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Monday, March 1, 2021

Substance dependence

From Wikipedia, the free encyclopedia

Substance dependence
Other namesDrug dependence
SpecialtyPsychiatry

Substance dependence, also known as drug dependence, is an adaptive state that develops from repeated drug administration, and which results in withdrawal upon cessation of drug use. A drug addiction, a distinct concept from substance dependence, is defined as compulsive, out-of-control drug use, despite negative consequences. An addictive drug is a drug which is both rewarding and reinforcing. ΔFosB, a gene transcription factor, is now known to be a critical component and common factor in the development of virtually all forms of behavioral and drug addictions, but not dependence.

Within the framework of the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), substance dependence is redefined as a drug addiction, and can be diagnosed without the occurrence of a withdrawal syndrome. It was described accordingly: "When an individual persists in use of alcohol or other drugs despite problems related to use of the substance, substance dependence may be diagnosed. Compulsive and repetitive use may result in tolerance to the effect of the drug and withdrawal symptoms when use is reduced or stopped. This, along with Substance Abuse are considered Substance Use Disorders." In the DSM-5 (released in 2013), substance abuse and substance dependence have been merged into the category of substance use disorders and they no longer exist as individual diagnoses.

Addiction and dependence glossary
  • addiction – a biopsychosocial disorder characterized by persistent use of drugs (including alcohol) despite substantial harm and adverse consequences
  • addictive drug – psychoactive substances that with repeated use are associated with significantly higher rates of substance use disorders, due in large part to the drug's effect on brain reward systems
  • dependence – an adaptive state associated with a withdrawal syndrome upon cessation of repeated exposure to a stimulus (e.g., drug intake)
  • drug sensitization or reverse tolerance – the escalating effect of a drug resulting from repeated administration at a given dose
  • drug withdrawal – symptoms that occur upon cessation of repeated drug use
  • physical dependence – dependence that involves persistent physical–somatic withdrawal symptoms (e.g., fatigue and delirium tremens)
  • psychological dependence – dependence that involves emotional–motivational withdrawal symptoms (e.g., dysphoria and anhedonia)
  • reinforcing stimuli – stimuli that increase the probability of repeating behaviors paired with them
  • rewarding stimuli – stimuli that the brain interprets as intrinsically positive and desirable or as something to approach
  • sensitization – an amplified response to a stimulus resulting from repeated exposure to it
  • substance use disorder – a condition in which the use of substances leads to clinically and functionally significant impairment or distress
  • tolerance – the diminishing effect of a drug resulting from repeated administration at a given dose

Withdrawal

Withdrawal is the body's reaction to abstaining from a substance upon which a person has developed a dependence syndrome. When dependence has developed, cessation of substance-use produces an unpleasant state, which promotes continued drug use through negative reinforcement; i.e., the drug is used to escape or avoid re-entering the associated withdrawal state. The withdrawal state may include physical-somatic symptoms (physical dependence), emotional-motivational symptoms (psychological dependence), or both. Chemical and hormonal imbalances may arise if the substance is not re-introduced. Psychological stress may also result if the substance is not re-introduced.

Infants also suffer from substance withdrawal, known as neonatal abstinence syndrome (NAS), which can have severe and life-threatening effects. Addiction to drugs such as alcohol in expectant mothers not only causes NAS, but also an array of other issues which can continually affect the infant throughout his/her lifetime.

Risk factors

Dependence potential

The dependence potential of a drug varies from substance to substance, and from individual to individual. Dose, frequency, pharmacokinetics of a particular substance, route of administration, and time are critical factors for developing a drug dependence.

An article in The Lancet compared the harm and dependence liability of 20 drugs, using a scale from zero to three for physical dependence, psychological dependence, and pleasure to create a mean score for dependence. Selected results can be seen in the chart below.

Drug Mean Pleasure Psychological dependence Physical dependence
Heroin 3.00 3.0 3.0 3.0
Cocaine 2.39 3.0 2.8 1.3
Tobacco 2.21 2.3 2.6 1.8
Barbiturates 2.01 2.0 2.2 1.8
Alcohol 1.93 2.3 1.9 1.6
Benzodiazepines 2.23 1.7 2.1 2.8
Amphetamine 1.67 2.0 1.9 1.1
Cannabis 1.51 1.9 1.7 0.8
Ecstasy 1.13 1.5 1.2 0.7

Capture rates

Capture rates enumerate the percentage of users who reported that they had become dependent to their respective drug at some point.

Drug % of users
Cannabis 9%
Alcohol 15.4%
Cocaine 16.7%
Heroin 23.1%
Tobacco 31.9%

Biomolecular mechanisms

Psychological dependence

Two factors have been identified as playing pivotal roles in psychological dependence: the neuropeptide "corticotropin-releasing factor" (CRF) and the gene transcription factor "cAMP response element binding protein" (CREB). The nucleus accumbens (NAcc) is one brain structure that has been implicated in the psychological component of drug dependence. In the NAcc, CREB is activated by cyclic adenosine monophosphate (cAMP) immediately after a high and triggers changes in gene expression that affect proteins such as dynorphin; dynorphin peptides reduce dopamine release into the NAcc by temporarily inhibiting the reward pathway. A sustained activation of CREB thus forces a larger dose to be taken to reach the same effect. In addition, it leaves the user feeling generally depressed and dissatisfied, and unable to find pleasure in previously enjoyable activities, often leading to a return to the drug for another dose.

In addition to CREB, it is hypothesized that stress mechanisms play a role in dependence. Koob and Kreek have hypothesized that during drug use, CRF activates the hypothalamic–pituitary–adrenal axis (HPA axis) and other stress systems in the extended amygdala. This activation influences the dysregulated emotional state associated with psychological dependence. They found that as drug use escalates, so does the presence of CRF in human cerebrospinal fluid. In rat models, the separate use of CRF inhibitors and CRF receptor antagonists both decreased self-administration of the drug of study. Other studies in this review showed dysregulation of other neuropeptides that affect the HPA axis, including enkephalin which is an endogenous opioid peptide that regulates pain. It also appears that µ-opioid receptors, which enkephalin acts upon, is influential in the reward system and can regulate the expression of stress hormones.

Increased expression of AMPA receptors in nucleus accumbens MSNs is a potential mechanism of aversion produced by drug withdrawal.

Physical dependence

Upregulation of the cAMP signal transduction pathway in the locus coeruleus by CREB has been implicated as the mechanism responsible for certain aspects of opioid-induced physical dependence. The temporal course of withdrawal correlates with LC firing, and administration of α2 agonists into the locus coeruleus leads to a decrease in LC firing and norepinephrine release during withdrawal. A possible mechanism involves upregulation of NMDA receptors, which is supported by the attenuation of withdraw by NMDA receptor antagonists. Physical dependence on opioids has been observed to produce an elevation of extracellular glutamate, an increase in NMDA receptor subunits NR1 and NR2A, phosphorylated CaMKII, and c-fos. Expression of CaMKII and c-fos is attenuated by NMDA receptor antagonists, which is associated with blunted withdrawal in adult rats, but not neonatal rats While acute administration of opioids decreases AMPA receptor expression and depresses both NMDA and non-NMDA excitatory postsynaptic potentials in the NAC, withdrawal involves a lowered threshold for LTP and an increase in spontaneous firing in the NAc.

Diagnosis

DSM classification

"Substance dependence", as defined in the DSM-IV, can be diagnosed with physiological dependence, evidence of tolerance or withdrawal, or without physiological dependence. DSM-IV substance dependencies include:

Management

Addiction is a complex but treatable condition. It is characterized by compulsive drug craving, seeking, and use that persists even if the user is aware of severe adverse consequences. For some people, addiction becomes chronic, with periodic relapses even after long periods of abstinence. As a chronic, relapsing disease, addiction may require continued treatments to increase the intervals between relapses and diminish their intensity. While some with substance issues recover and lead fulfilling lives, others require ongoing additional support. The ultimate goal of addiction treatment is to enable an individual to manage their substance misuse; for some this may mean abstinence. Immediate goals are often to reduce substance abuse, improve the patient's ability to function, and minimize the medical and social complications of substance abuse and their addiction; this is called "harm reduction".

