Origins of the Modern Euthanasia Movement
As the ink on my medical degree was still drying, I covered a hospital's oncology service at night, taking care of cancer patients admitted for chemotherapy. The prognoses of the patients were variable: Some underwent aggressive treatment with anticipated remission; others received brief palliative treatment to improve their quality of life before the end. The experience taught me how medicine deals not only with disease itself, but with the dis-ease that both illness and life circumstances create.
I recall in powerful detail a woman in her 60s with stage IV lung cancer in her liver and bones. The oncology team measured her remaining time in weeks and months rather than years. In the evenings, I would give the woman morphine for her pain. She often requested extra doses to mitigate the ravages of disease.
It wasn't always pain that preoccupied her, though. Her children and ex-husband could not or did not come to see her. No visitors sat by her bedside. Her frustrations emerged in unseemly ways. She lashed out at the nurses caring for her: cursing at them, screaming at them, making awful accusations about their competency or concern. Every night a different nurse took care of her so others wouldn't get burned out. They often called me to help deal with the patient's anger — outbursts amplified by solitude and abandonment.
During a singularly challenging evening, the patient asked to see me. I found myself at her bedside, standing uncomfortably as she railed against my incompetence as a physician, accusing me and the nurses of abandoning her and ignoring her suffering. She told me how horrible her life was, how she needed it to end. Finally, she begged: "Please, just kill me. Give me enough morphine to end it. I've suffered enough!"
What could I say? Her request felt far beyond the bounds of what I could do to relieve her condition. I told her I couldn't kill her, but that I could give her an opiate dose to ease her pain. As I walked out the door, she called after me: "Coward!"
My response that night was reflexive. But as I mature professionally and observe the external political influences on medicine, I have become more aware of a growing movement that would have called on me to grant this woman's request.
The practices of physician-assisted suicide (PAS) — in which a physician gives a patient medication so the patient can take it to die — and euthanasia, in which a physician directly injects a patient with a deadly drug, have gained immense traction in the West since my nights as a freshman doctor. In 1950, a poll revealed that 36% of Americans approved of allowing a doctor to end a patient's life. In 1998, the same proposal elicited 59% approval. In 2015, the approval number was close to 70%. Differences in the way this question was worded may have affected the results, but the overall trend is clear.
These changing views have influenced state law in recent decades. In 1994, Oregon became the first state to legalize PAS. Since then Washington, Montana, Vermont, California, Colorado, Maine, the District of Columbia, New Jersey, Hawaii, and New Mexico have joined the list. As a result, the number of people who have died by assisted suicide in the United States rose from around 850 in 2018 to over 1,300 in 2021.
Other Western nations have witnessed a similar trend. In Switzerland, the number of people who received assisted suicide per year rose from 60 to 600 between 2000 and 2015. In Belgium, euthanasia case numbers increased from 235 in 2003 to 3,423 in 2023 — the latter of which was about 15% higher than it had been the preceding year. Over roughly the same period, the number of patients euthanized in the Netherlands quadrupled, from approximately 2,000 to 8,720. In Canada, the number jumped from 4,480 in 2018 to 10,064 in 2021. By 2022, PAS and euthanasia cases made up 4% of deaths nationwide.
The types of patients granted access to PAS and euthanasia have also expanded. In 2009, Luxembourg passed a bill to legalize both forms of assisted suicide; today, eligible patients include those without a terminal illness. Belgium amended a law in 2014 to permit terminally ill children to request euthanasia. A 2001 Dutch act extended access to PAS and euthanasia to children as young as 12 years old.
The medical decisions behind many of these deaths raise ethical questions. In the Netherlands, physicians can legally put to death people who cite autism or intellectual disabilities as the primary motivation for their request. Some patients have reported loneliness as their reason for seeking PAS or euthanasia. One patient who did not want to live in a nursing home requested and was granted approval for assisted suicide. Meanwhile, suicidal patients in places like New Zealand are offered assisted suicide when seeking medical care for suicide prevention.
Perhaps the most shocking stories of unfettered access to PAS and euthanasia come from Canada, as Alexander Raikin powerfully documented in The New Atlantis. Canadian patients who ask for medical assistance in dying (MAID) due to inadequate financial resources are often granted that request. Military veterans seeking treatment for post-traumatic stress disorder (PTSD) or a wheelchair ramp are asked if they would like to apply for MAID instead. As one patient told Raikin: "Even at 65, I don't want to die....I really don't want to die. I just can't afford to live." At least one physician approved him for MAID.
