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Historical Approaches to Euthanasia: The Unfinished Story of a Concept

Various ethics committees in Belgium, Canada, Denmark, Luxembourg, Portugal, and France have made attempts to describe the notion of euthanasia. Opinion No 063 (January 27, 2000) of the National Advisory Committee on Ethics shows that there has been no concensus on the definition of this concept. It is therefore necessary to review historical background of euthanasia from ancient times to modern period to better understand its potential applications in divergent contexts.Studies devoted to euthanasia usually involve two modalities, namely active and passive. The active modality entails the act of deliberately killing a patient with or against their will in order to relieve persistent suffering, while the passive modality deals with the rational valid refusal of life-sustaining medical interventions necessary for the patient's life and health. The goal of this article is to present different historical approaches to euthanasia from two modalities and engage the bioethics community in a discussion on legal, social, and ethical issues of euthanasia all over the world.


Introduction
Defining euthanasia is far from being an easy task. To date, no consensus has been reached around the concept of euthanasia, including among those who agree that it's not the disguised elimination of "undesirables".
Opinion No 063 (January 27, 2000) of the National Advisory Committee on Ethics is the best illustration of this lack of consensus. In their opinion, the definitions of euthanasia proposed by various similar committees (Belgian, Canadian, Danish, Luxembourg and Portuguese) are listed in the appendix. Although they mention and state in a fairly recurring manner an identical syntax and terminology, these definitions diverge in practically every respect and do not suggest any restraint of a common template.

A Philosophical History of Euthanasia
The historical study of euthanasia practice demonstrates four different significations to euthanasia: the gentle death; the compassionate euthanasia; the utilitarianist and eugenistic euthanasia.

Ancient Times
During this period, several concepts overlap and become intertwined according to collective or individual principles. Euthanasia was a practice that responded to the desire for a beautiful death, a gentle Kutafin Law Review Volume 8 Issue 1 (2021) A.Haddadi, F.Ravaz Historical Approaches to Euthanasia: the Unfinished Story of a Concept death or a suicide. The Greek poet Cratinos (5th century BC) used the word euthanatôs to designate both a beautiful death and a gentle death. For Posidippus (c. 300 B.C.), euthanasia expressed both the practice of a good death and a sweet death: man "desires nothing better than a sweet death" (Fragment 16). More contemporary, Suetonius 1 traces the end of the life of Emperor Augustus. In his narrative, he describes him embraced by the arms of Livia, taking advantage of a euthanasia (quick death without suffering) which he had always wished for.
However, the expectation from a euthanasia venture is far from being a linear, fixed and reproducible rationale. In a specific context, a violent death, a suicide, a suicidal surrender would become the best salvation and an unprecedented final shield. Reason will prefer them because, although they are far from being good, they will at least ensure the gentleness of death.
The accounts of the Greek historian Polybius (202-120 B.C.) report that after the bitter military defeat of the king of Sparta Cleomenes, the latter expressed a final de-sire: to commit suicide in order to have a beautiful and dishonorless death (euthanatesai), thus avoiding captivity to his enemies. 2 In the turmoil of his political disgrace, and his supposed escape, Cicero (106-43 BC) also wished for a good death (euthanasia). Disavowed by his best friend Atticus, he wrote that his death would be a symbol of betrayal and desertion. 3 Finally, Flavius Joseph tells the story of four lepers who decided to surrender to the guru enemy, preferring to have their throats cut and thus benefit from a "gentler" death, rather than face a death of an uncertain nature outside the city. 4 Thus, according to Bacon, euthanasia clearly appears to be carried by two exclusive and in some respects quite opposite meanings: on the one hand, that of a gentle death, and on the other, that of suicide, considered to be irreversible and preferable to the torments of a hellish death.

