Right to die

The right to die is a concept based on the opinion that human beings are entitled to end their life or undergo voluntary euthanasia. Possession of this right is often understood that a person with a terminal illness, or without the will to continue living, should be allowed to end their own life, use assisted suicide, or to decline life-prolonging treatment. The question of whom, if anyone, should be empowered to make this decision is often central to the debate.

For other uses, see Right to die (disambiguation).

Death of Socrates

Some academics and philosophers, such as David Benatar, consider humans to be overly optimistic in their view of the quality of their lives, and their view of the balance between the positive and the negative aspects of living.[1] This idea can be considered in terms of antinatalism and the lack of agency regarding one's birth and who should have authority over one's choice to live or die.

Proponents typically associate the right to die with the idea that one's body and one's life are one's own, to dispose of as one sees fit. However, a legitimate state interest in preventing irrational suicides is often up for debate. Pilpel and Amsel wrote:

Contemporary proponents of "rational suicide" or the "right to die" usually demand by "rationality" that the decision to kill oneself be both the autonomous choice of the agent (i.e., not due to the physician or the family pressuring them to "do the right thing" and commit suicide) and a "best option under the circumstances" choice desired by the stoics or utilitarians, as well as other natural conditions such as the choice being stable, not an impulsive decision, not due to mental illness, achieved after due deliberation, etc.[2]

Religious views on suicide vary from the Hindu and Jain practices of non-violent suicide through fasting (Prayopavesa and Santhara, respectively) to considering it a grave sin, as in Catholicism.

Ethics

The preservation and value of life have led to many medical advancements when it comes to treating patients. New devices and the development of palliative care has allowed humans to live longer than before. Prior to these medical advancements and care, those who were unconscious, minimally unconscious, and in a vegetative state life span was short due to no proper way to assist them with basic needs such as breathing and feeding. With the advancement of medical technology, it raises the question about the quality of life of a patient when they are no longer conscious. The right to self-determination and of others emerged and questions the definition of quality and sanctity of life; if one had the right to live, then the right to die must follow suit.[3][4] There are questions in ethics as to whether or not a right to die can coexist with a right to life. If it is argued, the right to life is inalienable, it cannot be surrendered, and therefore may be incompatible with a right to die.[5] A second debate exists within bioethics over whether the right to die is universal, only applies under certain circumstances (such as terminal illness), or if it exists. It is also stated that 'right to live' is not synonymous to 'obligation to live.' From that point of view, the right to live can coexist with the right to die.[6]

The right to die is supported and rejected by many. Arguments for this right include:

1. If one had a right to live, then one must have the right to die, both on their terms.
2. Death is a natural process of life thus there should not be any laws to prevent it if the patient seeks to end it.
3. What we do at the end of our lives should not be of concern to others.
4. If euthanasia is strictly controlled, we can avoid entering a slippery slope and prevent patients from seeking alternative methods which may not be legal.[3]

Arguments against include:

1. It can lead to a slippery slope; if we allow patients this right, it can expand and have dire consequences.
2. Give rise in pressuring those to end their lives or the lives of others; ethically immoral in human and medical standards.
3. "Throwing away" patients who are deemed no longer capable to be part of society.
4. Decrease in palliative end of life care due to the expectation of terminal patents to exercise their right to die.[3][7]

A court in the American state of Montana for example, has found that the right to die applies to those with life-threatening medical conditions. Suicide advocate Ludwig Minelli, euthanasia expert Sean W. Asher, and bioethics professor Jacob M. Appel, in contrast, argue that all competent people have a right to end their own lives. Appel has suggested that the right to die is a test for the overall freedom of a given society.[8]

The 1991 Patient Self-Determination Act passed by the US Congress at the request of the financial arm of Medicare does permit elderly Medicare/Medicaid patients (and by implication, all "terminal" patients) to prepare an advance directive in which they elect or choose to refuse life-extending and/or life-saving treatments as a means of shortening their lives to shorten their suffering unto certain death. The treatment refused in an advance directive under US law, because of the 1991 PSDA, does not have to be proved to be "medically futile" under some existing due-process procedure developed under state laws, such as TADA in Texas.[9]

By country

See also: Voluntary euthanasia § By country

As of June 2016, some forms of voluntary euthanasia are legal in Australia, Canada,[10] Colombia,[10] Belgium,[11] Luxembourg,[12] the Netherlands,[11] and Switzerland.[11]

Australia

Main article: Euthanasia in Australia

As euthanasia is a health issue, under the Australian constitution this falls to state governments to legislate and manage.

