Is it historically possible
for a consensus to be reached
on the subject of Euthanasia, voluntary or otherwise?
Andrew N. Papanikitas BSc (Hons), DHMSA
Classically euthanasia is defined as a good death from the Greek eu and thanatos. Whether the modern usage of the word euthanasia (to intentionally shorten somebodys life though action or inaction on the premise that it is for their good) is a euphemism is the subject of heated debate. Certainly the modern connotation is said to have arisen between in the period of 1870-1890.
The Oxford text book of palliative medicine breaks down euthanasia into several categories. Euthanasia is voluntary or imposed, depending on whether or not it is requested or agreed to by the patient. Imposed euthanasia falls into two categories: Involuntary, where the patient is able to agree but does not, and non-voluntary, in which the agreement of the patient cannot be obtained because of their physical or mental state. Euthanasia may also be classified according to how it may be administered. Active euthanasia involves a direct lethal intervention by a person other than the patient. Passive euthanasia involves the cessation or absence of treatment, in order that death might be hastened. Physician assisted suicide or doctor assisted dying are specified forms of voluntary active euthanasia carried out by members of the medical profession.
The moral acceptability of acts relating to life and death are influenced in any culture by moral and social factors. Active euthanasia is philosophically associated with suicide. Value of life is balanced against the good of the community. The modern ideal of euthanasia involves a patient in extreme pain or anguish which is symptomatic of an incurable and terminal disease. The arguments for this include: extreme (very likely intractable) pain, a terminal condition, incurable disability and the attendant sense of hopelessness. The basic arguments against the practise involve: possible misdiagnosis, the hope of constantly developing medical science, the patient may be mad or just depressed, and the slippery slope to involuntary euthanasia and practise on patients with transient conditions. There also religious and moral objections, and the idea that the healer should not intentionally act as executioner.
I will use my power to the best of my ability and judgement; I will abstain from harming or wronging any man by it. I will not give a fatal draught to anyone if I am asked, nor will I suggest any such thing... Whenever I go into a house I will go to help the sick and never with the thought of doing harm or injury. (from the Hippocratic Oath)
Edelstein claims that the relevant passage in the Hippocratic oath refers to suicide, not euthanasia, and that no evidence that it refers to anyone except the patient and the doctor, or learned medicine man. The desperately sick wished to know if medical treatment would help them in any way, and this extension of the diagnosis fell to the physician. The patient, friends or relatives would consult with the physician, who on confirming a poor prognosis directly or indirectly suggested suicide. Both suicide and infanticide were condoned in antiquity, and the physician was most likely the source of the poison a patient would use to end his own life. However, suicide did not always follow when human agency failed. The healing-sanctuaries of classical antiquity were popular with the critically ill, and some people just tolerated their pain and continued with life, though this was not as popular with the Romans. Of the Greeks, Pythagoras and his school opposed euthanasia and suicide unconditionally based on a sanctity of life argument. Plato attempted to moderate the idea that life must never be prematurely curtailed. In the Phaedo, Plato opposes assisted suicide on religious grounds. In his Republic (and to an extent in The Laws), he advocates the voluntary euthanasia of the disabled and incurables, as well as involuntary infanticide for defective new-borns, on utilitarian eugenic principles. Aristotles opposition to suicide appears unconditional, on the grounds that it violates a public duty. Like Plato, he holds cowardly self-murder to be reprehensible, and praises death in combat -defending a city for example. Aristotles arguments are irreligious, but based on civic responsibility, so it is no surprise that he favours infanticide in Platonic fashion. Seneca bases his support for assisted suicide on the premise of human autonomy, but gives antecedent conditions. The subject must be suffering chronically or incurably, and must weigh the pros and cons to ensure that the act is not an ill-timed flight from lifes duties. The philosophers of ancient Greece and Rome were in their personal ideologies as far from consensus as the worlds doctors are today. Attitudes around the ancient world were as different as the cultures that existed. Mesopotamian law forbade assisted suicide. In ancient Israel frankincense was allegedly used as a suicide drug. In India the incurable sick were thrown into the river Ganges to drown.
