What is euthanasia?

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 present, 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. Experts in US population trends indicate that by the year 2030, those over the age of sixty-five will comprise about 20 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 health care 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 opinion 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), defines 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, anxiety 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 as a solution for nonterminal patients as well. An example of the latter would be seriously deformed or retarded infants whose futures are judged to have a poor “quality of life” and who would be a serious burden on their families and society.

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 is not able to make decisions about his or her death because of an inability to communicate or a lack of mental facility. Each of these classes has advocates and antagonists. Some believe that voluntary euthanasia 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 abuses. 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 that that 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 because of the suffering of the infants’ caregivers. 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 the 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 passive euthanasia because in each the end is premeditated death with the motive of prevention of suffering. In fact, some argue that active euthanasia 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 as the types of medical treatment that can be withdrawn are debated. 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 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. In the meantime, one may 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 the 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 considers suffering and expense for the family legitimate reasons to withdraw medical treatment when death is imminent. Bishops from the Netherlands, in a letter to a government commission, state 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 state, “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, defines a person as one having the ability to think and reason. If a patient does not meet these criteria, according to Fletcher, his or her life may be ended out of compassion for the person he or she once was. The United Church of Christ illustrates 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 him or her to suffer. Those who give more weight to the first statement believe as well that God’s will allows for suffering and that the 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, differentiates 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 has opposed euthanasia in any form, cautioning against the possibility of sliding down a slippery slope toward making choices about death that reflect the caregivers’ “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 have not been publicized. Kevorkian believes 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 brain cancer.

The American Medical Association (AMA) has criticized this view, calling it a violation of professional ethics. When faced with pain and suffering, the AMA asserts 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 charge of second-degree murder in March 1999.

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 his or her 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 Hawaii, 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 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 can not be held liable assisiting 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.

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 living will 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 in the event that one becomes incapacitated to the point where one cannot choose. Living wills allow the patient to decide in advance and protect health care 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 his or her death is to choose a decision maker in advance. This person assumes a durable power of attorney 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 in the event that 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 decision, articles, and books suggest that the issues involved in euthanasia are 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 suggestion to this effect.” The AMA has 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 great 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 man would rebel against God if he prematurely shortens his life, because he violates 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 dependence 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. However, closely related and complex issues such as the treatment of pain in the terminally ill leave much room for development in human understanding.

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