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Euthanasia and Assisted Suicide

EUTHANASIA AND ASSISTED SUICIDE

Euthanasia is translated from Greek as "good death" or "easy death." As originally used, the term referred to painless and peaceful natural deaths in old age that occurred in comfortable and familiar surroundings. That usage is now archaic. As the word is currently understood, euthanasia occurs when one person ends the life of another person for the purpose of ending the killed person's pain or suffering.

Euthanasia is sometimes divided into different categories. "Voluntary euthanasia" is when a person is killed upon that person's request for reasons of ending suffering. "Involuntary or nonvoluntary euthanasia" is the mercy killing of a medically or legally incompetent person, such as a child or a demented elderly patient, at the request of, or by, a caregiver or family member.

Some people also use the term "passive euthanasia" to describe a death that occurs after undesired, life-sustaining medical treatment is withheld or withdrawn. This is a misnomer. Euthanasia, at least as the term is presently utilized, involves intentional killing. That being so, "passive euthanasia" is not euthanasia, since death, when it comesnot everyone who has life-sustaining treatment dies as a result of withheld treatmentis naturally caused by the underlying illness or injury.

Assisted suicide is closely related to euthanasia. An assisted suicide occurs when one person gives another person the instructions, means, or capability to bring about their own demise. In the context of the modern moral and public policy debates, the motive in assisted suicide, as in euthanasia, is to bring about an end to suffering. Suicide per se is not considered to be the same as "assisted suicide" because the former is an individual act while the latter involves a joint enterprise between the suicidal person and a helper to bring about death.

The Hippocratic oath explicitly prohibited doctors from giving their patients poisons to end life and thus, traditionally, euthanasia and assisted suicide have not been considered legitimate medical acts. Legalizing either practice would transform hastening patient deaths from an ethically proscribed and (usually) criminal act into a legitimate medical practice. Thus, widespread legalization would be a profound and dramatic shift in the traditional ethics of medical practice.

Euthanasia is currently illegal and punishable as murder throughout the United States. Assisted suicide is a felony akin to manslaughter in most states, proscribed either by statute or court interpretation of the common law. The federal government has outlawed the use of federal funds in assisted suicide.

Assisted suicide is, however, legal in Oregon, where state law authorizes physicians to write lethal prescriptions at the request of patients who have been diagnosed with a terminal illness reasonably likely to cause death within six months. In order for the assisted suicide to be legal, the prescribing physician must follow regulatory guidelines. These guidelines include: requiring a second opinion to verify the diagnosis; referral of the patient to a mental health professional if the doctor suspects the patient has a psychiatric or psychological condition that causes "impaired judgment"; a fifteen-day waiting period between request and prescription; and, reporting the assisted suicide to the Oregon Department of Health. Most current legalization proposals in the United States follow the format of the Oregon law.

Internationally, both euthanasia and assisted suicide are almost universally outlawed. There are a few exceptions to this general rule. In Colombia euthanasia is legal due to a ruling by that country's supreme court (Republic of Colombia Constitutional Court: Sentence: no. C-239/97: REF. EXPEDIENT no. D-1490. May 20, 1997). As of this writing the Colombia law has not gone into effect pending the creation of legal guidelines to govern the practice. Euthanasia and assisted suicide, while technically illegal, are practiced widely by doctors in the Netherlands. The Netherlands experience will be discussed in detail below. Assisted suicide is not illegal in Switzerland, where assisted suicides committed by physicians and laypersons alike are reportedly not prosecuted if based on alleviating suffering caused by serious illness.

The modern euthanasia movement

A few proposals to legalize euthanasia were made in the United States and Germany during the latter portion of the nineteenth century. However, it was not until after World War I that euthanasia advocacy began in earnest. In 1920, two highly respected German academics, Karl Binding, a law professor, and Alfred Hoche, a physician, wrote Permission to Destroy Life Unworthy of Life, which advocated euthanasia as a compassionate "healing treatment." The authors argued that mercy killing should be permitted for three categories of patients upon request of competent patients or the families of the incompetent: the terminally ill or mortally wounded, people who were unconscious, and disabled peopleparticularly those with cognitive impairments. The book, which may have coined the term "right to die," also promoted euthanasia of cognitively disabled people as a way of saving societal resources.

Binding and Hoche's book generated tremendous interest among Germany's intelligentsia and the public, which quickly came to support legalization of euthanasia. Euthanasia was popular enough in 1933 for Adolph Hitler to attempt to formally legalize the practice. However, strong opposition from the churches caused the German government to drop the proposal.

Euthanasia was also advocated in the United States during the 1930s. In 1938, the New York Times announced the formation of a national euthanasia society that eventually became known as the Euthanasia Society of America. In 1939, the group had drafted a proposed law permitting voluntary euthanasia. Dr. Foster Kennedy, the group's president, also called for the legalization of euthanasia for babies born with birth defects. The incipient euthanasia movement in the United States grew quiescent in the aftermath of the Holocaust as the world recoiled in horror to the news that between 1939 and 1945, German doctors killed more than 200,000 disabled people, including infants and the mentally retarded people.

After the war, organized euthanasia groups continued to exist in the United States but made little headway until the early 1980s, when societal changes that began in the 1960s and the resulting weakening of traditional moral values, as well as intellectual support by some within the medical intelligentsia, provided fertile ground for renewed euthanasia advocacy. In a dramatically short period of time, legalized euthanasia went from an "unthinkable" prospect to one of the most contentious and controversial issues debated in the public square.

Pros and Cons

Perhaps the strongest argument made on behalf of legalizing euthanasia or assisted suicide is that it, like abortion, is a "choice" issue. Proponents argue that euthanasia/assisted suicide is "the ultimate civil right," and that to deprive mentally competent, terminally ill people who want to end their suffering of a peaceful "aid in dying" is to fundamentally disrespect their right to personal autonomy. Proponents also argue that legalizing euthanasia/assisted suicide is a necessary "insurance policy" that will ensure that no one dies in painful agony or unremitting suffering. Advocates contend that euthanasia/assisted suicide is little different from pain control since both use strong drugs and patients' deaths are occasionally unintentionally hastened as a side effect of the narcotics used in palliation. They also claim that doctors commonly engage in euthanasia/assisted suicide surreptitiously and promote legalization as a way to protect vulnerable patients from abuses inherent in the current "unregulated" practice. Acknowledging worries about potential abuses, advocates assure that "protective guidelines" would protect the vulnerable from wrongful death while still permitting suffering patients who are eligible for euthanasia/assisted suicide to obtain a desired, peaceful "death with dignity." Proponents also claim that opposition to euthanasia/assisted suicide is based primarily in religion and that laws prohibiting the practice are thus unconstitutional because they violate the division between church and state.

Opponents counter that legalizing euthanasia/assisted suicide would lead society down a dangerous "slippery slope" with legalized killing eventually being permitted for disabled, elderly, and depressed people, as well as for those who are not mentally competent to request to die. Protective guidelines "do not protect," opponents declare, pointing to the Dutch experience with euthanasia as "proof" of both the reality of the slippery slope and the relative meaninglessness of guidelines. Opponents also argue that the economics of modern medicine would promote euthanasia/assisted suicide as a form of health care cost containment, noting that the drugs in an assisted suicide cost only about forty dollars, while proper care for a dying patient can cost tens of thousands of dollars. They also note that forty-four million Americans do not have health insurance, and that medicine is sometimes practiced in a discriminatory manner against racial and other minorities. Thus, they argue that "the last people to receive medical treatment will be the first to receive assisted suicide." Opponents also deny that there is widespread surreptitious euthanasia practiced in clinical medicine, citing several published studies as proof, and urge that hospice care and proper medical treatment provide the morally acceptable answers to the difficulties that are sometimes associated with the process of dying.

The people vote

There have been several attempts in the United States to legalize euthanasia and assisted suicide through state initiatives. The first attempt came in 1988, when euthanasia supporters attempted to qualify an initiative for the ballot in California, which would have permitted physicians to administer lethal injections for terminally ill patients who asked to have their deaths hastened. The attempt failed to garner enough signatures to qualify for the ballot. However, in 1991, Initiative 119, a similar proposal, was successfully placed on Washington's ballot. After initial polling showed voter support in excess of 70 percent, the initiative lost 54 to 46 percent. The pattern repeated itself in California in 1992, when a virtually identical proposal appeared on the California ballot in November 1992 as Proposition 161. After initial support in excess of 70 percent, the measure also lost by a margin of 54 to 46 percent.

Two years later, in Oregon, Measure 16the Oregon Death with Dignity Actqualified for the November 1994 ballot. Unlike the earlier failed initiatives, Measure 16 limited its scope to legalizing physician-assisted suicide. The measure passed narrowly, 51 to 49 percent. The law was soon overturned as a violation of the equal protection clause of the Fourteenth Amendment to the U.S. Constitution. However, this decision was itself overturned by the Ninth Circuit Court of Appeals on procedural grounds (Lee v. Oregon ). The United States Supreme Court refused to review the Ninth Circuit's opinion. An attempt by opponents to repeal Measure 16 through another ballot initiative, Measure 51, failed in November 1997 by a margin of 60 to 40 percent. The law was in effect as of 1999.

In 1998, supporters of assisted suicide qualified Proposal B for the November ballot in Michigan. Proposal B, like Measure 16, would have restricted legalization to assisted suicide and its terms were very similar to those of the Oregon law. The debate over Proposal B was complicated by two factors: Michigan was the home state of Dr. Jack Kevorkian and Kevorkian's attorney, Geoffrey Fieger, was the Democratic nominee for governor. Whatever the impact of these ancillary issues, when the votes were counted, Proposal B lost by an overwhelming 71 to 29 percent.

Jack Kevorkian

During the 1990s, Jack Kevorkian was undoubtedly the most well known assisted suicide and euthanasia advocate in the world. A retired pathologist from Michigan, Kevorkian made headlines internationally when he undertook a well publicized assisted-suicide campaign between 1990 and 1998 that reportedly ended the lives of approximately one hundred thirty people. Some of those whose deaths Kevorkian facilitated were terminally ill and diagnosed as having less than six months to live, but most were disabled or chronically ill. According to autopsy reports, four of the people whose suicides Kevorkian helped had no discernible organic illness.

Kevorkian's campaign began on 4 June 1990, when he assisted the suicide of Janet Adkins, a woman diagnosed with early Alzheimer's disease. At the time, Michigan had no law against assisted suicide and Kevorkian was not arrested. His next publicly acknowledged assisted suicide was conducted on 23 October 1991, when Kevorkian made headlines for assisting the suicide of two women at the same location, one with multiple sclerosis and another who complained of chronic, severe pelvic pain. Kevorkian was arrested for murder but the case was dismissed. The prosecution appealed and the state legislature hastily cobbled together a poorly worded, temporary criminal statute proscribing assisted suicide intended to "stop Kevorkian."

Kevorkian openly defied the law and was arrested, tried, and acquitted. The temporary prohibition lapsed but the prosecution's earlier appeal succeeded when the Michigan Supreme Court ruled that assisted suicide was a common law felony in Michigan (People of Michigan v. Jack Kevorkian ). Kevorkian was again arrested and tried. Once again, a jury found him not guilty. A third case against Kevorkian was later declared a mistrial because of the courtroom conduct of Kevorkian's lawyer, and the case was dropped. Kevorkian, it seemed, had a free hand.

In 1998, Kevorkian's actions grew increasingly erratic. In June, after he assisted the suicide of Joseph Tushkowski, a man with quadriplegia, Kevorkian held a press conference in which he claimed to have procured the man's kidneys, and offered them for organ transplant, "first come, first served." There were no takers. In late October, he videotaped himself lethally injecting Thomas Youk, an ALS (Lou Gehrig's disease) patient. Kevorkian then took the tape to CBSTelevision's news program 60 Minutes, which aired it to a nationwide audience, during which Kevorkian dared the authorities to prosecute him. Kevorkian was arrested and convicted of second-degree murder. He is currently in prison for a term of ten to twenty-five years.

Legal challenges

Proponents of legalization mounted a significant effort to have laws against assisted suicide declared unconstitutional, hoping to garner an "assisted suicide" Roe v. Wade (410 U.S. 113 (1973)) that would settle the issue nationally, as Roe did with abortion. They were unsuccessful. In Washington v. Glucksburg (117 S. Ct. 2258 (1997), the Supreme Court justices voted 90 that "the asserted 'right' to assistance in committing suicide is not a fundamental liberty interest protected by the Due Process Clause [of the Fourteenth Amendment]." The decision also emphasized that state laws banning assisted suicide were consistent expressions of the individual states' commitment to protecting all human life.

In the closely associated case of Vacco v. Quill (117 S. Ct. 2293 (1997)), the Supreme Court ruled against assisted-suicide advocates who had argued that New York's law proscribing assisted suicide violated the equal protection clause of the Fourteenth Amendment. They argued that since it is legal for terminally ill persons to refuse life-sustaining medical treatment and die immediately but illegal for terminally ill people who do not require life support to secure immediate death through physician-assisted suicide, New York violated its constitutional obligation to treat similarly situated people equally. In rejecting the argument, the Supreme Court ruled that the New York law actually treated similarly situated people alike: all patients are permitted to refuse unwanted treatment and none are allowed legal access to assisted suicide. The Court also ruled that there was a significant and rational distinction between refusing life-sustaining treatment and seeking assisted suicide. In the former circumstance, the doctor's intention may be to simply stop performing useless procedures when a patient will not benefit, while in assisted suicide, the doctor must without a doubt intend for the patient's death.

Both sides claimed victory in the Court's two rulings. Opponents were relieved that assisted suicide would not be "imposed" nationally by judicial fiat. Proponents took heart that several concurring opinions muddied the waters and seemed to indicate that the issue could be brought back to the courts for further review if a case of a patient with truly irremediable suffering were presented. Proponents also claimed that the Court's decision freed the states to experiment with laws concerning the end of life, perhaps including assisted suicide, although opponents pointed out that the issue of a state's right to pass a law legalizing assisted suicide had not been before the Court.

There have been at least three attempts to invalidate state laws proscribing assisted suicide based on privacy provisions contained in state constitutions. A lawsuit challenging Alaska's proscription is currently pending in that state's courts (Sampson v. State of Alaska, No. 3 AN9811288 CIV). A California Court of Appeals decision refused to permit a terminally ill man to have legal assistance with suicide so that his body could be cryogenically preserved. The most notable case to decide this issue in state courts was Krischer v. Florida (697 So.2d, 97 (1997)), in which the Florida Supreme Court ruled that the state's assisted-suicide prohibition did not violate the state constitution's guarantee of privacy.

Euthanasia in the Netherlands

The Netherlands has the most experience with physician-hastened death. Both euthanasia and assisted suicide remain crimes there but doctors who end their patients' lives will not be prosecuted if legal guidelines are followed. Among the guidelines are:

  • The request must be made entirely of the patient's own free will.
  • The patient must have a long-lasting desire for death.
  • The patient must be experiencing unbearable suffering.
  • There must be no reasonable alternatives to relieve suffering other than euthanasia.
  • The euthanasia or assisted suicide must be reported to the coroner.

