In general, one can choose death by euthanasia and physician-assisted suicide. Broadly understood, euthanasia means “good death”; however, current usage depicts a specific kind of dying, which is usually accomplished by the act of someone other than the one who dies. Physician-assisted suicide is a particular form of suicide, or dying, where a physician who possesses relevant knowledge and skills assists the one who wishes to die. Various religious perspectives offer ways to deal with the challenges presented by death and dying, pain and suffering, freedom and responsibility in health care, and the value of human life. All of these are present at the intersection of euthanasia, physician-assisted suicide, and religion.

Typically, euthanasia and physician-assisted suicide occur in the context of health care when patients face death and dying. Death and dying are fundamental to (and inevitable in) the human condition. Historically, death and dying happened as a consequence of incurable disease, unforeseen accident, war, or murderous action. With euthanasia and physician- assisted suicide, however, one can take control over the circumstances, the mode, and the health state at the time of death. This represents a technological transformation of the dying process—a transformation that many argue brings about individual and social goods (philosopher Daniel Callahan refers to this kind of phenomenon as “technological brinkmanship”; see Callahan 2000, 40–41).

As the Hippocratic Oath indicates, the ethical, legal, and theological issues of euthanasia and physician-assisted suicide are not necessarily new. Dating back several centuries, the oath prohibits a Hippocratic physician from prescribing poisons and other materials for his patient (see Edelstein 1967; Rietjens et al. 2006; Ramsey 1974; Campbell 1994). Interestingly, this is not lost in a Christian version of the Hippocratic Oath: “Neither will I give poison to anybody though asked to do so, nor will I suggest such a plan” (Lammers and Verhey 1998, 108).

Nevertheless, the advances in medicine have brought new energy to this topic. Because many diseases remain incurable, the best that health care providers can do is manage one’s painful symptoms as her illness marches on a path, often with intense suffering, before it ends in death. Many patients who have metastatic and terminal cancer experience this tragedy. For many commentators, this represents an intolerable reality. Instead, they wish to take matters into their own hands and seek voluntary euthanasia or physician assistance in their suicide.

From the perspective of various religions, these two practices—euthanasia and physician- assisted suicide—raise several ethical, legal, and theological issues. However, before discussing these issues, we will review the traditional distinctions of the term euthanasia. Then we will identify and describe the major ethical and legal issues in euthanasia and physician-assisted suicide. Finally, we will conclude with an overview of public policy considerations regarding both of these practices.

Traditional Distinctions of Euthanasia

Here, euthanasia is to be understood as the voluntary and intentional ending of a person’s life. Many ethicists have made three critical distinctions in the debates over euthanasia. First, there is a distinction between voluntary and involuntary euthanasia. Voluntary euthanasia happens either by or at the request of the recipient of the act. Involuntary euthanasia occurs without the consent of the individual, either because the patient is incompetent, because the patient’s wishes are not known, or because it is a policy to end the life of a person with certain traits (e.g., Nazi euthanasia policies). Most discussions of euthanasia reject any consideration of involuntary euthanasia, particularly in this last sense.

Second, there is a distinction between active and passive euthanasia. Active euthanasia occurs when someone performs an action that results in the death of the patient. Thus, one understands active euthanasia positively as the commission of a death- inducing action. Passive euthanasia occurs when someone does not perform an action, which results in the death of the patient. Thus, one understands passive euthanasia negatively as the omission of a life-preserving action. An example of active euthanasia is a doctor’s injecting a lethal dose of drugs into a patient to bring about the patient’s death. An example of passive euthanasia is a doctor’s intent to kill a patient by refusing to administer antibiotics to a patient suffering from a treatable form of pneumonia. (There may be other morally justifiable reasons and circumstances why the physician would not provide antibiotics to a patient without intending the patient’s death per se, but, for the sake of this example, we will consider the pneumonia to be the patient’s only diagnosis.)

