The Modern Art of Dying: A History of Euthanasia in the United States

Introduction
THE ETHICS OF THE DEATHBED: EUTHANASIA FROM ART TO TECHNIQUE
The year was 1818, and the Howe family had just moved to Brandon, Vermont, when the young mother fell ill.1 Hannah was thirty years old and suffered from consumption. Lying on her sickbed, and knowing her days were numbered, she turned to her husband with a weighty question: "Do you doubt of my being prepared to die?" The question of how to die well occupied Hannah's thoughts long before she fell ill. Imagining her deathbed, she had often wished that "she might die shouting, and have an easy passage over the Jordan of death."
As her day of departure approached, she continued to grow weaker in body and could not converse much. But when she heard talk of the happy death of a certain person she smilingly began waving her hand. Her husband then asked if she felt as though she could shout. "Yes," said she, and still waving her hand, she cried "Glory! Glory! Glory!"
The final day came. Through the course of the day, she appeared as usual and her mind was clear and serene. She was surrounded by friends and supported by her husband who documented her last hour. "I took her by the hand and asked her if her confidence held out? If Jesus was precious? And if she had a prospect of heaven? She pressed my hand, and said, 'yes,' and fell asleep in the arms of Jesus without a struggle or a groan."
Early nineteenth-century Americans named this triumphant passage to death "euthanasia." For them, the word signified a pious death blessed by the grace of God.

At a young age, Dr. Arthur E. Hertzler's daughter came down with a terminal illness, most likely typhoid fever.2 "In the saddest hour of my life, at the deathbed of my daughter," the nineteenth-century physician recalled, "on one side was the magnificent and always faithful Carrie the nurse, on the other side the incomparable Dr. Dampbell, calmly applying measures of resuscitation which he and I knew were utterly futile."
Futile though it was, the efforts of these professionals gave him an indescribable measure of comfort. "I know that my last conscious moments will picture that scene: nurse on one side of the bed, doctor on the other. Though scientifically futile, if my presence in a similar situation ever brought an equal amount of comfort to anyone I am sure it was more worth while than anything else I have ever done. Our mission in life is to lessen human suffering as much as we can."
"The ministers of the old days," wrote the doctor, "had an idea that something notable should take place at the moment of dissolution and seemed to think I should provide pabulum for their discourses." But quite to the contrary, Dr. Hertzler believed that "saints and sinners died alike," and that at the time of death, whatever might have been the antecedents, there was no pain.
For mid-nineteenth-century physicians, "euthanasia" meant a painless death accompanied by physician assistance.

In June 1887, Dr. Edward Thwing received a telegram summoning him to a distant city to tend to a relative stricken with apoplexy and hemiplegia.3 Given the age of the patient--a sixty-six-year-old widow--and the severity of the attack, death was assured within a day or two. She lingered, however, for five days, speechless and comatose. Her vigorous constitution succumbed slowly. Automatic movements, such as pulling at clothes, lifting her hand to her head, and other signs of restlessness continued until near the end.
The attending physician had left the case in Dr. Thwing's hands forty-eight hours earlier, believing that the patient's life would soon be over. Recalling the case Dr. Thwing noted: "The reality of suffering I could not admit, but the appearance of it in actions, purely reflex, was painful to me. As her only surviving kinsman, I took the responsibility of administering a mild anaesthetic, moistening a handkerchief at intervals from a vial containing two drachms of chloroform and six drachms of sulphuric ether." He held the handkerchief near the nostrils, but not too close so as to facilitate the free admixture of atmospheric air, and carefully studied the facial expression of the unconscious sufferer. After two or three minutes the stertor ceased. The spasmodic actions of the arm were arrested. Respiration became easier and there was a general repose. "Euthanasia," the physician reported, "was gained and an apparently painful dissolution avoided. Fifteen minutes after withdrawing the anaesthetic, the final breath came, without the slightest spasm of the glottis or respiratory muscles, without any other physical struggle or sound."
At the autopsy, one of the five physicians present described a case where, at the request of the parents, he had administered ether to a child suffocating in membranous croup and produced euthanasia, "not less to the relief of the parents than to that of the patient."

Only during the late nineteenth century did euthanasia gain its familiar meaning: the use of anaesthetics to guarantee a swift and painless death. Soon after, attempts were made to legalize euthanasia. The first pro-euthanasia organization in the United States, the Euthanasia Society of America, was founded in 1938. Today, proposals to legalize euthanasia are still being debated throughout the country, and one form of medically hastened death, physician-assisted suicide, is already legally practiced in Oregon.

