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16 Assisted death – an area of medicalisation of death
  1. Ole Johannes Hartling1,
  2. Theo Boer2,
  3. Morten Magelssen3,
  4. Morten Horn4
  1. 1Retired, Farum, Denmark
  2. 2Protestant Theological University, Groningen, Netherlands
  3. 3Centre for Medical Ethics at the University of Oslo, Oslo, Norway
  4. 4Department of Neurology Oslo University Hospital, Oslo, Norway


Introduction Assisted suicide and euthanasia can be seen as a result of a medicalization of death. It can be viewed as yet another example of the illusion as to the powers we have over life and death, and of our medical possibilities of controlling them.

As seen from the enclosed contributions in this seminar Ole Hartling, m.d., associate professor and former chairman of the Danish Council of Ethics will discuss assisted death – an area of medicalisation shrouded in good intentions and euphemisms but demanding on the patient-physician relationship.

Assisted suicide and euthanasia can be seen as a result of a medicalisation of death. It can be viewed as yet another example of the illusion as to the powers we have over life and death, and of our medical possibilities of controlling them.

Every so often embellishing language is being used to ‘sell’ the message of beneficial medical practises such as diagnostic and screening procedures. This also appertains to assisted death. The term ‘euthanasia’ is Greek and means ‘good death’, and thus in itself is a euphemism.

Even blatantly ruthless attitudes have been cloaked in suave language. There is mounting evidence that in countries that have legalized assisted death, patients with disabilities are being offered ‘a beautiful death’ instead of help. This disguises the risk that people with severe handicaps or chronic diseases may be indirectly coerced to choose death if they are denied needed assistance to maintain their existence.

Propagators of assisted death lean heavily on the concept of respecting the right to self-determination (individual autonomy).

However, whether autonomy is genuinely possible in connection with assisted dying is questioned as autonomy will always be relative to an assessment of the patient’s quality of life. Moreover, the patient cannot be uninfluenced by how their surroundings (for example family, friends and medical staff) regard his or her situation. The patient’s decision may seem autonomous, but it may well be an introjection of the disdain in which the patient is held by the community.

Finally, it is discussed how legalization of assisted dying can affect the patient-physician relationship. The conclusion is that if the distressed and despairing person is met with the understanding that now death is to be preferred, this, at the same time, carries the message that this person can be done without.

Morten Magelssen, a Norwegian medical doctor will focus on the distinction between treatment limitation and euthanasia, and argue that an exaggerated view of medicine’s power stands in danger of erasing this distinction.

Humility and realism vs. hubris and medicalization in the assisted dying debate.

Euthanasia on the one hand and treatment limitation on the other are clearly different courses of action. However, a lively philosophical debate has concerned whether the differences are morally relevant, and thus whether societies are justified in regulating them differently. In most countries, euthanasia is prohibited whereas treatment limitation (withdrawing or withholding life-prolonging treatment) is legally and morally accepted. A classical answer to the question of morally relevant differences is that whereas euthanasia involves both intending and causing the patient’s death, treatment limitation involves no such intention, and if life is shortened the patient dies from their disease, not from the physician’s actions.

This talk proposes to look at this issue from the perspective of medicalization. It will be argued that the classical answer presupposes a humble yet realistic view of the purposes and possibilities of medicine; whereas critics of the classical view stand in danger of promoting an inflated view of medicine’s powers, thus risking both hubris and an unhelpful medicalization. Specifically, if medicine’s powers over life and death are exaggerated, then death ensuing from treatment withdrawal becomes something suspect, a morally dubious causation of death from which the doctor cannot escape moral responsibility.

Finally, Morten Horn a Norwegian specialist in neurology will call into the question whether assisted dying cannot in reality be included in the concept of treatment being rather a negative treatment.

Assisted dying differs from all other forms of treatment – can be viewed as ‘negative treatment’

In medical ethics, much has been said about over-treatment, and about non-treatment decisions (NTDs), and about assisted dying (euthanasia or physician-assisted suicide). In this talk, I would present the view that all these issues – in themselves complex and with many ramifications – all relate to or are based on one fundamental, if hypothetical point in time: The moment of natural death.

All humans are expected to be living their lives up until the moment of natural death. However, in some patients (in fact, probably in most patients, in a modern society), life is prolonged through medical interventions, beyond that moment of natural death. This might be due to dramatic interventions, like cardiopulmonary resuscitation. Or it could be more subtle measures, like antihypertensive medication, which reduces the risk for cerebrovascular disease.

In other patients, death is hastened, either involuntarily, due to violence or accidents, or (at least nominally) voluntarily, due to either suicide or assisted dying interventions.

Using the simple model of a rolling car, I will try to explain the fundamental difference between prolonging life, and shortening life, relative to the (theoretical) moment of natural death.

In this model, the concept of non-treatment decisions becomes moot – because in actuality, there are only treatment decisions. All treatment relies on two conditions: That the intervention is medically indicated, and that the patient consents to treatment (explicitly or implicitly). If life is to be prolonged, such an intervention needs to fulfil these two conditions. Over-treatment consists of treatment that either fulfils no medical intervention, and/or goes against the patient’s wishes (explicit or implicit).

Assisted dying is a form of ‘treatment’ that is fundamentally different from all other kinds of medical treatment, in that it shortens, rather than prolongs life. Whether it is over-treatment or just appropriate treatment is difficult to tell; the main point is that it is treatment going in the opposite direction from all other forms of treatment. It may be seen as ‘negative treatment’, and fundamentally different from so-called non-treatment decisions with regards to the relation to the point of natural death.

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