This is the third of three articles on the dangers surrounding the legalisation of euthanasia.

In the final section, I will ask some questions that might suggest some possibilities regarding what people who believe legalizing euthanasia is a terrible error might be able to do to limit or discourage its use or extension.

If euthanasia is legal, what can we do to limit its use or extension? In other words, how might we achieve the goal of reducing to the minimum the number of people requesting euthanasia? In order to achieve that, we need to understand the reasons for their requests and to find ways to make those reasons no longer important to them. We also need to try to prevent extensions of the people who may access euthanasia and the abolition of safeguards, which restrict access to it.

Why do people ask for euthanasia?

Many people believe that pain is the most common reason that people ask for euthanasia, but pain is well down the list.

The three most common reasons are feelings of loss of dignity, loss of independence and of being a burden on others. Palliative care research shows many ways to change these feelings. For example, Dr Harvey Max Chochinov, a Canadian psychiatrist specializing in the care of terminally ill patients has developed a psychotherapeutic intervention called “dignity therapy”. In a book of that name, to which I have referred previously, he explains how helping the terminally-ill person to review and record their life story to leave as a record for future generations of their family gives them back a sense of their own worth. It also generates hope, through eliciting a feeling that something of themselves will have a presence in the future.

October 25: (1) We need to develop an anti-euthanasia vaccine – at warp speed     
October 27: (2) Good ethics depends on good facts – but euthanasia debates are full of distortions and omissions

Hope requires a sense of connection to the future. Hope is the oxygen of the human spirit. Without it our spirit dies, with it we can overcome even seemingly insurmountable obstacles. Dying people cannot have long-term hopes, but they can be given mini-hopes that make life worth living – that reignite their will to live. Common examples are of a person not dying until after their first grandchild is born or a beloved grandchild is married or graduates from university or an old friend from faraway is coming to visit. It is not uncommon to hear palliative care professionals say that many terminally ill people seem to choose when to die a natural death.

How can we help dying people find a “why to live”?

Dr Chochinov speaks of a psychological state he calls “hopelessness” as being the trigger for the person seeking medical assistance to end their life. Professor David Kissane, an Australian specialist palliative care psychiatrist, has identified a similar condition he calls “demoralization” with its accompanying loss of the will to live, as having the same effect of triggering requests for euthanasia.

These findings are consistent with the powerful insight of Nazi Concentration Camp survivor, Viktor Frankl, who, when asked how he helped other inmates to survive, famously quoted Friedrich Nietzsche. “Those who have a ‘why’ to live, can bear with almost any ‘how’”.

We all need to have hope and be able to find meaning in life, even when we are dying, indeed, especially when we are dying, if we are to have a “good death”. Euthanasia does not provide this, rather it eliminates the person and with that the possibility of finding hope and meaning. Helping dying people to find hope and meaning can be difficult and requires skilled carers interacting with both the dying person and their loved ones, which is one reason easy access to high quality palliative care is such an important safeguard against people choosing euthanasia.

Another reason why easy access to high quality palliative care is very important is that without that it is not possible to give an ethically and legally valid informed consent to euthanasia. Informed consent requires that all the medically indicated treatment options and the risks, harms, benefits, and potential benefits of each, including of refusing all treatment, must be disclosed to the patient to obtain their valid informed consent to the procedure which they choose.

Why is it important to recognise the potentiality of euthanasia?

The potentiality of legalizing euthanasia requires us to consider what kind of world we will have left for future generations. Might it be one in which no reasonable person would want to live? What message does legalizing euthanasia send to vulnerable people – fragile elderly people and people with disabilities? It is that they have “lives not worth living” or, even more reprehensibly, that they, themselves, do not have any worth?

Paradoxically, legalizing euthanasia tells them that they lack dignity, when the pro-euthanasia case is that euthanasia is necessary to respect their dignity. Likewise, the argument of pro-euthanasia advocates that legalizing euthanasia is necessary in order to respect the human rights of people with disabilities, including fragile elderly persons, is a two-edged sword. We need to keep in mind an old saying in human rights law: “Nowhere are human rights more threatened than when we act purporting to do only good”. Our sole focus on the good that we hope to achieve blinds us to the unavoidable risks and harms involved.

What will be the effects on healthcare institutions and professionals in the future of legalizing euthanasia? We already know that many professionals are psychologically traumatised by carrying it out, some developing PTSD. The Dutch Medical Society has recognised this problem and recommended, where possible, the use of assisted suicide, rather than euthanasia.

