Assisted Suicide and Euthanasia: A Comparative Analysis of Dutch and East Asian Cases

This article refers to:

From Reciprocity to Autonomy in Physician-Assisted Death: An Ethical Analysis of the Dutch Supreme Court Ruling in the Albert Heringa Case

The target article (Florijn 2022) describes a Dutch case that happened in 2008, where Albert Heringa helped his 98-year-old mother, whose general practitioner rejected her request for an assisted death, to commit suicide by mixing pills in her food. After a lengthy series of court cases that spanned from 2010 to 2019, the Dutch Supreme Court upheld the ruling of the Court of Appeal, and Heringa was convicted of the crime of assisted suicide with a conditionally suspended prison sentence of six months (Teller Report 2019). In this commentary, we present two similar cases of family-assisted suicide in East Asia. Since assisted suicide and euthanasia remain controversial issues worldwide, we aim to enrich the understanding of these issues through cross-cultural dialogue.

The first case is the “Nagoya High Court Decision of 1962,” which is one of the most important legal precedents involving the issue of death and dying in Japan. In this case, a son prepared poisoned milk to help his terminally-ill father commit suicide in line with his father’s request to spare him continued pain and suffering. The son was charged with “ascendant homicide” and was subsequently prosecuted. The Nagoya High Court identified strict conditions that must be fulfilled before one is legally permitted to end a suffering patient’s life: (1) the patient’s situation should be regarded as incurable with no hope of recovery, and death should be imminent; (2) the patient must be suffering from unbearable and severe pain that cannot be relieved; (3) the act of killing should be undertaken with the intention of alleviating the patient’ pain; (4) the act should be done only if the patient himself or herself makes an explicit request; (5) the euthanasia should be carried out by a physician, although if that is not possible, special situations will be admitted for receiving some other person’s assistance; and (6) the euthanasia must be carried out using ethically acceptable methods. This case met the first four criteria, but not the final two criteria. In the Japanese legal system, ascendant homicide, or the killing of one’s lineal ascendant or the lineal ascendant of one’s spouse, is considered a more serious crime than ordinary homicide and is punishable by capital punishment or life imprisonment. However, after consideration of the son’s filial duty to follow his father’s spoken directives, the Court imposed a lesser sentence for the defendant—four years imprisonment with three years suspended (Sass, Veatch, and Kimura 1998).

In the second case, a 54-year-old Chinese man, Liu Shabo, was prosecuted for helping his wife commit suicide in 1994. They were married for over 30 years and maintained a good relationship. After being diagnosed with advanced liver cancer, his wife frequently endured severe pain and requested him several times to bring sleeping pills for her to commit suicide. On the night of September 8, his wife begged him again to end her life due to her unbearable suffering. Mr. Liu could not stand the miserable situation of his wife any longer, yet he could not find any sleeping pills. In desperation, he prepared a cup of pesticide for his wife and let her die in his arms. Mr. Liu was later charged with the crime of homicide. However, while sorting through their mother’s belongings after her death, the couple’s children found a note saying that she wanted to die and end her suffering, and Mr. Liu eventually received a lesser sentence of three years in prison (Tomlinson 1995).

It is clear that there is a huge gap in legislation between the Netherlands and East Asian countries. As the first country to legalize euthanasia and assisted suicide, in 2001, the Netherlands permitted a physician to provide assisted dying to a patient whose suffering the physician assessed as unbearable. Furthermore, in the Netherlands, the debates currently have extended to whether healthy (older) people who value their life as completed should have access to assistance in dying based on their autonomous decision-making (Florijn 2022). In East Asia, many decades after the aforementioned legal precedents, similar cases still arise where dying persons who cannot bear the immense pain commit family-assisted suicide. While Japan is the first country to form case laws on euthanasia in Asia, there is still no statutory law permitting euthanasia and physician-assisted suicide, even after the six legal requisites for euthanasia established by the Nagoya High Court in 1962 were revised into four new legal requisites by the chief judge at the Yokohama District Court to make a legal distinction between murder and euthanasia in rendering a judgment in the murder case of a physician in 1995 (Hoshino 1996; Sass, Veatch, and Kimura 1998). Except for the “Act on Decisions on Life-Sustaining Treatment for Patients in Hospice and Palliative Care or at the End of Life” (2018) in Korea that permits the withdrawal of life-sustaining treatment from patients at the end of life, and Taiwan’s “Patient Right to Autonomy Act” (2019) in China, which allows treatment withdrawal from terminally ill patients and any patient who is in an irreversible coma, in a vegetative state, has severe dementia, or otherwise suffers from unbearable pain (Tanaka et al. 2020), euthanasia and physician-assisted suicide are still illegal in Korea and China.

