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Passive euthanasia occurs where the use of “extraordinary” life-sustaining measures are discontinued or refrained from. No more “heroic” efforts are made in an attempt to prolong life in hopeless cases where such prolongation seems an unwarranted extension of either suffering or unconsciousness. Generally speaking, the medical fraternity is more prone to withhold treatment than withdrawing it per se. Many countries around the globe have addressed the issue of passive euthanasia to decriminalize it. However, the two factions of for and against are convicted in their arguments. This research paper will brieﬂy address arguments in favor, namely, autonomy and the regulation of euthanasia and those against which are sanctity of life, slippery slope, danger of abuse, and the ﬁnancial burden argument. Discussing passive euthanasia, one cannot negate the importance of culture.
Simply put, euthanasia refers to the implementation of a decision to commit or omit an act at the request of a particular individual, with the effect that the life and suffering of that individual comes to an end before it needs to. However, current attitudes toward euthanasia have become much more complex and, subsequently, more confusing. This can be ascribed to a number of philosophical, medical, and religious changes that have occurred during the past 50 years and which have resulted in many different deﬁnitions of euthanasia.
At the core of the euthanasia debate lies the distinction between active and passive euthanasia. This distinction is based upon the difference between acting (killing) and omitting to act (letting die). Active or positive euthanasia refers to a positive, merciful act taken deliberately to end futile suffering or a meaningless existence. It is an act of commission, where death is induced, either by direct action to terminate life or by indirect action, such as injecting a lethal dose of morphine or potassium chloride, which will almost certainly hasten death. Passive or negative euthanasia, on the other hand, occurs where the use of “extraordinary” life-sustaining measures are discontinued or refrained from. No more “heroic” efforts are made in an attempt to prolong life in hopeless cases where such prolongation seems an unwarranted extension of either suffering or unconsciousness. Included in this deﬁnition is the omission of medication or other life-sustaining therapy, the refusal to perform surgery, the withholding of attempts to resuscitate when the patient’s vital system fails, and the withdrawal of artiﬁcially supplied nutrition and hydration. In essence, it is to refrain from any action which would probably delay death and instead to permit natural death to occur.
Passive Euthanasia’s Ethical Crossroad: To Withhold Or To Withdraw?
Approximately 1 in 5 American patients die in critical care units with over 90 % of deaths in critical care preceded by decisions to withhold or withdraw life-sustaining therapies. Health-care providers collaborate with patients’ families as decisions are made to limit treatment and care for both patients and their families during the dying process (Wiegand 2008).
One of the major contributors to the debate about withdrawing and withholding health care is the case of a Baby Doe born in Indiana with Down syndrome and a tracheoesophageal ﬁstula, which could have been repaired with an operation that the parents refused. The Indiana Supreme Court let the parents’ decision stand, and the infant subsequently died. Although the medical fraternity agrees that Baby Doe could have been saved and that the boy should not have been denied treatment (and food and water), the picture today is vastly different. Major advances in medicine have led to dramatic changes in physicians’ attitudes toward prolonging life. Despite intensive care, individuals may remain hopelessly ill, endure increased suffering, or linger in persistent vegetative states after medical interventions. According to the British Medical Association (2007), although bioethicists and legislators in most Western countries have rejected the distinction between withdrawing and withholding therapy, they have still acknowledged that psychologically and emotionally the two are not equivalent. The British Medical Association (2007, p. 19) stated that “many health professionals, as well as patients, feel an emotional difference between withholding and withdrawing treatment. This is likely to be linked to the largely negative impression attached to a decision to withdraw treatment, which can be interpreted as abandonment or ‘giving up on the patient.’”
Islamic law dictates that passive assistance in allowing a terminally ill patient to die would be permissible: (1) administering analgesic agents that might shorten the patient’s life with the purpose of relieving the physical pain or mental distress and (2) withdrawing a futile treatment with the informed consent of the immediate family members who act on the professional advice of the physicians in charge of the case and allowing death to take its natural course (Aramesh and Shadi 2007). The Israeli legislature ratiﬁed the Dying Patient Act in 2005 which established guidelines for the treatment of terminal patients according to Doron et al. (2014). The authors argue that although the legislation is restricted to a limited set of patients who ﬁt the deﬁnition of incurable according to the law, the types of interventions allowed by the law are extensive and provide acceptability for passive euthanasia by patient request and aggressive pain management even when shortening of life ensues. The law makes provision for a mechanism by which life support such as mechanical ventilation could be discontinued in an active but indirect manner such as placing respirators on timers (Doron et al. 2014).
