Life, death and the right to choose

We Europeans usually value one of the qualities our continent has produced is civilisation in its present and almost universal form. The exceptions are few and very far from this continent, yet for all of the ‘primitiveness’ of the way some of them live, there are traits here in modern Europe that carry vestiges of their view of the world.

Recent very good examples of this are referendums in Ireland and Portugal that are in principle about life and death. They raise the questions when does life begins and end under particular conditions which in both cases actually deny one of the most fundamental democratic principles, choice. Specifically, both asked when life begins and ends legitimately and how choices can be made in order to choose for an unborn, thus as yet intellectually undeveloped, human being and at the other end of life is asking whether an individual can choose to die, or in extremis because all decision making competence and independent survival are gone, to decide for them.

Dogma, contradictions and hypocrisy

One aspect of this is that it comes at a time of contradictory political turmoil. Religion has a foot in the door via political forces, which in an increasingly secular Europe seems to carry the bad smell of hypocrisy used as a useful tool by populists who inevitably deny religion is behind anything they say.

However, the symptoms of this malaise are apparent when particular sound bites across our continent are collated into common grounds the new right moral order uses. The one that provides the most telling evidence of the connection is that where any degree of Islamophobia exists the use of such expressions as ‘Christian Europe’, ‘Christian society’ and other variants are used by leaders, amongst who we also hear or see statements about their beliefs, church attendance and how they are doing what they do for their nation as a Christian, including being guided by God. Those people are likely to be at the forefront of any popular actions regarding the life and death issue that I shall come to very soon. It is also notable that among those people there are those who encourage their electorates to remember that there are possibilities such as the reintroduction of capital punishment of those who transgress all societal standards through acts of terrorism, occasionally allowing the word Muslin to slip in before terrorism. Some of those people throw in other crimes for good measure. Murder, rape and at the extreme edge homosexuality, perhaps even forms of sexuality they consider ‘unchristian’, as yet unsaid but near enough touched on. In England and Wales there are even strong lobbies for the reintroduction of fox hunting and badger culls are being demanded, yet the religious dogma many of them subscribe to does not actually specify species with the doctrinal meme, ‘Thou shalt not kill’. The same people are as likely to be those who will rally against halal and kosher ritual slaughtering of animals to eat, despite their blood sports having no value other than arbitrary killing for their amusement.  So, there we have people who wish to control life and death on moral grounds who be the very people who lead campaigns against the right to choose at either end.

The referendums

On 25 May 66.4% of the 64.1% turnout of Irish voters approved legalisation of abortion in the Republic. Arguably that represent only 43% of all voters, but as ever the just over one third of the electorate who did not vote tend to show indifference to the question, thus allowing any analysis to state that a real terms majority is in favour. Four days later, 29 May, the Portuguese 230-seat parliament voted on euthanasia. The bill received 110 votes in favour and 115 votes against, with four abstentions, a relatively narrow majority against legalisation. That was naturally not a popular vote, a referendum offered to the entire electorate; however Portugal is still a very strongly Roman Catholic nation where it may well have shown an even larger majority against.

Crowds celebrate the result of the 2018 referendum on abortion in IrelandBoth of these votes, despite the different forms they took, illustrate how diverse Europe still is and is likely to remain for many years. To accentuate, if not simply worryingly illustrate, another part of the spectrum, the knock on of the Irish referendum has been to show us that the UK is actually a divided, unequal society.

Northern Ireland has never adopted the 1967 Abortion Act although it is a UK law. It has remained criminalised with very few exceptions. Recent public opinion has shown that a majority of the public would be in favour. Controversies about use of ‘morning after pills’ and the many revelations about women travelling to mainland UK are not taken into account by the majority governing party, albeit it at present and for around a year and a half they have not governed. Thus somewhere between the devil and the deep blue sea there is pressure for the Stormont government to act or else Westminster could vote on enactment of the Act. Given that Stormont is suspended, that means that Westminster holds the balance, but the majority DUP and PM Theresa May are holding out against any change. Campaigning in the communities and by parliamentarians of all parties could change the balance, thus the will of the DUP entirely undermined leading to the collapse of the UK government. Thus, when we look at the influence of these matters of life and death through every perspective what we find is that ultimately moral positions still have the potential to hold governments in thrall.

Choice or no choice, is euthanasia right or wrong?

Euthanasia is still the more emotive for rather difficult and often archaic moral reasons. In some respects it is still the mistaken bedfellow of suicide. The reason here is that what is probably most common is that because euthanasia in itself is of two kinds, active and passive, whereby the former is more commonly known, but the latter often treated as a form of suicide by those who base their view on religious and moral codes in which it is believed lives are only taken by those who are supreme, above humanity. Again there is a sad irony in there in that there is no real debate about wars and warlike conflicts with pacifists often ridiculed, dismissed or even demonised for a considerable number of reasons that usually defy the morality their accusers purport to uphold. Active euthanasia for such people is simply institutionalised murder. However, when one looks at groups, for instance evangelical protestants, who strongly oppose euthanasia is defying the will of their god, they will also as often as not advocate or support capital punishment using the biblical ‘eye for an eye, tooth for a tooth’ idiom as their reasoning.  Looking at the phenomenology of helping people die, in the simplest terms, the difference between the two forms of euthanasia is also seen as the difference between ‘letting die’ and ‘killing’. A very few countries such as Belgium, Netherlands, Colombia and Japan allow both forms of euthanasia, whereas Germany, Canada, India and South Africa allow only passive euthanasia. At the same time a distinction must be made between the two forms of euthanasia that are different to ‘assisted suicide’ and ‘assisted dying’. Assisted suicide is voluntarily helping someone commit suicide, whereas assisted dying is the term used mostly in the USA and UK and that generally refers to helping terminally ill patients commit suicide, often by providing the means and then ‘not watching’ when it happens.

