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The debate on the admissibility of euthanasia is ongoing almost everywhere around the globe. The debate shows much variety in depth and form and differs from area to area. Those differences are rooted in cultural backgrounds, religious perspectives, and views on life with longtime traditions. In this contribution the various types of euthanasia debates will be described, together with their origin in modern medicine and its social expectations. The perspective that every human being is subject to decay and will vanish from this Earth will be a central focus. How that focus is translated into the actual medical discourse today will be the leading question.
The debate on euthanasia seems to have spread around the globe and is ongoing on every continent, although not in every country. Why is that so? How should it be understood that the same debate has developed in countries with so divergent cultures and religions, rooted in very long traditions with fundamental differences in their approaches of life and death? The issues of death and dying, beliefs about a life after death, and respect for those who left this world or are going to leave have taken so many different expressions in those traditions that it is quite surprising to observe that the debate on euthanasia has become a global issue at all. Is that observation explained by the overall power and promises of modern medicine? Are the traditional views on death and dying losing their meaning in the confrontation with the ideology of technology-driven, rational societies? These issues have become core business of lawyers, ethicists, and health professionals, because the technological developments force societies to a reevaluation of the visions and moral conceptions on the ﬁnitude of human life in the light of today’s medical discourse. In order to describe a short encyclopedic overview of these issues, a short history of euthanasia is needed, mostly focused and based on the rise of modern medicine in the last century. After that the main types of euthanasia will be discussed as they are debated together within the groups of the main stakeholders. Finally the debate on euthanasia in terms of the morals of medicine in a global perspective will be described.
- Euthanasia is a Greek word, consisting of the contraction of the “eú,” meaning good, and “thánatos” meaning death. As such the word euthanatos can be found in later Greek writers, signifying a soft or beautiful death. It is mentioned that the Latin historian Suetonius used it to describe the death of Emperor Augustus. In his description, euthanasia was a good death, meaning that Augustus had reconciled himself with life and death. One can call this inward euthanasia as an evaluation of the person who dies. This interpretation is to be seen in the work of comedy writer Kratinos, living in the ﬁfth century BC. The modern use of the word euthanasia has an origin in the works of Thomas More (Utopia, 1516) and of diplomat and philosopher Francis Bacon, who between 1605 and 1623, in New Atlantis, is the ﬁrst author to claim that physicians should be able to give their patients a soft death without pain. Bacon himself already called this outward euthanasia. The Greek author Plutarch who was rather popular at that time may have inspired him.
The contraction between eú, good, and another word that signiﬁes some practice became more common in the late nineteenth century as is also shown in the word eugenics. In connection with eugenics, euthanasia was discussed as a practice to eliminate or to avoid human beings with a negative value, either within the perspective of racism or within that of a society as such. Richet, Nobel Prize winner in physiology, published in 1913 a book defending this type of euthanasia and was succeeded by Binding and Hoche in 1920 and Alexis Carrel, another winner of the Nobel Prize, in 1935 (Letellier et al. 2003: 15).
In the 1930s and later in the 1970s, the concept of voluntary euthanasia emerged, meaning a patient who asks his physician for assistance in dying. The practice was already known at that time. Louis Pasteur, for instance, provided lethal pills to ﬁve Russians who asked in vain for help against their agony of rabies, resulting from dog bites.
- Pasteur, however, was not a member of the medical profession but a scientist in chemistry and biology. The medical profession in general abstained itself from helping patients to die. The stated reasons for that position were, among others, a fear that trust in the profession might be compromised, echoing the age-old Hippocratic oath. Other arguments focused on the idea that one should not interfere in the crisis of a patient who is ﬁghting for his life, by speaking about an option to end life, also in the spirit of Hippocrates and Galen. Until fairly recent the means of the profession to turn the fate of a patient were quite limited, and physicians tended to be cautious in that situation, as the (juridical) expression “in dubiis abstine” (in doubt, withhold) shows. Only since roughly the last 100 years, this attitude underwent a change because of more sophisticated pharmaceutics, like ether and morphine, and the rise of medical technology in general.
