euthanasia is always morally wrong essay

The Ethics of Euthanasia

Malleeka Suy | SQ Blogger | SQ Online (2021-2022)

Picture t his: It is the year 3020, and the Martian soil you have been drilling into has finally worked out. Colonizing Mars is taking shape, and soon your family can permanently live on this rusty, rocky planet. However, the effects of progress don’t go unnoticed; every time you move, your skin screams in pain. Everything you once loved doing has lost its appeal. Would you take death in your own hands or live until a painful end?

This moral dilemma seems straight out of a science-fiction novel for most, but euthanasia is a legitimate deliberation for patients with terminal and mental illnesses who deem their lives too painful to live on. It is a practice that is still heavily debated in modern bioethics. Among many definitions, the American Medical Association defines euthanasia as the administration of a lethal agent by a medical professional to a patient to relieve their intolerable or incurable suffering.

Although euthanasia is not a new scientific process, as it has been practiced since the time of the ancient Greeks more than three thousand years ago, it wasn’t generally accepted by Western medicine until recently. The Netherlands was the first country to allow legal euthanasia and assisted suicide in 2002, totaling 1.7-2.8% of total deaths. Euthanasia is generally illegal in the United States, but in a nationwide 2017 American poll , 73% of the public were in favor of euthanasia, and 57% said euthanasia is morally acceptable. These numbers are nearly double the initial poll in 1947. If I had to guess why, it may be partly because of progressive exposure to mental health and its effects. This may have allowed people to understand and empathize with the circumstances and support what euthanasia stands for: a release from an unbearable life.

Euthanasia is especially controversial among general society and the bioethical community. One main argument for the support of euthanasia is grounded in personal autonomy–our ability to act independently– since living life is about minimizing physical pain and maximizing dignity and control . This idea is rooted in ancient times when physicians considered dying with peace and dignity a human right. An article from Stanford’s Encyclopedia of Philosophy regards autonomy as self-determination, so choices about how and when people die is them taking responsibility for their lives. Terminally ill patients in Oregon mentioned how they chose euthanasia because their condition stripped them of their independence and ability to engage in activities that gave their life meaning. After all, what is the meaning of life if we cannot live it?

Another article by the Linacre Quarterly highlights how the ethics of compassion justify the use of euthanasia. From a humanitarian standpoint, we can show compassion by suffering and sympathizing with patients and respecting their wishes of euthanasia as their “remedy.” Kenneth L. Vaux, a consultant in medical ethics, notes in his article that physicians would give a lethal dose to their loved ones out of love if they were dying and suffering, so he finds it “strange and hypocritical” that doctors cannot legally do so for their patients. He claims that “we have lost empathy, sympathy, and the covenant of care with those who have entrusted their lives to us because they believe we embody those very qualities.” Vaux also asks: “Having barred the door to Death, are we not then obliged at some point to open it?” He suggests that since doctors bring life into the world every day, consensually ending a patient’s life for their benefit should be no different.

Despite popular social support, there are many arguments against euthanasia as well–the most popular being religion. Several faiths, such as Christianity, see euthanasia as a form of murder and find it to be morally unacceptable because it may weaken society’s respect for the sanctity of life. Religious groups actively argue against euthanasia, and for this reason, euthanasia became a debate of preservation and purity of life.

Even though medicine is rooted in science, some physicians also use religion as justification against practicing euthanasia. Contrary to public British opinion, studies show that most UK doctors do not support legislation permitting euthanasia due to their religiosity or faith, and less than a quarter of doctors would be willing to practice euthanasia if it became legal.

Physicians also have a professional obligation to fulfill that becomes morally blurred with euthanasia. For more than 2,500 years, doctors have taken the Hippocratic Oath to do no harm and treat those under their care. Does bringing death by euthanasia violate the Hippocratic Oath, or is it in line with a doctor’s mission? Would acting under Hippocrates then make a doctor a hypocrite?

Because of this subjectivity, doctors sometimes feel uncertain about administering euthanasia. Even if a patient is under a lot of pain and medication, how can doctors be sure that their decision was made rationally? In a Dutch article , an experienced psychiatrist dealing with a patient’s invisible suffering made him uncertain about assessing how deeply rooted their suffering really was, and therefore how moral it would be to allow euthanasia to happen. The fickle nature of the human mind makes many physicians and ethicists question whether or not euthanasia should be a normal practice.

Physicians often have their own reservations about euthanasia and how they cope with patients who wish for it. They frequently feel pressured by the patient or the patient’s relatives to perform euthanasia. A 2011 survey among Dutch physicians also found that 86% of physicians dread the emotional burden of performing euthanasia. One physician recounts how a patient told them, “If you won’t perform euthanasia, I might go to a railway line or climb a high building.” This form of blackmail can lead to dangerous expectations, where future normativity of the practice is anticipated or even praised.

Instead of placing the burden on doctors, what if the government or even robots could control euthanasia? Although this faceless jurisdiction seems like a good solution, critics argue that euthanasia would be normalized and twisted for eugenic purposes, adding to the nightmare of AI domination and impeding the sanctity and preciousness of life. These speculations seem inconceivable, but history has unfortunately seen it happen, such as in Hitler’s Germany, where Aktion T4, a Euthanasia Program systematically murdered patients with disabilities to restore the “integrity” of the German nation, thrived. Perhaps then a grimmer alternative to the use of euthanasia is the elimination of incurable, disabled, or elderly patients. Mechanization of euthanasia would also impact the patient and the medical profession, both in what it means to be human and obeying the Hippocratic Oath. Routinization of the practice could also increase the desires of people’s wishes to end their lives, whether individually justified or not.

References:

https://jamanetwork.com/journals/jama/article-abstract/2532018

https://plato.stanford.edu/entries/euthanasia-voluntary/#MoraCaseForVoluEuth

http://www.cirugiaycirujanos.com/frame_esp.php?id=308

https://www.sciencedirect.com/science/article/pii/S0885392414003066?via%3Dihub

https://www.healthline.com/health/what-is-euthanasia#making-a-decision

https://livinganddyingwell.org.uk/wp-content/uploads/2020/02/Redefining-Physicians-Role-in-Assisted-Dying.pdf

https://shibbolethsp.jstor.org/start?entityID=urn%3Amace%3Aincommon%3Aucsd.edu&dest=

https://www.jstor.org/stable/3561966&site=jstor

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https://journals.sagepub.com/doi/10.1177/0269216310397688

https://www.nejm.org/doi/10.1056/NEJMclde1310667

https://medicine.missouri.edu/centers-institutes-labs/health-ethics/faq/euthanasia

https://news.gallup.com/poll/211928/majority-americans-remain-supportive-euthanasia.aspx

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https://encyclopedia.ushmm.org/content/en/article/euthanasia-program

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Why is the ethics of euthanasia wrong?

Affiliation.

• 1 Vytautas Magnus University, Gimnazijos g. 7, LT-3000 Kaunas, Lithuania.
• PMID: 16294446

Human beings are made in the image and likeness of God and are therefore of intrinsic worth or value, beyond all prices. Almost all Christian pro-life arguments spring from the fountain of personal dignity. Euthanasia would make moral sense only if it were possible to say, morally, that this dignity had vanished. To commit euthanasia is to act with the specific intention that somebody should be nobody. This is the fundamental error of all immorality in human relations. To commit euthanasia is to fail to see the intrinsic worth or dignity of the person. The judgement that what has worth, intrinsically, somehow does not have worth, is both logically and morally wrong. The ethics of euthanasia is based on dualistic anthropology and wrong moral presuppositions underlying the defence of euthanasia, namely, proportionalism and consequentialism. The basic claim of proponents of the ethics of euthanasia is that human persons are consciously experiencing subjects whose dignity consists of their ability to made choices and to determine their own lives. Bodily life, according to them, is a condition for personal life because without bodily life one cannot be a consciously experiencing subject. It means that bodily life is distinct from personal life. Thus, the body and bodily life are instrumental goods, goods for the person, not goods of the person. It thus follows that there can be such a thing as a life not worth living--one can judge that bodily life itself is useless or burdensome, and when it is, the person, i.e., the consciously experiencing subject, is at liberty to free himself of this useless burden. Today a key in fighting euthanasia and assisted suicide is better care for the sick and dying. The dignity of the sick cannot be erased by illness and suffering. Such procedures are not private decisions; they affect the whole society. Death with dignity, in the end, is the realisation that human beings are also spiritual beings. We have to promote the way of caring for the dying in which mercy is extended to the patients without inducing death.

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We have a right to die with dignity. The medical profession has a duty to assist

Distinguished Professor of Philosophy and Director: Centre for Applied Ethics, Stellenbosch University

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Anton van Niekerk is director of the Centre for Applied Ethics and Head of the Unit for Bioethics in that Centre. The Unit receives an annual contribution from Mediclinic, but that is not for the exclusive use of Anton van Niekerk.

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Euthanasia represents one of the oldest issues in medical ethics. It is forbidden in the original Hippocratic Oath, and has consistently been opposed by most religious traditions since antiquity – other than, incidentally, abortion, which has only been formally banned by the Catholic Church since the middle of the 19th century.

Euthanasia is a wide topic with many dimensions. I will limit myself in this article to the issue of assisted death, which seems to me to be one of the most pressing issues of our time.

Desmond Tutu, emeritus archbishop of Cape Town, raised it again on his 85th birthday in an article in the Washington Post. He wrote:

I have prepared for my death and have made it clear that I do not wish to be kept alive at all costs. I hope I am treated with compassion and allowed to pass onto the next phase of life’s journey in the manner of my choice.

Assisted death can take the form of physician assisted suicide (PAS) . Here a suffering and terminal patient is assisted by a physician to gain access to a lethal substance which the patient himself or herself takes or administers. If incapable of doing so, the physician – on request of the patient – administers the lethal substance which terminates the patient’s life.

The latter procedure is also referred to as “voluntary active euthanasia” (VAE). I will not deal with the issue of involuntary euthanasia –where the suffering patient’s life is terminated without their explicit consent -– a procedure which, to my mind, is ethically much more problematic.

