The term euthanasia often elicits a variety of responses from individuals. The reactions may be related to one’s understanding of what euthanasia is, one’s experience with end-of-life decision making, one’s religious or spiritual belief system, or any number of other factors. This review will attempt to clarify some of the definitions associated with different types of euthanasia, as well as present a historical perspective of the discourse on euthanasia in order to provide a context for the more current developments in the area. Attitudes toward euthanasia found across the major racial-ethnic groups within the United States will be explored. International perspectives on euthanasia legislation will also be discussed. Finally, some of the arguments for and against legalizing euthanasia are offered.
Terms And Definitions
Before beginning a discussion on euthanasia, it is helpful to review some of the terms that are often associated with this area. Euthanasia is derived from the Greek words “eu” and “thanatos” which literally mean “good death.” The term has come to mean bringing about a gentle and easy death. Active euthanasia entails an active intervention by a physician to end life. Passive euthanasia is deliberately withdrawing or withholding medical treatment that would help the person live longer (this may or may not involve the intention of hastening death). Examples of this are removing a feeding tube or withdrawing artificial life support interventions. Voluntary euthanasia is euthanasia that is performed at the request of the person who dies. Involuntary euthanasia is ending the life of an able person without her or his consent or against the person’s will. Nonvoluntary euthanasia is ending the life of a person who is not able to give permission. The individual who carries out the euthanasia may do so for the other person’s “best interests.” Physician-assisted suicide is closely related to voluntary euthanasia, but the physician only prescribes rather than administers a lethal drug to the person.
Overview Of The Historical Discourse About Euthanasia
Prior to World War II, perspectives on euthanasia were significantly influenced by ancient Greek practices and discourse. Euthanasia is generally understood as a hastening of one’s own death and thus was often discussed in terms of suicide. Even in ancient Greece there was some disagreement about the acceptability of euthanasia and suicide. Some argued that suicide is an offense against the state and one’s family. On the other hand, there also was an ideal espousing the perfect balance between physical and mental well-being, which was used as a foundation for tolerating euthanasia. Aristotle and Plato endorsed a form of eugenics in order to ensure an optimal state with the worthiest citizens. Furthermore, in areas of ancient Greece in which the state allowed suicide, individuals who sought official permission to take their lives were supplied with poison by the local magistrate. Suicide was also an option for stoics when life was judged as not being in harmony with nature. The disharmony could be the result of illness, physical deformity, or pain. Although there was much disagreement over the acceptability of suicide and euthanasia, the ancient Greeks were perhaps the first to rationally consider the grounds for hastening death. They also suggested that in certain circumstances hastening death was indeed the most humane thing to do.
With the rise of Christianity and through the middle ages, suicide was denounced. Harsh religious and civil penalties were imposed against the body and property of the deceased. Christianity viewed that it was not an individual’s privilege to decide how or when to die. That right was reserved for the will of God. With the advent of the Renaissance came the rediscovery of ancient Greek and Roman thought, as well as resurgence in scientific, empirical investigation. There was also an increased interest in facilitating a comfortable and easy death. This led to greater flexibility in thought relating to suicide, although this was primarily confined to philosophical writings.
By the 18th century, the discourse had moved away from being largely confined to the philosophical realm and flexibility in thought was observed in many segments of society. Physicians were discussing the responsibilities to their patients as far as facilitating a natural and humane death. Also, the public stigma against suicide was declining. This is evidenced by the easing of consequences levied against the family, estate, and body of an individual who died as a result of suicide. Hastening one’s death was seen as more acceptable when an individual was experiencing an incurable disease or great suffering.
During the 19th century and into the early 20th century, there was increased attention to an individual’s right to choose when and how to die. Further, physicians were arguing that attention needed to be given to the needs and desires of terminally ill patients who deserved to have their pain alleviated. Arguments were also made for alleviating the suffering and burden of individuals classified as “hopeless idiots,” “imbeciles,” and “monstrosities.” These pleadings were sometimes made to legislatures in an effort to obtain state sanction of physician-assisted hastening of death. Although these bills received a significant amount of public support, there were often as many or more opponents to them.