Treatments for addiction vary widely according to the types of drugs involved, amount of drugs used, duration of the drug addiction, medical complications and the social needs of the individual. Determining the best type of recovery program for an addicted person depends on a number of factors, including: personality, drugs of choice, concept of spirituality or religion, mental or physical illness, and local availability and affordability of programs.

Many different ideas circulate regarding what is considered a successful outcome in the recovery from addiction. Programs that emphasize controlled drinking exist for alcohol addiction. Opiate replacement therapy has been a medical standard of treatment for opioid addiction for many years.

Treatments and attitudes toward addiction vary widely among different countries. In the US and developing countries, the goal of commissioners of treatment for drug dependence is generally total abstinence from all drugs. Other countries, particularly in Europe, argue the aims of treatment for drug dependence are more complex, with treatment aims including reduction in use to the point that drug use no longer interferes with normal activities such as work and family commitments; shifting the addict away from more dangerous routes of drug administration such as injecting to safer routes such as oral administration; reduction in crime committed by drug addicts; and treatment of other comorbid conditions such as AIDS, hepatitis and mental health disorders. These kinds of outcomes can be achieved without eliminating drug use completely. Drug treatment programs in Europe often report more favorable outcomes than those in the US because the criteria for measuring success are functional rather than abstinence-based. The supporters of programs with total abstinence from drugs as a goal believe that enabling further drug use means prolonged drug use and risks an increase in addiction and complications from addiction.

Residential

Residential drug treatment can be broadly divided into two camps: 12-step programs and therapeutic communities. 12-step programs are a nonclinical support-group and spiritual-based approach to treating addiction. Therapy typically involves the use of cognitive-behavioral therapy, an approach that looks at the relationship between thoughts, feelings and behaviors, addressing the root cause of maladaptive behavior. Cognitive-behavioral therapy treats addiction as a behavior rather than a disease, and so is subsequently curable, or rather, unlearnable. Cognitive-behavioral therapy programs recognize that, for some individuals, controlled use is a more realistic possibility.

One of many recovery methods are 12-step recovery programs, with prominent examples including Alcoholics Anonymous, Narcotics Anonymous, Drug Addicts Anonymous and Pills Anonymous. They are commonly known and used for a variety of addictions for the individual addicted and the family of the individual. Substance-abuse rehabilitation (rehab) centers offer a residential treatment program for some of the more seriously addicted, in order to isolate the patient from drugs and interactions with other users and dealers. Outpatient clinics usually offer a combination of individual counseling and group counseling. Frequently, a physician or psychiatrist will prescribe medications in order to help patients cope with the side effects of their addiction. Medications can help immensely with anxiety and insomnia, can treat underlying mental disorders (cf. self-medication hypothesis, Khantzian 1997) such as depression, and can help reduce or eliminate withdrawal symptomology when withdrawing from physiologically addictive drugs. Some examples are using benzodiazepines for alcohol detoxification, which prevents delirium tremens and complications; using a slow taper of benzodiazepines or a taper of phenobarbital, sometimes including another antiepileptic agent such as gabapentin, pregabalin, or valproate, for withdrawal from barbiturates or benzodiazepines; using drugs such as baclofen to reduce cravings and propensity for relapse amongst addicts to any drug, especially effective in stimulant users, and alcoholics (in which it is nearly as effective as benzodiazepines in preventing complications); using clonidine, an alpha-agonist, and loperamide for opioid detoxification, for first-time users or those who wish to attempt an abstinence-based recovery (90% of opioid users relapse to active addiction within eight months or are multiple relapse patients); or replacing an opioid that is interfering with or destructive to a user's life, such as illicitly-obtained heroin, dilaudid, or oxycodone, with an opioid that can be administered legally, reduces or eliminates drug cravings, and does not produce a high, such as methadone or buprenorphine – opioid replacement therapy – which is the gold standard for treatment of opioid dependence in developed countries, reducing the risk and cost to both user and society more effectively than any other treatment modality (for opioid dependence), and shows the best short-term and long-term gains for the user, with the greatest longevity, least risk of fatality, greatest quality of life, and lowest risk of relapse and legal issues including arrest and incarceration.

In a survey of treatment providers from three separate institutions, the National Association of Alcoholism and Drug Abuse Counselors, Rational Recovery Systems and the Society of Psychologists in Addictive Behaviors, measuring the treatment provider's responses on the "Spiritual Belief Scale" (a scale measuring belief in the four spiritual characteristics of AA identified by Ernest Kurtz); the scores were found to explain 41% of the variance in the treatment provider's responses on the "Addiction Belief Scale" (a scale measuring adherence to the disease model or the free-will model of addiction).

Behavioral programming

Behavioral programming is considered critical in helping those with addictions achieve abstinence. From the applied behavior analysis literature and the behavioral psychology literature, several evidence based intervention programs have emerged: (1) behavioral marital therapy; (2) community reinforcement approach; (3) cue exposure therapy; and (4) contingency management strategies. In addition, the same author suggests that social skills training adjunctive to inpatient treatment of alcohol dependence is probably efficacious. Community reinforcement has both efficacy and effectiveness data. In addition, behavioral treatment such as community reinforcement and family training (CRAFT) have helped family members to get their loved ones into treatment. Motivational intervention has also shown to be an effective treatment for substance dependence.

Alternative therapies

Alternative therapies, such as acupuncture, are used by some practitioners to alleviate the symptoms of drug addiction. In 1997, the American Medical Association (AMA) adopted, as policy, the following statement after a report on a number of alternative therapies including acupuncture:

There is little evidence to confirm the safety or efficacy of most alternative therapies. Much of the information currently known about these therapies makes it clear that many have not been shown to be efficacious. Well-designed, stringently controlled research should be done to evaluate the efficacy of alternative therapies.

Treatment and issues

Medical professionals need to apply many techniques and approaches to help patients with substance related disorders. Using a psychodynamic approach is one of the techniques that psychologists use to solve addiction problems. In psychodynamic therapy, psychologists need to understand the conflicts and the needs of the addicted person, and also need to locate the defects of their ego and defense mechanisms. Using this approach alone has proven to be ineffective in solving addiction problems. Cognitive and behavioral techniques should be integrated with psychodynamic approaches to achieve effective treatment for substance related disorders. Cognitive treatment requires psychologists to think deeply about what is happening in the brain of an addicted person. Cognitive psychologists should zoom in to neural functions of the brain and understand that drugs have been manipulating the dopamine reward center of the brain. From this particular state of thinking, cognitive psychologists need to find ways to change the thought process of the addicted person.

Cognitive approach

There are two routes typically applied to a cognitive approach to substance abuse: tracking the thoughts that pull patients to addiction and tracking the thoughts that prevent them from relapsing. Behavioral techniques have the widest application in treating substance related disorders. Behavioral psychologists can use the techniques of "aversion therapy", based on the findings of Pavlov's classical conditioning. It uses the principle of pairing abused substances with unpleasant stimuli or conditions; for example, pairing pain, electrical shock, or nausea with alcohol consumption. The use of medications may also be used in this approach, such as using disulfiram to pair unpleasant effects with the thought of alcohol use. Psychologists tend to use an integration of all these approaches to produce reliable and effective treatment. With the advanced clinical use of medications, biological treatment is now considered to be one of the most efficient interventions that psychologists may use as treatment for those with substance dependence.

