Untitled Document

Michael A. Amos
Biology Senior Seminar 410
Euthanasia Paper
Stan Grove
November 29th, 2006.

The morality of Euthanasia is solely dependent on the individual ethics and belief system of physician and patient families, and is therefore not dependant on a global or societal view of the issue.
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“I will give no deadly medicine to any one if asked, nor suggest any such counsel”...
About 400 B.C. - The Hippocratic Oath (By the "Father of Medicine' Greek physician Hippocrates)

As one of the top moral, ethical, and politically charged debates of our time, the term Euthanasia has come to have many different meanings to individuals, and is thus ambiguous at best. The historical meaning of Euthanasia is of Greek origin and the root-word, Euthanatos, or easy death. The Merriam-Webster online dictionary technically defines it as, “the act or practice of killing or permitting the death of hopelessly sick or injured individuals (as persons or domestic animals) in a relatively painless way for reasons of mercy” (Euthanasia, 2006). As societal views on understanding Euthanasia have changed, the word had many prefixed words attached to it, helping each one establish a more clear definition. Euthanasia.com posts several of these, displaying the term Euthanasia on its own as a word, is not nearly as concise or expanded enough as it should be considering the implications and repercussions it can have. Voluntary (When the person who is killed has requested to be killed), non-voluntary (When the person who is killed made no request and gave no consent) , involuntary (When the person who is killed made an expressed wish to the contrary), By-Action (Intentionally causing a person's death by performing an action such as by giving a lethal injection), and By-Omission Euthanasia (Intentionally causing death by not providing necessary and ordinary, usual and customary, care or food and water) are several of an array of society’s attempts to bring to light a more concrete form of the name (Euthanasia Definitions, 2006).

Euthanasia was common in ancient Greece and Rome. Its acceptance was challenged by the ‘minority of physicians’ who were part of what was known the Hippocratic School. Increasing Christian presence served to reinforce the Hippocratic position on euthanasia. Views on Euthanasia settled for a while, only to resurface in the 19th century with the revolution of what is known today as anesthesia. In the mid to late 17th century, a man named Samuel Williams suggested the first proposals of intentionally ending a patient’s life by using anesthetics and morphine. The publication of Williams's euthanasia proposal plunged the medical profession into much turmoil, discussion, and debate. At the turn of the 17th century, controversy over euthanasia had not only come to include the medical profession, but a vast spectrum of lawyers and social scientists (Gupta et al., 2006). The controversy surrounding Euthanasia stems from many aspects. The question and debate of whose choice is it to end a life, whether that person be terminally ill, capable or incapable of making a sound decision to end their life, is only a minute fraction of the issue. Doctors sworn to help people are in a difficult moral situation when they believe the best thing for a patient is to terminate life; or possibly, the patient would like to terminate their own life, and the doctor is at odds with the patients family’s wish to preserve life. Again the question is of, “Whose choice is it anyway”? It is here, where we see the emergence of the ethics, morality, consent, physician obligations to standards, cultural differing opinions, views and other various factors that come into the vast spectrum. In order for one to draw a valid conclusion about this debate, several important aspects of the topic need to be discussed in-depth. Undoubtedly, the legal, cultural, ethical, and the moral implications all arise from both opponent and proponent positions. This discussion, is intended to enlighten its reader to form their own conclusion on whether the morality of euthanasia is solely dependent on the individual ethics and belief system of the physician and/or the patient’s family, or, whether it is dependant on a global or societal view of the issue.

