Euthanasia

Euthanasia (from Ancient Greek: ευθανασία, "good death") is the practice of ending the life of a human or animal who is incurably ill in a painless or minimally painful way, for the purpose of limiting suffering. Laws around the world vary greatly with regard to euthanasia, and are constantly subject to change as cultural values shift and better palliative care, or treatments become available. It is legal in some nations, while in others it may be criminalized.

Euthanasia can be conducted in various ways. In order to distinguish certain methods, more specific terminology may be used when discussing euthanasia.

Euthanasia by means
Euthanasia may be conducted passively, non-aggressively, and aggressively. Passive euthanasia entails the withholding of common treatments (such as antibiotics, drugs, or surgery) or the distribution of a medication (such as morphine) to relieve pain, knowing that it may also result in death (principle of double effect). Passive euthanasia is the most accepted form, and it is a common practice in most hospitals. Non-aggressive euthanasia entails the withdrawing of life support and is more controversial. Aggressive euthanasia entails the use of lethal substances or force to kill and is the most controversial means.

Euthanasia by consent
Euthanasia may be conducted with or without consent. Involuntary euthanasia is conducted against someone’s will and equates to murder. This practice is almost always considered wrong and is rarely debated. Involuntary euthanasia can be administered when the person is incapable of making a decision and it is thus left to a proxy. One recent example of non-voluntary euthanasia is the Terri Schiavo case. This is highly controversial, especially because multiple proxies may claim the authority to decide for the patient. Voluntary euthanasia is euthanasia with the person’s direct consent, but is still controversial for reasons discussed below.

Other designations
Some important designations of euthanasia consists of mercy killing, animal euthanasia, and physician-assisted suicide which is a term for aggressive voluntary euthanasia. The Canadian Council of Animal Care (CCAC) states that euthanasia is "to kill an animal painlessly, and without distress." The CCAC further explains a physical euthanasia technique called Cervical dislocation and a secondary technique called Exsanguination.

History
The term euthanasia comes from the Greek words “eu” and “thanatos” which combined means “good death”. Hippocrates mentions euthanasia in the Hippocratic Oath, which was written between 400 and 300 B.C. The original Oath states: “To please no one will I prescribe a deadly drug nor give advice which may cause his death.” Despite this, the ancient Greeks and Romans generally did not believe that life needed to be preserved at any cost and were, in consequence, tolerant of suicide in cases where no relief could be offered to the dying or, in the case of the Stoics and Epicureans, where a person no longer cared for his life.

The English Common Law from the 1300’s until today also disapproved of both suicide and assisting suicide. However, in the 1500s, Thomas More, in describing a utopian community, envisaged such a community as one that would facilitate the death of those whose lives had become burdensome as a result of "torturing and lingering pain".

Modern history
Since the 19th Century, euthanasia has sparked intermittent debates and activism in North America and Europe. According to medical historian Ezekiel Emanuel, it was the availability of anesthesia that ushered in the modern era of euthanasia. In 1828, the first known anti-euthanasia law in the United States was passed in the state of New York, with many other localities and states following suit over a period of several years. After the civil war, voluntary euthanasia was promoted by advocates, including some doctors. Support peaked around the turn of the century in the U.S. and then grew again in the 1930’s.

Euthanasia societies were formed in England in 1935 and in the U.S.A. in 1938 to promote aggressive euthanasia. Although euthanasia legislation did not pass in the U.S. or England, in 1937, doctor-assisted euthanasia was declared legal in Switzerland as long as the person ending the life has nothing to gain. During this period, euthanasia proposals were sometimes mixed with eugenics. While some proponents focused on voluntary euthanasia for the terminally ill, others expressed interest in involuntary euthanasia for certain eugenic motivations (e.g., mentally "defective"). During this same era, meanwhile, U.S. court trials tackled cases involving critically ill people who requested physician assistance in dying as well as “mercy killings”, such as by parents of their severely disabled children.

Prior to World War II, the Nazis carried out a controversial and now-condemned euthanasia program. In 1939, Nazis, in what was code named Action T4, involuntarily euthanized children under three who exhibited mental retardation, physical deformity, or other debilitating problems whom they considered "life unworthy of life”. This program was later extended to include older children and adults.