Medicinal approach

Another approach is to use medicines that interfere with the functions of the drugs in the brain. Similarly, one can also substitute the misused substance with a weaker, safer version to slowly taper the patient off of their dependence. Such is the case with Suboxone in the context of opioid dependence. These approaches are aimed at the process of detoxification. Medical professionals weigh the consequences of withdrawal symptoms against the risk of staying dependent on these substances. These withdrawal symptoms can be very difficult and painful times for patients. Most will have steps in place to handle severe withdrawal symptoms, either through behavioral therapy or other medications. Biological intervention should be combined with behavioral therapy approaches and other non-pharmacological techniques. Group therapies including anonymity, teamwork and sharing concerns of daily life among people who also suffer from substance dependence issues can have a great impact on outcomes. However, these programs proved to be more effective and influential on persons who did not reach levels of serious dependence.

History

The phenomenon of drug addiction has occurred to some degree throughout recorded history. Modern agricultural practices, improvements in access to drugs, advancements in biochemistry, and dramatic increases in the recommendation of drug usage by clinical practitioners have exacerbated the problem significantly in the 20th century. Improved means of active biological agent manufacture and the introduction of synthetic compounds, such as fentanyl and methamphetamine, are also factors contributing to drug addiction.

For the entirety of US history, drugs have been used by some members of the population. In the country's early years, most drug use by the settlers was of alcohol or tobacco.

The 19th century saw opium usage in the US become much more common and popular. Morphine was isolated in the early 19th century, and came to be prescribed commonly by doctors, both as a painkiller and as an intended cure for opium addiction. At the time, the prevailing medical opinion was that the addiction process occurred in the stomach, and thus it was hypothesized that patients would not become addicted to morphine if it was injected into them via a hypodermic needle, and it was further hypothesized that this might potentially be able to cure opium addiction. However, many people did become addicted to morphine. In particular, addiction to opium became widespread among soldiers fighting in the Civil War, who very often required painkillers and thus were very often prescribed morphine. Women were also very frequently prescribed opiates, and opiates were advertised as being able to relieve "female troubles".

Many soldiers in the Vietnam War were introduced to heroin and developed a dependency on the substance which survived even when they returned to the US. Technological advances in travel meant that this increased demand for heroin in the US could now be met. Furthermore, as technology advanced, more drugs were synthesized and discovered, opening up new avenues to substance dependency.

Society and culture

Demographics

Internationally, the U.S. and Eastern Europe contain the countries with the highest substance abuse disorder occurrence (5-6%). Africa, Asia, and the Middle East contain countries with the lowest worldwide occurrence (1-2%). Across the globe, those that tended to have a higher prevalence of substance dependence were in their twenties, unemployed, and men. The National Survey on Drug Use and Health (NSDUH) reports on substance dependence/abuse rates in various population demographics across the U.S. When surveying populations based on race and ethnicity in those ages 12 and older, it was observed that American Indian/Alaskan Natives were among the highest rates and Asians were among the lowest rates in comparison to other racial/ethnic groups.

Substance Use in Racial/Ethnic Groups
Race/Ethnicity Dependence/Abuse Rate
Asian 4.6%
Black 7.4%
White 8.4%
Hispanic 8.6%
Mixed race 10.9%
Native Hawaiian/

Pacific Islander

11.3%
American Indian/

Alaskan Native

14.9%

When surveying populations based on gender in those ages 12 and older, it was observed that males had a higher substance dependence rate than females. However, the difference in the rates are not apparent until after age 17.Drug and Alcohol Dependence reports that older adults abuse drugs including alcohol at a rate of 15-20%. It's estimated that 52 million Americans beyond 12 years old have abused a substance.

Substance Use in Different Genders w/ Respect to Age 
Age Male Female
12 and older 10.8% 5.8%
12-17 5.3% 5.2%
18 or older 11.4% 5.8%

Alcohol dependence or abuse rates were shown to have no correspondence with any person's education level when populations were surveyed in varying degrees of education from ages 26 and older. However, when it came to illicit drug use there was a correlation, in which those that graduated from college had the lowest rates. Furthermore, dependence rates were greater in unemployed populations ages 18 and older and in metropolitan-residing populations ages 12 and older.

Illicit Drug Dependence Demographics (Education, Employment, and Regional)
Education level Rates Employment status Rates Region Rates
high school 2.5% un-employed 15.2% large metropolitan 8.6%
no-degree, college 2.1% part-time 9.3% small metropolitan 8.4%
college graduate 0.9% full-time 9.5% non-metropolitan 6.6%

The National Opinion Research Center at the University of Chicago reported an analysis on disparities within admissions for substance abuse treatment in the Appalachian region, which comprises 13 states and 410 counties in the Eastern part of the U.S. While their findings for most demographic categories were similar to the national findings by NSDUH, they had different results for racial/ethnic groups which varied by sub-regions. Overall, Whites were the demographic with the largest admission rate (83%), while Alaskan Native, American Indian, Pacific Islander, and Asian populations had the lowest admissions (1.8%).

Legislation

Depending on the jurisdiction, addictive drugs may be legal, legal only as part of a government sponsored study, illegal to use for any purpose, illegal to sell, or even illegal to merely possess.

Most countries have legislation which brings various drugs and drug-like substances under the control of licensing systems. Typically this legislation covers any or all of the opiates, amphetamines, cannabinoids, cocaine, barbiturates, benzodiazepines, anesthetics, hallucinogenics, derivatives and a variety of more modern synthetic drugs. Unlicensed production, supply or possession is a criminal offence.

Usually, however, drug classification under such legislation is not related simply to addictiveness. The substances covered often have very different addictive properties. Some are highly prone to cause physical dependency, while others rarely cause any form of compulsive need whatsoever. Also, under legislation specifically about drugs, alcohol and nicotine are not usually included.

Although the legislation may be justifiable on moral or public health grounds, it can make addiction or dependency a much more serious issue for the individual: reliable supplies of a drug become difficult to secure, and the individual becomes vulnerable to both criminal abuse and legal punishment.

It is unclear whether laws against illegal drug use do anything to stem usage and dependency. In jurisdictions where addictive drugs are illegal, they are generally supplied by drug dealers, who are often involved with organized crime. Even though the cost of producing most illegal addictive substances is very low, their illegality combined with the addict's need permits the seller to command a premium price, often hundreds of times the production cost. As a result, addicts sometimes turn to crime to support their habit.

United States

In the United States, drug policy is primarily controlled by the federal government. The Department of Justice's Drug Enforcement Administration (DEA) enforces controlled substances laws and regulations. The Department of Health and Human Services' Food and Drug Administration (FDA) serve to protect and promote public health by controlling the manufacturing, marketing, and distribution of products, like medications.

The United States' approach to substance abuse has shifted over the last decade, and is continuing to change. The federal government was minimally involved in the 19th century. The federal government transitioned from using taxation of drugs in the early 20th century to criminalizing drug abuse with legislations and agencies like the Federal Bureau of Narcotics (FBN) mid-20th century in response to the nation's growing substance abuse issue. These strict punishments for drug offenses shined light on the fact that drug abuse was a multi-faceted problem. The President's Advisory Commission on Narcotics and Drug Abuse of 1963 addressed the need for a medical solution to drug abuse. However, drug abuse continued to be enforced by the federal government through agencies such as the DEA and further legislations such as The Controlled Substances Act (CSA), the Comprehensive Crime Control Act of 1984, and Anti-Drug Abuse Acts.

In the past decade, there have been growing efforts through state and local legislations to shift from criminalizing drug abuse to treating it as a health condition requiring medical intervention. 28 states currently allow for the establishment of needle exchanges. Florida, Iowa, Missouri and Arizona all introduced bills to allow for the establishment of needle exchanges in 2019. These bills have grown in popularity across party lines since needle exchanges were first introduced in Amsterdam in 1983. In addition, AB-186 Controlled substances: overdose prevention program was introduced to operate safe injection sites in the City and County of San Francisco. The bill was vetoed on September 30, 2018 by California Governor Jerry Brown. The legality of these sites are still in discussion, so there are no such sites in the United States yet. However, there is growing international evidence for successful safe injection facilities.

