The literal meaning of euthanasia is “good death,” but in current world culture, euthanasia is being promoted as a means to quickly end the life of someone who is deemed to be ill, suffering, or whose life has lost value according to others.
Euthanasia by action directly and intentionally causes a person's death and is usually carried out by a physician who either injects a lethal drug into a patient or withdraws or denies treatment from a patient. With an injection, the patient dies from the foreign substance rather than the underlying disease. Euthanasia by action is considered a homicide and is currently illegal in all of the American states. Active euthanasia is legal only in the Netherlands.
Euthanasia by omission intentionally causes a person's death by withholding or withdrawing medical treatment, including but not limited to nutrition and hydration (food and fluids). Without basic nourishment and treatment, death by starvation is imminent, rather than death from the underlying disease.1
Although there is no clear legal standard that applies to denial or withdrawal of treatment (since many courts have reached different conclusions), there are clear moral standards, particularly in regard to incompetent patients. Actions of the courts have led to mass confusion and ambiguity about appropriate courses of action, and now some states require “clear and convincing evidence,” such as a legal document or directive signed by a patient when competent, before treatment can be withheld or withdrawn while other states simply leave the decision to the health care professionals. The conflicts and lawsuits arise when the doctors and patients or families of the patients disagree on the course of action – usually when the family is requesting that the patient continue receiving treatment.
Each situation is unique in that what is good or tolerated by one patient may not be beneficial for another. The wishes of the patient and/or family in these situations should be respected. Treatment that could be withheld or withdrawn can vary from something as minimal as antibiotics or maintenance medications to more complicated treatments such as use of a ventilator, kidney dialysis, major surgery, or transplants. If the patient dies a natural death from the underlying disease, withholding or withdrawing of life-support systems should not automatically be considered as acts of euthanasia or physician-assisted suicide.
What is assisted suicide?
Assisted suicide occurs when someone provides an individual with the information, guidance, and means to take his or her own life with the intention that these tools and information will be used for the commission of suicide.
Physician-Assisted Suicide (PAS) occurs when a licensed physician provides the means for someone to kill himself through the use of legally prescribed drugs and instructs the person on how to use them. (Physicians may also speed a patient to his death by denying or withdrawing life-saving treatment; however, this is considered euthanasia by omission, not physician-assisted suicide, even though the physician is involved in the denial or withdrawal of treatment.)
PAS is now legal in the state of Oregon and the Netherlands. PAS is outlawed in most, but not all, of the remaining United States. In the past ten years, referenda ballot questions to legalize physician-assisted suicide have been defeated in the states of California , Washington , Michigan , and Maine .
Why be concerned with euthanasia? Why is it currently a high-profile issue?
Euthanasia and assisted suicide involve many complex issues of illness and medical treatment: perceived patient suffering; the patient's physical state and medical needs; and social, emotional, and psychological issues. In addition, there is a need to understand that euthanasia cannot be controlled, even with “safeguards,” once it has been accepted.
Dr. Jack Willke, in his book, Assisted Suicide and Euthanasia, refers to the “mark down” price on human life. Euthanasia assigns a value to a human life and determines whether or not that life is worth saving. The value of that price tag continues to diminish, accelerating the downward slide on the slippery slope of euthanasia. Abortion opened the door to the “markdown” mentality by allowing only one exception for an abortion, then another, and another until we finally reached abortion on demand for the full nine months of pregnancy in the United States. The acceptance of wholesale killing of the unborn based on situation and convenience fueled the resolve and rhetoric of the euthanasia proponents, who began to say, “People should have the right to die with dignity. Prolonging their lives only increases their pain and suffering, and creates hardship for families.” The “mark down” mentality that Dr. Willke refers to has now been placed on those who are older, ill, or have disabilities. Thus, the very lives of more of the most vulnerable individuals are in danger. Those who are the targets of euthanasia are not those in severe pain or with tubes attached to their bodies. They are everyday people who have just grown old or fallen ill and cannot eat or swallow on their own or care for themselves autonomously. They have a prolonged illness or a trauma that has left them unable to respond, yet they are fully capable of partial or complete recovery.
Some suggest those with illness would be better off dead to avoid suffering pain, fear, depression, and other medical conditions and inconveniences. When their pain is appropriately managed, patients will become less depressed, more responsive to treatments, and feel hopeful. The will to live then becomes more powerful than the wish to die.