These guidelines are similar to those proposed in legalization proposals in the United States, although the Oregon law requires a terminal illness, a limitation not included in the Dutch guidelines. On the other hand, the Oregon guidelines do not require that the patient be experiencing unbearable suffering or that there be no reasonable alternatives to relieve suffering other than assisted suicide.

There have been several professional studies conducted into Dutch euthanasia practice. Most have reported that approximately 2,700 deaths are caused each year in the Netherlands by either euthanasia or assisted suicideapproximately 3 percent of all Dutch deaths. Proponents claim this relatively low figure rebuts opponent's fears that euthanasia will become a relatively routine event. Opponents counter that this figure is horrifying: if the same percentage of Americans died with the direct assistance of doctors, it would amount to approximately sixty-eight thousand annual deaths, more than tripling the U.S. suicide rate.

Opponents also claim that the number of people actually killed by Dutch doctors is significantly understated in these studies. They note that the term "euthanasia" is very narrowly defined by the Dutch government, with the effect if not the design of undercounting the actual number of euthanasia deaths. If a doctor kills a patient with barbiturates and a curare-like poison at the patient's request, the Dutch classify the death as "euthanasia." However, if the patient is killed by an intentional overdose of morphine administered with the primary intention of ending the patient's life, it is not considered euthanasia because morphine is a palliative agent. Yet, intentional morphine overdoses may exceed "euthanasia" deaths. In 1990, according to a Dutch government report, 8,100 patients died through the intentional morphine-overdose method of mercy killing. A latter study found that about 1,500 die annually through the intentional morphine-overdose method of killing. Whatever the actual annual figure, if intentional morphine-overdose deaths are counted as euthanasia, the statistical mercy killing rate in the Netherlands significantly exceeds the published statistics.

Opponents point to the many documented cases of chronically ill people, as well as to terminally ill people, put to death by doctors at the patient's request as further proof of euthanasia's many dangers. A Dutch documentary showed a young woman in remission from anorexia requesting doctor-induced death because she was afraid of resuming food abuse. Her doctor assisted her suicide without legal consequence. Another documented case showed an asymptomatic, HIV-positive patient assisted in suicide because he feared future suffering.

Opponents point with alarm to the Dutch Supreme Court's decision approving euthanasia for cases of severe depressioneven in the absence of physical illness (State v. Chabot, Supreme Court of the Netherlands, Criminal Chamber, 21 June 1994, nr. 96.972). This decision resulted from the case of a Dutch psychiatrist who assisted the suicide of a woman who wanted to end her life because her children had died. The court supported the psychiatrist's actions, ruling that for purposes of judging the propriety of euthanasia or assisted suicide, suffering is suffering and it does not matter whether the cause is physical or psychological.

Another disturbing statistic that is found consistently in studies into Dutch euthanasia practices demonstrates to opponents the ultimate danger of euthanasia: approximately one thousand Dutch patients are euthanized each year by their doctors "without request or consent," in other words, involuntary or nonvoluntary euthanasia. Since euthanasia is only supposed to be allowed for people who consistently ask to be killed, the fact of involuntary killing demonstrates the unworkability of guidelines. Proponents counter that the number, while too high, has been relatively constant over several years, thus belying fears of the slippery slope.

Pediatric euthanasia has also become a part of Dutch euthanasia practice. Opponents point with alarm to a 1997 study published in the British medical journal The Lancet indicating that about 8 percent of all infants who die in the Netherlands are euthanizedapproximately 80 per year. Pediatric euthanasia, they claim, is a human rights abuse and a proof that guidelines do not protect vulnerable patients. Proponents counter this criticism with the defense that the infant-euthanasia deaths are only of the most severely impaired babies, most of whom would not live anyway, and note that the parents make the decision based on their judgment of what is best for their children.

Opponents also claim that Dutch euthanasia is "beyond significant control" since approximately 59 percent of euthanasia and assistedsuicide deaths are not reported to the coroner as required by the guidelines. Thus, they claim that the actual number of Dutch patients killed is probably far higher than the statistics seem to show. Proponents admit that unreported euthanasia deaths are a problem but counter that full legalization would remove fear of prosecution thereby increasing compliance with reporting requirements.

In 1999 the Dutch government announced its intention to formally legalize euthanasia. As with anything having to do with euthanasia, the announcement was extremely controversial: the proposed law would permit the euthanasia of children as young as twelve at the request of the child, even if the parents object.

The Oregon experience

Assisted suicide has been legal for too short a time in Oregon to know its actual impact. As of 1999, just one study has been conducted analyzing the Oregon experience. Published in the New England Journal of Medicine in 1999, the study reported that fifteen people died legally by assisted suicide in the calendar year 1998. None was in intractable pain. One feared future pain. The primary reason the patients gave for requesting assisted suicide, according to the prescribing doctors who were interviewed for the study, was fear of future dependency.

Proponents of the Oregon law claimed that the study demonstrated that legalized assisted suicide is a rare procedure and that the law's guidelines work to protect vulnerable people. They also stressed that the deaths were apparently peaceful with none of the patients suffering side effects, such as extended coma, about which opponents had warned. Moreover, they noted that financial pressures did not appear to be a factor in any of the cases.

Opponents countered that the law was "sold" to voters as a last resort measure for people in extreme pain, but none of the patients fits that description, thereby demonstrating the existence of the "slippery slope." Disability rights activists argued that once assisted suicide is deemed a proper response to fears of dependency, as was the case in the fifteen Oregon deaths, it cannot be logically limited to terminally ill people since disabled and elderly people also face dependency issues and for far longer periods of time. Opponents also noted with alarm that six of the people who died by assisted suicide consulted with two or more doctors before finding a physician willing to write a lethal prescription. Moreover, some of the patients knew the prescribing doctor for a very short time, indicating, opponents contend, that some of the prescriptions were written for political rather than medical purposes.

Conclusion

The assisted suicide/euthanasia debate is still in its infancy, with the ultimate outcome very much in doubt. Public opinion polls show solid majority support for limited legalization, but the polls also demonstrate that popular support drops significantly when specific details of legislative proposals are examined. Oregon was a major breakthrough for advocates of assisted suicide but five states have outlawed assisted suicide since Oregon's Measure 16 passed in 1994, and one state passed legislation subjecting a person who assists in a suicide to civil liability. One thing is clear: euthanasia/assisted suicide controversy is likely to be a significant source of societal contention and political argument for many years to come.

Wesley J. Smith

See also Abortion; Criminalization and Decriminalization; Excuse: Theory; Homicide: Legal Aspects; Justification; Necessity; Suicide: Legal Aspects; Victimless Crime.

BIBLIOGRAPHY

Byock, Ira. Dying Well: The Prospect for Growth at the End of Life. New York: Putnam, 1997.

Chin, Hedberg et al. "Legalized Physician-Assisted Suicide in OregonThe First Year's Experience." New England Journal of Medicine 340, no. 7 (February 1999): 577589.

Hendin, Herbert. Seduced by Death: Doctors, Patients, and the Dutch Cure. New York: Norton, 1997.

Humphry, Derek, and Clement, Mary. Freedom to Die: People, Politics and the Right-to-Die Movement. New York: St. Martin's, 1998.

Kamisar, Yale. "Some Non-Religious Views Against Proposed 'Mercy-Killing' Legislation." Minnesota Law Review 42 (1958): 9691042.

. "Physician-Assisted Suicide: The Problems Presented by the Compelling, Heart-wrenching Case." Journal of Criminal Law and Criminology 88 (1998): 11211146.

Keizer, Bert. Dancing with Mister D: Notes on Life and Death. New York: Doubleday, 1996.

Keown, John, ed. Euthanasia Examined: Ethical, Clinical and Legal Perspectives. Cambridge, U.K.: Cambridge University Press, 1997.

Marker, Rita. Deadly Compassion: The Death of Ann Humphry and the Truth about Euthanasia. New York: Morrow, 1993.

New York Task Force on Life and the Law. When Death Is Sought: Assisted Suicide and Euthanasia in the Medical Context. New York: New York Task Force on Life and the Law, 1994.

Peck, M. Scott. Denial of the Soul: Spiritual and Medical Perspectives on Euthanasia and Mortality. New York: Harmony Books, 1997.

Quill, Timothy E. Death and Dignity: Making Choices and Taking Charge. New York: Norton, 1993.

Smith, Wesley J. Forced Exit: The Slippery Slope from Assisted Suicide to Legalized Murder. New York: Times Books, 1997.

Uhlmann, Michael E., ed. Last Rights: Assisted Suicide and Euthanasia Debated. Grand Rapids, Mich.: Wm. B. Eerdmans Publishing Company.

van der Heide, van der Maas et al. "Medical End-of-Life Decisions Made for Neonates and Infants in the Netherlands." The Lancet 350 (July 1997): 251253.

Williams, Glanville. The Sanctity of Life and the Criminal Law. London: Faber and Faber, 1958.

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Euthanasia

Euthanasia

The word euthanasia translates from Greek roots as "good death." The Oxford English Dictionary states that the original meaning, "a gentle and easy death," has evolved to mean "the actions of inducing a gentle and easy death." This definition is consistent with contemporary use of the term. For example, the Canadian Senate Special Committee on Euthanasia and Assisted Suicide defined euthanasia as "the deliberate act undertaken by one person with the intention of ending the life of another person in order to relieve that person's suffering where that act is the cause of death" (Senate of Canada 1995, p. 15). Euthanasia is generally classified in terms of certain subcategories, depending upon whether or not the person who dies by euthanasia is considered to be competent or incompetent and whether or not the act of euthanasia is considered to be voluntary, nonvoluntary, or involuntary.

Definitions of Euthanasia

Euthanasia is considered to be voluntary when it takes place in accordance with the wishes of a competent individual, whether these wishes have been made known personally or by a valid advance directivethat is, a written statement of the person's future desires in the event that he or she should be unable to communicate his or her intentions in the future. A person is considered to be competent if he or she is deemed capable of understanding the nature and consequences of the decisions to be made and capable of communicating this decision. An example of voluntary euthanasia is when a physician gives a lethal injection to a patient who is competent and suffering, at that patient's request.

Nonvoluntary euthanasia is done without the knowledge of the wishes of the patient either because the patient has always been incompetent, is now incompetent, or has left no advance directive. A person is considered incompetent when he or she is incapable of understanding the nature and consequences of the decision to be made and/or is not capable of communicating this decision. In the case of nonvoluntary euthanasia, the wishes of the patient are not known. An example of nonvoluntary euthanasia is when a doctor gives a lethal injection to an incompetent elderly man who is suffering greatly from an advanced terminal disease, but who did not make his wishes known to the physician when he was competent. Another example would be a father who asphyxiates with carbon monoxyde a congenitally handicapped child who was never considered to be competent.

Involuntary euthanasia is done against the wishes of a competent individual or against the wishes expressed in a valid advance directive. Examples of involuntary euthanasia include a son who gives a lethal overdose of medication to his father who is suffering from cancer, but the father does not want the overdose. Another example is a physician who, despite the advance directive of a patient indicating that he or she does not want any actions to hasten death, gives a lethal injection to the patient who is now unconscious and suffering from the final stages of a terminal illness.

Although the above definitions may seem clear, there is much confusion in the words used to describe euthanasia and other actions that result in hastening death. The term "mercy killing" is often used to describe situations of nonvoluntary and involuntary euthanasia. In several European countries, for example the Netherlands, the difference between euthanasia, homicide, suicide, and assisted suicide appears to be relatively clear. However, in the United States and Canada there is much confusion concerning the use of the term assisted suicide and physician-assisted suicide.

Definitions of Assisted Suicide

Assisted suicide is usually defined as a specific situation in which there is a suicide, that is, an act of killing oneself intentionally. Adding the word "assisted" to suicide implies that another person provided assistance by supplying the means (e.g., giving the person a gun or prescribing lethal medication), the knowledge (information about the use of the gun or how to take a lethal dose of medication), or both. In North America, assisted suicide has also been used in the media to refer to situations that appear to have been direct acts to end the life of a person intentionally initiated by another person. This is because assisted suicide has lesser legal sanctions than the act of killing another person even if the homicide is for the relief of pain and suffering in a terminally ill individual and can be called "euthanasia." For these reasons, Jack Kevorkian (the pathologist who made media headlines in the 1990s for his involvement in the deaths of over 130 individuals) claimed that his participation in the deaths of several patients was assisted suicide rather than euthanasia.

Sometimes there may be a fine line between what is considered assisted suicide and euthanasia. For example, during the period between July 1996 and March 1997, when euthanasia was legal in the Northern Territory of Australia, a machine was invented whereby a physician attached the patient to a computer-operated pump that contained lethal substances. Although the physician hooked up and turned on the apparatus, the lethal injection was only given after the patient responded to a question on the computer screen by pressing on a key.

Arguments in Favor of Euthanasia

Arguments in favor of euthanasia are generally based upon beliefs concerning individual liberty, what constitutes a "good" or "appropriate" death, and certain life situations that are considered unacceptable. These arguments are generally based upon moral or religious values as well as certain beliefs concerning the value and quality of human life. They also often suppose that people are capable of making rational decisions, even when they are suffering and terminally ill.

The good death. According to this view, certain ways of dying are better than others. Usually a good death is described ideally as drifting into death in a pleasing environment as one falls asleep. The ancient Roman orator and statesman Cicero said that a good death is the ideal way of respecting natural law and public order by departing from the earth with dignity and tranquility. Euthanasia can be seen as a way to assure that a person dies in a dignified and appropriate manner.

Individual liberty. In his Essay on Suicide, the eighteenth-century Scottish philosopher David Hume stated that all individuals in a free society should be able to choose the manner of their death. Some people, for example, feel that this right must be tempered by the obligation to not cause harm to others.

Right to maintain human dignity. This argument is similar to the concept of the good death, except that the objective is to avoid a poor quality of life during the dying process rather than seek out a particular idealized way of dying the good death. There are great individual differences in what constitutes a dignified way to live and die. Commonly mentioned indignities to justify premature death include: being a burden to others, living a deteriorated state incapable of normal daily activities, having to be placed in a hospital or a nursing home, and being dependent upon intrusive medical apparatus to continue living or engaging in everyday tasks. The general public often assumes that certain chronic and terminal illnesses inevitably result in a poor quality of life. However, research suggests that the psychosocial environment determines quality of life as much or more than the nature of the illness, per se.

Reduction of suffering. In 1516 the English statesman and author Sir Thomas More described euthanasia to end suffering in his book Utopia as "those that are ill from incurable diseases they comfort by sitting and talking with them, and with all means available. But if the disease is not only incurable but also full of continuous pain and anguish, then the priests and magistrates exhort the patient saying that he has become . . . irksome to others and grievous to himself; that he ought to . . . dispatch himself out of that painful life as out of a prison or torture rack or else allow his life to be ended by others" (More 1964, pp. 186187). In 1994 the philosophy professor Margaret Battin wrote that euthanasia to reduce suffering has two components: to avoid future pain and suffering and to end current pain and suffering. This definition generally assumes that the pain is not only intolerable but interminable.

