Euthanasia and Afterlife Beliefs

Euthanasia

Euthanasia is one of a number of terms used to describe the practice of prematurely bringing about the end of a person's life. Recent scholarly work distinguished between voluntary euthanasia, that is, when a person's life is ended at their request and involuntary euthanasia, which is when their life is ended without their consent or wish. ³ The most obvious example of involuntary euthanasia was the Nazi euthanasia programme in World War II (more below).

Other terms used to describe practices similar to euthanasia include ‘assisted dying’, which is also known as assisted suicide and can take place with or without the aid of a medical practitioner, as well as the phrase, ‘dying with dignity’. ⁴ The phrase, ‘withdrawal of treatment’, while not always regarded as euthanasia, is similar and often takes place in intensive-care units. Withdrawal of treatment occurs when machines supporting life are switched off and the person receives no other form of life-supporting treatment. ⁵

Assisted suicide is controversial and opposed by those who argue that it can be confused with dying with dignity or because it is often proposed by others who believe that the right to end one's life should not be limited only to those who are at the end of their life. ⁶ Another unstated reason for opposing assisted suicide might be the existence of the organization known as Dignitas, which has operated in Switzerland since the late 1990s, provides fee-based assisted dying and since 1998 has helped more than 1,000 people die. ⁷ The argument that the right to die should not be restricted only to the end of life was raised by two participants (Edward, aged 77, Australian Capital Territory; Scott, aged 62, Australian Capital Territory) who believed that individuals had the right to choose the time of their death with or without the approval of the medical profession. ⁸ Their views are examined in more detail below.

As the hospital has been for some time now the fairly usual setting for death, ⁹ and therefore also for the practice of euthanasia, a brief account follows of how it is understood by some Australian, British and North American medical researchers. In a 2020 study of British laypersons' attitudes to sedation and euthanasia, a distinction was made between death from terminal anaesthesia, which was referred to as continuous deep sedation (or being kept continuously unconscious), and death from the administration of medication, that is, ‘physician-assisted dying’. In their opening paragraph, the authors noted:

The use of sedation in end-of-life care … remains controversial. While gradual sedation to alleviate intractable suffering is generally accepted, there is more opposition towards deliberate and rapid sedation to unconsciousness (so-called ‘terminal anaesthesia’ …).

Their research was possibly conducted in the context of the double-effect principle, the meaning of which is that medical practitioners should avoid administering patients with medication to ease pain and suffering if the intention is bring about their death. ¹⁰ The researchers seemed therefore to be exploring how laypersons regarded terminal anaesthesia in the context of what they claimed was a general acceptance of gradual sedation. ¹¹

Sedation and how it is used is a sensitive topic for the medical profession, other health professionals and the public, touching as it does on the double-effect rule and the intentions of medical practitioners when administering sedatives to people in pain at the end of life. A 2018 article distinguished between three types of sedative use: double-effect sedation; parsimonious direct sedation; and sedation to unconsciousness and death. The author argued against sedation to unconsciousness and death – which it could be argued the layperson might have difficulty distinguish from terminal unconsciousness – because it was simply another form of euthanasia, which is illegal in many states of the USA: ‘sedation to unconsciousness and death, in which the clinician's aim is total unconsciousness, is not justified by the rule of double effect and only seems justifiable if euthanasia is justifiable’. ¹²

The distinction that was made in the 2020 study of British layperson's attitudes to sedation and euthanasia helped in clarifying a definition for euthanasia. Its authors appeared to explicitly understand physician-assisted dying to be euthanasia and terminal anaesthesia to be something else entirely. In their view, perhaps euthanasia was seen to occur when with consent medical practitioners actively intervened to hasten or bring on death and that death that occurred as a result of terminal anaesthesia was not euthanasia or could not yet be included in the definition of euthanasia.

Euthanasia has a controversial history, not least because its practice challenges the central belief of the Judeo-Christian tradition, which is the sanctity of human life. Because it is seen as a gift from God, taking a life is forbidden and severely punished. In the eyes of many believers, euthanasia is still a form of murder.

