Euthanasia and assisted suicide raises profound issues of importance for society, the medical profession and nursing. Despite the ongoing battle, the theoretical and practical parameters of euthanasia and assisted suicide are still debatable in society today.
Euthanasia and assisted suicide can be used interchangeably, but in actual fact, assisted suicide is not to be confused with euthanasia. According to Boylan (2000) in classic Greek, euthanasia means “good death” (p. 195). It has also come to be known as mercy killing, which involves taking an action that will end a life that is afflicted with a terminal disease and that is characterized by intense suffering.
The word euthanasia is somewhat ambiguous and has several possible meanings. Hence, it is appropriate at this point to explain what is meant by this term. Richardson (2000) explains euthanasia as being divided into two different categories: active and passive. Active, also referred to as commission, is the act of bringing about ones death; passive, or omission, is intentionally withholding a life saving medical procedure, therefore allowing them to die. Singer (2000) continued to explain that the above categories are further broken down into three additional subcategories: voluntary, involuntary, and non-voluntary. Voluntary euthanasia occurs when an individual is a competent recipient and consciously requests that his or her life be ended; involuntary is whether or not the act is consistent with his or her wishes; and non-voluntary involves no consultation because the patient is unable to communicate their wishes as with infants and the unconscious.
An associated concept is assisted suicide. Singer (1999) outlines the Senate committee's definition of assisted suicide as “the act of intentionally killing oneself with the assistance of another who deliberately provides the knowledge means or both” (p.99). He continues to explain that with physician-assisted suicide, a physician is the person who provides the assistance.
The purpose of this paper is to provide the reader with a background in euthanasia as well as assisted suicide and the most relevant historical events. We will outline the various points of view from an ethical, legal, and religious perspective. Considering these views, we have also examined and incorporated nursing implications as they relate to our practice.
Debates about the ethics of euthanasia and assisted suicide date back as far as Ancient Greece and Rome (Emanuel, 1994). However, Emanuel (1994) dates the first reference to euthanasia in the English literature to be in 1516 by Sir Thomas More. He wrote that, “if life became unbearable for the incurably ill, the magistrates and priests did not hesitate to prescribe euthanasia” (p. 3). The incurable ended their lives willingly by starvation or drugs, hoping to dissolve their lives without any sensation of death.
Research failed to obtain any significant historical events for the sixteenth century concerning euthanasia. It was not until the seventeenth century that the debate on euthanasia revived with Francis Bacon extending his belief about science. He believed that science should help relieve man's estate by arguing that the physician's duty was not only to restore health but to mitigate pain and sorrow; and not only when such mitigation may conduce to recovery, but when it may serve a fair and easy passage (Emanuel, 1994).
The beliefs from the seventeenth century carried over into the late eighteenth century. Samuel D. Williams, a non-physician, addressed the Birmingham Speculative Club on the topic of euthanasia in 1870. Williams advocated the use of chloroform or other medication not just to relieve the pain of dying, but to intentionally end a patient's life (Emanuel, 1994).
Over the next thirty-five years the debate on euthanasia continued with the most notable event occurring in 1905 and 1906. At this time Charles Eliot Norton, a renowned Harvard professor, delivered a speech advocating euthanasia. Based on Norton's speech, Ohio state representative, Hunt, introduced a bill to legalize euthanasia. This prompted significant interest. However, Hunt's bill was rejected by the Ohio legislation that same year (Emanuel, 1994).
After 1906, interest in euthanasia dwindled. It regained interest in the late 1930's, amid the turmoil of the outbreak of war. This era involved a shift from voluntary to involuntary euthanasia whereby Adolph Hitler ordered widespread mercy killing of the sick and disabled (The History Place, 1996). The Nazi euthanasia program to eliminate life unworthy of life first focused on newborns and very young children. Children up to the age of three who showed symptoms of mental retardation, physical deformity, or other symptoms were those targeted. The program quickly expanded to include older disabled children and adults (The History Place, 1996).
