Euthanasia: Issues of Society and the Acceptance of Suicide and Voluntary Death

"Has any one supposed it lucky to be born?
I hasten to inform him or her it is just as lucky to die, and I
know it."

-Walt Whitman, Leaves of Grass.

Introduction:

One political and social issue that consumes Americans today is the right to decide one's own fate, or that of someone else. This topic divides into multiple subtopics, including euthanasia, physician-assisted suicide, and assisted suicide. Is it possible to regulate death? Is it not worse, in some cases, for a person to continue living than it would be if he or she were to die? Most people associate melancholy and pain with death. Thus, the majority of modern legislature is more negatively inclined towards the possibility that more pain might be brought by continuing life than by ending it. However, in recent times, a new trend has developed that moves in the direction of a more positive view of mortality. The presiding conflict within all three of these issues is with regards to whose right it is to determine whether or not a person should continue to live.

Literature Review:

The word "euthanasia" derives from the Greek language, and essentially means "good death" (Roberts/Gorman 331). However, a number of variations have developed as a result of the range in politics both worldwide and throughout time. Depending on the value that a given society places on life - that is tangible life that we now associate as being above ground rather than separately in the clouds and six feet belowground - euthanasia may or may not be acceptable.
In her article, "Helping Desperately Ill People Die," Marcia Angell outlines three variations on euthanasia which are present in today's debate. The first is the act of withholding life-sustaining treatment. In this instance, a physician refrains from beginning a treatment, or terminates a previously initiated one. Second on Angell's list is assisted suicide, the general example for which is when a physician writes a prescription for his or her patient's overdose, and therefore supplies the means of suicide. However, by this method, the patient has the power to either complete his or her agenda, or to prolong life until the most unbearable moment, leaving the physician in a passive position. Finally, Angell includes the actual word, euthanasia, as a form of assisted death in which the physician plays an explicitly active role. The patient might have requested the euthanasia, but it is the doctor that has to physically administer the treatment, whether through lethal injection, or another method. This scenario would apply to incapacitated patients.

Even in today's world, there is a multiplicity of views on the idea of death as a better alternative to life. In order to understand the euthanasia debate that is current within the United States, it helps to understand some of the developing relevant legislation abroad. For example, in April of 2001, the Upper House of the Dutch Parliament passed a bill on euthanasia, called the Termination of Life on Request and Assisted Suicide (Review Procedures) Act. This act had been approved by the Dutch Lower House of Parliament in November of 2000, and the act went into effect on the first day of April in 2002 (www.nvve.nl/english/). The NVVE makes available a copy, online, of the legislation issued by the Dutch Parliament with regards to euthanasia and assisted suicide. The law includes that they, the Dutch, "have considered that it is desired to include a ground for exemption from the criminal liability for the physician who with due observance of the requirements of due care to be laid down by law terminates a life on request or assists in a suicide of another person." In his article, entitled "Euthanasia" (www.mala.bc.ca/www/ipp/euthanas.htm), Richard Dunstan reviews the euthanasia legislation in the Netherlands; he essentially states that it requires that the patient request his or her life to be terminated, and that the physician consults with a second physician previous to executing the assisted suicide. Furthermore, the coroner has to be informed both before and after the death of the patient.

In the United States, the debate over euthanasia came into greater focus in 1975 with the case of Karen Ann Quinlan. Quinlan, while attending a party, collapsed after she consumed a combination of alcohol and barbiturates. She went into a coma, and was placed on a respirator and a feeding tube. When her parents insisted that they did not want the only reason for Karen to keep living to be her respirator, and asked that the respirator be removed, the hospital in charge of Karen's care refused to comply. The case went to the New Jersey Supreme Court, which, in 1976, ruled to allow the Quinlan's to have Karen's respirator removed. Karen's parents decided to leave the feeding tube in, and Karen continued to live for 9 years, proving that the respirator was not the only thing keeping her alive (Torr 12).

In the years since the Quinlan incident, legislation has developed to regulate the issue of assisted suicide and other forms of euthanasia. The State of California passed the first Natural Death Act in 1976, subsequently followed in suit by ten other states, in order to protect physicians who were unsuccessful in treating terminal illnesses, and to legalize living wills (www.longwood.edu/library/death.htm). A living will, also known as an advance directive, "is a legal document that informs the family, hospital, and physicians of individual wishes in the case of incapacitation." In order to be valid, the living will must be signed while the patient is still mentally competent (Roberts/Gorman 16).

