II. HISTORICAL ASPECTS

The history sustaining and ending of human life in the West has three facets: a chronology of the meanings of euthanasia, the major cultural heritages that have influenced the beliefs and actions of physicians, and changing modes of medical practice. This entry explores this multifaceted history from its ancient Hebrew origins to the rise of the "right to die" and "death and dying" movements after the 1960s.

The Meanings of Euthanasia

All the meanings of the term euthanasia can be related to the etymology of the Greek term euthanatos: eu meaning "good" and thanatos meaning "death." At the present time the word is used to denote a doctor's painlessly terminating the life of a suffering, terminally ill patient who wishes to die: physician produced or physician induced death (Oxford English Dictionary). Advocates for euthanasia often call it mercy killing.

The current meaning is actually the second way the term was used in Western history. The term's first and most longstanding use denoted a gentle and natural or noninduced death. The Roman historian Suetonius (c. 69–135 c.e.) described how Augustus Caesar was "blessed with an easy death" when he expired peacefully at age seventy-five: "For almost always on hearing that anyone had died swiftly and painlessly, [Augustus] prayed that he and his might have a like 'euthanasia'" [here euthanatos is inserted in the Latin text] (Suetonius, p. 281).

Francis Bacon (1561–1626) appears to have been the first scholar to maintain that the practice of medicine should include knowledge and skill that enable doctors to help patients to die easily and naturally. Bacon entitled this dimension of medicine euthanasia exteriori ("outward euthanasia") to distinguish it from "that euthanasia, or sweet calm dying, procured by a due preparation of the soul" in religious literature on consoling the dying (Bacon, pp. 124–125; Beaty). By saying that doctors should help patients "make a fair and easy passage out of life" Bacon meant that they should enable patients to die as Augustus Caesar had or like the aged Antoninus Pius, who died calmly "as though he were falling asleep" (Bacon; Bryant). This analysis of what Bacon proposed corrects the claim that he advocated doctor-induced death (Fletcher; Wilson; Emanuel).

For the next two centuries the term denoted physician-aided natural dying. The replacement of this meaning by the current understanding of euthanasia occurred between 1870 and the 1920s. A defense of doctor-induced peaceful death was made by Samuel D. Williams in 1870, after which heated debate ensued in Great Britain and the United States (Williams, 1872; Vanderpool, 1997). The fact that the debate has continued accounts for the current use of the term.

The meaning of euthanasia in its original sense continued into the 1920s, but its equation with mercy killing was so common by the turn of the century that some suggested that the original term should be replaced with the term euphoria ("Euphoria vs. Euthanasia"; Rosenberg and Aronstam). Later proponents of the duty of doctors to help patients die peacefully and naturally dropped such terminology in favor of phrases such as caring for the dying (Worcester; Alvarez).

Third, during the first four decades of the twentieth century the practice of extinguishing the lives of unwanted persons also was called euthanasia. Newspapers, films, books, physicians, professors such as Harvard's Charles Eliot Norton, clergy, scientists such as the Nobel laureate Alexis Carrel, and other eugenicists in the West called for euthanasia, that is, a painless extermination of various groups: "lunatics," "degenerates," "cripples," and others ("Dr. Norton on Euthanasia"; "The Right to Kill"; Pernick). That eugenics euthanasia movement played a complex role in Nazi ideology and the legitimization of Nazi genocide (Pernick).

Fourth, at times euthanasia was identified with the use of sedatives to "secure easy deaths" to the point of shortening life (South Carolina Medical Association, p. xvii). Fifth, the term occasionally was associated with what is now called assisted or physician-assisted suicide (Sperry, 1948), in part because some of the legislative bills sponsored by the Euthanasia Society of America were essentially assisted-suicide bills (Sperry, 1950).

Sixth, euthanasia became attached to the practice of withdrawing terminally ill persons from life-prolonging medical measures. After 1970 that practice commonly was termed passive or indirect euthanasia to distinguish it from active or voluntary euthanasia: doctor-produced death (Vanderpool, 1997). Although some authors disassociated the right to refuse life-sustaining measures from the term euthanasia (Pope Pius XII; Rynearson), the distinction between active and passive euthanasia made as early as 1884 ("Editorial: Permissive Euthanasia") had significant staying power.

An understanding of the major cultural heritages that informed and still inform the beliefs and actions of physicians sets the stage for the history of euthanasia and the sustaining of life in medical practice.

Hebraic and Jewish Perspectives

The Hebrew Scriptures proclaim an understanding of human life that has been immensely influential in Western history. Humans are created by God (Genesis 2:2–27), life and consciousness are gifts of God, and as Lord of life, God alone should determine when and how humans die (Job 1:21). As God's property, no individual has the right to destroy his or her life as if it were self-owned. It also is not lawful wantonly to take the life of another person (Exodus 20:13, Genesis 9:5–6).

On the basis of this legacy, Jewish tradition requires that when life is threatened by illness or injury, it must be sustained if possible. Because Jews were and are obligated to prolong their lives, they must not settle in communities where no physician is available. Obligations to save and extend life are drawn from Scripture: "You shall not stand idly by the blood of your neighbor" (Leviticus 19:16). Advanced medical interventions are urged for critically ill persons as long as it seems probable that those treatments will save or prolong life (Bleich). Rabbinic debate continues over situations in which life can be prolonged for a while, but at the expense of great pain and no hope for a real cure. Past and present, Jewish authorities have held that active pain relief can be undertaken at the risk of a patient's dying sooner (Jakobovits; Brody).

