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Euthanasia

We cannot choose the moment of our birth. And death usually comes in its own time, not ours. Sometimes, however, we can decide to end our life. The reasons for suicide are various. Most common is the desire to end intractable suffering. Faced with the prospect of a prolonged period of pain and suffering at the end of life, most rational people would prefer euthanasia – a “good death.” This term first came into English in Francis Bacon’s Advancement of Learning (Book II, X.7). Bacon was encouraging physicians to assuage the pains and agonies of death: to practice what we now call palliative care.

Over the course of time “euthanasia” became differentiated from palliative care, and now generally means the inducement of death so as to prevent intolerable pain and suffering in patients with incurable disease (Young, 2012; Sumner 2011). Euthanasia may be voluntary or involuntary, based on whether the patient provides consent or not. Involuntary euthanasia, where the patient does not provide consent although capable of so doing, is sometimes distinguished from non-voluntary euthanasia (“mercy killing”), where the patient is unable to either object or consent. Some would consider both involuntary and non-voluntary euthanasia as equivalent to murder and limit the term euthanasia to cases wherein consent is explicit. Euthanasia may be active or passive, based on whether death is induced by the administration of a lethal medication or by the withdrawal of life-sustaining treatment, nutrition or hydration. Active euthanasia may be initiated by the patient, in which case it is essentially suicide, or by someone else (a physician or a nurse acting under the direction of a physician), in which case it can be described as assisted suicide or assisted dying. Sometimes voluntary euthanasia, where the lethal medication is administered to the patient, is distinguished from assisted suicide, where the patient takes the drug, but this distinction appears unnecessary. When the word is unmodified, euthanasia generally means physician-assisted suicide performed at the request of the patient.

Historical Backgound

Our attitudes to euthanasia have changed over the centuries (Dowbiggin, 2005). Developments in religion, law, and medicine have all contributed to these changes. Over the past century or so medicine has increased its ability to treat disease and manage pain. We are now more able to make end-of-life decisions than we have ever been. Nevertheless, the decisions remain extremely difficult, since they involve our cherished belief in the sanctity of human life and our ancient laws against killing (Pappas, 2012). Any proposal for euthanasia must address our general prohibition of suicide.

In the Eastern religions, suicide was not forbidden. In India, a wife could cast herself on the funeral pyre of her husband in the process of sati. Elderly yogis with no remaining responsibilities could seek death by starvation – prayopavesa. In Japan, suicide by means of seppuku could preserve one’s honor. Since one of the goals of Buddhism is to relinquish any attachment to the world, suicide might even be considered as a means to this release, though this should only come after enlightenment has been attained (Attwood, 2004). However, some Chinese and Japanese Buddhist monks sought enlightenment through a process of sokushinbutsu or self-mummification, accomplished by slow starvation and self-suffocation.

In the Abrahamic religions, however, suicide was considered an unpardonable sin, tantamount to murder (Cholbi, 2012). Suicide was contrary to the commandment “Thou shalt not kill” (Exodus 20:13). The main scriptures, however, do not specifically prohibit killing oneself. The Bible provides various examples of suicide (Samson, Saul, Judas) without ever stating that this is prohibited. However, the scriptures convey a general sense that one should not interfere with divine providence: “My times are in thy hand” (Psalm 31:15). One verse of the Qur’an (4:29) is sometimes translated as “Do not kill yourselves,” though it is more usually rendered as “Do not kill each other.”

Through most of its history, the Christian Church has adamantly condemned suicide. The body of a suicide was denied burial in consecrated ground and the soul denied access to salvation. In recent years, the churches have relaxed their condemnation, though suicide is still considered a mortal sin. Until recently, suicide was illegal in almost all European countries, and the property of the suicide was confiscated by the state. Part of the reason why Christian societies have been so severe in their condemnation of suicide may have been the attractiveness of heaven. Without severe sanctions, believers might easily choose the happiness of an after-life to the suffering of a present life.

During the Renaissance and Enlightenment, thinkers began to question the Church’s stance. When one is coming to the end of life and faced with unrelenting pain, one should be able to choose a quick and painless death rather than undergo prolonged and unnecessary suffering

In Thomas More’s Utopia

…when any is taken with a torturing and lingering pain, so that there is no hope either of recovery or ease, the priests and magistrates come and exhort them, that, since they are now unable to go on with the business of life, are become a burden to themselves and to all about them, and they have really out-lived themselves, they should no longer nourish such a rooted distemper, but choose rather to die since they cannot live but in much misery; being assured that if they thus deliver themselves from torture, or are willing that others should do it, they shall be happy after death: since, by their acting thus, they lose none of the pleasures, but only the troubles of life, they think they behave not only reasonably but in a manner consistent with religion and piety; because they follow the advice given them by their priests, who are the expounders of the will of God. Such as are wrought on by these persuasions either starve themselves of their own accord, or take opium, and by that means die without pain. (More, 1516, pp 140-141).

One cannot be sure whether More was advocating euthanasia or just presenting the policy for discussion. The title of his book means “nowhere” – only later did it assume the additional connotation of eutopia or “good place.” As a devout Roman Catholic, More likely supported his church’s opposition to euthanasia. Death should come when God wills, not when we want.

In an essay that was only published posthumously, David Hume provided a rational view of suicide. He proposed that it is no more contrary to divine providence than building houses to protect ourselves from the weather or cultivating the earth to prevent ourselves from starving. Furthermore, when we become old and infirm suicide is no longer contrary to our duties to society, since we may have become more of a burden than a benefit to our fellows. Thus

both prudence and courage should engage us to rid ourselves at once of existence, when it becomes a burthen. ’Tis the only way, that we can then be useful to society, by setting an example, which, if imitated, would preserve to every one his chance for happiness in life, and would effectually free him from all danger of misery. (Hume, 1777)

In the concluding note to his essay, Hume quoted Pliny the Elder who described suicide as an advantage that man possesses over God.

Deus non sibi potest mortem consciscere, si velit, quod homini dedit optimum in tantis vitæ poenis. [God cannot put himself to death even if he wanted to, since among the many ills of life he gave away this best of boons to man]. (Pliny, 79, Book II Chapter V)

The modern interpretation of euthanasia can probably be traced to the much-discussed essay on the subject by Samuel D. Williams published in 1870 (Kemp, 2002). He proposed

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 anæsthetic as may by-and-by supersede chloroform, so as to destroy consciousness at once, and put the sufferer at once 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. (Williams, 1870, p 212).