Many of the doctors, nurses and social workers in the health fields have been pressed by this issue. The article, Dilemmas Encountered by Hospice Workers When Patients Wish to Hasten Death, reports the results of a two phase survey given to Hospice nurses and social workers in Oregon. Phase I included an anonymous survey and phase II encompassed what was described as, “…semi structured, in-depth interviews with a sub sample of respondents to explore their experiences with assisted suicide, the clinical and ethical dilemmas they encountered, and their perceptions of the quality of dying in assisted suicide and voluntary refusal of food and fluids (VRFF) patients” (Jackson et al., 2006). It was found that both hastening death and Physician Assisted-Suicide (PAS) raised two issues of professional ethics; the first was that it provided a genuine opportunity for open discussion of ethics and morality in the workplace, and the second was that it presented some major dilemmas.
Opportunity, as summarized from the general results of the worker’s answers, was provided when “open discussion with patients about their concerns and fears about dying, and increased attention to symptom control on the part of all the professionals was involved”. As suggested by the summarization of the major dilemmas of the hospice nurses and social workers, these ranged from, “an increased sense of responsibility to adequately manage symptoms, challenges to the beliefs of patient autonomy, concerns about whether PAS is antithetical to hospice care, legal implications of carrying out orders, missed opportunities for patients to experience spiritual transformation, conflicts over whether helping patients redefine quality of life impinges on autonomy, and conflicts over whether to advocate for the patient or the family when PAS is being considered” (Jackson et al., 2006). A closer look into the major dilemmas faced by hospice nurses and social workers suggests that each individual responsible for these patients has their own unique sense of duty and moral obligation tied to the individual situation. One worker was quoted as responding to the questions as, “I felt like I was a failure at controlling ‘her’ symptoms because that’s my job to keep people comfortable, and when they choose PAS, they’re deciding that they’re not comfortable” (Jackson et al., 2006). This increased sense of responsibility is described the workers as being a “double-edged sword”. This is due to the fact that some workers’ definitions of responsibility place high value on managing the patient’s symptoms. The various testimonials of workers in this study strongly indicated that patients’ considerations of VRFF and PAS bring forth self-inflicted moral and ethical convictions. These feelings coincide with the experimental results and thus suggest an increased weight of burden upon that individual.

The legality of Euthanasia is an issue unto itself. Many persons believe that euthanasia is solely dependant upon geographical location in the sense that North American views tend to side with opposing the issue, while typical western-hemispherical views side with that of the proponents. Today, however, this is not exactly the case, and although from a broader standpoint, the preceding statement tends to be true due to laws imposed, in the U.S. more and more clear cases of legalizing euthanasia in specific states have appeared due to the changing views and stances individual doctors, nurses, family members, social workers, etc. Consequently, decisions vary concerning PAS. A summary of a study conducted on physicians in the U.S. concluded that, “60% agreed that PAS should be legal in some cases. 46% were willing, if PAS were legal, to prescribe lethal medication. 31% were unwilling to prescribe for moral reasons even if PAS would have been legal. 7% reported having written a prescription knowing that the patient intended to use it to take his/her own life” (Gupta et al., 2006). Based on these findings, one can safely deduce through the percentages (especially the 7%) that although some states deem PAS illegal, following these laws seems to be held only to the individual health care workers own moral understanding and position.

Views on euthanasia do not only vary on a global level, but also depend upon gender, race, culture, and ethnicity. One study found that, “as populations become both more diverse and continue to age, nurses will need to provide culturally and gender sensitive end-of-life interventions to increase patient/family satisfaction and allocate resources appropriately” (Duffy, et. al., 2006). In the article, “Cultural concepts at the end of life”, these varying attitudes were given a closer look via the study of ten focus groups. With ages ranging from 50-83 years old and “stratified by race/ethnicity and gender”, the study focused on questioning each group with a series of personal views, health care and situational scenarios with the intent of receiving a clearer understanding of the differences in cultural attitudes on euthanasia and PAS. Each of the several groups clearly had its own views, although some spilled over into varying groups. The most consistent findings in the study are of gender, women mostly stating they, “feel that family should take care of the individual or prefer to be at home”, while the men mainly felt, “ they’d prefer to die with dignity and good care, wanting little medical intervention”. It is said that “gender may also influence end-of-life preferences as women are more likely to experience more pain, be under-treated for pain, and less likely than men to prefer and receive aggressive treatment” (Bookwala et al 2001; Wenger et al 1995). Within the Arab group, it was clear that the family was the primary care givers to persons of older age and dying. Hospitals and nursing homes were “perceived as the most awful thing that can happen”, and in general the study was indicative that the Arab focus group was unfamiliar with the concept of hospice (Duffy, et. al., 2006). Within the Hispanic focus group, a major point of concern brought forth was the concept of dying with dignity and good care. Again nursing homes were seen as a place to avoid, but most individuals were, “receptive to hospitals and hospice care.” Gender differences were clearly displayed in this group as, “Hispanic women were against 'pulling the plug' and wanted extensive medical intervention at the end of life. Conversely, Hispanic men wanted the least amount of intervention at this point. Hispanic men reported they would refuse dialysis and pain medication to stay completely alert” (Duffy, et. al., 2006). The focus group on whites generally displayed responses similar to that of the black focus group. During the study, they specified that “they did not feel that it was the family's responsibility to take care of them and were open to hospice and nursing homes, but many preferred to die at home”. A major concern within this specific group tended to lie within, “what to expect physically, have choices, and be pain free, to have an advanced directive, and avoid extensive measures to extend life. White men wanted CPR, antibiotics, feeding tubes, and dialysis, but surprisingly enough, not life support” (Duffy, et. al., 2006). Lastly, the group that had focused on the Black opinion had found that, “Black men felt strongly that family and friends should not take care of them and did not want to burden them.” This was the only group that surprisingly enough suggested that “they were more likely to prefer to die away from home”. This group also showed preferences toward “staying in the intensive care unit, hospice, or nursing home versus going home and spending time with family” (Duffy, et. al., 2006). The gender differences between Black men and women in this group also correlated to that of the Hispanics. “Black women were opposed to assisted suicide and pulling the plug and wanted everything done, while Black men did not want everything done to maintain life as, 'pulling the plug was better than living like a vegetable'. It was also shown that “Black men preferred pain medications, antibiotics, and dialysis, but not life support and unlike Black women, Black men supported assisted suicide” (Duffy, et. al., 2006).