Justice. Gerald Gruman described euthanasia in order to achieve "justice" in society as "thrift euthanasia," where decisions are made to end lives of certain patients in situations where there is competition for limited resources in medical care. When there is a scarcity of certain medical resources in a society, not all people who are ill can continue to live. In such situations, one can suggest that "less valuable" individuals should give up their places to persons who contribute more to society; if they are unwilling, others should decide who should live and who should die. An extreme example is the eugenics programs based upon Darwinian concepts, such as those proposed by the German biologist Ernst Haeckel in 1904. Haeckel proposed that in order to reduce welfare and medical costs "hundreds of thousands of incurable lunatics, lepers, people with cancer" be killed by means of morphine or some other "painless and rapid poison" (1904). This approach inspired the National Socialists led by Adolf Hitler in their eugenics program.

Even if one disagrees with any form of eugenics program for economic reasons, one may still consider the fact that social pressure often exists in situations where medical resources are limited. The concept of "distributive justice"involves looking at the collective good or general welfare as something to be shared among the total membership of society. When resources are limited, society may question, for example, if it is worth expending tremendous resources to maintain the life of one incurably ill individual in a vegetative unconscious state rather than using those resources to help cure those who have promising prognoses for recovery.

Avoiding botched suicides. Molloy states that if euthanasia remains illegal, some people will be forced to attempt suicide or try to kill loved ones without any help. He contends that in some instances unsuccessful suicide attempts and botched euthanasia by others may result in a life situation that is worse than before. It can be argued that legalization of euthanasia will avoid suffering from botched attempts and the prosecution of loved ones who are acting sincerely at the request of a family member.

Control of existing practices. In countries where euthanasia is illegal there are clandestine practices by physicians and family members regardless of the laws. Proponents of euthanasia in the Netherlands often state that as long as euthanasia remains illegal in a country, physicians and other citizens will camouflage those activities and there will be no monitoring or control of what occurs. An advantage to legalizing euthanasia would be to control existing practices and ensure that there are fewer abuses.

Arguments against Euthanasia

The arguments against euthanasia include religious and ethical beliefs about the sancitity of life as well as a number of arguments allowing for euthanasia that will inevitably lead to a situation where some individuals will risk having their deaths hastened against their will.

Sanctity of human life. This belief, based upon religious values, considers human life sacred and inviolable. No person may take the life of another. For example, St. Augustine interpreted the biblical prescript against killing as being absolute, even including the taking of one's own life. Another argument for the sanctity of human life is that this constitutes one of the pillars of social order that must be maintained to avoid social breakdown. For example, St. Thomas Aquinas condemned suicide because it goes against one's obligation to oneself, the community, and God.

Wrong diagnoses and new treatments. According to this point of view, where there is life there is hope. It is possible that a terminal diagnosis is in error; some people thought to be dying from an incurable disease are victims of a mistaken diagnosis or may miraculously continue to live. Also, because of the rapid pace of advances in medical science, there may soon be a cure for diseases that are at the time of the euthanasia considered to be incurable. Thus, euthanasia may be a mistake if there is a possibility, however slight, that the person is not really going to die. For example, it can be said that many persons with AIDS (acquired immunodeficiency syndrome) who ended their life prematurely because of impending death may have continued to live for a long time because of the development of new treatments for the disease.

The Wedge or Slippery Slope. This argument maintains that when one accepts killing upon demand in certain situations, despite the best controls and regulations, there is a risk of abuses. Furthermore, there is concern that once the door is opened to justify murder under some intolerable circumstances, there is the possibility of developing broader criteria and making euthanasia more widespread. For example, in the Netherlands euthanasia and assisted suicide was first only available to those who were terminally ill. Since 1998 the regulations for euthanasia have been used to permit access to euthanasia and assisted suicide to persons who are not terminally ill but who suffer hopelessly from chronic physical or even psychological illnesses.

Protection of the weak, incompetent, and disadvantaged. This argument is similar to the Wedge or Slippery Slope argument. The concerns with the Protection of the Weak argument are that people who may be unable to make informed choices concerning euthanasia may be forced to opt for a premature death or may become victims of non-voluntary or involuntary euthanasia.

The value of suffering. Suffering may be seen as good for the soul, a heroic act, or the price to pay for one's sins in order to guarantee a better life in the hereafter. Jesus' suffering on the cross may be considered an example of an appropriate way to die. If suffering is admirable, then seeking to end suffering by euthanasia cannot be condoned.

The option of suicide is always available. Because suicide is always available and not illegal in most countries, one can argue that legalization of euthanasia is not necessary because a person can always find some means of committing suicide. Because of the dangers in legalizing euthanasia, one might instead encourage people to commit suicide rather than involving others in their deaths. One may further argue that those who "do not have the courage" to end their own lives may be too ambivalent and should not be put to death by others.

The impossibility of competent and rational decision making. The seventeenth-century philosopher Spinoza felt that the desire to survive is such an essential part of human nature that humans may not rationally prefer not to survive and kill themselves. According to this view, anyone who wants to die may not be acting rationally. Furthermore, one may question if it is possible when experiencing pain and suffering to make a rational decision before the pain and suffering is controlled. Finally, one may question whether or not most important human decision making is rational and why one should expect a person to be more rational when terminally ill. Major decisions such as choice of career, marriage partners, where to live, and whether or not to have children may be more emotional than rational. Also, there are no generally accepted criteria of what constitutes a rational argument in favor of euthanasia: What is logical and rational for one person may constitute reasons for continuing to fight against death in another person in a similar situation.

Choosing death for the wrong reasons. Many people consider euthanasia because they are experiencing pain and suffering. Ignorance of the availability of interventions to reduce pain and suffering may lead to a choice to end life. People involved in palliative care programs that focus upon reducing the suffering of terminally ill patients contend that better pain control and improvement of the psychosocial situation can alleviate a large proportion of the suffering and reduce the desire for euthanasia.

Undiagnosed clinical depression. It may be considered appropriate for people who are dying to feel sad and unhappy. However, some terminally ill persons may suffer from a more severe and potentially treatable psychiatric syndrome of clinical depression. In some instances, the depression may be a side effect of treatment of the illness or may be related to the psychosocial environment of an institution. According to this view, accurate diagnosis and treatment with antidepressant medication and/or psychotherapy is a preferable option to euthanasia.

Erosion of confidence in physicians. According to this argument, if physicians are allowed to kill some terminally ill patients then confidence in physicians may be diminished. Medical practictioners and proponents of this argument have suggested that only "specialists" should practice euthanasia if it is legalized so that physicians can maintain their reputation as advocates in the fight against death and the reduction of pain and suffering.

Compromising the right to choose by involving others in one's death. Brian Mishara has argued that humans generally experience tremendous ambivalence about ending their lives by suicide, so much so that most highly suicidal people change their minds before an attempt and the vast majority of persons who initiate a suicide attempt do not die from their attempt. He questions whether the involvement of a physician in ending a person's life may create a social situation where there is tremendous pressure to complete the suicidal act and die rather than exercising the choice to continue to live. Once a physician has been convinced that euthanasia is acceptable and appropriate, it is not easy for a person to admit to the doctor that he or she is feeling ambivalent or scared and would like to put off the decision for a while. This analysis suggests that involving others in death can compromise people's rights to change their minds because of the social pressures to complete the act.

The Situation in the Netherlands

In the Netherlands, the practice of euthanasia and assisted suicide was legalized by legislative decree in November 2000. However, the practice of euthanasia has been tacitly condoned by jurisprudence since 1973. In 1973 a doctor was found guilty of giving her seventy-nine-year-old mother a lethal injection after repeated requests to end her suffering. The doctor was placed on probation for a year but this case generated considerable sympathy for the doctor and resulted in the Royal Dutch Medical Association producing a working paper on the topic. Furthermore, the Supreme Court of The Netherlands set out a number of considerations that would have to be met before an accused would be exonerated of euthanasia. Subsequently, the practice developed to not prosecute cases of euthanasia that respected those court guidelines. They include:

  • The request for euthanasia must come from the patient and be completely voluntary, well considered, and persistent.
  • The patient must have adequate information about his or her medical condition, the prognosis, and alternative treatments.
  • There must be intolerable suffering with no prospect for improvement, although the patient need not be terminally ill.
  • Other alternatives to alleviate the suffering must have been considered and found ineffective, unreasonable, and unacceptable to the patient.
  • The euthanasia must be performed by a physician who has consulted an independent colleague.
  • The physician must exercise due care, and there should be a written record of the case.
  • The death must not be reported to the medical examiner as a natural death.

There is tremendous popular support in the Netherlands for the practice of euthanasia and the legal precedents have now been passed into law by Parliament. Several studies have been conducted on the nature of the practice of euthanasia and assisted suicide as well as possible abuses. Most cases of euthanasia occur among terminally ill persons in the advanced stages of their disease and it is rare that the criteria are not respected. However, in the Netherlands there are no monetary considerations concerning the cost of health care because there is a socialized medical program. Furthermore, the society in the Netherlands is very different from many other societies because of the strong emphasis upon individual freedom of choice and limited government control.

The Euthanasia Act in the Australian Northern Territories

The parliament of the Northern Territory in Australia passed the Rights of the Terminally Ill (ROTI) Act in May 1995, which was in effect for nine months from July 1, 1996, to March 25, 1997, when the act was repealed by legislation passed by the parliament of Australia. The ROTI Act allowed a terminally ill patient who was experiencing what he or she deemed to be unacceptable levels of pain, suffering, and/or distress to request the medical practitioner to end his or her life by euthanasia, if the requirements of the law were met. The law stipulated that besides suffering and being terminally ill, the patient must be at least eighteen years old, there must be no cure available, no other palliative care options to alleviate the suffering available, and a second opinion as well as a psychiatric assessment to confirm that he or she is not suffering from a treatable clinical depression.

After the law was passed, five persons who officially sought to use the act received extensive media attention. Although the intention of the law was to allow for a patient's personal physician to provide assistance to terminate life as part of their care, only one physician in the territory accepted to participate in euthanasia practices: Philip Nitschke. During the period that the act was in effect, seven cancer patients applied for euthanasia with Nitschke. Four of the seven died by euthanasia; one committed suicide; one died a natural death; and another died from the effects of pain relief sedation.

The Oregon Death with Dignity Act

In November 1994 the Death with Dignity Act was adopted by a referendum vote of Oregon residents of 51 percent against 49 percent. Soon after the act was passed, the act was contested on the grounds that it presumably threatened the lives of terminally ill persons and did not afford them equal protection. A judge granted an injunction on the grounds that the act put people at risk. However, in 1997, the injunction was lifted by the Ninth Court of Appeals, which dismissed the case. The law went into effect in 1997 after the U.S. Supreme Court declined to hear an appeal of the case. A second referendum in November 1997 found 60 percent in favor and 40 percent against this law. In November 2001 the U.S. Attorney General John Ashcroft issued a directive that would have prohibited doctors from prescribing lethal doses of controlled drugs to terminally ill patients. Immediately after issuing the directive, the U.S. District Court in Portland issued a temporary restraining order blocking Ashcroft from punishing physicians who wrote lethal prescriptions. In April 2002 the same court ruled that Ashcroft had over-stepped the authority of the Federal Controlled Substances Act when he declared that writing lethal prescriptions was not a legitimate medical purpose and threatened to revoke the license of physicians who wrote lethal-dose prescriptions to patients who requested one. This decision made the restraining order on Ashcroft permanent; however, as of this writing, the decision may be subject to appeal.

According to this law there are four criteria necessary for an assisted suicide to be conducted in the state of Oregon: (1) the person must be at least eighteen years old, (2) a legal resident of Oregon, (3) able to communicate his or her decisions about medical care, and (4) in the terminal phase of an illness that is defined as having a life expectancy of less than six months. If the patient is eligible, the request must be made twice in less than fifteen days and the request must be made in writing to a physician who then establishes that all the conditions have been met. A second physician must be consulted, and the first physician must inform the patient of all alternatives available. The physician can request that the person inform family members about the request, but this is not obligatory. The physician may then prescribe a lethal medication, which he or she must declare to the Oregon Health Division. This physician has no obligation to participate in the assisted suicide and is protected against any criminal liability under this act.

During the first four years since the law was applied (19982000), 140 prescriptions for lethal doses of medication were written, mainly to cancer patients, and 91 persons died after taking these medications. This constitutes fewer than one-tenth of 1 percent of terminally ill Oregonians dying by physician-assisted suicide.

Conclusions

Arguments for or against active euthanasia that are based upon moral or religious beliefs are impossible to resolve on the basis of empirical facts or logical arguments; these arguments are related to cultural values and practices. However, values and practices can change over time. Some practices that were considered barbaric at one time in history have become acceptable in the twenty-first century. The practice of euthanasia, its legalization, and acceptance in various societies is also influenced by public debate and media reports. With the increased acceptance and legalization of euthanasia in different societies, researchers are gaining more information about the practice of euthanasia and its effects. One of the central issues in the acceptance of euthanasia is weighing society's obligations to provide an easier access to death against society's obligations to provide the means for diminishing pain and suffering among those who may want to die prematurely by euthanasia.

See also: Bioethics; Black Stork; Good Death, The; Informed Consent; Kevorkian, Jack; Natural Death Acts; Suicide Types: Physician-Assisted Suicide

Bibliography

Battin, Margaret P. The Least Worst Death: Essays on Bioethics on the End of Life. New York: Oxford University Press, 1994.

Chin, Arthur E., et al. Oregon's Death with Dignity Act: The First Year's Experience. Portland: Department of Human Services, Oregon Health Division, Center for Disease Prevention and Epidemiology, 1999.

Cicero. Cato Maior de senectute, edited by J.G.F. Powell. Cambridge: Cambridge University Press, 1988.

Gruman, Gerlad J. "An Historical Introduction to Ideas about Voluntary Euthanasia: With a Bibliographic Survey and Guide for Interdisciplinary Studies." Omega: The Journal of Death And Dying 4, no. 2 (1973):87138.

Haeckel, Ernst. The Wonders of Life: A Popular Study of Biological Philosophy, translated by J. Mc Cabe. New York: Harper, 1904.

Hume, David. An Essay on Suicide. 1789. Reprint, Yellow Springs, OH: Kahoe and Co., 1929.

Kasimar, Yale. "Euthanasia Legislation: Some Non-Religious Objections." In T. L. Beauchamp and P. Seymour eds., Ethical Issues in Death and Dying. Englewood Cliffs, NJ: Prentice Hall, 1978.

Mishara, Brian L. "The Right to Die and the Right to Live: Perspectives on Euthanasia and Assisted Suicide." In A. Leenaars, M. Kral, R. Dyck, and S. Wenckstern eds., Suicide in Canada. Toronto: University of Toronto Press, 1998.

Molloy, William. Vital Choices: Life, Death and the Health Care Crisis. Toronto: Penguin Books, 1993.

More, Sir Thomas. Utopia. 1605. Reprint, New Haven, CT: Yale University Press, 1964.