Ann Humphry, deceased second wife of Derek Humphry and cofounder of the Hemlock Society, recognized this shortly before her death in 1991. Diagnosed with breast cancer, she told the American Medical News that “she had misgivings about the right to die movement, and that not enough emphasis was given to providing a supportive environment to those with life-threatening illness.” 2
Herbert Hendin, in Seduced by Death, makes a similar observation when he states, “Most of us have seen times when it may seem right for a doctor to help a terminally ill person die. Partly because of such experiences, when people are asked, 'Are you in favor of euthanasia?' most reply that they are, meaning little more than that they would rather die painlessly than painfully. When people are asked, 'If terminally ill, would you rather be given treatment to make you comfortable or have your life ended by a physician?' their responses are different.” 3
Why is voluntary euthanasia dangerous?
Supporters of euthanasia argue that the right of the individual to make medical treatment decisions should include the right to request active euthanasia or to be assisted with suicide. However, voluntary euthanasia should be rejected for these reasons:
|Misdiagnoses occur and will mislead patients into making irreversible decisions.|
|A request for assisted suicide is typically a cry for help. Counseling, assistance, positive alternatives, and symptom management are better solutions for very real problems.|
|Suicidal intent is typically transient. Of those who attempt suicide but are stopped, less than 4% go on to kill themselves in the next five years; less than 11% will commit suicide over the next 35 years. 4|
|Terminally ill patients who desire death are depressed, and depression is treatable. In one study, of the 24% of terminally ill patients who desired death, all had clinical depression. 5|
|Pain is controllable. Modern medicine offers the ability to control pain. A person who seeks to kill himself to avoid pain does not need legalized assisted suicide but a doctor better trained in palliative care techniques.|
|Society's endorsement of euthanasia will “teach” the weak and frail to feel they have a “duty” to die. As support systems collapse, vulnerable people will feel pressured to choose death.|
|In the U.S. , legalizing voluntary euthanasia by action means legalizing non-voluntary euthanasia. State courts have ruled time and again that if competent people have a right, the Equal Protection Clause of the United States Constitution's Fourteenth Amendment requires that incompetent people be “given” the same “right.”|
|Hospitals and insurance companies realize that killing is cheaper than providing treatment, especially long term treatment, placing more pressure on patients to choose death.|
|Problems are never solved by eliminating the people to whom the problems happen. The more difficult but humane response to human suffering is to address the problems with compassion and solutions.|
How does non-voluntary euthanasia happen?
Those who are competent are currently able to decide whether they want to accept or refuse food, fluids, or medical treatment.
As a matter of law, courts in almost every state have ruled that a competent individual has a right to refuse life-support systems and even food and water. The courts have further established that if competent individuals have a right to reject medical treatment or food and water, the same right can be exercised “on behalf of” an incompetent individual by a court or guardian deciding in the best interest of the patient.
To achieve this, courts have appointed third parties to make these decisions, called “substituted judgments” or guardians ad litem, for the incompetent person. The third party can be a loved one or even a stranger appointed by the court. This person is assigned the duty to review care records and ensure that all necessary treatments are ordered and provided. However, if that third party is also a relative who stands to inherit or benefit from the death of the person, an immediate conflict of interest may arise.
The third party may decide to hasten the death of the individual by deciding that death is a better solution, to end “suffering, pain, or discomfort,” even though the patient would disagree but cannot speak for himself. To make this non-voluntary right to die even more terrifying, death advocates are trying to redefine basic food and water as extraordinary “medical treatments.” Without basic sustenance, all of us would die, but those who cannot care or speak for themselves are especially vulnerable.
If euthanasia were to be legalized only for those who request such drastic action, such a precedent would inevitably be extended to incompetent persons who have not requested death. The courts need only take their previous rulings to allow “substituted judgments” by a third party to refuse medical treatment and extend this “right” to the incompetent person to be euthanized.
When is a person brain dead rather than brain damaged?
The term “brain death” is often used to describe patients perceived as being in a persistent vegetative state (PVS) or who have experienced severe brain impairment (usually from trauma or stroke). PVS describes a condition in which a person exhibits no recognizable psychological adaptive responses to the environment.6 A person in a PVS state experiences wake and sleep cycles and is not terminally ill. A patient in this condition is often erroneously called comatose and frequently prematurely diagnosed as “brain dead.”
