CHAPTER 6
EUTHANASIA AND ASSISTED SUICIDE

BACKGROUND

The Merriam-Webster dictionary definition of euthanasia, which derives from the Greek for "easy death," is "the act or practice of killing or permitting the death of hopelessly sick or injured individuals in a relatively painless way for reasons of mercy." This present-day definition differs from that of the classical Greeks, who considered euthanasia simply "one mode of dying." To the Greeks, euthanasia was a rational act by people who deemed their lives no longer useful. That these individuals sought the help of others to end their lives was considered morally acceptable.

The movement to legalize euthanasia in England began in 1935 with the founding of the Voluntary Euthanasia Society by such well-known figures as George Bernard Shaw, Bertrand Russell, and H. G. Wells. In 1936 the House of Lords (one of the houses in the English Parliament) defeated a bill that would have permitted euthanasia in cases of terminal illness. Nonetheless, it was common knowledge that physicians practiced euthanasia. The same year, it was rumored that King George V, who had been seriously ill for several years, was "relieved of his sufferings" by his physician, with the approval of his wife, Queen Mary.

The Euthanasia Society of America was established in 1938. In 1967 this group prepared the first living will. Renamed the Society for the Right to Die in 1974, it merged in 1991 with another organization called Concern for Dying and the two became Choice in Dying (CID). While CID took no position on physician-assisted suicide, it "advocated for the rights of dying patients." It also educated the public about the importance of advance directives and end-of-life issues. In early 2000 CID dissolved, although many of its staff remained to found Partnership for Caring, Inc. and continue its programs. That organization's goal was to "ensure that everyone in this country soon has access to quality end-of-life care." Then, in early 2004, Partnership for Caring merged with Last Acts, a coalition of professional and consumer organizations that work to improve end-of-life care. The merged organization has been named Last Acts Partnership, and its mission is to provide education, service, and counseling to people who need accurate and reliable information about end-of-life care. Last Acts Partnership is also an advocate for policy reform in end-of-life issues.

Euthanasia and the Nazis

The Nazis' version of euthanasia was a bizarre interpretation of an idea espoused by two German professors, Alfred Hoche and Karl Binding, in their 1920 book The Permission to Destroy Life Unworthy of Life. While initially advocating that it was ethical for physicians to assist in the death of those who requested an end to their suffering, the authors later argued that it was also permissible to end the lives of the mentally retarded and the mentally ill.

Some contemporary opponents of euthanasia fear that a society that allows physician-assisted suicide may eventually follow the path of Nazi dictator Adolf Hitler's euthanasia program, which began with the killing of physically and mentally impaired individuals and culminated with the annihilation of entire religious and ethnic groups considered by the Nazis to be unworthy of life. However, those supporting euthanasia argue that unlike the murderous Nazi euthanasia program designed by Hitler and his followers, modern-day proposals are based upon voluntary requests by individuals in situations of physical suffering and would be sanctioned by laws passed by democratic governments.

The Debate

In the United States the debate over euthanasia distinguishes between active and passive euthanasia. Active euthanasia, also called voluntary active euthanasia by those who distinguish it from the kind of euthanasia practiced by the Nazis, involves the hastening of death through the administration of lethal drugs, as requested by

the patient or another competent individual who represents the patient's wishes.

Passive euthanasia, on the other hand, involves foregoing medical treatment, knowing that such a decision will result in death. This action is not considered illegal because the underlying illness, permitted to run its natural course, will ultimately cause death. It is generally accepted in the United States that terminally ill individuals have a right to refuse medical treatment, as do those who are sick but not terminally so. But some people think that allowing patients to forego medical treatment is a practice tantamount to enabling suicide and is therefore morally reprehensible.

The debate about euthanasia in the United States has been expanded to include the question of whether a competent, terminally ill patient has the right to physician-assisted

suicide, in which a physician provides the means (such as lethal drugs) for the patient to self-administer and commit suicide. The distinction between the two actions, euthanasia and physician-assisted suicide, is at times difficult to define: a patient in the latter stages of Amyotrophic Lateral Sclerosis (ALS, or Lou Gehrig's disease), for example, is physically unable to kill him or herself; therefore, a physician who aids in such a person's suicide would technically be committing euthanasia.

SUICIDE

Different Cultures and Religions

Different religions and cultures have viewed suicide in different ways. Ancient Romans who dishonored themselves or their families were expected to commit suicide in order to maintain their dignity and, frequently, the family property. Early Christians were quick to embrace martyrdom as a guarantee of eternal salvation, but during the fourth century, St. Augustine discouraged the practice. He and later theologians were concerned that many Christians who were suffering in the world would see suicide as a reasonable and legitimate way to depart to a better place in the hereafter. The view of the Christian theologian St. Thomas Aquinas (circa 1225–74) is reflected in the contemporary Roman Catholic teaching that "suicide contradicts the natural inclination of the human being to preserve and perpetuate his life … and is contrary to love for the living God."

While Islam and Judaism also condemn the taking of one's own life, Buddhist monks and nuns have been known to commit suicide by self-immolation (burning themselves alive) as a form of social protest. In a ritual called suttee, which is now outlawed, widows in India showed devotion to their deceased husbands by being cremated with them, sometimes throwing themselves on the funeral pyres, although it was not always voluntary. Widowers (men whose wives had died), however, did not follow this custom.

Quasi-religious reasons sometimes motivate mass suicide. In 1978 more than 900 members of a group known as The People's Temple killed themselves in Jonestown, Guyana. In 1997 a group called Heaven's Gate also committed mass suicide in California. The devastating terrorist attacks of September 11, 2001, were the result of a suicidal plot enacted by religious extremist groups. The rash of suicide bombers in the Middle East has also been attributed to extremist groups that have twisted or misinterpreted the fundamental tenets of Islam to further their political objectives.

The Japanese people have traditionally associated a certain idealism with suicide. During the twelfth century, samurai warriors practiced voluntary seppuku (more commonly known as hara-kiri,) or ritual self-disembowelment, to avoid dishonor at the hands of their enemies. Some samurai committed this form of slow suicide to atone for wrongdoing or to express devotion to a superior who had died. Even as recently as 1970, famed author Yukio Mishima publicly committed seppuku. During World War II, Japanese kamikaze pilots inflicted serious casualties with suicidal assaults in which they would purposely crash their planes into enemy ships, killing themselves.

Suicide is still commonly practiced in modern Japan. In early 1998 several government officials and businessmen hanged themselves in separate incidents involving scandals that attracted public attention. The reasons given for the suicides ranged from proclaiming innocence to assuming responsibility for wrongdoing.

Suicide in America

With the exception of certain desperate medical situations, suicide in the United States is generally considered an unacceptable act, the product of irrationality or severe depression. It is often referred to as a permanent solution to a short-term problem.

In spite of this generally held belief, in 2001 suicide was the eleventh leading cause of death in America. Suicides outnumbered homicides 3 to 2, and there were twice as many deaths from suicide than deaths from HIV/AIDS. Nevertheless, since 1950, the national suicide rate has dropped from 13.2 suicides per 100,000 people to 10.7 per 100,000 in 2001. (See Table 6.1.)

The Centers for Disease Control and Prevention (CDC) did a five-year study of suicide patterns in different geographic regions across the country ("Regional Variations in Suicide Rates—United States, 1990–1994,"

Morbidity and Mortality Weekly Report, vol. 46, no. 34, August 29, 1997). The CDC found that the suicide rate in the United States was the highest in the West, at 14.7 suicides per 100,000 people. (See Table 6.2 and Figure 6.1.) No reason for this finding has yet been determined.

Gopal K. Singh and Mohammad Siahpush, both of the National Cancer Institute, compared the suicide rates in rural and urban populations in the United States. In "Increasing Rural–Urban Gradients in U.S. Suicide Mortality, 1970–1997," American Journal of Public Health, vol. 92, no. 7, July 2002, Singh and Siahpush reported significant rural–urban gradients in male suicide mortality rates over this time period, and noted that the rural–urban gap is widening. Male suicide mortality rates in rural areas increased over the time period, while rates in urban areas declined. Conversely, the rural–urban gap in suicide mortalities among females has closed. Suicide mortality rates for females in urban areas has decreased but has remained somewhat stable in rural areas. (See Figure 6.2.)

In explaining these differences, Singh and Siahpush suggest that both rural and urban areas have experienced profound social and demographic changes during the past three decades. They contend, however, that change has affected life in rural areas more than in urban areas. They note that high levels of social isolation are correlated with high suicide rates. Thus,

declines in traditional farm activity, the change from an agriculture-based economy to a more service- and manufacturing-oriented economy, and the substantial population loss due to birth deficits and out-migration in most rural communities can lead to a deemphasizing of traditional institutions such as the family and religion, a progressive weakening of social and community ties, and a loss of people's sense of community.

Suicide among Young People

According to the American Association of Suicidology, the rate of suicide among young people increased 200 percent between the 1950s and 1990s. During the 1990s death rates for suicide declined, but in some age groups the rate of suicide attempts actually rose. In 2001 suicide was the third leading cause of death among people ages 15 to 24 years, and more teens and young adults died from suicide than from AIDS, birth defects, cancer, chronic lung disease, heart disease, pneumonia and influenza, and stroke combined. While females are more likely to attempt suicides, males are more likely to die from their attempts.

In recent years clusters of suicides among young people have occurred in different areas of the country including Westchester County, New York; Bergenfield, New Jersey; Pierre, South Dakota; and Plano, Texas. Experts have found no significant pattern in any of these strings of suicides. They happened in rich and poor communities, and in urban, suburban, and rural areas.

While the overall suicide rate among black youths has been relatively low in comparison to white males, the rate rose among black males from 1950 through 1990. (See Table 6.1.) By 1990 the death rate for suicide among black males ages 25 to 44 years had risen to a high of 19.6 suicides per 100,000. After 1990 the suicide rate for young black males steadily declined and by 2001 it had dropped to 14.4 per 100,000. This rate remained relatively steady through 2001.

Death rates for suicide declined for white males ages 25 to 44 years from a 1995 high of 25.8 suicides per 100,000 to 22.9 per 100,000 in 2000. The rate rose slightly in 2001 to 24.0 per 100,000. In 1990 the highest suicide death rate among youth 15 to 24 years of age was 49.1 suicides per 100,000 people among male American Indian or Alaska Natives. (See Table 6.1.) By 2001 this rate fell to 24.7 per 100,000.

While death rates from suicide have declined among young adults aged 15 to 19 years from 1990 to 2001 (see Table 6.1), the percentage of high school students who attempted suicide increased from 7.3 percent in 1991 to 8.8 percent in 2001, and the percentage of students injured during a suicide attempt also rose from 1.7 percent to 2.6 percent during those same years). (See Table 6.3.) These statistics underscore the urgent need for prevention,

education, and support programs to help teens and young adults at risk.

The National Center for Injury Prevention and Control (NCIPC) sponsors initiatives to raise public awareness of suicide and institutes strategies to reduce suicide deaths. Along with support for research about risk factors for suicide in the general population, NCIPC also addresses high-risk populations with programs such as the American Indian/Alaska Native Community Suicide Prevention and Network Conference held in San Diego, California, in November 1998.

GAY AND LESBIAN ADOLESCENTS.

Gay and lesbian adolescents are two to three times more likely than heterosexual adolescents to attempt suicide, making suicide the leading cause of death among this group of young people. Adolescence (the transition to adulthood) is often a difficult period. For gay and lesbian adolescents, this transition is compounded by having to come to terms with their sexuality in a society generally unaccepting of homosexuality.

At this period in their lives, when the need to confide in and gain acceptance from friends and family may be crucial, gay and lesbian adolescents are often torn between choices that do not necessarily meet either of these needs. Those who are open about their sexual orientation risk disappointing or even alienating their families and facing the hostility of their peers. Teens who choose

not to disclose their homosexuality may suffer emotional distress because they have nowhere to turn for emotional support. In either scenario, despair, isolation, anger, guilt, and overwhelming depression may promote suicidal thoughts or actual suicide attempts.

THE RIGHT TO DIE

The American Constitution does not guarantee the right to choose to die. The U.S. Supreme Court, however, recognized as of 2004 that Americans have a fundamental right to privacy, or what is sometimes called the "right to be left alone." While the right to privacy is not explicitly mentioned in the Constitution, the Supreme Court has interpreted several amendments as encompassing this right. In Roe v. Wade (410 US 113, 1973), the High Court ruled that the Fourteenth Amendment protects the right to privacy against state action, specifically a woman's right to abortion. In the landmark Karen Ann Quinlan case, the Court held that the right to privacy included the right to refuse unwanted medical treatment and, as a consequence, the right to die.

THE RIGHT TO LIFE

The National Right to Life Committee (NRLC) opposes euthanasia of any kind, including the belief that people who do not have a good quality of life should have the right to choose to die. In "What's Wrong with Making Assisted Suicide Legal?" (NRLC, 1998), David N. O'Steen, executive director of NRLC, and Burke J. Balch, director of the NRLC medical ethics department, propose that people who are feeling suicidal should be helped with their problems, not helped to die.

O'Steen and Balch believe that the assumption that suicidal people are competent and are simply exercising their right to make a rational decision to die is false. They contend that suicidal people are usually depressed or mentally ill, and their attempts to end their lives do not necessarily stem from specific wishes to die. On the contrary, O'Steen and Balch feel these attempts are cries for help that should be answered.

They point to a number of studies showing that most terminally ill patients are suicidal not because they are sick but because they are depressed. Their solution is to treat the depression, not end it by euthanasia. In the case of the severely disabled who might be contemplating suicide, O'Steen and Balch report that most people with disabilities feel that it is the conduct of the able-bodied majority toward them, rather than their own physical or mental impairment, which makes their lives even more difficult. People with disabilities face many obstacles that are the result of social problems such as denial of access, discrimination in employment, and attitudes of aversion or pity instead of respect. The authors feel that true respect for the rights of people with disabilities would prompt actions to remove those obstacles, rather than "helping" them to commit suicide.

Assisted Suicide Funding Restriction Act of 1997

In April 1997 President Bill Clinton signed into law the Assisted Suicide Funding Restriction Act of 1997 (PL 105-12). (See Figure 6.3 for the statement President Clinton made on signing the bill.) The law bans federal funding

of "active means of causing death, such as by lethal injection or the provision of a lethal oral drug overdose." It does not, however, prohibit the use of federal funds for actions some consider to be passive euthanasia—withholding or withdrawing medical treatment or artificial nutrition and hydration, which may eventually lead to death. Neither does it prohibit "the use of items, goods, benefits, or services" to relieve pain or discomfort, even if they hasten death, so long as they are not intended to do so.

PHYSICIAN-ASSISTED SUICIDE

Dr. Quill: A Model Case …

A well-publicized case of physician-assisted suicide in 1991 continues to be a major topic of discussion among those in the medical, bioethical, and legal professions. Dr. Timothy Quill, in "Death and Dignity—A Case of Individualized Decision-Making" (New England Journal of Medicine, vol. 324, no. 10, March 7, 1991), wrote about helping a patient identified as Diane commit suicide. Dr. Quill, who had known Diane for eight years, had seen her battle and overcome alcoholism and depression. Eventually Diane was diagnosed with an acute form of leukemia. She was very sure not only that she would die during treatment, but also that she would suffer unbearably while undergoing chemotherapy (drug treatment to fight cancer). Diane decided that she would rather end her life than lose control over her body. Dr. Quill prescribed barbiturates that Diane subsequently used to kill herself.

Through an anonymous tip, authorities identified the real "Diane" whom Dr. Quill had helped to commit suicide.

As a result, the case was brought to a grand jury. Asked to decide whether Dr. Quill's action constituted a crime, the grand jury declined to recommend an indictment. Meanwhile, the New York State Department of Health's Board for Professional Misconduct considered his actions "legal and ethically appropriate."

Many observers were not surprised at the outcome of the grand jury proceedings. They cited growing public concern about how easily patients could lose control over end-of-life decisions. Some bioethicists thought that Dr. Quill's handling of Diane's case would make a suitable model for how physician-assisted suicides should be practiced. Many of Dr. Quill's colleagues lauded his act, some claiming that it was generally known that some doctors do assist in suicides. They were glad that, because of Dr. Quill's confession, the practice was now in the open.

… Or a Case of Misguided Judgment?

Dr. Herbert Hendin, a psychiatrist and psychologist as well as a world-renowned authority on suicide, claimed that "the doctor assisting a suicide is not simply a dispassionate observer responding to the patient's needs and wishes." In Seduced by Death: Doctors, Patients, and the Dutch Cure (New York: W. W. Norton and Company, 1997), Dr. Hendin noted that Dr. Quill's account of Diane's suicide belied his supposedly disinterested, albeit compassionate, response to his patient's request. Dr. Hendin believed "emotional involvement" on Dr. Quill's part "[had] clouded his judgment."

When Diane decided to refuse the treatment recommended by her oncologist (cancer specialist), Dr. Quill, instead of exploring with the patient the reason for her seemingly hasty decision, told his readers, "Together we lamented her tragedy and the unfairness of life." Dr. Hendin believed Diane must have been suffering from depression. Once she had told Dr. Quill of her decision to end her life, she calmed down. Dr. Hendin explained that suicidal people become less depressed after their decision: "Coping with the uncertainties of life and death is what agitates and depresses them."

