Euthanasia Research Paper

In modern times, the meaning of the concept has considerably changed. Though its core meaning of ‘good dying’ was preserved, it no longer refers to the quality (however defined) of the process of dying as such, but to the cooperation of someone else (the physician, the priest, or others) in making death easier for the dying. Francis Bacon, in a passage of his De dignitate et augmentis scientiarum (1623), was the first to distinguish two kinds of assistance to which, according to him, a dying patient has a claim, euthanasia interior, the ‘spiritual preparation of the soul’ for death, and euthanasia exterior, ‘whereby the dying may pass more easily and quietly out of life’ (Bacon 1857, p. 387). Bacon’s point was that the purely spiritual preparation provided by the priest was not enough.

What should be introduced was what we now call palliative medicine, the systematic effort to relieve pain and suffering of the dying by medical means. Euthanasia in this sense, Bacon insisted, was not only a natural part of the duties of the physician but also a requirement of plain humanity. Though psychological and spiritual assistance in dying is by now recognized as one of the central elements in the care for the dying (often, however, neglected in practice), the modern concept of euthanasia includes the ‘easing of death’ only in so far as this is effected by the application or nonapplication of medical means.

2. Five Types Of Euthanasia

The principal meanings of the term ‘euthanasia’ in ethical and legal discussion correspond to the various forms medical assistance in dying can take.

(a) Relieving suffering by palliative care, e.g., by giving pain-killing drugs and suppressing symptoms such as vomiting or shortness of breath. Palliative care for the dying is rarely referred to as ‘euthanasia’ in the absence of the more typical practices (b) and (c). However, the term ‘indirect euthanasia’ is generally applied to cases in which medical interventions aimed at relieving suffering (such as administering drugs or operating on a patient to make the dying process more tolerable) cause the patient’s death.

(b) Forgoing life-sustaining medical treatment (either by not initiating treatment or by terminating it at some point) where this implies that the patient dies at an earlier date than he or she would if treatment were continued and where the intention is wholly or primarily to reduce the patient’s suffering. This form of euthanasia is commonly referred to as ‘passive euthanasia,’ irrespective of whether withholding or withdrawing life-sustaining treatment is explicitly requested by the patient.

(c) Actively hastening death to shorten suffering, either by killing the patient (‘active euthanasia’), by assisting the patient to kill himself (‘assisted suicide’), or by putting the patient in a prolonged state of unconsciousness (e.g., by giving him or her a strong dose of narcotics) with the intention to withdraw life-sustaining treatment while the patient is in this state (‘terminal sedation’).

Interest in euthanasia of these three types has grown in proportion to the growth of modern medicine and its capacities to maintain life-functions in states of terminal disease and in reaction to a widespread tendency of physicians to preserve life in situations of imminent death at the cost of severe suffering. Political impulses towards making euthanasia a patient right continue to come primarily from the euthanasia and ‘right-to-die’ societies that have developed all over the world (the British ‘Voluntary Euthanasia Legalization Society’ was founded in 1935, the ‘Euthanasia Society of America’ in 1938). They vary, however, in the forms of euthanasia they want to see legalized by law and professional codes. All societies, including the Hospice movement, advocate the extension and improvement of psychological and palliative care for the dying as well as passive euthanasia where this is explicitly requested by the patient. The differences between them concern the extent to which they advocate active euthanasia (as well as the related forms of assisted suicide and terminal sedation). While for the Hospice movement (Twycross 1995) it has become a matter of principle to reject active euthanasia and assisted suicide, most euthanasia societies demand the legalization both of (physician-) assisted suicide and active euthanasia under what might be called the ‘paradigmatic euthanasia conditions’: (a) the patient is in an irreversible state of terminal illness, (b) the patient suffers intolerably, (c) the patient explicitly wishes to die, (d) this wish is not only momentary but constant. A number of societies, however, favor assisted suicide over active euthanasia as a more unambiguous expression of the patient’s autonomous will. At present, an officially approved and legal practice of active euthanasia exists in The Netherlands, an officially approved and legal practice of physician-assisted suicide in the state of Oregon, USA.

The common element of these three variants of euthanasia is that the primary and ultimate aim of giving euthanasia is the relief of suffering, either from physical pain or from other inconveniences of the patient’s condition. Shortening the life of the patient is either intended as a means to that end (active euthanasia, passive euthanasia, assisted suicide) or accepted as a side effect (indirect euthanasia). This common element is lacking in practices (d) and (e).