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Euthanasia and the slippery slope

From Wikipedia, the free encyclopedia

Critics of euthanasia sometimes claim that legalizing any form of the practice will lead to a slippery slope effect, resulting eventually in non-voluntary or even involuntary euthanasia. The slippery slope argument has been present in the euthanasia debate since at least the 1930s.

Lawyer Eugene Volokh argued in his article The Mechanism of the Slippery Slope that judicial logic could eventually lead to a gradual break in the legal restrictions for euthanasia, while medical oncologist and palliative care specialist Jan Bernheim believes the law can provide safeguards against slippery-slope effects, saying that the grievances of euthanasia opponents are unfounded.

The slippery slope

As applied to the euthanasia debate, the slippery slope argument claims that the acceptance of certain practices, such as physician-assisted suicide or voluntary euthanasia, will invariably lead to the acceptance or practice of concepts which are currently deemed unacceptable, such as non-voluntary or involuntary euthanasia. Thus, it is argued, in order to prevent these undesirable practices from occurring, we need to resist taking the first step.

There are two basic forms which the argument may take, each of which involves different arguments for and against. The first of these, referred to as the logical version, argues that the acceptance of the initial act, A, logically entails the acceptance of B, where A is acceptable but B is an undesirable action. This version is further refined into two forms based on how A entails B. In the first, it is argued that there "is no relevant conceptual difference between A and B" – the premises that underlie the acceptance of A logically entail the acceptance of B. Within the euthanasia debate, van der Burg identifies one of Richard Sherlock's objections to Duff and Campbell as fitting this model. Duff and Campbell had presented an argument for the selective non-treatment of newborns suffering from serious defects. In responding to Duff and Campbell's stance, Sherlock argued that the premises which they employed in order to justify their position would be just as effective, if not more so, in justifying the non-treatment of older children: "In short, if there is any justification at all for what Duff and Campbell propose for newborns then there is better justification for a similar policy with respect to children at any age."

The second logical form of the slippery slope argument, referred to as the "arbitrary line" version, argues that the acceptance of A will lead to the acceptance of A1, as A1 is not significantly different from A. A1 will then lead to A2, A2 to A3, and eventually the process will lead to the unacceptable B. As Glover argues, this version of the argument does not say that there is no significant difference between A and B, but instead argues that it is impossible to justify accepting A while also denying B – drawing a line at any point between the two would be creating an arbitrary cut-off point that would be unjustifiable. Glover provides the example of infanticide (or non-voluntary euthanasia) and severely deformed children:

"If it is allowable at birth for children with some grave abnormality, what will we say about an equally grave abnormality that is only detectable at three months? And another that is only detectable at six months? And another that is detectable at birth only slightly less serious? And another that is slightly less serious than that one?"

— Jonathan Glover

The second primary form of the slippery slope argument is that of the "Empirical" or "Psychological" argument. The empirical version does not rely on a logical connection between A and B, but instead argues that an acceptance of A will, in time, lead to an acceptance of B. The process is not a logical necessity, but one which will be followed through a process of moral change. Enoch describes the application of this form of the argument thus:

"Once we allow voluntary euthanasia, she argues, we may (or will) fail to make the crucial distinction, and then we will make the morally unacceptable outcome of allowing involuntary euthanasia; or perhaps even though we may make the relevant distinction, we will not act accordingly for some reason (perhaps a political reason, or a reason that has to do with weakness of will, or some other reason)."

— David Enoch

Glover, however, notes that this line of argument requires good evidence that this direction will be followed, as not all boundaries are thus pushed.

More generally, it has been argued that in employing the slippery slope there can be an "implicit concession", as it starts from the assumption that the initial practice is acceptable – even though it will lead to unacceptable outcomes in the future. Nevertheless, van der Burg argues that this is not a useful concession, as the outcomes are intended to make it clear that the initial practice was not justifiable after all.

Response to the logical versions

Countering the first logical version of the slippery slope argument, it is argued that the different types of euthanasia are sufficiently distinct that it is not "logically inconsistent" to support one version while denying the others. It is possible to support, for example, voluntary euthanasia while denying non-voluntary euthanasia, just as it is possible to support both – the distinction comes not from a logical inconsistency, but a choice of principles, such that a focus on euthanasia as personal choice will support voluntary euthanasia but not non-voluntary euthanasia, while a focus on a person's "best interests" may allow for the support of both. From a more practical perspective, another option when faced with the logical version of the argument is to simply accept the consequences. This was the response by Duff and Campbell to Sherlock. Rather than arguing that their premises were flawed, they argued that Sherlock was correct: their criteria could also be applied to older children, and thus it should be applied, as it was "probably the most caring policy generally."

In responding to the "arbitrary line" version of the slippery slope argument, it is argued that the stance relies on the "paradox of the heap", and that it is possible to draw a line between the acceptable and unacceptable alternatives. Furthermore, in the case of euthanasia, it is possible to draw hard lines between different types of practices. For example, there is a clear distinction between voluntary and non-voluntary euthanasia, such that the arbitrary line approach cannot be applied.

The empirical argument

Glover argues that the empirical argument needs to be backed by evidence, as there are situations where we do not seem to push boundaries. Generally, two examples are discussed – Action T4, the Nazi euthanasia program in Germany between 1939 and 1941, and the Groningen Protocol in the Netherlands, which has allowed for non-voluntary euthanasia of severely deformed newborns.

Lewis notes that the focus has been on voluntary to non-voluntary euthanasia, rather than physician-assisted suicide to voluntary euthanasia, as there have been no instances of the latter: in jurisdictions where physician-assisted suicide have been legalised, there have been no moves to legalise voluntary euthanasia, while jurisdictions that have legalised voluntary euthanasia also allowed physician-assisted suicide at the same time.

Action T4

Hartheim Euthanasia Centre, where over 18,000 people were killed.

Leo Alexander, in examining the events of the Holocaust during the Nuremberg Trials, stated that the origins of the Nazi programs could be traced back to "small beginnings", and presented a slippery slope argument. Others have argued that Action T4 is not an example of the empirical slippery slope, as euthanasia was still a criminal act in Germany during that time, and there is "no record of the Nazi doctors either killing or assisting in the suicide of a patient who was suffering intolerably from a fatal illness".

Euthanasia historian Ian Dowbiggin linked the Nazis' Action T4 to the resistance in the West to involuntary euthanasia. He believes that the revulsion inspired by the Nazis led to some of the early advocates of euthanasia in all its forms in the U.S. and U.K. removing non-voluntary euthanasia from their proposed platforms.

The Groningen Protocol

Non-voluntary euthanasia is sometimes cited as one of the possible outcomes of the slippery slope argument, in which it is claimed that permitting voluntary euthanasia to occur will lead to the support and legalization of non-voluntary and involuntary euthanasia. Some studies of the Netherlands after the introduction of voluntary euthanasia state that there was no evidence to support this claim while other studies state otherwise.

A study from the Jakobovits Center for Medical Ethics in Israel argued that a form of non-voluntary euthanasia, the Groningen Protocol, has "potential to validate the slippery-slope argument against allowing euthanasia in selected populations". Anesthesiologist William Lanier says that the "ongoing evolution of euthanasia law in the Netherlands" is evidence that a slippery slope is "playing out in real time". Pediatrician Ola Didrik Saugstad says that while he approves of the withholding of treatment to cause the death of severely ill newborns where the prognosis is poor, he disagrees with the active killing of such newborns. Countering this view, professor of internal medicine Margaret Battin finds that there is a lack of evidence to support slippery slope arguments. Additionally, it is argued that the public nature of the Groningen Protocol decisions, and their evaluation by a prosecutor, prevent a "slippery slope" from occurring.