Tragically, stories like these abound. A man in Ontario with bad back pain applied for assisted suicide rather than live in poverty: "I don't want to die," he told a local broadcaster, "but I don't want to be homeless more than I don't want to die." In Montreal, a woman with spina bifida was offered MAID twice, unprompted. In British Columbia, a 37-year-old woman with Ehlers-Danlos syndrome (a connective-tissue disease) opted for euthanasia even though she told family and friends that she wanted to live; she simply didn't have access to the care necessary to treat her illness. And in Quebec, a quadriplegic patient who came to the hospital with a virus was placed on a stretcher in the emergency room for four days. Though his partner told his doctors he needed an alternating-pressure mattress to prevent bed sores, hospital staff ignored the request, and the patient developed the worst bed sore of his life. He underwent multiple surgical treatments before finally saying that he preferred to die so he wouldn't "be a burden for long."
In a 1994 essay for the Annals of Internal Medicine on the history of euthanasia in the United States and Britain, Dr. Ezekiel Emanuel, a bioethicist at the University of Pennsylvania, observed that the debate over PAS and euthanasia has waxed and waned in familiar ways over the last 150 years. But while the arguments may be predictable, there are now far fewer barriers to PAS and euthanasia than ever before. How did we come to the point where wealthy democratic countries offer to kill people because they are homeless or lonely or disabled?
There isn't a simple answer to this question. But identifying the cultural influences behind the assisted-dying movement can help us understand why it has been so successful.
THE RELIGIOUS BULWARK
In Canto 13 of Dante's Inferno, Dante stumbles upon a forest in the seventh circle of hell. He wrote of the forest: "No green leaves...only black; no branches straight and smooth, but knotted, gnarled; no fruits were there, but briers bearing poison." These figures were once people who committed suicide or did violence to themselves. As divine punishment, they were perennially fixed in hell as twisted, poisonous trees.
Most religions portray suicide in this way, as a mortal sin deserving of severe repercussions. French historian Georges Minois points out in his book History of Suicide that killing oneself was long considered a diabolic temptation for which authorities often confiscated the estates of the deceased and inflicted punishments on their corpses. Christian theologians forbade it. St. Augustine argued in The City of God against the Pagans:
No divine precept or permission can be discovered which allows us to bring about our own death, either to obtain immortality or to avert or avoid some evil. On the contrary, we must understand the Law of God as forbidding us to do this, where it says, "Thou shalt not kill."
St. Thomas Aquinas, a Dominican friar, philosopher, and theologian of the 13th century, echoed this sentiment in his Summa Theologica:
It is altogether unlawful to kill oneself, for three reasons. First, because everything naturally loves itself, the result being that everything naturally keeps itself in being, and resists corruptions so far as it can. Wherefore suicide is contrary to the inclination of nature, and to charity whereby every man should love himself....Secondly, because every part, as such, belongs to the whole. Now every man is part of the community, and so, as such, he belongs to the community....Thirdly, because life is God's gift to man, and is subject to His power, Who kills and makes to live.
Even today, these attitudes reverberate throughout various denominations of Christianity and Judaism. "Faithfulness in the face of another's death will always care," wrote the late Protestant theologian Allen Verhey, "but it will not kill or assist in suicide." Noam Zohar, a philosophy professor at Bar-Ilan University, suggested that while Jewish law contains divergent views on the subject, a strong contingent of the tradition forbids suicide, even in dire circumstances.
These opinions reflect a general consensus among religious adherents that PAS and euthanasia are off limits. And in fact, multiple studies and surveys demonstrate that people with greater religious faith are more likely to oppose such practices. A Gallup poll from 2018 showed that only 37% of those who attend church weekly think the law should allow doctors to end a patient's life; the number in favor shot up to 86% among those who attend church rarely or never. Likewise, in a cross-sectional study from France surveying patients with incurable cancer, those who believed in God or practiced religion were less likely to favor PAS and euthanasia than their non-believing peers.
Predictably, the recent decline in religiosity, religious observance, and identification with religion coincides with a rise in the availability and use of assisted dying. In Pew Research Center surveys conducted in 2018 and 2019, 65% of American adults described themselves as Christians — down 12% from a decade earlier. The decrease occurred among both Protestants and Catholics. Meanwhile, the number of adults who identified as atheist and agnostic rose in tandem: Seventeen percent of Americans surveyed described their religion as "nothing in particular," up from 12% a decade prior.