There are many sides to the debate of euthanasia. Proponent’s arguments for euthanasia side with that of choice; opposition sides with ties closely intertwined to religious laws, such as the ten commandments, “Thou shall not kill,” and the moral implications of helping to take a life, rather than the doctoral oath of preserve life (The New Oxford Annotated Bible, 2001). Proponents suggest positions that, “It is human right born of self-determination. It would produce more good than harm, by putting an end to the inescapable suffering. There is no substantive distinction between active
euthanasia and the withdrawal of life-sustaining medical interventions (passive euthanasia); in fact, active euthanasia is more controlled and timely” (Gupta et al., 2006). Opponents would obviously disagree citing that,” Practitioners are increasingly willing to stop the futile treatments and use pain medications more aggressively and frequently; consequently there is no need for euthanasia. The distinction between active and passive euthanasia has to be maintained because of 'the intent' to deliberately end someone's life.” New findings suggest that medical advances in technology have also played a key-role in revitalizing opponent views of Euthanasia. It has been noted that, “The fear of being kept alive by technology along with the extrapolation of anesthetics to make death easier have been the facilitators for renewed of debates on euthanasia” (Gupta et al., 2006). Research findings suggest that the several most important of these arguments include: 1) Euthanasia is a rejection of the importance and value of human life; 2) Euthanasia can become a means of health care cost containment and 3) Euthanasia would not only be for people who are "terminally ill" (Euthanasia Definitions, 2006). First of all, it is stated that proponents of euthanasia do not place emphasis and value on human life, missing the fact that, “History has taught us the dangers of euthanasia and that is why there are only two countries in the world today where it is legal. That is why almost all societies - even non-religious ones - for thousands of years have made euthanasia a crime” (Euthanasia Definitions, 2006). This group side is aware most countries and governing states do not allow the active or passive practice of euthanasia, with a few exceptions to places which will be addressed in this the latterportion of this discussion. Secondly, it is believed (and with good reasons) that euthanasia can and will ultimately become a means of health care cost containment. To the everyday reader and the opposition, the notion may seem like a far-fetched idealism by a panic-stricken, antagonist ‘party’. Given figures and facts on the United States and countries around the world regarding health care, however, one can beg to differ. Conclusive reports point out that, “In the United States, thousands of people have no medical insurance; studies have shown that the poor and minorities generally are not given access to available pain control.” Also, it was stated that, “There is a greater and greater emphasis being placed on managed care and many doctors are at financial risk when they provide treatment for their patients” (Euthanasia Definitions, 2006). The implications are disheartening and demoralizing to say the least, but may surely be a reality with the increase in the ‘baby boomer’ generation and the recent moves in Canada and the United States to privatize and/or maintain a privatized healthcare system. This is due to the fact that privatized healthcare systems place patient costs on the patient and receive the direct benefit of the profits as opposed to government subsidized healthcare systems in which they do not. If a doctor at a private hospital has to maintain care for a terminally ill patient for a prolonged period of time, then the hospital is losing money. Wesley J. Smith, a senior fellow at the Discovery Institute quoted the harsh reality saying, “...drugs used in assisted suicide cost only about $40, but that it could take $40,000 to treat a patient properly so that they don't want the "choice" of assisted suicide..." (Euthanasia Definitions, 2006).

