Can Euthanasia be Voluntary?

Archbishop Peter Jensen | 18 March 2003

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Voluntary euthanasia is the unfinished business of the moral revolution of the mid-20th century. In the name of human freedom, censorship of sexually explicit material was rejected; abortion on demand was instituted; and the nature of marriage was changed. In the 1960s and 1970s there was also agitation for voluntary euthanasia or assisted suicide to become lawful in Australia. This agitation did not become a full-scale movement and, indeed, was resisted by government. Nonetheless, the experience of voluntary euthanasia in the Netherlands and the successful adoption of the other parts of the humanist agenda brought voluntary euthanasia to the forefront in the late 20th century. As we all know, one of the foremost advocates for this is the Australian, Dr Phillip Nitshke, and the Northern Territory passed the Rights of the Terminally Ill Act in 1996 – an Act later invalidated by the Federal Government.

The continued rejection by Federal and State governments of legislation allowing for voluntary euthanasia is, at first sight, extremely puzzling. What evidence we have indicates a considerable public acceptance of this idea. The politician who is prepared to make this part of his or her stated policies would almost certainly gain considerable support. Suicide itself has been decriminalised, though it is a crime to assist someone else to commit suicide. Voluntary euthanasia presupposes a right to suicide even if it requires assistance in the doing of it. Hence some people prefer to call it ‘assisted suicide’. There have been television documentaries offering favourable support, and even at the level of popular television dramas the issues have been canvassed sympathetically.

The case in favour of voluntary euthanasia is powerful, clear and simple. It consists of two parts. First there is the relief of suffering. When faced with the suffering, mental or physical, of the terminally ill, and when faced with the prospect or the actuality of our own suffering, we determine to prevent it. We do not allow fatally ill animals to suffer; why should we stand by and see humans go through pain which is beyond help and for no good purpose? The great virtue of compassion should move us to allow this for others even if we do not allow it for ourselves.

Secondly, there is the rights of the individual. Where a person is of a sufficient age to take responsibility, and where the person’s reason is sound, they must have the right to make their own choice about their life. Others must not make this choice for them. That is why we speak of voluntary euthanasia. On its own, the original meaning of ‘euthanasia’ is that of a good death, or as we may say ‘a death with dignity’. To add the word ‘voluntary’ is to insist that the choice for such a death must be mine alone. If others deny me that choice and kill me without my permission, even if they think that it is in my best interests, they deprive me of my rights. As well, however, if others deny me that choice and refuse to allow me or assist me to take my own life, they too deny me my rights.

Despite these arguments I am going to say that the acceptance of voluntary euthanasia would be very dangerous indeed, and would change the nature of the health care professions. There are a number of problems with the proposal, but the difficulty I want to address today is this: I do not think that we can truly talk of euthanasia being voluntary. I realise that talk of individual rights has become very persuasive in the contemporary world. It seems to be fundamental to the way we think and view each other and ourselves. But it is worth noting that this is not the only possible way of viewing the world. There is really clash of philosophies here. The triumph of the individualistic philosophy is at the expense of what may be called ‘relational philosophy’. Your choice about voluntary euthanasia may well depend upon whether you favour an individualistic or a relational philosophy.

Voluntary euthanasia is to be distinguished from that euthanasia made infamous by Nazism during the 1930s and 1940s in which mentally incapable and elderly patients were summarily executed, being regarded as dangerous to the genetic make-up of the people and as a burden to the State. Indeed, it is the activities of the Nazis, which I think held our society back, even from voluntary euthanasia in the 1960s and 1970s. We all agree that whatever happens we must not have a society in which people are killed simply because they are old, incapable or decayed. The free, mature consent of the individual is crucial.

Furthermore, in speaking of voluntary euthanasia we are not directly addressing those agonising decisions about the end of life which so frequently face the medical profession. Since the whole ethos of the profession has always been toward the preservation of life, doctors have, if anything, erred on the side of keeping life going. Despite the consultation with relatives there remains a loneliness inevitably attendant upon the physician’s choice to cease striving, to allow the patient to die. Indeed there are legitimate choices about palliative care which may as a side-effect, so to speak, shorten the dying process. Someone has to make these decisions; we feel that there ought to be rational and ethical grounds for making them; we rightly hope that the relatives or, if possible, the patient may relieve us of the moral burden of the decision.

Little as I know about the practice of medicine, allow me to express my deep sympathy with those who have the daily responsibility for making such significant choices. We expect you to show wisdom, justice and compassion, but we find it as hard as you do to determine what should be done in concrete cases.

I well remember being asked what to do by a patient’s wife when, from the point of view of the medical profession, all hope of existence had passed, unless heroic surgical efforts were made, and even then only a vegetative life was the best possible outcome. Accompanied by a professional Christian ethicist I sat and thought about this real problem before us and concluded that in the end that either decision was morally justifiable. This apparently vague conclusion did not help the lady in question; she determined that her husband should live - to the surprise of the doctor and her two ethical advisers. Her husband has survived and has returned to a very significant level of human interaction. It would be consistent with my advice for him to have been allowed to die.

