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Euthanasia is translated from Greek as ‘‘good death’’ or ‘‘easy death.’’ As originally used, the term referred to painless and peaceful natural deaths in old age that occurred in comfortable and familiar surroundings. That usage is now archaic. As the word is currently understood, euthanasia occurs when one person ends the life of another person for the purpose of ending the killed person’s pain or suffering.
Euthanasia is sometimes divided into different categories. ‘‘Voluntary euthanasia’’ is when a person is killed upon that person’s request for reasons of ending suffering. ‘‘Involuntary or nonvoluntary euthanasia’’ is the mercy killing of a medically or legally incompetent person, such as a child or a demented elderly patient, at the request of, or by, a caregiver or family member.
Some people also use the term ‘‘passive euthanasia’’ to describe a death that occurs after undesired, life-sustaining medical treatment is withheld or withdrawn. This is a misnomer. Euthanasia, at least as the term is presently utilized, involves intentional killing. That being so, ‘‘passive euthanasia’’ is not euthanasia, since death, when it comes—not everyone who has lifesustaining treatment dies as a result of withheld treatment—is naturally caused by the underlying illness or injury.
Assisted suicide is closely related to euthanasia. An assisted suicide occurs when one person gives another person the instructions, means, or capability to bring about their own demise. In the context of the modern moral and public policy debates, the motive in assisted suicide, as in euthanasia, is to bring about an end to suffering. Suicide per se is not considered to be the same as ‘‘assisted suicide’’ because the former is an individual act while the latter involves a joint enterprise between the suicidal person and a helper to bring about death.
The Hippocratic oath explicitly prohibited doctors from giving their patients poisons to end life and thus, traditionally, euthanasia and assisted suicide have not been considered legitimate medical acts. Legalizing either practice would transform hastening patient deaths from an ethically proscribed and (usually) criminal act into a legitimate medical practice. Thus, widespread legalization would be a profound and dramatic shift in the traditional ethics of medical practice.
Euthanasia is currently illegal and punishable as murder throughout the United States. Assisted suicide is a felony akin to manslaughter in most states, proscribed either by statute or court interpretation of the common law. The federal government has outlawed the use of federal funds in assisted suicide.
Assisted suicide is, however, legal in Oregon, where state law authorizes physicians to write lethal prescriptions at the request of patients who have been diagnosed with a terminal illness reasonably likely to cause death within six months. In order for the assisted suicide to be legal, the prescribing physician must follow regulatory guidelines. These guidelines include: requiring a second opinion to verify the diagnosis; referral of the patient to a mental health professional if the doctor suspects the patient has a psychiatric or psychological condition that causes ‘‘impaired judgment’’; a fifteen-day waiting period between request and prescription; and, reporting the assisted suicide to the Oregon Department of Health. Most current legalization proposals in the United States follow the format of the Oregon law.
Internationally, both euthanasia and assisted suicide are almost universally outlawed. There are a few exceptions to this general rule. In Colombia euthanasia is legal due to a ruling by that country’s supreme court (Republic of Colombia Constitutional Court: Sentence: no. C-239/97: REF. EXPEDIENT no. D-1490. May 20, 1997). As of this writing the Colombia law has not gone into effect pending the creation of legal guidelines to govern the practice. Euthanasia and assisted suicide, while technically illegal, are practiced widely by doctors in the Netherlands. The Netherlands experience will be discussed in detail below. Assisted suicide is not illegal in Switzerland, where assisted suicides committed by physicians and laypersons alike are reportedly not prosecuted if based on alleviating suffering caused by serious illness.
The Modern Euthanasia Movement
A few proposals to legalize euthanasia were made in the United States and Germany during the latter portion of the nineteenth century. However, it was not until after World War I that euthanasia advocacy began in earnest. In 1920, two highly respected German academics, Karl Binding, a law professor, and Alfred Hoche, a physician, wrote Permission to Destroy Life Unworthy of Life, which advocated euthanasia as a compassionate ‘‘healing treatment.’’ The authors argued that mercy killing should be permitted for three categories of patients upon request of competent patients or the families of the incompetent: the terminally ill or mortally wounded, people who were unconscious, and disabled people—particularly those with cognitive impairments. The book, which may have coined the term ‘‘right to die,’’ also promoted euthanasia of cognitively disabled people as a way of saving societal resources.
Binding and Hoche’s book generated tremendous interest among Germany’s intelligentsia and the public, which quickly came to support legalization of euthanasia. Euthanasia was popular enough in 1933 for Adolph Hitler to attempt to formally legalize the practice. However, strong opposition from the churches caused the German government to drop the proposal.
