Introduction

The practice of euthanasia has grown in the past 40 years.  In 1950, one-third of Americans believed that doctors should be allowed to practice euthanasia.  By 1991, the figure had grown to nearly two-thirds of the Americans surveyed (Hamburg, 1992, p. 10).  According to a 1975 Gallup poll, 41% of the respondents believed that someone in great pain with "no hope of improvement" had the moral right to commit suicide.  By 1990, 66% of the people polled believed that it was acceptable to end their own life when recovery was not expected (Ames, 1991, p. 41).

The option that more and more patients, and their families, demand is to leapfrog dying if death is all that awaits.  While many people choose death, no one chooses dying.  Although there are no national statistics, anecdotal evidence suggests that more than half of hospital deaths follow a decision to limit or withhold life-sustaining treatment.  This is not suicide, or euthanasia, for both of those mean ending life.  It is, rather, a desire to end dying, to pass gently into the night without tubes running down the nose and a ventilator insistently inflating lungs that have grown weary from the insult (Begley, 1992, p. 44).

Attitudes towards euthanasia are changing.  As the Begley quote demonstrates, many people consider ending dying as being different than ending life.  This appears to be a matter of semantics.  Death, by either perspective, results in ending both life and the process of dying.

The moral principle of nonmaleficence espouses the belief of not inflicting harm on an individual (Beauchamp, 1989, p. 120).  The version of the Hippocratic oath, which is considered the source of the principle of nonmaleficence, approved by the American Medical Association (1975), states,

That into whatsoever house you shall enter, it shall be for the good of the sick to the utmost of  your power, your holding yourselves far aloof from wrong, from corruption, from the tempting of others to vice.

    That you will exercise your art solely for the cure of your patients, and will give no drug, perform no operation, for criminal purpose, even if solicited, far less suggest it (unpaginated).

At first reading, the Hippocratic oath and the principle of nonmaleficence could be considered to be in conflict with the practice of euthanasia.  In this paper, I will present the position that euthanasia is not in conflict with the principle of nonmaleficence or the Hippocratic oath but is a service to individuals who are suffering and waiting to die.

Euthanasia

By definition, euthanasia is derived from two Greek terms "eu", which means "good" and "thanatos," which means "death," and can be interpreted as signifying " a good death," a "beneficial death," or an "acceptable death."  Euthanasia is not considered killing.  Killing, by definition, implies the taking of life against the will of the person who is to die (Humphry, 1986, p. 86).

There are two types of euthanasia, passive and active.  Passive euthanasia is considered to be the act of allowing a person to die without attempting any "heroic measures" to sustain the life of the individual.  A famous example of a passive euthanasia case is that of Karen Ann Quinlan.  She lapsed into an irreversible coma following the ingestion of drugs and alcohol.  Her parents requested that she be taken off of a respirator but allowed her to be fed through a nasogastric tube.  She lived for almost ten years after she was removed from the respirator.  The act of passive euthanasia allows the individual to die naturally (Humphry, 1986, 1990; Beauchamp, 1989).

Active euthanasia involves the taking of positive steps to end the life of a terminally ill individual.  The Hemlock Society is a group which supports active euthanasia for the individual that rationally decides to end his or her life (Humphry, 1990, pp. 116-117).  The actions of Dr. Kevorkian, by developing and providing the "suicide machine" for individuals who were terminally ill and in pain, can be considered an act of active euthanasia (Kovorkian, 1991).

According to Beauchamp (1989), conditions that might lead to the discontinuance of treatment and the consideration of active or passive euthanasia is when treatment might be pointless, or the burdens of treatment may outweigh the benefits, and or the quality of life is poor.

Treatment is not obligatory when it offers no prospect of benefit to the patient because it is pointless.

    If the patient is not dead or dying, medical treatment is not obligatory if its burdens outweigh its benefits to the patient.  When patients are not irreversibly dying and their deaths are not imminent, medical treatment may be optional even if it could prolong life for an indefinite period.