In the decades subsequent to this essay, many groups in England, Europe and North America began to advocate the legalization of euthanasia.

Unworthy Lives

In the 20th Century euthanasia became entrammeled with another idea that promoted the good of society – “eugenics.” Unfortunately, joining the “good death” with the “good birth” led to actions of great evil.

Darwin’s Theory of Evolution had proposed that humanity’s current success derives from the selection of the fittest for survival and propagation. Followers of Darwin warned that we should not alter the course of evolution by social policies to protect the weak and vulnerable. Rather we should encourage our best and brightest to have more offspring, and we should prevent the feeble-minded, criminal and insane from multiplying. These ideas formed the basis of eugenics.

In the first few decades of the 20th Century several jurisdictions in North America and Europe enacted eugenic laws enforcing the sterilization of the mentally defective and the insane. The most efficient of such programs was brought in by the German Nazi government when it came to power in1933 (Proctor, 1988, Chapter 4; Pichot, 2001, Chapter 10). The Law for the Prevention of Genetically Diseased Offspring required the sterilization of patients suffering from feeble mindedness, schizophrenia, manic-depression, Huntington’s chorea and alcoholism. While the program was in operation between 1933 and 1939, about 400,000 patients were sterilized (compared to about 30,000 patients over a much longer period in the USA).

A more effective eugenics program would not only prevent offspring but also remove from society the costs involved in the long-term care of feeble-minded and mentally ill patients. The possibility of the involuntary euthanasia of patients who were a burden to society had been thoroughly evaluated in the 1920 book Permitting the Destruction of Unworthy Life by Karl Binding, a legal scholar, and Alfred Hoche, a physician. They considered the question

Is there human life which has so utterly forfeited its claim to worth that its continuation has forever lost all value both for the bearer of that life and for society?

They answered affirmatively, and proposed that society was justified in putting patients with incurable disease to death.

In 1939 the war began and the German sterilization program ceased. In its place a secret program called Operation T4 was instituted to provide a mercy death (Gnadentod) for the incurably sick and mentally ill. Patients were killed either in specially constructed gas chambers or by such other means as were found expedient. The number of patients euthanized by the time the war ended was probably around 400,000 (Proctor, 1988, Chapter 7; Pichot, 2001, Chapter 11). The techniques developed in the early stages of this program were then used when the Nazi government decided to murder Jews, homosexuals, communists, Gypsies, Slavs and prisoners of war.

The history of euthanasia in Germany is a horrifying example of the “slippery slope.” By accepting that some people have more of a right to life than others or that a doctor may agree to a patient’s request for death, we slide slowly and inexorably toward complete immorality. Leo Alexander, a medical expert at the Nuremberg trials, stated the problem of the “small beginnings:”

Whatever proportions these crimes finally assumed, it became evident to all who investigated them that they had started from small beginnings. The beginnings at first were merely a subtle shift in emphasis in the basic attitude of the physicians. It started with the acceptance of the attitude, basic in the euthanasia movement, that there is such a thing as a life not worthy to be lived. This attitude in its early stages concerned itself merely with the severely and chronically sick. Gradually the sphere of those to be included in this category was enlarged to encompass the socially unproductive, the ideologically unwanted, the racially unwanted and finally all non-Germans (Alexander, 1949).

Double Effects

For many years after the war, the ethics of active euthanasia were not discussed. We became more concerned with the relief of pain. New protocols were developed to facilitate analgesia, the speciality of palliative care became a medical specialty, and hospices became available to provide a peaceful and pain-free death to patients with terminal illness.

Sometimes, when medication dosages were increased to levels sufficient to relieve severe and unrelenting pain, death also resulted. Such protocols invoked the principle of “double effect:” that an action intended to bring about a morally desirable effect (the relief of pain) is not wrong if it also leads to a morally reprehensible effect (death) even when this second effect is foreseen. This state of affairs is both morally and medically confusing (McIntyre, 2001). Who is to say what is intended and what is just foreseen? The increased pain medication probably does not in itself bring about the death of the patient. Death results from a combination of causes: limiting the patient’s nutrition and hydration adds to the effects of sedation and the ongoing disease. “Terminal sedation” should probably not be considered as an example of double effect, but simply treated as a type of euthanasia.

End-of-Life Decisions

In the second half of the 20th Century, medicine developed techniques for cardiopulmonary resuscitation and mechanical ventilation. Although these procedures often prevented unnecessary death, they sometimes resulted in unresponsive patients being maintained alive without any reasonable hope for the return of normal consciousness.

These developments led to the principle that life need not be artificially continued if recovery is futile. A patient may decide to forego resuscitation or mechanical ventilation in such situations. This decision may be made by means of an advance directive or “living will.” In cases without such directives, the decision can be made by the patient’s family and caregivers. Accepting these protocols has been a long a complicated process that is outside of the main topic of this posting (see discussion in Pappas, 2012, Chapter 4). Issues remain for patients who have no advance directives and when the family and physicians disagree on whether to maintain life support. Nevertheless we have come to general terms with the idea of passive euthanasia when a patient is unresponsive and the prognosis is futile. Outside of a few jurisdictions, however, active euthanasia remains illegal.

Legalization of Voluntary Euthanasia

Voluntary euthanasia has been legal in Oregon since 1997 (Lindsay, 2009; Lee, 2014), in Switzerland at least since 1998, and in the Netherlands (Onwuteaka-Philipsen et al., 2012) and Belgium (Cohen-Almagor, 2009) since 2002. Each of these jurisdictions requires a formal application from a patient judged competent to understand the nature of their suffering and the consequences of their request (Lewis & Black, 2013).

The incidence of voluntary euthanasia is low but varies greatly among the jurisdictions. In Oregon the incidence is 0.2% of all deaths, but in Belgium and the Netherlands the incidence is between 1.5 and 3 % (the incidence in Switzerland is not accurately known). The incidence would be significantly higher if cases of euthanasia without consent, and cases of terminal sedation were included together with those of voluntary euthanasia.