There has been a massive increase in Belgium in the use of “terminal sedation” (sometimes called “slow euthanasia”), where the patient is permanently deeply sedated until they die. (“Terminal sedation” needs to be distinguished from “palliative sedation” which is justified pain and symptom management, when means other than sedation are not sufficient, and there is no primary intention to shorten life).

Moreover, what about respect for freedom of conscience of healthcare professionals and institutions who believe euthanasia is unethical? This is a major field of conflict among a wide variety of people and institutions.

A momentous decision

I have been pondering a great deal lately on what we can do about stopping the “euthanasia virus” pandemic. What would vaccinate us, as both individuals and societies, against it?

I have concluded that it is useless saying it is wrong or unethical or even dangerous — although it is very dangerous — and that we need a completely different approach, including along the lines of what we have to lose as individuals and societies by legalizing it.

Recently, I tried this approach in lecturing to the various classes I teach on ethics at the University of Notre Dame Australia Medical School. We discussed the ethics of euthanasia and the wisdom or otherwise of legalizing it. A clear majority of the students – probably, at a guess, at least 80 percent – are “progressive values” adherents – that is, for them respect for individual autonomy almost always takes priority as being the ethically preferable option. To my surprise, I had reports back from several tutors that students had told them that they were pro-euthanasia, but had never considered the issues I had raised and were now reconsidering their position.

 In short, we need indirect approaches, as well as direct ones and, for example, in influencing politicians we need to keep in mind that politics follows culture, so we need to change the culture.

Euthanasia is a very complex issue in terms of the forces that have led to the current situation, including such small yet hugely impactful changes as “time compression” – we expect everything to be instant. Applied to natural dying, which can take an extended period, euthanasia is the “quick fix”. I believe that the overall societal Zeitgeist has activated the push for legalized euthanasia and we have to change that Zeitgeist if we think, as I do, that legalizing euthanasia is a very, very bad idea.

I have written elsewhere that one step we need to take in order to move in that direction is to recover our sense of “amazement, wonder and awe” about both ourselves and our world. I believe that this experience will help to guide us ethically regarding what we should and most importantly should not do and the latter includes legalizing euthanasia.

I predict that History will see the decision whether to legalize euthanasia, as one of the two most momentous values decisions of the first half of the 21st Century. (The other decision is whether to allow the use of new molecular biology and genetic science and technologies to design our children and all their descendants, through alteration of the human germ line.)

We need a new iteration of the old virtue of Prudence, which can be re-named “wise ethical restraint”, and we need Hope and Courage.

For hope in relation to avoiding euthanasia, among other sources, I look to precedents for abolishing legislation, which, at the time it was enacted, was thought to be necessary and, I presume, ethical and beneficial to the people subjected to it, but that did great harm and, revisited with wiser, future eyes, was much later repealed.

A prime example is the eugenic legislation of the 1920s and 1930s in Canada, for instance, the Alberta and British Columbia “sexual sterilization” acts, which were only repealed in the 1970s. They had allowed Government health officials to authorise the sexual sterilization of mentally incompetent people, including institutionalized children.

Another powerful example are the laws that authorized and promoted  the separation of First Nations children from their families, the “stolen generations” in both Australia and Canada, in order to assimilate them into the dominant White Anglo-Celtic culture of that era. The first such legislation was enacted in Victoria in 1869 and Queensland followed in 1897. Such laws were not repealed in all Australian states until 1969. It is noteworthy that, as with euthanasia legislation, Victoria led the way.

Because all the other Australian states have now legalized euthanasia, it is of critical importance that NSW refuses to do so. At least then, among many other reasons, fragile and vulnerable people can find a safe refuge in Australia and we will still have a jurisdiction that avoids the many and various serious risks and harms of euthanasia.

To return to the euthanasia debate, for all our sakes, both those who are dying and those who are not yet dying, and for our descendants and their future societies, we must kill the pain and suffering of dying people, not the dying people with the pain and suffering.

References will be supplied if requested.   

© 2021 Margaret Somerville

Margaret Somerville AM, DSG, FRSC, FRSN, DCL is Professor of Bioethics at the University of Notre Dame Australia School of Medicine (Sydney campus). She is also Samuel Gale Professor of Law Emerita, Professor...