Canada and Europe have even lower levels of religious observance. Though 38% of Americans in a 2022 survey stated that religion is "very important" to them, only a quarter of Canadians said the same. Fewer Canadians describe themselves as Christian today than did several years ago, while the numbers who identify as atheist or agnostic have risen. Similarly, across Europe, the percentage of people who state that religion is very important in their lives is quite low: 19% in Norway, 10% in the United Kingdom, 10% in Germany, and so forth.
Sociological data can be inexact and merely correlative. However, given the ideological bulwark that religious belief places against PAS and euthanasia, religion's decline is likely a significant factor in the sea change of opinion on assisted dying. Remove the convictions that place fundamental moral restrictions on suicide, and the barrier to PAS and euthanasia becomes that much easier to overcome.
"MY BODY, MY CHOICE"
The decline of religion accounts for only part of the story, however. Other major social changes that have affected opinions on assisted dying are the burgeoning patient-autonomy movement and the rise of dualism.
Lewis Grossman, a historian and professor of law at American University, points out in his book Choose Your Medicine that the United States experienced a broad patients'-rights revolution in the 1970s. In 1973, the American Hospital Association disseminated the first Patient's Bill of Rights, which included "the right to refuse treatment to the extent permitted by law." At the same time, informed consent became a basic principle of medical care.
This movement has since influenced dozens of issues. Even the recent hesitancy surrounding Covid-19 vaccines relied on personal-autonomy arguments. In a rally against the vaccine mandates a few years ago, anti-vaccination groups co-opted the slogan "My Body, My Choice" from the pro-choice movement. As Tucker Carlson, a former commentator for Fox News and now an independent media personality, said of the mandates: "I thought that American physicians agreed that compulsory medical care was unethical, it was immoral and could never be imposed on anyone. When did we forget that?"
The emphasis on patient autonomy also appears in matters not mired in heated debate. For example, the Centers for Medicare and Medicaid Services' bonus payments to hospitals now rely on quantitative "patient experience" scores collected from patient surveys. Billions of dollars hinge on patients' reported satisfaction, forcing doctors across the country to cater to their patients' desires. Even the widespread availability of direct-to-consumer testing (for Covid-19, genetic abnormalities, and other conditions) demonstrates the centrality of autonomy: Some testing is now in the patient's hands.
Regardless of where one stands on these issues, patient autonomy — the right to choose, the right to refuse, and the right to have control over oneself — drives medical policy in the United States. The burgeoning availability of PAS and euthanasia are no exception. Arguments in favor of both procedures rely primarily on the idea of patient control. Dr. Timothy Quill — who in 1997 was a lead plaintiff in a lawsuit challenging the prohibition of PAS — puts his argument in terms of autonomy: "As a physician," he asserts, "I believe that patients and families should be given as much choice as possible in what happens to them towards the end of their lives." Similarly, the non-profit organization Compassion & Choices emphasizes patient choice in its mission statement:
We envision a patient-driven system that honors an individual's values, religious views and spiritual beliefs. We are working toward an America that respects everyone's right to make their own end-of-life care decisions, in consultation with doctors and loved ones. We advocate for expanded options to ensure everyone can die peacefully and with dignity.
The same is true in Canada and Europe. In justifying its MAID laws, the Canadian government cited patient autonomy as a primary rationale. Gilles Genicot, once the co-chairman of Belgium's Federal Commission for the Control and Evaluation of Euthanasia, made a similar point in 2015. Patients themselves often cite control over how they die as a reason for supporting PAS and euthanasia. Clearly, the patients'-rights revolution fuels support for legalizing assisted dying.
In addition to prioritizing control over our own bodies, we increasingly see our bodies as separate from our minds — an idea referred to as "dualism." The concept is as old as Western civilization: Plato and Aristotle explored it in antiquity. It was philosopher René Descartes, however, who popularized the idea during the 17th century.
In Meditations on First Philosophy, Descartes argued that the mind and body are not just separate; they are two fundamentally different substances with different physical properties. He also believed that the body is controlled by, and thus in some sense lesser than, the mind.
