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Euthanasia: A Global Issue
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The Humanist Institute

Euthanasia: A Global Issue

Gerald A. Larue

Globalization has meant the spread new ethical values as well as the spread of modern medicine and public health. Efforts to prolong lives of terminally ill patients often produce extended and painful dying. The new issues surround active euthanasia, which involves direct intervention by someone other than the patient. Despite objections from some traditional religions, right-to-die societies emerge worldwide. Ethical standards must be created that can deal with patient autonomy, informed choice and consent, sanctity and quality of life, patient's rights, treatment futility, medical personnel "playing God." The 1973 "Plea for Beneficent Euthanasia" by U.S. humanists was a major landmark.

Longevity has become a global reality. The benefits of modern health research, the conquest of childhood diseases, improved sanitation, new medications, and technical procedures have raised the projected life span for newborns and contributed to dramatic increases in world population. Unfortunately, not all long-lived individuals die peacefully. Some die painful, torturous deaths. When life is without quality, when pain and discomfort rob life of its significance, some persons cry out for release through death—a good death through euthanasia. Euthanasia has become a complex global issue for the 21st century, with different cultures wrestling with the variety of ethical, religious and legal factors involved in helping someone to die legally. This essay touches on some of the humanistic ethical dimensions involved in efforts to legalize euthanasia.

It can be assumed that, given a choice, most human beings would choose a gentle or easy death devoid of pain or suffering and without loss of dignity, identity, autonomy, or the ability to reason. Unfortunately, most patients, including the elderly, do not enjoy the privilege of making such a choice. For some, dying involves a long, distressful process, characterized by misery, feelings of nausea or suffocation, with intubations, debilitation, and degeneration. Efforts to control pain with drugs are not always successful and the attempts often render the patient insensible and in danger of severe brain injury. "Euthanasia," which can be simply defined as "a good death" or perhaps "a beneficent death," has emerged as a global end-of-life issue that has special relevance for the elderly, although the term embraces all ages.

The Longevity Factor

Dramatic increases in human longevity, made during the twentieth century, have transformed the expected life span at birth in developed countries from 47 years in 1900 to the late '70s today and in developing countries to just over 60 years of age today. [1] It is anticipated that by the year 2020, the elderly will constitute about 25 percent of the world population. Obviously, the issue of death-with-dignity will become increasingly important.

The Medical Factor and Death with Dignity

As medical expertise and technology continue to spread throughout the world, moral, ethical, social, and legal health issues arise, each related, in one way or another, to the prolongation of life and to the ways in which many individuals, particularly the elderly, end their lives. Today, life can be sustained indefinitely by the use of machinery and intubations. In some cases, patients, who have suffered severe brain damage and have entered a persistent vegetative state in which they are cognitively unaware, are kept alive for years. [2] Efforts to prolong life have produced instances where terminally ill patients suffer horrific deaths despite efforts to control pain. The question arises: how do individuals who are being kept alive achieve "a death with dignity?"

The Euthanasia Issue.

Euthanasia has acquired a number of different labels. For example, euthanasia can be voluntary or involuntary, [3] passive or active. [4] Passive voluntary euthanasia occurs when, in accord with a terminally ill patient's expressed wish, life-supports are removed and the patient is permitted to die "naturally" or "as a consequence of the disease." Some patients die immediately; others linger on for hours or days finally dying from dehydration and starvation. Involuntary euthanasia—that is the bringing about of a person's death without the consent of the person—is almost always treated as homicide, even when the act can be recognized as producing a "merciful death."

Active voluntary euthanasia (often termed "aid-in-dying") refers to death caused, in response to the terminally ill patient's expressed will, through direct intervention by someone other than the patient. Death may be induced by the administration of lethal medications or by lethal injection. [5]

There is debate as to whether there is really any difference between active and passive euthanasia. In the minds of some, the removal of life-supports, or passive euthanasia, is to be differentiated from active euthanasia, which is defined as "doing something to terminate life." On the other hand, for many ethicists, "passive euthanasia" has become a "weasel term" serving only to deny responsibility and perhaps to exonerate the medical staff and the doctor from being accused of having "done" something to cause the patient's death.

