Euthanasia

A Health Ethics Project

I.  Introduction

Euthanasia is the intentional killing by act or omission of a dependent human being for his or her alleged benefit. (The key word here is "intentional". If death is not intended, it is not an act of euthanasia)

Voluntary euthanasia is when the person who is killed has requested to be killed.

Non-voluntary euthanasia is when the person who is killed made no request and gave no consent.

Involuntary euthanasia is when the person who is killed made an expressed wish to the contrary.

Assisted suicide is when someone provides an individual with the information, guidance, and means to take his or her own life with the intention that they will be used for this purpose. When it is a doctor who helps another person to kill themselves it is called "physician assisted suicide."

Euthanasia By Action means intentionally causing a person's death by performing an action such as by giving a lethal injection.

Euthanasia By Omission means intentionally causing death by not providing necessary and ordinary (usual and customary) care or food and water.

    II. Background  

Euthanasia has been accepted in some forms by various groups or societies throughout history. In ancient Greece and Rome helping others die or putting them to death was considered permissible in some situations. For example, in the Greek city of Sparta newborns with severe birth defects were put to death. Voluntary euthanasia for the elderly was an approved custom in several ancient societies. However, as Christianity developed and grew powerful in the West, euthanasia became morally and ethically abhorrent and was viewed as a violation of God's gift of life. Today most branches of Christianity, Judaism, and Islam condemn active euthanasia, although some permit restricted forms of passive euthanasia.

Following traditional religious principles, Western laws have generally treated the act of assisting someone in dying as a form of punishable homicide (unlawful killing). However, in modern times laws have become more secular. Those who wish to legalize euthanasia have argued that, under principles of individual liberty (such as those expressed in the Constitution of the United States), individuals have a legal right to die as they choose. Most countries (including the United States), however, have not fully adopted this position and retain restrictions on euthanasia.

The first organizations to promote the legalization of voluntary euthanasia in the United States and Great Britain formed in the 1930s. For several decades these organizations remained small and had little impact. However, in the late 1970s the pro-euthanasia movement gained significant momentum after a highly publicized incident in the United States. In 1975 a 21-year-old woman named Karen Ann Quinlan suffered a respiratory arrest that resulted in severe and irreversible brain damage and left her in a coma. Several months later, after doctors informed them that their daughter's recovery was extremely unlikely, Quinlan's parents requested that artificial means of life support be removed. The hospital refused this request.

After a lengthy legal battle, in 1976 the Quinlans obtained a court order allowing them to remove the artificial respirator that was thought to be keeping their daughter alive. The New Jersey Supreme Court ruled that the Quinlans could disconnect the device so that the patient could "die with dignity." This decision spawned increased discussion of the scope of patients' rights to control their death. (Although the respirator was removed in 1976, Quinlan began to breathe on her own. She lived until 1985 without ever regaining consciousness.)

In the early 1990s the decision of Nancy B. v. Hotel-Dieu de Quebec in Canada played a similar role in promoting public awareness of the issues surrounding euthanasia. In this case, a young woman paralyzed as a result of the rare disease known as Guillain-Barré syndrome wished to have the artificial breathing mechanism that kept her alive disconnected. Concluding that such refusal of treatment was permissible, in January 1992 a Québec superior court judge authorized the woman's physician to remove the respirator.

In 2002 the parliament of Belgium legalized active euthanasia under limited conditions. Like the Dutch law, the Belgian law allows physicians to perform euthanasia only for patients who are suffering unbearably with no hope of improvement. The patient must make a voluntary, well-considered, and repeated request to die, and the request must be put in writing. Other physicians must be consulted to confirm the patient's condition. Additionally, each act of euthanasia must be reported to a government commission for review.

III. Laws

As laws have evolved from their traditional religious underpinnings, certain forms of euthanasia have been legally accepted. In general, laws attempt to draw a line between passive euthanasia (generally associated with allowing a person to die) and active euthanasia (generally associated with killing a person). While laws commonly permit passive euthanasia, active euthanasia is typically prohibited.

Laws in the United States and Canada maintain the distinction between passive and active euthanasia. While active euthanasia is prohibited, courts in both countries have ruled that physicians should not be legally punished if they withhold or withdraw a life-sustaining treatment at the request of a patient or the patient's authorized representative. These decisions are based on increasing acceptance of the doctrine that patients possess a right to refuse treatment.

