or mercy killings performed on animals, see
Animal euthanasia.
Euthanasia (from the
Greek:
εὐθανασία meaning "good death": εὖ,
eu (well or good) + θάνατος,
thanatos (death)) refers to the practice of intentionally ending a life in order to relieve
pain and
suffering.
There are different
euthanasia laws in each country. The British
House of Lords Select Committee on
Medical Ethics
defines euthanasia as "a deliberate intervention undertaken with the
express intention of ending a life, to relieve intractable suffering".
[1] In the
Netherlands, euthanasia is understood as "termination of life by a doctor at the request of a patient".
[2]
Euthanasia is categorized in different ways, which include voluntary, non-voluntary, or involuntary.
Voluntary euthanasia is legal in some countries and U.S. states.
Non-voluntary euthanasia is illegal in all countries.
Involuntary euthanasia is usually considered murder.
[3]
As of 2006, euthanasia is the most active area of research in contemporary
bioethics.
[4]
Definition
Like other terms borrowed from history, "euthanasia" has had
different meanings depending on usage. The first apparent usage of the
term "euthanasia" belongs to the historian
Suetonius who described how the Emperor
Augustus, "dying quickly and without suffering in the arms of his wife, Livia, experienced the 'euthanasia' he had wished for."
[5] The word "euthanasia" was first used in a medical context by
Francis Bacon
in the 17th century, to refer to an easy, painless, happy death, during
which it was a "physician's responsibility to alleviate the 'physical
sufferings' of the body." Bacon referred to an "outward euthanasia"—the
term "outward" he used to distinguish from a spiritual concept—the
euthanasia "which regards the preparation of the soul."
[6]
In current usage, one approach to defining euthanasia has been to
mirror Suetonius, regarding it as the "painless inducement of a quick
death".
[7]
However, it is argued that this approach fails to properly define
euthanasia, as it leaves open a number of possible actions which would
meet the requirements of the definition, but would not be seen as
euthanasia. In particular, these include situations where a person kills
another, painlessly, but for no reason beyond that of personal gain; or
accidental deaths which are quick and painless, but not intentional.
[8][9]
Thus another approach is to incorporate the notion of
suffering into the definition.
[8] The definition offered by the
Oxford English Dictionary
incorporates suffering as a necessary condition, with "the painless
killing of a patient suffering from an incurable and painful disease or
in an irreversible coma",
[10]
and this approach can be seen as a part of other works, such as Marvin
Khol and Paul Kurtz's "a mode or act of inducing or permitting death
painlessly as a relief from suffering".
[11]
However, focusing on this approach to defining euthanasia may also lead
to counterexamples: such definitions may encompass killing a person
suffering from an incurable disease for personal gain (such as to claim
an inheritance), and commentators such as
Tom Beauchamp &
Arnold Davidson have argued that doing such would constitute "murder simpliciter" rather than euthanasia.
[8]
The third element incorporated into many definitions is that of
intentionality – the death must be intended, rather than being
accidental, and the intent of the action must be a "merciful death".
[8]
Michael Wreen argued that “the principal thing that distinguishes
euthanasia from intentional killing simpliciter is the agent's motive:
it must be a good motive insofar as the good of the person killed is
concerned”,
[12]
a view mirrored by Heather Draper, who also spoke to the importance of
motive, arguing that "the motive forms a crucial part of arguments for
euthanasia, because it must be in the best interests of the person on
the receiving end."
[9] Definitions such as that offered by the
House of Lords Select Committee on
Medical Ethics
take this path, where euthanasia is defined as "a deliberate
intervention undertaken with the express intention of ending a life, to
relieve intractable suffering."
[1] Beauchamp & Davidson also highlight
Baruch Brody's
"an act of euthanasia is one in which one person ... (A) kills another
person (B) for the benefit of the second person, who actually does
benefit from being killed".
[13]
Draper argued that any definition of euthanasia must incorporate four
elements: an agent and a subject; an intention; a causal proximity,
such that the actions of the agent lead to the outcome; and an outcome.