Care of the Dying from the Middle ages to the Enlightenment
Suicide of the sick is unusual in the West after about 2 AD, which Fye attributes to a change in philosophy and the sacredness of life in Judaeo-Christian teachings. There was, however, a Jewish ambivalence to the sanctity of life. Suicide was possibly condoned in the face of apostasis under torture, in penitential or altruistic circumstances, and to avoid death under torture. Over the centuries, writers such as John Donne have remarked that the New Testament of the Bible never is explicit in condemnation of suicide. Life and suffering is sanctified in the face of easy death, with the exception of virgins committing suicide to avoid sexual defilement, which is condoned. St. Augustine is the first author to challenge the sainthood of the suicidal virgins, on the grounds that it opposes the sixth commandment, namely murder. Endurance is extolled as a virtue. Conversely, the question as to whether medicine could ever prolong life was heavily disputed in the medical schools of Palermo, Fez, and even Paris. Many Arab and Jewish doctors denied this power outright, and declared such an attempt to interfere with the order as blasphemous.
Illich attributes the disappearance of the sacredness attached to the body in the middle ages to the advent of dissection and clinical science. The first dissections from 1375 onwards were initially declared obscene, and over the next several centuries were the subject of much controversy.
In his Utopia of 1516, Sir Thomas More discusses assisted suicide: "...if a disease is not only distressing but also agonising without cessation, then the priests and public officials exhort this man...to free himself from this bitter life...or else to permit others to free him..."
He does not discuss the physicians role, but proposes assisted suicide on an ad hoc basis, when sanctioned by a priest. Around 1606-1608 John Donne wrote Biothanatos in defence of the morality of suicide against St Thomas Aquinas assertion that it violated the law of nature, of the community, and of God. Donne argues that some people naturally desire to die, that suicides would be justified if the intention of the act were not self-promoting, and that no scriptural evidence backs Aquinas claim. In On Suicide, David Hume appeals to human autonomy, and some possible benefits of induced death, whereas Immanuel Kant (held by many to be the defender of autonomy) uses suicide as an example of a wrongful act. In Suicide and Euthanasia Brody explains that this is because Kantian autonomy is placed within a framework of universally valid moral principles. Illich talks of dignified death in the seventeenth century, involving a superstitious separation of the critically ill from the dying, in whom medical intervention or involvement was avoided. Remedies against pain multiplied under the direction of the conscious dying person, who could even indicate when they wished to be lowered, from the bed to the earth... and when the prayers were to start. The physician, was not expected at the death-bed but, when present, could perform two opposite functions: To assist healing, or to hasten an easy and speedy death. However, he had a duty to recognise that the patient was already dying before withdrawing.
Francis Bacon was the first to discuss prolongation of life as a new medical task, the third of three offices: Preservation of health, cure of disease, and prolongation of life. Bacon also asserts that, They ought to acquire the skill and bestow the attention whereby the dying may pass more easily and quietly out of life. Bacon refers to this as outward euthanasia, or the easy dying of the body, as opposed to the preparation of the soul.
The bourgeoisie who could afford to eliminate social death by avoiding retirement created childhood to keep their young under control, and in the eighteenth century a new myth about the value of the old developed. Primitive hunters, gatherers and nomads had usually killed them... now the Patriarch appeared as a literary ideal.
