Euthanasia

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For mercy killings not performed on humans, see animal euthanasia.
For the program to kill people with disabilities in Nazi Germany, see Action T4.

Euthanasia (from Greek: ευθανασία -ευ, eu, "good", θανατος, thanatos, "death") is the practice of terminating the life of a person or an animal because they are perceived as living an intolerable life, in a painless or minimally painful way either by lethal injection, drug overdose, or by the withdrawal of life support. Euthanasia is a controversial issue because of conflicting religious and humanist views.

Contents

[edit] Terminology

Euthanasia of humans as a topic is often highly-charged—emotionally, politically, and morally. Terminology and laws shift over time, geographically and globally, causing a great deal of confusion.

Euthanasia is not the removal of medical machinary or drugs to in order to keep a person alive.

Following the broad definition of euthanasia as outlined by James Rachels, euthanasia may employ methods such as taking a patient off life support. Both active and passive euthanasia can be voluntary, nonvoluntary or involuntary.[citation needed] (See Karl Binding and Alfred Hoche for one of the first uses of the three types of euthanasia.)

Physician assisted dying is where doctors provide a prescription for a terminally ill patient to hasten their death. This is seen as morally distinct from euthanasia because the physician does not cause the patient's death but gives the patient choice of the time and circumstances of his or her own death. Physician assisted dying is the terminology used by the state of Oregon to describe the action of its Death With Dignity law.

Responding to requests from Oregon patients and their families, the Oregon Health Division changed their usage in October 2006 from "physician-assisted suicide" to "physician-assisted death." The American Public Health Association made the same change in November 2006.

Voluntary euthanasia occurs with the fully informed request of a decisionally-competent adult patient or that of their surrogate (proxy). (Example: Thomas Youk with ALS was assisted by Jack Kevorkian.) This should not be confused with death after treatment is stopped on the instructions of the patient himself, either directly or through a do not resuscitate (DNR) order. Enforcing a DNR order has never been considered assisted suicide or suicide of any kind, at least in the eyes of the law. Patients of sound mind have always had a right to refuse treatment. It could be defined as a happy death.

Nonvoluntary euthanasia occurs without the fully informed consent and fully informed request of a decisionally-competent adult patient or that of their surrogate (proxy). An example of this might be if a "patient" has decisional capacity but is not told they will be euthanized; or, if a patient is not conscious or lacks decisional-capacity and their surrogate is not told the patient will be euthanized.

Involuntary euthanasia occurs over the objection of a patient or their surrogate (proxy). An example of this might be if a patient with decisional capacity (or their surrogate) is told what will happen. The patient (or surrogate) refuses yet the patient is euthanized anyway. This is generally considered murder. If a patient slated for euthanasia changes his or her mind at the last minute, the doctor is categorically required by law to honor that wish. In most countries removing or denying treatment without the clear instructions of the patient is usually seen as murder.[citation needed]

Terminal sedation is a combination of medically inducing a deep sleep and stopping other treatment, with the exception of medication for symptom control (such as analgesia). It is considered to be euthanasia by some, but under current law and medical practice it is considered a form of palliative care.

Animal euthanasia is commonly referred to by the euphemism "put to sleep".

Mercy Killing is a term used for some cases of euthanasia. Typically it refers to euthanasia by a someone other than a doctor, such as a parent, who perceives the individual to be suffering. In some cases, the individual cannot consent. In other cases, the individual can consent, but is not asked or refuses. Lastly, in some cases the individual consents, and it may even be them who initiates the discussion.

[edit] Eugenics described as euthanasia

In Nazi Germany the term euthanasia was misused for the T-4 Euthanasia Program, which was actually a eugenics project. The objectives were to save expense and to preserve the genetic quality of the German population by killing those considered unworthy of life and sterilizing those considered unfit to breed. Since it was not for the benefit of the victims, it does not fit the definition of euthanasia as merciful. It has nevertheless tainted the word, especially in German-speaking countries, as one of the main advocates of euthanasia in Germany after World War II was Werner Catel, a leading Nazi doctor directly involved in T-4. The currently accepted German term is the older "Sterbehilfe" (literally "helping to die"), which is used in contemporary German discussions.

