Euthanasia and Assisted Suicide

Euthanasia and physician-assisted suicide refer to a deliberate action taken to end a life to relieve persistent pain.

Euthanasia is only legal in a select few countries and U.S. States.

In most countries, euthanasia is against the law and may carry a jail sentence. In the United States, the law varies between states.

Euthanasia has long been a controversial and emotive topic.

The definitions of euthanasia and assisted suicide vary.

One useful distinction is:

Euthanasia: A doctor is allowed by law to end a person’s life by painless means, as long as the person and their family agree.

Assisted suicide: A doctor assists an individual in taking their own life if the person requests it.

Voluntary and involuntary euthanasia

Euthanasia may be voluntary or involuntary.

Voluntary: When euthanasia is conducted with consent. Voluntary euthanasia is currently legal in Australia, Belgium, Canada, Colombia, Luxembourg, the Netherlands, Spain, Switzerland, and New Zealand.

It is also legal in the U.S. states of Oregon, Washington, D.C., Hawaii, Washington, Maine, Colorado, New Jersey, California, and Vermont.

Non-voluntary: When euthanasia is conducted on a person who is unable to consent due to their current health condition.

In this situation, the decision is made by another appropriate person, on behalf of the individual, based on their quality of life.

Involuntary: When euthanasia is performed on a person who would be able to provide informed consent, but does not, either because they do not want to die, or because they were not asked.

This is called murder, as it’s often against the person’s will.

Passive and active euthanasia

There are two procedural classifications of euthanasia:

Passive euthanasia is when life-sustaining treatments are withheld. The definitions are not precise.

If a doctor prescribes increasing doses of strong pain-management medications, such as opioids, this may eventually be toxic for the individual. Some may argue that this is passive euthanasia.

Others, however, would say this is not euthanasia, because there is no intention to take life.

Active euthanasia is when someone uses lethal substances or forces to end the person’s life, whether by the individual themself or somebody else.

Active euthanasia is more controversial, and it is more likely to involve religious, moral, ethical, and compassionate arguments.

What is assisted suicide?

Assisted suicide has several different interpretations and definitions.

One is:

“Intentionally helping a person take their own life by providing drugs for self-administration, at that person’s voluntary and competent request.”

Some definitions include the words, “to relieve intractable (persistent, unstoppable) suffering.”

The role of palliative care

Since pain is the most visible sign of distress or persistent suffering, people with cancer and other life-threatening, chronic conditions will often receive palliative care.

Opioids are commonly used to manage pain and other symptoms.

The adverse effects of opioids include drowsiness, nausea, vomiting, and constipation.

They can also be addictive. An overdose can be life-threatening.

Refusing treatment

In many countries, including the U.S., a person can refuse treatment that is recommended by a health professional, as long as they have been properly informed and are “of sound mind.”

History

One argument against euthanasia or physician-assisted suicide is the Hippocratic Oath, dating back some 2,500 years. All doctors take this oath.

The Hippocratic Oath

The original oath included, among other things, the following words:

“I will neither give a deadly drug to anybody who asks for it, nor will I suggest this effect.”

There are variations of the modern oath.

One states:

“If it is given to me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my frailty.”

As the world has changed since the time of Hippocrates, some feel that the original oath is outdated. In some countries, an updated version is used, while in others, doctors still adhere to the original.

As more treatments become available, for example, the possibility of extending life, whatever its quality, is an increasingly complex issue.

Euthanasia in the United States

In the U.S. and other countries, euthanasia has been a topic of debate since the early 1800s.

In 1828, the first anti-euthanasia law in the U.S. was passed in New York State. In time, other states followed suit.

In the 20th century, Ezekiel Emanuel, a bioethicist of the American National Institutes of Health (NIH), said that the modern era of euthanasia was ushered in by the availability of anesthesia.

In 1938, a euthanasia society was established in the U.S. to lobby for assisted suicide.

Physician-assisted suicide became legal in Switzerland in 1937, as long as the doctor ending the patient’s life had nothing to gain.

During the 1960s, advocacy for a right-to-die approach to euthanasia grew.

The Netherlands decriminalized doctor-assisted suicide and loosened some restrictions in 2002. In 2002, doctor-assisted suicide was approved in Belgium.