Doctors who induce death to spare patients from pain are considered murderers (Exodus 20:13, Carmi). Destroying those who are socially unwanted is absolutely prohibited. This includes neglecting or killing severely deformed newborns (Bleich).

Although it forbids mercy killing, Judaism defends the morality of letting fatally ill persons die naturally. The meaning of honorable death (Mita Yafa) in the Talmud centers on merciful dying, not mercy killing (Carmi). Each dying person should be comforted by relatives, friends, and physicians. Prayers for life to end are permissible. Once a patient is near death, treatments that interrupt dying should be discontinued (Bleich).

Greco-Roman Antiquity

By the fifth century b.c.e. Greek physicians and elite citizens were praising health as one of the greatest human goods. The goals of the physician's art were "to bring health in all cases of sickness [and] preservation of health to those who are well" (Hippocratic Corpus, "Regimen in Acute Diseases," p.71). Greek physicians recognized the limitations of their art. Modestly conceived, their goals were "to do away with the sufferings of the sick, to lessen the violence of their diseases, and to refuse to treat those who are overmastered by their diseases" (Hippocratic Corpus, "The Art," p. 193). Physicians would abuse their art and ruin their reputations if they attempted to prolong the lives of the severely sick and injured. A terminally-ill patient's death would be blamed on the physician's lack of skill, so it behooved the physician to refuse even to try to treat at all. Galen (131–201 c.e.) and other Roman physicians adapted those values and goals to Roman life and its institutions.

Although the Greek heritage is unambiguous about the limits of life prolongation, it includes two traditions related to physician-aided death. Vastly influential in Western medicine, the Hippocratic Oath has physicians swear that they will not "give a deadly drug to anybody if asked for it" or even "make a suggestion" to that effect (Edelstein, p. 6). Debate continues over whether that oath reflects a Pythagorean origin or some other origin (Edelstein, Carrick, Anagnastopoulos). Insofar as it reflects opinions of the Pythagorean sect, it would oppose physician-assisted euthanasia in an almost Hebraic sense. With the gods as keepers and humans as their possessions, people sin against the gods if they seek to escape from their posts in life. Insofar as it is non-Pythagorean, the oath could reflect the philosophical logic of Plato (c. 427–348 b.c.e.) and Aristotle (384–322 b.c.e.): Because health is one of the greatest human goods and restoration of heath is the ultimate end of medicine, the termination of life is contrary to medical practice (Anagnastopoulos).

In contrast to the prohibition of physician-assisted death in the oath, Plato, Aristotle, and Stoic philosophers from Zeno (c. 336–264 b.c.e., Greece) to Seneca (4 b.c.e.–65 c.e., Rome) argued that incurably sick adults who consume vital resources of the city—the polis—should die from neglect or be put to death involuntarily (Carrick; Anagnastopoulos). Similarly, deformed and sickly infants should be exposed or drowned for the good of the community, the highest and greatest human end according to Plato and Aristotle. Exposure included taking newborns to rock caverns or casting them into the sea. By law in Sparta and Rome newborns were examined by nonparents for anatomic flawlessness and vigor to determine which ones should be exposed (Amundsen, 1987).

Seneca praised the ability of humans to choose when to end their lives. People should quit life nobly rather than await the cruel endings "either of disease or of man" (Seneca, quoted in Carrick, p. 145). Certain elite citizens, virgins, married women, slaves, common persons, and soldiers ended their lives when they were faced with humiliation, a fearful future, illness, or old age (Van Hooff).

Opposed to suicide in those instances, Aristotle held that death is "the most terrible of all things" (quoted in Carrick, p. 51). Suicide also conflicted with Aristotle's theory of human virtue: the nobility of facing death bravely versus the cowardly quitting of life when one is faced with misfortune.

Christianity

Christianity emerged from Judaism and flourished in the Roman world. The early churches regarded Hebrew Scripture as the authoritative word of God even as they reinterpreted it as forecasting the life, death, and resurrection of Jesus. Christians thus inherited Hebraic and Jewish teachings about life and death.

EARLY CHRISTIANITY. Christians regarded God as the creator and sustainer of human life and opposed suicide in response to suffering or despair. Contrary to the myth that Christians were inclined to commit suicide to escape from life and be with God, Christ, and their departed loved ones, early Christians ardently opposed self-induced death (Amundsen, 1998).

With Jesus as their model, Christians added new themes to Jewish opposition to suicide and mercy killing. They accented the redemptive dimensions of suffering (2 Corinthians 12:7–10, Hebrews 12:5–11). Faced with pain and death, they too should exclaim, "Not my will, but thine be done" (Luke 22:42). Beginning with the early church (James. 5:10), Christians praised Job, who endured grave suffering steadfastly. Patience and steadfastness were valued all the more because of frequent persecutions (1 Peter 4:12–5:1).