Post-War history
Due to outrage over Nazi euthanasia, in the 1940s and 1950s there was very little public support for euthanasia, especially for any involuntary, eugenics-based proposals. Catholic church leaders, among others, began speaking against euthanasia as a violation of the sanctity of life. (Nevertheless, owing to its principle of double effect, Catholic moral theology did leave room for shortening life with pain-killers and what would could be characterized as passive euthanasia. ) On the other hand, judges were often lenient in mercy-killing cases. During this period, prominent proponents of euthanasia included Glanville Williams (The Sanctity of Life and the Criminal Law) and clergyman Joseph Fletcher ("Morals and medicine"). By the 1960s, advocacy for a right-to-die approach to voluntary euthanasia increased.

A key turning point in the debate over voluntary euthanasia (and physician assisted dying), at least in the United States, was the public furor over the case of Karen Ann Quinlan. The Quinlan case paved the way for legal protection of voluntary passive euthanasia. In 1977, California legalized living wills and other states soon followed suit.

In 1990, Dr. Jack Kevorkian, a Michigan physician, became infamous for encouraging and assisting people in committing suicide which resulted in a Michigan law against the practice in 1992. Kevorkian was tried and convicted in 1999 for a murder displayed on television. In 1990, the Supreme Court approved the use of non-aggressive euthanasia.

In 1994, Oregon voters approved doctor-assisted suicide and the Supreme Court allowed such laws in 1997. The Bush administration failed in its attempt to use drug law to stop Oregon in 2001. In 1999, non-aggressive euthanasia was permitted in Texas.

In 1993, the Netherlands decriminalized doctor-assisted suicide, and in 2002, restrictions were loosened. During that year, physician-assisted suicide was approved in Belgium. Australia's Northern Territory approved a euthanasia bill in 1995, but that was overturned by Australia’s Federal Parliament in 1997.

Most recently, amid government roadblocks and controversy, Terri Schiavo, a Floridian who was in a vegetative state since 1990, had her feeding tube removed in 2005. Her husband had won the right to take her off life support, which he claimed she would want but was difficult to confirm as she had no living will and the rest of her family claimed otherwise.

Arguments for and against voluntary euthanasia
Since World War II, the debate over euthanasia in Western countries has centered on voluntary euthanasia (VE) within regulated health care systems. In some cases, judicial decisions, legislation, and regulations have made VE an explicit option for patients and their guardians. Proponents and critics of such VE policies offer the following reasons for and against official voluntary euthanasia policies:

Reasons given for voluntary euthanasia:

 * Choice: Proponents of VE emphasize that choice is a fundamental principle for liberal democracies and free market systems.
 * Quality of Life: The pain and suffering a person feels during a disease, even with pain relievers, can be incomprehensible to a person who has not gone through it. Even without considering the physical pain, it is often difficult for patients to overcome the emotional pain of losing their independence.
 * Economic costs and human resources: Today in many countries there is a shortage of hospital space. The energy of doctors and hospital beds could be used for people whose lives could be saved instead of continuing the life of those who want to die which increases the general quality of care and shortens hospital waiting lists. It is a burden to keep people alive past the point they can contribute to society.
 * Pressure: All the arguments against voluntary euthanasia can be used by society to form a terrible and continuing psychological pressure on people to continue living for years against their better judgement. One example of this pressure is the risky and painful methods that those who genuinely wish to die would otherwise need to use, such as hanging.
 * Sociobiology: Currently many if not most euthanasia proponents and laws tend to favor the dying or very unhealthy for access to euthanasia. However some highly controversial proponents claim that access should be even more widely available. For example, from a sociobiological viewpoint, genetic relatives may seek to keep an individual alive (Kin Selection), even against the individual's will. This would be especially so for individuals who are not actually dying anyway. More liberal voluntary euthanasia policies would empower the individual to counteract any such biased interest on the part of relatives.

Reasons given against voluntary euthanasia:

 * Professional role: Critics argue that VE could unduly compromise the professional roles of health care employees, especially doctors. They point out that European physicians of previous centuries traditionally swore some variation of the Hippocratic Oath, which in its ancient form excluded euthanasia: "To please no one will I prescribe a deadly drug nor give advice which may cause his death.."  However, since the 1970s, this oath has largely fallen out of use.
 * Moral: Some people consider euthanasia of some or all types to be morally unacceptable. This view usually treats euthanasia to be a type of murder and voluntary euthanasia as a type of suicide, the morality of which is the subject of active debate.
 * Theological: Voluntary euthanasia often has been rejected as a violation of the sanctity of human life. Specifically, some Christians argue that human life ultimately belongs to God, so that humans ought not make the choice to end life. Orthodox Judaism takes basically the same approach, however, it is more open minded, and does, given certain circumstances, allow for euthanasia to be exercised under passive or non-aggressive means. Accordingly, some theologians and other religious thinkers consider VE (and suicide generally) as sinful acts, i.e. unjustified killings.
 * Feasibility of implementation: Euthanasia can only be considered "voluntary" if a patient is mentally competent to make the decision, i.e., has a rational understanding of options and consequences. Competence can be difficult to determine or even define.
 * Necessity: If there is some reason to believe the cause of a patient's illness or suffering is or will soon be curable, the correct action is sometimes considered to be attempting to bring about a cure or engage in palliative care.
 * Wishes of Family: Family members often desire to spend as much time with their loved ones as possible before they die. Therefore, the wishes of the family may outweigh the patient's right to control his or her own life.
 * Consent under pressure: Given the economic grounds for voluntary euthanasia (VE), critics of VE are concerned that patients may experience psychological pressure to consent to voluntary euthanasia rather than be a financial burden on their families. Even where health costs are mostly covered by public monies, as in various European counties, VE critics are concerned that hospital personnel would have an economic incentive to advise or pressure people toward euthanasia consent. While VE proponents concede that personal and even socialized economic costs may add to the motivations for consent, they point out that health systems offer sufficient exceptions so as to relieve the pressure on hospital personnel.

Euthanasia and the Law
During the 20th Century, efforts to change government policies on euthanasia have met limited success in Western countries. Country policies are described here in alphabetical order, followed by the exceptional case of The Netherlands. Euthanasia policies have also been developed by a variety of NGOs, most notably medical associations and advocacy organizations.

Roman Catholic policy
The Catholic policy on euthanasia rests on several core principles of Catholic ethics, including the sanctity of human life, the dignity of the human person, concomitant human rights, due proportionality in casuistic remedies, the unavoidability of death, and the importance of charity. The most important official Catholic statement is the 1980 Declaration on Euthanasia issued by the Sacred Congregation for the Doctrine of the Faith.

In Catholic medical ethics, official pronouncements tend to strongly oppose active euthanasia, whether voluntary or not. , while allowing dying to proceed without medical interventions that would be considered "extraordinary" or "disproportionate." Though the Church tends not to use the term, this policy might be equated to a limited form of passive euthanasia, although Church statements can be ambivalent. The Declaration on Euthanasia states that: "'When inevitable death is imminent... it is permitted in conscience to take the decision to refuse forms of treatment that would only secure a precarious and burdensome prolongation of life, so long as the normal care due to a sick person in similar cases is not interrupted.'"The Declaration concludes that doctors, beyond providing medical skill, must above all provide patients "with the comfort of boundless kindness and heartfelt charity".

Protestant policies
Protestant denominations vary widely on their approach to euthanasia and physician assisted death. Since the 1970s, Evangelical churches have worked with Roman Catholics on a sanctity of life approach, though the Evangelicals may be adopting a more exceptionless opposition. While liberal Protestant denominations have largely eschewed euthanasia, many individual advocates (e.g., Joseph Fletcher) and euthanasia society activists have been Protestant clergy and laity. As physician assisted dying has obtained greater legal support, some liberal Protestant denominations have offered religious arguments and support for limited forms of euthanasia.

Jewish policies
Not unlike the trend among Protestants, Jewish movements have become divided over euthanasia since the 1970s. Generally, Orthodox Jewish thinkers oppose voluntary euthanasia, often vigorously, though there is some backing for voluntary passive euthanasia in limited circumstances. Likewise, within the Conservative Judaism movement, there has been increasing support for passive euthanasia (PAD) In Reform Judaism responsa, the preponderance of anti-euthanasia sentiment has shifted in recent years to increasing support for certain passive euthanasia (PAD) options.

Islamic policies
Islam categorically forbids all forms of suicide and anything associated with suicide. It is forbidden for a Muslim to willfully plan, or come to know, the time of his own death in advance. If a Muslim were to decide in advance when he himself would die, then it is believed that this would be an insult to Allah. All this is stated, for example, in Fredrick Forsyth's novel, The Afghan. In fact, a Muslim who commits suicide is not even given burial rights. The precedent for all of this thinking comes from the Prophet Mohammed having absolutely refused to bless the body of a person who had committed suicide, despite the fact that the person killed himself to relieve severe pain from incurable disease.

