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Euthanasia and Assisted Suicide: Frequently Asked Questions
Rita L. Marker and Kathi Hamlon
1. Where are euthanasia and assisted suicide legal?
Oregon, the Netherlands and Belgium are the only jurisdictions in the world where laws specifically permit euthanasia or assisted suicide. Oregon permits assisted suicide.(1) The Netherlands and Belgium permit both euthanasia and assisted suicide.(2)
In 1995 Australias Northern Territory approved a euthanasia bill.(3) It went into effect in 1996 but was overturned by the Australian Parliament in 1997. Also, in 1997, Colombias Supreme Court ruled that penalties for mercy killing should be removed.(4) However the ruling does not go into effect until guidelines, still to be drafted, are approved by the Colombian Congress.
2. What is the difference between euthanasia and assisted suicide?
One way to distinguish them is to look at the last act the act without which death would not occur.
Using this distinction, if a third party performs the last act that intentionally causes a patients death, euthanasia has occurred. For example, giving a patient a lethal injection or putting a plastic bag over her head to suffocate her would be considered euthanasia.
On the other hand, if the person who dies performs the last act, assisted suicide has taken place. Thus it would be assisted suicide if a person swallows an overdose of drugs that has been provided by a doctor for the purpose of causing death. It would also be assisted suicide if a patient pushes a switch to trigger a fatal injection after the doctor has inserted an intravenous needle into the patients vein.
3. Doesnt modern technology keep people alive who would have died in the past?
Modern medicine has definitely lengthened life spans. A century ago, high blood pressure, pneumonia, appendicitis, and diabetes likely meant death, often accompanied by excruciating pain. Women had shorter life expectancies than men since many died in childbirth. Antibiotics, immunizations, modern surgery and many of todays routine therapies or medications were unknown then.
4. Should people be forced to stay alive?
No. A lot of people think that euthanasia or assisted suicide is needed so patients wont be forced to remain alive by being "hooked up" to machines. But the law already permits patients or their surrogates to withhold or withdraw unwanted medical treatment even if that increases the likelihood that the patient will die. Thus, no one needs to be hooked up to machines against their will.
Neither the law nor medical ethics requires that "everything be done" to keep a person alive. Insistence, against the patients wishes, that death be postponed by every means available is contrary to law and practice. It is also cruel and inhumane.
There comes a time when continued attempts to cure are not compassionate, wise, or medically sound. Thats when hospice, including in-home hospice care, can be of great help. That is the time when all efforts should be directed to making the patients remaining time comfortable. Then, all interventions should be directed to alleviating pain and other symptoms as well as to the provision of emotional and spiritual support for both the patient and the patients loved ones.
5. Does the government have the right to make people suffer?
Absolutely not. Likewise, the government should not have the right to give one group of people (e.g. doctors) the power to kill another group of people (e.g. their patients).
Activists often claim that laws against euthanasia and assisted suicide are government mandated suffering. But this claim would be similar to saying that laws against selling contaminated food are government mandated starvation.
Laws against euthanasia and assisted suicide are in place to prevent abuse and to protect people from unscrupulous doctors and others. They are not, and never have been, intended to make anyone suffer.
6. But shouldnt people have the right to commit suicide?
People do have the power to commit suicide. Worldwide, about a million people commit suicide annually.(5) Suicide and attempted suicide are not criminalized. Each and every year, in the United States alone, there are 1.5 times as many suicides as there are homicides.(6) And suicide is one of the ten most common causes of death in Great Britain.(7)
Suicide is an all too common tragic, individual act. Indeed, the Surgeon General of the United States is currently campaigning to reduce the rate of suicide.(8)
Euthanasia and assisted suicide are not private acts. Rather, they involve one person facilitating the death of another. This is a matter of very public concern since it can lead to tremendous abuse, exploitation and erosion of care for the most vulnerable people among us.
Euthanasia and assisted suicide are not about giving rights to the person who dies but, instead, they are about changing public policy so that doctors or others can directly and intentionally end or participate in ending another persons life. Euthanasia and assisted suicide are not about the right to die. They are about the right to kill.
