The historical practice of euthanasia is in contrast to prohibitions through legislative acts of contemporary days.Â Regardless of these present restraints, unsettled matters concerning the applications of euthanasia continue to raise questions.Â Euthanasia and its related practices have become a source of many debates and argument. Some questions involve uncertainty in defining the act, what line does one draw in deciphering cases where euthanasia is ethically permissible, playing an important part in physician-patient scenarios.Â Additional thoughts relating to euthanasia question the truth in liberal tendencies becoming more prevalent in this presently advancing and technologically comfortable world. The nature and scope of the definition of dying prompts the issues surrounding euthanasia and its ethnical conduct: Is it right to commit suicide" Is it ethical for someone else to assist the suicide, Is it moral to put others death at their own request or at the request of family members. Other questions arise in the actions and the circumstances under which these unclearly termed actions are performed, how euthanasia is defined and under which conditions it applies. Conflicting thoughts stem from such questions, and where such thoughts arise, ethical debates in support or in disagreement inevitably follow, should euthanasia be banned, and should a patient's request be ignored even under excruciating pain, and make a voluntary and enduring request to be helped to die.Â These questions are important as they help to define society and its culture. The definition of Euthanasia would change the perspective on dealing with and responding to issues of life, ritual, and death serves to shape the nature of the society. Hence, it is necessary for society in attempt to decide righteous concept and action; the ethical conduct for the various actors in each communities when people faces death.Once examining the arguments concerning euthanasia practice on both sides, and gathering evidence of supporting facts, it can be maintained that the argument opposing euthanasia is valid and ethical.
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There are several reasons why this debate has surfaced. Death has existed for thousands of years. Each culture has developed its own rituals and mechanisms for dealing with death. These mechanisms serve to provide solace, a sense of continuity, and allow the culture to continue even as the members of the community cannot. However, our own culture has experienced many shattering changes that have altered the nature of dying. Suddenly we are forced to rethink the issue of death and we must decide what types of behavior are ethical when someone is dying. Perhaps the main reason that death has changed in western culture has to do with advances in medicine and technology. Many of the diseases that have historically killed people are now no longer a threat to most individuals. Medicine has made a variety of advances in the treatment of diseases such as smallpox, tuberculosis, malaria, pneumonia, polio, influenza, and measles. People now rarely die of such traditional causes. Life expectancy has risen and the quality of life has also changed fundamentally during the past 100 years. Not only does almost everyone in the Western world have enough to eat, also people eat higher on the food chain. There is a great deal more meat and animal fat in modern diets. Just these differences alone have changed death significantly. People now develop heart disease, adult onset diabetes, cancers, and AIDS. These types of diseases are more the result of lifestyle than bacteria. With these new diseases, suffering is often more prolonged and treatment is frequently quite painful. Also, as people are living longer, the diseases of the aged have become increasingly prevalent. Many more people now suffer from problems like senile dementia and Alzheimer's disease. These diseases ruin the mind while preserving the body, allowing life to continue long after any quality that the life might have is gone.
Throughout history, death has been a family affair. People usually died in the home after a short bout with an illness or as the result of an accident. Today, increasingly, death occurs in an institutional setting such as a convalescent home or a hospital, after a variety of technologies are applied in an attempt to prolong the life of the sick person. Often these technologies can be quite effective. People can now live for months and even years attached to a variety of tubes and technologies.
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"About 75% of all deaths in 1987 occurred in hospitals and long term care facilities, up from 50% in 1950 . . . The Office of Technology Assessment Task Force estimated in 1988 that 3775 to 6575 persons were dependent on mechanical ventilation and 1,404,500 persons were receiving artificial nutritional support. This growing capability to forestall death has contributed to the increased attention to medical decisions near the end of life." (CEJA, 1992, p. 2229)
People realize that the chances of facing the institutionalization of death increase daily, and they feel a profound lack of control. Surveys have consistently indicated that a large majority of people in the United States would like to be allowed to end their lives before incurable and painful diseases finally kill them (CEJA, p. 2229).
