Much debate has arisen in the United States among physicians, religious leaders, lawyers, and the general public over the question of what constitutes actively causing death and what constitutes merely allowing death to occur naturally. The physician is faced with deciding whether measures used to keep patients alive are extraordinary in individual situations, e.g., whether a respirator or artificial kidney machine should be withdrawn from a terminally ill patient. The Supreme Court's decision in Cruzan v. Director, Missouri Dept. of Health set a precedent for the removal of life-support equipment from terminal cases.
Popular movements have supported the legalization of the living will, a statement written by a mentally alert patient that can be used to express a wish to forgo artificial means to sustain life during terminal illness. In 1977, California became the first to pass a state law to this effect, known as the death-with-dignity statute. The absence of a written living will complicated the case of Terri Schiavo, a Florida woman who was in a persistent vegetative state from 1990 until 2005, when she died after having her feeding tube removed. In 2000 her husband, who was her legal guardian, won the right to remove it based upon what he stated were her orally expressed wishes, but legal challenges from her parents and Florida governor Jeb Bush and attempted government interventions through Florida and federal legislation delayed the tube's removal for five years. (See Schiavo case.)
Societies advancing the cause of positive euthanasia were founded in 1935 in England and 1938 in the United States. End-of-Life Choices (formerly the Hemlock Society) is one controversial group that has pressed for right-to-die legislation on a national level. Positive euthanasia is for the most part illegal in the United States, but physicians may lawfully refuse to prolong life when there is extreme suffering.
In the early 1990s, Dr. Jack Kevorkian, a Michigan physician, gained notoriety by assisting a number of people to commit suicide and became the object of a state law (1992) forbidding such activity. Kevorkian, who had been tried and acquitted repeatedly in the assisted deaths of seriously ill people, was convicted of murder in Michigan in 1999 for an assisted suicide that was shown on national television. Meanwhile, in 1997, the Supreme Court upheld state laws banning assisted suicide (in most U.S. states assisting in a suicide is a crime).
In Oregon in 1994, voters approved physician-assisted suicide for some patients who are terminally ill; the law went into effect in 1997, following a protracted court challenge. In 2001 the Bush administration sought to undermine the law with a directive issued under the federal Controlled Substances Act, but Oregon sued to prohibit the enforcement of it, and the Supreme Court ruled (2006) that the federal government had exceeded its authority. Voters in Washington state approved a similar measure in 2008, and in 2008 the Montana supreme court ruled that state law did not bar a terminally ill patient from seeking a prescription from a physician for the drugs necessary for suicide.
Since 1937 assisted suicide has not been illegal in Switzerland as long as the person who assists has no personal motive or gain. In 1993, the Netherlands decriminalized, under a set of restricted conditions, voluntary positive euthanasia (essentially, physician-assisted suicide) for the terminally ill, and in 2002 the country legalized physician-assisted suicide if voluntarily requested by seriously ill patients who face ongoing suffering. Belgium (2002) and Luxembourg (2008) also have legalized euthanasia for certain patients who have requested it.
See also bioethics.
See P. Singer, Rethinking Life and Death (1994); H. Hendin, Suicide in America (rev. ed. 1995). See also studies by J. Rachels (1986) and R. Wennberg (1989).
Euthanasia (literally "good death" in Ancient Greek) refers to the practice of ending a life in a painless manner. As of 2008, some forms of euthanasia are legal in Belgium, Luxembourg, The Netherlands, Switzerland, the U.S. state of Oregon, the Autonomous Community of Andalusia (Spain), and Thailand. Stances on euthanasia vary greatly; it is called murderous by some and merciful by others. Such controversy arises in part from the serious moral issues attached to the subject and in part from the fact that "euthanasia" is an umbrella term that describes a number of different methods. Accordingly, more specific terminology is often needed in order to facilitate constructive discussions on the topic.
English Common Law from the 1300s until the middle of the last century made suicide a criminal act in England and Wales. Assisting others to kill themselves remains illegal in that jurisdiction. However, in the 1500s, Thomas More, in describing a utopian community, envisaged such a community as one that would facilitate the death of those whose lives had become burdensome as a result of "torturing and lingering pain".
The first major effort to legalize euthanasia in the United States arose as part of the eugenics movement in the early years of the twentieth century. In an article in the Bulletin of the History of Medicine, Brown University historian Jacob M. Appel documented extensive political debate over legislation to legalize physician-assisted suicide in both Iowa and Ohio in 1906. Appel indicates social activist Anna S. Hall was the driving force behind this movement. In his book A Merciful End, Ian Dowbiggen has revealed the role that leading public figures, including Clarence Darrow and Jack London, played in advocating for the legalization of euthanasia.