Euthanasia was legal within the Northern Territory during parts of 1996 - 1997 as a result of the territory parliament passing Rights of the Terminally Ill Act 1995. As a territory and not a state, the federal government under Prime Minister John Howard amended the Northern Territory (Self-Government) Act 1978 (amongst others) to ensure that territories of Australia are no longer able to legislate on euthanasia.[13] This reversed the legal status of euthanasia in the Northern Territory, where it has remained illegal since. The federal government is not able to legislate restrictions on health issues for the six Australian states in the same manner.[14]

On 29 November 2017, the Victorian Government passed the Voluntary Assisted Dying Act 2017 (Victoria), legalising physician-assisted suicide.[15] The laws came into effect on 19 June 2019 and feature 68 safeguards designed to protect the vulnerable.[16][17] As of February 2020, Victoria is the only Australian state with legalised assisted death, though it will soon be available in Western Australia following the passing of the Voluntary Assisted Dying Act 2019.[18]

Belgium

In 2002, the Belgian parliament legalized euthanasia.[19]

Canada

Main article: Euthanasia in Canada

As of August 2011 a British Columbia Supreme Court judge had been requested to speed up a right-to die lawsuit so that Gloria Taylor could have a doctor assist her in committing suicide. She suffered from Lou Gehrig's disease.[20] She died of an infection in 2012.

A British Columbia civil liberties lawsuit is representing six plaintiffs and challenges the laws that make it a criminal offence to assist seriously and incurably ill individuals to die with dignity.

On 6 February 2015 the Supreme Court of Canada ruled that denying the right to assisted suicide is unconstitutional. The court's ruling limits physician-assisted suicides to "a competent adult person who clearly consents to the termination of life and has a grievous and irremediable medical condition, including an illness, disease or disability, that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition." The ruling was suspended for 12 months to allow the Canadian parliament to draft a new, constitutional law to replace the existing one.[21]

The court decision includes a requirement that there must be stringent limits that are "scrupulously monitored." This will require the death certificate to be completed by an independent medical examiner, not the treating physician, to ensure the accuracy of reporting the cause of death.[22]

The Canadian Medical Association (CMA) reported that not all doctors were willing assist in patient's death due to legal complications and went against what a physician stood for. Many physicians stated that they should have a voice when it comes to helping a patient end their life.[23] However, the belief in late 2015 was that no physician would be forced to do so but the CMA was offering educational sessions to members as to the process that would be used.[24]

On 17 June 2016, legislation passed both houses of the Parliament of Canada and received Royal Assent to allow euthanasia within Canada.[25][10]

Colombia

Main article: Legality of euthanasia § Colombia

On 20 May 1997, the Constitutional Court of Colombia decriminalised piety homicide, for terminally ill patients, stating that "the medical author cannot be held responsible for the assisted suicide of a terminally ill patient" and urged Congress to regulate euthanasia "in the shortest time possible".[26]

On 15 December 2014, the Constitutional Court had given the Ministry of Health and Social Protection 30 days to publish guidelines for the healthcare sector to use in order to guarantee terminally ill patients, with the wish to undergo euthanasia, their right to a dignified death.[27]

India

Main article: Euthanasia in India

Since 2018, the Supreme Court of India has legalized passive euthanasia in India during a case involving Aruna Shanbaug under strict conditions, namely that the patient's consent (or relatives) is needed, and that the patient must be terminally ill or vegetative state.

Netherlands

Main article: Euthanasia in the Netherlands

The Netherlands legalized voluntary euthanasia in 2002. Under current Dutch law, euthanasia and assisted suicide can only be performed by doctors, and that is only legal in cases of "hopeless and unbearable" suffering. In practice this means that it is limited to those suffering from serious and incurable medical conditions (including mental illness) and in considerable suffering like pain, hypoxia or exhaustion. Helping somebody to commit suicide without meeting the qualifications of the current Dutch euthanasia law is illegal.[28] These criteria concern the patient's request, the patient's suffering (unbearable), the infaust prognosis (hopeless), the information provided to the patient, the absence of reasonable alternatives, consultation of another physician and the applied method of ending life.[28]

In February 2010, citizens' initiative called Uit Vrije Wil (Out of Free Will) further demanded that all Dutch people over 70 who feel tired of life should have the right to professional help in ending it. The organization, initiated by Milly van Stiphout and Yvonne van Baarle, started collecting signatures in support of this proposed change in Dutch legislation. A number of prominent Dutch citizens supported the initiative, including former ministers and artists, legal scholars and physicians. Among them were former politicians Frits Bolkestein, Hedy d'Ancona and Jan Terlouw, as well as television personality Mies Bouwman.[29][30][31] This initiative has never been legalised.

