Euthanasia

Euthanasia is defined as the intentional termination of a life, which may be active (resulting from specific actions causing death) or passive (resulting from the refusal or withdrawal of life-sustaining treatment), and voluntary (with the patient’s consent) or involuntary (on behalf of infants or others who are incapable of making this decision, such as comatose patients).

The Controversy Surrounding Euthanasia

In the past, the role of the doctor was clear: the physician should minimize suffering and save lives whenever possible. In the twenty-first, it is possible for these two goals to be at odds. Saving lives in some situations seems to prolong the misery of the patient. In other cases, procedures or treatments may only marginally postpone the time of death. Advances in medical technology enable many to live who would have died just a few years ago, and massive amounts of money are spent each year on medical research with the goal of prolonging life. According to the Centers for Disease Control and Prevention, US population trends indicate that by the year 2060, those sixty-five and over will comprise about 25 percent of the country’s total population. These people will probably be healthy and alert well into their eighties; however, in the last years of their lives, they will probably require significant medical care, putting financial stress on the healthcare system.

The complex issues surrounding death, suffering, and economics create demands for answers to difficult ethical questions. Does all life have value? Should one fight against death even when suffering is intense? Should suffering be lessened if the time of death is brought nearer? Should a patient be given the right to refuse medical treatment if the result is death? Should others be allowed to make this decision for the patient? Should other factors, such as the financial or emotional burden on the family, be part of the decision-making process? Once a decision has been made to terminate suffering by death, is there any ethical difference between discontinuing medical treatment and giving a lethal dosage of painkilling medication? Should laws be put into place that offer guidelines in these situations, or should each case be decided on an individual basis? And who should decide? There is a wide range of opinions and much uncertainty involving euthanasia and what constitutes a “good” death.

Euthanasia comes from a Greek word that can be translated as “good death” and is defined in several ways, depending on the philosophical stance of the one giving the definition. Tom Beauchamp, in his book Health and Human Values (1983), defined euthanasia as

putting to death or failing to prevent death in cases of terminal illness or injury; the motive is to relieve comatoseness, physical suffering, or a serious sense of burdensomeness to self and others. In euthanasia, at least one other person causes or helps to cause the death of one who desires death or, in the case of an incompetent person, makes a substituted decision, either to cause death directly or to withdraw something that sustains life.

Most patients who express a wish to die more quickly are terminally ill; however, euthanasia is sometimes considered a solution for nonterminal patients as well.

When discussing the ethical implications of euthanasia, the types of cases have been divided into various classes. A distinction is made between voluntary and nonvoluntary euthanasia. In voluntary euthanasia, the patient consents to a specific course of medical action in which death is hastened. Nonvoluntary euthanasia would occur in cases in which the patient unable to make decisions about their death because of an inability to communicate or a lack of mental facility. Each of these classes has advocates and antagonists. Some believe that should always be allowed, but others would limit voluntary euthanasia to only those patients who have a terminal illness. Some, although agreeing in principle that voluntary euthanasia in terminal situations is ethically permissible, nevertheless oppose euthanasia of any type because of the possibility of abuse. With nonvoluntary euthanasia, the main ethical issues deal with when such an action should be performed and who should make the decision. If a person is in an irreversible coma, most agree the person’s physical life could be ended; however, arguments based on “quality of life” can easily become widened to include persons with physical or mental disabilities. Infants with severe deformities can sometimes be saved but not fully cured with medical technology, and some individuals would advocate nonvoluntary euthanasia in these cases due to suffering. Some believe that family members or those who stand to gain from the decision should not be allowed to make the decision. Others point out that the family is the most likely to know what the wishes of the patient would have been. Most believe that medical care personnel, although knowledgeable, should not have the power to decide, and many are reluctant to institute rigid laws. The possibility of misappropriated self-interest from each of these parties magnifies the difficulty of arriving at well-defined criteria.

The second type of classification is between passive and active euthanasia. Passive euthanasia occurs when sustaining medical treatment is refused or withdrawn, and death is allowed to take its course. Active euthanasia involves the administration of a drug, or some other means that directly causes death. Once again, there are many opinions surrounding these two types. One position is that there is no difference between active and because in each, the end is premeditated death with the motive of prevention of suffering. In fact, some argue that is more compassionate than letting death occur naturally, which may involve suffering. In opposition, others believe that there is a fundamental difference between active and passive euthanasia. A person may have the right to die but not the right to be killed. Passive euthanasia, they argue, is merely allowing a death that is inevitable to occur. Active euthanasia, if voluntary, is equated with suicide because a human being seizes control of death; if nonvoluntary, it is considered murder.

