MIND MOVES Marie MurrayBioethical issues are at the forefront of public debate. When they concern the inception or cessation of life, anxiety is intensified, debate is deepened, and ideological differences can become dogmatically divisive.
Indeed, they may become so emotionally laden that people regress into positions that admit no other conviction but their own. This is because life and death decisions, personal liberty and interpersonal responsibility, the right to choose and choosing what is right, self-determination or social consensus are extraordinarily ethical, complex and crucial at this time.
One critical ethical issue is euthanasia or assisted suicide; a topic gathering momentum as individual countries face the debate on whether legalising euthanasia means legalising human murder or legalising humane merciful release for dying citizens from the indignities of the final stages of debilitating illness.
We are at our most vulnerable before birth and before death. It is at entry and exit to human existence that we depend upon others for our safety; the security of our journey into or out of this world, the inviolability of our human rights and the definitions of human viability.
Those in favour of assisted suicide say that a person has the right to choose the moment and manner of death if death is imminent, inevitable and otherwise likely to be one of personal indignity, prolongation of pain or the misery felt by family members witnessing the suffering of their loved one. They speak about dying on one's own terms, about painless, mercy killing being a merciful release from life. Is it not cruel to prolong the agonies of life's end: to maintain people in pervasive vegetative states, breathing cadavers in incapacity and immobility? If animals are put out of their misery, do humans not deserve equal compassion? They say a citizen has the right to die with dignity. They believe that one is competent to make "living will" choices during life about later death. Death should be permitted and assisted.
Those against assisted suicide question the hidden coercion and level of choice a citizen has in a society prepared to use medical means to terminate life. They point to the slippery slope from stringent controls to flexible conditions once we author life and death. They fear euthanasia becoming a death warrant for the disabled, becoming paediatric euthanasia, then eugenics, then economic valuations of viability.
Euthanasia is not about dying with dignity; it is another step towards the death of the dignity of life. It is not dying on one's own terms but the terms of a society that may soon permit only the perfect to survive.
Euthanasia may be active, passive, voluntary, involuntary and non-voluntary. These distinctions make its ethical exigencies even more complex and contentious. The difference between carrying out an act that ends life or not acting in a way that prolongs life is central to the argument. What is described as the Principle of Double Effect suggests that the intention of an act or its omission determine its ethics. Letting life go gently, naturally, providing pain relief, is appropriate palliative care. Intent defines euthanasia. Many who agree with voluntary euthanasia would not sanction non-voluntary or involuntary euthanasia, because in these situations the person is unable to make a choice or actively does not wish to die.
But it behoves those who believe in voluntary euthanasia to remember that the request for death by a person who is terminally ill may mask unidentified treatable clinical depression. Depression will be dangerously under-diagnosed if we translate its symptoms of helplessness, worthlessness and morbid hopelessness into requests for death.
The request to die, the so-called "living will" may reflect loss of the "will to live" - a classic emotion in clinical depression or a psychologically vulnerable time in chronic illness: time of darkest night and lowest ebb. If requests for death are responded to, not by pulling the plug but by providing love, compassion, counselling and care, they may transform into a living will to live. The desire to die may be a right. But promoting the desire to live is the task of mental health professionals, a flexible supportive medical and social service and richly resourced palliative care.
Healthcare cannot be morally neutral nor can healthcare workers allow legislation to deny them ethical self-governance however sanitised the terminology. Medicine and murder must be mutually exclusive. We need hospice not "hemlock" societies, care not Kovorkianism, lest we lapse into "permitting the destruction of life not worthy of life", "termination without specific request" or the euphemisms of eugenics.
There are dangers when single case compassion becomes the basis for societal legislation, the danger that as professionals we might, in the words of philosopher Neuhause, "guide the unthinkable on its passage through the debatable on its way to becoming the justifiable until it is finally established as the unexceptional". Holocaustic history records our capacity to do so with fatal rapidity.
mmurray@irish-times.ie.
Maire Murray is director of psychology at St Vincent's Hospital, Fairview Dublin. The motion that "this house would legalise euthanasia" will be debated tomorrow at Theatre M, Arts Block, Belfield Campus, UCD, Dublin 4. Further information: Dr Siobhán O'Sullivan of the Irish Council for Bioethics - www.bioethics.ie