Arguments For and Against Euthanasia

Arguments For and Against Euthanasia Euthanasia: Whose decision is it I. Introduction In a 1988 issue of the Journal of the American Medical Association, an article titled Its Over Debbie describes how an anonymous doctor administers a fatal dose of morphine to a woman dying of ovarian cancer (Anonymous, 1988). In a 1989 issue of the New England Journal of Medicine, ten doctors associated with the nations leading hospitals and medical schools declare their belief that it is not immoral for a physician to assist in the rational suicide of a terminally ill person (Wanzer, et. al., 1989). In 1991, the New England Journal of Medicine published a detailed account written by Dr. Timothy Quill which discussed his decision to help a patient suffering from leukemia commit suicide (Quill, 1991). In 1990, Dr. Jack Kervorkian uses his suicide machine to help a woman suffering from Alzheimers disease, one Janet Adkins, end her life in the back of a Volkswagen bus (Risen, 1990). Janet was the first of twenty patients who have been aided by Kervorkian in the past three years. He rem ains committed to his practice. In 1991 the Hemlock Society publishes a how-to manual on committing suicide. Entitled Final Exit, it zooms to the top of the national best seller lists and stays there for several weeks (Altman, 1991). Each of these events has served to provoke ever widening media coverage of the issues surrounding euthanasia and physician assisted suicide, and a national debate has arisen around these practices. This debate is not merely limited to attorneys and physicians. Suddenly, these issues and this debate are now a part of life in mainstream America, and many Americans face dilemmas that did not exist in simpler times; dilemmas that many would rather not have to face. II. Review of the Literature a. Euthanasia: The Nature of the Debate It is this sudden change in the way Americans are dealing with death, the nature and scope of the debate about dying, which prompts this analysis of the issues surrounding euthanasia. This debate is largely a debate about what is ethical. Questions the debate attempts to answer include: Is it right to commit suicide? Is it ethical for someone else to help? Is it right to put others to death at their own request or at the request of family members? These questions are important because they help to define our society and our culture. The way people deal with and respond to issues of life, ritual, and death serves to shape the nature of our society. This is why society must attempt to decide what is right; what is ethical conduct for the various actors in our communities when we face death. There are several reasons why this debate has surfaced in the 1980s. Death is nothing new, it has existed for thousands of years. Each culture has developed its own rituals and mechanisms for dealin g with death. These mechanisms serve to provide solace, a sense of continuity, and allow the culture to continue even as the members of the community cannot. However, our own culture has experienced many shattering changes that have altered the nature of dying. Suddenly we are forced to rethink the issue of death and we must decide what types of behavior are ethical when someone is dying. Before we can examine the debate about the ethics of dying, we must examine why the debate exists. Perhaps the main reason that death has changed in western culture has to do with advances in medicine and technology. Many of the diseases that have historically killed people are now no longer a threat to most individuals. Medicine has made a variety of advances in the treatment of diseases such as smallpox, tuberculosis, malaria, pneumonia, polio, influenza, and measles. People now rarely die of such traditional causes. Life expectancy has risen to almost 75 years in the United States. The quality o f life has also changed fundamentally during the past 100 years. Not only does almost everyone in the United States have enough to eat, but people eat higher on the food chain. There is a great deal more meat and animal fat in modern diets. Just these differences alone have changed death significantly. People now develop heart disease, adult onset diabetes, cancers, and AIDS. These types of diseases are more the result of lifestyle than bacteria. With these new diseases, suffering is often more prolonged and treatment is frequently quite painful. Also, as people are living longer, the diseases of the aged have become increasingly prevalent. Many more people now suffer from problems like senile dementia and Alzheimers disease. These diseases ruin the mind while preserving the body, allowing life to continue long after any quality that the life might have is gone. If what we die of has changed, perhaps the way that we die has changed even more. Throughout history, death has been a family affair. People usually died in the home after a short bout with an illness or as the result of an accident. Today, increasingly, death occurs in an institutional setting such as a convalescent home or a hospital, after a variety of technologies are applied in an attempt to prolong the life of the sick person. Often these technologies can be quite effective. People can now live for months and even years attached to a variety of tubes and technol ogies. About 75% of all deaths in 1987 occurred in hospitals and long term care facilities, up from 50% in 1950 . . . The Office of Technology Assessment Task Force estimated in 1988 that 3775 to 6575 persons were dependent on mechanical ventilation and 1,404,500 persons were receiving artificial nutritional support. This growing capability to forestall death has contributed to the increased attention to medical decisions near the end of life. (CEJA, 1992, p. 2229) People realize that the chances of facing the institutionalization of death increase daily, and they feel a profound lack of control. Surveys have consistently indicated that a large majority of people in the United States would like to be allowed to end their lives before incurable and painful diseases finally kill them (CEJA, p. 2229). Because of the changes that have impacted death, with regard to both how and where we die, the debate about how we should be allowed to die has been renewed. This paper will examine the s everal facets of this debate. It will define the terms that are relevant to the debate, examine the legal state of euthanasia today, discuss the ethics of euthanasia by examining arguments made by proponents and opponents of euthanasia, and by applying several Normative Ethical Theories to the issue. Finally, it will explore the power implications that infuse the debate on euthanasia and present arguments in favor of moving toward a care based ethic of dying and away from the current rights based ethic. b. Definitions If we are to effectively understand the debate about the right to die in the United States, it is imperative that a few basic terms be understood. The first and most important term is euthanasia. Originating from the Greek terms eu (happy or good) and thanatos (death), euthanasia means literally happy death or good death. The American Medical Associations Council on Ethical and Judicial Affairs defines the term as follows: Euthanasia is commonly defined as the act of bringing about the death of a hopelessly ill and suffering person in a relatively quick and painless way for reasons of mercy. In this report, the term euthanasia will signify the medical administration of a lethal agent to a patient for the purpose of relieving the patients intolerable and incurable suffering. (p. 2230) Other sources have defined euthanasia variously: The act or practice of painlessly putting to death persons suffering from incurable conditions of diseases. (Wolhandler, 1984, p. 363), . . . to refuse un wanted medical treatment or to have ongoing care withdrawn even though the patient will die if treatment is terminated. (Adams, et. al., 1992, p. 2021). Euthanasia is a general term that can actually mean a variety of different things depending upon the context in which it is used. For this reason, a number of supporting terms has become the convention when discussing euthanasia. These terms help to narrow the subject matter and distinguish between different types of euthanasia. The important terms that help to subdivide and classify euthanasia by type are voluntary/involuntary and active/passive. Voluntary euthanasia is a death performed by another with the consent of the person being killed. This consent may be in writing as in the case of a living will or advance directive. Involuntary euthanasia is a death performed by another without the consent of the person being killed. The AMAs Council on Ethical and Judicial Affairs makes three distinctions concerning consent and euthanasia: Voluntary euthanasia is euthanasia that is provided to a competent person on his or her informed request. Non-voluntary euthanasia is the provision of euthanasia to an incompetent person according to a surrogates decision. Involuntary euthanasia is euthanasia performed without a c ompetent persons consent.