Passive euthanasia, although generally more publicly acceptable than active euthanasia, has become a topic of controversy, with debate centering on the types of medical treatment that can be withdrawn. A distinction is sometimes made between ordinary and extraordinary means. Defining these terms is difficult, since what may be extraordinary for one patient is not for another, depending on other medical conditions that the patient may have. In addition, what is considered an extraordinary technique today may be judged ordinary in the future. Another way to assess whether passive euthanasia should be allowed in a particular situation is to weigh the benefits against the burdens for the patient. Although most agree that there are cases in which high-tech equipment such as respirators can be withdrawn, there is a question about whether the administration of food and water should ever be discontinued. Here the line between passive and active euthanasia is blurred.

Religious and Legal Implications

Decisions about death concern everyone because everyone will die. Eventually, each individual will be the patient who is making the decisions or for whom the decisions are being made. One may also be called upon to make decisions for others. Even those not directly involved in the hard cases are affected, as taxpayers and subscribers to medical insurance, by the decisions made on behalf of others. In a difficult moral issue such as this, individuals look to different institutions for guidelines. Two sources of guidance are the church and the law.

In 1971, the Roman Catholic Church issued Ethical and Religious Directives for Catholic Health Facilities. Included in this directive is the statement that

[I]t is not euthanasia to give a dying person sedatives and analgesics for alleviation of pain, when such a measure is judged necessary, even though they may deprive the patient of the use of reason or shorten his life.

This thinking was reaffirmed by a 1980 statement from the Vatican that considered suffering and expense for the family legitimate reasons to withdraw medical treatment when death was imminent. Bishops from the Netherlands, in a letter to a government commission, stated that

[B]odily deterioration alone does not have to be unworthy of a man. History shows how many people, beaten, tortured and broken in body, sometimes even grew in personality in spite of it. Dying becomes unworthy of a man, if family and friends begin to look upon the dying person as a burden, withdraw themselves from him. . . .

When speaking of passive euthanasia, the bishops stated, “We see no reason to call this euthanasia. Such a person after all dies of his own illness. His death is neither intended nor caused, only nothing is done anymore to postpone it.” Christians from Protestant churches may reflect a wider spectrum of positions. Joseph Fletcher, an Episcopal priest, defined a person as one having the ability to think and reason. If a patient did not meet these criteria, according to Fletcher, their life may be ended out of compassion for the person they once were. The United Church of Christ illustrated this view in its policy statement:

When illness takes away those abilities we associate with full personhood…we may well feel that the mere continuance of the body by machine or drugs is a violation of their person.…We do not believe simply the continuance of mere physical existence is either morally defensible or socially desirable or is God’s will.

These varied positions generally are derived from differing emphases on two truths concerning the nature of God and the role of suffering in the life of the believer. First is the belief that God is the giver of life and that human beings should not usurp God’s authority in matters of life and death. Second, alleviation of suffering is of critical importance to God since it is not loving one’s neighbor to allow them to suffer. Those who give more weight to the first statement believe as well that God’s will allows for suffering and that suffering can be used for a good purpose in the life of the believer. Those who emphasize the second principle insist that a loving God would not prolong the suffering of people needlessly and that one should not desperately fight to prolong a life which God has willed to die.

C. Everett Koop, former surgeon general of the United States, differentiated between the positive role of a physician in providing a patient “all the life to which he or she is entitled” and the negative role of “prolonging the act of dying.” Koop opposed euthanasia in any form, cautioning against the possibility of sliding down a slippery slope toward making choices about death that reflect the caregiver’s “quality of life” more than the patient’s.

Jack Kevorkian, a Michigan physician, became the best-known advocate of assisted suicide in the United States. From 1990 to 1997, Kevorkian assisted at least sixty-six people in terminating their lives. According to Kevorkian’s lawyer, many other assisted suicides were not publicized. Kevorkian believed that physician-assisted suicide is a matter of individual choice and should be seen as a rational way to end tremendous pain and suffering. Most of the patients assisted by him spent many years suffering from extremely painful and debilitating diseases, such as multiple sclerosis, bone cancer, and cancer.

