Voluntary euthanasia

Voluntary euthanasia (from the Greek ευθανασία meaning "good death": ευ-, eu- (well or good) + θάνατος, thanatos (death)) refers to the practice of ending a life in a painless manner. Voluntary euthanasia (VE) and physician-assisted suicide (PAS) have been the focus of great controversy in recent years.

As of 2009, some forms of voluntary euthanasia are legal in Belgium, Luxembourg, the Netherlands, Switzerland, and the U.S. states of Oregon and Washington.

Assisted suicide
Assisted suicide is where the patient actively takes the last step in their death. The term "assisted suicide" is contrasted with "active euthanasia" when the difference between providing the means and actively administering lethal medicine is considered important, though in practice, the distinction can appear very hard to draw. For example, Swiss law on assisted suicide allows assisted suicide, while all forms of active euthanasia (like lethal injection) remain prohibited.

Some jurisdictions declare that a person dying as a result of physician assisted suicide does not commit suicide. This ensures that terminally ill people choosing assisted suicide options do not have reduced insurance claims compared to people dying in "natural" way. For example, the Oregon Death with Dignity Act defines that "... participation under the Act is not suicide, so should not affect insurance benefits by that definition."

Other terminology
Voluntary refusal of food and fluids (VRFF) or Patient Refusal of Nutrition and Hydration (PRNH) is bordering on euthanasia. Some authors classify it as a form of passive euthanasia, while others treat it separately because it is treated differently from legal point of view and often perceived as a more ethical option. VRFF is sometimes suggested as a legal alternative to euthanasia in jurisdictions disallowing euthanasia.

History
The term euthanasia comes from the Greek words "eu"-meaning good and "thanatos"-meaning death, which combined means “well-death” or "dying well". Hippocrates mentions euthanasia in the Hippocratic Oath, which was written between 400 and 300 BC The original Oath states: “To please no one will I prescribe a deadly drug nor give advice which may cause his death.” Despite this, the ancient Greeks and Romans generally did not believe that life needed to be preserved at any cost and were, in consequence, tolerant of suicide in cases where no relief could be offered to the dying or, in the case of the Stoics and Epicureans, where a person no longer cared for his life.

English Common Law from the 14th century until the middle of the last century made suicide a criminal act in England and Wales. Assisting others to kill themselves remains illegal in that jurisdiction. However, in the 16th century, Thomas More, considered a saint by Roman Catholics, described a utopian community and envisaged such a community as one that would facilitate the death of those whose lives had become burdensome as a result of "torturing and lingering pain", see The meaning of the work.

Modern history
Since the 19th Century, euthanasia has sparked intermittent debates and activism in North America and Europe. According to medical historian Ezekiel Emanuel, it was the availability of anesthesia that ushered in the modern era of euthanasia. In 1828, the first known anti-euthanasia law in the United States was passed in the state of New York, with many other localities and states following suit over a period of several years. After the Civil War, voluntary euthanasia was promoted by advocates, including some doctors. Support peaked around the turn of the century in the US and then grew again in the 1930s.

In an article in the Bulletin of the History of Medicine, Brown University historian Jacob M. Appel documented extensive political debate over legislation to legalize physician-assisted suicide in both Iowa and Ohio in 1906. Appel indicates social activist Anna S. Hall was the driving force behind this movement. According to historian Ian Dowbiggin, leading public figures, including Clarence Darrow and Jack London, advocated for the legalization of euthanasia.

Euthanasia societies were formed in England in 1935 and in the USA in 1938 to promote euthanasia. Although euthanasia legislation did not pass in the USA or England, in 1937, doctor-assisted euthanasia was declared legal in Switzerland as long as the doctor ending the life had nothing to gain. During this same era, US courts tackled cases involving critically ill people who requested physician assistance in dying as well as “mercy killings”, such as by parents of their severely disabled children.

Post-War history
During the post-war period, prominent proponents of euthanasia included Glanville Williams (The Sanctity of Life and the Criminal Law) and clergyman Joseph Fletcher ("Morals and medicine"). By the 1960s, advocacy for a right-to-die approach to voluntary euthanasia increased.

Australia
In 1996, the world's first euthanasia legislation, the Rights of the Terminally Ill Act 1996, was passed in the Northern Territory of Australia. Four patients died under the Act, using a euthanasia device designed by Dr Philip Nitschke. The legislation was overturned by Australia’s Federal Parliament in 1997. In response to the overturning of the Act, Dr Nitschke founded EXIT International. In 2009, an Australian quadriplegic was granted the right to refuse sustenance and be allowed to die. The Supreme Court of Western Australia ruled that it was up to Christian Rossiter, aged 49, to decide if he was to continue to receive medical care (tube feeding) and that his carers had to abide by his wishes. Chief Justice Wayne Martin also stipulated that his carers, Brightwater Care, would not be held criminally responsible for following his instructions. Rossiter died on September 21, 2009 following a chest infection.