Passive form of euthanasia

The term “voluntary active euthanasia” suggests that there also is a passive form of euthanasia. It is passive in the sense that nothing is “actively” done to kill the patient, but that nothing is done to deter the process of dying either, and that the termination of life-support which is clearly futile, is permitted.

However, the moral significance of the distinction between “active” and “passive” euthanasia is increasingly questioned by ethicists. The reason simply is the credibility of arguing that administering a lethal agent is “active”, but terminating life support (for example switching off a ventilator) is “passive”. Both clearly are observable and describable actions, and both are the direct causes of the patient’s death.

There are a number of reasons for the opposition to physician assisted suicide or voluntary active euthanasia. The value bestowed on human life in all religious traditions and almost all cultures, such as the prohibition on murder is so pervasive that it is an element of common, and not statutory, law.

Objections from the medical profession to being seen or utilised as “killers” rather than saviours of human life, as well as the sometimes well-founded fear of the possible abuse of physician assisted suicide or voluntary active euthanasia, is a further reason. The main victims of such possible abuse could well be the most vulnerable and indigent members of society: the poor, the disabled and the like. Those who cannot pay for prolonged accommodation in expensive health care facilities and intensive care units.

Death with dignity

In support of physician assisted suicide or voluntary active euthanasia, the argument is often made that, as people have the right to live with dignity, they also have the right to die with dignity. Some medical conditions are simply so painful and unnecessarily prolonged that the capability of the medical profession to alleviate suffering by means of palliative care is surpassed.

Intractable terminal suffering robs the victims of most of their dignity. In addition, medical science and practice is currently capable of an unprecedented prolongation of human life. It can be a prolongation that too often results in a concomitant prolongation of unnecessary and pointless suffering.

Enormous pressure is placed upon both families and the health care system to spend time and very costly resources on patients that have little or no chance of recovery and are irrevocably destined to die. It is, so the argument goes, not inhumane or irreverent to assist such patients – particularly if they clearly and repeatedly so request – to bring their lives to an end.

I am personally much more in favour of the pro-PAS and pro-VAE positions, although the arguments against do raise issues that need to be addressed. Most of those issues (for example the danger of the exploitation of vulnerable patients) I believe, can be satisfactorily dealt with by regulation.

Argument in favour of assisted suicide

The most compelling argument in favour of physician assisted suicide or voluntary active euthanasia is the argument in support of committing suicide in a democracy. The right to commit suicide is, as far as I am concerned, simply one of the prices we have to be willing to pay as citizens of a democracy.

We do not have the right, and we play no discernible role, in coming into existence. But we do have the right to decide how long we remain in existence. The fact that we have the right to suicide, does not mean that it is always (morally) right to execute that right.

It is hard to deny the right of an 85-year-old with terminal cancer of the pancreas and almost no family and friends left, to commit suicide or ask for assisted death. In this case, he or she both has the right, and will be in the right if exercising that right.

Compare that with the situation of a 40-year-old man, a husband and father of three young children, who has embezzled company funds and now has to face the music in court. He, also, has the right to commit suicide. But, I would argue, it would not be morally right for him to do so, given the dire consequences for his family. To have a right, does not imply that it is always right to execute that right.

My argument in favour of physician assisted suicide or voluntary active euthanasia is thus grounded in the right to suicide, which I think is fundamental to a democracy.

Take the case of a competent person who is terminally ill, who will die within the next six months and has no prospect of relief or cure. This person suffers intolerably and/or intractably, often because of an irreversible dependence on life-support. This patient repeatedly, say at least twice a week, requests that his/her life be terminated. I am convinced that to perform physician assisted suicide or voluntary active euthanasia in this situation is not only the humane and respectful, but the morally justified way to go.

The primary task of the medical profession is not to prolong life or to promote health, but to relieve suffering. We have a right to die with dignity, and the medical profession has a duty to assist in that regard.

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Euthanasia and assisted dying: the illusion of autonomy—an essay by Ole Hartling

Read our coverage of the assisted dying debate.

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As a medical doctor I have, with some worry, followed the assisted dying debate that regularly hits headlines in many parts of the world. The main arguments for legalisation are respecting self-determination and alleviating suffering. Since those arguments appear self-evident, my book Euthanasia and the Ethics of a Doctor’s Decisions—An Argument Against Assisted Dying 1 aimed to contribute to the international debate on this matter.

I found it worthwhile to look into the arguments for legalisation more closely, with the hope of sowing a little doubt in the minds of those who exhibit absolute certainty in the matter. This essay focuses on one point: the concept of “autonomy.”

(While there are several definitions of voluntary, involuntary, and non-voluntary euthanasia as well as assisted dying, assisted suicide, and physician assisted suicide, for the purposes of brevity in this essay, I use “assisted dying” throughout.)

Currently, in richer countries, arguments for legalising assisted dying frequently refer to the right to self-determination—or autonomy and free will. Our ability to self-determine seems to be unlimited and our right to it inviolable. The public’s response to opinion poll questions on voluntary euthanasia show that people can scarcely imagine not being able to make up their own minds, nor can they imagine not having the choice. Moreover, a healthy person answering a poll may have difficulty imagining being in a predicament where they simply would not wish to be given the choice.

I question whether self-determination is genuinely possible when choosing your own death. In my book, I explain that the choice will always be made in the context of a non-autonomous assessment of your quality of life—that is, an assessment outside your control. 1

All essential decisions that we make are made in relation to other people. Our decisions are affected by other people, and …

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Voluntary Euthanasia

The entry sets out five conditions often said to be necessary for anyone to be a candidate for legalized voluntary euthanasia (and, with appropriate qualifications, physician-assisted suicide), outlines the moral case advanced by those in favor of legalizing voluntary euthanasia, and discusses the five most important objections made by those who deny that voluntary euthanasia is morally permissible and who are, in consequence, opposed to its being legalized.

1. Introduction

2. five conditions often proposed as necessary for candidacy for voluntary euthanasia, 3. a moral case for voluntary euthanasia, 4. five objections to the moral permissibility of voluntary euthanasia, other internet resources, related entries.

When a person performs an act of euthanasia, she brings about the death of another person because she believes the latter’s present existence is so bad that he would be better off dead, or believes that unless she intervenes and ends his life, his life will very soon become so bad that he would be better off dead. Accordingly, the motive of the person who performs an act of euthanasia is to benefit the one whose death is brought about. (This also holds for many instances of physician-assisted suicide, but use of the latter term is usually restricted to forms of assistance which stop short of the physician ‘bringing about the death’ of the patient, for example, those involving means that have to be activated by the patient.)

It is important to emphasize the motive of benefiting the person who is assisted to die because well-being is a key value in relation to the morality of euthanasia (see Section 3 below). Nonetheless, the defensibility of the contention that someone can be better off dead has been the subject of extensive philosophical deliberation. Those who claim that a person can be better off dead believe this to be true when the life that remains in prospect for that person has no positive value for her (a possibility which is discussed by e.g., Foot, 1977; McMahan 2002; Bradley 2009), whereas some of those who hold that a person’s life is inviolable deny that a person can ever be better off dead (e.g., Keown in Jackson and Keown 2012). A Kant-inspired variant on this latter position has been advanced by Velleman (1999). He considers that a person’s well-being can only matter if she is of intrinsic value and so that it is impermissible to violate a person’s rational nature (the source of her intrinsic value) for the sake of her well-being. Accordingly, he holds that it is impermissible to assist someone to die who judges that she would be better off dead and competently requests assistance with dying. The only exception is when a person’s life is so degraded as to call into question her rational nature, albeit he thinks it unlikely that anyone in that position will remain competent to request assistance with dying. This position appears to be at odds with the well-established right of a competent patient to refuse life-prolonging medical treatment, at least when further treatment is refused because she considers that her life no longer has value for her and further treatment will not restore its value to her. (For further reasons to reject arguments for the inviolability of the life of a person, including Velleman’s, see e.g., McMahan 2002; Young 2007; Sumner 2011, 2017.)

Because our concern will be with voluntary euthanasia – that is, with those instances of euthanasia in which a clearly competent person makes a voluntary and enduring request to be helped to die (or, by extension, when an authorised proxy makes a substituted judgment by choosing in the manner the no-longer-competent person would have chosen had he remained competent) – a second key value is the competence of the person requesting assistance with dying. There will be occasion to mention non-voluntary euthanasia – instances of euthanasia where a person lacks the competence at the time when a decision is to be made to request euthanasia and has not previously competently declared a preference for it via an advance directive (see the entry on advance directives ) – only when consideration is given to the claim that permitting voluntary euthanasia will lead via a slippery slope to permitting non-voluntary euthanasia. Nothing will be said here about involuntary euthanasia , where a competent person’s life is brought to an end despite an explicit expression of opposition to euthanasia, beyond saying that, no matter how honorable the perpetrator’s motive, such a death is, and ought to be, unlawful.

Debate about the morality and legality of voluntary euthanasia has been, for the most part, a phenomenon of the second half of the twentieth century and the beginning of the twenty first century. Certainly, the ancient Greeks and Romans did not believe that life needed to be preserved at any cost and were, in consequence, tolerant of suicide when no relief could be offered to a dying person or, in the case of the Stoics and Epicureans, when a person no longer cared for his life. In the sixteenth century, Thomas More, in describing a utopian community, envisaged such a community as one that would facilitate the death of those whose lives had become burdensome as a result of ‘torturing and lingering pain’. But it has only been in the last hundred years that there have been concerted efforts to make legal provision for voluntary euthanasia. Until quite recently there had been no success in obtaining such legal provision (though assisted suicide, including, but not limited to, physician-assisted suicide, has been legally tolerated in Switzerland for a number of decades). However, the outlook changed dramatically in the 1970s and 80s because of a series of court cases in the Netherlands which culminated in an agreement between the legal and medical authorities to ensure that no physician would be prosecuted for assisting a patient to die as long as certain guidelines were strictly adhered to (see Griffiths, et al., 1998). In brief, the guidelines were established to permit physicians to practise voluntary euthanasia in those instances in which a competent patient had made a voluntary and informed request to be helped to die, the patient’s suffering was unbearable, there was no way of making that suffering bearable that was acceptable to the patient, and the physician’s judgements as to diagnosis and prognosis were confirmed after consultation with another physician.