The criticized this view, calling it a violation of professional ethics. When faced with pain and suffering, the AMA asserted that it is a doctor’s responsibility to provide adequate “comfort” care, not death. In the AMA’s view, Kevorkian served as “a reckless instrument of death.” Three trials in Michigan for assisting in suicide resulted in acquittals for Kevorkian before another trial delivered a guilty verdict on the of second-degree murder in March 1999. Kevorkian remained in prison until his 2007 parole as he stated that should he had been released early, he would have resumed assisted suicides.

During the course of reevaluating the issues involved in terminating a life, the law has been in a state of flux. The decisions that are made by the courts act on the legal precedents of an individual’s right to determine what is done to their own body and society’s position against suicide. The balancing of these two premises has been handled legally by allowing refusal of treatment (passive euthanasia) but disallowing the use of poison or some other method that would cause death (active euthanasia). The latter is labeled “suicide,” and anyone who assists in such an act can be found guilty of assisting a suicide, or of murder. Following the Karen Ann Quinlan case in 1976, in which the family of a comatose woman secured permission to withdraw life-sustaining treatment, the courts routinely allowed family members to make decisions regarding life-sustaining treatment if the patient could not do so. The area of greatest legal controversy involves the withdrawal of food and water. Some courts have charged doctors with murder for the withdrawal of basic life support measures such as food and water. Others have ruled that invasive procedures to provide food and water (intravenously, for example) are similar to other medical procedures and may be discontinued if the benefit to the patient’s quality of life is negligible.

In 1994, 51 percent of the voters in Oregon passed the world’s first “death with dignity” law. It allowed physician-assisted suicide. Doctors could begin prescribing fatal overdoses of drugs to terminally ill patients. The vote was reaffirmed in 1997 by 60 percent of the state’s voters, despite opposition from the Catholic Church, the AMA, and various antiabortion and right-to-life groups. The Ninth United States Circuit Court of Appeals in San Francisco then lifted a lower court order blocking implementation of the law. Doctors in Oregon became free to prescribe fatal doses of barbiturates to patients with less than six months to live. Physicians were required to file forms with the Oregon Health Division before prescribing the overdose. Then, there would be a fifteen-day waiting period between the request for suicide assistance and the approval of the prescription. Opponents of the Oregon law charged that it perverted the practice of medicine and forced many suffering people to “choose” an early death to save themselves from expensive medical care or pain that could be manageable if physicians were aware of new methods of pain control. The National Right to Life Committee indicated that it would continue to fight implementation of the law in federal courts.

Since 1999, several states, including Connecticut, New Hampshire, Massachusetts, and Kansas, have witnessed attempts to legalize physician-assisted suicide, but the cases have either been withdrawn or defeated by voters or in the state legislature. In November 2008, Washington state passed its own death with dignity act by voter initiative, with 57.8 percent of votes cast in favor of the law. In a 2009 case, the state of Montana ruled that a physician cannot be held liable for assisting in suicide. In May 2013, Vermont Governor Peter Shumlin signed into law the Patient Choice and Control at End of Life Act, thereby legalizing physician-assisted suicide in the state. Similar to Montana, a state court in New Mexico ruled in early 2014 that terminally ill patients in the state have the constitutional right to receive "aid in dying." Seven years later, in 2021, the state became the ninth to codify physician-assisted suicide through an established law. The number of states allowing physician-assisted suicide continued to expand as, by 2023, it was legal in eleven jurisdictions: California, Colorado, District of Columbia, Hawaii, Montana, Maine, New Jersey, New Mexico, Oregon, Vermont, and Washington.

Still, it continued to be a battle often played out in the media to get to that point. The right-to-die movement and the push for legalizing physician-assisted suicide picked up steam once more following the highly publicized story of twenty-nine-year-old Brittany Maynard, who left her home state of California to move to Oregon to end her life in late 2014 in accordance with the state's death with dignity law following a diagnosis of terminal brain cancer. Several states renewed efforts to introduce legislation regarding physician-assisted suicide as her story dominated the media; according to an early 2015 Gallup poll, 68 percent of Americans feel that physicians should be legally able to aid terminally ill patients in ending their lives. Almost one year after Maynard's death, the governor of California signed the End of Life Act into law, which made the practice of physicians prescribing lethal doses of medications to terminally ill patients legal in that state as well. By 2021, while California's law had come under judicial challenge beginning in 2018, the states of Colorado, Hawaii, New Jersey, Maine, and New Mexico had also passed death with dignity laws allowing for physician-assisted suicide for those who are terminally ill, typically with stipulations regarding the amount of time that a person is medically judged to have left to live as well as the amount of time between an active request for medication to assist in dying and the reception of the medication. At the same time, a few countries, such as Belgium, the Netherlands, and Spain, legalized medical aid in dying to alleviate suffering at the federal level. In the early 2020s, ten countries worldwide had legalized some form of assistance in dying.

