Euthanasia : A fight for respect and autonomy

This study discusses an ethical dilemma on “Euthanasia”. The purpose of this study is to analyze the ethical controversies associated with euthanasia. This study will present an in-depth analysis of a clinical scenario with regard to the concept of health-related quality of life, patient’s autonomy, and other legal, social, and religious perspectives. A four quadrant approach is performed to analyze the scenario.


INTRODUCTION
Euthanasia is defined as a process which is aimed to cause painless death in a person to end his/her life (Bukhardt and Nathianiel, 2002).It is classified in two ways: active or passive and voluntary or involuntary.Active euthanasia can be referred as an act of commission; for example, something is done to end the patient's life.Whereas, passive euthanasia can be referred as an act of omission; for example, something is not done that would have preserved the patient's life (Fry et al., 2011).Voluntary euthanasia comes as a patient's request for taking actions to end his/her life or to withdraw all lifesaving treatments.On the contrary, involuntary euthanasia occurs when the patient's life is ended without his/her choice disregarding his competency to decide (Bukhardt and Nathianiel, 2002).
In addition, euthanasia can also be defined with respect to being assisted in suicide.Assisted suicide is defined as, "the patients receive the means of death from someone, such as a physician, but (the patient) activate the process themselves" (Bukhardt and Nathianiel, 2002).Whereas, active assisted voluntary euthanasia is cited as "an act in which the physician both provides the means of death and administers it, such as lethal dose of medication" (Bukhardt and Nathianiel, 2002).

CASE REPORT
Mr. X has been struggling for almost two decades against his quadriplegic state, as a result of a spinal cord injury.His mother had been taking care of him for a long time and was a great support to him, as was his fiancée, who was with him despite knowing the fact that he will never be able to walk on his own feet and perform his activities of daily living by himself.Even though receiving great support from his loved ones, he was still depressed.He knew that his disease was not curable and his prognosis was poor.He was on continuous renal dialysis therapy.Moreover, he was aware that all the treatment options were futile as his condition was deteriorating day by day.His prolonged suffering made him question about his quality of life and he demanded euthanasia.
Mr. X was a renowned businessman by profession.Because he had earned a lot of fame and money at a very young age, he came across a number of envious people who made every effort to bring suffering to him.
Not surprisingly, one day, he was betrayed by his rival via a car accident.When he regained his consciousness, he found that now he had to remain quadriplegic and bed-ridden for his entire life.After twenty years of suffering, he finally decided to opt for euthanasia.His demand for voluntary euthanasia caused everyone in the care team to confront a number of ethical, legal, religious and societal issues.Before analyzing this case scenario, let's understand what euthanasia is.
On the basis of the definitions of euthanasia, it could be concluded that Mr. X's case was that of active voluntary euthanasia; whereby, he required the assistance of his physician to end his life.Moreover, he wanted legal support in order to protect himself and his doctor from being blamed for attempting euthanasia.Here, the dilemma appears: whether euthanasia should be allowed to him or not?In order to critically analyze Mr. X's case, a four quadrant's approach will be used.

Four quadrants approach
This approach was given by "Jonsen, Siegler and Winslade" in 1982 (Sokol, 2008).It is used by clinicians as it provides a structured framework in order to reach an "informed, morally justified decision" (Sokol, 2008).This approach is applied to Mr. X's case because it analyzes his case from all possible angles that could lead to a sound and justified ethical decision.The approach consists of four themes or quadrants that are "medical indications, patient preferences, quality of life and contextual features" (Sokol, 2008) as described below:

First quadrant-medical indications
In this quadrant, the patient's medical condition is analyzed, treatment options are identified, and all the treatment options are ruled out that may benefit the patient in any way (Sokol, 2008).

Second quadrant-patient preferences
In this quadrant, the patient's wishes and desires are given importance, provided if the patient is competent.However, if the patient is not competent, his presumed wishes are assessed (Sokol, 2008).

Third quadrant-quality of life
In this quadrant, the aim is to consider all those aspects that may ensure the patient's quality of life.Also, since quality of life has a subjective component to it too, this quadrant views it in light of the patient's preference Pirani and Badruddin 105 (Sokol, 2008).

