Opposition Against the Idea of Legalizing Euthanasia Essay

1) your paper engages in an issue of rational controversy (i.e. you have an opponent that isn’t a straw man!)

2) your paper is attempting to answer a question that doesn’t demand only empirical investigation in order to resolve or make progress in resolving (i.e. you can make progress just sitting and reflecting)

3) you engage in a debate you care about and are invested in (i.e. you care about getting an answer to this controversy)

4) the controversy targeted by your paper is a debate you can make a productive contribution to (this might be hard to anticipate, but you need to aim for this)

include in the outline every point, idea, argument, and observation you would plan on including in the paper. This assignment, in short, is to do all the intellectual work behind the writing of the paper.

First Writing Assignment
Writing philosophically is difficult, and difficult to do well. Most philosophy papers require more
extensive preparation in order to communicate clearly the contributions of the author. For this reason I
have designed the first “paper” in this course to not be a paper at all.
For this assignment I want you to compose a detailed outline in preparation for a full paper. You will not
have to write this paper now (but you will be doing so for the second assignment). As such, the
emphasis is on the “detailed” of “detailed outline”. I want to see you include in the outline every point,
idea, argument, and observation you would plan on including in the paper. This assignment, in short, is
to do all the intellectual work behind the writing of the paper.
Length is a subjective matter for this assignment, but I don’t imagine that you can do an adequate job in
under two pages. You’re going to have to identify (even if you don’t fully explain) the ideas you plan on
including, and it should be clear to me what are the claims you plan to make in the paper and how you
will defend them. Remember again that philosophical writing is and should be denser then much other
academic writing. I’m not going to be too formal about my evaluation here, I just want to see you
making an authentic effort to get into the exploration of your chosen topic.
Grading for this assignment will concern almost entirely the conceptual depth and density with which
you compose your outline. A thesis with a couple throw-away defenses will not cut it. If you follow the
attached procedure, you should find yourself with more than enough to build a detailed, complex
discussion of your topic. Clarity and organization will also factor into your grade for this assignment, so
even though this is only an outline, it may still be a good idea to do some revisions!
As far as acceptable topics go, I have decided to let you have more or less free reign in what you want to
work on. We’re only a few weeks into the semester and there isn’t a wide variety of topics available for
you to choose from if I limited you to course material. So instead I propose the following: pick a topic of
some more general universal import. Something related to how to understand the Human Condition,
Experience, or the way the World is in general would make great topics. It would also be hard to go
wrong with taking a topic related to Ethics or Morality. Another useful guide for considering a topic is to
pick something related to possible perspectives we can take on our lives and the world. Philosophy
doesn’t limit itself to a particular one or type of these perspectives, and it wouldn’t be too controversial
to say that philosophy lives in the space where we compare these perspectives against each other.
Pick a narrow topic, but don’t limit it by contextualizing it to just your experience or into some restricted
conditions. Approach whatever issue you pick as if it was part of a discussion that would not be limited
to a specific cultural or other circumstantial background. Finally, as I have tried to articulate in class, I
want you to really dive into whatever question or issue you want to explore – don’t just poke at the
issue from afar, speaking to what others have or would say on the issue. Try to get inside the question;
imagine it from the vantage point of someone who has to make a decision on how to answer that
question and what things you think they should be considering. I think the philosophers we’ve already
read may give you a good idea of what this kind of engagement looks like, but if you are having any
further trouble with picking out a topic or in figuring out how I want you to approach it, please contact
me so we can talk about it. Consider me available for assistance throughout the week up to the day the
assignment is due.
The attached summary of my lecture for next week may also be of assistance. Please take a look:
These steps do not necessarily need to follow rigidly in the order they are presented in, but they are all
covering facets of the overall process that are good to keep in mind.
#1: Picking a topic
There are 2 general categories of motivations philosophers have in picking topics to discuss:
–
–
Sometimes a philosopher already has an answer to some question that we wonder about and so
they start with the knowledge of where they want to go (their conclusion) and the process
becomes a matter of giving a defense of this answer/position. Maybe you already have an
opinion on some matter that you would like to work with to see what can be said for it.
Other times (many times!), a philosopher just starts with a question they are curious about and
wants to explore more. In this case they may not have an immediate answer, or even a starting
guess, and the process becomes exploring the question and what things will be considerations
we will have to weigh. Perhaps you are in this boat where you’ve wondered about something
but are not yet confident or comfortable claiming that a particular answer to that question is the
right one. This is totally ok! You don’t have to have all the answers before you start out on the
journey of writing a philosophy paper.
Whatever your motivation is, you want the paper to end up engaging with a matter of some substance
and significance. You don’t want a paper that ends up defending an uncontroversial answer to a
question that no one finds perplexing. Don’t be afraid to try to tackle something you are not 100%
confident about. The philosophical process is an ongoing one where we sort out the various
considerations together, rather than accepting answers based on the authority of the author.
Also be looking for potential opponents. This will be easy if you are approaching things from the first
direction mentioned above, but even if you are starting with the second, you should end up making a
claim by the end of the process and being aware of the other possible answers out there that will be in
disagreement is good. If you can find a strong opponent to your conclusion, that is a good sign you have
a substantial topic.
In balance with all of this is making sure that you are able to accomplish (more or less) what you set out
to defend. If your topic is too broad it will be impossible to give a satisfactory defense of what you are
trying to claim. Too narrow, and you run the risk of it being insubstantial. This is a hard balancing act
that mostly requires experience to judge, but a sensitivity to this possibility even for new students of
philosophy is a good thing in my opinion.
#2: Identifying a thesis
Your thesis is your conclusion that you will be spending the paper trying to defend. Every philosophy
paper needs a claim like this. Even if you are starting out just exploring a question, by the end of things
you need to adopt some position on that question and make whatever case you can. Again, don’t feel
like you have to be dogmatic about your opinion before you can set about defending it. You can even
say as much in your paper! You can say something like, “I’m not completely confident this is the right
answer because of x, y, z (reasons that may be in tension with your conclusion), but reasons a, b, c (or
however many you have) seem to make a good case for my conclusion”. Such modesty is totally
appropriate when the situation calls for it (i.e. there must be some reasons x, y, z available!), but also
don’t make the mistake of being overly modest when you have in fact presented strong support for your
conclusion!
Finally, I want to emphasize that while defining a thesis may happen at the start of this process it also
may not. In either case, most theses will get modified and adjusted as you go about the work of putting
together the paper. You may find that the arguments you come up with are able to justify a stronger
thesis then what you originally had in mind, or you may find it is too hard to defend your original thesis
and you’ll have to weaken it. Be open to this possibility as you go to work.
Two variables are particularly important when defining a thesis:
–
–
Scope: this is similar to the suggestions I’ve been making regarding the journals. Don’t make
your topic to broad – find a manageable topic that you’ll be able to give a good treatment to in
the space you have available. Since you are only doing an outline, you may feel you can be more
ambitious, but just keep in mind that the bigger the topic, the more you’ll have to say to support
any conclusions you draw about it.
o Example:
▪ We never know anything (too broad)
▪ The subjectivity of perception undermines our claims to know things on the
basis of our experience (much more manageable)
Strength: this is parallel to scope in that the stronger the thesis, the more defense is required in
support. Let’s look at a couple of examples to explain:
▪ The subjectivity of perception undermines our claims to know things on the
basis of our experience
• (this is still a strong claim since it rules out a number of ways we may try
to justify knowledge based on experience, AND because inferring from
our experience is a commonly accepted basis for knowledge)
▪ The subjectivity of perception threatens to undermine our claims to know things
on the basis of our experience
• This is weaker since “threatens” does not yet assert that the threat is
successful. All that would be required for this thesis is to provide
reasonable support to the existence of a concern that is in tension with
our claims to knowledge based on experience.
o In this example, the first is stronger not only because if true it rules out more opponents,
but also because it controversially denies something we usually take to be
o
o
uncontroversial. The more controversial the claim, the stronger it is and the more
defense it requires
Strength also concerns the force in which a claim is asserted:
▪ Example:
• We possibly don’t know
• We plausibly don’t know
• We don’t know
• We certainly don’t know
• We necessarily can’t know
▪ These proceed in increasing strength
Watch strength because it is tempting to assert our claims more forcefully in order to
express confidence, but confidence doesn’t always come with enough supporting
reasons to justify it! Philosophers are never (ideally) convinced of something only on the
basis of the conviction of the one arguing – conviction is not a substitute for giving good
reasons in support.
