Euthanasia

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Euthanasia (literally "good death" in Ancient Greek) refers to the practice of ending a life, usually through lethal injection. It is illegal in most countries.

Euthanasia is a controversial subject, not only because there are many moral dilemmas associated with it, but also because the very word can be defined in many ways. At one end of the disagreement, opponents say euthanasia is a merciful method of death. At the other end, the opponents of euthanasia consider this sinful.

Euthanasia can be produced in more than one way. In order to distinguish certain methods, more specific terminology may be used when discussing euthanasia.

Classification of euthanasia

Euthanasia by consent

Euthanasia may be conducted with consent (voluntary euthanasia) or without consent (involuntary euthanasia). Involuntary euthanasia is conducted where an individual makes a decision for another person incapable of doing so. The decision can be made based on what the incapacitated individual would have wanted, or it could be made on substituted judgment of what the decision-making would want were he or she in the incapacitated person's place, or finally, the decision could be made by assessing objectively whether euthanasia is the most beneficial course of treatment. In any case, euthanasia by proxy consent is highly controversial, especially because multiple proxies may claim the authority to decide for the patient and may or may not have explicit consent from the patient to make that decision.^[1]

Euthanasia by means

Euthanasia may be conducted passively, non-aggressively, and aggressively. Passive euthanasia entails the withholding of common treatments (such as antibiotics, pain medications, or surgery) or the distribution of a medication (such as morphine) to relieve pain, knowing that it may also result in death (principle of double effect). Passive euthanasia is the most accepted form, and it is a common practice in most hospitals. Non-aggressive euthanasia entails the withdrawing of life support and is more controversial. Aggressive euthanasia entails the use of lethal substances or forces to kill and is the most controversial means.

Other designations

Some important designations of euthanasia consist of mercy killing and animal euthanasia. The Canadian Council of Animal Care (CCAC) states that euthanasia is "to kill an animal painlessly, and without distress."^[2] The CCAC further explains a physical euthanasia technique called Cervical dislocation and a secondary technique called Exsanguination.^[2]

History

The term euthanasia comes from the Greek words "eu"-meaning good and "thanatos"-meaning death, which combined means “well-death” or "dying well". Hippocrates mentions euthanasia in the Hippocratic Oath, which was written between 400 and 300 B.C. The original Oath states: “To please no one will I prescribe a deadly drug nor give advice which may cause his death.”^[3] Despite this, the ancient Greeks and Romans generally did not believe that life needed to be preserved at any cost and were, in consequence, tolerant of suicide in cases where no relief could be offered to the dying or, in the case of the Stoics and Epicureans, where a person no longer cared for his life.^[1][4]

English Common Law from the 1300s until the middle of the last century made suicide a criminal act in England and Wales. Assisting others to kill themselves remains illegal in that jurisdiction. However, in the 1500s, Thomas More, in describing a utopian community, envisaged such a community as one that would facilitate the death of those whose lives had become burdensome as a result of "torturing and lingering pain".^[1][5]

Modern history

Since the 19th Century, euthanasia has sparked intermittent debates and activism in North America and Europe. According to medical historian Ezekiel Emanuel, it was the availability of anesthesia that ushered in the modern era of euthanasia. In 1828, the first known anti-euthanasia law in the United States was passed in the state of New York, with many other localities and states following suit over a period of several years.^[6] After the Civil War, voluntary euthanasia was promoted by advocates, including some doctors.^[7] Support peaked around the turn of the century in the U.S. and then grew again in the 1930s.

The first major effort to legalize euthanasia in the United States arose as part of the eugenics movement in the early years of the twentieth century. In an article in the Bulletin of the History of Medicine, Brown University historian Jacob M. Appel documented extensive political debate over legislation to legalize physician-assisted suicide in both Iowa and Ohio in 1906.^[8] Appel indicates social activist Anna S. Hall was the driving force behind this movement.^[8] In his book A Merciful End, Ian Dowbiggen has revealed the role that leading public figures, including Clarence Darrow and Jack London, played in advocating for the legalization of euthanasia.^[9]

Euthanasia societies were formed in England in 1935 and in the U.S.A. in 1938 to promote aggressive euthanasia. Although euthanasia legislation did not pass in the U.S. or England, in 1937, doctor-assisted euthanasia was declared legal in Switzerland as long as the person ending the life has nothing to gain.^[10][3] During this period, euthanasia proposals were sometimes mixed with eugenics.^[11] While some proponents focused on voluntary euthanasia for the terminally ill, others expressed interest in involuntary euthanasia for certain eugenic motivations (e.g., mentally "defective").^[12] During this same era, meanwhile, U.S. court trials tackled cases involving critically ill people who requested physician assistance in dying as well as “mercy killings”, such as by parents of their severely disabled children.^[13]

