Keywords

Euthanasia, Death, Morals, Ethical theory

Introduction

With the increase in life expectancy, discussions about the possibility of intervening in the life cycle, accelerating or extending the moment of death, were reinvigorated, perhaps being one of the central questions of ethics applied to health [1].

Traditionally there is strong resistance from health professionals to life interruption, on the grounds that the medical function is to save lives. However, there is a great incongruity in this claim, since the "detachment of the apparatus" so that "life goes on its course", known as passive euthanasia, is considered a routine procedure [1].

We will seek in this article to define euthanasia as well as orthatanasia, misthanasia and dysthanasia for from this to discuss the different philosophical, moral and ethical visions that surround the theme and finally to present alternatives to the practice and discussions of some cases.

Method

This is an exploratory qualitative study that will seek to define, in a first moment, the concepts of euthanasia as well as its correlates (dysthanasia, orthothanasia and misthanasia) and from them to bring discussions about these themes, in the light of thinkers, modernists and postmodernists. Finally, it will search in the literature, emblematic cases of euthanasia for analysis.

Euthanasia: Bibliographic Review and Discussion

In 1988, the Journal of the American Medical Association (Jama) published an anonymous report that sparked the international debate on euthanasia [2]:

The call came in the middle of the night. [...] A nurse informed me that a patient was having difficulty getting rest, could I please see her. [...] As I trudged along, bumping sleepily against walls and corners and not believing I was up again, I tried to imagine what I might find at the end of my walk. Maybe an elderly woman with an anxiety reaction, or perhaps something particularly horrible. I grabbed the chart from the nurses' station on my way to the patient's room, and the nurse gave me some hurried details: a 20-year-old girl named Debbie was dying of ovarian cancer. She was having unrelenting vomiting apparently as the result of an alcohol drip administered for sedation. Hmmm, I thought. Very sad. As I approached the room, I could hear loud, labored breathing. I entered and saw an emaciated, dark-haired woman who appeared much older than 20. She was receiving nasal oxygen, had an IV, and was sitting in bed suffering from what was obviously severe air hunger. [...] A second woman, also dark-haired but of middle age, stood at her right, holding her hand. Both looked up as I entered. [...] She had not responded to chemotherapy and was being given supportive care only. It was a gallows scene, a cruel mockery of her youth and unfulfilled potential. Her only words to me were, "Let's get this over with". I retreated with my thoughts to the nurses' station. The patient was tired and needed rest. I could not give her health, but I could give her rest. I asked the nurse to draw 20 mg of morphine sulfate into a syringe. Enough, I thought, to give Debbie something that would let her rest and to say good-bye. Debbie looked at the syringe, then laid her head on the pillow with her eyes open, watching what was left of the world. I injected the morphine intravenously and watched to see if my calculations on its effects would be correct. Within seconds her breathing slowed to a normal rate, her eyes closed, and her features softened as she seemed restful at last. The older woman stroked the hair of the new-sleeping patient. I waited for the inevitable next effect of depressing the respiratory drive. With clocklike certainty, within four minutes, the breathing rate slowed even more, then became irregular, then ceased. The dark-haired woman stood erect and seemed relieved. It's over, Debbie.

Due to the argumentative subtleties inherent in the subject, it is necessary to discuss the definition of euthanasia, differentiating it from other practices that are sometimes confused, such as orthothanasia, dysthanasia and misthanasia [1].

Euthanasia and dysthanasia are medical procedures that concern the death of the human being and the most appropriate way of dealing with it. Euthanasia seeks to provide the suffering patient with a good, gentle and painless death, being an act of mercy, according to the etymology of the word ("Good Death"), giving priority to the quality of human life in its final phase - eliminating the suffering, while the dysthanasia seeks the prolongation of the quantity of human life, fighting death [3].

Voluntary euthanasia is practiced when the patient wishes to die, is informed about his clinical situation and is not depressed at the time of the decision, differing from the involuntary euthanasia that occurs when the patient does not wish to die or his will is unknown [1].

Euthanasia differs from social euthanasia, or misthanasia (miserable death) because it has no relation with the search for a good, smooth and painless death. The most common form of misthanasia in Latin America is the default of structural assistance, where the absence or precariousness of medical care services ensures that people with physical or mental disabilities or with diseases that could be treated die early, live in pain and suffering in principle avoidable. Another form of misthanasia is a medical error (malpractice) where patients suffer, for example, with delayed diagnoses or lack of the correct forms of analgesia. There is also negligent misthanasia, which occurs when there is omission of relief when the physician-patient relationship has already been established or the patient is abandoned [3].