7. Isnt "kill" too strong a word for euthanasia and assisted suicide?
No. The word "kill" means "to cause the death of."(9)
In 1989, a group of physicians published a report in the New England Journal of Medicine in which they concluded that it would be morally acceptable for doctors to give patients suicide information and a prescription for deadly drugs so they can kill themselves.(10) Dr. Ronald Cranford, one of the authors of the report, publicly acknowledged that this was "the same as killing the patient."(11)
While changes in laws have transformed euthanasia and assisted suicide from crimes into "medical treatments" in Oregon and the Netherlands, the reality has not changed patients are being killed.
Proponents of euthanasia and assisted suicide often use euphemisms like "deliverance," "death with dignity," "aid-in-dying" and "gentle landing." If a proposed change in public policy has to be promoted with euphemisms, this may be due to the fact that the use of accurate, descriptive language would make its chilling reality too obvious.
8. Wouldnt euthanasia or assisted suicide only be available to people who are terminally ill?
No. There are two problems here the definition of "terminal" and the changes that have already taken place to extend euthanasia or assisted suicide to those who arent "terminally ill."
There are many definitions for the word "terminal." For example, Jack Kevorkian who participated in the deaths of more than 130 people before he was convicted of murder said that a terminal illness was "any disease that curtails life even for a day."(12) Dutch psychiatrist Dr. Boudewijn Chabot who provided a fatal dose of drugs to a depressed, but physically healthy, woman, stated that "persistently suicidal patients are, indeed, terminal."(13)
Oregons assisted suicide law defines "terminal" as a condition which will "within reasonable medical judgment, produce death within six months."(14) A prognosis of six month to live is also the basis upon which patients qualify for hospice coverage under Medicare.(15) However, federal officials note that about 10% of patients live longer than the anticipated six-month life expectancy.(16)
The use of a six-month prognosis to qualify a patient for assisted suicide or euthanasia was challenged in the World Federation of Right to Die Societies' newsletter as well:
The Dutch who describe "terminal" as a "concrete expectancy of death," have made no attempt to predict when that concrete expectancy will be fulfilled.(18) Even a Dutch physician who has carried out euthanasia is reluctant to say how long the patient might have lived otherwise since "any estimate of the extent of shortening of life can only be very general" and this has no "absolute value."(19)
The idea that euthanasia and assisted suicide should only be practiced if a patient has a terminal condition has never been accepted in the Netherlands.(20) Under both the previous guidelines and the new law in the Netherlands, unbearable suffering of either a physical or mental nature has been the factor that qualifies one for induced death.(21)
It appears that not even the prerequisite of subjective unbearable suffering will be maintained for much longer. Discussion now centers on whether assisted suicide should be available to elderly people who are healthy but "tired of life." Dutch Minister of Justice Els Borst has said, "I am not against it if it can be carefully controlled so that only those people of advanced age who are tired of life can use it."(22)
Assisted suicide for non-terminally ill patients has also been advocated repeatedly in the United States.
In 1994, the influential New England Journal of Medicine published an article recommending legalization that would permit assisted suicide not only for individuals who have terminal conditions but also for those with "incurable debilitating illnesses." (23)
Likewise, the Hemlock Society, citing the fact that many people fear becoming a burden, has publicly supported a mans legal attempt to "empower his wife to have a doctor end his life by lethal injection, without criminal liability, should he be stricken by a debilitating illness."(24)
Within two years after the passage of Oregons assisted suicide law, a model law was drafted that would give doctors the right to provide assisted suicide if "the patient has a terminal illness or an intractable and unbearable illness."(25)
A 1995 article in the journal, Suicide and Life-Threatening Behavior, concluded that suicide is a rational choice for those with "hopeless conditions." As defined, "Hopeless conditions include, but are not necessarily limited to terminal illnesses, severe physical and/or psychological pain, physically or mentally debilitating and/or deteriorating conditions, or quality of life no longer acceptable to the individual."(26)
In a May 1996 speech to the prestigious American Psychiatric Association, George Delury -- who portrays himself as a loving husband who "helped" his non-terminally ill wife die (27) -- suggested that "hopelessly ill people or people past age sixty just apply for a license to die." He said that such a license should be granted without examination by doctors.(28)
At a 1998 international meeting held in Zurich, Switzerland, right-to-die activists issued a declaration calling for the availability of assisted suicide and euthanasia for those suffering "severe and enduring distress."(29)
A new proposal in South Australia, if approved, would make euthanasisa and assisted suicide available to those who are "hopelessly ill." According to the "Dignity in Dying Bill 2001":
