The twentieth century has seen great strides in the advancement of medicine and life-sustaining technology, resulting in improved life expectancy and quality of life for people around the world. Improvements in medicine, however, raise questions about the appropriateness of life-sustaining treatments in the case of people who are terminally ill and experiencing acute pain and suffering. In the late twentieth century, end-of-life issues came to the forefront of public attention, resulting in an ongoing discussion about ethical, legal, and political implications of physician-assisted suicide (PAS) and euthanasia.
ISSUES SURROUNDING CONTROVERSIAL END-OF-LIFE DECISIONS
Part of the controversy surrounding end-of-life decisions such as PAS and euthanasia results from a lack of clear communication as to what these actions entail. Euthanasia refers to someone (often a physician) intentionally taking an action that ends another person’s life with the stated intent of alleviating or preventing perceived suffering. Euthanasia involves the direct administration of lethal medication by a person other than the terminally ill patient. "Assisted suicide is the deliberate and knowing provisions of information, the means, and/or help to another person for the act of suicide" (American Association of Suicidology 1996, p. 6). In PAS, the assister is a medical doctor. Such assistance is typically in the form of a prescription for a lethal dose of medication that the terminally ill patient may use as a means to end his or her life. The critical distinction between these practices is that in euthanasia the physician (or somebody else) actively administers the lethal medication, while in PAS the patient is given the means to bring about his or her own death.
There are various types of euthanasia, including voluntary, nonvoluntary, and involuntary. Voluntary euthanasia refers to deliberate termination of a patient’s life upon that person’s explicit and direct request. Nonvoluntary euthanasia occurs when the patient is unconscious or incompetent and is thus unable to make a decision. Involuntary euthanasia takes place when the patient is competent and aware but his or her consent is not obtained. It should be noted that involuntary euthanasia is not an acceptable practice even in countries where voluntary euthanasia is currently legalized. The involuntary termination of a patient’s life is not supported by legislation and is considered homicide around the world. This distinction has led several authors to argue that euthanasia is by definition voluntary and that terms such as nonvoluntary and involuntary euthanasia are contradictory and misleading (Materstvedt Clark, Ellershaw, et al., 2003).
In addition, distinction has been made between active and passive euthanasia. Active euthanasia is the procedure whereby a physician (or someone else) shortens a person’s life, usually through the administration of a lethal dose of medication. Passive euthanasia refers to the practice of withholding or withdrawing a futile or ineffective treatment upon the patient’s request (American Association of Suicidology 1996). Several researchers have argued against the use of this latter term by pointing out that practices such as withholding and withdrawing treatment are ethically and legally distinct from active euthanasia (Materstvedt, Clark, Ellershaw, et al. 2003). This view is consistent with practices in countries such as the United States and Israel where euthanasia is illegal, but withholding and withdrawing treatment are acceptable medical practices (Ganz, Benbenishty, Hersch, et al. 2006). However, in other countries the term passive euthanasia is still used. Similarly, providing high doses of pain-relieving medication, even if this may shorten a patient’s life, is seen as distinct from euthanasia (Materstvedt, Clark, Ellershaw, et al. 2003). This is also the case with terminal sedation, a practice whereby pain medication is used to bring about unconsciousness, after which life-support equipment is withdrawn (Parpa, Mystajudou, Tsilika, et al. 2006).
ARGUMENTS REGARDING PAS AND EUTHANASIA
A firm grasp on the definitions of PAS and euthanasia as well as on the alternatives that exist to these practices is essential for an informed understanding of the debate surrounding end-of-life decision-making. As of the early twenty-first century, more empirical data are necessary in order to evaluate the accuracy of arguments in favor of and against PAS and euthanasia.
Proponents of assisted suicide and euthanasia claim the practices exist but are hidden, and legalizing such acts would allow for stricter government regulation and control (Quill and Battin 2004). In addition, involving medical practitioners in the decision-making process would allow for professional and expert judgment to be made regarding the validity of end-of-life decisions. Another fundamental argument in favor of legalizing PAS and euthanasia is maximizing personal autonomy and self-determination. According to this view, a terminally ill patient who is enduring unbearable pain or suffering is entitled to the right of choosing death with dignity and peace. Alleviation of unnecessary suffering and maintaining the quality of life of terminally ill patients are the paramount goals behind PAS and euthanasia. Some proponents of PAS claim that this practice is ethically different from euthanasia, as in PAS the patient is the one who performs the act of ending his or her life.
Opponents of euthanasia and PAS point out the potential for abuse if these practices are granted legal recognition (Foley and Hendin 2002). Critics of PAS and euthanasia often refer to the threat of a slippery slope. They fear that once voluntary euthanasia or PAS for terminally ill patients becomes legally permissible, other forms of medicalized killing, such as involuntary euthanasia for mentally incompetent and/or disabled individuals would increase. Many medical professionals state that euthanasia and PAS are prohibited under the Hippocratic Oath and violate the fundamental ethical principles of nonmalefi-cence and beneficence. Furthermore, these professionals argue that the need for such end-of-life decisions can be eliminated with the provision of appropriate palliative care and the effective use of pain control medication.
Questions have also been raised about the stability and rationality of end-of-life requests (Foley and Hendin, 2002). In addition, patients may request PAS or euthanasia as a result of experiencing hopelessness and depression rather than acute physical pain or suffering. Alternatively, the patients may feel obligated to alleviate their families from unnecessary burden and thus feel pressured to end their lives. Finally, many opponents claim that the sanctity of human life overrules concerns of personal autonomy and that the protection of human life should be of paramount importance in end-of-life medical cares.
