1. Executive Summary
This paper intends to examine the disruptive changes that euthanasia has brought to us. Euthanasia, a controversial medical innovation and practice, has revolutionized the way we perceive life and death. Such changes are evident when the past without euthanasia and the current right to die is contrasted. Areas that euthanasia has influenced such as the legal systems and social ethical issues will be discussed. In addition, different religious viewpoints on euthanasia will be investigated. The main focus of the paper will be on the future implications of Euthanasia. With the greying global population, will euthanasia be justifiable? In light of this, future alternatives to euthanasia will be discussed. An exclusive case study on Singapore’s stand on euthanasia will also be analyzed to bind the topic back to local context.
2. Introduction
Euthanasia is the painless killing of a patient suffering from a terminal and agonizing disease or in a perpetual coma.
Euthanasia can be classified into 3 different categories: Voluntary, Involuntary and Non-Voluntary. The main difference between voluntary and non-voluntary euthanasia is the will of the subject being euthanized. In voluntary euthanasia, the subject requests to die and fully consents to the killing. In non-voluntary euthanasia, the subject is not willing to die but is euthanized anyway, against his will. Involuntary euthanasia, on the other hand, involves taking the life of a subject who cannot or is unable to show his will to live or die, without consent.
Euthanasia can be carried out passively or actively. Active euthanasia, such as a lethal injection, involves intentionally performing an act to end the subject’s life. Passive euthanasia, such as switching off life support machine, is the withdrawal of an act that would have otherwise saved the subject. While the former involves an intervention, the latter form of euthanasia lets nature takes its course.
Although the line between euthanasia and physician assisted suicide is thin, a distinction should be made. The difference lies in the autonomy in which the lethal act is carried out. Euthanasia takes place when a third party performs the lethal act, intentionally killing the patient. On the other hand, if the person who dies performs the lethal act with the guidance of a third party, it is considered assisted suicide.
Currently, the most common forms of active euthanasia in countries that legalize it are lethal injections and drug overdose.
3. Historical Perspective
3.1. Origin of the concept of Euthanasia
The true origin of euthanasia is unknown although it can be traced back to the ancient Greeks and Romans who coined the term euthanasia, which means ‘good death’ or ‘happy death’. In general, before the birth of Christianity, ancient Greek physicians supported euthanasia as opposed to prolonged agony of the terminally ill. In classical Athens, the city magistrates even kept a supply of poison for the terminally ill who wished to die.
However, in the late middle ages, many religious groups such as Christians and Jews were against euthanasia, as it “violates God’s authority over life”. During the renaissance period, many reformists challenged the Church’s opposition to euthanasia. However, such efforts were futile as many countries outlawed euthanasia and criminalized the act of mercy killing.
Subsequently, bills were passed to challenge the law but to no avail. The public opinion towards euthanasia remains uncertain.
3.2. Nazi’s euthanasia initiative
During World War 2, the Nazi regime implemented a euthanasia initiative. Under the authority of Adolf Hitler, selected physicians are to euthanize individuals who are considered ‘incurable’.
However, the ‘incurable’ individuals were not terminally ill. Mentally and physically disabled innocent parties were predominantly regarded as ‘incurable’. Victims selected for the initiative were misled into the euthanasia initiative- the killings were carried out in hospitals, which are places that are regarded safe.
By 1941, some 200 000 disabled Germans had been put to death, totally unaware, by a variety of methods, including starvation and lethal injections. The operation was known as ‘Aktion T-4’
The world saw the realization of the possible abuse of euthanasia and its adversities- there was a total betrayal of trust. Non-voluntary euthanasia was carried out and for the wrong purpose. Euthanasia advocates found it hard to defend their stand.
3.3. The first assisted suicide and gradual acceptance of euthanasia
On the contrary, the general public became more receptive to euthanasia. Dr Jack Kevorkian, widely known as Dr Death, carried out the first assisted suicide in 1990, on Janet Adkins, an Alzheimer's disease sufferer who feared an excruciating future.
Although his act was heavily criticized for violating the Hippocratic oath, there are subsequent progresses on the acceptance of euthanasia. In 1994, the Death with Dignity Act is passed in Oregon. Consequently, Netherlands, Belgium, State of Washington and Luxembourg legalized physician assisted suicide and/or euthanasia.
