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Ethical and legal

Should euthanasia be legalized?

Sylvia Hampton, Eastbourne District General Hospital, Sussex

Patients are now kept alive far longer than their ancestors could ever have been. In cases of terminai illness where there is an accompanying decline in the patient's quality of life, nurses must he aware of the implications of euthanasia.

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Ms Hampton is a Staff Nurse at Eastbourne District General Hospital, Sussex, and is currently studying for a BSc in Nursing Studies

he term euthanasia is derived from the Greek word thanatos meaning death and the prefix eu meaning good (Russell, \977). However, the modern meaning is slightly different; although the Concise Oxford Dictionary still refers to an 'easy or painless death,' it also defines euthanasia as 'a method of producing this; putting to death m this manner,' which refers to a way of ending a person's suffering by bringing premature death, using either active treat- ment (drugs) or passive treatment (with- drawing or withholding intravenous fluids, food or drugs).

Nurses cannot ignore its existence as it is already a part of life when dealing with death (Williams, 1958). The doctor who or- ders a large dose of diamorphine for a ter- minally ill patient, decides not to site an intravenous infusion, or says that a patient IS not for resuscitation is involving the nurse in his decision. The order may be given for the best of reasons, e.g. a drug such as diamorphine that is given to a pa- tient to alleviate pain will also depress breathing. Similarly, the nurse who re- quests diamorphine for a patient, simply for the relief of unbearable pain, knows that it will also hasten death. This could be seen as a straight choice between prolonging life or relieving suffering.

Euthanasia can be split into four groups: active, passive, voluntary and involuntary. Active euthanasia involves the doctor pre- scribing a drug that will send a patient to a peaceful death, as in the recent case of Dr Cox; the nurses in this case were affect- ed even though they did not assist with ad- ministering the drug (Hart, 1992). Passive euthanasia involves withholding any treat- ment that may prolong life. Voluntary eu- thanasia is a request from the patient (some- times in the form of a living will) that he or she should not suffer and be kept alive any longer because the quality of life is so bad. Involuntary euthanasia takes place without the patient's consent; the patient may well be unconscious and unable to state a preference.

Euthanasia and the law There have been Instances of nurses' in- volvement in euthanasia, e.g. the case of 'the angels of death' (Martin, 1991) in 1983, in which four nurses systematically killed patients at Lainze hospital. The nurses claimed that this was done out of pity for the patients, who were crying and groaning in pain. The prosecutor asked for the stiff- est sentence possible

' . . . to ensure that this can never happen again, and so that the elderly could go into hospital without the fear of being murdered.'

However, should nurses consider eutha- nasia as an option in the future to relieve suffering?

Mercy killing, or voluntary euthanasia, IS not recognized by the law in this coun- try; however, the Homicide Act 1957 made provision for diminished responsibility and suicide pacts. Nevertheless, the law is clear that active euthanasia is illegal, and the Brit- ish Medical Association (1984) supports this; any person found assisting in the death or suicide of another faces a charge of mur- , der.

The law is not as explicit about the ac- countability of nurses when caring for suf- fering patients, and whether they should treat actively or not. Kennedy (1978) stated that anyone refusing treatment should have his wish respected, and that a doctor is not obliged to start treatment that is of no bene- fit to the patient.

Nowell-Smith (1989) said that if death is handled properly and within the prescrip- tion of the law, the patient will have time to change Kis mind before the final act (as is practised in the Netherlands). However, in that country between 1990 and 1991, there were 4941 cases of morphine over- doses administered without the patient's consent, and 2700 voluntary euthanasia deaths, exposing the fact that nearly half of the euthanasia deaths occurred without the patient being offered the right to ex- press his wishes (Trevelyan, 1992).

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Should euthanasia be legalized?

Darlmhire (1987) argues that nurses often allow doctors to make life and death decisions. '

Passive euthanasia is less clear in terms of the law; however, in 1977, Lord Hail- sham, the Lord Chancellor, stated that 'the Kxw is perfectly plain; if you have a living body, you have got to keep it alive if you can' (Penson and Fisher, 1991).

Proposals for legal reform concerning eu- thanasia have been brought to the House of Lords and House of Commons on seven occasions but have been dismissed each time, the fear being that if euthanasia were to be legalized, where would the line be drawn in choosing who lives or dies? (Whitfield, 1987).

Darbyshire (1987) argues that nurses of- ten allow doctors to make hfe and death decisions. Ellis (1991) said that nurses should take time to find out the patient's wishes and represent them, and so abide by the UKCC's (1992) Code of Professional Conduct which states that nurses 'in the practice of professional accountability shall take account of the customs, values and spiritual beliefs of patients/clients'.

If a nurse is involved in litigation follow- ing a medical decision, he/she should be able to show that the Code of Professional Conduct was followed before complying with that decision, and that the decision was made for the highest reasons.

The grieving process Kubler-Ross (1969) identified several stages of grieving that terminal patients had to work through to come to final, peaceful ac- ceptance. These stages are varied, not en- dured in any specific order, and may be ex- perienced more than once. They are an es- sential part of the grieving process for ter- minally ill patients and their relatives.