This is a study of the history of euthanasia in the United States. The question before us is, How did the notion of euthanasia as the medical hastening of death emerge as a characteristically modern way of dying? To ask how euthanasia became possible is not to seek a simple causal explanation but rather to search for the deeper historic significance of this phenomenon. Reversing Rilke's question "What kind of beings are they then, who finally must be scared away by poison?"4 we may ask, Who is this modern man, for whom medical euthanasia has become a compelling way of dying? The answer lies in nineteenth-century changes in the ethics governing the deathbed, changes that still inform the way we die today.
What makes the medical hastening of death a modern way of dying is not simply that the time of death, in addition to the manner of dying, is determined by human will. That would make the medical hastening of death no different from suicide. Suicide is always an extraordinary act performed under extraordinary circumstances, whereas the medical hastening of death is meant to be a routinized response to a problem we all know we may face, the onset of a fatal illness. Attempts to institutionalize the medical hastening of death and legalize the practice are thus a significant aspect of the modern idea of euthanasia.
The first proposal to legalize medical euthanasia dates back to 1870, and it bears a striking resemblance to similar proposals made over a century later. These later proposals require that euthanasia be performed only by a professional physician and characteristically limit its scope to patients who are both hopelessly ill and suffering. History, to be sure, records "euthanasia" proposals prior to the nineteenth century. But these earlier proposals, made by Thomas More and Francis Bacon, differ in several important ways from those of the late nineteenth century.5 Most notably, More's proposal does not mention physicians at all,6 and Bacon's does not endorse active killing.7 Furthermore, the earlier proposals emerged in the philosophical and imaginary genre of utopias. The nineteenth-century proposals were the first to endorse the medical practice of euthanasia as an actual matter of a public policy.
It is common to think of the current euthanasia debate in relation to mid-twentieth-century advances in medical technique. But the modern problem of dying, namely the condition of hopeless suffering for which euthanasia is one proposed solution, predates the technical advances that are so commonly associated with it, such as life-support systems and advanced surgery. This study, in seeking euthanasia's deeper origins and significance, begins at the turn of the nineteenth century, when the modern problem of dying and the framework for its solution first emerged. It ends precisely where most scholarship on the topic begins--in the 1960s--and shows how most of what took place in the latter half of the twentieth century can be traced back to these earlier developments. This little-known story of euthanasia is the focus of the present study.8
The origins of medical euthanasia, I will argue, lie in a movement of dying from the domain of religion through that of medicine and finally into the jurisdiction of positive law and public policy. It is a movement that itself is driven, following Heidegger, by what I refer to as the rise of technique and the decline of art in our world.9 The story of euthanasia must be understood at three different levels. First, we must know the bare facts, the tale of the individuals and the movements that promoted the legalization of euthanasia in the late nineteenth and early twentieth centuries. Second, we must trace the emergence of euthanasia as a modern way of dying by following the gradual transformation of the ethics governing the deathbed.10 Finally, at a higher level of significance, we should reflect on the expanding technical search for mastery over death11 and the gradual shift of dying from a work of art to a product of technique. While the first level of analysis requires no further elaboration at this point, a brief discussion of the two other levels may shed light on the structure of the study as a whole.
The Changing Ethics of the Deathbed
In less than two centuries, the meaning of "euthanasia" has changed several times, and in radical ways. Though my interest lies more in the cultural history of practices than in the history of words and ideas, the history of deathbed practices can be told by tracking the unfolding definitions of "euthanasia" itself. These semantic changes capture the historic shifts in the ethics of the deathbed--understood broadly as the rules governing the conduct of dying, including religious, medical, and legal codes of conduct.
The literal meaning of "euthanasia" is quite removed from its contemporary usage. "Euthanasia" is a compound of two Greek words--eu and thanatos, which together signify a "good death" or an "easy death."12 For centuries, this literal sense was the only one conveyed by the word. An eighteenth-century medical definition of euthanasia is "a soft easy Passage out of the World, without Convulsions or Pain."13 This image of a good death is not foreign to the modern sensibility. But "good death" as "easy death" was exclusively a matter of divine providence or good fortune, and beyond human control. Euthanasia, in its original sense, was a death one could hope for but never be assured of.
For centuries, the deathbed in the Christian world was governed by religion, and euthanasia signified a death blessed by the grace of God. The dying person was encouraged to follow a certain course of behavior on his deathbed, which would constitute a holy way of dying and exemplify a holy way of living. These rules of conduct governing the last hour of life were put in writing and published in short manuals, known as ars moriendi, or "the art of dying." This mainly Protestant tradition was highly popular through the eighteenth century.14 In the United States, it made its final public appearance in the early nineteenth century, when the art of dying itself entered its terminal stage.