Dr. Hendin believed that Dr. Quill's failure to challenge Diane's presumption that the cancer treatment would fail opened the door to her next decision—to commit suicide with Dr. Quill's help. Although Dr. Quill told Diane that he could not assist in her suicide, Dr. Hendin claimed in his article that Dr. Quill "appears to have conveyed

to her … that her request 'made perfect sense'," and he subsequently referred her to the Hemlock Society. Founded in 1980, the Hemlock Society advocates for choice and dignity at the end of life and the legal availability of the means to hasten death. Dr. Hendin felt it probably confused the patient to hear Dr. Quill saying that he was "leav[ing] the door open for her to change her mind," while he simultaneously directed her to a place that could help her fulfill her wish of death. "Quill once again powerfully shaped the clinical interaction between himself and his patient," wrote Dr. Hendin.

Dr. Hendin pointed out that, at her last meeting with Dr. Quill, Diane promised she would reunite with the doctor "in the future at her favorite spot on the edge of Lake Geneva, with dragons swimming in the sunset." According to Dr. Hendin, "death as a metaphor for reunion in a magical netherworld is a common fantasy among suicidal people. That both doctor and patient shared it suggests that neither really came to grips with the fact of death."

Dr. Quill, an active advocate of the legalization of physician-assisted suicide, joined two other physicians and three patients in 1994 to sue the New York State Attorney General for violating the Fourteenth Amendment by banning physician-assisted suicide. The Supreme Court ruled on this case in June 1997, reversing an earlier ruling made by the Court of Appeals for the Second Circuit. The Supreme Court distinguished between withdrawing life-sustaining treatment and physician-assisted suicide, and differentiated between physician actions taken to relieve pain and suffering and those intended to hasten death.

REQUESTS TO DIE AND PHYSICIAN COMPLIANCE

As various states enacted right-to-die legislation, researchers sought to determine physicians' attitudes

toward assisting in patient death. Ezekiel J. Emanuel reviewed the data compiled in various reports in "Euthanasia and Physician-Assisted Suicide: A Review of the Empirical Data from the United States" (Archives of Internal Medicine, vol. 162, no. 2, January 28, 2002). As shown in Table 6.4, Emanuel found substantial support among medical students for the legalization of either euthanasia or physician-assisted suicide (PAS) among American physicians. Many physicians expressed support for euthanasia and PAS. A majority of both Oregon medical students (52 percent) and non-Oregon medical students (60 percent), when asked if they would be willing to perform PAS if it was legal, stated that they would. However, when practicing oncologists (oncology is the specialty devoted to care of cancer patients) were asked if they would administer or prescribe drugs to end the life of a patient with metastatic cancer at the patient's request, the percents were much lower. Emanuel also noted some interesting conclusions in his report: most of the public support for these interventions was only for patients in excruciating pain, yet patients most likely to request the interventions are those who are depressed and feel hopeless. (See Table 6.5.) Emanuel also noted that 1 percent or less of all dying Americans receive euthanasia or PAS.

Patients Requesting Assisted Suicide and Euthanasia

Diane E. Meier, et al., studied various characteristics of patients requesting and receiving euthanasia and PAS, and reported the results in "Characteristics of Patients Requesting and Receiving Physician-Assisted Death" (Archives of Internal Medicine, vol. 163, no. 13, July 14, 2003). The 1,902 physicians who responded to the researchers' survey reported 415 recent requests for aid in dying. Of these requests, 361 (89 percent) came from patients alone or in conjunction with their families. Only 46 requests (11 percent) came from the family alone. (See Table 3.1 in Chapter 3.) Of the requests, 52 percent were for a lethal prescription, 25 percent for a lethal injection, and 23 percent for either a prescription or an injection.

Meier and her colleagues found that the patients requesting euthanasia or PAS were predominantly male (61 percent), 46 to 75 years old (56 percent), and of white European descent (89 percent). Almost half (47 percent) were college graduates and had a primary diagnosis of cancer. A large number were experiencing severe pain (38 percent) or severe discomfort other than pain (42 percent). Many were described by their physicians as dependent (53 percent), bedridden (42 percent), and expected to live less than 1 month (28 percent). (See Table 3.1 in Chapter 3.) Physicians were most likely to honor requests for a lethal prescription or a lethal injection if the patient was in severe pain or in severe discomfort other than pain, but less likely to honor the request if the patient was depressed at that time. (See Table 3.2 in Chapter 3.)

Reasons for Assisted Suicide Requests

In an earlier study, "A National Survey of Physician-Assisted Suicide and Euthanasia in the United States" (New England Journal of Medicine, vol. 338, no. 17, April 23, 1998), Meier and her colleagues surveyed physicians across medical specialties and throughout the country "to assess the prevalence of requests for assistance with suicide or euthanasia and of compliance with such requests." The physicians were asked to describe the reasons patients were requesting assistance to die. The patients' reasons, as perceived by the physicians, were:

• Discomfort other than pain (reported by 79 percent of the physicians);
• Loss of dignity (53 percent);
• Fear of uncontrollable symptoms (52 percent);
• Actual pain (50 percent);
• Loss of meaning in life (47 percent);
• Being a burden (34 percent);
• Dependency (30 percent).

Interestingly, the patients' primary concerns were not physical (pain and suffering), but were more likely to be focused on loss of control, being a burden or dependent on others, and loss of dignity.

PAIN NOT THE MAJOR REASON FOR REQUESTS TO DIE.

Ezekiel Emanuel, an associate professor at Harvard Medical School and a member of the National Bioethics Advisory Commission, suggests that, contrary to popular belief, pain is not the major motivation behind a patient's request to die. In "Whose Right to Die?" (Atlantic Monthly, March 1997), Dr. Emanuel reported that empirical studies support this fact. Washington State physicians who received requests to assist in death or to perform euthanasia indicated that severe pain played a role in patient decisions in only about one-third of the requests. Dr. Emanuel's own study of cancer patients in Boston revealed that patients in pain were more likely to oppose euthanasia and physician-assisted suicide.

According to Dr. Emanuel, studies in the Netherlands—where assisted suicide and euthanasia have been practiced for many years—provide more evidence that pain is a minor factor in requests to end one's life. (The Netherlands, Belgium, and the state of Oregon in the United States are the only places in the world where physician-assisted suicide is legal.) A 1996 update of the Dutch government's landmark Remmelink Report illustrated that, while pain played some role in 32 percent of the requests, there was not a single case in which pain was the only reason for requesting assistance to die.

The findings of Dr. Emanuel's study are remarkably similar to those reported by Meier and her colleagues from the national physician survey discussed in the previous section. Dr. Emanuel found that the major reasons for assisted suicide and euthanasia requests ranged from depression to hopelessness to fear of loss of dignity and being a burden. His Boston study also showed that depressed patients were more likely to discuss euthanasia, to stockpile drugs for future suicide, and to have read the suicide manual Final Exit by the Hemlock Society.

NURSES AND PATIENT REQUESTS FOR ASSISTED SUICIDE

According to a national survey, one in five nurses who worked in adult critical care units have hastened a patient's death. In this survey, "The Role of Critical Care Nurses in Euthanasia and Assisted Suicide" (New England Journal of Medicine, vol. 334, no. 21, May 23, 1996), David A. Asch, MD, defined euthanasia and assisted suicide as circumstances in which a person performs an act with the specific intent of causing or hastening a patient's death. In this category Dr. Asch included intentional overdose of narcotics or other substances, or providing explicit advice to patients about how to commit suicide. Withholding and withdrawing life-sustaining treatment, such as removing a mechanical ventilator, were not included.

A total of 852 nurses responded to the survey. Sixteen percent (129 nurses) reported that they had participated in active euthanasia and assisted suicide at least once in their careers. Sixty-five percent of those nurses who participated at least once in active euthanasia or assisted suicide had done so three or fewer times, while 5 percent reported doing so more than 20 times.

Based on the responses, Dr. Asch estimated that at least 7 percent (58 nurses) had engaged in euthanasia or assisted suicide at least once without a request from either the patient or a surrogate. Eight percent (62 nurses) indicated having done so at least once without a request from the attending physician. These 62 nurses further indicated some instances in which they practiced euthanasia or assisted suicide following an attending physician's explicit request, or with the physician's advance knowledge.

Reasons given by the nurses for practicing euthanasia or assisted suicide included concern about the overuse of life-sustaining technology; a sense of responsibility for the patient's welfare; a desire to relieve suffering; and a desire to overcome the perceived unresponsiveness of physicians toward that suffering.

Some experts questioned the accuracy of the survey's results and considered the survey questions ambiguous. Others claimed that the interpretation of euthanasia and assisted suicide was questionable in cases in which the dispensing of pain-relieving medicine resulted in death. Many nurses expressed concern that publicizing the results of the study would undermine the patients' and families' trust in nurses who work in intensive care units.

Individually and as members of professional associations, nurses continue to grapple with questions about end-of-life care and patient requests for assisted suicide. To assist all nurses in providing competent and compassionate care for the dying, the Oncology Nursing Society (ONS) published a position paper and practice guidelines, "The Nurse's Responsibility to the Patient Requesting Assisted Suicide," in January 2001. (Oncology nurses care for terminally ill patients more often than nurses in other clinical settings.)

The ONS guidelines encourage nurses to engage in frank discussions with patients requesting assisted suicide, while actively seeking to identify and address patients' previously unmet needs. Although ONS guidelines definitively prohibit nurse involvement in assisted suicide, the professional society also cautions nurses to "resist the inclination to abandon terminally ill patients who request assisted suicide." The guidelines advise that, "In state(s) where assisted suicide is legal, the nurse may choose to continue to provide care or may withdraw from the situation after transferring responsibility for care to a nursing colleague."

SUPPORTERS OF ASSISTED SUICIDE

End-of-Life Choices

On July 21, 2003, the Hemlock Society officially became End-of-Life Choices. The organization advocates for legislation to allow Americans to live with the freedom of choosing a dignified death, and also informs and educates the public about the right to die.

End-Of-Life Choices was founded as the Hemlock Society in 1980 by Derek Humphry, a journalist from England. In 1975 Humphry helped his wife take her own life, to end the pain and suffering caused by her terminal bone cancer. Humphry recounted this incident in Jean's Way: A Love Story (New York: Harper and Row, 1978). The book launched his career in the voluntary euthanasia movement two years later.

In 1991 Humphry published Final Exit: The Practicalities of Self-Deliverance and Assisted Suicide for the Dying (Eugene, OR: The Hemlock Society). The suicide manual, which was on the New York Times best-seller list for 18 weeks, gave explicit instructions on how to commit suicide. While Humphry insisted that his how-to book was addressed only to those who were terminally ill, and not those suffering from depression, some physicians were concerned about how the book would affect those suffering from depression. Dr. Sherwin B. Nuland felt that depression was not a strong enough justification for teaching people how to kill themselves, to help them do it, or to bestow blessing on it (How We Die, New York: Alfred A. Knopf, 1994). In his opinion, no one with judgment impaired by depression is in a position to make a critical decision about ending his or her life.

In October 1991, while Final Exit was selling out at bookstores, Humphry's second wife, Ann Wickett, whom he had divorced the year before, committed suicide. She had been diagnosed with cancer and was reportedly depressed.

Humphry retired from the Hemlock Society in 1992, but his more recent activities have also sparked controversy. In 1999 he recorded a video depicting a variety of methods for committing suicide. Though it had been available from the Hemlock Society USA for several months, the video drew even more criticism when it aired on public television in Oregon a number of times in 2000. Critics asserted that this airing provided dangerous information, particularly to people who were depressed or mentally ill and to children.

Dr. Kevorkian

Dr. Jack Kevorkian first earned the nickname "Dr. Death" when, as a medical resident, he would photograph patients at the time of death to gather data that would help him differentiate death from coma, shock, and fainting. During his study and residency, he suggested unconventional ideas, such as the harvesting of organs from death row inmates. His career as a doctor was also "checkered" (Dr. Kevorkian's own word) and notable for controversy.

In the late 1980s Dr. Kevorkian retired from pathology work and pursued an interest in the idea of physicianassisted suicide, becoming one of its best-known and most passionate advocates. He constructed a machine that would allow a patient to press a red button and self-administer a lethal dose of poisonous potassium chloride, along with thiopental, a painkiller. With the use of this device, Kevorkian claims to have assisted in more than 130 suicides.

The first patient to commit suicide with Dr. Kevorkian's assistance and his suicide device, called Mercitron, was Janet Adkins. Adkins, a Hemlock Society member, sought Dr. Kevorkian's aid because she did not want to wait until she lost her cognitive abilities to Alzheimer's disease. In June 1990 Adkins committed suicide in Dr. Kevorkian's van in a public campground.

In 1991 Dr. Kevorkian assisted in the deaths of two Michigan women on the same day. Sherry Miller, 43, had multiple sclerosis; Marjorie Wantz, 58, complained of a painful pelvic disease. Neither one was terminally ill, but court findings showed that they both suffered from depression. In 1996 Dr. Kevorkian was tried for the assisted deaths of Miller and Wantz under the common law that considers assisted suicide illegal. He was acquitted.

Dr. Kevorkian continued to draw media attention with increasingly controversial actions. In February 1998, twenty-one-year-old Roosevelt Dawson, a paralyzed university student, became the youngest person to commit suicide with Dr. Kevorkian's help. In June 1998 Dr. Kevorkian announced that he was donating kidneys from Joseph Tushkowski, a quadriplegic whose death he had assisted. His actions were denounced by transplant program leaders, medical ethicists, and most of the public. The organs were refused by all medical centers and transplant teams.

In October 1998 Dr. Kevorkian euthanized fifty-two-year-old Thomas Youk, a man afflicted with Lou Gehrig's disease, at the patient's request. Dr. Kevorkian videotaped the death and gave the video to the CBS television show 60 Minutes for broadcast. The death was televised nationwide in November 1998 during primetime and included an interview with Dr. Kevorkian. He taunted Oakland County, Michigan, prosecutors to file charges against him. They did, and Kevorkian was convicted of second-degree murder in March 1999. On April 13, 1999, the seventy-year-old retired pathologist was sentenced to 10 to 25 years in prison. While in prison, Dr. Kevorkian has staged three hunger strikes and has been subjected to force-feeding by prison officials. As of May 2004, Dr. Kevorkian remained in prison. He will not be eligible for parole until May 2007.

THE BATTLE OVER LEGALIZING PHYSICIAN-ASSISTED SUICIDE

In 2004 Oregon was the only state with a law allowing physician-assisted suicide, and then only in limited circumstances. Attempts to allow assisted suicide have been defeated in California, Washington, Michigan, Maine, Wyoming, and Hawaii. In 2004, 35 states had explicit laws against assisted suicide. Nine states had "common law" provisions against assisted suicide. This means there was a precedent of customs, usage, and court decisions that would support prosecution of an individual assisting in a suicide. Three states (North Carolina, Utah, and Wyoming) have abolished their common law provisions and do not have statutes criminalizing assisted suicide, but they do not have laws allowing it either.

Oregon

In November 1994 Oregon voters approved Measure 16 by a vote of 51 to 49 percent, making Oregon the first jurisdiction in the United States to legalize physician-assisted suicide. Under the Death with Dignity Act, a mentally competent adult resident of Oregon who is terminally ill (likely to die within six months) may request a prescription for a lethal dose of medication to end his or her life. (See Table 6.6 to see what the Oregon law does and does not do.) Critics charge that assisted death is now "state-subsidized" because Medicaid money may be used to pay for physician-assisted suicide for the poor.

Between 1994 and 1997 the Death with Dignity Act was kept on hold due to legal challenges. In November 1997, 60 percent of Oregonians voted to defeat a measure to repeal the 1994 law (40 percent of voters voted in favor of repealing the Act). Immediately after this voter reaffirmation of the Death with Dignity Act, the Drug Enforcement Administration (DEA) warned Oregon doctors that they could be arrested or have their medical licenses revoked for prescribing lethal doses of drugs. DEA administrator Thomas Constantine, under pressure from some members of Congress, stated that prescribing a drug for suicide would be a violation of the Controlled Substances Act (PL 91-513) because assisted suicide was not a "legitimate medical purpose." Janet Reno, who was then the U.S. Attorney General, overruled Constantine and decided that that portion of the Controlled Substances Act would not apply in states that legalize assisted suicide. Those opposed to the practice observed that it was inconsistent, citing the government's opposite ruling in states that have legalized marijuana for medical use. (Reno maintained that the prescription of marijuana is still illegal, regardless of its medicinal value.)

In response to the DEA decision, Congress moved toward passage of the Pain Relief Promotion Act. This law would prevent the use of federally controlled drugs for the purpose of assisted suicide and euthanasia. It would also strengthen protections for doctors who use narcotics to manage patients' pain, provide research grants, and establish a program for palliative care. As of June 2000, the House had passed the measure (HR 2260) by 271 to 156. In April 2000 it was favorably reported out of the Senate Judiciary Committee; however, a scheduled vote was stalled in the Senate, and as of June 2004 the Act had not been passed.

On November 6, 2001, John Ashcroft, who succeeded Janet Reno as U.S. Attorney General, overturned Reno's 1998 ruling that prohibited the DEA from acting against physicians who use drugs under Oregon's physician-assisted suicide law. Attorney General Ashcroft said that taking the life of terminally ill patients is not a "legitimate medical purpose" for federally controlled drugs. The Oregon Medical Association and Washington State Medical Association opposed Attorney General Ashcroft's ruling, and even physicians opposed to assisted suicide expressed concern that the ruling might compromise patient care and that any DEA investigation might discourage physicians from prescribing pain medication to patients in need.