Finally, when deciding on a thesis, it can be useful to get straight on the following two things:
–
What is the precise question my thesis is supposed to be an answer to?
What are my motivations behind defending this thesis and not another?
These should help you get starting identifying what kinds of reasons and considerations you want to be
bringing up in the course of the paper and what stuff is actually off track. It also helps make sure you are
defending only what you need/want to, without leaving out anything OR adding claims you really might
not need to in order to get your point across.
#3: the first pass
The next step is to make a (revisable) list of the points, observations, arguments etc that first strike you
as you approach the question, topic, or position that is your chosen subject. Most of the papers I’ve
gotten in the past from students only make it this far. And while this is a crucial step in the process of
writing a paper, it is not the end of the road.
If you are starting with a question: listing the various significant considerations related to answering the
question should give you an idea of what answer you want to pick up and run with. After this step might
be a good time to go back to #2 and work out defining a thesis.
If you are starting with an answer: First look to why you are at this point convinced of your position.
What has maybe been in the “back of your head” when you’ve formed this opinion in the past. Once
you’ve got down what has led you to this position up to this point, spend time seeing if you can’t
brainstorm some new reasons for the position that you may not have considered before but which
provide additional support.
#4: the second pass: filling gaps
This stage is for looking over your list of considerations and seeing if anything needs to be added in
order to just make your story sensible. Perhaps you make a leap in logic that could be filled in so that
your reader can follow what’s going on. It is easy to make assumptions as far as how your audience will
understand what you are trying to say, and this stage is just to take a step back to see how much you
may be taking for granted and fixing that.
#5: the third pass: validity/sufficiency
This time going through your list you should be looking for ways in which a reader could agree to all your
points while still disagreeing with your thesis. See if what you’ve said is really enough to convince
anyone who doesn’t take issue with your arguments.
Example:
–
Today is a Monday, so you should give me $5.
o Someone can agree with the truth of the premise (that today is Monday) without
agreeing that the conclusion (you should give me $5) follows from this point.
A less silly example:
–
We need an America with strong values, and I haven’t ever broken the law (unlike my opponent
who has held 3 parking violations in his life), so you should vote for me.
o Again, the premises may be true, and they may even provide SOME support for the
conclusion, but maybe not ENOUGH support – like I hope is clear in this case!
If you find that someone could take a (sensible) stance that agrees with you on your premises but not
your conclusion, then see if you can’t fix this by providing more support or including more premises that
forge a tighter link between your conclusion and the premises. Sometimes the answer is to weaken the
conclusion too!
#6: the fourth pass: soundness
Here you should now look for ways the truth of your points could be called into question. Perhaps there
is some controversy over your claims in support of your conclusion. Get clear on how such objections
might go and find ways to address them (or avoid them by adjusting the claims in your argument).
Sincerely going through this step will probably help you find much more to say in your paper if you were
originally worried you might not have enough to say. Remember charity! (try to make your opponents
look as strong as possible so that you give them a fair presentation and so that when you argue against
them you are accomplishing more)
#7: the fifth pass: perspective
Now step REALLY back and look for ways in which your topic may be approached in alternative ways.
Compare and contrast, but first just do this for yourself (don’t necessarily include it in the paper) as a
way of exploring the ideas related to the issue. The similarities and differences between your
perspective and others may possibly not contribute to the discussion of what answers we have the best
reasons for. If such similarities/differences DO contribute, then they may be a good addition, but don’t
just put them in automatically (this is the biggest source of “space filling” which I will not appreciate so
much – remember how I talked about how I want you to get “into” the issue of giving an answer and not
just talking about different ways people COULD answer).
This step can take the longest and demand the most imagination on your part (in addition to holding a
lot of things up in the air at the same time), but many times it is where things are the most dynamic in
terms of getting straight on your own view and the best way to go about defending it.
(if you didn’t start with a thesis, but instead with a question, you should probably do this step alongside
step #3)
#8: Organization
Another CRUCIAL step. This is where you decide what order to place your content in. Many things can
inform this including:
–
–
Argumentative structure: generally keep claims and the arguments they support together
o This is probably already obvious. If you have a chain of reasoning, don’t split it up with
other points that are not relevant to that chain.
Uncontroversial -> controversial
o Start with the more uncontroversial and move to the controversial
Simple -> complex
Common -> uncommon
Direct -> indirect connection to the “source” material (this being wherever the discussion
begins)
o Along with this is: significant -> less significant to your core position
o The idea here is to start with the stuff that matters more to your discussion and leave
the curiosities toward the end. If there’s one point or set of points that you think are the
most important reasons for your conclusion, don’t save them all for the very end unless
this contradicts all the other variables listed here
In general, you also want to be clear in alerting your reader to 1) where you’re going and 2) how you are
planning to get there. Philosophical papers should not be like leading us blinding through a bunch of
points to a surprise answer. This virtue of philosophical writing becomes more important at the draft
stage of paper composition (as opposed to the outline stage), but it is still good to mention now.
A final note on Audience
Identifying an audience is important when defining a thesis, but most of the time it won’t be necessary
to imagine any substantial philosophical views on their part. For example, Jackson may be imagining
certain philosophical beliefs of his readers in his paper on Mary (this is why he puts in the 3 clarifications
in order to head off possible objections) since he is arguing against a certain common view (physicalism).
But his paper is a very focused addition to an ongoing conversation. Your papers will probably not have
so specific a purpose, so don’t worry too much about such things.
My advice if you are going to imagine an audience is to imagine someone who is open, curious, but
critical (in a non-antagonistic sort of way). They will listen to whatever you want to say, but they won’t
just accept your arguments rolling over, unless you really do provide good reasons in defense of your
position. I, for some reason, always imagine Morgan Freeman, but go for whatever works for you. Think
of an audience that will be a part of that whole co-operative truth seeking thing with you.
Hope this helps!!!!
Let me know if there is any way I can help you out more!!!
tim
Thesis: Compared with the right to life, human dignity is equally important.
A person should have the right to decide to keep his life, or to give up his life with dignity,
therefore, under patient’s consent, euthanasia should be allowed.
Argument1:
Argument2:
Argument 3:
Possible objections:
1. How to confirm if this is patient’s real intention
Because the vast majority of suicide is not the purpose of the person involved, but a means to
achieve the result .
For example, those who choose to commit suicide after suffering a severe strike do not really
want to die, but do not want to face reality. Suicide is just a means to escape reality. After solving
this problem, there will be no suicidal thoughts.
Specific to euthanasia. Just as some old people can go out for the sake of their children and
grandchildren, you can hardly guarantee that no sick old people will choose euthanasia (means) in
order not to drag their children and grandchildren (purpose).
Although this is the choice of the elderly, it is not the real will of the elderly. It is just an
alternative action passively based on economic thinking, and it is irreversible.
!
EUTHANASIA!
(Contemporary debates of applied ethics)!
!
Summary of “In Defense of Voluntary Active Euthanasia and!
Assisted Suicide” by Michael Tooley and!
“A Case Against Euthanasia” by Daniel Callahan!
!
Before I start summarising the two articles, I would like to put on the top of this work the most
common description of the term “euthanasia”. So Euthanasia is: “the painless killing of a patient
suffering from an incurable and painful disease or in an irreversible coma. Origin: early 17th cent.
(in the sense ‘easy death’): from Greek, from eu ‘well’ + thanatos ‘death’.”1 The topic of euthanasia
is one that is shrouded with much ethical debate and ambiguity. In the beginning of his work,
Michael Tooley clearly describes what is his main goal, i.e. to defend the claims that first: neither
voluntary active euthanasia nor assisting someone to commit suicide is in any way morally wrong;
secondly, there should be no laws prohibiting such actions, in the relevant cases. After that it is
really important to make the distinction of the tree considered types of euthanasia, which are:
voluntary, non-voluntary and involuntary euthanasia. Voluntary euthanasia refers to euthanasia
performed at the request of the patient. Involuntary euthanasia is the term used to describe the
situation where euthanasia is performed when the patient does not request it, with the intent of
relieving their suffering – which, sometimes can be considered as a murder. Non-voluntary
euthanasia relates to a situation where euthanasia is performed when the patient is incapable of
making a decision.
