case study about mercy killing

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• Indian J Palliat Care
• v.27(3); Jul-Sep 2021

Regulating Death: A Brief History of Medical Assistance in Dying

Unique reports of suicide and euthanasia date back more than 2 millennia, reflecting evolving philosophies of death and dying as expressions of the mores dominating a given era. One longstanding theme in the history of decisions to die has been staunch opposition founded in religious claims that one’s body is a trust from the divine (and therefore not wholly in their ownership). The role of the physician has also been traditionally estranged from participation in such decisions, dating back to rudimentary conceptions of medical ethics in the Hippocratic notion primum non nocere (‘first, do no harm’). However, fundamental principles in the modern philosophy of medicine lend support to the idea that physicians can be justified in actions which cause some harm, in so far as they are acting to fulfil a greater ethical imperative. This brief historical review explores the inception of modern North American medical assistance in dying (MAiD) policy through a series of critical case studies in the unfolding of its practice. Medically assisted dying has presently been legalised in Canada and some United States jurisdictions, but with critical caveats surrounding circumstances of mature minors, advance directives and mental illness as participants’ sole underlying medical condition. While the modern regulations surrounding MAiD continue to take shape, the palliative care community is well-positioned to both guide and scrutinise the ethics of this practice.

In Athens, 399 BCE, the Greek philosopher Socrates – imprisoned and sentenced to death by hemlock on the charges of impiety and corrupting Athenian youth – famously raised a cup of the poison to his lips. [ 1 ] Descriptions of Socrates’ equanimity at the end of his life, and of his refusal to escape this fate when the opportunity presented itself, have invited the question of whether Socrates’ death was a case of euthanasia or suicide. [ 2 ] The distinction may seem peripheral, but we can imagine it likely to have been an important consideration for both Socrates and the jailer who provided his poison.

Medical assistance in dying (MAiD) is a modern name for an ancient idea, which has been a source of enduring contention for ethicists since the days of hemlock. The tools for suicide, euthanasia, and the expansive grey area between the two (ostensibly including MAiD) have evolved dramatically, but many fundamental questions have remained the same: who owns a life, and what are the ethical implications in advancing (or otherwise choosing not to delay) a death? The present article cannot, given its commitment to brevity, claim to offer a complete history of MAiD. Instead, it aims to introduce some of the answers to these questions through a historical lens by presenting a background for the philosophies of assisted dying, followed by several landmark cases in MAiD’s development. This abbreviated history of MAiD’s practice portrays how we can appreciate medical decisions regarding death and dying as expressions of the mores dominating any given era.

The Hippocratic Oath appears to contain a specific condemnation of MAiD: ‘(…) I will not give a drug that is deadly to anyone if asked (for it), nor will I suggest the way to such a counsel.’ [ 3 ] Ancient Greek and Roman physicians did, nevertheless, sometimes offer such drugs to their patients for the purpose of euthanasia. [ 4 ] However, in the centuries to follow, many major religions opposed euthanasia for a variety of reasons. Among these were notions that life was a trust from God, and to shorten or prolong it would interfere with God’s plan; that artificially shortening life could preclude admission to the afterlife or reincarnation; and that suffering may have a divine purpose which ought to be accepted. [ 5 ] St. Thomas Aquinas condemned suicide on behalf of the Christian church in the 13 th century, claiming that its completion interferes with the natural inclination of self-perpetuation, injures communities, and violates God’s authority. [ 6 ] Common Law similarly forbade suicide and physician-assisted suicide (PAS) in the British and French colonies that spread West to the Americas and, although Renaissance philosophers had begun to challenge ecclesiastical authority in Europe, several centuries would pass before the legalisation of human euthanasia developed widespread interest. [ 7 ]

The middle ages did supply a philosophy which would later find application in medical and ethical decision-making, coopted into arguments justifying PAS. For example, the Rule of Double Effect (ironically first appearing in Aquinas’s Summa Theologica ) describes how – in situations where one cannot possibly avoid all harmful actions – an action that intends to prevent harm may be justified even if the outcome is harmful. [ 6 , 8 ] In medicine, this has been applied in scenarios where a physician might act to pharmacologically treat a patient’s suffering, knowing that the intervention may inadvertently hasten the end of life. The Danish philosopher Søren Kierkegaard developed a similar concept in 1843, describing granular conceptions of human ethics which are broadly applicable to the discussion of MAiD although not specifically applied to euthanasia in the canon. Kierkegaard’s ‘Tragic Hero’ character type would customarily abandon one ethical commitment in favour of another with a higher ethical imperative, therefore retaining social justification despite forgoing the former. [ 9 ] Applying this reasoning to MAiD: a tragic physician could forego the traditional ethical commitments to a patient – which include preserving life – in favour of imperatives to alleviate suffering and defend patient autonomy.

Neither formulation resolves the question of whether or not voluntary death could ever represent a higher ethical imperative, and several historical anecdotes poignantly illustrate uncertainty about this, even within the medical firmament. Samuel Williams petitioned in 1872 for euthanasia (using the term ‘mercy killing’) in medical cases of untreatable illness through analgesic medications, which were undergoing revolutionary developments at the time; a contemporaneous editorial in the Journal of the American Medical Association protested the suggestion that doctors ‘don the robes of an executioner.’ [ 10 , 11 ]

In 1915, Dr. Harry Haiselden (Chicago, IL) recommended that the parents of a newborn with severe physical abnormalities not consent to a potentially life-saving surgery – presenting arguments tied to the eugenics movement – and, with the agreement of the parents, the baby died without treatment. [ 12 , 13 ] Public support for euthanasia waxed and waned in North America throughout the mid-20 th century, increasing during the Great Depression (1930s) and decreasingly sharply in the immediate aftermath of World War II (1940s) when euthanasia raised fears of association with National Socialism. [ 14 ] Suicide was decriminalised in Canada in 1972, but the involvement of another party remained criminal. [ 15 ] Jack Kevorkian, known also as ‘Dr. Death,’ was one of the most prominent supporters and enactors of assisted suicide at this time in the United States: After reportedly assisting over 100 terminally ill patients to affect their own death, Kevorkian administered a lethal injection to a consenting patient unable – due to advanced amyotrophic lateral sclerosis (ALS) – to administer it to himself. The case was videotaped and broadcast by Kevorkian to advocate for voluntary euthanasia but, because his actions violated Michigan law, he was imprisoned for 8 years on the charge of second-degree homicide. [ 16 ] Amidst evolving controversy about euthanasia, a Canadian doctor writing under the pseudonym Dr. Gifford-Jones argued in 2013 that because Switzerland has long been recognised as provider of euthanasia for those who desire it (and meet Swiss regulatory standards), the only real barrier presented to North American patients by anti-euthanasia laws was the purchase of ‘a one-way ticket to Zurich.’ [ 17 , 18 ]