Alleviating Care, the Contemporary Medical Response to the Wish for Gentle Death
As early as under the First Dynasty in Egypt, at the end of the fourth millennium B.C., end-of-life houses were founded in temples. The future doctors learned the art of treating the dying. Then religions, including Christianity, took care of the weak and the dying.
Thus, in the Middle Ages, the brotherhoods of the "good death" and the Hotels Dieu provided emotional, spiritual, social support and care to the needy and the incurable.
Much later, on the initiative of the Association of the "Dames du Calvaire", founded in 1842, Francis Bacon, an English politician, scientist and philosopher, urged medicine -through two texts published in 1605 and 1623 and rather similar in content -to commit itself to two pre-rogatives: to provide care and to alleviate pain until the last breath.
The initial dark and disturbing meaning of euthanasia then became fleeting, giving way to that of a gentle death accompanied by care and comfort. This was Bacon's new paradigm, which was summed up as euthanasia exteriore (physical euthanasia). Indeed, according to him, "it is the task of the physician not only to restore health, but also to alleviate suffering and pain, not only when a softening is conducive to healing, but also when it can help one to pass away peacefully and easily, in the manner of Augustus, Anthony the Pious and Epicurus, whose deaths were much like a benign and pleasant sleep." In his text, Bacon (1991) was the first -if not, one of the first -to formulate a plea in favor of euthanasia. In his 1623 publication, F. Bacon (1991) reasserted the thought brought out in his article published in 1605. He insisted on the role of the physician, who should no longer limit himself to curative action, but should also work to alleviate the pain of illnesses, even when these were to prove fatal.
The aim was to ensure a gentle and peaceful death, and to "help those who are dying to leave this world more gently and easily. With this new paradigm dedicated to the end of life, Bacon thus made explicit his notion of external euthanasia which prepares the bodywhich, according to him, is very highly desirable -and which is in no way comparable to the notion of internal euthanasia, which aims at preparing the soul" (Bacon, 1623 Bacon's approach seems pragmatic, rational and leaves no room for misunderstanding by the practical momentum it suggests. According to him, the euthanasia of the body is precisely about a total attenuation of pain, if possible, and is not a cryptic method that induces premature death. It would thus be an outlet facilitated by the absence of pain.

Utilitarianist Euthanasia
Utilitarianism, a doctrine in political philosophy or social ethics, recommends working, or not, to maximize collective well-being, understood as the sum or the average of the well-being of all sentient and affected beings.
This doctrine thus conceives the waste of well-being as an injustice. Theorized by J.S. Mill (1863) on the foundations established by Jeremy Bentham (1748-1832), "utilitarianism designates the doctrine" which recognizes utility as a rule, without wishing to designate this or that way of applying this rule. "It is also the principle according to which the only thing desirable as an end is happiness, the presence of pleasure and the absence of pain, otherwise formulated" (Mill, 1863). The usefulness of life would thus depend on the preponderance of pleasure over pain, its defect would de facto formulate the uselessness of the latter. Given these considerations, consequentialist theories are in fact the most important and robust set of arguments for the proponents of euthanasia.
In this regard, the Scottish philosopher D. Hume was quick to point out that, however well structured, the Thomistic thesis, 5 pamphlet against euthanasia, had little resistance to consequentialist theories. It should also be noted that the theories that make dignity or existential rights the centerpiece of bioethical reflection may, in view of the interpretation they give to these notions, authorize -if not at least recommend -the practice of euthanasia.
Moreover, the utilitarianist concept, the spearhead of contemporary "pro-euthanasia" associations, is very old. According to Plutarch, a Greek-born philosopher, biographer, moralist and leading thinker of ancient Rome (46-125 AD), the fate of a newborn child did not depend on the will of its father. The latter had to submit it to the attentive examination of the oldest. If the newborn child was strong and free of defects, the wise men would order his father to raise him and grant him one of 9,000 plots of land. On the other hand, if the child's condition was marked by any weak-ness or deformity, the death sentence for him was without appeal, considering that this was preferable on the one hand for the child himself and on the other hand for the rest of the community. 6 For his part, Strabo (58 BC-25 AD) reports the practice to Ceos of a form of population regulation justified by a concern for food security. All people reaching the age of sixty were forced to drink hemlock (a true elixir of death!) (Strabon, 1971). According to Valerius Maximus (1st century BC-1st century AD), a lethal preparation based on hemlock, was "offered" to any person likely to provide before the Six Hundred (Sen-ate of the city) details and reasons for his will to kill himself. "A courageous procedure tempered with kindness, not allowing one to leave life without reason, while offering to the one who clearly knows why he wishes to leave it a quick way of fulfilling his destiny" (Valere, 1995).
This concept of utilitarian death is also widely reported by Thomas More (1478-1535) in his book Utopia. Whenever the illness was deemed incurable and burdened by continuous and unbearable suffering, magistrates and priests would commit the sick person, who had unfortunately become a burden both to himself and to the community, to accept death. He would have the choice of carrying out this task himself or to invest a third party in it. His wise and saving action would be a deliverance and a mark of piety towards the deities. In order to do this, the patient would abstain from eating or would chose to be put to sleep. It is important to emphasize, however, that no suspension of care or killing was involved against will. Those who took their own lives without the approval of the priests and the Senate were deprived of a burial (More, Prévost, 1978). Far from being the defender -because very opposed -of the right to suicide, Thomas More reports only in his work a description of the dynamic and rational system of thought of the Utopians (More, Prévost, 1978).
This concept was also widely observed among the Eskimos of Nunaga, the Chukchee of Northeastern Siberia and the Yuit of the St. Lawrence Islands. In these communities, euthanasia represented the ultimate and obligatory stage of an honorable life. The elderly person, unfortunately becoming much less necessary to family life and incapable of deploying sufficient strength to run after the dogs, would charge his favorite son to help him die by either stabbing, shooting, harpooning, strangling or hanging him. As in the case of the E people of Northeastern Siberia, the "old" person who was bedridden or simply exhausted by life had to make a vow to be killed. Often causing fear and amazement, this request was in practice a moral constraint for the community and forced it to respond. If the request was maintained and strongly reaffirmed, it became irreversible. Indeed, it could provoke the Kelets (evil spirits) who could not find appeasement as long as the "deadly" enterprise was not completed. Once the decision had been taken and the "executioner" known, the work was very quickly accomplished (Baechler, 1981).