After that we can see the important dichotomy of “active” and “passive” cases of euthanasia. Active
euthanasia refers to the deliberate act, usually through the intentional administration of drugs, to end
a terminally ill patient’s life. On the other hand, supporters of euthanasia use “passive euthanasia”
to describe the deliberate withdrawal of life-prolonging medical treatment resulting in the patient’s
death. We can conclude that the main difference between active voluntary euthanasia and assisted
suicide is that in physician-assisted suicide, the patient performs the killing act. Physician-assisted
suicide refers to a situation where a physician intentionally assists a patient, at their request, to end
his or her life, for example, by the provision of information and drugs. It must be noted that
1
The description is taken from “The Oxford Dictionary of English”
euthanasia is currently illegal in most of the countries in the world, although, there are a handful of
countries and states where acts of euthanasia are legally permitted under certain conditions. There
are many arguments that have been put forward for and against euthanasia. Following the article
we can see the consideration of one very important side of the whole question, which is the defence
of the assisted suicide and voluntary active euthanasia and later the author had contrasted it with the
voluntary passive case of euthanasia. Michael Tooley gives the readers an exhaustive list of
premises that are in big favour and protection of the voluntary active euthanasia and after that we
can see the successful logical verification of each of them. “Provided that one does not have any
obligations to others that would make it wrong for one to provide someone with voluntary active
euthanasia, then the difference between helping someone to end his or her life, and doing it for that
person, cannot be morally significant.”2 So we can consider that every patient has the right to make
the decision by his or her own about whether and how the should die, based on the principles of
autonomy without causing harm to others. As every individual should have the right to control their
life and make their decisions concerning death. In this case it is more than obvious, I think, that by
performing euthanasia more good than harm would be done to the suffering patient. It is a famous
view that the fundamental moral values of society require that no person should be let to suffer and
die in suffering, instead of that merciful act of euthanasia should be permissible. And in that way
the patient can peacefully reach their dignified death.
It was proven that voluntary active euthanasia and assisted suicide are not morally wrong in
themselves. Tooley actually synthesised it in one perfect description of the case: “The only intrinsic
difference between voluntary active euthanasia and voluntary passive euthanasia is that the former
is a case of killing, and the latter a case of letting die.”3 It is a common fact that usually supporters
of euthanasia claim that active euthanasia is not morally worse than passive euthanasia – the
withdrawal or withholding of medical treatments that result in a patient’s death. With this view, it is
argued that active euthanasia should be permitted just as passive euthanasia is allowed. It is
interesting to see that in the last chapter of his article Michael Tooley is using as an example the
theory of James Rachels, who is a well-known proponent of the euthanasia. He thinks that there is
no moral difference between killing and letting die, because the intention is usually similar based on
a utilitarian point of view. Rachels even argues that “Historical and anthropological evidence that
approval of killing in one context does not necessarily lead to killing in different circumstances”
2
Tooley M., “In Defense of Voluntary Active Euthanasia and Assisted Suicide”, p. 167, in
“Contemporary debates of applied ethics”, Blackwell;
3
Thereinafter.
and of course we can see the usage of this argument in Tooley`s article.4 So the active euthanasia
actually is considered as more humane than the passive one. Never mind the religious arguments
against the euthanasia case (and they are really serious), I think that a big percentage of the
reasonable persons in one society should agree that a quick and painless death (active euthanasia) is
much better for one human being than a slow painful and sometimes “everlasting” process of dying,
similar to torturing. So we can put a moral question here that can deal with the cases of euthanasia:
Is it better for a patient to experience a quick and painless death possible with one pill, or the
patient`s life must be prolongated with a breathing machine (for example) next to their until they
finally die? Opponents of euthanasia argue that there is a clear moral distinction between actively
terminating a patient’s life and withholding treatment which ends a patient’s life. Letting a patient
die from an incurable disease may be seen as allowing the disease to be the natural cause of death
without moral responsibility. But life-support treatment merely postpones death and when
interventions are withdrawn, the patient’s death is caused by the underlying disease. Central to the
argument against euthanasia is society’s view of the sacred status of life, and this can have both a
secular and a religious basis. The essential element is that human life must be respected and
preserved. The Christian view sees life as a gift from God, who ought not to be ended by the taking
of that life. Similarly the Islamic faith says that it is only God`s will to give life and cause death.
The withdrawal of treatment is permitted when the condition of the patient is futile, as this is seen
as allowing the natural course of death. Some sides and opinions against the act of euthanasia was
just mentioned in the above rows, but now we should go deep to the other side of the topic in the
case against euthanasia and see the main problems that Daniel Callahan rises in his article. Callahan
is worried about the social consequences of legalising euthanasia. He thinks that proponents of
euthanasia mistakenly interpreted the decision to end one’s life (with assistance) as a private
decision, and consequently as something that should be left in the zone of self-determination. We
can consider that as wrong because euthanasia is necessarily a social act: something that requires
the assistance of another individual. Otherwise, I mean without the assistance of another individual
we can consider the act of ending ones`s life as a suicide. For example the common views of the
society in a situation of voluntarily active euthanasia and in spite of patient`s consent, considers it
as primordially wrong. Callahan who`s work is against the act of euthanasia describes the practice
of active voluntary euthanasia as “consenting adult killing”.
4
Tooley M., “In Defense of Voluntary Active Euthanasia and Assisted Suicide”, p. 174, in
“Contemporary debates of applied ethics”, Blackwell;
Here I think is important to pay much more attention to the serious contrast of situations of killing
and letting die. The reason this is important when it comes to euthanasia is that some people think
that there is no problem for an individuals to refuse life-preserving medical treatment (and let
themselves die), but do not think it is acceptable for the same individuals (with assistance from their
doctors or families) to take active steps toward killing themselves. And that can create a case of
serious moral dilemma and confusion in the society. It is a common case that euthanasia advocates
are trying to exploit the openness of people to the passive forms of euthanasia when defending its
active forms. They do this by arguing that there is no important moral difference between killing
and letting die. As it was mentioned above the name of James Rachels is often used as a “symbol”
as he was perhaps the leading proponent of this argument. Of course unsurprisingly Callahan rejects
it. He thinks that proponents of the “no difference” argument are wrong and confused, because they
fail to appreciate the nature of a doctor’s decision to “let someone die”. Basically, he points out that
life is fatal and that ultimately, doctors can’t prevent death, they can only postpone it. Thus, they
aren’t really killing people when they are retreating the treatment, they are just making unavoidable
decisions about the best use of medical resources. Probably Callahan’s analysis is a little uncertain
here. There are complex issues to be addressed in determining what counts as a cause of something,
and he fails to discuss those. On the other hand we can see Tooley’s argument, which opposes
Callahan’s, that does not rely on this killing versus letting die distinction and so the issue can be
sidestepped by the euthanasia advocates. As we proceed with the article we can find, as it was
already noted one of Callahan’s primary worries about euthanasia i.e., if euthanasia is worldwide
legalised, it will be add to the range of permissible killing in society. And if we add it to the range of
permissible killing, sure we will find ourselves in a very difficult and disturbing situation. He
illustrates his point by a reference to a study done on the regulation of euthanasia in the Netherlands
(“The Dutch experience”). Throughout the 1970s and 1980s, Dutch courts allowed certain
conditions for euthanasia cases. Although the legal situation has changed more recently, it is this
period that is covered by the study referenced by Callahan. The study, which dates from 1992, was
an anonymous survey of the Dutch physicians who were responsible for ensuring that the
conditions mentioned by the courts were being met. Despite repeated assurances over the preceding
years, the survey found that 50 percent of euthanasia cases went unreported, and that 1/3 were cases
of non-voluntary euthanasia. Callahan finds this shocking and a dramatic illustration of the totally
wrong road that our society can go on. Probably it is worth recalling the observation made by
Tooley here: what matters here is not whether there are undesirable cases of euthanasia in the
Netherlands, but whether there are more such cases than when compared to countries that don’t
have legalised euthanasia? After all, just because a practice has not been legalised does not mean it
is not taking place(a lot of examples can be given) Tooley thinks that when the appropriate
comparative exercise is carried out, the results lead us away from Callahan’s pessimistic view of
euthanasia and assisted suicide. At the end of his article Callahan makes an interesting observation.