From … [Christianity’s] earliest days … Christian theologians asserted that no human being had the right to dispose of life as he or she pleased – only God could decide for death. This belief was elaborated in Church law during the Renaissance, when moral horror at suicide joined prohibitions against infanticide, abortion and contraception; later, capital punishment joined the list. All came to seem the same crime, that of judging when life should end. ¹³

Arguments against the legalization of euthanasia included that it was opposed by or caused guilt in medical practitioners, would put pressure on the elderly who were not ill to consent to ‘rational suicide’ as an end-of-life option and gradually be extended to non-consensual practice. ¹⁴ Despite such concerns about its use, misuse and legality, euthanasia has been unofficially practised since at least the early decades of the Twentieth Century, as is suggested in this account of the final hours of King George V:

‘The King’s life is moving peacefully towards its close, was the final notice issued by George V’s doctor, Lord Dawson, at 9.30pm on the night of 20 January 1936. Not long afterwards, Dawson injected the king with 750mg of morphine and a gram of cocaine – enough to kill him twice over – in order to ease the monarch’s suffering, and to have him expire in time for the printing presses of the Times, which rolled at midnight. ¹⁵

Its most notorious state-sanctioned practice in recent memory was, however, the Nazi euthanasia programme in World War II. Involving psychiatrists, physicians and nurses, ¹⁶ it was designed to remove from German society people whose lives were regarded as worthless: ‘Hitler saw the sick as an economic burden on the healthy and wanted to rid the German race of the “polluting” effect of the “undesirables”’. After military conquests, the programme was extended to occupied countries during the War, including, ‘children in institutions, prisoners of war, hospital patients, as well as concentration camp and extermination camp prisoners’. ¹⁷

Chief among the targets of the Nazi euthanasia programme were the mentally disabled. On German soil, the rationale used to justify their ‘mercy killing’ was the belief that ‘if only the afflicted … could understand the misery and worthlessness of their lives, they would not want to live’. In occupied territory, however, no such indulgence applied: ‘Jews, Poles, or Russians in any mental facility were not selected. Regardless of their condition, they were simply killed’. ¹⁸

As mentioned at the outset, ‘assisted dying’ is now one of the more commonly used terms in place of euthanasia – perhaps to signify much the same by another name or perhaps because it avoids the connotation of state-sanctioned ending of life or murder that is associated with euthanasia. In a recent case, the French film maker Jean-Luc Goddard was reported in 2022 to have made use of assisted dying because he was suffering from ‘incapacitating illnesses’ and did not wish to continue living ‘at any cost’. ¹⁹ End-of-life decisions such as those taken by the doctor attending King George V and the film director Goddard were possible because of the increased medicalization of death, where, argued the French historian Ariès, ‘the time of death can be lengthened to suit the doctor’:

The doctor cannot eliminate death, but he can control its duration, from the few hours it once was, to several days, weeks, months, or even years. It has become possible to delay the fatal moment; the measures taken to soothe pain have the secondary effect of prolonging life. ²⁰

While drugs can be used to ease pain and might therefore have the effect of prolonging life, as many have observed, the same pain-soothing measures mentioned in the previous quotation can have the effect also of hastening death and is an example of medically assisted suicide, such as occurred in the case of King George V when his doctor administered the dose of morphine and cocaine.

How and under what circumstances euthanasia is made available in the twenty-first century is fairly important because, according to German sociologists Ulrich Beck and Elizabeth Beck Germsheim, it is increasingly likely to be seen and possibly practised as a solution for the aged-care problem in advanced western economies. Arguing that the increasing trend towards individualization in the West has had important consequences for ageing populations, Beck and Beck-Gernsheim noted firstly that, as more women entered the work force and domestic gender relations were renegotiated, fewer women would be willing or able to perform care work for elderly family members:

To what extent will the state and society be prepared to create a wide and flexible range of care facilities? … Medical technology in making life ever longer, seeing it through acute crises and chronic illnesses … highlights a simple truth: apparatuses can prolong life, but they cannot care for people.

The second consequence they observed was the continuing effect of class on an individual's experience of old age, which has been apparent for some time in countries like Australia and England: ‘the rich [will] simply purchase good and expensive care themselves on the “senior services market”, while the less well-off receive no help because they cannot pay for it’. ²¹

As the majority of those from this sample who said that they believed in an afterlife were Christian, it is worth considering the proposition that a connection might exist between viewing euthanasia as a form of murder and a belief in an afterlife. At its simplest, this connection is as follows. Because life is God's gift, it is precious and must be preserved at all costs.

