The terms ‘lethal injection,’ ‘physician-assisted suicide,’ ‘mercy killing,’ ‘death with dignity,’ and more are all turns of phrase commonly interchanged. But, do they really mean the same thing? How do people today view this kind of death? Is it moral? It is these kinds of questions that commonly circulate around the conversation of assisted death.
Euthanasia and Physician-Assisted Suicide (PAS) are two terms that are most frequently and incorrectly exchanged. Both fall under the larger umbrella of assisted death. Euthanasia, however, is specifically defined as a “deliberate intervention undertaken with the express intention of ending a life in order to relieve intractable suffering” . Within that, there are two different types of euthanasia: active and passive. In active euthanasia, one directly and intentionally causes the death of the patient. Passive euthanasia, on the other hand, causes death of a patient through the withholding or removal of life support. Assisted suicide, or PAS, is known as when a physician provides assistance and the means of death to people that are looking to hasten their passing. There is often a blurred line between these assisted death cases.
Jack Kevorkian, for example, was a physician who facilitated the suicide of several people under his care. If a terminally ill patient requested his help, he attached a “homemade suicide machine” that injected a lethal dose of drugs when activated. Since he technically did not directly cause the death, he evaded criminal conviction until he finally did personally administer the drug to a patient without any arms or legs. Due to illegality, Kevorkian was convicted of second degree murder by voluntary active euthanasia . There is a third type of assisted death―palliative sedation―which is when, with consent, a patient is sedated to the point of unconsciousness/death to prevent further pain and suffering. Most of the modern controversy lies around PAS and euthanasia, with PAS being much more widely accepted. In contrast, euthanasia is strongly debated by many people in the modern medical and public world alike.
Regarding the medical field today, euthanasia is largely controversial. There lies a difference between moralities and doctoral obligation for physicians requested to do the task. In one study, 256 physicians in Rhode Island were asked questions regarding their thoughts on euthanasia; all were asked to simulate a scenario in which a patient with respiratory problems was reaching respiratory failure. From the study, 86% agree to give the patient narcotics that would ease his/her suffering and possibly cause respiratory compromise, 59% agreed that they would turn the respirator off if the patient was wholly dependent with no hope of coming off, 9% agreed to give the patient a lethal prescription amount to end his/her life, and 1% agreed to administer lethal injection. This provides interesting results―neither PAS nor euthanasia are entirely popular among such physicians surveyed, but very few agreed to physically carry out the task. However, 28% of respondents agreed that they would comply with more requests if lethal administration was legal.
For hundreds of years, the topic of euthanasia has been under debate in the scientific community. A main argument that has prevailed among those against it is the fact that euthanasia disobeys one of the main oaths one takes when one becomes a doctor. The Hippocratic Oath, originally from the time of Hippocrates from 460-377 B.C., is credited with the clause “do no harm.” This standard was typically recited at the end of a medical student’s graduation . It has since been modernized but is currently known to be:
“Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty.” 
This oath, in short, declares that a physician will not take the life of his/her patient. It is for this role as a professional that many healthcare providers today are against or hesitant to readily carry out the action of euthanasia.
Among the medical community, autonomy is a term that is undisputedly vital in the actions of a physicians. Patient autonomy is the idea that doctors have an obligation to “provide competent patients with the opportunity to make an informed decision about their medical treatment”―in short, informed consent . Determining the autonomy of end-of-life decisions is commonly ambiguous in the medical field, but to the majority, the patient’s wishes regarding life and death issues should usually be followed. This is either with or without the physician’s support behind the decision. Those who would not comply simply justify their withholding to their moral beliefs/obligations. It is interesting to observe that when the death of the patient is indirect, many more are likely to respect patient autonomy than if the death was directly caused (lethal pain medication dosage & lethal injection). This puts controversy in the belief that the physicians’ first priority is the wishes of those being treated.
The ethics of autonomy and other viewpoints on euthanasia play a significant role in how it is viewed by the modern community. The word ‘euthanasia’ itself can have differing definitions, and it may seem unclear to the general public what it actually is. The word ‘euthanasia’ is “derived from the Greek eu and thanatos, which translates as ‘good death’ or ‘dying well,’” which gives the connotation of positivity . Descriptions of euthanasia contrast the positive roots of the word due to the darkness in ending a life. A portion of the negative modern stigma towards euthanasia is derived from the possibility that it may be forcing death upon an unwilling participant, either against their will, not knowing their will, or with a lack of consent from the patient. Death and dying generally creates grief in the American society, causing a lack of support for the act.