In the early 1990s, a Canadian named Sue Rodriguez received a diagnosis of ALS, which would be fast progressing and fatal. Rodriguez became a national leader in the right-todie debate while seeking a physician to help her end her own life once she had lost the ability to do so herself. Rodriguez asked Canadian parliament, ‘If I cannot give consent to my own death, whose body is this? Who owns my life?’ [ 19 ] The Supreme Court ruled against her 5–4. [ 20 ] The case came down to a conflict within Canada’s Charter of Rights and Freedoms: Section 7 describes individuals’ rights surrounding their own person, while Section 1 states that rights in other sections may be limited for the broader social good. [ 21 ] This is the Rule of Double Effect or Kierkegaard’s ‘Tragic Hero’ applied in opposition to assisted dying: foregoing individual liberty in favour of broader public safety or social good. Rodriguez took her own life in 1994, in British Columbia, with the help of an anonymous physician; [ 22 ] no charges were laid.

Current ethical arguments in favour of MAiD include respect for patient autonomy and evidence that assisted dying does not impact patient views of the doctor-patient relationship. [ 23 ] Conversely, arguments against MAiD include balancing patient autonomy with a fundamental respect for human dignity and a reverence for life, as well as concerns for the stability and motivations of an individual’s decision-making – with the legalisation of MAiD, many have concerns that money, guilt or coercion could play an inappropriate role in the decision to pursue assisted dying. [ 23 ] Recently, non-profit organisations such as Dying With Dignity have increased the public awareness of MAiD in North America through persistent advocacy campaigns. Although healthcare delivery is under provincial jurisdiction in Canada, the federal government is implicated in discussions of assisted suicide as murder is a federal offence. The Canadian province of Quebec declared itself in favour of MAiD in December 2015, anticipating the federal Bill C-14 (June 2016), which became the first Canadian legislation to legalise MAiD, albeit with several caveats. [ 24 ] Specifically, Bill C-14 does not allow MAiD in circumstances of mature minors, advance directives, or mental illness as the sole underlying medical condition – all three scenarios remain controversial issues. However, it does provision an impending 5-year review to revisit these circumstances with new evidence when it is available. [ 24 ]

Current MAiD legislation mixes a common language of its practice with certain geographical nuances, and international debate continues with a focus on universally defining the term and determining the exact circumstances under which it will and will not be permitted. These explorations attempt to address the ambiguity inherent in determining what conditions constitute a life so unbearable that the option of euthanasia can be ethically justified. They also raise the question of how much demand there would be for MAiD if there was greater accessibility of quality palliative care. While MAiD is legally recognised in Canada, its practice remains uncommon but not insignificant: as of June 2018, almost 4000 Canadians have chosen MAiD (accounting for <1% of deaths in Canada). [ 25 ] This has been partially attributed to a ‘Disability Paradox,’ wherein patients with severely limiting disease report a higher quality of life than others might expect them to have. [ 26 ] Nevertheless, to think critically about the ethics of MAiD while its regulations and limitations continue to take form, we must continue to engage with the core questions of who may decide which lives are and are not ‘worth living,’ and what rights and obligations should be recognised for both patients expressing an interest in MAiD and the physicians committed to caring for them.

Acknowledgements

The author would like to thank Dr. Pier Bryden for her mentorship throughout the research process, as well as Drs. Harvey Schipper, Neil MacDonald, and Jacalyn Duffin for contributing their invaluable expertise on the history of MAiD to this project.

How to cite this article: Brenna CTA. Regulating death: A brief history of medical assistance in dying. Indian J Palliat Care 2021;27:448-51.

This work has not been previously published, although an earlier adaption of the same research is made privately available within the University of Toronto MD Program curriculum as an educational piece for the benefit of medical students.

Declaration of patient consent

Patient’s consent not required as there are no patients in this study.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.

mercy killing

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A mercy killing is the intentional ending of life of a person who is suffering from a terminal, painful illness. The term–also called  “right to die” –is most often used to describe voluntary euthanasia, though it is also used in reference to non-voluntary euthanasia and involuntary euthanasia.

Voluntary euthanasia is considered either passive or active. Passive voluntary euthanasia is when a person dies after refusing or withdrawing their consent for lifesaving medical intervention. This is legal in many countries, including the United States following  Cruzan v. Missouri Department of Health , where the  Supreme Court  decided that a competent person had “ a constitutionally protected right to refuse lifesaving hydration and nutrion .” Active voluntary euthanasia, on the other hand, generally occurs when a person is administered large doses of painkilling medication. This term includes  assisted suicide , where a patient is provided with the medication to end their own life. The term also includes  physician assisted suicide , where a licensed medical professional administers the medication. Active voluntary euthanasia is legal in  some  countries, to some extent. These countries include  Belgium ,  Canada ,  Colombia ,  Luxembourg ,  the Netherlands ,  Switzerland , and some states in  Australia . In the United States, the Supreme Court refused to recognize active voluntary euthanasia as a Constitutional right in  Washington v. Glucksberg . However,  some states  have recognized a right to active voluntary euthanasia through  death with dignity statutes .  

Non-voluntary euthanasia, on the other hand, involves a patient who is unable to consent to life-ending measures. Involuntary euthanasia involves a patient who does not or resists such measures. Both are illegal in all countries.

[Last updated in June of 2020 by the  Wex Definitions Team ]

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APPENDIX. Mercy Killing: Case History

From the book the modern art of dying.

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Strong public support for right to die, more americans discussing - and planning - end-of-life treatment, summary of findings.

Public attitudes on these and many other end-of-life issues are unchanged from 1990, despite advances in lifesaving technology, the aging of the population, and the controversy associated with the Terri Schiavo case. Most Americans believe it should be up to individuals ­ not the government or medical professionals ­ to ultimately determine their end-of-life medical decisions.