(p. 2230) Wolhandler compares the terms in a different context.Those who condemn euthanasia of both kinds would call the involuntary form murder and the voluntary form a compounded crime of murder and suicide if administered by the physician, and suicide alone if administered by the patient himself. As far as voluntary euthanasia goes, it is impossible to separate it from suicide as a moral category; it is, indeed, a form of suicide. Voluntary euthanasia may involve participation of second parties. (p. 366) The distinction between active and passive euthanasia is not nearly as clear as the previous distinction. Although many authors claim that the difference between the two types cannot be identified or is irrelevant at best, much of the debate on the subject is over this distinction and most of the current legal issues turn on this distinction. While this paper will contend that the difference between the two should not be recognized, it is both useful and important to know where the line is drawn. The AMA, which is strongly opposed to active euthanasia, has seen fit to endorse passive euthanasia in appropriate situations. The Council on Ethical and Judicial Affairs makes the distinction as follows: The physician is obligated only to offer sound medical treatment and to refrain from providing treatments that are detrimental, on balance, to the patients well being. When a physician withholds or withdraws a treatment on the request of a patient, he or she has fulfilled the obligation to offer sound treatment to the patient. The obligation to offer treatment does not include an obligation to impose treatment on an unwilling patient. In addition, the physician is not providing a harmful treatment. Withdrawing or withholding is not a treatment, but the foregoing of a treatment. (p. 2231) According to Wolhandler, (p. 367) it is t he nature of the acts performed by the second party that distinguishes between active and passive euthanasia. The courts have held that acts of omission (removal of respiratory assistance, hydration, and feeding tubes) are allowable behavior. Although unplugging a respirator and switching off a dialysis machine are arguably acts of commission, an increasing number of judges and commentators have accepted these acts as permissible passive euthanasia in both voluntary and involuntary settings. Gifford (1993) describes the difference between the two types of euthanasia this way: Passive euthanasia involves allowing a patient to die by removing her from artificial life support systems such as respirators and feeding tubes or simply discontinuing medical treatments necessary to sustain life. Active euthanasia, by contrast, involves positive steps to end the life of a patient, typically by lethal injectiond (p. 1546) The right to passive euthanasia has also been termed the right to die by some authors (Adams, et. al., p. 2021-22). With an understanding of the different types of euthanasia, we can now define some other key terms. It is important to understand how physician assisted suicide differs from euthanasia, and it is also necessary to define the terms advance directive and competence since they are crucial in determining the difference between voluntary and involuntary euthanasia. The term physician assisted suicide is somewhat self-explanatory. It occurs when a physician provides aid to a patient so they can commit suicide. However, it is also necessary to see the difference between this type of action and euthanasia. The AMAs Council on Ethical and Judicial Affairs states that Euthanasia and assisted suicide differ in the degree of physician participation. Euthanasia entails a physician performing the immediate life ending action (e.g., administering a lethal injection). Assisted suicide occurs when a physician facilitates a patients death by providing the necessary means and/or information to enable the patient to perform the life-ending act (e.g., the physician provides sleeping pills and information about the lethal dose, while aware that the patient may commit suicide). (p. 2231) It is important to realize that the difference between euthanasia and assisted suicide lies in the behavior of the physician. This difference in behavior has recently become a major legal battleground that will be explored in the following pages. The advance directive has recently become an important new device to aid the terminally ill. Many states have legalized the advance directive, partly in an attempt to avoid dealing with problems associated with active euthanasia, and partly to help ease the burdens on the dying and their families. Singer (1992) provides a good definition of advance directive and explains how it is used. An advance directive is a written document completed by a competent person that aims to guide medical treatment after the person becomes incompetent. There are two types: instruction directives, which focus on the types of life-sustaining treatment that the person would want under various clinical situations, and proxy directives, which focus on who the person would want to make health care decisions if the person were unable to do so. (p. 22) The advance directive is useful because it can theoretically eliminate the need for involuntary euthanasia. It ensures that a voluntary decision is made in advance, even if the individual could not make such a situation at a later date. If everyone made use of the advance directive, there would be no need to debate policy decisions that must be made in the case of an incompetent person on life support. Because advance directives have neither been accepted nor widely used by the general public, many of the problems that could potentially be solved remain. This situation caused right to die groups in both California and Washington to propose ballot initiatives that would legalize active euthanasia (Gifford, p. 1550-51). Although active euthanasia is not legal in any United States jurisdiction, passive euthanasia is generally allowed at the request of a competent individual. Because of this it is critical to understand what constitutes competence. Courts have defined legal competence as the mental ability to make a rational decision, which includes the ability to perceive, appreciate all the relevant facts, and to reach a rational judgement upon such facts. In the euthanasia context, legal competence is the incurable s ability to understand that in requesting active euthanasia he is choosing death over life. Only clear and convincing evidence should suffice for a finding of an incurables competence. (Wolhandler, p. 366-67) c. The Legal State of Euthanasia With a knowledge of the meaningful terms that will be involved, it is important to discuss the legal state of euthanasia in the United States today. As technology has placed more and more people on life sustaining devices in this country, the courts have had to deal with several cases that pertain to euthanasia in a variety of ways. This section of the paper is designed to review those cases