The Nineteenth Century
It is generally regarded that the medical profession overtook the theological monopoly on death in the nineteenth century. The first half of that century saw the improving sophistication of diagnosis and prognosis, and the growing body of scientifically derived information on which these could be based. Only patients accurately diagnosed as incurable might feasible propose active euthanasia in the modern usage of the term. Until the end of the nineteenth century euthanasia was regarded as a peaceful death, and the art of its accomplishment. An oft quoted nineteenth century document is, De euthanasia medica prolusio, the inaugural professorial lecture of Carl F.H.Marx, a medical graduate of Jena. It is mans lot to die states Marx. He argues that death either occurs as a sudden accident or in stages, with mental incapacity preceding the physical. Philosophy and religion may offer information and comfort, but the Physician is the best judge of the patients ailment, and administers alleviation of pain where cure is impossible. To Marx it is the priest and not the physician who is the quasi-harbinger of death. The physician is associated in the patients eyes with hope and relief, and may take the role of counsellor, even to the point where he reassures the patients religious beliefs. Depending on their character, he argues, patients will or will not accept death, and struggle or passively succumb. In his view babies born with congenital difficulties, or with acquired disease should be treated no differently, despite their inability to articulate their anguish.
Marx does not feel that that his form of euthanasia, which refers to palliative medicine without homicidal intention, was an issue until the nineteenth century. The concept of palliation does not occur to most physicians, he complains, who lose interest when they lose hope of a medical cure. His noble concept involves three methods: Firstly the alleviation of the symptoms with medical guidance and foresight, next the avoidance or removal of anything which cause the patient pain or distress, and thirdly the cheering of the patient with gracious and convincing comfort. All this must involve the people and things of most importance to the patient. Marx advocates stress-free, competent, and peaceful environment, and discusses the siting of rooms, their ventilation, and the best type of bed and care. He discusses treatment of side-effects of long-term critical illness, such as bed sores and acknowledges that there are some patients who cannot and some who will not, communicate their distress. Patients are warned of heroic surgical treatment on the grounds that it is hazardous even with experts, and recommended to symptomatic and palliative indication. Analgesics had been in use for over a thousand years, but a key innovation of the nineteenth century was the isolation of morphine by Serturner in 1816. The hypodermic syringe pioneered by Pravaz and Wood in the 1850s assured a rapid route and accuracy of dose. Consequently Marx advocates the use of various narcotics as sedatives, soporifics, antidepressants, and antispasmodics, dependent upon the patient and the condition. Just like his British contemporaries, he was quick to warn that these drugs might be hazardous. Marxs intention is to relieve symptoms, and the doctor is discouraged from giving any treatment which is unnecessarily burdensome to the patient, either by physic or surgery.
Now when at first inspection death has apparently arrived, as shown by the cooling off of the body, cessation of respiration and the heart beat. The duty towards the diseased is not yet fulfilled. Instances are known where individuals at that stage, after all cessation of motor function, have perceived over a number of hours everything which took place around them. Marx then goes to extremes, waiting for rigor mortis before pronouncing somebody dead.
He concludes: When the Physician has become adept at this art in medicine, he may be in good and cheerful mood he may in some day expect a like service from others. To the best of his ability he has undertaken to perform euthanasia, athanasia he is unable to give.
The prevailing social conditions of the latter nineteenth century began to favour active euthanasia. Darwins work and related theories of evolution had challenged theology. The use of anaesthesia in childbirth was opposed by many clergy, who faced ridicule when Queen Victoria took the option. Consequently, one argument against the removal of the dying process, the sanctity of life, became less of a hindrance. The first popular advocate of active euthanasia in the nineteenth century, was not a physician, but a schoolmaster. In 1870 Samuel Williams wrote the first paper to deal with the concept of medicalised euthanasia.
"In all cases it should be the duty of the medical attendant, whenever so desired by the patient, to administer chloroform, or any other such anaesthetics as may by and by supersede chloroform, so as to destroy consciousness at once, and put the suffer at once to a quick and painless death; precautions being adopted to prevent any possible abuse of such duty; and means being taken to establish beyond any possibility of doubt or question, that the remedy was applied at the express wish of the patient."