When life is over, believers are promised an eternal spiritual life. The promise of eternal life is conditional, however, on believers refusing to agree to the premature termination of their mortal life. Such a perceived connection might explain the strength of anti-euthanasia arguments and lobbying from conservative Catholics and other Christians. ²²

Afterlife Beliefs

Belief in an afterlife has a very long history with roots in ancient civilizations in Egypt and the Middle East as well as in ancient Greece and Rome, ‘mythologised … in Hades or Valhalla, in Hell or Paradise’. ²³ All four major religious traditions, namely Buddhism, Christianity, Hinduism and Islam, share a belief in life after death.

In the case of Christianity and Islam, it is a belief in resurrection of the soul; in the case of Buddhism a belief in re-birth; and in Hinduism a belief in reincarnation of the something approaching the essence of the person. ²⁴ As well, all four religious traditions share a similar understanding of a paradise or heavenly world where believers progress towards God, union with God or, in the case of Buddhism, to Nirvana, which is understood as, ‘a state of joy, happiness and peace’. ²⁵

As the second quotation at the head of the chapter suggests, however, the sociologist Norbert Elias viewed a belief in an afterlife as a means of easing people's fear about death and the time when they will cease to exist. Other ways of dealing with the fact that life was finite were, according to Elias, to banish any thought of death or to ‘look death in the face as a fact of our own existence’:

We can adjust our lives, and particularly our behaviour towards other people, to the limited span of every life. We might see it as our task to make the end, the parting from human beings, when it comes, as easy and as pleasant as possible, for others and for ourselves. ²⁶

The ‘Good Death’

As mentioned in the previous chapter, the idea of the good death was the focus of the work of Ariès and to some extent also that of Elias, ²⁷ who separately argued that, as death had been medicalized, it now most often took place in a hospital, while Ariès independently emphasized that this being so, its timing was largely in the hands of hospital staff. As mentioned as well in the previous chapter, when discussing what they had included or would include in an advance care or hoped an agent with their power of attorney (health care) would provide for their end of life, participants often described the sort of death that they hoped for or hoped to avoid, and in doing so indirectly drew on notions of the ‘good death’, most often loosely described as a pain-free or gentle death.

In the next section, participants' views on euthanasia are more fully discussed and notions of the good death were again present – expressed, for example, as a death without purposeless agony or pain – even when they held varying opinions on what or which practices or procedures comprised euthanasia. Some understood euthanasia to be equivalent to the withdrawal of treatment, not being resuscitated or palliative care, while others used terminology appropriate to the jurisdiction in which they lived, such as, ‘legalized euthanasia’ (Victoria, Australia), ‘medical aid in dying’ (California, USA) and ‘medical assistance in dying’ (Ontario and Vancouver, Canada).

Arguments in Favour

Principal arguments in favour of euthanasia were to avoid unnecessary suffering or deteriorated quality of life. Other arguments included participants' belief in their right to choose the time (and place) of their death and the right to end their life.

Previous Experience and Concerns

Almost all of those with previous experience of the practice of euthanasia or how it would have benefited the dying spoke of the very personal such as when their parents, children, friends or lovers were dying. In all, slightly less than one third of the sample spoke of their previous experience. And slightly more than a quarter of those who supported euthanasia cited concerns about its practice if it were made legal.

Only one participant had experience of euthanasia. In this case, it was a passive form of euthanasia – when he and his wife gave permission for their son's treatment to be withdrawn:

When my son died, we agreed for it to be switched off because it was clear that if he could be revived – he suicided on his tablets – he would be completely brain damaged and so we just let it happen. (Clive, aged 81, ACT)

Others had emotionally affecting accounts of witnessing the death of parents and friends where they could not request any form of euthanasia to ease the pain for them. These included Rowan (aged 71) from England who said: ‘I have known people with things like motor neurone disease who really could have done with the straightforward ability to request euthanasia’; and Seth (aged 68) from California: ‘I have seen a few people who have died of lung issues and that is really hard, that is really difficult’.