Based on Jesus's teaching that all humans are the children of a loving Father (Luke 15), Christians also displayed mercy and offered care for sick, infirm, and dying persons (Luke 4:16–21, 6:36, 8:26–56, 10:29–37). Believing that no human group should be despised or considered unworthy of life, they condemned cruel executions, abortion, infanticide, and suicide by the second century (Amundsen, 1987).

AUGUSTINE. Augustine (354–430 c.e.) developed systematic criticisms of suicide. Like Aristotle, he argued that self-inflicted death was cowardly. He also viewed it as contrary to the Sixth Commandment, "Thou shall not kill." He regarded suicide as a mortal sin because it excluded the possibility of repentance (Amundsen, 1989). With the establishment of Christianity as the official religion of the Roman Empire after 325, self-killing was equated with homicide. In central and northern Europe the properties of suicides were confiscated, their corpses were desecrated, and they were excluded from Christian burial grounds.

THOMAS AQUINAS AND MODERN ROMAN CATHOLICISM.

Thomas Aquinas (1225–1274) expanded on Augustine's arguments against suicide in ways that have shaped Catholic perspectives to the present time. Suicide and by extension induced euthanasia for sufferers were and are viewed as contrary to Christian tradition, natural law, the well-being of society, Christian compassion, and, most important, the dominion of God over human life (O'Malley; Sacred Congregation for the Doctrine of the Faith).

Through the centuries Catholics condemned physician-induced euthanasia as well as ending the lives of mentally or physically handicapped persons. At the same time, decades before the right to die movement began, Catholic authorities distinguished between "ordinary" and "extraordinary" medical treatments and argued that incurably ill persons in most circumstances had the right to refuse advanced medical interventions (Kelley; Pope Pius XII).

PROTESTANTISM. On issues involving life and death the Protestant reformers of the sixteenth century differed little from their early Christian and Roman Catholic predecessors. By the seventeenth century, however, certain Lutheran and Calvinist theologians were arguing that some self-inflicted deaths stemmed from mental imbalance. Holding that traditional arguments that cosigned the souls of suicides to eternal damnation were subject to human hubris, they also argued that the soul's eternal destiny was for God alone to decide (Ferngren). Directly countering the inclusive condemnation of Catholic heritage, the English poet and Anglican prelate John Donne (1572–1631) reasoned that some suicides did not violate natural law, human reason, Scripture, or the dominion of God over human life.

The lack of unanimity within seventeenth-century Protestantism increased in the ensuing centuries (Numbers and Amundsen 1998 [1986]). In the 1930s and afterward Anglican, Episcopalian, and Unitarian clergy played active roles in euthanasia societies in Great Britain and the United States. Beginning in the 1950s, a Protestant Episcopalian priest, Joseph Fletcher, became the most influential advocate of mercy killing in the United States (Fletcher; Vanderpool, 1997). Fletcher opposed the declaration against legalized mercy killing by his own denomination in 1952, by the Presbyterian General Assembly in 1951, and by the assertion of Willard L. Sperry, dean of the Harvard Divinity School, that legalized euthanasia cuts "against the whole basis and practice of medicine" (Sperry, 1948, p. 988).

Nevertheless, Jews, Catholics, and Protestants remained united about the virtue of helping persons die peacefully and naturally not by inducing death but by alleviating suffering and isolation through attentive care. The literature on consoling the dying that first flourished in Catholicism in the fifteenth century was adopted readily by Calvinists (Reformed Protestants) and Anglicans and transformed by Methodists and those in other denominations (Beaty; Vanderpool, 1998 [1986]). Francis Bacon rightly forecast how this literature harmonized with medical euthanasia in its original sense: special care of the dying.

The Law

Continental and Anglo-American law during the centuries following the advent of Christianity included a mixture of Roman law, the customs of various ethnic groups and communities, and canon laws developed and systematized by Roman Catholic jurists. Having inherited the Hebraic-Jewish conviction that God is the ultimate law-giver and judge and holding to the view that universal truths can be rationally discerned from the laws of nature, Catholic canonists sought systematically to adapt Roman law to Christian teaching (Plucknett). The cohesiveness, power, and geographical expansion of the Church enabled canon law to exert a profound influence on national laws, including the tradition of common law in England and its colonies.

Canon law was first adopted in England at the Council of Hereford in 673 c.e. Rooted in centuries of custom, canon law influenced the development of the common law from the time of the reforms of William the Conqueror (1027–1087 c.e.), to the vastly influential interpretations of the common law by Sir Edward Coke (1552–1654), to the present time (Plucknett; Williams, 1957). The canon laws adopted at the Council of Hereford included prohibition of suicide (Washington et al. v. Glucksberg et al.).

Savage penalties for suicide—bodily desecration, property forfeiture, and exclusion from Christian burial grounds— were set forth in common law by the thirteenth century and were rigorously enforced between 1500 and 1700. Coke wrote in 1644 that suicide is a category of murder and the property of suicides should be forfeited. In the middle of the sixteenth century, the Court at Common Bench—one of the pivotal councils of English sovereigns that developed and defined the common law—observed, as if it were taking a page from Thomas Aquinas, that suicide "is an Offence against Nature, against God, and against the King … To destroy one's self is contrary to Nature, and a Thing most horrible" (quoted in Washington et al. v. Glucksberg et al.)