(d) Withholding life-sustaining treatment from a patient in a persistent state of unconsciousness (as in so-called coma vigile) with the resulting (and mostly intended) death of the patient. In cases of this sort, the intention cannot be to relieve the patient’s suffering because an unconscious patient cannot experience suffering. (There is, however, a residual unclarity on this point. A minority of neurologists think that there is a small chance that consciousness in these patients survives.) Euthanasia in these cases is generally justified either by the patient’s presumed will not be kept alive in a persistent state of unconsciousness (as documented, e.g., by an advance directive), by the insistence of the family distressed by a treatment they often see as degrading and contrary to human dignity, or, in advanced stages, by considerations of medical futility (studies have shown that the probability of an ‘awakening’ from a so-called ‘vegetative state’ is about 1 percent after one year). Relevant jurisdiction in the US and the UK shows a tendency to allow the withdrawal of life-sustaining treatment after several years of ‘persistent vegetative state’ with the approval of the family.

(e) Ending the lives of adults and children seen as a burden to society or to parents. In German speaking countries, the German equivalent to the term ‘euthanasia’ inevitably evokes the National Socialist practice of killing children with malformations and the inmates of psychiatric hospitals and is normally replaced, in reference to practices (a)–(d), by Sterbehilfe (assistance in dying). Moreover, memories of the NS-‘Euthanasie’ explain at least part of the violent resistance, especially in German speaking countries, to philosophical justifications of infanticide (such as by Peter Singer, Singer 1993, Chap. 7). The motives behind the killing, with the cooperation of their physicians, of 70,000 patients of psychiatric institutions from 1940 to 1941 were partly economic (one criterion of selection was whether patients were able to work), partly an ideology of racial purity.

After stopping the active killing in 1941 a further 90,000 patients were exterminated by ‘softer’ methods such as under nourishing (Benzenhofer 1999, p. 129). Calling these killings ‘euthanasia’ was a deliberate euphemism, as was the term ‘lebensunwert’ (unworthy of living) used by the authors Binding and Hoche in a seminal book as early as 1920 and suggesting a poor subjective quality of life (the opposite of ‘a life worth living’) but in fact expressing an objective judgement about the usefulness of a life to society. Ideas of a selective killing of ‘useless’ lives have their roots in the Social Darwinism of the late nineteenth century, though there are important earlier philosophical models. A rigid eugenic policy involving compulsory abortion and exposition of ‘weak’ children (probably on the Spartan model) were a central characteristic of Plato’s Republic. A curious blending of euthanasia in the sense of relieving suffering and euthanasia in the sense of getting rid of people seen as a burden occurs in Thomas Morus’ Utopia (1516), where priests and state officials persuade the terminally ill to kill them-selves rather than to ‘survive their own death.’

3. Ethical Problems

While euthanasia in sense (a) is almost universally accepted and euthanasia in sense (e) almost universally rejected by medical ethics and medical law, ethical and legal discussion of euthanasia in each of the other meanings is highly controversial and of a particular emotional quality. There are at least four controversial issues.

(a) How to resolve the conflict between the principle of patient autonomy and the best interest principle in euthanasia situations. According to the principle of patient autonomy, medical treatment (except in emergency situations) must be based on the informed consent of the patient. If the patient is unconscious or otherwise unable to give valid consent, physicians are required to take into account the presumed consent of the patient, as indicated by written or oral advance directives, by the views expressed by the patient about how he or she would like to be treated in relevant situations and what else can be inferred from the patient’s beliefs and world-view. But the physician is also bound by the best interest principle which says that he or she should further the well-being of the patient in the best possible way. This is generally taken to entail an obligation to relieve suffering even without an explicit request. Generally, this principle is taken to be weighty enough to justify shortening the life of a patient with terminal illness if the intention of the physician is exclusively or primarily to relieve suffering.

Problems arise whenever the two principles come into conflict, as when a patient refuses an operation which, in all probability, would save his or her life at an acceptable level of subjective quality of life, whereas following his refusal would lead to instant death. There is considerable consensus among medical ethicists that a medical paternalism (i.e., treating the patient against his or her will, see Van De Veer 1986, Chap. 5) is objectionable even in cases of markedly ‘unreasonable’ patient wishes except when there is evidence that the patient is not sufficiently informed about his or her prospects, that his or her will is distorted by neurosis, psychosis, or excessive affect, or proves to be unstable under information. Though, on the best interest principle, the physician is called upon to persuade the patient to revise his or her decision, it is widely agreed that the physician should not resort to deception to change the patient’s will, since this undermines trust and infringes patient autonomy no less than compulsory treatment would.