Recently, the phrase "doctor-assisted-suicide" has been added to the euthanasia vocabulary. Acting in accord with the patient's wishes, a physician provides the terminally ill individual with lethal medication. The patient decides when to take the medication, so that the physician does not participate directly in the death. Of course, rational, but severely handicapped patients, such as those in the final stages of ALS (Amyotrophic Lateral Sclerosis), are automatically eliminated from this mode of dying because they are not able to take medication without assistance. In countries where suicide and assisted suicide are against the law, doctor-assisted-suicide would not be tolerated.

Recently, plastic-bag-death has received some publicity. Plastic-bag-death permits a terminally ill patient to commit suicide without incriminating others. The patient is supplied with sleeping pills, perhaps a glass of alcohol, such as vodka, to enhance the effectiveness of the sleeping potions, an airtight plastic bag large enough to fit comfortably over the head, a dust mask, and an elastic band. The provider leaves the premises. The patient, now alone, swallows the sleeping tablets, drinks the alcohol, dons the dust mask (to keep the plastic from adhering to the mouth and nose), pulls the plastic bag over the head and secures it with the elastic band around the neck. Any temporary breathing discomfort can be alleviated by extending the rubber band to permit air to enter. Ultimately, the patient falls asleep and dies quietly by asphyxiation.

Global Euthanasia and the Law

In the global community, because euthanasia is often loosely defined, the determination of the ways in which different legal systems handle the subject becomes too complex to explicate simply. It is possible to state that, throughout the world, passive voluntary euthanasia for the terminally ill is not often treated as illegal. The abandonment of so-called "heroic measures" and the removal of life-sustaining equipment including feeding tubes is not equated with the abandonment of the patient. Rather, the recognition of the principle of futility and the acknowledgment that "the disease has won" refocuses treatment from efforts to cure to palliative care. [6]

In those instances where the patient is not able to communicate wishes or where the patient has not provided advanced directives stipulating the conditions under which life-support is to be abandoned, medical staff and family are faced with a dilemma. The family may seek to exercise substituted judgment and, on the basis of statements the dying person made in the past, request the withdrawal of life support. In the absence of such statements, the medical staff and the family may seek to act in "the best interests" of the patient and seek to have life-support removed. Or, the patient may be placed in a hospice environment where efforts are made to control pain and to provide an easy death.

Active voluntary euthanasia and doctor-assisted-suicide are illegal in every country throughout the world except Colombia. In Holland, the Dutch government does not prosecute physicians who, in accord with terminally ill patient's request, provide lethal medications or give lethal injections. However, Dutch physicians must follow an established protocol. Euthanasia was voted into law in Northwest Australia but the enactment of the law is being held up and debated in law courts. In the state of Oregon in the USA, strong efforts to overturn the will of the people who voted for Ballot Measure 16, which legalized doctor-assisted suicide, were made by the Roman Catholic Church and some fundamentalist Protestant groups. The millions of dollars that were poured into the anti-freedom-of-choice legislation caused the issue to be placed on the ballot a second time where it was approved by an overwhelming majority. At the time of writing, new efforts are being made to find legal loopholes to thwart the will of the people.

In Canada, aid-in-dying and physician assisted-suicide are against the law. Doctors who participate in helping patients to die face possible imprisonment of up to 14 years.

In 1962, a high court in Nagoya, Japan, declared euthanasia legal under special circumstances and specified that it should be performed by a medical doctor. A 1990 survey of members of the Japan Medical Society revealed that 87 percent of its members would honor a patient's desire "to die with dignity." However, any euthanasia performed without patient consent is against the law.

In Mexico, Italy, and South Africa, euthanasia is treated as murder. Although no cases have been reported in Mexico, in Italy, when physician aid-in-dying comes to light, the law usually interprets the act as a physician responding to extenuating situations and sentences are meted out accordingly. In 1975, in South Africa, a medical doctor who gave his cancer-stricken father an overdose of Pentothal, received a suspended sentence and had his medical license suspended for two years.