The State of Oregon disagreed so vehemently with Attorney General Ashcroft's interpretation of the Controlled Substances Act that on November 7, 2001, Oregon's Attorney General filed suit, claiming that Ashcroft was acting unconstitutionally. A November 8, 2001 restraining order allowed the Death with Dignity Act to remain in effect while the case was tried.

On April 17, 2002, U.S. District Judge Robert E. Jones ruled in favor of the Death with Dignity Act. His decision read, in part:

State statutes, state medical boards, and state regulations control the practice of medicine. The [Controlled Substances Act] was never intended, and the [U.S. Department of Justice] and [Drug Enforcement Administration] were never authorized, to establish a national medical practice or act as a national medical board. To allow an attorney general—an appointed executive whose tenure depends entirely on whatever administration occupies the White House—to determine the legitimacy of a particular medical practice without a specific congressional grant of such authority would be unprecedented and extraordinary.… Without doubt, there is tremendous disagreement among highly respected medical practitioners as to whether assisted suicide or hastened death is a legitimate medical practice, but opponents have been heard and, absent a specific prohibitive federal statute, the Oregon voters have made the legal, albeit controversial, decision that such a practice is legitimate in this sovereign state.

The Justice Department appealed the ruling to the Ninth Circuit Court of Appeals. On May 26, 2004, the court stopped Attorney General John Ashcroft's attempts to override the Oregon law. The divided three-judge panel ruled that Ashcroft overstepped his authority when he declared that physicians who prescribe lethal drug doses are in violation of the 1970 federal drug law and when he instructed the federal Drug Enforcement Agency to prosecute the physicians. In addition, the Court noted that Ashcroft's interpretation of the Controlled Substances Acts violated Congress's intent.

ANALYSIS OF THE EFFECTS OF THE DEATH WITH DIGNITY ACT.

In March 1998 an Oregon woman in her mid-80s who had terminal breast cancer ended her life with a lethal dose of barbiturates. Hers was the first known death under Oregon's assisted-suicide law. By 2002 a total of 70 people had reportedly committed suicide with a doctor's assistance under the Death with Dignity Act. According to the Sixth Annual Report on Oregon's Death with Dignity Act (Portland: Oregon Department of Human Services, Office of Disease Prevention and Epidemiology, March 10, 2004), 38 Oregon patients used legal physician-assisted suicide in 2002, and 42 patients did so in 2003, bringing the total number of deaths under the Oregon law to 150 by the beginning of 2004. The report also noted that 58 prescriptions for lethal medication were written in 2002, and 67 in 2003. Prescriptions for lethal medication have increased every year since 1998, when 24 prescriptions were written.

The median age of people who took lethal medication in 2003 was 73 years, and 83 percent suffered from end-stage cancer. Physicians were asked if patients voiced any of seven end-of-life concerns that might have contributed to their requests for lethal medication. In nearly all cases, physicians reported that patients had multiple concerns contributing to the request. The most frequently cited concerns were losing autonomy (93 percent), a decreasing ability to participate in activities that make life enjoyable (93 percent), and loss of dignity (82 percent).

Based on the Oregon Health Division's annual reports, groups in favor of the legalization of assisted suicide conclude that the law is working as intended and without abuse. Opponents of the law continue to charge that the law discriminates against the elderly and seriously ill and express concern about reporting requirements. The Oregon Health Division admits that "Underreporting cannot be assessed, and noncompliance is difficult to assess because of the possible repercussions for noncompliant physicians reporting data to the division."

OREGON PHYSICIANS' ATTITUDES.

Bioethicists, physicians, legislators, and patient advocacy groups have watched with interest to learn whether the attitudes and practices of Oregon physicians would change in response to the passage of the Death with Dignity Act. In early 1999 researchers mailed questionnaires to 3,981 Oregon physicians to find out about their experiences with the Act. The responses of the 2,641 physicians who returned the survey by August 1999 were reported by Linda Ganzini, MD, et al., in "Oregon Physicians' Attitudes about and Experiences with End-of-Life Care since Passage of the Oregon Death with Dignity Act" (Journal of the American Medical Association, vol. 285, no. 18, May 9, 2001).

Dr. Ganzini and her colleagues found that 51 percent of responding physicians supported the Act, 32 percent opposed it, and 17 percent neither supported nor opposed it. Four out of five respondents said their attitude about the law was unchanged since it passed; however, among those whose feelings changed, nearly twice as many supported the Act as opposed it. Thirty percent considered prescribing lethal medication under the Act immoral or unethical, and 46 percent were unwilling to prescribe lethal medication. Despite their reluctance to assist patients to die, more than half of the respondents (53 percent) reported that if terminally ill, they would consider seeking physician assistance to end their own lives.

The researchers found that more than three-quarters of physicians who had cared for a terminally ill patient in the prior year had sought to improve their knowledge of depression, their ability to recognize and treat the illness, as well as prescribing pain medication. Nearly all respondents (91 percent) indicated some degree of comfort discussing the Act with patients and 36 percent said patients had asked them whether they would be willing to prescribe lethal medication. Nearly 60 percent of physicians who were not morally opposed to prescribing lethal medication expressed concerns about adhering to federal Drug Enforcement Agency law and feared public scrutiny and hospital sanction.

OPPOSITION TO PHYSICIAN-ASSISTED SUICIDE

Devaluing the Life of the Terminally Ill

In 1996 the Second and Ninth Circuit Courts of Appeals lifted the bans on assisted suicide in New York and Washington State, respectively, and both cases eventually went to the U.S. Supreme Court, which ruled on them in June 1997 (Washington et al. v. Harold Glucksberg et al. and Dennis C. Vacco, Attorney General of New York et al. v. Timothy E. Quill et al.). Kathleen M. Foley, MD, co-chief of the Pain and Palliative Care Service of the Memorial Sloan-Kettering Cancer Center in New York, was appalled at these rulings. In "Competent Care for the Dying Instead of Physician-Assisted Suicide" (New England Journal of Medicine, vol. 336, no. 1, January 2, 1997), Dr. Foley commented that the courts' response was a dangerous form of affirmative action that ran the risk of further devaluing the lives of terminally ill patients and providing an excuse for society to end its responsibility for their care.

Dr. Foley claimed that physicians are not adequately trained to deal with the dying, much less to determine the many symptoms associated with patients' requests to die. She feared that if physician-assisted suicide were legalized, it would take the place of a variety of interventions—therapeutic, psychological, and social—that might very well improve the life of dying patients. She was also concerned that patients, especially minorities who may already be distrustful of the health care system, might not seek medical or psychological treatment for fear that physicians might hasten their deaths.

Oppression of the Disabled

As an attorney for the Anti-Euthanasia Task Force, Wesley J. Smith is a staunch defender of the sanctity of human life and an outspoken opponent of assisted suicide. In his books Forced Exit: The Slippery Slope from Assisted Suicide to Legalized Murder (New York: Times Books, 1997) and Culture of Death: The Assault on Medical Ethics in America (San Francisco: Encounter Books, 2001) Smith warns that legalized euthanasia could become a form of oppression. Citing the Jim Crow laws (1880s–1960s), which discriminated against blacks, Smith raised the concern that a person's state of health might soon become a basis for the oppression of specific groups of people. He speaks specifically of the disabled as being further oppressed if physician-assisted suicide were legalized.

Disabled people tell of incidents where the able-bodied have told them that they would rather be dead than disabled, or that if they (the able-bodied) were disabled, they would soon give up and kill themselves. Such attitudes are also reportedly found in the health care system. Further, some observers think that the financial pressures exerted by private and government payers might lead to hastening the deaths of disabled patients.

EUTHANASIA IN THE NETHERLANDS

The Netherlands is currently the only country in which active euthanasia is practiced openly, even though technically it was illegal until April 10, 2001. Prior to that date, active euthanasia was a criminal offense under Article 293 of the Dutch Penal Code, which read, "He who takes the life of another person on this person's explicit and serious request will be punished with imprisonment of up to 12 years or a fine of the fifth category." At the same time, however, Section 40 of the same penal code stated that an individual was not punishable if he or she was driven by "an irresistible force" (legally known as force majeure) to put another person's welfare above the law. This might include a circumstance in which a physician is confronted with the conflict between the legal duty of not taking a life and the humane duty to end a patient's intolerable suffering.

Origin of Open Practice

In 1971 Dr. Geertruida Postma granted an elderly nursing home patient's request to die by injecting the patient with morphine and ending her life. The patient was her seventy-eight-year-old mother, who was partially paralyzed and was tied to a chair to keep her from falling. Dr. Postma was found guilty of murder, but her penalty consisted of a one-week suspended jail sentence and a one-year probation. This light sentence encouraged other physicians to come forward, admitting they had also assisted in patients' suicides.

Two years later the Royal Dutch Medical Association announced that, should a physician assist in the death of a terminally ill patient, it was up to the court to decide if the physician's action could be justified by "a conflict of duties." In Alkmaar, Netherlands, Dr. Schoonheim helped Marie Barendregt to die in 1982, using a lethal injection. The ninety-five-year-old, severely disabled Barendregt had initially signed an advance directive refusing artificial (life-prolonging) treatment. Dr. Schoonheim assisted in Barendregt's death with the knowledge of the patient's son and after consultation with two independent physicians. In 1984 the Dutch Supreme Court, ruling on this well-known Alkmaar case (the court case is referred to by the name of the city where the trial took place), found Dr. Schoonheim not guilty of murder.

Since then, each euthanasia case brought under prosecution has been judged on its individual circumstances. The force majeure defense has ensured acquittal, while compliance with the following guidelines for performing euthanasia laid down by the Royal Dutch Medical Association and the Dutch courts in 1984 has protected physicians from prosecution:

• The patient's wish to die must be expressed clearly and repeatedly.
• The patient's decision must be well informed and voluntary.
• The patient must be suffering intolerably, with no hope of relief; however, the patient does not have to be terminally ill.
• The physician must consult with at least one other physician.
• The physician must notify the local coroner that death resulting from unnatural causes has occurred.

However, several events led the Royal Dutch Medical Association to refine the 1984 guidelines. In 1994 a film showing a doctor putting a patient to death produced negative reactions worldwide. The practice of the so-called angels of death, traveling physicians who performed euthanasia where family doctors refused to assist in suicide, also generated unwelcome publicity. Finally, a startling announcement by the chief inspector of public health that doctors who refused to refer patients to another doctor would be found guilty of malpractice and disciplined led to the following changes in the guidelines:

• Physician-assisted euthanasia is preferable to active euthanasia. Physicians should let a patient self-administer lethal medication instead of giving the patient a lethal injection.
• The consulting physician must not have a personal or professional relationship to either the primary physician or patient.
• No doctor is required to perform euthanasia, but must refer the patient to one who will do it.
• Physicians must report all euthanasia performed.

On April 10, 2001, the Dutch Parliament voted 46 to 28 to legalize physician-assisted suicide by passing the Termination of Life on Request and Assisted Suicide (Review Procedures) Act. Arguments in favor of the bill included public approval ratings of 90 percent. In May 2001 the results of a Dutch public opinion poll revealed that nearly half of respondents favored making lethal drugs available to older adults who no longer wanted to live.

The Remmelink Commission and the 1990

Remmelink Report

In 1990 the Dutch government commissioned a landmark study to investigate the medical practice of euthanasia and physician-assisted suicide. The Commission of Inquiry into the Medical Practice Concerning Euthanasia is commonly known as the Remmelink Commission, named after the committee chairman Jan Remmelink, who was then the Attorney General of the Dutch Supreme Court.

According to the Remmelink Report (Paul J. van der Maas, MD, et al., "Euthanasia and Other Medical Decisions Concerning the End of Life," The Lancet, 1991; English version), 54 percent of the surveyed physicians had performed euthanasia or assisted suicide. Another 34 percent indicated that they might perform euthanasia or assisted suicide, although some might do it only in extreme situations. While 12 percent reported that they would never participate in euthanasia or assisted suicide, two-thirds of these physicians (8 percent of the total) would refer patients to another physician. Four percent would never have anything to do with such requests. Of the nearly 129,000 deaths in the Netherlands in 1990, 2,300 (1.8 percent) were the result of euthanasia, and 400 (0.3 percent) were assisted suicides.

The Remmelink Commission uncovered 1,040 deaths (0.8 percent of all deaths) from involuntary euthanasia. The Dutch do not refer to this practice as euthanasia, but call it "termination of life without patient's explicit request." Fourteen percent of these patients were fully competent, and 72 percent had not given any indication that they wanted to be euthanized. In 59 percent of the deaths, the physicians claimed that they had had discussions with the patients, who had expressed an interest in euthanasia before they became incompetent or unconscious. Nonetheless, these patients had never made an explicit request. (In the Netherlands it is accepted practice for physicians to offer euthanasia as an option to patients.) Another 8,100 patients died from a deliberate overdose of pain medication given by doctors, not to control pain but to hasten death. Sixty-one percent had not consented to the overdose.

The 1995 Remmelink Report

In 1995 another nationwide investigation was conducted in the Netherlands as a follow-up study of physician-assisted suicide and euthanasia. In "Euthanasia, Physician-Assisted Suicide, and Other Medical Practices Involving the End of Life in the Netherlands" (New England Journal of Medicine, vol. 335, no. 22, November 28, 1996), van der Maas and his colleagues reported on an update of the Remmelink Report.

The study consisted of two parts—interviews with 405 physicians and a study of death certificates through questionnaires returned by about 5,000 physicians. The results of the two-part 1995 study, as compared with the 1990 results, showed that the incidence of euthanasia among total deaths in the Netherlands increased from about 1.9 percent in 1990 to about 2.3 percent in 1995, and assisted suicides increased somewhat during the same period. (See Table 6.7.) The increases were attributed to an aging population, increased numbers of deaths from cancer as a result of decreased deaths from heart disease, rising availability of life-prolonging techniques, and changes in patients' attitudes toward euthanasia and physician-assisted suicide.

The 1995 update of the Remmelink Report also showed that the frequency with which patients' lives were terminated without their explicit requests (what Americans call involuntary euthanasia) decreased somewhat—from 0.8 percent in 1990 to 0.7 percent in 1995 (shown in the results of the death-certificate studies rather than interview studies). (See Table 6.7.)

The 2001 Remmelink Report

In 2001 a third study gathered data to compare with data from the 1991 and 1995 studies. The goal of these comparisons was to determine whether end-of-life practices had altered over this time span.

Research results from "Euthanasia and Other End-of-Life Decisions in the Netherlands in 1990, 1995, and 2001" (Bregie D. Onwuteaka-Philipsen, et al., Lancet, vol. 362, no. 9381, August 2, 2003), which includes results from the 1990 and 1995 reports, are shown in Table 6.7. All three studies involved the same interview and death-certificate studies so that data could be compared. In all three studies the difference between euthanasia and physician-assisted suicide rested with who administered the lethal dose of medication. With euthanasia, the physician administered the drugs to the patient. With physician-assisted suicide, the patient administered the drugs to him-or herself, but the physician prescribed the drugs.

The results for 2001, when compared with those of 1995, showed that the demand for physician-assisted death did not rise during that time span. The demand for euthanasia rose only slightly. The death-certificate studies showed the rate of euthanasia increased slightly from 2.4 percent of all deaths in 1995 to 2.6 percent in 2001. In interview studies no increase was found in 2001. The frequency with which patients' lives were terminated without their explicit requests remained stable from 1995 to 2001. As the author of the 2001 report confirmed:

The rate of euthanasia and explicit requests by patients for physicians' assistance in dying in the Netherlands seems to have stabilized, and physicians seem to have become somewhat more restrictive in their use. The continuing debate on whether and when physician-assistance in dying may be acceptable and on procedures to ensure transparency and quality assurance seems to have contributed to this stabilization.

Journal of Medical Ethics Report

The Journal of Medical Ethics, a British publication, released a report in February 1999 based on its own research in the Netherlands. According to this report, studies conducted in 1996 revealed that the safeguards established by the Royal Dutch Medical Association were not being followed. Almost two-thirds of euthanasia and physician-assisted suicide cases went unreported. In 20 percent of euthanasia cases, the patient did not make a request; for 17 percent of these patients, there were other available treatment options.

Despite the law's "unbearable suffering" requirement, more than half of doctors listed the patient's primary concern as "loss of dignity." Taking into account all situations with explicit intention to end life, the number of deaths increased from 3,200 to 24,500 ("Euthanasia Does Not Seem to Be under Effective Control in the Netherlands," Journal of Medical Ethics, February 16, 1999).

Mental Suffering Acceptable as a Reason for Performing Assisted Suicide and Euthanasia

In 1994 the Dutch Supreme Court ruled that euthanasia may be performed in cases of mental suffering. In the landmark Assen case, which used the defense of force majeure, the court exonerated a Dutch psychiatrist who had helped a patient commit suicide. The patient, Hilly Bosscher, although severely mentally distressed, was physically healthy. After a disastrous marriage that ended in divorce, and the deaths of her sons (one to suicide and the second to cancer), Bosscher wanted to die. She refused treatment for her depression, claiming that her mental suffering was such that nothing would help. Dr. Boudewijn Chabot was acquitted of assisted suicide because the patient was rational and had not been diagnosed with any psychiatric illness. Thereafter, the Dutch guidelines included information advocating that physicians be allowed to assist depressed people to commit suicide.