briefly and to assess how the rulings in those cases have set the policy for the practice of euthanasia today. The courts first dealt with euthanasia in the Quinlan case in 1976. Karen Ann Quinlan lapsed into a coma after mixing a variety of pills and alcohol at a party. After it became apparent that she would not be revived, her parents went to court to have her respirator removed. The New Jersey Supreme Court ruled that her parents had the right to have the respirator removed and that Karen be allowed to die. Ironically, because her parents did not request removal of feeding and hydration tubes , she survived nine more years curled in a fetal position in a New Jersey rest home (Wolhandler, p. 366). In this case, the New Jersey court effectively sanctioned nonvoluntary passive euthanasia. The next prominent case was decided by the New York Supreme Court in Superintendent of Belchertown State School v. Saikewicz. Here the court found that a competent patient had the right to refuse medical treatment, allowing for a patient to decide in cases of voluntary passive euthanasia (Gifford, p. 1575-76). Later, in Satz v. Perlmutter, a Florida District Court of Appeals came to essentially the same conclusion (Wolhandler, p. 372-73). In Severns v. Wilmington Medical Center, the Delaware Supreme Court gave the husband of a comatose woman the right of guardianship and the authority to remove her respirator or withhold other treatment as he saw fit. In this case the court relied on previous decisions made in Quinlan, Saikewicz, and Satz for its finding (Wolhandler, p. 373). In Thor v. Su perior Court (California), the court granted the request to withhold treatment from a severely depressed quadriplegic only after a psychiatric evaluation determined that the request was based on poor quality of life and not just on severe depression (Pugliese, 1993, p. 1326). The courts have not restricted the right of passive euthanasia to just the terminally ill. Elizabeth Bouvia was a relatively young woman who suffered from severe cerebral palsy and attempted to starve herself to death in a California hospital by requesting the removal of a nasogastric feeding tube. She was denied this request because the hospital feared it would be party to suicide. The California court of appeals ordered the physicians to remove the tube and argued that she had the right to enlist the assistance of others in ending her life (Sprung, 1990, p. 2213). The courts have also found that doctors and hospitals must at least obtain consent from third parties that would have a significant interest in the patients outcome if the patient is incompetent. In the case of Helga Wanglie, a Minnesota court denied a hospital administrator permission to disconnect her respirator against the wishes of her husband (Gifford, p. 1571). In sum, these cases indicate an emerging consensus that courts will generally allow treatment to be withheld from patients who are terminally ill if it is in the best interests of the patient and at the request of patients or family members. It is this emerging consensus that made the U.S. Supreme Courts decision in the Cruzan case so interesting. In the only euthanasia case heard to date by the U.S. Supreme Court, the justices, in a 5-4 decision, allowed to stand the decision made by the Missouri Court of Appeals not to disconnect the life support apparatus from Nancy Cruzan (Cruzan v. Director, Missouri Dept. of Health, 1990). Although the court did find that a right to refuse treatment could be found in the Due Process clause of the Fourteenth Amendment, and did not prohibit the courts from looking in other areas for this right (Adams, et. al., p. 2025), it also upheld the right of the State of Missouri to require . . . clear and convincing evidence that Ms. Cruzan would have desired withdrawal of these treatments. (Newman, 1991, p. 175). In the realm of physician assisted suicide, only two major cases have been decided. In the case against Dr. Timothy Quill that arose because of the publication of his article in the New England Journal of Medicine, the grand jury for the state of New York refused to return an indictment (Bender, 1992, p. 524). In the more publicized case of Dr. Jack Kervorkian, the courts have not yet decided on the constitutionality of the Michigan law that bans physician-assisted suicide. Kervorkian is currently free on bond and continues to aid other patients who wish to commit suicide (Pugliese, p. 1300-05).(1) A brief assessment of the cases described above indicates that the courts have essentially legalized voluntary passive euthanasia, finding justification to refuse or have medical treatment withheld in the constitutional right to privacy, the common law right of self determination, or the more general concept of autonomy (Gifford, p. 1575-78). With regard to involuntary passive euthanasia, the courts are generally supportive of the practice, but they have the right to insist on a more stringent standard of evidence before approving such procedures. The courts have generally employed a balancing test that weighs the patients right to privacy and self-determination against the interest of the state in preserving life. The interests of potential third parties that might desire that the patient continue to live, and the ethical image of the medical profession (Adams, et. al., p. 2022). In cases of assisted suicide, some states have laws against the practice, the AMA forbids it, most juries are refusing to find the actors guilty, and the courts have yet to decide the question. Both voluntary and involuntary active euthanasia remain illegal. d. The Debate About Euthanasia The movement to legalize active euthanasia has existed for quite some time. Initially popularized in Britain during the 19th century, it gained some adherents in the United States during the 1920s. It was the Nazi program of active euthanasia in the 1930s and 4os that cast a pall of disrepute over the practice that remains today. The revival of this movement today can largely be attributed to the onset of the issues discussed at the beginning of this paper, and to the efforts of the Hemlock Society, a group of individuals that actively promotes the right to dignified death. The Hemlock Society recently promoted ballot initiatives in both Washington and California that would have legalized active euthanasia in those states (Gifford, 1993). This revival of the right to die movement has led to hotly contested debate about the practices of active euthanasia and physician assisted suicide. This paper will attempt to encapsulate this debate by presenting the arguments made by both opponents and supporters of these procedures. Since arguments made by both sides are used in cases of euthanasia and assisted suicide, the generic term euthanasia is used for simplicity to suggest the concept of aided death unless otherwise indicated. Those opposed to euthanasia and assisted suicide present a variety of arguments in support of a ban. e. The Case Against Euthanasia Euthanasia destroys societal respect for life. By becoming commonplace and used in medical practice along with more traditional methods of healing, society becomes desensitized toward death to the point where life is no longer valuable. This attitude serves to degrade humanity and leads to a variety of social ills. In a society that devalues life, people have no compunctions about committing violent crimes and murdering others. The overall quality of life becomes seriously undermined and society as a whole deteriorates (Doerflinger, 1989, p. 16-19, Koop, 1989, p. 2-3). Once euthanasia becomes legal, opponents contend, the potential for abuse at the hands of caregivers vastly increases. Closely related to this argument is the argument that those who enjoy the exercise of power over others might become intoxicated with it and actually come to enjoy killing. One step down the path toward euthanasia simply makes it that much easier in the future to take further steps. This argument is al so referred to as the wedge theory or the slippery slope. One of the most outspoken opponents of euthanasia, University of Michigan professor of law Yale Kamisar, has articulated a three pronged attack that utilizes the wedge theory, the risk of abuse, and the risk of mistake. The proponents of the wedge theory argue that Once society accepts that life can be terminated because of its diminished quality, there is no rational way to limit euthanasia and prevent its abuse. According to this theory, voluntary euthanasia is just the thin edge of a wedge that, once in place, will be driven deeply into our society. Kamisar concludes that legalized voluntary euthanasia inevitably would lead to legalized involuntary euthanasia because it is impossible to draw a rational distinction between those who seek to die because they are a burden to themselves and those whom society seeks to kill because they are a burden to others.