Because of the changes that have impacted death, with regard to both how and where we die, the debate about how we should be allowed to die has been renewed. This paper will examine the several facets of this debate. It will define the terms that are relevant to the debate, examine the legal state of euthanasia today, discuss the ethics of euthanasia by examining arguments made by proponents and opponents of euthanasia, and by applying several Normative Ethical Theories to the issue. Finally, it will explore the power implications that infuse the debate on euthanasia and present arguments in favor of moving toward a care based ethic of dying and away from the current rights based ethic.
Â Â The linchpin argument of euthanasia proponents concerns the right to die. They contend individual has certain rights guaranteed under the law and the Constitution which allow them to choose when they can die or not. These rights are generally argued from the standpoint of autonomy or self-determination, or from the constitutional right to privacy. Proponents contend that individual liberty is a fundamental constitutional guarantee, and that the right to privacy protects the right of an individual to choose to die. Wolhandler argues forcefully that the constitutional right to privacy elucidated inÂ Griswold v. ConnecticutÂ and expanded inÂ Roe v. Wade, also applies to euthanasia; thus protecting the individual from the purview of the state if that person chooses assisted suicide or active euthanasia. He also argues that the protection of the right to self determination is the key to democracy and the social contract on which this nation is built when he says:
"Recognition of the right of self-determination is the condition for the concept of a community not based on force. Force used to impose on others, against their wishes, what one thinks is best for them is thus not allowed. This view undergirds a peaceable accommodation to the fact that there is a pluralism of moral beliefs: although one may not be able to agree about what constitutes good life or good death, one can agree to let each make his own choices, as long as those choices do not involve direct and significant violence against others." (p. 370)
There is some doubt, however, about whether the Supreme Court in its current configuration would be willing to extend a right that is not specifically stated in the Constitution to cover such practices (Gifford, p. 1576-77). In theÂ CruzanÂ decision, the Court seemed quite willing to let questions of this nature be settled by the states (Cruzan, p. 2842). As we have already seen, the argument for privacy and autonomy has generated considerable support in the realm of passive euthanasia. It is the support that the courts have given to passive euthanasia that provides the basis for a second and perhaps the most crucial argument. This is the argument that the passive/active distinction made by the courts and the medical profession is invalid, cannot be made, and in actuality does not exist. If it can be proven that this distinction is invalid, then all of the rights that allow for passive euthanasia would then allow active euthanasia as well. Advocates present a variety of different reasons for why the active/passive "bright line" cannot exist.
The first argument in support of this position claims that court decisions about the interest of the state make the active/ passive distinction irrelevant. According to Adams, et. al. (p. 2034), "when considering the state's interest in preserving an individual's life in a suicide assistance case, a court should find that, absent evidence of coercion or the patient's incompetence, the state's interest is negligible compared with the patient's interest." This logic would presumably apply to cases of active euthanasia as well.
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A second argument concerns the transparent nature of the distinction itself.
"It is sometimes claimed that the "passive" techniques are morally acceptable because they allow for a natural death, while "active" techniques independently cause death. But in the modern medical setting, these terms and distinctions are ephemeral. The concept of natural death in the hospital has lost its meaning. 'If you want to have a natural death,' says Dr. Alan Stone, 'you have to stay out of the doctor's hands.' If you make it alive to the hospital, medical technology derails nature and alters the course, experience, and timing of death." (Newman, p. 166)Â
In this respect, the nature of technology almost demands that euthanasia be deployed as an option in some cases, because it prolongs life unnaturally. Additionally, the nature of the activities involved in both active and passive euthanasia, as well as the decision making process, makes the active/passive distinction a difficult one to understand. Adams says that
"Opponents of physician assisted suicide argue that it is fundamentally different from the refusal of treatment. Their arguments rely on the existence of alleged bright line distinctions between suicide and natural death, killing and letting die, or active and passive euthanasia. These distinctions rest, in part, on supposed differences between acts and omissions. However, the attempt to draw such bright line distinctions between acts and omissions fails in practice and in theory. It is often difficult, in the hospital or the courtroom, to state decisively whether something is an act or an omission. Is a physician who turns off a functioning respirator "actively" turning off a machine or "omitting "to provide air? Is a patient who refuses food and water "actively" starving or "omitting" to eat?" (p. 2028)Â
A third argument examines a specific death situation that has blurred the active or passive line to the point where it no longer exists. When people are in a great deal of pain, the amount of medication required to provide relief from the pain can be so great as to cause death. When a physician administers pain medication in a significant dose, is this active or passive? Vaux (1989, p. 20) states that
"A second class of actions can be designated "double effect euthanasia." Theologically and morally it is acceptable for a patient to choose palliative treatments that may result in death and for a physician to administer potentially lethal analgesia in the relief of pain. And many ethicists argue that the administrator of a lethal dosage is not culpable if his primary intent is to relieve suffering, though the ensuing death may be foreseeable, so long as the patient and family consent. We might understand Debbie's case(4)Â best from this perspective."Â
Clearly, in a case like this it is difficult to see whether the act should be considered active or passive. Thus, the main argument made by proponents of euthanasia argues that the courts have already allowed certain fundamental rights to protect the process of passive euthanasia, and since there is no logical or fundamental difference between active and passive euthanasia, or at least no way to demarcate such a difference clearly, then active euthanasia and assisted suicide ought to be legal as well. Interestingly, it may be just this type of logic that opponents of euthanasia see as the "slippery slope" discussed earlier.