Although the laws vary from state to state, most states allow residents to make their wishes known regarding terminal health care either by writing a or by choosing a durable power of attorney. A living will is a document in which one can state that some medical treatments should not be used if one becomes incapacitated to the point where one cannot choose. Living wills allow the patient to decide in advance and protect healthcare providers from lawsuits. Which treatment options can be terminated and when this action can be put into effect may be limited in some states. Most states have a specific format that should be followed when drawing up a living will and require that the document be signed in the presence of two witnesses. Often, qualifying additions can be made by the individual that specify whether food and water may be withdrawn and whether the living will should go into effect only when death is imminent or also when a person has an incurable illness, but death is not imminent. A copy of the living will should be given to the patient’s physician and become a part of the patient’s medical records. The preparation or execution of a living will cannot affect a person’s life insurance coverage or the payment of benefits. Since the medical circumstances of one’s life may change, and a person’s ethical stance may also change, a patient may change the living will at any time by signing a written statement.

A second way in which a person can control what kind of decisions will be made regarding their death is to choose a decision maker in advance. This person assumes a and is legally allowed to act on the patient’s behalf, making medical treatment decisions. One advantage of a durable power of attorney over a living will is that the patient can choose someone who shares similar ethical and religious values. Since it is difficult to foresee every medical situation that could arise, there is more security with a durable power of attorney in knowing that the person will have similar values and will, therefore, probably make the same judgments as the patient. Usually, a primary agent and a secondary agent are designated if the primary agent is unavailable. This is especially important if the primary agent is a spouse or a close relative who could, for example, be involved in an accident at the same time as the patient.

Perspective and Prospects

Although large numbers of court decisions, articles, and books suggest that the issues involved in euthanasia are more recent products of medical technology, these questions are not new. Euthanasia was widely practiced in Western classical culture. The Greeks did not believe that all humans had the right to live, and in Athens, infants with disabilities were often killed. Although, in general, they did not condone suicide, Pythagoras, Plato, and Aristotle believed that a person could choose to die earlier in the face of an incurable disease and that others could help that person to die. Seneca, the Roman Stoic philosopher, was an avid proponent of euthanasia, stating that

Against all the injuries of life, I have the refuge of death. If I can choose between a death of torture and one that is simple and easy, why should I not select the latter? As I choose the ship in which I sail and the house which I shall inhabit, so I will choose the death by which I leave life.

The famous Hippocratic oath for physicians acted in opposition to the prevailing cultural bias in favor of euthanasia. Contained in this oath is the statement, “I will never give a deadly drug to anybody if asked for it . . . or make a to this effect.” The AMA reaffirmed this position in a policy statement:

the intentional termination of the life of one human being by another—“mercy killing”—is contrary to that for which the medical profession stands and is contrary to the policy of the American Medical Association.

The English poet John Donne, in his Devotions upon Emergent Occasions, wrote extensively on the concept of suffering in the severely ill. He wrote, “Affliction is a treasure, and scarce any man hath enough of it.” In addition, Jewish and Christian theology have traditionally opposed any form of euthanasia or suicide, avowing that since God is the author of life and death, life is sacred. Therefore, a person would rebel against God if they prematurely shorten their life because they violate the Sixth Commandment: “Thou shalt not kill.” Suffering was viewed not as an evil to be avoided but as a condition to be accepted. The apostle Paul served as an example for early Christians. In 2 Corinthians, he prayed for physical healing, yet when it did not come, he accepted his weakness as a way to increase his on God. This position was affirmed by Saint Augustine in his work De Civitate Dei (413-426; The City of God) when he condemned suicide as a “detestable and damnable wickedness” that was worse than murder because it left no room for repentance. These strong indictments from the Church against suicide and euthanasia were largely responsible for changing the Greco-Roman attitudes toward the value of human life. They were accepted as society’s position until the advent of technologies in the late twentieth century that made it possible to extend life beyond what would have been the point of death.