(2) (Wolhandler, p. 377) Many who raise the wedge or slippery slope a rgument use the Nazi experience with euthanasia as an empirical example of this process in action. They argue that a public policy of murder inexorably follows from an initial, limited step, namely the adoption of a carefully defined euthanasia program, and that a program designed to get rid of those with lives unworthy of life quickly degenerated into the holocaust (Newman, p. 167). What follows is a description of the Nazi euthanasia program excerpted from Liftons (1986) book: National Socialist euthanasia or mercy death was a program of killing persons with unworthy lives. These persons were not moribund, and their families, with the rarest exceptions, wanted them to live. It was not a good death, as the word denotes, but a systematic program of killing without any mercy whatsoever . . . The program, referred to in the National Socialist bureaucracy as T4, was not based on any law, but was initiated by a secret order traceable to Hitler and his chief physician, Karl Brandt . Ment al hospitals were required to report all chronic schizophrenics, manic-depressives, mental defectives, epileptics, and later, debilitated old persons. A separate division, the Public Transport division for the Sick, took care of the collection and transport of such patients to institutions where they were put to death . Relatives received false death certificates and even letters of condolence . . . It is estimated that during two years of this program, ninety thousand persons went to their deaths. While this description of the Nazi euthanasia program is indeed chilling, it provides within it a devastating attack against using it as justification for the slippery slope argument. Proponents of euthanasia in the United States point out that the Nazi program was not one of euthanasia, but a program of mass murder disguised as euthanasia. Gifford (p. 1570) sums up the response of several authors by stating that The Nazis hid their racist, eugenic agenda behind the term euthanasia, termi nating in secret the lives of undesirables. It must never be forgotten that the Nazi euthanasia program was never euthanasia at all. That the Nazis co-opted the term for their own purposes should not obscure the fact that their motive was, from the very beginning, entirely different from that of todays euthanasia proponents. The current euthanasia movement is anything but covert. The Hemlock Society and other supporters of the right to receive aid in dying have spent millions of dollars to publicize their efforts. In this context, death is presented as a positive alternative to pain and suffering, not a utilitarian tool. Proponents of euthanasia also attempt to refute the slippery slope argument in a variety of other ways. They contend that the current mechanisms used by the courts could easily prevent any slide toward involuntary euthanasia,(3) that the current practice of passive euthanasia proves that the slope isnt all that slippery since we havent witnessed any massive killing programs, and that the example of how forced sterilization in the U.S. has diminished rather than increased, provides a more appropriate example to rely on. Even Callahan (1989), a vocal opponent of active euthanasia, admits that the Nazi experience is not particularly applicable to the U.S. experience and that Lives are not b eing shortened. They are steadily being lengthened, and particularly for those who are the most powerless: sick children and the very old, the mentally and mentally retarded, the disabled and the demented (p. 4). Newman (1991) also attacks the concept of the slippery slope itself. Arguing that just pointing out that one type of action could conceivably lead to another constitutes a very unpersuasive argument and that for the premise to hold true, it must be shown that pressure to allow further steps will be so strong that these steps will actually occur. He also reminds us that such arguments are frequently abused in legal and social policy debate (p. 169). Besides Kamisar, the risk of abuse argument has also been put forth by a host of other authors who variously claim that assisted suicides might result in flagrant murders that may be perpetrated by deliberately forcing or coercing self-destruction and that others may advance personal motives by aiding in suicide (Adams, et. al., p. 2031); that when the entire medical profession is involved in euthanasia, including the poorly trained, the insensitive, the less skilled, there becomes the danger that physicians might not do whatever they can to avoid euthanasia if possible (Newman, p. 177); and that some people who enjoy the exercise of power over others might become addicted to the process (Doerflinger, p. 19). It is this fear of abuse that leads the AMAs Council on Ethical and Judicial Affairs to argue that the ban on active euthanasia is a bright line distinction that deters this type of potential abuse. They state: Allowing physicians to perform euthanasia for a limited group of patients who may truly benefit from it will present difficult line-drawing problems for medicine and society. In specific cases it may be hard to distinguish which cases fit the criteria established for euthanasia. For example, if the existence of unbearable pain and suffering was a criterion for euthanasia, the definition of unbea rable pain and suffering could be subject to different interpretations, which might lead to abuse of the process in the case of certain practitioners. (CEJA, p. 2232). Proponents of euthanasia argue that the risk of abuse, while certainly present, is not really much of a threat. This is true first, because laws against homicide are severe enough to provide a strong deterrent (Newman, p. 178); second, because a clear set of guidelines prescribing when active euthanasia is allowed will prevent confusion (Adams, et. al., Gifford); third, because we already risk the practice of abuse by allowing passive euthanasia, and such abuse has not occurred (Newman, p. 178); and finally, that the current state of illegality promotes an absence of discussion and actually encourages the practice of clandestine euthanasia (Newman, p. 177). As Gifford (p. 1572) succinctly puts it, what slope could be more slippery than one with no guardrails whatsoever? Additionally, the balancing tests already in place by the legal system should serve to eliminate this problem. Adams, et. al., (p. 2034) explain: For example, some opponents of physician-assisted suicide argue that pe rmitting some assisted suicides may lead to the killing of patients who want to live. This slippery slope argument expresses a utilitarian rationale for prohibiting suicide assistance. Others argue that suicide and the assistance of suicide is intrinsically evil, and that sanctioning them will damage the fabric of social morality. These and other utilitarian and moral considerations are encompassed within the states interest in preserving the sanctity of all life and affect its weight in the balance against the patients interest in self-determination. Opponents of euthanasia contend that there is no guarantee that euthanasia will be strictly voluntary. The potential for sub