The first legislative approval for voluntary euthanasia was achieved with the passage in the parliament of Australia’s Northern Territory of a bill enabling physicians to practise voluntary euthanasia. Subsequent to the Act’s proclamation in 1996, it faced a series of legal challenges from opponents of voluntary euthanasia. In 1997 the challenges culminated in the Australian National Parliament overturning the legislation when it prohibited Australian territories from enacting legislation to permit voluntary euthanasia on constitutional grounds. Australia is a federation consisting of six states and two territories. Unlike the territories, the states do have the constitutional right to enact such legislation and in 2017 the state of Victoria did just that. The legislation came into effect in 2019. In 2019, a second state, Western Australia, enacted legislation to enable voluntary medically assisted death. The legislation became effective in 2021. In 2021 three further states, Tasmania, South Australia and Queensland enacted legislation to enable voluntary medically assisted death which came into force in 2022 for the first two, and 2023 for the third. Finally, in 2022 NSW enacted legislation which came into force in 2023 resulting in voluntary medically assisted death being available in each of the states. Attempts are currently being made in both the Australian Capital Territory and the Northern Territory to introduce legislation in favor of voluntary medically assisted death that will avoid being vetoed by the federal parliament.

In November 2000, the Netherlands passed legislation to legalize the practice of voluntary euthanasia. The legislation passed through all the parliamentary stages early in 2001. The Belgian parliament passed similar legislation in 2002 and Luxembourg followed suit in 2009. (For a very helpful comparative study of relevant legislation see Lewis 2007. See also Griffiths, et al. 2008.)

In Oregon in the United States, legislation was introduced in 1997 to permit physician-assisted suicide after a referendum strongly endorsed the proposed legislation. Later in 1997 the Supreme Court of the United States ruled that there is no constitutional right to physician-assisted suicide; however, the Court did not preclude individual states from legislating in favor of physician-assisted suicide (so the Oregon legislation was unaffected). Since that time the Oregon legislation has been successfully utilised by a significant number of people and similar legislation has been passed in the state of Washington in 2009, in Vermont in 2013, and more recently still in California, Colorado, Florida, Hawaii, Iowa, Maine, Maryland, Massachusetts, Minnesota, New Jersey, New Mexico and the District of Columbia. A series of judicial decisions in the state of Montana in 2008 and 2009 established that the state could not prohibit physician-assisted suicide but legislation has not yet been introduced to codify the legal situation. A number of the remaining states are currently considering physician-assisted suicide bills.

A similar legal position to that in Montana obtained in the nation of Colombia from the late 1990s as a result of a majority ruling by its Constitutional Court in favor of the legality of physician-assisted suicide but legislative provision was finally made only quite recently. In 2021, Spain legalized voluntary euthanasia. In Austria and Germany courts have authorised physician-assisted suicide but no legislative backing for the practice has been introduced, while in Italy legislation for voluntary medically assisted death has been passed in one house of the bicameral parliament. In Portugal legislation for physician-assisted suicide was passed but was subsequently rejected by the Constitutional Court.

In Canada, the province of Quebec introduced legislation permitting medical aid in dying in 2014. The legislation came into effect in 2016 at around the same time that the Canadian National Parliament passed legislation permitting both physician-assisted suicide and voluntary euthanasia throughout all of the Canadian federation. (For a brief account of events leading up to the enactment of the various pieces of legislation in Canada see Downie and Schuklenk 2021.)

New Zealand held a referendum in 2019 which resulted in approval for the introduction of legislation for voluntary medically assisted death. The legislation came into effect late in 2021.

In the following countries legislative proposals for voluntary medically assisted death are presently under review: the Czech Republic, France, Ireland, the Isle of Man, Japan, Jersey, South Korea, the Philippines, Slovenia and the United Kingdom.

With that brief sketch of the historical background in place, we will proceed first to consider the conditions that those who have advocated making voluntary medically assisted death legally permissible have typically insisted should be satisfied. Consideration of the proposed conditions will establish a framework for the moral interrogation that will follow in Sections 3 and 4. Section 3 will outline the positive moral case put forward by those who want voluntary euthanasia and physician-assisted suicide to be legally permissible. Section 4 will be devoted to scrutinising the most important of the objections that have been levelled against that case by those opposed to the legalization of voluntary euthanasia and physician-assisted suicide.

Advocates of voluntary euthanasia typically contend that if a person

• is suffering from a terminal illness;
• is unlikely to benefit from the discovery of a cure for that illness during what remains of her life expectancy;
• is, as a direct result of the illness, either suffering intolerable pain, or only has available a life that is unacceptably burdensome (e.g., because the illness has to be treated in ways that lead to her being unacceptably dependent on others or on technological means of life support);
• has an enduring, voluntary and competent wish to die (or has, prior to losing the competence to do so, expressed a wish to be assisted to die in the event that conditions (a)-(c) are satisfied); and
• is unable without assistance to end her life,

there should be legal and medical provision to facilitate her being allowed to die or assisted to die.

It should be acknowledged that these conditions are quite restrictive, indeed more restrictive than many think appropriate. In particular, the first condition restricts access to voluntary euthanasia to those who are terminally ill . While that expression is not free of all ambiguity, for present purposes it can be agreed that it does not include those who are rendered quadriplegic as a result of accidents, or sufferers from chronic diseases, or individuals who succumb to forms of dementia like Alzheimer’s Disease, to say nothing of those afflicted by ‘existential suffering’. Those who consider that cases like these show the first condition to be too restrictive (e.g., Varelius 2014, Braun, 2023) may, nonetheless, agree that including them as candidates for legalized voluntary euthanasia is likely to make it far harder in many jurisdictions to gain sufficient support for legalization (and so to make it harder to help those terminally ill persons who wish to die). Even so, they believe that voluntary euthanasia should be permitted for those who consider their lives no longer worth living, not just for for the terminally ill. Whether those who judge that their lives are no longer worth living, and so believe their lives are in that sense ‘complete’, should be afforded medical assistance with dying, has recently become a pressing concern in Belgium and the Netherlands. Several court cases have affirmed that such assistance may sometimes be provided for individuals in the former category even though the question remains as to whether it is properly a medical responsibility to render assistance with dying to someone who believes her life is complete despite her not suffering from a terminal medical condition (see, e.g., Young 2017). Relatedly, the issues of whether those suffering from a disability which will not reasonably foreseeably lead to death and those suffering because of a mental illness should be able to access medical assistance with dying have recently been the subject of intense debate in Canada. The debate culminated in disabled individuals, whose conditions are the cause of enduring, intolerable and irremediable suffering, being given access to medical assistance with dying as long as they are capable of making a competent request for that assistance. An intention to make a similar arrangement for those whose sole underlying condition is a mental illness was flagged for introduction in 2024, but has been temporarily shelved until further research has been conducted on the issue. It seems likely that the changes that have been made, or mooted, in these jurisdictions to the eligibility conditions for medical assistance with dying will lead to an expansion of the eligibility conditions for voluntary medically assisted death in other jurisdictions.

The fifth condition further restricts access to voluntary euthanasia by excluding those capable of ending their own lives, and so may be thought unduly restrictive by those who would wish to discourage terminally ill patients from attempting suicide. There will be yet others who consider this condition to be too restrictive because competent patients can always refuse nutrition and hydration (see, e.g., Bernat, et al. 1993; Savulescu 2014). Though this is true, many competent dying persons still wish to have access to legalized medically assisted death, rather than having to rely on refusing nutrition and hydration, so that they may retain control over the timing of their deaths and avoid needlessly prolonging the process of dying.

The second condition is intended simply to reflect the fact that it is normally possible to say when someone’s health status is incurable. So-called ‘miracle’ cures may be proclaimed by sensationalist journalists, but progress toward medical breakthroughs is typically painstaking. If there are miracles wrought by God that will be quite another matter entirely, but it is at least clear that not everyone’s death is thus to be staved off.

The third condition recognises what many who oppose the legalization of voluntary euthanasia do not, namely, that it is not only a desire to be released from pain that leads people to request help with dying. In the Netherlands, for example, pain has been found to be a less significant reason for requesting assistance with dying than other forms of suffering like frustration over loss of independence (see e.g., Marquet, et al. 2003; Onwuteaka-Philipsen, et al. 2012; Emanuel, et al. 2016). Sufferers from some terminal conditions may have their pain relieved but have to endure side effects that, for them, make life unbearable. Others may not have to cope with pain but, instead, with having to rely on forms of life support that simultaneously rob their lives of quality (as with, e.g., motor neurone disease). Yet others struggle with psychological distress and various psychiatric conditions and believe these conditions ought to be counted among the forms of suffering that qualify competent individuals to access medical assistance with dying. There has been greater recognition of, and support for, this position in those jurisdictions that make the role of unbearable suffering central to the determination of the eligibility of competent individuals for medical assistance with dying (see the discussion above of the first condition). Even so, inclusion of these forms of suffering highlights legitimate issues to do with the competence of at least some of those who suffer from them. (For a helpful recent study of the handling of requests for assistance with dying by psychiatric patients in the Netherlands see Kim, et al. 2016.)

A final preliminary point is that the fourth condition requires that the choice to die not only be uncoerced and competent but that it be enduring. The choice is one that will require time for reflection, and, almost certainly, discussion with others, so should not be settled in a moment. Nonetheless, as with other decisions affecting matters of importance, adults are presumed to choose voluntarily and to be competent unless the presence of defeating considerations can be established. (See the entry on decision-making capacity .) The burden of proof of establishing lack of voluntariness, or lack of competence, is on those who refuse to accept an adult person’s choice. There is no need to deny that this burden can sometimes be met (e.g., by pointing to the person’s being in a state of clinical depression). The claim is only that the onus falls on those who assert that an adult’s choice is not competent. (There are different issues to be faced when the competence of at least some older children and adolescents is at issue. In the Netherlands, for example, those aged twelve and older have sometimes been found to be competent to make end-of-life decisions for themselves. However, the topic will not be pursued further here because the focus of the entry is on competent adults.)