Two men briefly described what their parents experienced when dying and how euthanasia would have eased their suffering:

Having seen my mother suffer through dementia and then a long process when her body stopped functioning to when she actually died, I think euthanasia is an appropriate way to end a life that’s just a burden to everyone around you. (Harrison, aged 56, Victoria)

My father turned into a vegetable in a terrible hospital with early-onset Alzheimer’s … I saw both parents and my stepfather suffer needlessly really for the last few years of their lives when everyone around them was sick of them. It was a terrible thing. (Warren, aged 50, Western Australia)

A number of participants were fairly sure that euthanasia was already being practised in countries where it was still illegal. These included Douglas (aged 80) from Victoria who did not support euthanasia but had no qualms about the withdrawal of treatment and Bruce (aged 56) who was from Victoria also and who recounted his father's death:

My father died of leukaemia and he was in a lot of pain … He was a doctor. He knew all the doctors in the … hospital, he had worked there, so he just said, ‘Look, do it for me’, and we all knew that. It has been going on for quite some time but quite subtly.

More than a quarter who supported euthanasia raised concerns about its practice if legalized. The principal concerns were firstly that it could be used by unscrupulous relatives or an unsympathetic state to end a dying person's life prematurely, secondly that more humane means of killing were needed and thirdly that vested interests in the health industry were opposed to improving the end of life and making euthanasia available.

Misuse of euthanasia was raised by a small group. Their concerns centred on its misuse by either relatives of the dying person or the state. Questionable motives of relatives concerned Rowan (aged 71) from England who said that while he thought, ‘the law on euthanasia is too strict at the moment’, he argued for safeguards, ‘against pressure from families to push people out to get hold of their estate. That is a serious danger’. A view which Donovan (aged 55) from England echoed: ‘It is a fantastic idea but not to be misused, not to be used by greedy relatives that want to bump off grandma to get her house’. Two participants expressed concerns about the overreach of the state. The first said

I believe in euthanasia but not to be decided on by anyone other than me or my agent. I don’t want the state to do it if you are becoming too much of a burden. (Joel, aged 74, California)

And the second said that he was concerned about reports that he had read about the potential for euthanasia services to be abused in Holland.

Two men were worried about the means that are at present available for killing those who wish to end their life. Both were in their 40s. The first said: ‘The thought of dying in Switzerland in a warehouse on an industrial estate does not fill me with great joy’ (Aiden, aged 42, England). The second participant raised a similar point but in the context of changes that were needed, powerfully making the case for doing so now:

I think euthanasia is something that ought to be available and I hope it is available. But I do worry about it because when you think about the American experience, where they are very enthusiastic about killing people judicially, they seem to be unable to do it humanely. I have never really read any discussion as to why that is, and how your experience of Dignitas, which is the end-of-life place, would differ from death row in the States.

I certainly don’t want to be in position where I am feeling oxygen-starved or distressed and you do hear stories even about these very well-appointed euthanasia places in Switzerland and elsewhere of things not being easy, and I don’t think we should be sweeping that under the carpet. I know it sounds awful to say that we should be researching humane ways of killing people, but if we can do it for animals … that should be what happens to us. (Anton, aged 45, England)

It is very difficult if not impossible to envisage any government anywhere openly discussing or raising in public how the state itself or private companies should improve the killing services that were provided for those who wished to end their life. If it is true, as Anton suggested, that euthanasia providers were leaving people struggling for breath or in extreme distress in the last moments of their life, there would be a strong argument for publicly discussing how to improve and regulate such killing services.

One participant drew on his understanding of working in the modern health system to explain his concerns if euthanasia were made more easily available to assist in people's end of life. The fears that Toby (aged 64) from British Columbia enumerated mirrored those that German sociologists Beck and Beck Gernsheim claimed had already begun, as mentioned in the Introduction. Drawing on his experience in the Canadian health system, Toby said that he was worried that vested interests in the health industry were opposed to improving the end of life and making euthanasia available. Because of his conviction, the strength of his argument and its underlining some of the arguments of Beck and Beck-Gernsheim that were mentioned in the Introduction, I have quoted it in full:

In western countries, we still don’t have enough people to take care of seniors and our economy is not going to be robust enough to manage to care for all seniors. I am worried about that and I am not sure if that’s going to create more pressure for expanded options in medical assistance for dying … or if people will be left to languish like they have, which has been so obvious with the situation of Covid, where people are under-cared for and warehoused as if they are some kind of disposable chicken in a coop.