Based on this, she offered a definition incorporating those elements,
stating that euthanasia "must be defined as death that results from the
intention of one person to kill another person, using the most gentle
and painless means possible, that is motivated solely by the best
interests of the person who dies."
[14]
Prior to Draper, Beauchamp & Davidson had also offered a definition
which includes these elements, although they offered a somewhat longer
account, and one that specifically discounts
fetuses in order to distinguish between abortions and euthanasia:
[15]
"In summary, we have argued ... that the death of a
human being, A, is an instance of euthanasia if and only if (1) A's
death is intended by at least one other human being, B, where B is
either the cause of death or a causally relevant feature of the event
resulting in death (whether by action or by omission); (2) there is
either sufficient current evidence for B to believe that A is acutely
suffering or irreversibly comatose, or there is sufficient current
evidence related to A's present condition such that one or more known
causal laws supports B's belief that A will be in a condition of acute
suffering or irreversible comatoseness; (3) (a) B's primary reason for
intending A's death is cessation of A's (actual or predicted future)
suffering or irreversible comatoseness, where B does not intend A's
death for a different primary reason, though there may be other relevant
reasons, and (b) there is sufficient current evidence for either A or B
that causal means to A's death will not produce any more suffering than
would be produced for A if B were not to intervene; (4) the causal
means to the event of A's death are chosen by A or B to be as painless
as possible, unless either A or B has an overriding reason for a more
painful causal means, where the reason for choosing the latter causal
means does not conflict with the evidence in 3b; (5) A is a nonfetal
organism."
[16]
Wreen, in part responding to Beauchamp & Davidson, offered a six part definition:
"Person A committed an act of euthanasia if and
only if (1) A killed B or let her die; (2) A intended to kill B; (3) the
intention specified in (2) was at least partial cause of the action
specified in (1); (4) the causal journey from the intention specified in
(2) to the action specified in (1) is more or less in accordance with
A's plan of action; (5) A's killing of B is a voluntary action; (6) the
motive for the action specified in (1), the motive standing behind the
intention specified in (2), is the good of the person killed."
[17]
Wreen also considered a seventh requirement: "(7) The good specified
in (6) is, or at least includes, the avoidance of evil", although as
Wreen noted in the paper, he was not convinced that the restriction was
required.
[18]
In discussing his definition, Wreen noted the difficulty of justifying euthanasia when faced with the notion of the subject's "
right to life". In response, Wreen argued that euthanasia has to be voluntary, and that "involuntary euthanasia is, as such, a great wrong".
[18]
Other commentators incorporate consent more directly into their
definitions. For example, in a discussion of euthanasia presented in
2003 by the European Association of Palliative Care (EPAC) Ethics Task
Force, the authors offered: "Medicalized killing of a person without the
person's consent, whether nonvoluntary (where the person in unable to
consent) or involuntary (against the person's will) is not euthanasia:
it is murder. Hence, euthanasia can be voluntary only."
[19] Although the EPAC Ethics Task Force argued that both
non-voluntary and
involuntary euthanasia
could not be included in the definition of euthanasia, there is
discussion in the literature about excluding one but not the other.
[18]
Classification of euthanasia
Euthanasia may be classified according to whether a person gives
informed consent into three types: voluntary, non-voluntary and involuntary.
[20][21]
There is a debate within the medical and bioethics literature about
whether or not the non-voluntary (and by extension, involuntary) killing
of patients can be regarded as euthanasia, irrespective of intent or
the patient's circumstances. In the definitions offered by Beauchamp
& Davidson and, later, by Wreen, consent on the part of the patient
was not considered to be one of their criteria, although it may have
been required to justify euthanasia.
[8][22] However, others see consent as essential.
Voluntary euthanasia
Euthanasia conducted with the consent of the patient is termed
voluntary euthanasia.
Active voluntary euthanasia is legal in Belgium, Luxembourg and the
Netherlands. Passive voluntary euthanasia is legal throughout the U.S.
per
Cruzan v. Director, Missouri Department of Health. When the patient brings about his or her own death with the assistance of a physician, the term
assisted suicide is often used instead. Assisted suicide is legal in Switzerland and the U.S. states of Oregon, Washington and Montana.