These forms of misthanasia are based on the fragility of human nature - whether by negligence, imprudence or malpractice - and not by the deliberate intention of harming someone, unlike misthanasia by misconduct, as defined by Martin: "misthanasia for malpractice occurs when the physician and/or his/her associates, freely and on purpose, use medicine to violate the human rights of a person, for their own benefit or not, directly or indirectly damaging the patient to the point of underestimating their dignity and cause a painful and/or early death" [3].

An example of misthanasia for malpractice is the removal of a vital organ for transplantation before the person has died [3].

Orthothanasia (art of dying well) rejects all forms of misthanasia, without, however, falling into the trap of euthanasia or dysthanasia. Orthotanasia seeks to deal with the terminal patient, helping him to face his destiny with greater tranquility, maintaining a distinction between healing and caring, between maintaining life and allowing the person to die, when the time comes [3].

Death and immortality in the context of post-modernity

It is important to understand the difference in view of death and immortality between modernity and postmodernity in order to contextualize euthanasia.

In the tale El immortal, by Jorge Luis Borges, 1949, Joseph Catafilos of Smyrna, after a long road arrives at Cidade dos Immortals. There, in a leafy labyrinthine palace, he faces the completely senseless architecture of the place: dead-end corridors, unattainable windows, doors leading to empty cubicles, stairs that after a few turns in the majestic darkness of the dome led to nothingness. Nothing seemed to make sense there, things had no purpose. However, the forms resembled the memories of those found in the cities of mortals. This was probably a city built by immortals who had previously experienced the experience of mortality, needing to represent everything they had previously learned and now become useless. By this time the immortals had already abandoned the building and lay in shallow sand pits, dirty, naked, bearded. So, Joseph understood [4,5]:

There is nothing very remarkable about being immortal; with the exception of mankind, all creatures are immortal, for they know nothing of death. What is divine, terrible, and incomprehensible is to know oneself [...] Death (or reference to death) makes men precious and pathetic; their ghostliness is touching; any act they perform may be their last; there is no face that is not on the verge of blurring and fading away like the faces in a dream. Everything in the world of mortals has the value of the irrecoverable and contingent. Among the Immortals, on the other hand, every act (every thought) is the echo of others that preceded it in the past, with no visible beginning, and the faithful presage of others that will repeat it in the future, advertiginem. There is nothing that is not as though lost between indefatigable mirrors. Nothing can occur but once, nothing is preciously in peril of being lost. The elegiac, the somber, the ceremonial are not modes the Immortals hold in reverence.s

Everything in human life counts, therefore, humans are mortal and know this. This gives meaning to what they do, therefore, the knowledge of mortality also implies knowledge of the possibility of immortality, even spiritual. If death were ever defeated, there would be no more sense in laboriously joined together in order to make sense of their incredibly brief lives. The point crucial, as the Immortal El tale refers, is the dream of attaining immortality, not immortality itself [4].

The relentless reality of death makes immortality an attractive proposition. Realizing the dream of immortality takes a lot of effort. In history we find two principal strategies to this: one of collective immortality, where individual human beings are mortal, however, not the whole to which they belong (the State, the Church, the Party, the Cause), which will live far beyond any of the members; the other strategy is that of individual immortality, where all men individually must die, but some (the "important") can be preserved in the memory of their fellows, preserved by the perpetuity of memory for their individual achievements, which no one else has realized [4].

Unlike the first strategy, the second was inadequate to mass consumption, because it depended exactly on individuality. Some people were able to ascend to this individuality, for they stood out for the deeds that the multitude was unable to accomplish [4].

Postmodern society is marked by the discrediting of many of the ambitions of the modern era. Among such abandoned dreams is the prospect of suppressing the social inequalities generated, of guaranteeing to every individual a possibility of equal access to everything good and desirable that society has to offer [4].

According to Bauman (1997), throughout the modern period social exclusion was seen as a temporary phenomenon, where the unemployed were characterized as a "reserve army of labor". The old utopias of social equality of yesteryear are now replaced by postmodernist rationalism. The concept of "structural unemployment" is emerging. These people, not being required as producers and also useless as consumers, can be easily dismissed by economic logic [4].

There is a link between the economic devaluation of these human beings and the cultural tendency that is increasingly emphasized in refusing the will to live the right to live for those who are too weak or insignificant to demand and secure this right. In order to try to alleviate the contradictions between professed values and practical behavior, we choose culturally acceptable justifications, such as the euthanasia of old people because of the right to choose death, to a kind of life that society has refused to give meaning to [4].

