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 directive—that 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. 186–187). 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 (1998–2000), 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.
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.
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BRIAN L. MISHARA