Investigations of patients undergoing voluntary euthanasia indicate no clear evidence that vulnerable populations are unfairly targeted, or that coercion plays a significant role in the patients’ decisions. In Oregon most patients requesting euthanasia were white, well-educated, and medically insured (Lindsay, 2009). Furthermore, euthanasia does not substitute for adequate palliative care, since most patients ultimately seeking euthanasia have already tried palliative care or been admitted to a hospice.

Nevertheless, two significant issues remain unanswered. The first is the incidence of euthanasia without explicit consent. Although this is not reported in Oregon, it has been documented in Belgium and the Netherlands. When faced with an incurable patient in severe pain who is not able to provide consent, a compassionate physician may nevertheless proceed with euthanasia. The incidence of this is extremely difficult to assess, particularly if one includes “terminal sedation.” The incidence of euthanasia without consent probably equals the incidence with consent (Cohen-Almagor, 2009; Lewis &Black, 2013; Meussen et al., 2010, Onwuteaka-Philipsen et al., 2012).

The second issue concerns the euthanasia of patients with psychiatric disorders. This has become particularly frequent in Belgium (Thienpont et al., 2015; Aviv, 2015). By arguing that mental anguish can cause as much suffering as physical pain, one can make a philosophical case for euthanasia to relieve “existential suffering” (Varelius, 2014). However, we usually believe that psychiatric disorders can be treated, and that even without treatment depression will alleviate with the passage of time. Psychiatric patients are certainly vulnerable and often may have difficulty providing fully informed consent. Thienpont et al. (2015) report that the female/male ratio was 3.3 for psychiatric patients requesting euthanasia and 2.9 for those patients who were ultimately euthanized. They suggest that this is in keeping with the increased incidence of psychiatric disease in women, but the ratio is nevertheless disconcerting.

Objections to Euthanasia

Euthanasia has engendered much public debate (Andorno & Baffone, 2014; Materstvedt et al., 2003; New England Journal of Medicine, 2013; Quill & Greenlaw, 2008; Somerville, 1993, 2014; Smith, 2006; Sumner, 2011, Young, 2012). The main reason for making euthanasia legal is that individuals have a right to decide that a rapid painless assisted death is preferable to one that is prolonged and painful, and to have medical assistance in bringing this about. The main objections are

(i) Euthanasia is unnecessary if there is adequate palliative care. A variant of this argument is that if euthanasia becomes legal, patients and physicians will prefer euthanasia to palliative care. Palliative and hospice care can render the end of life peaceful and pain-free in most patients. Nevertheless, pain medication must sometimes be brought to such levels that the treatment of pain becomes essentially the same as euthanasia.

(ii) Patients may not be able to provide proper informed consent. A state of state of severe pain and distress may preclude proper consent – the patient may agree to anything to stop the pain. This objection could be countered if the patient simply confirmed a previous decision made before the terminal period.

(iii) Patients near the end of life may be very vulnerable to coercion. Opponents of euthanasia suggest that families and caretakers may improperly convince disabled or elderly patients to accept euthanasia. Their ulterior motive might be to be relieved of the expense and effort involved in the care of their elderly relative or to free up an inheritance.

(iv) Allowing voluntary euthanasia is a “slippery slope” that will ultimately lead to killing all individuals whose lives are considered “unworthy.” If we become used to letting people die, we may become inured to killing and allow the old, the disabled and the mentally defective to be euthanized without consent. The story of Jack Kevorkian (Pappas, 2012, Chapter 5) represents the horrors of the slippery slope. Though there may have been some support for his early actions, ultimately he was killing patients who were obviously unable to give consent. Refutations of the slippery-slope argument hinge on strong safeguards to guarantee proper consent and strict sanctions against euthanasia outside of the legal guidelines (Stingl, 2010). The slope may be slippery but we can construct barriers to prevent us from falling into the abyss.

Public Opinion

Despite the objections, the great majority of people in North America support the legalization of voluntary euthanasia. Gallup polls (McCarthy, 2014) show that about 70% of respondents in the USA answer yes to the question

When a person has a disease that cannot be cured, do you think doctors should be allowed by law to end the patient’s life by some painless means if the patient and his or her family request it?

Support varies with the wording of the question (Saad, 2010). Only 51% agree if the question is worded:

When a person has a disease that cannot be cure and is living in severe pain, do you think that doctors should or should not be allowed by law to assist the patient to commit suicide if the patient requests it?

Both Somerville (1993) and Callahan (2008) have remarked how easily public opinion on euthanasia may be swayed by the choice of words.

In a Canadian poll taken in 2013 at the behest of an anti-euthanasia group the key findings were that

Canadians are about twice as likely to support (63%) as to oppose (32%) a law allowing physician-assisted suicide in Canada. Support is slightly lower for legalizing euthanasia (55% vs. 40% who oppose it), which is likely due in part to providing respondents with information about the rate of euthanasia deaths occurring without patient consent in Belgium. (Environics, 2013).

A year later, an Ipsos-Reid poll performed for a pro-euthanasia group showed 84% of Canadian respondents in favor of physician-assisted suicide. (Ramsay, 2015).

A final survey worth noting is one conducted by the Canadian Medical Association (2011). They found in a survey of their members that

only 20% of respondents would be willing to participate if euthanasia is legalized in Canada, while twice as many (42%) would refuse to do so. Almost a quarter of respondents (23%) are not sure how they would respond, while 15% did not answer.

The Hippocratic Oath asserts

I will neither give a deadly drug to anybody who asks for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy.

Most present day physicians do not swear to this oath, but the idea that a physician should not bring about death has merit. When one is sick and in pain, a physician who will not kill is preferable to one who might be willing to do so. Even if ultimately one could choose suicide.

Canadian Law

In Canada active euthanasia is a crime though suicide is not. The Canadian Supreme Courts has examined the issues of euthanasia in three cases: Rodriguez vs British Columbia (1993), R vs Latimer (2001), and Carter vs Canada (2015).

In 2001 Sue Rodriguez, suffering from amyotrophic lateral sclerosis, wished to be allowed to die by means of assisted suicide when she became totally incapacitated. She wanted to live life to its fullest, and therefore did not wish to take her life before becoming unable to do so. She proposed that the law prohibiting physician-assisted suicide was discriminatory

since it prevents persons physically unable to end their lives unassisted from choosing suicide when that option is in principle available to other members of the public without contravening the law.