In 1993 a political action committee, Oregon Right to Die, is founded to write and subsequently pass the Oregon Death with Dignity Act. This committee proves successful in 1994 when Oregon voters approve the Death with Dignity Act. This act permits terminally ill patients, under proper safeguards, to obtain a physicians prescription to end life in a humane and dignified manner. Australian's Northern Territory would be the next to approve a euthanasia bill in 1995, passing voluntary euthanasia as law. It went into effect in 1996, however, they were not as successful as the state of Oregon, with the bill being overturned by the Australian Parliament in 1997 (Humphry, 2003).
By 1998, a Michigan physician, Dr. Jack Kevorkian, assists the suicide of his ninety- second patient. His home state then passed a new law making such actions a crime. Although assisted suicide was now illegal, Kevorkian continued on helping people die and by November 1998, he had assisted in one hundred and twenty deaths. A year later in 1999, Dr. Jack Kevorkian, was sentenced to ten to twenty-five years imprisonment for the second degree murder of Thomas Youk. He showed the video of his death by injection on national television (Humphry, 2003). The following year in 2000, the Netherlands legalized euthanasia with Belgium following in 2002 (Humphry, 2003).
The arguments propounded for and against euthanasia have changed neither in form nor substance in almost one hundred and twenty years (Emanuel, 1994). They predate by many decades those arguments made in Nazi Germany, and also appealing to current philosophical traditions. There tends to be a general pattern of public interest in euthanasia that seems to flourish at different times throughout the last century. It is evident that people have a continuing desire to gain control over their death so that they can die in a compassionate and painless manner (Emanuel, 1994).
The question still remains as to why people want the option of euthanasia or assisted suicide? According to Snyder (2001) some individuals want more control over the process of dying. He continues to explain that some fear pain or a protracted death involving unwanted respirators, feeding tubes, and other technology. Others regret having watched their loved ones die without effective pain and symptom control and are also concerned they will not receive good care when they need it. Many are concerned about becoming a burden on their families. Loss of dignity or self image is also feared as is the idea of winding up in a long term care facility or other setting.
The ethical arguments in support of euthanasia center on the physician's duty to relieve the suffering patients experience and on the understanding of the duty to respect patient autonomy (Snyder, 2001). Deciding to end ones life and having control over the timing and manner of death are extremely private matters which do no harm to others. Many people involved in medicine believe active physician assistance for a group of seriously ill and dying patients at their request can be morally justified (Beauchamp & Childress, 2001). Beauchamp and Childress (2001) also stated, “under clearly monitored supervision, such acts and assistance in dying should be made legally permissible” (p. 144).
Whether legally permissible or not, there are many people who will go through extreme measures to end the suffering of their loved ones. The story of Tracy Latimer sparked much interest in the media in 1994. She was a twelve-year old girl and a long time sufferer of severe cerebral palsy. Her father, knowing her misery, arranged to end her pain and suffering by using carbon monoxide from an automobile. Tracy herself was unable to express any wishes in this matter; however, many people saw the father's actions as compassionate and approved of what he had done (Nadeau, 1998). Section 241 of the Criminal Code states “everyone who councils a person to commit suicide or aids or abets a person to commit suicide, whether suicide ensues or not, is guilty of an indictable offense and liable to imprisonment for a term not exceeding fourteen years” (Potter & Perry, 2001; Duhaime, 2004). Because Tracey's father's actions were not legally permissible, he was convicted of second degree murder (Nadeau, 1998; Ross-Kerr & Wood, 2003).
The case of Sue Rodriquez is another example of the legalities related to euthanasia. Rodriquez had been diagnosed with amyotrophic lateral sclerosis. She asked to be assisted to die at such time as her condition might become unbearable to her (Ross-Kerr & Wood, 2003). Section 14 of the Criminal Code says “no person is entitled to consent to have death inflicted on him, and such consent does not affect the criminal responsibility of any person by whom consent is given” (Potter & Perry, 2001; Duhaime, 2004). Therefore, the Supreme Court of British Columbia dismissed her case. Although she was denied assistance, she died in 1994 with the assistance of an unknown physician (Nadeau, 1998; Ross-Kerr & wood, 2003).