Years after the Quinlan tragedy, in 1990, the American Medical Association recognized the concept of withdrawing/withholding life support of a patient who is terminally ill and consents to such a measure (www.longwood.edu/library/death.htm). In the same year, a college student named Nancy Cruzan was left with permanent brain damage after a car accident, and needed feeding tubes to keep her alive. The Supreme Court ruled that "competent individuals have a constitutionally protected liberty interest in terminating such life support," and when Cruzan's parents sued for that reason, the court ruled in their favor (Burns 446). Following the Cruzan Supreme Court Ruling, Congress passed the Patient Self-Determination Bill that that requires federally funded hospitals to inform patients of their right to refuse treatment (www.longwood.edu/library/death.htm).

In 1991 and 1992, voters in Washington State and California placed initiatives on the ballot for Death with Dignity Acts. The initiatives were defeated in both states by 54%-46%. In 1994, the Supreme Court ruled that states do not have the right to outlaw physician-assisted suicide entirely, overturning initiatives by the legislatures in New York State and in Washington State to entirely prohibit assisted suicide.

Also in 1994, Oregon passed a Death with Dignity Act, which allowed physicians to assist in suicide by prescribing lethal doses of medication to their patients. A revote was taken in 1997 that reaffirmed support (www.longwood.edu/library/death.htm). In November of 2001, Attorney General John Ashcroft issued the Ashcroft Directive which stated that "a doctor could lose his or her federal registration to prescribe controlled substances if the registration is used to prescribe federally controlled substances for assisted suicide" (www.internationaltaskforce.org/ashover.htm). Earlier this year, and throughout 2002 after the Directive was issued, various courts throughout the nation marked it as unconstitutional and issued temporary injunctions against Ashcroft's anti-euthanasia attempt (www.talkleft.com/archives/002101.html).

The law today says that murder is illegal. Yet the law also says that suicide is legal. One of the central conflicts within the debate over euthanasia is whether it should be considered murder or suicide. And, if this method of treatment does not fit into one of these categories or the other, can it be classified as both murder and suicide simultaneously? Opponents of assisted death who argue that euthanasia is intrinsically murder apply the Hippocratic Oath as part of their argument. In an article published in the journal, St. Anthony's Messenger, Daniel P. Sulmasy discusses the Hippocratic Oath (Sulmasy 10-11), an oath that doctors take before they practice medicine. It is outlined as follows:

a. "I will use treatment to help the sick according to my ability and judgment."
b. "I will refuse to treat those who are overmastered by their disease, realizing that, in such cases, medicine is powerless."
c. "I will not give poison to anyone though asked to do so, nor will I suggest such a plan."

With regards to this oath, Daniel Sulmasy describes point b as an illustration of the act of withdrawing or withholding treatment. He acknowledges that it is not always possible to save a patient via medicine, and it is better at times to leave be, however not abandon, a patient who is beyond salvation. On the other hand, Sulmasy claims that is explicit in part c of the oath that euthanasia in the form of physician-assisted suicide, and anything else other than recognizing hopeless patients, is against the Hippocratic Oath. Therefore, it would be unquestionably immoral for a doctor to succumb to a request to assist in a patient's suicide.
Sulmasy also makes a distinction between what he defines to be killing, and another act, which he calls throughout his piece, "allowing to die." He says that in acts such as physician-assisted suicide, although the patient is ultimately responsible for carrying out the suicide, the physician is aware of the patient's intent when the he or she requests the prescription. That would fall under a violation of part c of the Hippocratic Oath. However, it is acceptable for a doctor to "allow a patient to die" by, for example, disconnecting a ventilator or feeding tube from a patient who will die in eventuality anyway (Sulmasy 13-14); an act such as this would be permissible under the second part of the oath. And, even though a physician might not desire the patient's death, he or she may intend the death and therefore it is murder because the patient died by the hands of another who did not have to commit the act (Sulmasy 15). Therefore, legislation in favor of physician-assisted suicide would place those practicing medicine in a position of immorality.

However, advocates of physician-assisted suicide claim that there are flaws in the argument that it goes against the Hippocratic Oath. Primarily, these advocates believe that "the Physician who complies with a plea for final release from a patient who is facing death under unbearable conditions is doing good, not harm, and his or her actions are entirely consonant with the Hippocratic tradition," as stated by Peter Rogatz, founder of Compassion in Dying of New York, in his article published in the magazine, The Humanist. Rogatz also wonders what prompts anti-assisted death activists to claim that more harm comes of writing a prescription than of pulling the plug in withdrawal of life support, since both measures are to the same end. Why, if a patient is inevitably going to pass away painfully, is it worse to let him or her commit suicide by overdose than to deprive him or her of air or food, or both, so that the person suffocate or starve to death?
Some advocates of euthanasia maintain that there are certain instances in which suicide is a rational act. They believe that it is legitimate not to want to suffer, and that, therefore, it is also acceptable if a person wants to utilize death as a means of avoiding that unnecessary suffering when death is the only option. They touch upon the very human fear of pain and death, and the natural comfort that comes of knowing that one's death will be exempt of pain. Some points for consideration of this concept are that "the decision should be an autonomous one, a personal choice made in the absence of outside pressure. The individual should be mentally competent to make a life-and-death decision, and the decision should be made in the absence of treatable clinical depression" (Espejo/McKhann 37).

