ENG - Euthanasia (from the Greek eu = good + thanatos = death) refers to the practice of ending a life in a painless manner. Many different forms of euthanasia can be distinguished, including animal euthanasia and human euthanasia, and within the latter, voluntary and involuntary euthanasia. Voluntary euthanasia and physician-assisted suicide have been the focus of great controversy in recent years.
As of 2009, some forms of euthanasia are legal in Belgium, Luxembourg, The Netherlands, Switzerland, the U.S. states of Oregon and Washington the Autonomous Community of Andalusia (Spain), and Thailand.
Classification of euthanasia
Euthanasia by consent
Euthanasia may be conducted with consent (voluntary euthanasia) or without consent (involuntary euthanasia). Involuntary euthanasia is conducted where an individual makes a decision for another person incapable of doing so. The decision can be made based on what the incapacitated individual would have wanted, or it could be made on substituted judgment of what the decision maker would want were he or she in the incapacitated person's place, or finally, the decision could be made by assessing objectively whether euthanasia is the most beneficial course of treatment. In any case, euthanasia by proxy consent is highly controversial, especially because multiple proxies may claim the authority to decide for the patient and may or may not have explicit consent from the patient to make that decision.
Euthanasia by means
Euthanasia may be conducted passively, non-actively, and actively. Passive euthanasia entails the withholding of common treatments (such as antibiotics, chemotherapy in cancer, or surgery) or the distribution of a medication (such as morphine) to relieve pain, knowing that it may also result in death (principle of double effect). Passive euthanasia is the most accepted form, and it is a common practice in most hospitals. Non-active euthanasia entails the withdrawing of life support and is more controversial. Active euthanasia entails the use of lethal substances or forces to kill and is the most controversial means. An individual may use a euthanasia machine to perform euthanasia on himself / herself.
Assisted suicide is a form of euthanasia where the patient actively takes the last step in their death. The term "assisted suicide" is contrasted with "active euthanasia" when the difference between providing the means and actively administering lethal medicine is considered important. For example, Swiss law on assisted suicide allows assisted suicide, while all forms of active euthanasia (like lethal injection) remain prohibited.
Some jurisdictions declare that a person dying as a result of physician assisted suicide does not commit suicide. This ensures that terminally ill people choosing assisted suicide options do not have reduced insurance claims compared to people dying in "natural" way. For example, the Oregon Death with Dignity Act defines that "... participation under the Act is not suicide, so should not affect insurance benefits by that definition."
The term euthanasia comes from the Greek words "eu"-meaning good and "thanatos"-meaning death, which combined means “well-death” or "dying well". Hippocrates mentions euthanasia in the Hippocratic Oath, which was written between 400 and 300 B.C. The original Oath states: “To please no one will I prescribe a deadly drug nor give advice which may cause his death.” Despite this, the ancient Greeks and Romans generally did not believe that life needed to be preserved at any cost and were, in consequence, tolerant of suicide in cases where no relief could be offered to the dying or, in the case of the Stoics and Epicureans, where a person no longer cared for his life.
English Common Law from the 1300s until the middle of the last century made suicide a criminal act in England and Wales. Assisting others to kill themselves remains illegal in that jurisdiction. However, in the 1500s, Thomas More, in describing a utopian community, envisaged such a community as one that would facilitate the death of those whose lives had become burdensome as a result of "torturing and lingering pain".
Prior to and during World War II, Nazi Germany conducted a euphemistically named "euthanasia program", code-named Action T4.
This program was based on eugenics and grounded in the view that the state is responsible for providing racial hygiene. Even though this program was referred to as an "euthanasia program", the Nazi German use of the term euthanasia differs from the common current view and use of the term.
"Of course, I had always known that the use of the term 'euthanasia' by the Nazi killers was a euphemism to camouflage their murder of human beings they had designated as 'life unworthy of life'; that their aim was not to shorten the lives of persons with painful terminal diseases but to kill human beings they considered inferior, who could otherwise have lived for many years."
— The Origins of Nazi Genocide: From Euthanasia to the Final Solution, H. Friedlander, UNC Press, 1997
In the Western sphere, judges were often lenient in mercy-killing cases despite continuing religious opposition. During the post-war period, prominent proponents of euthanasia included Glanville Williams (The Sanctity of Life and the Criminal Law) and clergyman Joseph Fletcher ("Morals and medicine"). By the 1960s, advocacy for a right-to-die approach to voluntary euthanasia increased.