Though the paper was reprinted many times, it was seemingly ignored by the British medical profession, and in 1873 Lionel Tollemache took up his arguments in the Fortnightly Review. Writing under the clear influence of utilitarianism and social Darwinism, he describes the incurable sick as a useless to society and burdensome to the healthy. At the time, his views were simply dismissed as revolutionary. However, similar views were emerging with the new science of eugenics, as ideas of sterilising the mentally ill, those with hereditary disorders, and the disabled, became fashionable. In 1889 Nietche bemoaned the burden of the incurable on society, but the most infamous and renowned case of mass involuntary euthanasia did not take place until the Nazi domination of Germany.
Euthanasia in Nazi Europe
According to Adolf Hitlers speech in August 1929, if Germany got one million children and removed seven hundred to eight hundred thousand of the weakest people, there would be an increase in the strength of the nation. In July 1937 a law was passed to sterilise those with hereditary conditions, which at the time included feeblemindedness and alcoholism. The Euthanasia programme, Aktion T4, commenced in 1939 with the extermination of five-thousand mentally and physically handicapped children. The extermination of adults followed, initially on an ad hoc basis, and later systematically though a front organisation: The Reich committee for the scientific registration of serious hereditary and congenitally based illnesses. Grey postal vans collected those judged unfit to live and took them to asylums, where they were gassed. The public were not informed of any of these resolutions. As vans returned empty from the asylums patients began to resist, and were restrained or sedated. Relatives received standard condolences. False death certificates were issued, the overloaded administration began to make mistakes, and workers from the secret death camps were indiscreet when drunk. Although the churches and legal institutions did not protest, prominent individuals did. In 1941 Bishop von Galen of Munster denounced the programme publicly and with corrosive accuracy;
"It is only necessary for some secret edict to order that the method developed for the mentally ill should be extended to other Unproductive people, that it should applied to those suffering from incurable lung disease, to the elderly who are frail or invalids, to the severely disabled soldiers. Then none of our lives will be safe any more. Some commission can put us on the list of the unproductive, who in their opinion will have become worthless life."
In 1941 as a result of public outcry and the excession of a target figure of seventy thousand deaths, the gassing of mental patients was halted. Aktion 14f13 and later Aktion Brandt directed euthanasia at sick concentration camp inmates, forced labourers from the east, and the racially undesirable.
The unpopularity of such euphemistically termed cases of euthanasia resulted in a new approach by Nazi officials: the propaganda film. Documentary footage stigmatising the handicapped led onto feature length dramas. Some films were only shown to hardened SS initiates (there were plans for films showing the gassing process), but many were directed at the public. According to Burleigh in History Today, the object was twofold: to occlude the realities of murder through the agency of sentiment, and secondly to shift responsibility from the state onto every individual through the device of human interest drama, and hence secure their collusive passivity, if not consent.
One such drama is Ich klage an (I accuse), which is about a pioneering scientist whose beautiful wife develops multiple sclerosis . Her condition is diagnosed by an anti-euthanasia doctor, whose own stance is eroded through a sub-plot (a baby who he has saved turns into a deformed child). When despite his best efforts the scientist fails to discover a cure, he kills his wife by overdose. The servants accuse him of murdering her for money and he stands trial, to be vindicated by a retired major who speaks of wretches inhabiting luxurious asylums. The film was seen by eighteen million people. It was unpopular in Roman Catholic areas, where is was seen as an attempt to refute protests and sermons. Younger doctors were enthusiastically in favour. Their elders were lest trusting of fatal diagnoses, with more faith in patients recuperative powers. The poorer citizens of the Third Reich were generally positive, on the basis of future legislative safeguards. Such surveys were carried out secretly by Nazi agents. They do not record what Multiple Sclerosis sufferers thought about the matter. Its is perhaps cautionary that a totalitarian regime represents the best example of a consensus on the issue of euthanasia. However in this case the medical profession were functionaries to the policies of the Nazi party. How many German doctors were simply obeying orders is itself a matter for debate.