Clearly the five conditions set out above are likely to require some refinement if complete agreement is to be reached but there is sufficient agreement for us to proceed without further ado to consideration of the cases for and against legalization of voluntary euthanasia. (However, for a fuller discussion of issues concerning the definition of ‘euthanasia’ see, e.g., Beauchamp and Davidson 1979.)

One central ethical contention in support of voluntary euthanasia is that respect for persons demands respect for their autonomous choices as long as those choices do not result in harm to others. Respect for people’s autonomous choices is directly connected with the requirement for competence because autonomy presupposes competence (cf., Brock 1992). People have an interest in making important decisions about their lives in accordance with their own conception of how they want to live. In exercising autonomy, or self-determination, individuals take responsibility for their lives; since dying is a part of life, choices about the manner of their dying and the timing of their death are, for many people, part of what is involved in taking responsibility for their lives. Many are concerned about what the last phase of their lives will be like, not merely because of fears that their dying might involve them in great suffering, but also because of the desire to retain their dignity, and as much control over their lives as possible, during this phase. A second contention in support of voluntary euthanasia was mentioned at the beginning of this entry, namely the importance of promoting the well-being of persons. When someone is suffering intolerable pain or only has available a life that is unacceptably burdensome (see the third condition above), and he competently requests medical assistance with dying, his well-being may best be promoted by affording him that assistance. When harnessed together, the value to individuals of making autonomous choices, and the value to those individuals who make such choices of promoting their own well-being, provide the moral foundation for requests for voluntary euthanasia. Each consideration is necessary for moral justification of the practice, but taken in isolation neither suffices (see, e.g., Young 2007, 2017; Sumner 2011, 2017).

The technological interventions of modern medicine have had the effect of stretching out the time it takes for many people to die. Sometimes the added life this brings is an occasion for rejoicing; sometimes it drags out the period of significant physical and intellectual decline that a person undergoes with the result that life becomes no longer worth living. Many believe there is no single, objectively correct answer as to when, if at all, a person’s life becomes a burden and hence unwanted. If they are right, that simply points up the importance of individuals being able to decide autonomously for themselves whether their own lives retain sufficient quality and dignity to make life worth living. Others maintain that individuals can be in error about whether their lives continue to be worth living (cf., Foot 1977). The conditions outlined above in Section 2 are intended by those who propose them to serve, among other purposes, to safeguard against such error. But it is worth adding that in the event that a person who considers that she satisfies those conditions is judged by her medical attendants to be in error about whether it would be worth her continuing to live, the likely outcome is that those attendants will refuse to provide medical assistance with dying. (Evidence that will be mentioned below shows that this happens more frequently than might be predicted in jurisdictions in which medically assisted dying has been legalized. (There are discussions of the principles at stake in such matters in Young 2007; Wicclair 2011; Sumner 2020.) Unless a patient is able to be transferred to the care of other medical professionals who accept her assessment, she will have to rely on her own resources (e.g., by refusing nutrition and hydration). Even so, other things being equal, as long as a critically ill person is competent, her own judgement of whether continued life is a benefit to her ought to carry the greatest weight in any end-of-life decision making regardless of whether she is in a severely compromised and debilitated state. The idea that a competent individual’s autonomous judgment of the value to her of continued life should trump an assessment by others of her well-being should not be thought surprising because precisely the same happens when a competent patient refuses life-prolonging treatment.

Suppose, for the sake of argument, that it is agreed that we should respect a person’s competent request for medical assistance with dying (e.g., so as to enable her to achieve her autonomously chosen goal of an easeful death). It might be thought that in such an eventuality different moral concerns will be introduced from those that arise in connection with competent refusals. After all, while competent patients are entitled to refuse any form of medical treatment, they are not entitled to insist on the administration of forms of medical treatment that have no prospect of conferring a medical benefit or are not being provided because of a scarcity of medical resources or their affordability. While each of these points is sound, it remains the case that medical personnel have a duty to relieve suffering when that is within their capacity. Accordingly, doctors who regard medical assistance with dying as an element of appropriate medical care will consider it morally permissible to agree to a request for assistance with dying by a competent dying patient who wishes to avoid unbearable suffering. The reason for claiming only that this is morally permissible rather than morally obligatory will be explained in a subsequent paragraph. (For further reflections on the issue of responses to requests for medical assistance see, for instance, Dworkin 1998; Sumner 2011, 2017, 2020; Young 2007, 2017.)

Notwithstanding this response, as was seen earlier, at least some proponents of voluntary medically assisted dying wish to question why medical assistance with dying should be restricted to those covered by, in particular, the first three conditions set out above in Section 2. If people’s competent requests for medically assisted death should be respected why impose any restrictions at all on who may have access to medically assisted death? Why, for example, should those suffering from depression, or forms of dementia, not be eligible for medically assisted dying? Most proponents of voluntary medically assisted dying hold that there are at least two reasons for restricting access to it to those who satisfy the conditions set out earlier (or, a modified set that takes account of the concerns canvassed in the discussion of those proposed conditions). First, they contend that there are political grounds for doing so, namely, that because legalizing medically assisted dying for competent individuals is politically contested, the best hope for its legalization lies in focusing on those forms of suffering most likely to effect law reform. That is why some proponents deny the eligibility even of sufferers from conditions like ‘locked-in’ syndrome, motor neurone disease, and multiple sclerosis for voluntary medically assisted dying since, strictly, they are not terminally ill, and reliance has to be placed in consequence on their claim to be suffering unbearably. Second, and relatedly, most proponents of the legalization of medical assistance with dying have been cautious about supporting medically assisted death for those suffering from, for example, depression and dementia, because not only are they not terminally ill, but their competence to request assistance with dying is apt to be called into question, particularly in instances where they have given no prior indication of their preference for such assistance. Restricting access to medical assistance with dying to those whose suffering is less likely to be disputed avoids becoming embroiled in controversy. As was noted earlier, some critics of the restrictive approach (e.g., Varelius 2014) take a harder line and claim that it should not even be necessary for a person to be suffering from a medical condition to be eligible for medical assistance with dying; it should be enough to be ‘tired of life’. Only in a few jurisdictions, viz., Switzerland, the Netherlands and Belgium, has this issue been seriously broached. Regardless of what may happen in those jurisdictions, those seeking the legal provision of medical assistance with dying in other jurisdictions seem likely to maintain that if such assistance is to be seen as a legitimate form of medical care it has to be provided in response to a medical condition (rather than because someone is ‘tired of life’), and, indeed, restricted to those who satisfy the conditions outlined earlier in Section 2 (or some similar set of conditions). In short, these latter hold that making an autonomous request for assistance with dying is necessary, but should not be sufficient, for triggering such assistance.

There is one final matter of relevance to the moral case for voluntary medically assisted death on which comment must be made. The comment concerns a point foreshadowed in a previous paragraph, but it is also linked with the remark just made about the insufficiency of an autonomous request for assistance with dying to trigger that assistance. It is important to make the point that respect has to be shown not only for the dying person’s autonomy but also for the professional autonomy of any medical personnel asked to lend assistance with dying. The value (or, as some would prefer, the right) of self-determination does not entitle a patient to try to compel medical professionals to act contrary to their own moral or professional values. Hence, if voluntary euthanasia is to be legally permitted, it must be against a backdrop of respect for professional autonomy. Similarly, if a doctor’s view of her moral or professional responsibilities is at odds with her patient’s competent request for euthanasia, she should make provision, where it is feasible to do so, for the transfer of the patient to the care of a doctor who faces no such conflict. Given that, to date, those who contend that no scope should be permitted for conscientious objection within medical practice have garnered very little support for that view, making use of referrals and transfers remains the most effective means of resolving such disagreements.

Opponents of voluntary euthanasia have endeavored in a variety of ways to counter the very straightforward moral case that has been laid out above for its legalization (see, for example, Keown 2002; Foley, et al. 2002; Biggar 2004; Gorsuch 2006). Some of the counter-arguments are concerned only with whether the moral case warrants making the practice of voluntary euthanasia legal, whereas others are concerned with trying to undermine the moral case itself. In what follows, consideration will be given to the five most important counter-arguments. (For more comprehensive discussions of the morality and legality of medically assisted death see Biggar 2004; Gorsuch 2006; Young 2007; Sumner 2011, 2017; Keown 2018).

4.1 Objection 1

It is sometimes said (e.g., Emanuel 1999; Keown in Jackson and Keown 2012) that it is not necessary nowadays for people to die while suffering from intolerable or overwhelming pain because the provision of effective palliative care has improved steadily, and hospice care is more widely available. Some have urged, in consequence, that voluntary euthanasia is unnecessary.

There are several flaws in this contention. First, while both good palliative care and hospice care make important contributions to the care of the dying, neither is a panacea. To get the best palliative care for an individual involves trial and error, with some consequent suffering in the process; moreover, even the best care fails to relieve all pain and suffering. Perhaps even more importantly, high quality palliative care commonly exacts a price in the form of side-effects such as nausea, incontinence, loss of awareness because of semi-permanent drowsiness, and so on. A rosy picture is often painted as to how palliative care can transform the plight of the dying. Such a picture is misleading according to those who have closely observed the effect of extended courses of treatment with drugs like morphine. For these reasons many skilled palliative care specialists acknowledge that palliative care does not enable an easeful death for every patient. Second, even though the sort of care provided through hospices is to be applauded, it is care that is available to only a small proportion of the terminally ill and then usually only in the very last stages of the illness (typically a matter of a few weeks). Notwithstanding that only relatively few of the dying have access to hospice care it is worth drawing attention to the fact that in, Oregon, to cite one example, a high proportion of those who have sought physician-assisted suicide were in hospice care. Third, and of greatest significance for present purposes, not everyone wishes to avail themselves of palliative or hospice care. For those who prefer to die on their own terms and in their own time, neither option may be attractive. As previously mentioned, a major source of distress for many dying patients is the frustration that comes with being unable to satisfy their autonomous wishes. Fourth, as also indicated earlier, the suffering that occasions a desire to end life is not always traceable to pain caused by illness. For some, what is intolerable is their forced dependence on others or on life-supporting machinery; for these patients, the availability of effective pain control is not the primary concern. (In relation to the preceding matters see Rietjens, et al. 2009 and Onwuteaka-Philipsen et al. 2012 for findings for the Netherlands; and, for Oregon, Ganzini, et al. 2009.)