In Britain, groups supporting euthanasia have been active for decades but both euthanasia and physician-assisted suicide are treated as homicide. Unofficial estimates suggest that the number of unreported cases run in the thousands annually.

France treats euthanasia as homicide, but at the same time the actions of French doctors who specialize in what is termed "helping patients to die" are regarded as easing a patient's suffering and pain rather than deliberately causing death.

In Germany, the term "death-help" is substituted for "euthanasia" to avoid any comparison with the genocide that occurred during the Nazi regime. Both euthanasia and doctor-assisted-suicide are illegal and punishable by up to five years in prison.

Although euthanasia is not legal in Israel, the courts acknowledge that there are situations in which a doctor may take into consideration a patient's expressed wish not to have life prolonged by artificial means. In other words, passive voluntary euthanasia can be tolerated under certain circumstances.

Although survey after survey reveals that many medical doctors support the right of terminally ill patients to request aid-in-dying and have expressed a willingness to comply with these requests, there are also many doctors who oppose active voluntary euthanasia and their opposition is supported by law. Physicians, who support and honor the right of terminally ill patients to choose the time and mode of their demise, may participate surreptitiously in the patient's death. The medical mode of ending the patient's life in accord with the patient's will is by increasing morphine dosage under the guise of seeking to control pain. Of course the physician knows that the morphine will have a "double effect" and kill the patient, but it is assumed that doctor's intent was not to kill but to ease suffering. Therefore, when frail, elderly, terminally ill, individuals request euthanasia, some medical personnel will cooperate by increasing the morphine dosage in the assurance that they will be protected from litigation by the "double effect" argument. These physicians believe that to prolong the life of a terminally ill and suffering person by drug therapy, blood transfusions or surgical intervention is unethical.

In response to worldwide pleas for euthanasia from the terminally ill, and for compassionate and merciful release from prolonged and useless suffering, "right-to-die" societies have been formed in countries throughout the world. [7] Discussion, debate and dialogue involve members of the healing community, philosophers, ethicists, psychologists, and representatives of major religious bodies which have taken pro or con stands on the issues involved. [8] In their efforts to legitimize active euthanasia for the terminally ill, these right-to-die advocates argue that, in certain circumstances, a strong legal and moral case for voluntary euthanasia can be made on the basis of compassion and recognition of human rights:

a. when the disease is terminal and the patient is in intractable pain.

b. when no other means to relieve intolerable suffering are left.

c. when the reason for ending that suffering, if necessary by ending the life of the  person, is the reason for the act of euthanasia.  

Right-to-die societies insist that both passive and active euthanasia must be rigidly controlled by laws that establish procedures, protocols and safeguards designed to regulate the careful application of euthanasia to certain qualified, terminally ill persons. Such laws would serve to protect the elderly from being coerced or exploited or devalued on the basis of age or handicaps or costs of treatment.

Ethical Issues

Moral, ethical and religious issues pertaining to euthanasia embrace subjects as diverse as "patient autonomy," "quality of life," "sanctity of life," "death with dignity," "patient's rights," and "playing God." Medical personnel and their patients, both old and young, wrestle with problems associated with treatment futility, [9] informed choice, [10] right-to-die, [11] autonomy versus paternalism, beneficence versus maleficence, and so on, each of which impacts, either directly or indirectly, on the issue of euthanasia.

What is most important in any discussion of global euthanasia is the recognition of the varied ethnic, national and religious differences to be found and respected in communities throughout the world. At the same time, the ethical issues that are raised by the subject of euthanasia are all embracing and include the following:

1. Patient Autonomy

In democratic countries, where individual freedom to choose is accepted as a civil right, end-of-life decisions should be made, primarily, by the patient. Self-determinism pays respect to an individual's personal values and enables the individual to be responsible for his or her own life. To deny competent individuals, and in particular elderly persons, the right to choose not only denies respect for their lifetimes of decision making but smacks of medical paternalism. [12] Obviously, attitudes towards the process of dying will vary. Religious and cultural traditions including local customs will tend to dictate patterns to be followed. However, the empowerment of the elder and recognition of the elder's personal values must not be denied. In most countries, however, elderly patients who wish to exercise their autonomy and choose immediate death over lingering death, are denied their right to choose.

