Euthanasia and Assisted Suicide: Murder or Mercy Killing?

Joe Flynn & Bryce Boyd

            “My siblings and I watched our mother die a horrific death from throat cancer.  No one can appreciate the value of physician-assisted suicide without such an experience.  Mom spent her last days begging us over and over to help her die. With a trach inserted, she silently mouthed desperate words, and her frenzied handwriting pleaded to ‘make it quick and easy.’  She was terrorized by thoughts of slowly suffocating.  Her death would be worse.  The cancer was wrapped around her neck blood vessels, so her death was a race between her brain slowly exploding in one stroke after another when blood could not drain from her head, or her heart exploding trying to pump blood into her head.  She made the choice to stop hydration and food.  Because she was well nourished, she did not lose consciousness in the 2 days, nor die in the 7 days that the doctor predicted.  The doctor, fearful of being jailed for causing her death, severely under-medicated her and she kept waking up in agony.   We spent weeks hoping her body would give out before the cancer could slowly squeeze her to death.  It was torture for everyone, but especially for Mom.  Those who say that pain medication and psychiatric help is all that is needed to help someone facing death have it all wrong.  Neither would be of any use to my mother.  Modern society has already tinkered with life by inventing antibiotics and other life saving procedures.  We have eradicated most of the quick killers, leaving humans with slow, torturous deaths.  To help people die ‘quick and easy’ is as important as helping them in birth.”[1]                

Linda Kay’s last memories of her mom will be that of her mom dying a slow, painful death, and begging for mercy and Linda not being able to provide that mercy.  Whether euthanasia or assisted suicide should be legalized is one of the most pressing questions facing legislators, health care professionals, their patients and indeed all members of society today.  The topic goes back as far as Hippocrates.   In this paper we will examine both sides of the argument, what the laws are today regarding euthanasia and assisted suicide, and what we feel the law should be.

            Before talking about the argument it is important to differentiate among a number of terms.  The word euthanasia originated from the Greek language: eu means “good” and thantos means “death.”[2]  Today the word means any action that helps one achieve a painless death.[3]  The terms involuntary and voluntary euthanasia mean different things as does active and passive euthanasia.  Involuntary euthanasia is when someone other than the patient decides to stop treatment in order to end an unconsenting person’s life.[4]  Voluntary euthanasia is when the patient decides on their own to stop treatment in order to terminate their life.  In short, involuntary euthanasia occurs without the patients consent and voluntary euthanasia occurs with the patients consent.[5]

            Passive euthanasia is when the doctor withholds treatment and allows nature to take its course.  Some examples of passive euthanasia would be: removing life support equipment, stopping medical procedures, stopping food and water which will cause the person to dehydrate or starve to death, and not delivering CPR to a person whose heart has stopped.[6]  Active euthanasia is when the patient’s death results from a direct action of the doctor.  An example of this would be a doctor injecting controlled substances into the patient, thus causing a painless death.[7]

            Physician assisted suicide is when the physician supplies information and/or the means of committing suicide, to a person, so that they can easily terminate their own life.[8]  An example of this would be a doctor prescribing a lethal dose of sleeping pills.  With assisted suicide the patient commits the final act and not the doctor.[9]

            The distinction between active and passive euthanasia is thought to be crucial for medical ethics.  In the United States it is considered permissible to withhold treatment and allow a patient to die.[10]  However, unlike consensual passive euthanasia, active euthanasia is never legal.[11] 

Physician assisted suicide is only allowed in Oregon.  Even then it is only permitted under very tightly controlled conditions.[12]  Oregon’s Death with Dignity Act specifically permits competent, terminally ill adult Oregon residents to obtain prescriptions from their doctors for the purpose of lethal self-administration.[13]  Although the Act allows physician assisted suicide, it specifically prohibits euthanasia and declares that self-administration of a lethal dose of drugs in accordance with the provisions of the Act "shall not, for any purpose, constitute suicide, assisted suicide, mercy killing or homicide."[14]  The attending physician is assigned specific responsibilities under the Act, including to determine whether the patient has a terminal disease, whether the patient is competent, whether the patient is a resident of Oregon, and, perhaps most importantly, to ensure that the patient has made an informed decision.[15]  Before a patient may qualify to end his or her life under the Act, a consulting physician must also confirm the attending physician's diagnosis that the patient has a terminal disease and independently determine that the patient is competent and has made a voluntary and informed decision.[16]  The attending or consulting physician must also refer the patient to a psychological counselor if either doctor believes that the patient "may be suffering from a psychiatric or psychological disorder or depression causing impaired judgment."[17]  In such a case, the Act specifically prohibits the prescription of medication for the purpose of ending the patient's life until the counselor determines that the patient is not suffering from depression or any other psychological disorder.[18]  The patient is also encouraged to notify family members of his decision, and the Act requires a waiting period between the patient's request and physician's prescription of the medication.[19]