Evidently, the world is progressing towards an increased acceptance of euthanasia.
4. Current Situation
4.1. Impact of Euthanasia on the legal systems
§ Difference in country’s legal systems in governing Euthanasia
Ever since the revolution of euthanasia, countries have been passing laws to prohibit or govern the use of euthanasia. The level of permissiveness and receptiveness of euthanasia differs among countries, resulting in a disparity between the legal systems of various countries regarding the issue on euthanasia. In other words, there is no universal law on the use of euthanasia and the position of law regarding this issue is thus not conclusive.
Why do different countries respond differently to euthanasia in their legal systems? There are a few factors that can be considered. Firstly, the religious context must be taken into account. Religious countries tend to oppose to euthanasia more than secular countries because most religions condemn euthanasia for interfering with God’s power to determine life and death. Secular countries, on the other hand, pass laws independent of the religions of the people.
Secondly, the receptiveness of countries towards euthanasia depends on the responsiveness of the countries’ healthcare system. Countries with healthcare systems that have greater transparency and integrity are likely to have higher approval rates for euthanasia- there is greater public confidence and the fear that euthanasia will be abused and misused is minimized.
Thirdly, the autonomy of the people must also be considered. Euthanasia is more likely to be accepted in countries that values personal autonomy. In countries that value personal autonomy, rights and free will of the people are encouraged and euthanasia gives an individual a right to die willingly.
Figure 1. Percentage of the Population That Approve of Euthanasia. SOURCE.—European Values Study 1999 and World Values Survey 2000, Own Calculations (Weighted Data).
As such, it is more probable for secular countries with high personal autonomy and a responsible healthcare system to legalize euthanasia. In light of this, voluntary euthanasia has been permissible by law in Belgium and the Netherland since 2002 and in Luxembourg since 2009. In the United States, only Oregon and Washington have legalized physician-assisted suicide.
However, critics have found the law to be flawed. In the case of Belgium, doctors find it totally unacceptable as the law allows the termination of life of patients who are incurable but still have years to live, such as the case of cancer patients, because the fear of abuse is great. Moreover, the law does not help the underage, as euthanasia is restricted to patients that are 18 and above. Lastly, it is unclear if physicians can suggest euthanasia to their patients at all, which is different from a patient requesting for euthanasia, considering the suggestions of physicians will have a great influence on the patient’s decision.
Evidently, different laws have been passed to regulate euthanasia or illegalize it. Even so, countries that legalize euthanasia faced the problem of loopholes in their laws. As a result, the legal position regarding euthanasia remains unsettled.
§ Suicide Tourism
What is legal in a country may be punishable crime in another. Due to such legislative differences, patients who requests for euthanasia but is restricted by the law of his country are now travelling to countries that legalize euthanasia to carry out their will, without the risk of being criminalized. Such an occurrence, known as suicide tourism, shows the stark cultural difference that exists between places that accept and tolerate the practice, and those that repels it.
One of the most common cited examples regarding this issue is Switzerland. The Swiss government permits assisted suicide on foreigners and the Swiss charity Dignitas alone has helped some 150 Britons end their lives in Zurich. In January 2003, Reginald Crew - who suffered from motor neurone disease - became the first Briton to publicly travel to Switzerland to be euthanized.
A main concern of suicide tourism is the spike in the number of foreigners travelling to Switzerland to be euthanized, many of them who are not terminally ill. In response to this, an initiative to outlaw suicide tourism was proposed but was subsequently rejected by 78% of the voters. More than 278,000 votes were cast. Concerns over suicide tourism will be minimal if the authorities ensure that criteria for euthanasia is strictly adhered to the tourists are closely monitored.
However, this sparked off a debate on whether it is fair for foreigners to travel miles to have a dignified death. Besides, not all terminally ill patients who requests to be euthanized can afford to travel to places like Switzerland to do so legally. As a result the difference in legal perspectives of countries and hence suicide tourism, countries that ban euthanasia such as the United Kingdom are constantly pressured to outlaw the ban and it is possible that in the near future, these countries will succumb to such pressure.
4.2. Impact of Euthanasia on society and ethical issues
§ Controversy over Euthanasia
Euthanasia has questioned many ethical issues and the benefits and costs of it on society remain highly debatable. One of the common arguments for euthanasia is that it ends the prolonged suffering of the terminally ill. Sometimes, the pain of the incurable illness is so unbearable that the patients feel that they are better off dead. Voluntary euthanasia entitles such patients the right to die a fast and painless death as oppose to having to endure a slow and agonizing one.