In developed countries, a Living Will, drawn up by a competent individual, provides a legally recognized means for the expression of personal end-of-life wishes. A second document, often titled "The Durable Power of Attorney for Health Care," enables an individual to select a trusted person and to give that individual the power of attorney for health care, thereby ensuring that a patient, no longer be able to communicate wishes, will still be given a voice regarding treatment. Beyond the importance of legal protection for the terminally ill, respect for the personhood of the terminally ill should be expressed through loving, supportive care.

Voluntary passive euthanasia, which is provided in response to the expressed wish of terminally ill patients who do not want to be "kept alive" on machines, is given wide support by ethicists and the medical personnel. The patient's expressed wish may be a witnessed verbal statement or be provided in written form as in a Living Will or through an appointed attorney for health care. Problems arise when an otherwise healthy person has entered a persistent vegetative state without having expressed their wishes or intentions concerning end-of-life treatment. Such persons can be kept alive by medications and gastric tube feeding for many years. [13]

In cases where medical personnel are ready to admit that continuing treatment is futile, and where there is no way of ascertaining the wishes of the patient, involuntary passive euthanasia may be practiced on the basis of what is known as "substituted judgment." Relatives or other involved individuals seek to act according to "what the patient would choose" or in "the best interests" of the patient. Some hospitals have established "ethics committees" to provide guidance.

2. Informed Choice, Informed Consent

Patient autonomy automatically includes the right to full information concerning the nature and development of the terminal illness, the choices for treatment that remain, the anticipated consequences of each form of treatment, and what will occur if the patient refuses treatment. Such information is often withheld from the elderly person. Paternalistic physicians may seek to shield the elderly patient from the truth or from a full evaluation of a terminal disease in the belief that the elderly are less able than younger persons to handle troublesome information. When medical personnel conclude that further treatment is futile and that nothing can be done to stop the progress of the disease, all competent patients, including elderly patients, need to be fully informed. Only then can the informed patient make an informed choice between alternate treatments and comprehend the consequences of choosing no treatment. Informed choice also provides the terminally ill patient with time and opportunity to make closure with those who matter most.

Informed choice immediately raises the issue of the patient's capacity to make a medical decision. [14] Capacity concerns include:

a. the patient's ability to understand the decision or choice s/he is making and to appreciate its relevance to his or her situation.

b. the patent's ability to understand the nature and consequences of the medical procedure

c. the ability to relate treatment to the patient's personal goals and values

d. the ability to make reasonable decisions based on rational thinking and rational reasons

This is to say that the determination of capacity must not rest upon the health care provider's personal standards; the patient should not be expected or required to give the same response that the physician might give.

Should the patient find that end-of-life prospects promise only continuing pain and misery, and should the patient request euthanasia as a way to end life, both the medical staff and the hospital must be equally free to choose to cooperate or not cooperate, depending on personal or institutional ethical standards. In other words, although doctor and hospital may choose not to honor a patient's wishes for euthanasia, both the right of the patient to be fully informed and the right to choose are essential in maintaining the dignity and autonomy of the terminally ill individual. The patient is free to choose another hospital and another physician.

3. Playing God: Sanctity of Life, Quality of Life

For some, the sanctity-of-life thesis rests upon the theological argument that life is a gift or a loan from God and that only God should determine when that gift or loan should be returned. Those who seek to end their life are, therefore, "playing God." The thesis has been challenged for not every person will accept a theological interpretation of life. [15]

Sanctity of life may argue biologically. Each human life marks the end product of millions of years of evolution. Each person is absolutely unique, with a personal DNA and a lived life that can never be duplicated. As a one-of-a-kind individual life, the preciousness and sanctity of that existence is to be honored and revered. However, as we shall see below, some are born with defective genes. An encephalic infant will have a life span of a few hours or a few days. Nothing can be done to replace the missing brain. The infant will automatically die. In most instances, the newborn is place in an isolation unit, receiving a minimal amount of care. Sustaining nourishment and health care is reserved for infants who will survive. Neither God or nature provides for us equally.