In an English case on withholding and withdrawing life-prolonging medical treatment (Airedale NHS Trust v. Bland  AC 789), Hawley (2007) states that it was decided that treatment could be withdrawn so a patient could die. The well-known case of Tony Bland came about when he was left in a persistent vegetative state following the Hillsborough football stadium tragedy. Bland was resuscitated but was left in a persistent vegetative state, which led the House of Lords rule (three to two) that life-prolonging artiﬁcial nutrition and hydration could be withdrawn from Bland to allow him to die (Hawley 2007). Consequently, medical associations such as the British General Medical Council and British Medical Association have published guidance on withholding and withdrawing life-prolonging treatment. Taking the aforementioned into account, it can be deducted that passive euthanasia has been decriminalized and has attained acceptance in many legal cultures. Keeping this in mind, it is important to take cognizance of the changing health landscape worldwide and how this may inﬂuence the increase of passive euthanasia.
State Of Health Care In The Twenty-First Century
According to the WHO (2015) in 2012, the global life expectancy at birth was 68.1 years for men and 72.7 years for women. At the global level, both male and female life expectancies in 2012 have increased by 6 years since 1990, with gains recorded across all country-income groups. Recent increases have been largest in low-income countries, where both male and female life expectancies increased by around 9 years – from 51.2 to 60.2 years for men and from 54.0 to 63.1 years for women. In low-income countries, such gains in life expectancy are equivalent to an average increase of 3 days per week – or 10 h every day. This has been achieved despite the ongoing HIV/AIDS pandemic affecting many low-income countries in sub-Saharan Africa during this same period. The main driver of this improvement in life expectancy at birth has been the rapid decrease in child mortality seen in many countries since 2000.
With the eradication of many childhood illnesses and infectious diseases such as smallpox, more people are surviving to an age at which they risk death from chronic, degenerative diseases of the circulatory and respiratory systems and cancers. Therefore, the longer a person lives, the greater the risk of exposure to carcinogens, impaired immune function, alterations in host genome, and declining physical and mental conditions. Life can now be prolonged by means of modern technology in situations where the decision is based largely on technical criteria rather than on considerations for the patient who may be suffering grave pain. Dare (1987) estimates that although some cancer patients (30–40 %) never experience any pain, approximately 40 % of patients experience severe pain at some time during their illness, while about 5 % of all cancer patients suffer intolerable pain which cannot be controlled. When the pain suffered by a terminally ill patient reaches a certain level, consciousness becomes constricted to the point where choices other than not prolonging the agony cannot be appreciated. It is in cases such as these when the health-care team and patient (or proxy/surrogate if the patient is not competent) need to make an informed decision to withdraw or withhold treatment.
Although academically debatable, the reality is that passive euthanasia presents an ethical and moral question, the answer to which is inﬂuenced by every sphere of human existence and relations without a simple yeah or nay answer. No wonder then that this is a subject which has given and still gives rise to ﬁerce and well-developed arguments, both in favor of and against the legalization of passive euthanasia.
Arguments In Favor Of Euthanasia
Autonomy is seen as the linchpin of the right to die and is one of the core principles shared by almost every member of society. Although the argument (from a Kantian perspective) is that only rational individuals can exercise this right, the legal status of proxy/surrogate (someone with the best interest of the patient at heart) rights counters that autonomy can only rest with an individual to make a decision about his/her own health care when competent. Doron et al. (2014) argues that part of our social contract is the principle that the individual retains whatever is not surrendered to the state. In an open, pluralistic, and democratic society, an individual thus has the right to determine what is done to his or her body by virtue of self-determination or proxy approval. Accordingly, an individual has a right to choose death over a life of pain and suffering, provided the decision to die is well informed, is made only after careful thought and deliberation, and is made by after consultation with either a competent patient or his/her proxy. By deﬁnition, this means that a knowledgeable, communicative understanding of the exact consequences of the decision should be present.
Opponents of passive euthanasia often cite the quality of life argument; however, consideration of quality of life should not involve a comparison between different human lives and that to prolong or postpone death can reasonably be seen as non-beneﬁcial to the patient. Taking this into account, it cannot be wrong for individuals who do not value life to wish for death or to value death more than life.
Regulation Of Euthanasia (Active And Passive)
Many opponents of euthanasia argue that there exists a legitimate concern that adopting euthanasia practices as a matter of policy and law would present dangers to society. However, there is much to be said for permitting or regulating behavior. Simply making behavior illegal is not an adequate solution since it usually results in driving the behavior underground, often with disastrous consequences for society. This has been clearly illustrated by the banning of alcohol. Advocates contend that allowing a small number of passive euthanasia cases under carefully controlled and narrowly restricted conditions would be better than acceding to the secret and unregulated activities (Bachman et al. 1996) reported in many countries.