Euthanasia societies were formed in England in 1935 and in the U.S.A. in 1938 to promote aggressive euthanasia. Although euthanasia legislation did not pass in the U.S. or England, in 1937, doctor-assisted euthanasia was declared legal in Switzerland as long as the person ending the life has nothing to gain. During this period, euthanasia proposals were sometimes mixed with eugenics. While some proponents focused on voluntary euthanasia for the terminally ill, others expressed interest in involuntary euthanasia for certain eugenic motivations (e.g., mentally "defective"). During this same era, meanwhile, U.S. court trials tackled cases involving critically ill people who requested physician assistance in dying as well as “mercy killings”, such as by parents of their severely disabled children.
Prior to and during World War II, the Nazis carried out an involuntary euthanasia program, largely in secret. In 1939, Nazis, in what was code-named Action T4, killed children under three who exhibited mental retardation, physical deformity or other debilitating problems which they considered gave the disabled child "life unworthy of life”. This program was later extended to include older children and adults.. Inmates of mental asylums in Germany and Austria would be transported to an intermediate facility, from where they would be retransported to one of six killing centres at Brandenburg near Berlin (January 1940 - September 1940), Grafeneck near Stuttgart (January 1940 - December 1940), Hartheim near Linz in Austria (January 1940 - December 1944), Sonnenstein/Pirna near Dresden (April 1940 - August 1943), Bernburg near Magdeburg (September 1940 - April 1943), Hadamar near Koblenz (January 1941 - August 1941). Religious protest especially but not limited to Catholic prelates caused Hitler to order the official cancellation of T4 but postwar investigation made it clear that the practice continued in institutes where personnel were sympathetic to eugenic policies.
The T4 program of the Nazis was extended to killing of concentration camp inmates when Philipp Bouhler,the head of the T4 program, allowed Heinrich Himmler to utilize T4 doctors, staff and facilities to kill concentration camp prisoners who were "most seriously ill" in a program designated "14f13".
A key turning point in the debate over voluntary euthanasia (and physician assisted dying), at least in the United States, was the public furor over the case of Karen Ann Quinlan. The Quinlan case paved the way for legal protection of voluntary passive euthanasia. In 1977, California legalized living wills and other states soon followed suit.
In 1990, Dr. Jack Kevorkian, a Michigan physician, became infamous for encouraging and assisting people in committing suicide which resulted in a Michigan law against the practice in 1992. Kevorkian was tried and convicted in 1999 for a murder displayed on television. Also in 1990, the Supreme Court approved the use of non-aggressive euthanasia.
In 1994, Oregon voters approved the Death with Dignity Act, permitting doctors to assist terminal patients with six months or less to live to end their lives. The U.S. Supreme Court allowed such laws in 1997. The Bush administration failed in its attempt to use drug law to stop Oregon in 2001, in the case Gonzales v. Oregon. In 1999, non-aggressive euthanasia was permitted in Texas.
In 1993, the Netherlands decriminalized doctor-assisted suicide, and in 2002, restrictions were loosened. During that year, physician-assisted suicide was approved in Belgium. Belgium's at the time most famous author Hugo Claus, suffering from Alzheimer's disease, was among those that asked for euthanasia. He died in March 2008, assisted by an Antwerp doctor. Australia's Northern Territory approved a euthanasia bill in 1995, but that was overturned by Australia’s Federal Parliament in 1997.
Most recently, amid U.S. government roadblocks and controversy, Terri Schiavo, a Floridian who was in a vegetative state since 1990, had her feeding tube removed in 2005. Her husband had won the right to take her off life support, which he claimed she would want but was difficult to confirm as she had no living will and the rest of her family claimed otherwise.
In Catholic medical ethics official pronouncements strongly oppose active euthanasia, whether voluntary or not, while allowing dying to proceed without medical interventions that would be considered "extraordinary" or "disproportionate." The Declaration on Euthanasia states that:
"When inevitable death is imminent... it is permitted in conscience to take the decision to refuse forms of treatment that would only secure a precarious and burdensome prolongation of life, so long as the normal care due to a sick person in similar cases is not interrupted."The Declaration concludes that doctors, beyond providing medical skill, must above all provide patients "with the comfort of boundless kindness and heartfelt charity".
Although the Declaration allows people to decline heroic medical treatment when death is imminently inevitable, it unequivocably prohibits the hastening of death and restates Vatican II's condemnation of "crimes against life 'such as any type of murder, genocide, abortion, euthanasia, or willful suicide'". [Emphasis added.]
