Euthanasia, Greek for good death, refers to the termination of the life of a person suffering from a painful and incurable medical condition. Also known as mercy killing,

Euthanasia, Greek for "good death," refers to the termination of the life of a person suffering from a painful and incurable medical condition. Also known as "mercy killing," euthanasia is distinguished from suicide by the necessary participation of a third party, typically either a physician or family member.

Twenty-first-century disputes over euthanasia are often seen as a by product of advances in biomedical technology capable of prolonging a person's life indefinitely. Indeed, the moral and legal aspects of euthanasia are extremely complicated, as experts distinguish between active and passive euthanasia as well as voluntary and involuntary euthanasia. Additional issues include the definition of a "terminal" illness and whether pain, an intractable disease, or both, are required to make the practice morally acceptable.

Such complexity has led to a variety of legal positions worldwide. The United States officially forbids euthanasia, while some European countries, such as Switzerland, Germany, Poland, and Norway, are more lenient, allowing for a variety of mitigating circumstances and reduced criminal penalties. In 1993 the Netherlands passed a law prescribing guidelines for medically assisted suicide; Uruguay has exempted mercy killing from criminal prosecution since 1933. To help untangle these issues and better understand euthanasia, this article will consider the history of euthanasia, the "right to die" movement, and physician-assisted suicide within an American social and legal context.

Mercy Killing

Mercy killing, practiced since antiquity, has been debated throughout history. Ancient Greek, Indian, and Asian texts describe infanticide as an acceptable solution for children physically unsuited for or incapable of living. In Plato's Phaedo, when Socrates drinks hemlock, a poison, he maintains his dignity in death, an action immortalized in the modern pro-euthanasia organization, the Hemlock Society.

While many other Greeks, including Aristotle and the Stoics, sanctioned euthanasia, most early Christian thinkers condemned the practice. Both Saint Augustine and Saint Thomas Aquinas prohibited active euthanasia and suicide on the grounds that it was an affront to the sanctity of life and usurped the divine right of life and death. They did, however, permit passive euthanasia—the discontinuation of life-saving treatments—even though death would then be imminent. In the seventeenth and eighteenth centuries European thinkers went even farther, as Francis Bacon, David Hume, and Immanuel Kant considered both active and passive euthanasia morally acceptable.

However, early American laws specifically forbade assisted suicide; New York enacted statutes against the practice in 1828, and both the Field Penal Code (1877) for the Dakota Territory and later the Model Penal Code followed suit. Yet the polio epidemics of the 1920s and 1930s tested these legal codes, as many protested the potential for dependence on the new Drinker tanks or "iron lungs." By the end of the decade proponents of mercy killing sought legal protection, establishing the Euthanasia Society of America in 1938 to promote the practice as well as legislation. Similar organizations formed in Great Britain and Germany, although revelations of indiscriminate and inhumane Nazi practices ultimately led to the condemnation of the movement by the Roman Catholic Church following World War II and helped defeat legislation in Connecticut (1959), Idaho (1969), Oregon (1973), and Montana (1973).

"right to Die"

Debate over euthanasia resurfaced in the 1970s amid growing concern over individual rights, the Karen Ann Quinlan case, and the "right to die" movement. In 1975 Quinlan, a twenty-one-year-old who had accidentally overdosed on barbiturates, alcohol, and valium, slipped into a coma, and was kept alive by a respirator and other medical apparatus. The "sleeping beauty" case captivated the nation, as the public debated who was responsible for the decision to maintain or disconnect the machines and the indignity of being kept alive by medical technology.

Ultimately, Quinlan's case helped redefine "brain death" and the legal framework for voluntary and involuntary decision making. The New Jersey Supreme Court ruled in 1976 that, given her "irreversible condition" and the right to privacy guaranteed by the Constitution, her family, the appropriate surrogates, could remove her from life support. The court's approval of passive euthanasia fueled the "right to die" movement; by 1977 thirty-eight legislatures had submitted over fifty bills to enact legislation expanding the power of attorney and sanctioning living wills, precursors to "do not resuscitate" orders. At the same time, the American Medical Association renewed its opposition to euthanasia, arguing that passive euthanasia—the removal of life support—is ethically acceptable only in "terminal" cases where "extraordinary procedures" are required to maintain life in a manner inconvenient and inefficient for the patient. Remarkably, Quinlan lived in a vegetative state unassisted until 1985, by which time a "right of refusal" was generally accepted, supported by the due process clause of the Constitution giving individuals the right to make decisions free from unreasonable governmental interference.

