By: Milan K. Sheth, M.A. in Biomedicine-Eastern Mennonite University
The legality and ethics of palliative physician-assisted suicide (PAS) has been a controversial debate as individuals continue to question the righteousness of doctors assisting in the suicide of patients with a life expectancy of six months or less (1).
The purpose of this article is to explore the theological, ethical, and scientific perspectives of both sides of the debate; one side asserts that PAS protects those who are sick and promotes holistic health in the final stages of life, while the other side states that PAS is unethical, blasphemous, and sinful. Both arguments rely on exploring respect for individual autonomy; it is by choice and with recognition of the rights of competent people to choose the timing and manner of their death when faced with terminal illness.
PAS has undergone vast transformations throughout history. In the 17th century, common law prohibited suicide in the American colonies (2). The first use of the word “Euthanasia,” Eu (good) and Thanatosis (death), transcribed to “Gentle and Easy Death” (2). Despite the meaning of its Greek origin, euthanasia was forbidden amongst ancient Greek practitioners. Physicians followed the teachings of the Bible’s sixth command, “thou shalt not kill” (Exodus 20:13, The New King James Version), and as a result, prevented euthanasia from becoming a common practice for centuries. On the other hand, in Sparta, it was common practice for a newborn male to be screened for any signs of physical or mental disability. If a newborn male showed any signs of physical or mental weakness, then the child would be killed. This practice was viewed as a way to protect the society from disease, illness, and burden, as well as protecting the afflicted individual from a lifetime of suffering (2).
In the 16th and 17th centuries, Renaissance and Reformative writers began to challenge the church (3). Judeo-Christian traditions believed God placed man on earth as the protector of all life, and, as a result, one could not escape through one’s own will. This theology marked euthanasia as a crime and the action regarded as murder. By the 19th century, philosophers and even clergymen protested that the church was too authoritative with regard to ethical matters. If an individual was suffering and made the choice to end his or her own life, then the individual should have been able to do so, regardless of religious implications. Even so, the American Evangelical Christians rejected suicide and euthanasia with respect to the sixth commandment (3).
The first U.S. statute outlawing assisted suicide, Death with Dignity, was enacted in New York on December 10, 1828 (2). Many other northern states followed suit, but it was not until the early 1870s that Samuel Williams, a prominent and popular advocate for euthanasia, published a paper advocating the use of morphine and other drugs for assisted suicide (2). Williams’ paper stated the following:
“In all cases, it should be the duty of the medical attendant, whenever so desired by the patient, to administer chloroform, or any other such anesthetics as may by and by supersede chloroform, so as to destroy consciousness at once, and put the sufferer at once to a quick and painless death; precautions being adopted to prevent any possible abuse of such duty; and means being taken to establish beyond any possibility of doubt or question, that the remedy was applied at the express wish of the patient” (16).
Williams’s paper was influential, but the American Medical Association would begin to publicly attack his proposals in 1885. The Association claimed that William’s proposal was blasphemous and an “attempt to make the physician don the robes of the executioner” (4). Despite the Association’s attacks, Samuel William’s revolutionary proposals, coupled with new science, coincided with a shift in public opinion.
Public polls taken in the early 1930s indicated changes in the way that populations viewed euthanasia. In 1937, nearly 45% of Americans believed that mercy killing of infants born with mental or physical disabilities was permissible (2). This claim, coined by the chief surgeon at the German-American Hospital in Chicago, Harry Haiselden, was reminiscent of 17th century practices. Harry Haiselden was infamous for refusing to perform surgery on children born with severe birth defects and instead advocated for their deaths. Populations began to tolerate the idea of mercy killings, sparking immense debate amongst theological, social, and political circles.