    Judgement that treatments are optional often presuppose or otherwise rely on standards of the quality of life.  Any attempt to make life - understood as a set of vital logical processes - unconditionally good in itself is a "vitalism" that should be rejected in favor of a view that life is only conditionally good.  The maintenance of biological life thus should not automatically be considered a (net) benefit to the person.

    It is [also] important not to confuse quality of life for the patient with the quality or the value of life for others.  Quality of life is not tantamount to social worth or group preferences (pp. 155-158).

The quality of life question should be a personal assessment of the individual's perception of his or her value of life, not the value assessed by others.

Principle of Nonmaleficence

The principle of nonmaleficence is considered by some rule-deontological and rule-utilitarian theorists to be the foundation of social morality.  Some philosophers view nonmaleficence and beneficence as similar and distinct obligations of human life.  Beneficence suggests the acts of mercy, kindness, and charity.  It includes any form of action that benefits another (Beauchamp, 1989, p. 194).

Philosopher, William Frankena believes that the principle of beneficence includes four elements, one which is the principle of nonmaleficence.
 1. One ought not to inflict evil or harm.
 2. One ought to prevent evil or harm.
 3. One ought to remove evil or harm.
 4. One ought to do or promote good.

Nonmaleficence is distinguished from and part of the principle of beneficence by its commitment to not inflict harm to an individual.  Beneficence involves positive acts of preventing harm, removing harm, and promoting good  (Beauchamp, pp. 121-123).

The principle of nonmaleficence supports several moral rules.  Rules prohibiting harmful actions are at the core of morality - for example, "Don't kill," "Don't cause pain," "Don't deprive of freedom of opportunity," and "Don't deprive of pleasure," (Beauchamp, p. 125).

The principle of double effect, which is a part of the principle of nonmaleficence, provides for the understanding that good can come out of a bad act.

The principle of double effect has been invoked to support claims that an act having a harmful effect such as death does not always fall under moral prohibitions such as the rule against killing (Beauchamp, p. 127).

Death can be considered a major harm to the human being.  It therefore could be considered a conflict with the principle of nonmaleficence.

Discussion

The morality and the legality of euthanasia should be two different discussions and considerations.  The legality of euthanasia should be an evolution from the moral principles and beliefs of society regarding euthanasia. For the purpose of this discussion, I will focus on a moral consideration of the individual's right of choice regarding his or her death by euthanasia as a non-violation of the moral principle of nonmaleficence.

The morality of euthanasia could be justified by the moral principle of nonmaleficence even though there may appear to be dilemma with the principle of "do[ing] no harm."

    Moral dilemmas take at least the following two general forms.  (1) Some evidence indicates that act X is morally right, and some evidence indicates that act X is morally wrong, but the evidence on both sides is inconclusive.  (2) The agent believes that, on moral grounds, he or she both ought not to perform act X (Beauchamp, 1989).

The act of euthanasia does not cause the dying individual harm because the harm to the individual is in the pain and or suffering of his or her continued life.

Morally, the terminating of an individual's life, either passively or actively, could be considered a positive response to the terminally ill person by relieving his or her pain and suffering.  An element of suffering could be considered the lack of a quality of life, as determined by the suffering individual.  In the situation where the individual is incapacitated from making a decision regarding his or her quality of life, this decision would fall to a proxy person who would be expected to act in the manner consistent with the dying person's desires.

In order for an act with a good and bad effect to be justified, the principle of nonmaleficence's double effect principle specifies that four conditions need to be satisfied.
 1. The action itself (independent of its consequences) must  not be intrinsically wrong (it must be morally good or at least morally neutral).

 2. The agent must intend only the good effect and not the bad effect.

 3. The bad effect must not be a means to the end of bringing about the good effect; that is, the good effect must be achieved directly by the action and not by way of the bad effect.