In order to understand the rise of medical euthanasia in the United States, it is crucial to comprehend this moment of transition, when the ars moriendi tradition finally faded from view. To explore its significance, the first chapter of this study examines the way in which Methodists, the largest organized religious community in early nineteenth century America, taught Americans how to die. More than any other religious group, Methodists were concerned throughout life with forming the proper disposition regarding death. They would gather around the deathbeds of neighbors and relatives to view the final departure and to meticulously document the hour of death. The final hour was a time of great exultation, in which the dying person, surrounded by family and friends, would approach the end like a fearless soldier ready to die a triumphant death. It is precisely this way of dying that the most celebrated of all New England Puritans, Cotton Mather, termed "euthanasia."15
The Methodist ethic of dying contrasted most strikingly with traditional Catholic notions of death. For Catholics, dying constituted the passing over a bridge between this world and the world to come. Deathbed rituals were a rite de passage, preparing those who were dying for their final journey into a better world. For Methodists, however, dying belonged to this world and signified the culmination of life, which subsequently lost its unique transformative power. The art of dying became an art of holy living, and dying became a problem of life proper. It is at this turning point in the history of dying that our story begins.
In the course of the nineteenth century, a relatively short span of time, both the sense of euthanasia and the law governing the deathbed changed. The decline of the art of holy dying was captured in an 1861 edition of the Sick Man's Passing Bell, an ars moriendi book first published early in the seventeenth century. The edition has a melancholy tone and especially laments the fact that when a man is dying, both the physician and the lawyer are sent for, but the "physician of the soul stands outside the door."16
A new way of dying was emerging, and its most visible sign was the increasingly dominant presence of the physician at the bedside. While physicians did attend the deathbed in earlier centuries, it was only in the nineteenth century that treatment of the dying, as such, became a medical concern and medically regulated. Whereas in previous centuries the medical doctor would leave the bedside when it was clear that the patient was hopelessly ill, a new ethic developed in which the physician was expected to remain present at the deathbed. The law of the deathbed had shifted from religion to medicine.
The idea of euthanasia changed accordingly. Euthanasia now stood for the new task of the medical profession--to assist dying patients in their last hours, short of hastening death. Euthanasia no longer meant a good death but rather signified the actions taken by physicians to achieve such a death.
The second chapter attempts to understand the new role of the physician at the deathbed and how this role opened the way for a claim that physicians should not merely help the patient to die an easy death but also actively hasten death. Why, until the present day, is the task of hastening death put in the hands of physicians, whose duty and expertise are precisely its opposite--to prolong life?
This new competence of the medical profession emerged neither from new scientific knowledge nor from technical advances in medicine. On the contrary, the physician's role at the deathbed was secured long before he had any medical treatment to offer the dying patient. It is precisely because physicians did not have the means to cure dying patients but nevertheless felt obliged to care for them that medical euthanasia emerged as a possible solution to the problem of dying. The second chapter shows the logic of these developments, in which euthanasia lost its benign sense of easing death and acquired a much more controversial meaning as a way to bring about death.
The third and fourth chapters examine attempts to legalize euthanasia, in the sense of hastening death, at the turn of the twentieth century. Until quite recently, the act of hastening death was unquestionably forbidden by law, as well as opposed by the medical profession. A famous story is related of Napoleon's physician, Desgenettes, who refused the emperor's request that he fatally drug severely plague-stricken soldiers to keep them from falling into enemy hands. Similarly, John Keats, dying of tuberculosis, could not persuade his physician to administer an overdose of laudanum.17 And yet it was not uncommon for physicians, in the privacy of the bedroom, to administer drug overdoses with the clear intention of bringing to an end the misery of their dying patients. What made euthanasia proposals scandalous was the fact that they turned a discreet, behind-closed-doors practice into a public affair. In attempting to make euthanasia legitimate, they also sought to bring the ethics of the deathbed under the jurisdiction of state law.
The question here, however, is not, How did the once-illegal practice of euthanasia become legal? After all, the medical hastening of death is still mostly illegal in the United States as well as around the world. Rather, we should ask, How did legalized euthanasia become a thinkable, even if not fully actualized, way to die?
The "legalization" of euthanasia entailed much more than repealing the prohibition of the practice; it called for its regulation. Whereas decriminalization is a removal of the legal sanction, regulation brings the practice under the domain of law. Proponents of legalized euthanasia viewed the law as an instrument to shape the conditions and safeguards under which euthanasia could be performed. Law was to play a central role in institutionalizing euthanasia, turning it from a discreet medical practice into a matter of public policy reform.