Eugenist Ethanasia: Hygienists, Eugenists and State Crime
Among the most outstanding research interests of Sir Francis Galton (1822-1911), anthropologist, explorer, geographer, inventor, meteorologist, writer, proto-geneticist, psychomotor therapist, British statistician and cousin of Charles Darwin, was the establishment of a process that would allow the systematic and scientific selection of what could be considered the elite of humanity -or rather of the United Kingdom. As such, together with his disciple Karl Pearson, with whom he founded "Biometrika", a journal devoted to this concept, he is undoubtedly considered the founder of the British school of biometry and eugenics. The admitted objective of this selection process was to cleanse the hereditary heritage of all degenerative factors. In 1888, Georges Vacher de Lapouge, a French anthropologist, magistrate, then librarian, took up the challenge again by developing the racist theory outlined by Gobineau at the end of the 19th century and theorizing eugenics. Through his work, Vacher de Lapouge established that eugenism was the result of eugenics. In the wake of this, anthropologists, doctors and biologists, supported by a strong popular support, created societies and journals oriented towards eugenics. From 1907 to 1940, the appropriation of this principle and its accommodation worked at the highest level in many states. In fact, in 35 states in the USA, two Canadian provinces, Germany, Denmark, Finland, Norway, Sweden and Switzerland were promulgated laws of sterilization, voluntary or imposed, against people suffering from pathologies deliberately supposed to be hereditary, strongly considered as dangerous for society. Among these illnesses were mental disorders of all degrees of severity, sexual offences and so-called socially dangerous tendencies, which, according to several experts at the time, were more a form of social deviance and in no way a pathological state, even when admitting an anachronistic interpretation (Morange, 1996) (Veuille, 1999). Charles Richet, while awarded the Nobel Prize for Medicine and Physiology in 1913, wrote in 1912, the year of the creation of the French Eugenics Society, in "La Sélection Naturelle", that he "saw no social necessity in preserving (the) abnormal children." Alfred Hoche, a psychiatrist, and Karl Binding, a lawyer, had "Die Freigabe der Vernichtung lebensunwerten Lebens" [The Liberalization of the Destruction of a Life Not worth Living] published in Leipzig in 1920. Although the title is self-explanatory, the variousoften contradictory -critical analyses dedicated to this publication hardly revealed the inhibiting character of forced eugenic euthanasia.
These analyses are strongly corroborated by the writings of Karl Binding: "The will to live of each individual, even of the sickest and most tortured human beings, must be respected (...). It goes without saying that there will be no question of liberalizing the homicide of a mentally handicapped person as long as he is happy with his life" (Morange, 1996) (Veuille, 1999). The investigation of a request for euthanasia was carried out by a commission, whose deliberations only took place -upon request -if it was unanimous. The introduction of a request for liberalization (request for euthanasia) was thus made either by the patient himself, who was suffering from a fatal illness, or by the patient's doctor or by a relative delegated to do so. If it was established that the request was admissible, an expert was appointed to carry out the act and a report would ultimately be drawn up for the commission.
Contrary to the doctrine of K. Binding, which incited to respect the desire to live of the sick including those supposedly useless to the society, that of A. Hoche advocated the concept of "mentally dead"