4.2 Objection 2

A second, related objection to the moral and legal permissibility of voluntary euthanasia turns on the claim that we can never have sufficient evidence to be justified in believing that a dying person’s request to be helped to die is competent, enduring and genuinely voluntary.

It is certainly true that a request to die may not reflect an enduring desire to die (just as some attempts to commit suicide may reflect only temporary despair). That is why advocates of the legalization of voluntary euthanasia have argued that a cooling off period should normally be required before euthanasia is permitted to ensure that the request is enduring. That having been said, to claim that we can never be justified in believing that someone’s request to die reflects a settled preference for death is to go too far. If a competent person discusses the issue with others on different occasions over time, and remains steady in her resolve, or privately reflects on the issue for an extended period and does not waver in her conviction, her wish to die surely must be counted as enduring.

But, it might be asked, what if a person is racked with pain, or mentally confused because of the measures taken to relieve her pain, and is, in consequence, unable to think clearly and rationally about the alternatives? It has to be agreed that a person in those circumstances who wants to die should not be assumed to have a truly voluntary and enduring desire to die. However, there are at least two important points to make about those in such circumstances. First, they do not account for all of the terminally ill, so even if it is acknowledged that such people are incapable of agreeing to voluntary euthanasia that does not show that no one can ever voluntarily request help to die. Second, it is possible in at least some jurisdictions for a person to indicate, in advance of losing the capacity to give competent consent, how she would wish to be treated should she become terminally ill and suffer either intolerable pain or an unacceptable loss of control over her life (cf., for instance, Dworkin 1993). ‘Living wills’ or ‘advance directives’ are legal instruments for giving voice to people’s wishes while they are capable of giving competent, enduring and voluntary consent, including to their wanting help to die. As long as they are easily revocable in the event of a change of mind (just as civil wills are), they should be respected as evidence of a well thought-out conviction. (For more detailed consideration of these instruments see the entry on advance directives .)

Perhaps, though, what is really at issue in this objection is whether anyone can ever form a competent, enduring and voluntary judgement about being better off dead, rather than continuing to suffer from an illness, prior to suffering such an illness (cf., Keown in Jackson and Keown 2012). If this is what underlies the objection it is surely too paternalistic to be acceptable. Why is it not possible for a person to have sufficient inductive evidence (e.g., based on the experience of the deaths of friends or family) to know her own mind, and act accordingly, without having had direct experience of such suffering?

4.3 Objection 3

According to the traditional interpretation of the ‘doctrine of double effect’ it is permissible to act in a way which it is foreseen will have a bad effect, provided only that

• the bad effect occurs as a side-effect (i.e., indirectly) to the achievement of the act that is directly aimed at;
• the act directly aimed at is itself morally good or, at least, morally neutral;
• the good effect is not achieved by way of the bad, that is, the bad must not be a means to the good; and
• the bad effect must not be so serious as to outweigh the good effect.

Hence, it is permissible, according to the doctrine of double effect, to, for example, alleviate pain (a good effect) by administering a drug, knowing that doing so will shorten life, but impermissible to administer the same drug with the direct intention of terminating a patient’s life (a bad effect). This latter claim is said to apply regardless of whether the drug is given at the person’s request.

This is not the appropriate forum for a full consideration of the doctrine, for which see the entry on the doctrine of double effect . However, there is one very important criticism to be made of the application of the doctrine that has direct relevance to the issue of voluntary euthanasia.

On the most plausible reading, the doctrine of double effect can be relevant to the permissibility of voluntary euthanasia only when a person’s death is bad for her or, to put it another way, a harm to her. Sometimes the notion of ‘harm’ is understood simply as damage to a person’s interests whether consented to or not. At other times, it is understood, more strictly, as damage that has been wrongfully inflicted. On either understanding of harm, there can be instances in which death for a person does not constitute a harm for her because it will either render her better off, or, as some would insist, no worse off, when compared with remaining alive. Accordingly, in those instances, the doctrine of double effect can have no relevance to the debate about the permissibility of voluntary euthanasia. (For extended discussions of the doctrine of double effect and its bearing on the moral permissibility of voluntary euthanasia see, e.g., McIntyre 2001; Woodward 2001; Cavanaugh 2006; Young 2007; Sumner 2011, 2017.)

4.4 Objection 4

As was noted earlier in Section 3, there is a widespread belief that so-called passive (voluntary) euthanasia, wherein life-sustaining or life-prolonging measures are withdrawn or withheld in response to a competent patient’s request, is morally permissible. The reason why passive (voluntary) euthanasia is said to be morally permissible is that the patient is simply allowed to die because steps are not taken to preserve or prolong life. This happens, for example, when a dying patient requests the withdrawal or the withholding of measures whose administration would be medically futile, or unacceptably burdensome. By contrast, active (voluntary) euthanasia is said to be morally impermissible because it is claimed to require an unjustifiable intentional act of killing to satisfy the patient’s request (cf., for example, Finnis, 1995; Keown in Jackson and Keown 2012; Keown 2018).

Despite its popularity and widespread use, the distinction between passive and active euthanasia is neither particularly clear nor morally helpful. (For a fuller discussion, see McMahan 2002.) Whether behavior is described in terms of acts or omissions (a distinction which underpins the alleged difference between active and passive voluntary euthanasia and that between killing a person and letting her die), is often a matter of pragmatics rather than anything of deeper moral importance. Consider, for instance, the practice (once common in hospitals) of deliberately proceeding slowly to a ward in response to a request to provide assistance for a patient who has been assigned a ‘not for resuscitation’ code. Or, consider ‘pulling the plug’ on a respirator keeping an otherwise dying patient alive, as against not replacing the oxygen supply when it runs out. Are these acts or omissions? If the answers turn on merely pragmatic considerations the supposed distinction between passive euthanasia and active euthanasia will be hard to sustain.

Even supposing that the distinction between acts and omissions, and the associated distinction between killing and letting die, can be satisfactorily clarified (on which see the entry doing v. allowing harm ), there remains the issue of whether these distinctions have moral significance in every circumstance. Consider a case of a patient suffering from motor neurone disease who is completely respirator dependent, finds her condition intolerable, and competently and persistently requests to be removed from the respirator so that she may die. Even the Catholic Church in recent times has been prepared to agree that it is permissible, in a case like this, to turn off the respirator. No doubt this has been because the Catholic Church considers such a patient is only being allowed to die. Even were it to be agreed, for the sake of argument, that such a death should be regarded as an instance of letting die, this concession would not show that it would have been morally worse had the patient been killed at her request (active voluntary euthanasia) rather than being allowed to die (passive voluntary euthanasia). Indeed, supporters of voluntary medically assisted death maintain that since death is beneficial in such an instance (or, at the very least, leaves the dying person no worse off), actively bringing about the death is morally to be preferred to just allowing it to happen because the desired benefit is achieved sooner and thus with less suffering.

Opponents of voluntary euthanasia claim, however, that the difference between active and passive euthanasia is to be found in the agent’s intention: if someone’s life is intentionally terminated she has been killed, whereas if she is just no longer being aggressively treated, her death should be attributed to the underlying disease. Many physicians would say that their intention in withholding or withdrawing life-sustaining medical treatment in such circumstances is simply to respect the patient’s wishes. This is plausible in those instances where the patient competently requests that aggressive treatment no longer be given (or, the patient’s proxy makes such a request). But it will often be implausible. In many cases the most plausible interpretation of a physician’s intention in withholding or withdrawing life-sustaining measures is that it is to end the patient’s life. Consider the palliative care practice of ‘terminally sedating’ a patient after a decision has been made to cease aggressive treatment. Suppose (as sometimes happens) that this is then followed by withholding artificially supplied nutrition. In these latter instances the best explanation of the physician’s behavior is that the physician intends thereby to end the life of the patient. What could be the point of the action, the goal aimed at, the intended outcome, if not to end the patient’s life? (Cf. Winkler 1995.) No sense can be made of the action as being intended to palliate the patient’s diseased condition, or to keep the patient comfortable. Nor is it appropriate to claim that what kills the patient is the underlying disease. What kills the patient is the act of depriving her of nutrition (i.e., of starving her to death). The point can be generalized to cover many more instances involving either the withdrawal or the withholding of life-sustaining medical treatment. In short, there is no good reason to think that whereas so-called passive voluntary euthanasia is morally acceptable active voluntary euthanasia never can be.

But we can go further. Giving titrated doses of morphine that reach levels beyond those needed to control pain, or removing a respirator from a sufferer from motor neurone disease, seem to many of us to amount to intentionally bringing about the death of the person being cared for. To be sure, as was acknowledged above, there are circumstances in which doctors can truthfully say that the actions they perform, or omissions they make, will bring about the deaths of their patients even though it was not their intention that those patients would die. So, for instance, if a patient refuses life-prolonging medical treatment because she considers it futile, it can be reasonable to say that her doctor’s intention in complying with the request was simply to respect her wishes. Nevertheless, as we have seen, there are other circumstances in which it is highly stilted to claim, as some doctors continue to do, that they had no intention of bringing about death.