The Pew Research Center’s survey, conducted Nov. 9-27, 2005 among 1,500 adults, finds that while overall attitudes are largely stable, people are increasingly thinking about ­ and planning for ­ their own medical treatment in the event of a terminal illness or incapacitating medical condition. Public awareness of living wills, already widespread in 1990, is now virtually universal, and the number saying they have a living will has more than doubled ­ from just 12% in 1990 to 29% today.

People also are much more willing to discuss sensitive end-of-life issues with their loved ones than they were a generation ago. Nearly seven-in-ten (69%) of those who are married say they have had a conversation with their husband or wife about their spouse’s wishes for end-of-life medical care; only about half reported doing so in 1990 (51%). Among those with living parents, 57% say they have spoken with their mother ­ and 48% with their father ­ about the parent’s requests for end-of-life treatment.

There is strong sentiment in favor of letting close family members decide whether to continue medical treatment for a terminally ill loved one who is unable to communicate their own wishes. Roughly three-quarters (74%) say a family member should be permitted to make this decision, which is little changed from 1990 (71%).

Though most Americans say it is sometimes morally acceptable for people with dire medical conditions to take their own lives, acceptance of this practice is highly dependent on circumstances. Six-in-ten feel that people have a moral right to end their lives if they suffer from great pain and have no chance for improvement. But this view changes under less extreme circumstances. For example, just 29% say a person has a moral right to end their life if he or she has become burdensome to family, with 62% saying someone in that situation does not have a moral right to take their life.

The survey finds that in many ways, public attitudes toward death and dying defy easy categorization. A majority believes that it is at least sometimes justifiable for a person to kill their spouse, again in extreme circumstances. Roughly six-in-ten (61%) feel that the ‘mercy killing’ of a spouse is always (6%) or sometimes (55%) justified, if the spouse “was suffering terrible pain from a terminal disease.” About half as many (29%) say such an act is never justified, although that represents a significant increase since 1990 (20%).

People’s views of end-of-life policies and practices do not perfectly mirror their own treatment preferences. While there has been an increase since 1990 in the percentage saying that people generally have a moral right to end their own life if they are facing an incurable illness and great pain (from 55% in 1990 to 60% now), there has also been an increase in the percentage who say they would personally want everything possible done to save their lives in many situations. About a third (34%) now say they would tell their doctor to do “everything possible” to save their life even if faced with a terminal illness and great pain; in 1990, fewer (28%) indicated they wanted everything done to save them in that case.

Other Findings

• People who have helped make end-of-life medical treatment decisions for loved ones are more likely than others to have a living will or to have discussed their wishes for end-of-life care. In addition, more of those who have gone through this experience believe in a moral right to suicide in certain circumstances, and favor ending their own medical treatment in the face of an incurable disease and great pain.
• By a wide margin, the public continues to disapprove of congressional action in 2005 that directed the federal courts to hear the case of Terri Schiavo, the brain-damaged Florida woman who later died after her feeding tube was removed.
• The Democratic Party has a modest advantage with the public in dealing with end-of-life issues. About one-third (34%) say the Democrats could do a better job with such issues, while 22% favor the Republicans.
• There is very little consistency in public attitudes toward what have been characterized as “life” issues ­ abortion, the death penalty, and end-of-life questions. However, abortion opponents, and opponents of the death penalty, are more likely than those who accept these practices to favor doing everything possible to save a life regardless of the circumstances, as well as to oppose physician-assisted suicides.

Right to Die Laws Favored

The increase in support has been more pronounced among those over the age of 50 (from 72% to 83% approval), white Catholics (from 80% to 91% approval), and among those who have given a great deal of thought to end-of-life issues (from 79% to 87% approval).

In instances where a terminally ill patient is unable to communicate, the public supports allowing the closest family member to decide whether to continue medical treatment; 74% agree with this approach, while only 15% say that relatives should not be allowed to make such decisions. Here, too, the public is united across political and demographic lines, with approximately three-quarters of Republicans (72%), Democrats (78%), and independents (74%) saying that family members should be able to make treatment decisions for sick relatives.

This strong support for allowing the removal of medical treatment and for allowing family members to make these decisions is reflected in public opinion on the Terri Schiavo controversy. Nearly three-quarters (72%) of the public say that Congress should have stayed out of the Schiavo case, while fewer than one-in-five (17%) say Congress, in its effort to ensure that Schiavo continued to receive medical treatment, did the right thing by requiring federal courts to hear the case. This is essentially unchanged from a July 2005 survey, which found only 20% saying Congress did the right thing.

Large majorities of all social and demographic groups, including Republicans and evangelical Protestants, say that Congress should have stayed out of the Schiavo case. Similarly, even among people who believe that doctors and nurses should make every effort to save a patient’s life, as well as those who think family members should not be able to decide whether to continue medical treatment if a patient’s wishes are not known, solid majorities say that Congress overstepped its bounds in the Schiavo case.

Assisted Suicide: Stark Religious Differences

On this issue, Americans are divided along religious and political lines. By two-to-one (61%-30%) white evangelical Protestants oppose physician-assisted suicide laws; by nearly identical margins, white mainline Protestants and seculars approve of such laws. Catholics, on balance, oppose such laws (by 50%-40%).

Small majorities of Democrats (52%) and independents (52%) approve of allowing physician-assisted suicide. Most Republicans oppose these laws (by 55%-34%), and conservative Republicans oppose them by a margin of two-to-one (62%-29%).

Views on assisted suicide are also affected by the amount of thought given to end-of-life issues; 57% of those who have given a great deal of thought to these issues approve of legal assisted suicide, a view shared by only 35% of those who have given little or no thought to these matters.

Politics of End-of-Life Issues

Support for allowing patients to die.

The vast majority of Americans ­70% ­ say that there are sometimes circumstances in which a patient should be allowed to die; only 22% believe that doctors and nurses should always do everything possible to save the life of a patient. The number of people who think there are times when medical treatment should be ended has changed little since 1990, though the percentage believing that all possible efforts should be made has grown modestly during the period (from 15% in 1990).

Only among African Americans does a majority (51%) think doctors and nurses should always do everything possible to save a patient (40% disagree). In addition, 35% of those ages 18-29 say everything should be done to keep a patient alive; no more than one-in-five in any other age category agrees.