In the 1940s, the euthanasia movement found itself scrambling to deny that the form of euthanasia it supported was the same as Nazi murder (2). During this time, the German Nazi Party accepted euthanasia as a practice for crippled children and “useless” patients (2). But who has the right to define “useless?” During the Holocaust, the German Nazi Party utilized euthanasia to kill thousands of individuals. As a result, the euthanasia movement grew defensive in an attempting to separate euthanasia from the murders performed by the Nazi Party. The Nazi Party of Germany changed their version of the Hippocratic Oath in 1935, replacing the clause “do not harm” with Gesundheit, “an oath to the health of the Nazi Party. (2). This amendment proved increasingly dangerous as it removed obligation from the German physicians to heal or render aid to the nearly eleven million individuals killed during the Holocaust. Each death was justified for the health and well-being of Nazi Germany. The primary duty of German physicians began to transition from one of the patient to one of the Nazi Party.
A public poll performed in 1937 claimed that 53% of American physicians defended PAS (2). By the 1970s, conversations regarding euthanasia became a prominent discussion amongst medical practitioners, and in 1976, a significant landmark in the history of PAS occurred which challenged national and international law. In 1976, 21-year-old Karen Ann Quinlan, a resident of New Jersey, fell into an irreversible coma after attending a party where she ingested alcohol and barbiturates. She lived in a hospital where doctors declared she was in a “persistent vegetative state” (5).
Her parents, as a result of the declaration, advocated for the removal of her respirator. Her respirator was a life-saving device and, if removed, would end her life. Her parents went to court to have her respirator removed; their intent was to protect their daughter from a lifetime of suffering. The case went to the Supreme Court and, in 1976 Karen Ann Quinlan was the first individual to be detached from a life-saving machine (5). This case was very significant in the euthanasia movement; it drew both national and international attention to end-of-life issues and remains a legal landmark to this day.
That same year, California Governor Edmund G. Brown Jr. signed the California Natural Death Act (2). This act marked California as the first state to grant terminally ill patients the right to end their own life (2). The state of California recognized patients’ right to authorize the withdrawal of life-sustaining medical treatment, performed by a doctor, when diagnosed with six months or less to live.
Protocols to address PAS began developing, and the American Medical Association released its primary procedure in 1984. The American Medical Association only allowed a physician to withhold or withdraw treatment from a patient who was nearing death if the patient gave informed consent on two separate occasions and met other necessary criteria. Alternatively, physicians could discontinue life support of a patient in a permanent coma if granted informed consent. These protocols were developed further into six steps (6) as a way to safeguard personal, socio-cultural, medical, and economic ethics. While PAS was not universally supported in the United States, surveys in the early 1990s showed that more than half of Americans supported physician-assisted death (4). So if the majority of the population supported PAS, why did it remain so controversial?
In 1999, the arrest of Dr. Jack Kevorkian deeply challenged public opinion. During this time, while PAS had been gaining some popular support, it still was not common practice. Individuals within the country understood the protocols set in place and the majority consensus supported such protocols. However, when Dr. Jack Kevorkian, a euthanasia advocate and pathologist, was arrested in 1999 for publishing a video of Thomas Youk’s death by PAS, the public began to seriously question the ethicality of euthanasia (4).
Dr. Jack Kevorkian administered the lethal injection to Thomas Youk, a 52-year-old male suffering from Lou Gehrig’s disease (4). Thomas Youk asked Dr. Kevorkian to administer the lethal injection, thereby giving Dr. Kevorkian informed consent. However, doctors did not diagnose Thomas Youk with six months or less to live.
Dr. Jack Kevorkian administered the lethal injection to Mr. Youk on September 17, 1998, while Dr. Kevorkian videotaped the death. The video gained remarkable national and international attention. Suddenly, the practice of euthanasia was publicly displayed; it had a face, a name, and a life; it became incredibly personal. Dr. Kevorkian had performed several other injections, but this was the first publicly displayed. As a result, the state of Michigan charged Dr. Kevorkian in the case of voluntary euthanasia, and he served eight years in prison.
He famously noted at his trial: “Dying is not a crime.”
