Voluntary euthanasia is where a person's life is ended at their request in order to relieve them of suffering. Voluntary euthanasia (VE) and physician-assisted suicide (PAS) have been the focus of intense debate in recent years.
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Some forms of voluntary euthanasia are legal in the Australian state of Victoria, Belgium, Colombia, Luxembourg, the Netherlands, and some provinces in Canada. It will soon be legal in Western Australia as well.
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Voluntary refusal of food and fluids (VRFF) (also called voluntarily stopping eating and drinking, or VSED) or Patient Refusal of Nutrition and Hydration (PRNH) is bordering on euthanasia. Some authors classify it as a form of passive euthanasia, while others treat it separately because it is treated differently from legal point of view and often perceived as a more ethical option. VRFF is sometimes suggested as a legal alternative to euthanasia in jurisdictions disallowing euthanasia.
Assisted suicide is a practice in which a person receives assistance in bringing about their death, typically people suffering from a severe physical illness, in which the final step in the process is actively performed by the person concerned. In physician-assisted suicide (also called physician aid-in-dying or PAD) a physician knowingly provides a competent but suffering patient, upon the patient's request, with the means by which the patient intends to end his or her own life. Assisted suicide is contrasted with "active euthanasia" when the difference between providing the means and actively administering lethal medicine is considered important. For example, Swiss law allows assisted suicide while all forms of active euthanasia (like lethal injection) remain prohibited.
The examples and perspective in this section deal primarily with Europe and do not represent a worldwide view of the subject. (December 2009)
The term euthanasia comes from the Greek words "eu"-meaning good and "thanatos"-meaning death, which combined means "well-death" or "dying well". Hippocrates mentions euthanasia in the Hippocratic Oath, which was written between 400 and 300 BC The original Oath states: "To please no one will I prescribe a deadly drug nor give advice which may cause his death". Despite this, the ancient Greeks and Romans generally did not believe that life needed to be preserved at any cost and were, in consequence, tolerant of suicide in cases where no relief could be offered to the dying or, in the case of the Stoics and Epicureans, where a person no longer cared for his life.
English Common Law from the 14th century until the middle of the last century made suicide a criminal act in England and Wales. Assisting others to kill themselves remains illegal in that jurisdiction. However, in the 16th century, Thomas More, considered a saint by Roman Catholics, described a utopian community and envisaged such a community as one that would facilitate the death of those whose lives had become burdensome as a result of "torturing and lingering pain", see Utopia (book) § Interpretation.
Since the 19th century, euthanasia has sparked intermittent debates and activism in Europe and the Americas. According to medical historian Ezekiel Emanuel, it was the availability of anesthesia that ushered in the modern era of euthanasia. In 1828, the first known anti-euthanasia law in the United States was passed in the state of New York, with many other localities and states following suit over a period of several years. After the Civil War, voluntary euthanasia was promoted by advocates, including some doctors. Support peaked around the start of the 20th century in the US and then grew again in the 1930s.
In an article in the Bulletin of the History of Medicine, Brown University historian Jacob M. Appel documented extensive political debate over legislation to legalize physician-assisted suicide in both Iowa and Ohio in 1906. Appel indicates social activist Anna Sophina Hall, a wealthy heiress who had watched her mother die after an extended battle with liver cancer, was the driving force behind this movement. According to historian Ian Dowbiggin, leading public figures, including Clarence Darrow and Jack London, advocated for the legalization of euthanasia.
In 1937, doctor-assisted euthanasia was declared legal in Switzerland as long as the doctor ending the life had nothing to gain. During this same era, US courts tackled cases involving critically ill people who requested physician assistance in dying as well as "mercy killings," such as by parents of their severely disabled children.
During the post-war period, prominent proponents of euthanasia included Glanville Williams (The Sanctity of Life and the Criminal Law) and clergyman Joseph Fletcher ("Morals and medicine"). By the 1960s, advocacy for a right-to-die approach to voluntary euthanasia increased.
Since March 2018, passive euthanasia is legal in India under strict guidelines. Patients must consent through a living will, and must be either terminally ill or in a vegetative state.
