Euthanasia

Voluntary euthanasia is conducted with the consent of the patient. Active voluntary euthanasia is legal in Belgium, Luxembourg and the Netherlands. Passive voluntary euthanasia is legal throughout the US per Cruzan v. Director, Missouri Department of Health. When the patient brings about their own death with the assistance of a physician, the term assisted suicide is often used instead. Assisted suicide is legal in Switzerland and the U.S. states of California, Oregon, Washington, Montana and Vermont.

Non-voluntary euthanasia is conducted when the consent of the patient is unavailable. Examples include child euthanasia, which is illegal worldwide but decriminalised under certain specific circumstances in the Netherlands under the Groningen Protocol. Passive forms of non-voluntary euthanasia (i.e. withholding treatment) are legal in a number of countries under specified conditions.

Involuntary euthanasia is conducted against the will of the patient.

Voluntary, non-voluntary and involuntary types can be further divided into passive or active variants.[26] Passive euthanasia entails the withholding treatment necessary for the continuance of life.[3] Active euthanasia entails the use of lethal substances or forces (such as administering a lethal injection), and is more controversial. While some authors consider these terms to be misleading and unhelpful, they are nonetheless commonly used. In some cases, such as the administration of increasingly necessary, but toxic doses of painkillers, there is a debate whether or not to regard the practice as active or passive.[3]

The term euthanasia, in the earlier sense of supporting someone as they died, was used for the first time by Francis Bacon. In his work, Euthanasia medica, he chose this ancient Greek word and, in doing so, distinguished between euthanasia interior, the preparation of the soul for death, and euthanasia exterior, which was intended to make the end of life easier and painless, in exceptional circumstances by shortening life. That the ancient meaning of an easy death came to the fore again in the early modern period can be seen from its definition in the 18th century Zedlers Universallexikon:

Euthanasia: a very gentle and quiet death, which happens without painful convulsions. The word comes from ευ, bene, well, and θανατος, mors, death.[30]

The concept of euthanasia in the sense of alleviating the process of death goes back to the medical historian, Karl Friedrich Heinrich Marx, who drew on Bacon's philosophical ideas. According to Marx, a doctor had a moral duty to ease the suffering of death through encouragement, support and mitigation using medication. Such an "alleviation of death" reflected the contemporary zeitgeist, but was brought into the medical canon of responsibility for the first time by Marx. Marx also stressed the distinction between the theological care of the soul of sick people from the physical care and medical treatment by doctors.[31][32]

Euthanasia in its modern sense has always been strongly opposed in the Judeo-Christian tradition. Thomas Aquinas opposed both and argued that the practice of euthanasia contradicted our natural human instincts of survival,[33] as did Francois Ranchin (1565–1641), a French physician and professor of medicine, and Michael Boudewijns (1601–1681), a physician and teacher.[28]^: 208[29] Other voices argued for euthanasia, such as John Donne in 1624,[34] and euthanasia continued to be practised. In 1678, the publication of Caspar Questel's De pulvinari morientibus non-subtrahend, ("On the pillow of which the dying should not be deprived"), initiated debate on the topic. Questel described various customs which were employed at the time to hasten the death of the dying, (including the sudden removal of a pillow, which was believed to accelerate death), and argued against their use, as doing so was "against the laws of God and Nature".[28]^{: 209–211} This view was shared by others who followed, including Philipp Jakob Spener, Veit Riedlin and Johann Georg Krünitz.[28]^: 211 Despite opposition, euthanasia continued to be practised, involving techniques such as bleeding, suffocation, and removing people from their beds to be placed on the cold ground.[28]^{: 211–214}

Suicide and euthanasia became more accepted during the Age of Enlightenment.[29] Thomas More wrote of euthanasia in Utopia, although it is not clear if More was intending to endorse the practice.[28]^{: 208–209} Other cultures have taken different approaches: for example, in Japan suicide has not traditionally been viewed as a sin, as it is used in cases of honor, and accordingly, the perceptions of euthanasia are different from those in other parts of the world.[35]