            There are many different reasons why people decide they want to commit suicide.  Some reasons would be: 1) They have a terminal illness and do not want to diminish their assets by incurring large medical costs as their death approaches.  They would rather die sooner, and pass on their assets to their beneficiaries;[20]  2) A serious disorder or disease has adversely affected their quality of life to the point where they no longer wish to continue living;[21]  3) They have been diagnosed with a degenerative, progressive illness like ALS, Huntington’s Disease, Multiple Sclerosis, AIDS, or Alzheimer’s and they fear a gradual loss of the quality of life in the future as their disease progresses;[22]  4) They have lost their independence and must be cared for continually.  Some feel that this causes an unacceptable loss of personal dignity;[23]  5) They realize that they will be dying in the near future and simply want to have total control over the process.[24] 

            People arguing for euthanasia and assisted suicide feel that decisions about death are personal and that competent people should have the right to choose the circumstances of their death.  They agree that the state has an interest in protecting life.  However, in the end, they feel individuals should be given the right in deciding when life has become an unendurable hardship.  A prohibition on assisted death excessively limits our personal liberty.[25]

            Supporters will also argue that assisted suicide is the compassionate thing to do.  They feel that ending suffering, at times, takes priority over extending life.  At a patient’s request, it may sometimes be more merciful and loving to end suffering than to extend a joyless, unendurable life.  You cannot always relieve suffering and in these cases assisted suicide can be a compassionate response to unbearable suffering.[26]

            Some, but not all, supporters feel that since passive euthanasia is acceptable, then active euthanasia should be as well since they believe there is no moral distinction between the two.[27]  These people argue that if it is all right to withhold treatment and let the patient die, then it should be all right to take action and help the patient die.  The doctor only withholds treatment when he/she knows the patient is going to die and the patient does not want to prolong the death.  However, by just withholding the treatment the patient will take longer to die and suffer more than they would if the doctor would just take direct action and give a lethal injection shot.  When the decision to withhold treatment is made, then active euthanasia actually becomes preferable to passive euthanasia for the patient.[28]  A law that says a person may be allowed to dehydrate and wither, but not be given an injection that would end their life without suffering, seems like a patently cruel law.  These people believe that if a doctor lets a patient die, for humane reasons, he is in the same moral position as if he had given the patient a lethal injection for humane reasons.[29]

            A big reason why some people are against the legalization of euthanasia and physician assisted suicide is the fear that some people will want to die because they are suffering from clinical depression and not because of the intense pain and impending death.  The opposition also feels that doctors cannot predict with accuracy the amount of time that someone has to live and whether or not the disease is terminal.[30]  Just about every doctor can tell stories about patients who were supposed to die but made miraculous recoveries.  If someone chooses euthanasia, they will reduce their chance of a miraculous recovery from low to zero.[31]

            Another fear is that by making assisted suicide and/or euthanasia available, some people will be pressured into accepting euthanasia by their families.  The pressure may occur in very subtle ways from the families who want to be relieved of the financial and social burden of care.  Most patients already feel bad about imposing these burdens on those who care for them.  Opponents feel euthanasia as an option, would lead to many patients choosing death when they are not yet ready to die.[32]  That is why we feel it is important that only specialists who are accustomed to interacting with seriously ill, physically and mentally disabled patients, and who can remain emotionally detached from the decision, should perform capacity determinations.

            Opponents feel that euthanasia threatens the practice and development of palliative care.  This kind of care deals with controlling pain and creating supportive social environments.[33]  The concern is to make the patients as comfortable as possible at the end of their life.  They argue that if euthanasia had been legal forty years ago then we may never have known the advances in the control of pain, nausea, breathlessness and other terminal symptoms that we have developed treatments for in the last 20 years.[34]  They fear that by accepting euthanasia now, we may delay the discovery of effective treatments for diseases now considered terminal.[35]  In the Netherlands, where euthanasia is widely used, the motivation to improve palliative care has all but evaporated.  The issue of caring for the terminally ill is dealt with by debating who will be eligible for euthanasia.[36]  Opponents feel euthanasia becomes a way to ignore the genuine needs of terminally ill people.[37]

