The word “euthanasia” comes from the combination of the Greek words “EU” and “Thanatos” and means “ good death” and it was first used by the English philosopher Francis Bacon, who supported that "the role of medicine is to restore health and alleviate pain, not only when relief can lead to cure, but also when medicine may provide a peaceful and easy death". It is the painless assisted death, guided by compassion to those suffering from serious injuries, organ failure or incurable diseases. But as it becomes possible to extend the life of patients even without any hope of recovery because of technological advances, the term negative or passive euthanasia has also been used.

Passive euthanasia implies the withdrawal of any technical support that will occur to physical death due to the failure of one or more vital organs. In addition, this term is also connected with the cases where there is a strong and persistent demand by the patient to end his life before the expected, without the simultaneous organ failure, but mainly since there are permanent physical injuries that result in very serious mental disorders (depression).

The term euthanasia refers, as mentioned, to the cause of death to patients with incurable disease suffering without hope of treatment. The assisted death is always attempted by a physician and in some cases (e.g. brain death) even without the demand of the patient ( 7 ). King of England George V was subjected to this kind of euthanasia. In 1936, both Queen Mary and Prince of Wales Edward H (the later King of England) ordered Lord Dawson, the royal physician, to proceed to euthanasia for King George. Lord Dawson injected morphine and cocaine to assure him a painless death in time ( 8 ).

It is the active or direct intervention in the dying patient to release him from his suffering. This procedure regards to severely ill people while death occurs with a medical procedure, usually by drug injection. The decision to active euthanasia can be made by adult conscious patients, or relatives, friends or physicians for the unconscious ( 9 ).

Intentional discontinuation of treatment to a patient so as death will occur physically due to organ malfunctions. It is the cause of any artificial support used for extending "life" to an incurable person suffering from a disease. Different types of support include various devices to support breathing and heart, serum and blood transfusions, artificial oxygen supply, permanent catheters, etc ( 9 ).

A mentally stable patient, suffering from a degenerative end-stage disease that will lead to a complete loss of cognitive capacities and death, denies hospitalization and treatment, and asks help to achieve a premature death. He decides to end his life before undergoing the consequences of the disease. Assisted suicide can be as simple as getting drugs for committing suicide within the reach of the patient or help with intravenous injection ( 10 ).

Eugenic euthanasia involves people mentally retarded, physically disabled and unable to work with severe health problems unable to live a painless and independent life. The eugenic euthanasia (direct or indirect) is for the purpose of the health of society and for the discharge of the financial and psychological burden. This form of euthanasia tends to be extinguished due to the integration of people with “special needs” in differentmodern societies. Nowadays, eugenic euthanasia refers to children born with malformations, incurable diseases, without brain or malformations that result in neonatal death short time after birth. Therefore, abortion is also considered a type of eugenic ( 10 , 11 ).

Voluntary euthanasia is a way to reduce uncertainty about "end of life" care. Powered by the 'Right to die' group, in the voluntary euthanasia the patient signs a written statement (Living Will) where he makes a testament of how he wants the treatment to be or even that he refuses treatment if he becomes mentally unable to make a decision about his death ( 12 ).

Both the Orthodox and the Catholic Church have expressed their opinions on the issue of euthanasia. Theologians proclaim that life is a gift from God and no one is allowed to make decisions about it, denying the right of euthanasia even if it is the patient’s decision. The duty of every human being is to adjust his life to God's plan. The volitional death or suicide is just as reprehensible as a homicide, because in this way the sovereignty of God isn’t taken into account and the property of God is getting destroyed.

The Roman Catholic Church differs very slightly from the Orthodox Church only accepting the denial of a patient to be treated with any other than the traditional therapies. It even approves the discontinuation of such treatment when no possible health improvement is expected ( 13 ). Somehow this interpretation downgrades human meaning since it seems as if every patient is an object belonging only to God without having any will. But if euthanasia is incompatible with Christian guidance, we could say that refusing life support also promotes God’s fortune to be destroyed ( 13 – 15 ).