Non-voluntary euthanasia
Euthanasia conducted where the consent of the patient is unavailable is termed
non-voluntary euthanasia. Examples include
child euthanasia, which is illegal worldwide but decriminalised under certain specific circumstances in the Netherlands under the
Groningen Protocol.
Involuntary euthanasia
Euthanasia conducted against the will of the patient is termed
involuntary euthanasia.
Passive and active euthanasia
Voluntary, non-voluntary and involuntary euthanasia can all be further divided into passive or active variants.
[23] A number of authors consider these terms to be misleading and unhelpful.
[1]
Passive euthanasia entails the withholding of common treatments, such as antibiotics, necessary for the continuance of life.
[1]
Active euthanasia entails the use of lethal substances or forces,
such as administering a lethal injection, to kill and is the most
controversial means.
History
According to the historian N. D. A. Kemp, the origin of the contemporary debate on euthanasia started in 1870.
[24] Nevertheless, euthanasia was debated and practiced long before that date. Euthanasia was practised in
Ancient Greece and Rome: for example,
hemlock was employed as a means of hastening death on the island of
Kea, a technique also employed in
Marseilles and by
Socrates in Athens. Euthanasia, in the sense of the deliberate hastening of a person's death, was supported by Socrates,
Plato and
Seneca the Elder in the ancient world, although
Hippocrates
appears to have spoken against the practice, writing "I will not
prescribe a deadly drug to please someone, nor give advice that may
cause his death" (noting there is some debate in the literature about
whether or not this was intended to encompass euthanasia).
[25][26][27]
Euthanasia was strongly opposed in the
Judeo-Christian tradition.
Thomas Aquinas opposed both and argued that the practice of euthanasia contradicted our natural human instincts of survival.,
[28]
as did Francois Ranchin (1565–1641), a French physician and professor
of medicine, and Michael Boudewijns (1601–1681), a physician and
teacher.
[26]:208[29] Nevertheless, there were voices arguing for euthanasia, such as
John Donne in 1624,
[30] and euthanasia continued to be practised. Thus in 1678, the publication of Caspar Questel's
De pulvinari morientibus non subtrahend, ("
On the pillow of which the dying should not be deprived"),
initiated debate on the topic. Questel described various customs which
were employed at the time to hasten the death of the dying, (including
the sudden removal of a pillow, which was believed to accelerate death),
and argued against their use, as doing so was "against the laws of God
and Nature".
[26]:209–211 This view was shared by many who followed, including Philipp Jakob Spener, Veit Riedlin and
Johann Georg Krünitz.
[26]:211
In spite of opposition, euthanasia continued to be practised, involving
techniques such as bleeding, suffocation and removing people from their
beds to be placed on the cold ground.
[26]:211–214
Suicide and euthanasia were more acceptable under Protestantism and during the
Age of Enlightenment,
[29] and
Thomas More wrote of euthanasia in
Utopia, although it is not clear if More was intending to endorse the practise.
[26]:208–209
Other cultures have taken different approaches: for example, in Japan
suicide has not traditionally been viewed as a sin, and accordingly the
perceptions of euthanasia are different from those in other parts of the
world.
[31]
Beginnings of the contemporary euthanasia debate
In the mid-1800s, the use of
morphine to treat "the pains of death" emerged, with
John Warren recommending its use in 1848. A similar use of
chloroform
was revealed by Joseph Bullar in 1866. However, in neither case was it
recommended that the use should be to hasten death. In 1870 Samuel
Williams, a schoolteacher, initiated the contemporary euthanasia debate
through a speech given at the Birmingham Speculative Club, which was
subsequently published in a one-off publication entitled
Essays of the Birmingham Speculative Club, the collected works of a number of members of an amateur philosophical society.