Europe
In 1957 in Britain, Judge Devlin ruled in the trial of Dr John Bodkin Adams that causing death through the administration of lethal drugs to a patient, if the intention is solely to alleviate pain, is not considered murder even if death is a potential or even likely outcome. In 1993, the Netherlands decriminalized doctor-assisted suicide, and in 2002, restrictions were loosened. During that year, physician-assisted suicide was approved in Belgium. Belgium's at the time most famous author Hugo Claus, suffering from Alzheimer's disease, was among those that asked for euthanasia. He died in March 2008, assisted by an Antwerp doctor.

United States
A key turning point in the debate over voluntary euthanasia (and physician assisted dying), at least in the United States, was the public furor over the case of Karen Ann Quinlan. The Quinlan case paved the way for legal protection of voluntary passive euthanasia. In 1977, California legalized living wills and other states soon followed suit.

In 1980 the Hemlock Society USA was founded in Santa Monica by Derek Humphry. It was the first group in America to provide information to the terminally ill in case they wanted a hastened death. Hemlock also campaigned and partially financed drives to reform the law. In 2003 Hemlock was merged with End of Life Choices, which changed its name to Compassion and Choices.

In 1990, Dr. Jack Kevorkian, a Michigan physician, became infamous for encouraging and assisting people in committing suicide which resulted in a Michigan law against the practice in 1992. Kevorkian was tried and convicted in 1999 for a murder displayed on television. Also in 1990, the Supreme Court approved the use of non-active euthanasia.

In 1994, Oregon voters approved the Death with Dignity Act, permitting doctors to assist terminal patients with six months or less to live to end their lives. The U.S. Supreme Court allowed such laws in 1997. The Bush administration failed in its attempt to use drug law to stop Oregon in 2001, in the case Gonzales v. Oregon. In 1999, non-active euthanasia was permitted in Texas.

Most recently, amid U.S. government roadblocks and controversy in the Terri Schiavo case, where a Floridian who was in a vegetative state since 1990, had her feeding tube removed in 2005. Her husband had won the right to take her off life support, which he claimed she would want but was difficult to confirm as she had no living will and the rest of her family claimed otherwise.

In November 2008, Washington Initiative 1000 made Washington the second U.S. state to legalize physician-assisted suicide.

China and Hong Kong
While active euthanasia remains illegal in China, it is gaining increasing acceptance among doctors and the general populace.

In Hong Kong, support for euthanasia among the general public is higher among those who put less importance on religious belief, those who are non-Christian, those who have higher family incomes, those who have more experience in taking care of terminally ill family members, and those who are older.

Arguments for and against voluntary euthanasia
Since World War II, the debate over euthanasia in Western countries has centered on voluntary euthanasia within regulated health care systems. In some cases, judicial decisions, legislation, and regulations have made voluntary euthanasia an explicit option for patients and their guardians. Proponents and critics of such voluntary euthanasia policies offer the following reasons for and against official voluntary euthanasia policies:

Reasons given for voluntary euthanasia

 * Choice: Proponents of voluntary euthanasia emphasize that choice is a fundamental principle for liberal democracies and free market systems.
 * Quality of Life: The pain and suffering a person feels during a disease, even with pain relievers, can be incomprehensible to a person who has not gone through it. Even without considering the physical pain, it is often difficult for patients to overcome the emotional pain of losing their independence.
 * Opinion of Witnesses: Those who witness others die are "particularly convinced" that the law should be changed to allow assisted death.
 * Economic costs and human resources: Today in many countries there is a shortage of hospital space. The energy of doctors and hospital beds could be used for people whose lives could be saved instead of continuing the life of those who want to die which increases the general quality of care and shortens hospital waiting lists. It is a burden to keep people alive past the point they can contribute to society, especially if the resources used could be spent on a curable ailment.