- A ﬁnal remark concerns the legal aspects. Plato already discussed the possibility of statedriven (outward) euthanasia in his works, but that philosophical idea never was turned into actual law. The same fate happened to many initiatives within the Western world to propose laws allowing euthanasia under certain conditions. If such legal initiatives or actual law proposals would have been accepted, like the Ohio law proposal from 1906, it seems very likely that the global morality on acceptability of active euthanasia for vulnerable suffering people who are left without options for improvement, would have taken a different turn. However, the tradition of legal ruling concerning interventions to end life has taken a different direction and is still founded on the basis that citizens have a right to be protected against an untimely death. The death penalty has been practiced for ages, as a warning that the protection of innocent citizens is one of the pillars of the trust in both the law and the state. Allowing innocent people to die, inward or outward euthanasia, either by their own action or by the action of others, is not consistent with that notion of trust. And in the same vein, until quite recently, there has not been a place in law or legal regulations for ideas on the right of citizens to decide in certain circumstances to give up their life. In places where legal regulations acknowledge a positive right of an individual to choose to end his life, it has required complex legal constructs. And this observation shows a strange contrast when it is compared to the relative unproblematic ways in accepting legalized elimination of people with a seemingly negative social value, not only in case of the death penalty, but also, for example, in Germany, North American states, Canada, and other countries with respect to eugenics, sterilization, and the neglect of disabled newborns. In legal studies on euthanasia in the ﬁrst half of the twentieth century, euthanasia, as outward euthanasia, often is treated on the same level as eugenics and the right of a state to end the life of “those not worth living.” This difference in the awareness of the involved complexities points to a disturbing normative dimension in international laws concerning differing respect between coming into life and leaving it by a voluntary act.
Euthanasia, as it is debated since the end of the twentieth century, is deﬁned in different ways. The British House of Lords Select Medical Ethics Committee’s deﬁnition may be seen as a “broad” one. It deﬁnes euthanasia as: “a deliberate intervention undertaken with the express intention of ending a life, to relieve intractable suffering” (Walton of Detchant and L 1995: 312; Harris 2001: 367). A narrower deﬁnition is to be seen in Dutch law where euthanasia is deﬁned as: “ending of the life of a patient on his explicit request by a physician in a situation of unbearable and endless (or hopeless) suffering” (Dutch law 2001).
In order to understand these differences between countries and their legal framing of the euthanasia debate, it is helpful to introduce the basic four distinctions used to describe actions in end-of-life care that qualify as euthanasia. These distinctions are:
Inward means a good death from the inner perspective of the dying person; outward means a good death caused by external means, either by the patient or by someone else. In the latter case, the word mercy killing is also used.
Voluntary means with the expressed wish or consent of the patient. Involuntary means against the wish or consent of the patient and nonvoluntary without the wish or consent of the patient.
Direct means with an intervention that causes death. Indirect: without an intervention aiming for the patient to die.
Active means as the result of an action made by someone else than the patient. Passive by not taking or stopping an action to sustain the life of a patient.
The distinctions can be deﬁned as exclusive denials.
Examples of medical actions that are considered as euthanasia:
- Withholding a treatment that can be considered as necessary or lifesaving, e.g., installing a ventilator, starting kidney dialysis, etc.
- Withdrawing a treatment: stopping a ventilator, etc.
- Sedation without food or water supply, with and without consent of the patient
- Active administration of a lethal drug, with or without consent of the patient
All these examples worldwide have been classiﬁed as types of euthanasia. Sometimes an intervention is speciﬁed as passive or indirect euthanasia, but the debates always focus on the acceptance of the act of euthanasia, leading to different reactions: from the side of patients, physicians, and their institutional representations, judges and legal authorities, and the public. Not only in Europe, Canada, or the United States of America but also in Latin America, India, China, and Japan, a variety of reactions can be observed in public debates and in medical and legal journals. All of these countries and factions show a moral struggle with concepts and practices of euthanasia, expressing different norms and values within a seemingly uniform practice of medicine, but embedded in different cultures. For that reason it is not only the precise deﬁnitions that are important for the debate, but even more the moral complexities of the cultures they function within. To unravel this complexity, the following factors will be discussed: medical technology, healthcare systems, voicing of patients, and changes in the medical profession.
During the last 150 years, the debate on euthanasia has kept some pace with the development of technology and pharmaceutical products. Especially and foremost the introduction in the nineteenth century of anesthetics, such as ether, chloroform, and opiates like morphine, fueled the debate on outward euthanasia. Much later, in the twentieth century, the introduction of ventilation technology and organ transplantation caused debates on the deﬁnition of death and conceptions of the (presumed) will to live and die of patients. The use of withholding and/or not starting treatment then became part of a broader debate on euthanasia, in both senses, the inward and outward sense, leading to the distinctions of indirect/ direct and active/passive euthanasia. In these debates, technology as such was not considered in itself a means to realize euthanasia, but the debate arose again and again because of the difﬁculties in decision-making, the settlement on the goals of medical interventions, and an awareness that the use of technology blurs the boundaries between life and death, while it results in a power over life and death by technology that needs to be ethically justiﬁed in its use. The increasing facilities to control biological life and death of human beings were, in other words, not accompanied by a growing awareness of the need for a fundamental ethical deliberation and guidance in their use.
