The most difficult aspect of euthanasia: who defines intolerable suffering?

Even if strict conditions for euthanasia were to be stipulated by legislation, their application requires interpretation on a case-by-case basis. Self-determination has become the most essential of values, says Professor of Social Ethics Jaana Hallamaa.

The majority of Finns have declared their support for euthanasia. Demands for providing every individual the right to make independent decisions on the most important issues of their life, such as death, are prevalent in their reasoning. Society should provide assistance in a suicide when intolerable suffering cannot be alleviated through any other measure.

According to Jaana Hallamaa, a professor in social ethics at the University of Helsinki, there are partly contradictory aspirations in the reasons given in a citizens’ initiative submitted to the Finnish Parliament for enacting the legalisation of euthanasia. Hallamaa serves as the chair of the National Advisory Board on Social Welfare and Health Care Ethics (ETENE) and participated in drafting the Board’s latest statement (in Finnish only) on euthanasia in autumn 2017.

 “Proponents of legalised euthanasia emphasise the need for extremely strict legal criteria for granting permission for euthanasia. However, it is a totally different matter when people start describing circumstances where they themselves would wish to be euthanised: from the start, it has been stated that euthanasia will be carried out only in cases of serious, terminal diseases.” Hallamaa points out that individuals may, however, wish for euthanasia to put an end even to curable or treatable disorders.

Death as a potential business

Legislation in the Netherlands, Belgium, Luxembourg, Colombia and Canada permits euthanasia and assisted suicide. In Finland, supporters of euthanasia are using the practice prevalent in the Benelux countries as their primary point of reference.

In these countries, inducing the death of another person is a crime, yet no charges will be pressed nor sentences passed, as long as the legal terms are met. This includes informed and repeated appeals for euthanasia by a person suffering from a chronic, usually terminal, serious disease. Persistent intolerable suffering experienced by the affected individual that cannot be alleviated through any other measure is also grounds for euthanasia.

In the Benelux countries, euthanasia cannot be carried out before another, independent physician in addition to the patient’s personal physician has determined that all required criteria are met. After the patient’s death, the physician must submit a report on the process to an euthanasia review committee. In the event that the preconditions stipulated by law have not been fulfilled, the committee will submit the documents to prosecuting authorities. So far, no charges have been pressed for violations of the law.

After the enactment of the legislation in the Netherlands, prevalence of euthanasia as the cause of death has multiplied, even though terminal care has been improved and overall mortality in the country has not risen.

Most euthanasia cases are overseen by family physicians, but there are private businesses operating in the Netherlands whose practitioners carry out euthanasia.

 “These activities have raised questions on whether financial interests are loosening the criteria for euthanasia,” notes Hallamaa.

Who determines intolerable suffering?

According to Hallamaa, the euthanasia-related criteria most open to interpretation is, however, the meaning of a patient’s intolerable suffering and the grounds on which it can be assessed by someone else. Suffering can also be existential or mental pain, or pain and agony caused by social reasons.

 “In the Netherlands, euthanasia rights also cover people suffering from memory disorders and mental health patients,” remarks Hallamaa.

The decision to act on a desire to die with dignity, recorded in the living will of a patient affected by dementia, must be made by someone else than the patient. Severe mental disorders manifest as the absence of meaningfulness, reducing the patient’s life to nothing but suffering. When can a patient’s request be considered genuinely voluntary and premeditated? Emphasis on self-determination is one solution, when permission for euthanasia is granted purely on the grounds of the patient’s request.

A solution for senselessness through euthanasia?

Demands for validating self-determination have led to, for example, the establishment of groups in the Netherlands that believe society should guarantee a pleasant death for any reason when so desired by an individual.

This way of thinking differs greatly from a notion based on Christianity, predominant in western countries for centuries, according to which life is a gift whose delights and miseries must be equally cherished.

The sensation of being in control of one’s own life is important. How does death relate to self-determination?

 “You cannot choose not to die, but you can choose when you die,” Hallamaa summarises.

 “Basically, individuals have an opportunity to end their life at any time, but not necessarily the means to do so in a quick, clinical and painless way. Suicide is seen as a brutal act,” he goes on.

Hallamaa identifies religious arguments in the debate on euthanasia, even though they have been presented in a veiled form.

The notions of alleviating suffering or the suffering of the innocent, for example, can usually be derived from Christian tradition.

In today’s world, with its emphasis on individualism, people may think they are making independent decisions uninfluenced by religion – a growing share of the population is no longer part of any religious community. Reasoning based on religion is often considered problematic also because no single religious conviction should determine how others are to lead their lives.

 “It is a fallacy to think we can make individual decisions independent of cultural undercurrents or other people,” says Hallamaa.

He points out that life is not an individual sport, but rather founded on sharing.

 “Therefore, the end of life does not only signify one person leaving behind an empty space. Death always affects other people too, also when the time of death has been actively chosen.”

Distance to death impacts stand on euthanasia

Based on surveys concerning euthanasia, the positivity of people’s perspective on euthanasia is commensurate with their distance to death.

Young respondents favour the legalisation of euthanasia more than the elderly. Most criticism towards euthanasia among healthcare professionals is expressed by those, who play a role in the care of dying patients.

It seems to be easier to accept death when it is not in sight and close by.

According to Hallamaa, changes in attitudes may impair the development of terminal care and the alleviation of treatable symptoms.

 “The right to life is the most fundamental of all human rights. States are obligated to safeguard and protect this basic right by, among other things, organising sufficient health care services for their citizens. In the event that euthanasia will be an option, would it end up being the most natural choice, surpassing attempts at offering care that corresponds with a patient’s needs – as well as the opportunity to experience death not based on a human decision?

Death touches

The latest issue of the Teologia.fi online publication (in Finnish and Swedish only), representing theology in Finnish universities, features death as its main theme. The issue includes 11 popular articles with different perspectives on death.

Theme articles and their authors:

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