Penalties against suicide were removed in England in 1823, followed by abolishment of suicide as a crime in 1961 (Markson). Beginning with Pennsylvania in 1701, the harsh common law penalties enacted in several American colonies were also abolished (Washington et al. v. Glucksberg et al.).

Nevertheless, laws in England, the majority of American states, and most western democracies associated assisted suicide with homicide and with suicide as a grievous wrong (MacDonald; Markson; Washington et al v. Glucksberg et al.). Considered a criminal offense ranging from second degree murder to manslaughter, laws against assisted suicide never contained exceptions for those who helped to end the lives of persons who were terminally ill, fatally wounded, or condemned to death (Washington et al v. Glucksberg et al.). American statutes that explicitly outlawed assisted suicide were first enacted in New York in 1828, then most other American jurisdictions. The Model Penal Code of the twentieth century, including its official 1980 draft, opposes anyone's "willingness to participate in taking the life of another, even though the act may be accomplished with the consent, or at the request, of the suicide victim" (quoted from Washington et al v. Glucksberg et al.).

Criminalization of assisted suicide was and is based on States' interests to protect and preserve human life, prevent suicides by persons who are young, elderly, or suffering from mental disorders, and protect the ethical integrity and healing roles of the medical profession (Washington et al v. Glucksberg et al.; Kamisar). The relatively high incidences of acquittals, suspended sentences, and reprieves of citizen- and doctor-induced euthanasia proves that, "The Law in Action is as malleable as the Law On the Books is [in almost every State] uncompromising" (Kamisar, p. 408).

Secular Legacies

As minority opinions in the dominant Christian culture, various humanists from the sixteenth through the eighteenth centuries spoke of the permissibility of suicide for seriously sick and injured persons. Enamored with Greco-Roman culture, Michel de Montaigne (1533–1592) voiced the unorthodox views that the "most voluntary death is the finest" and that "God gives us permission" to take our lives "when he reduces us to such a condition that living is worse than dying" (Montaigne, 1946 [1580], p. 338).

Skepticism, secular interests, and an emphasis on personal pleasure became more pervasive during the seventeenth and eighteenth centuries. English playwrights such as John Dryden (1631–1700) and Deists such as Charles Blount (1654–1693) defended certain suicides motivated by honor, suffering, lost love, or self-willed destiny (Ferngren). These themes informed the thought of one of the Enlightenment's most influential representatives, David Hume (1711–1776).

HUME. Hume began his essay "On Suicide" (1963 [1783]) with an attack on "superstition and false religion," which compel a person to prolong "a miserable existence … lest he offend his Maker" (pp. 252–253). He held that overwhelming suffering and wishes to die should be regarded as calling persons from life "in the clearest and most express terms" (p.259). Like Socrates and Plato, Hume argued that persons plagued with suffering that negates social usefulness are not obligated to prolong their lives. He also held that each person's "native liberty" consists of carrying out an autonomous course of action in keeping with one's "chance for happiness" (p. 261).

Hume's critics included Immanuel Kant (1724–1824), who censured self-killing because it cannot be willed as a universal action without undermining the possibility of morality, that is, the existence of rational beings. Kant also viewed suicide as a violation of one's duty to God, the sovereign of all life. Unlike Kant, nineteenth-century thinkers such as Friedrich Nietzsche (1844–1900) adopted Hume's view that autonomous persons have the right to end their lives when disease extinguishes pleasure and social usefulness.

DARWINISM. Charles Darwin's (1809–1892) theory of evolution played a pivotal role in reshaping Western religion, science, literature, and political philosophy and policy (Vanderpool, 1973). The secular understanding of the world advanced by Darwin and Darwinians directly affected views of euthanasia. The Darwinian theme that human progress depends on the survival of the fittest through natural selection engendered a Westernwide eugenics movement that promoted active interventions to rid the world of the "unfit" (Vanderpool, 1973; Pernick). Other Darwinians argued that euthanasia in the form of doctor-induced painless death was permissible because "nature certainly knows nothing" of the sacredness of life ("Euthanasia," p. 91) and "the doctrine of evolution" justifies shortening the lives of sufferers in the face of outmoded religious opposition (South Carolina Medical Association, p. xv).

EXPERIMENTAL MEDICAL SCIENCE. Well before the Darwinian revolution physician scientists performed extensive laboratory experiments on the physiology of death and resuscitation from which they developed a mechanistic understanding of life and death. After describing his experiments on "the laws of the vital functions," the British doctor A. P. W. Philip concluded that human life is not "a subject of peculiar mystery" (p. 211).

That mechanistic understanding led to the dominant twentieth-century view that the human body is a physicalchemical and mechanical entity that can and should be salvaged with sufficient repair. Ivan Pavlov's (1849–1936) vivisection experiments with dogs proved how severe and sequential injuries could be repaired one after the other to the point where a dog's death could be seen to represent a failure in technical mastery. This was the backdrop to ever greater attempts to sustain human life and to the neglect of care for dying patients after 1945.

Modes of Medical Practice to 1870

In keeping with the cultural heritages of Judaism, Christianity, and experimental medical science, physicians from the seventeenth century to 1870 focused on mitigating the effects of disease and the ultimate goals of saving and sustaining human life. In the eighteenth century the goal of saving life engendered a Western-wide movement to establish humane societies to rescue persons who appeared to be dead from drowning and other causes. Imbued with a sense of progress, physicians, human society members, and others discovered many means by which life could be restored and extended: manual breathing methods, ammonia, strychnine, bloodletting, tongue stretching, and electric shocks (Liss).