Dharmic Religions
In Theravada Buddhism, a monk can be expelled for praising the advantages of death, even if they simply describe the miseries of life or the bliss of the after-life in a way that might inspire a person to commit suicide or pine away to death. In caring for the terminally ill, one is forbidden to treat a patient so as to bring on death faster than would occur if the disease were allowed to run its natural course.

Euthanasia protocol
Euthanasia can be accomplished either through an oral, intravenous, or intramuscular administration of drugs. In individuals who are incapable of swallowing lethal doses of medication, an intravenous route is preferred. The following is a Dutch protocol for parenteral (intravenous) administration to obtain euthanasia:

Intravenous administration is the most reliable and rapid way to accomplish euthanasia and therefore can be safely recommended. A coma is first induced by intravenous administration of 20 mg/kg sodium thiopental (Nesdonal) in a small volume (10 ml physiological saline). Then a triple intravenous dose of a non-depolarizing neuromuscular muscle relaxant is given, such as 20 mg pancuronium bromide (Pavulon) or 20 mg vecuronium bromide (Norcuron). The muscle relaxant should preferably be given intravenously, in order to ensure optimal availability. Only for pancuronium bromide (Pavulon) are there substantial indications that the agent may also be given intramuscularly in a dosage of 40 mg.

With regards to nonvoluntary euthanasia, the cases where the person could consent but was not asked are often viewed differently from those where the person could not consent. Some people raise issues regarding stereotypes of disability that can lead to non-disabled or less disabled people overestimating the person's suffering, or assuming it to be unchangeable when it could be changed. For example, many disability rights advocates responded to Tracy Latimer's murder by pointing out that her parents had refused a hip surgery that could have greatly reduced or eliminated the physical pain Tracy experienced. Also, they point out that a severely disabled person need not be in emotional pain at their situation, and claim that the emotional pain, if present, is due to societal prejudice rather than the disability, analogous to a person of a particular ethnicity wanting to die because they have internalized negative stereotypes about their ethnic background. Another example of this is Keith McCormick, a New Zealander Paralympian who was "mercy-killed" by his caregiver, and Matthew Sutton.

With regards to voluntary euthanasia, many people argue that 'equal access' should apply to access to suicide as well, so therefore disabled people who cannot kill themselves should have access to voluntary euthanasia.

Others respond to this argument by pointing out that if a nondisabled person attempts suicide, all measures possible are taken to save their lives. Suicidal people are often given involuntary medical treatment so that they will not die. This argument states that it is due to societal prejudice, namely that disabled people are of lower worth and that any unhappiness must be due to the disability, which results in greater support of voluntary euthanasia by disabled people than suicide by nondisabled people.'''

Euthanasia in the arts
The films Children of Men and Soylent Green, as well as the book The Giver, depict instances of government-sponsored euthanasia in order to strengthen their dystopian themes. The protagonist of Johnny Got His Gun is a brutually mutilated war veteran whose request for euthanasia furthers the work's anti-war message.

The recent films Mar Adentro and Million Dollar Baby argue more directly in favor of euthanasia by illustrating the suffering of their protagonists. These films have provoked debate and controversy in their home countries of Spain and the United States respectively.

A recurring character in Black Jack by Osamu Tezuka is a former war doctor who specializes in euthanasia. However, he is frequently prevented when the protagonist saves the patient instead.

Neutral (approx.)

 * Battin, Margaret P., Rhodes, Rosamond, and Silvers, Anita, eds. Physician assisted suicide: expanding the debate. NY: Routledge, 1998.


 * Emanuel, Ezekiel J. 2004. "The history of euthanasia debates in the United States and Britain" in Death and dying: a reader, edited by T. A. Shannon. Lanham, MD: Rowman & Littlefield Publishers.


 * Kopelman, Loretta M., deVille, Kenneth A., eds. Physician-assisted suicide: What are the issues? Dordrecht: Kluwer Academic Publishers, 2001. (E.g., Engelhardt on secular bioethics)


 * Magnusson, Roger S. “The sanctity of life and the right to die: social and jurisprudential aspects of the euthanasia debate in Australia and the United States” in Pacific Rim Law & Policy Journal (6:1), January 1997.


 * Palmer, “Dr. Adams’ Trial for Murder” in The Criminal Law Review. (Reporting on R. v. Adams with Devlin J. at 375f.) 365-377, 1957.


 * PCSEPMBBR, United States. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. 1983. Deciding to forego life-sustaining treatment: a report on the ethical, medical, and legal issues in treatment decisions. Washington, DC: President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research: For sale by the Supt. of Docs. U.S. G.P.O.