After examining evidences from Oregon (which also had a form of legalised euthanasia) he notes
that very few people actually voluntarily took advantage of euthanasia. In practice, those who suffer
from painful and terminal illnesses tend to make the decision of taking palliative care, no matter
how devastating their lives have become. Given the concerns he has already expressed, Callahan
thinks there is no good reason to legalise euthanasia simply to serve for the needs of some minority.
It can be seen that euthanasia is indeed a contentious issue, with the heart of the debate lying at
active voluntary euthanasia and physician-assisted suicide. Its legal status, prohibition and
criminalisation of the practice of euthanasia and assisted suicide reflects the legal status quo and the
human rights that are present in most other countries around the world. In contrast, there are only a
few countries and states that have legalised acts of euthanasia and/or assisted suicide. The many
arguments that have been put forward for and against euthanasia, and the handful that have been
outlined provide only a very small drop into the ethical debate and controversy surrounding the
topic of euthanasia. At the end we can mention the special relation between the doctor and the
patient and the role of the physician. The most common opinion on this relationships is that active
voluntary euthanasia and physician-assisted suicide undermine the doctor-patient relationship,
destroying the trust and the confidence and of course breaks the moral code. From the Hippocratic
Oath we know that a doctor’s role is to help and save lives, not end them. But it is also true that
doctors should always do what is the best for the patient, and in many cases the best thing in one
patient`s “evolution” is to end their life. My personal opinion is that it is not worth living anymore
if a person is not capable of remembering the name and faces of their relatives, if it is not capable of
breathing by their own, if it is not capable of enjoying the gifts of nature, etc. So it is better to have
a short but complete – eventful and satisfactory life, than to prolongate the death for years and to
feel alive at all. Or to put it in other words, it is better when a person die, his or her love ones to
suffer and weep than to rest that this person is finally gone.
THE
HISTORY
OF
MEDICINE
The History of Euthanasia Debates in the United States
and Britain
Ezekiel J. Emanuel, MD, PhD
• Debates about the ethics of euthanasia and physician-assisted suicide date from ancient Greece and
Rome. After the development of ether, physicians began advocating the use of anesthetics to relieve the
pains of death. In 1870, Samuel Williams first proposed
using anesthetics and morphine to intentionally end a
patient’s life. Over the next 35 years, debates about the
ethics of euthanasia raged in the United States and
Britain, culminating in 1906 in an Ohio bill to legalize
euthanasia, a bill that was ultimately defeated.
The arguments propounded for and against euthanasia in the 19th century are identical to contemporary
arguments. Such similarities suggest four conclusions:
Public interest in euthanasia 1) is not linked with advances in biomedical technology; 2) it flourishes in
times of economic recession, in which individualism
and social Darwinism are invoked to justify public
policy; 3) it arises when physician authority over medical decision making is challenged; and 4) it occurs
when terminating life-sustaining medical interventions
become standard medical practice and interest develops in extending such practices to include euthanasia.
Ann Intern Med. 1994;121:793-802.
From Dana-Farber Cancer Institute, Boston, Massachusetts. For
the current author address, see end of text.
I n the midst of divisive public debates, we frequently
look to history and past epochs to gain guidance and
understanding, to explore the genesis of our ideas and
practices, and to critically compare them with alternatives.
In the debate over euthanasia, commentators have examined ancient Greece and Rome, where “many people
preferred voluntary death to endless agony. This form of
‘euthanasia’ was an everyday reality . . . [and] many physicians actually gave their patients the poison for which
they were asked” (1-5). For instance, “the Stoic founder,
Zeno committed suicide in his old age prompted by the
agonizing pain of a foot injury” (3). Pliny the Younger,
whose letters recorded the details of everyday life in
first-century Rome, described a typical case:
[Titius Aristo] has been seriously ill for a long time . . .
He fights against pain, resists thirst, and endures the
unbelievable heat of his fever without moving or
throwing off his coverings. A few days ago, he sent for
me and some of his intimate friends, and told us to ask
the doctors what the outcome of his illness would be,
so that if it was to be fatal, he could deliberately put
an end to his life (6).
This widespread acceptance of euthanasia in ancient
Greece and Rome was challenged by the minority of
physicians who were part of the Hippocratic school and
had pledged “never [to] give a deadly drug to anybody if
asked for it, nor . . . make a suggestion to this effect”
(1-4). The ascent of Christianity, with its view that man’s
life was a trust from God, reinforced the Hippocratic
position on euthanasia (2, 4, 5) and culminated between
about the 12th and 15th centuries in the consistent opposition to euthanasia among European physicians (2).
There has also been extensive study of euthanasia in
20th-century Germany (7-11). Both proponents and opponents of euthanasia and physician-assisted suicide have
frequently cited these historical examples in support of
their positions (12-15).
Yet, ancient Greece and Rome and 20th-century Germany are of limited relevance in helping us to understand
contemporary U.S. debates about euthanasia. Ancient
Greece and Rome were pagan societies with slaves and
cultural values that celebrated aristocratic and martial
virtues; they also had no well-developed medical professions. Germany in the early 20th century considered the
“Volk” more important than the individual and had no
democratic tradition. Such differences between these societies and our own minimize their usefulness in illuminating contemporary interest in euthanasia.
Little known and studied, however, are the debates on
euthanasia and physician-assisted suicide that occurred in
the United States and Britain during the late 19th and
early 20th centuries (16, 17). Given the continuity of
cultural traditions and political values between this era
and our own and the fact that organized medicine originated in that period, examination of these past debates on
euthanasia may help illuminate the justifications currently
offered for euthanasia and arguments against it.
Early Modern Discussions of Euthanasia
Possibly the first reference to euthanasia in the English
literature was made in 1516 (16) when Sir Thomas More
wrote in Utopia:
They console the incurably ill by sitting and talking
with them and by alleviating whatever pain they can.
Should life become unbearable for these incurables the
magistrates and priests do not hesitate to prescribe
euthanasia . . . When the sick have been persuaded of
this, they end their lives willingly either by starvation
or drugs, that dissolve their lives without any sensation
of death. Still, the Utopians do not do away with
anyone without his permission, nor lessen any of their
duties to him (18).
In the 17th century, Francis Bacon extended his belief
that science should help relieve man’s estate by arguing
that the physician’s duty was to “not only restore the
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health, but to mitigate pain and dolours; and not only
when such mitigation may conduce to recovery, but when
it may serve a fair and easy passage” (19). Over the next
200 years, as part of a general attack on religious authority, writers such as John Donne, Montesquieu, and other
English and French philosophers attacked prohibitions
against suicide (16). Although they did not explicitly advocate euthanasia, the arguments they invoked could have
been extended to justify this practice. For instance, David
Hume wrote an essay titled “On Suicide,” in which he
argued “that Suicide may often be consistent with interest
and with our duty to ourselves, no one can question, who
allows that age, sickness, or misfortune, may render life a
burden, and make it worse even than annihilation” (20).
Although intellectuals voiced interest in euthanasia and
suicide, “there does not seem to have been any impact on
medical practice” or any stimulation of a broader, sustained public interest in these topics; they did not resonate with public attitudes and seem to have had no practical repercussions (16).
Anesthesia and Proposals for Euthanasia
The 19th century witnessed a revolution in the use of
anesthesia (16, 21). Morphine was isolated early in the
century. In 1846, John Warren did the first operation with
ether anesthesia (Figure 1). In 1848, Warren published
Etherization; With Surgical Remarks, in which he suggested
that ether might be used “in mitigating the agonies of
death” (22). He described etherizing a 90-year-old woman
to treat the “pain of mortification . . . [and pain] of the
abdomen with convulsive twitchings of the limbs . . . with
perfect relief.” During the U.S. Civil War, physicians became more experienced in the use of hypodermic morphine to relieve pain and this practice spread (16, 21). In
1866 in the British Medical Journal, Joseph Bullar reported using chloroform to palliate pain during the deaths
of four patients (23). Warren and Bullar never recommended using ether, chloroform, or morphine to end a
patient’s life but only to relieve “the pains of death” (22).
