EUTHANASIA AND ASSISTED SUICIDE

PIETER ADMIRAAL
EDITORS SUMMARY
Pieter Admiraal, MD, PhD, an anesthesiologist and specialist in
palliative care for cancer patients, presents a review of the social
and cultural attitudes about euthanasia and assisted suicide.
Throughout history it was sometimes approved and sometimes
forbidden, approved because it was a way out for suffering,
terminally ill persons, or for reasons of dignity, forbidden because
it violated the rule against killing and letting God instead of the self
be master of ones life. In the last and this century many physicians
supported it and legislation was proposed but never approved. The
Nazi brutalities were not euthanasia, but they tended to put on hold
any legislative initiatives. These are only now starting again,
beginning in the Netherlands and now also in the USA.
A short history of euthanasia
The word euthanasia originated in Greece. It comes from two Greek words, eu (good),
and thanatos (death). In its most neutral form, then, euthanasia means a good death. Since
most of us would want a good death for ourselves and for others, this cannot be the aspect of
euthanasia that engenders so much dispute today. Instead, that dispute comes from social,
cultural, and religious values that come into conflict about duties we have to die well and duties
others have to assist us.
Conflicts of this sort have always surrounded the idea. Plato and Socrates regarded
suffering as a result of painful disease to be a sufficient reason for stopping life through suicide.
We all know that Socrates died by taking hemlock, not because of a painful illness, but for a
noble reason, to uphold the very rule of law that had condemned him to death. Platos and
Socrates views on the matter diverged from those of Aristotle, who argued that suicide was not
courageous and was an offense against the state. Pythagoras and Epicures also condemned
suicide. Yet in some city-states of Ancient Greece, suicide was approved. Magistrates kept a
supply of poison for anyone who wished to die. Perhaps it was against this widespread
acceptance that the Hippocratic physicians took an oath to give no deadly drug, as they were
part of a reform movement of physicians influenced by Pythagorean ethics.
The Stoics, another later branch of Ancient Greek and then Roman philosophy, accepted
suicide as an option when life was no longer acceptable for any serious reason. To the Romans,
suicide for halting life during painful terminal illness was acceptable. Due to the Stoic influence,
the idea of dying well was a summum bonum, the highest good, and part of a noble life: A good
death gives honor to a whole life, said Epictetus, a Roman Stoic thinker. In Rome, people were
permitted, sometimes expected, to commit suicide to escape from disgrace at the hands of an
enemy, or scandal (as it is in Japan even today), or as an alternative to public execution (as Field
Marshall Rommel, a German hero, was given the option by the Nazis when it was learned he had
plotted to kill Hitler).

With the advent of Christianity in the Roman Empire, this viewpoint waned. Under the
growing influence of this religion, and its acceptance as the official religion of Rome at the time
of Constantine, suicide was no longer acceptable. The rule against killing had its origin in the
Christian view of the Commandment, Thou shalt not kill, and the pacifism of Christ and the
early Church. Life was seen as a gift from God over which persons had to take ordinary care. St
Augustine, for example, argued that suicide was against the Sixth Commandment, against
killing, and that life and suffering were divinely ordained for the individual. The moment of
death was in Gods hands, and to usurp it was a sinful act of pride, a denial of Gods power over
human life. Persons who committed suicide were usually buried outside the city walls, at a
crossroads, where that cross might ward off the devil seeking the troubled soul of the individual.
Growing intolerance of suicide continued. In AD 553 the Council of Orleans officially
denied funeral rites to anyone who had killed themselves, and in 693 the Council of Toledo
announced excommunication for attempted suicide. From early times, then, persons who were
successful at suicide could not be buried in the churchyard. This intolerance culminated in the
thirteenth century with St Thomas Aquinas. Aquinas, the great theologian, argued that suicide
was the most dangerous of sins and against not only Divine Law but the law of nature (selfpreservation). His views certainly reflected an unbroken tradition of Christianity about suicide
and any assisting thereof.
Yet perfect unanimity is hard to maintain, and probably never existed. Some softening of
views occurred during the Renaissance, after the grisly fourteenth century when the plagued
wiped out a third of the population in Europe. Death was everywhere. It touched everyone.
Intensive study of Ancient Greek and Roman sources and their cultures rehabilitated earlier
pagan values. During the Reformation, for example, Luther favored euthanasia and seemed to
cause his own death when he went for an extended walk knowing he had heart trouble. Sir
Thomas More, the famous saint and martyr for the Catholic Church and adversary of the English
King Henry VIII, published in 1516 in his Utopia the need for voluntary euthanasia for terminal
patients. This was an acceptable measure for control of suffering in the ideal society he
envisioned.
The idea continued to take hold among serious thinkers and physicians. In 1742 in
Scotland, philosopher David Humes essay Of Suicide was published in Essays, Moral,
Political and Literary. In 1794 Paradys, a physician, recommended in his Oratio de Euthanasia
(an Oration concerning Euthanasia) an easy death for an incurable and suffering patient.
Interest continued high in euthanasia later in the nineteenth century, both in Europe and in the
USA. Books on euthanasia and euthanasia societies existed in both places over a hundred years
ago, with draft legislation proposed as well. Karl Marx, in his Medical euthanasia, criticized
physicians who treated diseases instead of patients, and pledged a better alleviation of suffering.
Schopenhauer said, as soon as the terrors of life ...outweigh the terrors of death, a man will put
an end to his life. Thus, right to the end of the nineteenth century and into the early twentieth,
physicians spoke openly about the possibility of euthanasia. Because of a Prussian equivalent of
a national health plan, there was even open discussion a hundred years ago of the need for the
state to provide euthanasia for persons who became incompetent to request it (Adolf lost, Das
Recht auf dem Tod [The Right to Die], 1895).