In the U.S., formal ethics committees now exist in hospitals and nursing homes, and advance health directives, or living wills, are common around the world.

These became legal in California in 1977, with other states soon following suit.

In the living will, the person states their wishes for medical care should they become unable to make their own decision.

In 1990, the Supreme Court approved the use of non-active euthanasia.

In 1994, voters in Oregon approved the Death with Dignity Act, allowing physicians to assist people with terminal conditions who were not expected to survive more than 6 months.

The US Supreme Court adopted such laws in 1997, and Texas made non-active euthanasia legal in 1999.

In 2008, 57.91% of voters in Washington state chose in favor of the Death with Dignity Act, and the act became law in 2009.

Controversy

Various arguments are commonly cited for and against euthanasia and physician-assisted suicide.

Arguments for

Freedom of choice: Advocates argue that the person should be able to make their own choice.

Quality of life: Only the individual knows how they feel, and how the physical and emotional pain of illness and prolonged death impacts their quality of life.

Dignity: Every individual should be able to die with dignity.

Witnesses: Many who witness the slow death of others believe that assisted death should be allowed.

Resources: It makes more sense to channel the resources of highly skilled staff, equipment, hospital beds, and medications toward lifesaving treatments for those who wish to live, rather than those who do not.

Humane: It is more humane to allow a person with intractable suffering to be allowed to choose to end that suffering.

Loved ones: It can help to shorten the grief and suffering of loved ones.

We already do it: If a beloved pet has intractable suffering, it is seen as an act of kindness to put it to sleep.

Why should this kindness be denied to humans?

Arguments against

The doctor’s role: Healthcare professionals may be unwilling to compromise their professional roles, especially in light of the Hippocratic Oath.

Moral and religious arguments: Several faiths see euthanasia as a form of murder and morally unacceptable. Suicide, too, is “illegal” in some religions.

Morally, there is an argument that euthanasia will weaken society’s respect for the sanctity of life.

Patient competence: Euthanasia is only voluntary if the patient is mentally competent, with a lucid understanding of available options and consequences, and the ability to express that understanding and their wish to terminate their own life.

Determining or defining competence is not straightforward.

Guilt: Patients may feel they are a burden on resources and are psychologically pressured into consenting.

They may feel that the financial, emotional, and mental burden on their family is too great.

Even if the costs of treatment are provided by the state, there is a risk that hospital personnel may have an economic incentive to encourage euthanasia consent.

Mental illness: A person with depression is more likely to ask for assisted suicide, and this can complicate the decision.

Slippery slope: There is a risk that physician-assisted suicide will start with those who are terminally ill and wish to die because of intractable suffering.

Possible recovery: Very occasionally, a patient recovers, against all the odds. The diagnosis might be wrong.

Palliative care: Good palliative care makes euthanasia unnecessary.

Regulation: Euthanasia cannot be properly regulated.

Statistics

How many people die each year?

In countries where euthanasia or assisted suicide are legal, they are responsible for between 0.3 and 4.6% of deaths, over 70% of which are linked to cancer.

In Oregon and Washington states, fewer than 1% of physicians write prescriptions that will assist suicide each year.

What happens to the body after death?

When someone dies, it may be the end of their journey through this world, but this is not the case with their body. Instead, it will begin the long process of shedding its components.

So, what happens when bodies decompose, and why should we learn about it?

Decomposition is what naturally occurs to bodies after death. What is there to know about it?

For the majority of us, contact with the bodies of people who have passed away begins and ends with the sad occasion of a funeral.

And even then, what we usually get is either an urn with the person’s cremated remains or a body laid out neatly in a casket, having been carefully prepared for the occasion by a funeral home.

Under natural conditions, if the body is left out in a natural environment or placed in a shallow grave, a lifeless body begins to slowly disintegrate, until only the bones are left for future archeologists to dig up.

What happens in decomposition?

Although many of us may think of decomposition as synonymous with putrefaction, it is not. The decomposition of a human body is a longer process with many stages, of which putrefaction is only one part.

Decomposition is a phenomenon through which the complex organic components of a previously living organism gradually separate into ever simpler elements.