When creating legislation for euthanasia, the ethical principle of autonomy is paramount. Autonomy is the notion that the people should be able to make the choices for their own lives as much as possible. In the United States, there is a lack of uniform law for euthanasia, unlike countries such as the Netherlands and Belgium. This lack in decision leads to deep debates about what should be done. After all, the morals of a physician can align with aiding “in any way possible to prolong life and to heal, not to take life away,” where “many physicians refuse to practice euthanasia and it is often difficult to find someone who will do it” . With that said, the United States does not authorize euthanasia based on the previously mentioned standards for physicians. Instead, there is an option of PAS that can be taken advantage of in a few states―California, Colorado, Hawaii, Montana, Oregon, Vermont, and Washington―but this statute only allows for the prescription of life ending medication to be written, not to be administered by the physician themselves . This is where the definition of euthanasia can be murky, as the United States may not technically have a policy for euthanasia in place, but physicians in some states can still assist in aid-in-dying. The unclear policy is unfair to the public because it can be seen as deceiving, triggering concern for people who can no longer make autonomous decisions and the possibility that they may be taken advantage of. To minimize issues with the process of aid in dying, the general protocol in the few states that allow it is the need for two oral requests and a written request, with several waiting periods in between . These procedures are put into place to ensure that physicians obtain the full consent of the patient and to ensure the patient is of sound mind in order to minimize any ethical challenges associated with aid-in-dying.
While there is a portion of the American public that supports aid-in-dying, there is also a proportion of opposition that believes that any shortening of life is immoral because there are other ways to alleviate pain, such as palliative care and hospice services. The extreme opposition also note that euthanasia and aid-in-dying can open the door to abuse of the law, comparing it to the Nazi extermination and slow starvation of physically warped, mentally defective, incurably sick, and unproductive people . There is a fear that “physicians will no longer try their best to give comfort and care to the patients near the end of life,” and that it is only a method of ridding the world of ‘inadequate people’ .
However, patients do “have the autonomous right to make decisions concerning the ends of their lives” and their “physicians have an obligation to act in the patient’s best interest as determined by the patient in concert with the advice of the physician” . It is expected that the checks and balances system within the medical field will play an important role in the advancement of euthanasia and aid-in-dying laws in the United States, so it does not become corrupt. It is important to note that the patient may also factor in their financial situation to the decision of requesting aid-in-dying. Living on medication and/or constant use of a machine is expensive and can wipe a family clean of any savings or assets. Not allowing a terminally ill patient the right to make the decision of death is taking away their ability to possibly save their family from the distress of being able to afford the patient’s end of life care. Some argue that it should not be “the role of the doctor to prolong life to the very last second, but to seek to restore a patient’s state of health, and if that is not possible, then to alleviate suffering,” which includes the intensified suffering caused by financial hardship .
The ethical dilemma of ‘when is it acceptable to perform euthanasia?’ arises during the debate of the policy. Who should be allowed to take advantage of the law: only those with a terminal illness, or those with mental or emotional pain caused by a mood disorder, too? Considering all aspects of the advancement in policy will allow for a more content public opinion. Giving a precise definition to the medical procedures of euthanasia and aid-in-dying is also key to educating the public on what the legislation is actually for. Euthanasia sparks great debate because of its clash with our ethical standards in the United States, specifically the right of autonomy. People feel that they should have the choice in their death, particularly in extreme cases of a terminal diagnosis.
Allowing for a standard of choice in death varies from culture to culture. In many European countries, the past decade has had an “increasing debate about the acceptability and regulation of euthanasia and other end-of-life decisions in medical practice” . People in Europe are wishing to die a ‘good death’ which is “now being connected to choice and control over the time, manner, and place of death” . This is connected with the option of euthanasia, which is becoming a popular new concept in several countries; the legalization of euthanasia in the Netherlands, Belgium, and Luxembourg has sparked an intense debate across Europe.
Euthanasia is the practice of intentionally ending a life to relieve pain and suffering of a person. Physician-administered euthanasia “describes a situation where a doctor administers a lethal dosage of drugs to a patient, at the patient’s request, in order to bring about his or her death” . In many countries, this practice is considered illegal; however, “the Netherlands is one of the few places in the world where euthanasia and physician-assisted suicide are legal under specific circumstances” .
