Euthanasia

Euthanasia engenders debates over courage and cowardice, glory and defeat, and dignity and suffering. Ultimately, the euthanasia debate is about who we are as human beings. Are we masters of ourselves, if not of our universe, or are we more like subjects of a ruler whose reasoning we struggle to understand? Are we Prometheus or are we Job?

All concerns over end-​of-​life decision making ultimately are concerns about euthanasia. For those who follow in the footsteps of Job, euthanasia is a dangerous concept, and the word itself has only negative connotations. For those who follow in the footsteps of Prometheus, the word euthanasia harks back to its original meaning in the Greek: ευθανασ íα: ευ, eu, meaning “good,” and θα′νατoς , thanatos, meaning “death.”

In some major respects, the moral foundations of our culture are in direct conflict with each other. Joseph Campbell explains that “the ultimate loyalty of the Bible … is not to mankind but to God … , whereas the sympathy of the Greeks, finally, is for man; and the respect of the Greeks, for man’s reason.” Modern Western traditions are now a mix of these two diametrically opposed perspectives. Campbell continues: “Monday, Tuesday, Wednesday, Thursday, Friday, and Saturday, we are humanists with the Greeks; Sunday, for half an hour, Levantines, with the Prophets: and the following Monday, groaning on some equally troubled psychotherapist’s couch.”

No ethical debate in our culture exemplifies this fundamental philosophical contradiction more than the debate over end-​of-​life decision making. From Karen Ann Quinlan to Terri Schiavo, families, courts, legislatures, and society in general continue this ancient debate. When is it acceptable to allow individuals to hasten their own deaths or for them to request that others do it for them? Is it ever acceptable to hasten the death of another without their consent or even against their will? What if the person has left no indication of his wishes or is incapable of making this decision because of diminished capacity?

In all ancient cultures, it was thought that the gods held considerable influence over man’s fate. However, in some cultures, like the Greek, humans took pride in challenging their deities, whereas in others, like the Judeo-​Christian culture, humans took pride in unquestioning obedience. To the Greeks, euthanasia meant having the courage to control fate in the face of inevitable death, defeat, or indignity, and to do so was merciful and/​or honorable. To ancient Jews and Christians, euthanasia, regardless of the circumstances, was an affront to God, a challenge to his ultimate authority, and neither noble nor courageous. The modern-​day confusion of these traditions has muddled our vocabulary and our laws with respect to end-​of-​life decisions in general and euthanasia in particular.

The terminology used to discuss euthanasia is constantly in flux. Usually, people signal their acceptance of some aspect of euthanasia by calling it something else (e.g., letting die, letting nature take its course, assisted dying, death with dignity, mercy medication, and aid in dying). Conversely, people signal their disapproval of forms of letting die or assisted dying by calling it euthanasia.

Broadly speaking, euthanasia is the killing of a person, including possibly oneself or an animal, in a merciful way for the purpose of relieving suffering or some other undesirable condition. Some of the most common limitations on what is considered euthanasia include the following claims: Euthanasia is distinguishable from suicide because in euthanasia someone kills another, whereas suicide is, by definition, self-​inflicted. Euthanasia is not murder because the killing done in euthanasia is done with the intention of alleviating pain and suffering, not inflicting it. Treatment refusals that result in death are neither euthanasia nor suicide because in such cases nature or God is the direct cause of death. Similarly, cases where mercy medication results in death are not euthanasia because the death is only incidental to the primary goal of easing pain. Although each of these distinctions holds moral sway with those making them, they are of secondary importance to some more fundamental distinctions that need to be made.

There are five basic concepts that need to be understood and agreed on before any discussion of euthanasia or end-​of-​life decisions in general can proceed with coherent results.

1. Voluntary euthanasia is the term used for requesting to be killed or killing oneself to escape some inevitable ill fate. The killing is voluntary because either the person does it himself or requests that another do it for him. The ill fate that is usually at issue is intractable pain, a terminal illness (imminent death from an incurable disease), or an irreparable harm to one’s dignity. For most people, the term euthanasia does not apply unless at least the first two of these conditions are met; killing another merely to preserve that person’s dignity is usually considered murder, and to kill oneself under such circumstances is suicide.