But Fewer Would Halt Treatment for Themselves

Fewer Americans (44%) say they would ask to end care if they had an illness that made them totally dependent on another person for all of their care, while 38% say they would want everything done to save them. There is an almost even division of opinion over ending treatment if a person had no hope of improvement and had difficulty functioning; 42% say they would ask that treatment be halted in that case, while 43% say they would tell their doctor to do everything possible. Since 1990, there has been a modest increase in the numbers who say they want everything done medically under these scenarios.

As with the general question of whether there are circumstances under which care should be stopped, African Americans and younger people are more likely than others to say they would personally want every effort made to save their life. By contrast, older respondents ­ those ages 50 and older ­ are significantly less likely than others to say they would want this type of care. White evangelicals and people who attend religious services at least once per week are also more apt than others to want every effort made on their behalf.

Views of a Parent’s Treatment Wishes

There are no significant differences in opinion about what a person’s mother or father would want done in these circumstances, with one notable exception. In a situation where an illness left the person totally dependent on a family member or another person for care, mothers were thought more apt to choose to have all possible efforts made to save her life (by 47% to 37%), while more respondents thought their fathers would tilt the other way if faced with such a choice (45% stop treatment, 41% do everything possible). For both mothers and fathers in this scenario, there was a significant increase since 1990 in the desire to have all possible efforts at treatment (up nine percentage points for fathers, up 14 points for mothers).

The wishes of respondents were usually, but not always, the same as the wishes of the parent they described. Among respondents who said they would opt to stop treatment if personally faced with a terminal illness and great pain, 71% also said their parent would likely make the same choice; 16% said their parent would probably opt for all available treatment.

More See Doctors as Responsive

People who have played a role in determining the end-of-life treatment of a family member or loved one are more likely than others to believe that doctors and nurses pay close attention to patients’ wishes: 41% say they pay a lot of attention, and 34% say they pay at least some attention. Better educated people are also more likely to think doctors and nursers are paying close attention. Four-in-ten college graduates think doctors are paying a lot of attention to patients about whether or not they want treatment to keep them alive. This is up 16% since 1990 when 24% of college graduates felt this way, the largest increase among any demographic group.

A Moral Right to End One’s Own Life?

There are significant gender and racial differences over the moral right to suicide. Men are more likely than women to support a right to end one’s own life in a situation where there is no hope of improvement and great pain (66% for men, 54% for women). A solid majority of whites (62%) say a person has a moral right to end their life under such circumstances, compared with just 43% of African Americans.

Attitudes on this question are also strongly related to the respondent’s religious beliefs, as well as to party and ideology. Fewer than half of white evangelical Protestants (42%) believe that an individual suffering a great deal of pain with no hope of improvement has a moral right to end their life, compared with 73% of white mainline Protestants. Most Catholics (60%) support the moral right to suicide under these circumstances, as do an overwhelming majority of seculars (78%). Similarly wide disparities are seen in terms of church attendance, with frequent attenders less supportive of such a right.

There are wide differences between Republicans and Democrats on this question as well. Fully 83% of liberal Democrats think people have a moral right to end their own lives under these circumstances, while just 41% of conservative Republicans agree. Moderate and liberal Republicans (63%) and conservative and moderate Democrats (62%) fall in between.

Many See ‘Mercy Killing’ as Sometimes Justified

Most Americans (55%) say that killing a spouse who is terminally ill and suffering from terrible pain is sometimes justified, but far fewer (6%) believe it is always justified. Only 29% say it is never justified, though that is up from 20% when the question was first asked in 1990. White evangelical Protestants are more likely than other religious groups to believe that killing a spouse is never justified, but even among this group only about half (47%) hold this view.

Despite the widespread sentiment that killing a spouse, or helping a spouse commit suicide, is sometimes justified, most people say they cannot imagine actually taking such actions themselves. Only about a third (36%) say they could imagine helping a loved one commit suicide, and even fewer (29%) say they could imagine killing a loved one.

Severely Handicapped Infants

Compared with 15 years ago, more people say that infants born with severe handicaps ­ no matter how severe ­ should receive as much medical treatment as possible. Overall, 60% feel this way, up from 52% in 1990. Just 28% believe that parents have the right to refuse treatment that might save the infant’s life, down from 32% in 1990. African Americans (84%) and younger respondents (70%) are more likely than others to favor providing as much treatment as possible.

Only about half of college graduates (48%) support making every effort medically to save a severely handicapped infant ­ though that is still larger than the percentage saying parents should have the right to refuse treatment (36%).

Support for providing the most treatment possible increases to 65% among people with only a high school diploma and to 73% among those who did not finish high school.

Catholic Priests Raise End-of-Life Issues

Catholic clergy stand out in their attention to end-of-life issues; half of Catholics who attend church at least monthly say that their clergy speak out on these matters, compared with 28% of evangelical Protestants and 16% of mainline Protestants.

More Catholics than Protestants also report hearing about abortion (71%) and the death penalty (35%) from their clergy.

How Generations Have Changed

One of the most striking changes between 1990 and 2005 is the growth in the number of people who say they have a living will ­ up 17 points, from 12% in 1990 to 29% now. This growth occurred across generations; while the number saying they have living wills increased the most in the oldest cohort (up 38 points), it also grew by at least 20 points in each of the other three cohorts tracked over this time period.

Over the past three decades, increased acceptance of a moral right to suicide has been greatest (from 29% to 46%) among the oldest cohort ­ those Americans who were between the ages of 48 and 62 in 1975, and are now ages 78 to 92. But younger generations also are more supportive of a moral right to end one’s life now compared with 1975.

Abortion, Death Penalty and End-of-Life Issues

Relatively few Americans subscribe to what may be termed as a consistent “ethic of life” ­ opposing both abortion and the death penalty, and favoring the use of all medical means to keep terminally ill patients alive. Abortion opponents and death penalty opponents alike overwhelmingly believe that there are circumstances in which doctors and nurses should let a patient die.

Attitudes toward the death penalty bear less relationship to views about end-of-life issues. For example, just over half (53%) of death penalty supporters approve of legalizing physician-assisted suicide, compared with 40% of death penalty opponents. Differences on other questions are of similar magnitude.