Nevertheless, in keeping with the admonition of Francis Bacon in the seventeenth century, a number of notable physicians lectured and wrote about the duty "to soothe the last moments of existence" (Ferriar, p. 392). Addressing his German faculty of medicine colleagues, Carl F. H. Marx termed the physician's "skilful alleviation of suffering" as "that science, called euthanasia, which checks oppressing features of illness, relieves pain, and renders the … inescapable hour a most peaceful one" (p. 405). Marx and others stressed shared themes: the painlessness of dying versus myths about "death agonies," the necessity of not disturbing dying patients, the comforting presence of physicians, expertise in symptom relief, the skilled use of opiates, the immorality of purposefully shortening life, and steadfast opposition to "dangerous and dubious treatment measures" to prolong life (p. 407).

These advocates of euthanasia in its original sense of helping patients to die naturally and peacefully appealed to moral, philosophical, and spiritual values: how close attention to the process of dying causes "the physical process of death [to lose] much of its horror" for patients and physicians alike (Ferriar, p. 392), the virtue of alleviating "the supreme anguish of the patient's mind" (Marx, p. 411), the humanity of caring for "a powerless and suffering creature" when "the scene of life is closing" (Dendy, p. 121), and the assurance that humane and steadfast care "will ever prove consolation to the hearts of attached friends" (Dendy, p.124). Predicated on these values, end-of-life care was deemed "not unworthy of the attention of the most scientific physician" (Dendy, p. 124).

All these physicians strongly opposed futile life-prolonging measures utilized by inexperienced and uninformed practitioners. Physicians ought to be able to know "when any hope [of cure] has departed" (Marx, p.405) and they should honor the moral principle of refraining from harm. John Ferriar criticized "ignorant practitioners" who "torment" dying patients with "liquors of different kinds" (pp. 393, 397). W. C. Dendy spoke of the cruelty of using stimulants such as brandy or ammonia "when hope is gone" (p. 122). Marx decried the use of caustics, "external irritants," "and other tortures" (p. 409).

In the first half of the nineteenth century when educated physicians were closing ranks against poorly trained and unorthodox practitioners, this tradition of terminal care was set forth as a profession. Thomas Percival's (1740–1804) widely published code of medical ethics shaped the codes of several U.S. medical societies and became the primary moral foundation for membership in the new American Medical Association (AMA). The AMA's Code of Ethics was unanimously adopted in 1847, and its sections on the care for dying patients were lifted verbatim from Percival's Medical Ethics. When doctors find that they cannot "revive expiring life," they should "soothe the bed of death" and not "abandon a patient because the case is deemed incurable, for [their] attendance may continue to be highly useful … by alleviating pain … and by soothing mental anguish" (Code of Medical Ethics of the American Medical Association p. 221).

Medical Practice and Turmoil: 1870–1945

SUSTAINING LIFE AND CARING FOR THE DYING. The ability to cure diseases and repair injuries increased exponentially between 1870 and 1945. The sophisticated advances in surgery and curative medicine during this time were symbiotic with the creation and explosive growth of modern hospitals. Increasing from 200 in 1873 to 4,438 in 1928, these hospitals were monuments to scientific medicine. They became and remain the central places in which an ever increasing number of medical specialists treate countless patients from all walks of life. Within these hospitals, new techniques for resuscitation and life prolongation were readily developed and adopted: "the struggle to reactivate the whole organism" with blistering benzine compresses (Jellinek, p. 216), injections of epinephrine via long hypodermic needles directly into the failing heart in the 1900s, open-chest message during cardiac surgery in the 1930s, and positive- and negative-pressure ventilation apparatuses and masks in the 1930s (Liss; Hermreck).

The resulting institutionalization of curative medicine and life-sustaining techniques detracted from care for dying patients. The increasing lack of concern is mirrored in revisions of the AMA Code of Ethics. The two paragraphs on care for the dying in the 1847 code were reduced to four lines in 1903, then to this part of a sentence in 1912: "a physician should not abandon or neglect the patient because the disease is deemed incurable" (Vanderpool, 1997, p. 40).

Only a few increasingly isolated physicians continued to explore and write about "the medical art" of "euthanasia" as "aid of an easy, gentle, and placid death" (Munk, pp. 4–5). By the late 1920s doctors were beginning to leave dying patients in care of nurses, clergy and sorrowing relatives. Alfred Worcester considered "this shifting of responsibility" to be "unpardonable" (p. 33). Worcester also lamented the lack of teaching about terminal care in medical schools and decried the increasing use of "modern methods of resuscitation" such as cardiac stimulation for dying patients. Worcester exclaimed that his peers "ought to know better" (p. 47). Beyond his criticisms, Worcester published a lengthy book chapter that outlined what medical students should be taught about care of the dying. Years later Walter C. Alvarez praised Worcester's "excellent little book" as one "every physician in the land should read and re-read" (Alvarez, p. 87).

DOCTOR-INDUCED DEATH FOR THE DESPERATELY ILL.