Prior to and during World War II, the Nazis carried out an involuntary euthanasia program, largely in secret. In 1939, Nazis, in what was code-named Action T4, killed children under three who exhibited mental retardation, physical deformity or other debilitating problems which they considered gave the disabled child "life unworthy of life”. This program was later extended to include older children and adults.^[3]. Inmates of mental asylums in Germany and Austria would be transported to an intermediate facility, from where they would be retransported to one of six killing centres at Brandenburg near Berlin (January 1940 - September 1940), Grafeneck near Stuttgart (January 1940 - December 1940), Hartheim near Linz in Austria (January 1940 - December 1944), Sonnenstein/Pirna near Dresden (April 1940 - August 1943), Bernburg near Magdeburg (September 1940 - April 1943), Hadamar near Koblenz (January 1941 - August 1941).

The T4 program of the Nazis was extended to killing of concentration camp inmates when Philipp Bouhler,the head of the T4 program, allowed Heinrich Himmler to utilize T4 doctors, staff and facilities to kill concentration camp prisoners who were "most seriously ill" in a program designated "14f13". ^[14]

Post-War history

Due to outrage over Nazi euthanasia, in the 1940s and 1950s there was very little public support for euthanasia, especially for any involuntary, eugenics-based proposals. Catholic church leaders, among others, continued speaking against euthanasia as a violation of the sanctity of life. (Nevertheless, owing to its principle of double effect, Roman Catholic moral theology did leave room for shortening life with pain-killers and what could be characterized as passive euthanasia.^[15]) On the other hand, judges were often lenient in mercy-killing cases. ^[16] During this period, prominent proponents of euthanasia included Glanville Williams (The Sanctity of Life and the Criminal Law) and clergyman Joseph Fletcher ("Morals and medicine"). By the 1960s, advocacy for a right-to-die approach to voluntary euthanasia increased.

A key turning point in the debate over voluntary euthanasia (and physician assisted dying), at least in the United States, was the public furor over the case of Karen Ann Quinlan. The Quinlan case paved the way for legal protection of voluntary passive euthanasia.^[17] In 1977, California legalized living wills and other states soon followed suit.

In 1990, Dr. Jack Kevorkian, a Michigan physician, became infamous for encouraging and assisting people in committing suicide which resulted in a Michigan law against the practice in 1992. Kevorkian was tried and convicted in 1999 for a murder displayed on television.^[10][3] Also in 1990, the Supreme Court approved the use of non-aggressive euthanasia.^[18]

In 1994, Oregon voters approved the Death with Dignity Act, permitting doctors to assist terminal patients with six months or less to live to end their lives. The U.S. Supreme Court allowed such laws in 1997.^[1] The Bush administration failed in its attempt to use drug law to stop Oregon in 2001, in the case Gonzales v. Oregon.^[10] In 1999, non-aggressive euthanasia was permitted in Texas.

In 1993, the Netherlands decriminalized doctor-assisted suicide, and in 2002, restrictions were loosened. During that year, physician-assisted suicide was approved in Belgium. Belgium's at the time most famous author Hugo Claus, suffering from Alzheimer's disease, was among those that asked for euthanasia. He died in March 2008, assisted by an Antwerp doctor. Australia's Northern Territory approved a euthanasia bill in 1995, but that was overturned by Australia’s Federal Parliament in 1997.^[10][1][3]

Most recently, amid U.S. government roadblocks and controversy, Terri Schiavo, a Floridian who was in a vegetative state since 1990, had her feeding tube removed in 2005. Her husband had won the right to take her off life support, which he claimed she would want but was difficult to confirm as she had no living will and the rest of her family claimed otherwise.^[10]

Arguments for and against voluntary euthanasia

Since World War II, the debate over euthanasia in Western countries has centered on voluntary euthanasia (VE) within regulated health care systems. In some cases, judicial decisions, legislation, and regulations have made VE an explicit option for patients and their guardians.^[19] Proponents and critics of such VE policies offer the following reasons for and against official voluntary euthanasia policies:

Reasons given for voluntary euthanasia:

• Choice: Proponents of VE emphasize that choice is a fundamental principle for liberal democracies and free market systems.^[1]
• Quality of Life: The pain and suffering a person feels during a disease, even with pain relievers, can be incomprehensible to a person who has not gone through it. Even without considering the physical pain, it is often difficult for patients to overcome the emotional pain of losing their independence. ^[1] Moreover, despite modern painkillers, there is little available to deal with the problem of 'breathlessness', which makes many ailing patients feel they will suffocate.^[20]
• Economic costs and human resources: Today in many countries there is a shortage of hospital space. The energy of doctors and hospital beds could be used for people whose lives could be saved instead of continuing the life of those who want to die which increases the general quality of care and shortens hospital waiting lists. It is a burden to keep people alive past the point they can contribute to society, especially if the resources used could be spent on a curable ailment.^[21]

Reasons given against voluntary euthanasia:

• Professional role: Critics argue that voluntary euthanasia could unduly compromise the professional roles of health care employees, especially doctors. They point out that European physicians of previous centuries traditionally swore some variation of the Hippocratic Oath, which in its ancient form excluded euthanasia: "To please no one will I prescribe a deadly drug nor give advice which may cause his death.." However, since the 1970s, this oath has largely fallen out of use.
• Moral: Some people consider euthanasia of some or all types to be morally unacceptable.^[1] This view usually treats euthanasia to be a type of murder and voluntary euthanasia as a type of suicide, the morality of which is the subject of active debate.
• Theological: Voluntary euthanasia has often been rejected as a violation of the sanctity of human life. Specifically, some Christians argue that human life ultimately belongs to God, so that humans should not be the ones to make the choice to end life. Orthodox Judaism takes basically the same approach, however, it is more open minded, and does, given certain circumstances, allow for euthanasia to be exercised under passive or non-aggressive means. Accordingly, some theologians and other religious thinkers consider voluntary euthanasia (and suicide generally) as sinful acts, i.e. unjustified killings.^[22]
• Feasibility of implementation: Euthanasia can only be considered "voluntary" if a patient is mentally competent to make the decision, i.e., has a rational understanding of options and consequences. Competence can be difficult to determine or even define.^[1]
• Necessity: If there is some reason to believe the cause of a patient's illness or suffering is or will soon be curable, the correct action is sometimes considered to attempt to bring about a cure or engage in palliative care.^[1]
• Wishes of Family: Family members often desire to spend as much time with their loved ones as possible before they die.
• Consent under pressure: Given the economic grounds for voluntary euthanasia (VE), critics of VE are concerned that patients may experience psychological pressure to consent to voluntary euthanasia rather than be a financial burden on their families. ^[23] Even where health costs are mostly covered by public money, as in various European countries, VE critics are concerned that hospital personnel would have an economic incentive to advise or pressure people toward euthanasia consent.^[24]

Euthanasia and the Law

Main article: Euthanasia and the Law

During the 20th Century, efforts to change government policies on euthanasia have met limited success in Western countries. Country policies are described here in alphabetical order, followed by the exceptional case of The Netherlands. Euthanasia policies have also been developed by a variety of NGOs, most notably medical associations and advocacy organizations.

Euthanasia and religion

Catholic teaching

Catholic teaching condemns euthanasia as a "crime against life".^[25] The teaching of the Catholic Church on euthanasia rests on several core principles of Catholic ethics, including the sanctity of human life, the dignity of the human person, concomitant human rights, due proportionality in casuistic remedies, the unavoidability of death, and the importance of charity.^[26] The Church's official position is the 1980 Declaration on Euthanasia issued by the Sacred Congregation for the Doctrine of the Faith.^[26]

In Catholic medical ethics official pronouncements strongly oppose active euthanasia, whether voluntary or not^[27], while allowing dying to proceed without medical interventions that would be considered "extraordinary" or "disproportionate." The Declaration on Euthanasia states that:

"When inevitable death is imminent... it is permitted in conscience to take the decision to refuse forms of treatment that would only secure a precarious and burdensome prolongation of life, so long as the normal care due to a sick person in similar cases is not interrupted."

The Declaration concludes that doctors, beyond providing medical skill, must above all provide patients "with the comfort of boundless kindness and heartfelt charity".

Although the Declaration allows people to decline heroic medical treatment when death is imminently inevitable, it unequivocably prohibits the hastening of death and restates Vatican II's condemnation of "crimes against life 'such as any type of murder, genocide, abortion, euthanasia, or willful suicide'". ^[25] [Emphasis added.]