A 1999 study by Jochemsen and Keown from the Dutch Christian Lindeboom Institute published in the peer reviewed Journal of Medical Ethics, argued that euthanasia in the Netherlands is not well-controlled and that there is still a significant percentage of cases of euthanasia practiced illegally. Raanan Gillon, from the Imperial College School of Medicine, University of London commented in 1999 that "what is shown by the empirical findings is that restrictions on euthanasia that legal controls in the Netherlands were supposed to have implemented are being extensively ignored and from that point of view it is surely justifiable to conclude, as Jochemsen and Keown do conclude, that the practice of euthanasia in the Netherlands is in poor control". A similar conclusion was presented in 1997 by Herbert Hendin, who argued that the situation in The Netherlands demonstrated a slippery slope in practice, changing the attitudes of doctors over time and moving them from tightly regulated voluntary euthanasia for the terminally ill to the acceptance of euthanasia for people suffering from psychological distress, and from voluntary euthanasia to the acceptance of non-voluntary and potentially involuntary euthanasia.

An October 2007 study, published in the Journal of Medical Ethics, found that "rates of assisted dying in Oregon and in the Netherlands showed no evidence of heightened risk for the elderly, women, the uninsured (inapplicable in the Netherlands, where all are insured), people with low educational status, the poor, the physically disabled or chronically ill, minors, people with psychiatric illnesses including depression, or racial or ethnic minorities, compared with background populations. The only group with a heightened risk was people with AIDS."

A 2009 review study of euthanasia in the Netherlands concluded that no slippery slope effect has occurred, while another study of the same year found that abuse of the Dutch euthanasia system is rare. In 2010, a study found that there is no evidence that legalizing assisted suicide will lead us down the slippery slope to involuntary euthanasia.

Most critics rely predominantly on Dutch evidence of cases of "termination of life without an explicit request" as evidence for the slide from voluntary euthanasia to non-voluntary euthanasia. One commenter wrote that critics who rely on this slippery slope argument often omit two important elements, thereby using flawed logic. First, the argument is only effective against legalization if it is legalization which causes the slippery slope; and secondly, it is only effective if it is used comparatively, to show that the slope is more slippery in the Netherlands than it is in jurisdictions which have not legalized assisted suicide or euthanasia.  Since these questions have not been addressed by critics, little attention has been paid to available evidence on causation and comparability.

Research review studies

In the most recent review paper on euthanasia in the Netherlands, namely the 2009 paper entitled Two Decades of Research on Euthanasia from the Netherlands. What Have We Learnt and What Questions Remain? written by researchers from the Department of Public Health in the Netherlands, it was found that "public control and transparency of the practice of euthanasia is to a large extent possible" and that "[n]o slippery slope seems to have occurred". The researchers find that the legalization of euthanasia in the Netherlands did not result in a slippery slope for medical end-of-life practices because:

  1. The frequency of ending of life without explicit patient request did not increase over the studied years;
  2. There is no evidence for a higher frequency of euthanasia, compared with background populations, among:

In 2010, 4050 persons died from euthanasia or from assisted suicide on request. According to research done by the Vrije Universiteit (Amsterdam), University Medical Center Utrecht and Statistics Netherlands, and published in The Lancet, this is not more than before the introduction of the "Termination of Life on Request and Assisted Suicide (Review Procedures) Act" in 2002. Both in the Netherlands and in Belgium, the number of termination of life without explicit request for terminally ill patients, decreased after the introduction of the legislation about the termination of life. In effect, the legislation did not lead to more cases of euthanasia and assisted suicide on request.

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Euthanasia

From Wikipedia, the free encyclopedia

Euthanasia (from Greek: εὐθανασία; "good death": εὖ, eu; "well" or "good" + θάνατος, thanatos; "death") is the practice of intentionally ending a life to relieve pain and suffering.

Different countries have different euthanasia laws. The British House of Lords select committee on medical ethics defines euthanasia as "a deliberate intervention undertaken with the express intention of ending a life, to relieve intractable suffering". In the Netherlands and Belgium, euthanasia is understood as "termination of life by a doctor at the request of a patient". The Dutch law, however, does not use the term 'euthanasia' but includes the concept under the broader definition of "assisted suicide and termination of life on request".

Euthanasia is categorized in different ways, which include voluntary, non-voluntary, or involuntary:

As of 2006 euthanasia had become the most active area of research in bioethics. In some countries divisive public controversy occurs over the moral, ethical, and legal issues associated with euthanasia. Passive euthanasia (known as "pulling the plug") is legal under some circumstances in many countries. Active euthanasia, however, is legal or de facto legal in only a handful of countries (for example: Belgium, Canada and Switzerland), which limit it to specific circumstances and require the approval of counselors and doctors or other specialists. In some countries - such as Nigeria, Saudi Arabia and Pakistan - support for active euthanasia is almost non-existent.

Definition

Like other terms borrowed from history, "euthanasia" has had different meanings depending on usage. The first apparent usage of the term "euthanasia" belongs to the historian Suetonius, who described how the Emperor Augustus, "dying quickly and without suffering in the arms of his wife, Livia, experienced the 'euthanasia' he had wished for." The word "euthanasia" was first used in a medical context by Francis Bacon in the 17th century, to refer to an easy, painless, happy death, during which it was a "physician's responsibility to alleviate the 'physical sufferings' of the body." Bacon referred to an "outward euthanasia"—the term "outward" he used to distinguish from a spiritual concept—the euthanasia "which regards the preparation of the soul."

In current usage, euthanasia has been defined as the "painless inducement of a quick death". However, it is argued that this approach fails to properly define euthanasia, as it leaves open a number of possible actions which would meet the requirements of the definition, but would not be seen as euthanasia. In particular, these include situations where a person kills another, painlessly, but for no reason beyond that of personal gain; or accidental deaths that are quick and painless, but not intentional.

Another approach incorporates the notion of suffering into the definition. The definition offered by the Oxford English Dictionary incorporates suffering as a necessary condition, with "the painless killing of a patient suffering from an incurable and painful disease or in an irreversible coma", This approach is included in Marvin Khol and Paul Kurtz's definition of it as "a mode or act of inducing or permitting death painlessly as a relief from suffering". Counterexamples can be given: such definitions may encompass killing a person suffering from an incurable disease for personal gain (such as to claim an inheritance), and commentators such as Tom Beauchamp and Arnold Davidson have argued that doing so would constitute "murder simpliciter" rather than euthanasia.

The third element incorporated into many definitions is that of intentionality – the death must be intended, rather than being accidental, and the intent of the action must be a "merciful death". Michael Wreen argued that "the principal thing that distinguishes euthanasia from intentional killing simpliciter is the agent's motive: it must be a good motive insofar as the good of the person killed is concerned." Likewise, James Field argued that euthanasia entails a sense of compassion towards the patient, in contrast to the diverse non-compassionate motives of serial killers who work in health care professions. Similarly, Heather Draper speaks to the importance of motive, arguing that "the motive forms a crucial part of arguments for euthanasia, because it must be in the best interests of the person on the receiving end." Definitions such as that offered by the House of Lords Select committee on Medical Ethics take this path, where euthanasia is defined as "a deliberate intervention undertaken with the express intention of ending a life, to relieve intractable suffering." Beauchamp and Davidson also highlight Baruch Brody's "an act of euthanasia is one in which one person ... (A) kills another person (B) for the benefit of the second person, who actually does benefit from being killed".

