An ambulance screeches to a halt, and emergency personnel rush a woman into the emergency room. As a result of an accident at a swimming pool, she has no pulse and no respiration. Working rapidly, the trauma team reestablishes a heartbeat through electric shock. A respirator is connected. An EEG and other tests reveal extensive and irreversible brain damage. What should be done?

This is an example of the kinds of problems faced in the field of bioethics, the study of the interface between human values and technological advances in health and life sciences. Bioethics grew from two bases: respect for individual freedom and the impossibility of establishing any single version of morality by rational argument or common sense. Both of these bases rely increasingly on empirical evidence (Borry, Schotsmans, & Dierickx, 2005). In practice, bioethics emphasizes the minimization of harm over the maximization of good, and the importance of individual choice. That is, bioethics requires people to weigh how much the patient will benefit from a treatment relative to the amount of suffering he or she will endure as a result of the treatment. Examples of the tough choices required are those facing cancer patients with respect to whether they agree to aggressive treatment for cancer that is likely to be fatal, or those facing family members who are asked whether to turn off a life-support machine that is attached to their loved one.

In the arena of death and dying, the most impor­tant bioethical issue is euthanasia—the practice of ending life for reasons of mercy. The moral dilemma posed by euthanasia becomes apparent when we try to decide the circumstances under which a person’s life should be ended, which implicitly forces us to put a value on the life of another (Elliott & Oliver, 2008). It also makes us think about the difference between “killing” and “letting die” at the end of life (Dickens, Boyle, & Ganzini, 2008). In our society this dilemma occurs most often when a person is being kept alive by machines or when someone is suffering from a terminal illness. These are the issues Ernesto and Paulina face in the opening vignette.

498 CHAPTER 13

Active Euthanasia. Euthanasia can be carried out in two different ways: active and passive. Active euthana­sia involves the deliberate ending of someone’s life, which may be based on a clear statement of the person’s wishes or be a decision made by someone else who has the legal authority to do so. Usually, this involves situations in which people are in a persistent vegetative state or suf­fer from the end stages of a terminal disease. Examples of active euthanasia would be administering a drug overdose, disconnecting a life-support system, or end­ing a person’s life through so-called mercy killing.

Most Americans favor such actions as disconnec­ting life support in situations involving patients in a persistent vegetative state, and even for the con­cept of assisted death, but feelings also run strongly against it for religious or other reasons (Dickens et al., 2008). Similarly, Israelis hold a range of opin­ions (Leichtentritt & Rettig, 2000), as do Germans (Oehmichen & Meissner, 2000). A Swedish study showed that better education about palliative care (care aimed at pain management) options reduced the number of requests for active euthanasia (Valverius, Nilstun, & Nilsson, 2000). A system­atic survey of laypersons and health care profes­sionals in The Netherlands and Belgium found that most laypeople and health care professionals said they would support euthanasia under certain spe­cific conditions (Teisseyre, Mullet, & Sorum, 2005). Respondents assigned most importance to patients’ specific requests for it and supported these requests; they did not view patients’ willingness to donate organs, without another compelling reason, as an acceptable reason to request euthanasia.

Taking one’s own life through ritual suicide has never been popular in the United States due to religious and other prohibitions. In other cultures, such as Japan, suicide is viewed as an honorable way to die under certain circumstances. Asian Americans have the highest suicide rate in the United States, and their suicide notes are more likely to reveal that they felt they were a burden on their families (Pascual, 2000). Nationwide, less than one-third of Americans in most ethnic groups oppose physician-assisted suicide or the Oregon Death With Dignity law (Braun, Tanji, & Heck, 2001; Harris Interactive, 2007), and there is even less
support among Americans of Filipino and Hawaiian ancestry (Braun et al., 2001).

Several countries—including Switzerland, Bel­gium, and Colombia—tolerate physician-assisted sui­cide. In 1984, the Dutch Supreme Court eliminated prosecution of physicians who assist in suicide if five criteria are met:

1. The patient’s condition is intolerable with no hope for improvement.

2. No relief is available.

3. The patient is competent.

4. The patient makes a request repeatedly over time.

5. Two physicians must review the case and agree with the patient’s request.

The Dutch Parliament approved the policy in April 2001, making The Netherlands the first coun­try to have an official policy legalizing physician- assisted suicide (Deutsch, 2001).