Action in the 20th century

In 1931, a health officer in Leicester, England, named Dr Millard, published his
Voluntary Euthanasia Legalization Bill. He made the following specific proposals:
1.
2.
3.
4.
5.

An application for a euthanasia permit may be filed by a dying person, stating that he has
been informed by two medical practitioners that he is suffering from a fatal and incurable
disease, and that the process of death is likely to be protracted and painful.
The application must be attested to by a Magistrate, and accompanied by two medical
certificates.
The application and certificates must be reviewed by the patient and relatives as
interviewed by a euthanasia referee.
A court will then review the application, certificates, the testimony of the referee and any
other representatives of the patient. It will then issue a permit to receive euthanasia to the
applicant and a permit to administer euthanasia to the medical practitioner.
The permit would be valid for a specific period, within which the patient would
determine if and when he wished to use it.

In its requirements for consultation and deliberation, the resemblance to the rules the
Dutch use to become immune from prosecution during administration of euthanasia is
remarkable. This bill was discussed for five years, but was defeated by the House of Lords in
1936.
A year prior to that, in 1935, the British Voluntary Euthanasia Society was founded, the
first in the world. Shortly thereafter, a similar one was started in the USA, the Euthanasia
Society of America (1938). In 1939 this society proposed a bill to legalize euthanasia in New
York State, but it was never introduced into the Legislature. During the ten years preceding the
Second World War, several court cases dealing with assisted suicide and mercy killing occurred
in the USA and Great Britain. Although all suspects in these cases were found guilty, the
sentences in most cases were very mild.
What happened in Germany prior to and during the Second World War clearly had an
impact on the euthanasia movement. Euthanasia, as we have been discussing it, was legalized by
Hitler. A physician could help to put a patient out of his or her misery if they were suffering
during a terminal illness. But this comforting measure was mixed up with others that were, in
any event, terrible. Earlier, by 1920, two physicians, K. Binding and A. Hoche, published a book
contributing to the concept of eliminating valueless life (Die Vernichtung des lebensunwertens
Lebens). Arguments about the best way to kill life not worthy of life, wasted, or worthless
lives were discussed and published. These lives were those of the physically or mentally
handicapped, the senile, the retarded, and psychiatric patients not able to work after five years in
an institution. Nazi party physicians spearheaded efforts toward social hygiene, one step of
which was to sterilize those with hereditary illnesses, something done in America already, and
which China contemplates doing today. This was stopped in 1941 officially by Hitler after
protests from the Churches. By then perhaps 90 000 patients had been sterilized.
During the war itself, due to Nazi nationalist and racial ideology, the most evil crime of
the century took place, the Holocaust, in which 6 million Jews and 3 million gypsies, socialists,
and protesters were exterminated. This became possible through total control by the National