Draper argued that any definition of euthanasia must incorporate four elements: an agent and a subject; an intention; a causal proximity, such that the actions of the agent lead to the outcome; and an outcome. Based on this, she offered a definition incorporating those elements, stating that euthanasia "must be defined as death that results from the intention of one person to kill another person, using the most gentle and painless means possible, that is motivated solely by the best interests of the person who dies." Prior to Draper, Beauchamp and Davidson had also offered a definition that includes these elements. Their definition specifically discounts fetuses to distinguish between abortions and euthanasia:

In summary, we have argued ... that the death of a human being, A, is an instance of euthanasia if and only if (1) A's death is intended by at least one other human being, B, where B is either the cause of death or a causally relevant feature of the event resulting in death (whether by action or by omission); (2) there is either sufficient current evidence for B to believe that A is acutely suffering or irreversibly comatose, or there is sufficient current evidence related to A's present condition such that one or more known causal laws supports B's belief that A will be in a condition of acute suffering or irreversible comatoseness; (3) (a) B's primary reason for intending A's death is cessation of A's (actual or predicted future) suffering or irreversible comatoseness, where B does not intend A's death for a different primary reason, though there may be other relevant reasons, and (b) there is sufficient current evidence for either A or B that causal means to A's death will not produce any more suffering than would be produced for A if B were not to intervene; (4) the causal means to the event of A's death are chosen by A or B to be as painless as possible, unless either A or B has an overriding reason for a more painful causal means, where the reason for choosing the latter causal means does not conflict with the evidence in 3b; (5) A is a nonfetal organism.

Wreen, in part responding to Beauchamp and Davidson, offered a six-part definition:

Person A committed an act of euthanasia if and only if (1) A killed B or let her die; (2) A intended to kill B; (3) the intention specified in (2) was at least partial cause of the action specified in (1); (4) the causal journey from the intention specified in (2) to the action specified in (1) is more or less in accordance with A's plan of action; (5) A's killing of B is a voluntary action; (6) the motive for the action specified in (1), the motive standing behind the intention specified in (2), is the good of the person killed.

Wreen also considered a seventh requirement: "(7) The good specified in (6) is, or at least includes, the avoidance of evil", although as Wreen noted in the paper, he was not convinced that the restriction was required.

In discussing his definition, Wreen noted the difficulty of justifying euthanasia when faced with the notion of the subject's "right to life". In response, Wreen argued that euthanasia has to be voluntary, and that "involuntary euthanasia is, as such, a great wrong". Other commentators incorporate consent more directly into their definitions. For example, in a discussion of euthanasia presented in 2003 by the European Association of Palliative Care (EPAC) Ethics Task Force, the authors offered: "Medicalized killing of a person without the person's consent, whether nonvoluntary (where the person is unable to consent) or involuntary (against the person's will) is not euthanasia: it is murder. Hence, euthanasia can be voluntary only." Although the EPAC Ethics Task Force argued that both non-voluntary and involuntary euthanasia could not be included in the definition of euthanasia, there is discussion in the literature about excluding one but not the other.

Classification

Euthanasia may be classified into three types, according to whether a person gives informed consent: voluntary, non-voluntary and involuntary.

There is a debate within the medical and bioethics literature about whether or not the non-voluntary (and by extension, involuntary) killing of patients can be regarded as euthanasia, irrespective of intent or the patient's circumstances. In the definitions offered by Beauchamp and Davidson and, later, by Wreen, consent on the part of the patient was not considered as one of their criteria, although it may have been required to justify euthanasia. However, others see consent as essential.

Voluntary euthanasia

Voluntary euthanasia is conducted with the consent of the patient. Active voluntary euthanasia is legal in Belgium, Luxembourg and the Netherlands. Passive voluntary euthanasia is legal throughout the US per Cruzan v. Director, Missouri Department of Health. When the patient brings about their own death with the assistance of a physician, the term assisted suicide is often used instead. Assisted suicide is legal in Switzerland and the U.S. states of California, Oregon, Washington, Montana and Vermont.

Non-voluntary euthanasia

Non-voluntary euthanasia is conducted when the consent of the patient is unavailable. Examples include child euthanasia, which is illegal worldwide but decriminalised under certain specific circumstances in the Netherlands under the Groningen Protocol.

Involuntary euthanasia

Involuntary euthanasia is conducted against the will of the patient.

Passive and active euthanasia

Voluntary, non-voluntary and involuntary types can be further divided into passive or active variants. Passive euthanasia entails the withholding treatment necessary for the continuance of life. Active euthanasia entails the use of lethal substances or forces (such as administering a lethal injection), and is the more controversial. While some authors consider these terms to be misleading and unhelpful, they are nonetheless commonly used. In some cases, such as the administration of increasingly necessary, but toxic doses of painkillers, there is a debate whether or not to regard the practice as active or passive.

History

The Death of Socrates, by Jacques-Louis David (1787), depicting Socrates prepared to drink hemlock, following his conviction for corrupting the youth of Athens

Euthanasia was practiced in Ancient Greece and Rome: for example, hemlock was employed as a means of hastening death on the island of Kea, a technique also employed in Marseilles. Euthanasia, in the sense of the deliberate hastening of a person's death, was supported by Socrates, Plato and Seneca the Elder in the ancient world, although Hippocrates appears to have spoken against the practice, writing "I will not prescribe a deadly drug to please someone, nor give advice that may cause his death" (noting there is some debate in the literature about whether or not this was intended to encompass euthanasia).

Early modern period

The term euthanasia in the earlier sense of supporting someone as they died, was used for the first time by Francis Bacon. In his work, Euthanasia medica, he chose this ancient Greek word and, in doing so, distinguished between euthanasia interior, the preparation of the soul for death, and euthanasia exterior, which was intended to make the end of life easier and painless, in exceptional circumstances by shortening life. That the ancient meaning of an easy death came to the fore again in the early modern period can be seen from its definition in the 18th century Zedlers Universallexikon:

Euthanasia: a very gentle and quiet death, which happens without painful convulsions. The word comes from ευ, bene, well, and θανατος, mors, death.

The concept of euthanasia in the sense of alleviating the process of death goes back to the medical historian, Karl Friedrich Heinrich Marx, who drew on Bacon's philosophical ideas. According to Marx, a doctor had a moral duty to ease the suffering of death through encouragement, support and mitigation using medication. Such an "alleviation of death" reflected the contemporary zeitgeist, but was brought into the medical canon of responsibility for the first time by Marx. Marx also stressed the distinction between the theological care of the soul of sick people from the physical care and medical treatment by doctors.

Euthanasia in its modern sense has always been strongly opposed in the Judeo-Christian tradition. Thomas Aquinas opposed both and argued that the practice of euthanasia contradicted our natural human instincts of survival, as did Francois Ranchin (1565–1641), a French physician and professor of medicine, and Michael Boudewijns (1601–1681), a physician and teacher. Other voices argued for euthanasia, such as John Donne in 1624, and euthanasia continued to be practised. In 1678, the publication of Caspar Questel's De pulvinari morientibus non-subtrahend, ("On the pillow of which the dying should not be deprived"), initiated debate on the topic. Questel described various customs which were employed at the time to hasten the death of the dying, (including the sudden removal of a pillow, which was believed to accelerate death), and argued against their use, as doing so was "against the laws of God and Nature". This view was shared by others who followed, including Philipp Jakob Spener, Veit Riedlin and Johann Georg Krünitz. Despite opposition, euthanasia continued to be practised, involving techniques such as bleeding, suffocation, and removing people from their beds to be placed on the cold ground.

Suicide and euthanasia became more accepted during the Age of Enlightenment. Thomas More wrote of euthanasia in Utopia, although it is not clear if More was intending to endorse the practice. Other cultures have taken different approaches: for example, in Japan suicide has not traditionally been viewed as a sin, as it is used in cases of honor, and accordingly, the perceptions of euthanasia are different from those in other parts of the world.