Furthermore, Canadian citizens have a basic right to refuse medical care and treatment and they have a right to decide what medical treatments they accept or reject even if the rejection of a life saving procedure leads to their death (Beauchamp & Childress, 2001) However, autonomous action is incompatible with the authority of states, religious organizations, and other communities that legislates a person's decisions (Beauchamp & Childress, 2001). Somerville (2000) argued that if death is inevitably imminent for a person who wants and consents to euthanasia, then to provide it is no different from withdrawing life-support treatment from a person who refuses it and dies as a result. In both cases, death is the outcome, and the means used to achieve this end are not morally distinguishable and should not be legally distinguished. It is inconsistent to support the ethical and legal acceptability of certain withdrawals of treatment that result in death and not likewise to support euthanasia by lethal injection (Somerville, 2000).
Religious communities are often a source of support and direction for those confronting death. Therefore, religion is an important aspect to view when considering the debate on euthanasia. Burdette, Hill and Moulton (2005) outlined two broad points of view which define the religious debate. They explain on one side of the religious spectrum, there are those who prefer autonomy in deciding between life and death. This stand point is primarily championed by mainline Protestant groups and emphasizes an individual's right to control end of life care. Their argument is that God has granted humanity the right of personal choice and that this authority must extend to matters of life and death. On the opposing side of the ethical debate are those who favor the absolute dominion of God. According to this point of view, God holds exclusive authority over the transition from life to death. Some religious affiliations support autonomy in such matters, while others may view assisted suicide and euthanasia as a usurpation of God's authority (Burdette, Hill & Moulton, 2005). Whether religious affiliates are moved by either of these views may depend on their religious involvement. For example, Terry Schiavo, a 41-year-old brain-damaged woman became the centerpiece of a right-to-die battle. Her husband Michael Schiavo, who was appointed guardian, gave the order to have her feeding tube removed (The Law Center, 2005). Her parents, believers of the Catholic faith, fought to retain guardianship and have the feeding tube reinserted (Girsh, 2005). The
Catholic faith does not support euthanasia or suicide stating “God alone is the Lord of life from its beginning until its end: no one can under any circumstance claim from himself the right directly to destroy an innocent human being” (Burdette, Hill, & Moulton, 2005, p. 83).
Despite her parents efforts the courts ruled in favor of Michael Schiavo resulting in the removal of Terry's feeding tube on March 18, 2005. On March 31, 2005, thirteen days later, Terry Shiavo passed away (The Law Center, 2005).
A similar case took place in 1975. Karen Ann Quinlan, a 21-year-old collapsed and within hours, entered a coma from which she would never recover. Her parents, also Roman Catholics, had a different view than Terry Schiavo's parents. Although both practiced the same religion they had opposing views. They believed that when faced with terminal illness, one may well be disposed to ending life, and one's immediate family may support this method of death (Lane, 2005). Karen Ann Quinlan's parents fought to put an end to their daughter's misery. They argued that their daughter would not want to be kept alive by extraordinary means. However, in this case, the courts ruled to allow her treatment to be stopped but artificial feeding to be continued. She maintained this position as a living corpse until June 1985, when she eventually died of pneumonia (Lane, 2005).
The focus on euthanasia in ethical debates is on the involvement of physicians with the nurse's involvement receiving seldom attention. However, nurses occupy a central position in the care of the terminally ill patient (De Beer, Gastmans, & Dierckx de Casterle, 2004).
The role of the nurse in carrying out euthanasia can vary from simply being there for the patient to the actual administration of the lethal medication. Nurses will inevitably be involved in assisted suicide issues in one of three ways: first, patients may confide to a nurse when they are considering hastening death; second, the patient may expressly request advice or assistance from a nurse; third, a nurse may witness a request, be present during discussion, or remain with the patient during his or her dying moment (Coughennower, 2003). Nurses must be prepared to deal with the issue of assisted suicide. Guiding principles in this setting include advocacy and nonabandonment.