Lastly, euthanasia would not only be for people who are quoted to be what is loosely defined as "terminally ill." We must ask ourselves who is deemed worthy or knowledgeable or even culturally endowed enough to judge what the term ‘terminally ill’ should represent. Terminally ill may not be defined the same in the United States of America as it is in the Netherlands or China. There are some who say “terminal” can refer to an immanent death within 6 months or less. Other laws “define a ‘terminal’ condition as one from which death will occur in a ‘relatively short time’” (Euthanasia Definitions, 2006). Medical experts are also stated to acknowledge that the prediction of a specific individual’s life expectancy is ‘virtually impossible’ and mainly depends on that of the particular individual (Euthanasia Definitions, 2006). Due to the recent confusion of the term, “euthanasia activists have dropped references to terminal illness, replacing them with such phrases as ‘hopelessly ill,’ ‘desperately ill,’ ‘incurably ill,’ ‘hopeless condition,’ and ‘meaningless life’ stating that ‘Hopeless condition’ was defined to include 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” (Euthanasia Definitions, 2006). Simply put, this definition could apply to any particular individual who has a suicidal thought or impulse. One may be compelled to ask themselves, “What may the ramifications of living in a society that takes such comments literally?” Sadly, we could see an unprecedented amount of people ‘put to death’ simply for commenting on bad work-week and “wanting to die” as a result. There would be no clarifications anymore on someone’s literal statement, as opposed to someone talking out their feelings of stress and anxiety. The possible concern and report on a coworker’s mention of ‘wanting to die’ might place a serious inquiry upon the individual who made the statement (possibly jokingly) and have them dismissed and hospitalized.

Oregon: In the United States of America, the only state to pass the PAS law (not euthanasia) is Oregon. Entitled the ODDA or Oregon Death with Dignity Act, if terminally ill and above legal age in the state, one may choose this PAS route. The eligible patient-applicant, if approved may be administered by a doctor a fatal dose of a salt or ester known as barbituric acid. It is noted that recently, “the Supreme Court of United States is opening the door to many more such laws across the United States for ending the lives of the terminally ill. In a 6-3 vote, justices ruled that a federal drug law could not be used to prosecute Oregon doctors who prescribed overdoses intended to facilitate the deaths of terminally ill patients” (Gupta et al., 2006).