These considerations should settle matters but do not do so for those who maintain that killing, in medical contexts, is always morally unjustified – a premise that underwrites much of the debate surrounding this fourth objection. But this underlying assumption is open to challenge and has been challenged by, for instance, Rachels 1986 and McMahan 2002. One of the reasons the challengers have given is that there are cases in which killing a competent dying person when she requests assistance with dying, is morally preferable to allowing her to die, namely, when taking the latter option would serve only to prolong her suffering against her wishes. Further, despite the longstanding legal doctrine that no one can justifiably consent to be killed (on which more later), it surely is relevant to the justification of an act of killing that the person killed has autonomously decided that she would be better off dead and so asks to be helped to die.

4.5 Objection 5

It is sometimes said that if society allows voluntary euthanasia to be legalized, we will then have set foot on a slippery slope that will lead us eventually to support other forms of euthanasia, including, in particular, non-voluntary euthanasia. Whereas it was once the common refrain that that was precisely what happened in Hitler’s Germany, in recent decades the tendency has been to claim that experience with legalized euthanasia in the Netherlands and Belgium, in particular, has confirmed the reality of the slippery slope.

Slippery slope arguments come in various versions. One (but not the only) way of classifying them has been to refer to logical, psychological and arbitrary line versions. The common feature of the different forms is the contention that once the first step is taken on a slippery slope the subsequent steps follow inexorably, whether for logical reasons, psychological reasons, or to avoid arbitrariness in ‘drawing a line’ between a person’s actions. (For further discussion see, e.g., Rachels 1986; Brock 1992; Walton 1992.)

We need first to consider whether, at the theoretical level, any of these forms of argument is powerful enough to refute the case for the legalization of voluntary euthanasia. We will then be in a position to comment on the alleged empirical support from the experiences of Hitler’s Germany and, more recently, of legalized euthanasia in the Netherlands and elsewhere, for the existence of a slippery slope that supposedly comes into being with the legalization of voluntary euthanasia.

To begin with, there is nothing logically inconsistent in supporting voluntary euthanasia while maintaining the moral inappropriateness of non-voluntary euthanasia. (However, for an attempt to press the charge that there is such an inconsistency see, e.g., Keown 2022.) Undoubtedly, some advocates of voluntary euthanasia wish also to lend their support to some acts of non-voluntary euthanasia, for example, for those in persistent vegetative states who have never indicated their wishes about being helped to die, or for certain severely disabled infants for whom the outlook is hopeless. (See, e.g., Kuhse and Singer 1985; Singer 1994; Stingl 2010; Sumner 2017.) Others believe that the consent of the patient is strictly required if euthanasia is appropriately to be legalized. The difference is not a matter of logical acumen; it is to be explained by reference to the importance placed on key values by the respective supporters. Thus, for example, those who insist on the necessity for a competent request by a patient for medical assistance with dying typically believe that such a request is the paramount consideration in end-of-life decision making (even when it is harnessed to the value of individual well-being), whereas those who consider a person’s best interests to be the paramount consideration are more likely to believe in the justifiability of instances of non-voluntary euthanasia like those mentioned above.

Next, it is hard to see why moving from voluntary to non-voluntary euthanasia is supposed to be psychologically inevitable. Why should those who support the legalization of voluntary euthanasia, because they value the autonomy of the individual, find it psychologically easier, in consequence, to endorse the killing of those who are not able competently to request assistance with dying? What reason is there to believe that they will, as a result of their support for voluntary euthanasia, be psychologically driven to endorse a practice of non-voluntary euthanasia?

Finally, since there is nothing arbitrary about distinguishing voluntary euthanasia from non-voluntary euthanasia (because the line between them is based on clear principles), there can be no substance to the charge that only by arbitrarily drawing a line between them could non-voluntary euthanasia be avoided were voluntary euthanasia to be legalized.

What, though, of Hitler’s Germany and the recent experience of legalized voluntary euthanasia in the Netherlands and elsewhere? The former is easily dismissed as an indication of an inevitable descent from voluntary euthanasia to non-voluntary. There never was a policy in favor of, or a legal practice of, voluntary euthanasia in Germany in the 1920s to the 1940s (see, for example, Burleigh 1994). There was, prior to Hitler coming to power, a clear practice of killing some disabled persons. But it was never suggested that their being killed was justified by reference to their best interests; rather, it was said that society would be benefited. Hitler’s later revival of the practice and its widening to take in other groups such as Jews and gypsies was part of a program of eugenics , not euthanasia.

Since the publication of the Remmelink Report in 1991 into the medical practice of euthanasia in the Netherlands, it has frequently been said that the Dutch experience shows that legally protecting voluntary euthanasia is impossible without also affording shelter to the non-voluntary euthanasia that will follow in its train (see, e.g., Keown 2018). In the period since that report there have been regular national studies of the practice of euthanasia in the Netherlands (see, e.g., Rietjens, et al. 2009; Onwuteaka-Philipsen, et al. 2012; van der Heide, et al. 2017). The findings from these national studies have consistently shown that there is no evidence for the existence of such a slippery slope. Among the specific findings the following are worth mentioning: of those terminally ill persons who have been assisted to die about sixty per cent have clearly been cases of voluntary euthanasia as it has been characterised in this entry; of the remainder, the vast majority of cases were of patients who at the time of their medically assisted deaths were no longer competent. It might be thought that these deaths ought to be regarded as instances of non-voluntary euthanasia. But, in fact, it would be inappropriate to regard them as such. Here is why. For the overwhelming majority of these cases, the decisions to end life were taken only after consultation between the attending doctor(s) and close family members, and so can legitimately be thought of as involving substituted judgements. Moreover, according to the researchers, the overwhelming majority of these cases fit within either of two common practices that occur in countries where voluntary euthanasia has not been legalized, namely, that of terminal sedation of dying patients, and that of giving large doses of opioids to relieve pain while foreseeing that this will also end life. In a very few cases, there was no consultation with relatives, though in those cases there were consultations with other medical personnel. The researchers contend that these instances are best explained by the fact that families in the Netherlands strictly have no final legal authority to act as surrogate decision-makers for incompetent persons. For these reasons the researchers maintain that non-voluntary euthanasia is not widely practised in the Netherlands.

That there have only been a handful of prosecutions of Dutch doctors for failing to follow agreed procedures (Griffiths, et al. 1998; Asscher and van de Vathorst 2020), that none of the doctors prosecuted has had a significant penalty imposed, that a significant proportion of requests for medical assistance with dying are rejected as unjustifiable, and that the Dutch public have regularly reaffirmed their support for the agreed procedures suggests that, contrary to the claims of some critics, the legalization of voluntary euthanasia has not increased the incidence of non-voluntary euthanasia. A similar picture to the one in the Netherlands has emerged from studies of the operation of the law concerning physician-assisted suicide in Oregon. Indeed, in a recent wide-ranging study of attitudes and practices of voluntary euthanasia and physician-assisted suicide covering two continents, a prominent critic of these practices has concluded (in agreement with his co-authors) that little evidence exists of abuse, particularly of the vulnerable (see Emanuel, et al., 2016). Unfortunately, insufficient time has elapsed for appropriate studies to be conducted in the other jurisdictions that have legalized either voluntary euthanasia or physician-assisted suicide (but for some relevant evidence see e.g., White, et al. 2022). Finally, some commentators have pointed out that there may, in reality, be more danger of the line between voluntary and non-voluntary euthanasia being blurred if euthanasia is practised in the absence of legal recognition, since there will, in those circumstances, be neither transparency nor monitoring (which cannot be said of the Netherlands, Belgium, Oregon and so on).

None of this is to suggest that it is not necessary to ensure the presence of safeguards against potential abuse of legally protected voluntary euthanasia. This is particularly important for the protection of those who have become incompetent by the time decisions need to be taken about whether to assist them to die. Furthermore, it is, of course, possible that the reform of any law may have unintended effects. However, if the arguments outlined above are sound (and the experience in the Netherlands, Belgium and Luxembourg, along with the more limited experience in several states in the United States and in Canada, is, for the present, not only the best evidence we have that they are sound, but the only relevant evidence), that does not seem very likely.

It is now well-established in many jurisdictions that competent patients are entitled to make their own decisions about life-sustaining medical treatment. That is why they can refuse such treatment even when doing so is tantamount to deciding to end their life. It is plausible to think that the fundamental basis of the right to decide about life-sustaining treatment – respect for a person’s autonomy and her assessment of what will best serve her well-being – has direct relevance to the legalization of voluntary euthanasia (see, e.g., Dworkin 1998; Young 2007, 2017; Sumner 2011, 2017). In consequence, extending the right of self-determination to cover cases of voluntary euthanasia does not require a dramatic shift in legal policy. Nor do any novel legal values or principles need to be invoked. Indeed, the fact that suicide and attempted suicide are no longer criminal offences in many jurisdictions indicates that the central importance of individual self-determination in a closely analogous context has been accepted. The fact that voluntary euthanasia and physician-assisted suicide have not been more widely decriminalized is perhaps best explained along a similar line to the one that has frequently been offered for excluding the consent of the victim as a justification for an act of killing, namely the difficulties thought to exist in establishing the genuineness of the consent. But, the establishment of suitable procedures for giving consent to voluntary euthanasia and physician-assisted suicide is surely no harder than establishing procedures for competently refusing burdensome or otherwise unwanted medical treatment. The latter has already been accomplished in many jurisdictions, so the former should be achievable as well.

Suppose that the moral case for legalizing voluntary euthanasia and physician-assisted suicide does come to be judged more widely as stronger than the case against legalization, and they are made legally permissible in more jurisdictions than at present. Should doctors take part in the practice? Should only doctors perform voluntary euthanasia? These questions ought to be answered in light of the best understanding of what it is to provide medical care. The proper administration of medical care should promote the welfare of patients while respecting their individual self-determination. It is these twin values that should guide medical care, not the preservation of life at all costs, or the preservation of life without regard to whether patients want their lives prolonged should they judge that life is no longer of benefit or value to them. Many doctors in those jurisdictions where medically assisted death has been legalized and, to judge from available survey evidence, in other liberal democracies as well, see the practice of voluntary euthanasia and physician-assisted suicide as not only compatible with their professional commitments but also with their conception of the best medical care for the dying. That being so, doctors of the same conviction in jurisdictions in which voluntary medically assisted death is currently illegal should no longer be prohibited by law from lending their professional assistance to competent terminally ill persons who request assistance with dying because of irremediable suffering or because their lives no longer have value for them.