Coughennower (2003) suggested that since all nurses face the issues of euthanasia personally and professionally, a proactive approach may be best. She further explains that ethically, the nurse needs to be aware of their code of ethics as articulated by their nursing association. Legally, the nurse must know the law in his or her own state in which they practice. Also, the nurse must practice within the framework of the state's nurse practice act. It is necessary for nurses to evaluate their own personal views about assisted suicide and euthanasia, developing a position consistent with their beliefs. It is important to keep in mind that their beliefs may conflict with other cultural ideals; therefore, it is the nurses' responsibility to examine and respect the patient's beliefs about end-of-life issues.
Christine Malevre, a Paris nurse, was faced with such an ethical dilemma. On January 31st 2003, Christine was sentenced to ten years in prison and banned from nursing for life for the murders of six patients between 1997 and 1998. She claims that she acted out of compassion and was merely helping to end people's suffering. Many of the families of the patients who died deny that their relatives had asked to die. She did not obtain documentation proving that the patients had requested assistance; therefore, Malevre has been unable to prove her claim (Girsh, 2003).
De Beer, Gastmans, & Dierckx de Casterle (2004) suggest that in spite the fact that the responsibility lies in principle with the physicians, and nurses are given a supporting role as assistants, the involvement of nurses in euthanasia is situation dependent and contributes to an extreme lack of clarity regarding nurses' involvement. They believe the continuity of care and the closeness with the patient place nurses in a privileged position for listening to and registering the patient's euthanasia request, for determining what the reasons may be for the request, for reporting the request to the attending physician and for assisting and supporting the patient and family. The strong personal involvement in caring for these patients and the specific expertise in this area permit nurses to be a “skilled companion” for these patients. A companion who is willing and competent to encounter the other as a person, to ascertain his or her needs and, together with the patient, to seek the most dignified answer in an interdisciplinary context (De Beer, Gastmans, & Dierckx de Casterle, 2004).
Euthanasia and assisted suicide have been an ongoing debate for centuries and continues to warrant even today in the twentieth century. Within this debate lie the ethical, legal, and religious points of view. Some believe that it should be the right of the individual to choose their fate when it comes to dying; others believe that it is the will of God to decide these matters (Burdette, Hill, and Moulton 2005). Historically, the trend seems to be pro euthanasia and assisted suicide, stating in many documentations that patients should not be left to suffer in extreme pain or with severe illness (Lane, 2005). Today, this still appears to be the overtone of the debate, however, issues of ethics and legalities seem to be the only thing stopping the acceptance of euthanasia and assisted suicide as an accepted practice. This is evident by the numerous attempts made across the United States in the 1990's to legalize euthanasia and assisted suicide (Coughennower, 2003).
Lee (1998) believes lonely deaths are often the result of criminalizing aid in dying. She argues that people who are determined enough will find the information they need to carry out the act and often they send their families away because they do not want to involve their
loved ones in criminal conduct. “They obtain and hoard drugs, and one day are found with lethal secobarbital in their body and a plastic bag over their head” (p. 549). For a competent adult who chooses to die, there doesn't appear to be much purpose in a law that would forbid
them from committing suicide if they are physically able to do so (Dunstan, 2005). Dunstan (2005) also raises an important question, “why should they be refused help - legally permissible help- in killing themselves if that is what they want?” (p. 13). He suggests in considering this, there would have to be strict laws and guidelines to be followed to avoid abuse or misuse of such legislation.
The broad social debate on euthanasia, which in Belgium and the Netherlands has already led to a euthanasia law, leads us to believe that nurses will increasingly be confronted with euthanasia requests and will therefore be more involved in care for these patients (De Beer, Gastmans, & Dierckx de Casterle, 2004). Awareness of the specific contribution made by nurses in caring for these patients seems to be lacking in the social debate, in research, and in clinical practice. Optimal care for patients who explicitly request euthanasia demands a better understanding of how nursing expertise and care can most effectively be employed in the interdisciplinary care context, so that the patient receives the most humane care available (De
Beer, Gastmans, & Dierckx de Casterle, 2004). It is obvious that euthanasia and assisted suicide are extremely complex issues and in order to determine if we can do better with end of life care it will require nursing to examine its very soul (Coughennower, 2003).