doi: 10.56294/shp202355

REVIEW

Autonomy and the End of Life: Reflections from Medicine and the Law

Autonomía y Final de la Vida: Reflexiones desde la Medicina y la Ley

Ana Margarita Graz¹ *, Daniel Coso¹ *

¹Universidad Abierta Interamericana, Facultad de Medicina y Ciencias de la Salud, Carrera de Medicina. Buenos Aires. Argentina.

Cite as: Graz AM, Coso D. Autonomy and the End of Life: Reflections from Medicine and the Law. South Health and Policy. 2023; 2:55. https://10.56294/shp202355

Submitted: 18-08-2022            Revised: 10-01-2023            Accepted: 10-05-2023             Published: 11-05-2023

Editor: Dr. Telmo Raúl Aveiro-Róbalo

Corresponding author: Ana Margarita Graz *

ABSTRACT

End-of-life decisions (EOLD) represented a complex challenge in the medical, ethical, legal and cultural spheres in Argentina. Despite their frequency in clinical practice, these issues were not addressed in sufficient depth in medical training or in the local scientific literature. From an anthropological point of view, it was observed that Western culture reduced death to a biological fact, in contrast to other cultures that conceived of it as a transition or transformation. Euthanasia, understood as an action or omission to hasten death and avoid suffering, generated a wide-ranging ethical and philosophical debate. Although Thomas More introduced it from a humanist perspective, the term was distorted by the Nazi regime, being used to justify extermination. This provoked strong social and religious resistance, which persisted over time. In Argentina, Law 26.742 allowed patients to refuse disproportionate treatments and to establish advance directives, without authorising active euthanasia. Recent studies and surveys revealed a social shift towards a more secular and autonomous view of the human being, with growing support for the right to decide on the end of life. However, the legal framework has not yet addressed this demand. In view of this, the need for medical education that integrates the bioethical approach, for interdisciplinary work in care and for a legislative debate in line with social changes, in order to guarantee a dignified, autonomous and respectful death, was highlighted.

Keywords: Euthanasia; Dignified Death; Personal Autonomy; Law 26.742; Health Professionals.

RESUMEN

Las decisiones al final de la vida (DFV) representaron un desafío complejo en el ámbito médico, ético, legal y cultural en Argentina. A pesar de su frecuencia en la práctica clínica, estas temáticas no fueron abordadas con suficiente profundidad en la formación médica ni en la literatura científica local. Desde una mirada antropológica, se observó que la cultura occidental redujo la muerte a un hecho biológico, en contraste con otras culturas que la concibieron como tránsito o transformación. La eutanasia, entendida como acción u omisión para acelerar la muerte y evitar sufrimientos, generó un amplio debate ético y filosófico. Aunque Tomás Moro la introdujo desde una visión humanista, el término fue distorsionado por el régimen nazi, utilizándose como justificación de exterminios. Esto provocó fuertes resistencias sociales y religiosas, que persistieron en el tiempo. En Argentina, la Ley 26.742 permitió a los pacientes rechazar tratamientos desproporcionados y establecer directivas anticipadas, sin autorizar la eutanasia activa. Estudios y encuestas recientes revelaron un cambio social hacia una visión más secular y autónoma del ser humano, con creciente apoyo al derecho a decidir sobre el final de la vida. Sin embargo, el marco legal aún no contempló esa demanda. Frente a ello, se destacó la necesidad de una educación médica que integre el enfoque bioético, del trabajo interdisciplinario en la atención y de un debate legislativo acorde a los cambios sociales, para garantizar un morir digno, autónomo y respetuoso.

Palabras clave: Eutanasia; Muerte Digna; Autonomía de la Persona; Ley 26.742; Profesionales de la Salud.