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• Sumner, L., 2011, Assisted Death: A Study in Ethics and Law , Oxford: Oxford University Press.
• –––, 2017, Physician-Assisted Death: What Everyone Needs to Know , New York: Oxford University Press.
• –––, 2020, “Conscientious Refusal to Provide Medically Assisted Dying”, University of Toronto Law Journal , 71: 1–31.
• van der Heide, A., J.van Delden and B. Onwuteaka-Philipsen, 2017, “End-of-Life Decisions in the Netherlands over 25 Years”, New England Journal of Medicine , 377: 492–494.
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• Velleman, J., 1999, “A Right of Self-Termination?”, Ethics , 109: 606–628.
• White, B., L. Willmott, K. Del Villar, J. Hewitt, E. Close, L. Greaves, J. Cameron, R. Meehan and J. Downie, 2022, “Who is Eligible for Voluntary Assisted Death?: Nine Medical Conditions Assessed Against Five Legal Frameworks”, University of New South Wales Law Journal , 45: 401–444.
• Wicclair, M., 2011, Conscientious Objection in Health Care: An Ethical Analysis , Cambridge: Cambridge University Press.
• Winkler, E., 1995, “Reflections on the State of Current Debate Over Physician-Assisted Suicide and Euthanasia”, Bioethics , 9: 313–326.
• Woodward, P., (ed.), 2001, The Doctrine of Double Effect: Philosophers Debate a Controversial Moral Principle , Notre Dame, Indiana: University of Notre Dame Press.
• Young, R., 2007, Medically Assisted Death , Cambridge: Cambridge University Press.
• –––, 2017, “An Argument in Favor of the Morality of Voluntary Medically Assisted Death”, in M. Cholbi (ed.), Euthanasia and Assisted Suicide: Global Views on Choosing to End Life , Santa Barbara: Praeger.

How to cite this entry . Preview the PDF version of this entry at the Friends of the SEP Society . Look up topics and thinkers related to this entry at the Internet Philosophy Ontology Project (InPhO). Enhanced bibliography for this entry at PhilPapers , with links to its database.

• Medically Assisted Dying , an annotated bibliography authored by Robert Young (La Trobe University)
• Eight Reasons Not to Legalize Physician Assisted Suicide , by David Albert Jones, online resource at the Anscombe Bioethics Centre website.

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The Ethical Dilemmas of Euthanasia

June 01, 2010 2 Comments

Discussion of euthanasia often elicits strong emotion, which is not surprising as it involves life and death issues. For over 2000 years it has been a prohibited medical practice. But now?

Euthanasia is legal in the Netherlands, Belgium and Luxembourg. Physician Assisted Suicide (PAS) is legal in Oregon and Washington State in the US. There are serious discussions going on in Montana, Singapore and Spain. In The UK, over 100 Brits have died under the arrangements in Switzerland, and the government is developing guidelines for prosecution of those who assist in such suicides. The Swiss authorities are having a similar debate themselves, with the final outcome far from clear.

In Australia legislation concerning end-of-life issues has been dealt with on a state basis. In 1995 the Northern Territory passed legislation allowing euthanasia, but it was overturned by the Federal Parliament in 1997. Last year a bill was tabled in the Federal Senate trying to reactivate it. Recently bills have been debated in Victoria, Tasmania and South Australia. Legislation for euthanasia has been twice considered and rejected by the NSW parliament. It just keeps coming back. 

Why are we having this debate in Western countries at a time when we have more medical cures than ever before in human history? What is going on?

In this paper I will first discuss the definitions of the terms of the debate. I will then consider arguments for and against euthanasia, before giving a Christian perspective.

Definitions

In the euthanasia debate, inadequate definitions have been a real barrier in attempts to find clear community consensus. It is no secret that many euthanasia advocates have muddied the waters by bracketing euthanasia with other accepted end-of-life practices in order to increase public support. We need to keep our definitions clear so we all know what we’re talking about. 

The word euthanasia is taken from Greek eu thanos , meaning ‘good death’.  However, this is not particularly helpful as both sides claim the advantage of bringing about a good death, and indeed, the question of what constitutes a good death is at the heart of the euthanasia debate. We would all like to see people in our communities dying with dignity and without suffering.  The question is, how do we go about achieving this?

I define euthanasia as: ‘An act where a doctor intentionally ends the life of a person, by the administration of drugs, at that person’s voluntary and competent request, for reasons of compassion’. I prefer to keep the definition narrow, so we can evaluate each end of life scenario individually.

The terms active/ passive, and voluntary/involuntary should be avoided when referring to euthanasia, as they are ambiguous and confusing.   For example, there is no such thing as involuntary euthanasia.  It is a contradiction of terms.  If someone is killed without their consent, even in a medical setting, it is not euthanasia, it is murder.  I will discuss the active/passive distinction in a moment.

I define Physician Assisted Suicide (PAS) as: ‘The situation where a doctor intentionally helps a person to commit suicide by providing drugs for self-administration, at that person’s voluntary and competent request’.  In PAS the doctor is distanced from the act but morally it is no different from euthanasia as the motive, intention and outcome are the same.  As they are similar in moral terms, I will use euthanasia and PAS interchangeably in this paper.

To understand the debate we also need to be clear on what euthanasia is not.  Euthanasia needs to be distinguished from the withdrawal of treatment, and management of symptoms at the end of life.

In discussions of legislation for euthanasia and PAS, the focus population has always been those who do not have long to live. When a patient is in the terminal stages of their illness, a time may come when treatments aimed at cure either no longer work (they are futile) or the burden of side-effects such as nausea and vomiting may be so overwhelming that they cancel out any benefit of treatment.  At this stage the treatment may be not prolonging life so much as prolonging the process of dying.  At this time a decision may be made to stop, or not to start, such a treatment.  The decision is made carefully in full consultation with the patient and their family and it is not euthanasia because the intention is not to kill the patient, but to allow the underlying disease to take its course.  Full supportive care will remain in place so the patient is kept comfortable.

Another situation which if often confused with euthanasia is adequate symptom control in the terminally ill.  In all areas of care we seek direction from the patient as to where we should place our efforts.  Very occasionally in the terminal stages of disease the distressing nature of a patient’s symptoms may require the careful sedation of the patient. The most common indication would be delirium or extreme agitation.  Once again this will be done carefully in consultation with the patient and their family and we will seek to preserve the dignity of the patient.  The doses are titrated to allow regular awakening so that the patient and their loved ones can communicate. It is not euthanasia because the intention is not to kill the patient, but to alleviate their distressing symptoms.

Some people would call this practice of symptom control passive euthanasia because of a myth in the community that use of morphine shortens the life of the patient.  They argue that if we already practice that type of euthanasia, there is no reason not to practice the other type of euthanasia, using lethal injection, which they call active euthanasia.  You see the problem.

But it is all based on a myth, that morphine shortens the life of the patient.  This myth causes lots of problems for palliative care workers.  It’s been around for years, and we don’t seem to be able to squash it.  It makes people scared to use what is an excellent treatment for pain.  Let me state clearly that research has shown that morphine in therapeutic doses does not shorten life.  Indeed, not only does it not shorten life, it may in fact prolong it.  A study in 2005 showed increased survival of patients in a Newcastle hospice on high doses of morphine. [i]

Stopping futile and burdensome treatment and maintaining adequate symptom control are good medical practices at the end of life and should be encouraged in clinically appropriate situations.  When the public has a better understanding of end-of-life care it reduces the call for euthanasia because there is less suffering experienced along with an increased sense of control for the patient.

Arguments for euthanasia

• Euthanasia is a compassionate response to the suffering of the terminally ill which is perceived (often wrongly) to be otherwise unrelievable.

2.Euthanasia is an expression of autonomy – that a competent individual should have the right to make self-governing choices, especially in the face of increasing support for euthanasia in public opinion polls.

• Legalisation is called for as a way to regulate the alleged existing practice of euthanasia in order to provide protections for patients and doctors under the law.

Arguments against euthanasia

• Sanctity of human life forbids it.
• Euthanasia is unnecessary due to the availability of palliative care to relieve suffering in the terminally ill.
• There are negative social consequences of legalising euthanasia.
• There is danger of abuse due to the slippery slope which is created with the legalisation of euthanasia.

Let me unpack these for you.

Responding to suffering

It is true that many people experience pain and suffering when they are dying , and this has led to a situation where too many of us have seen someone die badly.  Perhaps they were in pain, treated without dignity, or experiencing spiritual turmoil.   Maybe this is your experience.

This should not happen, but it still does and is an important factor in the call for the legalisation of euthanasia. It has been the experience of many people campaigning most strongly for the cause. We must do better.

I don’t know how many dying patients I have cared for as a palliative care doctor, but I imagine it must be in the thousands. I would like to assure you that at the end of your life, you will not be faced with just two options – pain and suffering on the one hand, or euthanasia on the other.  There is another option, which explains why euthanasia is increasingly unnecessary: palliative care.

Palliative care is specialised care for dying people, which aims to maximise quality of life, and assist families and carers during and after the death. Its intention is to liberate patients from the discomfort of their symptoms, and neither hastens nor defers death. An old slogan for palliative care was ‘we will help you live until you die’. 

Currently, only a fraction of those people who would benefit from palliative care, receive it.  Why is this?

The main reason is that, although churches established the first hospices in the 19 th century, the modern palliative care movement is relatively new. While students now receive training in pain control, there are many doctors in the community who are not aware of what can be done. The discovery that different types of pain respond to different treatments has revolutionised care of the dying.