Saint Augustine of Hippo. Augustine: The City of God, edited by T. Merton and translated by M. Dods. New York: Modern Library, 1950.

Senate of Canada. On Life and Death: Report of the Senate Special Committee on Euthanasia and Assisted Suicide. Ottawa: Minister of Supply and Services, 1995.

Spinoza, Benedictus. The Ethics, translated by R. H. M. Elwes. 1677. Reprint, New York: Dover Publications, 1951.

BRIAN L. MISHARA

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Euthanasia

EUTHANASIA

[Greek, good death.] The term normally implies an intentional termination of life by another at the explicit request of the person who wishes to die. Euthanasia is generally defined as the act of killing an incurably ill person out of concern and compassion for that person's suffering. It is sometimes called mercy killing, but many advocates of euthanasia define mercy killing more precisely as the ending of another person's life without his or her request. Euthanasia, on the other hand, is usually separated into two categories: passive euthanasia and active euthanasia. In many jurisdictions, active euthanasia can be considered murder ormanslaughter, whereas passive euthanasia is accepted by professional medical societies, and by the law under certain circumstances.

Passive Euthanasia

Hastening the death of a person by altering some form of support and letting nature take its course is known as passive euthanasia. Examples include such things as turning off respirators, halting medications, discontinuing food and water so as to allowing a person to dehydrate or starve to death, or failure to resuscitate.

Passive euthanasia also includes giving a patient large doses of morphine to control pain, in spite of the likelihood that the painkiller will suppress respiration and cause death earlier than it otherwise would have happened. Such doses of painkillers have a dual effect of relieving pain and hastening death. Administering such medication is regarded as ethical in most political jurisdictions and by most medical societies.

These procedures are performed on terminally ill, suffering persons so that natural death will occur sooner. They are also commonly performed on persons in a persistent vegetative state; for example, individuals with massive brain damage or in a coma from which they likely will not regain consciousness.

Active Euthanasia

Far more controversial, active euthanasia involves causing the death of a person through a direct action, in response to a request from that person. A well-known example of active euthanasia was the death of a terminally ill Michigan patient on September 17, 1998. On that date, Dr. jack kevorkian videotaped himself administering a lethal medication to Thomas Youk, a 52-year-old Michigan man with amyotrophic lateral sclerosis. CBS broadcast the videotape on 60 Minutes less than a week later. Authorities subsequently charged Kevorkian with first-degree premeditated murder, criminal assistance of a suicide, and delivery of a controlled substance for administering lethal medication to a terminally ill man. There was no dispute that the dose was administered at the request of Mr. Youk, nor any dispute that Mr. Youk was terminally ill. A jury found Kevorkian guilty of second-degree murder in 1999. He was sent to prison.

Physician-Assisted Suicide

Somewhat of a hybrid between passive and active euthanasia is physician-assisted suicide (PAS), also known as voluntary passive euthanasia. In this situation, a physician supplies information and/or the means of committing suicide (e.g., a prescription for lethal dose of sleeping pills, or a supply of carbon monoxide gas) to a person, so that that individual can successfully terminate his or her own life.

Physician-assisted suicide received greater public attention after Dr. Kevorkian, a retired pathologist from Michigan, participated in his first such procedure in 1990. Kevorkian set up a machine that allowed a 54-year-old woman suffering from Alzheimer's disease (a degenerative neurological condition) to press a button that delivered a lethal poison into her veins. Kevorkian went on to assist in the suicides of dozens of individuals suffering from terminal, debilitating, or chronic illnesses. In 1992, Michigan passed an assisted-suicide bill (Mich. Comp. Laws § 752.1021) that was specifically designed to stop Kevorkian's activities, but technicalities and questions as to its constitutionality delayed its implementation, thus allowing Kevorkian to continue assisting suicides—often in direct opposition to court injunctions.

Kevorkian was charged with murder several times but was not initially found guilty. When murder charges were brought against him for his first three assisted suicides, for example, they were dismissed because Michigan, at that time, had no law against assisted suicide. In 1994, Kevorkian was tried and found not guilty of assisting in the August 1993 suicide of Thomas W. Hyde Jr. In December 1994, however, Michigan's supreme court ruled in People v. Kevorkian, 447 Mich. 436, 527 N.W. 2d 714, that there is no constitutional right to commit suicide, with or without assistance, and upheld the Michigan statute that made assisted suicide a crime. The following year, the U.S. Supreme Court refused to hear Kevorkian's appeal from the state supreme court's ruling.

Observers disagree about the humanity of Kevorkian's activities. Some see him as a hero who sought to give suffering people greater choice and dignity in dying. Others point to his lack of procedural precautions and fear that the widespread practice of assisted suicide will lead to the unnecessary death of people who could have been helped by other means, including treatment for depression. Many opponents of assisted suicide find the same faults in the practice that they see in other forms of euthanasia. They envision its leading to a devaluation of human life and even to a genocidal killing of vulnerable or so-called undesirable individuals.

The U.S. Supreme Court has made two important rulings on assisted suicide. In washington v. glucksberg, 521 U.S. 702, 117 S.Ct. 2258, 138 L.Ed.2d 772, 65 (1997), three terminally ill patients, four physicians, and a non-profit organization had brought action against the state of Washington for declaratory judgment, that a statute banning assisted suicide violated due process clause. On June 26, 1997, the Supreme Court unanimously upheld the right of states to prohibit assisted suicide, holding that: (1) asserted right to assistance in committing suicide was not a fundamental liberty interest protected by due process clause, and (2) Washington's ban on assisted suicide was rationally related to legitimate government interests. In Vacco v. Quill, 521 U.S. 793, 117 S.Ct. 2293, 138 L.Ed.2d 834 (1997), physicians challenged the constitutionality of New York statutes making it a crime to aid a person in committing suicide or attempting to commit suicide. The Supreme Court held that New York's prohibition on assisting suicide did not violate the equal protection clause of the fourteenth amendment.

Involuntary Euthanasia

The term involuntary euthanasia is used to describe the killing of a person who has not explicitly requested aid in dying. This term is most often used with respect to patients who are in a persistent vegetative state and who probably will never recover consciousness.

Euthanasia Considerations

Euthanasia is a divisive topic, and different interpretations of its meaning, practice, and morality abound. Those who favor active euthanasia and a patient's right to die, do not acknowledge a distinction between active and passive euthanasia. They assert that the withdrawal of life-sustaining treatment cannot be distinguished in principle from affirmative steps to hasten a patient's death. In both situations, they argue, a person intends to cause the patient's death, acts out of compassionate motives, and causes the same outcome. In their view, turning off a life-sustaining respirator switch and giving a lethal injection are morally equivalent actions.

Opponents of active euthanasia argue that it undermines the value of, and respect for, all human life; erodes trust in physicians; desensitizes society to killing; and contradicts many people's religious beliefs. Moreover, they maintain that the intentions and natures of active and passive euthanasia are not essentially the same. In active euthanasia, a person directly intends to cause death and uses available means to achieve this end. In passive euthanasia, a person decides against using a certain form of treatment and then directs that such treatment be withdrawn or withheld, accepting but not intending the patient's death, which is caused by the underlying illness.

While people cite differing reasons for choosing to end their own lives, those suffering from a terminal illness typically state that a serious disorder or disease has adversely affected their quality of life to the point where they no longer wish to continue living. Under such circumstances, patients may have been diagnosed with a degenerative, progressive illness such as ALS, Huntington's disease, multiple sclerosis, AIDS, or Alzheimer's disease. Patients with such illnesses often fear, with good reason, a gradual loss of the quality of life in the future as the disease or disorder progresses, or they might already have lost a good deal of their independence and thus might require continuous care. Some feel that this loss of autonomy causes an unacceptable loss of personal dignity. Others realize that they will be dying in the near future and simply want to have total control over the process. Some point out that in addition to physical considerations, they do not want to diminish their assets by incurring large medical costs as their death approaches. They feel that they ought to have the option to die sooner and to pass on their assets to their beneficiaries.

Euthanasia and Physician-Assisted Suicide

Imagine that you are suffering from a disease that is terminal, debilitating, and very painful. Should you have the right to die when you wish rather than live in continued agony? Should your doctor be legally free to help you take your own life, perhaps by prescribing some pills and telling you their fatal dosage? Or should the law forbid anyone—including doctors—to assist in the suicide of another human being? These are just some of the questions that surround the issue of physician-assisted suicide, a widely debated ethical issue in modern medicine.

Physician-assisted suicide is a form of voluntary euthanasia. In other words, it involves a patient voluntarily acting to end his or her life. Physician-assisted suicide differs from conventional suicide in that it is facilitated by a physician who confirms the patient's diagnosis, rules out conditions such as depression that may be clouding the patient's judgment, and finally provides the means for committing suicide. Such action usually consists of taking a lethal overdose of prescription medication. However, the over 130 patients who were assisted by Dr. jack kevorkian between 1990 and 1998 chose to press a button which delivered a lethal poison into their veins, or to put on a mask that emitted carbon monoxide into their lungs. Assisted suicide is a felony offense in most states and is also expressly forbidden in the American Medical Association's (AMA's) Code of Medical Ethics. In 1999, Kevorkian was found guilty of second-degree murder in an assisted suicide case. He was sentenced to serve 10 to 25 years.

The debate surrounding physician-assisted suicide in the United States has been influenced by medical practices in other countries, particularly the Netherlands, which legalized both active euthanasia and physician-assisted suicide, in April 2001 (effective 2002). Physician-assisted suicide in the Netherlands is conducted within strict guidelines that include the following requirements: the patient's request for assisted suicide must be voluntary, the patient must be experiencing intolerable suffering, all other alternatives for treatment must have been explored, and the physician must consult another independent physician before proceeding. A study commissioned by the Dutch government indicated that, in 2001, about 3,500 deaths, or 2.5 percent of the 140,000 death cases that were reported in the Netherlands that year, occurred by active euthanasia. The study, known as the Remmelink Report, defined euthanasia as the termination of life at the patient's request. Figures also indicated that 300 deaths, or 0.2 percent, were caused by physician-assisted suicide.

In the United States, the debate on legalizing assisted suicide began in earnest in the 1970s. On one side of the debate have been patients' rights groups who have lobbied for what they call the right to die—or the right to choose to die, as some have clarified it— of terminally ill patients. The strongest opposition to the legalization of physician-assisted suicide has come from physicians' groups such as the AMA and from religious groups that are morally opposed to the practice.

One person who has done much to make the case for physician-assisted suicide is Derek Humphry, a former journalist who founded the Hemlock Society, in 1980, after seeing the pain and suffering his first wife experienced when she died from cancer. In 2003, the organization changed its name to End-of-Life Choices, which encompasses more clearly the issues supported by its members. With a new name and a new motto, "Dignity Compassion Control," the organization continues to advocate for the right of terminally ill people to choose voluntary euthanasia, or what Humphry has termed self-deliverance.

Humphry has written several books on the subject of voluntary euthanasia, including Jean's Way (1978), which recounts his struggle to assist his wife's death in 1975; Final Exit: The Practicalities of Self-Deliverance and Assisted Suicide for the Dying (1991), a controversial book that gives detailed advice on how terminally ill people may take their own life; and Lawful Exit: The Limits of Freedom for Help in Dying (1993), which contains Humphry's own recommendations for legislation that would legalize physician-assisted suicide and active voluntary euthanasia. In Humphry's words, the "right to choose to die" is "the ultimate civil liberty."

Humphry presents physician-assisted suicide as a merciful, dignified option for people whose illness has eroded their quality of life beyond the limits of tolerance. He also points out that what he calls beneficent euthanasia occurs every day in medical facilities as physicians make decisions regarding the end of life. Others, including some medical ethicists, go so far as to claim that a decision to withhold antibiotics, oxygen, or nutrition from a terminally ill patient is no less "active" a form of euthanasia than is administering a fatal dose of morphine. Indeed, they see the common practice of withholding life support as more open to potential abuse than the practice of physician-assisted suicide. The former, they argue, is a less visible, less easily regulated decision. Proponents of physician-assisted suicide also claim that diseases kill people in far more cruel ways than would any means of death that a physician might provide for an irreversibly ill patient. As a result, they see the action of assisting in suicide as entirely compatible with the physician's duty to the patient.

However, Humphry has been an open critic of Kevorkian's work. He has described Kevorkian's theory and practice of assisted suicide as open-ended euthanasia. Noting Kevorkian's lack of precautionary measures such as the use of waiting periods and second opinions, Humphry sees any wider application of Kevorkian's methods as potentially leading to abuse and tragedy. "The thinking people in our movement are appalled by it," Humphry said. "If you have Kevorkian's type of euthanasia, it will be a slippery slope. Kevorkian's is a recipe for skiing down a glacier."

Detractors of physician-assisted suicide also use the familiar "slippery slope" argument, proposing that once physician-assisted suicide is legalized, other forms of euthanasia will more likely be practiced as well. They see assisted suicide as potentially leading to situations in which elderly, chronically ill, and handicapped people, along with others, are killed through active, nonvoluntary euthanasia. Related to this idea is the view that widespread practice of physician-assisted suicide might claim the lives of those whose intolerable suffering is caused by treatable depression. They point out that terminally ill people or others in pain are often also suffering from depression, and that despite their illness, their feelings of hopelessness can often be addressed through means such as counseling and antidepressant medication.

The Catholic Church is one of many religious organizations that opposes euthanasia and assisted suicide. In Pope John Paul II's words, medical killings such as those caused by assisted suicide are "crimes which no human law can claim to legitimize." Basing its arguments on passages from the Bible, Catholic theology has for many centuries opposed all forms of suicide. Catholicism argues that innocent human life may not be destroyed for any reason whatsoever.

The debate over physician-assisted suicide eventually reached the Supreme Court. In 1994, an advocacy group known as Compassion in Dying filed two lawsuits (Compassion in Dying et al v. Washington and Quill et al v. Vacco) challenging the constitutionality of state laws banning assisted dying in Washington and New York. Compassion in Dying won in the District Court in Washington. Chief Judge Barbara Rothstein wrote, "There is no more profoundly personal decision, nor one which is closer to the heart of personal liberty, than the choice which a terminally ill person makes to end his or her suffering and hasten an inevitable death." In New York, Compassion in Dying lost and filed an appeal in the Second Circuit.

In 1995, Washington's Compassion ruling was overturned by the Ninth Circuit Court of Appeals, reinstating the anti-suicide law. In 1996, however, after reconsideration, the Ninth Circuit Court of Appeals issued a reversal decision in Compassion v. Washington. That decision held that assisted dying was protected by liberty and privacy provisions of the U.S. Constitution. The majority wrote that, "Those who believe strongly that death must come without physician assistance are free to follow that creed, be they doctors or patients. They are not free, however, to force their views, their religious convictions, or their philosophies on all the other members of a democratic society, and to compel those whose values differ with theirs to die painful, protracted, and agonizing deaths."