New Zealand

Main article: Euthanasia in New Zealand

Euthanasia is illegal in New Zealand. In 2015, lawyer and cancer sufferer Lecretia Seales brought a case (Seales v Attorney-General) to the High Court to challenge New Zealand law for her right to die with the assistance of her GP, asking for a declaration that her GP would not risk conviction.[32][33] However legislation is to legalize euthanasia for terminally ill patients is to be voted upon in the 2020 general election.

Peru

Peru legally forbids euthanasia.[34] In 2020, a legal challenge to the law was launched by Ana Estrada, aimed at decriminalizing the practice.[34]

United States

Main article: Euthanasia in the United States

The term right to die has been interpreted in many ways, including issues of suicide, passive euthanasia, active euthanasia, assisted suicide, and physician-assisted suicide.[35]

Major right to die cases

Karen Quinlan

The right to die movement in the US began with the case of Karen Quinlan in 1975 and continues to raise bioethical questions of one's quality of life and the legal process of death. Karen Quinlan, 21, lost consciousness after consuming alcohol and tranquilizers at a party.[36] She soon began to experience respiratory problems, which then prevented oxygen from flowing to her brain. That led her to slip into a comatose state in which a respirator and a feeding tube were used to keep her alive and breathing.[37][36] Quinlan did not have a proxy or living will and had not expressed her wishes if something ever happened to her to those around her, which made it difficult to decide what the next step should be.

Karen Quinlan's parents understood that their daughter would never wake up and that prolonging her life may be more damaging and it would not be of quality life.[36][38] Her father sought out the right to be Karen's legal guardian and petitioned for the removal of the respirator that was keeping her alive. The court, however, argued that the removal of the ventilator, which would lead to Karen's death, would be considered unlawful, unnatural, and unethical. Quinlan's lawyer made the counterargument that the removal of the respirator would allow Karen to have a natural death, which is natural and ethical. The Quinlans won the court case and were appointed as the legal guardians of their daughter. The respirator was removed in 1976, but Karen continued to live without the ventilator until 1985.[37][38] The case continues to raise bioethical questions of one's quality of life and the legal process of death. It also case brings up many important issues that are still being addressed to this day.[38][39] One of the critical points that the Quinlan case brings up is the patient's right to deny or withdraw treatment. Cases in which the patient rejected or withdrew treatment were then unheard of and went against medical ethics in preserving one's life. Debates on allowing patients the right to self-determination were controversial, and they would be evaluated for the next couple of decades from state to state. The case also brought up whether family members and those who are close to the patient are allowed in the decision making process. Since Karen had no written documentation, voiced no decision, and appointed no proxy, a lengthy legal battle was caused between the Quinlan family and the state in determining Karen's best interest and determining if she would want to live or die. That had a significant influence on the use and establishment of advance directives, oral directives, proxies, and living wills.[40]

Nancy Cruzan

Nancy Cruzan's gravestone

Another major case that further propagated the right to die movement and the use of living wills, advance directives and use of a proxy was Cruzan v. Director, Missouri Department of Health. In 1983, Nancy Cruzan suffered a car accident, which left her permanently in a vegetative state. Her status as an adult and lack of an advance directive, living will, or proxy led to a long legal battle for Cruzan's family in petitioning for the removal of her feeding tube, which was keeping her alive since the accident. Nancy had mentioned to a friend that under no circumstances would she want to continue to live if she were ever in a vegetative state, but she was not a strong enough statement to remove the feeding tube.[41] Eventually, the Cruzan family won the case and had their daughter's tube removed. The case brought great debate if the right to die should be approved from state to state or as a whole nation.[42]

Terri Schiavo

The Terri Schiavo case occurred between 1990 and 2005. This case was controversial due to a disagreement between Terri's immediate family members and her husband. In the Quinlan and Cruzan cases, the family was able to make a unanimous decision on the state of their daughters. Schiavo suffered from a cardiac arrest which led to her collapse and soon after began to have trouble breathing. The lack of oxygen to her brain caused irreversible brain damage, leaving her in a vegetative state and required a feeding tube and ventilator to keep her alive. Terri left no advance directive or had a discussion with her parents or husband about what she may have wanted if something were to happen to her. Soon after, her husband was appointed as her legal guardian.[42]