Third, there is a distinction between direct and indirect euthanasia. Here, one’s intention plays a key role in establishing whether the action is direct or indirect. In addition, the Principle of Double Effect is applicable, which enables one to determine the nature of the agent’s intent and whether the action is morally permissible. (In short, ethicists use the Principle of Double Effect to determine whether an act that produces both good and bad effects is morally permissible.) In direct euthanasia, an agent intends the death of the patient as the sole end. In indirect euthanasia, an agent does not intend the death of the patient either as the end sought or as a means to a further end. However, many prefer not to use the term indirect euthanasia, because this may confuse foregoing or withdrawing treatment with the intentional killing of a patient.

Historically, many confuse the last two distinctions: an active euthanasia act was direct; a passive euthanasia act was indirect. However, this is misleading because (1) there are two sets of criteria that distinguish these two terms (i.e., observation in the former, and the Principle of Double Effect in the latter), and (2) one distinction is descriptive of the action (i.e., commission versus omission), the other distinction is evaluative of the action (i.e., direct euthanasia is not morally permissible whereas an indirect euthanasia might be). Therefore, some ethicists suggest that these distinctions remain separate and avoided.

Additional reasons exist for avoiding these terms and they include the following: First, using the generic term euthanasia to speak of both direct killing and withdrawing therapy is confusing methodologically and psychologically. Second, many ethicists debate whether there is in fact a moral difference between active and passive euthanasia. Limiting the term euthanasia to the intentional killing of an individual at least circumvents that debate. Third, some ethicists think it is better to identify the moral legitimacy of foregoing or withdrawing a therapy as a separate issue. In this instance, one is focusing on benefit to the patient, which precludes considerations of killing the patient.

Many bioethicists frequently discuss the ethics of voluntary euthanasia in connection with the ethics of physician-assisted suicide. In fact, many see physician-assisted suicide as a form of voluntary euthanasia. However, there are key differences. First, suicide is a self-induced interruption of the life process and typically occurs in a nonmedical context; that is, many individuals who commit suicide in general are not suffering from a life- threatening disease. Second, while voluntary euthanasia and physician-assisted suicide may share motivations (e.g., mercy, compassion, and respect of autonomy), the ways in which one performs them differ significantly. In voluntary euthanasia, a physician or another person commits the act. In physician-assisted suicide, a physician cooperates but does not commit the act. Instead, the physician helps the patient commit the act. Third, many debate the distinction between voluntary euthanasia and palliative care. This does not occur in the context of physician-assisted suicide. Therefore, there are important issues to untangle in considering voluntary euthanasia in the continuum of care in modern hospitals. There is less of a need to disentangle issues between physician-assisted suicide and other forms of medical care.

Indeed, one study compared the clinical practices of terminal sedation (which is, according to the study, a palliative care protocol that induces a coma to relieve pain) and euthanasia in the Netherlands (Rietjens et al. 2006). These researchers found that both practices frequently involve patients who suffer from cancer. On the one hand, clinicians tended to use terminal sedation to address severe physical and psychological suffering in dying patients; on the other hand, clinicians tended to engage in euthanasia to protect patients’ dignity during their last phase of life. In addition, clinicians employing terminal sedation tended to order benzodiazepines and morphine; clinicians participating in euthanasia tended to order barbiturates. Furthermore, the time interval between the administration of the drug and the patients’ deaths ranged from one hour to seven days for terminally sedated patients and tended to be less than one hour for euthanized patients.

Ethical Issues in Euthanasia

Several ethical issues involved in the debates over euthanasia and physician-assisted suicide remain controversial despite the lengthy debates over them. These issues relate to the various legal and theological issues, too. Here is a survey of some major ethical issues: human dignity, patient autonomy, prevention of harm, protection of the marginalized, and protection of professional integrity in health care.

First, among the most well known ethical issues in the debates over euthanasia and physician-assisted suicide is human dignity. Despite its pervasive use, the term suffers from ambiguity. At least two fundamental ways exist in which human dignity functions in ethical debates: as an expression of (1) intrinsic worthiness or (2) attributed worthiness. In the first sense, one may understand human dignity as an expression of intrinsic or inherent worthiness. This may directly relate to certain religious beliefs; in the Judeo- Christian traditions, the belief that God created humankind in his own image and likeness translates to an inviolable intrinsic worth. In contrast, one may understand human dignity as an attributed worth. On the one hand, one may suffer indignity as a result of the conditions or properties of one’s life—for example, many would consider it undignified to live with a very poor quality of life as in complete dependence on machines to live and being bed-ridden. On the other hand, one may suffer indignity as the consequence of others’ actions—for example, ignoring the incontinence of a bed-bound patient or neglecting senile elderly patients because of some repugnance to old age.