The judgment of the court was that the blanket prohibition of assisted suicide was justified since its purpose was to protect life. The court expressed concerns about the possible abuse of assisted suicide were it to be legalized, the difficulties in creating appropriate safeguards against such abuse, and the need to protect those members of society who might be vulnerable to such abuse. The court therefore decided against her request. Sue Rodriguez committed suicide with the assistance of an anonymous physician in 1994.

In 1993, Robert Latimer brought about the death of his 12-year old daughter Tracy by means of carbon monoxide poisoning. Tracy suffered from severe cerebral palsy, epilepsy and mental retardation. She had undergone numerous operations to relieve her spastic and painful state. Faced with further surgery for her constantly dislocating hip, her father decided that dying would be preferable to continuing a life of pain and torture. Latimer was convicted of second degree murder and given the minimum 10-year sentence allowed for this crime. The case went through several appeals. In 2001, the Supreme Court considered a request to reduce the sentence, but affirmed both the conviction and the sentence. They found no justification for non-voluntary euthanasia. Robert Latimer began serving his sentence in 2001 and was release in 2010.

The Supreme Court of Canada re-considered the law prohibiting physician-assisted suicide in its judgment of Carter vs Canada. The case was instigated by Lee Carter, who had been forced to take her mother, suffering from an incurable neurodegenerative disease, to Switzerland for assisted suicide, since this was not legally available in Canada. The court summarized the reasoning of the 1993 Rodriguez judgment:

The object of the prohibition is not, broadly, to preserve life whatever the circumstances, but more specifically to protect vulnerable persons from being induced to commit suicide at a time of weakness.

However, the court acknowledged that since that 1993 judgment assisted suicide had been legalized in several jurisdictions and that safeguards against abuse have been effective. The court agreed that some people may wish to end their lives but not have the ability to do so without the assistance of a physician. The law prohibiting such assistance thus discriminates against these individuals:

An individual’s response to a grievous and irremediable medical condition is a matter critical to their dignity and autonomy. The prohibition denies people in this situation the right to make decisions concerning their bodily integrity and medical care and thus trenches on their liberty. And by leaving them to endure intolerable suffering, it impinges on their security of the person.

The court therefore temporarily invalidated the law prohibiting physician-assisted dying and called upon the federal government to provide new legislation more consistent with the Canadian Bill of Rights. However, the present government seems loath to address the issue, despite the weight of public opinion (Ramsay, 2015). The government of the Province of Quebec has voted to allow euthanasia, although this decision may be legally contested by the federal government.

Where Do I Stand?

Euthanasia should be legal when a patient with an incurable illness is suffering pain that cannot be adequately relieved by analgesic medication. The diagnosis and prognosis should be confirmed by at least two physicians. Modern palliative care should have been provided and demonstrated to be inadequate. Euthanasia should only be allowed at the patient’s request and only after his physicians have ensured that the request is freely made.

Terminally ill patients who are in obvious pain but unable to consent to euthanasia pose a significant problem for both medicine and the law. We need to develop guidelines and safeguards to allow consent to euthanasia from the family and caretakers in these cases. Otherwise non-voluntary euthanasia may occur and go unreported.

In the absence of unrelenting pain, euthanasia of the elderly, the demented, and the mentally defective should continue to be prohibited.

At the present time there is no adequate justification for assisted suicide for existential suffering. Euthanasia in psychiatric patients is far too susceptible to abuse to be allowed.

Physicians should not be forced to provide euthanasia. Nevertheless, any patient requesting euthanasia should be referred to other physicians who can evaluate the request, judge its validity and conduct the euthanasia. Such referrals should be readily available.

 

References

Alexander, L. (1949). Medical science under dictatorship. New England Journal of Medicine, 241, 39-47.

Andorno, R., & Baffone, C. (2014). Human rights and the moral obligation to alleviate suffering. In R. M. Green & N. J. Palpant (Eds.) Suffering and Bioethics. (pp. 184-199). New York; Oxford University Press.

Attwood, M. (2004) Suicide as a response to suffering. Western Buddhist Review, 4

Aviv, R. (2015). The Death Treatment. New Yorker, June 22, 2015, pp. 56-65.

Bacon, F. (1605, translated by D. Price, 1893). The advancement of learning. London: Casell.

Binding, K., & Hoche, A., (1920, translated by W.E. Wright, P. Deer, & R. Salomon, 1992). Permitting the destruction of unworthy life: its extent and form. Leipzig: Felix Meiner. Translation published in Issues in Law and Medicine, 8, 231-265.

Callahan, D. (2008).  Organized obfuscation: Advocacy for Physician-Assisted Suicide. Hastings Center Report, 38(5), 30-32

Canadian Medical Association (2011). Physician views on end-of-life issues vary widely: CMA survey

Carter v. Canada (Attorney General), 2015 Supreme Court of Canada 5, [2015] 1 S.C.R. 331. Case 35591.

Cholbi, M. (2012). Suicide. Stanford Encyclopedia of Philosophy.

Cohen-Almagor R. (2009). Belgian euthanasia law: a critical analysis. Journal of Medical Ethics 35, 436–439.

Dowbiggin, I. R. (2005). A concise history of euthanasia: Life, death, God, and medicine. Lanham, MD: Rowman & Littlefield.

Environics (2013). Canadians’ Attitudes towards End-of-life Issues. Ottawa: Environics.

Hume, D. (1777). Of suicide.

Kemp, N. D. A. (2002). Merciful release: The history of the British euthanasia movement. Manchester, UK: Manchester University Press.

Lee, B. C. (2014). Oregon’s experience with aid in dying: findings from the death with dignity laboratory. Annals of the New York Academy of Sciences, 1330, 94–100.

Lewis, P., & Black, I. (2013). Adherence to the request criterion in jurisdictions where assisted dying is lawful? A review of the criteria and evidence in the Netherlands, Belgium, Oregon, and Switzerland. Journal of Law, Medicine and Ethics, 41, 885-898.

Lindsay, R. A. (2009). Oregon’s experience: evaluating the record. American Journal of Bioethics, 9, 19–27.