However, is pain always the motivation behind euthanasia? Apparently, it is not so. A study conducted in a nursing home in Netherlands concluded that pain was the main rationale in only 11% of the euthanasia requests. Instead, the leading motivating factors of euthanasia are the patient’s loss of dignity and severe depression. Surprisingly, pain plays a small role in a patient’s decision for euthanasia. Instead, scientific studies reveal that psychological factors rather than physical pain motivate euthanasia. Yet, the argument for euthanasia is still valid if countries that legalize euthanasia implements law that closely monitors the motivating factors of the terminally ill patients, allowing euthanasia only for those who are suffering immense pain and are not psychologically affected.
Another argument for euthanasia is that it is cost-effective. In 2009, the Medicare in the US paid $50 billion of hospital bills during the last 2 months of patients' lives – that is more than the budget of Department of Education. The cost of dying is huge yet ineffective- it is estimated that 20 to 30 percent of these medical expenditures had no meaningful impact. Extrapolating from Dutch records, euthanasia may cut total health spending in U.S by 0.07 per cent. The saving from hastening death by euthanasia may be US$20,000 (S$29,600) for each family. Many of the times, terminally ill patients undergo aggressive treatments and medication although the chances of survival are slim and they will eventually die. Yet, doctors cannot suggest euthanasia to be carried out when the patient is unaware of the end-of-life option because it is illegal to do so. Hence, euthanasia should be legalized to reduce the wastage of resources and promote effectiveness in the healthcare system. However, such an argument is sensitive to ethical problems.
On the other hand, arguments against euthanasia usually cite that it devalues the sanctity of life since it intervenes the natural process of death. However, in voluntary euthanasia, it is the choice of the terminally ill, the patient is not obligated to die and he has the right to choose. As such, I do not see this as devaluing human life. In fact, death is not natural all the time. Freak accidents and death from diseases are not part of natural death, yet they are widely accepted.
In addition, the opponents of euthanasia also fear of abuse of euthanasia. The abuse of euthanasia such as non-voluntary euthanasia takes away lives of people against their will. This is tantamount to murder. However, with proper and deterrent laws regulating euthanasia, the concern of abuse will be minimized and euthanasia can use for a good purpose.
Evidently, euthanasia has challenged society’s morality in many ways. As the debate on euthanasia continues, society is eventually opening to such a possibility.
§ Implications of Euthanasia on vulnerable parties
One of the most worrying ethical issues of euthanasia is the impact of euthanasia on society’s vulnerable parties. Vulnerable parties, in the context of euthanasia, refers to people who are unable to express their will or are likely to be pressurized or receive undue influence to end their lives. These people include the terminally ill elderly, infants with no chance of survival as well as patients that are virtually brain dead.
Individuals who are unable to express their wills
For individuals who are unable to express their will such as infants and patients who suffer from brain dysfunction, someone has to help them make a choice if euthanasia is to be carried out. However, the question of concern is, does anybody, besides the individual, have the rights to help the individual make a decision concerning life and death? No problem will arise if the decision made by the third party is in line with the will of the vulnerable party. However, what happens if the decision made is against the will of the patient?
The Groningen Protocol
Delving into the case of infants, the Groningen Protocol regulates cases in which a decision is made to actively end the lives of newborns. The question under consideration now is the cases in which a newborn can be euthanized under this protocol. First, there are infants with no chance of survival; these are infants that will die despite intensive medical treatments. Secondly, there are infants that will survive if given intensive care but will have a poor prognosis of life. Lastly, there are infants that do not have life-threatening diseases but will have poor quality of life despite treatments.
Under the protocol, passive euthanasia is actually encouraged for infants in the first category. Whether or not euthanasia should be carried out to infants under the second and third categories will depends on parents, physicians and an outside legal body. Considering the condition of the infant, a team of physician must agree that euthanasia is the best solution and parents must agree to it. The legal body must ensure that the decision is strictly justified.