Belgium to Follow the Netherlands

In October 2001 Belgium became the second country to legalize euthanasia. The legislation passed by 44 to 23 votes in the Belgian senate, with two abstentions and two senators failing to vote. The law will apply to competent adults who have an incurable illness causing unbearable, constant suffering and patients in a persistent vegetative state who made their wishes known within the prior five years in front of two witnesses.

Switzerland and Euthanasia

Euthanasia is not legal in Switzerland, but the country allows suicide assisted by physicians or people with no medical training. Since 1937 suicide has been legal in Switzerland. The Swiss criminal code additionally states that suicide may be assisted for altruistic reasons, but that assisted suicide is a crime if motivated for financial gain or for what it deems "negative" reasons.

SHOULD THE UNITED STATES FOLLOW THE NETHERLANDS?

Advocates of assisted suicide point to the Dutch system as a model for the United States, claiming that the United States could establish guidelines not unlike those in the Netherlands. However, Richard M. Doerflinger, in Life at Risk (Washington, DC: National Conference of Catholic Bishops, April 1998), reported that the 1994 Dutch law that regulates euthanasia now allows euthanasia of severely handicapped newborns. Doerflinger felt that the Dutch court's reasoning invalidly equates euthanasia with discontinuing the use of life support and providing relief for pain.

The New York State Task Force on Life and the Law, a commission comprised of persons from various disciplines, studied the feasibility of legalizing physician-assisted suicide. In its comprehensive 1994 report, When Death Is Sought: Assisted Suicide and Euthanasia in the Medical Context, the Task Force concluded that legalizing or legitimizing euthanasia would carry the substantial risk that patients might be assisted in suicide without adequate counseling and exploration of other avenues. The members of the commission feared that for some people the system might even work to encourage euthanasia. Further, they thought that the risk was unacceptably high enough that vulnerable individuals with limited control over their lives, such as the disabled, the elderly, and the poor, might be discriminated against.

Unlike the Netherlands, which provides medical care to all, the United States does not provide health insurance to its citizens. The number of uninsured people continues to increase, rising from 30.5 million in 1979 (13.5 percent of the population) to approximately 43.6 million in 2002 (15.2 percent of the population). Uninsured people are already at risk because they are often unable to obtain needed medical care. Legalized assisted suicide could make them even more vulnerable to potential abuses of resource allocations. Might a hospital be more likely to recommend euthanasia for a nonpaying patient who is draining the hospital resources than for one who is covered by insurance?

Physician-Patient Relationships

Current American medical practice does not differ much from that in the 1980s, when the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research investigated the relationship between patients and doctors. In Making Health Care Decisions: The Ethical and Legal Implications of Informed Consent in the Patient-Practitioner Relationship (Washington, DC: U.S. Government Printing Office, 1982), the President's Commission observed:

In addition to making a recommendation, the doctor's self-perceived role is to get the patient to go along with this recommendation if there is any hesitancy on the patient's part. This is done by some explanation about the need for the recommended treatment and the consequences of not heeding the recommendation. But in the doctor's view there is no decision for the patient to make, except whether to get proper medical care.

If assisted suicide is legalized, it becomes a treatment option that may be recommended by physicians. As the President's Commission noted, physicians often believe that they know the best treatment for their patients. Yet, as the New York State Task Force pointed out, physicians' judgments may not always be impartial. Their professional judgment is shaped by their own attitudes toward illness and euthanasia in general, and toward each patient in particular.

In April 1997 the New York State Task Force on Life and the Law issued a supplement to When Death Is Sought: Assisted Suicide and Euthanasia in the Medical Context. The Task Force, in this most recent report on the topic of assisted suicide and euthanasia, reiterated its initial 1994 finding that physician-assisted suicide would be seriously harmful to a large number of people. The Task Force claimed that the widespread interest in physician-assisted suicide is a symptom of a bigger problem—our failure as a nation to alleviate the pain and suffering of terminally ill patients. The Task Force recommended that even if physician-assisted suicide were legalized, the national priority should be the improvement of end-of-life medical care for everyone.

In 2001 the American College of Physicians–American Society of Internal Medicine (ACP–ASIM) released its position on physician-assisted suicide in "Physician-Assisted Suicide" (Annals of Internal Medicine, vol. 135, no. 3, August 7, 2001). The organization stated that it does not support the legalization of physician-assisted suicide, noting that not only would the routine practice of physician-assisted suicide raise serious ethical concerns, it "would undermine the patient-physician relationship and the trust necessary to sustain it.…"

EUTHANASIA AND ASSISTED SUICIDE

Euthanasia is translated from Greek as "good death" or "easy death." As originally used, the term referred to painless and peaceful natural deaths in old age that occurred in comfortable and familiar surroundings. That usage is now archaic. As the word is currently understood, euthanasia occurs when one person ends the life of another person for the purpose of ending the killed person's pain or suffering.

Euthanasia is sometimes divided into different categories. "Voluntary euthanasia" is when a person is killed upon that person's request for reasons of ending suffering. "Involuntary or nonvoluntary euthanasia" is the mercy killing of a medically or legally incompetent person, such as a child or a demented elderly patient, at the request of, or by, a caregiver or family member.

Some people also use the term "passive euthanasia" to describe a death that occurs after undesired, life-sustaining medical treatment is withheld or withdrawn. This is a misnomer. Euthanasia, at least as the term is presently utilized, involves intentional killing. That being so, "passive euthanasia" is not euthanasia, since death, when it comes—not everyone who has life-sustaining treatment dies as a result of withheld treatment—is naturally caused by the underlying illness or injury.

Assisted suicide is closely related to euthanasia. An assisted suicide occurs when one person gives another person the instructions, means, or capability to bring about their own demise. In the context of the modern moral and public policy debates, the motive in assisted suicide, as in euthanasia, is to bring about an end to suffering. Suicide per se is not considered to be the same as "assisted suicide" because the former is an individual act while the latter involves a joint enterprise between the suicidal person and a helper to bring about death.

The Hippocratic oath explicitly prohibited doctors from giving their patients poisons to end life and thus, traditionally, euthanasia and assisted suicide have not been considered legitimate medical acts. Legalizing either practice would transform hastening patient deaths from an ethically proscribed and (usually) criminal act into a legitimate medical practice. Thus, widespread legalization would be a profound and dramatic shift in the traditional ethics of medical practice.

Euthanasia is currently illegal and punishable as murder throughout the United States. Assisted suicide is a felony akin to manslaughter in most states, proscribed either by statute or court interpretation of the common law. The federal government has outlawed the use of federal funds in assisted suicide.

Assisted suicide is, however, legal in Oregon, where state law authorizes physicians to write lethal prescriptions at the request of patients who have been diagnosed with a terminal illness reasonably likely to cause death within six months. In order for the assisted suicide to be legal, the prescribing physician must follow regulatory guidelines. These guidelines include: requiring a second opinion to verify the diagnosis; referral of the patient to a mental health professional if the doctor suspects the patient has a psychiatric or psychological condition that causes "impaired judgment"; a fifteen-day waiting period between request and prescription; and, reporting the assisted suicide to the Oregon Department of Health. Most current legalization proposals in the United States follow the format of the Oregon law.

Internationally, both euthanasia and assisted suicide are almost universally outlawed. There are a few exceptions to this general rule. In Colombia euthanasia is legal due to a ruling by that country's supreme court (Republic of Colombia Constitutional Court: Sentence: no. C-239/97: REF. EXPEDIENT no. D-1490. May 20, 1997). As of this writing the Colombia law has not gone into effect pending the creation of legal guidelines to govern the practice. Euthanasia and assisted suicide, while technically illegal, are practiced widely by doctors in the Netherlands. The Netherlands experience will be discussed in detail below. Assisted suicide is not illegal in Switzerland, where assisted suicides committed by physicians and laypersons alike are reportedly not prosecuted if based on alleviating suffering caused by serious illness.

The modern euthanasia movement

A few proposals to legalize euthanasia were made in the United States and Germany during the latter portion of the nineteenth century. However, it was not until after World War I that euthanasia advocacy began in earnest. In 1920, two highly respected German academics, Karl Binding, a law professor, and Alfred Hoche, a physician, wrote Permission to Destroy Life Unworthy of Life, which advocated euthanasia as a compassionate "healing treatment." The authors argued that mercy killing should be permitted for three categories of patients upon request of competent patients or the families of the incompetent: the terminally ill or mortally wounded, people who were unconscious, and disabled people—particularly those with cognitive impairments. The book, which may have coined the term "right to die," also promoted euthanasia of cognitively disabled people as a way of saving societal resources.

Binding and Hoche's book generated tremendous interest among Germany's intelligentsia and the public, which quickly came to support legalization of euthanasia. Euthanasia was popular enough in 1933 for Adolph Hitler to attempt to formally legalize the practice. However, strong opposition from the churches caused the German government to drop the proposal.

Euthanasia was also advocated in the United States during the 1930s. In 1938, the New York Times announced the formation of a national euthanasia society that eventually became known as the Euthanasia Society of America. In 1939, the group had drafted a proposed law permitting voluntary euthanasia. Dr. Foster Kennedy, the group's president, also called for the legalization of euthanasia for babies born with birth defects. The incipient euthanasia movement in the United States grew quiescent in the aftermath of the Holocaust as the world recoiled in horror to the news that between 1939 and 1945, German doctors killed more than 200,000 disabled people, including infants and the mentally retarded people.

After the war, organized euthanasia groups continued to exist in the United States but made little headway until the early 1980s, when societal changes that began in the 1960s and the resulting weakening of traditional moral values, as well as intellectual support by some within the medical intelligentsia, provided fertile ground for renewed euthanasia advocacy. In a dramatically short period of time, legalized euthanasia went from an "unthinkable" prospect to one of the most contentious and controversial issues debated in the public square.

Pros and Cons

Perhaps the strongest argument made on behalf of legalizing euthanasia or assisted suicide is that it, like abortion, is a "choice" issue. Proponents argue that euthanasia/assisted suicide is "the ultimate civil right," and that to deprive mentally competent, terminally ill people who want to end their suffering of a peaceful "aid in dying" is to fundamentally disrespect their right to personal autonomy. Proponents also argue that legalizing euthanasia/assisted suicide is a necessary "insurance policy" that will ensure that no one dies in painful agony or unremitting suffering. Advocates contend that euthanasia/assisted suicide is little different from pain control since both use strong drugs and patients' deaths are occasionally unintentionally hastened as a side effect of the narcotics used in palliation. They also claim that doctors commonly engage in euthanasia/assisted suicide surreptitiously and promote legalization as a way to protect vulnerable patients from abuses inherent in the current "unregulated" practice. Acknowledging worries about potential abuses, advocates assure that "protective guidelines" would protect the vulnerable from wrongful death while still permitting suffering patients who are eligible for euthanasia/assisted suicide to obtain a desired, peaceful "death with dignity." Proponents also claim that opposition to euthanasia/assisted suicide is based primarily in religion and that laws prohibiting the practice are thus unconstitutional because they violate the division between church and state.

Opponents counter that legalizing euthanasia/assisted suicide would lead society down a dangerous "slippery slope" with legalized killing eventually being permitted for disabled, elderly, and depressed people, as well as for those who are not mentally competent to request to die. Protective guidelines "do not protect," opponents declare, pointing to the Dutch experience with euthanasia as "proof" of both the reality of the slippery slope and the relative meaninglessness of guidelines. Opponents also argue that the economics of modern medicine would promote euthanasia/assisted suicide as a form of health care cost containment, noting that the drugs in an assisted suicide cost only about forty dollars, while proper care for a dying patient can cost tens of thousands of dollars. They also note that forty-four million Americans do not have health insurance, and that medicine is sometimes practiced in a discriminatory manner against racial and other minorities. Thus, they argue that "the last people to receive medical treatment will be the first to receive assisted suicide." Opponents also deny that there is widespread surreptitious euthanasia practiced in clinical medicine, citing several published studies as proof, and urge that hospice care and proper medical treatment provide the morally acceptable answers to the difficulties that are sometimes associated with the process of dying.

The people vote

There have been several attempts in the United States to legalize euthanasia and assisted suicide through state initiatives. The first attempt came in 1988, when euthanasia supporters attempted to qualify an initiative for the ballot in California, which would have permitted physicians to administer lethal injections for terminally ill patients who asked to have their deaths hastened. The attempt failed to garner enough signatures to qualify for the ballot. However, in 1991, Initiative 119, a similar proposal, was successfully placed on Washington's ballot. After initial polling showed voter support in excess of 70 percent, the initiative lost 54 to 46 percent. The pattern repeated itself in California in 1992, when a virtually identical proposal appeared on the California ballot in November 1992 as Proposition 161. After initial support in excess of 70 percent, the measure also lost by a margin of 54 to 46 percent.

Two years later, in Oregon, Measure 16—the Oregon Death with Dignity Act—qualified for the November 1994 ballot. Unlike the earlier failed initiatives, Measure 16 limited its scope to legalizing physician-assisted suicide. The measure passed narrowly, 51 to 49 percent. The law was soon overturned as a violation of the equal protection clause of the Fourteenth Amendment to the U.S. Constitution. However, this decision was itself overturned by the Ninth Circuit Court of Appeals on procedural grounds (Lee v. Oregon ). The United States Supreme Court refused to review the Ninth Circuit's opinion. An attempt by opponents to repeal Measure 16 through another ballot initiative, Measure 51, failed in November 1997 by a margin of 60 to 40 percent. The law was in effect as of 1999.

In 1998, supporters of assisted suicide qualified Proposal B for the November ballot in Michigan. Proposal B, like Measure 16, would have restricted legalization to assisted suicide and its terms were very similar to those of the Oregon law. The debate over Proposal B was complicated by two factors: Michigan was the home state of Dr. Jack Kevorkian and Kevorkian's attorney, Geoffrey Fieger, was the Democratic nominee for governor. Whatever the impact of these ancillary issues, when the votes were counted, Proposal B lost by an overwhelming 71 to 29 percent.

Jack Kevorkian

During the 1990s, Jack Kevorkian was undoubtedly the most well known assisted suicide and euthanasia advocate in the world. A retired pathologist from Michigan, Kevorkian made headlines internationally when he undertook a well publicized assisted-suicide campaign between 1990 and 1998 that reportedly ended the lives of approximately one hundred thirty people. Some of those whose deaths Kevorkian facilitated were terminally ill and diagnosed as having less than six months to live, but most were disabled or chronically ill. According to autopsy reports, four of the people whose suicides Kevorkian helped had no discernible organic illness.

Kevorkian's campaign began on 4 June 1990, when he assisted the suicide of Janet Adkins, a woman diagnosed with early Alzheimer's disease. At the time, Michigan had no law against assisted suicide and Kevorkian was not arrested. His next publicly acknowledged assisted suicide was conducted on 23 October 1991, when Kevorkian made headlines for assisting the suicide of two women at the same location, one with multiple sclerosis and another who complained of chronic, severe pelvic pain. Kevorkian was arrested for murder but the case was dismissed. The prosecution appealed and the state legislature hastily cobbled together a poorly worded, temporary criminal statute proscribing assisted suicide intended to "stop Kevorkian."

Kevorkian openly defied the law and was arrested, tried, and acquitted. The temporary prohibition lapsed but the prosecution's earlier appeal succeeded when the Michigan Supreme Court ruled that assisted suicide was a common law felony in Michigan (People of Michigan v. Jack Kevorkian ). Kevorkian was again arrested and tried. Once again, a jury found him not guilty. A third case against Kevorkian was later declared a mistrial because of the courtroom conduct of Kevorkian's lawyer, and the case was dropped. Kevorkian, it seemed, had a free hand.

In 1998, Kevorkian's actions grew increasingly erratic. In June, after he assisted the suicide of Joseph Tushkowski, a man with quadriplegia, Kevorkian held a press conference in which he claimed to have procured the man's kidneys, and offered them for organ transplant, "first come, first served." There were no takers. In late October, he videotaped himself lethally injecting Thomas Youk, an ALS (Lou Gehrig's disease) patient. Kevorkian then took the tape to CBSTelevision's news program 60 Minutes, which aired it to a nationwide audience, during which Kevorkian dared the authorities to prosecute him. Kevorkian was arrested and convicted of second-degree murder. He is currently in prison for a term of ten to twenty-five years.

Legal challenges

Proponents of legalization mounted a significant effort to have laws against assisted suicide declared unconstitutional, hoping to garner an "assisted suicide" Roe v. Wade (410 U.S. 113 (1973)) that would settle the issue nationally, as Roe did with abortion. They were unsuccessful. In Washington v. Glucksburg (117 S. Ct. 2258 (1997), the Supreme Court justices voted 9–0 that "the asserted 'right' to assistance in committing suicide is not a fundamental liberty interest protected by the Due Process Clause [of the Fourteenth Amendment]." The decision also emphasized that state laws banning assisted suicide were consistent expressions of the individual states' commitment to protecting all human life.

In the closely associated case of Vacco v. Quill (117 S. Ct. 2293 (1997)), the Supreme Court ruled against assisted-suicide advocates who had argued that New York's law proscribing assisted suicide violated the equal protection clause of the Fourteenth Amendment. They argued that since it is legal for terminally ill persons to refuse life-sustaining medical treatment and die immediately but illegal for terminally ill people who do not require life support to secure immediate death through physician-assisted suicide, New York violated its constitutional obligation to treat similarly situated people equally. In rejecting the argument, the Supreme Court ruled that the New York law actually treated similarly situated people alike: all patients are permitted to refuse unwanted treatment and none are allowed legal access to assisted suicide. The Court also ruled that there was a significant and rational distinction between refusing life-sustaining treatment and seeking assisted suicide. In the former circumstance, the doctor's intention may be to simply stop performing useless procedures when a patient will not benefit, while in assisted suicide, the doctor must without a doubt intend for the patient's death.