 * Robertson, John. 1977. Involuntary euthanasia of defective newborns: a legal analysis. In Death, dying, and euthanasia, edited by D. J. Horan and D. Mall. Washington: University Publications of America. Original edition, Stanford Law Review 27 (1975) 213-269.


 * Stone, T. Howard, and Winslade, William J. “Physician-assisted suicide and euthanasia in the United States” in Journal of Legal Medicine (16:481-507), December 1995.

Viewpoints
Appel, Jacob. 2007. A Suicide Right for the Mentally Ill? A Swiss Case Opens a New Debate. Hastings Center Report, Vol. 37, No. 3.

Dworkin, R. M. Life's Dominion: An Argument About Abortion, Euthanasia, and Individual Freedom. New York: Knopf, 1993.

Fletcher, Joseph F. 1954. Morals and medicine; the moral problems of: the patient's right to know the truth, contraception, artificial insemination, sterilization, euthanasia. Princeton, N.J.K.: Princeton University Press.

Kamisar, Yale. 1977. Some non-religious views against proposed 'mercy-killing' legislation. In Death, dying, and euthanasia, edited by D. J. Horan and D. Mall. Washington: University Publications of America. Original edition, Minnesota Law Review 42:6 (May 1958).

Kelly, Gerald. “The duty of using artificial means of preserving life” in Theological Studies (11:203-220), 1950.

Panicola, Michael. 2004. Catholic teaching on prolonging life: setting the record straight. In Death and dying: a reader, edited by T. A. Shannon. Lanham, MD: Rowman & Littlefield Publishers.

Rachels, James. The End of Life: Euthanasia and Morality. New York: Oxford University Press, 1986.

Sacred congregation for the doctrine of the faith. 1980. The declaration on euthanasia. Vatican City: The Vatican.

Neutral

 * Euthanasia and Religion - various religious views of euthanasia
 * The Ethics of Euthanasia - a UK site that looks at the issues, case studies and ethical and Christian responses
 * Religion and Ethics - Euthanasia - many views of euthanasia, for, against, and religious, from the BBC
 * Euthanasia ProCon.org - "Should euthanasia be legal?" - Pros, cons, history, laws, polls, and biographies of key players in debate
 * Issue Guide on the Right to Die - Analysis of public opinion and policy alternatives from Public Agenda Online
 * Dutch Ministry of Foreign Affairs - FAQ brochures explaining Dutch policy on euthanasia
 * Ministry of Health, Welfare and Sport - Information on Dutch euthanasia legislation

Support

 * Stanford Encyclopedia of Philosophy entry
 * - Euthanasia World Directory international information on voluntary euthanasia, assisted suicide, and self-deliverance
 * Final Exit Network provides guides to self-deliverance for the terminally and hopelessly ill to end their suffering
 * Compassion & Choices - provides education, support and advocacy for the choice-in-dying movement
 * Dignity in Dying - leading campaigning organisation promoting patient choice at the end of life
 * World Federation of Right To Die Societies
 * Assisted Suicide
 * Suicide & Euthanasia- Presents pro-choice arguments from a Biblical perspective.
 * Voluntary Euthanasia- Atheist Foundation of Australia Inc
 * A defense of euthanasia
 * Pro Euthanasia Dr Philip Nitschke - (Australian) Euthanasia law reform advocacy website, currently based in New Zealand.
 * Euthanasia and the Right to Life
 * Euthanasia Clinic - Roger Graham. Founder of Assisted Euthanasia Society of Paradise (AESOP), expelled from Cambodia for proposing Euthanasia Tourism, advocate for a Compassionate Law, an activist for Euthanasia since 1971.

Opposition

 * Euthanasia.com
 * Not Dead Yet (the disability rights group opposing Assisted Suicide)
 * Is Killing Kind?
 * Christian Study on euthanasia
 * www.carenotkilling.org.uk - Care, NOT Killing: a UK alliance promoting palliative care, opposing euthanasia and assisted suicide
 * euthanasia.com
 * National Right to Life articles on euthanasia
 * International Task Force against Euthanasia- many resources
 * Non-religious arguments against euthanasia
 * A Papal encyclical dealing with a number of issues of life and death including euthanasia
 * A brief presentation of the issue and the Christian Catholic viewpoint on it
 * The Rosicrucian Fellowship's viewpoint: Suicide and Euthanasia
 * Scholarly articles on Euthanasia from the Wisconsin Lutheran Seminary Library

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