            One of the strongest arguments against physician-assisted suicide and euthanasia is that of the “slippery slope.”  The basic argument is that once physician-assisted suicide is legal or sanctioned, it will soon lead to the practice of voluntary euthanasia.[38]  This is because physician-assisted suicide relies upon a person being able-bodied enough to carry out the suicide and therefore this discriminates against those who are not capable of suicide because of their disability or illness.  Then, voluntary euthanasia, they believe, will lead to non-voluntary euthanasia because it will be purported that the incompetent, such as the comatose, newborns, and the demented are unable to request voluntary euthanasia.[39]  The final danger is, that as euthanasia becomes increasingly acceptable, involuntary euthanasia will be provided to competent patients, who in the opinions of others, should have requested euthanasia, but have not done so.[40]

            The Netherlands experience with sanctioned euthanasia has shown that this could be a legitimate concern.  Statistics show that there are about 9,700 requests for physician-assisted suicide or euthanasia made each year in the Netherlands.[41]  Of these 9,700 requests about 3,600 are granted and in roughly 1,000 of these cases non-voluntary will occur.[42]  In many cases patients who were no longer competent were given euthanasia even though they could not have freely, explicitly, and repeatedly requested it.  About half of these patients had expressed a wish for euthanasia before becoming unconscious or mentally incompetent; however, they were unable to reaffirm their requests when the euthanasia was performed.[43]

            The Netherlands experience has also shown that there should be a particular concern for the elderly.  Fifteen percent of the euthanasia acts performed on nursing home patients were not initiated by a request for it.[44]  In another 15 percent of the cases there was no consultation with a second physician and in seven percent no more than one day elapsed between the first request and the actual euthanasia act.[45]  In nine percent of these interventions something other than euthanasia could have been tried to relieve the patient’s suffering.[46]

            We believe the slippery slope can be avoided by implementing the safeguards imposed in Oregon’s Death With Dignity Act.  The Dutch do not stipulate that a patient must be terminally ill, and they do not require that a patient be experiencing physical pain or suffering, a patient can be experiencing psychological suffering only.[47]  These are two important safeguards in preventing the slippery slope.  With our legal system it is not possible that non-voluntary euthanasia could become a common practice.  You could argue that allowing murder in self-defense could lead to allowing all sorts of murder.  To make all assisted suicide illegal assumes that we are not capable of differentiating the good from the bad.  A system with appropriate safeguards might not be perfect, but perfection is not required.  What is needed is a means by which competent individuals, fully informed of the facts and consequences of their decisions, may, if they choose, end their pain and suffering in a manner consistent with human dignity.  The specific and numerous safeguards of Oregon’s Act ensure that the patient is making a voluntary and informed decision, effectively protecting the patient's autonomy and bodily integrity.  The Act's stringent safeguards ensure, to the greatest extent possible, and perhaps more effectively than situations involving treatment withdrawal, that the patient is acting voluntarily and making an informed decision.  The Act reasonably assures not only that the diagnosis of a terminal illness is correct, but also that the patient is not depressed, acting impulsively, or under the coercive control of another person.

            The numbers of people in Oregon using the Act all but prove the slippery slope can be avoided.  Assisted suicide accounts for about one in every 1,000 deaths in Oregon.[48]  Since 1998 there have been only 171 people to use the Act and the highest number of people using the Act in one year is 42.[49]  So far, exactly none of the horrifying predictions of critics have come to pass.  There have been no major complications or botched suicide attempts.[50]  There have been no migrations of suicidal outsiders moving to Oregon to end their lives.  No one has yet failed to satisfy the law's requirements that two doctors agree the patients are mentally competent and have less than six months to live.[51]

            There is also a religious argument against euthanasia and assisted suicide.  The traditional Christian belief is that life is a gift from God, and that “each individual is its steward.”[52]  Thus only God can start a life, and only God should be allowed to end one.  Therefore, an individual who commits suicide is committing a sin.  Catholic theology says that a deliberate effort to hasten someone’s death is wrong whether achieved by gunshot or starvation.[53]  Morally, what is important is that one intends the person’s death, either as an end in itself, or as a means to another end, such as ending the person’s suffering.[54]  Many Christians believe that suffering is sent by God and serves a purpose and ending life to relieve suffering interferes with the role that suffering plays in God’s plan.[55]

            Many people feel it is God’s place to decide the time and place of a person’s death.  That is totally respectable.  We are not asking them to change their beliefs.  These people would probably never choose assisted suicide.   However, for each deeply religious person in North America, there are many nominally religious or secular people.  There are adults who have liberal religious beliefs and treat euthanasia as a morally desirable option in some cases.  There are also many Secularists, Atheists, Agnostics etc. who actively disagree with religiously based arguments.  When considering the religious argument to euthanasia ask yourself “Do devout believers have the right to take their own personal beliefs and extend them to the entire population?  Should the personal beliefs of some religious folks decide public policy for all adults, including religious liberals, Humanists, Atheists, Agnostics, etc?”  By legalizing euthanasia people will not be forced to choose euthanasia.  It will just be there as an option.