However, society has yet to accept suicide as a potentially rational decision. Opponents to the rational suicide argument believe that suicide is never a rational act because it is only during absolute desperation that a person would choose such an end. Such desperation would indicate that the person is in an irrational state of mind. These opponents believe wholeheartedly in the human desire to live forever. How could a person possibly rather die than get what they can out of the remaining days of his or her life? The Journal of Suicide and Life-Threatening Behavior, as quoted by the International Anti-Euthanasia Task Force, defines a "hopeless condition" as "including terminal illness, severe physical or psychological pain, physical or mental debilitation or deterioration, or a quality of life that is no longer acceptable to the individual" (www.internationaltaskforce.org/ashover.htm).

This brings about another debate on what should exactly be considered a palatable reason to want to kill oneself. What happens to severe anorexics that have been through extensive psychological and psychiatric treatment to no avail? At what point should the psychiatric world give up? What of people in the depths of severe, inconsolable, and virtually untreatable, depression? Should they be sentenced to a life of suicide watch? The Netherlands have even gone as far as to legalize severe depression as a case for assisted suicide (Espejo/McKhann 36). Those who reject the claim that suicide can be rational do not believe that anyone could possibly be so hopeless as to believe that death is the best answer to such despair. And they would be appalled to know that anyone gave up on an anorexic.

Furthermore, to the point of irrationality as a constant throughout suicide, the patient's family, during a time that would lead a family to end the suffering of a loved one by terminating his or her life, is probably in an unstable state of mind, as well. If a patient is debilitated, he or she has no say in the situation. The only way to determine whether or not the patient would desire euthanasia is through a living will. Therefore, it is the state's responsibility to determine the fate of a patient (Roberts/Gorman 28) by ensuring that everything possible be done to keep the patient alive.

Statistically, a substantial amount of support exists for assisted death. This was not always the case, but, over time, it is apparent that more and more of the public agree with the concept. In a survey published by the Roper Center for Public Opinion Research at the University of Connecticut in 1992 on the Public Opinion of Physician Aid-in-Dying from 1947-1991, researchers gathered results from surveys over the years. In 1947, a Gallup study showed that only 37% of those surveyed supported assisted death, while 54% opposed it, and 9% were unsure. In 1950, the same Gallup survey showed that 36% supported the concept, and 64% were in opposition, while this time no one was unsure. However, the end of the survey reveals that in a study done by the National Opinion Research Center in 1991, 70% of those surveyed agreed with some form of euthanasia, while only 25% disagreed, and 5% were unsure (Roberts/Gorman 123). A 1991 Roper Poll of the West Coast, reported in the Hemlock Quarterly, showed that 60% of those surveyed believed that "doctors should be allowed to prescribe lethal drugs if patients are terminally ill and request drugs in order to end their lives, if and when they decide to." Only 32% of those surveyed opposed this statement. 54% of the respondents to this same survey even agreed with the statement that "doctors can give lethal injections in cases where patients want to die but can't give themselves lethal injection" (Roberts/Gorman 125). All of the above statistics highlight a general majority that would support legislation to allow physician-assisted suicide on some level.

On the other hand, a look at a May 1996 poll in USA Today alludes to the fact that there is, indeed, support for some form of euthanasia, but that there is less support when the issue becomes more personal. This survey reported that 75% of Americans did support physician-assisted suicide. But only 51% would personally consider the measure as an answer if they themselves were to fall terminally ill. In addition, support was largely dependent on age. For example, 62% of those who answered the survey between the ages of 18 and 29 said that they would support this pro-assisted suicide legislation. Only 51% of those aged 65 and above supported it. In the end, however, that 51% is still a majority of pro-euthanasia respondents over age 65 (www.cwfa.org).

Personal Argument:

My personal belief is that, in accordance with American core values, there is no question that euthanasia should be legal. Still, after all of my research, I am willing to concede that there are valid arguments in opposition to the practice of euthanasia in its various forms. Death is a difficult concept to grasp, given that there is no one person in our society who knows what comes during and afterwards. For a person who has been raised to fear death and believe that it is terrible, the idea that someone might choose to die, or that a doctor may terminate the life of another, is unfathomable. Life is precious; an experience that each person is only entitled to once, as far as we know, and extinguishing it prematurely is sacrilegious for many.