The power of state legislation to overrule common-law tradition was not as clear to jurists at the turn of the twentieth century as it is in the twenty-first. The general notion that the state could revise basic principles of common law to form new public policies became self-evident only at the turn of the twentieth century.18 Early attempts to legalize and regulate euthanasia took place precisely during this time of transition in which law became an integral part of public policy. The third chapter will draw our attention to this change in the concept of law and show how the history of euthanasia is as much a history of law as it is of dying.
Chapter 4 begins where chapter 3 ends: at the point when it is already clear that law is an instrument of public policy. Euthanasia, the term as well as the practice, underwent one final change. The practice, which to this point had been a specific medical solution to the specific issue of dying, now expanded. The medical hastening of death was now offered as a possible end to all kinds of suffering, such as that of the "physical handicapped" and the "mentally retarded." Furthermore, euthanasia came to be viewed as one part of a set of practices meant to control biological processes at both ends of life. Dying was no longer only a problem of the suffering individual; it had become a broader social concern.
Chapter 4 explores the history of the Euthanasia Society of America (ESA) and the way in which the society attempted, through the use of positive law, to turn euthanasia into public policy. In particular, it examines how the ESA fought to distinguish its euthanasia proposals from those of the Nazis, who wished to terminate all "life unworthy of living."
The fifth chapter considers another means of hastening the death of dying patients, one that does not go by the name of "euthanasia." In what I call "lethal dosing," the physician injects the patient increasing doses of pain-relief medication, intending only to relieve pain but knowing that it will probably hasten death. Despite its affinity with euthanasia, lethal dosing became a mundane practice openly encouraged by the medical profession without first being legalized. The metamorphosis of dying into a product of technique is all but accomplished with the disappearance of this practice of lethal dosing from public scrutiny.
It is quite remarkable that the practice of euthanasia underwent such a dramatic evolution in little more than a century. It is hard to imagine two ways of dying as distinct from one another as the Methodist death prevalent in early nineteenth-century America and the medically hastened death advocated in the latter half of the twentieth century. Yet not only do these two deaths bear the same name--euthanasia--but also manifest humanity's same wish to transform dying into a doing, and thus to bring death under the power of art at one end and technique at the other.
The final chapter addresses a different form of taking life that will be referred to as "mercy killing." Mercy killings are performed not by the medical profession but rather by a family member, such as when a daughter kills her cancer-ridden father. Mercy killings are noteworthy in that while the law clearly prohibits the practice and the state often presses charges against perpetrators, with few exceptions most mercy killers have been acquitted. On the part of the courts as well as the general public, the act of mercy killing is neither condemned nor approved; rather, it is viewed as being beyond the scope of man-made law. This merciful act of violence is contrasted to medical euthanasia to exemplify the difficulty in regulating the taking of human life and to point out the often-overlooked limits of positive law.
Dying from Art to Technique
Ethical considerations governing the deathbed have moved from religion through medicine to positive law and public policy. These transformations do not tell the full story of euthanasia, and themselves have a deeper historical significance. There are familiar theories to understand these historical changes, of which two are worth mentioning: the disenchantment of the world, as elaborated by Max Weber,19 and the rise of biopolitics, the term used by Michel Foucault to refer to government practices ordering biological processes.20 On the surface, these two understandings appear to be unrelated: one explains the decline of the old world, while the other describes the rise of a new order. Often the history of dying has suffered from a narrow focus on one of these processes at the expense of neglecting the other.21 This study accepts in principle the basic truth of both notions but seeks to expand the discussion by exploring their necessary interdependence. The inner relationship between the disenchantment of the world and the rise of biopolitics is evident if these two historical moments are rethought as one: namely, as the decline of art and the rise of technique in the modern world.22
Dying in the Christian world up until the nineteenth century was a work of art. The term "art" is used here in a specific sense that requires elaboration. Art is often conceived of as a sphere of cultural enterprise that centers around specifically designed art objects such as paintings, sculptures, or music. We thus expect to find art today in galleries, exhibitions, and concert halls. But this was not always the case, and the confinement of art to one sphere of human existence is a modern phenomenon that points to a general decline of art.
True art, as Heidegger observed, is known by its power to make the fullness of a life world visible through one being in that world. The Gothic cathedral is a work of art for it makes manifest in one being that which was most essential in the medieval Christian world. It is in the cathedral that Christians come together as a people to worship God and to face the truth of birth and death, this world and the world to come.
Dying, too, can be a work of art to the extent that in this one moment of life, the whole world of the dying can become present. In the life of the Christian believer, dying was a unique moment in the course of life. Yet it is precisely this uniqueness that allowed dying to capture life as a whole. Death was a moment of truth in which the dying person and those attending the deathbed faced the ultimate truths of Christendom: immortality of the soul, sin, and God's saving grace. Like the Gothic cathedral, dying could make visible the relation between man and God, heaven and earth.23