The complex euthanasia debate

The inherent conflict between self-determination and the sanctity of life makes the law far from simple. 

Euthanasia and assisting another in committing suicide are both highly emotive and contentious issues. Certainly, a clinician confronted with a request by a client to help them commit suicide should refuse for a number of reasons, not least that it is illegal. What then is the situation legally and morally when a legally competent client requests withdrawal of treatment that will certainly result in their death? A recent case is illustrative of some fine distinctions to be made.

Client (J) was a patient of the hospital involved in the proceedings for a considerable period of time. Aged 27 years, he had since the age of 7 been a quadriplegic. The court noted that from 2005 to 2013 J’s ventilation was stable, which enabled him to remain an outpatient. However, in March 2013, J was admitted to the intensive care unit of the hospital with ventilator associated pneumonia and collapse of the left lung. Ultimately the left lung failed to ever expand again. A larger tracheotomy was required. Since May 2013, there had been increasing episodes of autonomic dysreflexia, which were associated with extreme respiratory distress. J’s condition meant he required full-time carers.

At the time of the proceedings, J was receiving what generally could be described as life-sustaining treatment. In the absence of that treatment, which included artificial ventilation, J would almost certainly die. J had decided that he no longer wanted to receive the life-sustaining treatment and expressed a wish that it cease the day after the proceedings, so as to coincide with his 28th birthday. He signed a request to that effect, which was tendered to the court. Further evidence was that once the respirator was turned off, J would require medications during the palliative care phase of him dying. The hospital and its clinicians understandably sought a declaration from the court that if they acceded to J’s request they would be acting lawfully.

The legal principles are clear that whilst the common law recognises two sometimes conflicting interests – namely a competent adult’s right of autonomy and self-determination, (the right to control his or her own body) and the interest of the state in protecting and preserving the lives and health of its citizens – it is generally the case that whenever there is a conflict between a capable adult’s exercise of the right to self-determination and the state’s interest in preserving life, the right of the individual must prevail. The corollary is that except for emergency situations, a clinician who provides treatment contrary to the wishes of a mentally competent adult patient acts unlawfully and probably commits a battery.

In such a situation, is there any difference morally between a positive act of assistance (for example providing the medication for an overdose) and a negative act of not intervening when a client refuses to eat and will certainly die? After all, the result is the same, namely death. However, the law reports are littered with cases where courts have forced medical treatment on clients, against their wishes, when championing that the sanctity of life outweighs the individual’s autonomy, by determining a lack of competency. In J’s case, what makes the difference? At what stage is the withdrawal of medical treatment and the inevitable death of the client tantamount to assisted suicide?

One traditional view, in medical ethics and in law, is that the withdrawal of life sustaining treatment (LST) is logically akin to withholding the treatment. Accordingly, in this view, neither withholding nor withdrawal of the LST causes the patient’s death. Rather, the patient dies from their underlying condition. Hence, withholding LST is an omission and so does not cause death. However, in an alternative view that logic contains a flaw because arguably, the same analysis cannot apply to withdrawing LST since an act(s) is involved. For example, withdrawing ventilation requires the clinician to switch off a ventilator. The act clearly has a causal link to the consequences or outcome, namely death. Accordingly, the act of withdrawal causes death (which is more akin to the illegal act of euthanasia). In any event, should such a distinction matter where there exists a duty of care? It certainly does not for those who hold that the sanctity of life is paramount.

Another view has questioned the moral relevance of the narrow distinction between killing (causing death) and letting die. For no such distinction is made in the criminal law concerning turning off a respirator without consent, as this would amount to murder. Rather than obsess over the question of whether withdrawal of LST is letting die or killing, it might be thought better to bypass this question and simply ask whether withdrawing LST or giving a lethal injection is justified in the circumstances or not. Again, if you priortise the sanctity of life, then there will never be grounds for justification.

It is beyond this article to canvass in depth all the legal arguments and moral views in this area of healthcare. Suffice to say that there are many apparent contradictions amongst various commentators, but as the University of Southampton school of law’s John Coggon recently stated in reference to the context of the euthanasia and assisted dying debates, “… the one thing on which almost everyone seems to be agreed is that the current law is a mess.”

Scott Trueman is a lecturer in the school of nursing, midwifery and nutrition at James Cook University.

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