In April 1996, the Second Circuit joined the Ninth in recognizing constitutional protection for assisted dying in the Quill case, holding that the New York statutes criminalizing assisted suicide violate the equal protection clause of the fourteenth amendment. However, on June 26, 1997, the U.S. Supreme Court reversed both the Ninth and Second Circuit Court in washington v. glucksberg, 521 U.S. 702, 117 S.Ct. 2258, 138 L.Ed.2d 772 (1997) and Vacco v. Quill, 521 U.S. 743, 117 S.Ct. 2293, 138 L.Ed.2d 834 (1997). The Court ruled that state laws against assisting a suicide are not unconstitutional, but also stated that patients have a right to aggressive treatment of pain and other symptoms, even if the treatment hastens death. The Court wrote, "Throughout the Nation, Americans are engaged in an earnest and profound debate about the morality, legality and practicality of physician assisted suicide. Our holding permits this debate to continue, as it should in a democratic society."

Ultimately then, the voters and representatives of the states and the legal system itself will have to decide whether or not physician-assisted suicide will be legalized. Regardless of what side prevails in the debate, the exchange of ideas that it creates may lead to a greater understanding of the difficult choices surrounding death in our time.

further readings

Cohen-Almagor, Raphael. 2001. The Right to Die With Dignity: An Argument in Ethics, Medicine, and Law. New Brunswick, N.J.: Rutgers Univ. Press.

End of Life Choices. Available online at <www.endoflifechoices.org> (accessed August 25, 2003).

Hendin, Herbert. 2002. "The Dutch Experience." Issues in Law & Medicine (spring).

cross-references

Death and Dying; Physicians and Surgeons.

Some patients who decide that they wish to commit suicide are unable or unwilling to accomplish the act without assistance from their physician. Physician-assisted suicide helps them to die under conditions, and at the time, that they wish. PAS is currently legal in the U.S., only in the state of Oregon, under severe restrictions. In other states, a terminally ill patient who wishes to die must continue living until their body eventually collapses, or until a family member or friend commits a criminal act by helping them to commit suicide.

Historical Considerations

Traditional Christian beliefs concerning all forms of suicide were well documented by Thomas Aquinas during the thirteenth century. He condemned all suicide (whether assisted or not) on the theory that it violated one's natural desire to live. Among European writers, Michel de Montaigne was the first major dissenter on this issue. During the sixteenth century, he wrote a series of essays arguing that suicide should be a matter of personal choice, a human right. He concluded it to be a rational option under certain circumstances.

Attempting to commit suicide was once a criminal act. It has been decriminalized for many decades in most jurisdictions. However, assisted suicide remains a criminal act throughout the United States, with the exception of the state of Oregon. In that state, it is permitted under tightly controlled conditions.

Oregon's Euthanasia Law

In 1994, voters in the state of Oregon approved a ballot measure that would have legalized euthanasia under limited conditions. Under the Death With Dignity law, a person who sought physician-assisted suicide would have to meet certain criteria:

  • The person must be terminally ill.
  • The person must have six months or less to live.
  • The person must make two oral requests for assistance in dying.
  • The person must make one written request for assistance in dying.
  • The person must convince two physicians that he or she is sincere and not acting on a whim, and that the decision is voluntary.
  • The person must not have been influenced by depression.
  • The person must be informed of "the feasible alternatives," including, but not limited to, comfort care, hospice care, and pain control.
  • The person must wait for 15 days.

Under the proposed law, a person who met all requirements could receive a prescription of a barbiturate that would be sufficient to cause death. Physicians would be prohibited from inducing death by injection or carbon monoxide.

The national right to life committee, supported by the Roman Catholic Church, obtained a court injunction to delay implementation of the measure. The law stalled in the appeals process. In the meantime, the measure was not enacted. In 1997, there was a second public referendum, and the law was enacted. Within 24 hours of the announcement of the results, state officials had forms for physicians to record instances of assisted suicide. These were later distributed to physicians in the state. The form is entitled "Request for Medication to End My Life in a Humane and Dignified Manner."

Immediately after the law was affirmed, Thomas Constantine, the administrator of the federal drug enforcement administration (DEA), wrote a policy statement which said that prescribing drugs to help terminally ill patients kill themselves would be a violation of the Controlled Substances Act. Nevertheless, on March 26, 1998, a woman in her mid-eighties died from a lethal dose of barbiturates, which had been prescribed by her doctor under the Oregon law. She was the first person to publicly use the law to commit suicide. She had been fighting breast cancer for 20 years and recently had been told by her doctor that she had less than two months to live. She had been experiencing increased difficulty breathing. She made a tape recording in which she stated, "I'm looking forward to it. I will be relieved of all the stress I have." Her personal doctor would not help her end her life, so she turned to an advocacy group, Compassion in Dying. That group located a doctor to assist her. She fell into a deep sleep about five minutes after taking the lethal dose of pills, and she died peacefully about 25 minutes later. Attorney General janet reno officially reversed Constantine's ruling a few weeks later, stating that doctors who use the law to prescribe lethal drugs to terminally ill patients will not be prosecuted and that drug laws were intended to block illegal trafficking in drugs, not to cover situations like the Oregon suicide law.

Despite significant controversy, by the end of 1998, one prediction of the anti-choice forces had not materialized: there was no rush of people to Oregon to seek an easy end to life. While it was predicted that many would take advantage of the law, of the 23 terminally ill individuals who applied to end their own lives in 1998, 15 committed suicide, usually within a day of receiving the prescription. Six died from their illnesses without using the medication. Two remained alive at the end of 1998. From 1998 to 2002, 129 people have opted for physician assisted suicide.

In early 2001, Oregon state senator Ron Wyden wrote Attorney General john ashcroft asking that the george w. bush administration not mount an attack on the state law permitting assistance in suicide. Ashcroft wrote a letter to Asa Hutchinson, chief of the Drug Enforcement Administration. He declared that assisting a terminally ill patient to commit suicide is not a "legitimate medical purpose" for federally controlled drugs. He said that physicians who use drugs to help patients die face suspension or revocation of their licenses to prescribe federally controlled drugs. This was contrary to the position taken by Janet Reno, his predecessor. The attorney general of Oregon, Hardy Myers, quickly initiated a lawsuit to have the Ashcroft's directive declared unconstitutional. The federal district court in Oregon issued a temporary injunction, which prevents the federal government from enforcing Ashcroft's interpretation of the Controlled Substances Act (CSA). The state of Oregon requested that the court block the federal department of justice from taking legal action against Oregon doctors who prescribe medication to help their patients commit suicide. A federal judge ruled in favor of the state law in 2002, and the Department of Justice appealed the decision to the U.S. Court of Appeals for the Ninth Circuit. Both sides have stated that they will appeal the decision if they lose.

Other States

According to the online website, Euthanasia.com, 35 states have legislated against assisted suicide, while nine other states have cited it as a crime under common law. Still more states have introduced or passed statutes criminalizing assisted suicide. These statutes forbid a person to knowingly assist or aid another in committing suicide. Some also prohibit soliciting, advising, or encouraging another to commit suicide. Some statutes penalize assisted suicide under guidelines established for murder or manslaughter, whereas others make it a unique offense with separate penalties. Few courts have interpreted the assisted-suicide statutes, because prosecutions for assisted suicide are rare. In cases of assisted suicide, a state usually prosecutes individuals for murder or manslaughter. The Ohio state supreme court, however, ruled in 1996 that assisted suicide is not a crime.

further readings

Behuniak, Susan M. 2003. Physician-Assisted Suicide: The Anatomy of a Constitutional Law Issue. Lanham, Md.: Rowman & Littlefield.

Dyck, Arthur J. 2001. When Killing Is Wrong: Physician-Assisted Suicide and the Courts. Cleveland, Ohio: Pilgrim Press.

Euthanasia.com. Available online at <www.euthanasia.com> (accessed November 10, 2003).

Palmer, Larry I. 2000. Endings and Beginnings: Law, Medicine, and Society in Assisted Life and Death. Westport, Conn.: Praeger.

cross-references

Death and Dying.

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Euthanasia and Assisted Suicide

Euthanasia and Assisted Suicide

ISSUES SURROUNDING CONTROVERSIAL END-OF-LIFE DECISIONS

ARGUMENTS REGARDING PAS AND EUTHANASIA

INTERNATIONAL VIEWS OF PAS AND EUTHANASIA

CONCLUSION

BIBLIOGRAPHY

The twentieth century has seen great strides in the advancement of medicine and life-sustaining technology, resulting in improved life expectancy and quality of life for people around the world. Improvements in medicine, however, raise questions about the appropriateness of life-sustaining treatments in the case of people who are terminally ill and experiencing acute pain and suffering. In the late twentieth century, end-of-life issues came to the forefront of public attention, resulting in an ongoing discussion about ethical, legal, and political implications of physician-assisted suicide (PAS) and euthanasia.

ISSUES SURROUNDING CONTROVERSIAL END-OF-LIFE DECISIONS

Part of the controversy surrounding end-of-life decisions such as PAS and euthanasia results from a lack of clear communication as to what these actions entail. Euthanasia refers to someone (often a physician) intentionally taking an action that ends another persons life with the stated intent of alleviating or preventing perceived suffering. Euthanasia involves the direct administration of lethal medication by a person other than the terminally ill patient. Assisted suicide is the deliberate and knowing provisions of information, the means, and/or help to another person for the act of suicide (American Association of Suicidology 1996, p. 6). In PAS, the assister is a medical doctor. Such assistance is typically in the form of a prescription for a lethal dose of medication that the terminally ill patient may use as a means to end his or her life. The critical distinction between these practices is that in euthanasia the physician (or somebody else) actively administers the lethal medication, while in PAS the patient is given the means to bring about his or her own death.

There are various types of euthanasia, including voluntary, nonvoluntary, and involuntary. Voluntary euthanasia refers to deliberate termination of a patients life upon that persons explicit and direct request. Nonvoluntary euthanasia occurs when the patient is unconscious or incompetent and is thus unable to make a decision. Involuntary euthanasia takes place when the patient is competent and aware but his or her consent is not obtained. It should be noted that involuntary euthanasia is not an acceptable practice even in countries where voluntary euthanasia is currently legalized. The involuntary termination of a patients life is not supported by legislation and is considered homicide around the world. This distinction has led several authors to argue that euthanasia is by definition voluntary and that terms such as nonvoluntary and involuntary euthanasia are contradictory and misleading (Materstvedt Clark, Ellershaw, et al., 2003).

In addition, distinction has been made between active and passive euthanasia. Active euthanasia is the procedure whereby a physician (or someone else) shortens a persons life, usually through the administration of a lethal dose of medication. Passive euthanasia refers to the practice of withholding or withdrawing a futile or ineffective treatment upon the patients request (American Association of Suicidology 1996). Several researchers have argued against the use of this latter term by pointing out that practices such as withholding and withdrawing treatment are ethically and legally distinct from active euthanasia (Materstvedt, Clark, Ellershaw, et al. 2003). This view is consistent with practices in countries such as the United States and Israel where euthanasia is illegal, but withholding and withdrawing treatment are acceptable medical practices (Ganz, Benbenishty, Hersch, et al. 2006). However, in other countries the term passive euthanasia is still used. Similarly, providing high doses of pain-relieving medication, even if this may shorten a patients life, is seen as distinct from euthanasia (Materstvedt, Clark, Ellershaw, et al. 2003). This is also the case with terminal sedation, a practice whereby pain medication is used to bring about unconsciousness, after which life-support equipment is withdrawn (Parpa, Mystajudou, Tsilika, et al. 2006).

ARGUMENTS REGARDING PAS AND EUTHANASIA

A firm grasp on the definitions of PAS and euthanasia as well as on the alternatives that exist to these practices is essential for an informed understanding of the debate surrounding end-of-life decision-making. As of the early twenty-first century, more empirical data are necessary in order to evaluate the accuracy of arguments in favor of and against PAS and euthanasia.

Proponents of assisted suicide and euthanasia claim the practices exist but are hidden, and legalizing such acts would allow for stricter government regulation and control (Quill and Battin 2004). In addition, involving medical practitioners in the decision-making process would allow for professional and expert judgment to be made regarding the validity of end-of-life decisions. Another fundamental argument in favor of legalizing PAS and euthanasia is maximizing personal autonomy and self-determination. According to this view, a terminally ill patient who is enduring unbearable pain or suffering is entitled to the right of choosing death with dignity and peace. Alleviation of unnecessary suffering and maintaining the quality of life of terminally ill patients are the paramount goals behind PAS and euthanasia. Some proponents of PAS claim that this practice is ethically different from euthanasia, as in PAS the patient is the one who performs the act of ending his or her life.

Opponents of euthanasia and PAS point out the potential for abuse if these practices are granted legal recognition (Foley and Hendin 2002). Critics of PAS and euthanasia often refer to the threat of a slippery slope. They fear that once voluntary euthanasia or PAS for terminally ill patients becomes legally permissible, other forms of medicalized killing, such as involuntary euthanasia for mentally incompetent and/or disabled individuals would increase. Many medical professionals state that euthanasia and PAS are prohibited under the Hippocratic Oath and violate the fundamental ethical principles of nonmaleficence and beneficence. Furthermore, these professionals argue that the need for such end-of-life decisions can be eliminated with the provision of appropriate palliative care and the effective use of pain control medication.

Questions have also been raised about the stability and rationality of end-of-life requests (Foley and Hendin, 2002). In addition, patients may request PAS or euthanasia as a result of experiencing hopelessness and depression rather than acute physical pain or suffering. Alternatively, the patients may feel obligated to alleviate their families from unnecessary burden and thus feel pressured to end their lives. Finally, many opponents claim that the sanctity of human life overrules concerns of personal autonomy and that the protection of human life should be of paramount importance in end-of-life medical cares.

INTERNATIONAL VIEWS OF PAS AND EUTHANASIA

Both euthanasia and PAS were legalized in the Netherlands in 2002 after they had been tolerated for more than 30 years (Materstvedt, Clark, Ellershaw, et al. 2003). Belgium legalized euthanasia in September 2002, and did not legalize PAS (Adams and Nys 2003). Physician-assisted suicide, but not euthanasia, was legalized in Oregon in 1994 with the Death with Dignity Act, and began to be in use in 1997 (Materstvedt, Clark, Ellershaw, et al. 2003). In 2006, the Oregon Department of Human Services announced that it will no longer use the term physician-assisted suicide to describe deaths under the Death with Dignity Act (Colburn 2006) because the act itself specifies that deaths that occur following the provisions of the law are not to be considered suicide. Although active euthanasia is illegal in Switzerland, assisting in the suicide of a terminally ill patient is considered a crime only if the death, and therefore the motive behind the assistance, benefits the person who assists the suicide (Schildmann, Herrmann, Burchardi, et al. 2006). Although Australias Northern Territory was the first jurisdiction to legalize euthanasia in 1995, the Rights of the Terminally Ill Act was repealed nine months later by an act of the Commonwealth (Materstvedt, Clark, Ellershaw, et al. 2003).