In Theravada Buddhism a lay person daily recites the simple formula: "I undertake the precept to abstain from destroying living beings. For Buddhist monastics (bhikkhu) however the rules are more explicitly spelled out. For example, in the monastic code (Patimokkha), it states:
In other words, such a monk or nun would be expelled irrevocably from the Buddhist monastic community (sangha). The prohibition against assisting another in their death includes circumstances when a monastic is caring for the terminally ill and extends to a prohibition against a monastic's purposively hastening another's death through word, action or treatment.
American Buddhist monk Thanissaro Bhikkhu wrote:
Euthanasia can be accomplished either through an oral, intravenous, or intramuscular administration of drugs. In individuals who are incapable of swallowing lethal doses of medication, an intravenous route is preferred. The following is a Dutch protocol for parenteral (intravenous) administration to obtain euthanasia:
Intravenous administration is the most reliable and rapid way to accomplish euthanasia and therefore can be safely recommended. A coma is first induced by intravenous administration of 20 mg/kg sodium thiopental (Nesdonal) in a small volume (10 ml physiological saline). Then a triple intravenous dose of a non-depolarizing neuromuscular muscle relaxant is given, such as 20 mg pancuronium bromide (Pavulon) or 20 mg vecuronium bromide (Norcuron). The muscle relaxant should preferably be given intravenously, in order to ensure optimal availability. Only for pancuronium bromide (Pavulon) are there substantial indications that the agent may also be given intramuscularly in a dosage of 40 mg.
With regards to nonvoluntary euthanasia, the cases where the person could consent but was not asked are often viewed differently from those where the person could not consent. Some people raise issues regarding stereotypes of disability that can lead to non-disabled or less disabled people overestimating the person's suffering, or assuming it to be unchangeable when it could be changed. For example, many disability rights advocates responded to Tracy Latimer's murder by pointing out that her parents had refused a hip surgery that could have greatly reduced or eliminated the physical pain Tracy experienced. Also, they point out that a severely disabled person need not be in emotional pain at their situation, and claim that the emotional pain, if present, is due to societal prejudice rather than the disability, analogous to a person of a particular ethnicity wanting to die because they have internalized negative stereotypes about their ethnic background. Another example of this is Keith McCormick, a New Zealander Paralympian who was "mercy-killed" by his caregiver, and Matthew Sutton.
With regards to voluntary euthanasia, many people argue that 'equal access' should apply to access to suicide as well, so therefore disabled people who cannot kill themselves should have access to voluntary euthanasia.
The films Children of Men and Soylent Green, as well as the book The Giver, depict instances of government-sponsored euthanasia in order to strengthen their dystopian themes. The protagonist of Johnny Got His Gun is a brutally mutilated war veteran whose request for euthanasia furthers the work's anti-war message.
The recent films Mar Adentro and Million Dollar Baby argue more directly in favor of euthanasia by illustrating the suffering of their protagonists. These films have provoked debate and controversy in their home countries of Spain and the United States respectively.
Appel, Jacob. 2007. A Suicide Right for the Mentally Ill? A Swiss Case Opens a New Debate. Hastings Center Report, Vol. 37, No. 3.
Dworkin, R. M. Life's Dominion: An Argument About Abortion, Euthanasia, and Individual Freedom. New York: Knopf, 1993.
Fletcher, Joseph F. 1954. Morals and medicine; the moral problems of: the patient's right to know the truth, contraception, artificial insemination, sterilization, euthanasia. Princeton, N.J.K.: Princeton University Press.Derek Humphry, Ann Wickett (1986). The right to die: understanding euthanasia. San Francisco: Harper & Row.
Kamisar, Yale. 1977. Some non-religious views against proposed 'mercy-killing' legislation. In Death, dying, and euthanasia, edited by D. J. Horan and D. Mall. Washington: University Publications of America. Original edition, Minnesota Law Review 42:6 (May 1958).
Kelly, Gerald. “The duty of using artificial means of preserving life” in Theological Studies (11:203-220), 1950.
Panicola, Michael. 2004. Catholic teaching on prolonging life: setting the record straight. In Death and dying: a reader, edited by T. A. Shannon. Lanham, MD: Rowman & Littlefield Publishers.
Paterson, Craig. Assisted Suicide and Euthanasia: An Natural Law Ethics Approach. Aldershot, Hampshire: Ashgate, 2008.
Rachels, James. The End of Life: Euthanasia and Morality. New York: Oxford University Press, 1986.
Sacred congregation for the doctrine of the faith. 1980. The declaration on euthanasia. Vatican City: The Vatican.
Tassano, Fabian. The Power of Life or Death: Medical Coercion and the Euthanasia Debate. Foreword by Thomas Szasz, MD. London: Duckworth, 1995. Oxford: Oxford Forum, 1999.