Home > Genocide and Crimes Against Humanity > Euthanasia

Literally meaning a "good death" (from the Greek eu and thanatos), and frequently defined as a gentle or easy death, euthanasia ordinarily refers to intentional death in a medical setting or achieved by medical means. The noun is usually modified by adjectives—active, passive, voluntary, nonvoluntary, and involuntary—that identify the moral and legal concerns surrounding death by euthanasia. By definition, euthanasia is distinct from, although often confused with, physician-assisted suicide. The morality and legality of euthanasia are a central subject of health law and medical ethics, where the major arguments involve the individual's right to die and the doctor's ability to hasten the death of ill or suffering patients. Distinguishing the different types of euthanasia is central to understanding the moral and legal debate about its practice and legalization.

During the 1930s, Germany developed state-sponsored euthanasia programs to end lives that the government deemed "unworthy of living," and these programs became the source of the Final Solution and the medicalized killing that was later conducted in the concentration camps. Hence, the specter of genocide haunts more recent discussions about any death by medical means. Analogies to Nazi practice and concerns about unrestricted killing under the German euthanasia programs continue to influence moral and legal arguments about the need for limits to death by euthanasia.

Types of Euthanasia

Euthanasia hastens death. It may do so by active or passive means employed by a doctor or other agent. Active euthanasia occurs by an affirmative act that intentionally causes death, for instance, by a lethal injection by a doctor upon a patient that ends the patient's life. Passive euthanasia occurs when medical treatment is withheld or withdrawn, with awareness that death will result from the omission of care. For example, a doctor or other individual may decide not to place or keep a patient on a respirator or feeding tube. Active refers to "causing death," while passive means "letting die."

"Causing death," namely killing another human person, is usually prohibited by the criminal law of homicide. Hence, active euthanasia is illegal in most Western nations, except the Netherlands and Belgium. In contrast, passive euthanasia has not been subject to the same criminal sanction, although some nations punish it as the crime of not helping someone in danger. Many writers have challenged the moral distinction between active and passive upon which these legal conclusions are based, arguing that intentionally causing a patient's death and intentionally letting an individual die are morally equivalent and should face similar legal bans. Moreover, active and passive may be words too simple to deal with complex clinical situations that have aspects of both causing death as well as omitting necessary care to sustain life (e.g., by withholding nutrition and hydration in some circumstances). Nonetheless, the difference between causing death and letting die remains the basis for many legal and ethical prohibitions against active but not passive euthanasia.

The adjectives active and passive focus on the nature of the actions of the medical professional (or family member or friend) who hastens death. By contrast, the words voluntary, nonvoluntary, and involuntary refer to the level of the patient's consent to euthanasia. Voluntary euthanasia occurs at the patients' request or with their consent. The nonvoluntary patients' consent is absent because these individuals are unable to give consent—they may be unconscious or otherwise incapacitated. Involuntary euthanasia is imposed against the patient's wishes or will.

The patient's level of participation in euthanasia, whether voluntary, nonvoluntary, or involuntary, is significant because a patient's informed consent to medical care became a primary concern after the revelations arising from the Nuremberg trials. Nonvoluntary and involuntary actions are unsatisfactory forms of consent. The level of patient participation also explains the distinction between euthanasia and physician-assisted suicide. In physician-assisted suicide, the medical professional provides the means of death to the patient, who uses them to commit suicide. Euthanasia, however, is done to the patient by another person. Recent legal debates about medicalized death have argued the advantages and disadvantages of physician-assisted suicide over voluntary, active euthanasia. In both cases, the patient consents to death, but only in physician-assisted suicide is the patient the agent of death. One is suicide, whereas the other is killing, or mercy killing, or murder.

Medical ethics codes have disfavored both voluntary, active euthanasia and physician-assisted suicide, both of which are distinguished from the common medical practice of providing pain-relieving medication to patients with the knowledge that it will hasten death. In such cases, deaths are foreseen but not intended, and so, according to the principle of double effect, do not qualify as either physician-assisted suicide or euthanasia. Because death is not intended, such provision of death-hastening therapeutic drugs is not ordinarily grounds for prosecution even in nations that criminalize voluntary, active euthanasia. In practice, some doctors who are prosecuted for euthanasia insist that they were just providing pain relief. Critics have argued that the moral and medical distinction between foreseeing and intending death is too slim a reed to support the legal difference.

Death with Dignity

Debate about euthanasia intensifies when patients and doctors request death with dignity and defend the right to die. Supporters of a right to die argue that hastening the death of suffering or terminally-ill patients who request death is not unjustified killing but instead promotes human dignity and patient autonomy. Advocates of a right to die have challenged traditional legal bans on euthanasia and suicide.