In 1996, the world's first euthanasia legislation, the Rights of the Terminally Ill Act 1996, was passed in the Northern Territory of Australia. Four patients died through assisted suicide under the Act, using a device designed by Dr Philip Nitschke. The legislation was overturned by Australia's Federal Parliament in 1997. In response to the overturning of the Act, Nitschke founded EXIT International. In 2009, an Australian quadriplegic was granted the right to refuse sustenance and be allowed to die. The Supreme Court of Western Australia ruled that it was up to Christian Rossiter, aged 49, to decide if he was to continue to receive medical care (tube feeding) and that his carers had to abide by his wishes. Chief Justice Wayne Martin also stipulated that his carers, Brightwater Care, would not be held criminally responsible for following his instructions. Rossiter died on 21 September 2009 following a chest infection.
It is legal in Victoria since June 2019, and will soon be legal in Western Australia.
In New Zealand's 2020 general election the country included a binding referendum asking voters if the End of Life Choice Act 2019 should pass. The Act would legalise voluntary euthanasia for patients with a terminal illness and less than six months left to live if approved by two doctors. New Zealand is the first country to put euthanasia legalisation to a referendum. On the 17th of October 2020, 65.91% of voters supported the passing of the act; a majority. On the 21st of November, 2021 the act will be put into place.
On 20 May 1997, the Constitutional Court of Colombia decriminalised piety homicide, for terminally ill patients, stating that "the medical author cannot be held responsible for the assisted suicide of a terminally ill patient" and urged Congress to regulate euthanasia "in the shortest time possible".
On 15 December 2014, the Constitutional Court had given the Ministry of Health and Social Protection 30 days to publish guidelines for the healthcare sector to use in order to guarantee terminated ill patients, with the wish to undergo euthanasia, their right to a dignified death.
In 1957 in Britain, Judge Devlin ruled in the trial of Dr John Bodkin Adams that causing death through the administration of lethal drugs to a patient, if the intention is solely to alleviate pain, is not considered murder even if death is a potential or even likely outcome. In 1993, the Netherlands decriminalized doctor-assisted suicide, and in 2002, restrictions were loosened. During that year, physician-assisted suicide was approved in Belgium. Belgium's at the time most famous author Hugo Claus, suffering from Alzheimer's disease, was among those that asked for euthanasia. He died in March 2008, assisted by an Antwerp doctor.
A key turning point in the debate over voluntary euthanasia (and physician assisted dying), at least in the United States, was the public furor over the Karen Ann Quinlan case. The Quinlan case paved the way for legal protection of voluntary passive euthanasia. In 1977, California legalized living wills and other states soon followed suit.
In 1980 the Hemlock Society USA was founded in Santa Monica by Derek Humphry. It was the first group in the United States to provide information to the terminally ill in case they wanted a hastened death. Hemlock also campaigned and partially financed drives to reform the law. In 2003 Hemlock was merged with End of Life Choices, which changed its name to Compassion and Choices.
In 1990, Dr. Jack Kevorkian, a Michigan physician, became famous for educating and assisting people in committing physician-assisted suicide, which resulted in a Michigan law against the practice in 1992. Kevorkian was tried and convicted in 1999 for a murder displayed on television. Also in 1990, the Supreme Court approved the use of non-active euthanasia.
In 1994, Oregon voters approved the Death with Dignity Act, permitting doctors to assist terminal patients with six months or less to live to end their lives. The U.S. Supreme Court allowed such laws in 1997. The Bush administration failed in its attempt to use drug law to stop Oregon in 2001, in the case Gonzales v. Oregon.
In 2005, amid U.S. government roadblocks and controversy, Terri Schiavo, a Floridian who had been in a vegetative state since 1990, had her feeding tube removed. Her husband had won the right to take her off life support, which he claimed she would want but was difficult to confirm as she had no living will and the rest of her family claimed otherwise.
In November 2008, Washington Initiative 1000 made Washington the second U.S. state to legalize physician-assisted suicide.
China and Hong Kong
Euthanasia is a criminal offense in China. For example, in Shanghai a 67-year-old man was sentenced to 5 years in prison when he euthanized his 92-year-old mother when she emerged from a hospital procedure only able to move one finger and one toe. The sentence was considered lenient because he had displayed filial piety toward his mother.