The legalization of PAS and euthanasia in several nations signals changes in public awareness of end-of-life issues. However, countries with legal endorsement of these interventions are the exception rather than the rule. A 2001 survey conducted by the Council of Europe (2003) revealed that a majority of European nations do not have laws concerning assisted suicide and euthanasia. Of those nations that do have laws, the overwhelming majority oppose the practices. A 1999 study by Luigi Grassi, Katia Magnani, and Mauro Ercolani, published in the Journal of Pain & Symptom Management, found that only 15 percent of Italian physicians favored euthanasia and assisted suicide. In Ireland, where suicide was considered a crime until 1993, discussions of euthanasia and assisted suicide have been taboo (Phillips 1997).

Euthanasia is not a legal option in Germany and physicians are obligated to prevent harm, which may also include cases of attempted suicide. However, suicide and assisted suicide are not considered criminal acts because of an artifact of German law (Schildmann, Herrmann, Burchardi, et al. 2006). This creates a precarious situation in which assisted suicide is theoretically an option for German physicians but may lead to legal sanctions if an argument is made that there was a duty to protect the patients life. As of 2003, open discussion on PAS and euthanasia does not exist in Bosnia-Herzegovina (Haraçic 2003), and Estonia has not engaged in a public debate surrounding end-of-life issues (Koorits 2003). In Greece, only 8.1 percent of the general public and 2.1 percent of physicians favor PAS, although 56.7 percent of the surveyed medical doctors had administered terminal sedation (Parpa, Mystajudou, Tsilika, et al. 2006). In Russia, euthanasia is seen as contrary to the physicians duty to preserve and promote human life and is therefore considered unethical and illegal (Leenaars and Connolly 2001). In contrast, a large percentage of physicians in China may approve of euthanasia, although such acts are not officially legalized (Leenaars and Connolly 2001). In India, 50 percent of medical students favor euthanasia (Leenaars and Connolly 2001). Israeli medical doctors view euthanasia, PAS, and withdrawing of treatment as being forbidden by Jewish ethics and law; however, withholding of treatment is an accepted practice (Ganz, Benbenishty, Hersch, et al. 2006).

Issues of culture, religion, and national history are critical when attempting to explain the observed differences in beliefs about end-of-life decision-making. Several authors have hypothesized that positive attitudes toward PAS and euthanasia are the product of highly industrialized, individualistic societies (Kemmelmeier, Wieczorkowska, Erb, and Burnstein 2002). For example, an increase in positive attitudes regarding autonomy in the United States beginning in the late twentieth century has been correlated with a shift toward more positive attitudes regarding assisted suicide (Kemmelmeier, Wieczorkowska, Erb, and Burnstein 2002). In collectivistic societies such as Japan, arguments about the right to self-determination hold less appeal and end-of-life decisions are seen as prerogatives of the family as well as of the individual patient (Konishi and Davis 2001).

This picture is complicated by differences in religion. Most religions of the world uphold the sanctity of human life and prohibit actions that intentionally hasten death. Catholicism officially disapproves of euthanasia and PAS, as does the Christian Eastern Orthodox Church (Parpa, Mystajudou, Tsilika, et al. 2006). There are a variety of branches of Judaism, some of which oppose the active shortening of human life but deem interventions that artificially extend the agony of terminally ill patients unnecessary, therefore allowing withholding and withdrawing treatment (Gesundheit, Steinberg, Glick, et al. 2006). Islam does not recognize a patients right to die but allows for non-treatment decisions such as withholding and withdrawal of treatment to be made by the patients family and community (Sachedina 2005). Islamic law also condones the use of pain-reducing medication at the risk of shortening the life of a terminally ill patient (Sachedina 2005).

Views about euthanasia and PAS are further affected by national history. The term euthanasia, for example, evokes negative memories in many German-speaking countries where the term was used during the Nazi regime to refer to the systematic extermination of six million Jews and more than 200,000 mentally ill and physically disadvantaged people, as well as the Roma (Schildmann, Herrmann, Burchardi, et al. 2006) and other groups. Such historical experiences have prohibited public discussions of euthanasia in Germany (Schildmann, Herrmann, Burchardi, et al. 2006).

CONCLUSION

Given the advances in life-sustaining technology and medical treatments, the controversy surrounding end-of-life decision-making is likely to continue, at least in technologically advanced countries. Open discussion of PAS and euthanasia is complicated by a constantly evolving terminology and differing cultural, religious, and national ideals. People need to stay informed of current developments and research on these issues in order to be prepared to face the end-of-life dilemmas of the future.

SEE ALSO Death and Dying; Morbidity and Mortality; Suicide

BIBLIOGRAPHY

Adams, Maurice, and Herman Nys. 2003. Comparative Reflections on the Belgian Euthanasia Act 2002. Medical Law Review 11: 353376.

American Association of Suicidology. 1996. Report of the Committee on Physician-Assisted Suicide and Euthanasia. Suicide and Life-Threatening Behavior 26 (suppl.): 119.

Colburn, Don. 2006. Death Acts Alias Has State Tongue-Tied. The Oregonian. November 11. http://www.oregonlive.com/.

Council of Europe, Steering Committee on Bioethics. 2003. Replies to the Questionnaire for Member States Relating to Euthanasia. Strasbourg, France: Council of Europe. http://www.coe.int/t/e/legal_affairs/legal_cooperation/bioethics/activities/euthanasia/1INF(2003)8e_replies_euthanasia.pdf.

Foley, Kathleen, and Herbert Hendin, eds. 2002. The Case Against Assisted Suicide: For the Right to End-of-Life Care. Baltimore, MD: Johns Hopkins University Press.

Ganz, F. D., J. Benbenishty, M. Hersch, et al. 2006. The Impact of Regional Culture on Intensive Care End of Life Decision Making: An Israeli Perspective from the ETHICUS Study. Journal of Medical Ethics 32: 196199.

Gesundheit, Benjamin, Avraham Steinberg, Shimon Glick, et al. 2006. Euthanasia: An Overview of the Jewish Perspective. Cancer Investigation 24: 621629.

Grassi, Luigi, Katia Magnani, and Mauro Ercolani. 1999. Attitudes toward Euthanasia and Physician-Assisted Auicide among Italian Primary Care Physicians. Journal of Pain & Symptom Management 17: 188196.

Haračić, Midhat. 2003. From Bosnia-Herzegovina. Palliative Medicine 17: 128.

Kemmelmeier, Markus, Grazyna Wieczorkowska, Hans-Peter Erb, and Eugene Burnstein. 2002. Individualism, Authoritarianism, and Attitudes toward Assisted Death: Cross-Cultural, Cross-Regional, and Experimental Evidence. Journal of Applied Social Psychology 32: 6085.

Konishi, Emiko, and A. J. Davis. 2001. The Right-to-Die and the Duty-to-Die: Perceptions of Nurses in the West and in Japan. International Nursing Review 48: 1728.

Koorits, Ursula. 2003. From Estonia. Palliative Medicine 17: 127.

Leenaars, Antoon, and John Connolly. 2001. Suicide, Assisted Suicide and Euthanasia: International Perspectives. Irish Journal of Psychological Medicine 18: 3337.

Materstvedt, Lars, David Clark, John Ellershaw, et al. 2003. Euthanasia and Physician-Assisted Suicide: A View from an AEPC Ethics Task Force. Palliative Medicine 17: 97101.

Parpa, Efi, Kyriaki Mystajudou, Eleni Tsilika, et al. 2006. The Attitudes of Greek Physicians and Lay People on Euthanasia and Physician-Assisted Suicide in Terminally Ill Cancer Patients. American Journal of Hospice and Palliative Medicine 23: 297303.

Phillips, Pat. 1997. Views of Assisted Suicide from Several Nations. Journal of the American Medical Association 278: 969971.

Quill, Timothy E., and Margaret P. Battin, eds. 2004. Physician-Assisted Dying: The Case for Palliative Care and Patient Choice. Baltimore, MD: Johns Hopkins University Press.

Sachedina, Abdulaziz. 2005. End-of-Life: The Islamic View. The Lancet 366: 774779.

Schildmann, Jan, Eva Herrmann, Nicole Burchardi, et al. 2006. Physician-Assisted Suicide: Knowledge and Views of Fifth-Year Medical Students in Germany. Death Studies 30: 2939.

Elena Yakunina

Jessica Richmond

James L. Werth Jr.

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Euthanasia

Euthanasia


The passage from life to death should be serene and dignified, not an agonizing ordeal. This conception of eu (good) thanasia (death) is expressed in the term itself as it comes from Greek antiquity. A serene death might be achieved through skilled and compassionate care, as well as by the dying person's own sense of having lived a righteous life. There were circumstances, however, in which hastening the end of a life seemed the only apparent way to relieve suffering. A fatally injured or wounded individual might implore another person to put an end to the suffering. Mercy killing, as it became known, occurred on battlefields throughout the world. Animals with painful and fatal injuries would also be released from their suffering.

The root conception of euthanasia has divided itself into two branches. Prevention and reduction of suffering is the primary mission of the hospice or palliative care movement (Saunders 1997). State of the art medication, skilled nursing care, and family support enhance the possibilities of maintaining a meaningful quality of life until the end. The other branch advocates the principle and practice of avoiding suffering by foreshortening life. Health care professionals, ethicists, clergy, and the general public are all faced with the question of what guidelines should be used in attempting to help people to end their lives without pain and other distressing symptoms. Should people rely upon palliative care—and only palliative care—in every instance? Or is it acceptable—even obligatory—to terminate a life to prevent further suffering?


Euthanasia: History, Controversy, Facts

Objective discussion of euthanasia has become increasingly difficult since this term became associated with state-sponsored mass murder in Nazi Germany. Robert J. Lifton (1986) documents in The Nazi Doctors how these doctors took the lives of thousands of their fellow citizens on orders from the government. These unfortunates were institutional residents who required shelter and care but were neither terminally ill nor in pain. They were "useless eaters" whose murder was thinly disguised as euthanasia. The fact that this program could be carried out without effective protest became a stepping stone for the subsequent slaughter of Jews and Romi (Gypsies) in the Holocaust.

This cynical abuse of the euthanasia concept was itself encouraged by two previous movements (Pernick 1996). Eugenics had as its mission the weeding out of "inferior" genetic stock from the population in order to upgrade society with the finest human specimen. Sterilization of people deemed to have undesirable characteristics was to be the major tool, but other possibilities were also being considered. In the United States one of these other possibilities gained some influential advocacy: infants born with impairments should be allowed to perish or perhaps be "mercifully" put to death immediately. The Black Stork movement did not succeed in its aims, but raised enough clamor to attract the attention of people who would later become active in the Nazi movement.

Awareness of the Nazi mass murders has made many people wary of any movement that speaks favorably of euthanasia. It has generated the slippery slope argument: Permitting any action to end a person's life in any situation might lead to many more deaths. People who give high priority to the slippery slope argument often are sympathetic to the plight of a particular person who is suffering greatly. They might assent to some form of euthanasia in this instance, but fear that such a precedent would make it easier to end the life of somebody whose condition is less serious, and so on until one has slipped way down the slope. Proponents believe that adequate safeguards through legislation, regulation, and due process can limit euthanasia to the situations in which it is most appropriate.

One of the most controversial issues centers on the use of active versus passive euthanasia. Active euthanasia occurs when something is done with the specific intention of ending a person's life, such as injecting a lethal medication. Passive euthanasia occurs when interventions that might prolong life are withheld, such as deciding against connecting a dying person to a life support. This distinction, though, is not always so straightforward. Is "pulling the plug" a form of active or passive euthanasia? It might be considered active because it requires an intentional action to turn off life support services. However, the weight of opinion now considers withdrawal of interventions to be a passive form of euthanasia: one stops doing something.

The distinction is consequential because some people who reject active euthanasia do accept passive euthanasia as a practice that provides benefits to the dying person without violating ethical standards and religious values. Legislation and court decisions also tend to treat active and passive euthanasia differently. The situation is even more complicated. It can also be argued that it is an evasion to regard passive euthanasia as acceptable while condemning active interventions because both approaches result in an earlier death. Perhaps passive euthanasia is also sometimes unintentionally cruel because the person continues to suffer while life runs out (Rachels 1989). Whether or not we should continue to focus on the active versus passive distinction is a controversy that does not seem close to resolution.

Support has not come easily for even the more limited forms of euthanasia: withholding or withdrawing life support interventions. The living will was introduced in 1968 as a document expressing an individual's wish to avoid "artificial means and heroic measures" at the end of life (Scofield 1989). This document did not have the force of law, depending instead on the willingness of physicians to accept the patient's request. The landmark case of Karen Ann Quinlan in 1975 aroused enormous public and professional controversy in addition to the personal distress experienced by her parents (Kastenbaum 2001). The young woman lapsed into a coma after a party and never recovered consciousness. Physicians believed she would die if taken off the ventilator. Courts first ruled against and then in favor of the request to withdraw this intervention. To the astonishment of many, Quinlan lived another ten years, though without showing any signs of mental life. Courts have since made a variety of rulings with the overall effect of accepting withdrawing of treatment under specified circumstances. The significant principle of informed consent has also received support: a mentally competent person has the right to reject proposed treatments. Advance directives—more flexible and refined versions of the living will—now provide individuals with an improved opportunity to state their preferences for end-of-life care, thereby reducing the burden of decision making on the part of others (King 1996). Furthermore, most state legislatures have passed natural death acts that affirm a person's right to avoid the prolongation of suffering or a persistent vegetative state.

Very much still gripped by controversy is the proposition that society should honor "death on demand" (Baird and Rosenbaum 1989; Cohen 1988; Gomez 1991; Kevorkian 1991; Scherer and Simon 1999; Singer 1996). Should physicians be permitted—or even required—to end a terminally ill and suffering person's life by lethal injection or similar means? Proponents argue that the individual has the right to die as well as the right to live. Society fails dying people, consigning them to agony and despair. It is time to shake off outmoded tradition and provide a quick and merciful ending for those in terminal torment.

Opponents muster arguments from a variety of perspectives. "Thou shalt not kill" and "Man should not play God" are objections that are based on religious faith. "Doctors should not kill" expresses the view that the physician's reputation and role would be compromised by also becoming an agent of death. The prohibition against doctors providing lethal medicines is traced back to the Hippocratic Oath (fifth century b.c.e.), but in reality physicians have been divided on this subject since antiquity, and the Oath itself does not command as much power in the medical community as one might suppose (Edelstein 1943; Kevorkian 1991). Another objection has already been noted: the slippery slope is sure to become even more treacherous if physician-assisted death is countenanced. For every death that occurs after due process, many others will take place on whim and impulse.

Perhaps the most formidable criticism comes from people who are familiar with hospice care. Jack Kevorkian, M.D., the most conspicuous advocate and practitioner of physician-assisted death in the United States, has been charged with ignorance both of palliative care measures, depression, and family dynamics (Kaplan 2000). According to these criticisms, Kevorkian has performed and encouraged medical homicides on people who (1) could have found relief through competent management of their symptoms, (2) needed treatment for depression, and (3) were not terminally ill in the first place. Studies reported by Kalman J. Kaplan and his colleagues provide some support for these charges. After being associated with more than a hundred deaths, Kevorkian was found guilty and jailed on charges of second degree murder.