[32]:794 Williams' proposal was to use chloroform to deliberately hasten the death of terminally ill patients:
That in all cases of hopeless and painful illness,
it should be the recognized duty of the medical attendant, whenever so
desired by the patient, to administer choloroform or such other
anaesthetic as may by-and-bye supersede chloroform – so as to destroy
consciousness at once, and put the sufferer to a quick and painless
death; all needful precautions being adopted to prevent any possible
abuse of such duty; and means being taken to establish, beyond the
possibility of doubt or question, that the remedy was applied at the
express wish of the patient.
—Samuel Williams (1872) ,
Euthanasia Williams and Northgate: London.[32]:794
The essay was favourably reviewed in
The Saturday Review, and an editorial speaking against the essay appeared in
The Spectator.
[24]
From there it proved to be influential, and other writers came out in
support of such views: Lionel Tollemache wrote in favour of euthanasia,
as did
Annie Besant, the essayist and reformer who later became involved with the
National Secular Society, considering it a duty to society to "die voluntarily and painlessly" when one reaches the point of becoming a 'burden'.
[24][33] Popular Science also analyzed the issue in May 1873, assessing both sides of the argument.
[34]
Nevertheless, Kemp notes that at the time, medical doctors did not
participate in the discussion; it was "essentially a philosophical
enterprise... tied inextricably to a number of objections to the
Christian doctrine of the sanctity of human life".
[24]
Early euthanasia movement in the United States
Felix Adler, circa 1913, the first prominent American to argue for permitting suicide in cases of chronic illness
The rise of the euthanasia movement in the United States coincided with the so-called
Gilded Age
– a time of social and technological change that encompassed an
"individualistic conservatism that praised laissez faire economics,
scientific method, and
rationalism", along with major
depressions, industrialisation and conflict between corporations and labor unions.
[32]:794
It was also a time that saw the development of the modern hospital
system, seen as a factor in the emergence of the euthanasia debate.
[35]
Robert Ingersoll
argued for euthanasia, stating in 1894 that where someone is suffering
from a terminal illness, such as terminal cancer, they should have a
right to end their pain through suicide. Felix Adler offered a similar
approach, although, unlike Ingersoll, Adler did not reject religion,
instead arguing from an
Ethical Culture
framework. In 1891, Alder argued that those suffering from overwhelming
pain should have the right to commit suicide, and, furthermore, that it
should be permissible for a doctor to assist – thus making Adler the
first "prominent American" to argue for suicide in cases where people
were suffering from chronic illness.
[36] Both Ingersoll and Adler argued for voluntary euthanasia of adults suffering from terminal ailments.
[36]
However, Dowbiggin argues that by breaking down prior moral objections
to euthanasia and suicide, Ingersoll and Adler made it possible for
others to stretch the definition of euthanasia.
[37]
America also saw the first attempt to legalise euthanasia, when
Henry Hunt introduced legislation into the
General Assembly of
Ohio in 1906.
[38]:614 Hunt did so at the behest of
Anna Hall,
a wealthy heiress who was a major figure in the euthanasia movement
during the early 20th century in the United States. Hall had watched her
mother die after an extended battle with
liver cancer,
and had dedicated herself to ensuring that others would not have to
endure the same suffering. Towards this end she engaged in an extensive
letter writing campaign, recruited
Lurana Sheldon and
Maud Ballington Booth, and organised a debate on euthanasia at the annual meeting of the
American Humane Association in 1905 – described by
Jacob Appel as the first significant public debate on the topic in the 20th century.
[38]:614–616 Hunt's bill called for the administration of an
anesthetic
to bring about a patient's death, so long as the person is of lawful
age and sound mind, and was suffering from a fatal injury, an
irrecoverable illness or great physical pain. It also required that the
case be heard by a physician, required informed consent in front of
three witnesses, and then required the attendance of three physicians
who had to agree that the patient's recovery was impossible. A motion to
reject the bill outright was voted down, but the bill itself failed to
pass, 79 to 23.