In Hong Kong, support for euthanasia among the general public is higher among those who put less importance on religious belief, those who are non-Christian, those who have higher family incomes, those who have more experience in taking care of terminally ill family members, and those who are older.
Arguments for and against
Since World War II, the debate over euthanasia in Western countries has centered on voluntary euthanasia within regulated health care systems. In some cases, judicial decisions, legislation, and regulations have made voluntary euthanasia an explicit option for patients and their guardians. Proponents and critics of such voluntary euthanasia policies offer the following reasons for and against official voluntary euthanasia policies:
The pain and suffering a person feels during a disease, even with pain relievers, can be incomprehensible to a person who has not gone through it. Even without considering the physical pain, it is often difficult for patients to overcome the emotional pain of losing their independence.
Today in many countries there is a shortage of hospital space. Medical personnel and hospital beds could be used for people whose lives could be saved instead of continuing the lives of those who want to die, thus increasing the general quality of care and shortening hospital waiting lists. It is a burden to keep people alive past the point they can contribute to society, especially if the resources used could be spent on a curable ailment.
Critics argue that voluntary euthanasia could unduly compromise the professional roles of health care employees, especially doctors. They point out that European physicians of previous centuries traditionally swore some variation of the Hippocratic Oath, which in its ancient form excluded euthanasia: "To please no one will I prescribe a deadly drug nor give advice which may cause his death.." However, since the 1970s, this oath has largely fallen out of use.
Some people, including many Christians, consider euthanasia of some or all types to be morally unacceptable. This view usually treats euthanasia to be a type of murder and voluntary euthanasia as a type of suicide, the morality of which is the subject of active debate.
If there is some reason to believe the cause of a patient's illness or suffering is or will soon be curable, the correct action is sometimes considered to attempt to bring about a cure or engage in palliative care.
Feasibility of implementation: Euthanasia can only be considered voluntary if a patient is mentally competent to make the decision, i.e., has a rational understanding of options and consequences. Competence can be difficult to determine or even define.
Consent under pressure: Given the economic grounds for voluntary euthanasia, critics of voluntary euthanasia are concerned that patients may experience psychological pressure to consent to voluntary euthanasia rather than be a financial burden on their families. Even where health costs are mostly covered by public money, as in most developed countries, voluntary euthanasia critics are concerned that hospital personnel would have an economic incentive to advise or pressure people toward euthanasia consent.
Non-voluntary euthanasia is sometimes cited as one of the possible outcomes of the slippery slope argument, in which it is claimed that permitting voluntary euthanasia to occur will lead to the support and legalization of non-voluntary and involuntary euthanasia.
Physicians who are in favor of euthanasia state that to keep euthanasia or physician-assisted suicide (PAS) illegal is a violation of patient freedoms. They believe that any competent terminally-ill patient should have the right to choose death or refuse life-saving treatment. Suicide and assistance from their physician is seen as the only option those patients have. With the suffering and the knowledge from the doctor, this may also suggest that PAS is a humane answer to the excruciating pain.
An argument against PAS is the violation of the Hippocratic oath that some doctors take. The Hippocratic oath states "I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan".
Another reason for prohibiting PAS and euthanasia is the option of abusing PAS if it were to become legal. Poor or uninsured patients may not have the money or no access to proper care will have limited options, and they could be pressured toward assisted death.
During the 20th century, efforts to change government policies on euthanasia have met limited success in Western countries. Euthanasia policies have also been developed by a variety of NGOs, most notably medical associations and advocacy organizations.
There are many different religious views on the issue of voluntary euthanasia, although many moral theologians are critical of the procedure.