In the mid-1800s, the use of morphine to treat "the pains of death" emerged, with John Warren recommending its use in 1848. A similar use of chloroform was revealed by Joseph Bullar in 1866. However, in neither case was it recommended that the use should be to hasten death. In 1870 Samuel Williams, a schoolteacher, initiated the contemporary euthanasia debate through a speech given at the Birmingham Speculative Club in England, which was subsequently published in a one-off publication entitled Essays of the Birmingham Speculative Club, the collected works of a number of members of an amateur philosophical society.[36]^: 794 Williams' proposal was to use chloroform to deliberately hasten the death of terminally ill patients:

That in all cases of hopeless and painful illness, it should be the recognized duty of the medical attendant, whenever so desired by the patient, to administer chloroform or such other anaesthetic as may by-and-bye supersede chloroform – so as to destroy consciousness at once, and put the sufferer to a quick and painless death; all needful precautions being adopted to prevent any possible abuse of such duty; and means being taken to establish, beyond the possibility of doubt or question, that the remedy was applied at the express wish of the patient.

— Samuel Williams (1872), Euthanasia Williams and Northgate: London.[36]^: 794

The essay was favourably reviewed in The Saturday Review, but an editorial against the essay appeared in The Spectator.[37] From there it proved to be influential, and other writers came out in support of such views: Lionel Tollemache wrote in favour of euthanasia, as did Annie Besant, the essayist and reformer who later became involved with the National Secular Society, considering it a duty to society to "die voluntarily and painlessly" when one reaches the point of becoming a 'burden'.[37][38] Popular Science analyzed the issue in May 1873, assessing both sides of the argument.[39] Kemp notes that at the time, medical doctors did not participate in the discussion; it was "essentially a philosophical enterprise ... tied inextricably to a number of objections to the Christian doctrine of the sanctity of human life".[37]

Felix Adler, circa 1913, the first prominent American to argue for permitting suicide in cases of chronic illness

The rise of the euthanasia movement in the United States coincided with the so-called Gilded Age, a time of social and technological change that encompassed an "individualistic conservatism that praised laissez-faire economics, scientific method, and rationalism", along with major depressions, industrialisation and conflict between corporations and labour unions.[36]^: 794 It was also the period in which the modern hospital system was developed, which has been seen as a factor in the emergence of the euthanasia debate.[40]

Robert Ingersoll argued for euthanasia, stating in 1894 that where someone is suffering from a terminal illness, such as terminal cancer, they should have a right to end their pain through suicide. Felix Adler offered a similar approach, although, unlike Ingersoll, Adler did not reject religion. In fact, he argued from an Ethical Culture framework. In 1891, Adler argued that those suffering from overwhelming pain should have the right to commit suicide, and, furthermore, that it should be permissible for a doctor to assist – thus making Adler the first "prominent American" to argue for suicide in cases where people were suffering from chronic illness.[41] Both Ingersoll and Adler argued for voluntary euthanasia of adults suffering from terminal ailments.[41] Dowbiggin argues that by breaking down prior moral objections to euthanasia and suicide, Ingersoll and Adler enabled others to stretch the definition of euthanasia.[42]

The first attempt to legalise euthanasia took place in the United States, when Henry Hunt introduced legislation into the General Assembly of Ohio in 1906.[43]^: 614 Hunt did so at the behest of Anna Sophina Hall, a wealthy heiress who was a major figure in the euthanasia movement during the early 20th century in the United States. Hall had watched her mother die after an extended battle with liver cancer, and had dedicated herself to ensuring that others would not have to endure the same suffering. Towards this end she engaged in an extensive letter writing campaign, recruited Lurana Sheldon and Maud Ballington Booth, and organised a debate on euthanasia at the annual meeting of the American Humane Association in 1905 – described by Jacob Appel as the first significant public debate on the topic in the 20th century.[43]^{: 614–616}