9. Wouldnt euthanasia and assisted suicide only be at a patients request?
No. As one of their major goals, euthanasia proponents seek to have euthanasia and assisted suicide considered "medical treatment." If one accepts the notion that euthanasia or assisted suicide is a good medical treatment, then it would not only be inappropriate, but discriminatory, to deny this good treatment to a person solely because that person is too young or mentally incapacitated to request it.
In the United States, a surrogates decision is often treated, for legal purposes, as if the patient had made it. That means that, if euthanasia is legal, a court challenge could result in a finding that a surrogate could make a request for death on behalf of a child or an adult who doesnt have decision-making capacity.
In the Netherlands, a 1990 government sponsored survey found that .8% of all deaths in the Netherlands were euthanasia deaths that occurred without a request from the patient.(31) And in a 1995 study, Dutch doctors reported ending the lives of 948 patients without their request.(32)
Suppose, however that surrogates were not permitted to choose death for another and that doctors did not end patients lives without their request. The fact still remains that subtle, even unintended, pressure would still be unavoidable.
Such was the case with an elderly woman who died under Oregon's assisted suicide law:
10. Could euthanasia or assisted suicide be used as a means of health care cost containment?
Yes. Perhaps one of the most important developments in recent years is the increasing emphasis placed on health care providers to contain costs. In such a climate, euthanasia or assisted suicide certainly could become a means of cost containment.
These implications were acknowledged during a historic argument before the U.S. Supreme Court. Arguing against assisted suicide, acting solicitor general Walter Dellinger said, "The least costly treatment for any illness is lethal medication."(34)
In the United States alone, millions of people have no medical insurance and studies have shown that the elderly, the poor and minorities are often denied access to needed treatment or pain control.(35) Doctors are being pressured by HMOs to reduce care; "futile care guidelines" are being instituted, enabling health facilities to deny necessary and wanted interventions; and health care providers are often likely to benefit financially from providing less, rather than more, care for their patients.(36)
Canadians are faced with such long delays getting treatment in the countrys overcrowded health care system that the Canadian government has contracted for Canadians to be treated out of the country.(37)
Many British doctors and nurses have concluded that the only way to secure the future of the National Health Service (NHS) is to make more treatments available only to those who can pay privately for them.(38) And a survey by the Nuffield Trust and the nurses' magazine, Nursing Times, found that the NHS is failing to care adequately for hundreds of thousands of patients who die each year, many without proper care or pain relief.(39)
Savings to governments could become a consideration. Drugs for assisted suicide cost about $35 to $45, making them far less expensive than providing medical care. This could fill the void from cutbacks for treatment and care with the "treatment" of death.
For example, the Oregon Medicaid program pays for assisted suicide for poor residents as a means of "comfort care."(40) In addition, spokespersons for non-governmental health insurance plans have said the coverage of assisted suicide is "no different than any other covered prescription."(41)
Legalized euthanasia or assisted suicide raises the potential for a profoundly dangerous situation in which the "choice" of assisted suicide or euthanasia is the only affordable option for some people.
11. Certainly people wouldnt be forced into euthanasia or assisted suicide, would they?
Oregons assisted suicide law does not allow anyone to "coerce" or use "undue influence" to obtain a request for assisted suicide.(42) However, there is absolutely nothing in the Oregon law to prevent HMOs, managed care companies, doctors or anyone else from suggesting, encouraging, offering, or bringing up assisted suicide with a patient who has not asked about it.
Emotional, financial and psychological pressures could become overpowering for depressed or dependent people. If the choice of euthanasia or assisted suicide is considered as good as a decision to receive care, some people will feel guilty for not choosing death.