Materstvedt, L., Clark, J. D., Ellershaw, J., Førde, R., Boeck Gravgaard, A.-M., Müller-Busch, H. C., Josep Porta i Sales, J., & Rapin C.-H. (2003). Euthanasia and physician-assisted suicide: a view from an EAPC Ethics Task Force. Palliative Medicine, 17, 97-101

McCarthy, J. (2014). Seven in 10 Americans back euthanasia: Support strong for past two decades.

Meeussen, K., Van den Block, L., Bossuyt, N., Echteld, M., Bilsen, J., & Deliens, L. (2010) Physician reports of medication use with explicit intention of hastening the end of life in the absence of explicit patient request in general practice in Belgium. BMC Public Health, 10, 186

More, T. (1516/edited by S. Duncombe, 2012) Utopia. Brooklyn, NY: Autonomedia.

New England Medical Journal (2013) Clinical decisions: Physician-assisted suicide. With commentary by Boudreau, J. D., & Somerville, M. A. (Physician-assisted suicide should not be permitted) and by Biller-Andorno, N. (Physician-assisted suicide should be permitted). New England Medical Journal, 368, 1450-1452.

Onwuteaka-Philipsen, B.D., Brinkman-Stoppelenburg, A., Penning, C., Jong-Krul, G.J., van Delden, J.J., & van der Heide, A. (2012) Trends in end-of-life practices before and after the enactment of the euthanasia law in The Netherlands from 1990-2010: A repeated cross-sectional survey. Lancet, 380, 908–915.

Pappas, D. (2012). The euthanasia/assisted suicide debate. Santa Barbara, CA: Greenwood (ABC-CLIO).

Pliny the Elder (79 CE, translated by Bostock, J. & Riley, T. H., 1855) Natural History.  Perseus Digital Library

Pichot, A. (2001, translated by Fernbach, D., 2009).The pure society: From Darwin to Hitler. London: Verso.

Proctor, R. (1988). Racial hygiene: Medicine under the Nazis. Cambridge, Mass: Harvard University Press.

Quill, T. E., & Greenlaw, J. (2008). Physician-assisted death. In M. Crowley (Ed.) From Birth to death and bench to clinic: the Hastings center bioethics briefing book for journalists, policymakers, and campaigns. (pp. 137-142).Garrison, NY: Hastings Center.

R vs Latimer (2001). Supreme Court of Canada [2001] 1 SCR 3 1 Case number 26980

Ramsay, B. (2015). On assisted suicide, Ottawa isn’t listening. Toronto Star, July 27, 2015.

Rodriguez vs British Columbia (1993). Supreme Court of Canada [1993] 3 SCR 519 Case number 23476.

Saad, L. (2013). U.S. Support for Euthanasia hinges on how it’s described: Support is at low ebb on the basis of wording that mentions “suicide.”

Somerville, M. A. (1993). The song of death: the lyrics of euthanasia. Journal of Contemporary Health Law and Policy, 9, 1-76.

Somerville, M. A. (2014). Exploring interactions between pain, suffering, and the law. In R. M. Green & N. J. Palpant (Eds.) Suffering and Bioethics. (pp. 201-229). New York; Oxford University Press.

Smith, W. J. (2006). Forced exit: Euthanasia, assisted suicide, and the new duty to die. New York: Encounter Books.

Stingl, M. (2010). Voluntary and nonvoluntary euthanasia: is there really a slippery slope? In M. Stingl (Ed.) The price of compassion: Assisted suicide and euthanasia. (pp. 141-158). Peterborough, ON, Canada: Broadview Press.

Thienpont, L., Verhofstadt, M., Van Loon, T., Distelmans, W., Audenaert, K., & De Deyn. P.P. (2015). Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study. BMJ Open 5, e007454.

Varelius J. (2014) Medical expertise, existential suffering and ending life. Journal of Medical Ethics, 40, 104–107.

Williams, S. D Jr. (1870) Euthanasia. In Essays by Members of the Birmingham Speculative Club. (pp. 210-237). London: Williams & Norgate.

Young, R. (2012). Voluntary euthanasia. Stanford Encyclopedia of Philosophy.

 




Kitsch

The term “kitsch” came into being in Germany toward the end of the nineteenth century (Dorfles, 1969; Calinescu, 1987; Riout, 2004). The etiology of the word is unknown. One possible source is the verb kitschen meaning “to collect rubbish” (Rugg, 2002); another is verkitschen, “to make cheaply” (Dutton, 1998). Words used to describe kitsch – “tacky,” “tawdry,” “garish,” “chintzy,” “schmaltzy” and “cheesy” – suggest cheapness, ostentation, triteness and sentimentality. Garden gnomes are a classic example.

garden gnomes

Kitsch is bad art. However, the judgment of whether something is kitsch or not is highly subjective. Everyone has a personal idea of what is beautiful. In the words of David Hume

Beauty is no quality in things themselves: It exists merely in the mind which contemplates them; and each mind perceives a different beauty. One person may even perceive deformity, where another is sensible of beauty; and every individual ought to acquiesce in his own sentiment, without pretending to regulate those of others. (Hume, 1757, section 7).

Nevertheless, Hume goes on to state that most people would agree to some general principles of beauty:

It appears then, that, amidst all the variety and caprice of taste, there are certain general principles of approbation or blame, whose influence a careful eye may trace in all operations of the mind. Some particular forms or qualities, from the original structure of the internal fabric, are calculated to please, and others to displease (section 12).

Experience and education allow one to understand and apply these principles. Thus we develop good taste. Kitsch is the art of bad taste.

The Rise of Kitsch

Kitsch is a phenomenon of the modern age. There has always been bad art, but this never became popular or widespread. In the past, bad art did not sell. Much of kitsch’s success in modern times derives from a commercial system that encourages its production and consumption. Kitsch is the art of the consumer society.

A major factor leading to kitsch was thus the rise of the bourgeoisie (Moles, 1971; Calinescu, 1987). In the nineteenth century the middle class expanded greatly. The upper middle class wanted to buy things of beauty, but they had not the education to do so with good taste. The lower middle class became able to purchase things beyond the bare necessities, but they were unable to pay for original art and settled for imitations. Industry quickly provided these and consumer kitsch was born.