Hunt's bill called for the administration of an anesthetic to bring about a patient's death, so long as the person is of lawful age and sound mind, and was suffering from a fatal injury, an irrevocable illness, or great physical pain. It also required that the case be heard by a physician, required informed consent in front of three witnesses, and required the attendance of three physicians who had to agree that the patient's recovery was impossible. A motion to reject the bill outright was voted down, but the bill failed to pass, 79 to 23.[36]^: 796[43]^{: 618–619}

Along with the Ohio euthanasia proposal, in 1906 Assemblyman Ross Gregory introduced a proposal to permit euthanasia to the Iowa legislature. However, the Iowa legislation was broader in scope than that offered in Ohio. It allowed for the death of any person of at least ten years of age who suffered from an ailment that would prove fatal and cause extreme pain, should they be of sound mind and express a desire to artificially hasten their death. In addition, it allowed for infants to be euthanised if they were sufficiently deformed, and permitted guardians to request euthanasia on behalf of their wards. The proposed legislation also imposed penalties on physicians who refused to perform euthanasia when requested: a 6–12-month prison term and a fine of between $200 and $1,000. The proposal proved to be controversial.[43]^{: 619–621} It engendered considerable debate and failed to pass, having been withdrawn from consideration after being passed to the Committee on Public Health.[43]^: 623

After 1906 the euthanasia debate reduced in intensity, resurfacing periodically, but not returning to the same level of debate until the 1930s in the United Kingdom.[36]^: 796

Euthanasia opponent Ian Dowbiggin argues that the early membership of the Euthanasia Society of America (ESA) reflected how many perceived euthanasia at the time, often seeing it as a eugenics matter rather than an issue concerning individual rights.[41] Dowbiggin argues that not every eugenist joined the ESA "solely for eugenic reasons", but he postulates that there were clear ideological connections between the eugenics and euthanasia movements.[41]

The Voluntary Euthanasia Legalisation Society was founded in 1935 by Charles Killick Millard (now called Dignity in Dying). The movement campaigned for the legalisation of euthanasia in Great Britain.

In January 1936, King George V was given a fatal dose of morphine and cocaine to hasten his death. At the time he was suffering from cardio-respiratory failure, and the decision to end his life was made by his physician, Lord Dawson.[44] Although this event was kept a secret for over 50 years, the death of George V coincided with proposed legislation in the House of Lords to legalise euthanasia.[45]

Hartheim Euthanasia Centre, where over 18,000 people were killed.

A 24 July 1939 killing of a severely disabled infant in Nazi Germany was described in a BBC "Genocide Under the Nazis Timeline" as the first "state-sponsored euthanasia".[46] Parties that consented to the killing included Hitler's office, the parents, and the Reich Committee for the Scientific Registration of Serious and Congenitally Based Illnesses.[46] The Telegraph noted that the killing of the disabled infant—whose name was Gerhard Kretschmar, born blind, with missing limbs, subject to convulsions, and reportedly "an idiot"— provided "the rationale for a secret Nazi decree that led to 'mercy killings' of almost 300,000 mentally and physically handicapped people".[47] While Kretchmar's killing received parental consent, most of the 5,000 to 8,000 children killed afterwards were forcibly taken from their parents.[46][47]

The "euthanasia campaign" of mass murder gathered momentum on 14 January 1940 when the "handicapped" were killed with gas vans and killing centres, eventually leading to the deaths of 70,000 adult Germans.[48] Professor Robert Jay Lifton, author of The Nazi Doctors and a leading authority on the T4 program, contrasts this program with what he considers to be a genuine euthanasia. He explains that the Nazi version of "euthanasia" was based on the work of Adolf Jost, who published The Right to Death (Das Recht auf den Tod) in 1895. Lifton writes:

Jost argued that control over the death of the individual must ultimately belong to the social organism, the state. This concept is in direct opposition to the Anglo-American concept of euthanasia, which emphasizes the individual's 'right to die' or 'right to death' or 'right to his or her own death,' as the ultimate human claim. In contrast, Jost was pointing to the state's right to kill. ... Ultimately the argument was biological: 'The rights to death [are] the key to the fitness of life.' The state must own death—must kill—in order to keep the social organism alive and healthy.[49]