Part of my concern about the end of life for me but for others as well, is that there are a lot of vested interests in how that will look … Physicians are required to do everything possible because otherwise they feel that they are going to end up with a law suit on their hands or someone is going to hold them to account for not doing X or Y. At a certain point, this is doing harm. For an older person, if there is a nice way to exit and the likelihood of improvement is really minimal, they don’t … [extend their life] …

There are also vested interests in the form of the unscrupulous health-care providers, of which there are many. I am not going to pretend that all doctors and all nurses are wonderful, because they are not. Having worked in the health system, I know there are people that I wouldn’t trust. I am just worried that, unless I have a really solid advocate, that decisions could be made, not just for myself but for others as well, that are really not in our own best interest.

Toby's concerns were threefold: that inadequate material conditions might result in more older people choosing euthanasia through sheer despair; that in obedience to their Hippocratic oath, some medical practitioners will prolong life unnecessarily; and that some health care providers also might be tempted to prolong life unnecessarily in order to maximize their profits.

Equivocal or Opposed

A small group of four participants who were equivocal about euthanasia or did not support it gave two principal reasons for their points of view. The first was that they would rather rely on their personal optimism or will in the face of death and the second that they preferred withdrawal of treatment instead of euthanasia.

In the following extract, Quinn (aged 60) from Victoria recounted his previous experience of serious illnesses. Although he did not explicitly oppose euthanasia, it was not an option that occurred to him at his ‘sickest’. And his attitude suggested that, even in the face of another stint of cancer or heart illness, he never would, preferring to rely on an innate optimism and something suggesting denial:

I haven’t thought about … [euthanasia]. It has never really worried me so much. Even when I’ve been at my sickest with cancer and heart problems, I never thought that that was the end of it … I’m not a defeatist and I’m not a pessimist. I’m always an optimist so I always think the best outcome, which isn’t always good when you know that the worst outcome is what’s going to happen and you think … “How do you prepare for something if you don’t know it’s ever going to happen?” I don’t know this.

Damon (aged 40) from the ACT held a slightly similar view, which was not based on his own experience but which he arrived at after the death of his grandparents, one of whom had dementia, the other keeping their mental capacity to the end.

In terms of euthanasia, I can’t necessarily imagine myself doing it because I am pretty stubborn … If I was in massive pain, I would be like, “Just drug me out up and whatever happens, happens”. But I want to see how it plays out.

One participant positively objected to euthanasia because it was illegal but said that he would not object to withdrawal of treatment:

As for euthanasia, at this stage, I’d have to say No. I am also aware of facilities to allow people to die without being euthanised. A withdrawal of treatment is not the same as euthanasia, which is a determination to end your life. A withdrawal of treatment can see the same purpose. (Douglas, aged 80, Victoria)

In summary, those with equivocal views about euthanasia or who did not support it were not entirely closed to its possibility at some future point. In Quinn's case would he be more likely to consider it if his optimism failed and for Damon if his will weakened? Meanwhile, Douglas was not opposed to what is known as ‘peaceful’ euthanasia.

No Belief in an Afterlife

Those who said that they did not believe in the afterlife comprised one group that was quite certain that there was no life after death and another group that wrestled with the idea, entirely comprising men who had been brought up as Christians, and in the end rejected it. As mentioned, there was a third group that made no mention of the afterlife when answering the question.

Among the quite-certain refusers were atheists and agnostics as well as a handful who, while they did not believe in life after death, found it an enticing idea. Atheists either stated that they had no belief in the afterlife or drew on reason or science to support them. Those who simply stated that they had no belief in life after death included Nicholas (aged 72) from New South Wales: ‘no sense of an afterlife’; Ethan (aged 58) from England: ‘I think we just expire and that's it’; and Harrison (aged 56) from Victoria: ‘end of life happens … I certainly don't want to live forever’. Those who used reason to support their unbelief in the afterlife included Toby (aged 64) from British Columbia: ‘there is no evidence that such a thing exists, any kind of life after death including reincarnation’; and Roland (aged 50) from Victoria: ‘as science would have it … when you are brain dead … the ability to do anything is gone … That's the end of life. That's it. Full stop’.