However, these arguments are largely based on religious beliefs - Judeo-Christian beliefs - and I believe that these should remain separate from legislation in our society. Some of the people in our nation are atheist, some are Buddhist, some are Wiccan, and some worship movie stars in the same manner as others worship deities. And there are some whose spiritual beliefs hail death as a beautiful time in which to celebrate a person and ensure his or her soul a safe and peaceful passage to the afterlife, or on to another life, however sad for those left behind.

America has always been based on independence. From the time that the Pilgrims weighed anchor in Massachusetts Bay to break away from oppression and begin with fresh opportunities, this land was founded on the principles of individualism. And, while death has long been viewed as strictly tragic, it should be the prerogative of those who do not view it in such a depressing light to choose it. I am of that opinion; to me, the decision to die falls under the same category as any other civil right. I do not consider myself to be free if I am not granted the right to govern my own body even in death. Obviously, we would never deny someone who is on his or her sick bed the right to try to live if that is what he or she wants. By the same token, why should we deprive that same patient of the right to pass on if the last wish he or she has is to relieve the pain of a terminal illness? The answer is that we should not deny such a wish.

Conclusion:

In conclusion, a thorough examination of statistics and literature on the topic of euthanasia reveals that there is a growing consensus that some form of euthanasia should be legislatively supported. To begin with, the past thirty to forty years have seen a development of legislature to protect both doctors and patients from misunderstandings and accusations during death. These ideas have transformed, throughout the years, as people's concepts of death have changed, to become more targeted towards serving the independent desires of each patient. Although each of these laws is debated extensively as it is passed, more and more of them are emerging with majority support in the end. In addition, the arguments of those opposed to euthanasia tend to have their roots in belief systems that are not representative of the entire public. It would be wrong to limit the rights of every citizen for the satisfaction of only a portion of the population.

Finally, statistical review shows that there is at least over a decade of majority support through results from various national research groups.

It is clear that the end of this debate is still a long way off. After all, this nation is not only full of seekers of independence, but also full of seekers of debate. And it is one of our core beliefs to place a high value on our Founding Fathers' slogan of "life, liberty, and the pursuit of happiness." But, in that value that we place on life, we also place a large emphasis on each individual's perception of life's value. As each American in turn recognizes that distinction, our nation grows closer not only to the legalization of euthanasia, but to the reality of what we stand for as a union.

BIBLIOGRAPHY OF SOURCES

1. Angell, Marcia. "Helping Desperately Ill People to Die," Regulating How We Die: the Ethical, Medical, and Legal Issues Surrounding Physician-Assisted Suicide (Editor: Linda L. Emanuel). 1998. Cambridge, MA: Harvard University Press.

2. Burns, James MacGregor. Government by the People: National, State, and Local Version; 20th Edition. 2004. Upper Saddle River, NJ: Pearson Education, Inc.

3. Chun, Trudy, Wallace Marian. "Euthanasia and Assisted Suicide: The Myth of Mercy Killing." March 3, 2001. www.cwfa.org.

4. Dunstan, Robert. "Euthanasia," 1995. Lane, Bob, Dunstan Robert. Euthanasia: the Debate Continues. 2001: Institute of Practical Philosophy at Malaspina University-College. http://www.mala.bc.ca/www/ipp/euthanas.htm.

5. International Task Force on Euthanasia and Assisted Suicide. "Overview of Oregon vs. Ashcroft." 2003. www.internationaltaskforce.org/ashover.htm.

6. Longwood University Library. Doctor Assisted Suicide - A Chronology. Page last updated April 17, 2002. www.longwood.edu/library/death.htm.

7. McKhann, Charles F. "A Time to Die," Opposing Viewpoints: Suicide. 2003. Farmington Hills, MI: Greenhaven Press.

8. NVVE (Right to Die-NL), Dutch Parliament. Termination of life on Request and Assisted Suicide (Review Procedures) Act. In effect on April 1, 2002. www.nvve.nl/english/.

9. Roberts, Carolyn S., Gorman, Martha. 1996. Euthanasia: A Reference Handbook. Santa Barbara, CA: ABC-CLIO, Inc.

10. Rogatz, Peter. "The Virtues of Physician-Assisted Suicide," The Humanist, vol. 61. November/December 2001.

11. Sulmasy, Daniel P. "Death with Dignity: A Franciscan Doctor's Perspective," St. Anthony's Messenger. January 1996.

12. Talk Left. "Court Rules Against New Ashcroft Directive." January 30, 2003. www.talkleft.com/archives/002101.html.

13. Torr, James D. Euthanasia: Opposing Viewpoints. 2000. San Diego, CA: Greenhaven Press, Inc.