Since these East Asian countries share a similar cultural background and are deeply influenced by Confucianism, we explore the common cultural factors that played a crucial role in blocking the legislation of euthanasia and physician-assisted suicide in these countries.

First, the Confucian view of life and death emphasizes life rather than death. Life has been valued as something precious that one should not easily give up (Zhang et al. 2021c); death is a taboo that is not widely discussed. Accordingly, people are influenced to shy away from choosing a more peaceful way to die even in cases of terminal illnesses and to prolong their lives as long as possible. Second, Confucianism emphasizes “xiao” (filial piety) as a virtue to be held above all else, which requires care, obedience, and devotion toward one’s parents and elderly family members. Whether all parents and the aged receive good care can be seen as a test of social harmony (Fan 1999). If one’s life was ended prematurely, his/her children would suffer both private and public moral condemnation. Therefore, people generally do not agree with euthanasia or physician-assisted suicide for their family due to the fear of being regarded as “unfilial” and their concern over their individual reputations. Third, Confucianism believes that the family is the most fundamental unit in social organizations and emphasizes the importance of interpersonal relations. Compared to Western countries, the aforementioned countries in East Asia traditionally place more emphasis on families rather than individuals. As such, elderly individuals may entrust their healthcare decisions to their family members. Family-based decision-making is regarded as a reasonable approach; healthcare professionals have largely relied on the opinions of the family members rather than the patient’s explicit consent, especially when it comes to a cancer diagnosis (Kwon et al. 2015; Masaki, Ishimoto, and Asai 2014; Zhang et al. 2021a, 2021b). Hence, death is regarded as a family event and not an individual event (Sass, Veatch, and Kimura 1998). Fourth, influenced by the concept of “ren” (humaneness, benevolence, love), which is the core principle of Confucianism, physicians always perceive medicine as the art of humaneness (Nakazawa et al. 2019; Zhang et al. 2021c). Traditional medical ethics require physicians to value every life and try their best to prevent death. Moreover, in East Asian medical practice, where physicians are increasingly wary of possible lawsuits, there is an increasing dependency on clearly defined legal documents (Kwon et al. 2015). Therefore, in the absence of legal protection, few physicians dare to help patients seeking euthanasia or assisted suicide. When faced with a conflict between their duty to protect life and relieve suffering, most physicians prefer to protect their patients’ lives.

In sum, since attitudes and behaviors toward death in East Asian countries are largely influenced by local culture, the process of legalizing euthanasia and assisted suicide has met a great deal of resistance. Furthermore, whether elderly people who value life as completed should be granted the option of euthanasia and physician-assisted suicide may face more controversy and opposition in these countries. Although euthanasia and physician-assisted suicide are not widely understood and accepted in East Asian countries, there are growing calls to legalize them. Based on an analysis of important historical cases and Confucian culture in East Asia, we attempt to compare the differences between the Netherlands and East Asian countries regarding assisted suicide and euthanasia. We believe that such a dialogue will be beneficial for critical thinking on the relevant laws and policies, as well as the consideration of Western bioethics and East Asian culture in a complementary manner.

DISCLOSURE STATEMENT

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the National Key R&D Program of China [Grant No. 2018YFC0114500]; and Medical Science and Technology Program of Henan Province [Grant No. LHGJ20200025].