In modern terms, the use of "euthanasia" in the context of Action T4 is seen to be a euphemism to disguise a program of genocide, in which people were killed on the grounds of "disabilities, religious beliefs, and discordant individual values".[50] Compared to the discussions of euthanasia that emerged post-war, the Nazi program may have been worded in terms that appear similar to the modern use of "euthanasia", but there was no "mercy" and the patients were not necessarily terminally ill.[50] Despite these differences, historian and euthanasia opponent Ian Dowbiggin writes that "the origins of Nazi euthanasia, like those of the American euthanasia movement, predate the Third Reich and were intertwined with the history of eugenics and Social Darwinism, and with efforts to discredit traditional morality and ethics."[41]^: 65

On 6 January 1949, the Euthanasia Society of America presented to the New York State Legislature a petition to legalize euthanasia, signed by 379 leading Protestant and Jewish ministers, the largest group of religious leaders ever to have taken this stance. A similar petition had been sent to the New York Legislature in 1947, signed by approximately 1,000 New York physicians. Roman Catholic religious leaders criticized the petition, saying that such a bill would "legalize a suicide-murder pact" and a "rationalization of the fifth commandment of God, 'Thou Shalt Not Kill.'"[51] The Right Reverend Robert E. McCormick stated that

The ultimate object of the Euthanasia Society is based on the Totalitarian principle that the state is supreme and that the individual does not have the right to live if his continuance in life is a burden or hindrance to the state. The Nazis followed this principle and compulsory Euthanasia was practiced as a part of their program during the recent war. We American citizens of New York State must ask ourselves this question: "Are we going to finish Hitler's job?"[51]

The petition brought tensions between the American Euthanasia Society and the Catholic Church to a head that contributed to a climate of anti-Catholic sentiment generally, regarding issues such as birth control, eugenics, and population control. However, the petition did not result in any legal changes.[41]

The Roman Catholic Church condemns euthanasia and assisted suicide as morally wrong. It states that, "intentional euthanasia, whatever its forms or motives, is murder. It is gravely contrary to the dignity of the human person and to the respect due to the living God, his Creator". Because of this, the practice is unacceptable within the Church.[72] The Orthodox Church in America, along with other Eastern Orthodox Churches, also opposes euthanasia stating that "euthanasia is the deliberate cessation of human life, and, as such, must be condemned as murder."[73]

Many non-Catholic churches in the United States take a stance against euthanasia. Among Protestant denominations, the Episcopal Church passed a resolution in 1991 opposing euthanasia and assisted suicide stating that it is "morally wrong and unacceptable to take a human life to relieve the suffering caused by incurable illnesses."[73] Protestant and other non-Catholic churches which oppose euthanasia include:

The Church of England accepts passive euthanasia under some circumstances, but is strongly against active euthanasia, and has led opposition against recent attempts to legalise it.[83] The United Church of Canada accepts passive euthanasia under some circumstances, but is in general against active euthanasia, with growing acceptance now that active euthanasia has been partly legalised in Canada.[84]

Euthanasia is a complex issue in Islamic theology; however, in general it is considered contrary to Islamic law and holy texts. Among interpretations of the Qur'an and Hadith, the early termination of life is a crime, be it by suicide or helping one commit suicide. The various positions on the cessation of medical treatment are mixed and considered a different class of action than direct termination of life, especially if the patient is suffering. Suicide and euthanasia are both crimes in almost all Muslim majority countries.[85]

There is much debate on the topic of euthanasia in Judaic theology, ethics, and general opinion (especially in Israel and the United States). Passive euthanasia was declared legal by Israel's highest court under certain conditions and has reached some level of acceptance. Active euthanasia remains illegal, however the topic is actively under debate with no clear consensus through legal, ethical, theological and spiritual perspectives.[86]