Would euthanasia damage doctors?
Last week, the Quebec College of Physicians and Surgeons tentatively approved euthanasia. That means it's essential that we look, specifically, at the impact that euthanasia would have on physicians and the profession of medicine, in order to understand why this approval is a very bad idea.
In mainstream media, and therefore in the general public forum, the euthanasia debate has been focused, almost entirely, on the impact that legalizing euthanasia (a term I use in this article to include physician-assisted suicide) would have at the individual level. But we must also consider the impact legalizing it would have at institutional, governmental and societal levels. We need to explore not only the practical realities, such as the possibilities for abuse, that allowing euthanasia would open up, but also, the effect that doing so would have on important values and symbols that make up the intangible fabric that constitutes our society.
For example, what would be its likely impact on major societal institutions, such as medicine and law, which help to establish those values and carry the message of the need to respect them?
Legalizing euthanasia would damage the foundational societal value of respect for human life. If euthanasia is involved, how we die cannot be just a private matter of self-determination and personal beliefs, because, as American philosopher Daniel Callahan says, "Euthanasia is an act that requires two people to make it possible and a complicit society to make it acceptable." The British House of Lords, likewise, rejects euthanasia because of the harm it would cause to societal values and institutions: "The prohibition on intentionally killing is the cornerstone of law and human relationships, emphasizing our basic equality."
One important reason to protect health-care institutions is that they are value-creating, value-carrying and consensus-forming for society as a whole.
In a secular, pluralistic society, medicine and law are the principal institutions that maintain the value of respect for human life in society as a whole. Changing the law to allow physicians to carry out euthanasia -- making an exception to the norm that we must not kill each other --would seriously damage these institutions' capacity to carry that value.
In short, we need to be concerned about the impact that legalizing euthanasia would have on the institution of medicine, not only in the interests of protecting it for its own sake, but also because of the harm to society that damage to the profession would cause.
And what might be the impact of the legalization of euthanasia, internally, on the profession of medicine and its practitioners?
As the Canadian Medical Association wrote in a letter distributed to all members of Parliament just before the first debate on Bill C-384, "CMA's policy on this matter is clear: 'Canadian physicians should not participate in euthanasia or assisted suicide'." And surveys consistently show that physicians in various countries are more opposed to euthanasia than the general public. For instance, a 2009 survey by the British Royal College of Physicians showed 73 per cent of its members opposed euthanasia, whereas up to 82 per cent of the British general public approved of it. Important insights could be gained by pondering the causes of such disparities.
Euthanasia takes physicians and medicine beyond their fundamental roles of caring, healing and curing, whenever possible. It involves them, no matter how compassionate their motives, in the infliction of death on those for whom they provide care and treatment. It can be described, as the London-based Institute of Medical Ethics does in its report, "Working Party on the Ethics of Prolonging Life and Assisting Death," as "a merciful act of clinical care," or, as the Quebec College of Physicians and Surgeons characterizes it, "part of appropriate care in certain particular circumstances" and, therefore, it may seem appropriate for physicians to administer. But the same act is also accurately described as "killing." This means, as American psychiatrist and ethicist Willard Gaylin put it, that euthanasia places "the very soul of medicine on trial."
There are very few institutions in today's secular societies, if any, with which everyone identifies except for those -- such as medicine -- that make up the health-care system. These, therefore, are of unusual importance when it comes to carrying values, creating them, and forming consensus around them. We must take great care not to harm their capacities in this regard and, consequently, must ask whether legalizing euthanasia would run a high risk of causing this type of harm.
The kinds of questions we need to ask include: How would legalizing euthanasia affect medical and nursing education? What impact would physician role models carrying out euthanasia have on medical students and young physicians? Would we devote time to teaching students how to administer death through lethal injection? (There has been a medical malpractice case in the Netherlands for "botched" euthanasia -- the patient didn't die.) Would they be brutalized or ethically desensitized? (And we cannot afford to underestimate the desensitization and brutalization from carrying out euthanasia.) Do we adequately teach pain-relief treatment at present? Would euthanasia be a required procedure, that is, a student must perform it competently, in order to graduate? Can we even imagine teaching medical students how to kill their patients?
A fundamental value and attitude that we reinforce in medical students, interns and residents, and in nurses, is an absolute repugnance to killing patients. It would be very difficult to communicate to future physicians and nurses such a repugnance in the context of legalized euthanasia.
Physicians' and nurses' absolute rejection of intentionally inflicting death is necessary to maintaining people's and society's trust in both their own physicians and the profession of medicine as a whole. This is true, in part, because physicians and nurses have opportunities to kill that are not open to other people.
Physicians and nurses need a clear line that powerfully manifests to them, their patients, and society that they do not inflict death. Both their patients and the public need to know with absolute certainty -- and be able to trust -- that is the case. Anything that blurs that line, damages that trust, or makes physicians or nurses less sensitive to primary obligations to protect and respect life is unacceptable. Legalizing euthanasia would do all of these.
Consider the outraged reactions against physicians carrying out capital punishment through lethal injection -- the same procedure as euthanasia -- when laws provide for them to do so. We do not consider their involvement acceptable -- not even for those physicians who personally are in favour of capital punishment. We, as a society, need to say powerfully, consistently, and unambiguously, that killing each other is wrong (except as a last resort to save human life, as in self defence), and we can't do that if we legalize euthanasia.
It is sometimes remarked that physicians have difficulty in accepting death, especially the deaths of their patients. This raises the question of whether, in inculcating a total repugnance to killing, we have evoked a repugnance to death as well. In short, there might be confusion between inflicting death and death itself. We know that failure to accept death, when allowing death to occur would be appropriate, can lead to overzealous and harmful measures to sustain life. We are most likely to elicit a repugnance to killing, while fostering an acceptance of death, and to avoid confusion between these, if we speak of a repugnance to killing (although that is an emotionally powerful word).
Moreover, it is a very important part of the art of medicine to sense and respect the mystery of life and death, to hold this mystery in trust, and to hand it on to future generations -- including future generations of physicians. We need to consider deeply whether legalizing euthanasia would threaten this art, this trust, and this legacy.
Finally, it's a controversial suggestion, but it has been proposed that if we were to legalize euthanasia, we should take the "medical cloak" off it, that is, physicians should not be the ones to carry it out. Some of the reasons are discussed above, but other reasons include that it causes people to fear physicians, to fear accepting pain relief treatment, and to fear hospice and palliative medicine and care. As well, placing a medical cloak on euthanasia makes it seem safe, ethical and humane, because those are the characteristics we associate automatically with medical care, when, in fact, we all need to question the acceptability of legalizing euthanasia.
One suggestion for alternative practitioners, that has shocked even people who are euthanasia advocates, is to consider having specially trained lawyers. The justification put forward for this choice is that they understand how to properly interpret and strictly apply laws and, for these people, ensuring that is the major concern, not euthanasia itself. One of my physician friends, who supports euthanasia, responded to this suggestion with, "Margo, we can't have lawyers killing people!" I agree wholeheartedly, and neither should we have physicians killing people.
Margaret Somerville is director of the Centre for Medicine, Ethics and Law at McGill University, and author of The Ethical Imagination: Journeys of the Human Spirit.
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