Beginnings of the contemporary euthanasia debate

In the mid-1800s, the use of morphine to treat "the pains of death" emerged, with John Warren recommending its use in 1848. A similar use of chloroform was revealed by Joseph Bullar in 1866. However, in neither case was it recommended that the use should be to hasten death. In 1870 Samuel Williams, a schoolteacher, initiated the contemporary euthanasia debate through a speech given at the Birmingham Speculative Club in England, which was subsequently published in a one-off publication entitled Essays of the Birmingham Speculative Club, the collected works of a number of members of an amateur philosophical society. Williams' proposal was to use chloroform to deliberately hasten the death of terminally ill patients:

That in all cases of hopeless and painful illness, it should be the recognized duty of the medical attendant, whenever so desired by the patient, to administer chloroform or such other anaesthetic as may by-and-bye supersede chloroform – so as to destroy consciousness at once, and put the sufferer to a quick and painless death; all needful precautions being adopted to prevent any possible abuse of such duty; and means being taken to establish, beyond the possibility of doubt or question, that the remedy was applied at the express wish of the patient.

— Samuel Williams (1872), Euthanasia Williams and Northgate: London.

The essay was favourably reviewed in The Saturday Review, but an editorial against the essay appeared in The Spectator. From there it proved to be influential, and other writers came out in support of such views: Lionel Tollemache wrote in favour of euthanasia, as did Annie Besant, the essayist and reformer who later became involved with the National Secular Society, considering it a duty to society to "die voluntarily and painlessly" when one reaches the point of becoming a 'burden'. Popular Science analyzed the issue in May 1873, assessing both sides of the argument. Kemp notes that at the time, medical doctors did not participate in the discussion; it was "essentially a philosophical enterprise ... tied inextricably to a number of objections to the Christian doctrine of the sanctity of human life".

Early euthanasia movement in the United States

Felix Adler, circa 1913, the first prominent American to argue for permitting suicide in cases of chronic illness

The rise of the euthanasia movement in the United States coincided with the so-called Gilded Age, a time of social and technological change that encompassed an "individualistic conservatism that praised laissez-faire economics, scientific method, and rationalism", along with major depressions, industrialisation and conflict between corporations and labour unions. It was also the period in which the modern hospital system was developed, which has been seen as a factor in the emergence of the euthanasia debate.

Robert Ingersoll argued for euthanasia, stating in 1894 that where someone is suffering from a terminal illness, such as terminal cancer, they should have a right to end their pain through suicide. Felix Adler offered a similar approach, although, unlike Ingersoll, Adler did not reject religion. In fact, he argued from an Ethical Culture framework. In 1891, Adler argued that those suffering from overwhelming pain should have the right to commit suicide, and, furthermore, that it should be permissible for a doctor to assist – thus making Adler the first "prominent American" to argue for suicide in cases where people were suffering from chronic illness. Both Ingersoll and Adler argued for voluntary euthanasia of adults suffering from terminal ailments. Dowbiggin argues that by breaking down prior moral objections to euthanasia and suicide, Ingersoll and Adler enabled others to stretch the definition of euthanasia.

The first attempt to legalise euthanasia took place in the United States, when Henry Hunt introduced legislation into the General Assembly of Ohio in 1906. Hunt did so at the behest of Anna Sophina Hall, a wealthy heiress who was a major figure in the euthanasia movement during the early 20th century in the United States. Hall had watched her mother die after an extended battle with liver cancer, and had dedicated herself to ensuring that others would not have to endure the same suffering. Towards this end she engaged in an extensive letter writing campaign, recruited Lurana Sheldon and Maud Ballington Booth, and organised a debate on euthanasia at the annual meeting of the American Humane Association in 1905 – described by Jacob Appel as the first significant public debate on the topic in the 20th century.

Hunt's bill called for the administration of an anesthetic to bring about a patient's death, so long as the person is of lawful age and sound mind, and was suffering from a fatal injury, an irrevocable illness, or great physical pain. It also required that the case be heard by a physician, required informed consent in front of three witnesses, and required the attendance of three physicians who had to agree that the patient's recovery was impossible. A motion to reject the bill outright was voted down, but the bill failed to pass, 79 to 23.

Along with the Ohio euthanasia proposal, in 1906 Assemblyman Ross Gregory introduced a proposal to permit euthanasia to the Iowa legislature. However, the Iowa legislation was broader in scope than that offered in Ohio. It allowed for the death of any person of at least ten years of age who suffered from an ailment that would prove fatal and cause extreme pain, should they be of sound mind and express a desire to artificially hasten their death. In addition, it allowed for infants to be euthanised if they were sufficiently deformed, and permitted guardians to request euthanasia on behalf of their wards. The proposed legislation also imposed penalties on physicians who refused to perform euthanasia when requested: a 6–12-month prison term and a fine of between $200 and $1,000. The proposal proved to be controversial. It engendered considerable debate and failed to pass, having been withdrawn from consideration after being passed to the Committee on Public Health.

After 1906 the euthanasia debate reduced in intensity, resurfacing periodically, but not returning to the same level of debate until the 1930s in the United Kingdom.

Euthanasia opponent Ian Dowbiggin argues that the early membership of the Euthanasia Society of America (ESA) reflected how many perceived euthanasia at the time, often seeing it as a eugenics matter rather than an issue concerning individual rights. Dowbiggin argues that not every eugenist joined the ESA "solely for eugenic reasons", but he postulates that there were clear ideological connections between the eugenics and euthanasia movements.

1930s in Britain

The Voluntary Euthanasia Legalisation Society was founded in 1935 by Charles Killick Millard (now called Dignity in Dying). The movement campaigned for the legalisation of euthanasia in Great Britain.

In January 1936, King George V was given a fatal dose of morphine and cocaine to hasten his death. At the time he was suffering from cardio-respiratory failure, and the decision to end his life was made by his physician, Lord Dawson. Although this event was kept a secret for over 50 years, the death of George V coincided with proposed legislation in the House of Lords to legalise euthanasia.

Nazi Euthanasia Program

Hartheim Euthanasia Centre, where over 18,000 people were killed.

A 24 July 1939 killing of a severely disabled infant in Nazi Germany was described in a BBC "Genocide Under the Nazis Timeline" as the first "state-sponsored euthanasia". Parties that consented to the killing included Hitler's office, the parents, and the Reich Committee for the Scientific Registration of Serious and Congenitally Based Illnesses. The Telegraph noted that the killing of the disabled infant—whose name was Gerhard Kretschmar, born blind, with missing limbs, subject to convulsions, and reportedly "an idiot"— provided "the rationale for a secret Nazi decree that led to 'mercy killings' of almost 300,000 mentally and physically handicapped people". While Kretchmar's killing received parental consent, most of the 5,000 to 8,000 children killed afterwards were forcibly taken from their parents.

The "euthanasia campaign" of mass murder gathered momentum on 14 January 1940 when the "handicapped" were killed with gas vans and killing centres, eventually leading to the deaths of 70,000 adult Germans. Professor Robert Jay Lifton, author of The Nazi Doctors and a leading authority on the T4 program, contrasts this program with what he considers to be a genuine euthanasia. He explains that the Nazi version of "euthanasia" was based on the work of Adolf Jost, who published The Right to Death (Das Recht auf den Tod) in 1895. Lifton writes:

Jost argued that control over the death of the individual must ultimately belong to the social organism, the state. This concept is in direct opposition to the Anglo-American concept of euthanasia, which emphasizes the individual's 'right to die' or 'right to death' or 'right to his or her own death,' as the ultimate human claim. In contrast, Jost was pointing to the state's right to kill. ... Ultimately the argument was biological: 'The rights to death [are] the key to the fitness of life.' The state must own death—must kill—in order to keep the social organism alive and healthy.