However, just as physicians deemed the use of narcotics
and anesthetics for pain relief (21) appropriate medical
practice and began endeavoring to study “the management of the dying [and] the treatment best adapted to the
relief of the sufferings” (24), the discussion changed significantly. In 1870, a nonphysician, Samuel D. Williams,
addressed the Birmingham Speculative Club on the topic
of euthanasia (25). Going beyond the suggestions of Warren and Bullar, Williams advocated the use of chloroform
or other medications not just to relieve the pain of dying,
but to intentionally end a patient’s life:
The main object of the present essay being merely to
establish the reasonableness of the following proposal:
-That in all cases of hopeless and painful illness, it
should be the recognized duty of the medical attendant,
whenever so desired by the patient, to administer chloroform or such other anaesthetic as may by-and-by supersede chloroform-so as to destroy consciousness at once,
and put the sufferer to a quick and painless death; all
needful precautions being adopted . . . to establish, beyond the possibility of doubt or question, that the remedy
was applied at the express wish of the patient (25).
Such an isolated speech, made before a provincial club
by a relatively obscure person, might have vanished un794
15 November 1994
Figure 1. Dr. John C. Warren, Professor of Surgery, Harvard
Medical School, author of Etherization; With Surgical Remarks.
(Courtesy of the Boston Medical Library.)
noticed from the public arena, like the suggestions of
More and Bacon. Williams’s speech, however, was not
ignored. It was reprinted as a book in 1872 (25) and
favorably reviewed and quoted at length in the widely
circulated Popular Science Monthly (26). Williams’s arguments were praised by the most prominent British literary
and political journals of the day (27-30) as “remarkable”
for their “considerable ingenuity” and “plausibility.” Yet,
many of these journals rejected his views because “so
great would be the danger that such a practice would be
abused” (28).
Williams’s proposal seemed to touch a deep but unarticulated view. The latter third of the 19th century in
Britain and the United States is now known as the Gilded
Age and was characterized by an individualistic conservatism that praised laissez faire economics, scientific
method, and rationalism and opposed authority, reverence for tradition, and sentimental attachments. It was a
time of industrialization, intense corporate competition,
and unprecedented strikes and clashes between labor
unions and the corporations trying to crush them. It was
also a time in which free market policies caused wild
economic oscillations and major depressions were sparked
by the panic of 1873, the droughts of the 1880s, and the
stock market crash of 1893. This raw individualism, economic competition, and rationalism was reinforced and
sanctioned by appeals to Darwinism (31). After publication of Origin of Species in 1859, intellectuals rushed to
incorporate Darwinism into their theories; Darwin’s book
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gave the imprimatur of rigorous science to sociology, economics, and other disciplines. Primarily through the work
of Herbert Spencer in Britain and William Graham Sumner in the United States, the concepts of “survival of the
fittest” and “struggle for existence” became “the store of
ideas to which solid and conservative men appealed when
they wished to reconcile their fellows” to the practices
and hardships associated with the era’s individualism and
laissez faire policies (31-33). As one historian said, social
Darwinism “serves students of the American mind as a
fossil specimen from which the intellectual body of the
period [1870-1900] can be reconstructed” (31).
19th Century Physicians and Euthanasia
Publication of Williams’s euthanasia proposal prompted
much discussion within the medical profession. The Medical and Surgical Reporter ran an article in 1873 that asked
“Whether, when a patient is past all hope, a victim to a
fatal disease, entailing great agony . . . [and] he and the
family alike beseech us to ‘put an end to his misery,’ we
ought to do so?” (34). In April 1879, the South Carolina
Medical Association heard a report from its Committee
on Ethics regarding active euthanasia; the association vigorously debated the issue, as well as whether to keep its
discussion secret (35, 36). Over the next few years, other
medical societies debated euthanasia; British and U.S.
medical journals included editorials about it that often
referred to Williams’s original proposal (37-40).
In the 1870s and 1880s, most physicians held the view
that “opium is administered to the dying, as an anodyne
to relieve pain . . . [not to throw] the patient into a sleep
from which he may not awake” (41). Dr. Wilhite of South
Carolina was typical in arguing that “physicians might
soften suffering, but not hasten death” (35). An 1884
editorial in the Boston Medical and Surgical Journal was
more poetic:
Perhaps logically it is difficult to justify a passive more
than an active attempt at euthanasia; but certainly it is
much less abhorrent to our feelings. To surrender to
superior forces is not the same thing as to lead an
attack of the enemy upon one’s own friends (38).
Although anesthesia, the germ theory of disease, improved diagnostic tests, and effective surgical operations
were helping allopathic physicians of the 1880s to consolidate their authority as well as their control over licensing
and medical school training requirements, their authority
was far from secure (42). They faced the old challenges
from Sectarians—homeopaths and Eclectics—as well as
new ones from practitioners of Christian Science and
osteopathy. In this precarious position, allopathic physicians perceived Williams’s ideas on euthanasia as another
effort to undermine them. In a characteristic editorial,
The Journal of the American Medical Association attacked
Williams’s proposal as nothing more than an attempt to
make “the physician don the robes of an executioner”
(38).
Early Efforts to Legalize Euthanasia
By the 1890s, the euthanasia debate had expanded beyond the medical profession to include lawyers and social
Figure 2. Editorial published in The New York Times on 6 January 1906 commenting on Charles Eliot Norton’s endorsement of
euthanasia.
scientists (43). The antagonism between physicians and
lawyers was present even then; lawyers attacked physician
authority with a call for greater patients’ rights. Beginning
in about 1890, New York lawyer Albert Bach frequently
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spoke at conferences in support of euthanasia. At the
1895 Medico-Legal Congress, for instance, he endorsed
euthanasia on the grounds that patients should have the
right to end their lives (44). Simeon Baldwin, in his 1899
Presidential Address to the American Social Science Association, justified euthanasia by attacking the “pride of
many in the medical profession to prolong such lives at
any cost of discomfort or pain to the sufferer” (45). (Mr.
Baldwin was later to become President of the American
Bar Association and to actively oppose the nomination of
Louis Brandeis to the Supreme Court because of the
latter’s progressive policies.) Physicians vigorously contested these points, claiming, among other things, that
accepting them would “bring the profession into discredit” (46-51).
At the turn of the century, this debate entered the lay
press and political forums (52). Probably the most notable
event occurred in 1905 or 1906. Charles Eliot Norton, a
renowned Harvard professor, delivered a speech advocating euthanasia. His position inspired a wealthy woman,
Anna Hill, whose mother was suffering from cancer, to
campaign for the legalization of euthanasia in Ohio. Ohio
State Representative Hunt introduced “An Act Concerning Administration of Drugs etc. to Mortally Injured and
Diseased Persons,” a bill to legalize euthanasia that
prompted significant interest (53, 54). The New York
Times reported on the bill (55), carried editorials condemning both the bill and Norton’s role in inspiring it
(Figure 2) (56), and published charged letters for and
against euthanasia (57-59). Attacking Norton, Hill, and
Hunt, the British Medical Journal asserted that “America
is a land of hysterical legislation” in which
every now and again [the legalization of euthanasia] is
put forward by literary dilettanti who discuss it as an
academic subtlety or by neurotic “intellectuals” whose
high-strung temperament cannot bear the thought of
pain. The medical profession has always sternly set its
face against a measure that would inevitably pave the
way to the grossest abuse and would degrade them to
the position of executioners (60).
Hunt’s bill was rejected by the Ohio legislature, 79 to
23. (It was reported in the British Medical Journal (60)
and the Medical Record (54) in 1906 and by Reiser (17)
that an even more extreme bill to legalize euthanasia not
just for incurable adults but also for “hideously deformed
or idiotic children” was introduced into the Iowa State
Legislature by Dr. R.H. Gregory. An extensive search of
newspapers from the time and of the Iowa legislative
record failed to corroborate these reports.)