According to Bauman (1997), the right of to live forever in memory, passes, step by step, with the evolution of medical resources, to be replaced by the biological perpetuation of the being, through a drastic inversion of the modern strategy of collective survival by an individualizing biological immortality - the conservation of the "most deserving". Banalize death so that the multitude do not aim for what you are unlikely to achieve: biological eternal life (when and if it is possible), reserving only the lives "eligible as deserving" [4].

Eutanasia: Philosophical, moral and ethical foundation

The moment of dying must be a natural right of the patient who must be respected in the name of maintaining his dignity. Because of this, the practice of euthanasia is guided at its core by solidarity with suffering and respect for the individual will. This rationale meets two principles discussed in bioethics: the principle of autonomy and the principle of dignity.

Autonomy means a person's self-determination to make decisions that affect their life, their health, their physical-psychological integrity, their social relationships. It refers to a human being's ability to decide what is "good" or what is his or her "well-being" [3].

Therefore, the autonomous person is one who has freedom of thought, is free of internal or external constraints to choose among the alternatives presented to him.

In addition to the freedom of choice, the autonomous act also presupposes freedom of action, it requires the person to be able to act according to the choices made and the decisions made. Therefore, when there is no freedom of thought or options, when there is only one alternative of choice, or when there is no freedom to act according to the desired alternative or option, the action undertaken cannot be considered autonomous [3].

In this case we can say that the autonomy of the individual, who wants to carry out euthanasia and does not achieve it by being stopped by the state, is not respected by depriving one of the basic principles that govern ethics [6].

Also, the right to euthanasia is based on the principle of dignity. Respect for the autonomy of the person is combined with the principle of the dignity of human nature, accepting that the human being is an end in itself, not only a means of satisfying the interests of third parties, commercial, industrial, or the professionals themselves and health services. Respecting the autonomous person presupposes the acceptance of ethical-social pluralism, characteristic of our time [3].

The principle of autonomy is still understood according to Kant as "the ground of the dignity of the human and of every rational nature" [7].

To deny euthanasia is to extract from the individual his dignity. If dignity is founded on its autonomy, denying the right to freedom of choice and action goes contrary to the principle of human dignity.

It can also be sustained by euthanasia, for other reasons, in Nietzsche [8]:

Morality for physicians: The sick man is a parasite of society. In a certain state it is indecent to live longer. To go on vegetating in cowardly dependence on physicians and machinations, after the meaning of life, the right to life, has been lost, that ought to prompt a profound contempt in society [...]. To die proudly when it is no longer possible to live proudly. Death freely chosen, death at the right time [...].

For him, in a more drastic view, the state of complete medical dependency not only leads to loss of the meaning of life, but loss of the right to life, and euthanasia is a form of liberation from this condition of misery.

Despite undeniable points of support for euthanasia, certain issues cannot be neglected. Much of the objection to this theme lies also in the protection of human dignity. Through euthanasia the pain is eliminated by eliminating its carrier.

The Sacred Congregation for the Doctrine of the Faith defines euthanasia as an act or omission which, by its nature or in its intentions, causes death and the end of all pain [3].

In this way we can see that there are two elements in the practice of euthanasia: the elimination of pain and elimination of the pain bearer. Euthanasia is condemned, not for the relief of pain, but for the direct and purposeful death of the patient [3].

As Martin puts it, "good intentions do not necessarily lead to good results". When through a doctor, one deliberately takes away a patient's life, not only his ability to feel carried, but any existential possibility [3].

Euthanasia can also be seen as naturally contradictory, as Kant puts it [7]:

One person, through a series of evils that have accumulated to the point of hopelessness, feels weary of life but is still so far in possession of his reason that he can ask himself whether it might be contrary to the duty to himself to take his own life. Now he tries out whether the maxim of his action could become a universal law of nature. But his maxim is: 'From self-love, I make it my principle to shorten my life when by longer term it threatens more ill than it promises agreeableness'. The question is whether this principle of self-love could become a universal law of nature. But then one soon sees that a nature whose law it was to destroy life through the same feeling whose vocation it is to impel the furtherance of life would contradict itself, and thus could not subsist as nature; hence that maxim could not possibly obtain as a universal law of nature, and consequently it entirely contradicts the supreme principle of all duty.

In addition to moral theology, the Western legal tradition and the tradition of medical ethics are also contrary to euthanasia, as we will see later.