There are several signs that a body has begun its process of decomposition. Perhaps the three best-known ones, which are often cited in crime dramas, are livor mortis, rigor mortis, and algor mortis.

Livor mortis, or lividity, refers to the point at which a deceased person’s body becomes very pale, or ashen, soon after death. This is due to the loss of blood circulation as the heart stops beating.

The blood begins to settle, by gravity, to the lowest portions of the body,” causing the skin to become discolored.

This process may begin after about an hour following death and can continue to develop until the 9–12 hour mark postmortem.

In rigor mortis, the body becomes stiff and completely unyielding, as all the muscles tense due to changes that occur in them at a cellular level.

Rigor mortis settles in at 2–6 hours after death and can last for 24–84 hours. After this, the muscles become limp and pliable once more.

Another early process is that of algor mortis, which occurs when the body goes cold as it “ceases to regulate its internal temperature.”

How cold a body will go largely depends on its ambient temperature, which it naturally matches within about 18–20 hours after death.

Other signs of decomposition include the body assuming a greenish tinge, skin coming off the body, marbling, tache noire, and, of course, putrefaction.

Other signs of decomposition

The greenish tint that the body may assume after death is due to the fact that gases accumulate within its cavities, a significant component of which is a substance known as hydrogen sulfide.

Putrefaction is ‘nature’s recycling process.’

As for skin slippage — in which the skin neatly separates from the body — it might sound less disturbing once we remember that the whole outer, protective layer of our skin is made out of dead cells.

“The outer layer of skin, stratum corneum, is dead. It is supposed to be dead and fills a vital role in water conservation and protection of the underlying (live) skin.

This layer is constantly being shed and replaced by the underlying epidermis. Upon death, in moist or wet habitats, the epidermis begins to separate from the underlying dermis, and it can then easily be removed from the body.

When the skin comes off a dead person’s hands, it is typically known as “glove formation.”

A phenomenon known as “marbling” occurs when certain types of bacteria found in the abdomen migrate to the blood vessels, causing them to assume a purple-greenish tint. This effect gives the skin on some body parts — usually the trunk, legs, and arms — the appearance of marble (hence its name).

Moreover, in instances wherein the eyes remain open after death, “the exposed part of the cornea will dry up, leaving a red-orange to black discoloration. This is referred to as “tache noire,” which means “black stain” in French.

Finally, there is putrefaction. It is facilitated by the concerted actions of bacterial, fungal, insect, and scavenger agents over time, until the body is stripped of all soft tissue and only the skeleton remains.

The stages of decomposition

The first one, the fresh stage, refers to the body right after death, when few signs of decomposition are visible. Some processes that may begin at this point include greenish discoloration, livor mortis, and tache noire.

At the second stage of decomposition, the bloated stage, is when putrefaction begins. Gases that accumulate in the abdomen, therefore causing it to swell, give the body a bloated appearance.

Down to the bones

During the third stage, that of decay, the skin breaks down due to putrefaction and the action of maggots, allowing the accumulated gases to escape.

Partly for this reason, this is when the body emanates strong, distinctive odors.

The first note of a putrefying human body is of licorice with a strong citrus undertone. Not a fresh, summer citrus, mind you — more like a can of orange-scented industrial bathroom spray shot directly up your nose.

Add to that a day-old glass of white wine that has begun to attract flies. Top it off with a bucket of fish left in the sun.

That is what human decomposition smells like.

Postdecay is the next-to-last stage of decomposition, in which the body is reduced to skin, cartilage, and bone. At this point, various types of beetles usually come in to remove the softer tissue, leaving only the bones behind.

The final stage of decomposition is the skeletal stage, in which only the skeleton — and sometimes hair — is left.

How long it takes for a body to decompose largely depends on the geographical area in which the body is found and the interaction of environmental conditions.

If a body is found in a dry climate, with either very low or very high temperatures, it could mummify.

Why learn all of this?

Scientists have noted that, for instance, the mistaken idea that dead bodies can easily spread disease is “a myth too tough to die.

This problem is particularly bad in the case of fatalities that are caused by natural disasters. Yet, as the dedicated World Health Organization (WHO) page clearly states, “dead bodies from natural disasters generally do not cause epidemics.”