The Millennial Medical Apocalypse
Illich follows the course of death as; Gods call, a natural event, a force of nature, and now untimely except in the very old. It was only in the 20th century that death whilst under treatment by clinically trained practitioners becomes regarded as a civil right. In the same breath, Illich demonstrates a case where medical interference in not so much a right but a requirement:
I know of a woman, who tried, unsuccessfully, to kill herself. She was brought to the hospital in a coma, with two bullets lodged in her spine. Using heroic measures, the surgeon kept her alive and considers her a double success: She lives, and she is totally paralysed so that he no longer needs to worry about her ever attempting suicide again Illich believes it is not until The Great War that scientific medicine is confident enough to attempt heroic rescues on every life.
Illich makes a direct comparison between medical power over the end and nuclear holocaust: Armageddon has become a possible consequence of mans direct decision. An uncanny analogy exists between atomic and cobalt bombs: both are deemed necessary for the good of mankind, both are effective in providing man with power over the end. Medicalized social rituals represent one aspect of social control by means of the self-frustrating war against death.
Death has become the ultimate form of consumer resistance, shouts Illich and today, the man best protected against setting the stage for his own dying is the sick person in critical condition.
Six decades after Williams and Tollemach the voluntary euthanasia society was formed in 1935 by a group of high-profile physicians, largely at the encouragement of Dr C. Killick-Millard. In 1931 he had discussed the subject in his presidential address to the Society of the Medical Officers of Health. The societys patrons included many literati such as Harold Laski, G.H. Trevelyan, and H.G. Wells, as well as some prominent clergy. The groups aim was to see legislation in the united kingdom in favour of voluntary euthanasia or physician assisted suicide. Millards draft bill was given a second reading in parliament on the 1st of December after an introduction by Lord Ponsonby. Though, if his biography is to be believed, he favoured the principle, Lord Dawson of Penn opposed the bill, supported by lord Horder and the Archbishop of Canterbury. The Bill was defeated in both houses. Interestingly, Penn opposed the bill , not because he feared a slippery slope of increasing abuse, but in his opinion, proper legislation would make it impossible to practise active euthanasia.
In 1991 the Lancet reported the result of a nation-wide study in the Netherlands on euthanasia and other medical decisions concerning the end of life (MDEL). The paper concluded that the practise was already widespread in Holland and that mercy killing would bring the practise of mercy killing into the open. I and heighten the medical awareness of end of life medical decisions. The double effect, whereby life of a patient was shortened as a side effect of palliative treatment, was at one end of the spectrum. A deliberate lethal intervention, requested or not, was at the other. The paper asserts that non -treatment decisions and active euthanasia are hardest to perform when unrequested by the patient, and that the desire to treat disease would itself restrain euthanatic practise. It also stated a public demand for MDEL, and that because of demographic shifts towards older populations, greater numbers of cancer deaths, and a growth in the number of life prolonging technologies it was not impossible that requests for euthanasia would increase.
In 1994-5 saw the UK house of lords committee report, that of the New York State task force on life and the law, and the report from the Canadian senate. These committees comprised people with different views on the intrinsic morality of euthanasia, yet the move to legalise was opposed by all three. The main argument of the house of the house of lords committee was that societys prohibition of intentional killing protected everyone impartially. On the issue of euthanasia, the interest of the individual could not be separated from the interest of society. It is curious that Aktion T4 in Nazi Germany used the same argument, with a diametrically opposite result.
In 1995 Van der Maas et al reviewed their survey of the Dutch medical attitudes to active euthanasia, by looking at changes in opinion from 1966 to its decriminalisation in 1991. They found that experience of the dying and of active euthanasia made the practise, initially hard, easier to accept.
Active euthanasia for the voluntary and competent patient seems so plausible and liberal. Yet it suggests a technological solution to a perennial human problem. We can effectively abolish not death but dying, the process which leads to death. We can hide the misery but not the ultimate nightmare itself. If we can ethically and legally do that for the requesting person, why not for each and every suffer of terminal misery? The possibility of a swift and painless death will inevitably become the necessity. The privilege granted to the competent will be seen as a right of which others less fortunate than the competent should not be deprived. In the end, banishing the misery of dying may not be the undiluted benefit that it appears to be from a glance.