Kutafin Law Review Volume 8 Issue 1 (2021)
A.Haddadi, F.Ravaz Historical Approaches to Euthanasia: the Unfinished Story of a Concept individuals whose lives would be a burden on the community. This life was judged to be worthless, precisely in the context of the time, marked by a competition between nations, which made them to free them-selves from any elements that would disable their ascent and excellence (Goffi, 2004).
In 1925, Hitler completed Mein Kampf, a work in which he exposed, in a style loaded with hatred, his conception of a hegemonic, bellicose, racist world and compiled, while supporting them, all the eugenic theses. In 1933, largely in view of the dominant socio-political context, public opinion was ready to adopt these theses. As a matter of fact, at the congress of April 1933, having gathered in Bremen nearly 500 eugenists, it was declared: "All unproductive life is considered a life without value." Under the express impulse of Hitler a committee of euthanasia was then created. Composed of 25 doctors, including 7 holders of the chair of neurology and psychiatry, it stood under the absolute authority of Professor Linden.
All the structural tools were thus ready to carry out the operation launched by Hitler against the mentally ill on September 1, 1939, bearing the name Aktion T4, and also Aktion Gnadentot (Grace of Death). It should be noted that this "makabre" action was directed from number 4 Tiergartenstrasse in Berlin. Recruitment of patients eligible for Aktion T4 was determined by their ability to take on a job. All hospital and asylums directors were asked to fill out a questionnaire to determine the capacity of each res-ident to work. Patients who were declared unfit for work, sometimes simply because of the protecting spirit of the managers of these institutions, were transferred to "charitable" foundations, not for hospital care as had been announced, but for certain death. The reasons for death most often mentioned were then bronchopneumonia or idiopathic weight loss. The organization of this dark enterprise began with the transfer of patients to the said charitable foundations, which was carried out by a company created specifically for this purpose. In order to keep away the curious onlookers, large signs surrounding these foundations warned of a risk of contagion. The nursing staff, recruited on a voluntary basis, had to pledge allegiance to the Reich, committing themselves to absolute obedience and infinite discretion. Any violation of this pact would result in the certain death of the offender. However, in the face of exacerbated and overt opposition from religious authorities who were silent and docile at first, and a significant fringe of the army and a growing number of doctors, Hitler suspended the macabre work on August 24, 1941. The death toll attributed to Aktion T4 amounted to 100,000 disabled and 75,000 elderly   (Ternon and Helman, 2000).
The disclosure of these crimes in the post-war period had the effect of discrediting any type of so-called humanitarian euthanasia. In his book "L'Art de mourir: Défense et technique du suicide secondé", Charles Binet-Sanglé, in 1919, reiterated the reasoning behind the right to assisted suicide and described several modalities of painless suicide. In the same work, he insisted on the interest of setting up a statefunded euthanasia institute. However, regardless of the formulation of super-vised suicide, clandestine, assisted or not, all these practices refer to hygienic and eugenic crimes practiced in the name of the State. Moreover, a few decades later, a few trials marked public opinion, to say the least (Daviani, 1970;Putte, 1962). Nevertheless, it should be said that the acquittal of the perpetrators of these homicides was the norm, notwithstanding the fact that they did not correspond to any euthanasia notion. Nevertheless, they have the merit of having participated to some extent in advancing the cause of euthanasia.