Death penalty opponents and abortion opponents share common ground ­ and differ with those on the opposite side of both issues ­ in their personal views of when to halt end-of-life medical treatment. Both groups are fairly evenly divided over whether all medical steps should be taken to save their lives, or whether treatment should be halted. By contrast, solid majorities of those who support the death penalty, and those who believe abortion should be generally available, say they would want medical treatment halted if they had a disease with great pain and no hope of improvement.

Recent Experience with a Loved One’s Illness

Overall, 10% of the public has actually helped in making decisions about how much medical treatment should be given to a terminally ill or comatose friend or relative. Women over age 50 are more likely to report having made these important medical decisions than are people in other age groups; 15% of all women in this age group have made such a medical decision recently. College graduates (14%) and those with higher incomes (15% for those with family income of more than $75,000) are more likely than others to have made such medical decisions.

End-of-Life Planning

There also are striking differences in the ways in which people who have recently experienced the terminal illness of a friend or relative ­ and those who have not ­ approach end- of-life issues. Generally, those who have faced such situations are much more likely to have thought about their own end of life treatment and planned accordingly.

And those who have taken on a more significant role on behalf of a gravely ill relative or friend ­ by helping decide on their medical treatment ­ are even more active in thinking about and planning for their own end-of-life treatment.

Fully 64% of those who have recently helped make decisions about the medical treatment of a terminally ill or comatose friend or relative say they have given a great deal of thought to their own preferences in such circumstances. That compares with 45% of those who have had a relative or close friend recently suffer from a terminal illness or coma, but did not participate in treatment decisions; and just 28% of those who have had no recent experience with the serious illness of a close friend or relative.

Similarly, nearly half of those who helped determine medical treatment of a gravely ill loved one (46%) have their own end-of-life wishes written down. That compares with about a third (32%) of those who have experienced the illness of a close friend or relative but did not take part in the decision making, and just 24% among those with no recent experience with a loved one facing death.

Talking About Treatment

While fewer young people than older Americans have discussed their end of life treatment wishes with anyone, they are more likely than other age groups to talk with a parent ­ 30% have done so, the highest percentage in any age group. People ages 65 and older, by contrast, are much more likely than younger people to have discussed their end of life treatment plans with one of their children (40%).

Since 1990, there has been a sizable drop in the percentage of Americans who say, in an open-ended format, that they have discussed their wishes for end-of-life medical treatment with ‘no one.’ Just 19% say that currently, while another 10% say they have given no thought to their end-of-life treatment. That compares with 44% in 1990 who either had talked with no one, or had given no thought to their care.

Talking With Spouses and Parents

Roughly equal numbers of married men (70%) and women (69%) say that they have had a conversation with their spouse about their wishes for end-of-life treatment. But women are much more likely than men to have had a conversation with their mother about her treatment.

Nearly two-thirds of women (65%) say they have had a conversation with their mother about her end-of-life treatment wishes. Only about half of men (48%) have talked with their mothers about such issues. Far fewer women have talked with their fathers about their end-of-life medical decisions. And men are no more likely to have discussed these issues with their fathers than with their mothers (45% father/48% mother).

Views on Aging

The public expresses a broader array of worries about getting old. Health concerns ­ including worries about cancer and other diseases, mental health, and insurance worries ­ are mentioned most frequently (39%). Roughly one-in-five (19%) worry most about not having enough money in old age and 8% voice concern about losing their ability to care for themselves and being a burden on others. These worries have changed only modestly over the past 15 years.

Nearly a third of those ages 65 and older (31%) say ‘nothing’ when asked what worries them most about getting old. Only about one-in-ten or fewer in other age categories express no worries about getting old. Health concerns are mentioned most frequently by people ages 50-64. Compared with other age groups, those ages 18-29 express a relatively high level of concern over dying. One-in-ten of those under 30 say that their biggest worry about getting old is dying; far fewer people in older age categories, especially those ages 65 and older (2%) express that concern.

Making the Century Mark

However, there has been an increase since 1990 in the percentages of African Americans, young people and women who say they would like to live to 100. Nearly two-thirds of blacks (65%) say they would like to live to see the century mark, up from 53% in 1990. That compares with just 39% of whites who want to live to 100.

More than half of those under age 30 (55%) say they would like to live to be 100, up from 44% in 1990. By comparison, just 36% of those ages 50 and older want to live that long. More women also express a desire to live to 100 than did so 15 years ago (39% vs. 31%); still, more men than women continue to say they want to live to 100. In addition, people who register the highest levels of personal happiness are more likely than those who are less happy with their lives to want to live to 100 (51% vs. 40%).

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Mercy killings guidance given to prosecutors in England and Wales

CPS lists factors to consider when determining whether it is appropriate to bring charges

Prosecutors in England and Wales have been provided with guidance on when it may not be appropriate to bring charges in cases of mercy killings.

Mercy killings are not defined in statute and it is not a defence to murder or manslaughter. On Thursday, the Crown Prosecution Service (CPS) for the first time set out a list of factors to consider when determining whether it is appropriate to bring charges.

The updated guidelines, which also cover suicide pacts, say that a prosecution is less likely if the deceased person had reached a voluntary, clear, settled and informed decision that they wished for their life to end, and if the suspect was motivated only by compassion.

Another factor to consider is if their assistance “may be characterised as reluctant, in the face of significant emotional pressure due to the victim’s wish for their life to end”.

Max Hill KC, the director of public prosecutions (DPP), said: “It is vital our prosecutors are given the clearest possible additional guidance to make decisions on whether the legal test for criminal charges has been met in these complex cases.

“A prosecution will usually take place unless the prosecutor is satisfied that there are public interest factors tending against prosecution which outweigh those tending in favour. Each case must be considered on its own facts and on its own merits.

“Prosecutors must decide the importance of each public interest factor in the circumstances of each case and go on to make an overall assessment.”

Factors tending in favour of prosecution include the suspect influencing the victim not to seek medical treatment, palliative care or independent professional advice, or denying them access to such treatment, care or support. Another is the suspect acting in their capacity as a medical doctor, nurse or other healthcare professional to the victim in their care.

Previous guidance, now removed, included the statement: “Subject to sufficiency of evidence, a prosecution is almost certainly required, even in cases such as ‘mercy killing’ of a sick relative.”