(b) Whether actively discontinuing treatment (e.g., by turning the switch of a respirator) is normatively equivalent to strict inaction (e.g., by ‘freezing’ oxygen pressure on a level that is insufficient for the patient to survive). Ethicists and jurists predominantly take both modes of action to be normatively equivalent. They see no morally significant difference between ‘active’ and ‘passive’ discontinuing nor between not starting treatment and terminating treatment. (Discontinuing treatment with the result or the intention of a patient’s death in a euthanasia situation generally counts as ‘passive’ even if involving positive action because the state of the patient is merely restored to the condition in which it was before treatment.) There is, however, a considerable psychological difference. Physicians and nurses find it much easier to let a patient die ‘passively’ because causality is attributed to external factors instead of one’s own behavior.

(c) Whether active killing should be allowed to doctors (or to others) in euthanasia situations. Voluntary active euthanasia, i.e., actively killing a patient to end his or her suffering on the patient’s explicit wish is an attractive option because of substantial doubts whether all states of suffering in the last phase of a patient’s life (e.g., in some forms of end-stage cancer) can be effectively relieved by discontinuing treatment and palliative measures. Furthermore, many of the ethical arguments against active euthanasia on the level of principles suffer from the fact that they attribute much more normative weight to the distinction between activity (killing) and passivity (letting die) than is thought acceptable, and indeed desirable, in other medical contexts where the physician has not only a duty not to do harm but also a duty to treat. In particular, the question arises how the acceptance of indirect euthanasia (which also involves active intervention) by most legislatures can be made consistent with the rejection of voluntary active euthanasia. The crucial difference is that death is intended as a means to reducing suffering in the latter, while it is accepted as a side effect in the former. This difference is regarded as highly relevant by the doctrine of ‘double effect’ of Catholic moral theology, but not generally by legal systems.

More compelling arguments against legalizing active euthanasia are pragmatic considerations of potential misuse and abuse. Establishing a practice of active euthanasia risks that the autonomy of the patient is overruled by the wishes of relatives, the standards of the medical profession, and the interests of society. In The Netherlands, the only country where active euthanasia is openly practiced, along with a publicly approved practice of voluntary euthanasia (about 2,300 cases per year), there goes a secret practice of nonvoluntary euthanasia (about 1,000 cases per year) which deliberately disregards the procedural rules laid down by the Royal Dutch Medical Association. Though far from proving that a practice of voluntary euthanasia necessarily has a practice of nonvoluntary euthanasia in its wake, the opponents of the legalization of active euthanasia have a point in quoting the ‘Dutch experience’ (see Thomasma and Marshall 1998) as a warning. Surely, physician-assisted suicide (which is only rarely practiced in the Netherlands) is, wherever it is possible, preferable as an alternative to voluntary euthanasia, not least because it asserts the autonomy of the patient (see Quill 1993).

4. Social Research On Euthanasia

Social science studies about the practice of passive and active euthanasia have begun to be undertaken only recently, partly after the model of the Dutch Remmelink report which was done in 1990–1 at the request of the Dutch government in preparation of euthanasia legislation. This nationwide study included interviews with 405 physicians (carried out by 30 experienced physicians and five other academics) and a questionnaire study with the physicians of a sample of 7,000 recently deceased persons. The main result of this study was a surprisingly high incidence of euthanasia in The Netherlands prior to regulation. Fiftyfour percent of the physicians interviewed confirmed that they had practiced active euthanasia or assisted suicide on request of patients and a further 34 percent said that they could conceive of situations in which they would be prepared to do so (van der Maas et al. 1991, p. 669). Twenty-seven percent said that at some time they had ended a patient’s life without his or her explicit request and a further 32 percent said that they would prepared to do so under appropriate circumstances. Five years later the study was repeated showing that the situation in The Netherlands had changed only slightly (van der Maas et al. 1996). Substantially lower figures were found in an Australian and a British questionnaire study in which 29 percent (12 percent) of all doctors who returned a completed questionnaire confirmed that they had taken active steps to end a patient’s life. A large proportion of the British respondents (46 percent) said, however, that they would consider taking active steps to bring about death if it was legal to do so (Kuhse and Singer 1988, p. 623, Ward and Tate 1994, p. 1332). The importance of cultural factors is highlighted by the contrast between figures for The Netherlands and for Germany, where active euthanasia is still largely a taboo and where questionnaire studies show that the proportion of physicians practicing active euthanasia is maximally 5 percent (Kirschner and Elkeles 1998, p. 251).

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