INTRODUCTION

Decisions concerning the end of life (EDL) are frequently made in our environment. Paradoxically, the subject of death and its circumstances is not addressed in undergraduate and postgraduate medical training in Argentine universities. Likewise, it is a subject that is largely overlooked in the general medical literature of our country, although not in anthropological and philosophical literature.^(1,2,3) The idea of death is part of a broad and heterogeneous set of social ideas and thoughts that are part of a people’s culture. Anthropologically, almost all human cultures have shown concern, anguish, or fear in the face of death, as well as a sense of annihilation or salvation. For other cultures, death is a process and a transition to another form of existence. In our Western culture, with its biological and physical-mechanical model, the idea of death is one of the poorest from an anthropological point of view.⁽⁴⁾ To address the ethical problems of dying and its conflicts, it is necessary to establish the most important values to consider in this situation: the value of human life, its autonomy, and the value of dying with dignity. When the sick person is not faced with this conflictive situation, no reasonable ethic finds it challenging to maintain and defend the value of human life. However, whenever a problematic situation arises, conflict of values helps to methodologically analyze these situations close to death, whether due to old age or illness. The expression “dying with dignity” or “orthothanasia” does not in itself constitute a legal right but rather an ethical expression that does not refer directly to dying but to the manner of dying. The term “euthanasia” derives from two Greek words, “eu” and “thanatos.” This word was artificially created, as it did not exist in ancient Greece. However, the idea of “good death” existed, clearly expressed in the writings of the great physician of Cos, Hippocrates, and referred to the medical practice of shortening life.⁽⁵⁾ It is any medical treatment that objectively and intentionally, directly (by action) or indirectly (by omission), hastens death, either by the voluntary or involuntary preference of the patient, expressed through their family.

From a religious point of view, the Judeo-Christian religion upholds the meaning of death, considering it to be God’s will, just like life. Therefore, any intervention to destroy it is deemed against divine will. The concept of euthanasia was first used in ⁽⁶⁾ in the Dialogue of Consolation, giving as requirements: intolerable and incurable illness, freedom of the person, moral opinion of religious leaders, and social circle.⁽⁷⁾ In the 1930s, the concept of euthanasia became fashionable as a result of Nazi experiments during World War II. Social euthanasia was promoted by racist social movements that led to some of the most abhorrent mass exterminations in history, such as that of the Nazis against the Jewish and Gypsy peoples. Thus, the use of the term “euthanasia” is considered a euphemism to hide a program of genocide in which people were murdered for “disabilities, religious beliefs, and individual values” that were at odds with the Nazi regime.⁽⁸⁾ In 1980, the Catholic Church, through the “Sacred Congregation for the Doctrine of the Faith,” concluded that treatment for the dying should be proportional to the expected therapeutic effect and should not be disproportionate, painful, distressing, risky, or burdensome, nor should it be intended or aimed at ending a patient’s life.⁽⁵⁾ The joint position announced by the Anglican Church and the Catholic Bishops’ Conference of England in 1993 was to strongly oppose euthanasia legislation because life is a gift from God, and nothing is above it.⁽⁹⁾

DEVELOPMENT

Decisions concerning the end of life (DLE) are a complex web of ethical, cultural, medical, and social factors. Although they are common in clinical practice, in Argentina —as pointed out by ⁽¹⁾ — they are not given sufficient attention in medical training or the local scientific literature, despite their bioethical relevance.

From an anthropological perspective, different cultures interpret death in many ways. ⁽⁴⁾ warns that in the West, influenced by a mechanistic biomedical model, death has lost its symbolic content and become a purely biological phenomenon. This contrasts with cultures that understand it as a transition or transformation.

Euthanasia, understood as the deliberate action or omission to hasten the death of a patient to spare them suffering, has been widely debated in philosophy, religion, and medicine. The term, derived from the Greek eu (good) and Thanatos (death), was taken up by ⁽⁶⁾ in his work Utopia, with a humanistic and moral approach to “good dying.” The Hippocratic tradition, however, condemned any deliberate intervention to end life.

During the 20th century, euthanasia was subject to political and ideological manipulation, especially under the Nazi regime, where it was used as a euphemism to justify extermination programs.^(8,10) This historical use distorted the concept, generating ethical and social resistance that is still present today.

From the perspective of modern bioethics, authors such as ^(5,7) have argued that the dignity of dying must respect both the autonomy of the patient and the intrinsic value of life. Medical ethics proposes a careful assessment based on the principle of proportionality of treatment and respect for the patient’s wishes, clearly differentiating between orthothanasia, euthanasia, and assisted suicide.

Similarly, empirical studies such as those by ^(11,12) in the US reveal the ethical tension faced by healthcare professionals when receiving requests for euthanasia or assisted suicide. Medical attitudes, influenced by religious, cultural, and legal factors, vary significantly between countries.^(13,14)

Euthanasia cannot be separated from the social and political context. The PULSAR survey, conducted by the University of Buenos Aires (UBA), is a national study that seeks to understand Argentine society’s beliefs, values, and perceptions in relation to various aspects of the country’s reality. In 2024, it showed that there is growing interest in Argentina in the right to decide about the end of life, which is linked to a more secular and autonomous conception of the human being. A more secular and autonomous conception of the human being is understood as thinking about and valuing human life from a non-religious, rational, and individual freedom-centered perspective.^{(15,16,17,18)}

Legal framework

In Argentina, the legal framework related to euthanasia and dignified death is centered on Law 26.742, passed on May 9, 2012, which modifies Law 26.529 on the rights of patients in their relationship with health professionals and institutions.⁽¹⁹⁾

The most relevant sections of Law 26.742:

●  Autonomy of will: The patient can accept or refuse medical therapies or procedures, including the possibility of revoking their decision later. In cases of irreversible, incurable, or terminal illnesses, patients may refuse surgical procedures, artificial resuscitation, or the withdrawal of life-sustaining measures that are extraordinary or disproportionate to the prospect of improvement or that cause excessive suffering.