Until the late 1970s, whether or not patients possessed a legal right of refusal was highly disputed. One factor that may have contributed to growing acceptance of this right is the ability to keep individuals alive for long periods of time—even when they are permanently unconscious or severely brain-damaged. Proponents of legalized euthanasia believe that prolonging life through the use of modern technological advances, such as respirators and kidney machines, may cause unwarranted suffering to the patient and the family. As technology has advanced, the legal rights of the patient to forgo such technological intervention have expanded.

Only one U.S. state, Oregon, has enacted a law allowing physicians to actively assist patients who wish to end their lives. However, Oregon's law concerns assisted suicide rather than active euthanasia. It authorizes physicians to prescribe lethal amounts of medication that patients then administer themselves.

In response to modern medical technology, physicians and lawmakers are slowly developing new professional and legal definitions of death. Additionally, experts are formulating rules to implement these definitions in clinical situations—for example, when procuring organs for transplantation. The majority of states have accepted a definition of brain death—the point when certain parts of the brain cease to function—as the time when it is legal to turn off a patient's life-support system, with permission from the family.

In 1995 the Northern Territory of Australia became the first jurisdiction to explicitly legalize voluntary active euthanasia. However, the federal parliament of Australia overturned the law in 1997. In 2001 The Netherlands became the first country to legalize active euthanasia and assisted suicide, formalizing medical practices that the government had tolerated for years. Under the Dutch law, euthanasia is justified (not legally punishable) if the physician follows strict guidelines. Justified euthanasia occurs if (1) the patient makes a voluntary, informed, and stable request; (2) the patient is suffering unbearably with no prospect of improvement; (3) the physician consults with another physician, who in turn concurs with the decision to help the patient die; and (4) the physician performing the euthanasia procedure carefully reviews the patient's condition. Officials estimate that about 2 percent of all deaths in The Netherlands each year occur as a result of euthanasia.

In 2002 the parliament of Belgium legalized active euthanasia under limited conditions. Like the Dutch law, the Belgian law allows physicians to perform euthanasia only for patients who are suffering unbearably with no hope of improvement. The patient must make a voluntary, well-considered, and repeated request to die, and the request must be put in writing. Other physicians must be consulted to confirm the patient's condition. Additionally, each act of euthanasia must be reported to a government commission for review.

IV. Prevalence

Although establishing the actual prevalence of active euthanasia is difficult, studies suggest that the practice is not common in the United States. In a study published in 1998 in the New England Journal of Medicine, only about 6 percent of physicians surveyed reported that they had helped a patient hasten his or her own death by administering a lethal injection or prescribing a fatal dose of medication. (Eighteen percent of the responding physicians indicated that they had received requests for such assistance.) However, one-fifth of the physicians surveyed indicated that they would be willing to assist patients if it were legal to do so. No comparable data are available for Canada. However, in 1998 the Canadian Medical Association (CMA) proposed that a study of euthanasia and physician-assisted suicide be undertaken due to poor information on the subject.

V. Ethical concerns

The issue of euthanasia raises ethical questions for physicians and other health-care providers. The ethical code of physicians in the United States has long been based in part on the Hippocratic Oath, which requires physicians to do no harm. However, medical ethics are refined over time as definitions of harm change. Prior to the 1970s, the right of patients to refuse life-sustaining treatment (passive euthanasia) was controversial. As a result of various court cases, this right is nearly universally acknowledged today, even among conservative bioethicists (see Medical Ethics).

The controversy over active euthanasia remains intense, in part because of opposition from religious groups and many members of the legal and medical professions. Opponents of voluntary active euthanasia emphasize that health-care providers have professional obligations that prohibit killing. These opponents maintain that active euthanasia is inconsistent with the roles of nursing, caregiving, and healing. Opponents also argue that permitting physicians to engage in active euthanasia creates intolerable risks of abuse and misuse of the power over life and death. They acknowledge that particular instances of active euthanasia may sometimes be morally justified. However, opponents argue that sanctioning the practice of killing would, on balance, cause more harm than benefit.

Supporters of voluntary active euthanasia maintain that, in certain cases, relief from suffering (rather than preserving life) should be the primary objective of health-care providers. They argue that society is obligated to acknowledge the rights of patients and to respect the decisions of those who elect euthanasia. Supporters of active euthanasia contend that since society has acknowledged a patient's right to passive euthanasia (for example, by legally recognizing refusal of life-sustaining treatment), active euthanasia should similarly be permitted. When arguing on behalf of legalizing active euthanasia, proponents emphasize circumstances in which a condition has become overwhelmingly burdensome for a patient, pain management for the patient is inadequate, and only a physician seems capable of bringing relief. They also point out that almost any individual freedom involves some risk of abuse and argue that such risks can be kept to a minimum by using proper legal safeguards.