In 1995, the world's first euthanasia legislation, the Rights of the Terminally Ill Act 1995, was passed in the Northern Territory of Australia. Four patients died under the Act, using a euthanasia device designed by Dr Philip Nitschke. The legislation was overturned in 1997 by Australia’s Federal Parliament in 1997. In response to the overturning of the Act, Dr Nitschke founded EXIT International.
In 1957 in Britain, Judge Devlin ruled in the trial of Dr John Bodkin Adams that causing death through the administration of lethal drugs to a patient, if the intention is solely to alleviate pain, is not considered murder even if death is a potential or even likely outcome. In 1993, the Netherlands decriminalized doctor-assisted suicide, and in 2002, restrictions were loosened. During that year, physician-assisted suicide was approved in Belgium. Belgium's at the time most famous author Hugo Claus, suffering from Alzheimer's disease, was among those that asked for euthanasia. He died in March 2008, assisted by an Antwerp doctor.
A key turning point in the debate over voluntary euthanasia (and physician assisted dying), at least in the United States, was the public furor over the case of Karen Ann Quinlan. The Quinlan case paved the way for legal protection of voluntary passive euthanasia. In 1977, California legalized living wills and other states soon followed suit.
In 1980 the Hemlock Society USA was founded in Santa Monica by Derek Humphry. It was the first group in America to provide information to the terminally ill in case they wanted a hastened death. Hemlock also campaigned and partially financed drives to reform the law. In 2003 Hemlock was merged with End of Life Choices, which changed its name to Compassion and Choices.
In 1990, Dr. Jack Kevorkian, a Michigan physician, became infamous for encouraging and assisting people in committing suicide which resulted in a Michigan law against the practice in 1992. Kevorkian was tried and convicted in 1999 for a murder displayed on television. Also in 1990, the Supreme Court approved the use of non-aggressive euthanasia.
In 1994, Oregon voters approved the Death with Dignity Act, permitting doctors to assist terminal patients with six months or less to live to end their lives. The U.S. Supreme Court allowed such laws in 1997. The Bush administration failed in its attempt to use drug law to stop Oregon in 2001, in the case Gonzales v. Oregon. In 1999, non-aggressive euthanasia was permitted in Texas.
Most recently, amid U.S. government roadblocks and controversy in the Terri Schiavo case, where a Floridian who was in a vegetative state since 1990, had her feeding tube removed in 2005. Her husband had won the right to take her off life support, which he claimed she would want but was difficult to confirm as she had no living will and the rest of her family claimed otherwise.
In November 2008, Washington Initiative 1000 made Washington the second U.S. state to legalize physician-assisted suicide.
While active euthanasia remains illegal in China, it is gaining increasing acceptance among doctors and the general populace. Support for euthanasia is predicted by decreasing importance of religious belief, higher family income, experiences in taking care of terminally ill family members, being non-Christian, and increasing age.
Arguments for and against voluntary euthanasia
Since World War II, the debate over euthanasia in Western countries has centered on voluntary euthanasia (VE) within regulated health care systems. In some cases, judicial decisions, legislation, and regulations have made VE an explicit option for patients and their guardians.
Proponents and critics of such VE policies offer the following reasons for and against official voluntary euthanasia policies:
Reasons given for voluntary euthanasia:
- Choice: Proponents of VE emphasize that choice is a fundamental principle for liberal democracies and free market systems.
- Quality of Life: The pain and suffering a person feels during a disease, even with pain relievers, can be incomprehensible to a person who has not gone through it. Even without considering the physical pain, it is often difficult for patients to overcome the emotional pain of losing their independence.
- Economic costs and human resources: Today in many countries there is a shortage of hospital space. The energy of doctors and hospital beds could be used for people whose lives could be saved instead of continuing the life of those who want to die which increases the general quality of care and shortens hospital waiting lists. It is a burden to keep people alive past the point they can contribute to society, especially if the resources used could be spent on a curable ailment.