Arguments For and Against Euthanasia Arguments For and Against Euthanasia Euthanasia: Whose decision is it I. Introduction In a 1988 issue of the Journal of the American Medical Association, an article titled Its Over Debbie describes how an anonymous doctor administers a fatal dose of morphine to a woman dying of ovarian cancer (Anonymous, 1988). In a 1989 issue of the New England Journal of Medicine, ten doctors associated with the nations leading hospitals and medical schools declare their belief that it is not immoral for a physician to assist in the rational suicide of a terminally ill person (Wanzer, et. al., 1989). In 1991, the New England Journal of Medicine published a detailed account written by Dr. Timothy Quill which discussed his decision to help a patient suffering from leukemia commit suicide (Quill, 1991). In 1990, Dr. Jack Kervorkian uses his suicide machine to help a woman suffering from Alzheimers disease, one Janet Adkins, end her life in the back of a Volkswagen bus (Risen, 1990). Janet was the first of twenty patients who have been aided by Kervorkian in the past three years. He rem ains committed to his practice. In 1991 the Hemlock Society publishes a how-to manual on committing suicide. Entitled Final Exit, it zooms to the top of the national best seller lists and stays there for several weeks (Altman, 1991). Each of these events has served to provoke ever widening media coverage of the issues surrounding euthanasia and physician assisted suicide, and a national debate has arisen around these practices. This debate is not merely limited to attorneys and physicians. Suddenly, these issues and this debate are now a part of life in mainstream America, and many Americans face dilemmas that did not exist in simpler times; dilemmas that many would rather not have to face. II. Review of the Literature a. Euthanasia: The Nature of the Debate It is this sudden change in the way Americans are dealing with death, the nature and scope of the debate about dying, which prompts this analysis of the issues surrounding euthanasia. This debate is largely a debate about what is ethical. Questions the debate attempts to answer include: Is it right to commit suicide? Is it ethical for someone else to help? Is it right to put others to death at their own request or at the request of family members? These questions are important because they help to define our society and our culture. The way people deal with and respond to issues of life, ritual, and death serves to shape the nature of our society. This is why society must attempt to decide what is right; what is ethical conduct for the various actors in our communities when we face death. There are several reasons why this debate has surfaced in the 1980s. Death is nothing new, it has existed for thousands of years. Each culture has developed its own rituals and mechanisms for dealin g with death. These mechanisms serve to provide solace, a sense of continuity, and allow the culture to continue even as the members of the community cannot. However, our own culture has experienced many shattering changes that have altered the nature of dying. Suddenly we are forced to rethink the issue of death and we must decide what types of behavior are ethical when someone is dying. Before we can examine the debate about the ethics of dying, we must examine why the debate exists. Perhaps the main reason that death has changed in western culture has to do with advances in medicine and technology. Many of the diseases that have historically killed people are now no longer a threat to most individuals. Medicine has made a variety of advances in the treatment of diseases such as smallpox, tuberculosis, malaria, pneumonia, polio, influenza, and measles. People now rarely die of such traditional causes. Life expectancy has risen to almost 75 years in the United States. The quality o f life has also changed fundamentally during the past 100 years. Not only does almost everyone in the United States have enough to eat, but people eat higher on the food chain. There is a great deal more meat and animal fat in modern diets. Just these differences alone have changed death significantly. People now develop heart disease, adult onset diabetes, cancers, and AIDS. These types of diseases are more the result of lifestyle than bacteria. With these new diseases, suffering is often more prolonged and treatment is frequently quite painful. Also, as people are living longer, the diseases of the aged have become increasingly prevalent. Many more people now suffer from problems like senile dementia and Alzheimers disease. These diseases ruin the mind while preserving the body, allowing life to continue long after any quality that the life might have is gone. If what we die of has changed, perhaps the way that we die has changed even more. Throughout history, death has been a family affair. People usually died in the home after a short bout with an illness or as the result of an accident. Today, increasingly, death occurs in an institutional setting such as a convalescent home or a hospital, after a variety of technologies are applied in an attempt to prolong the life of the sick person. Often these technologies can be quite effective. People can now live for months and even years attached to a variety of tubes and technol ogies. About 75% of all deaths in 1987 occurred in hospitals and long term care facilities, up from 50% in 1950 . . . The Office of Technology Assessment Task Force estimated in 1988 that 3775 to 6575 persons were dependent on mechanical ventilation and 1,404,500 persons were receiving artificial nutritional support. This growing capability to forestall death has contributed to the increased attention to medical decisions near the end of life. (CEJA, 1992, p. 2229) People realize that the chances of facing the institutionalization of death increase daily, and they feel a profound lack of control. Surveys have consistently indicated that a large majority of people in the United States would like to be allowed to end their lives before incurable and painful diseases finally kill them (CEJA, p. 2229). Because of the changes that have impacted death, with regard to both how and where we die, the debate about how we should be allowed to die has been renewed. This paper will examine the s everal facets of this debate. It will define the terms that are relevant to the debate, examine the legal state of euthanasia today, discuss the ethics of euthanasia by examining arguments made by proponents and opponents of euthanasia, and by applying several Normative Ethical Theories to the issue. Finally, it will explore the power implications that infuse the debate on euthanasia and present arguments in favor of moving toward a care based ethic of dying and away from the current rights based ethic. b. Definitions If we are to effectively understand the debate about the right to die in the United States, it is imperative that a few basic terms be understood. The first and most important term is euthanasia. Originating from the Greek terms eu (happy or good) and thanatos (death), euthanasia means literally happy death or good death. The American Medical Associations Council on Ethical and Judicial Affairs defines the term as follows: Euthanasia is commonly defined as the act of bringing about the death of a hopelessly ill and suffering person in a relatively quick and painless way for reasons of mercy. In this report, the term euthanasia will signify the medical administration of a lethal agent to a patient for the purpose of relieving the patients intolerable and incurable suffering. (p. 2230) Other sources have defined euthanasia variously: The act or practice of painlessly putting to death persons suffering from incurable conditions of diseases. (Wolhandler, 1984, p. 363), . . . to refuse un wanted medical treatment or to have ongoing care withdrawn even though the patient will die if treatment is terminated. (Adams, et. al., 1992, p. 2021). Euthanasia is a general term that can actually mean a variety of different things depending upon the context in which it is used. For this reason, a number of supporting terms has become the convention when discussing euthanasia. These terms help to narrow the subject matter and distinguish between different types of euthanasia. The important terms that help to subdivide and classify euthanasia by type are voluntary/involuntary and active/passive. Voluntary euthanasia is a death performed by another with the consent of the person being killed. This consent may be in writing as in the case of a living will or advance directive. Involuntary euthanasia is a death performed by another without the consent of the person being killed. The AMAs Council on Ethical and Judicial Affairs makes three distinctions concerning consent and euthanasia: Voluntary euthanasia is euthanasia that is provided to a competent person on his or her informed request. Non-voluntary euthanasia is the provision of euthanasia to an incompetent person according to a surrogates decision. Involuntary euthanasia is euthanasia performed without a c ompetent persons consent.