Both sides claimed victory in the Court's two rulings. Opponents were relieved that assisted suicide would not be "imposed" nationally by judicial fiat. Proponents took heart that several concurring opinions muddied the waters and seemed to indicate that the issue could be brought back to the courts for further review if a case of a patient with truly irremediable suffering were presented. Proponents also claimed that the Court's decision freed the states to experiment with laws concerning the end of life, perhaps including assisted suicide, although opponents pointed out that the issue of a state's right to pass a law legalizing assisted suicide had not been before the Court.

There have been at least three attempts to invalidate state laws proscribing assisted suicide based on privacy provisions contained in state constitutions. A lawsuit challenging Alaska's proscription is currently pending in that state's courts (Sampson v. State of Alaska, No. 3 AN–98–11288 CIV). A California Court of Appeals decision refused to permit a terminally ill man to have legal assistance with suicide so that his body could be cryogenically preserved. The most notable case to decide this issue in state courts was Krischer v. Florida (697 So.2d, 97 (1997)), in which the Florida Supreme Court ruled that the state's assisted-suicide prohibition did not violate the state constitution's guarantee of privacy.

Euthanasia in the Netherlands

The Netherlands has the most experience with physician-hastened death. Both euthanasia and assisted suicide remain crimes there but doctors who end their patients' lives will not be prosecuted if legal guidelines are followed. Among the guidelines are:

• The request must be made entirely of the patient's own free will.
• The patient must have a long-lasting desire for death.
• The patient must be experiencing unbearable suffering.
• There must be no reasonable alternatives to relieve suffering other than euthanasia.
• The euthanasia or assisted suicide must be reported to the coroner.

These guidelines are similar to those proposed in legalization proposals in the United States, although the Oregon law requires a terminal illness, a limitation not included in the Dutch guidelines. On the other hand, the Oregon guidelines do not require that the patient be experiencing unbearable suffering or that there be no reasonable alternatives to relieve suffering other than assisted suicide.

There have been several professional studies conducted into Dutch euthanasia practice. Most have reported that approximately 2,700 deaths are caused each year in the Netherlands by either euthanasia or assisted suicide—approximately 3 percent of all Dutch deaths. Proponents claim this relatively low figure rebuts opponent's fears that euthanasia will become a relatively routine event. Opponents counter that this figure is horrifying: if the same percentage of Americans died with the direct assistance of doctors, it would amount to approximately sixty-eight thousand annual deaths, more than tripling the U.S. suicide rate.

Opponents also claim that the number of people actually killed by Dutch doctors is significantly understated in these studies. They note that the term "euthanasia" is very narrowly defined by the Dutch government, with the effect if not the design of undercounting the actual number of euthanasia deaths. If a doctor kills a patient with barbiturates and a curare-like poison at the patient's request, the Dutch classify the death as "euthanasia." However, if the patient is killed by an intentional overdose of morphine administered with the primary intention of ending the patient's life, it is not considered euthanasia because morphine is a palliative agent. Yet, intentional morphine overdoses may exceed "euthanasia" deaths. In 1990, according to a Dutch government report, 8,100 patients died through the intentional morphine-overdose method of mercy killing. A latter study found that about 1,500 die annually through the intentional morphine-overdose method of killing. Whatever the actual annual figure, if intentional morphine-overdose deaths are counted as euthanasia, the statistical mercy killing rate in the Netherlands significantly exceeds the published statistics.

Opponents point to the many documented cases of chronically ill people, as well as to terminally ill people, put to death by doctors at the patient's request as further proof of euthanasia's many dangers. A Dutch documentary showed a young woman in remission from anorexia requesting doctor-induced death because she was afraid of resuming food abuse. Her doctor assisted her suicide without legal consequence. Another documented case showed an asymptomatic, HIV-positive patient assisted in suicide because he feared future suffering.

Opponents point with alarm to the Dutch Supreme Court's decision approving euthanasia for cases of severe depression—even in the absence of physical illness (State v. Chabot, Supreme Court of the Netherlands, Criminal Chamber, 21 June 1994, nr. 96.972). This decision resulted from the case of a Dutch psychiatrist who assisted the suicide of a woman who wanted to end her life because her children had died. The court supported the psychiatrist's actions, ruling that for purposes of judging the propriety of euthanasia or assisted suicide, suffering is suffering and it does not matter whether the cause is physical or psychological.

Another disturbing statistic that is found consistently in studies into Dutch euthanasia practices demonstrates to opponents the ultimate danger of euthanasia: approximately one thousand Dutch patients are euthanized each year by their doctors "without request or consent," in other words, involuntary or nonvoluntary euthanasia. Since euthanasia is only supposed to be allowed for people who consistently ask to be killed, the fact of involuntary killing demonstrates the unworkability of guidelines. Proponents counter that the number, while too high, has been relatively constant over several years, thus belying fears of the slippery slope.

Pediatric euthanasia has also become a part of Dutch euthanasia practice. Opponents point with alarm to a 1997 study published in the British medical journal The Lancet indicating that about 8 percent of all infants who die in the Netherlands are euthanized—approximately 80 per year. Pediatric euthanasia, they claim, is a human rights abuse and a proof that guidelines do not protect vulnerable patients. Proponents counter this criticism with the defense that the infant-euthanasia deaths are only of the most severely impaired babies, most of whom would not live anyway, and note that the parents make the decision based on their judgment of what is best for their children.

Opponents also claim that Dutch euthanasia is "beyond significant control" since approximately 59 percent of euthanasia and assistedsuicide deaths are not reported to the coroner as required by the guidelines. Thus, they claim that the actual number of Dutch patients killed is probably far higher than the statistics seem to show. Proponents admit that unreported euthanasia deaths are a problem but counter that full legalization would remove fear of prosecution thereby increasing compliance with reporting requirements.

In 1999 the Dutch government announced its intention to formally legalize euthanasia. As with anything having to do with euthanasia, the announcement was extremely controversial: the proposed law would permit the euthanasia of children as young as twelve at the request of the child, even if the parents object.

The Oregon experience

Assisted suicide has been legal for too short a time in Oregon to know its actual impact. As of 1999, just one study has been conducted analyzing the Oregon experience. Published in the New England Journal of Medicine in 1999, the study reported that fifteen people died legally by assisted suicide in the calendar year 1998. None was in intractable pain. One feared future pain. The primary reason the patients gave for requesting assisted suicide, according to the prescribing doctors who were interviewed for the study, was fear of future dependency.

Proponents of the Oregon law claimed that the study demonstrated that legalized assisted suicide is a rare procedure and that the law's guidelines work to protect vulnerable people. They also stressed that the deaths were apparently peaceful with none of the patients suffering side effects, such as extended coma, about which opponents had warned. Moreover, they noted that financial pressures did not appear to be a factor in any of the cases.

Opponents countered that the law was "sold" to voters as a last resort measure for people in extreme pain, but none of the patients fits that description, thereby demonstrating the existence of the "slippery slope." Disability rights activists argued that once assisted suicide is deemed a proper response to fears of dependency, as was the case in the fifteen Oregon deaths, it cannot be logically limited to terminally ill people since disabled and elderly people also face dependency issues and for far longer periods of time. Opponents also noted with alarm that six of the people who died by assisted suicide consulted with two or more doctors before finding a physician willing to write a lethal prescription. Moreover, some of the patients knew the prescribing doctor for a very short time, indicating, opponents contend, that some of the prescriptions were written for political rather than medical purposes.

Conclusion

The assisted suicide/euthanasia debate is still in its infancy, with the ultimate outcome very much in doubt. Public opinion polls show solid majority support for limited legalization, but the polls also demonstrate that popular support drops significantly when specific details of legislative proposals are examined. Oregon was a major breakthrough for advocates of assisted suicide but five states have outlawed assisted suicide since Oregon's Measure 16 passed in 1994, and one state passed legislation subjecting a person who assists in a suicide to civil liability. One thing is clear: euthanasia/assisted suicide controversy is likely to be a significant source of societal contention and political argument for many years to come.

Wesley J. Smith

See also Abortion; Criminalization and Decriminalization; Excuse: Theory; Homicide: Legal Aspects; Justification; Necessity; Suicide: Legal Aspects; Victimless Crime.

BIBLIOGRAPHY

Byock, Ira. Dying Well: The Prospect for Growth at the End of Life. New York: Putnam, 1997.

Chin, Hedberg et al. "Legalized Physician-Assisted Suicide in Oregon—The First Year's Experience." New England Journal of Medicine 340, no. 7 (February 1999): 577–589.

Hendin, Herbert. Seduced by Death: Doctors, Patients, and the Dutch Cure. New York: Norton, 1997.

Humphry, Derek, and Clement, Mary. Freedom to Die: People, Politics and the Right-to-Die Movement. New York: St. Martin's, 1998.

Kamisar, Yale. "Some Non-Religious Views Against Proposed 'Mercy-Killing' Legislation." Minnesota Law Review 42 (1958): 969–1042.

——. "Physician-Assisted Suicide: The Problems Presented by the Compelling, Heart-wrenching Case." Journal of Criminal Law and Criminology 88 (1998): 1121–1146.

Keizer, Bert. Dancing with Mister D: Notes on Life and Death. New York: Doubleday, 1996.

Keown, John, ed. Euthanasia Examined: Ethical, Clinical and Legal Perspectives. Cambridge, U.K.: Cambridge University Press, 1997.

Marker, Rita. Deadly Compassion: The Death of Ann Humphry and the Truth about Euthanasia. New York: Morrow, 1993.

New York Task Force on Life and the Law. When Death Is Sought: Assisted Suicide and Euthanasia in the Medical Context. New York: New York Task Force on Life and the Law, 1994.

Peck, M. Scott. Denial of the Soul: Spiritual and Medical Perspectives on Euthanasia and Mortality. New York: Harmony Books, 1997.

Quill, Timothy E. Death and Dignity: Making Choices and Taking Charge. New York: Norton, 1993.

Smith, Wesley J. Forced Exit: The Slippery Slope from Assisted Suicide to Legalized Murder. New York: Times Books, 1997.

Uhlmann, Michael E., ed. Last Rights: Assisted Suicide and Euthanasia Debated. Grand Rapids, Mich.: Wm. B. Eerdmans Publishing Company.

van der Heide, van der Maas et al. "Medical End-of-Life Decisions Made for Neonates and Infants in the Netherlands." The Lancet 350 (July 1997): 251–253.

Williams, Glanville. The Sanctity of Life and the Criminal Law. London: Faber and Faber, 1958.

Euthanasia and Assisted Suicide

ISSUES SURROUNDING CONTROVERSIAL END-OF-LIFE DECISIONS

ARGUMENTS REGARDING PAS AND EUTHANASIA

INTERNATIONAL VIEWS OF PAS AND EUTHANASIA

CONCLUSION

BIBLIOGRAPHY

The twentieth century has seen great strides in the advancement of medicine and life-sustaining technology, resulting in improved life expectancy and quality of life for people around the world. Improvements in medicine, however, raise questions about the appropriateness of life-sustaining treatments in the case of people who are terminally ill and experiencing acute pain and suffering. In the late twentieth century, end-of-life issues came to the forefront of public attention, resulting in an ongoing discussion about ethical, legal, and political implications of physician-assisted suicide (PAS) and euthanasia.

ISSUES SURROUNDING CONTROVERSIAL END-OF-LIFE DECISIONS

Part of the controversy surrounding end-of-life decisions such as PAS and euthanasia results from a lack of clear communication as to what these actions entail. Euthanasia refers to someone (often a physician) intentionally taking an action that ends another person’s life with the stated intent of alleviating or preventing perceived suffering. Euthanasia involves the direct administration of lethal medication by a person other than the terminally ill patient. “Assisted suicide is the deliberate and knowing provisions of information, the means, and/or help to another person for the act of suicide” (American Association of Suicidology 1996, p. 6). In PAS, the assister is a medical doctor. Such assistance is typically in the form of a prescription for a lethal dose of medication that the terminally ill patient may use as a means to end his or her life. The critical distinction between these practices is that in euthanasia the physician (or somebody else) actively administers the lethal medication, while in PAS the patient is given the means to bring about his or her own death.

There are various types of euthanasia, including voluntary, nonvoluntary, and involuntary. Voluntary euthanasia refers to deliberate termination of a patient’s life upon that person’s explicit and direct request. Nonvoluntary euthanasia occurs when the patient is unconscious or incompetent and is thus unable to make a decision. Involuntary euthanasia takes place when the patient is competent and aware but his or her consent is not obtained. It should be noted that involuntary euthanasia is not an acceptable practice even in countries where voluntary euthanasia is currently legalized. The involuntary termination of a patient’s life is not supported by legislation and is considered homicide around the world. This distinction has led several authors to argue that euthanasia is by definition voluntary and that terms such as nonvoluntary and involuntary euthanasia are contradictory and misleading (Materstvedt Clark, Ellershaw, et al., 2003).

In addition, distinction has been made between active and passive euthanasia. Active euthanasia is the procedure whereby a physician (or someone else) shortens a person’s life, usually through the administration of a lethal dose of medication. Passive euthanasia refers to the practice of withholding or withdrawing a futile or ineffective treatment upon the patient’s request (American Association of Suicidology 1996). Several researchers have argued against the use of this latter term by pointing out that practices such as withholding and withdrawing treatment are ethically and legally distinct from active euthanasia (Materstvedt, Clark, Ellershaw, et al. 2003). This view is consistent with practices in countries such as the United States and Israel where euthanasia is illegal, but withholding and withdrawing treatment are acceptable medical practices (Ganz, Benbenishty, Hersch, et al. 2006). However, in other countries the term passive euthanasia is still used. Similarly, providing high doses of pain-relieving medication, even if this may shorten a patient’s life, is seen as distinct from euthanasia (Materstvedt, Clark, Ellershaw, et al. 2003). This is also the case with terminal sedation, a practice whereby pain medication is used to bring about unconsciousness, after which life-support equipment is withdrawn (Parpa, Mystajudou, Tsilika, et al. 2006).

ARGUMENTS REGARDING PAS AND EUTHANASIA

A firm grasp on the definitions of PAS and euthanasia as well as on the alternatives that exist to these practices is essential for an informed understanding of the debate surrounding end-of-life decision-making. As of the early twenty-first century, more empirical data are necessary in order to evaluate the accuracy of arguments in favor of and against PAS and euthanasia.

Proponents of assisted suicide and euthanasia claim the practices exist but are hidden, and legalizing such acts would allow for stricter government regulation and control (Quill and Battin 2004). In addition, involving medical practitioners in the decision-making process would allow for professional and expert judgment to be made regarding the validity of end-of-life decisions. Another fundamental argument in favor of legalizing PAS and euthanasia is maximizing personal autonomy and self-determination. According to this view, a terminally ill patient who is enduring unbearable pain or suffering is entitled to the right of choosing death with dignity and peace. Alleviation of unnecessary suffering and maintaining the quality of life of terminally ill patients are the paramount goals behind PAS and euthanasia. Some proponents of PAS claim that this practice is ethically different from euthanasia, as in PAS the patient is the one who performs the act of ending his or her life.

Opponents of euthanasia and PAS point out the potential for abuse if these practices are granted legal recognition (Foley and Hendin 2002). Critics of PAS and euthanasia often refer to the threat of a slippery slope. They fear that once voluntary euthanasia or PAS for terminally ill patients becomes legally permissible, other forms of medicalized killing, such as involuntary euthanasia for mentally incompetent and/or disabled individuals would increase. Many medical professionals state that euthanasia and PAS are prohibited under the Hippocratic Oath and violate the fundamental ethical principles of nonmaleficence and beneficence. Furthermore, these professionals argue that the need for such end-of-life decisions can be eliminated with the provision of appropriate palliative care and the effective use of pain control medication.

Questions have also been raised about the stability and rationality of end-of-life requests (Foley and Hendin, 2002). In addition, patients may request PAS or euthanasia as a result of experiencing hopelessness and depression rather than acute physical pain or suffering. Alternatively, the patients may feel obligated to alleviate their families from unnecessary burden and thus feel pressured to end their lives. Finally, many opponents claim that the sanctity of human life overrules concerns of personal autonomy and that the protection of human life should be of paramount importance in end-of-life medical cares.

INTERNATIONAL VIEWS OF PAS AND EUTHANASIA

Both euthanasia and PAS were legalized in the Netherlands in 2002 after they had been tolerated for more than 30 years (Materstvedt, Clark, Ellershaw, et al. 2003). Belgium legalized euthanasia in September 2002, and did not legalize PAS (Adams and Nys 2003). Physician-assisted suicide, but not euthanasia, was legalized in Oregon in 1994 with the Death with Dignity Act, and began to be in use in 1997 (Materstvedt, Clark, Ellershaw, et al. 2003). In 2006, the Oregon Department of Human Services announced that it will no longer use the term “physician-assisted suicide” to describe deaths under the Death with Dignity Act (Colburn 2006) because the act itself specifies that deaths that occur following the provisions of the law are not to be considered suicide. Although active euthanasia is illegal in Switzerland, assisting in the suicide of a terminally ill patient is considered a crime only if the death, and therefore the motive behind the assistance, benefits the person who assists the suicide (Schildmann, Herrmann, Burchardi, et al. 2006). Although Australia’s Northern Territory was the first jurisdiction to legalize euthanasia in 1995, the Rights of the Terminally Ill Act was repealed nine months later by an act of the Commonwealth (Materstvedt, Clark, Ellershaw, et al. 2003).