Many factors contributed to the post-1870 turmoil over the morality of doctors' inducing the deaths of suffering and incurable patients. Several of these preceded the development of modern hospitals by a few decades, but included factors—such as the discovery of anesthesia—that made modern surgery in these hospitals possible. The factors underlying the debate included the resurgence of secular challenges to traditional Jewish and Christian understandings of human life and death in the second half of the nineteenth century, the discovery and refinements of anesthesia after 1846, the development the hypodermic syringe (introduced in the United States in 1856) by which morphine could be injected by physicians with quick and powerful results, paternalistic physician supervision of patients with dread disease in modern hospitals, and the public's increasing reliance on physicians to relieve their aches and pains (Vanderpool, 1997, p. 37).

Turmoil over the painlessly putting to death of incurable sufferers began after the speech by Samuel D. Williams before the Birmingham Speculative Club in 1870 was turned into a pamphlet and seized upon as newsworthy. Williams defended the proposition that in "all cases of hopeless and painful illness it should be the recognized duty of the medical attendant, whenever desired by the patient to administer chloroform … or … other anesthetic … so as to destroy consciousness at once, and put the sufferer at once to a quick and painless death" ("Euthanasia," p. 90).

Williams's speech became newsworthy for several reasons. It directly challenged doctors who regularly used chloroform and hypodermic morphine and were responsible for dealing with catastrophic illness and determining when patients' conditions were incurable. It challenged lawyers because Williams's proposition was illegal. It alarmed the clergy because of the clergy's historical opposition to induced death. It engaged the American public because opiates were unregulated before 1920 and because dying persons often were cared for at home.

Through the years journals and newspapers perpetuated the debate and reported about euthanasia societies, attempts to legalize euthanasia, and individuals who admitted to ending the lives of desperately sick persons or were brought to trial for doing so ("Euthanasia"; Rosenberg and Aronstam; "Shakers Justify Killing Sister"; "Physician Admits to 'Mercy' Killings"). The arguments set forth in the early years of the debate became fixtures in the years to come (Vanderpool, 1997).

Proponents argued that euthanasia is merciful and that refusal to perform it is cruel. Doctors have the duty to alleviate pain as well as prolong life. Life racked with pain is hardly sacred, and evolution undermines the value of individual life ("Euthanasia"). The fact that some physicians were already practicing it surreptitiously attests to its moral acceptability. People deserve "at least as much kindness and sympathy" as animals that readily are put out of their misery (Wolbarst, p. 354).

Medical societies and most physicians found "insuperable objections" to the practice (Victor Robinson, 1913, p.145). Intentionally ending the lives of suffering patients repeatedly was declared to be antithetical to the traditions of medicine. That "ghastly" practice would undermine the physician's premier goal of saving life and turn doctors into executioners ("The Moral Side of Euthanasia"). Euthanasia was a crime, and legalized euthanasia would be abused by devious physicians and nonphysicians. It would display cruelty to dying patients who would question their worth and fear for their lives rather than receive the care they deserved. It would devalue suffering, cheapen life, and undermine the dominion of God. Between 1906 and 1969 opponents of physician-caused death in Great Britain and the United States united to defeat the many attempts to legalize euthanasia.

KILLING UNWANTED HUMAN BEINGS. Advocacy to end the lives of unwanted human beings—euthanasia in the third sense—emerged in Europe and the United States toward the end of the nineteenth century. Those who promoted euthanasia for "defectives" often claimed that civilized sentimentality "nullified nature's methods of eliminating the unfit" ("Foreign Letters," p. 1617). Others spoke of the "benevolent extermination of degenerates," (Smith, p.50) the "inhumanity" of not relieving a "gibbering driveling idiot" from his or her misery (William Robinson, p. 88), and the need to "liberate" retarded and insane persons from "tortured mentalities" (Wolbarst, 1935, p. 332). Those despised groups were thought to be interfering with the progressive evolution of the human race (Smith).

Devotees of eugenic euthanasia differed over which groups should be eliminated and how their lives should be ended: denying treatment to newborn "monstrosities" and/or actively ending the lives of insane persons and/or others. After Dr. J. J. Haiselden created a storm of controversy between 1915 and 1919 over his refusal to save the lives of several severely defective newborns and young children, eugenic euthanasia rhetoric continued, but its practice remained hidden and rare in the United States (Pernick).

In Germany proposals for exterminating unwanted persons became political policy. In 1868 Ernst Haeckel (1834–1919), a disciple of Darwin, argued that Germany's physical and mental incurables should be put to death painlessly. Haeckel praised the Spartans for killing their deformed and weak children, in contrast to the "antiselection" of Christian compassion for the infirm and sickly (Lifton).

Germany was considered the new polis. Each doctor should become a "physician to the Volk" for the "perfection of the health" of the people (Lifton, p. 30). The "biological body of the German people" should be invigorated through programs of physical fitness and the science of "race hygiene" (Ernst, p. 574). Preceded by the recommendation of a child-welfare pioneer Sigmund Engle that "cripples, high-grade cretins, idiots, and children with gross deformities" should be destroyed painlessly (quoted in Pernick, p. 23), a jurist Karl Binding and academic psychiatrist Alfred Hoche called for the elimination of mentally ill and retarded persons in their influencial book titled Release and Destruction of Lives Not Worth Living, 1920.

