Moral Permissibility of Euthanasia: A Case Discussion from Bangladesh Golam Azam Tangina Sharmin† Abstract Euthanasia or mercy killing is, now a day, a major problem widely discussed in medical field. Medical professionals are facing dilemma to take decision regarding their incompetent patient while tend to do euthanasia. The dilemma is by nature moral i.e. whether it is morally permissible or not. In some countries of Europe and in some provinces of USA euthanasia is legally permitted fulfilling some conditions. It is claimed by Rachels that in our practical medical practice we do euthanasia by forbidding patients from taking drugs. He concludes that if that type of euthanasia can be practiced in our society without any hesitation then why assisting euthanasia will not be permitted 1 . There are so many arguments both pro and con of euthanasia. But it is not the function of the current paper to discuss all the arguments. Philippa Foot in her article „Euthanasia‟ and J Velleman in his article titled as „A Right to Self-termination‟ discussed about the permissibility of euthanasia. The objective of the paper is to justify their arguments and then come to a conclusion regarding the permissibility of euthanasia. The focus will be given mainly on nonvoluntary active and non-voluntary passive euthanasia. The method of discussion will be that an example will be given from Bangladesh and then the arguments provided by Foot and Velleman in their above mentioned papers will be discussed to justify the act of euthanasia on concerned patient. In the last section of the paper the situation of Bangladesh will also be considered for the permissibility of euthanasia i.e. whether the act of euthanasia can be permitted in our country considering the existing socio-cultural-religious practice. Keywords: Euthanasia, moral permissibility, Bangladesh, Velleman, Phillipa Foot. * Assistant Professor, Department of Philosophy, University of Dhaka † Lecturer, Department of Philosophy, Rajshahi ( Govt. Titumir) College, Rajshahi (Dhaka) 1 Rachels J (1974), Active and Passive Euthanasia, in The New York Journal of Medicine, Vol.292, no.2 pp. 78-80 The Dhaka University Studies, December 2006 158 Introduction Euthanasia is one of the basic issues in bio-medical ethics, particularly in respect of decision making in medical practices. It is important in the sense that it involves the life of human being, the dignity of the person and also the autonomy of the patient. There are several aspects of discussion regarding the act of euthanasia. There are also different types of euthanasia depending on the actions taken to the patient. Sometimes it is called killing (mercy) the person, letting someone die, and also physicians assisted suicide. The aim of the paper is not to deal with all these controversial etymological debate. Here euthanasia will mean simply passive euthanasia i.e. letting the patient die by way of stopping the treatment. For the convenient of my discussion we will cite an example from Bangladesh aiming to consider moral justifiability of euthanasia. There are two sides of the discussion, one is purely moral discussion where the arguments of Philippa Foot and J. David Velleman will be considered and the other is the socio-economic reality of the case of the country concerned. One of the inherent major tendencies of the paper is also to extend the discussion about euthanasia among the community of developing world. In this regard, the objection raised by the opponents of euthanasia will be refuted at first, then the moral justification of euthanasia will be analyzed and at the end it will be shown that the socio-economic reality do not permit us to continue expensive treatment even to the great man of the country. It is also because that the great men are always „great‟ for the wellbeing of the people. So from the point of efficiency, stopping treatment to the great man will become more reasonable. A Case Discussion In this section a case will be discussed and some problems will be extracted from the case to continue the moral discussion regarding the action of euthanasia. 159 Moral Permissibility of Euthanasia The Case and its Analysis Shamsur Rahman, one of the greatest poets in Bangladesh died on 17 August 2006. He was one of the dreamers of the country when it became independent in 1971. He played a vital role to establish our own culture and social norms. The whole nation was shocked to lose him forever. He had been suffering from various complex diseases like cardiac, respiratory, renal and gastroenterological disorders. He was suffering so severely that he was unable to recognize his wife, son, daughter and any close relatives. He was also unable to communicate with the doctor to explain his condition. The doctors had to depend on their prior experience and symptom. He lost his sense and was comatosed. The doctors were very much discomfited of him being alive again as a functional poet. Basically, as the total metabolism of his body became inactive, his life was nurtured by the artificial medications. It seems that the poet was waiting to welcome the messenger of death. As his sense left him, he cannot express his intention. Probably, the sufferings made him senseless for a couple of weeks. A panel of eight expert physicians, most of them are the professors, treated him for about a month. He was kept in ICU for about half a month. The doctors tried their best to keep him alive, but they could not. Before