Euthanasia is a complicated ethical issue that is treated with a lot of contradictory hypocrisy. There are different types of euthanasia. Despite all of them having the same result, they are given varying degrees of legality. Under English law, it is legal to ignore a patient’s wish to live if it is in their “best interests” to die but illegal to fulfil a patient’s wish to die, even if it is in their best interests. Not only are the repercussions for doctors contradictory, but the basis used to decide which versions of euthanasia to criminalise undermine the two most fundamental principles of medical ethics — autonomy (giving a competent adult the right to make informed decisions about their own medical treatment) and beneficence (acting in the best interests of the patient). Medical laws surrounding euthanasia need to be much more aligned with ethical reasoning, and not contradict medical ethics.
Before we can unpack the laws and ethics surrounding euthanasia, we must first understand what euthanasia really is, and the different forms it can take. Euthanasia is when X intentionally causes or permits the death of Y for Y’s benefit. Euthanasia can be classified as active or passive, and as voluntary, non-voluntary or involuntary. In England, active euthanasia is illegal but passive euthanasia is good medical practice, regardless of whether the euthanasia is voluntary, non-voluntary or involuntary.
Active euthanasia is when X performs an action that results in Y’s death, for Y’s benefit. It is illegal in the UK, but legal in the Netherlands, Switzerland, and some parts of the United States. Passive euthanasia is when X allows Y to die by withholding or withdrawing life prolonging treatment. This is not only legal in the UK, but is seen as good medical practice. When a healthcare team thinks that it is in a terminally ill patient’s best interests to die, medical treatment can be withdrawn or withheld. There must be sufficient evidence to suggest that the patient is in a lot of pain, with a poor quality of life that will only get worse if life is prolonged. Under English law, the withholding or withdrawal of treatment under these circumstances is accepted on the grounds that it is in the patient’s best interests and in accordance with the patient’s wishes.
However, under these same circumstances, if a patient asks a doctor to inject them with a lethal dose of a substance to kill them quickly and painlessly, the doctor could be charged with murder or attempted murder. This is what happened with Dr Cox, who was asked by a patient if he could inject her with a lethal dose of potassium chloride. He complied out of compassion for his patient, a 70 year old woman with severe rheumatoid arthritis, who was expected to die naturally in a few days or weeks. Despite respecting his patient’s autonomy and beneficence, Dr Cox was charged with attempted murder, exposing a clear disparity between medical law and medical ethics. He was charged with attempted murder, rather than murder, because the cause of death could not be established. The patient may have simply succumbed to her condition – a further testament to the severity of her illness. The difference between legal and illegal euthanasia is therefore not about whether or not a patient wants to die and if it is in their best interests, but how the patient dies. The law does not allow you to ‘willingly’ kill someone, but it does allow you to ‘willingly’ let them die.
One of the strongest arguments for a distinction between passive and active euthanasia is that the former simply allows nature to take its course. In contrast, active euthanasia involves accelerating or interfering with nature, removing any possibility of a medical breakthrough. If a patient has died of natural causes, it makes sense that no one is charged for their death, as their killer was biological rather than human. Whereas with active euthanasia, a human causes the death, and should face the legal consequences. Additionally, decriminalising active euthanasia creates an opportunity for potential misuse of euthanasia, with fatal consequences. Although the vast majority of medical professionals are kind, caring, and supportive individuals who dedicate their lives to improving people’s lives, there may be a small minority who might exploit active euthanasia to kill people for malicious reasons. One of the main purposes of the law is to protect us by acting as a deterrent to crime and providing a way to get justice if a crime is committed. Making active euthanasia illegal protects patients from misuse, but if there was a larger focus on autonomy and consent for euthanasia in the law, then that protection would still be in place without criminalisation. Patients would be protected by the need to provide evidence of their desire to die.
There is a clear difference between killing someone and letting someone die, but ultimately, their death results from the choices the doctor has made. It could be argued that passive euthanasia is an active decision to do nothing, and is therefore the same as active euthanasia. By choosing not to do everything in your power to keep someone alive, you have actively decided that they should die, in the same way as if you had killed them. Passive euthanasia is essentially fatal criminal negligence, but because it is in the patient’s best interests, it is seen as moral and legal. If euthanasia is truly about the patient’s autonomy and best interests, then why is there a distinction between active and passive euthanasia? Surely the difference in legality should be between voluntary, involuntary and non-voluntary euthanasia.
Voluntary euthanasia is when Y competently requests death for him/herself, such as a competent adult wanting to die. Involuntary euthanasia is when death is against Y’s competent wishes, but X permits or imposes death for Y’s benefit. Non-voluntary euthanasia is when Y is not competent to express a preference, such as if Y is a severely disabled newborn. All three types of euthanasia are legal when passive but illegal when active. Not making the distinction between these types of euthanasia in medical law undermines patient autonomy – the most important principle of medical ethics.
In the NHS, no one is entitled to treatment because they want it. Your healthcare team offers different courses of treatment and gives you all the relevant information to allow you to make an informed decision of whether to accept the courses of treatment they have offered. If an offer of a certain treatment or procedure is not on the table, you cannot make your healthcare team give it to you, even if that offer could potentially prolong your life. A Do Not Resuscitate order (DNR) can be issued to a patient without their consent if their healthcare team does not think that resuscitation is in the patient’s best interests – this is involuntary passive euthanasia. This means that under English law, it is legal to ignore a patient’s wish to live if it is in their “best interests” to die but illegal to fulfil a patient’s wish to die, even if it is in their best interests. These contradictory situations both ignore the patient’s autonomy. Additionally, it is illegal to provide life-saving treatment to those who do not want it (such as Jehovah’s Witnesses refusing blood transfusions). This means it is legal to withhold treatment from those who don’t consent to treatment and those who do consent to treatment, but illegal to give treatment to people who haven’t consented for it. Therefore, legally, autonomy can only be ignored if it results in a patient dying, not in saving their life. How is this a fair application of the law?
There needs to be a change in the way that euthanasia is criminalised and applied. A distinction should not be made between active and passive euthanasia, as both types involve making a decision that results in someone’s death. Instead, legal distinctions should be made between voluntary, involuntary and non-voluntary euthanasia, because a patient’s autonomy over whether they should live or die is more important than their health care team’s perception of their best interests. If a patient wants to live, that is their best interest, so involuntary euthanasia should be illegal, regardless of whether it is active or passive. In a similar way, voluntary euthanasia should be legal, irrespective of whether it is active or passive. Non-voluntary euthanasia is more complex, encompassing a plethora of different situations. A case-by-case approach should be adopted, irrespective of whether the euthanasia is active or passive. Autonomy is the centre-piece of medical ethics, so it must be the focus of medical law too.