On June 1, 2007, the state released Dr. Kevorkian on parole under the condition that he would not offer advice, participate, or be in the present act of any form of suicide (2). At this time, he was under the supervision of the state and not allowed to have any influence on others attempting to perform euthanasia or interested in the act of euthanasia. Consequently, if Dr. Kevorkian promoted or spoke about the procedure of assisted suicide, he would return to jail for a life sentence. Dr. Kevorkian died on June 10, 2011, at 83 from thrombosis (7).
Dr. Kevorkian’s actions, coupled with his case regarding Thomas Youk in 1999, sparked a lot of conversation within the euthanasia movement. Public opinions shifted and the procedures involved in enacting any form of legislation thickened. Many individuals sought doctors, such as Dr. Kevorkian, to end their lives because they had lost all quality of life. This perspective held the belief that if an individual was not guaranteed a basic right—the right not to suffer—then PAS should be justified.
To date, only six states have legalized PAS (8). The first state was California followed shortly by Vermont, Colorado, Oregon, and Washington (9). Each of these states sought legality via legislation with only one state, Montana, legalizing PAS via court ruling (9). As of 2012, 44 states consider physician-assisted death as illegal (8).
The legalization of PAS poses significant questions in multiple sectors. For the purposes of this paper, we will continue to explore the theological, ethical, medical, and economic perspectives.
The theological perspective is multifaceted. One approach poses that respect for individual autonomy pays respect to religious freedom. Physicians must respect religious preferences in discussing physician-assisted death with terminally ill patients, but, regardless of religious background, individuals first and foremost have the individual right to choose PAS. This perspective challenges much of the church’s belief. For example, in Judeo-Christian theology, the sixth commandment states “thou shalt not kill” (Exodus 20:13, The New King James Version).
In Hinduism, if an individual commits suicide, he or she neither goes to hell nor to heaven but remains in the earth’s consciousness as a bad spirit (10). Rather than rise to heaven, this soul wanders aimlessly till they complete their actual allotted life time (10). As in Judeo-Christian theology, Hinduism theology believes PAS is condemnable, unethical, and, therefore, illegal.
With respect to individual autonomy, let’s explore a case study example in which a 17 year-old Hindu child who has battled Leukemia from birth. Is PAS an option for this child? From a theological perspective, with respect to the Hindu culture, Hinduism generally prohibits suicide (10). In most cultures, many people believe God is the only entity with the right to end human life. Hinduism generally prohibits suicide because it disrupts the timing of the cycle of death and rebirth (10). As a result of that disruption, bad karma accumulates within the soul, and it prevents the soul from obtaining moksa (liberation). Karma is the net consequence of both good and bad decisions made within a lifetime; the quality of one’s karma dictates the nature of their next life (10). Moksa is the ultimate goal of Hinduism and rests in the ongoing accumulation of good karma. The more bad karma a soul generates, the further away the soul becomes from moksa (10).
From the Hindu perspective, euthanasia breaches the teachings of ahimsa (non-violence). Ahimsa represents the clause, “do no harm” and when a physician assists in a patient’s death, they are viewed as intentionally doing harm (11). The concerns of PAS rest in the teachings of ahimsa, the beliefs of karma, and the ultimate goal of moksa. As a result of these beliefs, the practice of euthanasia would actively damage the good karma of both the physician and the patient, limiting both parties from obtaining moksa.
So, would euthanasia be appropriate for a Hindu child who was born with and suffers from Leukemia? From a theological perspective and with respect to Hindu culture and theology, this child would neither seek nor practice euthanasia. The practice of euthanasia would have dire consequences for the soul’s spiritual progress, and, as a result, the soul would remain wandering aimlessly until it completed its actual allotted lifetime as defined by the higher consciousness (11). It is critical to note that, even when this soul has completed its actual allotted lifetime, the soul would return to hell to suffer with greater intensity (Sinha, 2012). According to Dr. V. Sinha of Indian Psychiatry Journal, “Suicide puts an individual’s spiritual clock in reverse” (10).