Euthanasia can be accomplished either through an oral, intravenous, or intramuscular administration of drugs, or by oxygen deprivation (anoxia), as in some euthanasia machines. In individuals who are incapable of swallowing lethal doses of medication, an intravenous route is preferred. The following is a Dutch protocol for parenteral (intravenous) administration to obtain euthanasia:
Intravenous administration is the most reliable and rapid way to accomplish euthanasia. A coma is first induced by intravenous administration of 20 mg/kg sodium thiopental (Nesdonal) in a small volume (10 ml physiological saline). Then a triple intravenous dose of a non-depolarizing neuromuscular muscle relaxant is given, such as 20 mg pancuronium bromide (Pavulon) or 20 mg vecuronium bromide (Norcuron). The muscle relaxant should preferably be given intravenously, in order to ensure optimal availability. Only for pancuronium bromide (Pavulon) are there substantial indications that the agent may also be given intramuscularly in a dosage of 40 mg.
With regards to voluntary euthanasia, many people argue that 'equal access' should apply to access to suicide as well, so therefore disabled people who cannot kill themselves should have access to voluntary euthanasia.
In popular culture and the arts
Apart from The Old Law, a 17th-century tragicomedy written by Thomas Middleton, William Rowley, and Philip Massinger, one of the early books to deal with euthanasia in a fictional context is Anthony Trollope's 1882 dystopian novel, The Fixed Period. Ricarda Huch's novel The Deruga Case (1917) is about a physician who is acquitted after performing euthanasia on his dying ex-wife.
"Quality of Mercy" in The Prosecution Rests is a fable exploring the facets of aging, Alzheimer's disease, and euthanasia. The story line makes no judgement but frees the reader to decide.
The plot of Christopher Buckley's 2007 novel Boomsday involves the use of 'Voluntary euthanasia' of seniors as a political ploy to stave off the insolvency of social security as more and more of the aging US population reaches retirement age.
The films Children of Men and Soylent Green depict instances of government-sponsored euthanasia in order to strengthen their dystopian themes. The protagonist of the film Johnny Got His Gun is a brutally mutilated war veteran whose request for euthanasia furthers the work's anti-war message. The recent films Mar Adentro and Million Dollar Baby argue more directly in favor of euthanasia by illustrating the suffering of their protagonists. These films have provoked debate and controversy in their home countries of Spain and the United States respectively.
In March 2010, the PBS Frontline TV program in the United States showed a documentary called "The Suicide Tourist" which told the story of Professor Craig Ewert, his family, and the Swiss group Dignitas, and their decision to help him commit assisted suicide in Switzerland after he was diagnosed and suffering with ALS (Lou Gehrig's Disease).
The documentary film How to Die in Oregon follows the lives of select terminally ill individuals who weigh the options of continuing to live and euthanasia. This film employs emotional appeal to the audience on the controversial topic of voluntary euthanasia.
- Arthur Koestler, author, vice-president of EXIT (now the Voluntary Euthanasia Society).
- Bertrand Dawson, 1st Viscount Dawson of Penn – physician to George V, to whom he gave a lethal injection.
- Brittany Maynard
- Chantal Sébire
- George Exoo
- Derek Humphry – Founder of the Hemlock Society, President of ERGO, past-president of the World Federation of Right to Die Societies and author of Final Exit.
- Diane Pretty
- Dignitas (euthanasia group in Switzerland)
- Dr. Death (book by Jonathan Kellerman)
- Euthanasia device, a DIY option for individuals
- Euthanasia: Opposing Viewpoints (2000), listing key sources in an anthology
- Exit (Right-to-Die Organization)
- Final Exit (book)
- Futile medical care
- International Task Force on Euthanasia and Assisted Suicide
- Jack Kevorkian
- John Bodkin Adams, Eastbourne, England doctor, tried for murder in 1957 but claimed euthanasia. Acquitted.
- Kaishakunin – Assists in the Japanese ritual seppuku (suicide)
- Karen Ann Quinlan case and Terri Schiavo case – Cases of persistent vegetative state
- Killick Millard – Founder of the Voluntary Euthanasia Legalisation Society in Great Britain
- Peter Singer – bioethicist, utilitarian
- Philip Nitschke
- Principle of double effect
- Right to die
- Suicide tourism
- Terminal sedation
- Terry Wallis
- Ubasute - The concept of an infirm or elderly relative sacrificing themselves in feudal Japan so as not to be a burden on the younger generations.
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- "Voluntary Euthanasia". Stanford Encyclopedia of Philosophy. Retrieved 2 September 2009.