The concern about "being a burden" could serve as a powerful force that could influence the decision. The third annual report on deaths under the Oregon assisted suicide law illustrates this. In 63% of the deaths reported, fear of being a burden was expressed as a reason for requesting assisted suicide.(43)
Even the smallest gesture could create a gentle nudge into the grave. Such was evidenced in greeting cards sold at a national conference of the Hemlock Society.
According to the conference program, the cards were designed to be given to those who are terminally ill. One card in particular exemplified the core of the movement that would remove the last shred of hope remaining to a person faced with a life-threatening illness. It carried the message, "I learned youll be leaving us soon."(44)
12. Wouldnt legalized euthanasia and assisted suicide make certain that patients can die peacefully, surrounded by their families and doctors, instead of being suffocated by plastic bags or gassed to death with carbon monoxide?
No. Legalizing euthanasia and assisted suicide only legitimizes the use of plastic bags and carbon monoxide to kill vulnerable people.
For example, immediately following the passage of Oregons assisted suicide law, some who favor euthanasia and assisted suicide said the new law would permit the types of activities carried out by Jack Kevorkian.(45) Others said pills could lead to complications and only a lethal injection or suffocation with a plastic bag could ensure death.(46)
Official reports in Oregon have not provided information on problems and complications associated with assisted suicide deaths. If it were not for occasional news reports and inadvertent disclosures, assisted suicide in Oregon would seem problem free. However, two particularly troubling accounts have shattered that image:
During the campaign to legalize euthanasia in Australias Northern Territory, supporters painted pictures of a calm, peaceful death with the patient surrounded by loved ones. The Australian law(49) (which was later overturned(50)) legalized both euthanasia and assisted suicide.
Draft guidelines for its implementation recommended that family members should be warned that they may wish to leave the room when the patient is being killed since the death may be very unpleasant to observe. (Lethal injections often cause violent convulsions and muscle spasms.(51))
Although euthanasia and assisted suicide remained technically illegal in the Netherlands until 2001, for many years the Royal Dutch Association of Pharmacy has provided prescribing guidelines to prevent problems and to increase the efficiency of euthanasia and assisted suicide. Yet there are still a number of complications and problems reported with such deaths.(52)
Even Dutch euthanasia activists acknowledge these difficulties, stating in their own euthanasia society publication that, in one out of five cases of euthanasia or medically-assisted suicide, there are problems or complications.(53)
13. Since euthanasia and assisted suicide take place anyway, isnt it better to legalize them so theyll be practiced under careful guidelines and so that doctors will have to report these activities?
That sounds good but it doesnt work. Physicians who do not follow the "guidelines" will not report and, even when a physician does report information, there is no way to know if it is accurate or complete.
For example, the Oregon law requires the Oregon Health Division (OHD) to collect information and publish an annual statistical report about assisted suicide deaths.(54) However, the law contains no penalties for health care providers who fail to report information to the OHD. Moreover, the OHD has no regulatory authority or resources to ensure submission of information to its office.(55)
Thus, all information contained in the OHDs official reports is that which has been provided by the physicians who prescribed the lethal drugs and only that which the physicians choose to provide.
The OHD even admitted that reporting physicians may have fabricated their versions of the circumstances surrounding the prescriptions written for patients. "For that matter, the entire account could have been a cock-and-bull story. We assume, however, that physicians were their usual careful and accurate selves"(56) when providing information.
Furthermore, even if every physician reported each case and did so accurately, there would be no way to determine whether the deaths were accompanied with problems and complications since the Oregon law does not require that a physician be present when the patient dies. According to the third annual report issued by OHD, physicians were present at only 52% of reported deaths.(57)
In the Netherlands, prior to enactment of the 2001 law, physicians were assured that they would not be prosecuted for euthanasia or assisted suicide as long as they followed guidelines and filed a report after the patients death. However, official surveys of Dutch doctors, in which physicians were granted both immunity and anonymity, revealed that only 41% of euthanasia and assisted suicide deaths were reported.(58)
Cases which failed to meet practice guidelines were most likely to go unreported.(59)
14. Isnt euthanasia or assisted suicide sometimes the only way to relieve excruciating pain?
Quite the contrary. Euthanasia activists exploit the natural fear people have of suffering and dying. They often claim that, without euthanasia or assisted suicide, people will be forced to endure unbearable pain:
Such irresponsible claims fail to recognize that virtually all pain can be eliminated or that in those rare cases where it cant be totally eliminated it can be reduced significantly if proper treatment is provided.