keeping him in ICU, the doctors guessed and assumed that his life cannot be prolonged. In that situation some of his devotees claimed to send him abroad for better treatment but consulting with the team leader of the panel the Government decided not to send him to abroad. In this connection though the physicians consider the treatment of the patient as futile and suggest not to continue further treatment, the opponent of this view emphasized on the continuation of treatment until the poet dies naturally. Their arguments are like these; a) as the poet is the guardian of the nation, therefore the Government is responsible to do everything possible for him, b) it is the right of the poet to get the optimal service from the Government, c) the poet is the re-constructor of our social value, so it is the duty of the Government (on behalf of the whole nation) to send him The Dhaka University Studies, December 2006 160 abroad for better treatment and lastly d) being respected by the people, the poet deserves more dignity than others and the nation should show due respect to his dignity. On the other hand, the reasons for which the Government disagreed to continue the treatment were a) the government is not rich enough, b) the government did not get positive respond from the panel of the physicians formed for the treatment of the poet for his recovery if possible; c) he (the patient) was basically clinically dead. From the story (event) cited above, there raises some ethical questions. Such as, is it morally permissible to stop his treatment? Is it not the responsibility of the Government to show due respect to him by sending him abroad for better treatment? Firstly we would like to criticize the arguments given by those who emphasized to continue the treatment of the poet in that situation. The first argument is that the poet is the guardian of the nation (guardian in the sense that whenever the country falls in dilemmatic position regarding social and cultural affairs people as well as the Government seek his advice to solve the dilemma) , so the Government has the responsibility to do everything possible for his better treatment. It is a matter of respect. Though the Government has to show due respect to the poet, the thing is that our nation is not too rich by resources to spend as much resources as required for one specific person to keep him alive. The source of the Government resources is the taxes of the common people. Therefore, where there is no expectation of life or keeping him functionally alive, it is not reasonable to spend a lot of public money only to show respect to our poet. Rather, we think it is reasonable to reduce his sufferings so that he may die painlessly. If we want to show our respect to him, the Government may build up a monument and other things. Moreover, the culture and social norm for which the poet spent a long portion of his life to establish is not an individual endeavour, rather it‟s a social campaign and every citizen of the country played their role for the initiatives led by the poet. And he will remain alive within the activities introduced by him in national culture by way of mass practice. 161 Moral Permissibility of Euthanasia The second argument of this group is based on the notion of dignity of the poet. It is tended to show that the poet bears a high dignity among the people of the country and that‟s why the Government has to take proper initiatives to treat him as much as required. While explaining the notion of dignity from a historical point of view we find at least four different concept of dignity, "Cicero may represent the Cosmo-centric framework of Antiquity, which explains human dignity on the basis of nature (2). Thomas Aquinas represents the Middle Ages‟ Christo-centric framework, which explains human dignity in relation to Jesus Christ (3). Immanuel Kant can represent the logo-centric framework of Modernity, explaining human dignity as a tribute to reason (4).Whereas Mary Wollstonecraft, finally, represents the polis-centred framework of Post-Modernity, which explains human dignity in relation to social acceptability (5)" 2 . But in our discussion we will use the Kantian notion of „dignity‟. It means that dignity comes from within. Dignity of a man depends on his both intrinsic and extrinsic value/qualities. Among the intrinsic qualities is his rationality. So intrinsically the dignity of a layman and the poet is equal, because both are human being, both exercise his rationality and so. Velleman also discussed the sense of dignity from this point of view. For him, dignity is not a matter of degree. He says, "Dignity, unlike well-being, does not come in degrees that we are obliged to maximize;... it is not a value whose existence we are obliged to promote at all." 3 The dignity of the poet should be honored as a human being. But we want to say that the physically distressed people who are not getting decent minimum medicine to prolong their life are also human being. As they are also rational being, they also have dignity. No one can tell that the baby, who is now suffering from dengue fever, does not have the same potentiality like our poet. And in respect of the condition of poet, there was a very little possibility to bring him alive or to prolong his life as a functional one. On the other hand the dengue affected baby has the possibility to be cured if treated properly. Therefore dignity argument doesn‟t stand because whenever we go for thinking 