Up to this point, support for euthanasia existed primarily as an option for individuals who were terminally ill, as well as for individuals born mentally retarded and/or severely deformed. When legalization of euthanasia was sought, most bills had provisions for some type of a review of the request by representatives of the state, physicians, and perhaps members of the individual’s family, as well as sections delineating limitations on the persons eligible to make the request. In addition to efforts to pass legislation, an increasing number of court cases relating to euthanasia or mercy killings were publicized during this period of time. The consequences for individuals who assisted in the act of euthanasia were often light, as there was mixed concern and sympathy for the individuals due to the circumstances surrounding their actions.
The word euthanasia would forever become tainted by the events that occurred in Germany prior to and during World War II. In Germany, as in other countries including the United States and Britain, the idea that a certain quality of life was not worthy of living became popular. Arguments were put forth that suggested that euthanasia was a humane way to end the suffering of individuals with physical and/or mental “handicaps,” as well as alleviating the burden on their families and the state. In Germany, this policy became state sanctioned and was used as a justification for the murder of approximately 100,000 physically and/or mentally handicapped individuals. The methods used to kill these people were particularly brutal, and the actions came to light during the Nuremberg war trials. These events radically influenced the future of the discourse on euthanasia.
In the decade following World War II, there were a number of court cases in the United States involving individuals, often family members, who engaged in the “mercy killing” of someone who was terminally ill or severely disabled. There was a significant amount of public support for these individuals, and several of them were acquitted on bases such as temporary insanity. Those who were convicted of their charges were often given some measure of leniency. On the other hand, there was also significant opposition to euthanasia. Opponents often cited the slippery slope argument, stating that if euthanasia was sanctioned at any level, it could lead to the abuses experienced in Nazi Germany.
They argued that those events started from a belief that there was a life that was not worth living.
The debate continues into the present with passionate arguments on both sides. There have been developments in terms of legislation allowing for living wills and Oregon’s Death with Dignity Act, which is the first legislation passed in the United States legalizing physician-assisted suicide. Distinctions have been made between active and passive euthanasia, with passive euthanasia becoming more widely accepted and discussed in terms of end-of-life decision making. In addition, language has changed so that the term is rarely used in the United States because of concern that if people associated withholding or withdrawing treatment with “euthanasia” then these actions would not be requested by people or performed by medical professionals.
Cultural Issues Related To Euthanasia And End Of Life Within The United States
Individuals from a variety of backgrounds live in the United States and bring with them their own set of cultural values and beliefs that influence end-of-life decision making. This section will briefly discuss differences in beliefs about end-of-life decisions and voluntary euthanasia among five of the major cultural groups in the United States, including European Americans, African Americans, Latinos, Asian Americans, and Native Americans. It is important to note that there is a great deal of heterogeneity within each of these groups. Cultural influences other than “race,” including ethnicity, religious affiliation, the region in which one was raised, membership in other groups, and personal experiences with dying and death will also influence end-of-life decision making and views on voluntary euthanasia. When working with individuals from these cultural groups it is important to discuss these issues on an individual basis.
European Americans represent the dominant culture within the United States. Thus much of the mainstream values and discourse about euthanasia are reflective of western European values. These individuals, in general, view euthanasia more favorably than other groups. This is reflective of the values held as a group including a value for achievement and success, material comfort and consumerism, freedom, secular rationality, and autonomy. These values influence the desire for personal control in end-of-life decision making. Furthermore, the values of productivity and achievement as well as material comfort may influence a greater acceptance of voluntary euthanasia.
As a group, African Americans are generally less likely than European Americans to approve of voluntary euthanasia. Additionally, as a group, they are also less likely to approve of discontinuing life-prolonging treatments. A history of racism is one factor that may influence the views of African Americans about end of-life decisions. Because of past events, such as the Tuskegee Syphilis Study, many African Americans may experience a distrust of the institutional systems developed by the dominant European American culture, which may be compounded by the documented differences between the groups in terms of access to available health care. This distrust may also lead to a less favorable view of advanced directives and a concern about being allowed to prematurely die if life-sustaining care is not utilized to its maximum.
As a group, Latinos are more likely than African Americans to agree that there are situations in which voluntary euthanasia is acceptable, although the rate of agreement is generally lower than that of European Americans. There are certain cultural values that influence the preferences for end-of-life care for Latinos as a group. In particular, Latinos tend to have a more collectivistic rather than individualistic orientation than European Americans. There is less importance placed on individual decision making and more emphasis placed on the good of the family. There is also a value on focusing on the present rather than the past or the future. This value may hinder planning advanced directives. Finally, there may be a strong religious orientation that may prevent considering anything that may seem like “playing God” near the end of life.