To avoid serious abuses of euthanasia and the subsequent devaluation of human life, supporters of these acts suggest the careful regulation of such practices by law. The situation in the Netherlands is often cited as an example. The Dutch have established conditions that must be met before physicians may administer euthanasia. Where physicians apply euthanasia without such conditions being satisﬁed, they risk legal prosecution (Sagel-Grande 1998). According to the Dutch, the best way to minimize the possibility of abuse is to limit the availability of euthanasia to competent patients who request the act on the basis of their current situation instead of their hypothetical, future position. Use of such practices would be sharply limited, since euthanasia would also be denied to incompetent patients with an advanced directive (Angell 1988).
It is interesting to note that over 75 % of the respondents interviewed by Blendon et al. (1992) in the USA believed that the law should sanction the withdrawal of life support or life-sustaining treatment where a terminally ill patient requests it. Such sanction is seen as permitting individuals to have more personal control over their quality of life and death. In comparison with this, 90 % of Edmonton respondents (Genuis et al. 1994), 90 % of the British population (Wise 1996), and 48 % of the Michigan sample (Bachman et al. 1996) supported a competent patient’s right to have life support withdrawn on request.
According to sections 293 and 294 of the Dutch Penal Code, killing a person on request carries a maximum penalty of 12 years’ imprisonment and the maximum penalty for assisting in a suicide is 3 years’ imprisonment. In terms of section 289, terminating life without request amounts to manslaughter or murder. Consequently, everyone who commits euthanasia, assists in suicide, or ends human life without request is punishable, and exemption from punishment is only possible in terms of the general rules. Such a general reason for exemption from punishment can be found in section 40 of the Dutch Penal Code: “A person who commits an offence as a result of a force he could not be expected to resist (overmacht) is not criminally liable” (Sagel-Grande 1998, p. 104).
However, a new proposal for the procedure of euthanasia was introduced after 1996 in the Netherlands. Each case of euthanasia is scrutinized by the regional commission composed of physicians, ethicists, lawyers, and other professionals. The Dutch model is held by some to show that euthanasia can be embraced by a society in a controlled manner and monitored effectively.
Arguments Opposing Euthanasia
It is said that a society’s moral integrity can be measured by the way it treats its most frail and vulnerable members. Opponents of euthanasia argue that its legalization will reﬂect the movement away from efforts to improve the care of those most in need. Instead, legalization will amount to acceptance of the view that death is the preferred solution to the problems of illness, age, and depression.
Arguments against euthanasia are more familiar than arguments in favor of it. Strong legal, religious, and cultural taboos against the taking of human life reﬂect the supreme value placed on human life. Legitimate concerns exist that any compromise of this position might lead to acceptance of the notion that euthanasia is appropriate for the individual patient under certain circumstances. Such compromise should be opposed, as it would lead to the devaluation of life (Angell 1988). Related to this argument, according to Angell (1988), is the fear that devaluation would be selective and that euthanasia might occur too often among the weak and powerless in our society – the very old, the poor, and the handicapped.
Arguments against the legalization of euthanasia focus on four major themes. The sanctity of human life argument emphasizes the inviolability of our cultural prohibition against killing. Slippery slope arguments envision the legalization of voluntary euthanasia as inexorably leading to forms of involuntary euthanasia and an attendant devaluation of human life. Danger of abuse arguments envision the coercion of patients by their families, doctors, or health-care workers to request euthanasia and the disregard of euthanasia guidelines by physicians and institutions (Schanker 1996) who are committed to saving lives.
Taking the aforementioned into consideration (and due to limited space), focus will be turned to the dangers of abuse and the ﬁnancial burden argument in speciﬁc.
Financial Burden Argument
With the rising cost of health care, many governments, private insurers, and employers had to set limits on health-care coverage (Schanker 1996).
Society, Doron et al. (2014) argue, with pervasive societal pressures and demands, can force the medically indigent, such as the elderly, terminally ill, and poor, to die earlier simply to free up resources for the rest of society. The risk would be especially great where an elderly person feels there is no other option or fears being a ﬁnancial and emotional burden to society (Schanker 1996).
Research done in America and Britain illustrates this point. It was found that the main reason Americans would consider ending their lives stemmed primarily from fears of being a burden to their families (Blendon et al. 1992). Fifty-one percent of a British sample agreed that a patient should be granted a request for euthanasia if they were permanently and completely dependent on relatives, even though they might not be in pain or in danger of dying (Wise 1996).