2 Mettte lebech, What is Human Dignity, see, 3 J.David Velleman, A Right to Self-termination? In Ethics,1999, P-617 The Dhaka University Studies, December 2006 162 dignity for one person, we have to look at the dignity of other person as well. Moreover, the money required for the poet might be useful to up hold the dignity of many people in the sense used here i.e. to get rid of many rational being from sufferings. The dignity of a person isn‟t something that we can accept or decline, since it isn‟t a value for him; it‟s a value in him, which he can only violate or respect 4 . The third argument is that it is the right of the poet to get the optimal benefit of health care. It is because he bears the most social acceptability in the nation as one of the greatest poets of the country. Basically the argument comes from the inner feelings of the people of the country, they are affectionate to their poet, and they deeply love their poet. But if we discuss the issue objectively it is to be mentioned that as per health policy of the country every citizen has equal right to minimum health care. So constitutionally, the poet deserves right to health care. But it does not indicate that it‟s his right to get such expensive health care; the policy categorically tells about the „minimum‟ health service. Now, if the „minimum‟ means „keeping him in the ICU as long as he die naturally" then every citizen preserves the same right and they can claim the Government to give them the same facility. But the Government of Bangladesh does not have so many resources to fulfil the demands of all citizens. One of the main objectives of the health policy of the Government of Bangladesh is "To allocate more resources to support services for poor, vulnerable groups (women and children)". In this context, we think, it is better and reasonable to use the scarce resources reasonably aiming to reduce the suffering of as many people as possible. Therefore, the claim to keep the poet in ICU for a long time spending huge amount of public money does not stand. Moral Justification of Euthanasia to the Case Subject 4 Velleman, Ibid, P-613 163 Moral Permissibility of Euthanasia Now we would like to critically discuss whether it is morally permissible to stop treating the poet in this situation. We will explain the condition of the poet in the light of the arguments given by Velleman and Foot supporting the act of euthanasia. Velleman in his paper interprets the validity of the act of euthanasia considering the human being as a dignified being. He analyzed the Kantian view regarding the dignity of human being. He considers the dignity of a man as his supreme quality inheres in him. He thinks that it is not morally acceptable to kill or letting die a human being with dignity. He says, "We don‟t think that a person‟s death is morally acceptable so long as he can carry it off with dignity. Rather, we think that a person‟s death is acceptable if he is no longer live with dignity" 5 . The connotation of dignity is active rationality. In the case described earlier, the poet lost his competence; he also lost his power of reasoning i.e. rationality. It is because he became unable to take decision and recognize the persons and also to make communication. Therefore dignity was no longer present in him. So, from the point of Velleman, if the act of euthanasia can be done to him, it would not be like killing a man with dignity. Velleman emphasizes on the dignity of a man. So long as dignity exists in him, none can take decision to kill him. It indicates that if the man loses his dignity he might be considered for shortening his life aiming to lessen his sufferings. According to Velleman, "When a person cannot sustain both life and dignity, his death may indeed be morally justified. One is sometimes permitted, even obligated, to destroy objects of dignity if they would otherwise deteriorate in ways that would offend against that value"6. The condition of the poet in the case was so vulnerable that it was impossible for him to live as a functional poet. As the physicians suggest, he could no longer be cured and it was not possible to make him alive. All these suggestions of the physicians indicate that it would not possible for the poet to sustain his life with 5 Velleman, Ibid, P-617 6 Velleman, Ibid, P-617 The Dhaka University Studies, December 2006 164 dignity. Therefore the act of euthanasia would not be immoral if done to the poet. Velleman also mentions that, "He (the terminally ill patient) indeed be entitled to help in dying, and he will certainly have to participate in the relevant decisions" 7 . But the incompetence of the poet does not allow him to participate in decision making. Therefore either the surrogates of the poet or the physicians are to take decision. Judging everything sincerely, if they decide to shorten the life, we think it would not be morally wrong. The condition of the poet was in a very crucial position. Due to pain and other physical and metabolic disorder, he became incompetent. Velleman argues that, "Pain that tyrannizes the patient in this fashion undermines his rational agency, by preventing him from choosing any ends for himself other than relief. It reduces the patient to the psychological hedonist‟s image of a person-a pleasure-seeking, pain-fleeing animal-which is undignified indeed"8. Therefore, it can be said that if in this vulnerable condition a patient is helped to die, it would not like helping a