Fourth quadrant-contextual features
In this quadrant, the case scenario is analyzed from different contextual perspectives that may have an impact upon the decision.These include, but are not limited to, "economic, religious and cultural factors, confidentiality issues, and the impact of the decision on the patient's family and medical team" (Sokol, 2008).Considering Mr. X's situation, propositions based on the above mentioned controversy are: whether the option of euthanasia is justified; whether Mr. X has a right to decide about his life and treatment; whether the society should support his autonomy for euthanasia; and whether health care professionals should support his autonomy for euthanasia.Let's analyze these propositions through the four quadrant approach.

MEDICAL INDICATIONS
It can be inferred from Mr. X's case that he has compromised physiological and psychological needs.He was totally dependent upon his caregivers for all trivial tasks.It is apparent on medical grounds that Mr. X's condition was deteriorating and since he was quadriplegic, there was hardly any chance of his recovery in the near future.Therefore, sustaining his life was medically considered futile.Moreover, principle of nonmaleficence supports euthanasia with its moral rules of avoiding pain and suffering (Beauchamp and Childress, 2001).In this scenario, medical advancements such as hemodialysis and ventilator support are not appropriate for Mr. X because it would only prolong his life, continue his suffering, and provide lots of pain rather than provide him good quality of life.Therefore, Mr. X's medical indications suggest that his request for euthanasia is justified.

Patient's preferences
Mr. X is an autonomous and competent person.
Autonomy is defined as "having capacity of an individual to make an informed, un-coerced and rational decision" (Beauchamp and Childress, 2001).According to Beauchamp and Childress (2001), a competent individual has cognitive skills and independence of judgment.Mr. X preferred dying over living a dependent and compromised life.He was well aware of his futile treatment, poor prognosis, and his sufferings related to his physical health, his psycho-social wellbeing, and reduction of his financial resources.In his case, withdrawing treatment will end his life at once rather than making him slowly die every day.As he was already going through multi organ failure, restricting him for a natural death would cause more suffering and harm to him instead of providing him dignity and peaceful death.So active euthanasia is well justified in this case.Therefore, on the grounds of the principle of beneficence, which allows removing conditions that might harm others and prevent harm from occurring to others (Beauchamp and Childress, 2001), the act of euthanasia is justified.Moreover, based on the rights-based theory, a country's law should respect the right of a competent patient's decision and allow him to opt for voluntary euthanasia.However, it is very important to understand here that if euthanasia is allowed for Mr. X, then indirectly it means that the legal system supports euthanasia.Therefore as a consequence, every competent person who is suffering through any misery would urge for euthanasia.Ultimately, it would be very difficult to deal with all such cases.Yet, if the legal system supports Mr. X's wish, this will affirm that the law considers every individual's case as a separate case.So it is important that the legal system should evaluate individual needs of patients and decides for the patients accordingly.

Quality of life
The notion of quality of life of Mr. X is associated with 'no more suffering'.Therefore, the use of medical technologies (hemodialysis and ventilator) will be useless since it will only increase his suffering.Additionally, patients with prolonged suffering often undergo depression and lose their hopes.Considering this, prolonging Mr. X's life is not worthwhile.Although Mr. X had a strong social support initially, it is uncertain whether his social affiliation with others would persist in the long run since he was lacking finances.His compromised state is depicting his poor quality of life and therefore, on the basis of medical futility and potentially compromised quality of life, a strong case can be made to allow Mr. X for euthanasia.

Economical aspect
Initially, the patient was financially sound.He bore all the costs of his treatment.Since his condition was a prolonged state of despair and suffering, he would have to bear a financial setback soon.Lack of finances would lead to loss of caregiver's support and availability of continuous treatment.Hence, keeping the patient on ventilator for a long time is least likely to be beneficial for him.These evidences suggest that without finances, care cannot be continued.Adding to this fact, his futile state supports that he should not be forced to bear such high costs of treatment without any beneficial outcome.It is important to consider that if lack of finances becomes a reason to support euthanasia, then people might argue that those people who are underprivileged or are suffering from extreme poverty and hopelessness should also be allowed for euthanasia.People who are fed up of their lives, because of poverty or due to any other reason, are physically competent and can decide independently to end their life without involving their loved ones, society, or law.However, in this case, Mr. X is quadriplegic and he is dependent upon others.Therefore, euthanasia is justified for him.