Every physician will have to deal with many factors prior to performing euthanasia (Figure 1). The opinion that doctors should never assist suicide does not take into account the complexity of personal meanings that life can have, and the right of maximum defending its prolongation. Those opposed to euthanasia and assisted suicide support the idea of life as it is, with life continuation being the supreme value for every human being.

Life, however, is not always treated like this. The case of permanent vegetative state is the most representative example of circumstances in which many people have lost appreciation of the true meaning of life. A patient in a vegetative state has lost irreversibly any ability of conscious experience. In this case, it is hard to believe that life has values and thus, it is not considered good anymore with many people supporting unable of continuing living like this ( 16 – 18 ). The most difficult cases of euthanasia include vegetative states in which the patient is kept alive by artificial methods for an extended time. These patients are not dead but will die shortly after removing mechanical support. Nevertheless, since not all vegetative states are permanent, euthanasia should be considered as an option only in incurable cases of permanent vegetative state. Such situations become "permanent" when the type and cause of brain damage last over a period of time defined by medicine, even though many times it is proven that patients have overcome a vegetative state years after this defined period has been overtaken. Last but not least, it is important to mention that keeping in life such patients may result in the denial of treatment to other patients with larger and more essential needs due to high medical costs ( 19 , 20 ).

The case of patients with AIDS represents another category, which may justify euthanasia. These patients will retain mental clarity and awareness even on the last stage of the disease. During this painful period, they are very weak with a great weight loss. They usually suffer from other serious complications such as diarrhea, painful ulcers and pulmonary failure that cause severe breathing. At this point, forthcoming death is mathematically sure. However, patients may live endless months of agony, having lost their dignity and expecting fatal complications of the disease ( 21 , 22 ).

In general, refusal or withdrawal of treatment is defensible in the following cases: a) when the patient has full mental capacity or when he is represented by a regulator or when the patient has given written and signed instructions b) the intervention itself includes certain ethical criteria such as when the patient is suffering from a serious incurable disease that will lead to death with absolute accuracy, at a predicted time, and when the comparison between the benefits and the burden is disproportionate. Other criteria include: a) the "quality of life" b) financial issues c) age (that, alone, should not constitute a criterion), even though HIV infection and social status are not considered as criteria and a conflict resolution system that protects ethical patients’ values needs to be established( 23 – 25 ). Although both assisted suicide and euthanasia are considered forms of killing, US doctors are less opposed to them due to their less legal responsibilities. In fact, in the Netherlands active euthanasia is more preferable because of the special relationship that doctors usually tend to create with their patients, feeling more obliged to leave the latter decide on their own. However, in order to allow active euthanasia four conditions are required: 1) the patient must be mentally stable, 2) the patient requests euthanasia persistently and repeatedly, 3) the doctor that will be in charge must consult another physician and 4) the patient must suffer intolerably even when on strong painkillers ( 23 , 26 ). It has been suggested that patients who request euthanasia should be examined by mental health specialists so as to confirm that there are no suicidal intentions. However, this opinion is controversial since not all criteria are objective enough (eg until 1973 homosexuality was considered a mental disorder). In addition, the existence of a large cultural gap creates doubts as to whether the mental health specialists can understand the real intentions of their patients ( 27 , 28 ).

The right to refuse treatmentlays on respecting the autonomy of the patients. Although there is a disagreement about the scope and severity of human autonomy, recognition of one's personal rights is considered a necessity. No rights are more sacred than the rights of individuals to possess and control their life without the intervention of any other than the law. Any adult who is mentally stable has the right to decide the fate of their body ( 18 , 29 ). The death of an infant, born without a brain or of an elderly, who has irreversibly lost contact with the environment, is considered more of a death of an organ system than that of a human being. Another area related to euthanasia is obstetrics. When prenatal testing identifies malformations and incurable birth defects, the physician has to proceed to a form of euthanasia ( 30 – 32 ). There is an uncountable number of the moral and social questions surrounding these global practices.

