Saturday, April 7, 2012

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A further major difficulty with the discernment of genuine autonomy in those who are dying concerns the close association between the sincere wish to be dead and mental illness, present in up to 5% of those who wish to commit suicide or who request euthanasia. Numerous articles in the literature of psychiatry reveal that the great majority of patients who desire death during a terminal illness are suffering from a treatable mental illness, most commonly a depressive condition. This is not a diagnosis which can easily be made by the average doctor unless he or she has had extensive experience with depression and suicide, and it is frequently missed even in those already under medical care.


It has been suggested, therefore, that patients will be protected by having a psychiatrist see every person who requests euthanasia. But it is not so simple, since only those psychiatrists with extensive experience of terminal illness and suicide will be sufficiently qualified in this area. Frank Varghese, Professor of Psychiatry in Brisbane, believes that if these patients were always seen by someone with the appropriate experience, ‘it is unlikely euthanasia would ever go ahead’. Hendin and Klerman, American psychiatrists with extensive experience with suicide, comment that ‘there is still too much we do not know about such patients, too much study yet to be done before we could mandate psychiatric evaluation for such patients and define conditions under which assisted suicide would be legal’.


Depressive illnesses can be associated with a number of cognitive changes, including a significant and measurable decrease in intellectual functioning, diminished concentration, indecision, mild memory loss and sometimes confusion. In fact, serious debilitating illness of any kind can cause degrees of confusion and depression. When to these factors is added the lack of any objective criteria for assessing the degree of mental competence required for different kinds of decision-making, simple assumptions about the presence of genuine self-determination evaporate.


Yet another problem is the question of external influence on those who are ill by subtle, undetectable degrees of coercion which would negate freedom of choice and invalidate autonomy. In its Working Paper Number 8 of 18, titled Euthanasia, Assisting Suicide and the Cessation of Treatment, the Canadian Law Reform Commission described this possibility as ‘a constant danger’, and one that could not be protected against. The 14 Report of the Select Committee on Medical Ethics of the House of Lords concluded ‘It would be next to impossible to ensure that all acts of euthanasia were truly voluntary, and that any liberalisation of laws would not be abused’.


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When these difficulties are taken together, the conditions necessary for the genuine exercise of autonomy may be doubtful or absent in an unknown number of requests for euthanasia, possibly the majority. It is unlikely that these problems could ever be overcome by any arrangement of words in a draft bill, since they relate to human variables, unable to be measured or even discerned.


Some of the results of an over-ready resort to claims of rights in preference to a reasoned exploration of all the issues in dispute, already mentioned, will now be examined.


First, discussing individual rights cannot settle questions of right or wrong. Rather, it is a way of avoiding the issue. It is often said that, in a pluralistic society, what is ethical or moral is a matter for private determination. Despite that, there is real community consensus on the morality of most of the actions that are the subject of criminal law, and even the most liberal libertarians are as keen as others to articulate their grievance when they feel have been wronged. If, as a society, we cannot agree that it is wrong to take innocent life, that natural rights need respect and protection, and that the frailties of mind and body imposed by serious illness render the sick peculiarly vulnerable to manipulation by others who may resent them for social reasons, on what can we certainly agree? If we cannot agree on the morality of anything, then the law can be dispensed with, except in so far as it represents self-interest or mob rule.


Second, in any discussion of rights, each person may decide which rights they will enter into the debate, and which they will omit. What may seem to be a fair and reasonable treatment of an issue is easily distorted when important matters are omitted. No better example of this can be found than the near-total neglect of the undoubtedly genuine and equal right of every innocent person to their life, while highlighting only the asserted, but unproven, novel right to die. By this omission, the interests of an articulate select group are promoted at the expense of the vulnerable who will be left to take their chance at the hands of those who, in many instances, are already known to want some of them dead. Nothing could be more hypocritical or callous. If the state will not protect the weak, who will?


Third, when the ways are examined in which human rights are commonly promoted, the powerful are seen to have access to, and influence in, the media where they are argued. At present, the diminished autonomy of vulnerable groups is regularly taken advantage of, even as the egalitarian objectives of individual human rights are articulated. It was the view of the former Australian Human Rights Commissioner, Mr Brian Burdekin, from his experience, that the vulnerable sick were already ‘the most systematically abused and the most likely to be coerced’. Putting sole emphasis on individual rights has a proven record of breeding hatreds and ignoring the consequences for society, and of by-passing processes which show due regard for the interests of every group in the community.


Sociologists at Flinders University in South Australia in 14 published the results of a survey conducted among doctors and nurses, about their attitudes and practices regarding euthanasia. The survey discovered that on half the occasions doctors admitted they had carried out euthanasia, there had been no patient consent or request. It also uncovered the view of some of these professionals, the acknowledged guardians of health and life, that poor quality of life, mental disability and physical handicap should be sufficient reasons for active euthanasia, whether or not this was requested.


One of the surveyors, who had previously held no particular view on euthanasia, was moved by these findings to publicly express her disquiet that the very arguments about human rights used to promote euthanasia are in fact abused by its practice. She concluded ‘There is a danger that legalisation of active euthanasia, voluntary or non-voluntary, may expand the potential for further abuses.’ I consider legalisation could undermine the value placed on human life, and erode our sense of security. We need to ensure that the state continues to protect people.’


Conclusion.


Euthanasia cannot be considered without reference to human rights, but all relevant rights should be included. These will include the rights of every person to their life and to the standards of health care appropriate to their illness and, where the provision or quality of that care is demonstrably uneven, to the right to distributive justice to protect the equal rights of all the sick. No right should be included unless its existence has been validated beyond question.


It is not acceptable to want the law changed to uphold a spurious right or even a genuine right that has been shown cannot be protected. Whatever arguments may or may not be thought sufficient to support legalised euthanasia, an appeal to human rights has not been shown to be among them. The claimed rights are either unwarranted misrepresentations of rights, or are ‘wants’ masquerading as ‘rights’.








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