Evidently, with proper regulation of the process, a third party can make end-of-life decisions. The aim of the protocol is not to keep infants alive, but to ensure that they will have a good quality of life. Besides, whether such a decision will go against the will of the infants and brain dead patients, may be out of the question because such an argument is made based on the assumption that these vulnerable parties have the ability to think and have a will. However, do they really have a conscious mind to have a will? As such, euthanasia should not be condemned on the basis of the fear of possible abuse of it on vulnerable parties. With strict monitoring and regulation, euthanasia can be justifiable.
Individual likely to receive undue influence to end their lives
If euthanasia is legalized, individuals such as the disabled, terminally ill and elderly may resort to end-of-life decision, as they feel pressurized by families or peers and wish to reduce their burden. However, is it possible to influence such individuals so much that they lose their will to live? Ultimately, the choice lies with individuals and how strong their will to live is and euthanasia should not be judged based on the possible undue influence to end a life. In addition, before euthanasia is to be blame for allowing families to pressurize the elderly, why not seek ways to improve healthcare cost and promote family support? Ultimately, these are the roots of the problem.
Oregon’s Death with Dignity Act
With reference to the Oregon’s Death with Dignity Act, Oregon residents can end their lives through lethal medicines if they are terminally ill as confirmed by a physician. Most importantly, it must be ensured that the death if the terminally ill patient will not induce a benefit to anyone- the death must not carry incentives of any sort to other parties, and the decision must be solely made based on the patient own will.
Hence, with proper monitoring and regulation, the possible abuse of euthanasia on vulnerable parties can be overcome.
Figure 1: Number of DWDA Prescription Recipients and Deaths as of 2007, by Year, Oregon, 1998‐2007
§ Difference between Euthanasia and Suicide
Will the gradual acceptance of euthanasia lead to a greater approval of suicide or vice versa? To answer this question, the relationship between euthanasia and suicide must be investigated. Is there are difference in the concepts or are they associated with one another?
Suicide is the intentional killing of oneself. Euthanasia on the other hand is the mercy killing of an individual who is terminally ill. Although euthanasia is slowly gaining acceptance in some parts of the world, in most countries, suicide remains punishable by law. Suicide is induced by a lack of motivation to live and it is usually harsh and sudden. On the other hand, euthanasia is thought to be a philosophical act, which takes place after careful consideration.
Apparently, although euthanasia and suicide are concepts that are similar, they are not the same. Hence the case that euthanasia will lead to suicide is a slippery slope argument. In fact, euthanasia is a better alternative than suicide- individuals are granted the autonomy to die peacefully and can do so lawfully.
An example in case will be, Mme. Se ́bire, a French woman suffered agonizing pain from a facial deformity caused by a unusual type of tumor. After the French justice turns down her relentless requests for euthanasia, she decided to take her on life by overdosing on sleeping pills.
As such, euthanasia provides a better alternative to suicide and allows patients to terminate their life legally and peacefully.
4.3. Different religious viewpoints on Euthanasia
§ Difference in permissiveness of Euthanasia among different religions
As mentioned in the earlier part of the paper, religion plays an important factor in deciding whether a country legalizes or prohibits euthanasia. Under detailed analysis, it is evident that most religions condemn the practice of euthanasia although the extent in which they so varies.
Islam is strictly against euthanasia and condemns all acts that induce death. Christianity and the Catholic Church both take a strict position as well against euthanasia, declaring it tantamount to murder. However, the Catholic Church concedes that it is undesirable to extend a life of prolonged suffering. Protestants vary in their views on euthanasia. Liberal Protestants tolerate passive euthanasia, while more conservative Protestants denounce all forms. Buddhists, on the other hand, generally condemns euthanasia but allows for it if the subject has a peaceful state of mind at the time of death.
In summary, Muslims will be most against euthanasia; Christians and Catholics are in the middle of the spectrum, while the Protestants and Buddhist are comparatively more permissive towards Euthanasia.
5. Future Considerations
5.1. The Legal Future
§ Increased acceptance of Euthanasia in law
Richard John Neuhuas, “From the unthinkable, to the debatable, to the justifiable, on its way to the unexceptional.” This quote clearly illustrates the direction in which euthanasia is heading in in the legal systems. More countries are legalizing euthanasia or physician assisted suicide. In the past, euthanasia is unconceivable. Currently, it is on the road of being debatable and in some countries, justifiable. In the future, euthanasia may be just another medical procedure.