In Living with euthanasia Jonsen wonders what it would have happened had aid in dying, which failed to be legalised in Washington State (1991) and California (1992), been legalised in a fictional American state. He narrates of the act making persistent vegetative state a terminal condition, and of food and fluids to coma patients to be regarded as treatment, which could be withdrawn. He describes the debate in academic circles. Proponents cite human rights to autonomy and dignity. Opponents claim that the legislation is the first slip on a slippery slope to involuntary euthanasia. In front of television cameras such talk and the difference between omission and commission is dropped in favour of anecdotes from both sides of the fence.
This case reflects a larger issue. We have seen, in the last five years, a growing sympathy to enlarge the terms of the law. Jonsen illustrates his slippery slope arguments. There is a drive for advanced euthanasia directives, for patients who wish to be killed when they are incompetent. The are also the complaints of those who wish to die prior to the undignified terminal phase of their illnesses, as well as the call to remove the malformed and disabled new-born. Jonsens speculative history, frighteningly fleshes out his slippery slope argument.
In 1978 Fye concluded that though passive euthanasia is endorsed as an extension of conservatism, the controversy initiated over a century ago by the like of Tollemache and Williams continues today with little likelihood of resolution in the foreseeable future. Van der Maas et al concurred in that euthanasia is an issue which involves whole societies. Though public opinion is relevant medical euthanasia pre-eminently involves the medical profession. To make progress in debate there should be some agreement between medical profession and general public. However, even if public and medical profession agree to accept euthanasia in certain circumstances, legal regulations and ethical principles do not provide simple decision rules.
Perhaps this was what Lord Dawson of Penne was thinking when he wrote, The machinery of this bill would turn the sick room into a bureau and be destructive of our usefulness, the very idea of ...[it]...visited by officials and the patient, who is struggling with this dire malady, being treated as if it were a case of insanity...it would deter those who are, as I think, carrying out their mission of mercy.
He firmly believed that intervention at the end of life belonged to the wisdom and the conscience of the medical profession, and not to the law.
It must be admitted that active euthanasia would not have been as much of an issue, if the increase of the numbers of the elderly were not an item on the international agenda. JAMA crystallises the concern of over 40 countries: Can we afford the growing numbers of older persons? Will this lead to intergenerational conflict? Must there be stagnation in the productivity of society as a result? A consensus is impossible while the question can be defined in so many different ways. In her discussion of assisted suicide in antiquity, Danielle Gourevitch highlights the dangers both of harkening to ancient oaths and to those who disregarded them:
We speak of euthanasia; we do not know how long to protract the survival of the living corpse represented by the patient in an irreversible coma. One should undoubtedly not draw too close a parallel: the ancient physician leads a conscious thinking and reasoning person to his death; while for a modern physician...it is the very concept of death which has to be re-examined.
Does euthanasia, as cynics of healthcare might believe, represent an escape from an ever-growing medicalisation of life? Are we so afraid of dying that we would rather kill ourselves? Does it represent the equivalent of the emetic in the medicine bag of the enlightenment, a final panacea which works only in that it does what it is supposed to do? The debate of ideologies and practicalities begun in the mists of time rages on, at least for the present.
- A concept of natural euthanasia is dwelt upon by Herodotus in his Histories. He narrates the fables told by the philosopher Solon to King Croesus of Lydia: One is of two youths, Cleobis and Biton, who yoked themselves to a carriage to transport their mother to Olympia. When they arrived, their mother prayed to the Goddess Hera that they should receive the greatest gift. During the night they died. Solons moral is that they died happy and virtuous. In contrast, the living are not happy but lucky, because misfortune is yet to befall them. Herodotus, The Histories, P.51, ed. Burn A.R., Penguin Classics, Harmondsworth 1972
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