[edit] Legislation and national political movements

[edit] The United Kingdom

On November 5, 2006, Britain's Royal College of Obstetricians and Gynaecology submitted a proposal to the Nuffield Council on Bioethics calling for consideration of permitting the euthanasia of disabled newborns.[2] The report does not address the current illegality of euthanasia in the United Kingdom, but rather calls for reconsideration of its viability as a legitimate medical practice: "We would like the working party to think more radically about non-resuscitation, withdrawal of treatment decisions, the best interests test and active euthanasia as they are ways of widening the management options available to the sickest of newborns."

[edit] Australia

Euthanasia was legalized in Australia's Northern Territory, by the Rights of the Terminally Ill Act 1995. Soon after, the law was voided by an amendment by the Commonwealth to the Northern Territory (Self-Government) Act 1978. The powers of the Northern Territory legislature, unlike those of the State legislatures, are not guaranteed by the Australian Constitution. However, before the Commonwealth government made this amendment, three people had already been legally euthanised. The first person was a taxi driver, Bob Dent, who died on 22 September, 1996.

Although it is a crime in most Australian states to assist in euthanasia, prosecutions have been rare. In 2002, relatives and friends who provided moral support to an elderly woman who committed suicide were extensively investigated by police, but no charges were laid. The Commonwealth government subsequently tried to hinder euthanasia with the passage of the Criminal Code Amendment (Suicide Related Materials Offences) Bill 2004. In Tasmania in 2005 a nurse was convicted of assisting in the death of her elderly mother and father who were both suffering from illnesses. She was sentenced two and a half year jail but the judge later suspended the conviction because he believed the community did not want the woman put behind bars. This sparked debate about decriminalising euthanasia.

[edit] Belgium

The Belgian parliament legalized euthanasia in late September 2002. Proponents of euthanasia state that prior to the law, several thousand illegal acts of euthanasia were carried out in Belgium each year. According to proponents, the legislation incorporated a complicated process, which has been criticized as an attempt to establish a "bureaucracy of death".

[edit] The Netherlands

In the Netherlands the Termination of Life on Request and Assisted Suicide (Review Procedures) Act took effect on April 1, 2002. It legalizes euthanasia and physician assistance in dying in certain circumstances.

The law recognized a practice that had been tolerated for some 20 years. From the time that euthanasia first came to be widely practiced in the Netherlands, it was formally subject to review by boards of doctors in each hospital. The law essentially codified what had already become tolerated practice and unofficial law by judgments in the courts.

The law permits euthanasia and physician assisted dying when each of the following conditions is fulfilled:

  • the patient's suffering is unbearable with no prospect of improvement
  • the patient's request for euthanasia must be voluntary and persist over time (the request can not be granted when under the influence of others, psychological illness or drugs)
  • the patient must be fully aware of his/her condition, prospects and options
  • there must be consultation with at least one other independent doctor who needs to confirm the conditions mentioned above
  • the death must be carried out in a medically appropriate fashion by the doctor or patient, in which case the doctor must be present.
  • the patient is at least 12 years old (patients between 12 and 16 years of age require the consent of their parents)

The doctor must also report the cause of death to the municipal coroner in accordance with the relevant provisions of the Burial and Cremation Act. A regional review committee assesses whether a case of termination of life on request or assisted suicide complies with the due care criteria. Depending on its findings, the case will either be closed or brought to the attention of the Public Prosecutor. Finally, the legislation offers an explicit recognition of the validity of a written declaration of will of the patient regarding euthanasia (a "euthanasia directive"). Such declarations can be used when a patient is in a coma or otherwise unable to state whether they want euthanasia or not.

The legislation has wide support among the socially libertarian Dutch, who have one of the world's highest life expectancies. There is however persistent opposition, mainly organized by the churches.