Protestant policies

Protestant denominations vary widely on their approach to euthanasia and physician assisted death. Since the 1970s, Evangelical churches have worked with Roman Catholics on a sanctity of life approach, though the Evangelicals may be adopting a more exceptionless opposition. While liberal Protestant denominations have largely eschewed euthanasia, many individual advocates (e.g., Joseph Fletcher) and euthanasia society activists have been Protestant clergy and laity. As physician assisted dying has obtained greater legal support, some liberal Protestant denominations have offered religious arguments and support for limited forms of euthanasia. People such as Lutherans are taught euthanasia is wrong and that it is God who has the right over life and death^{[citation needed]}

Jewish policies

Like the trend among Protestants, Jewish medical ethics have become divided, partly on denominational lines, over euthanasia and end of life treatment since the 1970s. Generally, Jewish thinkers oppose voluntary euthanasia, often vigorously,^[28] though there is some backing for voluntary passive euthanasia in limited circumstances.^[29] Likewise, within the Conservative Judaism movement, there has been increasing support for passive euthanasia (PAD)^[30] In Reform Judaism responsa, the preponderance of anti-euthanasia sentiment has shifted in recent years to increasing support for certain passive euthanasia (PAD) options.^{[citation needed]}

Islamic policies

Islam categorically forbids all forms of suicide and any action that may help another to kill themselves.^{[31] [32]} It is forbidden for a Muslim to plan, or come to know through self-will, the time of his own death in advance^[33]. All this is stated, for example, in Fredrick Forsyth's novel, The Afghan. In fact, a Muslim who commits suicide is not even given burial rights. The precedent for all of this thinking comes from the Islamic prophet Muhammad having absolutely refused to bless the body of a person who had committed suicide. If an individual is suffering from a terminal illness, it is permissible for the individual to refuse medication and/or resuscitation. Other examples include individuals suffering from kidney failure - who refuse dialysis treatments and cancer patients who refuse chemotherapy.

Buddhism

There are many different views among Buddhists on the issue of euthanasia. Here are a few:

In Theravada Buddhism a lay person daily recites the simple formula: "I undertake the precept to abstain from destroying living beings."^[34] For Buddhist monastics (bhikkhu) however the rules are more explicitly spelled out. For example, in the monastic code (Patimokkha), it states:

"Should any bhikkhu intentionally deprive a human being of life, or search for an assassin for him, or praise the advantages of death, or incite him to die (thus): 'My good man, what use is this wretched, miserable life to you? Death would be better for you than life,' or with such an idea in mind, such a purpose in mind, should in various ways praise the advantages of death or incite him to die, he also is defeated and no longer in communion."^[35]

In other words, such a monk or nun would be expelled irrevocably from the Buddhist monastic community (sangha).^[36] The prohibition against assisting another in their death includes circumstances when a monastic is caring for the terminally ill and extends to a prohibition against a monastic's purposively hastening another's death through word, action or treatment.^[35]

American Buddhist monk Thanissaro Bhikkhu wrote:

Thus, from the Buddha's perspective, encouraging a sick person to relax her grip on life or to give up the will to live would not count as an act of compassion. Instead of trying to ease the patient's transition to death, the Buddha focused on easing his or her insight into suffering and its end.^[37]

The Dalai Lama was cited by the Agence-France Presse in a 18 September 1996 article entitled "Dalai Lama Backs Euthanasia in Exceptional Circumstances" regarding his position on legal euthanasia:

Asked his view on euthanasia, the Dalai Lama said Buddhists believed every life was precious and none more so than human life, adding: 'I think it's better to avoid it.'

'But at the same time I think with abortion, (which) Buddhism considers an act of killing ... the Buddhist way is to judge the right and wrong or the pros and cons.'

He cited the case of a person in a coma with no possibility of recovery or a woman whose pregnancy threatened her life or that of the child or both where the harm caused by not taking action might be greater.

"These are, I think from the Buddhist viewpoint, exceptional cases," he said. "So it's best to be judged on a case by case basis."

Euthanasia protocol

See also: Lethal injection#Euthanasia protocol

A now-unused machine that facilitated euthanasia through heavy doses of drugs. The laptop screen led the user through a series of steps and questions to ensure he or she was fully prepared. The machine is pictured on display in a museum.