Five participants found the idea of the afterlife enticing but rejected it. And their views are represented by the following:

I just can’t find it in me to believe it to be true, much as I would love it to be. It’s something we will only know in the doing. Indeed! [Laughs] … and anything we speculate on now can only be a function of what we believe and things in which we believe in this life. By definition, it is unknowable. One would hate to be proved wrong! [Laughs]. (Jonathon, aged 53, England)

I do not believe in an afterlife. It would be fantastic if there is and a pleasant surprise if it is. From the knowledge that I have and the understanding I have of the world, my belief is that that does not happen. (Declan, aged 42, Victoria)

Those who wrestled with and then rejected the afterlife beliefs that they had acquired when inducted into Christianity included a participant in his mid-70s who, despite his faith, regarded belief in life after death as a ‘necessary device’ used to influence followers (Andrew, aged 75, Ontario). For him, there was no heaven and no hell. Another man who was in his early 50s said that he had rejected Christianity because of his ‘very religious upbringing’ and therefore could not believe in life after death (Johann, aged 52, England).

Belief in an Afterlife

A relatively small group of six believed in life after death. Three of these believed in a Christian afterlife, two spoke of a belief in a spiritualism afterlife or in the spirit of the dead living on, and one in Buddhist reincarnation.

The views of the Christians are represented here by Ellis (aged 56) from England, whose belief touched on an understanding of the afterlife as a union with God:

I genuinely believe there is more. We are not encouraged in the Christian faith to enquire as to exactly what form that takes. It is not productive and also why worry? I genuinely believe that we can trust in God’s love, that there will be sufficient of what we love and sufficient of who we love and who we have loved that it will be a meaningful experience. I believe very definitely that is the case and that is about as far as it goes.

While the views of those who believed in a spiritualism afterlife or the spirit of the dead living on are represented here:

I am a very strong believer of life after death. I felt the rebirth because in my life I know so many things and I don’t know where I learnt them, I just know them. I attributed all this to previous lives and I have done a lot of previous-life experiences with re-birthing, regressions, and hypnotism. That was one of my little side-trips. When I got tired of being a hairdresser, I got into that. That was in the 1980s and I was into that for a long time. (Atticus, aged 88, California)

I have on occasion had a sense of someone’s spirit after death. Not a lot of the presence of someone’s presence, I mean. I can’t be categorical on that but, you know, I’m open to such a notion. I wouldn’t be categorical about it. (Clive, aged 81, ACT)

Christopher (aged 52) from New South Wales had been studying Buddhism for two years at the time of his interview. Brought up a Jehovah's Witness, he had had a difficult life after excommunicating himself from the Witnesses, being ostracized by some of his family, and contracting HIV. His belief in the afterlife was as follows:

I never expected to ever become spiritual because anytime anybody talked about spirituality or God, I would run the other way. I don’t have such a great view on who God is. I don’t agree with or like the way it’s been force-fed to people. I believe in some sort of energy or past life and … [that] we go through cycles and we learn through cycles and then when we have learnt we can help others in their pathway through their journey to the next realm … I feel that this life for me has been resolving some Karmic debt or some Karmic situation from a previous life. That’s the way I make sense of it. There is no other way of making sense of it otherwise.

Afterlife as a Possibility

A small group of about the same size as those who believed in an afterlife said that they were open to the idea of one. Their views are represented by extracts from two men, one in his 60s and one in his 50s.

No real strong beliefs in that way. I am not a particularly religious person. I tend to be fairly practical. It will be a surprise if there is something afterwards [after death]. If not, I won’t care [Laughs]. (Mason, aged 60, California)

No life after death. Of course, I am not certain about that. I am just completely uninterested in the idea of it. Our life is centred around what we experience now … If there is one, that is a bonus. If there isn’t one, that’s really no surprise. (Donovan, aged 55, England)

Living on in the Lives of Others

Two participants said that they believed the dead lived on in the lives of others, that is, that the dead remained alive in the memory of the living. Their views are represented in the following extract from the interview with Carter (aged 57) from New Zealand:

We live after death in the sense of the impact we have made on other people’s lives. They will carry a bit of me, all going well, for the rest of their lives and in terms of family stories, pass that on to them, so there is a kind of intellectual DNA and spiritual DNA that is passed on through doing your best to live a good life and being a positive force in the lives of others.

Carter's belief was a fairly idealistic one in that he seemed to be saying that the good he did would live on in the lives of others. It is entirely possible also that the bad that people do lives on in the lives of others, as is suggested in the psychological notion of generational trauma, which is gaining more currency.