In modern terms, the use of "euthanasia" in the context of Action T4 is seen to be a euphemism to disguise a program of genocide, in which people were killed on the grounds of "disabilities, religious beliefs, and discordant individual values". Compared to the discussions of euthanasia that emerged post-war, the Nazi program may have been worded in terms that appear similar to the modern use of "euthanasia", but there was no "mercy" and the patients were not necessarily terminally ill. Despite these differences, historian and euthanasia opponent Ian Dowbiggin writes that "the origins of Nazi euthanasia, like those of the American euthanasia movement, predate the Third Reich and were intertwined with the history of eugenics and Social Darwinism, and with efforts to discredit traditional morality and ethics."

1949 New York State Petition for Euthanasia and Catholic opposition

On 6 January 1949, the Euthanasia Society of America presented to the New York State Legislature a petition to legalize euthanasia, signed by 379 leading Protestant and Jewish ministers, the largest group of religious leaders ever to have taken this stance. A similar petition had been sent to the New York Legislature in 1947, signed by approximately 1,000 New York physicians. Roman Catholic religious leaders criticized the petition, saying that such a bill would "legalize a suicide-murder pact" and a "rationalization of the fifth commandment of God, 'Thou Shalt Not Kill.'" The Right Reverend Robert E. McCormick stated that

The ultimate object of the Euthanasia Society is based on the Totalitarian principle that the state is supreme and that the individual does not have the right to live if his continuance in life is a burden or hindrance to the state. The Nazis followed this principle and compulsory Euthanasia was practiced as a part of their program during the recent war. We American citizens of New York State must ask ourselves this question: "Are we going to finish Hitler's job?"

The petition brought tensions between the American Euthanasia Society and the Catholic Church to a head that contributed to a climate of anti-Catholic sentiment generally, regarding issues such as birth control, eugenics, and population control. However, the petition did not result in any legal changes.

Debate

Historically, the euthanasia debate has tended to focus on a number of key concerns. According to euthanasia opponent Ezekiel Emanuel, proponents of euthanasia have presented four main arguments: a) that people have a right to self-determination, and thus should be allowed to choose their own fate; b) assisting a subject to die might be a better choice than requiring that they continue to suffer; c) the distinction between passive euthanasia, which is often permitted, and active euthanasia, which is not substantive (or that the underlying principle–the doctrine of double effect–is unreasonable or unsound); and d) permitting euthanasia will not necessarily lead to unacceptable consequences. Pro-euthanasia activists often point to countries like the Netherlands and Belgium, and states like Oregon, where euthanasia has been legalized, to argue that it is mostly unproblematic.

Similarly, Emanuel argues that there are four major arguments presented by opponents of euthanasia: a) not all deaths are painful; b) alternatives, such as cessation of active treatment, combined with the use of effective pain relief, are available; c) the distinction between active and passive euthanasia is morally significant; and d) legalising euthanasia will place society on a slippery slope, which will lead to unacceptable consequences. In fact, in Oregon, in 2013, pain wasn't one of the top five reasons people sought euthanasia. Top reasons were a loss of dignity, and a fear of burdening others.

In the United States in 2013, 47% nationwide supported doctor-assisted suicide. This included 32% of Latinos, 29% of African-Americans, and almost nobody with disabilities.

A 2015 Populus poll in the United Kingdom found broad public support for assisted dying. 82% of people supported the introduction of assisted dying laws, including 86% of people with disabilities.

One concern is that euthanasia might undermine filial responsibility. In some countries, adult children of impoverished parents are legally entitled to support payments under filial responsibility laws. Thirty out of the fifty United States as well as France, Germany, Singapore, and Taiwan have filial responsibility laws.

Legal status

West's Encyclopedia of American Law states that "a 'mercy killing' or euthanasia is generally considered to be a criminal homicide" and is normally used as a synonym of homicide committed at a request made by the patient.

The judicial sense of the term "homicide" includes any intervention undertaken with the express intention of ending a life, even to relieve intractable suffering. Not all homicide is unlawful. Two designations of homicide that carry no criminal punishment are justifiable and excusable homicide. In most countries this is not the status of euthanasia. The term "euthanasia" is usually confined to the active variety; the University of Washington website states that "euthanasia generally means that the physician would act directly, for instance by giving a lethal injection, to end the patient's life". Physician-assisted suicide is thus not classified as euthanasia by the US State of Oregon, where it is legal under the Oregon Death with Dignity Act, and despite its name, it is not legally classified as suicide either. Unlike physician-assisted suicide, withholding or withdrawing life-sustaining treatments with patient consent (voluntary) is almost unanimously considered, at least in the United States, to be legal. The use of pain medication to relieve suffering, even if it hastens death, has been held as legal in several court decisions.

Some governments around the world have legalized voluntary euthanasia but most commonly it is still considered to be criminal homicide. In the Netherlands and Belgium, where euthanasia has been legalized, it still remains homicide although it is not prosecuted and not punishable if the perpetrator (the doctor) meets certain legal conditions.

In a historic judgment, the Supreme court of India legalized passive euthanasia. The apex court remarked in the judgment that the Constitution of India values liberty, dignity, autonomy, and privacy. A bench headed by Chief Justice Dipak Misra delivered a unanimous judgment.

Health professionals' sentiment

A 2010 survey in the United States of more than 10,000 physicians found that 16.3% of physicians would consider halting life-sustaining therapy because the family demanded it, even if they believed that it was premature. Approximately 54.5% would not, and the remaining 29.2% responded "it depends". The study also found that 45.8% of physicians agreed that physician-assisted suicide should be allowed in some cases; 40.7% did not, and the remaining 13.5% felt it depended.

In the United Kingdom, the assisted dying campaign group Dignity in Dying cites research in which 54% of General Practitioners support or are neutral towards a law change on assisted dying. Similarly, a 2017 Doctors.net.uk poll reported in the British Medical Journal stated that 55% of doctors believe assisted dying, in defined circumstances, should be legalised in the UK.

One concern among healthcare professionals is the possibility of being asked to participate in euthanasia in a situation where they personally believe it to be wrong. In a 1996 study of 852 nurses in adult ICUs, 19% admitted to participating in euthanasia. 30% of those who admitted to it also believed that euthanasia is unethical.

Religious views

Christianity

Broadly against

The Roman Catholic Church condemns euthanasia and assisted suicide as morally wrong. It states that, "intentional euthanasia, whatever its forms or motives, is murder. It is gravely contrary to the dignity of the human person and to the respect due to the living God, his Creator". Because of this, the practice is unacceptable within the Church. The Orthodox Church in America, along with other Eastern Orthodox Churches, also opposes euthanasia stating that "euthanasia is the deliberate cessation of human life, and, as such, must be condemned as murder."

Many non-Catholic churches in the United States take a stance against euthanasia. Among Protestant denominations, the Episcopal Church passed a resolution in 1991 opposing euthanasia and assisted suicide stating that it is "morally wrong and unacceptable to take a human life to relieve the suffering caused by incurable illnesses." Protestant and other non-Catholic churches which oppose euthanasia include:

Partially in favor of

The Church of England accepts passive euthanasia under some circumstances, but is strongly against active euthanasia, and has led opposition against recent attempt to legalise it. The United Church of Canada accepts passive euthanasia under some circumstances, but is in general against active euthanasia, with growing acceptance now that active euthanasia has been partly legalised in Canada.

Islam

Euthanasia is a complex issue in Islamic theology; however, in general it is considered contrary to Islamic law and holy texts. Among interpretations of the Koran and Hadith, the early termination of life is a crime, be it by suicide or helping one commit suicide. The various positions on the cessation of medical treatment are mixed and considered a different class of action than direct termination of life, especially if the patient is suffering. Suicide and euthanasia are both crimes in almost all Muslim majority countries.

Judaism

There is much debate on the topic of euthanasia in Judaic theology, ethics, and general opinion (especially in Israel and the United States). Passive euthanasia was declared legal by Israel's highest court under certain conditions and has reached some level of acceptance. Active euthanasia remains illegal, however the topic is actively under debate with no clear consensus through legal, ethical, theological and spiritual perspectives.

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