Medicalization Of Death
From a sociological and philosophical perspective, the developments in both the debate on euthanasia and the rise of technologies enabling control over life and death can be considered as a medicalization of the event of dying. While medicine has as its main goals to heal, cure, and care for those who are sick, the medicalization of the dying process and death itself asks for new goals that have to be deﬁned, as well as a reevaluation of the dying process itself. In the 1970s sociologists and philosophers like Zola, Illich, and Foucault analyzed the medicalization of dying and death in terms of alienation and expropriation. During that same period, a romantic view on death in the Middle Ages appeared, with the publications of historians such as the Frenchman Aries and a revival in the interest in works of the Dutch historian Huizinga. Illich, like Aries, focuses at Tolstoy’s novel The Death of Ivan Ilyich (1886), in which Tolstoy describes the artiﬁciality of the life of a magistrate who experiences authentic living while terminally ill (Illich 1975). “Natural death,” a common legal notion, is questioned in this way as a phenomenon that is denied while living within a culture of making a career, taking medicines to stay active, and being socially acceptable. The romantic antithesis to medicalized dying and death gave in the 1970s a new dimension to the already existing debate on euthanasia.
Some remarks need to be made in order to understand the global impact of the process of medicalizing dying and death.
In the ﬁrst place, the early analyses of Zola, Illich, and Foucault mainly concerned the social space that was reorganized. Dying as an event of life turned into a treatment condition in hospitals. The technology to sustain and care for the dying person is only available in sophisticated hospitals with the intensive care unit as the high-tech space through which life can be supported by using ventilators, control of bodily functions, and sophisticated medical drugs. The difference between homes as a safe place to die in the midst of the family becomes then the antithesis in the romantic view, even though the novel of Tolstoy already suggests that this place can be quite complex as well. The change from an intimate familiar surrounding of dying and death to a high-tech surrounding where machinery is dominantly present is considered as a source of alienation. The outward contextuality of dying and death is considered decisive for the quality of the process of dying.
Secondly, medicalization suggests that physicians have a prominent role or place in the transformation toward a medicalized death. This suggestion is sustained by the growing percentage of cases in which patients die as the consequence of a medical decision. In fact, however, physicians have not been eager to turn the process of dying into their business. Then and now, physicians in intensive care units try to prevent admitting patients whose death is imminent into their units. In their view the medical profession has as its main goals to cure, to care, and to heal, not to guide the dying. To send a patient home for the last period of their lives is still considered in many countries as a token of good practice, and overtreatment of dying patients is seen as medically problematic and socially undesirable.
To integrate the process of dying in medicine as far as needed into a human approach, comparable to the home care situation, has given rise to a new type of specialization: palliative care. Severely criticized by Ivan Illich and Foucault, who viewed palliative care as an ultimate grip of medicine on the process of dying, the movement of palliative care coming out of the work of Cicely Saunders, nevertheless, has proved to realize the contrary: in hospitals, hospices, and nursing homes, a humane death can be realized by the interdisciplinary work of various palliative care professionals.
Thirdly, as palliative care has shown, the introduction of technology in end-of-life care has not been unproblematic, mainly due to the reductionist character of technological reasoning. Key issues of care at the end of life easily become lost in the chain of technological reasoning and interventions. Only through taking care of the patient by identifying guiding values of the patient caretakers can guarantee that patients and their families experience a “good death.”
In the fourth place, a consequence of medicalization is that medical decision-making has not only become an inseparable part of the process of dying in hospitals but also at home. The basis and arguments for these medical decisions, however, have not been clear nor uniform for quite some time. Should a physician always strive for cure and restoration of health, and if not, where are the limits of care and on what grounds, outside the medical ﬁeld, should the relevant decisions be established? Questions like these have played a major role in the euthanasia debates, resulting in acceptance that a patient should have an important and decisive voice in end-of-life care. That acceptance is integrated in the communicative practice of palliative care, but also has resulted in what is called voluntary euthanasia and physician-assisted suicide.