Compassionate Euthanasia
One of the most striking episodes and undoubtedly one of those that best illustrate the compassionate nature of euthanasia is the epilogue of the six Russians taken charge of by Pasteur at the Hôtel-Dieu. According to Léon Daudet, then a young medical student, they were six Russians from a rural area, bitten by a wolf most probably suffering from rabies and transferred to Paris to be cared for by Pasteur's team at the Hôtel-Dieu. Using the usual protocol dedicated to this type of pathological situation, Pasteur had them injected with anti-rabies serum for eight days. Unfortunately, on the ninth day, the patients showed a noticeable worsening of their condition and complained of unbearable systemic pain, to the point of imploring the health care team to give them a certain and immediate death. "After consultation between the hospital's chief  ) and Pasteur, the decision was made. The pharmacist prepared five pills -one of the six patients having died, which were administered to the other five with all the discretion that is customary in such cases. When silence fell, (...) we all began to cry in horror. We were a nervous wreck, devastated" (Daude, 1915). The decision was taken in this way, collegial and secrete.
Although singular, the experience is part of the type of decisions that the con-science of all caregivers is confronted with and is de facto understood as a common fact of medical practice. However, is it acceptable and conceivable to admit a continuum between a specific case and the law, and if so, to consider that the reasons are always specific and not stereotyped, recognized only by certain individuals refractory to any civil law. It will thus be difficult to claim to be able to decide on the primacy of compassion and make it a right. "A fierce struggle to make compassionate euthanasia a right." Clearly, the twentieth century is marked by declarations in favor of compassionate euthanasia.
Following the creation of the Voluntary Euthanasia Association (VES) in 1935 in England, renamed EXIT, and the Society for the Right to Die in the United States in 1983, renamed the Euthanasia Society of America in 1975, many associations were created in the late 1970s. They all had as a common claim the right to die with dignity. They formed a world federation for the right to die. The number of their members is estimated at 500,000 worldwide. On July 1, 1974, Le Figaro, a newspaper whose editorial line has always been resolutely right-wing, published a manifesto in the form of a plea for the right to euthanasia. The latter was signed by 40 eminent academics and doctors, including three Nobel Prize winners: "We, the undersigned, declare, for ethical reasons, to be in favor of euthanasia. We believe that there is a mature moral conscience in our societies to develop a rule of humanitarian conduct regarding death and the dying. We deplore the insensitive morality and legal restrictions that impede the ethical case for euthanasia." In this text, the signatories of this manifesto implicitly demanded the awakening of the collective conscience and urged public opinion to overcome certain unfounded traditional concepts that would lead to suffering and agony at the time of death. Alas, this manifesto will not arouse much interest and has still to happen. On November 17, 1979, the militant article by Michel Lee Landa, a Franco-American writer with the title "Un Droit" (A Right), published worldwide, would be the genesis of the Association for the Right to Die with Dignity in 1980. The article, which advocated the need to recognize the right to die voluntarily and to be helped to do so, provoked strong reactions of support -for the legalization of this right -for people of very advanced age, for patients suffering from serious pathologies and for those suffering from serious handicaps. Three years after its creation, the ADMD has several thousand members. Its objective was to be a watchdog on the laws and regulations governing the right of individuals to be able to choose the conditions of their end of life. It also functioned as a movement of opinion, creating a kind of driving force to advance the debate of ideas in its favor (Pohier, 1998). The three main objectives of ADMD are: "The right to control pain, the right to refuse therapeutic persecution and the right to voluntary euthanasia, each member being free to claim for themselves only one or the other of these rights, but recognizing that the association must fight to ensure that all three rights are recognized and achievable for all those who would claim them" (Pohier, 1998).
In 1980 near Munich, Dr. Hacketal opened the Eubois Clinic for patients who ex-pressed a need for assisted suicide. Dr. Peter Admiraal took over this approach and set up a unit with a similar objective at the St. Hippolyte Hospital in Delft (ND). In 1990, in Detroit, Michigan, Dr. Jack Kevorkian's initiative was singular to say the least. Kevorkian developed a suicide machine that he named the Mercytron. Its use was based on the combination of three infusion solutions, one of serum to dilate the venous capital, the second of Pentothal to sedate the patient, and the third of potassium to ultimately cause cardio-circulatory arrest. It should be noted that Dr. Jack Kevorkian will be charged with four counts of assisted suicide, which will be ac-companied by four acquittals. However, on April 13, 1999, Dr. Jack Kevorkian will be sentenced to between ten and twenty-five years in prison for the second-degree murder of Thomas Youk. As Dr. Jack Kevorkian stated in one of his statements that he never understood a word his patient said, the assistance in suicide qualification was never retained.