Years later, her husband decided to remove Terri's feeding tube since the chances of her waking up were slim to none. Terri's family, however, argued against this decision and brought this case to court. The case was very turbulent and occurred over some years and involved the state and its legislators before a decision was made.[42] This brought up bioethical debates on discontinuation of Schiavo's life vs. allowing her to continue living in a permanent vegetative state. Those who were for preserving Terri's life stated that removing the tube would be ethically immoral since they do not know what she would have wanted. They challenged her physical and mental state and stated that she might have some consciousness; thus she deserved to continue living. Those for removing the tube argued for self-determination and that her quality of life was diminished.[42][43][44] The Schiavo case is the most recent and significant right to die case in which propagate the thought of having an advance directive or living will. It also further looks into other complications that can arise, such as family disagreements, which should have been accounted for when dealing with a right to die case.[42][44]

Legislation

As the health of citizens is considered a police power left for individual states to regulate, it was not until 1997 that the US Supreme Court made a ruling on the issue of assisted suicide and one's right to die. That year, the Supreme Court heard two appeals arguing that New York and Washington statutes that made physician-assisted suicide a felony violated the equal protection clause of the Fourteenth Amendment.[45] In a unanimous vote, the Court held that there was no constitutional right to physician-assisted suicide and upheld state bans on assisted suicide. While in New York this has maintained statutes banning physician-assisted suicide, the Court's decision also left it open for other states to decide whether they would allow physician-assisted suicide or not.

Since 1994, five states in the US have passed assisted suicide laws: Oregon, Washington, Vermont, California, and Colorado passed legislation in 1994, 2008, 2013, 2015, and 2016, respectively, that provides a protocol for the practice of physician-assisted suicide.[46] The law in these five states allows terminally ill adult patients to seek lethal medication from their physicians. In 2009, the Montana Supreme Court ruled that nothing in state law prohibits physician-assisted suicide and provides legal protection for physicians in the case that they prescribe lethal medication upon patient request. In California, the governor signed a controversial physician-assisted-suicide bill, the California End of Life Option Act, in October 2015 that passed during a special legislative session intended to address Medi-Cal funding,[47] after it had been defeated during the regular legislative session.[48] Because the bill was passed during a special session, it did not take effect until June 2016.[49][50]

In early 2014, New Mexico Second District Judge Nan Nash ruled that terminally ill patients have the right to aid in dying under the state constitution, i.e., making it legal for a doctor to prescribe a lethal dose of medication to a terminally ill patient.[51] The ultimate decision will be made with the outcome of New Mexico's Attorney General's appeal to the ruling. Organizations have been continuously pushing for the legalization of self-determination in terminally ill patients in states where the right to ending one's life is prohibited.[52]

Religion

Hinduism accepts the right to die for those who are tormented by terminal diseases or those who have no desire, no ambition or no responsibilities remaining. Death, however, is allowed by non-violent means such as fasting to the point of starvation (Prayopavesa).[53] Jainism has a similar practice named Santhara. Other religious views on suicide vary in their tolerance and include denial of the right as well as condemnation of the act. In the Catholic faith, suicide is considered a grave sin.[54]

See also

• Washington v. Glucksberg
• Vacco v. Quill

Initiatives Advance Directives Act (Texas) Initiative 1000 (Washington) Oregon Death with Dignity Act Groups Compassion & Choices of Oregon Dignitas Exit International World Federation of Right to Die Societies Final Exit Network Films How to Die in Oregon documentary film Right to Die? documentary film Books Final Exit

Individuals Elizabeth Bouvia Eluana Englaro Edward Brongersma Betty and George Coumbias David Goodall Tirhas Habtegiris Derek Humphry Richard Huxtable Jack Kevorkian Brittany Maynard Philip Nitschke Haleigh Poutre Diane Pretty Karen Ann Quinlan Sue Rodriguez Terri Schiavo Ramón Sampedro

Other related Advocacy of suicide Assisted suicide Bioethics / Medical ethics Do not resuscitate Euthanasia Force feeding Right to life Letting die Living will Patient refusal of nutrition and hydration

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Further reading

• Shaw D (September 2007). "The body as unwarranted life support: a new perspective on euthanasia". Journal of Medical Ethics. 33 (9): 519–21. doi:10.1136/jme.2006.020073. PMC 2598200. PMID 17761819.
• Appel JM (May–June 2007). "A suicide right for the mentally ill? A Swiss case opens a new debate". The Hastings Center Report. 37 (3): 21–3. doi:10.1353/hcr.2007.0035. PMID 17649899.
• (in Dutch) "Uit Vrije Wil — Burgerinitiatief voltooid leven"