Reasons given against voluntary euthanasia

 * Professional role: Critics argue that voluntary euthanasia could unduly compromise the professional roles of health care employees, especially doctors. They point out that European physicians of previous centuries traditionally swore some variation of the Hippocratic Oath, which in its ancient form excluded euthanasia: "To please no one will I prescribe a deadly drug nor give advice which may cause his death.."  However, since the 1970s, this oath has largely fallen out of use.
 * Moral/Theological: Some people, including many Christians, consider euthanasia of some or all types to be morally unacceptable. This view usually treats euthanasia to be a type of murder and voluntary euthanasia as a type of suicide, the morality of which is the subject of active debate.
 * Necessity: If there is some reason to believe the cause of a patient's illness or suffering is or will soon be curable, the correct action is sometimes considered to attempt to bring about a cure or engage in palliative care.
 * Feasibility of implementation: Euthanasia can only be considered "voluntary" if a patient is mentally competent to make the decision, i.e., has a rational understanding of options and consequences. Competence can be difficult to determine or even define.
 * Consent under pressure: Given the economic grounds for voluntary euthanasia, critics of voluntary euthanasia are concerned that patients may experience psychological pressure to consent to voluntary euthanasia rather than be a financial burden on their families. Even where health costs are mostly covered by public money, as in various European countries, voluntary euthanasia critics are concerned that hospital personnel would have an economic incentive to advise or pressure people toward euthanasia consent.

Slippery Slope
It has been claimed that permitting voluntary euthanasia to occur will lead to the support and legalization of non-voluntary and involuntary euthanasia, as a slippery slope. Although studies of the Netherlands after the introduction of voluntary euthanasia found that there was no evidence to support this claim, the introduction of legal non-voluntary euthanasia into the Netherlands in the form of the Groningen Protocol has led to renewed debate. The Groningen Protocol has been identified by some as having the "potential to validate the slippery-slope argument against allowing euthanasia in selected populations", and in examining the Netherlands situation, some researchers have claimed that the protocol is evidence that the slippery slope exists. For example, William Lanier points to the Groningen Protocol as evidence that a slippery slope is "playing out in real time", while Ola Didrik Saugstad warns neonatologists against taking a path down the slope which will end in the Dutch practice. Countering this view, others have argued that there is a lack of evidence upon which to form a determination, and it has been argued that the public nature of the decisions and their evaluation by a prosecutor prevent a "slippery slope" from occurring – although effectiveness of these legal restrictions has been brought into question, as it has been argued that the Netherlands have seen the gradual introduction of more lax legal restrictions since euthanasia was first legalized and there are still a significant percentage of cases of euthanasia practiced illegally ergo violating even the current legal permissions.

The mechanisms under slippery slope are discussed in literature. For example, The Mechanism of slippery slope in Harvard Law Review shows the judicial logic that could eventually lead to gradually break the legal restrictions for euthanasia.

Euthanasia opponent Ian Dowbiggin linked the Nazi's Euthanasia Program - Action T4 to the resistance in the West to involuntary euthanasia. He believes that the revulsion inspired by the Nazis led to some of the early advocates of euthanasia in all its forms in the U.S. and U.K. removing non-voluntary euthanasia from their proposed platforms.

Medical Ethics on Euthanasia
Euthanasia brings about many ethical issues regarding a patient’s death. Some physicians say euthanasia is a rational choice for competent patients to choose to die to escape unbearable suffering. Others feel that aiding in the patient’s death goes against a physician’s duty to preserve life.

For voluntary euthanasia In America
Physicians who are in favor of euthanasia state that to keep euthanasia or physician-assisted suicide (PAS) illegal is a violation of patient freedoms. They believe that any competent terminally-ill patient should have the right to choose death or refuse life-saving treatment. The U.S. Constitution does not state that the government can keep a person from committing suicide and if PAS was a right, patients could die with dignity and leave others with a positive memory and not what they had become. Suicide and assistance from their physician is seen as the only option those patients have. By allowing PAS and euthanasia, the patient can say their final goodbyes to their loved ones and leave the world by choice. With the suffering and the knowledge from the doctor, this may also suggest that PAS is a humane answer to the excruciating pain.

Not only will PAS and euthanasia help with psychological suffering and give autonomy to the patient, PAS can help reduce health care costs and free up doctors and nurses. By keeping a terminally-ill patient alive, the patient must pay for any medical necessary procedures. These procedures can include x-rays, prescribed drugs, or any lab tests that needs to be performed. All of these procedures can run up a medical costs ranging from $50,000 to $100,000. Since the bills will continue to come for the patient, they will lose more of the money they would want to leave behind for their family. If the patient wants to end the suffering, the reason for racking up the bills and keeping the patient alive are lacking (13). Also, the costly treatment to keep the terminally-ill patient alive from medical funding cannot be used for other types of care, like prenatal, where it would save lives and improve long-term quality of life. Along with reduced health care costs, more doctors and nurses could be freed up. A shortage of medical staff is a critical problem hospitals face and studies have found that understaffed hospitals make many mistakes and provide less quality care. Attending to terminally-ill patients, who would rather die, is not the best use of the medical staff. If PAS and euthanasia were legalized, more staff would have time to care for others and there would be an increase in the quality of care administered.