Currently under U.S. law, ending one’s own life is only allowed through the refusal of treatment and generally only if death is imminent even if treatment were continued. There are two exceptions: The first is that the termination of treatment is sometimes allowed in cases where death is not imminent (e.g., when a patient is in a persistent vegetative state). The second is that a person is sometimes, albeit rarely, allowed to end his own life by taking medication rather than refusing it (e.g., mercy medication and aid in dying). Mercy medication is allowed in several U.S. states. It refers to the use of dangerously high doses of pain medication to relieve the pain of dying patients. Aid in dying is currently allowed in only one state (i.e., in Oregon, competent adult citizens suffering from incurable diseases with a prognosis of 6 months or less to live may, if various additional conditions are met, legally obtain a deadly dose of medication for the purpose of killing themselves).

Voluntary euthanasia requires a voluntary act, decision-​making capacity, and informed consent. A person must overtly express his wishes, usually to a health care provider, family member, or friend. Advance directives are a formal way of recording such wishes and/​or appointing a surrogate decision maker for situations where patients cannot make decisions themselves. Under the Oregon Death with Dignity Act, patients must be capable of taking the lethal medication themselves; advance directives are not an option. Voluntary euthanasia can be either active or passive.

2. Involuntary euthanasia is the killing of someone against their will to help them escape some inevitable ill fate. When practiced on humans, involuntary euthanasia is generally considered murder and illegal. One exception is capital punishment, which some people consider a form of involuntary euthanasia. Involuntary euthanasia can be either active or passive.

3. Nonvoluntary euthanasia is killing someone who is incapable of giving consent to help them escape some inevitable ill fate. Both involuntary and nonvoluntary euthanasia are sometimes called mercy killing. Euthanizing animals is appropriately called nonvoluntary because animals cannot communicate their approval or disapproval, let alone understand what is happening. The same would be true of very young children or anyone who is permanently unconscious or sufficiently mentally incapacitated not to understand the ramifications of what is being considered. Currently under U.S. law, nonvoluntary euthanasia is legal under limited circumstances. Legally recognized surrogates are sometimes allowed to refuse or withdraw treatment from incompetent patients who either did not leave any indications of their end-​of-​life preferences or never had the capacity to make such decisions. Nonvoluntary euthanasia can be either active or passive.

4. Active euthanasia, which can be voluntary, involuntary, or nonvoluntary, involves an agent actively participating in hastening or causing death. Usually there must be a definitively identified physical action that is the cause of death. For example, swallowing deadly pills or giving oneself a lethal injection are examples of active voluntary euthanasia. Assisted suicide, if done with valid informed consent, is active voluntary euthanasia, while assisted “suicide” if done contrary to a person’s wishes is active involuntary euthanasia. Assisted suicide, if done where no consent is possible, is active nonvoluntary euthanasia. Killings associated with genocides predicated on ridding society of what proponents described as bad or useless elements of society are a form of active involuntary euthanasia.

5. Passive euthanasia, which can be voluntary, involuntary, or nonvoluntary, involves allowing a predictable death to occur without intervening to stop it. Often passive euthanasia is called letting die. Voluntary passive euthanasia is legal in the United States if a patient’s prognosis is hopeless. The refusal of treatment or request for withdrawal of treatment can be made directly by the patient at the time of treatment or in advance through a written directive. Involuntary passive euthanasia is illegal, but sometimes occurs (e.g., several health care professionals have been tried for mercy killings in cases where the patient or his or her surrogate clearly indicated a wish to continue treatment and the professional in charge of the patient’s health care independently decided to let the patient die). Generally, withholding or not initiating life-​saving treatment is illegal unless the patient or the patient’s surrogate has consented. Thus, nonvoluntary, but not involuntary, passive euthanasia is only an option available to surrogate decision makers and even then usually requires a convincing argument for why hastening the patient’s death is necessary to end some form of needless suffering.

In our society, the active/​passive distinction is the focus of much of the euthanasia debate, but from a libertarian perspective, only the voluntary/​involuntary distinction is of any great significance. Many courts have held that the withdrawal of a breathing or feeding tube is letting die (i.e., passive euthanasia) and therefore acceptable. Yet withdrawing treatment is clearly an overt action (the courts have extended the notion of acceptable passive euthanasia to this obviously active act because they do not want people to hesitate to initiate treatment for fear it will be impossible to stop it later). In contrast, some states that allow the withholding and withdrawing of other types of treatment have passed laws prohibiting the withholding and/​or withdrawing of nutrition and hydration even if a patient has voluntarily expressed a wish to refuse such treatment. Some states never allow such decisions, and others only allow them of competent patients, but not formerly competent patients (i.e., the state will not accept any form of advance directive as justification for the withholding or withdrawing of nutrition and hydration).