rational agency to embrace dying and hence the dignity of the patient is not undermined. The condition of the poet can be related in this connection. If the non-voluntary passive euthanasia i.e. if the treatment of the poet is stopped, it would not be letting him die as a dignified man because he was no longer a person with rational agency. And as per Velleman‟s version in this situation the patient becomes an undignified man 9 as stated by Velleman. Foot in her Euthanasia discusses the permissibility of euthanasia from two moral virtues, i.e. justice and charity. For her, justice is connected with the whole area of rights and duties correspondence 7 Velleman, Ibid, P-618 8 Velleman, Ibid, P-618 9 Note: Academically speaking „undignified animal‟ because if I say undignified man it becomes a self-contradictory statement since the term "undignified" means irrationality whereas "man" means animal with rationality. Therefore if we say "undignified man" we say „irrational rational animal‟a contradiction within the statement. 165 Moral Permissibility of Euthanasia to rights 10 . And charity is the virtue which attaches us to the good of others. An act of charity is in question only where something is not demanded by justice, but a lack of charity and of justice can be shown where a man is denied something which he needs and also his right. She holds that men have the right only to the kind of thing, that is, in general good e.g. a right to something that will make a man better off. For example drugs that may prolong one‟s life 11 .But the condition of the poet in the case is such that the drug is not fruitful to bring good to him. So according to Foot, as the drug does not work as a good for the poet, it might not be his right to get the drug. And if the medication is stopped due to its futility, then it will not be the in fringing to his right. Foot also holds that charity is the virtue that gives attachment to the good of others, and because life is normally a good, charity normally demands that it should be saved or prolonged. But as we defined an act of euthanasia that it seeks a man‟s death for his own sake-for his own good-charity will normally speak in favour of it 12 . ... if an act of euthanasia is not contrary to justicethat is, if it does not infringe rights then charity will rather be in its favour than against 13 . The condition of the poet in the case shows that life is no longer good for him if prolonged by medicine. Therefore the right to life or good is no longer infringed if euthanasia is done to him. Because life means life of active participation which is not possible for the poet to get back and as per analysis of the doctors it is also not good for him to get artificial medication all the time which increases sufferings. According to Foot, it is even more obvious that charity does not always dictate that life should be prolonged where a man‟s own wishes, hypothetical or actual, are not known 14 . She examines it compatible with charity to seek a man‟s death although he wanted to live, or at least had not let us know that he wanted to die. She opines that in this circumstance, active euthanasia would infringe 10 Philippa Foot, Euthanasia, in Philosophy and Public Affairs, 1977, p-97 11 Philippa Foot, Ibid, p-100 12 Philippa Foot, Ibid, p-106 13 Ibid 14 Philippa Foot, Ibid, p-107 The Dhaka University Studies, December 2006 166 his right to life, but passive euthanasia would not do so, unless he had some special right to life-preserving service from the one who allowed him to die 15 . Now, the condition of the poet in the case is such that due to his incompetence, the physicians were unable to know his wish regarding the prolongation or ending of his life either actually or hypothetically. Therefore, from the point of departure of Foot, the passive euthanasia i.e. stopping the treatment of the poet would not infringe his right and so it is not contrary to justice. The action which is not contrary to justice is not morally impermissible. Philippa Foot in her paper discussed the moral possibility of four types of euthanasia, voluntary active, voluntary passive, nonvoluntary active and non-voluntary passive euthanasia. She holds that among these, non-voluntary active euthanasia in never justified as it infringes the right of the patient and incompatible with the concept of justice and charity but other forms of euthanasia are sometimes compatible with both justice and charity. That‟s why these are sometimes morally permissible by condition that the purpose of the act of euthanasia is to benefit the one who dies 16 . The proposed action to be done to the poet in the case is a matter of non-voluntary passive euthanasia. It is non-voluntary in the sense that the physicians don‟t know his intention due to his unconscious condition and it is passive in the sense that the physicians are not going to insert any medicine in him to shorten his life. And one of the intentions of stopping the treatment is to reduce the suffering of the patient. Therefore, if passive euthanasia is done to the poet it would not be morally unjustified. There is a complexion in the case, that the poet did not give any advanced directives to commit euthanasia if he becomes incompetent. Although he is getting suffered, the physicians are not sure whether he wants by himself to be terminated. On the other hand, the surrogates of the poet also want that treatment be continued until he dies naturally. But the panel of the