Euthanasia, also known as assisted suicide, physician-assisted suicide (dying), doctor-assisted dying (suicide), and more loosely termed mercy killing, means to take a deliberate action with the express intention of ending a life to relieve intractable (persistent, unstoppable) suffering.
Some interpret euthanasia as the practice of ending a life in a painless manner. Many disagree with this interpretation, because it needs to include a reference to intractable suffering.
In the majority of countries euthanasia or assisted suicide is against the law. According to the National Health Service (NHS), UK, it is illegal to help somebody kill themselves, regardless of circumstances. Assisted suicide, or voluntary euthanasia carries a maximum sentence of 14 years in prison in the UK. In the USA the law varies in some states (see further down).
There are two main classifications of euthanasia:
- Voluntary euthanasia - this is euthanasia conducted with consent. Since 2009 voluntary euthanasia has been legal in Belgium, Luxembourg, The Netherlands, Switzerland, and the states of Oregon (USA) and Washington (USA).
- Involuntary euthanasia - euthanasia is conducted without consent. The decision is made by another person because the patient is incapable to doing so himself/herself.
There are two procedural classifications of euthanasia:
- Passive euthanasia - this is when life-sustaining treatments are withheld. The definition of passive euthanasia is often not clear cut. For example, if a doctor prescribes increasing doses of opioid analgesia (strong painkilling medications) which may eventually be toxic for the patient, some may argue whether passive euthanasia is taking place - in most cases, the doctor's measure is seen as a passive one. Many claim that the term is wrong, because euthanasia has not taken place, because there is no intention to take life.
- Active euthanasia - lethal substances or forces are used to end the patient's life. Active euthanasia includes life-ending actions conducted by the patient or somebody else.
Active euthanasia is a much more controversial subject than passive euthanasia. Individuals are torn by religious, moral, ethical and compassionate arguments surrounding the issue. Euthanasia has been a very controversial and emotive topic for a long time.
The term assisted suicide has several different interpretations. Perhaps the most widely used and accepted is "the intentional hastening of death by a terminally ill patient with assistance from a doctor, relative, or another person."
Some people will insist that something along the lines of "in order relieve intractable (persistent, unstoppable) suffering" needs to be added to the meaning, while others insist that "terminally ill patient" already includes that meaning.
Medical definitions of euthanasia
According to MediLexicon's medical dictionary:
- "A quiet, painless death." or
- "The intentional putting to death of a person with an incurable or painful disease intended as an act of mercy."
Active euthanasia is:
"A mode of ending life in which the intent is to cause the patient's death in a single act (also called mercy killing)."
Passive euthanasia is:
"A mode of ending life in which a physician is given an option not to prescribe futile treatments for the hopelessly ill patient."
Options for terminal patients or those with intractable suffering and pain
Patients with a terminal or serious and progressive illness in most developed countries have several options, including:
The World Health Organization (WHO) defines palliative care as:
"An approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual".
One goal of palliative care is for the patients and families to accept dying as a normal process. It seeks to provide relief from pain and uncomfortable symptoms while integrating psychological and spiritual features of patient care. Palliative care strives to offer a support system to help patients live their remaining time as actively as they can and to help families bereave and deal with the illness of a loved one.
Since pain is the most visible sign of distress among patients receiving palliative care, affecting about 70% of cancer patients and 65% of patients dying from non-malignant diseases, opioids are a very common treatment option.
These medicines form part of well-established treatment plans for managing pain as well as several other symptoms that patients encounter. Often, opioids are chosen during palliative care in spite of the side effects such as drowsiness, nausea, vomiting, and constipation.
Some type of palliative care is given to about 1.2 million Americans and 45,000 new patients each year in England, Wales, and Northern Ireland. About 90% of these patients have cancer, while the remaining patients have heart disease, stroke, motor neuron disease, or multiple sclerosis. The providers of the palliative care include in-patient care, hospital support services, community care, day care and outpatient care.
In the USA, UK and many other countries a patient can refuse treatment that is recommended by a doctor or some other health care professional, as long as they have been properly informed and are of sound mind. In the UK, the Mental Health Act 1983 excludes children and people under the age of 18 years.
According to the Department of Health, UK, nobody can give consent on behalf of an incompetent adult, such as one who is in a coma. Nevertheless, doctors take into account the best interests of the patient when deciding on treatment options. A patient's best interests are based on:
- What the patient wanted when he/she was competent
- The patient's general state of health
- The patient's spiritual and religious welfare.
An example in the UK
The doctor may decide the best option for a patient who is declared as clinically brain dead is to switch of the life-support machines; equipment without which the patient will die. The doctor in charge will talk to the patient's family. However, the final decision is the doctor's, and strict criteria must be met.