[32]:796[38]:618–619
Along with the Ohio euthanasia proposal, 1906 also witnessed the
creation of a second bill: Assemblyman Ross Gregory introduced a
proposal to permit euthanasia to the
Iowa
legislature. However, the Iowa legislation was far broader in scope
than that offered in Ohio. It allowed for the death of any person of at
least ten years of age who suffered from an ailment that would prove
fatal and cause extreme pain, should they be of sound mind and express a
desire to artificially hasten their death. In addition, it allowed for
infants to be euthanised if they were sufficiently deformed, and
permitted guardians to request euthanasia on behalf of their wards. The
proposed legislation also imposed penalties on physicians who refused to
perform euthanasia when requested: a 6–12 month prison term and a fine
of between $200 and $1000 dollars. Unsurprisingly, the proposal proved
to be controversial.
[38]:619–621
It engendered considerable debate but failed to pass, having been
withdrawn from consideration after being passed to the Committee on
Public Health.
[38]:623
After 1906 the euthanasia debate reduced in intensity, resurfacing
periodically but not returning to the same level of debate until the
1930s in the United Kingdom.
[32]:796
1930s
In January 1936,
King George V was given a fatal dose of morphine and
cocaine
in order to hasten his death. At the time he was suffering from
cardiorespiratory failure, and the decision to end his life was made by
his physician,
Lord Dawson.
[39] Although this remained a secret for over 50 years, the death of George V coincided with proposed legislation in the
House of Lords to legalise euthanasia. The legislation came through the British Volunteer Euthanasia Legalisation Society (now known as
Dignity in Dying),
[40] which was formed in 1935, although its formation can be traced back to a 1931 speech by
Dr Charles Killick Millard.
[24]
Euthanasia opponent Ian Dowbiggin argues that the early membership of
the Euthanasia Society of America (ESA) reflected how many perceived
euthanasia at the time, often seeing it as a eugenics matter rather than
an issue concerning individual rights.
[36]
Dowbiggin argues that not every eugenist joined the ESA "solely for
eugenic reasons", but he postulates that there were clear ideological
connections between the eugenics and euthanasia movements.
[36]
A 24 July 1939 killing of a severely disabled infant in
Nazi Germany was described in a
BBC "Genocide Under the Nazis Timeline" as the first "state-sponsored euthanasia".
[41]
Parties that consented to the killing included Hitler's office, the
parents, and the Reich Committee for the Scientific Registration of
Serious and Congenitally Based Illnesses.
[41] The Telegraph noted that the killing of the disabled infant—whose name was
Gerhard Kretschmar,
born blind, with missing limbs, subject to convulsions, and reportedly
"an idiot"— provided "the rationale for a secret Nazi decree that led to
'mercy killings' of almost 300,000 mentally and physically handicapped
people".
[42]
While Kretchmar's killing received parental consent, afterwards, most
of the 5,000 to 8,000 killed children were forcibly taken from their
parents.
[41][42]
Nazi Euthanasia Program (Action T4)
Nazi poster that reads "60,000
Reichsmark is the lifetime cost to the community of this genetic defective. Member of the [German] race, that's your money".
[43]
The "euthanasia campaign" of mass murder gathered momentum on 14
January 1940 when the "handicapped" were killed with gas vans and
killing centres, eventually leading to the deaths of 70,000 adult
Germans.
[44] Professor
Robert Jay Lifton, author of
The Nazi Doctors
and a leading authority on the T4 program, contrasts this program with
what he considers to be a genuine euthanasia. He explains that the Nazi
version of "euthanasia" was based on the work of
Adolf Jost, who published
The Right to Death
(Das Recht auf den Tod) in 1895. Lifton writes: "Jost argued that
control over the death of the individual must ultimately belong to the
social organism, the state. This concept is in direct opposition to the
Anglo-American concept of euthanasia, which emphasizes the
individual's
'right to die' or 'right to death' or 'right to his or her own death,'
as the ultimate human claim. In contrast, Jost was pointing to the
state's right to kill. [...] Ultimately the argument was biological:
'The rights to death [are] the key to the fitness of life.' The state
must own death—must kill—in order to keep the social organism alive and
healthy."
[45]
In modern terms, the use of "euthanasia" in the context of Action T4 is seen to be a
euphemism to disguise a program of
genocide, in which people were killed on the grounds "disabilities, religious beliefs, and discordant individual values".