Socialist Party of the engines of the State, social and political control exercised by the SS and the
Gestapo, and the German propensity to educate for total obedience to law and order.
Was this euthanasia? Of course not. It was murder, purely and simply. Thus the Nazi
experience actually has nothing to do with the contemporary debate. And yet in another way it
does. Everyone should be wary of the power of the state and of involuntary killing.
After the war the debate continued, but initiatives to include the right to euthanasia in the
United Nations charter, for example, initially supported by Eleanor Roosevelt, Chairman of the
United Nations Commission on Human Rights, were withdrawn as the revelation of Nazi
atrocities increased. Parties on either side of the debate became more and more alienated from
one another. New proponents emerged, and mainly religious opponents became more explicit in
their condemnations. As we have seen, the Roman Catholic Church considered euthanasia, like
abortion, to be against the law of God, i.e. to be a deliberate and direct attack on human life.
In 1956 the Pope reiterated this view to an International Congress of Doctors. But in 1957,
addressing another international group of physicians, he accepted the possibility of eventual lifeshortening use of drugs such as morphine to relieve unbearable pain, because there is no causal
link between that effect (death) and the intent (to relieve suffering). The idea of passive
euthanasia was therefore introduced into the mainstream of the debate, along with the
distinction between using ordinary rather than extraordinary means to preserve life.
Meanwhile, in 1954, Joseph Fletcher, an Episcopal priest-theologian, published Morals
and Medicine, one of the first books in secular bioethics. In the chapter, Euthanasia: Our
right to die he contradicted the Catholic view. He was a life-long proponent of euthanasia.
Glandville Williams, professor of law at Jesus College, Cambridge, in 1957 published The
Sanctity of Life and the Criminal Law, in which he stated: the greatest of all Commandments is
to love, and this surely means that euthanasia is permissible if performed truly and honestly to
spare the patient and not merely for the convenience of the living. These two arguments in
favor of euthanasia, that it is a right of an autonomous person and that it is a kindness or
benevolence of caregivers, are the mainstays of the movement. They are addressed, head-on, by
Leon Kass in this volume.
From the 1960s onward, two additional developments had remarkable influence on the
debate. It would be hard to overestimate them.
First, there was an unprecedented revolution, an explosion of progress, in medical
science, with major discoveries and inventions that had the cumulative effect of protecting life
against almost all disease and to prolong life for a much longer time than possible before. Heart
transplantation is only one technique among many, a brilliant inauguration of an age when,
perhaps, only the doctor might decide not only when life begins (see p. 23) but also when it ends
(see p. 163). Death and dying were increasingly denied.
The second influence was the attitude of patients themselves to this technology. A great
disappointment occurred. Prolonging life could also mean prolonging suffering. On top of this,
death, naturally, was not something one could ultimately escape. Witness that realization among
younger persons with the advent of the epidemic of acquired immunodeficiency syndrome. It
proves once again the vulnerability of human life.
One could almost predict the response. Patients wanted to decide for themselves about
their own lives. The right of self-determination became a world-wide movement. Ethicists and
religious leaders tempered their condemnation of euthanasia with concerns about unduly
prolonging life and protracted dying. These concerns stemmed not only from compassion, but
also from justice, the balance of marshalling our resources properly. At the same time, increased