The world is becoming more complicated every passing day. Society needs honest and capable professionals characterized by acuity, who will reconstitute in an unprejudiced and transparent way the fabric of societal groups worldwide ( 12 , 18 ). Very few people have the ability to take the boat ashore when it has started for unfathomed waters. Digging the pages of history does provide us with some very good examples where capable people possessed the necessary keenness and prowess of judgment and insight as leaders to guide and raise society. Since people remain unaware, access to school and university educational programs and healthcare systems are of vital significance within outline of this outstanding target ( 33 ). Designing and setting up medical institutes will help uproot diseases. These reforms will ad hoc convert the face of the world in a colossal scale; there will be a high target for people to pursue high-level academic studies; the prerequisite undoubtedly for rebuilding a prosperous society. The global healthcare structured system will definitely make steps of improvement, innovation, and aspiration ( 34 ).

Humans should be capable of creating an appropriate, balanced liberal society: trace of how humanity can pace, to remind us that it is feasible for the human race to succeed, move in the right direction, which is straightforward. Centuries of creativity, entrepreneurship, cold realism, openness and collaboration compose the separate components to come up with solutions to the challenges society is facing today in the areas of health, ethical accent and internal balance, global security, renewable sources of energy, and climate changes ( 35 , 36 ). A healthy family life plays a vital role in the well-being of society. So to speak, any parent will openly admit that sustaining a marriage and establishing a strong family unit is a difficult task. The process of giving birth and growing children up to adulthood in such a way that the children become productive members of society abounds with challenges, obstacles, and rewards. A strong, stable family unit is not only worthwhile, but it is also a requirement for maintaining a healthy, vailing productive society. A potential decline in the strength and unity of the family will have a negative impact on the institutional nature of society ( 37 , 38 ). Human personality possesses an inherent dignity. Every human being who is terminally ill but mentally capable bears the inalienable right to evade unendurable excruciating pain and decide on a dignified and compassionate death ( 12 , 14 , 24 ). Any mentally competent person who is suffering from an incurable and painful disease has the protected constitutional right to reject medical treatment, decide on a painless killing or even request an abortion in case of gestation. The practice of ending a life prematurely in order to relieve pain in an otherwise terminally ill patient seems to be a humane option ( 39 ). There is no need to lengthen the life of a patient with no chance of rejoining society, being productive again and having an impaired decision-making capacity. From a human rights perspective the freedom of thought, free consciousness, and the right to practice religion are well documented. Terminally ill subjects have the right on their physical and mental integrity, they possess the right to make a decision with regards to their privacy and self-determination. The constitutional right to hold and defend a belief is an absolute and crucial component of an integrated human personality. The desire to control ones’ own death, the wish to die in the unique family environment, being in a position to decide for one’s self are distinctive features of a completely different, separated from the mass, mature and unique human being ( 12 , 15 , 18 , 23 ).

Ethical dilemmas and thoughts appear when there are values, different ways to approach them and a subsequent conflict. Euthanasia can be either non-voluntary or voluntary; if it is performed on a person who is totally incapacitated and not being able to give or withhold consent regarding his death. Euthanasia raises the potential for a prominent and visible dangerous situation wherein physicians can be subject to legal proceedings with regards to the patients’ legal right of denying basic life-sustaining medical treatment or requesting an abortion. That being the case, euthanasia remains one of the most tormented terms in the court of justice and in bioethics ( 5 , 13 ).

In current trajectory, euthanasia application is considered to be extremely difficult for some societies to accept, due to contradicting ideas, cultural and societal differences, the instinct of survival and the influence of religion. Autonomy in these societies seems to be originated from outer sources rather than the patient's criteria ( 13 – 15 , 40 ).

