TCS Daily

Is the Case for Euthanasia Dying?

By Iain Murray - August 5, 2003 12:00 AM

A recent issue of the British Medical Journal (July 26) looked at current topics in "end of life" care. In other words, what science is currently telling us about the dying. While there were some non-related observations (including the interesting one that "fear of death is being replaced by fear of dying") the 800 pound gorilla in the living room of end of life care is euthanasia. Although one might think from the coverage of euthanasia that there is an unstoppable momentum towards its legalization, the evidence we have on the subject suggests that it is a less desirable solution than many think.


As Yvonne Mak of the University of Wales pointed out in her article, there has been very little research into what patients actually want. Most of the debate has so far focused on theoretical issues about suffering and dignity. Yet without the actual input from patients who do desire euthanasia we cannot know if the theory matches the actual desire. What Mak was able to glean from the limited qualitative research so far available was that patients' desire for death was not purely linked to their actual physical concerns, but had much more to do with their "psychosocial and existential issues."


In other words, the desire for euthanasia was not so much about pain and suffering as about their worldview and a perceived diminution of their quality of life within that worldview. As Mak put it, "disintegration [of the patient's sense of self-worth] was likely to occur earlier if patients had unresolved life events, personality problems, or poor social support had threatened their sense of wholeness." Patients whose sense of self-worth was reaffirmed by good quality end of life care tended to re-evaluate their need for euthanasia. The inference we might make from Mak's work is that doctors can help make the end of their patients' lives better by providing good psychological care, attuned to the individual patient's experiences, rather than by helping the end come quickly. As Mak says, "the desire for euthanasia must not be taken at face value."


This helps explain, perhaps, why euthanasia is rarely taken up where it is available. A study in the same issue by Dutch researchers from the Netherlands Institute for Health Services Research found that only about 3 in 10,000 patients request euthanasia. The reasons for requesting euthanasia have also changed in the last 25 years. In 1977, over half the requests for euthanasia were related to pain. Since then, as pain management has gotten better, that proportion has slipped to a quarter, with fear of deterioration and a sense of hopelessness having overtaken pain as more frequently stated reasons for the request. Although the number of requests overall has tripled since 1977, the low level of take-up of euthanasia might suggest that worries that its use might increase exponentially following legalization are misplaced. Yet its very rarity might also suggest that there is not the huge unrealized demand for it that its supporters sometimes give the impression there is.


The BMJ issue also contained an article that looked on the effect of euthanasia on surviving relatives in the Netherlands. Compared with natural death, the study found that relatives of those who had experienced euthanasia reported significantly less traumatic grief. However, this seems to be heavily influenced by "the opportunity to say goodbye." Natural deaths only sometimes progress such that relatives are able to say goodbye to their dying loved one. This is always the case with euthanasia. Natural deaths are therefore "handicapped" by being less predictable. Once this factor was taken into account, the association between cause of death and grief symptoms was "considerably weakened." Apart from the ability to plan, natural deaths and euthanasia are about as traumatic for the relatives.


It seems, therefore, that the case for euthanasia, as frequently presented, is problematic. What research we have on the subject indicates that much of the desire for euthanasia is psychological rather than physical in its perception. Good quality end of life care could significantly reduce demand. Indeed, increased availability of euthanasia might have the reverse effect, allowing doctors to accede to demands for euthanasia when a deeper diagnosis might reveal deeper psychological issues that are driving the desire. We would do well to consider the possibility that Anna Karenina might have demanded euthanasia.


Yet even without this realization, actual demand for euthanasia is tiny where it is available, although it has increased by 200 percent in 25 years, and the supposed benefit to relatives is probably less than supposed. What society needs to ask is whether the small benefit that might accrue to some individuals is worth the risk that it might reduce the quality of end of life care to others, leading to inappropriate outcomes and mistreatment? In the U.S., we should also consider that the threat of litigation over end of life care may lead to some perverse outcomes. It is possible we may find doctors recommending euthanasia for fear that they will be sued for allowing someone to live in pain. As Mak recommends, it is vital that we get more insight into what the patients actually desire before we go down that road.


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