The new guidelines on mercy killing (which falls under homicide law) are similar to those issued in 2010 for encouraging or assisting another person’s suicide, which is punishable by up to 14 years in prison under the Suicide Act 1961 .

Sarah Wootton, chief executive of Dignity in Dying, said: “We strongly welcome the new guidance issued by the CPS today, which distinguishes between malicious homicide and compassionate assistance to die and makes clear that acts of love and compassion should be treated differently to serious crimes by the criminal justice system. This is a victory for Dignity in Dying’s Compassion Is Not a Crime campaign and today’s guidance is a major milestone on the road to assisted dying law reform.”

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The Compassion Is Not A Crime campaign was led by Joy Munns, the daughter of Mavis Eccleston, who was charged with murder and manslaughter after her terminally ill husband, Dennis, asked her to help him end his life. The couple attempted to take their lives together in February 2018, but Mavis later recovered and was charged. In September 2019 she was unanimously acquitted by a jury . At the time the CPS clarified that it was in the public interest to prosecute Mavis.

Joy Munns said: “This new guidance might have saved our mom from a trial, but it wouldn’t have saved Dad from a bad death. The law put my parents in an impossible position. It must be properly reformed so that people like Dad can have the choice that so many dying people want.”

Her words were echoed by Wootton, who said that the new CPS guidance did not change the fact that the current law was not fit for purpose. She called on MPs to “do the right thing and introduce safeguarded, compassionate assisted dying laws”.

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A short legal history of killings motivated by mercy in Canada

Canadian courts have an awkward and uneven history in dealing with killings motivated by mercy.

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An Ottawa man charged with second-degree murder in the death of his spouse is expected to raise the issue of mercy killing as part of his legal defence.

A short legal history of killings motivated by mercy in Canada Back to video

Philippe Hébert, 69, is charged in connection with the death of his partner of 46 years, Richard Rutherford, a former principal dancer with the Royal Winnipeg Ballet. Rutherford was 87 and said to be in failing health when he was killed in the Smyth Road home that he shared with Hébert on April 15.

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Friends and neighbours have described Hébert as a loving and devoted caregiver to Rutherford. Hébert has been granted bail and will live under modified house arrest until his trial.

The country’s best-known case involved Robert Latimer, a Saskatchewan farmer who poisoned his cognitively impaired 12-year-old daughter, Tracy, a bedridden quadriplegic with metal rods in her spine. Latimer said his daughter lived in “incessant agony;” he killed her by placing her in his truck and venting its fumes into the cab.

Latimer was charged with second-degree murder, tried twice, and convicted, but the jury recommended he serve only one year behind bars rather than the mandatory minimum of 10 years. The trial judge agreed, saying anything else would amount to cruel and unusual punishment.

The Court of Appeal for Saskatchewan overturned the sentence and imposed the mandatory minimum. The Supreme Court of Canada upheld that outcome, but also made it clear the federal government could employ its “royal prerogative of mercy” in the case.

“Where the courts are unable to provide an appropriate remedy in cases that the executive sees as unjust imprisonment, the executive is permitted to dispense ‘mercy,’ and order the release of the offender,” the Supreme Court noted.

The Latimer case highlights the justice system’s profound ambivalence toward those who kill out of love, devotion or mercy.

“The person who kills from jealously, rage, greed, hatred is treated by the law in the same way as the person who kills from love,” said Prof. Arthur Schafer, the founding director of the Centre for Professional and Applied Ethics at the University of Manitoba.

Mercy killing is not a defence in law, he said in an interview, and someone charged with murder cannot use compassion as a justification: Legally, it’s irrelevant.

Yet, with the notable exception of Robert Latimer, Schafer said, Canadian courts have rarely sentenced mercy killers to serious jail time.

In the vast majority of such cases, Schafer said, juries have voted to acquit, or the Crown has opted to reduce the charge from second-degree murder to a lesser offence, such as manslaughter.

“Our law of homicide has a built-in rigidity: If you are convicted of murder, the law specifies that the judge has to sentence you to life imprisonment,” Schafer said. “In my opinion, it’s too blunt and crude an instrument to deal with cases that involve a genuine mercy killing.”

As a result, Schafer argued, “moral common sense” has been injected into the system by jury members and Crown attorneys who have exercised their discretion and ignored the strict letter of the law.

The 2016 legalization of euthanasia in Canada was expected to remove mercy killings from the country’s court dockets, but medical assistance in dying (MAID) is still restricted to people with the mental capacity to consent to the procedure. Schafer said that has left gaps in the system.

Among Canada’s notable “mercy killing” cases:

• In 2008, Canadian Forces Capt. Robert Semrau was charged with second-degree murder based on allegations that he fired two shots into a grievously wounded, unarmed Taliban fighter in Afghanistan’s Helmand province. He was the first Canadian soldier to stand trial for a battlefield death. His Gatineau trial heard evidence Semrau shot the Taliban fighter to end his suffering: Semrau told a fellow soldier it was a “mercy kill.” A military jury acquitted him of second-degree murder, but found him guilty of disgraceful conduct under the National Defence Act. In October 2010, Semrau was demoted and dismissed from the Canadian military.

• In 2006, Noel Lavery, 83, of Edmonton, was charged with second-degree murder after giving his wife, Sherry, one last drink and then suffocating her with a pillow. Sherry, 50, was a bedridden alcoholic cared for full-time by Lavery. “I was taking her pain away,” Lavery told police in his confession. In January 2012, Judge Donna Shelley convicted him of manslaughter because she doubted whether he intended to kill his wife given his state of physical and mental exhaustion. Lavery was sentenced to two years of house arrest.

• Tony Jaworksi, 88, of Winnipeg, was sentenced to time served in April 2006 after pleading guilty to manslaughter for stabbing his wife in the heart as she slept in a hospital bed. She was suffering from terminal colon cancer and dementia at the time. Jaworski sat with his wife of 62 years for six hours, holding her hand, before killing her. He then stabbed himself in the stomach. He was initially charged with second-degree murder, and spent 17 months in pre-trial custody, before the Crown reduced the charge to manslaughter and accepted a plea deal.