After 1906, the intensity of the British and U.S. interest
in euthanasia dwindled, although, as one editorialist
wrote, the issue was “like a recurring decimal” with periodic reappearances (61-65). This waning of interest occurred in a time when individualism and “social Darwinism were in full retreat” (31) and were being replaced by
the belief that government should promote the general
welfare; this belief was embodied in the Progressive
movement in the United States and in the election of the
Liberals in Britain (31, 33). This was also a time in which
the medical profession had almost completely “consolidated its authority” (42) over medical education and practice.
796
Figure 3. Dr. C. Killick Millard. Dr. Millard proposed a model
bill to legalize euthanasia in Britain in his Presidential Address
to the Society of Medical Officers of Health. He became the
secretary of the Voluntary Euthanasia Legislation Society in Britain in 1935. (Courtesy of the Wellcome Institute Library, London.)
The Voluntary Euthanasia Society of Britain
During the 1930s, the debate on euthanasia revived,
this time with much more vigor in Britain than in the
United States. Dr. C. Killick Millard, an early advocate of
compulsory vaccination and birth control, used the occasion of his Presidential Address to the Society of Medical
Officers of Health in Britain to propose a bill for the
legalization of euthanasia (Figure 3) (66, 67). Millard
gave a scholarly speech that reviewed the history of practices and attitudes toward euthanasia and suicide. His
intention was to take Samuel Williams’s ideas about euthanasia and “bring the proposed reform more within the
range of practical politics” by proposing an actual statute
(66). In 1935, growing interest in the subject (68, 69) was
further fueled by the London Daily Mail’s publication of
an unnamed “elderly country physician’s” confession that
during his career he had practiced euthanasia on five
patients. In both Britain and the United States, newspapers and magazines competed with each other, printing
patients’ requests for euthanasia, physicians’ testimonials
about past episodes of euthanasia, and denunciations of
the stories by medical organizations. Time ran a typical
magazine article portraying a suffering patient who desired euthanasia (Figure 4) (70-74).
In Britain, Millard’s views prompted the creation of the
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Voluntary Euthanasia Legislation Society, which was organized to campaign for the legalization of euthanasia
(75, 76). The leaders of this society were all prominent
physicians, and the society’s first meeting was held in the
British Medical Association House in London (77). The
idea of legalizing euthanasia was vigorously debated in
many public forums and in British and U.S. medical journals (78-85). A bill to legalize euthanasia was debated in
the House of Lords in 1936. After two Lords who were
also physicians spoke against it, the bill was rejected 35 to
14 (86, 87).
This defeat, the outbreak of World War II, the discovery of the Nazi death camps, and the recognition of the
role German physicians had played in genocide all served
to quell but not to completely eliminate consideration of
euthanasia (88). In the late 1950s, Ganville Williams and
Yale Kamisar revived the debate over the ethics of euthanasia in the British and U.S legal literature (89-91). In
1969, the first bill since 1936 to legalize euthanasia was
introduced into the British Parliament. Still, this interest
in euthanasia never sparked widespread public discussion
nor concern within the medical profession. In the 1970s
and early 1980s, euthanasia became a subject of more
extensive academic debate (92) in many countries and a
point of public contention, especially in the Netherlands
(93). With the increasing acceptance of patient autonomy
and the right-to-die in the United States, and the publication in 1988 of “It’s Over, Debbie” in The Journal of the
American Medical Association (94), the euthanasia debate
has once again become a matter of public concern in the
United States, Britain, and other countries.
The Arguments for Euthanasia
Although the mere occurrence of debates about euthanasia in Britain and the United States during the 19th
century is fascinating, of even greater interest is the fact
that the arguments and justifications advanced both for
and against euthanasia have hardly changed in over a
century. Some elements of style and phrasing aside, articles written on the topic in 1894 could be dated 1994.
Past U.S. and British advocates typically adduced the
same four arguments used today to justify euthanasia: 1)
It is a human right born of self-determination; 2) it would
produce more good than harm, mainly through pain relief; 3) there is no substantive distinction between active
euthanasia and the withdrawal of life-sustaining medical
interventions; and 4) its legalization would not produce
deleterious consequences. As Eugene Debs and Dr. Millard claimed in 1913 and 1931, respectively, patients have
a right to control the manner of their death and, more
specifically, terminally ill patients have the right to a quick
and painless death with physicians’ help.
Human life is sacred, but only to the extent that it
contributes to the joy and happiness of the one possessing it, and to those about him, and it ought to be
the privilege of every human being to cross the River
Styx in the boat of his own choosing, when further
human agony cannot be justified by the hope of future
health and happiness (64).
The proposition merely is that individuals, who have
attained to years of discretion, and who are suffering
from an incurable and fatal disease which usually entails a slow and painful death, should be allowed by
Figure 4. Article published in Time on 25 November 1935 recounting a patient’s request for euthanasia and reactions from
physicians and others.
law-//” they so desire and if they have complied with the
requisite conditions-to substitute for the slow and
painful death a quick and painless one. This, I submit,
should be regarded not merely as an act of mercy, but
as a matter of elementary human right (66) [emphasis in
the original].
It was further claimed that euthanasia would promote
patients’ well-being by relieving them of pain and would
reassure others that death would not be painful. As Albert Bach stated in 1896:
There are also cases in which the ending of human life
by physicians is not only morally right, but an act of
humanity. I refer to cases of absolutely incurable, fatal
and agonizing disease or condition, where death is
certain and necessarily attended by excruciating pain,
when it is the wish of the victim that a deadly drug
should be administered to end his life and terminate
his irremediable suffering (44).
Proponents went on to observe that no substantive
ethical distinction existed between active euthanasia and
the practice of withdrawing life-sustaining treatments or
giving narcotics for pain relief, which some call passive
euthanasia. If these latter interventions were deemed ethical, active euthanasia should be also. So Samuel Williams
argued in 1872:
The very medical attendant who would revolt from the
bare idea of putting a hopelessly suffering patient to
death outright, though the patient implored him to do
so, would feel no scruple in giving temporary relief by
opiates, or other anaesthetic, even though he were
absolutely sure that he was shortening the patient’s life
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by their use. Suppose, for instance, that a given patient
were certain to drag on through a whole month of
hideous suffering, if left to himself and Nature, but
that the intensity of his sufferings could be allayed by
drugs, which nevertheless would hasten the known inevitable end by a week;-there are few, if any, medical
men who would hesitate to give the drugs; . . . Is it not
clear that if you once break in upon life’s sacredness,
if you curtail its duration by never so little, the same
reasoning that justifies a minute’s shortening of it, will
justify an hour’s, a day’s, a week’s, a month’s, a year’s;
and that all subsequent appeal to the inviolability of
life is vain? (25).
perfectly justified in pushing such treatment to an extreme
degree, if that is the only way of affording freedom from
acute suffering . . . If the risks be explained to the friends
we are of opinion that even should death result the medical man has done the best he can for his patient” (97).
As editors of The Lancet suggested, opponents of euthanasia frequently emphasized the ethical distinction between active and passive or indirect euthanasia, between
intentionally using medications to kill a patient and using
morphine for pain relief.
Finally, proponents claimed that the legalization of euthanasia would not be a “slippery slope”; the justification
of euthanasia for terminally ill individuals who request it
was the individual’s good, and this would not apply to
involuntary euthanasia for incompetent patients or to killing the retarded or criminals for the good of society:
I should not hesitate to use morphia, or even chloroform, freely, with the intent to relieve pain; but surely
it should not be beyond the power of a capable physician to so grade the dosage as to keep the patient
free from pain but short of killing him. And should he
accidentally or unintentionally in such a case as this
administer an overdose, this is a very different thing
from willingly and knowingly poisoning the patient
(62) [1906].
As regards any application of this principle to the
elimination of the unfit or the degenerate, the imbecile, etc. as such, we find no such suggestion . . . It
would be entirely out of keeping with the consistently
expressed individualism
The fact that [euthanasia]
may be justifiable, perhaps even a duty of humanity,
under certain circumstances, exceptional circumstances, if you like – to yield to the pleas of the
sufferer himself for “the end of pain,” in no sense
supports the idea that any person or persons may
properly decide to eliminate the degenerate or the
imbecile against or in the absence of his express consent and desire [1906] (53).