Euthanasia was also advocated in the United States during the 1930s. In 1938, the New York Times announced the formation of a national euthanasia society that eventually became known as the Euthanasia Society of America. In 1939, the group had drafted a proposed law permitting voluntary euthanasia. Dr. Foster Kennedy, the group’s president, also called for the legalization of euthanasia for babies born with birth defects. The incipient euthanasia movement in the United States grew quiescent in the aftermath of the Holocaust as the world recoiled in horror to the news that between 1939 and 1945, German doctors killed more than 200,000 disabled people, including infants and the mentally retarded people.
After the war, organized euthanasia groups continued to exist in the United States but made little headway until the early 1980s, when societal changes that began in the 1960s and the resulting weakening of traditional moral values, as well as intellectual support by some within the medical intelligentsia, provided fertile ground for renewed euthanasia advocacy. In a dramatically short period of time, legalized euthanasia went from an ‘‘unthinkable’’ prospect to one of the most contentious and controversial issues debated in the public square.
Pros and Cons
Perhaps the strongest argument made on behalf of legalizing euthanasia or assisted suicide is that it, like abortion, is a ‘‘choice’’ issue. Proponents argue that euthanasia/assisted suicide is ‘‘the ultimate civil right,’’ and that to deprive mentally competent, terminally ill people who want to end their suffering of a peaceful ‘‘aid in dying’’ is to fundamentally disrespect their right to personal autonomy. Proponents also argue that legalizing euthanasia/assisted suicide is a necessary ‘‘insurance policy’’ that will ensure that no one dies in painful agony or unremitting suffering. Advocates contend that euthanasia/ assisted suicide is little different from pain control since both use strong drugs and patients’ deaths are occasionally unintentionally hastened as a side effect of the narcotics used in palliation. They also claim that doctors commonly engage in euthanasia/assisted suicide surreptitiously and promote legalization as a way to protect vulnerable patients from abuses inherent in the current ‘‘unregulated’’ practice. Acknowledging worries about potential abuses, advocates assure that ‘‘protective guidelines’’ would protect the vulnerable from wrongful death while still permitting suffering patients who are eligible for euthanasia/assisted suicide to obtain a desired, peaceful ‘‘death with dignity.’’ Proponents also claim that opposition to euthanasia/assisted suicide is based primarily in religion and that laws prohibiting the practice are thus unconstitutional because they violate the division between church and state.
Opponents counter that legalizing euthanasia/assisted suicide would lead society down a dangerous ‘‘slippery slope’’ with legalized killing eventually being permitted for disabled, elderly, and depressed people, as well as for those who are not mentally competent to request to die. Protective guidelines ‘‘do not protect,’’ opponents declare, pointing to the Dutch experience with euthanasia as ‘‘proof’’ of both the reality of the slippery slope and the relative meaninglessness of guidelines. Opponents also argue that the economics of modern medicine would promote euthanasia/assisted suicide as a form of health care cost containment, noting that the drugs in an assisted suicide cost only about forty dollars, while proper care for a dying patient can cost tens of thousands of dollars. They also note that forty-four million Americans do not have health insurance, and that medicine is sometimes practiced in a discriminatory manner against racial and other minorities. Thus, they argue that ‘‘the last people to receive medical treatment will be the first to receive assisted suicide.’’ Opponents also deny that there is widespread surreptitious euthanasia practiced in clinical medicine, citing several published studies as proof, and urge that hospice care and proper medical treatment provide the morally acceptable answers to the difficulties that are sometimes associated with the process of dying.
The People Vote
There have been several attempts in the United States to legalize euthanasia and assisted suicide through state initiatives. The first attempt came in 1988, when euthanasia supporters attempted to qualify an initiative for the ballot in California, which would have permitted physicians to administer lethal injections for terminally ill patients who asked to have their deaths hastened. The attempt failed to garner enough signatures to qualify for the ballot. However, in 1991, Initiative 119, a similar proposal, was successfully placed on Washington’s ballot. After initial polling showed voter support in excess of 70 percent, the initiative lost 54 to 46 percent. The pattern repeated itself in California in 1992, when a virtually identical proposal appeared on the California ballot in November 1992 as Proposition 161. After initial support in excess of 70 percent, the measure also lost by a margin of 54 to 46 percent.