VI. Arguments Against Euthanasia

1. Euthanasia would not only be for people who are "terminally ill"
2. Euthanasia can become a means of health care cost containment
3. Euthanasia will become non-voluntary
4. Euthanasia is a rejection of the importance and value of human life

1. Euthanasia would not only be for people who are "terminally ill." There are two problems here -- the definition of "terminal" and the changes that have already taken place to extend euthanasia to those who aren't "terminally ill." There are many definitions for the word "terminal." For example, when he spoke to the National Press Club in 1992, Jack Kevorkian said that a terminal illness was "any disease that curtails life even for a day." The co-founder of the Hemlock Society often refers to "terminal old age." Some laws define "terminal" condition as one from which death will occur in a "relatively short time." Others state that "terminal" means that death is expected within six months or less.

Even where a specific life expectancy (like six months) is referred to, medical experts acknowledge that it is virtually impossible to predict the life expectancy of a particular patient. Some people diagnosed as terminally ill don't die for years, if at all, from the diagnosed condition. Increasingly, however, euthanasia activists have dropped references to terminal illness, replacing them with such phrases as "hopelessly ill," "desperately ill," "incurably ill," "hopeless condition," and "meaningless life."

An article in the journal, Suicide and Life-Threatening Behavior, described assisted suicide guidelines for those with a hopeless condition. "Hopeless condition" was defined to include terminal illness, severe physical or psychological pain, physical or mental debilitation or deterioration, or a quality of life that is no longer acceptable to the individual. That means just about anybody who has a suicidal impulse .

2. Euthanasia can become a means of health care cost containment

"...physician-assisted suicide, if it became widespread, could become a profit-enhancing tool for big HMOs. "

"...drugs used in assisted suicide cost only about $40, but that it could take $40,000 to treat a patient properly so that they don't want the "choice" of assisted suicide..." ... Wesley J. Smith, senior fellow at the Discovery Institute.

Perhaps one of the most important developments in recent years is the increasing emphasis placed on health care providers to contain costs. In such a climate, euthanasia certainly could become a means of cost containment.

In the United States, thousands of people have no medical insurance; studies have shown that the poor and minorities generally are not given access to available pain control, and managed-care facilities are offering physicians cash bonuses if they don't provide care for patients. With greater and greater emphasis being placed on managed care, many doctors are at financial risk when they provide treatment for their patients. Legalized euthanasia raises the potential for a profoundly dangerous situation in which doctors could find themselves far better off financially if a seriously ill or disabled person "chooses" to die rather than receive long-term care.

Savings to the government may also become a consideration. This could take place if governments cut back on paying for treatment and care and replace them with the "treatment" of death. For example, immediately after the passage of Measure 16, Oregon's law permitting assisted suicide, Jean Thorne, the state's Medicaid Director, announced that physician-assisted suicide would be paid for as "comfort care" under the Oregon Health Plan which provides medical coverage for about 345,000 poor Oregonians. Within eighteen months of Measure 16's passage, the State of Oregon announced plans to cut back on health care coverage for poor state residents. In Canada, hospital stays are being shortened while, at the same time, funds have not been made available for home care for the sick and elderly. Registered nurses are being replaced with less expensive practical nurses. Patients are forced to endure long waits for many types of needed surgery. ¹

3. Euthanasia will only be voluntary, they say Emotional and psychological pressures could become overpowering for depressed or dependent people. If the choice of euthanasia is considered as good as a decision to receive care, many people will feel guilty for not choosing death. Financial considerations, added to the concern about "being a burden," could serve as powerful forces that would lead a person to "choose" euthanasia or assisted suicide.

People for euthanasia say that voluntary euthanasia will not lead to involuntary euthanasia. They look at things as simply black and white. In real life there would be millions of situations each year where cases would not fall clearly into either category. Here are two:

Example 1: an elderly person in a nursing home, who can barely understand a breakfast menu, is asked to sign a form consenting to be killed. Is this voluntary or involuntary? Will they be protected by the law? How? Right now the overall prohibition on killing stands in the way. Once one signature can sign away a person's life, what can be as strong a protection as the current absolute prohibition on direct killing? Answer: nothing.

Example 2: a woman is suffering from depresssion and asks to be helped to commit suicide. One doctor sets up a practice to "help" such people. She and anyone who wants to die knows he will approve any such request. He does thousands a year for $200 each. How does the law protect people from him? Does it specify that a doctor can only approve 50 requests a year? 100? 150? If you don't think there are such doctors, just look at recent stories of doctors and nurses who are charged with murder for killing dozens or hundreds of patients.