interest arose in providing care for the dying patient. The psychiatrist Dr Elizabeth Kubler-Ross
published her book On Death and Dying (1969), describing the stages of a dying person, and
suddenly the most popular course on college campuses and in medical schools became the one
on death and dying. The subject of dying was no longer taboo. Most importantly, however, the
attitude of doctors to their new-found power also changed. Different American and English polls
in the 1960s, asking whether euthanasia were acceptable for doctors, proved that up to 6070%
of the respondents answered Yes, if it were legal, and many admitted already performing
euthanasia in extreme circumstances.
Opposition, however continued. Many doctors opposed all forms of euthanasia, even
passive ones. The World Medical Association adopted 1968 resolutions opposed to euthanasia.
Beginning in 1975 with the case of Karen Ann Quinlan, the court system became more lenient
toward forms of euthanasia. Recall that Quinlan lapsed into a coma after taking a combination
of drugs and alcohol, and was in a persistent vegetative state. She was placed on a ventilator.
Counseled and supported by a parish priest and others, after three months the father signed a
release, on the basis of her previously expressed wishes, to permit her physicians to turn off the
respirator. The physicians and hospital refused. Her father went to court to be named her
guardian to authorize discontinuance of all extraordinary means of sustaining vital processes. In
appeal, the New Jersey Supreme Court agreed, and Karen was removed from the ventilator. The
physicians involved planned, actually, to defy the order of the court, but were successful in
weaning her off the respirator. She died about ten years later in a nursing home, never regaining
consciousness.
Other supreme courts of states, and in one case, the US Supreme Court, have decided
always in favor of individual directives against prolonging life, and in favor of passive
euthanasia. The Quinlan case profoundly influenced the Living Will statutes enacted in
36 states, as well as Durable Power of Attorney laws in most states (where one designates a
surrogate to speak for ones values about medical care during any time of incompetency). These
laws have the effect of legally recognizing ones right to die with dignity, i.e. to die with ones
values intact. In some states, the Living Will law was resisted most prominently by the
Right to Life movement, itself originating among Catholics and fundamentalists (like Baptists)
opposed to abortion. This group opposed Living Will legislation because it believed that persons
were thereby authorized to commit suicide (by not accepting medical technologies that could
prolong their lives). Such resistance was not a majority opinion in any case. The most extreme
and fundamentalist wings of this world-wide movement today are the Human Life Alliance and
the Club of Life.
In 1980 Derek Humphrey and Ann Wickett formed the Hemlock Society in America to
help people to learn how to commit suicide painlessly in the case of terminal illness. That same
year the World Federation of Right to Die Societies was formed from 27 groups in 18 countries.
Thus, the debate moved to the present day from more academic circles to much more public and
organized world-wide movements.
The Dutch experience
To a large extent on the European continent, nothing changed after the Second World
War. Almost all countries had been occupied by the Germans, most of their cities and
infrastructure having been destroyed, and their Jewish inhabitants exported and killed. Everyone
had had some terrible experience with the Nazis. In 1941, for example, Seyss-Inquart, the

German Commander in the Netherlands, tried to coerce Dutch physicians to participate in the
Nazi sterilization of the mentally handicapped and the extermination of the Jews. Without
hesitation these physicians refused, despite the fact that over 100 were promptly shipped off to
concentration camps.
The Dutch view of euthanasia as voluntary and as a good death was solidified by this
resistance to its abuse. The starting point of more public acceptance of medically induced
voluntary euthanasia occurred with the case of Dr Postma. In 1973 she was found guilty of
mercy-killing her mother, but was only given a one-week suspended sentence and a years
probation for this act. Also in 1973 the Dutch Society for Voluntary Euthanasia was founded. It
established a members aid service, giving members proper information about euthanasia, and
it acts as a mediator between patient and doctor, although it would never distribute lethal drugs
or offer physical help in dying. In 1980 this organization published Justifiable Euthanasia
(written by me), advising about the most suitable drugs and their proper administration for
euthanasia. This publication was sent to 19,000 doctors and 2100 pharmacists in the country.
The Royal Dutch Medical Association (RDMA) was a major influence in the Dutch
debate, and still is. In 1973 it had already issued a provisional statement on euthanasia: Legally
euthanasia should remain a crime, but that if a physician after having considered all the aspects
of the case, shortens the life of a patient who is incurably ill and in the process of dying, the court
will have to judge whether there was a conflict of duties which could justify the act of the
physician. Updating this view in 1984, the same association published its requirements for
doctors who assist in dying, to prevent prosecution. These were mostly taken from the
Rotterdam Court standards of 1981 for non-criminal aid-in-dying. These rules have
subsequently been confirmed in several court decisions. They are as follows:
1.
2.
3.
4.
5.

The request to die must be the voluntary decision of an informed patient.

The request must be well considered by a person having a clear and correct
understanding of his or her condition and of other possibilities. The person must be
capable of weighing these options, and must have done so.
The desire to die must be of some duration.
There must be physical or mental suffering which is unacceptable and unbearable.
Consultation with a colleague is obligatory.

