EUTHANASIA AND SENICIDE

"Euthanasia" is a word coined from the Greek language (eu, good or noble; thanatos, death) in the seventeenth century by Francis Bacon to refer to an easy, painless, happy death. It has now come to mean the active causation of a patient's death through the injection of a lethal dose of medication. Euthanasia differs from assisted suicide, in which the patient self-administers a lethal dose of a compound, usually prescribed by a physician who knows the patient intends to use it to end his or her life.

Assisted suicide and euthanasia differ from a patient's right to refuse or withdraw from unwanted treatment even if that refusal or withdrawal may cause death. The right to refuse or withdraw from unwanted treatment is based on the principle of informed consent that underlies the practice of medicine. That is it is the right of every patient, whether terminally ill or not, and has nothing per se to do with hastening death.

The difference between the two was affirmed by the U.S. Supreme Court in a case in which proponents of assisted suicide challenged a New York law prohibiting it (Vacco v. Quill ). They invoked the equal protection clause of the Fourteenth Amendment to the Constitution to argue that patients denied euthanasia were not being given the same right to hasten death as patients who could do so by choosing to withdraw from life support. The Supreme Court rejected their contention that the right to refuse life-sustaining medical treatment "is nothing more or less than assisted suicide."

The Court based its analysis on intent and causation, two legal principles used to distinguish acts that may have the same result. Under a causation analysis, the Court reasoned that a patient who refuses life-sustaining medical treatment dies from an underlying disease; a patient who self-administers lethal medication prescribed by a physician is killed by the medication. The physician's intent is different in the two situations; a doctor withdrawing or not administering treatment is complying with a patient's wishes, whereas a doctor assisting in a patient's suicide intends that the patient die.

Moreover, a patient who commits suicide with the help of a doctor has the specific intention of ending his or her life; a patient refusing or discontinuing treatment may not. Refusal of life-sustaining treatment is not identical with assisted suicide and everyone, regardless of physical condition, is entitled, if competent, to refuse life-sustaining medical treatment, whereas no one is allowed to assist a suicide. Thus the law applies evenhandedly to all, and protects all equally.

Historical background

Although throughout history individual philosophers from Plato and Seneca to Montaigne and Hume justified self-induced death for those who were severely sick and suffering, social policies aimed at discouraging suicide have reflected the religious view of life as a divine gift. The waning influence of religion contributed to the questioning of such policies. Physicians, however, were not significantly involved in this questioning until the discovery in the eighteenth century of analgesics and anesthetics that could relieve suffering in dying patients, as well as easily and painlessly end life.

Greater interest in medical euthanasia coincided with the birth in the early twentieth century of the modern hospital as an institution that could provide curative medical and surgical treatment. As medicine learned to control acute infectious disease, life expectancy gradually increased from a norm of forty in 1850 to almost double that figure in 2000. Degenerative and late-onset diseases made the discussion of end-of-life care more urgent, and the role of the physician more important.

Interest in euthanasia at the turn of the twentieth century coincided with the development of the eugenics movement in the United States and Europe. Stimulated by advances in genetics and a misguided attempt to hasten the process of natural selection that had recently been described by Charles Darwin, eugenics envisioned a perfection of the human race, initially through sterilization of the unfit or degenerate, variously defined as criminals, prostitutes, alcoholics, epileptics, and the mentally ill. Thirty states passed sterilization laws; eventually sixty thousand Americans were sterilized; and the movement was embraced by figures ranging from Theodore Roosevelt and Woodrow Wilson to Oliver Wendell Holmes.

Although Germany was not the first country to embrace eugenics, it took hold there more deeply than elsewhere, led by Ernest Haeckel, a famed and respected biologist and social scientist. Haeckel advocated euthanasia for the "hundreds of thousands of incurables—lunatics, lepers, people with cancer etc.. . .artificially kept alive," whom he saw as a drain on the economy and a threat to the health of the Aryan race (Gallagher). Alfred Hoche and Karl Binding, a psychiatrist and an attorney, respectively, built on Haeckel's work to write The Permission to Destroy Life Unworthy of Life (1920), an influential book much admired by Adolf Hitler. Hoche and Binding proposed that those who were retarded, deformed, or terminally ill, and those damaged by accident or disease, should be put to death to further racial hygiene and/or because they were a burden to society.