Countries that used to condemn euthanasia by law are now relaxing the laws, especially in non-Western countries. For instance, euthanasia was illegal under the Japanese’s Criminal Code. However, due to a court case in1962, the Nagoya High Court now ruled that one could legally end a patient's life if 6 requirements are explicitly fulfilled.
Recently, the India's Supreme Court ruled on 14th March 2011 that an Indian citizen has the right to die with dignity. Passive euthanasia is now permitted, but under watchful eye of the law. Active euthanasia remains outlawed because it went against the fundamental "right to life" principle in India's Constitution. Although opponents of euthanasia drew a parallel between euthanasia and sati, the court nonetheless felt that in view of several international rulings on the subject, passive euthanasia should be allowed upon the request of the patient.
Apart from the authorities, the general acceptance and openness to euthanasia of the public has a great influence on changing the legal stand on euthanasia. The Japan Society for Dying with Dignity, consisting of more than 100,000 members is the largest advocacy group for passive euthanasia. Such developments show that modern society gradually maturing and accepting what was initially unthinkable.
The implications of a legal future towards euthanasia will depend largely on the quality of the laws passed and close monitoring and regulation. If the laws are flawed, there is a great chance that euthanasia will be abused by people who get around the laws. Apart from having good laws governing the use of euthanasia, close monitoring and adherence to the law must be ensured to prevent abuse. Hence, if the laws governing euthanasia are complete, fair and are closely abided by, positive implications such as the increased in autonomy of the people in deciding their death can be expected. On the contrary, if the laws contain loopholes, the legal future will be disastrous as possible abuses arise.
5.2. The Ageing Population
There is no doubt that the world population is greying. United Nations forecasts predict an increase in the number of over 60 year olds from 10 to 22 percent by the year 2050. The ageing population challenges the notion of euthanasia. There are 2 possible scenarios that will arise: either an increase in support for euthanasia or a stronger objection against it.
Already, elderly in the Netherlands are so frightful of being euthanized by doctors that they carry cards indicating that they oppose euthanasia. If we extend this into the future, it may indicate that with a greying population, euthanasia will face stronger opposition. People who have not much control over their lives or are not are not as economically valuable, such as the elderly, are more likely to fear the potential abuse of euthanasia and hence display unfavorable opinions towards it.
The opposite scenario will occur if elderly accepts euthanasia as a mean of relieving prolonged suffering if terminal diseases cripple them. With a greater proportion of elderly, there will be an increase in the number of patients who suffer terminal disease due to old age. Euthanasia can be a mean for them to end their lives peacefully if they find it more humane to die than spend their last few years in agony.
As such the effects of the ageing population on the acceptability of euthanasia will largely depend on the attitudes of the elderly towards it.
§ Moral Hazard: Dying for Money
- elaborate next time-
5.3. Alternatives to Euthanasia
§ Modern palliative care
Many opponents of euthanasia believe that with proper palliative care, the need for euthanasia diminishes. According to the World Health Organization, palliative care is an approach that seeks to improve the quality of life of patients through the relief of suffering by offering a support system. Palliative care encourages life and views death as a natural process. The intention of it is to neither hasten nor delay death.
Although both euthanasia and palliative care are similar in the way that they view that death is inevitable, palliative care aims to kill the pain while euthanasia aims to kill the patient. It is argues that patients must experience the benefits of palliative care first before considering euthanasia. Only when palliative care fails to alleviate pain, can the patient use euthanasia as their last resort.
Palliative care is a rapidly advancing area of medicine and nursing and modern palliative care is changing the face of medicine. Dr Richard Hillier, chairman of the Association for Palliative Care said, “Where there was nothing 30 years ago, there were now hundreds of units and thousands of teams (providing palliative care)”. Specifically, according to a report done by Lancaster University, UK, since 2006, more than 150 countries are actively engaging and providing palliative care or developing a framework.
Although there is a significant global progress on palliative care, we are still a long way from comprehensive palliative care. According to the same report, only 15% of the countries have reached close integration of palliative care and mainstream healthcare services.
Evidently, by cutting down the cost of palliative care and increasing its awareness to the general public in the future, advances in palliative care could eventually rule out euthanasia. Advancement in palliative care not only extends the alternative in which a terminally ill patient can choose to die, it can also eliminate the pseudo choices for euthanasia that results from poor healthcare.