However, is it ethical that this Hindu child, born with and currently battling Leukemia for seventeen years, continues to suffer? Regardless of theological perspectives, the decisions made in PAS are incredibly ethical. The definition of an ethical argument is an individual with a freedom of choice, including the right to control their own body and life (1). In the case of PAS, an ethical argument pays recognition to protecting the state from creating laws that prevent individuals from being able to choose how and when they die (1). If an individual chooses to make decisions about their own body and life, it must not interfere with the safety and health of others (1).
For the purposes of this paper, I will take the ethical stance that PAS is a personal choice and helps alleviate the suffering of a terminal condition. In addition, I note that the concept of “quality of life” is critical to this aspect of the argument. Many individuals believe euthanasia is a solution to those who suffer from terminal illness, as it promotes a holistic and peaceful transition into the next life (12). If an individual chooses to end their life, then they can do so; life should only continue as long as a person feels their life is worth living.
If we take the case study of the Hindu child born with Leukemia and provide that individual the opportunity to utilize euthanasia to end suffering and promote a peaceful transition to the next life, it is critical we weigh the pros and cons. In the case of this child, parental consent would be necessary as they are under 18. The patient must present two informed consents to the physician, each at least fifteen days apart (10). In addition, a physician must diagnose a child with six months or less till death in all states (8)
. If the patient meets all of these qualifications, then they can seek treatment (if it is performed in a legalized state).
But is it right to assist someone in dying? Some believe that, if PAS becomes legal, it could abuse minority populations who experience immense socio-economic and cultural discrimination (10). Additionally, if states legalize PAS, they could use it to control population sizes and, therefore, harm vulnerable populations without the resources of developed countries who possess political, social, and economic power. A critical example of this viewpoint is the Holocaust, where physicians failed to provide medical care to minorities and amended laws to distort the Hippocratic Oath. If states legalize euthanasia, they must strictly enforce the protocols set in place to prevent another systematic genocide like the Holocaust.
It is by individual choice and under given circumstances that a patient can seek PAS. It is important to note individual autonomy, as well as ethics. To examine the medical ethics perspective, the traditional duty of a physician is to preserve life and to do no harm (13). Therefore, the practice of euthanasia is a direct violation of fundamental medical ethics. However, most public polls indicate that physician-assisted death is a choice issue. If the state allows termination of life sustaining measure such as dialysis and respirators, then how is PAS different? Individuals can legally choose to end life by ending life-sustaining support systems, but most do not have the freedom to choose physician-assisted death. We hold the scientific means of preserving and ending life. Many believe that, since physicians have the means to preserve life, it is their natural duty to do so at all cost (14).
Ultimately, it is the choice of the patient to request euthanasia. From a medical ethics perspective, it is never the choice of the physician. When a physician has the opportunity, under very specific circumstances, to suggest euthanasia treatment, they must remain incredibly mindful of individual autonomy, theological, and ethical perspectives. Further, only six states allow physicians to perform euthanasia. We will later explore international laws that encourage euthanasia. It is evident that current laws provide a strict framework when euthanasia is appropriate and ideally to safeguard physicians from performing euthanasia unlawfully.
Medical research has been driven for hundreds of years with the intent to cure illness and find solutions to fatal diseases. Physicians such as Dr. Peter Saunders feel that legalizing euthanasia would threaten advances in medical research. If euthanasia provides patients, as well as physicians, an easy way out, then fewer researchers will make the leap to discover incurable diseases. As noted by Dr. Saunders in Twelve Reasons Why Euthanasia Should Not Be Legalized,
“When the focus changes from curing the condition to killing the individual with said condition, this whole process is threatened” (7).
Beyond the medical-ethical perspectives, from an economic standpoint PAS is incredibly cost-effective compared to medical care (1). To date, drugs utilized for PAS can vary between $35-100 (1). End-of-life healthcare in the United States in 2011 cost upwards to $50 billion for individuals with two months or less of life. End-of-life care is remarkably expensive because of frequency of hospitalization, the increased need for specialists’ attention, and frequency and prevalence of medications (7). Many advocates for euthanasia from an economic standpoint remind the public that those who are terminally ill are most likely no longer working, and as such, no longer contributing to the economic well-being of society. Additionally, many believe legalizing PAS would relieve millions of families of both the personal and financial burdens of caring for elderly Americans with terminal illnesses who might choose PAS to end their lives peacefully (7). As such, from a strictly economic perspective, PAS is a cost-effective alternative to extensive medical treatment.
