Euthanasia

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]

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.

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.

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.

Euthanasia conducted against the will of the patient is termed involuntary euthanasia.

Voluntary, non-voluntary and involuntary euthanasia can all be further divided into passive or active variants.^[23] 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. A number of authors consider these terms to be misleading and unhelpful.^[1]

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 Despite 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]

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 in England, 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]

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. 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

The Voluntary Euthanasia Legalisation Society was founded in 1935 by Charles Killick Millard (now called Dignity in Dying), a movement that campaigned for the legalisation of euthanasia in Great Britain.

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.^[40]

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, most of the 5,000 to 8,000 children killed afterwards were forcibly taken from their parents.^[41][42]

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.^[43] 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."^[44]

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 of "disabilities, religious beliefs, and discordant individual values".^[45] 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 "euthanasia", but there was no "mercy" and the patients were not necessarily terminally ill.^[45] 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

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 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 euthanasia has been legalized, 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,^[46] which will lead to unacceptable consequences.^{[32]: 797–8}

Elisabeth Kübler-Ross, an eminent Swiss American psychiatrist (a pioneer in near-death studies and the author of the groundbreaking book On Death and Dying (1969), where she first discussed her theory of the five stages of grief), encouraged the hospice care movement, believing that euthanasia prevents people from completing their 'unfinished business'.^{[citation needed]}

West's Encyclopedia of American Law states that "a 'mercy killing' or euthanasia is generally considered to be a criminal homicide"^[47] and is normally used as a synonym of homicide committed at a request made by the patient.^[48]

The judicial sense of the term "homicide" includes any intervention undertaken with the express intention of ending a life, even to relieve intractable suffering.^[48][49][50] Not all homicide is unlawful.^[51] Two designations of homicide that carry no criminal punishment are justifiable and excusable homicide.^[51] 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".^[52] 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.^[53] 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.^[54] The use of pain medication in order to relieve suffering, even if it hastens death, has been held as legal in several court decisions.^[52]

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.^{[55][56][57][58]}

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 they believed that it was premature. Approximately 55% would not, and for the remaining 29%, it would depend on circumstances.^[59]

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.^[59]

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.^[60]

• Animal euthanasia
• Child euthanasia
• Child euthanasia in Nazi Germany
• Euthanasia in the Netherlands
• Coup de grâce
• Dysthanasia
• Euthanasia and the slippery slope
• Medical law
• Palliative sedation
• Principle of double effect
• Terri Schiavo case

• Hamowy, Ronald, ed. (2008). "Euthanasia". The Encyclopedia of Libertarianism. Thousand Oaks, CA: SAGE Publications, Cato Institute. pp. 156–58. ISBN 978-1-4129-6580-4. LCCN 2008009151. OCLC 750831024.
• Nitschke, Philip (2006). The Peaceful Pill Handbook. Exit International US Ltd. ISBN 978-0-9788788-0-1. {{cite book}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
• Rachels, James (1986). The end of life: Euthanasia and Morality. Oxford University Press. ISBN 978-0-19-286070-5.
• Torr, James D. (2000). Euthanasia: opposing viewpoints. San Diego: Greenhaven Press. ISBN 0-7377-0127-7.

• Physician assisted death from The Hastings Center

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