When the Nazis came to power, they legalized voluntary euthanasia, but soon adopted the Haeckel/Hoche/Binding proposals on a scale that even those three men could hardly have imagined. Under the T-4 program (Tiergartenstrasse 4 was the Berlin address from which the program was administered) German doctors ended the lives of several hundred thousand mentally ill children and adults with conditions considered incurable, ranging from schizophrenia to senility.

The postwar revulsion to the holocaust, and to the role of physicians in implementing it, discredited the euthanasia movement. A significant minority of advocates, however, while not stressing the eugenic aspects of euthanasia, continue to see it as a necessary social remedy for the increasing number of old people, the inadequacy of nursing homes, and the economic cost to families and society of caring for the elderly. In the words of Eliot Slater, an English psychiatrist and advocate of euthanasia, "When a chronically sick man dies, he ceases to be a burden on himself, on his family, on the health services and on the community."

In the past some nomadic tribes of Native Americans and Eskimos, such as the Shoshone (Steward) and the Ahtna (De Laguna and McClellan), motivated by the need to move in pursuit of food and other necessities, felt the need to abandon the elderly—a practice known as senicide. Derek Humphry, founder of the Hemlock Society, believes that social and economic necessity will force modern societies in the same direction. He writes, "One must look at the realities of the increasing cost of health care in an aging society, because in the final analysis, economics, not the quest for broadened individual liberties or increased autonomy, will drive assisted suicide to the plateau of acceptable practice." Pietr Admiraal, one of foremost Dutch practitioners of euthanasia, believes that by 2020 Europe may resort to euthanasia to deal with a large population of elderly people. Admiraal says he is glad he will not be alive to see it, but he remains a strong advocate of euthanasia (Hendin).

The revival of interest in euthanasia in the 1970s and 1980s, however, was primarily centered on compassion for suffering patients, most of whom were elderly. It was considered in part to have been a reaction to modern medical technology that permits maintenance of a pointless semblance of life and creates fear of painful and undignified death.

The modern argument

Compassion. Contemporary advocacy for euthanasia centers on compassion for patients whose suffering is considered to be incapable of relief in any other way or who wish to be protected from what they fear will be an undignified death. In the Netherlands, the only country where assisted suicide and euthanasia have long been legally sanctioned, guidelines require that the patient must be experiencing unbearable and unrelievable suffering before the physician can assist in a suicide.

Opponents of legalization point out that the overwhelming majority of patients requesting euthanasia change their mind when their suffering is addressed by a knowledgeable and caring physician. In the exceptional case, sedation may be necessary to relieve suffering. They see death as becoming undignified when patients are not valued or treated with respect.

Proponents counter that even if it is theoretically possible to provide a painless or dignified death to most or all suffering patients, the trained personnel or the social and medical systems that would permit it are not in place. In the meantime, they claim physician-assisted suicide is needed to end patient suffering.

Compassion can be misdirected, however, and is no guarantee against doing harm. Lewis Thomas, one of the deans of American medicine, wrote insightfully about the sense of failure and helplessness that physicians may experience in the face of death; such feelings may explain why they have such difficulty discussing terminal illness with patients. These feelings may also explain both doctors' tendency to use excessive measures to maintain life and their need to make death a medical decision. By deciding when patients die, and by making death a medical decision, the physician preserves the illusion of mastery over the disease and the accompanying feelings of helplessness. Compassion for the patient can become a rationalization for the physician's own emotional discomfort.

In overburdened families, compassion that requires the death of the patient can also be self-serving. An overburdened spouse justifies ending the life of an infirm husband or wife on the grounds of compassion. A Swedish study (Wasserman) examined the response of relatives to the suicide attempts of elderly patients with somatic illnesses. Family members, overwhelmed by what they felt were the relentless needs of the patient, were likely to delay calling the doctor, to urge nonresuscitation of the patient, and to have expressed wishes that the patient would die. Once help from social and welfare agencies was arranged, families were able to be genuinely compassionate and the patients wanted to live.