A living will (advance directive)
This is a legally binding document which anybody may draw up in advance if they are concerned that perhaps they will be unable to expresses their wishes at a later date. In the advance directive the individual states what they want to happen if they become too ill to be able to refuse or consent to medical treatment.
Euthanasia in history
The English medical word "euthanasia" comes from the Greek word eu meaning "good," and the Greek word thanatos meaning "death."
Hippocrates (ca. 460 BC - ca. 370 BC)
Euthanasia is mentioned in the Hippocratic Oath. The original oath states "To please no one will I prescribe a deadly drug nor give advice which may cause his death." Even so, the ancient Greeks and Romans were not strong advocates of preserving life at any cost, and were tolerant of suicide when no relief could be offered to the dying.
English Common Law
Suicide was a criminal act from the 1300s until the middle of the last century; this included assisting others to end their lives.
Thomas More (1478-1535)
An English lawyer, scholar, author and statesman; also recognized as a saint within the Catholic Church, once envisaged a utopian community as one that would facilitate the death of those whose lives had become burdensome as a result of torturing and lingering pain.
Since early 1800s
Since the early 1800s euthanasia has been a topic of debates and activism in the USA, Canada, Western Europe and Australasia. Ezekiel Emanuel (born 1957, USA), an American National Institutes of Health bioethicist said that the modern era of euthanasia was ushered in by the availability of anesthesia.
New York 1828
An anti-euthanasia law was passed in the state of New York in 1828. It is the first known anti-euthanasia law in the USA. In subsequent years many other localities and states followed suit with similar laws. Several advocates, including doctors promoted euthanasia after the American Civil War. At the beginning of the 1900s support for euthanasia peaked in the USA, and then rose up again during the 1930s.
In 1935 euthanasia societies emerged in England, and in 1938 in the USA.
Doctor assisted suicide became legalized in Switzerland in 1937, as long as the doctor ending the patient's life had nothing to gain.
After the Second World War Glanville Williams (1911-1997, Wales. A legal professor) and Joseph Fletcher (1905-1991, USA. An Episcopal priest, he later identified himself as an atheist) emerged as proponents of euthanasia.
During the 1960s advocacy for a right-to-die approach to euthanasia grew.
Rights of the Terminally Ill Act was passed in 1996 in the Northern Territory. Under the Act four patients died using a euthanasia device designed by Dr. Philip Nitschke. One year later the Act was overturned by the Federal Parliament. Dr. Nitschke responded by founding EXIT International, a pro-euthanasia group. In 2009 a quadriplegic patient, Christian Rossiter (49) was granted the right to refuse nourishment and be allowed to die; Chief Justice Wayne Martin specified that Brightwater, his caregiver, would not be held criminally responsible for following his instructions. A chest infection eventually ended Rossiter's life.
Euthanasia is illegal in the whole of the United Kingdom (England, Wales, Northern Ireland and Scotland). However, as the matter is now under the Scottish parliament in Scotland, it is possible that varying laws may eventually apply in future within the UK.
Currently, euthanasia is illegal across the UK.
The British Voluntary Euthanasia Society (known today as EXIT) was founded by Dr. Killick Millard (1870-1952) and Lord Moynihan (1865-1936) in 1935.
The society created A Guide to Self Deliverance, which included guidelines on how an individual could end his/her life. In 1980 the Voluntary Euthanasia Society of Scotland separated from the original society, and published How to Die with Dignity.
The Voluntary Euthanasia Society of Scotland has been urging the UK to change the law so that terminally ill patients may have the option of ending their lives.
Polls reveal that at least 80% of UK citizens and 64% of its GPs (general practitioners, primary care physicians) are in favor of the legalization of euthanasia (some polls give different results for health care professionals). However, Parliament has not passed any laws on this issue.
The Anglican Church - in 1997 Parliament voted 234-89 not to legalize euthanasia in the UK. MPs (Member of Parliament) have been against passing any laws because of the Church of England's (Anglican Church) view that "physician assisted suicide is incompatible with the Christian faith and should not be permitted by civil law."
1957 ruling - Judge Devlin ruled in the trial in 1957 of Dr. John Bodkin Adams that causing death through the administration of lethal drugs to a patient, if the intention was purely to alleviate pain, is not considered murder even if death is a potential or likely outcome.
The Suicide Act 1961 states that it is illegal to "aid, abet, counsel or procure the suicide of another" and sets a maximum prison sentence of 14 years. Doctors in the UK do often assist patients with their wishes by withholding treatment and reducing pain when death is a few days away and after consulting patients, relatives, and other health care professionals.