Debate On Euthanasia
The euthanasia debate from a global perspective seems to have two dominant dimensions:
- Euthanasia after and as result of the use of highly sophisticated technology and treatment that may support essential functions to stay alive
- Euthanasia after medical treatment and resulting in a request of patients for assistance in dying
In clinical practice these two dimensions can be used to determine the problems around euthanasia. The distinctions mentioned in the deﬁnitions above mainly arose in the disputes held on stopping (active, direct) or not installing (passive, indirect) ventilator machines and giving sedative treatment that will inevitably also have the side effect that the patient will die (passive, indirect) with (voluntarily) or without (involuntarily) the request or the consent of the patient (voluntarily if consent is reached; nonvoluntarily if the patient cannot communicate because of lack of conscious competence, young age, and status of disease). Nevertheless, some speciﬁc comments can be made as well:
Ad 1. With respect to the use of technology, identical ethical problems are similar all around the world, in spite of different cultural and religious value systems. Remarkable in this respect is what can be seen in countries like India or China, where physicians remain very reluctant in dealing with the issues at hand, even while the law and public opinion in those countries may favor treatment withdrawal or withholding treatment. India provides an exemplary case. Its high court has concluded that some cases of (passive) euthanasia could be allowed under the law. It seems therefore that the variety in cultural and religious values is becoming reinterpreted in laws that recognize the interest of people in the face of death (Indian Supreme Court 2011).
Ad 2. Concerning the requests of patients, a growing recognition of their wish to die in the face of suffering can be observed. The next problem is then what type of suffering must be present to allow a physician to grant the wish for assistance in dying. Questions as these have become ﬁercely debated in several countries of the world. The content, weight, and emotions of and in the debate are clearly controversial when one looks at the following statements in these debates:
(a) Every person has the right to ask for assistance in dying in any circumstance.
This broad statement in fact states the right to commit suicide with the help of others. Within the euthanasia debate, it plays a limited role. The support of a medical professional requires speciﬁc, medically deﬁned circumstances. In the Netherlands this statement is nevertheless debated among some of the proponents of euthanasia. If someone experiences that his life is over or when he is “ready with life itself,” should that person then be entitled to ask for support in dying from a physician? Or is the situation of such a person “located outside” of the realm of medicine, and should other disciplines, like psychology or philosophy, be involved? Questions like these are related to issues of the boundaries of medicalization. The domination of medicine over the process of dying is thought to imply that every wish to die should be dealt with by medical professionals, even if there is no medical disease or justiﬁcation.
(b) Every person who experiences some kind of suffering is allowed to ask for assistance in dying.
Suffering in this statement is not otherwise, nor clearly, speciﬁed. It may include, for instance, the beginning of Alzheimer’s disease/dementia, old age, psychiatric problems like depression or eating disorders, physical disabilities, and other medical conditions that have an impact on the quality of life, but as such are without an actual threat to life. Within the euthanasia debates in the Netherlands, Belgium, and Canada, it is argued that people who experience some kind of nonlife-threatening chronic suffering should not only be allowed to ask for medical assistance in dying, but can even exercise a human right to have their request granted. Medicalization of suffering means in this respect that a human right is acknowledged to be exempt of suffering and even to be able to ask publicly for termination of life if one considers that the best available means of using the system of healthcare. In addition, during the process of medicalization, the individual desire to die transforms from a longing to be free of suffering, a desire to be at rest, into a publicly recognized human right that should be acknowledged, also on an institutional level, in this case the access to and use of healthcare systems.
(c) Every person who experiences some kind of serious suffering that can be medically diagnosed as irreparable, refractory, and/or excruciating is allowed to ask for medical assistance in dying.
Suffering in this statement is considered a condition that can be diagnosed and treated. That is the area of palliative care and as such has always (but not in classical Greek medicine) been part of the practice of medicine. Within the euthanasia debate, discussion on the distinctions between passive and active and direct or indirect can be placed in this area. Noteworthy is that these distinctions all have to do with the sort of action taken by the physician, not so much with the result of that action. To alleviate pain and suffering, to comfort the patient as long as possible, and to prevent an agonizing death are goals that can be reached by following different pathways that are debated by using those distinctions. This area of palliative care has been the object of the critique of Zola and Illich, as if natural death is alienated from mankind in a culture of medical consumption and ego-centered well-being. Within the euthanasia debate, this corresponds with the acknowledgment of a right to die as a solemn, natural individual right that can be exercised without any dispute, for instance, by writing down a legal statement in which one demands assistance in dying if certain circumstances are actual that are speciﬁed by the individual without the consideration of anybody else, be it loved ones or healthcare professionals. In this way the alienation of Illich and Zola could be interpreted as the loss of the social context of dying, a loss of the sharing of meanings of life with other people in narratives, and caring and responding to each other’s needs.