In 1990, the RDMA and the Ministry of Justice agreed upon a notification procedure
about enthanasia with the following elements:
1.
2.
3.

The physician performing euthanasia or assisted suicide does not issue a declaration of a
natural death. He or she informs the local medical examiner by means of an extensive
questionnaire.
The medical examiner reports the death to the district attorney.
The district attorney decides whether a prosecution of the physician involved should be
inaugurated. If the doctor has complied with the five requirements listed above, the
attorney will not prosecute.

In effect this constitutes immunity from prosecution, although the act is still against the
law. The notification procedure acquired the force of law by being included under the Burial Act

of 1993. To this point, then, the Netherlands is the only country in the world where euthanasia is
accepted.
Following these guidelines, in 55% of cases the physician who performs euthanasia will offer
the patient a drink with a lethal dose of barbiturates. The patient will die in a deep coma as a
result of respiratory depression. About 70% of them will die within 3 hours. In most cases the
doctor will shorten this period using curare, a drug that paralyzes all muscles. In 45% of cases,
the doctor will give an injection containing both barbiturates and curare. The patient will die this
way within a few minutes. These drugs are only available to doctors with a prescription. The
physicians in question know their patient and the patients value system, and are acquainted with
the family. Most of these deaths occur in the familys home. These are important points, since
no euthanasia should be legalized if it is not part of a comprehensive program of caring for the
dying, such as that offered by hospice, and should be used as a treatment of last resort only.
Future challenges
Recent opinion polls in almost all countries of western Europe and in the USA have
proved that a majority of the populace, sometimes over 80%, answers yes to the question: Is
voluntary euthanasia in case of unbearable suffering acceptable for you, and should this be
legalized? But why has it not yet been legalized? Only in the Netherlands has it been
regulated, although it is still illegal. There are an estimated 3000 cases a year in the Netherlands,
and it has been practiced there as part of a total commitment to caring for the dying for over 20
years.
There have been four separate attempts, two in California, one in Washington, and one in
Oregon, to legalize euthanasia in the USA. Those efforts continue. Despite public support for
the concept, each time these efforts lost to a narrow majority of voters. This demonstrates that,
although the concept is fertile, making it legal is iffy for a lot of people. Strong campaigns
against legalization have been mounted by the Roman Catholic Church, other religious bodies,
state medical societies, and politicians and legislators.
There is no indication that the views of the Roman Catholic Church, Jewish bodies,
Islamic groups, and fundamentalists, will change. They rest on the principle of the sanctity of
life. Some Protestant reformed churches have accepted euthanasia under the rubric of
shortening unbearable suffering. The religious and medical groups in general find that there is
no need to legislate for euthanasia, since adequate pain control and passive euthanasia can be
used instead, and are already morally accepted. Meanwhile the growing secularization of all
elements of social life in the world contributes to independent thought. While religious leaders
do have an influence, it is waning. Surely legalization will occur in one or two places first, be
tried experimentally, and then will grow more popular when it is shown that abuses of this
power are kept in check.
Further, throughout the world there are different systems of justice. Sometimes efforts
will continue to legalize through public vote or through legislative action. At other times the
court system and the decisions of judges and/or juries will assist in the growth of acceptance of
euthanasia. Already in the state of Washington, a federal judge argued that a law restricting
assisted suicide there was unconstitutional, since it infringed the rights of individuals to die as
they wished. This decision will most certainly be taken on appeal to a higher court. In
Michigan, a state that formerly had no law against assisted suicide, one was created explicitly to
ban the actions of Dr Jack Kevorkian. He has already been tried under the law for assisting one