In 1997, the state legislation of legalized euthanasia on the continent of Australia was overturned by the Apex Court of Australia. This law had been enacted for only two years, beginning in1995 for the Northern territory. The Netherlands has one of the most prolong history’s of euthanasia and PAS. These methods have been actively practiced for over 15 years. Previous to 2001, however, the practice had not been codified into law and no formal guidelines were established (Gupta et al., 2006). The law here is the most relaxed of any place in the world, not limited to adults and even more shocking, a person does not have to be diagnosed to be terminally ill with any sort of medical disease. Admittedly,“The main basis for a request is hopeless and unbearable suffering, regardless of life expectancy” (Gupta et al., 2006). The only regulation of the abuse of this stems from a committee of highly regarded medical staff. Passed in 2002, what is known as the Belgian Act of Euthanasia, defines euthanasia as “intentionally terminating life by someone other than the person concerned at the latter's request." What makes this law so ambiguous in Belgium is that their definition of assisted suicide, differing only slightly, remains illegal. Like that of the Netherlands, requirements include that the patient should have attained the age of majority, with the clause that the request must be "voluntary, well-considered and repeated". Also, a stipulation mandates that the patient must show unequivocally that they are "in a futile medical condition of constant and unbearable physical or mental suffering that cannot be alleviated" (Gupta et al., 2006). In the country of Switzerland, a unique situation exists. Euthanasia by definition is stated to be, “‘murder upon request’ and is considered less severely than murder without the victim's request, homicide, but it remains illegal” (Gupta et al., 2006). Assisted Suicide, under the Swiss penal code, clearly states that, “suicideis not a crime and assisting suicideis a crime if and only if the motive is selfish” (Gupta et al., 2006). Under Swiss laws, acceptance of assisted suicide is upheld when given philanthropic and humane reasons. Shockingly, no physician need be involved and like Australia, the patient need not be what is defined as terminally ill so long as the motives remain what is said to be ‘unselfish’. Switzerland remains to be one of the few countries that also “allows voluntary organizations to help people, including foreigners, end their lives” (Gupta et al., 2006). Swiss regulation states that if the patient needs a lethal dosage of medication, the doctor’s prescription must be obtained. “Decriminalizing euthanasia was tried in 1997 but it was recommended to remain illegal because it would have created dangerous legal circumstances where a non-physician helper would have to be prosecuted where as the physician would not” (Gupta et al., 2006). Within the country of Great Britain, although the House of Lords passed a 2005 bill allowing “a competent and terminally ill person who has reached the age of majority and is suffering unbearably to request either assistedsuicide or voluntary euthanasia”, its set of guidelines like the state of Oregon, are more regulated. The thorough assessment by a physician of the patient’s pending death needs to be reviewed by a committee. “The patient must sign a written declaration of intent. If this has not been revoked within 14 days of the date on which the request was first made, the patient can receive the means to take his or her own life or, if the patient is physically unable to do that, have his or her life ended through voluntary euthanasia.

The morality of Euthanasia seems to ultimately lie within a ethics and belief system. Although global and societal views of the issue do play a prominent role in the carrying out of these acts, we ultimately do not see them dictating how individuals, be they doctors, nurses, social workers, or patients feel towards the topic. Speaking from the perspective of a Christian biology student, although my faith as a Roman Catholic dictates that my personal views should side with opposition to euthanasia, my position is inclined to side toward the pro-choice end of the spectrum. While I am well aware of the implications, we live in a society where opinion supported by formal-education reins supreme. Not adhering to a concrete moral and ethical guideline system depends on individuals morals and ethical guidelines; to some doctors, nurses, social workers, and family members, it may be deemed “unethical” or “inhumane” to keep a terminally-ill or suffering patient, client, or relative alive. It is in my humble opinion that a push towards following the state of Oregon would be the most logical, while maintaining and creating stricter guidelines to the administration of PAS and euthanasia.

1. Bookwala J (2001). Gender differences in older adults' preferences (or life-sustaining medical treatments and end-of-life values. Death Studies 2(25), 127-49.Retrieved November 17, 2006 from Academic Search Premier database.

2. Duffy, Sonia, Jackson, Frances, Schim, Stephanie, et. al., (2006). Cultural concepts at the end of life.Nursing Older People.8(18), 10-14. Retrieved November 9, 2006 from Academic Search Premier database.

5. Gupta, Deepak, Bhatnagar, Sushma, Mishra, and Seema (2006). Euthanasia: Issues Implied Within.Internet Journal of Pain. Symptom Control & Palliative Care. 2(4) from Academic Search Premier database.

6. Jackson, Ganzini, Harvath, Miller, Clark, and Smith. (2006). Dilemmas Encountered by Hospice Workers When Patients Wish to Hasten Death. Journal of Hospice & Palliative Nursing. 4(8), 200-209, Retrieved November 11, 2006 from Academic Search Premier database.

7. Wenger, Neil, Pearson (1995). Epidemiology of do-not-resuscitate orders Disparity by age, diagnosis, gender, race, and functional impairment. Arch Intern Medicine 19 (155), 2056-62. Retrieved November 17, 2006 from Academic Search Premier database.

8. The New Oxford Annotated Bible 3rd Edition (2001). New Revised Standard Version. Oxford University Press. 0.3-0.20(20) pg.11[Hebrew Bible]

Euthanasia: Perspectives on morality and choice