Euthanasia remains a criminal offense in cases not meeting the law's specific conditions, with the exception of several situations that are not subject to the restrictions of the law at all, because they are considered normal medical practice:

  • stopping or not starting a medically useless (futile) treatment
  • stopping or not starting a treatment at the patient's request
  • speeding up death as a side-effect of treatment necessary for alleviating serious suffering

Euthanasia of children under the age of 12 remains technically illegal, however Dr. Eduard Verhagen has documented several cases and, together with colleagues and prosecutors, has developed a protocol to be followed in those cases. Prosecutors will refrain from pressing charges if this Groningen protocol is followed.

In 1992 a proposal was made known as Drion's Pill. This fictional drug would be a set of 2 pills. The first pill could be taken without any harm, the second pill would have to be taken a couple of days later (and only then would work). This would give the patient the time to think things over. The drug was never developed, the proposal however indirectly started up the discussion of euthanasia in Netherlands.

In 2003, in the Netherlands, 1626 cases were officially reported of euthanasia in the sense of a physician assisting the death (1.2% of all deaths). Usually the sedative sodium thiopental is intravenously administered to induce a coma. Once it is certain that the patient is in a deep coma, typically after some minutes, a muscle relaxant is administered to stop the breathing and cause death.

Officially reported were also 148 cases of physician assisted dying (0.14% of all deaths), usually by drinking a strong (10g) barbiturate potion. The doctor is required to be present for two reasons:

  • to make sure the potion is not taken by a different person, by accident (or, theoretically, for "unauthorized" suicide or perhaps even murder)
  • to monitor the process and be available to apply the combined procedure mentioned below, if necessary.

In two cases the doctor was reprimanded for not being present while the patient drank the potion. They said they had not realized that this was required.

Forty-one cases were reported to combine the two procedures: usually in these cases the patient drinks the potion, but this does not cause death. After a few hours, or earlier in the case of vomiting, the muscle relaxant is administered to cause death.

By far, most reported cases concerned cancer patients. Also, in most cases the procedure was applied at home.

[edit] Switzerland

In Switzerland, deadly drugs may be prescribed to a Swiss person or to a foreigner, where the recipient takes an active role in the drug administration. More generally, article 115 of the Swiss penal code, dating from the 1940s, considers assisting suicide a crime if and only if the motive is selfish. The code does not give physicians a special status in assisting suicide, however they are most likely to have access to suitable drugs and the medical establishment have prohibited highly liberal physicians from prescribing deadly drugs further. When an assisted suicide is declared, a police inquiry may be started. Since no crime has been committed in the absence of a selfish motive, these are mostly open and shut cases. Prosecution happens if doubts are raised on the patient's competence to make an autonomous choice. This is rare.

[edit] United States

[edit] Early History

The first major effort to legalize euthanasia in the United States arose alongside the eugenics movement in the early years of the twentieth century. Brown University historian Jacob M. Appel, in a 2004 article in the Bulletin of the History of Medicine, documents extensive political debate over legislation to legalize physician-assisted suicide in both Iowa and Ohio in 1906. The driving force behind the movement was social activist Anna S. Hall.

[edit] Oregon

Oregon Ballot Measure 16 in 1994 established Oregon's Death with Dignity Act, which legalizes physician-assisted dying with certain restrictions, making Oregon the first U.S. state and one of the first jurisdictions in the world to officially do so. The measure was approved in the 8 November 1994 general election in a tight race. The final tally showed 627,980 votes (51.3%) in favor, and 596,018 votes (48.7%) against. In 2005, after several attempts by lawmakers at both the state and federal level to overturn the Oregon law, the United States Supreme Court ruled 6-3 to uphold the law after hearing arguments in the case of Gonzales v. Oregon.

[edit] Texas

In 1999, the state of Texas passed the Texas Futile Care Law. Under the law, in some situations, Texas hospitals and physicians have the right to withdraw life support on a patient whom they declare terminally ill.[3]

On March 15, 2005, six month old infant Sun Hudson was the first patient in which the "United States a court has allowed life-sustaining treatment to be withdrawn from a pediatric patient over the objections of the child's parent." [4]

In December 2005, doctors removed Tirhas Habtegiris, a young woman and legal immigrant from Africa, from life support against her family's wishes.