As a form of intrinsic worth, one may argue against euthanasia and physician-assisted suicide because such actions violate human dignity: intentionally killing a patient can never be an expression of respect for human dignity. As a form of attributed worth, one may argue for euthanasia and physician-assisted suicide because such actions may prevent such indignities. This is why some proponents suggest that euthanasia or physician-assisted suicide is a form of “death with dignity.” However, in a now famous article, “The Indignity of ‘Death with Dignity,’ ” the late theologian Paul Ramsey refuted this claim (Ramsey 1974).

Second, patient, or personal, autonomy relates to human dignity; here, autonomy is an exercise of self-rule whereby one controls the circumstances, the mode, and one’s health status at the time of one’s death. The fear of losing control over one’s life is a powerful motivator for euthanasia or physician-assisted suicide. Individuals who seek physician-assisted suicide often do not want to live long enough to experience that loss of control and independence. For them, living in such circumstances could be a nightmare. When proponents of euthanasia and physician-assisted suicide seek a right to die, their concept of patient autonomy supports this right.

In these ways, one uses patient autonomy in support of voluntary euthanasia and physician-assisted suicide. However, this may confuse different notions of freedom. Indeed, the loss of control may seem like a loss of freedom, but, in general, this is only one kind of freedom lost: the freedom of choice. Alternatively, if one thinks of freedom as freedom of being—or freedom to be fully human—then a choice of death may be the ultimate imprisonment. That is, if humans are fundamentally relational (a belief prevalent among the world’s major religions), then a choice to end all of one’s relationships in choosing death would be an act that denies a basic aspect of what it means to be human.

Notwithstanding this alternative, if individuals experience suffering and indignity (i.e., the loss of control or the corresponding fear) as they approach death during a terminal illness, this may be more of a critique of society’s inability to address the needs of the dying (Cahill 2005). In this sense, society may be effectively abandoning patients by not giving them the support and environment they need to flourish even in the last moments of physical life. Such circumstances make euthanasia and physician-assisted suicide logical choices.

Third, the prevention of harm is another ethical issue one finds in the debates over euthanasia and physician-assisted suicide. There are two aspects to this issue. On the one hand, proponents call for legalizing euthanasia or physician-assisted suicide (or both) as a way to regulate the practices. The intent behind this is to prevent harms to patients that are a direct consequence of the acts of euthanasia or physician-assisted suicide themselves. For example, without proper training or sufficient regulations, a patient may obtain and use an inadequate dose of lethal drugs. This may cause harm, because such a dose might not induce death and could leave the patient in an undesirable state (e.g., coma). On the other hand, proponents argue for euthanasia and physician-assisted suicide as a means of preventing harms related to the illness the patient has or the treatments that the patient would need to endure (e.g., chemotherapy). In this sense, the patient prevents the harms by bypassing both the experience of the disease process and the risks or burdens of the treatments for the disease.

Of course, some opponents to euthanasia and physician-assisted suicide find this line of reasoning difficult to accept. For them, it seems illogical to prevent harm by causing the end of the patient’s life. For some, the options of euthanasia and physician-assisted suicide are seen as failures of the health care system to deal adequately with the pain and symptoms of terminal illness and the dying process. Many claim that, with appropriate and accessible palliative care (pain and symptom management) and hospice care, the need or desire for euthanasia and physician-assisted suicide would diminish. However, this may not be as true as some hope: as discussed above, a principal concern is the loss of control, not the experience of pain per se.

