Euthanasia or mercy killing arises from its roots on Homerian epics with the meaning of a good or painless death (from the Greek eu, “good”, and thanatos, “death”) (1, 2). According to the European Association for Palliative Care (EAPC) ethics task force, Euthanasia is defined as “a doctor intentionally killing a person by the administration of drugs, at that person’s voluntary and competent request. Physician Assisted Suicide (PAS) was further defined as: “a doctor intentionally helping a person to commit suicide by providing drugs for self-administration, at that person’s voluntary and competent request” (3, 4). These definitions exclude terminal sedation, and withdrawing or withholding treatment. Patients’ rights and autonomy are increasingly relevant in medical decision-making and such issues need to be confronted.
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Euthanasia can further be classified as active or passive, where active euthanasia stands for direct administration of a lethal agent to the patient by another party, which may or may not be a physician, with a merciful intent. Active euthanasia can be voluntary (on the patient’s will), involuntary (without the consent of patient in cases where it could be obtained), or non-voluntary (in cases where consent of the patient cannot be obtained due to his physical or mental disabilities) (5). Passive euthanasia, on the other hand, refers to suppressing or withholding medical treatment with an intention of causing the patient’s demise. In contrast to this, in PAS, a patient self-administers a lethal substance prescribed by the doctor. This is in comparison to the concepts of double effect, terminal sedation and withdrawal/withholding life sustaining treatment. Double effect refers to the phenomena that a substance used with the primary objective of alleviating symptoms may possibly accelerate patient’s death due to a known but unintended effect. Terminal or palliative sedation is the intentional use of pharmacological agents to sedate a patient with the primary aim of reducing refractory symptoms and not intending to hasten death (4, 6). Hence, it is not assisted death when the intention is to relieve symptoms rather than hastening death. Withdrawal or withholding of life sustaining treatment, on the contrary, is done with an intention of inflicting patient’s death. Although it can at times be futile and not yield the desired results, it is widely acceptable today.
No matter what form of end of life care is chosen, it can be regarded ethically and legally acceptable only when the competent patient is completely informed and willfully choses the option (6).
In the last decade, with growing global economic crisis, pressures have been intensified to reduce the total health care expenditures per economy. This yields down to continuously contracting health care budgets, while the demand for healthcare provision continues to swell. Under such circumstances, where the priority is to reduce monetary costs, selecting the most desirable way to allocate resources can get tricky. Decisions regarding the delivery of health care at the end of life underscore the inherent conflict between economics and bioethics, and also reemphasize on the concept of Euthanasia (7).
The advent of modern technology has brought in new visions to the entire scenario. With the development of well-equipped technologically sound intensive care setups, physicians have gained ability to prolong or shorten the expected life of a critically ill patient and capacity to choose their time of death. Mechanochemical technologies allow for the resuscitation of failing functions, even though a person may be “brain-dead,” with no electrocardiography trace or reactions, and live only if fed artificially. Antibiotics for opportunistic infections in terminal cases may prolong physiologic signs, but whether such technology prolongs life is dubious (8). Boiling pressures from the patients’ family and more commonly, peers, often makes it much simpler to maintain an unnatural life than to allow a natural death. The mindset that doctors have the ability to keep severely ill patients alive for prolonged periods further complicates the issue. Physicians have also feared criminal or civil liability for hastening a patient’s death (9, 10).
With the background of a materialistic-atheistic world view and philosophy of life it is thinkable that a terminally ill life (euthanasia) or an early unborn life (abortion) is more easily at disposal. The concept of theological elevation of human life (the sanctity of life) and the tradition that the aim of medicine is, above all, to save lives are deeply embedded and sometimes difficult to reconcile with what may actually be best for the patient (11-14). The Hippocratic oath itself forbids physicians’ involvement in the intentional killing of any patients, as it states “I will neither give anyone, even if I was asked for, fatal poison, nor advise it”(15). For some terminally ill patients this can result in prolonged dying, accompanied by considerable emotional and financial burden.
Euthanasia or assisted suicide, and sometimes both have been legalized in a small number of countries and states, especially in the West. In all jurisdictions, laws and safeguards were put in place to prevent abuse and misuse of these practices. Individual autonomy is increasingly perceived as one of the major foundations of human rights, and patients’ free choice, consent and control are therefore central in health care today (16, 17). In countries that permit euthanasia, such as Belgium, Luxembourg and the Netherlands, patient autonomy is considered an important cornerstone in the legal regulation of euthanasia (18, 19).
In 2001, Netherlands became the first country to have formally legalized Euthanasia and PAS after about 30 years of public debate. Since the 1980s, guidelines and procedures for performing and controlling euthanasia have been developed and adapted several times by the Royal Dutch Medical Association in collaboration with that country’s judicial system (20, 21). Despite opposition, including that from the Belgian Medical Association, Belgium legalized euthanasia in 2002 after about 3 years of public discourse that included government commissions (22, 23). Luxembourg legalized euthanasia and pas in 2009. Switzerland is an exception, in that assisted suicide, although not formally legalized, is tolerated as a result of a loophole in a law dating back to the early 1900s that decriminalizes suicide. Euthanasia, however, is illegal (22).
Debating on the justification or otherwise of the Euthanasia is a complex issue and involves legal, religious and cultural implications. Books on Jurisprudence mention it sparingly without coating any legal authority (22, 24-26). Guidelines, personal views, and opinions on when to withhold or withdraw treatment or life-supporting systems, and who should have a say in such decisions, are provided in an abundance of papers (15, 23, 27-31). Most of these studies have been conducted across the West, including USA and Europe, with little research being conducted in the developing countries. Current economic and financial constraints add new dimensions to the decisions regarding such ethically and morally contentious issues and make them increasingly relevant in day-to-day practice. Such decisions are often multifaceted and complex, and increasingly, ethics committees and consultants are being called for assistance, although it is not universally agreed upon. Factual situation in our circumstances in the developing world is that the concept of patient autonomy hardly exists. The attendants willfully take a number of seriously ill patients away. The ventilators are switched off on a relative’s request or even on doctor’s decision. At times the only available life support equipment is transferred to another but better candidate for survival. Due to non-availability of equipment (even basic life support at times) expertise or funding, patients have to suffer, even if at the cost of their lives. In extreme conditions, terminally ill patients are also being used as donors for organ transplants, either because it is considered a noble cause or just out of poverty. National literature on ethics provides an insight into the nature and development of a dialogue on health issues within a population.
Overall, there is a dearth of published discourse on healthcare ethics in Pakistan. Values that are considered to stem from religious teachings predominate in discussions relating to medical ethics. A lack of effective policy and legislation concerning the ethical practice of medicine is reported to have negative effects on the profession. Consideration of ethical issues in health is at an early stage in the country and may reflect the situation in a large part of the developing world (32, 33).
The objectives of the manuscript are to investigate attitude and perceptions of the medical students, physicians and lay people on euthanasia and physician assisted suicide in a developing country like Pakistan.
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