The industrial revolution gave workers leisure time. So as not to be bored during this free time, people sought activities that were pleasing without requiring effort: entertainment rather than true art. Pleasurable relaxation was the goal of most of society; kitsch was the easiest means to this end. Abraham Moles (1971) considered kitsch to be l’art de bonheur the “art of happiness.”

One might therefore consider kitsch as the art of the people. The following is from Abraham Moles (1971, p. 28, the French is elegant and my translation necessarily inexact:

Le Kitsch est à ce titre essentiellement démocratique : il est l’art acceptable, ce qui ne choque pas notre esprit par une transcendence hors de la vie quotidienne, par un effort qui nous dépasse – surtout s’il doit nous faire dépasser nous-même. Le Kitsch est à la mesure de l’homme, quand l’art en est la démesure, le Kitsch dilue l’originalité à un degré suffisant pour la faire accepter par tous. [Kitsch is in this way essentially democratic: it is acceptable art, art which does not shock us to transcend everyday life, or require any extraordinary effort – especially any surpassing of our present selves. Kitsch stays within our easy reach, whereas art exceeds our grasp; kitsch dilutes originality enough to make it accessible to all.]

However, we cannot lay all the blame on the middle class. Aristocrats have often succumbed to ostentatious displays of wealth that would be generally considered kitsch. The “rich kitsch” of fake ruins and ceiling putti is every bit as bad as the poor kitsch of garden gnomes and fuzzy dice. Furthermore, the merchant class has sometimes displayed excellent taste. Patrons of fine art have come from wealthy members of the middle class as much as from the aristocracy.

Dwight Macdonald considered kitsch as essentially the same as the “mass culture” used to exploit the masses. He distinguished it from folk art which is created spontaneously by the people, and from high culture which is created for the elite:

Mass Culture is imposed from above. It is fabricated by technicians hired by businessmen; its audiences are passive consumers, their participation limited to the choice between buying and not buying. The Lords of kitsch, in short, exploit the cultural needs of the masses in order to make a profit and/or to maintain their class rule – in Communist countries, only the second purpose obtains. (Macdonald, 1953, p. 2-3)

Macdonald painted a pessimistic picture of our artistic future:

The Lords of kitsch sell culture to the masses. It is a debased, trivial culture that voids both the deep realities (sex, death, failure, tragedy) and also the simple, spontaneous pleasures, since the realities would be too real and the pleasures too lively to induce what Mr. Seldes calls ‘the mood of consent’: i.e., a narcotised acceptance of Mass Culture and of the commodities it sells as a substitute for the unsettling and unpredictable (hence unsalable) joy, tragedy, wit, change, originality and beauty of real life. The masses, debauched by several generations of this sort of thing, in turn come to demand trivial and comfortable cultural products. (Macdonald, 1953, p. 16, the reference to Seldes is to his 1950 book The Great Audience.)

However, I am not sure that we can always fault the taste of the masses. Popular culture can promote kitsch, but it can also make significant artistic contributions. Shakespeare was notoriously beloved of the masses. Furthermore, he gave the penny public what it wanted.

Macdonald considered as kitsch everything produced by the entertainment industry – radio, television, movies, and comics. Much is but not all. Some works in these modern art forms are both beautiful and significant.

Reproduction

A second factor in the development of kitsch was the development of techniques for reproduction. Multiple copies of an image could be cheaply produced and widely marketed (Benjamin, 1936; Dorfles, 1969; Moles, 1971). Reproductions lack the aura (and the value) of the originals. And when used for purposes other than those of the artist, they might be considered kitsch: Renoir images on biscuit tins, Pollock paintings on silken scarves, Rodin sculptures as bookends.

And yet, and yet. Art has always been reproduced. Engravings of pictures and casts of statues allowed the dissemination of artistic creations. How else can art history be taught or learned? Reproduction is not wrong. It is not forgery. However, reproductions may sometimes be disconcertingly different from the original. The deceptive quality of kitsch may lie “in its claim to supply its consumers with essentially the same kinds of beauty as those embodied in unique or rare and inaccessible originals” (Calinescu, 1987, p 252). Yet one can also say this about original artwork, which is an artist’s reproduction of an experience, not the experience itself.

Most would agree that plastic replicas of the Eifel Tower are kitsch. They serve no aesthetic purpose. In addition, such objects demonstrate “aesthetic inadequacy” (Calinescu, 1987) – their size and the materials they are made of contradict the aesthetic properties of the original.

However, visual art can be beautiful both in itself and in its contribution to our general set of images. A reproduction refers us to the image rather than to the original. Better a scarf should represent a Pollack painting than a cute kitten. The scarf is not the same as the painting, but it may still be pleasing to the eye and thoughtful to the mind.

What makes something kitsch rather than art?

So perhaps we need some criteria in terms of what is represented rather than with how or why it is reproduced. To say exactly why kitsch is bad can be difficult. Kulka (1996, pp 14-42) proposed that kitsch fulfills three conditions:

1. Kitsch depicts objects or themes that are highly charged with stock emotions.

2. The objects or themes depicted by kitsch are instantly and effortlessly identifiable.

3. Kitsch does not substantially enrich our associations relating to the depicted objects or themes.

The next few paragraphs will consider and qualify these three conditions.

Overcharged Emotions

Kulka’s first condition is often considered as “sentimentality.” This characteristic of kitsch may have stemmed in part from the Romantic movement in art (Broch, 1969). In the late eighteenth century, art began to consider emotions much more directly than before. People enjoyed having their feelings aroused. Art sought to bring the viewer or the reader to tears. Yet this could easily be overdone, resulting in mawkishness or melodrama. Over the top can be more uncomfortable than uplifting. Tears should not be wasted inappropriately.

bouguereau jeune mendiante

Typical examples of kitsch are paintings of the poor designed to evoke feelings of pity. Pity at someone else’s suffering is an important human emotion, but it is meaningless when it does not lead to some action to relieve the suffering. It is difficult to understand why anyone would want to hang paintings of begging children on one’s walls even if they are as technically accomplished as those of William-Adolphe Bouguereau, whose Little Beggar (Petite Mendiante, 1880) is shown on the right. Bouguereau (1825-1905) was a famous academic painter who became quickly and completely forgotten after his death. He has been recently championed by Fred Ross, whose Art Renewal website reacts against the lack of figurative painting in modern art.