Physician-assisted suicide and euthanasia can lower health care costs, free up doctors and nurses, and give back the right to the patient to practice autonomy. By keeping PAS and euthanasia illegal, each terminally-ill patient is being discriminated against because they are not able put this option into action. Those patients because of their disability do not have the same right as any other person in the United States.

Against voluntary euthanasia
Many physicians and medical staff have numerous reasons for prohibiting the legalization of PAS and euthanasia. A main reason against PAS is the violation of the Hippocratic oath that some doctors take. The Hippocratic oath states “I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan,”. By being a part of PAS and prescribing a lethal dosage of a drug could weaken the doctor-patient relationship because of the oath some doctors take (13).

Another reason for prohibiting PAS and euthanasia is the option of abusing PAS if it were to become legal. Poor or uninsured patients may not have the money or no access to proper care will have limited options, and they could be pressured towards assisted death. For emotionally and physiologically disturbed patients, they could abuse the PAS option and those patients could convince their doctor to help end their life. By keeping PAS and euthanasia illegal, doctors have opportunity to right their wrong diagnoses and prevent leaning towards suicide of a redeemable person (13), there are cases where patients who are not terminally ill are mistakenly admitted into hospices and such patients could become subject to euthanasia. By having more time with the terminally-ill patient, the doctor is giving them constant care and medical attention. Many people believe that the unbearable pain can be controlled to tolerable levels if given proper care from the hospital staff.

Voluntary euthanasia and the Law
During the 20th Century, efforts to change government policies on euthanasia have met limited success in Western countries. Country policies are described here in alphabetical order, followed by the exceptional case of the Netherlands. Euthanasia policies have also been developed by a variety of NGOs, most notably medical associations and advocacy organizations.

Voluntary euthanasia and religion
There are many different religious views among on the issue of voluntary euthanasia, although many moral theologians are critical of the procedure.

Euthanasia protocols
Euthanasia can be accomplished either through an oral, intravenous, or intramuscular administration of drugs, or by oxygen deprivation (anoxia), as in some euthanasia machines. In individuals who are incapable of swallowing lethal doses of medication, an intravenous route is preferred. The following is a Dutch protocol for parenteral (intravenous) administration to obtain euthanasia:

Intravenous administration is the most reliable and rapid way to accomplish euthanasia. A coma is first induced by intravenous administration of 20 mg/kg sodium thiopental (Nesdonal) in a small volume (10 ml physiological saline). Then a triple intravenous dose of a non-depolarizing neuromuscular muscle relaxant is given, such as 20 mg pancuronium bromide (Pavulon) or 20 mg vecuronium bromide (Norcuron). The muscle relaxant should preferably be given intravenously, in order to ensure optimal availability. Only for pancuronium bromide (Pavulon) are there substantial indications that the agent may also be given intramuscularly in a dosage of 40 mg.

With regards to voluntary euthanasia, many people argue that 'equal access' should apply to access to suicide as well, so therefore disabled people who cannot kill themselves should have access to voluntary euthanasia.

Literature
Apart from The Old Law, a 17th century tragicomedy written by Thomas Middleton, William Rowley, and Philip Massinger, one of the early books to deal with euthanasia in a fictional context is Anthony Trollope's 1882 dystopian novel, The Fixed Period. Ricarda Huch's novel The Deruga Case (1917) is about a physician who is acquitted after performing euthanasia on his dying ex-wife.

'Quality of Mercy' in The Prosecution Rests is a fable exploring the facets of aging, Alzheimer's disease, and euthanasia. The story line makes no judgment but frees the reader to decide.

In the book The Giver, euthanasia is used as a form of punishment.

Film
The films Children of Men and Soylent Green depict instances of government-sponsored euthanasia in order to strengthen their dystopian themes. The protagonist of the film Johnny Got His Gun is a brutally mutilated war veteran whose request for euthanasia furthers the work's anti-war message. The recent films Mar Adentro and Million Dollar Baby argue more directly in favor of euthanasia by illustrating the suffering of their protagonists. These films have provoked debate and controversy in their home countries of Spain and the United States respectively.

Media
In March 2010, the PBS FRONTLINE TV program in the United States showed a documentary called "The Suicide Tourist" which told the story of Professor Craig Ewert, his family, and the Swiss group Dignitas, and their decision to commit assisted suicide in Switzerland after he was diagnosed and suffering with ALS (Lou Gehrig's Disease).

Music
Thrash metal band Megadeth's 1994 album Youthanasia (the title is a pun on euthanasia) implies that society is euthanizing its youth.