Two years later, in Oregon, Measure 16— the Oregon Death with Dignity Act—qualified for the November 1994 ballot. Unlike the earlier failed initiatives, Measure 16 limited its scope to legalizing physician-assisted suicide. The measure passed narrowly, 51 to 49 percent. The law was soon overturned as a violation of the equal protection clause of the Fourteenth Amendment to the U.S. Constitution. However, this decision was itself overturned by the Ninth Circuit Court of Appeals on procedural grounds (Lee v. Oregon). The United States Supreme Court refused to review the Ninth Circuit’s opinion. An attempt by opponents to repeal Measure 16 through another ballot initiative, Measure 51, failed in November 1997 by a margin of 60 to 40 percent. The law was in effect as of 1999.
In 1998, supporters of assisted suicide qualified Proposal B for the November ballot in Michigan. Proposal B, like Measure 16, would have restricted legalization to assisted suicide and its terms were very similar to those of the Oregon law. The debate over Proposal B was complicated by two factors: Michigan was the home state of Dr. Jack Kevorkian and Kevorkian’s attorney, Geoffrey Fieger, was the Democratic nominee for governor. Whatever the impact of these ancillary issues, when the votes were counted, Proposal B lost by an overwhelming 71 to 29 percent.
During the 1990s, Jack Kevorkian was undoubtedly the most well known assisted suicide and euthanasia advocate in the world. A retired pathologist from Michigan, Kevorkian made headlines internationally when he undertook a well publicized assisted-suicide campaign between 1990 and 1998 that reportedly ended the lives of approximately one hundred thirty people. Some of those whose deaths Kevorkian facilitated were terminally ill and diagnosed as having less than six months to live, but most were disabled or chronically ill. According to autopsy reports, four of the people whose suicides Kevorkian helped had no discernible organic illness.
Kevorkian’s campaign began on 4 June 1990, when he assisted the suicide of Janet Adkins, a woman diagnosed with early Alzheimer’s disease. At the time, Michigan had no law against assisted suicide and Kevorkian was not arrested. His next publicly acknowledged assisted suicide was conducted on 23 October 1991, when Kevorkian made headlines for assisting the suicide of two women at the same location, one with multiple sclerosis and another who complained of chronic, severe pelvic pain. Kevorkian was arrested for murder but the case was dismissed. The prosecution appealed and the state legislature hastily cobbled together a poorly worded, temporary criminal statute proscribing assisted suicide intended to ‘‘stop Kevorkian.’’
Kevorkian openly defied the law and was arrested, tried, and acquitted. The temporary prohibition lapsed but the prosecution’s earlier appeal succeeded when the Michigan Supreme Court ruled that assisted suicide was a common law felony in Michigan (People of Michigan v. Jack Kevorkian). Kevorkian was again arrested and tried. Once again, a jury found him not guilty. A third case against Kevorkian was later declared a mistrial because of the courtroom conduct of Kevorkian’s lawyer, and the case was dropped. Kevorkian, it seemed, had a free hand.
In 1998, Kevorkian’s actions grew increasingly erratic. In June, after he assisted the suicide of Joseph Tushkowski, a man with quadriplegia, Kevorkian held a press conference in which he claimed to have procured the man’s kidneys, and offered them for organ transplant, ‘‘first come, first served.’’ There were no takers. In late October, he videotaped himself lethally injecting Thomas Youk, an ALS (Lou Gehrig’s disease) patient. Kevorkian then took the tape to CBSTelevision’s news program 60 Minutes, which aired it to a nationwide audience, during which Kevorkian dared the authorities to prosecute him. Kevorkian was arrested and convicted of second-degree murder. He is currently in prison for a term of ten to twenty-five years.
Proponents of legalization mounted a significant effort to have laws against assisted suicide declared unconstitutional, hoping to garner an ‘‘assisted suicide’’ Roe v. Wade (410 U.S. 113 (1973)) that would settle the issue nationally, as Roe did with abortion. They were unsuccessful. In Washington v. Glucksburg (117 S. Ct. 2258 (1997), the Supreme Court justices voted 9–0 that ‘‘the asserted ‘right’ to assistance in committing suicide is not a fundamental liberty interest protected by the Due Process Clause [of the Fourteenth Amendment].’’ The decision also emphasized that state laws banning assisted suicide were consistent expressions of the individual states’ commitment to protecting all human life.