Sanctity of life may also be viewed sociologically whereby equal value is assigned automatically to each human life thereby underscoring the recognition of the singular importance of each human being and the part played by each person in maintaining society. Therefore, it becomes the duty and responsibility of society to protect the individual from "playing God" by blocking any effort to shorten or end that life. However, in reality, it is clear that all human life is not believed to guarantee social equality and persons are not treated as of equal value. [16] Efforts to protect a terminally ill individual from seeking death can be viewed as an intrusion by the state into individual human rights. In other words, the law and the state are "playing God."

Modern medicine has been accused of "playing God" by keeping alive those who would, without technological support, die. It is at this point that sanctity of life doctrine clashes with "quality of life" experiences. Arguments claiming theological merit in suffering may encourage some to choose not to accept euthanasia, but the theology of one group cannot be sanctioned as acceptable for all. [17]

4. The Hospice Alternative

Pressures—emotional, physical, psychological, and spiritual—placed on the terminally ill and on their caregivers have given rise to an ever-expanding hospice movement. By accepting the fact that a disease cannot be overcome and that the life of the patient will probably end within a six-month period, hospice organizations provide palliative care for the patient and supportive care for the family. No effort is made to prolong life and no medications are provided to fight the disease. Pain control and patient comfort are primary. Hospice facilities offer 24-hour care. Familial in-home care is supported by hospice volunteers, who aid in alleviating burdens and stress associated with caring for a terminally ill individual. Although hospice care varies in quality from place to place, the end result is the enhancement of the significance of the life of the terminally ill elder and the easing of stress among care-givers—both of which also benefits the dying patient.

It is important to recognize that some pain is intractable and cannot be controlled, even in a hospice setting. In addition, psychological factors can produce additional sources of suffering including

a. coping with severe physical deterioration.

b. coping with the loss of personal privacy and dignity that comes with dependency upon others for almost every aspect of existence.

c. coping with the decline of mental faculties and the loss of personal identity. Hospice will not provide lethal medications for those who desperately wish to end their miserable existence.

5. Can the Rights of the Terminally Ill be Protected by Law?

The deep concern underlying this question is that, for the elderly, the right to die will become a duty to die. There is fear that elderly patients might be pressured by family, friends, the government, health care providers, social workers or by the example of other terminally ill patients, to choose euthanasia, even though that choice may not be in accord with their personal values. In other words, the implication is that those to whom the terminally ill elder would ordinarily look for succor, strength and support, now become life-opposers seeking, for the sake of economy, inheritance, weariness, or other reasons, to terminate the life of the elder.

The idea of the right to die becoming the duty to die is, of course, an abstract concern. There will always be greedy relatives who would prefer to have a terminally ill elder die sooner than later. However, under law, such persons will have to convince physicians and, perhaps, also hospital personnel, that the elder's life should be ended because of greed or some other malicious reason, rather than because of the ravages of the disease. To seek to pressure the terminally ill elder to ask for assistance in dying would be to aid and abet a suicide, which is punishable by law and which will remain a crime even after euthanasia laws are passed.

Could family members who are weary of caring for a frail terminally ill elder or who, because medical costs are reducing a possible inheritance from the elder, subtly or perhaps not so subtly, encourage the patient to request an early death? One can only acknowledge that such a scenario could occur. The best safeguard against such a situation would be the questions asked by a competent physician or counselor. Any violation of legalized euthanasia protocol would be subject to prosecution like any other violation of law.

No matter what potential dangers may be conjured up in protest, the legalization of active euthanasia or doctor-assisted suicide can provide terminally ill elders with a personal choice regarding how and when they will die. Such choice enhances autonomy and respects the personal values.