The voluntary aspect of voluntary, active euthanasia raises the question whether the law should permit euthanasia to which patients consent. In 1984, the Dutch Supreme Court recognized a defense against murder for doctors who commit voluntary, active euthanasia. In 2001, the Netherlands promulgated substantive standards to guide the legal practice of euthanasia in cases where certain safeguards are met. The Netherlands has provided the world a laboratory for observing the practice of euthanasia for over twenty years, but its legacy and lessons remain disputed.

In other Western nations, euthanasia remains illegal, while physician-assisted suicide is widely debated. During the 1990s in the United States, the state of Oregon passed legislation allowing physician-assisted suicide, and two federal appeals courts ruled that state laws banning assisted suicide are unconstitutional. In these instances, physician-assisted suicide was viewed as promoting death with dignity. The U.S. Supreme Court, however, upheld state laws against assisted suicide. The Supreme Court recognized a strong state interest in criminalizing physician-assisted suicide because the practice of legally assisted suicide may lead to episodes of nonvoluntary and even involuntary euthanasia. The Supreme Court invoked the popular "slippery-slope" argument that once assisted suicide is legalized, all forms of euthanasia may follow without restraint. Several justices cited the experience of the Netherlands, where some data suggest that euthanasia now occurs without patient consent, that is, involuntarily. The recurrent fear is that human lives, especially the lives of the vulnerable or unwanted, will be ended against their will, that patients will be pressured into requesting a death that they do not desire, and that depressed patients will choose easy death rather than receive appropriate medical care.

Ending the Lives of the Unwanted

The slippery-slope argument resonates with many individuals because of the legacy of Nazi Germany. The roots of the Nazi euthanasia program lay in the eugenics movement that was popular in both Germany and the United States in the late nineteenth and early twentieth centuries. Eugenics, literally "good genes," identified bad genes as the source of disease, mental retardation, and illness, as well as criminality. The medical or scientific solution to the problems of health and crime was to limit the heredity of bad genes. In Germany, the eugenics movement went beyond the sterilization of "defectives" to killing. German authors defended the state's right to end unhealthy or defective lives. State-sponsored sterilization and euthanasia were justified as protecting the state against those individuals it deemed unworthy of life.

With Hitler's commitment to racial purity and anti-Semitism, the Nazi government developed a systematic euthanasia program that culminated in the concentration camps and the Final Solution. Hitler ordered his physician, Karl Brandt, to develop a euthanasia program in 1939. The first to be killed were mentally retarded children, followed by mentally ill adults and the handicapped. Then the war expanded, and, among others, the Gypsies, Jews, and other concentration camp prisoners were subjected to medicalized killing. The medical apparatus was moved from the mental institutions to the concentration camps and, as Robert J. Lifton put it in his 1986 book, The Nazi Doctors: Medical Killing and the Psychology of Genocide, the doctors' euthanasia programs provided the "medical bridge to unrestrained genocide" by the Nazis.

At war's end, Brandt and other doctors were prosecuted at Nuremberg in the Medical Trials; Brandt was hanged for his crimes. Among numerous counts involving crimes of medical experimentation on unconsenting victims, Brandt and three others were charged with a war crime and crime against humanity for the euthanasia program. In The Nazi Doctors and the Nuremberg Code, edited by George Annas and Michael A. Grodin, these crimes are specified as follows:

[The] systematic and secret execution of the aged, insane, incurably ill, of deformed children, and other persons, by gas, lethal injections, and diverse other means in nursing homes, hospitals and asylums. . . . German doctors involved in the "euthanasia" program were also sent to the eastern occupied countries to assist in the mass extermination of Jews (1992, p. 101).

As Matthew Lippman notes in a 1998 article appearing in the Arizona Journal of International and Comparative Law, the Nuremberg Medical Trials set the precedent that state-sponsored euthanasia against nonnationals is a war crime and a crime against humanity.

In discussions about the morality and legality of euthanasia, analogies are frequently drawn to the Nazi doctors. Today's comatose patient may be the equivalent of yesterday's mentally retarded person, whose life is deemed unworthy of living. On the other hand, advocates of a right to die contrast Nazi state-sponsored killing with an individual's choice to die with dignity. On all sides, the moral and legal arguments about euthanasia are nuanced and contested.

SEE ALSO Eugenics; Germany; Medical Experimentation; Nuremberg Laws; Physicians

Leslie C. Griffin