Orthotanasia: An alternative?

Thinking about health only as the absence of disease, it is quite understandable that a chronic patient, however, still lucid, in suffering, but without eminent risk to life, asks for euthanasia. However, understanding that health also encompasses states of physical, mental, social and spiritual well-being, opens up some possibilities for these chronic patients. Creating hygienic conditions, giving comfort in clean rooms with cheerful colors and pleasant temperature the quality of life of these patients improves significantly [3].

The promotion of mental well-being, leading to a return to self-esteem, is extremely important so that, along with the patient, alternatives are found regarding the abbreviation of life. The resumption of social life as well as the concern for spiritual well-being are decisive factors in the overall promotion of their health [3].

For Martin, euthanasia in situations where life is not directly threatened is inappropriate from an ethical point of view, being essential not the investment in death but in the rescue to life [3].

A similar situation can be adopted in cases of terminal patients, where comfort and analgesia should be sought, without forgetting the emotional, social and spiritual mental well-being, allowing the person to be able to wait for his death [3].

Euthanasia: A discussion of cases

Another important discussion that we can address at this point is in extreme cases where even in a society where euthanasia is not accepted as intrinsic to human right - the right to die as the natural right of every man - there are cases that require further reflection on the topic.

As extreme cases, we want to refer to cases in which, even in a general context in which euthanasia is not accepted, the opposite principle could be softened allowing its realization.

We can talk about several cases in which euthanasia could be allowed. Let us, however, stick to emblematic cases in which many others could be analogous to these.

The first case we want to discuss is Diane Pretty. Diane was a Briton who suffered from a motor neuron disease, which had no cure. This disease caused slow degeneration of his body causing intense pain until his death. The British court in October 2001 refused Pretty's request for euthanasia [9].

Similar to this, another case that also catches our attention is Vincent Humbert. Humbert was a French fireman who at age 22 had a serious auto accident. After returning from the coma, it was found that he had been quadriplegic as well as blind and mute. The only movement he still had was that of the right thumb, a movement that allowed him, after a while, to learn to communicate. From the moment Humbert was able to communicate, he asked for the right to die, however, she was denied [10].

In that case, Humbert's mother ended three years later - at the request of her own son - by injecting a dose of barbiturate and causing her death [10].

Vincent Humbert wrote before that, a book entitled Je vous demande le droit de mourir (I ask you for the right to die, our translation). In this book, Humbert argues about his decision to end his life as a way to finally end his suffering. The release of the book must coincide with the occasion of his death, previously combined with his mother, Marie Humbert. The date established by the boy also marked the third year of his accident, which occurred on September 24, 2000 [10].

And the third case we would like to mention is that of the Spanish sailor and poet Ramon Sampedro. Its history turned into a film titled Mar Adentro, winner of the Oscar in 2005. Sampedro to the 25 years, became quadriplegic after a tragic dive in the sea of the coast of Galicia [11].

After this, Sampedro tried to obtain in justice the right to euthanasia, but had its request denied by the Spanish justice. In 1998, 29 years after the accident, he performed euthanasia even without the authorization of justice with the help of his friend, Ramona Maneiro. A very striking fact in this case is the argument expressed by Sampedro in his request to the judges in 1996: that "to live is a right, not an obligation" [11].

After reading these cases, the question remains whether people have the right to decide on their own life continuity.

Extremely sick patients, such as Diane Pretty, end up not benefiting from treatments that only support the patient's life [9]. It can often lead to a painful and time-consuming process until its inexorable death [10].

Now if a conscious individual, suffering from incurable disease or condition and causing severe suffering to him, wishes to have a quick and painless death as an end, it would be counter-productive to think that his life, as well as that of any person, should be guided by decisions of third parties. Therefore, the facts listed here make us think that euthanasia, in these cases, is perhaps a viable form of continuity to human treatment and maintenance of its dignity.

Conclusion

Throughout the reading we perceive the dichotomy between the visions favorable and contrary to euthanasia. This discussion is constrained by modern moral, ethical, philosophical, and legal values that conflict with postmodern utilitarianism.

Euthanasia within a concept of modernity cannot be contemplated since the dominant values of Christian morality are enforced by being incompatible with such practice. This morality is now absorbed by the standards of conduct accepted by most health professionals.

Diverging from this view, the postmodernist current of euthanasia can be contemplated, for death and immortality are treated as a factor of individualization.

We declare that all authors had equal participation in the execution of the present work. There were no sources of funding and the authors declare no conflict of interest in the production of this study.

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