Thesis: Euthanasia, and a common form of euthanasia, assisted suicide, should be legal processes through which aterminally ill individual may voluntarily end his or her own life. Summary: As of 2009, assisted suicide was legal in only three states: Oregon, Washington, and Montana. Since itsinception in those states, assisted suicide has proven to be an effective, but rarely employed means of allowing a terminallyill person to end his or her life in a dignified manner. Though the United States federal government has opposed measures toenact federal legislation that would legalize euthanasia and assisted suicide, the time has come for the federal governmentand the remainder of the states to recognize that, inherent in the right to live freely is the right to decide when to humanelyend one’s life. Introduction
To understand the debate surrounding euthanasia, one must first understand euthanasia and its related variations. Theterm euthanasia, taken from the Greek word for “easy death,” refers to the process by which a physician prescribes andadministers a fatal dose of drugs to a terminally ill individual in a controlled medical environment, thus causing their death ina quick and painless manner. Euthanasia is commonly referred to as physician-assisted suicide. Assisted suicide, a relatedform of euthanasia, describes the process by which a physician or pharmacist only prescribes the fatal drugs, leaving theterminally ill individual to ingest the drugs on their own, at a time of their choosing. As of 2009, physician-assisted suicidewas not legal in any state in America, while assisted suicide was legal in three states. The Federal Government & the Courts
A quartet of United States Supreme Court cases (Washington v. Glucksberg, Vacco v. Quill, Gonzales v. Oregon, and Cruzanv. Director, Missouri Department of Health) have helped to shape the legal landscape in the debate over euthanasia and anindividual’s right to refuse medical treatment. In Glucksberg and Vacco, companion cases decided in 1997, the SupremeCourt ruled that states have the authority to prohibit assisted suicide and against the notion that the right to die isguaranteed in the Constitution. More recently, in the 2006 Gonzales case, the Court held in a 6-3 opinion that the UnitedStates attorney general could not enforce a drug law, the Controlled Substances Act, against physicians and pharmacists as ameans of punishing them for prescribing fatal doses of drugs to terminally ill patients.
Finally, in the Cruzan case, theSupreme Court upheld the right of competent persons to refuse medical treatment, but ruled that clear and convincingevidence must exist of that person’s desire to limit the life-saving measures to be performed on them. The practical impact of these rulings is that, because the federal government cannot prosecute physicians and pharmacistswho prescribe drugs to terminally ill patients, the debate over euthanasia and assisted suicide in the US has primarily takenplace on the state level. Furthermore, while individuals have the constitutional right to prevent physicians from taking life-saving measures in the event of their incapacitation, they must make clear their desire, usually through a living will or a donot resuscitate order. Success at the State Level
In 1994, Oregon became the first state to pass an assisted suicide law. The Oregon Death with Dignity Act has served as amodel statute in other states’ attempts to pass assisted suicide legislation. The act has several important provisions that, readtogether, provide safeguards for the terminally ill, the physicians that diagnose their terminal illnesses, and the pharmaciststhat prescribe lethal drugs. The act requires first, that a patient be diagnosed by a physician as having a terminal illness thatwill end the patient’s life within six months. Then, upon the patient’s request, a physician or pharmacist that has no moral orprofessional objection to assisted suicide will prescribe a lethal dose of drugs that the patient can ingest at a time of theirchoosing. Notably, the act has several safeguards, among them a requirement that the patient’s initial request for aprescription be witnessed by two people; that a second physician concur in the initial diagnosis of a terminal illness givingthe patient no more than six months to live; a conclusion that the patient is of sound mind; and a waiting period underwhich the patient must wait fifteen days before making a second, and final, oral request for the lethal prescription.
These rules and safeguards ensure that only those who are both terminally ill and of a sound mind are able to obtain a lethaldose of drugs after having made a voluntary and informed decision. Additionally, and importantly, the act does not requirethose physicians or pharmacists opposed to assisted suicide to participate in, sanction, or play any role in bringing about thedeath of a term inally ill person. The Washington Initiative 1000, passed by voters in 2008, was based on the Oregon act and, consequently, wassubstantially similar in its provisions and safeguards. Most recently, in December, 2008, a Montana trial court judge ruled thatcompetent, terminally ill patients have the right to self-administer lethal doses of drugs prescribed by a physician, thoughthat decision has been appealed to the Montana Supreme Court. Because assisted suicide in Washington and Montana is relatively new, Oregon is the only state in which data concerning theuse of lethal drugs by the terminally ill has been compiled. In the eight-year period from 1998 to 2006, 455 lethalprescriptions were written for terminally ill individuals, and 292 of those individuals used that prescription to commit suicide.