By the 1990s, advocates of euthanasia such as the Hemlock Society (established 1980) campaigned for physician-assisted suicide or active euthanasia, reviving the debate over the limits of an individual's "right to die." Proponents argued that a painless injection or combination of drugs was far more humane than disconnecting a feeding tube and allowing the person to starve. Physicians, however, were caught in an ethical dilemma, given the Hippocratic Oath to do no harm, relieve suffering, and prolong life. For patients with intractable disease and consistent pain, the goals of relieving suffering and prolonging life are inherently contradictory. If the physician acts to end the suffering through assisted suicide, he or she violates the creed to do no harm and prolong life; if the physician refuses to act, suffering is prolonged rather than assuaged.

Physician-Assisted Suicide

Physicians, like the public, were divided over the morality of assisted suicide. The state of Washington failed to pass a "right to die" voter initiative in 1991, as did California the following year. However, in 1994, Oregon passed Measure 16, a"Death with Dignity Act" drafted by attorney Cheryl K. Smith, former legal counsel for the Hemlock Society. The act allowed physicians to prescribe and dispense, but not administer, the necessary lethal drugs. Remarkably, the bold new legislation was soon overshadowed by the figure of Dr. Jack Kevorkian, who quickly became a political lightning-rod for the "right to die" movement.

A retired pathologist, Dr. Kevorkian, or "Dr. Death" to his detractors, made headlines in the 1990s by assisting over 130 people to commit suicide. The author of Prescription: Medicide, Dr. Kevorkian made his reputation challenging a 1993 Michigan law prohibiting physician-assisted suicide. Backed by the American Civil Liberties Union, Kevorkian argued that the law, which had been expressly written to outlaw his practice of active euthanasia, denied individuals the right to choose how and when they died. However, Kevorkian's legal stance suffered when it was revealed that many of his patients' diseases were not terminal and were unverified. Unrepentant, the seventy-year-old physician continued his practice until a Michigan court sentenced him in 1999 to ten to twenty-five years in prison for the second-degree murder of Thomas Youk, a patient with Lou Gehrig's disease. Ultimately, Kevorkian's arrogance proved to be his downfall; the airing of Youk's suicide on the television program 60 Minutes infuriated the court, as did his participation in another assisted suicide while released on bail.

Proponents of active euthanasia received another series of setbacks in the late 1990s as the courts, supported by a broad coalition inflamed by rumors of pressure and a lack of consent in assisted suicides in Oregon, moved to derail the movement. Although the details of Oregon's euthanasia practice remain private, fears that assisted suicide was used to reduce health care costs and that patients were pressured to accept lethal drugs rather than treatment solidified an anti-euthanasia coalition of hospice organizations, medical associations, religious organizations, and pro-life groups. In 1997 the United States Supreme Court unanimously refused to issue an assisted-suicide Roe v. Wade decision in the case of Washington v. Glucksberg. Chief Justice William Rehnquist stated that assisted suicide posed substantial harm for individuals already at risk because of their age, poverty, or lack of access to quality medical care. Months later, the Florida Supreme Court refused to consider assisted suicide a right under the privacy statute of the Florida Constitution, and a bill legalizing the practice foundered in the Maine legislature the following year.

In the early 2000s the debate over physician-assisted suicide remained contested at the state level. The Supreme Court's decision in Washington v. Glucksberg remanded the decision on active euthanasia to the state courts because the justices argued that each state had the right to protect its residents and thus a federal decision was inappropriate. Indeed, the Court's position in Washington is similar to one taken in an earlier ruling on passive euthanasia. In Cruzan v. Director, Missouri Department of Health (1990), the Supreme Court held that a state could forbid termination of treatment in the absence of "clear and convincing evidence" of the patient's own wishes. While this gave individual states the freedom to determine appropriate standards for involuntary passive euthanasia, a majority of states adhered to the precedents set by the Quinlan case in making their determination. Advocates of physician-assisted suicide hoped that responsible practices in Oregon and the Netherlands would persuade their opponents, and they downplayed the economic arguments for active euthanasia amid a social climate decrying HMO (health maintenance organization) cost-cutting operations.

Bibliography

Doudera, A. Edward, and J. Douglas Peters, eds. Legal and Ethical Aspects of Treating Critically and Terminally Ill Patients. Ann Arbor, Mich.: AUPHA, 1982.

Humphry, Derek. Final Exit: The Practicalities of Self-Deliverance and Assisted Suicide for the Dying. Eugene, Ore.: Hemlock Society, 1991.

President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Deciding to Forego Life-Sustaining Treatment: A Report on the Ethical, Medical, and Legal Issues in Treatment Decisions. Washington, D.C.: U.S. Government Printing Office, 1983.

Schneiderman, Lawrence J., and Nancy S. Jecker. Wrong Medicine: Doctors, Patients, and Futile Treatment. Baltimore: Johns Hopkins University Press, 1995.

Weir, Robert F. Abating Treatment with Critically Ill Patients: Ethical and Legal Limits to the Medical Prolongation of Life. New York: Oxford University Press, 1989.

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