In the closely associated case of Vacco v. Quill (117 S. Ct. 2293 (1997)), the Supreme Court ruled against assisted-suicide advocates who had argued that New York’s law proscribing assisted suicide violated the equal protection clause of the Fourteenth Amendment. They argued that since it is legal for terminally ill persons to refuse lifesustaining medical treatment and die immediately but illegal for terminally ill people who do not require life support to secure immediate death through physician-assisted suicide, New York violated its constitutional obligation to treat similarly situated people equally. In rejecting the argument, the Supreme Court ruled that the New York law actually treated similarly situated people alike: all patients are permitted to refuse unwanted treatment and none are allowed legal access to assisted suicide. The Court also ruled that there was a significant and rational distinction between refusing life-sustaining treatment and seeking assisted suicide. In the former circumstance, the doctor’s intention may be to simply stop performing useless procedures when a patient will not benefit, while in assisted suicide, the doctor must without a doubt intend for the patient’s death.
Both sides claimed victory in the Court’s two rulings. Opponents were relieved that assisted suicide would not be ‘‘imposed’’ nationally by judicial fiat. Proponents took heart that several concurring opinions muddied the waters and seemed to indicate that the issue could be brought back to the courts for further review if a case of a patient with truly irremediable suffering were presented. Proponents also claimed that the Court’s decision freed the states to experiment with laws concerning the end of life, perhaps including assisted suicide, although opponents pointed out that the issue of a state’s right to pass a law legalizing assisted suicide had not been before the Court.
There have been at least three attempts to invalidate state laws proscribing assisted suicide based on privacy provisions contained in state constitutions. A lawsuit challenging Alaska’s proscription is currently pending in that state’s courts (Sampson v. State of Alaska, No. 3 AN–98– 11288 CIV). A California Court of Appeals decision refused to permit a terminally ill man to have legal assistance with suicide so that his body could be cryogenically preserved. The most notable case to decide this issue in state courts was Krischer v. Florida (697 So.2d, 97 (1997)), in which the Florida Supreme Court ruled that the state’s assisted-suicide prohibition did not violate the state constitution’s guarantee of privacy.
Euthanasia in The Netherlands
The Netherlands has the most experience with physician-hastened death. Both euthanasia and assisted suicide remain crimes there but doctors who end their patients’ lives will not be prosecuted if legal guidelines are followed. Among the guidelines are:
- The request must be made entirely of the patient’s own free will.
- The patient must have a long-lasting desire for death.
- The patient must be experiencing unbearable suffering.
- There must be no reasonable alternatives to relieve suffering other than euthanasia.
- The euthanasia or assisted suicide must be reported to the coroner.
These guidelines are similar to those proposed in legalization proposals in the United States, although the Oregon law requires a terminal illness, a limitation not included in the Dutch guidelines. On the other hand, the Oregon guidelines do not require that the patient be experiencing unbearable suffering or that there be no reasonable alternatives to relieve suffering other than assisted suicide.
There have been several professional studies conducted into Dutch euthanasia practice. Most have reported that approximately 2,700 deaths are caused each year in the Netherlands by either euthanasia or assisted suicide—approximately 3 percent of all Dutch deaths. Proponents claim this relatively low figure rebuts opponent’s fears that euthanasia will become a relatively routine event. Opponents counter that this figure is horrifying: if the same percentage of Americans died with the direct assistance of doctors, it would amount to approximately sixty-eight thousand annual deaths, more than tripling the U.S. suicide rate.
Opponents also claim that the number of people actually killed by Dutch doctors is significantly understated in these studies. They note that the term ‘‘euthanasia’’ is very narrowly defined by the Dutch government, with the effect if not the design of undercounting the actual number of euthanasia deaths. If a doctor kills a patient with barbiturates and a curare-like poison at the patient’s request, the Dutch classify the death as ‘‘euthanasia.’’ However, if the patient is killed by an intentional overdose of morphine administered with the primary intention of ending the patient’s life, it is not considered euthanasia because morphine is a palliative agent. Yet, intentional morphine overdoses may exceed ‘‘euthanasia’’ deaths. In 1990, according to a Dutch government report, 8,100 patients died through the intentional morphine-overdose method of mercy killing. A latter study found that about 1,500 die annually through the intentional morphine-overdose method of killing. Whatever the actual annual figure, if intentional morphine-overdose deaths are counted as euthanasia, the statistical mercy killing rate in the Netherlands significantly exceeds the published statistics.
Opponents point to the many documented cases of chronically ill people, as well as to terminally ill people, put to death by doctors at the patient’s request as further proof of euthanasia’s many dangers. A Dutch documentary showed a young woman in remission from anorexia requesting doctor-induced death because she was afraid of resuming food abuse. Her doctor assisted her suicide without legal consequence. Another documented case showed an asymptomatic, HIV-positive patient assisted in suicide because he feared future suffering.