 4. The good result must outweigh the evil permitted; that is there must be a proportionality or favorable balance between the good and bad effects of the action (Beauchamp, p. 128).

The action of passive or active euthanasia is not wrong if the individual, whose life is to be ended, consciously has requested that his or her life be ended.  The act of euthanasia is not intended to inflict harm on the individual but to end his or her pain and or suffering.  In order to not defy the third double effect condition, "the bad effect must not be a means to the end of bring about the good effect," the method of euthanasia should not inflict additional pain or suffering on the individual.  Therefore, it could be argued that the withholding of medical nutrition and hydration could be harmful to the conscious patient and should only be considered for unconscious, comatose individuals.

The American Medical Association has also made two influential pronouncements on this general subject.  In 1982, the AMA's Council on Ethical and Judicial Affairs stated that in cases of well-confirmed irreversible coma, "all means of life support may be discontinued."  In 1986, the council clarifies the earlier statement by specific reference on MN&H, holding that "life-prolonging medical treatment includes medication and artificially or technologically supplied respiration, nutrition, or hydration," (Beauchamp, p. 165).

Non-painful methods of euthanasia, such as drug overdose, could be considered an acceptable method for discontinuing the life of non-comatose individuals.  However, the decision on how to end one's life should be the decision of the dying individual, when he or she is capable of making that decision (Humphry, 1986, 1990).

The fourth condition of the double effect principle, of nonmaleficence, states that "the good result must outweigh the evil permitted."  The "evil" act could be argued since it could be considered that the "evil" act of ending an individual's life is a positive act, similar to the use of chemotherapy to eradicate cancer.  Euthanasia relieves the pain and or suffering of the individual's life, similar to where chemotherapy potentially ends the suffering of cancer. Therefore the "evil" act is good.

The principle of nonmaleficence states that no harm should be brought upon an individual.  However, if a person is suffering from intractable pain, is terminally ill, and or his or her quality of life is poor - from his or her perspective, than the use of euthanasia could be considered acceptable and the principle of nonmaleficence remains intact.  Physicians should be free to practice euthanasia, if requested by the individual or proxy, and not be in breach of their Hippocratic oath with the exception of the criminality of the act, which is a legal issue.  By practicing euthanasia, the physician is doing "good of the sick", by relieving/"curing" him or her of his or her pain and suffering in this life.  By relieving the individual of the pain of his or her condition, euthanasia is not inflicting evil or harm but is an act of nonmaleficence and beneficence towards the human being.
 

 REFERENCES:
 

American Medical Association.  (1975).  Hippocratic Oath.  [Brochure], unpaginated.
 

Ames, K.  (1991, August 26).  Last rights.  Newsweek, pp. 40-41.
 

Beauchamp, T. L. & Childress, J. F. (1989).  Principles of biomedical ethics - 3rd edition.  New York: Oxford University Press.
 

Begley, S.  (1991, August 26).  Choosing death.  Newsweek, pp. 43-46.
 

Gibbs, N.  (1990, March 19).  Love and let die.  Time, pp. 62-71.
 

Hamburg, J.  (1992, June 28).  Till we meet again.  Florida Magazine.
pp. 9-14.
 

Humphry, D.  (1986).  Let me die before I wake - Hemlock's book of self-deliverance for the dying.  New York: Grove Press.
 

Humphry, D. & Wickett, A.  (1990).  The right to die - An historical and legal perspective of euthanasia.  Eugene, OR: The Hemlock Society.
 

Humphry, D.  (1991).  Final exit.  Eugene, OR: The Hemlock Society.
 

Kevorkian, J.  (1991)  Prescription: Medicine - The goodness of planned death.  Buffalo, New York: Prometheus Books
 

Podolsky, D.  (1991, December 2).  A right-to-die reminder.  U.S. News & World Report.  p. 74.
 

Scofield, G.  (1990, January/February).  The calculus of consent.  Hastings Center Report.  pp. 44-47.