●  Informed consent: This is defined as a sufficient declaration of the patient’s will, issued after receiving clear and accurate information about their health status, proposed procedures, expected benefits, risks, and available alternatives.

● Advance directives: Any competent adult may issue advance directives regarding their health, consenting to or refusing specific medical treatments. In the presence of two witnesses, these directives must be formalized in writing before a notary public or judicial authority. However, the law establishes that directives involving euthanasia practices will not be accepted.^{(20,21,22,23)}

It is important to note that active euthanasia, understood as the direct action to cause the death of the patient, is not legal in Argentina. The law allows the refusal of treatments that artificially prolong life in irreversible situations but does not authorize actions intended to cause death actively.

In recent years, bills have been introduced to regulate euthanasia and assisted suicide in Argentina, but to date, none have been passed. The debate continues in the legislative and social spheres, reflecting diverse ethical, medical, and religious positions on the right to a dignified death.^{(24,25,26,27)}

From a medical point of view, this implies that:

● The professional must inform the patient about the prognosis and treatment options.

● The patient has the right to decide autonomously about the continuation of treatment.

● The healthcare team is not obliged to continue futile or painful treatments if the patient (or their legal representative) rejects them.^(28,29,30)

In everyday medical practice, especially in palliative care, intensive care, and gerontology, professionals face dilemmas such as:

How long should treatment be continued in patients with no chance of recovery?

How should requests to discontinue respirators, dialysis, or artificial feeding be handled?

What role does the family play in these decisions? ^(31,32,33)

Interdisciplinary work, clinical ethics committees, and the proper implementation of informed consent and advance directives are essential here.⁽³⁴⁾

CONCLUSIONS

Decisions surrounding the end of life represent an ethical, medical, legal, and cultural challenge of growing relevance in Argentine society. Despite their frequent occurrence in clinical practice, they remain inadequately addressed in medical training and public debate, reflecting a failure to integrate a mature and culturally sensitive bioethical perspective. Death, understood in various ways throughout history and across cultures, has been reduced in the West to a purely biological event, which limits the depth of the debate on dying well.^{(35,36,37,38)}

Euthanasia, subject to controversial interpretations and uses—from Thomas More’s humanistic view to its ideological manipulation by Nazism—continues to generate ethical tensions, especially in complex medical contexts. Although Argentine law recognizes the right of patients to refuse disproportionate treatment and endorses advance directives, it does not yet contemplate active euthanasia or assisted suicide, leaving open a legislative debate that challenges fundamental social values such as autonomy, dignity, and respect for life.^(39,40,41)

In this context, it is essential to promote comprehensive medical education that includes ethical reflection on death, to foster interdisciplinary dialogue in clinical care, and to move toward legal frameworks that reflect the cultural transformations of a society increasingly inclined to defend the right to decide about one’s own life and death. Only then will it be possible to build medical practices that are respectful, humane, and consistent with the values of those who are nearing the end of their lives?^(42,43)

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FUNDING

None.

CONFLICT OF INTEREST

None.

AUTHOR CONTRIBUTION

Conceptualization: Ana Margarita Graz, Daniel Coso.

Data curation: Ana Margarita Graz, Daniel Coso.

Formal analysis: Ana Margarita Graz, Daniel Coso.

Research: Ana Margarita Graz, Daniel Coso.

Methodology: Ana Margarita Graz, Daniel Coso.

Project management: Ana Margarita Graz, Daniel Coso.

Resources: Ana Margarita Graz, Daniel Coso.

Software: Ana Margarita Graz, Daniel Coso.

Supervision: Ana Margarita Graz, Daniel Coso.

Validation: Ana Margarita Graz, Daniel Coso.

Visualization: Ana Margarita Graz, Daniel Coso.

Writing – original draft: Ana Margarita Graz, Daniel Coso.

Writing – review and editing: Ana Margarita Graz, Daniel Coso.