Even though the term is widely used, there is no universal agreement within the international medical community as to the criteria to pronounce a person as brain dead. Tests measure some of the following in assessing the condition of the brain:
|Spontaneous response to outside stimulus|
|Oxygen flow to the brain|
|Brain stem activity|
However, the degrees to which some of these are present vary with each patient. Therefore, one can never confidently ascertain that all brain activity has ceased. “Brain death” is not a precise term and should not be used; rather, “PVS with qualifications” of the patient's condition is a more helpful approach and accurate diagnosis for a patient with impaired (even acutely impaired) brain function.
With brain damage, brain waves can still be detected, response to outside stimulus occurs, and the brain stem continues functioning to control heart rate, breathing, and other spontaneous functions. These functions could be assisted by mechanical devices, but the patient is very much alive as indicated by circulatory, respiratory, brain, or brain stem activity.
How should I approach my physician about euthanasia?
The best time to approach your physician is now, i.e., when you are not experiencing a critical or terminal illness. If you are currently struggling with a life-threatening condition, NOW is also the time for you to discuss your wishes with your doctors and family. Choose a time when dialogue can occur freely without pressure to make some type of decision. Call or write your physician in advance and inform him that you want to make an appointment to discuss your preferences for treatment, your views on assisted suicide, active euthanasia, and the withholding or withdrawing of nutrition and hydration. Such a call or letter affords your physician an opportunity to prepare for your visit, anticipate questions and responses, and allocate ample time to discuss these delicate matters with you. Bring a notepad so that you can record his responses, input, and suggestions.
Consider discussing specific end of life issues and treatment philosophy with him. Be sure to distinguish between whether the patient is terminally ill and in the final stages of dying, or if the patient is not terminally ill, but merely has some type of physical or mental disability. Depending on your conversation with him, you may inform him that you will be soon crafting a Pro-Life advance directive or Pro-Life will to live that outlines your treatment preferences should you need acute or long term care in an incapacitated state.
What questions should I ask in life-or-death situations involving a loved one's treatment?
Your mother has a stroke and is rushed to the hospital. You receive a call from the hospital emergency room that your daughter has been critically injured in an accident. Your infant son is born with a life-threatening condition. Your husband suddenly collapses from a heart attack.
These are critical health care situations which, unfortunately, thrust us into making decisions for which we are ill-prepared. To complicate matters, medical terms with which we are not familiar, communicated to us by “specialists” who are strangers, suddenly need to be mastered. At a time when we are in shock, worried, frightened, and vulnerable, we are asked to make decisions that may determine whether a loved one will live or die. Ask every single question that comes into your head and record the answer and the name of the person who gave you the answer. If you do not receive a clear answer from one health care professional, ask another one the same question. Persist until you understand exactly what is happening with your loved one. Knowledge is power during a crisis, and you must gather as much information about your loved one's condition as you can in order to make life-preserving treatment decisions.
Those faced with critical health care decisions for a loved one need the information necessary to determine whether a suggested course of treatment is one that aligns with your Pro-Life views. The following information is intended to familiarize you with some of the issues. If you are faced with such a situation, please call our office for more direct assistance.
Is the patient terminally ill?
If yes, is he expected to die within hours or within days? If death is truly expected within hours or a few days and will occur regardless of whether or not treatment is rendered, one is not morally obligated to use aggressive measures to treat the patient. However, one can still request and expect such measures, but the hospital will usually be resistant to doing so. At a minimum for a terminally ill patient, food, hydration, and pain management must be administered until his bodily systems can no longer process these. Transplants, surgeries, and other major medical procedures are not required morally, but infections, wounds, and other symptoms should be treated.
Is the patient competent or incompetent? Does the patient have the ability to understand his illness/condition and to discuss treatment options?
If the patient is competent, he should be making his own treatment decisions with the input of his family. Family members should be alert to feelings of depression or hopelessness on the part of the patient, and encourage decisions to employ treatment and care. Any competent patient can also refuse treatment against the wishes of his family.
If the patient is incompetent or incapacitated, consideration should be given to any statements or documents the patient has made or signed. These wishes should be respected as long as the family or medical professionals are not morally compromised. If wishes are not known, then the family must be vigilant in watching over the patient's care. Hospitals and health care facilities often make their own decisions regarding the prognosis and treatment of a patient if the family appears confused or disinterested in the care of the patient whose wishes were not made clear before incapacitation. The family must present a unified front to the hospital and doctors, signifying unwavering agreement on the course of action to preserve the life of their loved one.
Should the patient be resuscitated?