• In May 1998, Toronto’s Dr. Maurice Généreux became the first physician found guilty of aiding and abetting a suicide in Canada. He prescribed lethal doses of sleeping pills to two HIV-positive men, one of whom survived. Généreux was sentenced to two years in jail and lost the right to practise medicine. He later said he was motivated by a desire to help ease the mental anguish of his patients at a time when people were still dying from AIDS.

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Katrina & Beyond

New orleans hospital staff discussed mercy killings.

Carrie Kahn

Soon after Hurricane Katrina struck, the first unconfirmed reports surfaced of "mercy killings" -- euthanasia of patients -- at New Orleans hospitals. For months, the Louisiana attorney general has been investigating these charges. That investigation has centered on the actions of doctors and nurses at the city's Memorial Medical Center.

NPR has reviewed secret court documents related to the investigation and not yet released to the public. The documents reveal chilling details about events at Memorial hospital in the chaotic days following the storm, including hospital administrators who saw a doctor filling syringes with painkillers and heard plans to give patients lethal doses. The witnesses also heard staff discussing the agonizing decision to end patients' lives.

A nurse from New Orleans' Memorial Medical Center fans a patient waiting in the hospital's parking garage to be evacuated via helicopter, Sept. 1, 2005. According to court papers reviewed by NPR, in the chaotic days after Hurricane Katrina hit, eyewitnesses say they heard discussions that a decision had been made to end patients' lives. The discussions related to patients on Memorial hospital's seventh floor, a separate long-term patient care facility run by LifeCare Hospitals.

Angela McManus, 48, holds a photo of her mother Wilda Faye Sims-McManus. Her mother was 16 in the photo; she is holding a trophy for a singing contest. Wilda Faye was an acclaimed gospel singer. Carrie Kahn, NPR hide caption

Angela McManus, 48, holds a photo of her mother Wilda Faye Sims-McManus. Her mother was 16 in the photo; she is holding a trophy for a singing contest. Wilda Faye was an acclaimed gospel singer.

Angela McManus describes saying good-bye to her mother for the last time at Memorial hospital.

After Katrina struck the city, conditions at New Orleans' Memorial hospital were horrendous. The hospital was surrounded by water, power was out and back-up generators failed. Temperatures inside the hospital quickly soared past 100 degrees and patients were in distress.

Reports from the Frontline

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But it was on the seventh floor of the hospital were the situation was most dire. Memorial Medical Center leased the floor to LifeCare Hospitals, a separate long-term patient care facility. Lifecare Hospitals is based in Plano, Texas. LifeCare has facilities in nine states and considers itself an acute specialty hospital capable of treating the most complex of cases.

There, on the seventh floor of Memorial Medical Center, doctors and nurses were faced with few options. Conditions were deteriorating rapidly, evacuations were sporadic and security was compromised. Staff agonized whether to attempt to transport critically ill patients who might not survive the arduous evacuation. It appears another choice was considered: whether to end the lives of those who could not be moved. In the court documents reviewed by NPR, none of four key witnesses say they knew who made the decision to administer lethal doses of painkillers to the patients. But all four heard discussions that a decision had been made to end patients' lives. According to the documents, attorneys for LifeCare self-reported all of this to the Louisiana attorney general's office on Sept. 14, 2005.

Angela McManus' mother had been on the LifeCare floor for two weeks before Katrina hit. Wilda Faye McManus, 78, was battling a persistent infection due to complications from rectal cancer. Angela McManus says she was given a bed next to her mother and never left her side until Tuesday, the day after the hurricane. She says nurses told her that helicopters were coming for the seventh-floor patients and that McManus needed to get to the first floor and wait for evacuation boats.

Once on the first floor, McManus said, she could hear gunshots outside the hospital. She saw looters sacking a corner drug store. Many sources confirm that at this point, there were 2,000 people -- employees, patients and relatives -- trapped in the hospital. According to McManus, "The sewer lines had all backed up, and we were down there in all that stifling heat and this odor was horrendous. People were trying to get into the hospital just to get to higher ground, and they weren't allowing that... so they boarded the doors up, and we were just in there smothering all night long."

By Wednesday morning, Angela McManus learned her mother had not been evacuated as promised. She rushed back to the seventh floor and said her mother's condition had changed. "She was real lethargic," said McManus. "She would talk to me, then just doze back off. I was like, 'What's going on with her?' I was just sitting there talking to her and stroking her, and she was just sleeping and I'm like, 'Something is wrong'."

McManus says nurses told her that her mother had been sedated. She grew concerned because she says her mother's pain had been manageable with Tylenol and an occasional painkiller. She stayed with her mom for hours and sang gospel hymns to comfort her. According to McManus, attempts were made to evacuate other patients from the seventh floor. She recalls seeing workers desperately trying to get one woman out of the hospital, only to see that the woman died in the process.

Angela McManus became seriously frightened for her mother when she overheard nurses saying a decision was made not to evacuate LifeCare's DNR patients. "DNR means "do not resuscitate." It does not mean do not rescue, do not take care of," McManus said. She tried to rescind her mother's DNR order to no avail. On Wednesday evening, two full days after Katrina hit, Angela McManus says three New Orleans police officers approached her with guns drawn and told her she would have to leave. New Orleans police confirm that armed officers did evacuate non-essential staff from the hospital.

Confronted by police, McManus raced to her mother's bed. "I woke her up and I told her that I had to leave, and I told her that it was OK, to go on and be with Jesus, and she understood me because she cried," McManus recalled. "First she screamed, then she cried. And I said, 'Momma, do you understand?' And she said, 'Yes.' And she asked me, she asked me to sing to her one more time. And I did it, and everyone was crying, and then I left. I had to leave her there. The police escorted me seven floors down."

McManus says that when she left, only eight patients, including her mother, remained alive in LifeCare.

According to court documents reviewed by NPR, a key discussion took place on Thursday, Sept. 1, during an incident-command meeting held on the hospital's emergency ramp. A nurse told LifeCare's pharmacy director that the hospital's seventh-floor LifeCare patients were critical and not expected to be evacuated with the rest of the hospital. According to statements given to an investigator in the attorney general's office, LifeCare's pharmacy director, the director of physical medicine and an assistant administrator say they were told that the evacuation plan for the seventh floor was to "not leave any living patients behind," and that "a lethal dose would be administered," according to their statements in court documents.

