Introductory paper Palliative care and the euthanasia debate: recent developments

Euthanasia, as with other forms of medical involvement in the end(ing) of life, has long attracted the attention of health professionals, ethicists, lawyers and of course society more generally. So familiar are the main arguments that, as long ago as 1958, a prominent British lawyer referred to the debates as j̀aded’. In recent years, however, the debates have not only rehearsed established positions, they have also become increasingly nuanced. As this edition of Palliative M edicine contains a position statement on euthanasia from an Ethics Task Force of the European Association for Palliative Care, this is an ideal opportunity to take stock of current concerns at the end of life. Naturally, numerous authors continue to defend one (or sometimes more) of three `classic’ arguments relating to euthanasia. (1) The sanctity (or less theistically, inviolability) of life position has the longest history, and it still commands much support. In the UK, the Church of England has recently updated its well-known document opposing euthanasia, On Dying Well . The sanctity of life position has also underpinned a number of other scholarly contributions, in particular prominent anti-euthanasia writer John Keown’s recent book, which collects and connects much of his writing on the topic to date. For authors like Keown, life is of such intrinsic value and the s̀lippery slope’ dangers are so evident that euthanasia can not be tolerated, least of all on a legal footing; the `quality of life’ claims inherent in proposals for euthanasia are considered unjustifiable. (2) At the other end of the moral spectrum are those who argue that euthanasia can be a legitimate response to suffering or a low quality of life. Some contemporary bioethical and legal theorists are therefore content to defer to such judgements, at least when made by the patient him or herself. (3) This focus on the patient’s views and wishes introduces a third perspective, which derives from the obligation to respect patient autonomy, which has assumed central importance in much bioethical theorizing and, indeed, medical practice. Taking this focus, Margaret Otlowski has published a thorough analysis of the law in numerous common law jurisdictions, and has argued that voluntary euthanasia ought to be a valid legal option. More controversially, a recent edition of the British M edical Journal carried a guest editorial that argued to identical effect, and which / perhaps inevitably / prompted a flurry of antipathetic and also sympathetic correspondence. Some new perspectives have recently been brought to the debate. `Dignity’ is a concept long associated with euthanasia, particularly among those lobbying for what has been termed `death with dignity’, yet its precise meaning has seldom been clear. Fortunately, at least two new texts have sought to tackle the concept. The debate will not cease here, however, as both texts favour an interpretation that would justify voluntary euthanasia. Those who see life as of intrinsic value will surely protest that this is a misinterpretation of the dignity inherent in human life. Liezl van Zyl has also offered an innovative account of the ethics of euthanasia, which examines the issue from the perspective of `virtue ethics’. With so many discussions to date dominated by the language of principles, duties, rights and consequences, this renewed concentration on moral character is a refreshing development. Of course, a focus on the ethical values at stake sometimes risks missing another, increasingly relevant area of concern: that of the very concepts under discussion. There has, on occasion, been too little attention paid to what `euthanasia’ and related terms can be taken to mean. That is less so the case today, but increased attention to the concepts does not necessarily mean that we are any closer to agreed definitions. Verbal battles still rage, for example, over the existence or otherwise of `passive euthanasia’. Similarly, the doctrine of double effect, which permits death to occur provided it is merely a side effect of one’s intended / and justifiable / goal and has played a key role in justifying some of the practices of palliative care, has come under attack: its defenders are still called on to distinguish the administration of opioids and opiates and the use of t̀erminal sedation’ from s̀low euthanasia’. Another theme, most prominent in the USA, concerns the distinctions (if any) between `active voluntary euthanasia’ and (typically physician) `assisted suicide’. That latter development has spurred, and has been spurred by, some legislative developments in the USA. In Palliative Medicine 2003; 17: 94 /96