The legalization of PAS and euthanasia in several nations signals changes in public awareness of end-of-life issues. However, countries with legal endorsement of these interventions are the exception rather than the rule. A 2001 survey conducted by the Council of Europe (2003) revealed that a majority of European nations do not have laws concerning assisted suicide and euthanasia. Of those nations that do have laws, the overwhelming majority oppose the practices. A 1999 study by Luigi Grassi, Katia Magnani, and Mauro Ercolani, published in the Journal of Pain & Symptom Management, found that only 15 percent of Italian physicians favored euthanasia and assisted suicide. In Ireland, where suicide was considered a crime until 1993, discussions of euthanasia and assisted suicide have been taboo (Phillips 1997).

Euthanasia is not a legal option in Germany and physicians are obligated to prevent harm, which may also include cases of attempted suicide. However, suicide and assisted suicide are not considered criminal acts because of an artifact of German law (Schildmann, Herrmann, Burchardi, et al. 2006). This creates a precarious situation in which assisted suicide is theoretically an option for German physicians but may lead to legal sanctions if an argument is made that there was a duty to protect the patient’s life. As of 2003, open discussion on PAS and euthanasia does not exist in Bosnia-Herzegovina (Haraçic 2003), and Estonia has not engaged in a public debate surrounding end-of-life issues (Koorits 2003). In Greece, only 8.1 percent of the general public and 2.1 percent of physicians favor PAS, although 56.7 percent of the surveyed medical doctors had administered terminal sedation (Parpa, Mystajudou, Tsilika, et al. 2006). In Russia, euthanasia is seen as contrary to the physician’s duty to preserve and promote human life and is therefore considered unethical and illegal (Leenaars and Connolly 2001). In contrast, a large percentage of physicians in China may approve of euthanasia, although such acts are not officially legalized (Leenaars and Connolly 2001). In India, 50 percent of medical students favor euthanasia (Leenaars and Connolly 2001). Israeli medical doctors view euthanasia, PAS, and withdrawing of treatment as being forbidden by Jewish ethics and law; however, withholding of treatment is an accepted practice (Ganz, Benbenishty, Hersch, et al. 2006).

Issues of culture, religion, and national history are critical when attempting to explain the observed differences in beliefs about end-of-life decision-making. Several authors have hypothesized that positive attitudes toward PAS and euthanasia are the product of highly industrialized, individualistic societies (Kemmelmeier, Wieczorkowska, Erb, and Burnstein 2002). For example, an increase in positive attitudes regarding autonomy in the United States beginning in the late twentieth century has been correlated with a shift toward more positive attitudes regarding assisted suicide (Kemmelmeier, Wieczorkowska, Erb, and Burnstein 2002). In collectivistic societies such as Japan, arguments about the right to self-determination hold less appeal and end-of-life decisions are seen as prerogatives of the family as well as of the individual patient (Konishi and Davis 2001).

This picture is complicated by differences in religion. Most religions of the world uphold the sanctity of human life and prohibit actions that intentionally hasten death. Catholicism officially disapproves of euthanasia and PAS, as does the Christian Eastern Orthodox Church (Parpa, Mystajudou, Tsilika, et al. 2006). There are a variety of branches of Judaism, some of which oppose the active shortening of human life but deem interventions that artificially extend the agony of terminally ill patients unnecessary, therefore allowing withholding and withdrawing treatment (Gesundheit, Steinberg, Glick, et al. 2006). Islam does not recognize a patient’s right to die but allows for non-treatment decisions such as withholding and withdrawal of treatment to be made by the patient’s family and community (Sachedina 2005). Islamic law also condones the use of pain-reducing medication at the risk of shortening the life of a terminally ill patient (Sachedina 2005).

Views about euthanasia and PAS are further affected by national history. The term euthanasia, for example, evokes negative memories in many German-speaking countries where the term was used during the Nazi regime to refer to the systematic extermination of six million Jews and more than 200,000 mentally ill and physically disadvantaged people, as well as the Roma (Schildmann, Herrmann, Burchardi, et al. 2006) and other groups. Such historical experiences have prohibited public discussions of euthanasia in Germany (Schildmann, Herrmann, Burchardi, et al. 2006).

CONCLUSION

Given the advances in life-sustaining technology and medical treatments, the controversy surrounding end-of-life decision-making is likely to continue, at least in technologically advanced countries. Open discussion of PAS and euthanasia is complicated by a constantly evolving terminology and differing cultural, religious, and national ideals. People need to stay informed of current developments and research on these issues in order to be prepared to face the end-of-life dilemmas of the future.

SEE ALSO Death and Dying; Morbidity and Mortality; Suicide

BIBLIOGRAPHY

Adams, Maurice, and Herman Nys. 2003. Comparative Reflections on the Belgian Euthanasia Act 2002. Medical Law Review 11: 353–376.

American Association of Suicidology. 1996. Report of the Committee on Physician-Assisted Suicide and Euthanasia. Suicide and Life-Threatening Behavior 26 (suppl.): 1–19.

Colburn, Don. 2006. Death Act’s Alias Has State Tongue-Tied. The Oregonian. November 11. http://www.oregonlive.com/.

Council of Europe, Steering Committee on Bioethics. 2003. Replies to the Questionnaire for Member States Relating to Euthanasia. Strasbourg, France: Council of Europe. http://www.coe.int/t/e/legal_affairs/legal_cooperation/bioethics/activities/euthanasia/1INF(2003)8e_replies_euthanasia.pdf.

Foley, Kathleen, and Herbert Hendin, eds. 2002. The Case Against Assisted Suicide: For the Right to End-of-Life Care. Baltimore, MD: Johns Hopkins University Press.

Ganz, F. D., J. Benbenishty, M. Hersch, et al. 2006. The Impact of Regional Culture on Intensive Care End of Life Decision Making: An Israeli Perspective from the ETHICUS Study. Journal of Medical Ethics 32: 196–199.

Gesundheit, Benjamin, Avraham Steinberg, Shimon Glick, et al. 2006. Euthanasia: An Overview of the Jewish Perspective. Cancer Investigation 24: 621–629.

Grassi, Luigi, Katia Magnani, and Mauro Ercolani. 1999. Attitudes toward Euthanasia and Physician-Assisted Auicide among Italian Primary Care Physicians. Journal of Pain & Symptom Management 17: 188–196.

Haračić, Midhat. 2003. From Bosnia-Herzegovina. Palliative Medicine 17: 128.

Kemmelmeier, Markus, Grazyna Wieczorkowska, Hans-Peter Erb, and Eugene Burnstein. 2002. Individualism, Authoritarianism, and Attitudes toward Assisted Death: Cross-Cultural, Cross-Regional, and Experimental Evidence. Journal of Applied Social Psychology 32: 60–85.

Konishi, Emiko, and A. J. Davis. 2001. The Right-to-Die and the Duty-to-Die: Perceptions of Nurses in the West and in Japan. International Nursing Review 48: 17–28.

Koorits, Ursula. 2003. From Estonia. Palliative Medicine 17: 127.

Leenaars, Antoon, and John Connolly. 2001. Suicide, Assisted Suicide and Euthanasia: International Perspectives. Irish Journal of Psychological Medicine 18: 33–37.

Materstvedt, Lars, David Clark, John Ellershaw, et al. 2003. Euthanasia and Physician-Assisted Suicide: A View from an AEPC Ethics Task Force. Palliative Medicine 17: 97–101.

Parpa, Efi, Kyriaki Mystajudou, Eleni Tsilika, et al. 2006. The Attitudes of Greek Physicians and Lay People on Euthanasia and Physician-Assisted Suicide in Terminally Ill Cancer Patients. American Journal of Hospice and Palliative Medicine 23: 297–303.

Phillips, Pat. 1997. Views of Assisted Suicide from Several Nations. Journal of the American Medical Association 278: 969–971.

Quill, Timothy E., and Margaret P. Battin, eds. 2004. Physician-Assisted Dying: The Case for Palliative Care and Patient Choice. Baltimore, MD: Johns Hopkins University Press.

Sachedina, Abdulaziz. 2005. End-of-Life: The Islamic View. The Lancet 366: 774–779.

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Elena Yakunina

Jessica Richmond

James L. Werth Jr.

Euthanasia

The word euthanasia translates from Greek roots as "good death." The Oxford English Dictionary states that the original meaning, "a gentle and easy death," has evolved to mean "the actions of inducing a gentle and easy death." This definition is consistent with contemporary use of the term. For example, the Canadian Senate Special Committee on Euthanasia and Assisted Suicide defined euthanasia as "the deliberate act undertaken by one person with the intention of ending the life of another person in order to relieve that person's suffering where that act is the cause of death" (Senate of Canada 1995, p. 15). Euthanasia is generally classified in terms of certain subcategories, depending upon whether or not the person who dies by euthanasia is considered to be competent or incompetent and whether or not the act of euthanasia is considered to be voluntary, nonvoluntary, or involuntary.

Definitions of Euthanasia

Euthanasia is considered to be voluntary when it takes place in accordance with the wishes of a competent individual, whether these wishes have been made known personally or by a valid advance directive—that is, a written statement of the person's future desires in the event that he or she should be unable to communicate his or her intentions in the future. A person is considered to be competent if he or she is deemed capable of understanding the nature and consequences of the decisions to be made and capable of communicating this decision. An example of voluntary euthanasia is when a physician gives a lethal injection to a patient who is competent and suffering, at that patient's request.

Nonvoluntary euthanasia is done without the knowledge of the wishes of the patient either because the patient has always been incompetent, is now incompetent, or has left no advance directive. A person is considered incompetent when he or she is incapable of understanding the nature and consequences of the decision to be made and/or is not capable of communicating this decision. In the case of nonvoluntary euthanasia, the wishes of the patient are not known. An example of nonvoluntary euthanasia is when a doctor gives a lethal injection to an incompetent elderly man who is suffering greatly from an advanced terminal disease, but who did not make his wishes known to the physician when he was competent. Another example would be a father who asphyxiates with carbon monoxyde a congenitally handicapped child who was never considered to be competent.

Involuntary euthanasia is done against the wishes of a competent individual or against the wishes expressed in a valid advance directive. Examples of involuntary euthanasia include a son who gives a lethal overdose of medication to his father who is suffering from cancer, but the father does not want the overdose. Another example is a physician who, despite the advance directive of a patient indicating that he or she does not want any actions to hasten death, gives a lethal injection to the patient who is now unconscious and suffering from the final stages of a terminal illness.

Although the above definitions may seem clear, there is much confusion in the words used to describe euthanasia and other actions that result in hastening death. The term "mercy killing" is often used to describe situations of nonvoluntary and involuntary euthanasia. In several European countries, for example the Netherlands, the difference between euthanasia, homicide, suicide, and assisted suicide appears to be relatively clear. However, in the United States and Canada there is much confusion concerning the use of the term assisted suicide and physician-assisted suicide.

Definitions of Assisted Suicide

Assisted suicide is usually defined as a specific situation in which there is a suicide, that is, an act of killing oneself intentionally. Adding the word "assisted" to suicide implies that another person provided assistance by supplying the means (e.g., giving the person a gun or prescribing lethal medication), the knowledge (information about the use of the gun or how to take a lethal dose of medication), or both. In North America, assisted suicide has also been used in the media to refer to situations that appear to have been direct acts to end the life of a person intentionally initiated by another person. This is because assisted suicide has lesser legal sanctions than the act of killing another person even if the homicide is for the relief of pain and suffering in a terminally ill individual and can be called "euthanasia." For these reasons, Jack Kevorkian (the pathologist who made media headlines in the 1990s for his involvement in the deaths of over 130 individuals) claimed that his participation in the deaths of several patients was assisted suicide rather than euthanasia.

Sometimes there may be a fine line between what is considered assisted suicide and euthanasia. For example, during the period between July 1996 and March 1997, when euthanasia was legal in the Northern Territory of Australia, a machine was invented whereby a physician attached the patient to a computer-operated pump that contained lethal substances. Although the physician hooked up and turned on the apparatus, the lethal injection was only given after the patient responded to a question on the computer screen by pressing on a key.

Arguments in Favor of Euthanasia

Arguments in favor of euthanasia are generally based upon beliefs concerning individual liberty, what constitutes a "good" or "appropriate" death, and certain life situations that are considered unacceptable. These arguments are generally based upon moral or religious values as well as certain beliefs concerning the value and quality of human life. They also often suppose that people are capable of making rational decisions, even when they are suffering and terminally ill.

The good death. According to this view, certain ways of dying are better than others. Usually a good death is described ideally as drifting into death in a pleasing environment as one falls asleep. The ancient Roman orator and statesman Cicero said that a good death is the ideal way of respecting natural law and public order by departing from the earth with dignity and tranquility. Euthanasia can be seen as a way to assure that a person dies in a dignified and appropriate manner.

Individual liberty. In his Essay on Suicide, the eighteenth-century Scottish philosopher David Hume stated that all individuals in a free society should be able to choose the manner of their death. Some people, for example, feel that this right must be tempered by the obligation to not cause harm to others.

Right to maintain human dignity. This argument is similar to the concept of the good death, except that the objective is to avoid a poor quality of life during the dying process rather than seek out a particular idealized way of dying the good death. There are great individual differences in what constitutes a dignified way to live and die. Commonly mentioned indignities to justify premature death include: being a burden to others, living a deteriorated state incapable of normal daily activities, having to be placed in a hospital or a nursing home, and being dependent upon intrusive medical apparatus to continue living or engaging in everyday tasks. The general public often assumes that certain chronic and terminal illnesses inevitably result in a poor quality of life. However, research suggests that the psychosocial environment determines quality of life as much or more than the nature of the illness, per se.

Reduction of suffering. In 1516 the English statesman and author Sir Thomas More described euthanasia to end suffering in his book Utopia as "those that are ill from incurable diseases they comfort by sitting and talking with them, and with all means available. But if the disease is not only incurable but also full of continuous pain and anguish, then the priests and magistrates exhort the patient saying that he has become . . . irksome to others and grievous to himself; that he ought to . . . dispatch himself out of that painful life as out of a prison or torture rack or else allow his life to be ended by others" (More 1964, pp. 186–187). In 1994 the philosophy professor Margaret Battin wrote that euthanasia to reduce suffering has two components: to avoid future pain and suffering and to end current pain and suffering. This definition generally assumes that the pain is not only intolerable but interminable.

Justice. Gerald Gruman described euthanasia in order to achieve "justice" in society as "thrift euthanasia," where decisions are made to end lives of certain patients in situations where there is competition for limited resources in medical care. When there is a scarcity of certain medical resources in a society, not all people who are ill can continue to live. In such situations, one can suggest that "less valuable" individuals should give up their places to persons who contribute more to society; if they are unwilling, others should decide who should live and who should die. An extreme example is the eugenics programs based upon Darwinian concepts, such as those proposed by the German biologist Ernst Haeckel in 1904. Haeckel proposed that in order to reduce welfare and medical costs "hundreds of thousands of incurable lunatics, lepers, people with cancer" be killed by means of morphine or some other "painless and rapid poison" (1904). This approach inspired the National Socialists led by Adolf Hitler in their eugenics program.

Even if one disagrees with any form of eugenics program for economic reasons, one may still consider the fact that social pressure often exists in situations where medical resources are limited. The concept of "distributive justice"involves looking at the collective good or general welfare as something to be shared among the total membership of society. When resources are limited, society may question, for example, if it is worth expending tremendous resources to maintain the life of one incurably ill individual in a vegetative unconscious state rather than using those resources to help cure those who have promising prognoses for recovery.

Avoiding botched suicides. Molloy states that if euthanasia remains illegal, some people will be forced to attempt suicide or try to kill loved ones without any help. He contends that in some instances unsuccessful suicide attempts and botched euthanasia by others may result in a life situation that is worse than before. It can be argued that legalization of euthanasia will avoid suffering from botched attempts and the prosecution of loved ones who are acting sincerely at the request of a family member.

Control of existing practices. In countries where euthanasia is illegal there are clandestine practices by physicians and family members regardless of the laws. Proponents of euthanasia in the Netherlands often state that as long as euthanasia remains illegal in a country, physicians and other citizens will camouflage those activities and there will be no monitoring or control of what occurs. An advantage to legalizing euthanasia would be to control existing practices and ensure that there are fewer abuses.

Arguments against Euthanasia

The arguments against euthanasia include religious and ethical beliefs about the sancitity of life as well as a number of arguments allowing for euthanasia that will inevitably lead to a situation where some individuals will risk having their deaths hastened against their will.

Sanctity of human life. This belief, based upon religious values, considers human life sacred and inviolable. No person may take the life of another. For example, St. Augustine interpreted the biblical prescript against killing as being absolute, even including the taking of one's own life. Another argument for the sanctity of human life is that this constitutes one of the pillars of social order that must be maintained to avoid social breakdown. For example, St. Thomas Aquinas condemned suicide because it goes against one's obligation to oneself, the community, and God.