These preferences for passive over active forms of euthanasia are carried over into discussions of voluntary, involuntary, and nonvoluntary euthanasia. Nonvoluntary or even involuntary euthanasia, brought about by treating a patient with large amounts of pain medication in an attempt to relieve suffering (i.e., mercy medication), is allowed in some states. In such cases, the killing is considered passive in the sense that the patient’s death is incidental to the physician’s attempt to control pain. Conversely, voluntary euthanasia is generally only allowed if passive. The one notable exception is Oregon, where physician-​assisted suicide for terminally ill patients is legal.

Given these distinctions, it is logical, based on libertarian first principles of individual liberty and self-​determination, that a libertarian society would support an individual’s right to choose either passive or active euthanasia, regardless of whether he were terminally ill, and equally condemn any form of involuntary euthanasia whether passive or active and no matter how close to death a person may be. The only proper role of government would be to ensure voluntariness by creating safeguards to ensure that decisions regarding euthanasia be made by competent individuals who understand the consequences of their intended actions and give their full and informed consent freely. As long as these criteria are met, libertarian societies also would allow individuals to arrange for euthanasia while competent to be carried out at a later date should they become incapable of making their wishes known. For example, someone could have an advance directive requesting what could be understood as active nonvoluntary euthanasia (e.g., the advance directive requests active euthanasia should its author ever become permanently unconscious or ever advance to stage 3 of Alzheimer’s disease).

Libertarian theory, however, does not provide clear guidance with respect to incompetent individuals. Temporary incompetence can be dealt with by emphasizing efforts to bring about competency. For example, under certain circumstances, it may be appropriate to wait for children to mature sufficiently to make their own decisions. Patients who are unconscious, paralyzed, or heavily sedated to facilitate treatment could, if at all possible, be revived to assess their end-​of-​life wishes. But what if it is impossible to get informed consent?

A presumption that someone close to the incompetent patient should make decisions for that patient provides a workable solution. Although not necessitated by libertarian theory, such surrogate decision making is not inconsistent with libertarian theory. Having someone close to the incompetent patient, usually a family member, make decisions is preferable to having a court, a committee, or some other governmental entity making the decision. There is no doubt that family responsibilities can cause conflicts of interest, and therefore it should be possible to challenge a surrogate’s decision. However, anyone challenging a surrogate’s motives should bear the burden of showing that the surrogate has no reasonable grounds for making the proposed decision. When the choice is letting the family, however defined, decide based on its own cultural and religious norms, as opposed to letting the government apply some generalized independent standard of what is in the patient’s best interest, the choice should be clear: It is preferable to keep such personal and difficult decisions as private and as free of the interference of others as possible.

Whether you wish to live or die like Prometheus or like Job should be your decision or, barring your competence, the decision of those who love you, not a decision made by anyone else through government fiat or otherwise.

Further Readings

Arras, John D., and Bonnie Steinbock, eds. Ethical Issues in Modern Medicine. 5th ed. Mountain View, CA: Mayfield, 1999.

Campbell, Joseph. “Mythological Themes in Creative Literature and Art.” Joseph Campbell. The Mythic Dimension: Selected Essays 1959–1987. Antony Van Couvering and The Joseph Campbell Foundation, eds. New York: HarperCollins, 1997. 189.

Engelhardt, H. Tristram, Jr. The Foundations of Bioethics. New York: Oxford University Press, 1986.

Foley, Elizabeth Price. Liberty for All: Reclaiming Individual Privacy in a New Era of Public Morality. New Haven, CT: Yale University Press, 2006.

Hall, Mark A., Mary Anne Bobinski, and David Orentlicher. Bioethics and Public Health Law. New York: Aspen, 2005.

Jonsen, Albert R., Mark Siegler, and William J. Winslade. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. 6th ed. New York: McGraw-​Hill, 2006.