Descartes's dualist approach permeates thought, language, and policy in the West today. It's even evident in the way scientists write about the body. In a 2020 letter to the editor of Lifestyle Medicine about a paper the journal published on obesity, Sarah Redsell and her co-authors wrote that they "believe the contents of this paper are likely to cause unjustifiable harm to people in bigger bodies." The phrasing here is key: Professor Redsell and her colleagues do not think of people as having bigger bodies; they think of people as being in bigger bodies. In other words, they believe bodies house minds.
Dualism is also evident in our understanding of human sexuality. In a recent article for Air Mail, journalist Kat Rosenfield described how today, more than 20% of Gen Z adults identify as LGBTQ+ — a trend driven by the increasing number of individuals (primarily women) who identify as bisexual. Curiously, however, Rosenfield found that identifying as bisexual does not necessarily mean one engages in sexual encounters with both men and women. One may claim to be bisexual, but his sexual behavior is often heterosexual in nature. As Rosenfield concluded: "For those of us who went through puberty in the pre-Internet age, sexual orientation is inextricable from the embodied act of sex. But many Gen Z-ers reject this notion." For them, sexual orientation exists in the mind but not the body; it is something immaterial — a dualist proposition.
Changing ideas about gender demonstrate an increasing acceptance of dualism as well. If we assume that the body and the mind are distinct from one another, it follows that the body and the mind can be misaligned. Walter Bockting, a clinical psychologist and the founding director of the Gender and Sexuality Program at Columbia University, illustrates as much in describing treatments for transgender individuals. "Transgender people may undergo medical interventions to align their appearance with their gender identity," he observed. In other words, a transgender individual is said to have a mental gender that is distinct from the body's gender, and if the two are misaligned, they can be brought into alignment through medical and surgical interventions.
We in the West increasingly think this way about the human condition. A Reuters analysis showed that the number of U.S. children and teens who received a diagnosis of gender dysphoria tripled between 2017 and 2021. Similarly, instances of hormone treatments, puberty blockers, and top surgeries for gender-dysphoria diagnoses all increased significantly through 2021. Transgender identification in the United Kingdom rose five-fold between 2000 and 2018. In Canada, where Alexander Raikin uncovered the troubling lack of safeguards surrounding MAID, younger populations are as much as seven times more likely to identify as transgender or non-binary than older populations. Belgium, in addition to having some of the most permissive euthanasia laws in the world, also ranks highly among progressive nations on gender transitioning.
At first blush, the connection between dualism and euthanasia seems tenuous. After all, advocates of assisted dying hold that both mind and body disappear after death. Yet presumably a person requesting PAS or euthanasia believes that his mind works well even as his body deteriorates, and that his body must be eliminated while his mind remains unfettered. This proposition requires one to assume that the body and the mind are distinct entities. Thus, the growing acceptance of the mind as materially separate from the body facilitates support for and the use of assisted dying.
In such a scenario, the body is thought to be possessed by the mind, which can do what it pleases with the body. The latter can be remade or destroyed. "The elimination of one's embodied person through the precipitation of one's death," says Dr. Daniel Sulmasy, a professor of biomedical ethics at Georgetown University, is "not the act of a whole person, inasmuch as it falsely attempts to sunder person and body."
THE LOST ART OF DYING
The last cultural change relevant to the slippery slope of PAS and euthanasia springs from a recent and dramatic change in how we think about death and dying.
Confronting our own mortality was once an integral part of life. In ancient Rome, generals paraded through the streets after great victories, cheered on by triumphant crowds. As second-century Christian author Tertullian notes in his book Apologeticus, the general would be admonished from behind even while being celebrated: "Look behind thee; remember that thou art a man." Remember, in other words, that you are mortal; remember that you, too, will die.
This acceptance of one's ultimate end was a perennial theme throughout pre-modern times. Dr. Lydia Dugdale, a physician at Columbia University, pointed out in her book The Lost Art of Dying that a 15th-century handbook on the ars moriendi, or the art of dying, prepared its readers for death by directing them not to offer the dying false hope for recovery. Instead, family and friends were to gather at the dying person's bedside while he repented for his sins, and community members were to pray for him and for those who had already passed.
Dying also occurred in the public eye, as Philippe Ariès explained in his brilliant history, Western Attitudes toward Death. Children were brought into the dying family member's bedchamber. Dying was so communal, in fact, that according to Ariès, by the end of the 18th century, "doctors who were discovering the first principles of hygiene complained about the overcrowded bedrooms of the dying." In short, dying was a collective event, not an individual one.