Although there is a good deal of heterogeneity within each of the discussed groups, this is particularly true for Asian Americans. Individuals who come from regions with many different subcultures, languages, and values are lumped together under this label within the United States. This makes it especially difficult to make generalizations about this group. Furthermore, very little research has been performed investigating preferences for end-of-life care. These are limitations to the material presented regarding this group. In many Asian cultures there is a strong family orientation. Therefore, family members may be the ones making decisions about end-of-life care, rather than patient. In some Asian cultures, speaking of death is taboo, and so many Asian individuals may be reluctant to discuss advanced directives. There is also some evidence that suggests that at least some subgroups of Asians are more likely to request life-sustaining interventions and are more reluctant to withdraw life support than European Americans.
Very little data exist about end-of-life preferences of Native Americans. Much of the research that exists is in the form of case studies. In addition, there are hundreds of tribes, so the same problems with generalizations mentioned in the section on Asian Americans are present here. From the limited research available, there appear to be certain values that influence end of-life decision making for Native Americans. One example is the value of autonomy. Although Native Americans, in general, value autonomy, there is also an emphasis on cooperation and consensus; thus an individual may yield his or her own decision to the wishes of the group. Participation of cultural healers as well as the incorporation of traditional rituals and practices may also be particularly important when facing end of-life care. More work needs to be done in order to have a more complete understanding of Native American perspectives on end-of-life care and particularly voluntary euthanasia.
International Perspectives On Euthanasia
The world’s first euthanasia society was founded in London, England, in 1935. In 1976, the first international meeting of “right-to-die” groups occurred in Tokyo when representatives from six organizations gathered. Since then, the international movement has grown considerably, with the World Federation of Right-to-Die Societies being founded in 1980 with 27 groups from 18 countries; there are currently 38 member organizations representing 23 nations. Although there are efforts being made in many countries, the emphasis of this section will be on those nations where euthanasia is actually legal or being publicly practiced. The situations in Germany and Switzerland are complex regarding assistance in dying, and there is lack of clarity about the degree to which voluntary active euthanasia (VAE) versus assisted suicide is practiced; therefore, these countries will not be discussed below.
The country most associated with euthanasia is the Netherlands, because for decades this was the only place in the world where euthanasia was practiced openly by physicians, even though it was not explicitly legal. The movement began in the early 1970s when a physician, Gertruda Potsma, gave her dying mother a lethal injection and was given a light sentence. This led to the founding of the Dutch Voluntary Euthanasia Society (referred to as NVVE) which, in 1975, began aiding members in hastening their deaths.
In 1984, the Supreme Court in the Netherlands approved of VAE under certain circumstances and indicated that if a set of guidelines and procedures was met, physicians would not be prosecuted. In 1994, the Dutch parliament formalized the procedures but kept VAE as a criminal offense. The guidelines, based on recommendations from the Royal Dutch Medical Association, stated that a person could receive VAE if (a) the person makes an explicit request; (b) the decision is well-informed, free from coercion, and enduring; (c) there is no alternative acceptable to the person to alleviate suffering; (d) the attending physician exercises due care in deciding to agree to assist and consults with another physician (who must meet personally with the person); (e) a physician is the one to administer the medication; and (f) the physician reports the death to the medical examiner, who then reports to the local district attorney. Prosecutions would happen only if the guidelines were not followed.
In November 2000, the Lower House of the Dutch Parliament approved a bill allowing VAE and assisted suicide; the Upper House approved the bill in April 2001 but it was not to go into effect until April 1, 2002. The previous guidelines were kept in place with the “due care” aspect being clarified. To meet the due care requirements, the physician must (a) be convinced the decision is voluntary and well considered, (b) be convinced that the person is facing interminable and unendurable suffering, (c) have informed the person about the diagnosis and prognosis, and (d) be convinced that there is no other reasonable solution (and the person requesting VAE must also be convinced of this). Consultation must still take place. Five regional review committees, comprising, at a minimum, a legal expert, a physician, and an expert in ethics or philosophy, review the case to determine if the criteria are met; however, the public prosecutor has the authority to further investigate deaths.