Social aspect (Society and Justice)
Opponents of euthanasia will justify their reasons on the basis of ethics of care and will oppose the patient's decision for euthanasia.Being a member of society, Mr. X has a right to live and he will be accommodated with the available resources.Whereas, the pro-euthanasia lobby may feel that people like Mr. X are non-productive, consume more resources, and burden society; thus, they should be allowed to die.They will also think that advanced medical resources which are only utilized by him can be shared among all those who require it.These people after their recovery will strengthen the economy, the standards of living, and the welfare of society.Therefore, euthanasia is justified for quadriplegic patients who are not beneficial to the society.This decision is a hard decision and has no strong ethical grounding.The value of human life cannot be measured by how much economic outcome terminally ill patients can give.Resources should be allocated to the terminally ill patients as well.Johnstone (2010) stated, "Justice is a basic human need and as such warrants a broader conceptualization in nursing discourse that goes beyond its conventional conceptualization as a legal or ethical".

Religious aspect
Euthanasia is not appreciated in all major religions.From a Buddhist's perspective, it is considered immoral.This is on the basis of their belief that lives should be saved at all costs (Keown and Keown, 1995;Traina, 1995).In addition, Islam believes that life and death are in the hands of God and therefore, health care professionals have no right to take away another's life.They consider it as a gift of God (Engelhardt and Iltis as cited in Yousuf and Mohammed Fauzi, 2012).Muslims also believe that whatever suffering is in one's fate, it is an opportunity for him/her to neutralize his sins through suffering before he moves to heaven.Muslims believe that everyone has to die one day but to decide which day, is not in human's hand.Furthermore, suicide and killing innocent people is prohibited in Islam (Yousuf and Mohammed Fauzi, 2012).Besides Buddhism and Islam, Christianity also disregards this concept.According to their opinion, life is meant to be cherished.If a patient suffers through a terminal illness, then one of the alternative options would be to keep him under hospice services (Keown and Keown, 1995).Mr. X belonged to a Christian religion, where the religion teaches him to cherish his life.On the basis of religious preaching; euthanasia is not justified for him.

Legal aspect
Legally, it is possible that if euthanasia is legalized then there is a great possibility that it would be misused.Marginalized groups in the society might wish to end their lives because of their sufferings (Beauchamp and Childress, 2001).This study can't legalize euthanasia because there might be chances that every autonomous individual asks for mercy killing.In Mr. X's case, it is justified.However, it varies on individual basis.Therefore, euthanasia should not be legalized.Moreover, if euthanasia is allowed legally, then people in dire need of euthanasia would not have to strive for long to justify their case.This means that it will reduce the suffering of people like Mr. X rather than wasting their time, energy, and money for court justice.Countries like the Netherlands have legalized euthanasia and health care professionals who feel comfortable to assist patient with euthanasia are protected in legal terms (Singer, 2003).

IMPACT OF EUTHANASIA UPON THE FAMILY AND THE MEDICAL TEAM
The concept of euthanasia is well supported in the light of utilitarian theory.Utilitarianism is defined as "right action is that which has greatest utility" (Burkhardt and Nathaniel, 2002).According to this concept, any action is considered ethically just if it has its utility to a large number of people.The utility in Mr. X's case is alleviation of his own suffering and the suffering of his mother who was going through the pain of his son's disability and pitiful life.If the theory of utilitarianism is applied upon his case and euthanasia is allowed, then it would not only alleviate Mr. X's suffering, but also, the suffering of his mother and other close friends and relatives.Hence euthanasia is justified on the basis of utilitarian theory.A deontologist might not assist the patient to die.As according to this concept, the moral obligation of a health care professional is to perform duty, and their duty is to save life and not to kill (Beauchamp and Childress, 2001).Hence, if euthanasia is allowed, then it might challenge the patient's physician as he might question his duty; which is to save people's lives.

CONCLUSION
In the light of the four quadrant approach, various perspectives were analyzed from four dimensions: medical indications, patient's preference, quality of life and contextual features.The ethical theories and principles that were reviewed within each dimension appeared as two sides of the same coin in answering the euthanasia issue for Mr. X.These perspectives in Mr. X's case support his plea for euthanasia except the religious aspect which very strongly condemns it.Hence, Mr. X can be allowed for euthanasia.However, euthanasia cannot be generalized and it is recommended that every individual case should be analyzed independently.