 

Kitsch often exploits pity – sentimental pictures of sad-eyed children are sold in the millions. Pity is a complicated emotion (Kimball, 2004): although it is primarily related to empathy and compassion, pity slides easily into feeling of superiority and contempt. Nothing can be done – the poor have only themselves to blame. The description of Bouguereau’s Petite Mendiante on the Art Renewal website states “She looks at the viewer with desperation and exhaustion, causing a feeling of sadness in the viewer who knows she cannot be helped.” This comforting conclusion is more rationalization than fact:  as William Blake (The Human Abstract from Songs of Innocence and Experience, 1795) said

Pity would be no more
If we did not make somebody Poor

Distinguishing sentimentality from other emotions may be difficult. In J. D. Salinger’s 1959 story Raise High the Roof Beam Carpenters, Seymour Glass quotes the Zen scholar R. H. Blyth “We are being sentimental when we give to a thing more tenderness than God gives to it” (p. 78). However, unless we know how God feels about something, this is a difficult criterion to apply. Seymour recognizes that he is being tendentious, but he is sure that God would not be as enamored as his wife of kittens with “technicolor bootees on their paws.” Yet if we cannot appeal to God or some other absolute principle, how do we decide whether sentiments are high or tacky?

Opera is an art of great emotion. The plots are usually melodramatic, and some people may feel that grand opera borders on the realm of kitsch. The emotions are high and the audience’s involvement enhanced by the music. Yet high sentiment is not sentimentality. Opera opens itself up to meanings as deep as the emotions are high.

Art cannot exist without emotion. Art must move us to feel something about the world or about ourselves. The problem is that emotions can be used inappropriately, either commercially to sell worthless trinkets or politically to unite a population behind a party or its leader.

Kundera discusses political kitsch experience in The Unbearable Lightness of Being (p 251). A senator is moved by seeing children running on the grass.

Kitsch causes two tears to flow in quick succession. The first tear says: How nice to see children running on the grass. The second tear says: How nice to be moved, together with all mankind, by children running on the grass! It is the second tear that makes kitsch kitsch. The brotherhood of man or earth will be possible only on a base of kitsch. … And no one knows this better than politicians. Whenever a camera is in the offing they immediately run to the nearest child, lift it in the air, kiss it on the cheek. Kitsch is the aesthetic ideal of all politicians and all political parties and movements.

It is good to feel deeply even about simple things. It is wrong to indulge in these emotions for their own sake, to be to be carried away by them to foolish ends, or to use them falsely to gain the sympathy of others. Political advertising loves kitsch for its sentimentality and its immediacy (Lugg, 1999). Kitsch is the fastest way to a voter’s heart.

In his 1936 article The Work of Art in the Age of Mechanical Reproduction Walter Benjamin expresses his fear about the use of art for political purposes. He chillingly quotes the futurist Marinetti about the aesthetics of war:

War is beautiful because it establishes man’s dominion over the subjugated machinery by means of gas masks, terrifying megaphones, flame throwers, and small tanks. War is beautiful because it initiates the dreamt-of metalization of the human body. War is beautiful because it enriches a flowering meadow with the fiery orchids of machine guns. War is beautiful because it combines the gunfire, the cannonades, the cease-fire, the scents, and the stench of putrefaction into a symphony. War is beautiful because it creates new architecture, like that of the big tanks, the geometrical formation flights, the smoke spirals from burning villages …

This is art used to make the reader follow blindly in the path of fascism. The purpose of political kitsch it to stop critical thought. The viewer or reader succumbs to dangerous emotions and is carried away to inimical ends.

Effortless Appreciation

Kulka’s second condition is that kitsch is “immediately identifiable.” Greenberg (1939) suggested that all “academic” art – representational art created accorded to accepted conventions – is kitsch. He was reacting against the academic style of the late nineteenth century, the art of painters such as Bouguereau. He preferred modernist abstract art, which does not give its meaning easily. A skeptic might point out that some abstract art has no meaning to give. Indeed, some of the abstract art used to complement the furniture in modern dwellings is clearly kitsch. It is immediately identifiable as meaningless ornament, chosen on the basis of whether its color complements the sofa.

nerdrum self portrait with nose bleed

 

The art of Odd Nerdrum (1944- ) provides an interesting commentary on kitsch and its relation to representation. This Norwegian artist paints figurative rather than abstract art (Nerdrum & Li, 2007). His painting style is based on Rembrandt and Caravaggio. Some of his paintings are directly representational such as the Self-Portrait with Nosebleed on the left. The technique is breathtaking. The image is as powerful as it is disoncerting.

 

Most of his images are surrealist – haunting representations of embodied souls in life or afterlife. The painting below shows a group of five women and one boy lying on the ground. They are almost naked. They are wrapped in what seem to be burial shrouds. All are singing. Their eyes are closed; the two staffs suggest that perhaps two of them are blind. This dream-like image is difficult to interpret. Are they singing praises before the throne of God, awaiting the resurrection, or lamenting some tragedy?

nerdrum five singing women

Nerdrum has experienced great difficulty with art critics, who describe him as out of touch with our time. He was unable to get a university appointment despite his obvious talent. In defiant response he declared himself an “artist of kitsch” and published a manifesto to justify kitsch (Nerdrum, 1990). Although he is a painter who represents human bodies rather than abstract ideas, his work is not kitsch in the way we generally use the term. His claim is a reaction to Greenberg, who really did throw out the baby with the bathwater. Nerdrum’s impressive technique allows him to create images of great intensity. The paintings stay in the mind, slowly divulging deeper and deeper meanings.

Photography poses difficulties for the definition of kitsch, since nothing is as immediately identifiable as a photograph. Kulka tried to address some distinctions between photography and kitsch. Photography is perhaps too real to be kitsch. A photograph of a sunset is not kitsch.  It becomes kitsch if the photograph is printed on canvas to look like a painting, or on a poster with an inspirational quotation. Most photography is not art – it forms a record of something rather than an interpretation. Nevertheless, some photography can be considered art. Then the photograph captures an image in a manner that is meaningfully different from the usual, or preserves a significant moment of existence beyond the present.