[46]
Compared to the discussions of euthanasia that emerged post-war, the
Nazi program may have been worded in terms that appear similar to the
modern use of the euthanasia, but there was no "mercy" and the patients
were not necessarily terminally ill.
[46] Despite these differences, historian and euthanasia opponent
Ian Dowbiggin
writes that "the origins of Nazi euthanasia, like those of the American
euthanasia movement, predate the Third Reich and were intertwined with
the history of eugenics and
social Darwinism, and with efforts to discredit traditional morality and ethics."
[36]:65
Euthanasia debate
Historically, the euthanasia debate has tended to focus on a number of key concerns. According to euthanasia opponent
Ezekiel Emanuel, proponents of euthanasia have presented four main arguments: a) that people have a right to
self-determination,
and thus should be allowed to choose their own fate; b) assisting a
subject to die might be a better choice than requiring that they
continue to suffer; c) the distinction between passive euthanasia, which
is often permitted, and active euthanasia, which is not, is not
substantive (or that the underlying principle–the
doctrine of double effect–is
unreasonable or unsound); and d) permitting euthanasia will not
necessarily lead to unacceptable consequences. Pro-euthanasia activists
often point to countries like the
Netherlands and
Belgium, and states like
Oregon, where it has been made legal to argue that it is mostly unproblematic.
Similarly, Emanuel argues that there are four major arguments
presented by opponents of euthanasia: a) not all deaths are painful; b)
alternatives, such as cessation of active treatment, combined with the
use of effective pain relief, are available; c) the distinction between
active and passive euthanasia is morally significant; and d) legalising
euthanasia will place society on a
slippery slope,
[47] which will lead to unacceptable consequences.
[32]:797–8
Legal status
West's Encyclopedia of American Law states that "a 'mercy killing' or
euthanasia is generally considered to be a criminal homicide"
[48] and is normally used as a synonym of homicide committed at a request made by the patient.
[49]
The judicial sense of the term "
homicide" includes any intervention undertaken with the express intention of ending a life, even to relieve intractable suffering.
[49][50][51] Not all homicide is unlawful.
[52] Two designations of homicide that carry no criminal punishment are justifiable and excusable homicide.
[52]
In most countries this is not the status of euthanasia. The term
"euthanasia" is usually confined to the active variety; the University
of Washington website states that "euthanasia generally means that the
physician would act directly, for instance by giving a lethal injection,
to end the patient's life".
[53] Physician-assisted suicide is thus not classified as euthanasia by
the US State of Oregon, where it is legal under the
Oregon Death with Dignity Act, and despite its name, it is not legally classified as suicide either.
[54]
Unlike physician-assisted suicide, withholding or withdrawing
life-sustaining treatments with patient consent (voluntary) is almost
unanimously considered, at least in the United States, to be legal.
[55]
The use of pain medication in order to relieve suffering, even if it
hastens death, has been held as legal in several court decisions.
[53]
Some governments around the world have legalized voluntary euthanasia
but generally it remains as a criminal homicide. In the Netherlands and
Belgium, where euthanasia has been legalized, it still remains homicide
although it is not prosecuted and not punishable if the perpetrator
(the doctor) meets certain legal exceptions.
[56][57][58][59]
Physician sentiment
A survey in the United States of more than 10,000 physicians came to
the result that approximately 16% of physicians would ever consider
halting life-sustaining therapy because the family demands it, even if
believed that it was premature. Approximately 55% would not, and for the
remaining 29%, it would depend on circumstances.
[60]
This study also stated that approximately 46% of physicians agree
that physician-assisted suicide should be allowed in some cases; 41% do
not, and the remaining 14% think it depends.
[60]
In the United Kingdom, the pro-assisted dying group
Dignity in Dying cite conflicting research on attitudes by doctors to assisted dying: with a 2009
Palliative Medicine-published
survey showing 64% support (to 34% oppose) for assisted dying in cases
where a patient has an incurable and painful disease, while 49% of
doctors in a study published in
BMC Medical Ethics oppose changing the law on assisted dying to 39% in favour.
[61]