It is important to note how the economic standpoint interacts with our political systems. Euthanasia became a serious conversation among the Obama administration and Congressional Democrats in light of healthcare reforms enacted in 2016. As a result of political sensibilities, neither the Left nor the Right took a defensive stance for or against euthanasia. But regardless of a party’s stance, a feasible and practical way to get the United States out of debt would be implementing serious cost control in the healthcare industry (7).
Consequently, supporters of PAS also consider situations at the federal level. If states legalized euthanasia, state and federal programs could transfer medical resources from those who are ready to die to those who want to live (15). In order to help a physician be sure of a patient’s mental stability, the patient must first affirmatively choose PAS, and then provide informed consent on a minimum of two occasions. The United States does not practice a single-payer health care system; generally, while many individuals qualify for some form of government aid, families are primarily responsible for the care of their dying relatives. Therefore, having terminally ill relatives can be incredibly expensive. Therefore, if euthanasia is legalized, terminally ill patients may feel greater pressure to die for the hopes of relieving any financial burdens from their family. How does this affect palliative-care physicians?
Palliative care is more emotionally taxing than euthanasia (7). When a physician has to provide end-of-life care to patients with terminal illnesses, they are subject to longer term, more intensive care. Of course, euthanasia is first the decision of the patient, but, if we pay regards to our healthcare professionals, it is significant to note that euthanasia is less emotionally taxing than long-term hospice care. Regardless, it is important to recognize that this is not an either/or issue: either euthanasia or palliative care. Both options must be discussed with the patient and, even if the patient requests euthanasia, maybe short-term palliative care should supersede.
Many social advocates for euthanasia consider the implications to communities where euthanasia would impact. For example, many believe legalizing euthanasia would damage the fundamental principles with which our society was established. Claims that “all men are created equal” and the foundational societal value of respect for all human life is challenged when physicians actively assist terminally ill patients in death (7). From a societal perspective, it is not just a matter of self but a matter of community. Euthanasia requires, at minimum, two individuals. Additionally, advocates emphasize that euthanasia inhibits the practices of basic equality by putting the vulnerable and weak at risk. If euthanasia became legal, it would mark a significant cornerstone in law and human relationships; it desensitizes our basic equality.
A main concern that revolves around euthanasia from a societal perspective is the fear that disadvantaged populations would be disproportionately represented. However, studies in Oregon, a state that has legalized euthanasia, show differently (7). In the United States, vulnerable populations are socially disadvantaged groups and include ethnic minorities, individuals living below the poverty line, women, children, and the elderly. From a study performed in 2002, Oregon residents found that the majority of residents who sought PAS were Asian, college graduates, divorced, or suffering from cancer (7). Despite Oregon’s demographic, with 2.6% represented as African-American, no known African-American patients sought physician-assisted death (7). It is critical to recognize that this viewpoint is universal; we have a remarkable fear that, if we legalize euthanasia, it will disproportionately impact vulnerable populations. Experience has shown that this may not be the case.
When our society runs on the value of protection, equality, and consensus, it protects, saves, and prevents disease. As a result, if states legalize PAS, it marks an exception to a norm of systems. If we make an exception to the norm that we must do no harm, then we open the doors to further exceptions that could challenge and weaken the institutions’ capacity to maintain equality, protection, and consensus. Widespread passage of PAS raises a number of questions; how would it impact minority populations or vulnerable populations subject to racism, segregation, and poverty? How would the legalization impact physician-patient trust? For example, if euthanasia became legal and the states provided the power to the physician to aid in assisted death, then how would this affect the perspectives of minority groups who already hold fear of Western medicine? Suddenly, patients could begin to fear accepting pain-relief treatment or hospice and palliative care. Individuals could begin to fear physicians. If our society practiced euthanasia outside of the medical arena, would anyone view it as safe, ethical, or humane? Even though we question its legality, most individuals feel a greater sense of comfort knowing euthanasia’s association with medical care. We believe that, if we go to a doctor, we will be cured and, therefore, healed. We hold systems in place to check physicians which ensures that care is safe, ethical, and humane.