The Arguments against Euthanasia
British and U.S. opponents of euthanasia a century ago
made counter-arguments 1) challenging the assumption
that most deaths were painful; 2) emphasizing the willingness of practitioners to stop treatments and use pain
medications; 3) maintaining the distinction between active
and passive euthanasia; and 4) enumerating the adverse
consequences of legalizing euthanasia. Most critics of euthanasia noted that the justification for euthanasia was
empirically false. Citing many authorities, including Sir
William Osier, they vehemently claimed that death—and
the approach of death—are not usually painful and that
advocates “unconsciously exaggerate the amount and intensity of suffering that patients undergo in many mortal
illnesses” [1906] (43, 62).
Opponents argued that although in the past physicians
may have been overly aggressive in prolonging life, contemporary physicians were willing to withdraw futile interventions and to treat pain aggressively. For instance, in
The Lancet in 1899, a physician described a patient with
painful uterine cancer whose “death struggle was an awful
and most pitiable experience” (95). He then asked “would
it be justifiable to use morphia hypodermically? or to
what extent would the inhalation of chloroform be admissible in mitigation of so great agony and distress?” (95).
A correspondent replied that physicians are not only
justified in using, but are duty-bound to use, hypodermic
morphine (96). Similarly, the editors of The Lancet replied that “it would have been perfectly justifiable for him
to have used morphia hypodermically and patients are
frequently kept under chloroform cautiously administered
for hours to mitigate the sufferings . . . [A] practitioner is
798
Past arguments against euthanasia culminated in the
enumeration of five deleterious consequences that would
result from legalizing euthanasia; these are also frequently
voiced today. First, it was claimed that legalizing euthanasia would result in abuse: “[Euthanasia] would put into
the hands of unscrupulous parties a certain and easy
method of being rid of an objectionable relative” [1885]
(38, 46). Second, medicine was not an exact science, “apparently hopeless cases sometimes terminate in recovery
and that the predictions of the most skilled and competent physicians are sometimes not fulfilled” [1914] (98).
Permitting euthanasia could have the “most terrible result” of putting to death a person who would otherwise go
on to live a full life.
Third, legalizing euthanasia would place tremendous
pressure on patients to request it in order to relieve their
families of distress.
The patient knows that he is being a burden to his
loved ones, who are certainly sharing his agony. If the
agonized patient knows that he alone can cut short
their mental suffering by consenting to, or perhaps
suggesting euthanasia, he will find himself faced with a
hideous dilemma: he must either be so selfish as to
discard euthanasia and let his dear ones suffer, or, by
being generous, he must bid farewell to those last
sweetest, still hopeful, moments of life [1936] (99).
Fourth, legalizing euthanasia would undermine patients’ trust and thereby destroy the medical profession.
“Once an alteration was made in that conception of a
physician’s duty [by legalizing euthanasia] the whole public confidence in the medical profession would go” (61).
The doctor is eagerly awaited with the hope, not that
he will put the man out of pain, but that he will put
the pain out of the man. This new society aims at
putting the man out of existence. Let us make no
mistake about this; the change is so fundamental that
it will reach much further than even we contemplate,
and the whole status of the profession will be altered
in the minds of the people . . . [E]very doctor knows
that there are already enough shadows in the sickroom without adding that of the lethal chamber [1936]
(84).
Fifth, opponents of euthanasia argued that legalizing
voluntary euthanasia for terminally ill patients is “only the
thin end of a very big wedge” [1936] (81). Initially, the
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terminally ill could voluntarily request euthanasia, then
the aged could, and then involuntary euthanasia for “absolute idiots, incurably demented persons, and convicted
murderers” [1906] would be justified and tolerated (62).
Euthanasia and Advances in Medical Technology
Whereas current advocates of euthanasia claim that
advances in life-sustaining technology create interest in
this practice, this historical review suggests that there is
no inherent or causal link between actual advances in
biomedical technology and interest in euthanasia (100).
Physicians’ capability to use life-sustaining interventions
and to prolong patients’ dying postdates by centuries both
the debates in ancient Greece and the interest in euthanasia expressed by More and Bacon. More importantly,
the late 19th and early 20th century British and U.S.
campaigns for the legalization of euthanasia occurred before medicine had recourse to life-sustaining interventions. Medicine in the late 19th century was becoming
scientific through events such as the recognition of the
importance of the biological sciences, the identification of
the role of microorganisms in disease, and the implementation of the first diagnostic laboratory tests. Yet, the
therapeutic interventions available to physicians were
meager and ineffective. It was not until the turn of the
20th century that anesthesia and aseptic techniques combined to enable surgery to be a safe, curative intervention
(101). And life-sustaining medical interventions lagged
even further. Sulfonamides were introduced in 1932; penicillin was discovered in 1928 and became widely available
in 1941; Drinker and Shaw developed the first respirator
(the “iron lung”) in 1927 (102). The speeches by Williams, Bach, and Baldwin, and the proposed legislation in
Ohio all predate the development of effective life-sustaining medical technology. In addition, when effective lifesustaining medical technology did become widely available after World War II, no immediate resurgence of
public interest in euthanasia occurred. During the 1950s
and 1960s, medicine could sustain the lives of braindamaged patients. As Pope Pius XIFs comments on this
issue make clear, concern about keeping patients alive
existed, but popular interest in euthanasia did not.
If any technologic development stimulated the 19th
century interest in euthanasia, it was not that of lifesustaining technologies but of anesthetics, especially of
hypodermic morphine, ether, and chloroform, which make
death easier and medicalize it. Although fear of being
kept alive by medical technology may be a necessary
factor in motivating interest in euthanasia, this historical
review suggests that it is not the only one. Indeed, almost
all of the arguments made today to justify euthanasia
were made before modern medical technology existed and
could prolong life. What other factors—social, economic,
and cultural—might motivate interest in euthanasia and
make society receptive to it?
Social Darwinism, Individualism, and Euthanasia
These periods of widespread interest in euthanasia in
Britain and the United States contained many complex
interactions between leading individuals and social, political, economic, and cultural forces. At this time, it is
important to look beyond the differences to find generalizations, “see the patterns they compose,” and identify
threads of connection (103). I put forth three speculative
connections between the past and today. First, interest by
the medical profession and the public in euthanasia
erupts when economic depression coincides with the acceptance of social Darwinism for the justification of social
policies. Second, interest in euthanasia increases during
intense struggles over physician authority, especially over
physician control of the dying process and death. Third,
interest in euthanasia arises when easing the dying process, through pain medications or the withdrawal of unnecessary treatments, becomes an established medical
practice.
In the United States and Britain, the worst economic
recessions over the last 120 years occurred in the mid18708, mid-1890s, the 1930s, and the current time period
(104). Some of these periods were characterized by public
acceptance of individualism and social Darwinism. These
have been periods of rationalist, economic conservatism,
which celebrates individual self-assertion and accumulation rather than communal attachments and bonds; it
accepts the circumstances of the less fortunate as of their
own making rather than as a failure of the social order;
and it directs the government to promote economic competition rather than social welfare. In these periods, the
language of Darwinism becomes the idiom of public discourse. And with strain on government budgets, it legitimates resentment of the dependent and justifies cuts in
“safety net” programs.
This Darwinian public philosophy also changes the individual’s own perceptions. It legitimates the adoption of
the utilitarian logic of business—contracts, calculations of
costs and benefits, success and profit—rather than traditional bonds and respect for authority, as the proper
guide for individual action. When self-sufficiency is viewed
as the highest virtue, dependence as a vice, acceptance of
governmental aid as a drain, and rationalist calculations
of life as proper, the old and sick are categorized with the
“unfit.” Finally, with a shrinking safety net, individuals
come to fear sickness, especially chronic and terminal
illness, as a threat to their family’s well-being and their
own self-esteem and social standing.