Reasons given against voluntary euthanasia:
- Professional role: Critics argue that voluntary euthanasia could unduly compromise the professional roles of health care employees, especially doctors. They point out that European physicians of previous centuries traditionally swore some variation of the Hippocratic Oath, which in its ancient form excluded euthanasia: "To please no one will I prescribe a deadly drug nor give advice which may cause his death.." However, since the 1970s, this oath has largely fallen out of use.
- Moral: Some people consider euthanasia of some or all types to be morally unacceptable. This view usually treats euthanasia to be a type of murder and voluntary euthanasia as a type of suicide, the morality of which is the subject of active debate.
- Theological: Voluntary euthanasia has often been rejected as a violation of the sanctity of human life. Specifically, some Christians argue that human life ultimately belongs to God, so that humans should not be the ones to make the choice to end life. Orthodox Judaism takes basically the same approach, however, it is more open minded, and does, given certain circumstances, allow for euthanasia to be exercised under passive or non-aggressive means. Accordingly, some theologians and other religious thinkers consider voluntary euthanasia (and suicide generally) as sinful acts, i.e. unjustified killings.
- Feasibility of implementation: Euthanasia can only be considered "voluntary" if a patient is mentally competent to make the decision, i.e., has a rational understanding of options and consequences. Competence can be difficult to determine or even define.
- Necessity: If there is some reason to believe the cause of a patient's illness or suffering is or will soon be curable, the correct action is sometimes considered to attempt to bring about a cure or engage in palliative care.
- Wishes of Family: Family members often desire to spend as much time with their loved ones as possible before they die.
- Consent under pressure: Given the economic grounds for voluntary euthanasia (VE), critics of VE are concerned that patients may experience psychological pressure to consent to voluntary euthanasia rather than be a financial burden on their families. Even where health costs are mostly covered by public money, as in various European countries, VE critics are concerned that hospital personnel would have an economic incentive to advise or pressure people toward euthanasia consent.
Euthanasia and the Law
During the 20th Century, efforts to change government policies on euthanasia have met limited success in Western countries. Country policies are described here in alphabetical order, followed by the exceptional case of The Netherlands. Euthanasia policies have also been developed by a variety of NGOs, most notably medical associations and advocacy organizations.
Euthanasia and religion
There are many different views among Buddhists on the issue of euthanasia. Here are a few:
In Theravada Buddhism a lay person daily recites the simple formula: "I undertake the precept to abstain from destroying living beings."
For Buddhist monastics (bhikkhu) however the rules are more explicitly spelled out. For example, in the monastic code (Patimokkha), it states:
"Should any bhikkhu intentionally deprive a human being of life, or search for an assassin for him, or praise the advantages of death, or incite him to die (thus): 'My good man, what use is this wretched, miserable life to you? Death would be better for you than life,' or with such an idea in mind, such a purpose in mind, should in various ways praise the advantages of death or incite him to die, he also is defeated and no longer in communion."
In other words, such a monk or nun would be expelled irrevocably from the Buddhist monastic community (sangha). The prohibition against assisting another in their death includes circumstances when a monastic is caring for the terminally ill and extends to a prohibition against a monastic's purposively hastening another's death through word, action or treatment.
American Buddhist monk Thanissaro Bhikkhu wrote:
Thus, from the Buddha's perspective, encouraging a sick person to relax her grip on life or to give up the will to live would not count as an act of compassion. Instead of trying to ease the patient's transition to death, the Buddha focused on easing his or her insight into suffering and its end.
The Dalai Lama was cited by the Agence-France Presse in a 18 September 1996 article entitled "Dalai Lama Backs Euthanasia in Exceptional Circumstances" regarding his position on legal euthanasia:
Asked his view on euthanasia, the Dalai Lama said Buddhists believed every life was precious and none more so than human life, adding: 'I think it's better to avoid it.'
'But at the same time I think with abortion, (which) Buddhism considers an act of killing ... the Buddhist way is to judge the right and wrong or the pros and cons.'
He cited the case of a person in a coma with no possibility of recovery or a woman whose pregnancy threatened her life or that of the child or both where the harm caused by not taking action might be greater.
"These are, I think from the Buddhist viewpoint, exceptional cases," he said. "So it's best to be judged on a case by case basis."