[edit] Euthanasia protocol

See Lethal Injection for more information.

Image:Euthanasia machine (Australia).JPG
A machine that can facilitate Euthanasia through heavy doses of drugs. It is possible in this image to see the laptop screen that leads the user through a series of steps and questions, to the final injection, which is done by motors controlled by the computer. This series of questions is supposedly to prevent unprepared users from undergoing Euthanasia. [1].

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 thiopental sodium (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 dibromide (Pavulon) or 20 mg vecuronium bromide (Norcuron). The muscle relaxant should preferably be given intravenously, in order to ensure optimal availability. Only for pancuronium dibromide (Pavulon) are there substantial indications that the agent may also be given intramuscularly in a dosage of 40 mg.[5]

[edit] Ethics

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There are a number of conflicting beliefs about euthanasia. Different aspects of euthanasia are supported by different people. Some people argue against euthanasia based on the belief that only God should choose when someone dies. For the same reason, the Catholic church has long viewed suicide as a sin. Some people approve of some forms of euthanasia in principle, but fear that if some forms of euthanasia are legalized other forms of euthanasia that they do not support will come into practice. 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 disabled people responded to Tracy Latimer's death 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 black person wanting to die because they have internalized negative stereotypes about being black. 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.

[edit] Perceptions

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In the last 20 years, some states in the United States of America have faced voter ballot initiatives and "legislation bills" attempting to legalize euthanasia and assisted suicide. Some examples include: Washington voters saw Ballot Initiative 119 in 1991, California placed Proposition 161 on the ballot in 1992, and Michigan included Proposal B in their ballot in 1998. Public opinion concerning this issue has become increasingly important because widespread support could very well facilitate the legalization of these policies in other states, such as in Oregon.

While many people are aware of the ongoing debates concerning the issue of euthanasia and assisted suicide, it has been unclear where the majority of public opinion stands in the United States. A recent Gallup Poll survey did show that 75% of Americans supported euthanasia. Further research, however, has shown that there are significant differences in levels of support for euthanasia across distinct social groups. Recently, these attitudes have been receiving more attention since they not only could influence the legislation on this topic, but how patients are cared for in the future.

[edit] Religion

Some of the differences in public attitudes towards the right to die debate stem from the diversity of religion in the United States. The United States contains a wide array of religious views, and these views seem to correlate with whether euthanasia was supported. Using the results from past General Social Surveys performed, some patterns can be found. Respondents that did not affiliate with a religion were found to support euthanasia more than those who did.

Of the religious groups that were studied, which were mostly Christian in this particular study, conservative Protestants (including Southern Baptists, Pentecostals, and Evangelicals) were more opposed to euthanasia than non-affiliates and the other religious groups.

Moderate Protestants (including Lutherans and Methodists) and Catholics showed mixed views concerning end of life decisions in general. Both of these groups showed less support than non-affiliates, but were less opposed to it than conservative Protestants. Moderate Protestants are less likely to take a literal interpretation to Bible than their conservative counterparts, and some leaderships tend to take a less oppositional view on the issue. Despite the fact that the Catholic Church has come out in firm opposition to physician-assisted suicide, they share the nearly same level of support as moderate Protestants.

The liberal Protestants (including some Presbyterians and Episcopalians) were the most supportive of the groups. In general, they had looser affiliations with religious institutions and their views were similar to those of non-affiliates. Within all these groups, religiosity (identified as being frequency of church attendance and self-evaluation) also affected their level of opposition towards euthanasia. Individuals who attended church regularly and more frequently and considered themselves more religious were found to be more opposed than to those who had a lower level of religiosity <ref>Burdette, Amy M; Hill, Terrence D; Moulton, Benjamin E. Religion and Attitudes toward Physician-Assisted Suicide and Terminal Palliative Care. Journal for the Scientific Study of Religion, 2005, 44, 1, Mar, 79-93.</ref>.