Sometimes a patient or a patient's family will be asked to sign a “do not resuscitate” or “no code” order. If such a document is signed, no efforts will be made to restart a patient should his heart stop beating or beat erratically. NEVER sign a DNR order without first consulting with Texas Right to Life or a Pro-Life health care professional, especially if the health care facility is pressuring you to sign an order. These institutions cannot force you to sign a DNR order. Many times DNR orders are construed as license to withdraw and/or stop treatment.
DNR orders may be appropriate when a patient has an end-stage disease and is not expected to live more than a few hours or days. The restoration of heart function at this point does not restore life for any length of time because the patient is expected to die from the underlying disease. If a DNR order is signed, the signing should be completed after careful and deliberate consideration away from the health care facility and free from pressure.
Should the patient receive food and fluids?
Withdrawal of food and fluids speeds a person to his death, and a person usually dies a painful death of starvation within 12-14 days. In rare instances when a patient is within minutes to hours of his death, processing or digesting food and fluids may overtax the already failing bodily organs. In these cases, food and fluids may be removed or withheld since providing them is causing more harm than benefit to the patient. In other situations, if the patient is brain damaged, is not in imminent danger of death, or is unconscious, the removal of food and fluids will cause the patient to die of starvation and dehydration and is properly considered murder.
What if the patient has expressed a desire not to be kept alive on “machines”?
If the patient is competent, great care should be taken to understand specifically how the patient wishes to be treated. A general statement regarding “machines” should not be taken to mean specific treatments should be withheld or withdrawn. People in good health often make such casual statements. When they are later in a situation where machines could improve or restore their health, they welcome such therapies. If there is a written advance directive or Will-to-Live, then the wishes and treatment preferences expressed therein should be honored.
Should I sign a “Will-to-Live” document?
There is growing evidence that those who do not provide clear directions concerning their treatment preferences are more likely to be denied treatment than to receive appropriate care. Therefore, you must make your views known in some form of advance directive prior to becoming ill or incapacitated.
Two common advance directives are Pro-Life Wills-to-Live and health care powers of attorney. Wills-to-Live outline the desire for life saving medical treatment under certain medical conditions. Health care powers of attorney authorize a specified person to make decisions concerning the provision or withholding of life-sustaining measures when the signer is incompetent . The Will-to-Live is the Pro-Life advance directive document and not to be confused with the more common document known as the Living Will. The Living Will simply focuses on rejection of treatment methods as compared to the Will-to-Live that emphasizes a desire to receive proper care.
National Right to Life has developed the alternative, life-affirming Will-to-Live. This document presumes that food, fluids, and life-saving medical treatment are to be provided. However, the signer can also specify conditions under which this presumption does not fully apply, such as when death is imminent or when the signer is in the final stages of terminal illness. Suggestions are given for ways to list one's end-of-life directives with precision and detail.
The above questions were not designed to answer all of your questions, since the listing of all of the critical health care situations that might arise is impossible. These questions and issues are meant to stimulate questions you should ask in order to understand the implications of decisions in which you participate, particularly at a time when you feel overwhelmed and helpless. Treatment decisions are always complex, yet if you have asked some probing questions and gathered substantial information, you will be making a more informed decision.
NEVER let anyone rush or pressure you into a decision, especially a doctor or employee of a hospital or health care facility. Seek a second, and even a third, opinion if you are not satisfied. If you decide to remove life support systems, and your loved one dies, there is NO reversal of that decision.
- In rare circumstances when the provision of food and fluids will actually harm the patient because digestion or processing the food and fluids overtaxes the bodily organs (which by then are collapsing), there is no moral duty to continue administering food and fluids. A patient usually does not reach this point until he is within minutes to hours of death, and prematurely denying or withdrawing nourishment will speed the patient to his death.
- Death as a Salesman, Brian P. Johnston, p. 11, New Regency Publishing, 1997, Sacramento , CA .
- Seduced by Death, Herbert Hendin, M.D., p. 23, W.W. Norton & Company, 1998, New York , NY .
- Suicide Factsheets, NRLC Dept. of Medical Ethics, 419 7th Street NW , Washington , DC 20004 .
- Suicide Factsheets, NRLC Dept. of Medical Ethics, 419 7th Street NW , Washington , DC 20004 .
- Again as with brain death, there will be varying determinations of recognizable psychological adaptive responses to the environment. One doctor may consider blinking or turning one's head to follow the voice of a loved one as a recognizable response while other doctors may require different or additional responses to stimuli (such as a reaction when a foot is tickled). There are varying standards of what constitutes recognizable responses when applying the diagnosis of PVS.
Dest: Wisconsin Right to Life, www.WRTL.org