- See Senicide
- See Humphry and Wickett (1986:8–10) on More, Montaigne, Donne, and Bacon.
- "The earliest American statute explicitly to outlaw assisting suicide was enacted in New York in 1828, Act of 10 December 1828, ch. 20, §4, 1828 N. Y. Laws 19 (codified at 2 N. Y. Rev. Stat. pt. 4, ch. 1, tit. 2, art. 1, §7, p. 661 (1829)), and many of the new States and Territories followed New York's example." Thomas J. Marzen, Origins, Volume 27. p73-74.
- Humphry and Wickett 1986:11–12, Emanuel 2004.
- Appel, Jacob M. (2004). "A Duty to Kill? A Duty to Die". Bulletin of the History of Medicine. 78: 3610–634.
- Ian Dowbiggin (2003). A Merciful End: The Euthanasia Movement in Modern America. OUP. ISBN 978-0-19-515443-6.
- "euthanasia" Archived 26 March 2009 at the Wayback Machine. The Columbia Encyclopedia, Sixth Edition. 2001–07
- Zinn, C. (June 1995). "Australia passes first euthanasia law". BMJ. 310 (6992): 1427–8. doi:10.1136/bmj.310.6992.1427a. PMC 2549853. PMID 7613271.
- Brice, Arthur (14 August 2009). "Australian quadriplegic granted right to starve to death". CNN. Archived from the original on 17 August 2009. Retrieved 14 August 2009.
- "Stroke drug left in limbo by delay in benefits approval". The Australian.
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- "New Zealand to vote in referendum on euthanasia". The Guardian.
- Constitutional Court of Colombia (20 May 1997). "REPÚBLICA DE COLOMBIA Corte Constitucional Sentencia No. C-239/97" (PDF). Retrieved 24 November 2016.[dead link] (in Spanish)
- Redacción Salud (19 February 2015). "Los principios para regular la eutanasia" (in Spanish). ElEspectador.com. Archived from the original on 24 November 2016.
- Margaret Otlowski (1997). Voluntary Euthanasia and the Common Law. Oxford University Press. pp. 175–177. ISBN 9780198259961.
- For the UK see the Bland case.
- Cruzan v. Director, Missouri Department of Health
- Annals of Bioethics: Regional Perspectives in Bioethics; by Mark J. Cherry and John F. Peppin; Taylor & Francis, 10 Aug 2005, page 253 Archived 12 January 2016 at the Wayback Machine.
- Pu SD (April 1991). "Euthanasia in China: a report". J Med Philos. 16 (2): 131–8. doi:10.1093/jmp/16.2.131. PMID 2061698.
- Chong AM, Fok SY (December 2004). "Attitudes toward Euthanasia in Hong Kong – A Comparison Between Physicians and the General Public". Death Studies. 29 (1): 29–54. doi:10.1080/07481180590519769. PMID 15726742. S2CID 22888907. Chong AM, Fok SY (2009). "Attitudes toward euthanasia: implications for social work practice". Soc Work Health Care. 48 (2): 119–33. doi:10.1080/00981380802533298. PMID 19197770. S2CID 30564055.
- See Government policies below for specific examples
- Chapple, A.; Ziebland, S.; McPherson, A.; Herxheimer, A. (December 2006). "What people close to death say about euthanasia and assisted suicide: a qualitative study". J Med Ethics. 32 (12): 706–10. doi:10.1136/jme.2006.015883. PMC 2563356. PMID 17145910.
- See also Utilitarianism
- "Terminally ill patients often fear being a burden to others and may feel they ought to request euthanasia to relieve their relatives from distress." letter to the editor of the Financial Times by Dr David Jeffrey, published 11 January 2003.
- Prowse, Michael (4 January 2003). "THE FRONT LINE: Don't take liberties with the right to die" Financial Times: "If euthanasia became socially acceptable, the sick would no longer be able to trust either doctors or their relatives: many of those earnestly counselling a painless, 'dignified' death would be doing so mainly on financial grounds. Euthanasia would become a euphemism for assisted murder."