It is generally accepted that active euthanasia must be legalized to protect those, particularly health professionals, who aid in the death of the terminally ill from litigation. Those who oppose active euthanasia argue that any legislation that affords such protection can become a slippery slope whereby elderly persons who are not terminally ill might be euthanized, and the extended list of those who would be at risk includes the frail and the physically or mentally handicapped. Efforts to use what occurred in the death camps in Nazi Germany overlook the difference between a totalitarian state and a democratic government. [18] A careful examination of every piece of proposed euthanasia legislation makes it absolutely clear that the proposed programs include only the terminally ill who request euthanasia. It is also clear that the number of terminally-ill elderly who would be affected by proposed right-to-die legislation will be small. [19] The use of "fright techniques" and dishonesty employed by those opposed to the rights of the terminally ill to choose euthanasia have been labeled "unethical" and "shameful." [20]

Fears have been expressed that a terminally ill individual, particularly an elderly person, who is not in intractable pain may, simply because of depression, request aid in dying. Again, most legislative proposals recognize this fact and call for examination and diagnosis by a psychiatrist or other mental health expert.

6. Would Doctor-Patient Relationships be Weakened?

Opponents of doctor-assisted death argue that, if doctors are given the right to assist in the ending of their patients' lives, patients will no longer trust their doctors. They claim that legalization of doctor-assisted death would destroy the relationship between the physician and patient. The doctor will no longer be viewed solely as one dedicated to fighting of disease and preserving of life; now the doctor will have a second role as the one who causes death, thereby clouding the doctor's healing role. On the other hand, patients may view the doctor as a rescuer from a lingering death marked by intractable pain. Euthanasia, in any form, must be based on patient choice; the doctor can only become involved if invited to do so by the patient. For the doctor to recommend euthanasia would constitute a violation of physician responsibility which could result in litigation.

It has been pointed out that many doctors on graduation take the Hippocratic oath which prescribes beneficence and specifically outlaws medically assisted death (. . . To please no one will I prescribe a deadly drug, nor give advice which may cause his death). In response, it has been pointed out that many doctors have never taken the oath and further, that many who do, simply repeat it as an ancient formula without any belief in the deities who are called upon to witness the oath (Apollo, Aesculepius, Hygeia, Panacea). Students, teachers, and administrators in some hospitals have created their own formulas as part of graduation ceremonies. Further, the prohibition of abortion in the Hippocratic code dates the oath and renders it out-of-touch with medical practice in those countries where abortion is not illegal.

Conclusion and Challenge

What concerns us in this issue is the maximizing and empowering of the individual, particularly the terminally ill elderly person, so that, in accordance with their beliefs, their values, their associations, and their commitments, they may feel free to choose the manner of their dying. Their choice must be an informed choice which rests on the physician sharing all aspects of the development of their illness or disease, the presentation of all alternative approaches to the termination of life, and patients' right to choose the way in which they will die.

It is abundantly clear, that as the population of the world increases and the numbers of those facing terminal illness grow in proportion, the issue of euthanasia will become more important. This paper can only serve as a brief introduction to a global concern. The position of freethought groups has been expressed over and over again since 1973 when, together with prominent lawyers, physicians, philosophers, psychiatrists, Nobel-prize winners and clergy, representatives of the American Humanist Association and Ethical Culture Societies signed "A Plea For Beneficent Euthanasia." Their support for the terminally ill individual's right to choose euthanasia has been reaffirmed in more recent statements. [21]

[1] Childhood diseases (such as whooping cough, scarlet fever, diphtheria, tuberculosis, poliomyelitis, etc.) have been almost eliminated resulting in the survival of those who, in earlier times, would have perished and in an increase in the numbers of the aged. Emphases on sanitation and health care and progress in modern medical technology and pharmacology contribute to the prolongation of life.

[2] The persistent vegetative state is to be differentiated from coma.  In coma a patient either moves out of the state or into deeper coma.  In the persistent vegetative state, the cognitive functions of the brain are forever inactive.  Life is sustained only by the lower brain stem and by gastric-tube feeding.  PVS patients have been kept alive for as long as 37 years.