Although these issues have been debated by physicians and philosophers for centuries, there remains a heightened need for thoughtful discussion and resolution. The majority of nations, as well as major medical organizations such as the AMA, oppose euthanasia as contrary to the proper role of the physician and society. Though this position had come under review, it was reaffirmed by an AMA House of Delegates vote in 2019. However, also in 2019, the AMA relented slightly, opening up the possibility of medical professionals assisting in euthanasia should their conscience sanction it and stating that doing so would not violate their professional obligations. Still, these statements leave much open to argument and interpretation. However, closely related and complex issues, such as the treatment of pain in the terminally ill, leave much room for development in human understanding.

Bibliography

Booker, Brakkton. "California Governor Signs Physician-Assisted Suicide Bill into Law." NPR, 5 Oct. 2015, www.npr.org/sections/thetwo-way/2015/10/05/446115171/california-governor-signs-physician-assisted-suicide-bill-into-law. Accessed 24 July 2024.

Boudreau, J. Donald, and Margaret A. Somerville. “Euthanasia and Assisted Suicide: A Physician’s and Ethicist’s Perspectives.” Medicolegal and Bioethics, vol. 4, 2014, pp. 1–12.

Corr, Charles A., Clyde M. Nabe, and Donna M. Corr. Death and Dying, Life and Living. 7th ed., Wadsworth, 2013.

Dowbiggin, Ian Robert. A Merciful End: The Euthanasia Movement in Modern America. Oxford UP, 2003.

Eckholm, Erik. “New Mexico Judge Affirms Right to ‘Aid in Dying.’” The New York Times, 13 Jan. 2014, www.nytimes.com/2014/01/14/us/new-mexico-judge-affirms-right-to-aid-in-dying.html. Accessed 24 July 2024.

Fenigsen, Richard. “Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia. Part Two: Medicine versus Euthanasia.” Issues in Law & Medicine, vol. 28, no. 1, 2012, pp. 71–87.

Gorovitz, Samuel. Drawing the Line: Life, Death, and Ethical Choices in an American Hospital. Temple UP, 1993.

Harron, Frank, John Burnside, and Tom Beauchamp. Health and Human Values. Yale UP, 1983.

“In U.S., Support up For Doctor-Assisted Suicide.” Gallup, 27 May 2015, news.gallup.com/poll/183425/support-doctor-assisted-suicide.aspx. Accessed 24 July 2024.

Magnusson, Roger, and Peter H. Ballis. Angels of Death: Exploring the Euthanasia Underground. Yale UP, 2002.

Pappas, Demetra M. The Euthanasia/Assisted-Suicide Debate. Greenwood, 2012.

“Physician-Assisted Suicide Fast Facts.” CNN, 1 June 2021, www.cnn.com/2014/11/26/us/physician-assisted-suicide-fast-facts/index.html. Accessed 24 July 2024.

Rebman, Renée C. Euthanasia and the Right to Die: Pro/Con Issues. Enslow, 2002.

Sharp, Robert. “The Dangers of Euthanasia and Dementia: How Kantian Thinking Might Be Used to Support Non-Voluntary Euthanasia in Cases of Extreme Dementia.” Bioethics, vol. 26, no. 5, 2012, pp. 231–35.

Spring, Beth, and Ed Larson. Euthanasia. Multnomah, 1988.

“States Where Medical Aid in Dying is Authorized.” Compassion & Choices, 2024, www.compassionandchoices.org/resource/states-or-territories-where-medical-aid-in-dying-is-authorized. Accessed 24 July 2024.

Stoyles, B. J., and S. Costreie. “Rethinking Voluntary Euthanasia.” Journal of Medicine and Philosophy, vol. 38, no. 6, 2013, pp. 674–95.

Wennberg, Robert N. Terminal Choices: Euthanasia, Suicide, and the Right to Die. Eerdmans, 1989.

Wittenburg-Cox, Avivah. “A Designed Death – Where & When The World Allows.” Forbes, 22 Oct. 2022, www.forbes.com/sites/avivahwittenbergcox/2022/10/22/a-designed-death–where–when-the-world-allows-it/?sh=12334f6d7b3d. Accessed 24 July 2024.