Euthanasia
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Euthanasia (Greek: ευθανασία - ευ "good", θανατος "death") refers to assisted dying. The assistance ends the life of a person or an animal, in a painless or minimally painful way. Euthanasia is most often performed in a merciful way, in order to end suffering. This article discusses euthanasia in humans; a separate article covers animal euthanasia.
This topic is often highly-charged -- emotionally, politically, morally, etc. Terminology and laws shift over time and geographically/globally, causing a great deal of confusion.
First, euthanasia does not refer to "letting die" or "allowing to die." ( See terms: informed consent, decisional capacity, surrogate decision making, Living wills, Do Not Resuscitate ) In the United States, "letting die" or "allowing to die" refer to areas which have long been considered ethically and legally acceptable and permissible, including withholding and withdrawing of medical treatment such as dialysis or feeding tubes.
Nor does euthanasia refer to the witholding of hydration and nutition, two things in most cultures which have long been associated with "love and caring." While the concept of holding off on those two things may be counterintuitive, as a body's major organ systems try to shut down, a dying person often feels most comfortable without any fluids or food . To do otherwise is like "force feeding" a body that does not "want" or need to be fed or hydrated, and doing so may actually cause physical discomfort and suffering.
What euthanasia does include can be very confusing. Next are several summary statements which are followed by expanded definitions of each. Euthanasia (assisted dying) may employ methods that are either indirect or direct. Indirect methods of euthanasia are defined by a individual him or herself taking the final step inducing death. Direct methods are defined by the involvement of others (clinicians) who take the final step inducing death. Direct euthanasia can either be voluntary, nonvoluntary or involuntary.
Indirect euthanasia involves the indirect involvement of a clinician (e.g. physician, clinical nurse practitioner, pharmacist) as an agent who particpates only by providing the means for a patient to induce his/her own death. This could mean writing or filling a prescription for medications in a quantity large enough to cause death when taken by the patient. This kind of assistance is currently legal in the American state of Oregon. It became legal in 1998 as a result of the "Death with Digninity Act" which was passed in the state in 1994. In politically and emotionally loaded terms, this is frequently refered to as physician-assisted suicide.
Direct euthanasia involves the direct involvement of a clinician as agent in inducing a patient’s death. (e.g. administering a lethal drug by injection. ) Direct euthanasia is not currently legal anywhere in the US, but both direct and indirect euthanasia are legal in Belgium and the Netherlands.
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.)
A large part of the controversy surrounding euthanasia focuses upon the slippery slope argument. The fear is that indirect euthanasia and/or voluntary direct euthanasia will lead to acceptance of the nonvoluntary and involuntary types of euthanasia.
Nonvoluntary euthanasia occurs without the fully-informed consent and fully-informed request of a 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.
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.
In Nazi Germany the term "euthanasia" (Euthanasie) referred to the systematic killing of disabled children and adults under the T-4 Euthanasia Program. This program was cancelled (at least officially) after public disapproval was expressed. This has tainted the word in German-speaking countries; the alternate term is the older "Sterbehilfe", which means "help to die".
Legislation and national political movements
Australia
Euthanasia was legalized in Australia's Northern Territory, by the Rights of the Terminally Ill Act 1995. However, this law was soon 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.) Three people had already been legally euthanised, however, before the Commonwealth government made this amendment.
Although it has for some time been a crime in most Australian states to assist another to commit suicide, prosecutions have been rare. In Queensland recently (2002) a group of relatives and friends who provided moral support to an elderly woman who committed suicide were extensively investigated by police, but no charges were laid.
Belgium
After an extensive discussion the Belgian parliament legalized euthanasia in late September 2002. The new legislation, however, institutes a complicated process, which has been criticized as an attempt to establish a bureaucracy of death. Nevertheless, euthanasia is now legal and its proponents in the country hope that it will stop many illegal practices (it is said that several thousand illegal acts of euthanasia have been carried out in Belgium each year).