(p. 2230) Wolhandler compares the terms in a different context.Those who condemn euthanasia of both kinds would call the involuntary form murder and the voluntary form a compounded crime of murder and suicide if administered by the physician, and suicide alone if administered by the patient himself. As far as voluntary euthanasia goes, it is impossible to separate it from suicide as a moral category; it is, indeed, a form of suicide. Voluntary euthanasia may involve participation of second parties. (p. 366) The distinction between active and passive euthanasia is not nearly as clear as the previous distinction. Although many authors claim that the difference between the two types cannot be identified or is irrelevant at best, much of the debate on the subject is over this distinction and most of the current legal issues turn on this distinction. While this paper will contend that the difference between the two should not be recognized, it is both useful and important to know where the line is drawn. The AMA, which is strongly opposed to active euthanasia, has seen fit to endorse passive euthanasia in appropriate situations. The Council on Ethical and Judicial Affairs makes the distinction as follows: The physician is obligated only to offer sound medical treatment and to refrain from providing treatments that are detrimental, on balance, to the patients well being. When a physician withholds or withdraws a treatment on the request of a patient, he or she has fulfilled the obligation to offer sound treatment to the patient. The obligation to offer treatment does not include an obligation to impose treatment on an unwilling patient. In addition, the physician is not providing a harmful treatment. Withdrawing or withholding is not a treatment, but the foregoing of a treatment. (p. 2231) According to Wolhandler, (p. 367) it is t he nature of the acts performed by the second party that distinguishes between active and passive euthanasia. The courts have held that acts of omission (removal of respiratory assistance, hydration, and feeding tubes) are allowable behavior. Although unplugging a respirator and switching off a dialysis machine are arguably acts of commission, an increasing number of judges and commentators have accepted these acts as permissible passive euthanasia in both voluntary and involuntary settings. Gifford (1993) describes the difference between the two types of euthanasia this way: Passive euthanasia involves allowing a patient to die by removing her from artificial life support systems such as respirators and feeding tubes or simply discontinuing medical treatments necessary to sustain life. Active euthanasia, by contrast, involves positive steps to end the life of a patient, typically by lethal injectiond (p. 1546) The right to passive euthanasia has also been termed the right to die by some authors (Adams, et. al., p. 2021-22). With an understanding of the different types of euthanasia, we can now define some other key terms. It is important to understand how physician assisted suicide differs from euthanasia, and it is also necessary to define the terms advance directive and competence since they are crucial in determining the difference between voluntary and involuntary euthanasia. The term physician assisted suicide is somewhat self-explanatory. It occurs when a physician provides aid to a patient so they can commit suicide. However, it is also necessary to see the difference between this type of action and euthanasia. The AMAs Council on Ethical and Judicial Affairs states that Euthanasia and assisted suicide differ in the degree of physician participation. Euthanasia entails a physician performing the immediate life ending action (e.g., administering a lethal injection). Assisted suicide occurs when a physician facilitates a patients death by providing the necessary means and/or information to enable the patient to perform the life-ending act (e.g., the physician provides sleeping pills and information about the lethal dose, while aware that the patient may commit suicide). (p. 2231) It is important to realize that the difference between euthanasia and assisted suicide lies in the behavior of the physician. This difference in behavior has recently become a major legal battleground that will be explored in the following pages. The advance directive has recently become an important new device to aid the terminally ill. Many states have legalized the advance directive, partly in an attempt to avoid dealing with problems associated with active euthanasia, and partly to help ease the burdens on the dying and their families. Singer (1992) provides a good definition of advance directive and explains how it is used. An advance directive is a written document completed by a competent person that aims to guide medical treatment after the person becomes incompetent. There are two types: instruction directives, which focus on the types of life-sustaining treatment that the person would want under various clinical situations, and proxy directives, which focus on who the person would want to make health care decisions if the person were unable to do so. (p. 22) The advance directive is useful because it can theoretically eliminate the need for involuntary euthanasia. It ensures that a voluntary decision is made in advance, even if the individual could not make such a situation at a later date. If everyone made use of the advance directive, there would be no need to debate policy decisions that must be made in the case of an incompetent person on life support. Because advance directives have neither been accepted nor widely used by the general public, many of the problems that could potentially be solved remain. This situation caused right to die groups in both California and Washington to propose ballot initiatives that would legalize active euthanasia (Gifford, p. 1550-51). Although active euthanasia is not legal in any United States jurisdiction, passive euthanasia is generally allowed at the request of a competent individual. Because of this it is critical to understand what constitutes competence. Courts have defined legal competence as the mental ability to make a rational decision, which includes the ability to perceive, appreciate all the relevant facts, and to reach a rational judgement upon such facts. In the euthanasia context, legal competence is the incurable s ability to understand that in requesting active euthanasia he is choosing death over life. Only clear and convincing evidence should suffice for a finding of an incurables competence. (Wolhandler, p. 366-67) c. The Legal State of Euthanasia With a knowledge of the meaningful terms that will be involved, it is important to discuss the legal state of euthanasia in the United States today. As technology has placed more and more people on life sustaining devices in this country, the courts have had to deal with several cases that pertain to euthanasia in a variety of ways. This section of the paper is designed to review those cases