person to die and was acquitted by a jury. However, he may be tried for assisting two others (he
helped a total of 20 persons) before the law was enacted. This is a typically complex juridical
point, since an appeals court in Michigan has declared the law passed to outlaw assisted suicide
unconstitutional because it contains more than one provision (not because it outlaws assisted
suicide itself). In England, a physician was tried and convicted of deliberately ending the life of
a patient.
Generally speaking, courts and juries are open to euthanasia if physicians explain
carefully enough how they might follow rules that could eliminate abuse. The official stance of
most of the worlds medical associations, like the churches mentioned above, still maintains that
a doctors duty is to preserve life such that he or she cannot end it even upon request of the
patient. I see this official stance changing in the near future.
Perhaps the greatest fear of abuse is presented as the slippery slope argument: gradually
voluntary euthanasia will slip over into involuntary killing of the demented and the mentally
handicapped. This fear is based on the abuse of power that virtually defined the Nazi experience.
But is that fear rational? Are our countries like Germany at that time? After 20 years of
experience in the Netherlands there is no indication of a slippery slope occurring, although one
case did happen wherein a depressed patient petitioned her psychiatrist for euthanasia, and, after
consulting others, he finally complied.
Without question, the biggest challenge in the immediate future for the legalization of
euthanasia will be to spell out barricades against potential abuse. Once these are written into
legislative proposals, they have a good chance of being passed. Meanwhile, efforts to support
the right of a patient to request assistance will increasingly be successful in the courts.
Suggestions for further reading
Admiraal, P. Justifiable active euthanasia in the Netherlands. In Euthanasia: The Moral Issues,
ed. R. M. Baird and S. E.
Rosenbaum, pp. 125-8. Buffalo, NY: Prometheus Books, 1989. Battin, M. P. Ethical Issues in
Suicide. Englewood Cliffs, NJ: Prentice-Hall, 1982.
Brahams, D. Euthanasia: Doctor convicted of attempted murder. Lancet (1992), 340, 782-3.
Brody, H. Assisted death -a compassionate response to medical failure. New England Journal of
Medicine (1992), 327, 1384-8.
Callahan, D. The Troubled Dream of Life: Living With Mortality. New York: Simon & Schuster,
1993.
Campbell, C. S. Religious ethics and active euthanasia in a pluralistic society. Kennedy Institute
of Ethics Journal (1992), 2(3), 253-77.
Campbell, C. S. Aid-in-dying and the taking of human life. Journal of Medical Ethics (1992), 18,
12&-34.

Cundiff, D. Euthanasia Is Not the Answer: A Hospice Physicians View. Totowa, NJ: Humana
Press, 1992.
De Wachter, M. A. M. Euthanasia in the Netherlands. Hastings Center Report (.1992), 22(2), 2330.
Gomez, C. Regulating Death: Euthanasia and the Case of the Netherlands. New York: The Free
Press, 1991.
Graber, G. C. and Thomasma, D. C. Euthanasia: Toward an Ethical Social Policy. New York:
Crossroads/Continuum, 1989.
Humphry, D. and Wickett, A. The Right to Die: Understanding Euthanasia. New York: Harper
& Row, 1986.
Humphry, D. Final Exit. Secaucus, NJ: Carol Publishing, 1991.
Khuse, H. The Sanctity-of-Life Doctrine in Medicine: A Critique. New York: Oxford Press,
1987.
Kohl, M. Altruistic humanism and voluntary beneficent euthanasia. Issues of Law and Medicine
(1992), 8, 331-42.
Kushner, T. CQ Interview: Derek Humphry on death with dignity. Cambridge Quarterly of
Healthcare Ethics (1993), 2(1), 57-62.
Quill, T. E., Cassel, C. K. and Meier, D. E. Care of the hopelessly ill: Proposed clinical criteria
for physician-assisted suicide. New England
Journal of Medicine (1992), 327: 1380-4.
Rachels, J. Active and passive euthanasia. New England Journal of Medicine (.1982), 306, 63945.
State Commission on Euthanasia: Report on The Cases of Euthanasia. Den Haag, The
Netherlands: Staatsdrukkerj en Uitgeverj, 1985. Van der Maas, P. J., Van Delden, J. J.
M., Pijnenborg, L. and Looman, C. W. N. Euthanasia and other medical decisions
concerning the end of life. Lancet (1991), 338, 669-74.
Wanzer, S. H., Federman, D. D., Adelstein, S. J., Cassel, C. K., Cassem, E. H., Cranford, R. E. et
al. The physicians responsibility toward hopelessly ill patients: A second look. New
England Journal of Medicine (1989), 320, 844-9.
Welie, J. V. M. Euthanasia: Normal medical practice? Hastings Center Report (1992), 22(2), 348.

Welie, J. V. M. The medical exception: Physicians, euthanasia and the .Dutch criminal law.
Journal of Medicine and Philosophy Aug. (1992), 17, 419-37.