was no evidence of a slippery slope and no evidence of abuse of the law against vulnerable people (7). In Margaret Battins study data was collected from 4 nationwide studies carried out by the government into end of life decision making (1990, 1995, 2001 and 2005) and focused on elderly, minors, people with psychiatric illnesses including depression and chronically ill (7). Another paper by D Benator concludes that no matter what the law is people will always abuse it and even when euthanasia is illegal some people still abuse this law and carry it out for example in 1992 Dr Nigel Cox was charged with attempted murder of a patient after he gave her potassium chloride which killed her because she was in severe pain and asked him to end her life (8), so it may be better to legalise euthanasia and ensure its done correctly and in a dignified way for the patient (5).
In recent years in Netherlands and Belgium euthanasia has been allowed for children, the youngest child being 9, as well as adults (9). The GMC states children over 16 have the capacity to consent and those under 16 may have depending in factors such as maturity and capacity must be assessed (10). I believe that this shows evidence of a slippery slope in society due to the fact euthanasia was legalised and then was extended to children who could be considered a vulnerable group because there is a question if children as young as nine really understand the decision they are making. In the UK there is an extremely high level of expertise in children’s palliative care, having visited NI Children’s Hospice and seen that there are highly trained staff are on hand to ensure any terminally ill children are extremely comfortable in their last days and ensure that they enjoy every moment of life and I believe that making the most of every moment is better for a terminally ill child rather than euthanasia and facilities such as the children’s hospice help all the family make memories so families have good memories to look back on and also support families for up to 2 years after their bereavement. While Margaret Battins study showed no evidence of a slippery slope, her study only considered 4 government studies and did not consider some cases may not have been reported which would show evidence of a slippery slope and children as young as 9 being allowed euthanasia in Netherlands shows euthanasia being legalised does lead to a slippery slope in society.
Terminal Illness and Euthanasia
Some places that legalised euthanasia or physician assisted suicide state in laws governing this that the patient must be terminally ill an only have a certain amount of time left to live for example Oregon’s law states patient must only have 6 months to live (11,12). A patient is considered terminally ill if they have a disease that cannot be cured and will probably result in their death (13). If the UK were to introduce a law similar to this it could lead to a potential issue for people who have an incurable illness or paralysis who are unlikely to die quickly. These patients will not know when they will die but may feel that life isn’t worth living and that they would like euthanasia but as they would not fulfil the criteria could not have euthanasia under a law that states a person must have a certain time left to live (14,15) but under the definition of terminal illness they may actually be terminally ill as they have a condition that is incurable (15,16).
If law states the person must have less than six months to live this will raise problems with how accurate a doctors prediction can be of how long someone has to live (11,12). A study by Jason Lambden into life expectancy estimates in oncology patients with a terminal diagnosis found that doctors could only accurately predict how long patients had left to live to a year and even at that only 74% are accurate to within a year (17). Which means doctors could tell a patient they had only six months to live when in fact it may much longer and had the patient known this they may have chosen to spend longer with their families. Putting a definite time of how long a patient has to live on a decision such as this may result in people prematurely ending their lives when they may have had longer time left than estimated and ultimately could deprive a person and their family time together that could have been spent making memories.
The GMC has four key ethical principles for a doctor: Autonomy, Beneficence, Justice and Non Maleficence (18), under these four principles I believe that euthanasia should not be legalised in the UK because ultimately a doctors aim is to save lives and not to end them. A doctor must do no harm to patients and should only do what benefits the patient and for a patient who it is not known how long they will live there could be advances in treatment in the future that would help the persons condition, but they would not have a chance to access had they had euthanasia. Some would argue that by not allowing euthanasia the patients autonomy and justice is not fulfilled I would argue against this as the patient will have the right to choose still but they will be able to choose what sort of palliative care they want and where they want to die and it is justice for the patient as palliative care will ensure a pain free death spent with their family where the patient wants to die. There is also potential conflict between beneficence and non-maleficence, I feel euthanasia is not a benefit as you are shortening a patient’s life and what would be a benefit is good palliative care and ensuring the patient is comfortable.
Patients with Dementia
Patients who have dementia can access euthanasia in Netherlands and Belgium if they have a written directive stating they want euthanasia (19). However Dutch police are investigating a case of euthanasia for a woman with Alzheimer’s where a patients coffee was drugged without her knowing and she was then restrained while given a fatal injection (19,20). This case is an example of how vulnerable patients could be forced into euthanasia if it was legalised in UK.