(d) Every person who is terminally ill and whose death is imminent in a way that can only be medically controlled by using means that as a side effect will shorten his life, is entitled to have adequate medical treatment.
This statement can be considered as one of the most accepted by all parties in the euthanasia debate. It is conﬁrmed, for instance, by the principle of double effect that requires proportionate action between means and ends and with a good or morally neutral intention. This principle of double effect notably stems from the work of St. Thomas Aquinas who developed the principle as a possible defense of suicide and martyr hood. As such it refers back to the ﬁrst statement as considered under a. Although the last statement seems to be quite acceptable for almost everyone and can even be considered as an expression of shared, normal, and common medical practice in end-of-life care, it does contain some problems that will reintroduce the statements a through c, namely, the deﬁnitions of the imminence of death, of the phrase “to shorten life,” and of the word “adequate.” Since every human being will eventually die, the speciﬁc definition of the imminence of death is important. Does it mean a life expectancy of days, months, or years? Who is going to make this judgment for a terminal patient whose life expectancy as such is already uncertain? The same goes for the phrase “to shorten life.” Many medical treatments may have a life-shortening effect on patients, comparable to smoking or drinking alcohol. So the interpretation of the side effect, at least when the treatment is desired by the patient, that his life will possibly be shortened by some kind of medical treatment needs further qualiﬁcation. The same holds for the term “adequacy” which is likely to be the most debated term in the euthanasia debate: which intentions are morally good or neutral, what is the means-end relationship, and what is proportional and/or disproportional? These questions bring us back into the debate that is going on for more than 50 years.
As can be concluded from the former points, the debate on euthanasia continues to go around in an elliptical tour with the public acknowledgment of a so-called right to die as one pole and the goals of medicine to heal and cure as the other. Reevaluation of the human condition in the era of medical technology seems inevitably in need of a thorough analysis that is still pending.
The main values at stake in the debate on euthanasia can be summarized according to the elliptical poles of the euthanasia debate: (1) respect for life, (2) dignity, and (3) respect for personal autonomy:
- Respect for life
Respect for life is one of the highest values, shared by almost all cultures around the globe. The miracle of all things living, especially human beings, is revered as the cause for wonder and respect. Within medicine as a science, this value dates back thousands of years to Egyptian and Indian medicine. From there on it was transferred to Greek medicine by, or during the life of, Pythagoras who had a medical practice near Crotone in Italy. Respect for life extends itself of course beyond human beings. According to some, the boundary of this respect yields to all beings with a minimal presence of conscious life or the capacity to experience pain. Others argue that respect for life includes every form of life, pointing out in a deeper sense of respect, that all living beings are needed in a chain to feed other beings. In all its varieties, respect for life stresses the fundamental observation that life’s manifestations are beyond human control and judgment. All expressions of life should therefore be respected, including those forms that are outside its “normal” appearance. Within medicine respect for life is essential in dealing with patients. Care, cure, and prevention and their values are mainly derived from this basic value.
Within the frame of the euthanasia debate, the value of respect for life has been discussed in its profound meaning for human beings. Based on ancient Greek philosophers, a distinction is made between life as organic, biological life, following a natural pattern or order (Gr. Zoõs), and life as the life of a human being in a community, a city of man, in which the organic life is superseded by the conscious experience of truth, beauty, goodness, etc. (Bíos). If one argues that the biotic life supersedes the zootic life, then euthanasia can be a possibility. If one argues however that the zootic and biotic life should be in balance in order to develop a joyful and respectful life (Gr. eudaimonia), then euthanasia may become problematic and even impossible. The same holds for arguments that consider zootic life as having value dominance over cultural, biotic life. This type of consideration can be traced back in many religious views and their resulting attitudes toward the debate on euthanasia.
Perhaps the most controversial and discussed value within the global euthanasia debate is the concept of human dignity as a value. On the one hand, dignity refers to an inner state of being in which attitude, character, and moral ambitions or views come together. Within religions as Buddhism, Judaism, Christianity, and Islam, human dignity plays a central role when people face poverty, death, or abuse, while keeping up and holding on to their dignity according to their faith and moral beliefs. The inner strength of those beliefs provides a possibility to overcome even the hardest circumstances in their lives. This concept of dignity received a central position in Western philosophy. Starting with the work of Pico della Mirandola, who argues that human freedom is the ultimate ground for human dignity, the German philosopher Kant made it a fundamental concept in morality, arguing that next to the relative values in social life, every human being has a dignity that is expressed as the absolute value of being human as such. Human dignity therefore deserves respect that cannot be reduced to the relative structures or values of a society, like those of economy or price relativism. Nowadays the majority of international proclamations and conventions, including those of the World Medical Association and the World Health Organization, conﬁrm the value of human dignity. With respect to bioethics, the European Union also has conﬁrmed the central position of human dignity in its Oviedo agreement of 1997.