According to eye-witness accounts, LifeCare's pharmacy director said that later that Thursday morning, he found Dr. Anna Pou in the seventh-floor medical-charting room. According to his statement, Pou and two unnamed nurses informed him that it had been decided to administer lethal doses to LifeCare patients. From the court documents, it is not clear where the instruction came from. When asked what medication was to be given, the pharmacy director told the investigator from the AG's office that Pou showed him a big pack of morphine vials. The LifeCare pharmacy director stated that, before evacuating, he saw Pou and the two nurses enter the rooms of remaining LifeCare patients.

No one has been charged in the investigation. And nowhere in the documents or in independent interviews conducted by NPR does anyone confirm seeing doctors or nurses administering lethal drugs.

That's just one of the challenges facing Louisiana State Attorney General Charles Foti as he tries to piece together exactly what happened at Memorial Medical Center. For weeks, Foti has said he cannot comment on the ongoing investigation. The attorney general's spokeswoman, Kris Wartelle, says investigators have subpoenaed more than 70 witnesses and are examining volumes of evidence.

Despite repeated phone calls and letters, Dr. Pou could not be reached for comment. In a written statement, Pou's lawyer, Rick Simmons, said: "Dr. Pou and other medical personnel at Memorial hospital worked tirelessly for five days to save and evacuate patients, none of whom were abandoned." In a telephone interview, Simmons said, "Dr. Pou did not engage in any criminal actions." He said he is confident that the facts will reveal heroic efforts by the physicians and the staff in a desperate situation.

Tenet Healthcare Corporation, which owns Memorial Medical Center, declined to comment on tape for this report. On its Web site, Tenet expresses regret for the loss of life at Memorial and praises the work of its doctors and staff. Tenet acknowledges that investigators from the attorney general's office searched Memorial Hospital on Oct. 1, 2005, and removed records and other materials, particularly from the LifeCare facility. Tenet spokesman Harry Anderson said that evacuation plans for the seventh floor of Memorial were the sole responsibility of LifeCare Hospital.

LifeCare spokeswoman Paula Lovell would not comment on the investigation but stressed that the company is cooperating fully with the attorney general. "In deference to the ongoing effort of the AG's office, and out of respect to the families of patients, we are unable to make any comments on matters related to the investigation," Lovell said.

New Orleans Coroner Frank Minyard says it will be difficult to prove if lethal doses of morphine were given. As part of the investigation, he removed tissue samples for toxicology tests from all bodies found at Memorial. He would not say if he found traces of morphine in the samples.

Minyard says the bodies were not retrieved from the hospital until two weeks after the storm and were in advanced stages of decomposition. He says that undermines the accuracy of toxicology tests. "If these people had been treated for their pain prior to the storm, they are going to have it in their system. And they are sick people, and their system is not working like it should work," Minyard said.

In the absence of reliable forensic evidence, all parties say the patient charts containing morphine-dosage levels will be crucial to the case. The attorney general's office will not confirm whether he has seen them.

Meanwhile, investigators are relying on accounts by witnesses like Angela McManus, who is still waiting for answers about how her mother died. "You know, of course I don't know what God's will is," McManus said. "I don't know when he was calling her home. If he did in fact do it, OK. But if man decided that, I want to know that. My family needs peace of mind about that."

Angela McManus has retained a lawyer to investigate the circumstances of her mother's death. She wants answers.

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Hospital staff seen planning mercy killings before katrina hit.

Ethics and Values Case Study - Mercy Killing, Euthanasia

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A 24-year-old man named Robert who has a wife and child is paralyzed from the neck down in a motorcycle accident. He has always been very active and hates the idea of being paralyzed. He also is in a great deal of pain, an he has asked his doctors and other members of his family to "put him out of his misery." After several days of such pleading, his brother comes into Robert's hospital ward and asks him if he is sure he still wantes to be put out of his misery. Robert says yes and pleads with his brother to kill him. The brother kisses and blesses Robert, then takes out a gun and shoots him, killing him instantly. THe brother later is tried for murder and acquitted by reason of temporary insanity.

Was what Robert's brother did moral? Do you think he should have been brought to trial at all? Do you think he should have been acquitted? Would you do the same for a loved one if you were asked?

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Solution summary.

This solution offers an opinion-based response to four questions as they relate to case study focused on allowing someone to die by way of mercy death, mercy killing or euthanasia.

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You have asked for an opinion-based response to four questions as they relate to the above case study.

Was what Robert's brother did moral?

This question depends on what perspective you are looking at the situation from. From a medical professional perspective, Robert's brother did something very immoral. Medical ethics demands that life be preserved at all costs. This ethical thinking does not take into consideration various situations or even the wishes of a patient. For medical professionals, their moral directive is to preserve life, and in this case they would denounce Robert's brother's actions as immoral.

From a legal perspective, Robert's brother broke the law since one of the fundamental rights of an individual is the right to life (as in the US slogan "Life Liberty and the pursuit of Happiness") However, the law ...

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However it is still important to determine the Ethics and morality of Euthanasia as follows: 1. Identifying the ethical issues - The issue of mercy killing / euthanasia : is it moral, is it right? 2.

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Ethical problems of euthanasia . URL: http://www.bbc.co.uk/ ethics / euthanasia /overview/problems.shtml The solution provides information, assistance and advise in tackling the task (see above) on the topic of mercy killing or euthanasia .

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Experts also call involuntary euthanasia mercy killing . The UK's BBC has given out the following examples of situations that can lead to voluntary euthanasia (2010): A soldier has their stomach blown open by a shell burst.

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Rather, it would be argued that mercy killing is an act of mercy initiated by the mother's love and protection for her sons, which necessitated the need to end their pain resulted in ' mercy killing .'

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Lisa's journalism career spans two decades, and she currently serves as the Americas Day Editor for the Global News Desk. She played a pivotal role in tracking the COVID pandemic and leading initiatives in speed, headline writing and multimedia. She has worked closely with the finance and company news teams on major stories, such as the departures of Twitter CEO Jack Dorsey and Amazon’s Jeff Bezos and significant developments at Apple, Alphabet, Facebook and Tesla. Her dedication and hard work have been recognized with the 2010 Desk Editor of the Year award and a Journalist of the Year nomination in 2020. Lisa is passionate about visual and long-form storytelling. She holds a degree in both psychology and journalism from Penn State University.

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