One of the most controversial parts of the bill that was passed was the age of eligibility. After much discussion, it was decided that children aged 16 or 17 could receive VAE or assisted suicide if their parents are involved in the decision-making process, while those aged 12 to 15 would need parental consent.
It is estimated that approximately 3,500 deaths a year result from VAE, which corresponds to about 2.6% of all the deaths in a given year in the Netherlands.
In May 1995, the Northern Territory of Australia became the first place where a legislature passed a law allowing VAE, called the “Rights of the Terminally Ill Act.” The law was amended in February 1996 and put into effect in July 1996; however, because the territory is not considered independent, the Australian Federal Parliament had the ability to vote to rescind the Act and did so in March 1997. Prior to this action by the Parliament, the Act survived two court challenges and a legislative effort to repeal it within the Northern Territory itself.
Before it was rescinded, the amended Act required the person seeking VAE to consult with four physicians— one who would help the person die, a specialist in the person’s disease, a psychiatrist, and a palliative care specialist—and get the first three to sign a request form. The first person to try to use the Act, Max Bell, could not get a signature from a cancer specialist; Bob Dent, who had prostate cancer and died on September 22, 1996, was technically the first person to die under a voluntary euthanasia law. Three others, all patients of Philip Nitschke, did use the Act to hasten their deaths; two others had obtained all the signatures necessary but were unable to use the Act before Parliament acted.
In September 2002, Belgium passed a law similar to the one in the Netherlands. The first report of implementation of the law came from the Federal Commission of Control on Euthanasia in 2004.
In 1997, the Colombian Constitutional Court (the highest court in the country) ruled that it was not a crime to assist a terminally ill person who has given informed consent to die. However, although the Court ruled that VAE is constitutional, the country’s Parliament has not yet developed legal regulations or attempted to amend the constitution to overrule the Court.
Arguments For And Against Voluntary Active Euthanasia
Thus far, this entry has focused on the facts of euthanasia in the United States and internationally. At this point, it is necessary to outline some of the major arguments for and against VAE as an acceptable practice; as will be made clear, these are based on opinions and interpretations of the facts. Entire books have been written arguing either side of the debate, and thus this material is merely a brief review of the points made by proponents and opponents.
Arguments In Opposition To VAE
Coercion. There is significant concern that people may not be making free, fully informed choices. The possibility that people may be coerced into “choosing” VAE, especially because of financial issues or the feeling that they are a burden, is a strong argument against VAE.
Religious beliefs. A large number of people believe that only a Higher Power can give life and end it. In fact, religious beliefs are the strongest predictor of opposition to VAE. A related belief is that suffering can have meaning and value to the person and his or her loved ones.
Slippery slope. Another concern is that VAE will lead to involuntary euthanasia in general as well as for a larger group of people than would have “qualified” for VAE. This may happen both as a result of losing control as well as habituation to the practice of euthanasia.
Unnecessary. This argument is that most people can have their symptoms, especially pain, controlled through the use of hospice and palliative care efforts, thus there is no need to have VAE. A related concern is that allowing VAE would reduce interest in improving palliative care.
Arguments In Support Of VAE
Already happening. The basic idea here is that VAE is already happening, so by legalizing it and bringing it into the open it can be better regulated and problems can be minimized. The argument is supported by the fact that there already exist legal actions very similar to VAE.
Autonomy. The most commonly heard argument in support of VAE is that people have the right to decide for themselves the degree to which they want to have power over how and when they die. This is often phrased as “choice” or “self-determination” but ultimately it is about control.
Just one option of many. Related to the autonomy argument, this contention is that allowing VAE does not eliminate other options, it merely adds another to the list. Thus, a person could choose VAE or not, but at least it would be available for those who might want it legally.
Quality of life. This argument asserts that there is more involved than pain (and even it cannot be completely managed), there are other symptoms that cannot be controlled, there are personal perceptions of dignity, and the basic idea is that quality is preferred over quantity.
There are many forms of euthanasia, some of which are more practiced and more acceptable than others. Although significant attention has been given to euthanasia in a few countries, it is likely that interest in, and attention to, euthanasia will continue to grow wherever technology has advanced to the point where people perceive that they may be kept alive even though their lives have no meaning to them or they are suffering greatly. However, the fact that interest in euthanasia may be present does not mean that legalization is necessarily a good idea or that it is the best option for a given individual.
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- World Federation of Right-to-Die Societies, http://www.wnet/