Voters in Oregon passed the Death With Dignity Act in 1994, the first physician-assisted suicide law in the United States. In 2008, voters in Washington state passed a law essentially identical to the Oregon law.

The Death With Dignity law makes it legal for people to request a lethal dose of medication if they have a terminal disease and make the request voluntarily. Although the U. S. Supreme Court ruled in two cases in 1997 (Vacco v. Quill and Washington v. Glucksberg) that there is no right to assisted suicide, the court decided in 1998 not to overturn the Oregon law.

The Oregon law is more restrictive than the law in The Netherlands (Deutsch, 2001). The Oregon law provides for people to obtain and use prescriptions for self-administered lethal doses of medication. The law requires that a physician inform the person that he or she is terminally ill and describe alternative options (e. g., hospice care, pain control), and the person must be mentally competent and make two oral requests and a written one, with at least 15 days between each oral request. Such provisions are included to ensure that people making the request fully understand the issues and that the request is not made hastily.

Several studies have examined the impact of the Oregon law. The numbers of patients who received prescriptions and who died in the first 10 years in which the law was in effect (1998-2007) are shown in Figure 13.1. Over the 10-year period, a total

of 341 patients died under the terms of the law (Oregon Department of Human Services, 2008). Comprehensive reviews of the implementation of the Oregon law soon after its passage concluded that all safeguards worked and that such things as depression, coercion, and misunderstanding of the law were carefully screened (Orentlicher,

2000) . Available data also indicate that Oregon’s law has psychological benefits for patients, who are comforted by knowing they have this option (Cerminara & Perez, 2000).

There is no question that the debate over physi­cian-assisted suicide has only begun. As the tech­nology to keep people alive continues to improve, the ethical issues about active euthanasia in general and physician-assisted suicide in particular will continue to get more complex.

Passive Euthanasia. A second form of euthanasia, passive euthanasia, involves allowing a person to die by withholding available treatment. For exam­ple, chemotherapy might be withheld from a can­cer patient, a surgical procedure might not be performed, or food may be withdrawn. Again, these approaches are controversial. For example, Garrard and Wilkinson (2005) point out that the idea of passive euthanasia was attacked in February 2001 in a particularly clear and explicit way by an “Ethics Task Force” established by the European Association of Palliative Care (EAPC). The EAPC Task Force claimed that the expression “passive euthanasia” is a contradiction in terms because any ending of a life is by definition active. Despite these concerns, Garrard and Wilkinson (2005) conclude that there is really no reason to abandon the category pro­vided that it is properly and narrowly understood and provided that “euthanasia reasons” for with­drawing or withholding life-prolonging treatment are carefully distinguished from other reasons, such as family members not wanting to wait to divide the patient’s estate.

At a practical level, passive euthanasia can be viewed in at least two ways. On the one hand, few would argue with a decision not to treat a newly discovered cancer in a person in the late stages of Alzheimer’s disease if treatment would do noth­ing but prolong and make even more agonizing an

500 CHAPTER 13 already certain death. Indeed, a survey in England revealed that caregivers agreed that treatments could and should be withheld from dementia patients in the case of critical physical conditions (Tadros & Salib, 2001). On the other hand, many people argue against withholding nourishment from a terminally ill person; indeed, such cases often end up in court.

The first high-profile legal case involving passive euthanasia in the United States was brought to the courts in 1990; the U. S. Supreme Court took up the case of Nancy Cruzan, whose family wanted to end her forced feeding. The court ruled that unless clear and incontrovertible evidence is presented that an individual desires to have nourishment stopped, such as through a durable health care power of attorney or living will, a third party, such as a parent or partner, cannot decide to end it.

The most widely publicized and politicized case of passive euthanasia in the United States involved Terri Schiavo, who died in Florida in 2005. This extremely controversial case involving the with­drawal of forced feeding had its origins in a dis­agreement between Terri’s husband Michael, who said that Terri would have wanted to die with dignity and therefore the feeding tube should be removed, and her parents, who argued the opposite. The debate resulted in government officials, state and federal legislators, and courts getting involved. As discussed in the Current Controversies feature, such cases reveal the difficult legal, medical, and ethical issues as well as the high degree of emotion surrounding the topic of euthanasia and death with dignity.