Inconsistency between illegality and prosecution - even though 92 Britons have gone overseas for an assisted suicide, no relatives have ever been prosecuted for assisting them - some were charged, to later find that the charges were dropped. This discrepancy between the law and legal action prompted Debbie Purdy to launch a case to clarify whether her husband would be risking prosecution if he helped her travel to a clinic in Switzerland to die. On 30th August, 2009 a decision was made that the Director of Public Prosecutions had to clarify what the enforcement of the Suicide Act 1961 entailed.
The Netherlands decriminalized doctor-assisted suicide; in 2002 some restrictions were loosened. In 2002 doctor-assisted suicide was approved in Belgium.
A turning point in the euthanasia debate occurred after a public outcry over the Karen Ann Quinlan (1954-1985) case.
Karen Ann Quinlan Case - when Quinlan was 21 she lost consciousness after returning home from a party. She had consumed diazepam (Valium), dextropropoxyphene (an analgesic in the opioid category), and alcohol. She collapsed and stopped breathing twice for 15 minutes. She was hospitalized and eventually lapsed into a persistent vegetative state.
Several months later, while being kept alive on a ventilator, her parents asked the hospital to discontinue active care, so that she could be allowed to die. The hospital refused, there were subsequent legal battles, and a tribunal eventually ruled in her parent's favor. Quinlan was removed from the mechanical ventilation in 1976 - but she went on living in a persistent vegetative state until 1985, when she died of pneumonia.
Even today, Quinlan's case raises important questions in moral theology, bioethics, euthanasia, legal guardianship and civil rights. Health care professionals say her case has had an impact on medical and legal practice worldwide.
Since Quinlan's case, formal ethics committees now exist in hospitals, nursing homes and hospitals. Many say the development of advance health directives (living wills) occurred as a result of her case. In 1977, California legalized living wills, with other states soon following suit.
Quinlan's case paved the way for legal protection of voluntary passive euthanasia.
Derek Humphry (born 1930), a British-born American journalist founded the Hemlock Society in Santa Monica, California. At the time it was the only group in the USA to provide information to terminally ill patients in case they wished to hastened death. The society also campaigned and contributed financially to drives to amend legislation. In 2003 Hemlock merged with End of Life Choices, changing their name to Compassion and Choices.
In 1990 the Supreme Court approved the use of non-active euthanasia.
Dr. Jack Kevorkian (1928), an American pathologist, right-to-die activist, painter, composer, and instrumentalist, was tried and convicted in 1992 for a murder displayed on TV. He had already become infamous for encouraging and assisting people in committing suicide. He claimed to have assisted at least 130 patients to that end. He famously said that "dying is not a crime."
Oregon 1994 - Oregon voters approved the Death with Dignity Act in 1994, allowing physicians to assist terminal patients who were not expected to survive more than six months. The US Supreme Court adopted such laws in 1997. In 2001 the Bush administration tried unsuccessfully to use drug law to stop Oregon in 2001, in the case Gonzales v. Oregon. Texas introduced non-active euthanasia legally in 1999.
Terri Schiavo case - a seven-year long legal case which dealt with whether Terri Schiavo, a patient diagnosed as being in a persistent vegetative state for many years, could be disconnected from life support. In 1993, Michael Schiavo, her husband and guardian, asked the nursing home staff not to resuscitate her - however, the staff convinced him to withdraw the order.
In 1998, Michael petitioned the Sixth Circuit Court of Florida to remove her feeding tube under Florida Statutes Section 765.401(3). However, Robert and Mary Schindler (Terri's parents) argued that she was conscious and opposed the petition. Michael eventually transferred his authority over the issue to the court. The court concluded that the patient would not wish to continue life-prolonging measures.
Terri Schiavo's feeding tube was withdrawn on April 24, 2001, and reinserted some days later as legal decisions were made. This attracted the attention of the media, and subsequently that of politicians and advocacy groups, especially pro-life and disability rights groups.
Members of the Florida Legislature, the US Congress and even the President of the USA started talking about it. President Bush returned to Washington D.C from a vacation in March 2005 to sign legislation aimed at keeping Schiavo alive. This move turned the case into a national topic for most of the month.
The Schiavo case involved 14 appeals, several motions, petitions and hearings in the Florida courts, five suits in federal district court, Florida legislation was struck down by the Supreme Court of Florida, a subpoena by a congressional committee to qualify Schiavo for witness protection, and some other legal proceedings. Eventually the local court's decision to disconnect Schiavo from life support was acted upon on March 18th, 2005 - Schiavo died on March 31st.
Washington state - the Washington Initiative 1000 made Washington the 2nd state in the USA to legalize doctor-assisted suicide.
Arguments for and against voluntary euthanasia
We will look at the arguments for and against voluntary euthanasia in turn.