briefly and to assess how the rulings in those cases have set the policy for the practice of euthanasia today. The courts first dealt with euthanasia in the Quinlan case in 1976. Karen Ann Quinlan lapsed into a coma after mixing a variety of pills and alcohol at a party. After it became apparent that she would not be revived, her parents went to court to have her respirator removed. The New Jersey Supreme Court ruled that her parents had the right to have the respirator removed and that Karen be allowed to die. Ironically, because her parents did not request removal of feeding and hydration tubes , she survived nine more years curled in a fetal position in a New Jersey rest home (Wolhandler, p. 366). In this case, the New Jersey court effectively sanctioned nonvoluntary passive euthanasia. The next prominent case was decided by the New York Supreme Court in Superintendent of Belchertown State School v. Saikewicz. Here the court found that a competent patient had the right to refuse medical treatment, allowing for a patient to decide in cases of voluntary passive euthanasia (Gifford, p. 1575-76). Later, in Satz v. Perlmutter, a Florida District Court of Appeals came to essentially the same conclusion (Wolhandler, p. 372-73). In Severns v. Wilmington Medical Center, the Delaware Supreme Court gave the husband of a comatose woman the right of guardianship and the authority to remove her respirator or withhold other treatment as he saw fit. In this case the court relied on previous decisions made in Quinlan, Saikewicz, and Satz for its finding (Wolhandler, p. 373). In Thor v. Su perior Court (California), the court granted the request to withhold treatment from a severely depressed quadriplegic only after a psychiatric evaluation determined that the request was based on poor quality of life and not just on severe depression (Pugliese, 1993, p. 1326). The courts have not restricted the right of passive euthanasia to just the terminally ill. Elizabeth Bouvia was a relatively young woman who suffered from severe cerebral palsy and attempted to starve herself to death in a California hospital by requesting the removal of a nasogastric feeding tube. She was denied this request because the hospital feared it would be party to suicide. The California court of appeals ordered the physicians to remove the tube and argued that she had the right to enlist the assistance of others in ending her life (Sprung, 1990, p. 2213). The courts have also found that doctors and hospitals must at least obtain consent from third parties that would have a significant interest in the patients outcome if the patient is incompetent. In the case of Helga Wanglie, a Minnesota court denied a hospital administrator permission to disconnect her respirator against the wishes of her husband (Gifford, p. 1571). In sum, these cases indicate an emerging consensus that courts will generally allow treatment to be withheld from patients who are terminally ill if it is in the best interests of the patient and at the request of patients or family members. It is this emerging consensus that made the U.S. Supreme Courts decision in the Cruzan case so interesting. In the only euthanasia case heard to date by the U.S. Supreme Court, the justices, in a 5-4 decision, allowed to stand the decision made by the Missouri Court of Appeals not to disconnect the life support apparatus from Nancy Cruzan (Cruzan v. Director, Missouri Dept. of Health, 1990). Although the court did find that a right to refuse treatment could be found in the Due Process clause of the Fourteenth Amendment, and did not prohibit the courts from looking in other areas for this right (Adams, et. al., p. 2025), it also upheld the right of the State of Missouri to require . . . clear and convincing evidence that Ms. Cruzan would have desired withdrawal of these treatments. (Newman, 1991, p. 175). In the realm of physician assisted suicide, only two major cases have been decided. In the case against Dr. Timothy Quill that arose because of the publication of his article in the New England Journal of Medicine, the grand jury for the state of New York refused to return an indictment (Bender, 1992, p. 524). In the more publicized case of Dr. Jack Kervorkian, the courts have not yet decided on the constitutionality of the Michigan law that bans physician-assisted suicide. Kervorkian is currently free on bond and continues to aid other patients who wish to commit suicide (Pugliese, p. 1300-05).(1) A brief assessment of the cases described above indicates that the courts have essentially legalized voluntary passive euthanasia, finding justification to refuse or have medical treatment withheld in the constitutional right to privacy, the common law right of self determination, or the more general concept of autonomy (Gifford, p. 1575-78). With regard to involuntary passive euthanasia, the courts are generally supportive of the practice, but they have the right to insist on a more stringent standard of evidence before approving such procedures. The courts have generally employed a balancing test that weighs the patients right to privacy and self-determination against the interest of the state in preserving life. The interests of potential third parties that might desire that the patient continue to live, and the ethical image of the medical profession (Adams, et. al., p. 2022). In cases of assisted suicide, some states have laws against the practice, the AMA forbids it, most juries are refusing to find the actors guilty, and the courts have yet to decide the question. Both voluntary and involuntary active euthanasia remain illegal. d. The Debate About Euthanasia The movement to legalize active euthanasia has existed for quite some time. Initially popularized in Britain during the 19th century, it gained some adherents in the United States during the 1920s. It was the Nazi program of active euthanasia in the 1930s and 4os that cast a pall of disrepute over the practice that remains today. The revival of this movement today can largely be attributed to the onset of the issues discussed at the beginning of this paper, and to the efforts of the Hemlock Society, a group of individuals that actively promotes the right to dignified death. The Hemlock Society recently promoted ballot initiatives in both Washington and California that would have legalized active euthanasia in those states (Gifford, 1993). This revival of the right to die movement has led to hotly contested debate about the practices of active euthanasia and physician assisted suicide. This paper will attempt to encapsulate this debate by presenting the arguments made by both opponents and supporters of these procedures. Since arguments made by both sides are used in cases of euthanasia and assisted suicide, the generic term euthanasia is used for simplicity to suggest the concept of aided death unless otherwise indicated. Those opposed to euthanasia and assisted suicide present a variety of arguments in support of a ban. e. The Case Against Euthanasia Euthanasia destroys societal respect for life. By becoming commonplace and used in medical practice along with more traditional methods of healing, society becomes desensitized toward death to the point where life is no longer valuable. This attitude serves to degrade humanity and leads to a variety of social ills. In a society that devalues life, people have no compunctions about committing violent crimes and murdering others. The overall quality of life becomes seriously undermined and society as a whole deteriorates (Doerflinger, 1989, p. 16-19, Koop, 1989, p. 2-3). Once euthanasia becomes legal, opponents contend, the potential for abuse at the hands of caregivers vastly increases. Closely related to this argument is the argument that those who enjoy the exercise of power over others might become intoxicated with it and actually come to enjoy killing. One step down the path toward euthanasia simply makes it that much easier in the future to take further steps. This argument is al so referred to as the wedge theory or the slippery slope. One of the most outspoken opponents of euthanasia, University of Michigan professor of law Yale Kamisar, has articulated a three pronged attack that utilizes the wedge theory, the risk of abuse, and the risk of mistake. The proponents of the wedge theory argue that Once society accepts that life can be terminated because of its diminished quality, there is no rational way to limit euthanasia and prevent its abuse. According to this theory, voluntary euthanasia is just the thin edge of a wedge that, once in place, will be driven deeply into our society. Kamisar concludes that legalized voluntary euthanasia inevitably would lead to legalized involuntary euthanasia because it is impossible to draw a rational distinction between those who seek to die because they are a burden to themselves and those whom society seeks to kill because they are a burden to others.