[3] Voluntary euthanasia is death that occurs in accordance with the will of the patient; involuntary euthanasia takes place without the patient's assent and consequently is, in almost all settings, universally condemned.

[4]   Passive voluntary euthanasia permits a physician to act in accord with law, by "not doing anything" to "cause" death

[5] 70-year-old pathologist, Dr. Jack Kevorkian, demonstrated death by lethal injection on the CBS program 60 Minutes, November 29, 1998.  Thomas Youk, 52, suffering from an advanced stage of Lou Gehrig's Disease (ALS), was terrified of death by suffocation from the disease.  Through this dramatic act, focus on the issue of euthanasia has been moved from discussion of medical ethics to the wishes of the patient.

[6]   There is a growing body of literature discussing the medical problem of futility.  Many physicians have a difficult time "giving up" on their efforts to heal a patient.  On the other hand, patients can be subjected to a long, torturous dying process.  Daniel Callahan, "Medical Futility. Medical Necessity: The Problem Without a Name," Hastings Center Report 21:4 (1991) 30-35; John D. Lantos et al., "The Illusion of Futility in Medical Practice," American Journal of Medicine (July 1980) 81-84; Lawrence J. Schneiderman, Nancy Jecker and Albert R. Johnson, "Medical Futility: Its Meaning and Ethical Implications," Annals of Internal Medicine 112:12 (1990) 949-954; Tom Tomlinson and Howard Brody, "Futility and the Ethics of Resuscitation," Journal of the American Medical Association 264:10 (1990) 1276-1280; Stuart J. Youngner, "Who Defines Futility?" Journal of the American Medical Association 260:14 (1988) 2094-2095.

[7]   19 countries have one or more Right-to-Die organizations listed as members of the World Federation of Right to Die Societies: Australia (5), Belgium (2), Britain (2), Canada (4), Colombia (1), Finland (1), France (1), India (1), Israel (1), Japan (1), Luxembourg (1), Netherlands (1), New Zealand (2), Norway (1), South Africa (1), Spain (1), Sweden (1), Switzerland (2), United States of America (4).

[8]   For theological discussion, see Gerald A. Larue, Playing God: 50 Religions Views on Your Right to Die (Wakefield, Rhode Island & London: Moyer/Bell, 1996).

[9]   Howard Brody, "The Physician's Role in Determining Futility,"  Journal of the American Geriatric Society, 2 (1994) 875-878; Nancy Jecker, "Knowing When to Stop: The Limits of Medicine"  Hastings Center Report (May-June, 1991); Nancy Jecker, "Calling it Quits: Stopping Futile Treatment and Caring for Patients,"  The Journal of Clinical Ethics; John D. Lantos, "Futility Assessment and Doctor-Patient Relationship," Journal of the American Geriatric Society, 42 (1994) 868-870;  S. Van McCrary, Jeffrey W. Swanson, Stuart J. Youngner, Henry S. Perkins and William Winslade, "Physicians' Qualitative Assessment of Medical Futility," The Journal of Clinical Ethics, 5:2 (1994) 100-105; James Linderman Nelson, "Families and Futility,"  Journal of the American Geriatric Society, 42 (1994) 879-882; Robert Allan Pearlman, "Medical Futility: Where do we go From Here?"  Journal of the American Geriatric Society, 42 (1994) 904-905; Robert M. Veatch, "Why Physicians Cannot Determine if Care is Futile,"  Journal of the American Geriatric Society, 42 (1994) 871-874.