Canada
On January 28, 2005, Marcel Tremblay of Kanata, Ontario held a press conference to announce plans to kill himself, saying his life with pulmonary fibrosis was unbearable. After attending his own living wake, the 78-year-old man committed suicide at 11:51 pm Eastern time.[1] He had previously said he would be surrounded by his wife and adult children while he placed a bag over his head and filled it with helium. Tremblay said that he publicized his suicide plans to help change laws over assisted suicide. His lawyer said police were satisfied that Tremblay had a sound mind and that authorities would not intervene. Canada decriminalized committing suicide and attempting to commit suicide in 1972.
In the early 1990s, 42-year-old Sue Rodriguez, who had amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease), fought to overturn the law against assisted suicide. She lost her court battle, but was assisted in her dying with the help of an anonymous doctor. Under Canada's Criminal Code, assisting someone to die is illegal and punishable by up to 14 years in prison.
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 has asked repeatedly
- the patient's suffering is unbearable with no prospect of improvement
- the doctor has consulted an independent colleague prior to the act
- 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.
Statistics and methods
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.
Note that some medical authorities and investigative reporters claim there are substantial numbers of euthanasias in the Netherlands performed without consultation or official notice – see links below.
Oregon (United States)
Oregon Law, passed in 1997, states an individual must meet the following criteria:
1) 18 years of age or older,
2) a resident of Oregon,
3) capable of making and communicating health care decisions for him/herself, and
4) diagnosed with a terminal illness that will lead to death within six (6) months, verified by two physicians.
Note: It is up to the attending physician to determine whether these criteria have been met.
See also
Statistics and methods
In 2003, in Oregon 42 cases of physician assisted dying were reported (0.14% of all deaths), all by drinking a strong barbiturate potion, usually 9g of Pentobarbital. The doctor is not required to be present; in 12 cases he/she was.
Since 1998, 171 Oregonians have relied on the "Death with Dignity" law.
There were three cases of regurgitation. In each case at least one third of the potion was retained, which caused death anyway, though in one case only after 48 hours.
The time from ingestion to unconsciousness was 1 to 20 minutes (median 4 minutes), the time from ingestion to death 5 minutes to 48 hours (median 20 minutes).
External links
- Neutral
- Euthanasia and Religion - various religious views of euthanasia
- For euthanasia
- Compassion & Choices - provides education, support and advocacy for the choice-in-dying movement
- World Federation of Right To Die Societies
- Assisted Suicide
- End of Life Choices
- Voluntary Euthanasia- Atheist Foundation of Australia Inc
- Stanford Encyclopedia of Philosophy entry
- A defense of euthanasia
- Against euthanasia
- euthanasia.com
- National Right to Life articles on euthanasia
- International Task Force against Euthanasia- many resources
- Non-religious arguments against euthanasia
- Netherlands
- Official:
- For:
- Right to Die-NL - Dutch union for voluntary termination of life NVVE
- NRC Handelblad April 14, 2001 interview of Els Borst: Transparency in Euthanasia- Note that this is from an anti-euthanasia web site, but claims to be merely a translation of a Dutch article. Els Borst is a prominent Dutch advocate of Euthanasia.
- Against:
- Clinical Problems with the Performance of Euthanasia and Physician-Assisted Suicide in the Netherlands, NEJM, February 24, 2000
- Consultants or Facilitators? Medical Journal of Australia, 1999 Editorial- Cites original research, including that on alternative palliative care
- Wall Street Journal Article on Dutch Euthanasia The article claims that unofficial Euthanasia is performed on as many as sixteen adults per day (90% of adult physician-assisted deaths), and 8% of all infants, often without patient consultation, according to Dutch statistics. This source claims that many old Dutch people are afraid to go to the hospital.
- Weekly Standard Article Claiming Unauthorized Euthanasia of Dutch Infants
- December 18, 2000 National Review Opinion, Wesley Smith- Cites statistics showing frequent involuntary physician-assisted deaths in the Netherlands.
- Oregon