Thus, by introducing the word “voluntary”, the advocates of assisted suicide are making the necessary point that euthanasia can only be morally justified when it is agreed to by the subject, when a mature and balanced individual is making the decision for himself or herself. The word ‘voluntary’ suggests that we are taking personal responsibility, unaffected by internal factors that would distort the thinking process or external factors such as the manipulation of others. Consistent advocates of voluntary euthanasia recognise, therefore, that suicide is not just the province of the terminally ill. Such responsibility is able to be exercised by people of all ages (from adolescence onwards) and in all states of health. That is to say, a person may be able to commit themselves to voluntary euthanasia before they grow sick and even elderly. There is an important principle at stake here to which I will return.

Can we legislate for a euthanasia which will truly be voluntary? Let’s start by thinking about suicide itself. Have we got a right to take our own lives? Suicides used to be condemned totally and victims even buried in unconsecrated ground. Today we have a far greater sympathy with those who take their lives, and recognise that such an act is easily done at a time of immense stress or even by people who are mentally ill. Nonetheless, in general terms no responsible person advocates suicide or sees the suicide rate as anything else than tragic. Do we really want to say that suicide is a right for the individual?

Most of us agree that one of the great tests of morality is of love for others. ‘You must love your neighbour as yourself’ is the rule of morality widely accepted, if not practised. In a contemporary world our emphasis on human freedom and our determination to act as independent agents means that we think of suicide as a purely individual action. In fact, however, there are few suicides which do not have a major impact on others. The death of a loved person is always sad and sometimes tragic, but there is a special grief associated with suicide, a grief followed by feelings of guilt, despair and helplessness. In a profound sense, suicide reaches out and touches the lives of anyone who loves him or her. It is a declaration that I have nothing more to give you and you can receive nothing from me. We can come to understand the victim and our own relationship with him if there is a question of mental illness. It is very hard to accept the verdict of an otherwise sane person who chooses to leave our relationships in this way, even under conditions of extreme illness. Does it show love?

Even more significantly, we must recognise the reality of the copy-cat effect. When a suicide occurs in a community such as a school or college, or even in the wider community, it stimulates others to do the same. My suicide may be all about me; but it makes it easier for others to do the same, and so fails the test of love.

There is another point. When we talk about voluntary euthanasia it is usually the case that we are thinking of assisted suicide. In order for the suicide to be successful and not botched, advice is given, and others have to enter into the actual administration. If the advocates for voluntary euthanasia are aware of the possible abuses of euthanasia they will insist on elaborate legal precautions. These also involve a number of others in the whole activity. In short, my suicide is never a matter for myself alone, but is one in which the community as a whole, and individuals within it, have to take a similar responsibility for me or are deeply affected by the choice I have made.

This will be particularly clear if the community ever introduces assisted suicide. By making it legal we will have taken a step towards making it normal. By providing the necessary help we, as a community, will have involved ourselves in the moral decision that suicide can be justifiable, depending only on the choice of the individual. Is that a good message to send? We are not mere individuals. We always need, and involve others, which brings us to the nub of the problem: the clash between the individualistic and the relational philosophies of life.

Can euthanasia be voluntary? Most advocates, I think, agree that we are looking for mature, balanced and independent people to make the decision to commit suicide in this way. It has to be a high test because the issue is literally life and death. As I have already indicated, consistent voluntary euthanasia advocates will not restrict voluntary euthanasia to those who are at present suffering. They want it to be available at all stages of life and in whatever health the person is. We have already had one case in Australia of an otherwise healthy elderly person taking her life because she was tired of it. There is no reason, in theory, why young teenage men should not be justified in making the same decision and in seeking help to do it. And yet, I think that most of us believe it is not right for us to provide or encourage suicide in such a broad way.

The problem, of course, is in establishing that a really sick the person is sufficiently mature, balanced and independent for a decision of this nature. Terminally ill patients precisely may not meet this test. Certainly, as we all know, acute pain, physical or mental, diminishes our independence and distorts our view of the world. Can a person in such pain make a decision which can be called ‘voluntary’? The example of torture suggests that the word ‘voluntary’ is the wrong category for such a situation. A person in acute pain may seek release through death where palliative care, properly administered, may change the mood entirely.

Terminally ill patients want a dignified death; that is not to say that they want a premature one. Advocates of voluntary euthanasia appeal to our sense of compassion. But compassion needs eyes to see what is compassionate in a given situation. Surely the way of love is to provide the best palliative care and to surround the elderly and especially the terminally ill with the best and most compassionate care that we can provide. My fear is that the advent of voluntary euthanasia will end with us seeing the elderly, the incapacitated and long-term patients as burdensome. Indeed, I am told that some of the early evidence from the Netherlands showed doctors taking decisions about life and death into their own hands. The very ethos created by voluntary euthanasia will make it hard to respect the alleged voluntary aspect of it.