Wrong diagnoses and new treatments. According to this point of view, where there is life there is hope. It is possible that a terminal diagnosis is in error; some people thought to be dying from an incurable disease are victims of a mistaken diagnosis or may miraculously continue to live. Also, because of the rapid pace of advances in medical science, there may soon be a cure for diseases that are at the time of the euthanasia considered to be incurable. Thus, euthanasia may be a mistake if there is a possibility, however slight, that the person is not really going to die. For example, it can be said that many persons with AIDS (acquired immunodeficiency syndrome) who ended their life prematurely because of impending death may have continued to live for a long time because of the development of new treatments for the disease.

The Wedge or Slippery Slope. This argument maintains that when one accepts killing upon demand in certain situations, despite the best controls and regulations, there is a risk of abuses. Furthermore, there is concern that once the door is opened to justify murder under some intolerable circumstances, there is the possibility of developing broader criteria and making euthanasia more widespread. For example, in the Netherlands euthanasia and assisted suicide was first only available to those who were terminally ill. Since 1998 the regulations for euthanasia have been used to permit access to euthanasia and assisted suicide to persons who are not terminally ill but who suffer hopelessly from chronic physical or even psychological illnesses.

Protection of the weak, incompetent, and disadvantaged. This argument is similar to the Wedge or Slippery Slope argument. The concerns with the Protection of the Weak argument are that people who may be unable to make informed choices concerning euthanasia may be forced to opt for a premature death or may become victims of non-voluntary or involuntary euthanasia.

The value of suffering. Suffering may be seen as good for the soul, a heroic act, or the price to pay for one's sins in order to guarantee a better life in the hereafter. Jesus' suffering on the cross may be considered an example of an appropriate way to die. If suffering is admirable, then seeking to end suffering by euthanasia cannot be condoned.

The option of suicide is always available. Because suicide is always available and not illegal in most countries, one can argue that legalization of euthanasia is not necessary because a person can always find some means of committing suicide. Because of the dangers in legalizing euthanasia, one might instead encourage people to commit suicide rather than involving others in their deaths. One may further argue that those who "do not have the courage" to end their own lives may be too ambivalent and should not be put to death by others.

The impossibility of competent and rational decision making. The seventeenth-century philosopher Spinoza felt that the desire to survive is such an essential part of human nature that humans may not rationally prefer not to survive and kill themselves. According to this view, anyone who wants to die may not be acting rationally. Furthermore, one may question if it is possible when experiencing pain and suffering to make a rational decision before the pain and suffering is controlled. Finally, one may question whether or not most important human decision making is rational and why one should expect a person to be more rational when terminally ill. Major decisions such as choice of career, marriage partners, where to live, and whether or not to have children may be more emotional than rational. Also, there are no generally accepted criteria of what constitutes a rational argument in favor of euthanasia: What is logical and rational for one person may constitute reasons for continuing to fight against death in another person in a similar situation.

Choosing death for the wrong reasons. Many people consider euthanasia because they are experiencing pain and suffering. Ignorance of the availability of interventions to reduce pain and suffering may lead to a choice to end life. People involved in palliative care programs that focus upon reducing the suffering of terminally ill patients contend that better pain control and improvement of the psychosocial situation can alleviate a large proportion of the suffering and reduce the desire for euthanasia.

Undiagnosed clinical depression. It may be considered appropriate for people who are dying to feel sad and unhappy. However, some terminally ill persons may suffer from a more severe and potentially treatable psychiatric syndrome of clinical depression. In some instances, the depression may be a side effect of treatment of the illness or may be related to the psychosocial environment of an institution. According to this view, accurate diagnosis and treatment with antidepressant medication and/or psychotherapy is a preferable option to euthanasia.

Erosion of confidence in physicians. According to this argument, if physicians are allowed to kill some terminally ill patients then confidence in physicians may be diminished. Medical practictioners and proponents of this argument have suggested that only "specialists" should practice euthanasia if it is legalized so that physicians can maintain their reputation as advocates in the fight against death and the reduction of pain and suffering.

Compromising the right to choose by involving others in one's death. Brian Mishara has argued that humans generally experience tremendous ambivalence about ending their lives by suicide, so much so that most highly suicidal people change their minds before an attempt and the vast majority of persons who initiate a suicide attempt do not die from their attempt. He questions whether the involvement of a physician in ending a person's life may create a social situation where there is tremendous pressure to complete the suicidal act and die rather than exercising the choice to continue to live. Once a physician has been convinced that euthanasia is acceptable and appropriate, it is not easy for a person to admit to the doctor that he or she is feeling ambivalent or scared and would like to put off the decision for a while. This analysis suggests that involving others in death can compromise people's rights to change their minds because of the social pressures to complete the act.

The Situation in the Netherlands

In the Netherlands, the practice of euthanasia and assisted suicide was legalized by legislative decree in November 2000. However, the practice of euthanasia has been tacitly condoned by jurisprudence since 1973. In 1973 a doctor was found guilty of giving her seventy-nine-year-old mother a lethal injection after repeated requests to end her suffering. The doctor was placed on probation for a year but this case generated considerable sympathy for the doctor and resulted in the Royal Dutch Medical Association producing a working paper on the topic. Furthermore, the Supreme Court of The Netherlands set out a number of considerations that would have to be met before an accused would be exonerated of euthanasia. Subsequently, the practice developed to not prosecute cases of euthanasia that respected those court guidelines. They include:

• • The request for euthanasia must come from the patient and be completely voluntary, well considered, and persistent.
• • The patient must have adequate information about his or her medical condition, the prognosis, and alternative treatments.
• • There must be intolerable suffering with no prospect for improvement, although the patient need not be terminally ill.
• • Other alternatives to alleviate the suffering must have been considered and found ineffective, unreasonable, and unacceptable to the patient.
• • The euthanasia must be performed by a physician who has consulted an independent colleague.
• • The physician must exercise due care, and there should be a written record of the case.
• • The death must not be reported to the medical examiner as a natural death.

There is tremendous popular support in the Netherlands for the practice of euthanasia and the legal precedents have now been passed into law by Parliament. Several studies have been conducted on the nature of the practice of euthanasia and assisted suicide as well as possible abuses. Most cases of euthanasia occur among terminally ill persons in the advanced stages of their disease and it is rare that the criteria are not respected. However, in the Netherlands there are no monetary considerations concerning the cost of health care because there is a socialized medical program. Furthermore, the society in the Netherlands is very different from many other societies because of the strong emphasis upon individual freedom of choice and limited government control.

The Euthanasia Act in the Australian Northern Territories

The parliament of the Northern Territory in Australia passed the Rights of the Terminally Ill (ROTI) Act in May 1995, which was in effect for nine months from July 1, 1996, to March 25, 1997, when the act was repealed by legislation passed by the parliament of Australia. The ROTI Act allowed a terminally ill patient who was experiencing what he or she deemed to be unacceptable levels of pain, suffering, and/or distress to request the medical practitioner to end his or her life by euthanasia, if the requirements of the law were met. The law stipulated that besides suffering and being terminally ill, the patient must be at least eighteen years old, there must be no cure available, no other palliative care options to alleviate the suffering available, and a second opinion as well as a psychiatric assessment to confirm that he or she is not suffering from a treatable clinical depression.

After the law was passed, five persons who officially sought to use the act received extensive media attention. Although the intention of the law was to allow for a patient's personal physician to provide assistance to terminate life as part of their care, only one physician in the territory accepted to participate in euthanasia practices: Philip Nitschke. During the period that the act was in effect, seven cancer patients applied for euthanasia with Nitschke. Four of the seven died by euthanasia; one committed suicide; one died a natural death; and another died from the effects of pain relief sedation.

The Oregon Death with Dignity Act

In November 1994 the Death with Dignity Act was adopted by a referendum vote of Oregon residents of 51 percent against 49 percent. Soon after the act was passed, the act was contested on the grounds that it presumably threatened the lives of terminally ill persons and did not afford them equal protection. A judge granted an injunction on the grounds that the act put people at risk. However, in 1997, the injunction was lifted by the Ninth Court of Appeals, which dismissed the case. The law went into effect in 1997 after the U.S. Supreme Court declined to hear an appeal of the case. A second referendum in November 1997 found 60 percent in favor and 40 percent against this law. In November 2001 the U.S. Attorney General John Ashcroft issued a directive that would have prohibited doctors from prescribing lethal doses of controlled drugs to terminally ill patients. Immediately after issuing the directive, the U.S. District Court in Portland issued a temporary restraining order blocking Ashcroft from punishing physicians who wrote lethal prescriptions. In April 2002 the same court ruled that Ashcroft had over-stepped the authority of the Federal Controlled Substances Act when he declared that writing lethal prescriptions was not a legitimate medical purpose and threatened to revoke the license of physicians who wrote lethal-dose prescriptions to patients who requested one. This decision made the restraining order on Ashcroft permanent; however, as of this writing, the decision may be subject to appeal.

According to this law there are four criteria necessary for an assisted suicide to be conducted in the state of Oregon: (1) the person must be at least eighteen years old, (2) a legal resident of Oregon, (3) able to communicate his or her decisions about medical care, and (4) in the terminal phase of an illness that is defined as having a life expectancy of less than six months. If the patient is eligible, the request must be made twice in less than fifteen days and the request must be made in writing to a physician who then establishes that all the conditions have been met. A second physician must be consulted, and the first physician must inform the patient of all alternatives available. The physician can request that the person inform family members about the request, but this is not obligatory. The physician may then prescribe a lethal medication, which he or she must declare to the Oregon Health Division. This physician has no obligation to participate in the assisted suicide and is protected against any criminal liability under this act.

During the first four years since the law was applied (1998–2000), 140 prescriptions for lethal doses of medication were written, mainly to cancer patients, and 91 persons died after taking these medications. This constitutes fewer than one-tenth of 1 percent of terminally ill Oregonians dying by physician-assisted suicide.

Conclusions

Arguments for or against active euthanasia that are based upon moral or religious beliefs are impossible to resolve on the basis of empirical facts or logical arguments; these arguments are related to cultural values and practices. However, values and practices can change over time. Some practices that were considered barbaric at one time in history have become acceptable in the twenty-first century. The practice of euthanasia, its legalization, and acceptance in various societies is also influenced by public debate and media reports. With the increased acceptance and legalization of euthanasia in different societies, researchers are gaining more information about the practice of euthanasia and its effects. One of the central issues in the acceptance of euthanasia is weighing society's obligations to provide an easier access to death against society's obligations to provide the means for diminishing pain and suffering among those who may want to die prematurely by euthanasia.

See also: Bioethics; Black Stork; Good Death, The; Informed Consent; Kevorkian, Jack; Natural Death Acts; Suicide Types: Physician-Assisted Suicide

Bibliography

Battin, Margaret P. The Least Worst Death: Essays on Bioethics on the End of Life. New York: Oxford University Press, 1994.

Chin, Arthur E., et al. Oregon's Death with Dignity Act: The First Year's Experience. Portland: Department of Human Services, Oregon Health Division, Center for Disease Prevention and Epidemiology, 1999.

Cicero. Cato Maior de senectute, edited by J.G.F. Powell. Cambridge: Cambridge University Press, 1988.

Gruman, Gerlad J. "An Historical Introduction to Ideas about Voluntary Euthanasia: With a Bibliographic Survey and Guide for Interdisciplinary Studies." Omega: The Journal of Death And Dying 4, no. 2 (1973):87–138.

Haeckel, Ernst. The Wonders of Life: A Popular Study of Biological Philosophy, translated by J. Mc Cabe. New York: Harper, 1904.

Hume, David. An Essay on Suicide. 1789. Reprint, Yellow Springs, OH: Kahoe and Co., 1929.

Kasimar, Yale. "Euthanasia Legislation: Some Non-Religious Objections." In T. L. Beauchamp and P. Seymour eds., Ethical Issues in Death and Dying. Englewood Cliffs, NJ: Prentice Hall, 1978.

Mishara, Brian L. "The Right to Die and the Right to Live: Perspectives on Euthanasia and Assisted Suicide." In A. Leenaars, M. Kral, R. Dyck, and S. Wenckstern eds., Suicide in Canada. Toronto: University of Toronto Press, 1998.

Molloy, William. Vital Choices: Life, Death and the Health Care Crisis. Toronto: Penguin Books, 1993.

More, Sir Thomas. Utopia. 1605. Reprint, New Haven, CT: Yale University Press, 1964.

Saint Augustine of Hippo. Augustine: The City of God, edited by T. Merton and translated by M. Dods. New York: Modern Library, 1950.

Senate of Canada. On Life and Death: Report of the Senate Special Committee on Euthanasia and Assisted Suicide. Ottawa: Minister of Supply and Services, 1995.

Spinoza, Benedictus. The Ethics, translated by R. H. M. Elwes. 1677. Reprint, New York: Dover Publications, 1951.

BRIAN L. MISHARA

EUTHANASIA

[Greek, good death.] The term normally implies an intentional termination of life by another at the explicit request of the person who wishes to die. Euthanasia is generally defined as the act of killing an incurably ill person out of concern and compassion for that person's suffering. It is sometimes called mercy killing, but many advocates of euthanasia define mercy killing more precisely as the ending of another person's life without his or her request. Euthanasia, on the other hand, is usually separated into two categories: passive euthanasia and active euthanasia. In many jurisdictions, active euthanasia can be considered murder ormanslaughter, whereas passive euthanasia is accepted by professional medical societies, and by the law under certain circumstances.

Passive Euthanasia

Hastening the death of a person by altering some form of support and letting nature take its course is known as passive euthanasia. Examples include such things as turning off respirators, halting medications, discontinuing food and water so as to allowing a person to dehydrate or starve to death, or failure to resuscitate.

Passive euthanasia also includes giving a patient large doses of morphine to control pain, in spite of the likelihood that the painkiller will suppress respiration and cause death earlier than it otherwise would have happened. Such doses of painkillers have a dual effect of relieving pain and hastening death. Administering such medication is regarded as ethical in most political jurisdictions and by most medical societies.

These procedures are performed on terminally ill, suffering persons so that natural death will occur sooner. They are also commonly performed on persons in a persistent vegetative state; for example, individuals with massive brain damage or in a coma from which they likely will not regain consciousness.

Active Euthanasia

Far more controversial, active euthanasia involves causing the death of a person through a direct action, in response to a request from that person. A well-known example of active euthanasia was the death of a terminally ill Michigan patient on September 17, 1998. On that date, Dr. jack kevorkian videotaped himself administering a lethal medication to Thomas Youk, a 52-year-old Michigan man with amyotrophic lateral sclerosis. CBS broadcast the videotape on 60 Minutes less than a week later. Authorities subsequently charged Kevorkian with first-degree premeditated murder, criminal assistance of a suicide, and delivery of a controlled substance for administering lethal medication to a terminally ill man. There was no dispute that the dose was administered at the request of Mr. Youk, nor any dispute that Mr. Youk was terminally ill. A jury found Kevorkian guilty of second-degree murder in 1999. He was sent to prison.

Physician-Assisted Suicide

Somewhat of a hybrid between passive and active euthanasia is physician-assisted suicide (PAS), also known as voluntary passive euthanasia. In this situation, a physician supplies information and/or the means of committing suicide (e.g., a prescription for lethal dose of sleeping pills, or a supply of carbon monoxide gas) to a person, so that that individual can successfully terminate his or her own life.

Physician-assisted suicide received greater public attention after Dr. Kevorkian, a retired pathologist from Michigan, participated in his first such procedure in 1990. Kevorkian set up a machine that allowed a 54-year-old woman suffering from Alzheimer's disease (a degenerative neurological condition) to press a button that delivered a lethal poison into her veins. Kevorkian went on to assist in the suicides of dozens of individuals suffering from terminal, debilitating, or chronic illnesses. In 1992, Michigan passed an assisted-suicide bill (Mich. Comp. Laws § 752.1021) that was specifically designed to stop Kevorkian's activities, but technicalities and questions as to its constitutionality delayed its implementation, thus allowing Kevorkian to continue assisting suicides—often in direct opposition to court injunctions.

Kevorkian was charged with murder several times but was not initially found guilty. When murder charges were brought against him for his first three assisted suicides, for example, they were dismissed because Michigan, at that time, had no law against assisted suicide. In 1994, Kevorkian was tried and found not guilty of assisting in the August 1993 suicide of Thomas W. Hyde Jr. In December 1994, however, Michigan's supreme court ruled in People v. Kevorkian, 447 Mich. 436, 527 N.W. 2d 714, that there is no constitutional right to commit suicide, with or without assistance, and upheld the Michigan statute that made assisted suicide a crime. The following year, the U.S. Supreme Court refused to hear Kevorkian's appeal from the state supreme court's ruling.

Observers disagree about the humanity of Kevorkian's activities. Some see him as a hero who sought to give suffering people greater choice and dignity in dying. Others point to his lack of procedural precautions and fear that the widespread practice of assisted suicide will lead to the unnecessary death of people who could have been helped by other means, including treatment for depression. Many opponents of assisted suicide find the same faults in the practice that they see in other forms of euthanasia. They envision its leading to a devaluation of human life and even to a genocidal killing of vulnerable or so-called undesirable individuals.

The U.S. Supreme Court has made two important rulings on assisted suicide. In washington v. glucksberg, 521 U.S. 702, 117 S.Ct. 2258, 138 L.Ed.2d 772, 65 (1997), three terminally ill patients, four physicians, and a non-profit organization had brought action against the state of Washington for declaratory judgment, that a statute banning assisted suicide violated due process clause. On June 26, 1997, the Supreme Court unanimously upheld the right of states to prohibit assisted suicide, holding that: (1) asserted right to assistance in committing suicide was not a fundamental liberty interest protected by due process clause, and (2) Washington's ban on assisted suicide was rationally related to legitimate government interests. In Vacco v. Quill, 521 U.S. 793, 117 S.Ct. 2293, 138 L.Ed.2d 834 (1997), physicians challenged the constitutionality of New York statutes making it a crime to aid a person in committing suicide or attempting to commit suicide. The Supreme Court held that New York's prohibition on assisting suicide did not violate the equal protection clause of the fourteenth amendment.