Analysis of this data indicates that only around thirty-five terminally ill individuals die each year in Oregon as a result of theassisted suicide law. This data further suggests that physicians are carefully screening applicants, issuing on average onlyfifty-seven prescriptions per year. Finally, it is also clear that applicants carefully weigh the decision to use the prescription,judging by the fact that 35 percent of prescriptions issued to terminally ill patients—who have satisfied the numerousrequirements under Oregon’s Death with Dignity Act—went unused. International Law
Oregon, Washington, and Montana are not the only jurisdictions in the world in which forms of euthanasia are legal.Notably, assisted suicide, in some form, is legal in both Belgium and the Netherlands, the latter of which has also legalizedphysician assisted suicide. Additionally, Germany has no law legalizing assisted suicide, but has not traditionally penalizedthose who have helped to end the life of a terminally ill person. As researchers have noted, however, death and suicide havedifferent stigmas attached to them depending on, among other factors, where one lives and the culture in which one wasraised. Consequently, it is not surprising that assisted suicide has been legalized in certain parts of the world, while it remainsa crime elsewhere. In the United States, however, where an individual has always in been control of their mind, body, souland destiny, death and suicide do not have as negative a cultural connotation as they may have in other parts of the world. The Social, Ethical, Medical & Economic Reasons
Assisted suicide places the individual in control of his or her future, allowing the individual to decide how, when, and wherethey die. While an issue of self-determination, there are practical concerns that face the dying. Often, a terminally ill personwatches their savings account plummet while his or her medical costs and insurance premiums—assuming they are fortunateenough to have medical insurance—skyrocket. If they do not have insurance, it is unlikely they are able to afford even the most basic medications to controltheir pain or reduce their symptoms. Though their disease is incurable, in the later stages of their illness, they often take up a hospital bed and medicalresources, as well as the time of doctors, nurses and other hospital staff—time and health care dollars that could be expended on a person who can successfullybe treated and released.
Friends and relatives watch their loved one suffer without remedy, knowing that the illness is fatal, but unable to do anything besideswait. Assisted suicide provides a quick and painless death, in contrast to the expected months of suffering a terminally ill patient must endure under normalcircumstances. The decision to end life on their own terms saves precious medical resources, ensures that the patient’s family will not financially sufferunnecessarily as a result of the illness, and allows the patient, and their family and friends, to say goodbye on their own terms in a quick and painless way.Notably, these arguments apply with equal force to physician-assisted suicide, wherein a physician not only monitors the patient to be sure they remaincompetent, but also administers the drugs at a time of the patient’s choosing, thus helping to ensure that the patient’s death is quick and painless. Opposition to Euthanasia
Opposition to euthanasia comes in part from religious and social organizations that generally oppose measures that result in the death of an individual. Suchfeelings are indeed understandable, and it is difficult to change a person’s moral convictions. These organizations are free to petition their elected officials andto champion their causes—that right is fundamental to a democratic system. They also must, however, recognize the decisions made through a democraticprocess, as those initiatives in Oregon and Washington, where the majority of voters approved assisted suicide. (It is worth noting that some of these sameorganizations support the imposition of the death penalty for certain crimes, citing the biblical passage “an eye for an eye.” In other words, some of thesegroups support the death of an individual when society has deemed it acceptable, but not when the individual himself seeks to end his life.) Other opponents include some doctors and physicians, who have, as a condition of their license to practice medicine or dispense prescription medication, takena Hippocratic Oath requiring that they do no harm to patients. Importantly, however, the assisted suicide laws that have passed in Washington and Oregon donot by any means require the participation of physicians or pharmacists.
Consequently, those physicians or pharmacists with a moral, professional, or religiousopposition to assisted suicide need not participate in any way in the assisted suicide of a patient. The same holds true for physician-assisted suicide which, inthe countries where it is legal, is practiced voluntarily. Finally, some in the medical field express concern over whether the terminally ill are of sound mind whenconsenting to suicide. While this is a valid and serious concern, the laws passed in Oregon and Washington, requiring multiple examinations, medicallyconsistent diagnoses, a waiting period, and a conclusion that the patient is of sound mind, serve to dramatically lessen any possibility that an incompetentpatient could be prescribed a fatal dose of drugs. Choosing for Others, but not for Oneself
The death penalty is an authorized form of punishment in the federal criminal justice system, and also exists in well over half of the states. Through participationin the jury system and by electing officials into office who are charged with enforcing the death penalty, citizens have a role in determining which individualsare eligible for the death penalty and, more fundamentally, whether the death penalty as a form of punishment should persist, or should be repealed. Similarly,the United States Supreme Court has ruled that pregnant women have the right to choose—in many circumstances—whether to terminate their pregnancy.
These examples demonstrate the contradiction that exists in forty-seven of the United States, under which average citizens are capable of playing a vital role indeciding whether other individuals live or die. These same citizens, though, are not entrusted with the same authority to make that decision when it comes totheir own lives in the extreme case of an incurable, terminal illness. Such a contradiction cannot stand. To preserve the dignity of human life, it is imperativethat the remaining states and the federal government legalize euthanasia, whether in the form of physician-assisted suicide or assisted suicide, to provide asafe and dignified way for terminally individuals to end their suffering.