But there is a more profound question still. To what extent do any of us make completely voluntary decisions in the sense needed for voluntary euthanasia to become moral? Despite the attempt of our society to say that we are, above all, individuals, the fact of the matter is that human beings are communal creatures and understand ourselves in the light of what others think about us.

The question of whether a patient wants voluntary euthanasia would not, therefore, be settled by the patient making a mature and independent decision on their own. Such cases may perhaps occur, but they will become rarer as time goes on. It will be settled in case after case by what the patient thinks others around him or her to do. As medical professionals you know full well that patients continually look to you for guidance. There is a constant sense of helplessness for the patient within the hospital system. They depend upon you. Furthermore, it is a notorious fact that patients frequently misunderstand what doctors tell them. The fault may lie with the poor communication skills of the doctor. It may frequently lie with the stress and sense of helplessness of the patient. The most intelligent patients frequently misunderstand the reality of their situation. All the more is this the case when a disease is potentially or actually fatal. They will want to know whether you think that it is time for them to exit: and you will not always know that they are reading the signals in your tone, in your manner. ‘My’ right to assisted suicide will impact unfavourably on your right to continue to live to the end.

The death of a patient, however elderly, has very significant consequences in family life. It is frequently a turning point. The burden of looking after an elderly relative is now finished; an estate, perhaps a very rich estate, will now be divided. The patient is looking for advice and help about what they should do from the very people who will be most deeply affected by their death. In many cases, that death will be received with relief or even gratitude. Can we ever be sure that even the most loving family will not by covert or overt means point the patient towards an assisted suicide which will not be their true desire or even be in their best interests?

But there is something even more sinister here. At present our society as a whole, and hence our medical profession, believe in keeping alive. However, with the advent of the baby boomers into the latter end of their lives, the health services are going to be faced with a massive overload with vast financial implications. So far, our governments have resisted calls for voluntary euthanasia. Who can say, faced with the gigantic financial burden yet to be shouldered by the community, that governments will not accede to voluntary euthanasia primarily for fiscal reasons? In that event, the medical profession, so long regarded as a life giving force in the community, will also become the deliverers of death. The patient will never be able to be sure whether the advice given by his or her medical professional is activated by the interests of the patient or the needs of the system. I believe as health professionals with the highest standards, you will already have seen the possibilities of this in a system which is groaning even now. You will, I am sure, have resisted it, but it is difficult to resist the whole system if it is based covertly on a new and ambiguous principle.

I conclude with comments based on two experiences. The first, was observing at close range over a number of years, the death from cancer of my own mother. I knew of her indomitable will to live even to the end despite the suffering. I knew also that if one of us as members of her family had ever said to her that we would like her to go, in order that we did not suffer from her sufferings, she would have volunteered to exit earlier. Indeed we would not have had to say anything; a hint from us plus a system in which assisted suicide was a possibility, and she would have demanded her own death, hiding her true feelings from us. Her so-called voluntary euthanasia would have arisen from the manipulation of her family.

The second experience is that of being a Christian. The Bible clearly endorses the relational rather than the individualistic idea of being human. The view of the Bible is far more realistic than that of the modern individualistic philosophy with all its talk about ‘my rights’. The Bible does not see us merely as individuals. In the biblical word the individual is cherished. He or she is in the image of God, of that there is no doubt. On the other hand, the Bible sees us as parts of communities. The Bible’s chief value is not freedom but love. In fact, it sees love as the basis of true freedom. More than that, the Bible also teaches us, and everyday experience confirms it, that human beings cherished and love as they are by God, are deeply flawed. There is evil in our hearts as well as good. We cannot be trusted to be consistently and entirely good. We cannot trust ourselves and we cannot trust others.

The claim for voluntary euthanasia depends upon the philosophy that we are primarily individuals and it depends upon our view of human nature in which good will triumph. The truth of the matter is that, despite our compassion for the suffering and the urge we may have to help another person end their suffering rather than endure it, we cannot afford to take this responsibility upon ourselves. Even if in an individual case our motives are entirely good, the individual case must not open the doors for a general practice in which so often motives will be mixed or even worse. Our danger is that we are attempting to do a god-like thing without the power, wisdom or goodness of God.

What can we do? We should resist the call for voluntary euthanasia. We should continue to work towards life. We must continue to allow the dying to die, and we must do all we can to comfort their passing, to use our resources to relieve their pain, and to use our human resources to keep them in loving relationship until they pass from our help entirely. This, I think, is the path of wisdom; I am sure that it is the path that compassion needs to tread.

Peter Jensen
Archbishop of Sydney
March 18, 2003

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