(2) (Wolhandler, p. 377) Many who raise the wedge or slippery slope a rgument use the Nazi experience with euthanasia as an empirical example of this process in action. They argue that a public policy of murder inexorably follows from an initial, limited step, namely the adoption of a carefully defined euthanasia program, and that a program designed to get rid of those with lives unworthy of life quickly degenerated into the holocaust (Newman, p. 167). What follows is a description of the Nazi euthanasia program excerpted from Liftons (1986) book: National Socialist euthanasia or mercy death was a program of killing persons with unworthy lives. These persons were not moribund, and their families, with the rarest exceptions, wanted them to live. It was not a good death, as the word denotes, but a systematic program of killing without any mercy whatsoever . . . The program, referred to in the National Socialist bureaucracy as T4, was not based on any law, but was initiated by a secret order traceable to Hitler and his chief physician, Karl Brandt . Ment al hospitals were required to report all chronic schizophrenics, manic-depressives, mental defectives, epileptics, and later, debilitated old persons. A separate division, the Public Transport division for the Sick, took care of the collection and transport of such patients to institutions where they were put to death . Relatives received false death certificates and even letters of condolence . . . It is estimated that during two years of this program, ninety thousand persons went to their deaths. While this description of the Nazi euthanasia program is indeed chilling, it provides within it a devastating attack against using it as justification for the slippery slope argument. Proponents of euthanasia in the United States point out that the Nazi program was not one of euthanasia, but a program of mass murder disguised as euthanasia. Gifford (p. 1570) sums up the response of several authors by stating that The Nazis hid their racist, eugenic agenda behind the term euthanasia, termi nating in secret the lives of undesirables. It must never be forgotten that the Nazi euthanasia program was never euthanasia at all. That the Nazis co-opted the term for their own purposes should not obscure the fact that their motive was, from the very beginning, entirely different from that of todays euthanasia proponents. The current euthanasia movement is anything but covert. The Hemlock Society and other supporters of the right to receive aid in dying have spent millions of dollars to publicize their efforts. In this context, death is presented as a positive alternative to pain and suffering, not a utilitarian tool. Proponents of euthanasia also attempt to refute the slippery slope argument in a variety of other ways. They contend that the current mechanisms used by the courts could easily prevent any slide toward involuntary euthanasia,(3) that the current practice of passive euthanasia proves that the slope isnt all that slippery since we havent witnessed any massive killing programs, and that the example of how forced sterilization in the U.S. has diminished rather than increased, provides a more appropriate example to rely on. Even Callahan (1989), a vocal opponent of active euthanasia, admits that the Nazi experience is not particularly applicable to the U.S. experience and that Lives are not b eing shortened. They are steadily being lengthened, and particularly for those who are the most powerless: sick children and the very old, the mentally and mentally retarded, the disabled and the demented (p. 4). Newman (1991) also attacks the concept of the slippery slope itself. Arguing that just pointing out that one type of action could conceivably lead to another constitutes a very unpersuasive argument and that for the premise to hold true, it must be shown that pressure to allow further steps will be so strong that these steps will actually occur. He also reminds us that such arguments are frequently abused in legal and social policy debate (p. 169). Besides Kamisar, the risk of abuse argument has also been put forth by a host of other authors who variously claim that assisted suicides might result in flagrant murders that may be perpetrated by deliberately forcing or coercing self-destruction and that others may advance personal motives by aiding in suicide (Adams, et. al., p. 2031); that when the entire medical profession is involved in euthanasia, including the poorly trained, the insensitive, the less skilled, there becomes the danger that physicians might not do whatever they can to avoid euthanasia if possible (Newman, p. 177); and that some people who enjoy the exercise of power over others might become addicted to the process (Doerflinger, p. 19). It is this fear of abuse that leads the AMAs Council on Ethical and Judicial Affairs to argue that the ban on active euthanasia is a bright line distinction that deters this type of potential abuse. They state: Allowing physicians to perform euthanasia for a limited group of patients who may truly benefit from it will present difficult line-drawing problems for medicine and society. In specific cases it may be hard to distinguish which cases fit the criteria established for euthanasia. For example, if the existence of unbearable pain and suffering was a criterion for euthanasia, the definition of unbea rable pain and suffering could be subject to different interpretations, which might lead to abuse of the process in the case of certain practitioners. (CEJA, p. 2232). Proponents of euthanasia argue that the risk of abuse, while certainly present, is not really much of a threat. This is true first, because laws against homicide are severe enough to provide a strong deterrent (Newman, p. 178); second, because a clear set of guidelines prescribing when active euthanasia is allowed will prevent confusion (Adams, et. al., Gifford); third, because we already risk the practice of abuse by allowing passive euthanasia, and such abuse has not occurred (Newman, p. 178); and finally, that the current state of illegality promotes an absence of discussion and actually encourages the practice of clandestine euthanasia (Newman, p. 177). As Gifford (p. 1572) succinctly puts it, what slope could be more slippery than one with no guardrails whatsoever? Additionally, the balancing tests already in place by the legal system should serve to eliminate this problem. Adams, et. al., (p. 2034) explain: For example, some opponents of physician-assisted suicide argue that pe rmitting some assisted suicides may lead to the killing of patients who want to live. This slippery slope argument expresses a utilitarian rationale for prohibiting suicide assistance. Others argue that suicide and the assistance of suicide is intrinsically evil, and that sanctioning them will damage the fabric of social morality. These and other utilitarian and moral considerations are encompassed within the states interest in preserving the sanctity of all life and affect its weight in the balance against the patients interest in self-determination. Opponents of euthanasia contend that there is no guarantee that euthanasia will be strictly voluntary. The potential for sub