Derived from the Greek words ‘autos’ and ‘nomos’, autonomy was used primarily in bioethicalphilosophy,meaning self-governance and discipline. The term autonomy refers to obedience to objective moral law, it provides the framework for the creation of a self-sustained and independent society ( 42 , 43 ). Autonomous subjects are those persons capable of enforcing deliberate, decisive and meaningful choices, choices consistent with their own values, motives, and ideas – making and enforcing their own laws based on the way they grew up and on an often fully functional and competent brain. They are those persons with the cognitive and emotional strength, competence, and capacity to decide for themselves. Non-autonomous persons, on the other hand, cannot decide for themselves. They demonstrate the deficit to compare themselves with others. This may be because of familial, cultural, or social origin, lack of mental capacities or even worse the inability of the inappropriate adherence and dependence on others. Autonomy, as a rule, makes the patient’s ‘own priorities and ideas’ the focal point; but never the sole point, of medical care. Competent patients have a right to reject any and all medical care ( 44 ).

Patients forced by the intrinsic momentum of autonomy, possess the right to make choices on the type of healthcare they wish to receive. The right to a second opinion is an important corollary of this, as is the right to information. Patients can choose to have medical tests or operations, including the formation of medical advisory boards as required in these kind of circumstances. Based on their financial status, depending on the social circumstances, availability, and the level of the health care system, patients have the power to request pretty much everything nowadays in the developed and developing world ( 45 , 46 ) People express and exercise their autonomy in various ways. Supporters of euthanasia account for its legalization by reasoning that bias, prejudice, and fear against disability play a vital role; the wish of euthanasia should be respected ( 47 ).

The standard principle of autonomy permits patients to define the borders of their own life and death. Even if these borders seem straightforward, simultaneously they might appear not concise and perhaps whirred. Provided these borders are not seriously violated, they should be respected, and not disregarded, by medical doctors. The act of euthanasia involves, in reality, the ‘invasion’ of a subject’s physical and cognitive privacy. For the patient, euthanasia involves the occult debt of self-determination. Performing correctly and efficiently in a clinical setting under severe and continuous pressure in medical science might prove out to be the most tedious undertaking. For patients classified as terminally ill and not being able to consent to euthanasia, their right to terminate the unrelievable and excruciating pain and discomfort at their final stages of life is being impaired and waived ( 48 ).

Patients’ unwillingness to share medical and personal information with their physician would a major obstacle in the practice of medical science. Clinical doctors should demonstrate the principle of respect, discretion, avoidance of disclosure in the highest degree with terminally diseased patients, and their wishes. Not with standing that the medical confidentiality is protected by constitutional law, occasionally the principles of privacy and discretion turn out to be hard to serve for reasons of medico-public security ( 49 , 50 ).

Rational thinkingfor consent is a legal concept. Consent combined with the notion of justice is fundamental to the modern liberal fabric of democracy. John Stuart Mill noted concisely in his manuscript, On Liberty: ‘the only purpose for which power can be rightfully exercised over any member of a civilized society, against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant’ ( 51 ). The refusal of life-sustaining treatment in a terminal illness by a patient should not be regarded as an independent and sincere option. The prudent medical professional should keep in mind the possible distracting personal features of the patient’s life, i.e., disabilities, personality drawbacks, alcoholism, narcotics or psychiatric status that may severely affect an unbiased decision making procedure. Denial of treatment is triggered by problems such as insufficient communication within the societal groups, the absence of caring and prudence, the dominance of poor family interconnection or social relationships ( 14 , 16 , 17 , 20 , 24 ).

When the patients feel close to the end of their lives and suffer without being capable of relieving the pain, they no longer tend to worth living for. For many patients, the continuation of life under such conditions is not the supreme value anymore. Fear of losing control, together with the loss of dignity, combined with the financial burden that comes along too, appears to be one of the motivating factors that lead to euthanasia ( 52 – 54 ).