The notion of dignity has also been frequently used to defend the right to voluntary euthanasia, especially by the English movement of Dignity in Dying and its predecessor, the Voluntary Euthanasia Legalization Society of 1935. By recognizing a right of every human being to die according to his or her own values and beliefs, euthanasia ought to be a legally allowed option for those who voluntarily wish to die.
Along these lines of thought, another public notion of dignity also comes into view. If dignity is considered as the value that every human being has as being human, it becomes an ontological value that in its turn asks for respect. As such this ontological value does not necessarily need to be absolute, as the philosopher Kant stated in his opposition to the relative values of price and economy. In times of the Roman Empire, for instance, Dignitas aimed at the merits and honorability that someone gained throughout his life. Social status was qualiﬁed by dignity and to lose that dignity was one of the worst things to happen. This social use of the term dignity has received new emphasis in social Darwinism and other philosophical movements, culminating in the early twentieth century thinking about undigniﬁed human lives that should be destroyed or euthanized, as the history of Nazi Germany shows.
As such the value of human dignity in the euthanasia debate is blurred by two Bibliography :, one to the older, Roman tradition and one to the tradition of Enlightenment philosophy.
- Personal autonomy and choice
The last value that needs to be mentioned here is that of personal autonomy and choice. Although the notion of autonomy dates also back to the philosopher Kant and his notion of dignity, since the last quarter of the last century, it has become a value that underlies and determines individual rights and choices. Within political theories like neoliberalism, it is hard to argue that one should limit personal choice in whatever matter, so even those of life and death, as long as no one else is harmed. Personal choices ought to be respected, and varieties of social behavior in communities should be possible within the liberal boundaries of “do no harm.” In this way autonomy has become the moral value of the individual citizen who acts in a responsible way within and toward the institutions of modern society and economy. Autonomy so conceived is closely related to the human rights movement and a sense of equality, not only before the law but also in morality. Emancipatory movements have merged their concepts of autonomy with the economical deﬁnitions of the individual as an economic agent on a market that also deals in values and ways of life.
The global debate on euthanasia in the past 100 years seems to develop steadily in pace with the introduction of medical technology and the progress of medicalization of dying that follows within the framework of that technology. Physicians in many respects stay dedicated to the traditional goals of medicine, to heal, to cure, and to comfort patients. Following that road, the morally problematic aspects of medicalized dying are not answered for. Public discourse, especially its legal proponents in high courts, tends to formulate answers that follow the life world experiences of patients and their beloved, mainly by allowing direct and indirect forms of passive euthanasia. The legal discourse follows in this respect the rise of dignity and autonomy as the main values of individual decision-making. In the years to come, it should become clear whether these developments support the aspect of intrinsic dignity of every human being or whether the medicalized values of death and dying will also become part of a relative system of economics in healthcare. Especially the relative system of economical values of scarcity and fairness in distribution can endanger the supposed intrinsic value of human dignity, bestowing on patients a social obligation to leave this life when it is no longer deemed worthwhile.
- Dutch law. (2001). Wet toetsing levensbeëindiging op verzoek en hulp bij zelfdoding, art 2, zorgvuldigheidseisen. (Act of 12 April 2001, containing review procedures for the termination of life on request and assisted suicide and amendment of the Criminal Code and the Burial and Cremation Act (Termination of Life on Request and Assisted Suicide (Review Procedures) Act).
- Harris, N. M. (2001). The euthanasia debate. Journal of the Royal Army Medical Corps, 147(3), 367–370.
- Illich, I. (1975). Medical Nemesis. The expropriation of health. London: Calders & Boyars.
- Indian Supreme Court. (2011). Indian Supreme Court rules on right to die. The Indian Express, March 8, 2011.
- Letellier, Ph, et al. (2003). Ethical eye: Euthanasia I: Ethical and human aspects. Council of Europe Publishing, Strassbourg.
- Tolstoy L (1981). The death of Ivan Illych. Bantam Classics. London: New York.
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