Portugal has probably made the basic mistake of leaving a large margin of uncertainty because it was a very narrowly defined question, placed in the hands of parliamentarians rather than the electorate. Whilst that is a normal function of representative democracy it may in this case have done more to generate a margin that may narrow at any time but is not necessarily representative of public opinion. In that respect a referendum is probably far more likely to provide any kind of public view that supports a continued ban or legitimating it.

It can work when people are informed and able to choose

There has to be good reason such as in the Netherlands where a patient’s suffering must be intolerable and with no prospect of improvement or recovery. That need not be related to a terminal illness and is not limited to physical affliction such as pain, but may include, for example, the perspective of loss of dignity or increasing personal deterioration such as the fear of suffocation or drowning in one’s own vomit or blood. Belgium’s law is similar by stipulating that a patient’s suffering is constant and unbearable, but resulting from a serious and incurable disorder. There is no actual legal or medical requirement that a person is diagnosed as having a terminal illness, although additional checks can be demanded if the patient is evidently not terminally ill. In both countries a second doctor must see, but not necessarily physically examine, the patient to confirm their request is valid and suffering intolerable for which a number of doctors have been trained for those consultations. There are also age lines in both countries. In the Netherlands, a patient between ages 16 and 18 who is considered competent and well informed enough to decide may request euthanasia or assisted suicide. Parents or carers do not have a veto, but must be consulted. Under exceptional circumstances, competent patients aged between 12 and 16 may also qualify, but then only if their parents or carers consent. In Belgium, a patient under age of 18 may request euthanasia with parental consent. Reasonably thorough examination of the child’s competence is required, allowing for the difficulties extreme suffering may cause, however suffering based on a psychological condition is excluded.

Medical practitioners who are competent at administering or overseeing people dying of choice have been surveyed on decisions they have made at the end of their patients’ lives. The surveys have been carried out in a range of countries where euthanasia or assisted suicide are legally recognised, and those where they are not using an anonymous survey designed by Dutch researchers who have probably the longest and greatest practical experience.

How many people really do choose to be helped to die?

The most recent survey in the UK was back in 2007-08 when a 0.21% of all deaths rate of euthanasia was reported. A similar rate was reported in France in 2009 although euthanasia remains illegal. There is no legislation pending to legitimise it in either country. Belgian research found the rate prior to legalisation was unclear, with separate surveys reporting rates of 0.3% of all deaths in the region (in 2001-02) and 1.1% (in 1998). That rate has risen gradually since legalisation in 2002 to 4.6% of all deaths in the most recent survey during 2013. In fact, very low rates of assisted suicide are also reported in countries that either permit or prohibit it. None of the countries where those methods are used require judicial consent with the exception of that being proposed in the ‘Assisted Dying Bill’ that has a yet to go through parliament in the UK.

Where there is a legal intervention is after decease, when in the case of the Netherlands the doctor must report the case to the coroner, who in turn passes it to a regional committee. Should that committee find a doctor did not follow legal requirements, it is referred on to the prosecution service and to the medical regulatory body. Prosecutions would only follow in the case of obvious malpractice. In Belgium, the process is similar but with a single committee. Looking at the Portuguese decision in retrospect, it would appear that many of the above components of the full picture were left out in favour of using the questionable moral argument that does not resolve suffering. Yet it is a mixed morality. Ireland and Portugal are ostensibly still among the most catholic of European countries where the influence of Rome may have declined considerably in more secular urban areas but still holds the reins in many parts of rural areas. Portugal has legal abortion, as Ireland will soon, but the relief of suffering is not allowed. If one accepts that an unborn child is alive but has no choice and that a person who is still in control of their mind who is suffering intolerably and unnecessarily is not allowed to go with help of one kind or another, but who can in most countries take their own life without medical collusion, then the intellectual equation is illogical. Those with choice cannot, those without choice can be.

Finally, a close up look at Europe

If Europe is ever to grow closer together, many more values must be closely examined in order to find ways to share them. The table below shows the situation in the present 28 members of the EU, with the four EFTA states, four applicant states for EU membership and principalities either individually, Andorra and Monaco, or the Holy See and San Marino where most medical provision is in Italy within the boundaries of which both exist. The greatest anomaly within all of the nations included in the UK is where Northern Ireland has never adopted the Abortion Act.

By a large majority abortion is legal; by a small minority assisted suicide and euthanasia are both possible. In only Cyprus is suicide still illegal. The moral borderline between killing oneself and being helped to die in mainly comfortable and properly supervised conditions is a wide open gap that needs to be filled before Europe is able to share a mature attitude to life and death. From that point of view, I personally begin to understand why so very little media attention was paid to the Portuguese parliamentary decision whilst a vast feast was made of what happened in Ireland just days earlier.  It is a taboo best left unmentioned.  There is also a language that media probably wishes to avoid because of the amount of explanation required to elucidate ‘euthanasia’, ‘assisted suicide’ and ‘assisted dying’ or ‘turning off life support’ (which is actually euthanasia expressed euphemistically) for their readers. Yet what they are doing is contributing to a very necessary debate that has almost certainly been avoided for far too long. For Europe to grow together life and death are two unavoidable realities, therefore we should open a discourse that takes into account the reality that where we have countries that do not allow either or both assisted dying and abortion that where we have open borders those who choose can cross them to go wherever necessary. The resolution to that is to take into account all of the doctrinal and moral denominators with the pragmatic and secular, give all people choice without prohibition so that those who make choices either way are free to do so rather than have those choices made for them by politicians or clerics.