As we have noted, in the last third of the 19th century,
economic recessions occurred simultaneously with the affirmation of individualism and social Darwinism. Often,
advocates of euthanasia appealed to Darwinian ideas for
legitimation. Williams’s speech was suffused with references to Darwin and the “universal struggle . . . of the
strong over the weak” (25). Similarly, Baldwin in 1899
invoked the “one great all-dominating lesson which the
nineteenth century has taught, the law of evolution” in
support of a calm passage to death through euthanasia
(45). Advocates frequently attacked the belief in the “sacredness of life [as] still tinctured with ancient superstition and with metaphysical haziness” (64). They also
mocked “the greater sensibility and the greater power of
sympathy which [the euthanasia opponent] implies are
worth preserving, even at the cost of the poor old parent
who is forcibly maintained in a world which has become a
torment to him” (30). Conversely, 19th century opponents
frequently attacked euthanasia by attacking Darwinian
ideas. For instance, they attacked the “purely utilitarian
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[calculations in which] old people past their productive
periods could be easily disposed of [by euthanasia] as a
long step backward toward savagery” (50, 105).
The 1980s are reminiscent of the 1880s. Deep recessions occurred just when the economic and social policies
of Ronald Reagan in the United States and Margaret
Thatcher in Britain revived raw individualism, unfettered
capitalistic competition for survival, anti-union sentiments,
wholesale governmental deregulation, and curtailment of
social “safety net” programs for the poor, old, and sick.
As historian Eric Foner and others have suggested, there
has been a “resurrection in the 1980s of . . . the social
Darwinism mentality, if not the name itself (106, 107).
Although it is not respectable now to appeal openly to
social Darwinism, contemporary advocates of euthanasia
do justify euthanasia by appealing to individualism and
individual rights; opponents explicitly worry that discrimination against vulnerable groups and cost containment
focused on the elderly and terminally ill do influence
support for euthanasia (108, 109). Consistent with this
public philosophy, Americans are worried about their future and have indicated that the single most important
reason for endorsing euthanasia is to avoid being a burden on the family (110).
None of this is to say that the leading advocates of
euthanasia are overt or covert social Darwinists. Rather,
it suggests that society may be more receptive to appeals
for legalizing euthanasia because of the long economic
recession, the acceptance of survival of the fittest, the
laissez faire policies, and the affirmation of individual
rights that accompanies the “social Darwinism mentality.”
This idea may be supported by the fact that states with a
long tradition of individualism and laissez faire policies—
such as some Western states and New Hampshire—have
been at the forefront of current popular campaigns for
legalizing euthanasia.
Physician Authority and Euthanasia
In addition to these general factors that might inspire
interest in euthanasia, other factors impinge more directly
on medical practice. There have been continuous social,
cultural, and legal processes delineating the extent of
physician authority. It appears that the periods in which
physician authority is powerfully challenged are precisely
the periods of interest in euthanasia.
In the late 19th century, medicine was being transformed from a suspect and divided profession into one
with authority (42). Americans became willing to “surrender [their] private judgments” in matters of health to
physicians (101). Allopathic physicians were overcoming
the challenges posed by Sectarians, Christian Scientists,
and others. During this period, advocates of euthanasia
frequently couched their appeals in attacks on the “pride
of many in the medical profession” (45). They justified
euthanasia by arguing that patients, not physicians, had
the right to decide when patients’ lives should end. Concomitantly, many physicians viewed euthanasia as another
way to undermine the very “foundations of the existence
of the profession” (105). As Abraham Jacobi, president of
the American Medical Association, put it: If you legalize
euthanasia then “you would make true what Plato said of
800
the practice of medicine: It was no respectable calling”
(63).
There is a striking similarity between the past and the
present. In the early 1970s, the widely accepted authority
of the medical profession came under concerted attack in
the name of patient autonomy. This challenge has been
embodied in the progressive enumeration of patient
rights, especially the right to refuse medical care, even
life-sustaining care. The goals have been to remove physicians from decision making and to let individual patients
weigh the benefits and burdens of continued life (111). In
the view of many, the general acceptance of the patient’s
right to refuse medical care and the concomitant restriction of physician authority have set the stage for acceptance of euthanasia; the arguments that justify refusal of
life-sustaining treatment logically extend to euthanasia
(112). The interest in euthanasia may be a public condemnation of physician control over patients’ deaths. As
leading proponents of Washington State’s Proposition 119
argued:
My sense is that people do feel in many aspects of
their lives as if they are out of control. I suspect in this
one area [of death and euthanasia] people are saying
“Dammit, this is the one thing that I ought to be able
to control for myself” (110).
Thus, the current interest in euthanasia may be the
culmination of the 20-year effort to curtail physician authority over end-of-life decisions. Technology, and physicians’ control over technologic interventions, may be an
easily characterized but inaccurate surrogate for this
struggle to limit physician authority.
Expanding the Boundaries of Appropriate Practices
There seems to be a tendency within medicine to develop a new treatment or technology for a core, welldefined condition and then, once the treatment or technology is well accepted, to expand the range of its uses.
For instance, dialysis was developed for patients with
acute renal failure, then applied to young patients with
chronic renal failure who had no comorbid diseases, and
then to older patients with many comorbidities such as
diabetes. A similar tendency may be found with regard to
euthanasia in the 19th century and today.
The 19th century witnessed a marked development in
anesthesia. In the latter half of the century, a fierce
debate took place about whether it was better to relieve
suffering at some risk or whether “immunity of pain
merely should never be purchased at the risk of life” (21).
“By the 1870s, some use of anesthetics has been accepted
by all” physicians for surgery, childbirth, the relief of the
agonies of dying, and other conditions (16, 21, 24, 41).
Just when 19th century physicians became comfortable
with the use of anesthetics, there was an effort, initiated
by Williams, to expand their use to include euthanasia.
A similar pattern can be observed in the current U.S.
interest in euthanasia. Since the Quintan decision and the
passage of the California Natural Death Act (the first
living-will law) in 1976, there has been growing acceptance of the practice of withdrawing life-sustaining treatment. First, physicians accepted withdrawal of respirators
from patients in persistent vegetative states; now it has
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become acceptable to stop any kind of medical intervention, including artificial nutrition and hydration, from patients in any condition. Just when contemporary physicians became willing to regularly terminate life-sustaining
treatments, the effort to legalize euthanasia emerged
(113). Physicians’ acceptance of easing the dying process
or withholding life-sustaining treatments seems to have
induced interest in extending established practices to include euthanasia.
Conclusion
We are in the midst of a deep battle over the legalization of euthanasia, a battle that has profound implications
for the care of the terminally ill and aged and the social
understanding of medicine. This is not the first time that
this battle has been waged in Britain and the United
States; we have largely forgotten the exuberant euthanasia
debates that occurred between 1870 and 1936 in both
countries. Remembering those debates and trying to identify common threads among them may help us gain a
more enlightened perspective on our current concern with
euthanasia.
It seems clear that the arguments for and against euthanasia have changed neither in form nor substance in
almost 120 years. They predate by many decades those
arguments made in Nazi Germany, and they appeal to
various philosophical traditions. This history suggests that
factors other than technology play a critical role in making people receptive to euthanasia. In trying to identify
general patterns that might explain public interest in euthanasia in the United States and Britain, the resurgence
of individualistic conservatism, characteristic of both the
Gilded Age and the Reagan-Thatcher years, is striking, as
is the waning of interest in euthanasia in the early 20th
century when this individualistic public philosophy was
repudiated by Progressivism. It is also striking that British
and U.S. interest in euthanasia flourished at the two times
in the last century when the struggle over physician authority was most pronounced. Such connections raise important questions about what forces are driving our current interest in euthanasia and whether there are
alternative ways to achieve a compassionate and painless
death.
Acknowledgments: The author thanks Drs. Linda Emanuel, Lee Goldman,
Robert Mayer, Jane Weeks, and David Weinberg for their continuing
support and critical comments on the manuscript; Professors Barbara
Rosenkrantz, Allan Brandt, and Jeffrey Williamson for their helpful discussions on the medical and economic history of the time; Ms. Ruth
Bartels of the State Historical Society of Iowa and Ms. Linda Robertson
of the Iowa State Legislature Law Library for their efforts to locate
information on Dr. Ross Gregory and whether he submitted an euthanasia
bill in Iowa; and Ms. Elizabeth Daniels for her review of the manuscript
and her heroic efforts to track down pictures and old articles in magazines
and newspapers.
Requests for Reprints: Ezekiel J. Emanuel, MD, Dana-Farber Cancer Institute, 44 Binney Street, Boston, MA 02115.
Current Author Address: Dr. Emanuel, Dana-Farber Cancer Institute, 44
Binney Street, Boston, MA 02115.
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