Arguments for voluntary euthanasia
- Choice - freedom of choice is the cornerstone of free market systems and liberal democracies. The patient should be given the option to make their own choice.
- Quality of life - only the patient is really aware of what it is like to experience intractable (persistent, unstoppable) suffering; even with pain relievers. Those who have not experienced it cannot fully appreciate what effect it has on quality of life. Apart from physical pain, overcoming the emotional pain of losing independence is an additional factor that only the patient comprehends fully.
- Dignity - every individual should be given the ability to die with dignity.
- Witnesses - people who witness the slow death of others are especially convinced that the law should be altered so that assisted death be allowed.
- Drain on resources - in virtually every country there is never enough hospital space. Channeling the resources of highly-skilled staff, equipment, hospital beds and medications towards life-saving treatments makes more sense; especially when these resources are currently spent on terminal patients with intractable suffering who wish to die.
- Public opinion - in nearly all countries a significantly higher proportion of people are for euthanasia than against it. In a democracy legislation should reflect the will of the people.
- Humane - it is more humane to allow a person with intractable suffering to be allowed to choose to end that suffering.
- Loved ones - it helps shorten the grief and suffering of the patient's loved ones.
- We already do it - if a loved pet has intractable suffering we put it down. It is seen as an act of kindness. Why should this kindness be denied to humans?
- Prolongation of dying - if the dying process is unpleasant, the patient should have the right to reduce this unpleasantness. In medicine, the prolongation of living may sometimes turn into the prolongation of dying. Put simply - why should be a patient be forced to experience a slow death?
Reasons against voluntary euthanasia
The discussion regarding assisted suicide is set to continue indefinitely.
- The doctor's role - doctors and other health care professionals may have their professional roles compromised. The Hippocratic Oath, in its ancient form stated "To please no one will I prescribe a deadly drug nor give advice which may cause his death."
- Moral religious argument - several religions see euthanasia as a form of murder and morally unacceptable. At best, some see voluntary euthanasia as a form of suicide, which goes against the teachings of many religions. Euthanasia weakens society's respect for the sanctity of life.
- Competence - euthanasia is only voluntary if the patient is mentally competent - has a lucid understanding of available options and consequences. Determining or defining competence is not straightforward.
- Guilt - there is a risk patients may feel they are a burden on resources and are psychologically pressured into consenting. They may feel that the burden - financially, emotionally, mentally - on their family is overwhelming. Even if the costs of treatment are provided by the state, there is a risk hospital personnel may have an economic incentive to encourage euthanasia consent.
- Slippery slope - there is a risk things will start with those who are terminally ill and wish to die because of intractable suffering, and eventally begin to include other patients.
- The patient might recover - the patient might recover against all odds. The diagnosis might be wrong.
- Palliative care - good palliative care makes euthanasia unnecessary.
- How can you regulate it? Euthanasia cannot be properly regulated.
Physicians opinions on euthanasia
Medscape completed a survey of 10,000 American physicians in 2010. When asked "Would you ever consider halting life-sustaining therapy because the family demands it, even if you believed that it was premature?" 16.3% said they would and 54.5% said they would not.
When they were asked "Should physician-assisted suicide be allowed in some cases?" almost 46% said it should and nearly 41% said it should not - the rest responded that "it depends."
A survey of UK doctors asked whether a person with an incurable and painful disease, from which they will die, should be allowed by law to end their life. Roughly one third agreed that they should be allowed to choose while almost two thirds disagreed. They also found that doctors working in palliative care were more likely to be against assisted dying.
Who opts for euthanasia?
A literature review carried out in October 2013 investigated a number of aspects of euthanasia and assisted suicide in countries where it is legal. The following are some of the findings in regards to the underlying illness and demographics:
- In most regions, men opted for assisted suicide more often than women (except in Switzerland)
- The age group most commonly opting for euthanasia was the 60-85-year-olds, followed by 40-59-year-olds
- Most people who chose an assisted death were married, followed by widowed, then divorced
- The disease most commonly found in euthanasia cases was cancer - other diseases included amyotrophic lateral sclerosis (ALS), multiple sclerosis and cardiovascular disease
- The Netherlands reported the highest number of assisted deaths - 3,695 in 2011 (roughly 2.5% of all deaths)
- Overall, in states and countries where euthanasia is legal, between 0.1% and 2.9% of all deaths were assisted.
In the Netherlands, more than 85% of doctors say they would consider helping a patient die, with 1 in 3 saying they would consider it if a patient were suffering from early dementia or mental illness. This is according to a new study published in the Journal of Medical Ethics that surveyed almost 1,500 Dutch doctors on their attitudes toward euthanasia and physician-assisted dying.