On-line version ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.102 n.6 Cape Town Jun. 2012
FROM THE EDITOR
Euthanasia - no dignity in death in the absence of an ethos of respect for human lifes
The headline-grabbing story of Sean Davison, a non-medical professor at the University of the Western Cape who assisted his 86-year-old mother - herself a medical doctor - to kill herself by taking an overdose of morphine tablets dissolved in water, has evoked much interest, and unleashed an online campaign, Dignity SA, to legalise euthanasia in South Africa. The cancer-stricken doctor had already tried in vain to starve herself to death. 'Help me, you are a good boy. I want to die today,' she had pleaded with Sean.
Euthanasia, Greek for 'good death', has been with us for millennia. In ancient Greece, euthanasia - promoted by the likes of Socrates and Plato, but apparently opposed by Hippocrates - was generally accepted and widely practised, using hemlock to hasten death in cases of terminal and painful illness. Its practice continued through the 16th and 17th centuries, but soon came under increasing opposition from Christian thinkers such as Thomas Aquinas, and from the gradually professionalising medical fraternity.
Defining euthanasia has proved exceedingly difficult, and has exercised the minds of philosophers, moralists and ethicists alike for centuries. Definitions vary from a few sentences to whole book chapters, illustrating the elasticity of the concept and the perils inherent in trying to define its boundaries. Euthanasia advocacy has a long history globally, with the British organisation Dignity in Dying having been founded in 1935. Euthanasia groups exist in many countries, as do organisations opposed to it. However, to date physician-mediated euthanasia (including physician-assisted suicide) has been legalised in only four countries worldwide: Belgium, the Netherlands, Luxembourg and Switzerland.
According to constitutionalist Pierre de Vos, 'there is some ambivalence in our law about how to deal with the broad concept of euthanasia'.1 There is currently no single legislation regulating decision making and conduct by medical practitioners vis-a-vis end-of-life interventions broadly falling within the ambit of euthanasia. The law, such as it is, relies on bits of cognate legislation and case law.
In the 1990s, the South African Law Commission conducted an exhaustive review of the state of the law in this regard,2 concluding that 'At present, the position in our law is that the termination of a person's life is unlawful, even if the motive for such conduct is to end the person's unbearable suffering ... even where the suffering person has expressed the wish to die or has even begged to be killed.' The Commission reviews a selection of (mostly non-medical) cases of mercy killing that went to trial. The perpetrators were found guilty of murder, but - like Davison - none served an actual jail sentence, perhaps because of community sympathy, and '[t]he courts ... [sought to reflect] the sense of justice of the community regarding the blameworthiness of the accused by imposing very light sentences.'
The euthanasia debate boils down to the balance between the constitutional guarantees of the right to life and the rights to dignity and to autonomy. The British House of Lords Select Committee on Medical Ethics (cited in South African Law Commission2) holds that 'prohibition (of intentional killing) is the cornerstone of law and of social relationships. It protects each one of us impartially, [and] we do not wish that protection to be diminished'. They worry as well that euthanasia legalisation 'would inevitably open the way to its further erosion whether by design, by inadvertence, or by the human tendency to test the limits of any regulation'. Euthanasia proponents, on the other hand, argue that the right to life is not synonymous with an obligation to live. Permanent incapacitation, irreversible vegetative state, and terminal illness with intractable pain diminish human dignity, and '[I]t is harder morally to justify letting somebody die a slow and ugly death dehumanised than it is to justify helping to avoid it' (J M T Labuschagne, 'Dekriminalisasie van eutanasie', THRHR 1998;167, cited in South African Law Commission2).
To this writer, the case for legalised active voluntary euthanasia is compelling. As articulated by Posel (albeit in a different context),3 'the right to life [is not] merely a right to biological life . it [is] a claim and entitlement to a particular quality of life'. The rights to life and to dignity are not competing rights; rather, they are 'opposite sides of the same coin'. The right to life is the right to a (subjectively) dignified life.
That said, it does not follow that South Africa is a safe and appropriate place for liberalised voluntary euthanasia legislation. Euthanasia - a recourse of last resort - can only really be justified in a country with the very best medical care for all, a well-organised and universally accessible palliative care and support system, stable and well-functioning (particularly judicial) institutions, and a strong culture of respect for human life. In South Africa, with its 'severe constraints on health care facilities and the totally inadequate allocation of resources for highly effective medical treatments,4 there is a real risk of euthanasia becoming a substitute for proper care for the terminally ill and other patients in dire medical straits.
Even more damning for South Africa is the pervasive lack of an ethos of respect for human life. We are an extraordinarily violent society, with over 45 murders committed daily and interpersonal violence the second highest cause of death. Mob justice, police brutality and xenophobia abound. Needless deaths occur regularly in our hospitals through staff neglect and indifference. Health care providers think nothing of downing tools and walking off, abandoning critically ill patients, or of blocking ambulances with critical emergencies from entering health facilities during labour disputes.
In the circumstances, euthanasia cannot be at the top of the wish-list of things that must be accomplished in order to improve the human condition of South Africans.
Daniel J Ncayiyana
2. South African Law Commission. Euthanasia and the artificial preservation of life. Paper 71 Project 86, 1997. www.justice.gov.za/salrc/dpapers/dp71_prj86_1997.pdf (accessed 18 May 2012). [ Links ]
3. Posel D. Democracy in the time of AIDS. Interventions 2005;7(3):310-315 [ Links ]
4. Benatar SR. Dying and euthanasia. S Afr Med J 1992;82:35-38. [ Links ]