III. Deadlock in the Specification of the Euthanasic Act
Generally speaking, the care for patients at the end of life, whether hospitalized or at home, who are most often overwhelmed by significant suffering, is based on well-codified procedures. The latter respond to the logic of syndromic treatment whose enumeration, in view of the risks it evokes, allows the following classification: high-dose analgesia therapy; active reduction or cessation of intensive care, suspension of all extracorporeal vital substitutes, active or passive assistance in suicide, and finally inoculation of lethal substances. Their misuse is often envisaged for euthanasic purposes, either at the request of the patient himself or herself, or on a patient who is unconscious or unable to exercise their will, or, finally, against the patient's will. However, the five above-mentioned acts constituting the conduct to be followed in caring for the patient at the end of life -palliative care -require, on the one hand, clarification as to the absence of treatment. Indeed, this situation can only be considered as an act on the condition that it derives from a medical decision and not from negligence. On the other hand, a clarification concerning the often-concomitant practice of the various acts mentioned above. The possible association of several acts would heighten the action of this or that molecule which would ultimately anticipate the fatal event. There would thus be no difference between a strongly analgesic cocktail, or even sedation, and a frankly lethal cocktail, neither in terms of technique of application nor in terms of consciousness.
In this context of lack of consensus around the euthanasic act, two totally opposed visions remain. One is held by those who advocate the generalization of palliative care, such as JALMALV, SFAP, together with all the religious authorities, insisting on the total opposition between the first three acts, a veritable range of supportive and accompanying care, on the one hand, and acts 4 and 5 on the other hand, which constitute an assisted suicide and an assassination, or even a premeditated murder, respectively. The other, very amply supported by the signatories of the "appeal of the 132", a tribune published by the ADMD in France Soir, Libre-Pensée, Les Libres Exaministes Belges, supports the principle of a continuum between the five acts. The consequences of each of these acts would be closely involved in the ex-tension of their effects. Thus, according to this thesis, the cessation of respiratory substitution unfortunately induces death and would de facto imply the complicity of the caregiver, if not at least his or her complacency.

IV. Conclusion
At the end of this reflection a question remains open: that of the definition of euthanasia. Should it be an adaptive concept and therefore vary according to the various situations? Or should it avoid diversity?
It is common that the works that have been devoted to it rank it either according to an active modality -and in this case the act of deliberately killing a patient with or against his or her will is motivated by reasons that are, after all, clear in relation to his or her pathology, physical or moral suffering. Also included in this modality are actions useful for assisted suicide. Either in passive modality -which would mainly rely on suspending all organic sup-planting, limiting active therapeutics and the use of analgesics whose escalation of doses is strongly responsible for the advent of death. Attempting in this way to circumscribe the euthanasic act would first of all oblige us to grasp the versatility of the intention that carries it. It would therefore be erroneous to believe that this would amount to simply documenting the fields of possibilities in which the euthanasia question would arise. Beyond a banal, well-standardized definition, it is a concept that, by dint of use, imposes itself on humanity in the face of the test of time. In light of the expectations of a large part of contemporary societies, the question of euthanasia should be approached with serenity, but also head-on, as it is always raised and imposed. Thus, it is in no way useful, but rather harmful, to avoid the questioning inherited from the legitimacy of compassionate homicide under certain conditions, from the prohibition of murder when the pain is unbearable and rebellious to any painkiller, and from the need to free one-self from religious dogma where euthanasia is an imposed death that would be op-posed to natural death. This dogma sounds like the common assumption according to which, however violent it may be, natural death belongs to the one who under-goes it, whereas an imposed death, even if it is Kutafin Law Review Volume 8 Issue 1 (2021) A.Haddadi, F.Ravaz Historical Approaches to Euthanasia: the Unfinished Story of a Concept an absolute choice, would be foreign to him. Nevertheless, the ridge line that differentiates a natural death from an imposed death is often sinuous and very imprecise, for so-called natural death is never devoid of violence. Thus, rather than the relentless and lasting violence imposed by natural death -in some patients at the end of life -the moral violence of a life-saving euthanasia is unequivocally preferable.