These stages of grief involved denial, anger, bargaining, depression and, finally, peaceful acceptance; of all of these, depress- ion was the strongest and longest lasting stage to be w^orked through, and during this time there was sometimes even a desire for death. However, Kubler-Ross found that this was a natural feeling, and one that would give way to the final peacefulness and acceptance. If the nurse is supportive of euthanasia during the depressive stage, when the patient appears to be suffering un- bearable mental anguish, she/he may be denying the patient, and relatives, the peacefulness of the final stage which could leave the relatives with settled memories of their loved one's gentle passing. However, the patient's wishes are paramount and the patient may not wish to endure that period of terrible depression, or to involve loved

ones in the suffering, and may therefore welcome the release that euthanasia could give them.

Quality of life Antibiotics and other drugs keep people alive today long after death would have been a natural conclusion to their disease or condition, and many patients suffer pain and distress that were unknown to their an- cestors. Each day, therefore, doctors and nurses face the never-ending suffering of patients they have helped to keep alive. It may be that the quality of life of these pa- tients has diminished, but as each person judges quality of life through their own, possibly healthy, perspective, quality is only relative to their present condition and this could influence any decision made for euthanasia, whether through passive with- holding of intravenous fluids, or the admin- istration of a stronger dose of diamorphine to reduce the suffering. It could be thought arrogant of a healthy doctor or nurse to judge a sick patient's quality of life, as each person's perspective and attitude will change as circumstances evolve; as a pa- tient's advocate, it could also be arrogant for the nurse to presume that she/he knows best when refusing to listen to any entreaty a patient may make for an end to their suf- fering as they must surely have the right to choose the manner of their death. Ellis (1992) asked: 'What are we doing allowing those patients who wish for an early end to their suffering to linger in death?'

The patient's right to die Although the 'patient's right to die' (Humphry and Wickett, 1986) and *free- dom to die' (Russell, 1977) are discussed when a terminally ill patient has access to drugs and the opportunity to commit sui- cide, this very rarely occurs (Trevelyan, 1992). This does not necessarily mean that the patient does not wish for euthanasia; religion and the consideration of loved ones may influence their decision, and they may need the support of the medical team to make an informed decision. The moral as- pect should also be considered: whether it is right to keep a suffering patient alive long after the decision has been made not to treat actively.

There is also the problem that should eu- thanasia become legal, where would the line be drawn on a continuum from diagnosis to unconsciousness? Perhaps the line could be placed firmly in the centre of the con- tinuum, but this is difficult to pinpoint; or

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Should euthanasia be iegalized?

the decision could be that of the patient, in which case patients may choose to die at their most vulnerable time, very soon after being informed of the diagnosis, when they may have had several years in which to live active and fulfilled lives. There is also a possibility that, if legalized, euthanasia might be delayed too long while decisions are made, and so prolong the patient's suf- fering.

Another possibility is that patients and relatives may lose faith in nurses if they are known to be involved with active and pass- ive euthanasia, viewing them not as 'angels' but as executioners; however, a good law would ensure the protection of a patient's right to live, and any termination of life against these wishes would still be murder and punishable by law. On the other hand, for many people the knowledge that their wishes could be carried out legally could inspire confidence and relieve anxiety (Russell, 1977).

Approximately 12^/o of the public are in favour of active voluntary euthanasia (Ellis, 1992), but nurses in general are still unsure. Darbyshire (1987) argued that, with passive euthanasia, nurses all too often stop think- ing about ethics because 'others make the critical decisions and orders have to be obeyed*. Ellis (1992) said that these 'others' are usually doctors, whom nurses allow to make the most vital of decisions, e.g. 'not for resuscitation', 'terminate life support', 'ordinary interventions only'. Nevertheless, if euthanasia were ro be legalized, nurses would probably be involved with the deci- sions and, indeed, with the administration of the drug that would terminate life. As patients' advocates, nurses should now be

KEY POINTS I Euthanasia is a part of life when deaiing with death; 'not for resuscitation' orders or a decision to withhold intravenous fluids are passive euthanasia decisions.

\ Euthanasia is against the iaw.

»Many patients who wish for death during the early stages of the grieving process, come finally to peaceful acceptance and a gentle passing.

I Patients are being kept alive long after their ancestors would have succumbed to a natural conclusion to their disease.

> It could be arrogance for doctors and nurses to presume to judge a patient's quality of life from their own healthy perspec- tive.

I Nurse advocacy requires nurses to be well informed and cer- tain of their own feelings when caring for a terminal patient who is suffering; the euthanasia question wiil not disappear if their heads are in the sand.

deciding where they stand both morally and ethically. Their decision whether or not to treat actively should be an informed de- cision, and one that takes firmly into ac- count the patient's wishes.

Conclusion Whatever the future holds concerning the legalization of euthanasia, it is at present strictly illegal, and although it seems that passive euthanasia is practised by some in the caring professions (Williams, 1958; Trevelyan, 1992), this is still illegal, even if performed for the highest reasons. Death can be peaceful; palliative care, good pain management and a commitment to main- taining the quality of life until the natural point of death (Trevelyan, 1992), as practis- ed in the hospice movement, will ensure a 'good death'. But despite the development of the hospice movement, palliative care for the dying is not often addressed (Ellis, 1992).

Nurses are close to the patient during di- agnosis, suffering and death, and because of this closeness they need to re-evaluate their position and feelings about dying so that they can make an informed decision about euthanasia in the future. They must ensure that it is not their own fear of dying that influences this decision; as Fletcher (1966) said, 'It is the living who fear death, not the dying'. J f l ^

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