Eugenic beliefs infused the thinking of mainstream physicians, academicians, and scientists in Germany well before their adoption by Adolf Hitler (1889–1945) as National Socialist (Nazi) policy (Shevell). Physicians played a critical role in creating the concept of racial hygiene, supporting the Nazi rise to power, and administering sterilization and extermination programs (Ernst; White).

Shortly before Germany's invasion of Poland in September 1939 Hitler directed that children with severe mongolism, hydrocephaly, paralysis, and deformities be registered. In thirty pediatric departments across Germany doctors supervised the registering, sorting out, and killing of 5,000 children (Lauter and Meyer). Within months Hitler issued a decree that mentally incurable adolescents and adults should "be granted a mercy death." That decree created an agency that orchestrated physician-directed killing of over 70,000 persons in gas chambers disguised as showers (Shevell).

When they were stereotyped as destructive to the health of the body politic, Jews, Gypsies, and others were consigned to a massive, bureaucratic doctor-run extermination program that was modeled on its medical predecessors. Those programs lasted only six years, but their horror is unforgettable. After World War II the World Medical Association (WMA) and several national medical associations condemned the Nazi extermination programs.

Medical Practice and Debate: 1945–1960s

MERCY KILLING. The revulsion against Nazi practices did not curtail campaigns to legalize mercy killing (Vanderpool, 1997). At the end of the war a new campaign to legalize euthanasia backed by 1,776 physicians and 54 eminent clergypersons began in New York, and from 1945 through 1969 petitions were signed and legislative attempts were made in the United States and Great Britain (Wilson). In spite of those efforts and the passionate defense of euthanasia by Joseph Fletcher, bills to legalize mercy killing were not introduced for a vote or were voted down. At its meeting in 1950 the World Medical Association resolved that national medical associations should "condemn the practice of euthanasia in any circumstances" ("Official Notes").

THE PREEMINENCE OF PROLONGATION. Effective and sophisticated ways to save life were developed during and after World War II, including penicillin and other antibiotics and methods to overcome cardiac arrests through the use of open-chest heart massage in the 1950s and closed chest defibrillators in the 1960s. The reversal of cardiac arrest was called "the restoration of life after death" in the media (Bains, p. 1346). The use of nasogastric feeding tubes and blood transfusions became widespread, and mechanical ventilators as a "complete substitution of the spontaneous ventilation of the patient" were refined (Petty, p. 2).

Along with these technological advancements, the physician's duty to sustain life achieved a preeminent status in hospitals from the 1940s through the 1960s. Lest they betray their training, many doctors felt that they should do everything possible to sustain life rather than "just let the patient die" (Glaser and Strauss, p. 196). Even in the face of dire prognoses heroic treatments often were continued until a patient's organ systems deteriorated, extensive pain was experienced, the patient's family reached "an advanced stage of grieving," or a doctor's colleagues intervened (Glaser and Strauss, p. 199).

Graphic accounts of attempts to prolong life became news in the 1950s. No story was more influential than that of a widow's anguish over her husband's treatment in a metropolitan hospital in 1957. "If you are very ill," the widow said, "modern medicine can save you. If you are going to die it can prevent you from so doing for a very long time." She lamented the use of "all the latest wonder drugs, the tricks and artificial wizardry" that "deprived death of its dignity." Upon begging a doctor to "cease this torture," she was told that "they had to maintain life" ("A Way of Dying," pp. 53–54). The reasons for the priority of prolongation included the equation of medical practice with mastery of the new technologies, death as the ultimate evil, the equation of death with defeat and medical failure, and lost concern with care for the dying. "Who causes these extraordinary measures to be continued indefinitely?" one doctor asked. "In most cases, it is the physician himself" (Rynearson, p. 86).

CARE FOR THE DYING. The few physicians who perpetuated the tradition of natural dying displayed despair. Describing how he was "bringing comfort to the slowly dying" in their homes, Walter C. Alvarez wrote that dying persons "should never be cast off and neglected simply because they cannot be 'cured'" (pp. 89–90). Alvarez observed that "rarely does anyone ever discuss the subject in medical schools, at medical meetings, or in the journals." Like his predecessors, he decried the abuses of prolongation:

When I myself lie dying, I hope that I will have by me some wise and kindly physician who will keep interns from … puncturing my veins, or putting a tube down my nose, or giving me enemas and drastic medicines (p. 91).

Depicting his medical training between 1957 and 1960, Roger Bulger described how students were taught "the intricacies of every method or technique that might possibly bring someone back from extremis but no one has ever suggested that we ought to attempt to care" for the person beneath "the multiplicity of tubes that are entering him from every direction" (Bulger, pp. 23–24). In hospitals doctors probe and test, nurses are indifferent, and the dying "'crock' is a second class citizen" (Kohn, p. 1180).

SHORTENING LIFE AND ASSISTING IN SUICIDE. In the context of the preeminence of prolongation, instances of euthanasia in the fourth sense—painless death to the point of shortening life—were designated "invisible acts" by hospital personnel in the late 1950s (Glaser and Strauss, p. 198). At times, however, a patient's right to receive pain relief at the cost of abbreviating life was advocated openly (Fletcher; Ayd).