INTERNATIONAL VIEWS OF PAS AND EUTHANASIA
Both euthanasia and PAS were legalized in the Netherlands in 2002 after they had been tolerated for more than 30 years (Materstvedt, Clark, Ellershaw, et al. 2003). Belgium legalized euthanasia in September 2002, and did not legalize PAS (Adams and Nys 2003). Physician-assisted suicide, but not euthanasia, was legalized in Oregon in 1994 with the Death with Dignity Act, and began to be in use in 1997 (Materstvedt, Clark, Ellershaw, et al. 2003). In 2006, the Oregon Department of Human Services announced that it will no longer use the term "physician-assisted suicide" to describe deaths under the Death with Dignity Act (Colburn 2006) because the act itself specifies that deaths that occur following the provisions of the law are not to be considered suicide. Although active euthanasia is illegal in Switzerland, assisting in the suicide of a terminally ill patient is considered a crime only if the death, and therefore the motive behind the assistance, benefits the person who assists the suicide (Schildmann, Herrmann, Burchardi, et al. 2006). Although Australia’s Northern Territory was the first jurisdiction to legalize euthanasia in 1995, the Rights of the Terminally Ill Act was repealed nine months later by an act of the Commonwealth (Materstvedt, Clark, Ellershaw, et al. 2003).
The legalization of PAS and euthanasia in several nations signals changes in public awareness of end-of-life issues. However, countries with legal endorsement of these interventions are the exception rather than the rule. A 2001 survey conducted by the Council of Europe (2003) revealed that a majority of European nations do not have laws concerning assisted suicide and euthanasia. Of those nations that do have laws, the overwhelming majority oppose the practices. A 1999 study by Luigi Grassi, Katia Magnani, and Mauro Ercolani, published in the Journal of Pain & Symptom Management, found that only 15 percent of Italian physicians favored euthanasia and assisted suicide. In Ireland, where suicide was considered a crime until 1993, discussions of euthanasia and assisted suicide have been taboo (Phillips 1997).
Euthanasia is not a legal option in Germany and physicians are obligated to prevent harm, which may also include cases of attempted suicide. However, suicide and assisted suicide are not considered criminal acts because of an artifact of German law (Schildmann, Herrmann, Burchardi, et al. 2006). This creates a precarious situation in which assisted suicide is theoretically an option for German physicians but may lead to legal sanctions if an argument is made that there was a duty to protect the patient’s life. As of 2003, open discussion on PAS and euthanasia does not exist in Bosnia-Herzegovina (HaraciC 2003), and Estonia has not engaged in a public debate surrounding end-of-life issues (Koorits 2003). In Greece, only 8.1 percent of the general public and 2.1 percent of physicians favor PAS, although 56.7 percent of the surveyed medical doctors had administered terminal sedation (Parpa, Mystajudou, Tsilika, et al. 2006). In Russia, euthanasia is seen as contrary to the physician’s duty to preserve and promote human life and is therefore considered unethical and illegal (Leenaars and Connolly 2001). In contrast, a large percentage of physicians in China may approve of euthanasia, although such acts are not officially legalized (Leenaars and Connolly 2001). In India, 50 percent of medical students favor euthanasia (Leenaars and Connolly 2001). Israeli medical doctors view euthanasia, PAS, and withdrawing of treatment as being forbidden by Jewish ethics and law; however, withholding of treatment is an accepted practice (Ganz, Benbenishty, Hersch, et al. 2006).
Issues of culture, religion, and national history are critical when attempting to explain the observed differences in beliefs about end-of-life decision-making. Several authors have hypothesized that positive attitudes toward PAS and euthanasia are the product of highly industrialized, individualistic societies (Kemmelmeier, Wie-czorkowska, Erb, and Burnstein 2002). For example, an increase in positive attitudes regarding autonomy in the United States beginning in the late twentieth century has been correlated with a shift toward more positive attitudes regarding assisted suicide (Kemmelmeier, Wieczorkowska, Erb, and Burnstein 2002). In collectivistic societies such as Japan, arguments about the right to self-determination hold less appeal and end-of-life decisions are seen as prerogatives of the family as well as of the individual patient (Konishi and Davis 2001).
This picture is complicated by differences in religion. Most religions of the world uphold the sanctity of human life and prohibit actions that intentionally hasten death. Catholicism officially disapproves of euthanasia and PAS, as does the Christian Eastern Orthodox Church (Parpa, Mystajudou, Tsilika, et al. 2006). There are a variety of branches of Judaism, some of which oppose the active shortening of human life but deem interventions that artificially extend the agony of terminally ill patients unnecessary, therefore allowing withholding and withdrawing treatment (Gesundheit, Steinberg, Glick, et al. 2006). Islam does not recognize a patient’s right to die but allows for non-treatment decisions such as withholding and withdrawal of treatment to be made by the patient’s family and community (Sachedina 2005). Islamic law also condones the use of pain-reducing medication at the risk of shortening the life of a terminally ill patient (Sachedina 2005).
Views about euthanasia and PAS are further affected by national history. The term euthanasia, for example, evokes negative memories in many German-speaking countries where the term was used during the Nazi regime to refer to the systematic extermination of six million Jews and more than 200,000 mentally ill and physically disad-vantaged people, as well as the Roma (Schildmann, Herrmann, Burchardi, et al. 2006) and other groups. Such historical experiences have prohibited public discussions of euthanasia in Germany (Schildmann, Herrmann, Burchardi, et al. 2006).
CONCLUSION
Given the advances in life-sustaining technology and medical treatments, the controversy surrounding end-of-life decision-making is likely to continue, at least in technologically advanced countries. Open discussion of PAS and euthanasia is complicated by a constantly evolving terminology and differing cultural, religious, and national ideals. People need to stay informed of current developments and research on these issues in order to be prepared to face the end-of-life dilemmas of the future.