Opponents point with alarm to the Dutch Supreme Court’s decision approving euthanasia for cases of severe depression—even in the absence of physical illness (State v. Chabot, Supreme Court of the Netherlands, Criminal Chamber, 21 June 1994, nr. 96.972). This decision resulted from the case of a Dutch psychiatrist who assisted the suicide of a woman who wanted to end her life because her children had died. The court supported the psychiatrist’s actions, ruling that for purposes of judging the propriety of euthanasia or assisted suicide, suffering is suffering and it does not matter whether the cause is physical or psychological.
Another disturbing statistic that is found consistently in studies into Dutch euthanasia practices demonstrates to opponents the ultimate danger of euthanasia: approximately one thousand Dutch patients are euthanized each year by their doctors ‘‘without request or consent,’’ in other words, involuntary or nonvoluntary euthanasia. Since euthanasia is only supposed to be allowed for people who consistently ask to be killed, the fact of involuntary killing demonstrates the unworkability of guidelines. Proponents counter that the number, while too high, has been relatively constant over several years, thus belying fears of the slippery slope.
Pediatric euthanasia has also become a part of Dutch euthanasia practice. Opponents point with alarm to a 1997 study published in the British medical journal The Lancet indicating that about 8 percent of all infants who die in the Netherlands are euthanized—approximately 80 per year. Pediatric euthanasia, they claim, is a human rights abuse and a proof that guidelines do not protect vulnerable patients. Proponents counter this criticism with the defense that the infant-euthanasia deaths are only of the most severely impaired babies, most of whom would not live anyway, and note that the parents make the decision based on their judgment of what is best for their children.
Opponents also claim that Dutch euthanasia is ‘‘beyond significant control’’ since approximately 59 percent of euthanasia and assistedsuicide deaths are not reported to the coroner as required by the guidelines. Thus, they claim that the actual number of Dutch patients killed is probably far higher than the statistics seem to show. Proponents admit that unreported euthanasia deaths are a problem but counter that full legalization would remove fear of prosecution thereby increasing compliance with reporting requirements.
In 1999 the Dutch government announced its intention to formally legalize euthanasia. As with anything having to do with euthanasia, the announcement was extremely controversial: the proposed law would permit the euthanasia of children as young as twelve at the request of the child, even if the parents object.
The Oregon experience
Assisted suicide has been legal for too short a time in Oregon to know its actual impact. As of 1999, just one study has been conducted analyzing the Oregon experience. Published in the New England Journal of Medicine in 1999, the study reported that fifteen people died legally by assisted suicide in the calendar year 1998. None was in intractable pain. One feared future pain. The primary reason the patients gave for requesting assisted suicide, according to the prescribing doctors who were interviewed for the study, was fear of future dependency.
Proponents of the Oregon law claimed that the study demonstrated that legalized assisted suicide is a rare procedure and that the law’s guidelines work to protect vulnerable people. They also stressed that the deaths were apparently peaceful with none of the patients suffering side effects, such as extended coma, about which opponents had warned. Moreover, they noted that financial pressures did not appear to be a factor in any of the cases.
Opponents countered that the law was ‘‘sold’’ to voters as a last resort measure for people in extreme pain, but none of the patients fits that description, thereby demonstrating the existence of the ‘‘slippery slope.’’ Disability rights activists argued that once assisted suicide is deemed a proper response to fears of dependency, as was the case in the fifteen Oregon deaths, it cannot be logically limited to terminally ill people since disabled and elderly people also face dependency issues and for far longer periods of time. Opponents also noted with alarm that six of the people who died by assisted suicide consulted with two or more doctors before finding a physician willing to write a lethal prescription. Moreover, some of the patients knew the prescribing doctor for a very short time, indicating, opponents contend, that some of the prescriptions were written for political rather than medical purposes.
The assisted suicide/euthanasia debate is still in its infancy, with the ultimate outcome very much in doubt. Public opinion polls show solid majority support for limited legalization, but the polls also demonstrate that popular support drops significantly when specific details of legislative proposals are examined. Oregon was a major breakthrough for advocates of assisted suicide but five states have outlawed assisted suicide since Oregon’s Measure 16 passed in 1994, and one state passed legislation subjecting a person who assists in a suicide to civil liability. One thing is clear: euthanasia/assisted suicide controversy is likely to be a significant source of societal contention and political argument for many years to come.
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