Euthanasia in the fifth sense—assisting patients to end their lives—was practiced even more surreptitiously. Suffering patients who begged to die at times were relegated to a "dying room" where overdoses of pills were left at the bedside and patients were unwatched for long periods so that they could "manage" their own deaths (Glaser and Strauss). Stories of doctors giving overdoses of opiates for patients to take at home were told to clergypersons and known by physicians (Sperry, 1948). The extent of the practice of shortening life and assisting suicide in medical practice remains unknown.

TWO IMPENDING REFORMS. Descriptions of dreadful and often futile attempts to prolong life increased in medical and popular journals in the 1950s and 1960s. Those descriptions identified two problems: how to curtail life-prolonging attempts so that patients could die naturally (passive euthanasia) and how to care for sick persons and aged individuals at the end of life.

Father Gerald Kelly wrote a sophisticated analysis of the first problem in 1950, and a way to resolve it was announced by Pope Pius XII seven years later: "The doctor … has no separate or independent right where the patient is concerned … he can take action only if the patient … gives him permission" (p. 285). Despite opposition, several physicians, including non-Catholics, citing the widow's story and the pronouncement of the Pope, agreed that "the decision concerning further treatment should be in terms of the patient's own interests" (Rynearson, p. 86). In their articles those doctors occasionally outlined "components of the care of the dying patient": death with "dignity, respect and humanity," minimal pain, and familiar surroundings that promote sharing with family and friends (Rynearson, p. 87).

In 1966 Charles Hofling observed that the problem of determining when to terminate life by withholding various medical interventions had "thus far received little thoughtful, and very little authoritative, attention" from his fellow practitioners. In fact, "the typical approach has been to arrive at a course of action with a minimum of discussion." Convinced that this approach "will force the whole matter on the public's attention," he called for "multidisciplinary consultations" on the part of physicians, lawyers, clergy, sociologists, and "quite possibly" philosophers (pp. 43–46).

Those authors were the prophets of two impending reforms: the "right to die" movement and the "death and dying" movement.

Conclusions

An untutored glance at the title of this entry could give the impression that it would be far more conceptually balanced— though less provocative—if it were entitled "Ending and Sustaining Life, Historical Aspects." In fact, due to the multiple meanings of euthanasia in medical history, this entry does balance the many ways doctors have dealt with ending human life on the one hand and sustaining and extending life on the other.

This history is filled with an intriguing combination of continuities and tensions. The continuities surface in the first cultural legacy explored in this entry—Hebraic and Jewish perspectives. Its major motifs forecast enduring themes for the ensuing three thousand years: a commitment to saving and extending life whenever possible, a mandate to display concern and care for dying persons, and, based on the sacredness and ultimate value of human life, an opposition to mercy killing of incurably sick persons, disabled children and others.

Christianity inherited these motifs from Judaism and embedded them within Western culture to the extent that they became moral givens. The cultural transformation that occurred over the centuries included the way canon law infused common law and the way those motifs shaped codes of conduct, common commitments, and the increasing power of the medical profession.

Historical tensions were both exterior to and inherent within these continuities. Exterior to them, Nazi programs of extinguishing unwanted and despised persons appealed to Greco-Roman precedent, but due to the depth of Western cultural transformation that had occurred, became equated with unspeakable moral deviance. The Nazi programs secured the loyalty of a number of German physicians enamored by Aryan supremacy and eugenic-based notions of evolutionary progress. These programs were condemned as betrayals of professional ethics that continued to uphold the moral mandates transmitted to Western culture through Judaism and Christianity. Euthanasia in its current meaning— a doctor's terminating the life of a terminally ill patient— began and remained contentious because it drew upon factors that were both inherent within and external to the reigning motifs of Western medicine. Advocates of mercy killing appealed to the themes of mercy for sufferers of fatal illnesses and the cruelty of not relieving persons from pain. At the same time, against the strictures of common law and in the name of naturalistic evolution and/or secular notions of self-ownership and autonomy, these advocates countenanced circumscribed forms of homicide and assisted suicide.

Within the historic continuities, tensions developed between the primacy of prolonging human life and humanitarian care for the bodily, emotional, and spiritual needs of persons who could not be cured. By the eighteenth century physicians devoted to this humanitarian ideal began opposing the sustaining of life by every available means for persons at the end of life. The last decades of history covered by this essay end when experimental science provided means by which to extend life in hitherto fore unimagined ways. Devoted to the prolongation of life, scientific medicine became entrenched in modern hospitals and the preoccupation of medical training.

The agonizing stories of patients, the troubled concerns voiced by a handful of physicians, and the voices of historical continuity from the Pope and physicians with similar concerns declared that modern medicine was losing its moral moorings. The seeds for the impending reforms regarding the rights to refuse advanced life-prolonging treatment and to receive attentive humane end-of-life care were sown in the late 1950s and 1960s. Their germinating power lay in the fact that they were gleaned from dominant cultural motifs that had shaped the practice of medicine through centuries of Western history.

harold y. vanderpool (1995)

revised by author

SEE ALSO: Advance Directives and Advance Care Planning; Clinical Ethics; Death; Death, Definition and Determination of; Holocaust; Informed Consent; Medical Codes and Oaths; Palliative Care and Hospice; Right to Die: Policy and Law;Surrogate Decision-Making; and other Life Sustaining Treatment and Euthanasia subentries

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