The world continues to observe, wonder, and dispute about the legalization of euthanasia in the Netherlands. The issue became salient in 1973 when a doctor obeyed her dying mother's request to end her life. Eventually the Dutch Supreme Court made a ruling that has remained confusing to those not familiar with that nation's justice system. Euthanasia was illegal, but it was also acceptable—if it involves a competent person who has had full access to information and an adequate time to decide, and is in a situation of intolerable and hopeless suffering without any acceptable alternative remaining. The physician must also consult another independent doctor with experience in end-of-life care. Over the years doctors practicing euthanasia in the Netherlands have either followed these guidelines conscientiously, or found ways around the guidelines whenever it suited the physician's interests—depending on whose version of the events and which study one cares to believe. The legal side of the issue was clarified when the Dutch parliament passed and the Senate confirmed a pro-euthanasia legislative act (April 11, 2001).

Other nations are also struggling with the euthanasia decision. Australia's Northern Territory, for example, approved physician-assisted suicide for the terminally ill, but it proved difficult to find doctors willing to perform this act, and the measure itself was subsequently overturned at the national level. A voter-approved bill is on the books in Oregon, but the future of legalized physician-assisted death in the United States, as in most other nations, remains an open question.


See also:Death and Dying; Grief, Loss, and Bereavement; Hospice; Infanticide; Suicide


Bibliography

baird, robert m., and rosenbaum, stuart e., eds. (1989).euthanasia. the moral issues. buffalo, ny: prometheus press.

cohen, cynthia b. (1988). casebook on the termination of life-sustaining treatment and the care of the dying. bloomington: indiana university press.


edelstein, l. (1943). the hippocratic oath: text, translation, and interpretation. baltimore: johns hopkins university press.

gomez, c. (1991). regulating death. new york: free press.

greenberg, s. i. (1997). euthanasia and assisted suicide.springfield, il: charles c. thomas.

kaplan, k. j., ed. (2000). right to die versus sacredness oflife. amityville, ny: baywood.


kastenbaum, r. (2001). death, society, and human experience, 7th edition. boston: allyn & bacon.

kevorkian, j. (1991). prescription: medicide. buffalo, ny:prometheus press.

king, n. m. p. (1996). making sense of advance directives. rev. edition. washington, dc: georgetown university press.

lifton, r. j. (1986). the nazi doctors. new york: basicbooks.

pernick, m. s. (1996). the black stork. new york: oxforduniversity press.

saunders, c. (1997). "hospices worldwide: a missionstatement." in hospice care on the international scene, ed. c. saunders and r. kastenbaum. new york: springer.

scherer, j. m., and simon, r. j. (1999). euthanasia and the right to die. lanham, md: rowman & littlefield.

scofield, g. (1989). "the living will." in encyclopedia of death, ed. r. kastenbaum and b. kastenbaum. phoenix, az: oryx press.

singer, p. (1996). rethinking life and death. new york:st. martin's griffith.

robert kastenbaum

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"Euthanasia." International Encyclopedia of Marriage and Family. 2003. Encyclopedia.com. 30 Jun. 2016 <http://www.encyclopedia.com>.

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Euthanasia

EUTHANASIA

EUTHANASIA, Greek for "good death," refers to the termination of the life of a person suffering from a painful and incurable medical condition. Also known as "mercy killing," euthanasia is distinguished from suicide by the necessary participation of a third party, typically either a physician or family member.

Twenty-first-century disputes over euthanasia are often seen as a by product of advances in biomedical technology capable of prolonging a person's life indefinitely. Indeed, the moral and legal aspects of euthanasia are extremely complicated, as experts distinguish between active and passive euthanasia as well as voluntary and involuntary euthanasia. Additional issues include the definition of a "terminal" illness and whether pain, an intractable disease, or both, are required to make the practice morally acceptable.

Such complexity has led to a variety of legal positions worldwide. The United States officially forbids euthanasia, while some European countries, such as Switzerland, Germany, Poland, and Norway, are more lenient, allowing for a variety of mitigating circumstances and reduced criminal penalties. In 1993 the Netherlands passed a law prescribing guidelines for medically assisted suicide; Uruguay has exempted mercy killing from criminal prosecution since 1933. To help untangle these issues and better understand euthanasia, this article will consider the history of euthanasia, the "right to die" movement, and physician-assisted suicide within an American social and legal context.

Mercy Killing

Mercy killing, practiced since antiquity, has been debated throughout history. Ancient Greek, Indian, and Asian texts describe infanticide as an acceptable solution for children physically unsuited for or incapable of living. In Plato's Phaedo, when Socrates drinks hemlock, a poison, he maintains his dignity in death, an action immortalized in the modern pro-euthanasia organization, the Hemlock Society.

While many other Greeks, including Aristotle and the Stoics, sanctioned euthanasia, most early Christian thinkers condemned the practice. Both Saint Augustine and Saint Thomas Aquinas prohibited active euthanasia and suicide on the grounds that it was an affront to the sanctity of life and usurped the divine right of life and death. They did, however, permit passive euthanasia—the discontinuation of life-saving treatments—even though death would then be imminent. In the seventeenth and eighteenth centuries European thinkers went even farther, as Francis Bacon, David Hume, and Immanuel Kant considered both active and passive euthanasia morally acceptable.

However, early American laws specifically forbade assisted suicide; New York enacted statutes against the practice in 1828, and both the Field Penal Code (1877) for the Dakota Territory and later the Model Penal Code followed suit. Yet the polio epidemics of the 1920s and 1930s tested these legal codes, as many protested the potential for dependence on the new Drinker tanks or "iron lungs." By the end of the decade proponents of mercy killing sought legal protection, establishing the Euthanasia Society of America in 1938 to promote the practice as well as legislation. Similar organizations formed in Great Britain and Germany, although revelations of indiscriminate and inhumane Nazi practices ultimately led to the condemnation of the movement by the Roman Catholic Church following World War II and helped defeat legislation in Connecticut (1959), Idaho (1969), Oregon (1973), and Montana (1973).

"Right to Die"

Debate over euthanasia resurfaced in the 1970s amid growing concern over individual rights, the Karen Ann Quinlan case, and the "right to die" movement. In 1975 Quinlan, a twenty-one-year-old who had accidentally overdosed on barbiturates, alcohol, and valium, slipped into a coma, and was kept alive by a respirator and other medical apparatus. The "sleeping beauty" case captivated the nation, as the public debated who was responsible for the decision to maintain or disconnect the machines and the indignity of being kept alive by medical technology.

Ultimately, Quinlan's case helped redefine "brain death" and the legal framework for voluntary and involuntary decision making. The New Jersey Supreme Court ruled in 1976 that, given her "irreversible condition" and the right to privacy guaranteed by the Constitution, her family, the appropriate surrogates, could remove her from life support. The court's approval of passive euthanasia fueled the "right to die" movement; by 1977 thirty-eight legislatures had submitted over fifty bills to enact legislation expanding the power of attorney and sanctioning living wills, precursors to "do not resuscitate" orders. At the same time, the American Medical Association renewed its opposition to euthanasia, arguing that passive euthanasia—the removal of life support—is ethically acceptable only in "terminal" cases where "extraordinary procedures" are required to maintain life in a manner inconvenient and inefficient for the patient. Remarkably, Quinlan lived in a vegetative state unassisted until 1985, by which time a "right of refusal" was generally accepted, supported by the due process clause of the Constitution giving individuals the right to make decisions free from unreasonable governmental interference.

By the 1990s, advocates of euthanasia such as the Hemlock Society (established 1980) campaigned for physician-assisted suicide or active euthanasia, reviving the debate over the limits of an individual's "right to die." Proponents argued that a painless injection or combination of drugs was far more humane than disconnecting a feeding tube and allowing the person to starve. Physicians, however, were caught in an ethical dilemma, given the Hippocratic Oath to do no harm, relieve suffering, and prolong life. For patients with intractable disease and consistent pain, the goals of relieving suffering and prolonging life are inherently contradictory. If the physician acts to end the suffering through assisted suicide, he or she violates the creed to do no harm and prolong life; if the physician refuses to act, suffering is prolonged rather than assuaged.

Physician-Assisted Suicide

Physicians, like the public, were divided over the morality of assisted suicide. The state of Washington failed to pass a "right to die" voter initiative in 1991, as did California the following year. However, in 1994, Oregon passed Measure 16, a"Death with Dignity Act" drafted by attorney Cheryl K. Smith, former legal counsel for the Hemlock Society. The act allowed physicians to prescribe and dispense, but not administer, the necessary lethal drugs. Remarkably, the bold new legislation was soon overshadowed by the figure of Dr. Jack Kevorkian, who quickly became a political lightning-rod for the "right to die" movement.

A retired pathologist, Dr. Kevorkian, or "Dr. Death" to his detractors, made headlines in the 1990s by assisting over 130 people to commit suicide. The author of Prescription: Medicide, Dr. Kevorkian made his reputation challenging a 1993 Michigan law prohibiting physician-assisted suicide. Backed by the American Civil Liberties Union, Kevorkian argued that the law, which had been expressly written to outlaw his practice of active euthanasia, denied individuals the right to choose how and when they died. However, Kevorkian's legal stance suffered when it was revealed that many of his patients' diseases were not terminal and were unverified. Unrepentant, the seventy-year-old physician continued his practice until a Michigan court sentenced him in 1999 to ten to twenty-five years in prison for the second-degree murder of Thomas Youk, a patient with Lou Gehrig's disease. Ultimately, Kevorkian's arrogance proved to be his downfall; the airing of Youk's suicide on the television program 60 Minutes infuriated the court, as did his participation in another assisted suicide while released on bail.

Proponents of active euthanasia received another series of setbacks in the late 1990s as the courts, supported by a broad coalition inflamed by rumors of pressure and a lack of consent in assisted suicides in Oregon, moved to derail the movement. Although the details of Oregon's euthanasia practice remain private, fears that assisted suicide was used to reduce health care costs and that patients were pressured to accept lethal drugs rather than treatment solidified an anti-euthanasia coalition of hospice organizations, medical associations, religious organizations, and pro-life groups. In 1997 the United States Supreme Court unanimously refused to issue an assisted-suicide Roe v. Wade decision in the case of Washington v. Glucksberg. Chief Justice William Rehnquist stated that assisted suicide posed substantial harm for individuals already at risk because of their age, poverty, or lack of access to quality medical care. Months later, the Florida Supreme Court refused to consider assisted suicide a right under the privacy statute of the Florida Constitution, and a bill legalizing the practice foundered in the Maine legislature the following year.

In the early 2000s the debate over physician-assisted suicide remained contested at the state level. The Supreme Court's decision in Washington v. Glucksberg remanded the decision on active euthanasia to the state courts because the justices argued that each state had the right to protect its residents and thus a federal decision was inappropriate. Indeed, the Court's position in Washington is similar to one taken in an earlier ruling on passive euthanasia. In Cruzan v. Director, Missouri Department of Health (1990), the Supreme Court held that a state could forbid termination of treatment in the absence of "clear and convincing evidence" of the patient's own wishes. While this gave individual states the freedom to determine appropriate standards for involuntary passive euthanasia, a majority of states adhered to the precedents set by the Quinlan case in making their determination. Advocates of physician-assisted suicide hoped that responsible practices in Oregon and the Netherlands would persuade their opponents, and they downplayed the economic arguments for active euthanasia amid a social climate decrying HMO (health maintenance organization) cost-cutting operations.

BIBLIOGRAPHY

Doudera, A. Edward, and J. Douglas Peters, eds. Legal and Ethical Aspects of Treating Critically and Terminally Ill Patients. Ann Arbor, Mich.: AUPHA, 1982.

Humphry, Derek. Final Exit: The Practicalities of Self-Deliverance and Assisted Suicide for the Dying. Eugene, Ore.: Hemlock Society, 1991.

President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Deciding to Forego Life-Sustaining Treatment: A Report on the Ethical, Medical, and Legal Issues in Treatment Decisions. Washington, D.C.: U.S. Government Printing Office, 1983.

Schneiderman, Lawrence J., and Nancy S. Jecker. Wrong Medicine: Doctors, Patients, and Futile Treatment. Baltimore: Johns Hopkins University Press, 1995.

Weir, Robert F. Abating Treatment with Critically Ill Patients: Ethical and Legal Limits to the Medical Prolongation of Life. New York: Oxford University Press, 1989.

J. G.Whitesides

See alsoAssisted Suicide ; Death and Dying ; "Right to Die" Cases ; Washington v. Glucksberg .

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"Euthanasia." Dictionary of American History. 2003. Encyclopedia.com. 30 Jun. 2016 <http://www.encyclopedia.com>.

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euthanasia

euthanasia The ideals of bodily incorruptibility and immortality have been envisaged in many cultures and religions: Christianity, for instance, holds that, had man not sinned and been expelled from Paradise, there would have been no disease and death. In truth, mortality has been the great, omnipresent mystery — beyond man's powers and in the hands of the gods or fate. Hence man has tried to tame death.

On the one hand, there have been efforts to prolong life with a view to creating quasi-eternal existence on earth. With the alchemy of the Middle Ages, partly borrowed from the Arabs, an ambitious quest for the prolongation of life entered Western culture. The thirteenth-century cleric Roger Bacon claimed that Christian medicine would surpass pagan science by the conquest of senescence. Francis Bacon and the later philosophers of the Enlightenment expressed confidence that the advancement of science would produce the indefinite prolongation of life.

On the other hand, there has been the ambition of mastering death, not by preventing it, but by controlling its timing, means, and manner. Within traditional Christian culture, a good death (as prescribed by the ars moriendi — the art of dying well) was a Christian death; departing in a state of grace, denouncing Satan, praying to God, repenting one's sins, and (for Roman Catholics) receiving the sacraments.

Increasingly, from the eighteenth century, the good death became a rather more secularized concept, and within that framework euthanasia assumed relevance. In its original meaning, however, ‘euthanasia’ referred to any means for securing an ‘easy’ death; for example, by leading a temperate life or by cultivating an acceptance of mortality. The Discorsi della vita sobria (Discourses on the Temperate Life) of Luigi Cornaro (c.1463–1566!), written in his eighties and frequently consulted into the eighteenth century, featured both an easy (or holy) terminus in advanced years and the prospect of longer life — up to 120 years — through the pursuit of moderation in food, drink, and lifestyle.

Francis Bacon praised prolongevity as the ‘most noble’ purpose of medicine. He also argued that relief of suffering was a desideratum in terminal care, and that the physician may sometimes hasten death. The Enlightenment brought intense interest in prolongevity. Benjamin Franklin boldly declared senescence to be not a natural process but a ‘disease’ to be cured, and he predicted that longevity might stretch to a thousand years or more. The Marquis Condorcet and William Godwin speculated about virtually immortal life.