This changed dramatically in the 20th century with advances in medical technology. Hospitals transformed from poorhouses into medical-care facilities. Doctors fought death with miraculous treatments, which required intense training and specialized equipment. Patients no longer burdened their loved ones with dying. As Ariès wrote: "One no longer died at home in the bosom of one's family, but in the hospital, alone." His observation reflects the data: In 2000, 48% of deaths in the United States occurred in the hospital. Though that percentage has been steadily decreasing (it still sits at about a third), the majority of Americans continue to die in hospitals or hospital-like institutions, such as nursing homes and long-term care facilities. And yet, most of us would prefer to die at home. Such glaring discordance should give us pause.
This trend correlates with other concerning changes. As we increasingly separate ourselves from the dying process, we also separate ourselves from the dead body. Cremation rids us of and allows us to forget the decaying human being. In the United States, cremation rates recently reached 61%, and are expected to rise above 80% by 2045. In Canada, that rate is 75%.
Rising cremation rates paired with institutional deaths paint a broader picture of the problem: We avoid engaging with both the dead and the dying.
When one looks at polling for why patients request PAS or euthanasia, respondents report that they seek to control the circumstances of death, elude the loss of independence, and avoid burdening others. This represents a dramatic change from the way Westerners once thought about death. Dependence on others, the loss of one's faculties, and becoming a burden were once part and parcel of the process of dying. Today, we aspire to eliminate this process.
"Why do the sick believe that dying strips them of their worth and honor?" asks Dr. Dugdale. She continues:
[T]he very suggestion highlights how much we have lost the art of dying. If anything, the practices of the ars moriendi point to the deathbed as an opportunity for people to exercise dignity by dispensing words of hope and blessing to the family and friends who accompany them to their deaths. Such practices enhance, rather than diminish, dignity.
Lack of familiarity with death and dying walks arm in arm with the assisted-dying movement. Because we are no longer familiar with death, we fear it. Because we fear death, we try to control it. If we control it, we can find more dignity in it — at least, that's how the argument goes.
CONTRADICTIONS WITHIN THE MOVEMENT
Identifying the ideas at the core of the burgeoning support for PAS and euthanasia exposes the movement's origins; it also reveals its internal contradictions. We want to protect patients' autonomy so that they can relinquish their autonomy sooner by dying. We attempt to free our family and friends from the burden of our illnesses without freeing anyone from the burden of our deaths. We sever the mind from the body to make our passing simplistic but leave behind the complications of death, loss, and mourning.
Even so, the movement in support of PAS and euthanasia — and the foundational threads that support it — come from a decent place. Proponents want to alleviate suffering, both existential and physical; to mitigate shame, both public and private; to wrest control of life's most terrifying and certain event. It is difficult for anyone sympathetic to the plight of the miserable and ill to object to such intentions. However, the movement walks a tightrope: It asks doctors to respect human dignity while they kill or help to kill.
Alas, we appear to be losing our balance. Disturbing echoes of historical horrors resonate through the West today. In the 1930s and '40s, the Nazis cited economic uselessness as a dominant factor in judging whether a patient should live or die; in Canada today, a patient who is too poor to live is offered death instead of charitable or government assistance. The Nazis euthanized wounded German soldiers because the state refused to support them; in Canada, war veterans with PTSD who call for help are offered death. Nazi SS officers shot and killed disabled or mentally ill patients chosen for euthanasia; in the Netherlands, the law now permits physicians to euthanize people with autism or intellectual disabilities. Recently, in Belgium, nurses are alleged to have smothered a young woman with a pillow after palliative treatment failed to relieve her pain. In our tireless pursuit of a humane and dignified death, we devalue human life.
We need to rethink the cultural underpinnings of PAS and euthanasia. This begins with carefully considering where autonomy begins and ends for both physicians and patients, particularly when it comes to death. What might restrain the exponential growth of assisted dying? If religion continues to wane, what might take its place as a bulwark against PAS and euthanasia?
We also must familiarize ourselves with death — talk about it, think about it, even while we understandably dread seeing it. It is, after all, an experience we will all have.
I often think back on the patient I saw during my first week as a physician, the difficulty of her situation, and how easy it would have been to give her a deadly dose of morphine. But it would not have been merciful or understanding. I hope for another way for patients like her — one that champions the art of dying and struggles against the diminishment of human life.