Euthanasia can be accomplished either through an oral, intravenous, or intramuscular administration of drugs. In individuals who are incapable of swallowing lethal doses of medication, an intravenous route is preferred. The following is a Dutch protocol for parenteral (intravenous) administration to obtain euthanasia:

Intravenous administration is the most reliable and rapid way to accomplish euthanasia and therefore can be safely recommended. A coma is first induced by intravenous administration of 20 mg/kg sodium thiopental (Nesdonal) in a small volume (10 ml physiological saline). Then a triple intravenous dose of a non-depolarizing neuromuscular muscle relaxant is given, such as 20 mg pancuronium bromide (Pavulon) or 20 mg vecuronium bromide (Norcuron). The muscle relaxant should preferably be given intravenously, in order to ensure optimal availability. Only for pancuronium bromide (Pavulon) are there substantial indications that the agent may also be given intramuscularly in a dosage of 40 mg.^[38]

With regards to nonvoluntary euthanasia, the cases where the person could consent but was not asked are often viewed differently from those where the person could not consent. Some people raise issues regarding stereotypes of disability that can lead to non-disabled or less disabled people overestimating the person's suffering, or assuming it to be unchangeable when it could be changed. For example, many disability rights advocates responded to Tracy Latimer's murder by pointing out that her parents had refused a hip surgery that could have greatly reduced or eliminated the physical pain Tracy experienced. Also, they point out that a severely disabled person need not be in emotional pain at their situation, and claim that the emotional pain, if present, is due to societal prejudice rather than the disability, analogous to a person of a particular ethnicity wanting to die because they have internalized negative stereotypes about their ethnic background. Another example of this is Keith McCormick, a New Zealander Paralympian who was "mercy-killed" by his caregiver, and Matthew Sutton.^[39][40]

With regards to voluntary euthanasia, many people argue that 'equal access' should apply to access to suicide as well, so therefore disabled people who cannot kill themselves should have access to voluntary euthanasia.

Euthanasia in the arts

The films Children of Men and Soylent Green, as well as the book The Giver, depict instances of government-sponsored euthanasia in order to strengthen their dystopian themes. The protagonist of Johnny Got His Gun is a brutally mutilated war veteran whose request for euthanasia furthers the work's anti-war message.

The recent films Mar Adentro and Million Dollar Baby argue more directly in favor of euthanasia by illustrating the suffering of their protagonists. These films have provoked debate and controversy in their home countries of Spain and the United States respectively.

A recurring character in Black Jack by Osamu Tezuka is a former war doctor who specializes in euthanasia. However, he is frequently prevented when the protagonist saves the patient instead.

In the 1997 film "Critical Care," directed by Sidney Lumet, the plot centers around a doctor involved in a complex lawsuit involving two daughters of the doctor's patient. One daughter, an empty-headed model, is trying to have her father be allowed to die. Her sister, pretending to be an Evangelical Christian, is trying to keep the father alive. It is revealed that the father's date of death will determine whether the daughter will receive her father's entire estate. Eventually the doctor resolves the issue by making the women split the money, allowing him to be unbiased in his decision to allow euthanasia or not. Ultimately, he allows his patient to die.

Thrash metal band Megadeth's 1994 album Youthanasia (the title is a pun on euthanasia), implying that society is euthanasing its youth.

See also

• Euthanasia: Opposing Viewpoints (2000), listing key sources in an anthology
• Voluntary Active Euthanasia
• Futile medical care
• International Task Force on Euthanasia and Assisted Suicide
• Terminal sedation
• Senicide
• Dr John Bodkin Adams, Eastbourne, England doctor, tried for murder in 1957 but claimed euthanasia. Acquitted.
• Derek Humphry - President of the World Federation of Right to Die Societies.
• Diane Pretty
• Chantal Sébire
• Jack Kevorkian
• Arthur Koestler, author, vice-president of EXIT (now the Voluntary Euthanasia Society).
• Final Exit (book)
• Dr. Death (book by Jonathon Kellerman)
• Kaishakunin - Assists in the Japanese ritual seppuku (suicide)
• Karen Ann Quinlan and Terri Schiavo - Cases of persistent vegetative state
• Killick Millard - Founder of the Voluntary Euthanasia Legalisation Society in Great Britain
• Peter Singer - bioethicist, utilitarian
• Principle of double effect
• Terry Wallis
• Action T4 - Nazi Germany's program to kill disabled people, justified as "euthanasia"
• Bertrand Dawson, 1st Viscount Dawson of Penn - physician to George V, to whom he gave a lethal injection.

Notes and references

Notes

References

Selected bibliography

Neutral (approx.)

Viewpoints

External links

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