§ Upgrading healthcare services and infrastructure
To provide comprehensive palliative care, healthcare services and infrastructure must also be developed. According to Singapore’s Ministry of Health, efforts have been made by the healthcare authorities to expand the capacity of hospices and nursing homes and extend their reach. In addition, palliative care is now a medical subspecialty and the government has been seeking ways to increase training opportunities to develop a pool of healthcare personnel specialized in palliative care.
However, such enhancements must be done in cost-efficient and productive manner. The rationale behind this is that such developments, if made inefficiently, will escalate healthcare costs and patients will still choose euthanasia to end-their-life because it is a cheaper alternative.
Hence, if palliative care were to be efficient and accessible to the general public in the future, the healthcare facilities and services that support it must be developed productively such that the purpose of palliative care, which is to provide an alternative to euthanasia, is not defeated.
Human Organ Trafficking – elaborate next time-
§ The possible abuse of Euthanasia
§ Human Organ Trafficking: If euthanasia is legalized, unsavory acts and shrouded murders to feed to organ trade industry may be spurred.
Evidence: Top Russian Scientist Warns Euthanasia Will Increase Human Organ Trafficking
Implication: Severe human rights violation, increase in organized crimes, social instability.
6. Case Study: Singapore
6.1. The Government’s Stand
The Ministry is encouraging Advance Medical Directive (AMD) and palliative care. After the first year of introduction, only 10,000 people have signed AMDs.
Possible reasons for the low participation rate include the reluctance to discuss death or a lack of awareness. AMD, similar to passive euthanasia, is not about hastening or postponing death by medical intervention but encouraging natural death. While AMD extends a person's autonomy on the ways of dying, euthanasia is perceived as an act of killing.
A debate on legalizing euthanasia was sparked locally when Madam Lim Kim Keow, a patient who suffered the final stages of nerve sheath cancer, requested to be euthanized, which is illegal in Singapore. AMD was not enough for Madam Lim. “Everyday I have now is not a gift to me” she said. Unable to withstand her dependence on other people, she wants to die in dignity and she wants it at that moment with her choice of place, time and method of death.
Health Minister Khaw Boon Wan believes that Singaporeans are not ready to accept euthanasia. The National Council of Churches in Singapore condemns euthanasia as it diminishes “the value of human life. Similarly, the Hindu Community, Singapore Buddhist Federation and the Islamic Religious Council of Singapore perceive euthanasia tantamount to murder. Meanwhile, all four religious groups support AMD.
6.2. Moving towards palliative care
Apart from the developments of healthcare facilities and services to support palliative care in Singapore, activists form Hospice Care Group, which is sponsored by the Cancer Society. Initially, the Hospice Care Association, a non-governmental organization devoted to spur the development of hospices for palliative care, was partly funded by charities and patients still have to contribute to heir medical fees. Yet from 1994, the Government made funding available from the Central Provident Fund.
Currently, around 13 organizations provide palliative care services in Singapore. The ratio of palliative care to the population is 1: 333000 and Singapore is one of the 35 countries that are considered to have integrative palliative care. The medical curriculum has also factor in palliative care as a necessary module and all medical students have to be trained for this medical treatment.
7. Conclusion
The growing debate over whether people who possess the right to live also possess the right to die continues. The view towards euthanasia remains divided. While it is important to preserve and protect life, due regard must be given to the autonomy of an individual in choosing the method of death.
Whether euthanasia will be embraced in the future will largely depend on the public’s attitude towards it. If they are the rising stars and are keen and optimistic towards new technology, euthanasia will largely gain acceptance. While if they have a pessimistic outlook on euthanasia, the future of euthanasia will be gloomy.
Ultimately, the public’s degree of acceptance towards euthanasia will depend on how well it will be regulated and monitored by law. From session 5, we learnt that "The manager does the right things, the leader does things right." Applying this quote to the case on euthanasia, the leader here can be the government and law authorities- they have to implement laws that ensure that the country is going in the right direction. The managers in this case are doctors and medical staff- they should ensure that the medical practice of euthanasia is not abuse and abide by the law. It is important to have collaboration between the ‘leader’ and ‘manager’ of euthanasia to ensure that the law is comprehensive and closely monitored such that abuses will not occur and approval rates can increase.
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