Catholic teaching condemns euthanasia as a "crime against life". The teaching of the Catholic Church on euthanasia rests on several core principles of Catholic ethics, including the sanctity of human life, the dignity of the human person, concomitant human rights, due proportionality in casuistic remedies, the unavoidability of death, and the importance of charity. The Church's official position is the 1980 Declaration on Euthanasia issued by the Sacred Congregation for the Doctrine of the Faith.
In Catholic medical ethics official pronouncements strongly oppose active euthanasia, whether voluntary or not, while allowing dying to proceed without medical interventions that would be considered "extraordinary" or "disproportionate." The Declaration on Euthanasia states that:
"When inevitable death is imminent... it is permitted in conscience to take the decision to refuse forms of treatment that would only secure a precarious and burdensome prolongation of life, so long as the normal care due to a sick person in similar cases is not interrupted."
The Declaration concludes that doctors, beyond providing medical skill, must above all provide patients "with the comfort of boundless kindness and heartfelt charity".
Although the Declaration allows people to decline heroic medical treatment when death is imminently inevitable, it unequivocably prohibits the hastening of death and restates Vatican II's condemnation of "crimes against life 'such as any type of murder, genocide, abortion, euthanasia, or willful suicide'".
So due to its principle of double effect, Roman Catholic moral theology does leave room for shortening life with pain-killers and what could be characterized as passive euthanasia.
Protestant denominations vary widely on their approach to euthanasia and physician assisted death. Since the 1970s, Evangelical churches have worked with Roman Catholics on a sanctity of life approach, though the Evangelicals may be adopting a more exceptionless opposition. While liberal Protestant denominations have largely eschewed euthanasia, many individual advocates (e.g., Joseph Fletcher) and euthanasia society activists have been Protestant clergy and laity. As physician assisted dying has obtained greater legal support, some liberal Protestant denominations have offered religious arguments and support for limited forms of euthanasia. People such as Lutherans are taught euthanasia is wrong and that it is God who has the right over life and death.
There are two Hindu points of view on euthanasia. By helping to end a painful life a person is performing a good deed and so fulfilling their moral obligations. On the other hand, by helping to end a life, even one filled with suffering, a person is disturbing the timing of the cycle of death and rebirth. This is a bad thing to do, and those involved in the euthanasia will take on the remaining karma of the patient. However, the same argument suggests that keeping a person artificially alive on a life-support machines would also be a bad thing to do.
Islam categorically forbids all forms of suicide and any action that may help another to kill themselves. It is forbidden for a Muslim to plan, or come to know through self-will, the time of his own death in advance. The precedent for this comes from the Islamic prophet Muhammad having refused to bless the body of a person who had committed suicide. If an individual is suffering from a terminal illness, it is permissible for the individual to refuse medication and/or resuscitation. Other examples include individuals suffering from kidney failure who refuse dialysis treatments and cancer patients who refuse chemotherapy.
Mavavira Varadhmana explicitly allows a sharavak (follower of Jainism) full consent to put an end to his or her life if the sharavak feels that such a stage is near that moksha can be achieved this way. Liberation from the cycles of lives being the primary objective in the religion.
Like the trend among Protestants, Jewish medical ethics have become divided, partly on denominational lines, over euthanasia and end of life treatment since the 1970s. Generally, Jewish thinkers oppose voluntary euthanasia, often vigorously, though there is some backing for voluntary passive euthanasia in limited circumstances. Likewise, within the Conservative Judaism movement, there has been increasing support for passive euthanasia (PAD) In Reform Judaism responsa, the preponderance of anti-euthanasia sentiment has shifted in recent years to increasing support for certain passive euthanasia (PAD) options.
The Samurai tradition
The samurai ritual of seppuku is analogous to euthanasia, in that an assistant would behead the suicide after the suicide had fatally stabbed themselves in order to bring death swiftly and reduce the time the suicide was in pain. It was thus a form of voluntary euthanasia, or mercy killing. In line with Buddhist thinking, the seppuku ritual laid great emphasis on the suicide having a peaceful mind during the action.
In Japan, where the dominant religion is Shinto, 69% of the religious organisations agree with the act of voluntary passive euthanasia. The corresponding figure was 75% when the family asked for it. In Shinto, the prolongation of life using artificial means is a disgraceful act against life. Views on active euthanasia are mixed, with 25% Shinto and Buddhist organisations in Japan supporting voluntary active euthanasia.