            Many faith groups believe that human suffering can have a positive value for terminally ill patients.  For them, suffering can be an opportunity for learning handed down from God.  Some Christians prefer to moderate their use of painkillers, in order to accept at least a part of their sufferings and thus associate themselves in a conscious way with the sufferings of Christ when he was crucified.  These may be meaningful suggestions to some Christian believers.  However, can such arguments justify denying euthanasia to persons who do not share those beliefs?

            We would argue that under some carefully limited circumstances, it is permissible for a physician to assist a person in hastening death to end unwanted, intolerable, and unnecessary suffering.  This includes providing medicines or other means the patient can use to commit suicide or by directly administering medicines that end the patient's life.  Consider a person with an incurable illness such that life has become so burdensome that a desirable, meaningful, purposeful existence is no longer possible.  Suppose that person says, "My life is not worth living; I cannot stand it any longer; I want to end it now to avoid further pain, indignity, torment, and despair."  In the end, after all alternatives have been thoroughly considered, we believe this person has the right to make a choice to die and that it should be honored. 

            The role of the physician is to do what is best for the patient, and in some extreme situations this may include hastening death upon the voluntary request of the dying.  Many doctors protest that they are committed to preserve and enhance life, not to end it deliberately.  We suggest they ask themselves: “What is the best thing I can do to help my patients in whatever circumstances arise, given my special knowledge and skills?” In nearly every case the answer will be to preserve and enhance life.  But in some extreme, hopeless circumstances, the best service a physician can render may be to help a person hasten death in order to relieve intolerable, unnecessary suffering that makes life unbearable to the patient.  This would not contradict the physician’s role, it would enlarge it.  This is not to say it would be up to the physician to decide whether or not they wanted to kill the patient, it would just allow the physician to grant their patients requests.  In Oregon there is a statue which says "No health care provider shall be under any duty, whether by contract, by statute or by any other legal requirement to participate in the provision to a qualified patient of medication to end his or her life in a humane and dignified manner."[56]  If a doctor determines that aiding a terminally ill patient in ending his or her life does not constitute harm under the circumstances, the doctor may participate without violating his oath to do no harm; in contrast, another doctor who determines that participating in assisted suicide constitutes causing harm to the patient may choose not to participate and thus also avoid violating his oath.  In this way, physician assisted suicide laws effectively avoid a physician's personal oath violation, though they may create great dissension among the medical community, as will any law that exposes the absence of a uniform ethical medical standard to follow.

            When death becomes preferable to life, everyone would benefit if it were legal to show mercy.  Many families, each year, feel a great deal of helplessness as they watch their loved ones die in extreme agony.  They will pray for a quick and painless end but that does not always come.  Some day we may be experiencing these painful deaths for ourselves.  It would benefit everyone if choosing death in hopeless, intolerable situations were allowed under the law.

            The problems of prolonged dying are not new, however they have become worse in recent years because we now have the technology to extend life after some people would wish to be dead.  Merely having the right to refuse life-sustaining treatment does not solve the problem of prolonged dying for all patients.  Legalizing assisted suicide is like legalizing abortion, just because it is available does not mean you need to do it.  With proper and strictly enforced safeguards in place we can prevent abuse within the system.  We have faith in our citizens that they have the virtue and intelligence to distinguish between going far enough and going too far.  Nobody should be forced against their will to die a slow, painful, undignified death in front of their family and loved ones.

            Each state should consider implementing an act such as the Oregon Death with Dignity Act.  Recognition of a protected right to seek and accept assistance in suicide from a willing physician is not just important for the small number of terminally-ill patients who actually use it.  Those patients who do not choose to exercise their right to physician assisted suicide may gain comfort in the knowledge that the option exists if their suffering becomes intolerable.  For many, this will make it possible to live fuller, more complete, lives during the process of dying, since they need not fear a bad death.
            Without a law providing the comfort some terminally ill patients seek, the last days of life may leave patients feeling helpless and abandoned by the medical community and by society in general.  In the final words of the Nobel Prize-winning physicist Percy Bridgman, who scrawled a note before shooting himself and ending his battle with terminal cancer, "It isn't decent for society to make a man do this thing himself."[57]