[10]   J. Andrews, "Informed Consent Statutes and the Decision Making Process, " Journal of the American Medical Association, 262 (Dec., 1989) 3316-3319;  Nicholas J. Demo, "Informed Opinion on Informed Consent," JAMA, 261, (March, 1989) 1767-1772; C. H. Fellner and J. R. Marshall, "Kidney Donors—The Myth of Informed Consent," American Journal of Psychiatry, (Spring, 1989) 53-73; J. Katz, "The Silent World of Doctor and Patient,"  Hastings Center Report (Sept-Oct., 1989) 5-9; Elizabeth F. Loftus and James F. Fries, "Informed Consent May Be Hazardous to Your Health," JAMA 263 (1990) 3051-3056; Stuart F. Spicker, "Ethics in Diagnosis: Bodily Integrity, Truth-Telling, and the Good Physician," in The Ethics of Diagnosis, ed. Jose Luis Peset and Diego Garcia (Dordrecht, the Netherlands: Kluwer Academic Publishers, 1992) 107-122.

[11] For a general introduction, see Gerald A. Larue, Geroethics (Buffalo, New York: Prometheus Books, 1992) chap. 19, and the extensive bibliography listed there.  In addition, see: J.L. McIntosh, "Epidemology of Suicide in the United States" in Life Span Perspectives of Suicide: Time-lines in the Suicide Process, ed. A. A. Leenaars (New York: Plenum Press, 1991) 55-69;  M. Miller, Suicide After Sixty: Tie Final Alternative (New York: Springer Publishing Company, 1979); N.J. Osgood, and S. Thielman, "Geriatric Suicidal Behavior: Assessment and Treatment," in Suicide Over the Life Cycle: Risk Factors, Assessment and Treatment of Suicidal Patients ed S. J. Blumenthal and D J. Kupfer (Washington, D.C.: American Psychiatric Press, 1990) 341-379.

[12] Paternalism, or in view of the number of female doctors, maternalism, is an attitudinal posture whereby the physician treats the elderly patient in a parent-child and doctor-knows-best fashion.  The physician may withhold vital information in the belief that the patient might become upset with the facts or on the basis that the elderly patient is unable to process the data.

[13]   One of the most widely discussed cases in America was that of Nancy Cruzan, a young woman who entered a persistent vegetative state after a motor accident.  She was kept alive for more than seven years before the courts permitted the removal of the feeding tube and she was allowed to die by starvation.  So far as anyone knows, death by starvation does not involve suffering.  In the case of Nancy Cruzan there was no way to determine what she might have experienced.  In the discussion of medical ethics the two terms are often used interchangeably.

[14] Some confusion may exist between the terms "competency" and "capacity."   "Competency," which means "ability to perform a task, is a legal term and is determined in a court of law by a judge.  "Capacity," a medical term pertaining to the patient's ability to make medical decisions, is determined by a physician, often acting in accord with a psychiatrist.  

[15] In response to the theological argument, the ability of modern medicine to produce life through in vitro fertilization and to engage in embryo transplanting, makes the concept of divinely initiated life difficult to maintain.  The thesis faces further problems when consideration is given to medicine's ability to regenerate life in cases where a body, if left unattended, would ordinarily die, and to modern medicines ability to prolong life with machinery.

[16]   See Peter Singer, Rethinking Life and Death (New York: St. Martin's Press, 1994) 190-192.

[17]   For example, see the Roman Catholic "Declaration on Euthanasia," 1980, particularly section III, "The Meaning of Suffering for Christians and the Use of Painkillers" and the discussions in Gerald A. Larue, Playing God: 50 Religions' Views on Your Right to Die.

[18] For an extended discussion see "The Slippery Slope Theory" in Larue, Playing God, pp. 21-28.

[19] To date, only 10 persons in Oregon have requested aid-in-dying and because the protocol requires 14 days to pass between the request for lethal medication and the providing of the medication, two of those requesting aid in dying died before the doctor could provide them with the necessary medications to end their lives.

[20] Marshall Perron, Chief Minister of Northern Territory, Australia, commented in a speech on the dishonesty by the Australian Medical Association and the Right to Life groups that included those who "told traditional Aborigines that we will round the sick people up and put them down . . . " Reported on p. 1 of VESS (the newsletter of the Voluntary Euthanasia Society of Scotland), 15:3, (July, 1995).

[21] See Chapters 35 and 36 in Larue, Playing God: 50 Religions' Views on Your Right to Die.

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