Types of euthanasia

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The Basic Definitions

Euthanasia is generally classified as either "active" or "passive", and as either "voluntary" or "involuntary". Similar to euthanasia is "assisted suicide".

Active vs Passive

"Passive euthanasia" is usually defined as withdrawing medical treatment with the deliberate intention of causing the patient's death. For example, if a patient requires kidney dialysis to survive, and the doctors disconnect the dialysis machine, the patient will presumably die fairly soon. Perhaps the classic example of passive euthanasia is a "do not resuscitate order". Normally if a patient has a heart attack or similar sudden interruption in life functions, medical staff will attempt to revive them. If they make no such effort but simply stand and watch as the patient dies, this is passive euthanasia.

"Active euthanasia" is taking specific steps to cause the patient's death, such as injecting the patient with poison. In practice, this is usually an overdose of pain-killers or sleeping pills.

In other words, the difference between "active" and "passive" is that in active euthanasia, something is done to end the patient's life; in passive euthanasia, something is not done that would have preserved the patient's life.

An important idea behind this distinction is that in "passive euthanasia" the doctors are not actively killing anyone, they are simply not saving him. While we would usually applaud someone who saves another person's life, we do not normally condemn someone for failing to do so. If you rush into a burning building and carry someone out to safety, you will probably be called a hero. But if you see a burning building and people screaming for help, and you stand on the sidelines -- whether out of fear for your own safety, the belief that an inexperienced and ill-equipped person like yourself would only get in the way of the professional firefighters, or whatever -- if you do nothing, few would judge you for your inaction. You would surely not be prosecuted for homicide. (At least, not unless you started the fire in the first place.) Thus, proponents of euthanasia say that while we can debate whether active euthanasia should be legal, there can be no debate about passive euthanasia: You cannot prosecute someone for failing to save a life. Even if you think it would be good for people to do X, you cannot make it illegal for people to not do X, or everyone in the country who did not do X today would have to be arrested.

In practice, though, the distinction can get hazy. It's like the old joke about the child who says to his teacher, "Do you think it's right to punish someone for something that he didn't do?" "Why, of course not," the teacher replies. "Good," the child says, "because I didn't do my homework."

In fact we have many laws that penalize people for what they didn't do. You cannot simply decide not to pay your income taxes, or not bother to send your children to school, or not to obey a policeman's order to put down your gun.

The most common method of euthanasia in the United States today is withholding food and fluids. In other words, the patient is starved to death. This is routinely classified as "passive euthanasia". But in other circumstances, if you locked someone in a room and kept all food away from him so that he starved to death, you could surely be prosecuted not just for kidnapping -- locking the person in the room -- but also for homicide. I sincerely doubt that a court would pay much attention to a defense based on the argument that you did not kill this person, you simply failed to save his life when he was starving.

Voluntary vs Involuntary

"Voluntary euthanasia" is when the patient requests that action be taken to end his life, or that life-saving treatment be stopped, with full knowledge that this will lead to his death.

"Involuntary euthanasia" is when a patient's life is ended without the patient's knowledge and consent. This may mean that the patient is kicking and screaming and begging for life, but in practice today it usually means that the patient is unconscious, unable to communicate, or is too sick and weak to be aware of what is happening or to take any action on his own behalf.

While this distinction appears clear - the patient willing agreed to euthanasia or he did not - it too is often made ambiguous in court cases and some public debate.

It is not uncommon for courts to declare someone "legally incompetent". This does not mean that the person is stupid, but rather that the court believes that he is unable to make informed decisions and/or to communicate them to others. The judge then appoints a guardian to make decisions for this person. Usually this will be a close relative, like a spouse, parents, or children. But if no such person is available, or if the judge believes that none of the relatives have this person's best interests at heart, then someone else may be appointed: a social worker, a lawyer, etc. Children are routinely considered legally incompetent, and their parents are expected to make decisions for them. No one asks a two-year-old whether or not he wants to go to the dentist: that decision is normally made for him by his parents. A judge may conclude that a person is senile, mentally retarded, suffering from delusions, or has some other psychological problem that makes it impossible for him to make truly informed, rational decisions. If someone is in a coma or is otherwise so sick that she is unable to communicate, then even if she is capable of making informed decisions, there is no way for anyone else to know what her decisions are.

When courts declare someone legally incompetent and appoint a guardian, any decisions that the guardian makes are, for legal purposes, considered to be decisions of the incompetent person. A little thought will show that this must be so for the system to work: there would be little point in saying that you are authorized to make decisions for this comatose person ... except that you do not have the authority to sign anything that would otherwise require his signature. That would exclude almost all important decisions. But it can also lead to legal statements that are very misleading: Suppose Nancy Smith convinces a court that her grandfather, Fred Jones, is senile, and she is appointed his guardian. Then she decides that she wants to have him euthanized. He objects but he is too old and sick to fight her in court herself, so he gets his other granddaughter, Mary Brown, to fight for him. Because Nancy Smith's decisions are legally considered to be Fred Jones's decisions, the case will be referred to as "Brown versus Jones", and court documents will routinely describe this as Fred Jones choosing euthanasia and Mary Brown attempting to overrule this decision. News reports on the court case may or may not make clear who actually made the euthanasia decision.

It is not uncommon for medical personnel to treat someone as legally incompetent without any official court decision. For example, if someone is in the operating room under anesthesia, and there is a sudden crisis and a life-altering decision must be made now, it is often not possible to sew the person back up, wait for them to wake up, and then discuss the matter. A spouse or other close relative will be asked to make a decision on this person's behalf. Clearly under such circumstances it would be impractical to take this to court and hold hearings on the patient's competence and the suitability of the spouse as a guardian. But in euthanasia cases, the problem is often not that the patient is incapable of making and communicating a decision, but rather that those around her do not approve of her decision. Even when the legality of such actions is questionable, in real life the authorities are not going to intervene unless someone challenges it. And if the patient is weak, sick, and bed-ridden, she may not be capable of getting to court to protest. Unless there is another relative who disagrees with the decision to euthanize, the patient's wishes can simply be ignored.

Assisted suicide

In "assisted suicide", a doctor provides a patient with the means to end his own life, but the doctor does not administer it. For example, if a doctor gives you an injection of morphine sufficient to cause your death, this is euthanasia. But if the doctor puts the hypodermic needle beside your bed, explains to you what it is, and leaves, and you later inject yourself, this is considered assisted suicide.

The extremes

Clearly there is a big difference between "voluntary passive euthanasia" and "involuntary active euthanasia".

In voluntary passive euthanasia, a person decides for himself that medical treatment that he is receiving is making his life more unpleasant than the disease, and that he would rather end the treatment and go home. Presumably he concludes that a shorter but more comfortable life is preferable. Or perhaps he is simply tired of fighting, and wants to just give up and die.

In involuntary active euthanasia, one person decides that another person's life is no longer worth living or no longer of value, and has him killed.

While both of these things result in the person's death, they are so dramatically different that it strains the language to lump them both under the single term "euthanasia".

It reminds me of those gangster movies where the criminal says, "We ... ahem ... acquired this item from Mr Jones." What actually happened is that he beat Jones up and stole it. But by saying he "acquired" it, he neatly glosses over the subtle legal and moral distinctions between buying, borrowing, trading, stealing, and other methods of "acquiring" things.

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Posted 20 Nov 2001.

Copyright 2001 by Pregnant Pause
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