With the advent of drugs that can both prolong and terminate life, as well as medical technology that can keep patients technically alive even in comatose or vegetative states, many questions have been raised about the quality of life each person deserves and identifying the fine line that demarcates the end of life. In addition, in the United States—a country marked from its inception by the hallmarks of individuality and personal responsibility—citizens and lawmakers alike are wrestling with issues regarding the degree to which an individual or family member should be empowered to make personal, private decisions about whether to continue medical care or choose the time, place and manner of death. Activists on both sides of the euthanasia debate have lobbied lawmakers to enact legislation in support of their views. The right to die movement is gaining support as a humane alternative to a poor quality of life maintained solely through continuous medical intervention. Understanding the Discussion
Euthanasia: The practice of ending a person’s life either through an intentional act or by withholding medical care. The action is performed without malice, but with the intention of alleviating suffering or ending the pain of a terminal illness or poor quality of life. Hospice: An alternative program of care for patients in the final stages of life, in which efforts are not designed to treat the patient’s underlying illness but rather to provide pain management, symptom control, and family support. Informed consent: A patient’s expression of knowledge and acceptance of the risks, benefits, and alternative treatment options of a medical procedure and subsequent permission to a physician to perform the procedure. Physician-assisted suicide: A procedure in which a physician deliberately and knowingly provides lethal drugs at the individual’s request for the purpose of self-administration. Right to die: A belief that individuals should have the authority to choose the time, place and manner of their death. Terminal illness: A medical condition that is so advanced that treatment options are no longer available. History
Although modern medical advancements and increased patient autonomy have renewed public interest in the right to die, the practice of euthanasia has been in existence for centuries. Numerous Greek and Roman writings have revealed a belief that death, even if initiated by self or another person, was preferable to prolonged suffering. However, this belief was not universal. The Hippocratic Oath, which medical practitioners in the United States have traditionally recited or agreed to uphold as a basic tenet of their practice, is believed to have been penned about 400 BCE by the Greek physician Hippocrates, known as the “Father of Medicine.” The oath includes promises not to provide deadly medicine to any one if asked or even suggest such a course of action, and to never cause any patient harm. In the US, prohibitions against intentionally aiding in the death of another date back to the country’s formation. Early American statutes outlawed both suicide and assisted suicide. In the early 1900s, a physician’s grim decision brought euthanasia to the forefront of public debate. On November 12, 1915, a badly deformed child was born to Anna Bollinger.
Her doctor conferred with the hospital’s chief of staff, Dr. Harry J. Haiselden, who advised against performing surgery to save the child. Five days later, the baby girl died, and the case and Dr. Haiselden’s decision were widely debated. During the 1930s, widespread distress caused by the Great Depression and its accompanying economic turbulence led to a spike in suicide rates and discussions of euthanasia and a right to self-determination over end-of-life matters. Public opinion polls revealed a growing belief that euthanasia was acceptable under certain circumstances. While it seemed that public support for legalizing euthanasia was coalescing, World War II broke out and the world recoiled in horror as news of Nazi death camps and the calculated mass extermination of vulnerable members of society made international headlines. Such atrocities dampened support for any form of legalized assistance in initiating another’s death. For several decades, discussions of euthanasia simmered largely in the background. In 1976, the tragic case of twenty-one year old Karen Ann Quinlan once again moved the euthanasia debate to national headlines.
After consuming alcohol and prescription drugs at a party, Quinlan lost consciousness and ceased breathing. Quinlan was rushed to the hospital, where doctors declared that she was in a “persistent vegetative state,” with full recovery unlikely. Her adoptive parents fought a year-long legal battle for rights to make the final decision to remove her respirator, thereby likely ensuring the end of her life. Although the New Jersey Supreme Court ultimately ruled in favor of the Quinlan family, Karen continued breathing naturally after her respirator was removed for nearly a decade, until she finally succumbed to complications from pneumonia. In 1980, right to die advocate Derek Humphry formed the Hemlock Society, a grassroots organization that has worked to advance euthanasia legislation. In addition, growing consensus for patients’ rights, including the right to refuse medical care—and even life-sustaining care—refocused attention on the right to die movement. Over the next several decades, public support for autonomy in end of life decision making has increased, with several states enacting legislation that recognizes living wills, or a legal document in which a person expresses his or her wishes regarding life prolonging medical treatments, including the withdrawal or refusal of life-sustaining medical treatment. Euthanasia Today
The history of euthanasia in the US has been marked by several significant cases. The Quinlan case, although decided by a state supreme court, led to the advent of formal ethics committees in hospitals, nursing homes and hospices that provide support in complying with a patient’s advanced health care directives, or written instructions to family members and health care professionals about end of life care. In 1990, the US Supreme Court first ruled on the right to die movement in Cruzan v. Director, Missouri Department of Health. A car accident left Nancy Cruzan permanently unconscious and her parents requested that her feeding tube be withdrawn. After years of continuous care, most of the costs for Cruzan’s hospitalization were being paid by the State of Missouri. Although a Missouri district court granted the Cruzan family’s request to remove the tube, the director of the Missouri Department of Health took the case on appeal to the Missouri Supreme Court, arguing for clear proof of Nancy Cruzan’s end of life wishes. The case went before the US Supreme Court, which ruled that a competent person has a constitutionally protected right to refuse any medical treatment, although states have a right to insist on clear and convincing evidence as to a patient’s wishes. In this case, there
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