Active euthanasia would allow the individual control, choice, and a greater ability to face suffering and death effectively. According to Newman (p. 183),
"A total ban on assisted deaths might have another unintended, detrimental effect. Persons with diseases like Alzheimer's are now tempted to try suicide at an early stage of their disease when they are still mentally and physically fit. If they knew euthanasia were available later, perhaps through an advance directive or health care proxy, these individuals might choose to live longer, through a later stage of the illness."
It is also worthwhile to remember that Dr. Quill's patient was able to face death much more calmly knowing that she had the ability to end her life when she chose. This enabled her to spend her energy strengthening her connections with her family and enjoying the time she had left.
Euthanasia prevents state control. The state has no right to coerce the individual or control the body of the individual unless there is some sort of compelling interest. The balancing tests that courts use in the case of passive euthanasia are just as valid in the cases of assisted suicide and active euthanasia. Because there is no state interest in most cases, this proves that the practices stated above should be legal. Engelhart (1989, p. 8-9) argues that the state has no moral authority to prevent euthanasia. This is because euthanasia is a negatively established right. He says that
"The right to euthanasia, like most other rights to act freely by oneself or with consenting others, is established negatively. It does not depend on some claim that such liberty would be good, beneficial, or worth endorsing. Rather, it is a function or the failure to establish the authority of others, in particular, the state, to intervene coercively. With this, one comes face to face with the plausible limits of a secular state. One will need to live with individuals' deciding with consenting others when to end their lives, not because such is good, but because one does not have the authority coercively to stop individuals acting together in such ways. In a secular, pluralist society one will need to accept euthanasia by default."
These arguments constitute the major offensive positions taken by euthanasia advocates. The other two arguments, that euthanasia might actually increase the level of trust among patients and the public toward the medical profession, and that euthanasia would also prevent abuse by providing a clear set of guidelines regulating the behaviors of various actors, have already been dealt with as responses to the opponents of the practice.
The autonomy and beneficence principles are two leading arguments in support of euthanasia. Regardless of their seemingly lofty stance, they both have flaws that damage their positions as leading arguments. The autonomy claim is the
justification of euthanasia through upholding the values and requests of the patient.Â This means that the suffering patient has the right, the autonomous claim, to request their termination of life.Â However, John Safranek uncovers the underlying matter by pointing out that the existence of controversies regarding euthanasia stem from, "competing theories of the good," rather than,"autonomy and the sanctity of dignity of life" (Safranek 35).Â He claims that, "each side seeks the autonomy to attain its respected theory of good; neither can invoke autonomy to vindicate its attempt to achieve its good" (35).Â In other words, the use of autonomy as an argument defending the theory of good in euthanasia acts is concurrently undermining the autonomy of one whose theories of good lies against such acts.Â Because the autonomy principle, as well as one's ethical standing, is infringed upon regardless of what decision concerning euthanasia is made, the use of this principle as an argument for such an act is deemed invalid.