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.<ref>Thanissaro Bhikkhu, "Buddhist Monastic Code I: Chapter 4"</ref>

In Hinduism, death has been referred to both as the ultimate truth and as one of the stages in human life. In the Bhagavad Gita, Lord Krishna urges Arjuna to fulfill his destiny or Dharma, and not to worry about consequences as death levels all: whatever you give and take, you do it on this earth. In Hindu mythology, some humans were given the right to choose the time of their deaths. This was awarded to only the most pure in heart, suggesting that Hinduism does not disapprove of euthanasia.

[edit] Philosophy

Friedrich Nietzsche, in The Twilight of the Idols, calls for euthanasia, writing, "To die proudly when it is no longer possible to live proudly. . . From love of life, one should desire a different death: free, conscious, without accident, without ambush."[6]

[edit] Ethnicity

On many social and religious issues, Blacks are more conservative than Caucasians [7]. In the specific case of euthanasia, recent studies have shown Caucasians to be more accepting than Blacks. They are also more likely to have advance directives and to use other end of life measures.<ref>Werth Jr., James L.; Blevins, Dean; Toussaint, Karine L.; Durham, Martha R. The influence of cultural diversity on end-of-life care and decisions. The American Behavioral Scientist; Oct 2002; 46, 2; pg 204-219.</ref> Blacks are almost 3 times more likely to oppose euthanasia than Caucasians. The main reason for this discrepancy is attributed to the lower levels of trust in the medical establishment.<ref>Jennings, Patricia K.,Talley, Clarence R.. A Good Death?: White Privilege and Public Opinion. Race, Gender, & Class. New Orleans: Jul 31, 2003. Vol. 10, Iss. 3; pg. 42.</ref> Researchers believe that past history of abuses towards minority in medicine (such as the Tuskegee Syphilis Study) have made minority groups less trustful of the level of care they receive. Studies have also found that there are significant disparities in the medical treatment and pain management that Caucasians and non-Caucasian receive.<ref>Werth Jr., James L.; Blevins, Dean; Toussaint, Karine L.; Durham, Martha R. The influence of cultural diversity on end-of-life care and decisions. The American Behavioral Scientist; Oct 2002; 46, 2; pg 204-219</ref>

Among Blacks, education correlates to support for euthanasia. Blacks without a four-year degree are twice as likely to oppose euthanasia than those with at least that much education. Level of education, however, does not significantly influence any other racial group in the US. Some researchers suggest that Blacks tend to be more religious, a claim that is difficult to substantiate and define.<ref>Jennings, Patricia K.,Talley, Clarence R.. A Good Death?: White Privilege and Public Opinion. Race, Gender, & Class. New Orleans: Jul 31, 2003. Vol. 10, Iss. 3; pg. 42.</ref> Only Blacks and Caucasians have been studied in extensive detail. Although it has been found that non-Caucasian groups are less supportive of euthanasia than Caucasians, there is still some ambiguity as to what degree this is true.

[edit] Gender

The research has not found gender to be a significant factor in predicting opinion about euthanasia. However, some studies have shown that there are differences in views between males and females. A recent Gallup Poll found that 84% of males supported euthanasia compared to 64% of females.<ref>Moore, D. (2005 May 17). “Three in Four Americans Support Euthanasia.” The Gallup Organization.</ref> Some cite the prior studies showing that women have a higher level of religiosity and moral conservatism as an explanation. Within both genders, there are differences in attitudes towards euthanasia due to other influences. For example, one study found that Black women are 2.37 times more likely to oppose euthanasia than Caucasian women. Black men are 3.61 times more likely to oppose euthanasia than Caucasian men.<ref>Jennings, Patricia K.,Talley, Clarence R.. A Good Death?: White Privilege and Public Opinion. Race, Gender, & Class. New Orleans: Jul 31, 2003. Vol. 10, Iss. 3; pg. 42. </ref>

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Euthanasia

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