Involuntary Euthanasia

The term involuntary euthanasia is used to describe the killing of a person who has not explicitly requested aid in dying. This term is most often used with respect to patients who are in a persistent vegetative state and who probably will never recover consciousness.

Euthanasia Considerations

Euthanasia is a divisive topic, and different interpretations of its meaning, practice, and morality abound. Those who favor active euthanasia and a patient's right to die, do not acknowledge a distinction between active and passive euthanasia. They assert that the withdrawal of life-sustaining treatment cannot be distinguished in principle from affirmative steps to hasten a patient's death. In both situations, they argue, a person intends to cause the patient's death, acts out of compassionate motives, and causes the same outcome. In their view, turning off a life-sustaining respirator switch and giving a lethal injection are morally equivalent actions.

Opponents of active euthanasia argue that it undermines the value of, and respect for, all human life; erodes trust in physicians; desensitizes society to killing; and contradicts many people's religious beliefs. Moreover, they maintain that the intentions and natures of active and passive euthanasia are not essentially the same. In active euthanasia, a person directly intends to cause death and uses available means to achieve this end. In passive euthanasia, a person decides against using a certain form of treatment and then directs that such treatment be withdrawn or withheld, accepting but not intending the patient's death, which is caused by the underlying illness.

While people cite differing reasons for choosing to end their own lives, those suffering from a terminal illness typically state that a serious disorder or disease has adversely affected their quality of life to the point where they no longer wish to continue living. Under such circumstances, patients may have been diagnosed with a degenerative, progressive illness such as ALS, Huntington's disease, multiple sclerosis, AIDS, or Alzheimer's disease. Patients with such illnesses often fear, with good reason, a gradual loss of the quality of life in the future as the disease or disorder progresses, or they might already have lost a good deal of their independence and thus might require continuous care. Some feel that this loss of autonomy causes an unacceptable loss of personal dignity. Others realize that they will be dying in the near future and simply want to have total control over the process. Some point out that in addition to physical considerations, they do not want to diminish their assets by incurring large medical costs as their death approaches. They feel that they ought to have the option to die sooner and to pass on their assets to their beneficiaries.

Euthanasia and Physician-Assisted Suicide

Imagine that you are suffering from a disease that is terminal, debilitating, and very painful. Should you have the right to die when you wish rather than live in continued agony? Should your doctor be legally free to help you take your own life, perhaps by prescribing some pills and telling you their fatal dosage? Or should the law forbid anyone—including doctors—to assist in the suicide of another human being? These are just some of the questions that surround the issue of physician-assisted suicide, a widely debated ethical issue in modern medicine.

Physician-assisted suicide is a form of voluntary euthanasia. In other words, it involves a patient voluntarily acting to end his or her life. Physician-assisted suicide differs from conventional suicide in that it is facilitated by a physician who confirms the patient's diagnosis, rules out conditions such as depression that may be clouding the patient's judgment, and finally provides the means for committing suicide. Such action usually consists of taking a lethal overdose of prescription medication. However, the over 130 patients who were assisted by Dr. jack kevorkian between 1990 and 1998 chose to press a button which delivered a lethal poison into their veins, or to put on a mask that emitted carbon monoxide into their lungs. Assisted suicide is a felony offense in most states and is also expressly forbidden in the American Medical Association's (AMA's) Code of Medical Ethics. In 1999, Kevorkian was found guilty of second-degree murder in an assisted suicide case. He was sentenced to serve 10 to 25 years.

The debate surrounding physician-assisted suicide in the United States has been influenced by medical practices in other countries, particularly the Netherlands, which legalized both active euthanasia and physician-assisted suicide, in April 2001 (effective 2002). Physician-assisted suicide in the Netherlands is conducted within strict guidelines that include the following requirements: the patient's request for assisted suicide must be voluntary, the patient must be experiencing intolerable suffering, all other alternatives for treatment must have been explored, and the physician must consult another independent physician before proceeding. A study commissioned by the Dutch government indicated that, in 2001, about 3,500 deaths, or 2.5 percent of the 140,000 death cases that were reported in the Netherlands that year, occurred by active euthanasia. The study, known as the Remmelink Report, defined euthanasia as the termination of life at the patient's request. Figures also indicated that 300 deaths, or 0.2 percent, were caused by physician-assisted suicide.

In the United States, the debate on legalizing assisted suicide began in earnest in the 1970s. On one side of the debate have been patients' rights groups who have lobbied for what they call the right to die—or the right to choose to die, as some have clarified it— of terminally ill patients. The strongest opposition to the legalization of physician-assisted suicide has come from physicians' groups such as the AMA and from religious groups that are morally opposed to the practice.

One person who has done much to make the case for physician-assisted suicide is Derek Humphry, a former journalist who founded the Hemlock Society, in 1980, after seeing the pain and suffering his first wife experienced when she died from cancer. In 2003, the organization changed its name to End-of-Life Choices, which encompasses more clearly the issues supported by its members. With a new name and a new motto, "Dignity Compassion Control," the organization continues to advocate for the right of terminally ill people to choose voluntary euthanasia, or what Humphry has termed self-deliverance.

Humphry has written several books on the subject of voluntary euthanasia, including Jean's Way (1978), which recounts his struggle to assist his wife's death in 1975; Final Exit: The Practicalities of Self-Deliverance and Assisted Suicide for the Dying (1991), a controversial book that gives detailed advice on how terminally ill people may take their own life; and Lawful Exit: The Limits of Freedom for Help in Dying (1993), which contains Humphry's own recommendations for legislation that would legalize physician-assisted suicide and active voluntary euthanasia. In Humphry's words, the "right to choose to die" is "the ultimate civil liberty."

Humphry presents physician-assisted suicide as a merciful, dignified option for people whose illness has eroded their quality of life beyond the limits of tolerance. He also points out that what he calls beneficent euthanasia occurs every day in medical facilities as physicians make decisions regarding the end of life. Others, including some medical ethicists, go so far as to claim that a decision to withhold antibiotics, oxygen, or nutrition from a terminally ill patient is no less "active" a form of euthanasia than is administering a fatal dose of morphine. Indeed, they see the common practice of withholding life support as more open to potential abuse than the practice of physician-assisted suicide. The former, they argue, is a less visible, less easily regulated decision. Proponents of physician-assisted suicide also claim that diseases kill people in far more cruel ways than would any means of death that a physician might provide for an irreversibly ill patient. As a result, they see the action of assisting in suicide as entirely compatible with the physician's duty to the patient.

However, Humphry has been an open critic of Kevorkian's work. He has described Kevorkian's theory and practice of assisted suicide as open-ended euthanasia. Noting Kevorkian's lack of precautionary measures such as the use of waiting periods and second opinions, Humphry sees any wider application of Kevorkian's methods as potentially leading to abuse and tragedy. "The thinking people in our movement are appalled by it," Humphry said. "If you have Kevorkian's type of euthanasia, it will be a slippery slope. Kevorkian's is a recipe for skiing down a glacier."

Detractors of physician-assisted suicide also use the familiar "slippery slope" argument, proposing that once physician-assisted suicide is legalized, other forms of euthanasia will more likely be practiced as well. They see assisted suicide as potentially leading to situations in which elderly, chronically ill, and handicapped people, along with others, are killed through active, nonvoluntary euthanasia. Related to this idea is the view that widespread practice of physician-assisted suicide might claim the lives of those whose intolerable suffering is caused by treatable depression. They point out that terminally ill people or others in pain are often also suffering from depression, and that despite their illness, their feelings of hopelessness can often be addressed through means such as counseling and antidepressant medication.

The Catholic Church is one of many religious organizations that opposes euthanasia and assisted suicide. In Pope John Paul II's words, medical killings such as those caused by assisted suicide are "crimes which no human law can claim to legitimize." Basing its arguments on passages from the Bible, Catholic theology has for many centuries opposed all forms of suicide. Catholicism argues that innocent human life may not be destroyed for any reason whatsoever.

The debate over physician-assisted suicide eventually reached the Supreme Court. In 1994, an advocacy group known as Compassion in Dying filed two lawsuits (Compassion in Dying et al v. Washington and Quill et al v. Vacco) challenging the constitutionality of state laws banning assisted dying in Washington and New York. Compassion in Dying won in the District Court in Washington. Chief Judge Barbara Rothstein wrote, "There is no more profoundly personal decision, nor one which is closer to the heart of personal liberty, than the choice which a terminally ill person makes to end his or her suffering and hasten an inevitable death." In New York, Compassion in Dying lost and filed an appeal in the Second Circuit.

In 1995, Washington's Compassion ruling was overturned by the Ninth Circuit Court of Appeals, reinstating the anti-suicide law. In 1996, however, after reconsideration, the Ninth Circuit Court of Appeals issued a reversal decision in Compassion v. Washington. That decision held that assisted dying was protected by liberty and privacy provisions of the U.S. Constitution. The majority wrote that, "Those who believe strongly that death must come without physician assistance are free to follow that creed, be they doctors or patients. They are not free, however, to force their views, their religious convictions, or their philosophies on all the other members of a democratic society, and to compel those whose values differ with theirs to die painful, protracted, and agonizing deaths."

In April 1996, the Second Circuit joined the Ninth in recognizing constitutional protection for assisted dying in the Quill case, holding that the New York statutes criminalizing assisted suicide violate the equal protection clause of the fourteenth amendment. However, on June 26, 1997, the U.S. Supreme Court reversed both the Ninth and Second Circuit Court in washington v. glucksberg, 521 U.S. 702, 117 S.Ct. 2258, 138 L.Ed.2d 772 (1997) and Vacco v. Quill, 521 U.S. 743, 117 S.Ct. 2293, 138 L.Ed.2d 834 (1997). The Court ruled that state laws against assisting a suicide are not unconstitutional, but also stated that patients have a right to aggressive treatment of pain and other symptoms, even if the treatment hastens death. The Court wrote, "Throughout the Nation, Americans are engaged in an earnest and profound debate about the morality, legality and practicality of physician assisted suicide. Our holding permits this debate to continue, as it should in a democratic society."

Ultimately then, the voters and representatives of the states and the legal system itself will have to decide whether or not physician-assisted suicide will be legalized. Regardless of what side prevails in the debate, the exchange of ideas that it creates may lead to a greater understanding of the difficult choices surrounding death in our time.

further readings

Cohen-Almagor, Raphael. 2001. The Right to Die With Dignity: An Argument in Ethics, Medicine, and Law. New Brunswick, N.J.: Rutgers Univ. Press.

End of Life Choices. Available online at <www.endoflifechoices.org> (accessed August 25, 2003).

Hendin, Herbert. 2002. "The Dutch Experience." Issues in Law & Medicine (spring).

cross-references

Death and Dying; Physicians and Surgeons.

Some patients who decide that they wish to commit suicide are unable or unwilling to accomplish the act without assistance from their physician. Physician-assisted suicide helps them to die under conditions, and at the time, that they wish. PAS is currently legal in the U.S., only in the state of Oregon, under severe restrictions. In other states, a terminally ill patient who wishes to die must continue living until their body eventually collapses, or until a family member or friend commits a criminal act by helping them to commit suicide.

Historical Considerations

Traditional Christian beliefs concerning all forms of suicide were well documented by Thomas Aquinas during the thirteenth century. He condemned all suicide (whether assisted or not) on the theory that it violated one's natural desire to live. Among European writers, Michel de Montaigne was the first major dissenter on this issue. During the sixteenth century, he wrote a series of essays arguing that suicide should be a matter of personal choice, a human right. He concluded it to be a rational option under certain circumstances.

Attempting to commit suicide was once a criminal act. It has been decriminalized for many decades in most jurisdictions. However, assisted suicide remains a criminal act throughout the United States, with the exception of the state of Oregon. In that state, it is permitted under tightly controlled conditions.

Oregon's Euthanasia Law

In 1994, voters in the state of Oregon approved a ballot measure that would have legalized euthanasia under limited conditions. Under the Death With Dignity law, a person who sought physician-assisted suicide would have to meet certain criteria:

• The person must be terminally ill.
• The person must have six months or less to live.
• The person must make two oral requests for assistance in dying.
• The person must make one written request for assistance in dying.
• The person must convince two physicians that he or she is sincere and not acting on a whim, and that the decision is voluntary.
• The person must not have been influenced by depression.
• The person must be informed of "the feasible alternatives," including, but not limited to, comfort care, hospice care, and pain control.
• The person must wait for 15 days.

Under the proposed law, a person who met all requirements could receive a prescription of a barbiturate that would be sufficient to cause death. Physicians would be prohibited from inducing death by injection or carbon monoxide.

The national right to life committee, supported by the Roman Catholic Church, obtained a court injunction to delay implementation of the measure. The law stalled in the appeals process. In the meantime, the measure was not enacted. In 1997, there was a second public referendum, and the law was enacted. Within 24 hours of the announcement of the results, state officials had forms for physicians to record instances of assisted suicide. These were later distributed to physicians in the state. The form is entitled "Request for Medication to End My Life in a Humane and Dignified Manner."

Immediately after the law was affirmed, Thomas Constantine, the administrator of the federal drug enforcement administration (DEA), wrote a policy statement which said that prescribing drugs to help terminally ill patients kill themselves would be a violation of the Controlled Substances Act. Nevertheless, on March 26, 1998, a woman in her mid-eighties died from a lethal dose of barbiturates, which had been prescribed by her doctor under the Oregon law. She was the first person to publicly use the law to commit suicide. She had been fighting breast cancer for 20 years and recently had been told by her doctor that she had less than two months to live. She had been experiencing increased difficulty breathing. She made a tape recording in which she stated, "I'm looking forward to it. I will be relieved of all the stress I have." Her personal doctor would not help her end her life, so she turned to an advocacy group, Compassion in Dying. That group located a doctor to assist her. She fell into a deep sleep about five minutes after taking the lethal dose of pills, and she died peacefully about 25 minutes later. Attorney General janet reno officially reversed Constantine's ruling a few weeks later, stating that doctors who use the law to prescribe lethal drugs to terminally ill patients will not be prosecuted and that drug laws were intended to block illegal trafficking in drugs, not to cover situations like the Oregon suicide law.

Despite significant controversy, by the end of 1998, one prediction of the anti-choice forces had not materialized: there was no rush of people to Oregon to seek an easy end to life. While it was predicted that many would take advantage of the law, of the 23 terminally ill individuals who applied to end their own lives in 1998, 15 committed suicide, usually within a day of receiving the prescription. Six died from their illnesses without using the medication. Two remained alive at the end of 1998. From 1998 to 2002, 129 people have opted for physician assisted suicide.

In early 2001, Oregon state senator Ron Wyden wrote Attorney General john ashcroft asking that the george w. bush administration not mount an attack on the state law permitting assistance in suicide. Ashcroft wrote a letter to Asa Hutchinson, chief of the Drug Enforcement Administration. He declared that assisting a terminally ill patient to commit suicide is not a "legitimate medical purpose" for federally controlled drugs. He said that physicians who use drugs to help patients die face suspension or revocation of their licenses to prescribe federally controlled drugs. This was contrary to the position taken by Janet Reno, his predecessor. The attorney general of Oregon, Hardy Myers, quickly initiated a lawsuit to have the Ashcroft's directive declared unconstitutional. The federal district court in Oregon issued a temporary injunction, which prevents the federal government from enforcing Ashcroft's interpretation of the Controlled Substances Act (CSA). The state of Oregon requested that the court block the federal department of justice from taking legal action against Oregon doctors who prescribe medication to help their patients commit suicide. A federal judge ruled in favor of the state law in 2002, and the Department of Justice appealed the decision to the U.S. Court of Appeals for the Ninth Circuit. Both sides have stated that they will appeal the decision if they lose.

Other States

According to the online website, Euthanasia.com, 35 states have legislated against assisted suicide, while nine other states have cited it as a crime under common law. Still more states have introduced or passed statutes criminalizing assisted suicide. These statutes forbid a person to knowingly assist or aid another in committing suicide. Some also prohibit soliciting, advising, or encouraging another to commit suicide. Some statutes penalize assisted suicide under guidelines established for murder or manslaughter, whereas others make it a unique offense with separate penalties. Few courts have interpreted the assisted-suicide statutes, because prosecutions for assisted suicide are rare. In cases of assisted suicide, a state usually prosecutes individuals for murder or manslaughter. The Ohio state supreme court, however, ruled in 1996 that assisted suicide is not a crime.

further readings

Behuniak, Susan M. 2003. Physician-Assisted Suicide: The Anatomy of a Constitutional Law Issue. Lanham, Md.: Rowman & Littlefield.

Dyck, Arthur J. 2001. When Killing Is Wrong: Physician-Assisted Suicide and the Courts. Cleveland, Ohio: Pilgrim Press.

Euthanasia.com. Available online at <www.euthanasia.com> (accessed November 10, 2003).

Palmer, Larry I. 2000. Endings and Beginnings: Law, Medicine, and Society in Assisted Life and Death. Westport, Conn.: Praeger.

cross-references

Death and Dying.