As advances to medicine increase our longevity, we understand now that death can be suspended. A critical example is that of Karen Ann Quinlan, the 21-year-old who was on a life-support system for two years, until her parents chose to disconnect her respirator. There are numerous examples throughout history. We live in a time where death can be suspended, and some humans are no longer subject to fate’s immutable timeline.
These questions might be resolved through more widespread use of living wills. A living will is a written statement that details an individual’s desire regarding their end-of-life (1). This document includes specifics of medical treatment in light of an individual’s inability to express informed consent, as well as the advances of their possessions. This document acts as an active directive to physicians and, if ignored, can have immense legal consequences. Patients can use living wills to refuse life-saving treatment. A living will provides clear evidence to one’s wishes in regards to end-of-life care while they are of sound mind. If we as a society legalize this document with respect to state and individual, then many advocates of PAS bring to the forefront the similarities between living wills and euthanasia requests. There are many complications that impact an effective and appropriate living will and maybe the first step should be initiatives that better educate that public on living wills.
How does the rest of the world fare? In the United States, only six states have legalized PAS (9) though public consensus reflected in a Gallup Values and Beliefs survey in 2011, that “7 out of 10 Americans believe doctors should be legally allowed to assist terminally ill patients in committing suicide” (7). To date, this statistic remains consistent with increased support from 18-34 year-olds over the last two years. To date, euthanasia (physician administers life-ending medication to patient) is legal in four other countries: Belgium, Colombia, Luxembourg, and the Netherlands (7). Each of these countries remains progressive in their socio-political and cultural sectors. Regardless, only seven other countries have legalized assisted suicide (where a physician provides medication for patient to administer to self). These countries include Belgium, Finland, Luxembourg, The Netherlands, Japan, Canada, Switzerland, and Germany (17). The laws surrounding euthanasia have been deeply questioned in both the 20th and 21st century, and efforts to change government policies that legalize euthanasia have met limited success. Even so, Belgium legalized euthanasia in 2012, Colombia in 1997, Luxembourg in 2009, and the Netherlands in 2002 (7). Many countries have resisted legalizing euthanasia because of the perspectives they hold in the socio-cultural, economic, and ethical sectors. With so many factors to consider and with respect to individual situation, euthanasia remains an incredibly controversial debate today.
Conclusion
The connection between theology, autonomy, and medical ethics remains rooted in diversified influences. We have the scientific means of preserving and ending life. From a physician’s perspective, we hold the moral responsibility to prevent harm and promote health. If as physicians we have the means to preserve life, then it is the physician’s duty to do so. However, if we give the right to end life-sustaining support systems to patients, then we must respect their wishes and administer said treatment. Euthanasia remains a choice issue first and with respect to religious freedoms as discussed above, it is by choice of the patient, not the physician. Many debates over what is appropriate for end-of-life care could be solved by the use of a living will. There are numerous complications which can cause living wills to be negated and as such, the first step should be providing initiatives that better educate the public on living wills.
By identifying the ethical, theological, personal, and medical factors that influence PAS, individuals are able to gain a deeper understanding of this controversial debate. By bringing to light its initial intent, we are able to dissect this practice in contemporary light. With this perspective, we as individuals can begin to develop an opinion on euthanasia. When is it appropriate? When is it not? Should more states legalize its practice? As physicians, we must then ask, “Is it right and, if so, when?”
Milan Sheth is an alumnus of Eastern Mennonite University’s M.A. in Biomedicine program. Milan’s interests are in clinical/academic medicine and global health. He serves as an ambassador for International Service Learning and PreMed STAR. Milan advocates for students to gain experience in medically underserved areas. Milan intends to apply to medical school next year.
References
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