Fourth, the protection of marginalized groups from a socially instituted policy of euthanasia constitutes another ethical issue. Here, the principal concern is to protect those who do not exercise autonomy in choosing euthanasia and who, in fact, may resist it. Therefore, this ethical issue results when involuntary euthanasia becomes a social practice supported by political power. This particular issue lives in the shadows of the Holocaust and Nazi euthanasia policies. Despite this tragic episode in human history, contemporary debates persist. For example, some proponents claim that involuntary euthanasia may be justifiable for the severely handicapped.

This issue also incorporates elements of a slippery slope argument. In this case, opponents claim that legalizing voluntary euthanasia and physician-assisted suicide jeopardizes the disabled and other marginalized groups, because such decisions reflect a belief that certain lives are not worth living. Opponents are concerned that the disabled community represents certain kinds of life that those who would support euthanasia would not want to live. Thus, even if legalized euthanasia was restricted to voluntary forms and physician-assisted suicide, such practices are only a short step away from involuntary euthanasia of the severely disabled and then (with one more short step) from the moderately or even slightly disabled. For these opponents, it would be quite possible to slip and tumble down the slope to widespread involuntary euthanasia.

To take this perspective further, if involuntary euthanasia of the severely handicapped never became a reality, there remains a concern that a culture that supports voluntary euthanasia would undermine programs and relationships that promote the livelihood and well-being of persons who are physically and mentally challenged. Thus, there may be decreasing support for social assistance programs and increasing pressure to participate in euthanasia or assisted suicide.

Finally, the practices of euthanasia and physician-assisted suicide may undermine the professional integrity of medicine (and other health care professions like nursing). On the one hand, health care professionals do not want to abandon their patients at the end of life. On the other hand, health care professionals—as helping and healing professionals providing care—do not want to confuse their role or contribute in any way to an erosion of their professional ethos as healers. One concern is that this erosion may have a social consequence of confusing the role of healer and the role of executioner. In these circumstances, the trust in the physician-patient relationship is at risk; if physicians can no longer deal with death and dying appropriately and abandon their patients, patients will not trust doctors to be with them as they face their most difficult health crisis. Similarly, if a doctor supports euthanasia or physician-assisted suicide, a patient may be confronted with a doctor who may see euthanasia and physician-assisted suicide as the “easy way out” and may not trust her professional judgment about what is in her best interests.

Legal Issues in the United States

In 1991 and 1992, citizens in Washington and California, respectively, voted on two referenda; these referenda sought to sanction legally both euthanasia and physician-assisted suicide, or physician-assisted dying. In both cases, voters defeated these referenda by very narrow margins—about 54 percent to 46 percent in both cases. However, in 1994, the citizens of Oregon were asked to vote on Measure 16, which asked, “Shall law allow terminally ill adult Oregon patients voluntary informed choice to obtain physician’s prescription for drugs to end life?” (quoted in Campbell 1994, 9). In this case, the measure passed, which ultimately led to the Oregon Death with Dignity Act (see “The Oregon Death with Dignity Act,” in Beauchamp et al. 2008, 404–406). The critical difference between this Oregon statute and those proposed in Washington and California is its restriction to physician-assisted suicide.

When Oregonian voters approved this measure in November 1994 by a very narrow margin, Oregon became “the only place in the world where doctors may legally help patients end their lives” (Egan 1994, A1). However, that was not the end of the story. The day before the measure was to become law, its enactment was blocked by a court challenge. In August 1995, a federal judge ruled the measure unconstitutional because “with state-sanctioned and physician-assisted death at issue, some ‘good results’ cannot outweigh other lives lost due to unconstitutional errors and abuses” (“Judge Strikes Down Oregon’s Suicide Law,” A15).

