I would like to establish in a few words a distinction that is both common and problematic with respect to the terms of treatment or non-treatment to accelerate the process of death. They seem to be two different things although in reality they form the head and tail of the same coin. In the Western culture, the principles of autonomy and election bring implicitly the right of the citizens to accept or reject medical treatment. Nevertheless, these principles also imply that the person has the right to choose ending his own life by euthanasia. Well, we have what is known as passive euthanasia and active euthanasia. This distinction, which must be made, presents some doubts, ambiguities, etc. Here we must attack or face things that allow to differentiate distinct degrees of reaching a common objective, which is death. Well, when for example we allow death to arrive directly, using a lethal injection for example, or indirectly, related with termination of the treatment.

This difference leads to important discussions of a legal, moral and ethical type, although for example in these situations where passive death, that is let somebody die, is very well established and very accepted by public opinion, a distinction must be established between allowed natural death and death, pardon, termination of life by termination of assistance. That is, one must look for what is extraordinary and what is ordinary. There are specific differences between not treating and letting die and treat to die. There is a differentiation between cause and effect and it has to be regulated. The argument, for example that the act which produces a similar result when it is done with the intention of arriving at the death of a patient in an illicit manner, is murder and therefore the law regulates it with the law and nevertheless, for example the cutting down of life, for example people who have assisted respiration or are maintained alive artificially, when they are disconnected the result is the same it leads to the accelerated death of the patient and nevertheless the legal or ethical treatment is completely different. Therefore, this must be regulated, one thing is, for example, in the field of medical prescription, there is a clear difference between prescribing a lethal drug, it is perceived in a different form by justice as by society than administering a drug which can be lethal. Therefore the treatments are different and the perceptions of these concepts are distinct. And I believe that one has to know whether a person who chooses not to be treated and awaits the development of natural effects until dying commits suicide or not. For example, when in sedated state because of terminal illness, the nourishment aspects of the patient are not covered, that is nutrition is denied to the patient, it is also an act that could be considered "borderline" with these ethical aspects that regulate the acceleration of death. Therefore, we have to look for an identical objective at the moment of defining the legal and medical aspects, as much with euthanasia as with artificial reproduction; both need to be oriented towards the same objective and apart from that conceptual differentiation try to define the legal, ethical and constitutional framework of people.

If a doctor, because of his Hippocratic oath has to cure the patient, why is he not obliged to apply this Hippocratic oath when a patient refuses to be treated, not to improve, but to make him suffer less in his terminal estate? I think that all these things that appear very separated, are very inter-related. All this culture has to be changed, because when doctors have the idea that not applying a therapeutic treatment because the patient is rejecting this assistance is not euthanasia, don’t they understand this as a passive euthanasia or however they want to call it? Therefore a pragmatic compromise must be sought which combines all these until now conflictive arguments which are on the table. We are at this moment in a society which, on one side, is arriving to the extreme of the sacrosanct veneration of the principle of human life, that is, that life is an inalienable right. And on the other side, we are discussing things like passive euthanasia, abortion, etc. I believe that this has to be regulated in a clear way.

Until now we have found norms and laws which, on the basis of one current or another, establish which is licit and illicit in the case of suicide, passive euthanasia, pain handling, etc, on the theme of passive euthanasia and assisted suicide, to call it thus, that are based on treatments to relieve pain, pain handling and other systems of support. Another scepticism which is known is perhaps the wilfulness to which is left the theme of assisted suicide in the demands for termination of life in a rapid manner. Many patients ask for their lives to be ended, that they be given a treatment that permits an immediate success. There is as we might say a certain ambiguity with respect to the attitudes of the people involved because, for example, there are people, doctors especially, who say that it is illegitimate to proceed to this type of actuation, in spite of the fact that the patient in his individual and autonomous right can require it, because they say that the patient, by reason of his illness, in a terminal condition can be suffering mental confusion, deterioration of his consciousness, etc. At this moment, much of the existing legislation in some countries with respect to assisted suicide, the non-treatment of patients under express request, etc. is based on confused arguments. This is being done above all in developed countries, more occupied with problems which relate health with the perspective of cost-benefit, etc. But therefore, what happens with the other collectives which remain outside this field of action of supply and demand, of the market to call it that, the lonely, the poor, and others?

In order to avoid all this, one must work from two precepts of the medical condition in relation to assisted death, in such a way that starting from the proper Hippocratic oath, from the basic precepts by which the doctor has to rule himself in his profession, we can perhaps open the way to the globalisation of this concept of assisted death, artificial termination, etc. With respect to the religious communities, of all kinds, which register the sacrosanct condition of life as something apart from the human and more in the hands of the supreme being, they also have a type of vacuum with respect to ethics and codes that should be applied in their respective communities or societies in which this act, which little by little is a social act, a demand, although perhaps in isolated cases, etc.

One must look at the subject from the community perspective, and here the intervention of the State with respect to the free option of individuals which compose this State is important at the hour of protecting all those aspects which are relevant. Those who support and those who reject assisted death have some points in common, and it could be, for example, that they agree that the life of the person has to have guarantees of some minimum of comfort, of quality which permit his subsistence, his continuity until death, the final process, that is the exitus, appears in a natural form. The palliatives, the means that really improve the quality of life are as much a right as an obligation. And I believe that is the line by which one has to begin to work, trying to seek solutions within this initial agreement between both confronted parties. It would avoid in the first place in societies the subject of absolute prohibition without taking into account other types of considerations and would permit the flexibilisation of medical practice, combining it with individual and constitutional rights of individuals. It also has to be said that it is the inalienable right of all persons, of all individuals, to have an absolute control of the moment that they are going to die, and that is what has to be regulated immediately with assisted death.

GIJÓN (Spain), Scientific Committee Meetings on 27th and 28th November 1998