A study was carried out by Jakov Gather and Jochen Vollmann involving patients with dementia who wished to have physician assisted suicide and they concluded that if diagnosed early the patient does have capacity to consent to a decision regarding euthanasia, while this is not euthanasia the issue of consent is relevant to euthanasia as well as PAS (21). Capacity is assessed at that particular time and so it may mean that at the time of assessment the patient has capacity but by the time the patient actually undergoes euthanasia they may no longer have capacity, this creates issues as to whether the persons decision still stands. The patient may have changed their mind and I believe that the person must have capacity at the time that euthanasia is happening so in that case I believe euthanasia should not be legal.
It is also hard to judge how progressed the disease is and if the person really has capacity or not and this may lead to people with dementia being influenced by their family to have euthanasia when maybe the person wouldn’t want this as people with dementia would be vulnerable to being persuaded by their families as they don’t want to be a burden to them. The case of dementia is again another example of the potential slippery slope that legalising any form of euthanasia could create in society.
Mental illness and Capacity
Euthanasia may discriminate against people who have a mental illness, this is because all countries that offer euthanasia such as Belgium and the Netherlands state the person must have capacity to make the decision and there could be questions as to whether a person who has a mental illness has capacity (22,23). A person with mental illness undoubtedly suffer a lot of pain but a mental illness can impair their capacity to think about, weigh up and completely understand the decision meaning they are not fit to make a decision about ending their life (24). Mental illness can be treated and cured unlike a person who has a terminal illness. In February 2018 a 29 year old physically fit woman who suffered from depression was allowed to have euthanasia to end her life (25). Ms Brouwers spent 3 years in a mental health facility and felt depression made her life not worth living (25). The GMC states one of the key principles for a doctor is autonomy, but other key principles laid out by the GMC are non-maleficence and beneficence i.e. a doctor must do the patient no harm and should only do benefit (18). I believe in cases such as this involving a patient with mental illness requesting euthanasia,if a person is extremely mentally unwell it is unlikely that they can think clearly and truly understand the decision they are making so in cases like this I believe euthanasia should not be legalised as it is duty as a doctor to help the patient and not to harm them. In the UK significant amounts of money are spent on treatment of mental health and so rather than legalising euthanasia ensure that patients with mental illness get the correct treatment to help them get back to living a normal life. The other key principle the GMC has is justice, while the patient who is receiving euthanasia may feel they are getting justice I feel that if the patient is treated and after treatment feels well again, they would feel that they really did get justice as they would no longer feel that their life was not worth living.
If patients with mental illness are allowed access to euthanasia there is a potential for abuse, people who may not have the capacity are allowed euthanasia because they are thought to be a burden to society or their family. In the Netherlands in 1994 the supreme court made a ruling that stated that the seriousness of a person’s suffering does not depend on what is causing this pain or suffering, meaning there was no difference between physical or mental suffering and if a doctor assessed a patient and deemed that they met the criteria for assisted suicide they were eligible even if the illness was mental not physical (26). A study carried out by Kissane and Kelly into euthanasia in patients with mental illness in the Netherlands concluded prognosis and outcomes in this condition are uncertain, there is also a wide variation in treatment used in mental illness (27). They believe that allowing patients with a mental illness to have assisted suicide has greatly changed psychiatry and not for the better in the Netherlands (27).
One of the GMCs principles for doctors is justice (18), I believe that if euthanasia was legalised it could be doing an injustice to people in society who have mental illness as they may have access to this and may take it up but had this person been treated effectively their opinion on euthanasia may have been completely different and if they had not been mentally ill they may never have wanted euthanasia. I believe that when a person is mentally ill it is impossible to decide if the person has the capacity to decide about euthanasia or not, so it should not be legalised in such cases.
Conclusion
In conclusion I believe that the UK should not legalise any form of euthanasia because ultimately it leads to a slippery slope effect where people morals and ideas of what is normal in society will be irreversibly changed forever and it would lead to those people who are most vulnerable in society such as old, mentally ill and children being put at risk of non-voluntary or even involuntary euthanasia such as the case mentioned in the essay of a patient with Alzheimer’s in Netherlands (19). I also believe that as doctors there are standards and principles set out by the GMC, with the four main principles being autonomy, beneficence, justice and non-maleficence and if euthanasia was legalised I feel that as doctors we would be no longer fulfilling these principles as ultimately we would be harming our patients and not providing them justice and beneficence, instead of legalising euthanasia more funding should be used for research and training for palliative care, improving existing palliative care facilities, research into the best treatments for mental illness and into improving care for patients with mental illness.
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