It is a national and international scandal that so many people do not get adequate pain control. But killing is not the answer to that scandal. The solution is to mandate better education of health care professionals on these crucial issues, to expand access to health care, and to inform patients about their rights as consumers.
In 2001, the International Task Force will be publishing an important new book, Power over Pain, which will be an incredibly valuable tool for people to use in obtaining the pain relief they need.
Everyone whether a person with a life-threatening illness or a chronic condition has the right to pain relief. With modern advances in pain control, no patient should ever be in excruciating pain. However most doctors have never had a course in pain management so theyre unaware of what to do.
If a patient who is under a doctors care is in excruciating pain, theres definitely a need to find a different doctor. But that doctor should be one who will control the pain, not one who will kill the patient.
There are board certified specialists in pain management who can not only help alleviate physical pain but who are also skilled in providing necessary support to deal with emotional suffering and depression that often accompany physical pain.
15. Isnt opposition to euthanasia and assisted suicide just an attempt to impose religious beliefs on others?
No. Right-to-die leaders have attempted for a long time to make it seem that anyone against euthanasia or assisted suicide is trying to impose his or her religion on others. But thats not the case.
People on both sides of the euthanasia and assisted suicide controversies claim membership in religious denominations. There are also individuals on both sides who claim no religious affiliation at all. But its even more important to realize that these are not religious issues, nor should this be a religious debate.
The debate over euthanasia and assisted suicide is about public policy and the law.
The fact that the religious convictions of some people parallel what has been long-standing public policy does not disqualify them from taking a stand on an issue.
For example, there are laws that prohibit sales clerks from stealing company profits. Although these laws coincide with religious beliefs, it would be absurd to suggest that such laws should be eliminated. And it would be equally ridiculous to say that a person who has religious opposition to it shouldnt be able to support laws against stealing.
Similarly, the fact that the religious convictions of some euthanasia and assisted suicide opponents parallel what has been long-standing public policy does not disqualify them from taking a stand on the issues.
Throughout all of modern history, laws have prohibited mercy killing. The need for such laws has been, and should continue to be, debated on the basis of public policy. And people of any or no religious belief should have the right to be involved in that debate.
In Washington state, where an attempt to legalize euthanasia and assisted suicide by voter initiative in 1991 failed, polls taken within days of the vote indicated that fewer than ten percent of those who opposed the measure had done so for religious reasons.(62)
Voter initiatives have also failed in California,(63), Michigan(64) and Maine.(65) All failed following significant organized opposition from a coalition of groups including medical societies, nursing groups, hospice associations, civil rights groups and major state newspapers.
16. Where does the main support for euthanasia and assisted suicide come from?
The most visible and vocal proponents of euthanasia and assisted suicide are right-to-die organizations made up of committed activists who seek to change the laws. But, they are only able to pursue their agenda because of funding from a handful of extremely generous sources.
Far from reflecting any grassroots desire, the push for legalization of euthanasia and assisted suicide is a "top down" creation where the few seek to change the laws that affect everyone.(66)
17. Since suicide isnt against the law, why should it be illegal to help someone commit suicide?
Neither suicide nor attempted suicide is criminalized anywhere in the United States or in many other countries. This is not because of any "right" to suicide. When penalties against attempted suicide were removed, legal scholars made it clear that this was not done for the purpose of permitting suicide. Instead it was intended to prevent suicide. Penalties were removed so people could seek help in dealing with the problems theyre facing without risk of being prosecuted if it were discovered that they had attempted suicide.
Just as current public policy does not grant a "right" to be killed to a person who is suicidal because of a lost business, neither should it permit people to be killed because they are in despair over their physical or emotional condition. With legalized euthanasia or assisted suicide, condemned killers would have more rights to have their lives protected than would vulnerable people who could be pressured and exploited into what amounts to capital punishment for the "crime" of being sick, old, disabled or dependent.