But ‘euthanasia’ increasingly came to connote measures taken by the physician, including the possibility of hastening death to prevent pain or suffering. At the same time, the idea of dying well was secularized. The traditional good death scenario — calling upon God and renouncing Satan — gave way to an emphasis upon a quiet and peaceful death. Tranquil death, it was argued, should be like sleep. A peaceful death betokened a serene conscience, a life well lived. It squared with Romantic notions of the beauty of death, particularly in those who died young. Thus, in the new idea of euthanasia emerging in the nineteenth century, it was the duty of the doctor to ensure a peaceful death, by careful management, and judicious application of opiates to dull pain and induce coma. At the wishes of family or patient, the family doctor was doubtless the frequent agent of informal (and illegal) euthanasia in the nineteenth and twentieth century.

Any trend there had been towards the informal acceptance of euthanasia was rendered more problematic in recent times. The Nazis introduced legal euthanasia, approved by doctors, for selected people such as the severely mentally disabled, on the grounds that they had a life which was not worth living. The later extension to persons considered simply undesirable — Jews, Gypsies, and homosexuals — perverted euthanasia to supremely evil purposes. The Nazi ‘final solution’ has created suspicion that any broader acceptance, practice, or legalization of euthanasia would be the thin end of the wedge that in due course would lead to (possibly compulsory) public euthanasia programmes for problematic or costly people, especially the very old, the poor, and the demented.

In addition, death now increasingly occurs in public institutions, notably hospitals and hospices. This may make humane euthanasia more difficult, as physicians and nursing staff involved in such practices may be justifiably afraid that they thereby risk exposure and legal prosecution. Those liable to promote such exposure are established religious groups, including Roman Catholics, Orthodox Jews and pressure groups such as ‘Life’. They fundamentally disapprove of mercy killing on religious grounds, and may believe that suffering is God's will and that God alone should determine when life ends.

Yet the conditions of modern death and recent developments in medicine are also increasing advocacy and desire for euthanasia. Life-saving and life-supporting technologies now make it possible to interrupt and extend the natural dying process. Resuscitation or antibiotics may defer death, and life may be sustained by ventilators or tube feeding when there is no prospect of recovery. It has become widely accepted that withholding or withdrawing treatment in such circumstances — for example for those with advanced cancer or paralysis, or in a permanent vegetative state — is good medical practice and also legal. At the same time developments in palliative care aim to ease the pain and distress of the conscious dying person by the judicious use of drugs. Such drugs may hasten death, but provided the intention is to control symptoms this is accepted morally and legally by the doctrine of double effect. Whilst these humane approaches — non-treatment decisions, and drugs for symptom control — are generally accepted, there remains acute controversy about the deliberate administration of lethal doses of drugs or other measures to ensure death, whether as active euthanasia, or ‘physician-assisted suicide’.

Euthanasia may be squared with the professional ethics of the physician and with normal morality through the argument that, while it is the doctor's duty to save life, that duty does not run so far as to prolong life through artificial means in all circumstances.

Changes in opinion, public policy, and medical practice have been most marked in the Netherlands, where since 1984 the national medical association has accepted medical euthanasia, under strictly controlled circumstances. Although this remained unlawful until 2001, there were no prosecutions provided that doctors abided by strict guidelines based on a patient's valid request. By 1995 a survey suggested that active euthanasia (a physician humanely intervening to end a terminally-ill patient's life at the request of that patient) was taking place in around 1.8% of all deaths. (In some 87% of such cases, the patient was expected to be able to live, or to be kept alive, only for a further month.) Public acceptance of this practice had been facilitated by the development of ‘living wills’. Since 1994 in the Netherlands, physicians have been legally obliged to honour ‘living wills’ — a measure welcomed by the medical profession as it absolves them of legal problems. Acceptance of euthanasia seems equally widespread amongst religious and non-religious Dutch people, though members of the Dutch Reformed (Calvinist) Church still tend to be distrustful of the practice. Such practices have met with a much more divided reception elsewhere. In Britain, where euthanasia remains illegal, the pressure group Exit has been subject to prosecution, as has the controversial American pathologist, Dr Jack Kevorkian, who has advocated and participated in doctor-assisted suicide at the patient's request.

The advance of modern medicine presents deep dilemmas. If a patient is in a permanent coma, should life support measures be employed? And should a patient near death from both painful cancer and debilitating heart disease be resuscitated? No easy answers are available to any such questions, which set the sanctity of human life against the question of personal autonomy, and raise fundamental legal and moral questions as to the ownership of the body.

Roy Porter, and Bryan Jennett

Bibliography

Baruch, A. B. (ed.) (1989). Suicide and euthanasia: historical and contemporary themes. Kluwer, Dordrecht.
British Medical Association (2001). Withholding and withdrawing life-prolonging medical treatment: guidance for decision making. 2nd ed BMJ Books, London.


See also death; eugenics; suicide; vegetative state.

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COLIN BLAKEMORE and SHELIA JENNETT. "euthanasia." The Oxford Companion to the Body. 2001. Encyclopedia.com. 30 Jun. 2016 <http://www.encyclopedia.com>.

COLIN BLAKEMORE and SHELIA JENNETT. "euthanasia." The Oxford Companion to the Body. 2001. Encyclopedia.com. (June 30, 2016). http://www.encyclopedia.com/doc/1O128-euthanasia.html

COLIN BLAKEMORE and SHELIA JENNETT. "euthanasia." The Oxford Companion to the Body. 2001. Retrieved June 30, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1O128-euthanasia.html

euthanasia

euthanasia (yōō´thənā´zhə), either painlessly putting to death or failing to prevent death from natural causes in cases of terminal illness or irreversible coma. The term comes from the Greek expression for "good death." Technological advances in medicine have made it possible to prolong life in patients with no hope of recovery, and the term negative euthanasia has arisen to classify the practice of withholding or withdrawing extraordinary means (e.g., intravenous feeding, respirators, and artificial kidney machines) to preserve life. Accordingly, the term positive euthanasia has come to refer to actions that actively cause death. The term passive euthanasia is used when certain common methods of treatment, such as antibiotics, drugs, or surgery, are withheld or a large quantity of needed but ultimately lethal pain medication is supplied. By the end of the 20th cent. passive euthanasia was said to be a common practice among U.S. hospitals and physicians. With regard to euthanasia in animals, there are strict rules and guidelines that ensure ethical euthanasia and disposal.

Much debate has arisen in the United States among physicians, religious leaders, lawyers, and the general public over the question of what constitutes actively causing death and what constitutes merely allowing death to occur naturally. The physician is faced with deciding whether measures used to keep patients alive are extraordinary in individual situations, e.g., whether a respirator or artificial kidney machine should be withdrawn from a terminally ill patient. The Supreme Court's decision in Cruzan v. Director, Missouri Dept. of Health set a precedent for the removal of life-support equipment from terminal cases.

Popular movements have supported the legalization of the living will, a statement written by a mentally alert patient that can be used to express a wish to forgo artificial means to sustain life during terminal illness. In 1977, California became the first to pass a state law to this effect, known as the death-with-dignity statute. The absence of a written living will complicated the case of Terri Schiavo, a Florida woman who was in a persistent vegetative state from 1990 until 2005, when she died after having her feeding tube removed. In 2000 her husband, who was her legal guardian, won the right to remove it based upon what he stated were her orally expressed wishes, but legal challenges from her parents and Florida governor Jeb Bush and attempted government interventions through Florida and federal legislation delayed the tube's removal for five years. (See Schiavo case.)

Societies advancing the cause of positive euthanasia were founded in 1935 in England and 1938 in the United States. End-of-Life Choices (formerly the Hemlock Society) is one controversial group that has pressed for right-to-die legislation on a national level. Positive euthanasia is for the most part illegal in the United States, but physicians may lawfully refuse to prolong life when there is extreme suffering.

In the early 1990s, Dr. Jack Kevorkian, a Michigan physician, gained notoriety by assisting a number of people to commit suicide and became the object of a state law (1992) forbidding such activity. Kevorkian, who had been tried and acquitted repeatedly in the assisted deaths of seriously ill people, was convicted of murder in Michigan in 1999 for an assisted suicide that was shown on national television. Meanwhile, in 1997, the Supreme Court upheld state laws banning assisted suicide (in most U.S. states assisting in a suicide is a crime).

In Oregon in 1994, voters approved physician-assisted suicide for some patients who are terminally ill (the patients must administer the drugs); the law went into effect in 1997, following a protracted court challenge. In 2001 the Bush administration sought to undermine the law with a directive issued under the federal Controlled Substances Act, but Oregon sued to prohibit the enforcement of it, and the Supreme Court ruled (2006) that the federal government had exceeded its authority. Similar measures have since been approved, by voters, legislators, or the courts, in Washington state (2008), Montana (2009), and Vermont (2013).

Since 1937 assisted suicide has not been illegal in Switzerland as long as the person who assists has no personal motive or gain. In 1993, the Netherlands decriminalized, under a set of restricted conditions, voluntary positive euthanasia (essentially, physician-assisted suicide) for the terminally ill, and in 2002 the country legalized physician-assisted suicide if voluntarily requested by seriously ill patients who face ongoing suffering. Belgium (2002) and Luxembourg (2008) also have legalized euthanasia for certain patients who have requested it, and Canada's supreme court has overturned (2015) laws against physician-assisted suicide.

See also bioethics.

See P. Singer, Rethinking Life and Death (1994); H. Hendin, Suicide in America (rev. ed. 1995). See also studies by J. Rachels (1986) and R. Wennberg (1989).

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euthanasia

euthanasia The act of ending the life of a person or animal in order to prevent further suffering, e.g. from an incurable and painful disease. This can be achieved by administering a lethal drug or by withholding vital treatment. In human medicine euthanasia is fraught with ethical and legal problems, and is illegal in most countries. Where it is practised, strict safeguards are enforced to ensure that the patient's wishes are determined and adhered to. Euthanasia is widely performed in veterinary medicine.

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"euthanasia." A Dictionary of Biology. 2004. Encyclopedia.com. 30 Jun. 2016 <http://www.encyclopedia.com>.

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euthanasia

euthanasia the painless killing of a patient suffering from an incurable and painful disease or in an irreversible coma. The practice is illegal in most countries, although euthanasia in cases where the patient has given active consent is accepted in practice in the Netherlands.

The word is recorded from the early 17th century (in the sense ‘easy death’), and comes from Greek, from eu ‘well’ + thanatos ‘death’.

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ELIZABETH KNOWLES. "euthanasia." The Oxford Dictionary of Phrase and Fable. 2006. Encyclopedia.com. 30 Jun. 2016 <http://www.encyclopedia.com>.

ELIZABETH KNOWLES. "euthanasia." The Oxford Dictionary of Phrase and Fable. 2006. Encyclopedia.com. (June 30, 2016). http://www.encyclopedia.com/doc/1O214-euthanasia.html

ELIZABETH KNOWLES. "euthanasia." The Oxford Dictionary of Phrase and Fable. 2006. Retrieved June 30, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1O214-euthanasia.html

euthanasia

euthanasia (yooth-ăn-ay-ziă) n. the act of taking life to relieve suffering. compulsory e. termination of the life of a person (e.g. an infant) who cannot express his or her own wishes, which is universally illegal. voluntary e. euthanasia produced at the request of the patient, achieved by active steps, usually administration of a drug, or more passively, for example by deliberately withholding treatment. See also (assisted) suicide.

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"euthanasia." A Dictionary of Nursing. 2008. Encyclopedia.com. 30 Jun. 2016 <http://www.encyclopedia.com>.

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"euthanasia." A Dictionary of Nursing. 2008. Retrieved June 30, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1O62-euthanasia.html

euthanasia

eu·tha·na·sia / ˌyoō[unvoicedth]əˈnāzhə/ • n. the painless killing of a patient suffering from an incurable and painful disease or in an irreversible coma. The practice is illegal in most countries. ORIGIN: early 17th cent. (in the sense ‘easy death’): from Greek, from eu ‘well’ + thanatos ‘death.’

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"euthanasia." The Oxford Pocket Dictionary of Current English. 2009. Encyclopedia.com. 30 Jun. 2016 <http://www.encyclopedia.com>.

"euthanasia." The Oxford Pocket Dictionary of Current English. 2009. Encyclopedia.com. (June 30, 2016). http://www.encyclopedia.com/doc/1O999-euthanasia.html

"euthanasia." The Oxford Pocket Dictionary of Current English. 2009. Retrieved June 30, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1O999-euthanasia.html

euthanasia

euthanasia (Gk. ‘good death’) Inducing the painless death of a person (usually with a terminal illness), often by a drug. It is illegal in most countries. Voluntary euthanasia, the taking of life with the consent of the patient, is legal in the Netherlands. Passive euthanasia, the withholding of life-supporting treatment, is a form of voluntary euthanasia.

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"euthanasia." World Encyclopedia. 2005. Encyclopedia.com. 30 Jun. 2016 <http://www.encyclopedia.com>.

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"euthanasia." World Encyclopedia. 2005. Retrieved June 30, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1O142-euthanasia.html

euthanasia

euthanasia easy death XVII; means of bringing this about XVIII. — Gr. euthanasíā, f. EU- + thánatos death.

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T. F. HOAD. "euthanasia." The Concise Oxford Dictionary of English Etymology. 1996. Encyclopedia.com. 30 Jun. 2016 <http://www.encyclopedia.com>.

T. F. HOAD. "euthanasia." The Concise Oxford Dictionary of English Etymology. 1996. Encyclopedia.com. (June 30, 2016). http://www.encyclopedia.com/doc/1O27-euthanasia.html

T. F. HOAD. "euthanasia." The Concise Oxford Dictionary of English Etymology. 1996. Retrieved June 30, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1O27-euthanasia.html

euthanasia

euthanasia •astrantia • Bastia •Dei gratia, hamartia •poinsettia •in absentia, Parmentier •Izvestia •meteor, wheatear •Whittier • cottier • Ostia •consortia, courtier •protea • Yakutia • frontier • Althea •Anthea • Parthia •Pythia, stichomythia •Carinthia, Cynthia •forsythia • Scythia • clothier • salvia •Latvia • Yugoslavia • envier •Flavia, Moldavia, Moravia, Octavia, paviour (US pavior), Scandinavia, Xavier •Bolivia, Livia, Olivia, trivia •Sylvia • Guinevere • Elzevir •Monrovia, Segovia •Retrovir • effluvia • colloquia •Goodyear • yesteryear • brassiere •Abkhazia •Anastasia, aphasia, brazier, dysphasia, dysplasia, euthanasia, fantasia, Frazier, glazier, grazier, gymnasia, Malaysiaamnesia, anaesthesia (US anesthesia), analgesia, freesia, Indonesia, Silesia, synaesthesia •artemisia, Kirghizia, Tunisiaambrosia, crozier, hosier, osier, symposia

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"euthanasia." Oxford Dictionary of Rhymes. 2007. Encyclopedia.com. 30 Jun. 2016 <http://www.encyclopedia.com>.

"euthanasia." Oxford Dictionary of Rhymes. 2007. Encyclopedia.com. (June 30, 2016). http://www.encyclopedia.com/doc/1O233-euthanasia.html

"euthanasia." Oxford Dictionary of Rhymes. 2007. Retrieved June 30, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1O233-euthanasia.html

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