The Netherlands and Belgium passed a law in 2001 that created an exception to the Criminal Code. Under the Code, it is illegal to end another person’s life or assist in their suicide. However, the 2001 Act created an exception where the Code would not apply “if a physician had terminated the life, or assisted the suicide, of a patient on request and if certain ‘due care’ criteria had been observed” . This was the legalization of active voluntary euthanasia. Article 2 of this act states that the patient’s request is ‘voluntary and well-considered’ as well as their suffering being ‘lasting and unbearable.’
There is a key difference between the Netherlands and the United States regarding euthanasia. The Dutch 2001 law allows physician-administered euthanasia as well as physician assisted suicide, while only a few states in the United States allow it. Euthanasia is considered illegal, so the patient must consume the life-ending medication prescribed by the physician solely by themselves and without the help of others. Although euthanasia is legal in the Netherlands it has posed some concern about the overuse of the life-ending treatment. There have been three times as many deaths from physician-administered euthanasia and PAS. There was a total of 49,287 deaths from euthanasia or assisted suicide within the 15-year period from 2002 to 2016 . Within this data, there is a large predominance of physician administered euthanasia (96%) being used over physician assisted suicide.
Canada has also legalized patient administered euthanasia, and the overwhelming majority of deaths were also by physician administered euthanasia. Canada legalized the use of euthanasia because citizens claimed that not allowing them to make choices regarding their own body was taking away their right of liberty; “the court ruled that the right to liberty requires that the person is free to make decisions regarding his own body and medical treatment-it’s an aspect of the right to autonomy and self-determination” . A possibility for the difference between the use of PAE and PAS can be “with its direct involvement of a doctor in administering injections of lethal drugs and its placing of the patient in the position of passive recipient rather than active ingestor” . The legalization of physician administered suicide has had drastic effects on the increase of deaths in countries where it is legalized.
As mentioned previously, euthanasia is a widely debated topic. To test and compare attitudes towards euthanasia, Joachim Cohen used data from the 1999-2000 wave of the European Values Study to collect people’s attitudes of euthanasia from 33 different European countries. This dataset gives insight to a range of social, political, cultural, and economic differences between different populations of people; the questionnaire contained more than 300 questions that tested a number of independent variables including social class, educational level, religious beliefs, country of residence, etc. The dependent variable in the study was the acceptance of euthanasia. The total number of respondents was 41,125.
The acceptance of euthanasia varied greatly across the different countries. For example, the Netherlands, France, Sweden, and Belgium generally accepted euthanasia, while Poland, Romania, Turkey, and Malta did not. Combining all 33 European countries together, the mean score for acceptance on a scale from 1 to 10 was just below a 5 . The data also showed that men were more accepting of euthanasia than women. Furthermore, the acceptance decreased linearly with age, but increased with education level. The acceptance also decreased as the level of religious belief was increased.
There were also country-specific differences in euthanasia acceptance. Roman Catholics are usually less favorable towards euthanasia than other large Christian groups such as Protestants or Orthodox. The study supported previous findings that religion is a major factor related to euthanasia attitudes, as they consider euthanasia immoral. People who do not belong to a religious group are seen to be as the most accepting towards euthanasia.
The data concluded that there is not a common European attitude towards euthanasia. There are countries who have a public opinion that accepts euthanasia, while other countries have a public opinion that do not. “Given the sometimes very country-specific character of attitudes towards euthanasia, each country will have its own debate, influenced by its cultural backgrounds” .
The myriad perspectives one could take on the principle of euthanasia causes much of the confusion that surrounds it. There are scientific, ethical, and cultural stances to take; the medical directive, morality, and societal differences all play a role in the modern stigma around this concept of death. The notion of ‘do no harm’ is constantly questioned when direct physician involvement comes into play. The majority of physicians themselves seem to be against the fact of taking another’s life, even if it does provide relief and reflect their patient’s wishes. Being clear about the definition of euthanasia, and other forms of physician assisted suicide, and having a uniform protocol to follow is essential in the success of the legislation that coincides with ethical standards. Working with the patient and respecting the patient’s right to autonomy is also crucial in a successful practice. Although there are many different cultural differences regarding the acceptance of euthanasia, personal factors, such as: education level, age, and religion play a factor in supporting or disagreeing with the concept of euthanasia. Currently, in a vast majority of societies, euthanasia is not an acceptable practice. However, as the world continues to progress in technology and overall education, the legislation is subject to change.
Catie Drawdy, Katie Hawkes, and Avery Twyman
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