Film reopens euthanasia debate in Spain

It is a good new that Alejandro Amenábar's Spanish film "Mar adentro"
(The Sea Inside) is creating a debate about euthanasia.[1] In fact, the
problem of euthanasia has a long history of philosophical discussion. On
the whole, ancient Greek thinkers seem to have favoured euthanasia, even
though they opposed suicide. An exception is Hippocrates who in his oath
states that "I will not prescribe a deadly drug to please someone, nor
give advice that may cause his death." The entire oath places emphasis on
the value of preserving life and in putting the good of patients above the
private interests of physicians. These two aspects of the oath make it an
important creed for many heath care workers today. In medieval times,
Christian, Jewish, and Muslim philosophers opposed active euthanasia,
although the Christian Church has tolerated passive euthanasia.

During the Renaissance, Thomas More defended euthanasia in his book
Utopia. More supports that when there is an incurable illness, the patient
has the option to die, either through starvation or opium. In New
Atlantis, Francis Bacon writes that physicians are “not only to restore
the health, but to mitigate pain and dolours; and not only when such
mitigation may conduce to recovery, but when it may serve to make a fair
and easy passage.” But it has only been in the last hundred years that
there have been concerted efforts to make legal provision for voluntary
euthanasia.

The atrocities perpetrated by the Nazi regime included the so called
“euthanasia programme” which allowed the systematic mass murder. Since
then the word euthanasia is associated with negative feelings. During the
past decade, the debate about legalising euthanasia has grown in many
countries. In the nineteen seventies and eighties a series of court cases
in The Netherlands culminated in agreement being reached between the legal
and medical authorities to ensure that no physician would be prosecuted
for assisting a patient to die as long as certain guidelines were strictly
adhered to.[2, 3] In 2001, The Netherlands has become the first country in
the world to legalise euthanasia. The definition under Dutch law is
narrower - it means the termination of life by a doctor at the express and
voluntary wish of a patient. It is not a condition that the patient is
terminally ill or that the suffering is physical.

In 1997 the Swiss federal government commissioned a working group to
examine the issue of euthanasia, which concluded that euthanasia remain
illegal; however, most of the members suggested decriminalising cases in
which a judge was satisfied that euthanasia followed the insistent request
of a competent, incurable, and terminally ill patient in intractable
suffering. Rather than authorizing physicians to commit euthanasia, Swiss
law instead permits private suicide facilitation and physicians are
allowed to prescribe or supply a drug in lethal dose. The regulations are
the most open, in that the law requires neither a medical second opinion
nor the existence of a terminal illness as prerequisite to assistance in
dying.[4, 5]

In September 2002 the Belgiam Parliament legalised euthanasia after
an extensive discussion. The Belgiam euthanasia law is more far-reaching
than its Dutch counterpart.[6] It establishes different procedures for
terminally-ill patients and patients with incurable illnesses who still
have many years to live. Other European countries do not allow euthanasia
even if a patient wants to die, althogh medical end-of-life decisions can
take place.[7, 8]

The euthanasia controversy is part of a larger issue concerning the
right to die. The conventional doctrine sustains that passive euthanasia
is morally permissible in certain situations, but active euthanasia is
never morally permissible. However, in 1975 Rachels [9] broke ground by
arguing that in those situations in which passive euthanasia is
permissible, there can be no morally sound reason for prohibiting active
euthanasia. The ethical issue of euthanasia, or mercy killing, concerns
whether it is morally permissible for a third party to end the life of a
terminally ill patient who is in intense suffering. Euthanasia itself is
also far more than a simple moral “yes” or “no”, “active” and “passive”
euthanasia, or between mercy killing and deliberately letting someone die.
It is controversial because it brings into focus and conflict some very
powerful and competing values.[7, 10-14] Certainly one of society's
traditional attitudes, expressed morally, legally, philosophically, and
religiously is that human life merits special protection. The controversy
is between protection of human life and the right to decisional autonomy,
and as well raises the question of the extent to which the criminal law
should be used to enforce particular moral positions.

Amenabar’s "Mar adentro" portraits the patient who needs the help of
someone to cause his own death. The help to suicide is punished by the
Spanish Penal Code (article 143). The Law 41/2002 regulates the Patient
and Consumer Health Rights although euthanasia is not included. However,
the 1997 Oviedo Convention for the Protection of Human Rights and Dignity
of the Human Being with regard to the Application of Biology and Medicine
[15] is fully legal in Spain since 1 January 2000 and recognizes the right
to take a decision about his/her life under special conditions.
Furthermore, although the National Government disregards any legal change
in the near future, regional Authorities have been giving some
recommendations about medical treatments decisions at the end of life.[16]
However, the different regional laws may create discrimination by the site
of residence. Therefore, there is a need for a National general frame. So
far the discussion has been based on perspectives of medical
professionals, academics, and lawyers. Now it is time for consumer
opinions and patients' subjective experiences about this complex issue.

References

1. Casino G. Film reopens euthanasia debate in Spain.
http://bmj.bmjjournals.com/cgi/content/full/329/7470/864-a?etoc (accessed
9 October 2004)

2. Kater L. The Dutch model for legalizing end-of-life decisions.
Med Law 2003;22:543-550.

3. The new euthanasia law: Termination of Life on Request and
Assisted Suicide (Review Procedures) Act
http://www.nvve.nl/english/info/euthlawenglish.doc (accessed 9 October
2004)

4. Bosshard G, Fischer S, Bar W. Open regulation and practice in
assisted dying. Swiss Med Wkly 2002;132:527-534.

5. Une réglementation explicite de l'euthanasie passive et de
l'euthanasie active indirecte est envisagée.
http://www.ofj.admin.ch/themen/stgb-sterbehilfe/b2-com-f.htm (accessed 9
October 2004)

6. Deliens L, Bernheim JL, van der Wal G. A comparative study of the
euthanasia laws of Belgium and the Netherlands. Rev Med Liege 2003;58:485-
492.

7. van der Heide A, Deliens L, Faisst K et al., End-of-life decision
-making in six European countries: descriptive study. Lancet 2003;362:345-
350.

8. El Comité de Médicos de la UE acepta la renuncia de pacientes a
recibir tratamiento, pero descarta la eutanasia activa.
http://www.diariomedico.com/edicion/noticia/0,2458,535495,00.html
(accessed 9 October 2004)

9. Rachels J. Active and passive euthanasia. N Engl J Med 1975;
292:78-80.

10. Elliott C. Philosopher assisted suicide and eutanasia. BMJ
1996;313:1088-1089.

11. Somerville MA. "Death talk": debating euthanasia and physician-
assisted suicide in Australia. MJA 2003; 178: 171-174.

12. Hunt RW. "Death talk": debating euthanasia and physician-
assisted suicide in Australia. MJA 2003; 179: 57-60.

13. Swarte NB, van der Lee ML, van der Bom JG, van den Bout J,
Heintz APM. Effects of euthanasia on the bereaved family and friends: a
cross sectional study. BMJ 2003;327:189.

14. Mak YYW, Elwyn G, Finlay IG. Patients' voices are needed in
debates on euthanasia. BMJ 2003; 327: 213-215.

15. Convention for the protection of human rights and dignity of the
human being with regard to application of biology and medicine. Oviedo 4
April 1997. http://www.concourt.am/hr/rus/europe/164e.htm (accessed 9
October 2004)

16. Situación del Testamento Vital en España.
http://www.eutanasia.ws/dmdEspana.html (accessed 9 October 2004)

Competing interests:
None declared