Euthanasia is also justified by the beneficence principal, which refers to the physician's duty to respect their patients.Â According to the use of this principal as an argument, if an intolerably afflicted patient was to request lethal drugs on behalf of easing one's pain and lessening the burden of family members, the doctor is responsible for carrying out such requests. This also means that a doctor could defend himself of having committed a euthanasia act, based on the grounds that, "he had faced an unavoidable conflict of duties between his duty to prolong life and his duty to alleviate unbearable suffering" (Klotzko 25).Â There are questions that are raised based on this principal relating to the discernment of circumstances. There must be a distinction between the scenarios that call for the gratification of the patient, versus the
situations in which the inclinations and judgments of the physician should be carried out.Â Therefore, it is possible for the physician to act unethically and unnecessarily by terminating a life.
The final notes on the arguments supporting euthanasia and the imposing dangers that follow are found through observance of Nazi Germany and the presently legal occurrence of euthanasia in the Netherlands.Â The euthanasia occurrences in Nazi Germany are known to have taken place at an uncomfortably close time ago, and they make known the dark actuality that lives were unnecessarily terminated. What has the potential of becoming even more alarming is taking place in Europe once again, during this very time period. Among all ill-famed practices of Nazi Germany was the performance of euthanasia. This reference can be essentially utilized to uphold arguments against acts of euthanasia nowadays. Susan Benedict and Jochen Kuhla disclose in an article the origins and the progressions of the euthanasia program in Germany during the Nazi era, revealing the dangers of euthanasia progressing from a smaller scale towards a larger scale; perpetuating a domino effect.Â These same dangers are present today, as previously noted, as the debate of euthanasia practices makes itself known.Â They mention a Eugenics movement that had risen in Europe shortly after WWI, which encouraged thoughts on improving the human race.Â These thoughts became increasingly more widespread and often expressed correspondence to the idea that those who tainted the human race, those "not worth living," should have their lives ended (Benedict 247).Â Ideas of euthanasia were exposed through movies, literature, and even textbooks (248).Â It was not until the initiation of the Children's Euthanasia Program that negative thoughts of those handicapped, or those who became a "major burden" to family members, were put into action.Â This program brought deformed or retarded children into their clinics where they were killed by the consent of pediatricians and physicians (249).
In this presently fallible world, it is known that debates over interpreting euthanasia in varying conditions may cause liberal ideas to emerge more frequently. This is exemplified through the Netherlands of present-day. Although the Assembly of the Norwegian Medical Association condemned the application of euthanasia, a formerly introduced study shows that the guidelines, attitudes, and practices of physicians have not necessarily coincided with this fact (Forde 887). At what point in time and in what circumstance would a physician consider the practice for euthanasia? According to the study, a physician might actively end the life of one who is a "terminal patient in great pain and a poor quality of life who otherwise would have several more years to live" or might hasten death in order to, "alleviate pain" (887).Â 4% [66% of the 1,476 of Norwegian physicians who received questionnaires for the study] answered yes to the question of whether a physician should have that certain opportunity to "actively end the life of a terminal patient in great pain who requests this help."Â This study further proves and strengthens the risk of promoting and practicing euthanasia in any form.
By looking at the supporting stance of euthanasia and the main arguments laid out, one discovers flaws that create invalidity. This invalidity is proven further through acknowledging that the supporting argument for euthanasia is not in collective agreement, due to the lack of clarity in defining the term it stands for.Â Upon the observance of historical trends as well as the liberal tendencies and events of nowadays, one may conclude that having a contrasting stance in relationship to euthanasia is ethical and valid.
Dilemma of euthanasia is a power struggle, wherein the power of the patient is lost, that leads me to advocate a rethinking of our societal structures that surround and control our end of life processes. The discussion about euthanasia needs to be analyzed from a new viewpoint, a new paradigm, which will allow us to move outside the present debate that will inevitably empower either the medical or legal community. The debate must be shifted to center on an approach that will empower the patient, the family, and the community. The problem of euthanasia must be viewed from both philosophical and practical standpoints, by examining the metaphysics of quality and the ethic of care.