In March 1996, the legal situation changed radically for the nine western states in the jurisdiction of the United States Court of Appeals for the Ninth Circuit, including Oregon. In an 8–3 ruling, this court struck down a Washington State statute that made assisting in a suicide a felony. While this ruling held only for the states in the Ninth Circuit, a very critical precedent was set. The grounds for the ruling were privacy and autonomy. Judge Stephen Reinhardt, writing for the majority, said: “Like the decision of whether or not to have an abortion, the decision how and when to die is one of ‘the most intimate and personal choices a person may make in a lifetime,’ a choice ‘central to personal dignity and autonomy’ ” (Lewin 1996, A14). The ruling also argued that not only doctors should be protected from prosecution “but others like pharmacists and family members ‘whose services are essential to help the terminally ill patient obtain and take’ medication to hasten death” (Lewin 1996, A14). Thus, the window opened for a round of appeals and argumentation. Later, a unanimous ruling of the three-judge Second Circuit Court of Appeals in New York reinforced this ruling in April 1996. This court stated “that doctors in New York State could legally help terminally ill patients commit suicide in certain circumstances” (Bruni 1996, A1). As the ruling was appealed, a critical countrywide debate began.

Additionally, Michigan passed a law explicitly prohibiting physician-assisted suicide; this was in response to the activities of Jack Kevorkian, whose activities include physician- assisted suicide. However, this law has passed out of existence because of specific time limits. Furthermore, Kevorkian was brought to trial for acts committed while this law was in effect but was found not guilty based on the jury’s decision that his intent was to relieve pain, not to cause death. Notwithstanding this, another murder charge was brought against Kevorkian in 1999. In this case, he was convicted and sentenced to prison.

Finally, three United States Supreme Court cases have become landmark cases in the legal and ethical debates over physician-assisted suicide. In 1997, the U.S. Supreme Court adjudicated on two related cases (Beauchamp et al. 2008). First, the main question before the Court in Vacco v. Quill was whether New York’s prohibition on assisting suicide violated the Equal Protection Clause of the Fourteenth Amendment. The Court held that it did not. Second, the main question before the Court in Washington v. Glucksberg was whether the “liberty” (i.e., the right to refuse wanted life-saving medical treatment) specifically protected by the due process clause includes a right to commit suicide, which includes a right to assistance in suicide. The Court held that the right to assistance in suicide is not a fundamental liberty interest protected by the due process clause. In the 2006 case of Gonzalez v. Oregon, the main question before the Court was whether the Controlled Substances Act allows the U.S. attorney general to prohibit doctors from prescribing regulated drugs for use in physician-assisted suicide, notwithstanding a state law prohibiting it (Beauchamp et al. 2008, 413–418). The Court of Appeals held that the interpretive rule exercised by the attorney general to restrict use of certain drugs was invalid; the Supreme Court held that the Court of Appeals was correct: its decision was affirmed.

In summary, these cases have three implications. One, they demonstrate that it is not unconstitutional for states to ban assisted suicide while protecting patients’ rights to refuse life-sustaining treatment. Two, one cannot claim that physician-assisted suicide is a fundamental liberty interest protected in the same way as the right to refuse treatment. Finally, the executive branch at the federal level cannot use the Controlled Substances Act to restrict physician-assisted suicide at the state level (which basically protected the practice of physician-assisted suicide in Oregon).

Public Policy Considerations

In the end, there are many public policy considerations in the debates over euthanasia and physician-assisted suicide. However, there are four major considerations. The first consideration is, of course, the legalization and institutionalization of euthanasia and/or physician-assisted suicide. Here, institutionalization means the systematic integration of those interventions as organizational policy and professional practices. The legal issues in the United States mentioned above will continue to shape the possibility of legalization (or criminalization) of these practices. The second consideration is the fair availability and access to alternatives at the end of life; that is, public policy on euthanasia or physician-assisted suicide ought to consider adequate home health services, palliative care, and hospice as legitimate options to euthanasia and physician-assisted suicide. A third consideration includes adequate and necessary protections for marginalized individuals— especially the disabled, elderly, and sick—in society. If any public policy is to legitimize euthanasia and physician-assisted suicide, robust protections for these marginalized groups will be necessary. Finally, a fourth consideration is the protections for the health care professions, which ought to seek a separation between the roles of helping and healing and the roles of death-causing or -assisting. This will include sensitivity to the potential for conflicts of interest, reimbursement schedules, and the authenticity of both patient and provider judgments that choosing death is freely chosen. Many of the safeguards in Oregon’s statute recognize these and other procedural issues involved in implementing a policy of physician-assisted suicide.

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