- "Voluntary Euthanasia". Stanford Encyclopedia of Philosophy. 29 March 2010. Retrieved 13 June 2010.
- "Physician-Assisted Suicide: Ethical Topic in Medicine". depts.washington.edu. Archived from the original on 13 April 2017. Retrieved 27 October 2009.
- Davis, Jeremy; Mathison, Eric (April 2020). "The Case for an Autonomy-Centred View of Physician-Assisted Death". Journal of Bioethical Inquiry. 17: 345–356. doi:10.1007/s11673-020-09977-8.
- "Royal Alexandra Hospital v Joseph and Ors  NSWSC 422)". austlii.edu.au. Retrieved 27 April 2005.
- "Administration and Compounding of Euthanasic Agents". Archived from the original on 7 June 2008.
- Lundin, Leigh (April 2009). Fairstein, Linda (ed.). The Prosecution Rests. Quality of Mercy. MWA Anthologies. New York: Little, Brown & Company. pp. 221–233. ISBN 978-0-316-01252-2.
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- "How to Die in Oregon" Archived 7 February 2016 at the Wayback Machine. Dir. Peter Richardson. Clearcut Productions, 2011. Film.
- "Doyle: Mary Kills People is a killer of a good, provocative drama". The Globe and Mail.
- Giorgio Agamben (1998). Homo sacer: sovereign power and bare life. Translated by Daniel Heller-Roazen. Stanford, Calif: Stanford University Press. ISBN 978-0-8047-3218-5.
- Appel, Jacob (2007). "A Suicide Right for the Mentally Ill? A Swiss Case Opens a New Debate". Hastings Center Report. 37 (3): 21–23. doi:10.1353/hcr.2007.0035. PMID 17649899. S2CID 28038414.
- Battin, Margaret P., Rhodes, Rosamond, and Silvers, Anita, eds. Physician assisted suicide: expanding the debate. NY: Routledge, 1998.
- Brock, Dan. Life and Death Cambridge University Press, 1993.
- Raphael Cohen-Almagor (2001). The right to die with dignity: an argument in ethics, medicine, and law. New Brunswick, N.J: Rutgers University Press. ISBN 978-0-8135-2986-8.
- Dworkin, R. M. Life's Dominion: An Argument About Abortion, Euthanasia, and Individual Freedom. New York: Knopf, 1993.
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- Fletcher, Joseph F. 1954. Morals and medicine; the moral problems of: the patient's right to know the truth, contraception, artificial insemination, sterilization, euthanasia. Princeton, N.J.K.: Princeton University Press.
- Dennis J. Horan; David Mall, eds. (1977). Death, dying, and euthanasia. Frederick, MD: University Publications of America. ISBN 978-0-89093-139-4.
- Humphry, Derek; Wickett, Ann (1986). The Right to Die: Understanding Euthanasia (1st ed.). New York, NY: Harper & Row, Publishers, Inc. ISBN 978-0060155780. LCCN 85-45737. OCLC 12942139. Retrieved 25 November 2013.
- Humphry, Derek (26 November 2002). Final Exit: The Practicalities of Self-Deliverance and Assisted Suicide for the Dying (3rd ed.). New York, NY: Delta Trade Paperback. ISBN 978-0385336536. LCCN 2002-019403. OCLC 49247323. Retrieved 25 November 2013.
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- Kopelman, Loretta M., deVille, Kenneth A., eds. Physician-assisted suicide: What are the issues? Dordrecht: Kluwer Academic Publishers, 2001. (E.g., Engelhardt on secular bioethics)
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- Panicola, Michael. 2004. Catholic teaching on prolonging life: setting the record straight. In Death and dying: a reader, edited by T. A. Shannon. Lanham, MD: Rowman & Littlefield Publishers.
- Paterson, Craig, "A History of Ideas Concerning Suicide, Assisted Suicide and Euthanasia" (2005). Available at SSRN: http://ssrn.com/abstract=1029229
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- Rachels, James. The End of Life: Euthanasia and Morality. New York: Oxford University Press, 1986.
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- Sacred congregation for the doctrine of the faith. 1980. The declaration on euthanasia. Vatican City: The Vatican.
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