In elucidating his truly revolutionary metaphysics of quality, Pirsig (1991) argues that the world is not composed of substance, subject and object, mind and matter; it is composed instead primarily of value. He explains this radical concept by stating:
"The low value that can be derived from sitting on a hot stove is obviously an experience even though it is not an object and even though it is not subjective. The low value comes first, then the subjective thoughts that include such things as stove and heat and pain come second. The value is the reality that brings the thoughts into mind . . . Value is not a subspecies of substance, substance is a subspecies of value. When you reverse the containment process and define substance in terms of value the mystery (of where values exist in the world) disappears: substance is a "stable pattern of inorganic values"." (p. 99, 101) (parenthesis mine)
Using the terms quality, value, and moral almost interchangeably, Pirsig says that quality and morality is the primary reality of the world and that the world is primarily a moral order. There are two types of quality: static and dynamic quality. Dynamic quality is responsible for progress. It is the evolutionary force that has led to the explosion of life, the creation of cultures, cities, art, and literature. Static quality is responsible for preservation. Once a dynamic advance has occurred, static quality is what prevents the slide back down the evolutionary spiral. Retention of adaptations such as clothing, fur, tools; and things like libraries, ritual, and laws are examples of static quality or static patterns of value preserving the advances made by dynamic quality. (p. 107-121)
"What the evolutionary structure of the Metaphysics of Quality shows is that there is not just one moral system. There are many. In the Metaphysics of Quality there's the morality called the "laws of nature" by which inorganic patterns of value triumph over chaos; there is a morality called the "law of the jungle" where biology triumphs over the inorganic forces of starvation and death; there's a morality where social patterns triumph over biology, "the law"; and there is an intellectual morality, which is still struggling with its attempts to control society." (p. 158-159)
Pirsig also contends that the Metaphysics of Quality is an excellent device for resolving ethical dilemmas.
Because the Metaphysics of Quality takes such a fundamentally different view of the universe and because it claims to be able to easily resolve ethical dilemmas, it would be useful to use this new metaphysics to examine the seemingly intractable ethical problem of euthanasia.
In the case of euthanasia we can determine which courses of action are morally correct by examining the patterns of value that are associated with it. In the case of involuntary euthanasia, it would only be a moral or ethical action if the brain functions of the individual have ceased. This is because brain function indicates that the person has the capability of intelligent thought. Intelligence is at the highest pinnacle of evolution and cannot be taken away in order to preserve such lower order values such as social or biological quality. If a person has lost brain function, social and biological quality would indicate that involuntary euthanasia is acceptable. This is because medical resources can be used more effectively to preserve the biological and social quality for others, rather that using such resources on an individual whose intellectual and social quality have ceased to exist. We should not protect the biological quality of a functioning organism at the expense of social and intellectual quality.
In the case of active voluntary euthanasia and assisted suicide, it is crucial to realize that intellectual quality always supersedes social quality. Society therefore should not have the right or the capability to deny intellectual quality or intellectual choice. This has two implications: No one has the right to destroy intellectual quality, and therefore involuntary euthanasia performed on a person capable of independent thought cannot be allowed, even for the sake of societal good. Second, society cannot deny the right of a person to make an intellectual decision to end their life, even if that denial would be better for society.
The power of intellectual quality allows the thinking person the right to decide what to do with their life. The patient has the right to decide to end their life by whatever means they choose. The physician has the right to decide whether they are willing to help the individual with that choice, but cannot be coerced either by others or by a set of rules or laws. If the physician is unwilling to help either with the assistance of a suicide machine or with a lethal injection, that person has made an intellectual choice. If the physician is willing to help, because of compassion for the individual or for some other reason, this willingness is still an intellectual choice that should not be proscribed by laws, which are designed to preserve societal quality.
This unique view of making value judgments allows us to move from a dualistic life/death, healing/killing framework toward a more logical and moral ethic of care. Such a move places the intellectual capacity of the individual in the center of the issue and moves the rule based approach out. This also displaces the power roles of the legal system and the medical establishment. When the intellectual capacity of the individual and the dynamic quality which engenders it is placed in the forefront, the legal system and the medical establishment are placed in their appropriate roles of protecting the right of the individual so long as that right does not harm the rights of others, and helping the individual carry out decisions regarding their own medical condition. The individual once again returns to the role of actor, the legal system to the role of protector, and the medical establishment to the role of helper. The proper ethical choices are now made by the appropriate actors, and the individuals in all parts of the system are empowered.