Justifying euthanasia by compassion also opens the door to ending the lives of people who appear to be suffering but are not able to make their wishes known, and of those who are capable of consent but do not wish to do so or are simply not consulted. Abuses in all of these categories in the Netherlands have been a cause of concern (Hendin et al., 1997) but are rarely punished. Since there is no objective way of determining what is unbearable pain and suffering, when pain and suffering become all-important as criteria, the decision depends on the doctor's subjective assessment.

Choice. Partly for these reasons, advocates of legalization are increasingly not basing their argument on compassion for those who are suffering, but on the patient's right to choose. Oregon, the only state to legalize assisted suicide, while copying Dutch guidelines in many respects, did not make suffering a criterion for assisted suicide. Simply having a terminal illness, a prognosis of less than six months to live, and a wish to die are enough. How helpful are these criteria and what choice do Oregon patients really have?

When choice is the major determinant, physicians are not encouraged to inquire into the source of the desperation that usually underlies most requests for assisted suicide and euthanasia, an inquiry that leads patients and physicians to have the kind of discussion that often brings relief for patients and makes assisted suicide seem unnecessary. Nor are physicians asked or required by the Oregon law to make such an inquiry (Hendin et al. 1998).

When their suffering is addressed by a knowledgeable and caring physician, the over-whelming number of patients requesting euthanasia change their mind. For the exceptional case sedation may be necessary to provide relief. If confronted with a physician who does not know how to relieve their distress, and the choice is between continuing to suffer and an expedited death, the patient really has little choice. The debate over euthanasia is in part a debate over whether the need to reduce suffering in those who are terminally ill requires the legalization of euthanasia.

The ethical rationale of Peter Singer

The philosopher Peter Singer has attempted to give an ethical justification for euthanasia on the utilitarian principle that approves of actions that enhance the happiness of the individual—in this case the relief from suffering and the exercise of autonomy—as well as the happiness of others who are aware they have that option. Singer assumes that when guidelines are in place, as in the Netherlands, abuses such as non-voluntary euthanasia are rare; in fact the Dutch government's own sanctioned studies show they are common (Van der Maas et al., 1992, 1996). Moreover, there is substantial evidence that palliative care in the Netherlands has suffered and hospice care has lagged behind other countries because of the easier option of euthanasia. Thus, on purely utilitarian grounds there may be reason to reject euthanasia.

Singer is guided by another principle that influences his thinking on euthanasia. He believes that society has an obligation to protect only sentient persons (i.e., persons capable of reasoning, remembering, and recognizing others). Infanticide of a child with hemophilia is justified when it increases the happiness of the parents. Nonvoluntary euthanasia for the elderly could on the same principle be justified not only on grounds of compassion but also, Keough Singer does not explicitly say so, because it increases the happiness or lessens the burden on children. Philosophers have rejected Singer's position as dealing with the consequences of actions while ignoring the tradition in Western philosophy that judges the morality of actions not just by their consequences but also by the intentions that motivate them.

Conclusion

All relationships in a society are affected when society abandons infirm elderly persons and treats them as expendable. The Eskimo tribes that practiced senicide also were often obliged by the need for good hunters to practice female infanticide; more fortunately situated inland Eskimos, such as the Ihalmiut, who practiced neither, had a sense of their own antiquity, were more socially cohesive, and appear to have led happier lives (Mowat).

Americans are not, nor even with an increase in the elderly population are they likely to be, in the desperate situation of the Shoshone or the Ahnta. Providing the care needed by elderly persons who are seriously or terminally ill will, however, require improving the education of physicians in palliative care, removing regulations that restrict the ways in which physicians can treat pain, widening the availability of hospice care, fostering proper reimbursement for end-of-life care, and passing better-crafted surrogacy laws that, while protecting incompetent patients, also permit proxies to see to it that inappropriate treatments may be withdrawn from them. If all this is done, assisted suicide and euthanasia will not seem a necessary option to elderly patients and the issue of legalization of assisted suicide and euthanasia will become less relevant.

Herbert Hendin

See also Autonomy; Competency; Pain Management; Palliative Care; Refusing and Withdrawing Medical Treatment.

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