On the other hand, research conducted by Genuis et al. (1994) indicated that 65 % of the Edmonton population oppose the right to euthanasia for disabled, elderly persons on the basis that they feel themselves a burden to their families. Seventy-ﬁve percent opposed euthanasia for reasonably healthy, elderly persons who no longer enjoy life because of loneliness, fatigue, and various aches and pains.
The ﬁnancial burden argument is labeled by proponents as scare mongering. They refer to the Netherlands as the model example, where such practices do not commonly occur. However, as Sagel-Grande (1998) point out, almost all patients (99.4 %) in the Netherlands have health-care insurance, and 100 % of the population is insured against the cost of protracted illness. Therefore, there are no ﬁnancial incentives for hospitals, physicians, or family members to stop the care of patients.
The picture in many developing countries such as South Africa, however, is very different. Many citizens are poor and these patients are by necessity discharged early to be nursed at home – the purpose being to cut down on medical care costs. These patients are thus deprived of any possible life-prolonging interventions. This together with the emotional and physical burden often experienced by families caring for ill members of family may create a possibility for grave abuse, as Schanker argues (1996) should voluntary euthanasia be legalized before the ﬁnancial stressors in health-care system internationally are reasonably ameliorated. In the coming decades, the elderly population will increase dramatically, and, if the spread of dementia and social ills associated with poverty continues unabated, the health-care system will be burdened far beyond its present capacity (Schanker 1996).
Experience And Field Of Practice
Physicians in the medical specialities of oncology and hematology, who in their daily work have close and continuous contact with dying patients, hold more restrictive attitudes than physicians in laboratory specialities. Thus, the doctors who had least contact with terminally ill patients were the most likely to support the legalization of assisted suicide (Bachman et al. 1996). It is interesting to see that 52 % of physicians in Michigan (Bachman et al. 1996) and 51 % in Alberta (Genuis et al. 1994) would not be willing to participate in physician-assisted suicide or voluntary euthanasia if these practices were legalized.
Ethnicity And Euthanasia: An African Perspective
However, no legal system can ever be void of societal context, and Blendon et al. (1992) found that people from an African background were more opposed to euthanasia than those from a European background. The authors suggest that a possible explanation for this lies in the fact that members of the African ethnic groups are less likely to release power over their lives to others as well as major social factors, particularly religion and family, which provide a buffer of social forces which prevent self-destruction in any form.
African communities have an effective social support system and are stereotyped as looking after their own. For Africans, death and dying form an integral part of their everyday existence (Blendon et al. 1992). According to the African belief system, the soul of the departed person passes to the world of the ancestral spirits where it continues to live on (Blendon et al. 1992). However, if a person or a proxy decides to end his or her life prematurely, that person’s soul is doomed and becomes an evil spirit. The moral danger of the active and passive euthanasia debate is to become too ethnocentric and to argue that one size ﬁts all. The debate will have various outcomes in various parts of the world; however, the fact that we need to debate it is a step in the right direction to assert what is acceptable when we consider the plight of those who are at the end of their lives.
Both sides of the euthanasia debate are ﬁercely argued. Those favoring euthanasia focus on autonomy, mercy, and a patient’s right to autonomy (Schanker 1996; Wise 1996). Opponents, on the other hand, focus on arguments such as the sanctity of human life, the slippery slope, the danger of abuse, and the commitment made by physicians to save lives (Schanker 1996). The most serious difﬁculty faced by those proposing a rule of law based upon religious dogma is that it will only be convincing to those who accept the religious viewpoint, that is, those who are already believers. Moreover, as Key (1989) points out, modern law is not and should not be dictated by popular religion. There should not exist a simple equivalency between sin and crime; all crimes should not be seen as sins nor should all sins be seen as crimes. It has been argued, however, that a society may legitimately use the law to shape its basic institutions and practices to accord with its deepest convictions about right and wrong.
The problems posed for law and morality by the assertion of a right to die are complex (Key 1989). Moral dilemmas arise and become progressively more serious as medical science develops, and the body can be kept alive almost indeﬁnitely with respirators, pacemakers, renal dialysis, and artiﬁcial feedings (Key 1989).
At the core of all modern legal systems lies the fundamental assertion that human life should be protected. Legal systems, regardless of speciﬁc variations in cultural or social context, recognize the value of human life by prohibiting homicide and punishing acts, which constitute a danger or serious threat to the lives of other human beings. The modern law reformer faces two central questions. Firstly, does an individual have a right to die? Secondly, do individuals have a right to let someone else die? There is an inherent tension between the public interest in improving community health standards and preserving life, on the one hand, and the individual’s right to personal autonomy on the other (Key 1989).
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