The right to die: a cross-national analysis of agenda setting and innovation

Through theories of agenda setting and innovation, the origin, development, and enactment of right-to-die policy in four Western nations—the United States, the Netherlands, Germany, and Great Britain—are examined. Different social and government structures produced varied right-to-die politics in each of these countries, although similar issues received more emphasis in Europe. However, it is discovered that policy entrepreneurs, organizations, and governments are important in similar ways in moving the issue from the public to the governmental agenda and to policy innovations in each country. The paper is concluded with a discussion of elements to be included in a model of agenda setting and innovation and with a proposal for the application of theory to a wider range of policies. During the past several decades there has been a dramatic increase in the ability of medicine to extend life and prolong the dying process, and much has been written about the right to die in magazines and newspapers, in religious, legal, and medical journals, and in books. However, most of this writing focuses on ethics and is designed to influence policymakers and practitioners. There is surprisingly little political analysis of the right to die. One exception involves the use of theories of agenda setting and innovation to analyze how the right-to-die issue originated and developed into state and national policies in the United States (Glick, 1992). Fino and Strate (1993) also have examined agenda setting in the evolution of physician-assisted suicide in Michigan. The right to die is not unique to the United States. New frontiers in medical technology accompanied by new ethical issues have made the right to die a controversial political and social issue in virtually all advanced industrialized nations. In this paper we survey the evolution of this issue in the United States and three other Western countries in order to broaden the understanding of the right to die in comparable settings and to contribute to the agenda-setting and innovation literatures in the emerging field of comparative public policy. We begin by distinguishing the various forms of the right to die. Next, we highlight the major elements of agenda setting and innovation. We apply these concepts to the politics of the right to die in the United States, the Netherlands, Great Britain, and Germany. This set of four postindustrial democracies reflects our desire for a 'most-similar-systems' design in which points of resemblance are more salient than those of difference (Przeworski and Teune, 1970). Quantitative and qualitative comparative research has been done on the right to die in the United States (Glick, 1992), and we rely on that research here, but for the three European countries we must reanalyze and interpret secondary sources. Data on agenda setting and innovation are most complete for the Netherlands, where the right to die has become a well-developed national policy, and we can glean sufficient information for Germany and Great Britain to provide comparative case studies. 480 J D Smith, H R Glick However, this research is exploratory, and we support the recommendations of Cobb and Elder (1972) stated more than two decades ago that research on agenda setting and innovation with more complete comparable cross-national studies, such as those by Leichter (1979) and Reich (1991), needs to be undertaken. Definitions of the right to die^ There are several distinctive right-to-die policies and proposals, which can be arranged on a continuum from the least to the most active measures. Passive euthanasia refers to the withdrawal and withholding of treatment, usually for patients who are terminally ill or in a permanent vegetative state. It is the least active and most widely accepted policy and includes removal or nonuse of nasogastric and implanted feeding tubes, the disconnection of ventilators and respirators, and compliance with do-not-resuscitate (DNR) orders. Decisions by conscious and competent patients to refuse unwanted, potentially lifesaving or life-prolonging, medical treatments are also included under the term passive euthanasia. Active euthanasia occurs when doctors or others take overt action to end a patient's suffering before a natural end to life. It may be voluntary or involuntary. In the former, which has been accepted in the Netherlands, a patient and/or the family asks another person, most likely a doctor, to terminate the patient's life. In the latter, others take it upon themselves to kill the suffering patient. Assisted suicide is closely related to voluntary active euthanasia, but some political figures in the United States consider it more controversial and thus 'more active', but this is not so elsewhere. In both voluntary active euthanasia and assisted suicide the patient asks others for help, but in assisted suicide the patient has more responsibility for the act that kills. Most discussion about assisted suicide assumes that physicians will be the primary agents, usually through prescriptions for sleeping pills or a fatal 'lytic cocktail'. However, in Germany, physician-assisted suicide appears rare, but privately assisted suicide has been promoted by right-to-die groups as the only alternative to severe suffering in a nation which refuses to sanction anything other than physician-controlled withdrawal of treatment. Consequently, societies may develop different orientations to assisted suicide. Agenda setting and innovation Agenda setting is focused on how social conditions transform into problems and possibly become subjects for governmental action, and innovation involves the adoption of new solutions to those problems.