Lack of Meaning

Kitsch is minimally meaningful. The image tells us nothing more than what it portrays. There are no levels of interpretation. When there is something more than meets the eye, it is no longer kitsch. Kitsch is always serious; kitsch never makes you laugh. Kitsch is always comfortable; it never unsettles you. Kitsch preserves the status quo; it is the art that is loved by dictators

Common examples of kitsch are the souvenirs that we buy to remind ourselves of an intense experience (Olalquiaga, 1998). The image has significance only for the person who had the experience. For anyone else it is meaningless. A deeply kitsch experience is watching the slide show of someone else’s holiday.

Many kitsch images involve nostalgia. They provide false memories of a time that never was, when we lived innocently in cottages with thatched roofs that never leaked and gardens that bloomed forever. Such images are immensely popular. They are the stock art of bed-and-breakfast and retirement homes. One of the most successful artists of recent times was Thomas Kinkade (1958-2012), the “painter of light” who provided reproductions of his paintings through either the internet or franchised dealers (Orlean, 2001). One of his masterpieces is Nanette’s Cottage:

nanettes cottage

The painting shows a thatched cottage at evening with all the windows ablaze with light. The chimney is reinforced with an iron ‘N’ for Nanette and a heart shaped stone for love. A small rowboat is tied up in the stream at the edge of the garden, with a teddy bear still sitting on the seat. Upstream beyond the bridge other cottages all have their windows lit in neighborly solidarity with Nanette. Although the profusion of flowers indicates high summer, the home-fires are burning and smoke ascends from all the chimneys. In the further distance, a church steeple rises high enough to touch the sky. Prints of this image can be obtained in various sizes. Special prints can be “highlighted” by artists trained by Kinkade to give them a special depth of color. This adds immensely to their cost. Art for the millions.

Pop and Camp

Any kitsch that aspires to meaning becomes pop art. Warhol’s images of soup cans consider the role of advertising in modern life, and Lichtenstein’s comic-book images comment on our simplification of reality. Pop art is infused with humor whereas kitsch is usually serious.

Another extension of kitsch is camp. The camp sensibility is difficult to pin down (Sontag, 1966). The emotions of camp are always intense and usually unrestrained – the art is usually described as “over the top.” Camp wallows in the exaggerated passions of opera and melodrama. Camp art is often associated with gender ambiguity in all its variety. Camp is simultaneously serious and satirical. Irony is a necessary feature: camp art can be considered at many different levels.

Peter Hujar’s 1974 photograph of the transvestite Candy Darling on her deathbed is one of the great images of high camp. Candy, one of Andy Warhol’s superstars, died of lymphoma. The facial makeup and silken blouse provide an erotic vitality completely at odds with imminent death. If a beautiful lady has to die, she should do so with glamour.

hujar candy b

The photograph evokes stock emotions. The death of the maiden is a story that has been told too many times. What is happening is immediately identifiable. This is a deathbed scene.

Yet this is not kitsch. The image conveys many different levels of meaning. Hripsimé Visser describes Hujar’s photographs as “permeated by a realization of the human masquerade” (Stahel & Visser, 1994). Peter Hujar was homosexual and ultimately died of AIDS in 1987. He was well aware of the ambiguities of gender, and death was a common occurrence among his friends during the AIDS epidemic.

Nevertheless, the artist of the image is as much Candy Darling as Peter Hujar. The photograph proclaims a self that was created in defiance of her birth and maintained in the face of her death. One can be whoever one wants to be. Beauty can cheat Death, even if only for a moment. This is both posture and reality, both over the top and down to earth.

References

Benjamin, W. (1936). The work of art in the age of mechanical reproduction. Translation by A. Blunden, 1998, available at

Broch, H. (1969). Notes on the problem of kitsch. In Dorfles G (Ed.) Kitsch: The world of bad taste. (pp. 49-115) New York: Bell Publishing.

Calinescu, M. (1987). Five faces of modernity: Modernism, avant-garde, decadence, kitsch, postmodernism. Durham, NC: Duke University Press. (pp. 223-262).

Dorfles, G. (Ed.). (1969). Kitsch: The world of bad taste. New York: Bell Publishing.

Dutton, D. (1998). Kitsch. In J. Turner (Ed.) Dictionary of Art. London: Macmillan.

Greenberg, C. (1939) Avant-Garde and Kitsch. Partisan Review. 6(5): 34-49

Hume, D. (1757). Of the standard of taste.

Kimball, R. H. (2004). A plea for pity. Philosophy & Rhetoric, 37, 301–316.

Kulka, T. (1996). Kitsch and art. University Park, PA: Pennsylvania State University Press.

Kundera, M. (1984). The unbearable lightness of being. New York: Harper & Row.

Lugg, C. A. (1999). Kitsch: From education to public policy. New York: Falmer Press.

Macdonald, D. (1953). A theory of mass culture. Diogenes, 1(3), 1-17.

Moles, A. A. (1971). Le kitsch: L’art du bonheur. Paris: Mame.

Nerdrum, O. (2001). On kitsch. Oslo: Kagge Forlag

Nerdrum, O., & Li, B. (2007). Odd Nerdrum: Themes: paintings, drawings, prints and sculptures. Oslo, Norway: Press Publishing.

Olalquiaga, C. (1998). The artificial kingdom: A treasury of the kitsch experience. New York: Pantheon Books.

Orlean, S. (2001). Art for everybody. The New Yorker, October 15, 2001

Riout, D. (2004/2014). Kitsch. In B. Cassin (Ed.) Dictionary of untranslatables: a philosophical lexicon. (translated by Rendall, S., Hubert, C., Mehlman, J., Stein, N. and Syrotinski, M., translation edited by Apter, E., Lezra, J. and Wood, M.). (pp. 538-539). Princeton: Princeton University Press.

Rugg, W. (2002). Kitsch. In Theories of Media. Keywords Glossary. University of Chicago.

Salinger, J. D. (1959). Raise high the roof beam, carpenters. And Seymour: an introduction. Boston: Little, Brown. (Seymour’s quotation from Blyth sounds authentic but I have not been able to find its source in Blyth’s published works).

Sontag, S. (1966). Notes on “camp.” In Against interpretation, and other essays. (pp. 275-292). New York: Farrar, Straus & Giroux.

Stahel, U. & Visser, H. (1994). Peter Hujar: A Retrospective. New York: Scalo Publishers.