Legalized euthanasia would most likely progress to the stage where people, at a certain point, would be expected to volunteer to be killed. Think about this: What if your veternarian said that your ill dog would be better of "put out of her misery" by being "put to sleep" and you refused to consent. What would the vet and his assistants think? What would your friends think? Ten years from now, if a doctor told you your mother's "quality of life" was not worth living for and asked you, as the closest family member, to approve a "quick, painless ending of her life" and you refused how would doctors, nurses and others, conditioned to accept euthanasia as normal and right, treat you and your mother. Or, what if the approval was sought from your mother, who was depressed by her illness? Would she have the strength to refuse what everyone in the nursing home "expected" from seriously ill elderly people?

The movement from voluntary to involuntary euthanasia would be like the movement of abortion from "only for the life or health of the mother" as was proclaimed by advocates 30 years ago to today's "abortion on demand even if the baby is half born". Euthanasia people state that abortion is something people choose - it is not forced on them and that voluntary euthanasia will not be forced on them either. They are missing the main point - it is not an issue of force - it is an issue of the way laws against an action can be broadened and expanded once something is declared legal. You don't need to be against abortion to appreciate the way the laws on abortion have changed and to see how it could well happen the same way with euthanasia/assisted suicide as soon as the door is opened to make it legal.

4. Euthanasia is a rejection of the importance and value of human life. People who support euthanasia often say that it is already considered permissable to take human life under some circumstances such as self defense - but they miss the point that when one kills for self defense they are saving innocent life - either their own or someone else's. With euthanasia no one's life is being saved - life is only taken.

History has taught us the dangers of euthanasia and that is why there are only two countries in the world today where it is legal. That is why almost all societies - even non-religious ones - for thousands of years have made euthanasia a crime. It is remarkable that euthanasia advocates today think they know better than the billions of people throughout history who have outlawed euthanasia - what makes the 50 year old euthanasia supporters in 2005 so wise that they think they can discard the accumulated wisdom of almost all societies of all time and open the door to the killing of innocent people? Have things changed? If they have, they are changes that should logically reduce the call for euthanasia - pain control medicines and procedure are far better than they have ever been any time in history.

VII. Reasons for Euthanasia

1. Unbearable pain
2. Right to commit suicide
3. People should not be forced to stay alive

1. Unbearable pain as the reason for euthanasia
Probably the major argument in favor of euthanasia is that the person involved is in great pain. Today, advances are constantly being made in the treatment of pain and, as they advance, the case for euthanasia/assisted-suicide is proportionally weakened. Euthanasia advocates stress the cases of unbearable pain as reasons for euthanasia, but then they soon include a "drugged" state. I guess that is in case virtually no uncontrolled pain cases can be found - then they can say those people are drugged into a no-pain state but they need to be euthanasiaed from such a state because it is not dignified. See the opening for the slippery slope? How do you measure "dignity"? No - it will be euthanasia "on demand". The pro-euthanasia folks have already started down the slope. They are even now not stoping with "unbearable pain" - they are alrady including this "drugged state" and other circumstances.

Nearly all pain can be eliminated and - in those rare cases where it can't be eliminated - it can still be reduced significantly if proper treatment is provided. It is a national and international scandal that so many people do not get adequate pain control. But killing is not the answer to that scandal. The solution is to mandate better education of health care professionals on these crucial issues, to expand access to health care, and to inform patients about their rights as consumers. Everyone - whether it be a person with a life-threatening illness or a chronic condition - has the right to pain relief. With modern advances in pain control, no patient should ever be in excruciating pain. However, most doctors have never had a course in pain management so they're unaware of what to do. If a patient who is under a doctor's care is in excruciating pain, there's definitely a need to find a different doctor. But that doctor should be one who will control the pain, not one who will kill the patient. There are board certified specialists in pain management who will not only help alleviate physical pain but are skilled in providing necessary support to deal with emotional suffering and depression that often accompanies physical pain.

2. Demanding a "right to commit suicide" Probably the second most common point pro-euthanasia people bring up is this so-called "right." But what we are talking about is not giving a right to the person who is killed, but to the person who does the killing. In other words, euthanasia is not about the right to die. It's about the right to kill. Euthanasia is not about giving rights to the person who dies but, instead, is about changing the law and public policy so that doctors, relatives and others can directly and intentionally end another person's life. People do have the power to commit suicide. Suicide and attempted suicide are not criminalized. Suicide is a tragic, individual act. Euthanasia is not about a private act. It's about letting one person facilitate the death of another. That is a matter of very public concern since it can lead to tremendous abuse, exploitation and erosion of care for the most vulnerable people among us.