doctors has the hypothesis that, a) he is incompetent, b) he has no possibility to 15 Philippa Foot, Ibid, p-107 16 See, Philippa Foot, Ibid, p-108 167 Moral Permissibility of Euthanasia overcome the situation any more, c) the resources, to be provided to him are not in plenty. Again the fact is that the poet lost his rational dignity, and also autonomy. Here the point is that the poet did not produce any advanced directives for doing euthanasia. So the doctors do not have any right to terminate his life. The first thing is that there is no practice of euthanasia explicitly in Bangladesh let alone the procedures of advanced directives. There is no legal position and concern about euthanasia in national health policy in Bangladesh. People cannot imagine that advanced directives can be done in such vulnerable condition of a person, and there is no legal procedure for it. Another point is that, the opponents of euthanasia may argue that only the poet has the right to terminate his own life if he thinks that termination is good for him rather than being alive in vulnerable condition with sufferings. We think, two things are coherent here, a) the consent of the patient and b) the expectation of the surrogates. For the first concern it has been mentioned that the patient is comatose and hence cannot express his intention and for the second concern it can be told that till today, due to the lack of proper knowledge of the surrogates, the concerned physicians take the decisions regarding the patient subject to inform the surrogates the actual condition of the patients. If the doctors in good faith express their opinion, the surrogates normally accept it and it is the common practice. Therefore, though the opinion of the surrogates helps the physicians to take the final decision regarding the patient, the vital role in the whole process is conducted by the physician himself and hence the physicians are the main authority for decision making in context of the country. Conclusion Considering the case studied above from moral and logical point of view it can be deduced that doing euthanasia to the poet would not be morally impermissible. As the condition of the patient is vulnerable, by way of inductive generalization it can be said that from the point of view of equity and efficiency, it is reasonable to take decision for the termination of life of the concerned patient. Here equity connotes the minimum satisfactory treatment of the patient which includes proper diagnosis, unbiased opinion of the The Dhaka University Studies, December 2006 168 doctors, possibility of being functionally alive and proper medication. It also implies, for Marcel (2006), „1) the rejection of various forms of discrimination, 2) attempt to minimize unfairness and 3) giving priority to groups who have a relatively strong claim to life-saving treatment,....‟ 17 . It is equity in the sense that it is relatively fair and just. On the other hand efficiency in this context connotes the number of people assumed as beneficiary if the treatment is stopped and the cost that would be incurred for that treatment to be used for the large number of people. In countries like Bangladesh where the resources are very much scare and people are badly deprived of minimum decent treatment, it is exaggeration to keep a demented-vulnerable person in ICU for a long time with huge amount of Government resources. Therefore it is both moral and social expectation that more people are to be saved with limited resources. Another point is that the doctors can commit non-voluntary passive euthanasia i.e. stopping treatment to him rather that administering lethal injection in him because the patient is incompetent of his physical condition 18 / 19 . 17 Marcel Verweij, Equitable Access to Therapheutic and Prophylactic Measures, a Project Paper on Addressing Ethical Issues in Pandemic Influenza Planning, 2006, P-11 18 Note: Here poet Shamsur Rahman in exemplified for academic purpose. In the mind of the author the intention that acts seriously is that, in our cultural practice we emphasize our poet and other people more than the layman. Now, if an act of euthanasia is morally permissible to be done on such socially dignified person, in the same situation, the same action could be morally permissible to take in respect of other people as well. Here one thing is seriously considered i.e. the resources that are being used for the recovery of the patient is solely government resources, not the private. Rich people can choose better treatment in abroad with their own resources. The issue is confined to the facts where government resources are directly involved. It is because every person has the same right on public resources. The discussion of the moral permissibility of the act of euthanasia is significant because being a low income country our resources are very less in proportion to the claimers on it. So we need efficient distribution of this scarce resources i.e. wealth, facilities etc. 19 The assumption is basically done for the Government resources to meet the expenditure for the treatment of a demented patient. People who are rich or who are not dependent on Government resources are not subject to the consideration of charity or justice. Rich people might keep their patient as many days as they like to incurring money by themselves. 169 Moral Permissibility of Euthanasia References Foot, Philippa (1977). 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