Furthermore, there are certain demographic characteristics which reduce access to palliative care in the community - low income, non-urban location, acute care settings and nursing homes, ethnic or indigenous background, very old or very young age, and non-cancer diagnosis. [ii]

The World Health Organisation has developed a pain relief ladder which enables up to 90% patients to be pain-free using a basic approach which all doctors can learn. [iii]   Specialist centres can achieve even higher rates of success.  Not everyone needs to see a specialist or visit a hospice, but all dying patients would benefit from palliative care in some form.

Interestingly, one response to the brief legalisation of euthanasia in Australia was an increased injection of funds into palliative care services by the federal government. Since then, the argument for euthanasia on grounds of unrelieved suffering of dying patients has become much less prominent.  Palliative care in Australia is improving all the time, but we should not be complacent: the most common reason why palliative care services cannot help dying patients is because they are referred too late or not at all.  As the European Association for Palliative Care states in their position statement on euthanasia, our challenge is ‘to transform our care of the suffering and the dying, not to legalise an act which would all too easily substitute for the palliative competence, compassion and community that human beings need during the most difficult moments of their lives’. [iv]

We also need to recognise that suffering is not merely a medical problem but an existential problem which extends beyond physical pain. It is influenced by psychological, cultural and spiritual factors. The physical symptoms can be dealt with but the suffering may well remain. 

It is made worse by the fact that we, as a society, have lost touch with the spiritual concerns surrounding death.  Dying forces us to face the big issues of life – What does it all mean? What are we doing here? Western society is struggling to answer these questions. We are youth-obsessed and death-denying, and don’t know how to die properly anymore. We’re uncomfortable discussing it and we have lost our traditions in the West. I think we could be trained to die by example, but few of us have seen examples. Most members of the public have never seen a corpse and many people have long ignored the spiritual dimension when they face the mystery of death.  They’re unprepared, and it can be scary. 

Furthermore, we are immersed in a culture of comfort where we are more likely to reach for the quick fix than the stiff upper lip.  Christians understand the benefits of suffering, such as the opportunity to grow in perseverance, character and hope (Rom 5:3-4), but the wider community does not share this understanding.  It may be that what people are requesting in the call for legalised euthanasia is not so much a right to die, as the opportunity to avoid the process of dying itself.

In our community the fear of dying is promoted by numerous accounts of pain and misery experienced as life draws to a close.  There seems to be a desire in some people to go from a state of health, straight to a state of being dead, without having to ‘die’ at all.  In a society which has lost touch with the meaning of suffering, there is also, understandably, a loss of the willingness to endure it.

Medicine and protection of life

One aspect of the euthanasia debate that is often ignored is that it expects doctors to perform euthanasia.  I was asked recently whether the doctor uses a sterilised needle when performing euthanasia.  This encapsulates how antithetical euthanasia is to the way medicine is currently practised.  There seems to be an attempt to confer medical legitimation on the ending of life, but what will happen to doctor- patient relationships if patients can’t trust their doctor to always be a protector of life?  Will patients forgo medical care because of fear of euthanasia?

Euthanasia violates codes of medical ethics which have existed since antiquity. The Hippocratic Oath, taken by doctors on graduation since the 5 th century BC, specifically prohibits doctors from helping their patients die. Medical and palliative care associations all over the world are strongly opposed to the legalisation of euthanasia.

Dying as part of life

If we accept dying as a part of life we should all embrace, is there anything good about the dying process?

When a person is dying, he and his family find themselves in a crisis situation.  All the joys and regrets of the past, the demands of the present and fears for the future will be brought together.  Help may be needed to deal with things like guilt, depression and family discord, but in this time of crisis, there is the possibility of resolving old family problems and finding reconciliations which greatly strengthen the family group.  The time between diagnosis of a terminal condition and death is often a time of great personal growth.  I have seen this time and time again. When relatives think back on the last days of their loved one, how much better to remember a time of peace and reconciliation than one of anguish which is violently cut short.  Those at the coal face know very well that patients can and do choose the moment of death as a natural act if good care is available.

Legalising euthanasia

Arguments supporting euthanasia laws presuppose a world of ideal hospitals, doctors, nurses and families. But we don’t live in an ideal world.  We live in a fallen world where humans make mistakes and have selfish motives.  For this reason, legalisation of euthanasia holds a number of risks.

We cannot be sure that euthanasia, once legalised and socially accepted would remain voluntary. Vulnerable and burdensome patients may be subtly pressured to request termination of their lives, even though they don’t really want to.  Consider the difficulty of having a relative in hospital long term, the stress of daily visits – finding a parking space!  And sadly, the prospect of inheritance brings out the worst in a lot of people. These patients aren’t stupid.  They know what a burden they can be on others. Legal euthanasia introduces a factor which should not be present in the environment of a sick person.

With euthanasia legalised, would we remain a caring society ready, in times of financial constraint, to continue to invest money and resources into attempts to improve the care of the terminally ill? Palliative care is expensive and becoming more so as patients survive longer and develop more complex problems. It is a very labour intensive discipline. Public opinion can be influenced once a law is changed.  Is this what we want?  I believe western medicine has progressed as far as it has because we do value all human lives and continue to seek cures for the diseases which afflict us.

Another risk is that doctors may not be able to resist the extension of euthanasia to those who don’t, or can’t, consent to termination of their lives. Proponents of euthanasia will tell you that legal guidelines will prevent this happening. However, the Dutch Government’s Remmelink Report in 1991 [v] found that around one in three euthanasia deaths were without patient knowledge or consent (around 1000 each year). Government reviews showed similar results in 1995 [vi] and again more recently, [vii] despite the fact that there are stringent guidelines in place in Holland. One argument put forward to support euthanasia suggests that we need to regulate what is already taking place illegally. If those doctors performing euthanasia now are unwilling to obey the law, why do we think we could trust them to do so after it is changed?

Lastly, if euthanasia were legalised, would we avoid the intolerable abuses that other civilised countries have slipped into before us?  We say the holocaust could never happen again, but in the Nuremburg trials after WWII it was established that the extermination programmes of the Nazis had their origins in the promotion of mercy killing by German doctors in the 1920s [viii] .  Once you accept that some lives are not worth living, what will happen?

In the Netherlands, euthanasia was legalised in 2002 after 20 years of widespread practice under legal guidelines.  By the time the law had passed, the courts had already legitimized the death of patients who were not terminally ill. [ix] The Dutch are currently debating the need to allow the elderly to be euthanased when they are ‘tired of life’. [x] And early in 2005 a Dutch hospital published their guidelines on how to kill disabled newborns. [xi]   Are these the values we want to pass onto our children?

We ignore the lessons of the Netherlands at our peril. The discrimination, racism and triumph of expediency over justice in our society should warn us against naïve enthusiasm about proposals to decriminalise euthanasia.

Now I would like to look at what I think is the strongest argument for euthanasia – that of autonomy, the principle of self-determination, expressed here as the right of the individual to choose the timing and manner of their own death.

It is undeniable that after we have done all we can in palliative care and made sure the patient is mentally competent, there will be a small number of patients who still suffer and who request euthanasia. It is unlikely to be because of pain. There is little good research into why people actually request euthanasia, but the studies that have been done show the most common reasons are not related to physical factors but to psychosocial and existential factors—things like the fear of death and loss of control, fear of becoming a burden and of loss of dignity, fear of the future. [xii]   Patient desires are known to fluctuate over time, [xiii] but whatever the reason, euthanasia is what these patients want.  What are we to do with this small group of people who rationally request that their lives be terminated after all our attempts to care for them are still not enough?

There are a few things you need to check.  Suicidal thoughts are a symptom of depression. The first step when a patient is requesting euthanasia is to assess—and where appropriate treat—the patient for depression. Research shows that sometimes when patients expressed their fears at the end of life it was misinterpreted by healthcare providers as a request for euthanasia when it was really intended to be a cry for help. [xiv]

The incidence of depression in cancer patients has been measured as high as 45%. [xv] There are reports that 1 in 6 of patients who requested a lethal prescription in Oregon 2004-2006 were clinically depressed but not referred for counselling, (as the law requires). [xvi]  In any other group, a request for death would alert a doctor for urgent psychiatric review: why is this group of patients being treated differently?

Another thing to check is whether the patient aware of the rights they already have in terms of refusing life-prolonging treatment. I find many patients are not aware that this is an ethical and legal option.  No mentally competent patient has to undergo futile, burdensome or life-prolonging treatment if they don’t want to.  It can be hard as a doctor to accept this decision, but knowledge of the right to refuse treatment would ease many of the concerns felt by those who fear being kept alive by artificial means against their wishes.

Finally, if the suffering the patients wish to avoid is due to metaphysical or spiritual concerns, then it is not only patient autonomy, but also the social, psychological, religious and cultural concerns that need to be addressed.

But given that some people do still request euthanasia, how do we proceed?

The public debate is about whether we should change the law to allow euthanasia, not about whether euthanasia is right or wrong for individual cases.  Euthanasia is going to be ethically appropriate for some individuals whose morality recognizes autonomy as a priority. If you think that this world is all there is and living has become unbearable, the choice to end it all makes sense.

So from the community perspective there is a tension here – between those people who rationally request euthanasia and the vulnerable people who would be at risk of being killed against their will, as is happening now in the Netherlands. Autonomy – the right of the individual to determine the timing and manner of their own death – versus security – the right to protection and security as expressed in the values of the larger society.  How are we to resolve this? Is there a right to die that the government should support?

While as Christians we would say our bodies are not our own, legally, a man is free to end his life when he chooses.  But that does not mean he has a right to do so, and he certainly does not have the right to compel someone else to kill him.

Many people say that when they are facing death they would want to be able to request euthanasia.  A news poll from October last year commissioned by a Euthanasia support group found 85% of Australians in favour of euthanasia [xvii] (though I have questions about what exactly was asked and how well defined the questions were). Even if we accept that large numbers of people would like the option to request euthanasia though, the proportion of people actually requesting it when facing death is very different.  A study done in Sydney has shown that only 2.8% of patients in a palliative care service requested euthanasia when first seen. After palliative care commenced, this number was reduced to less than 1% of those referred. [xviii] I am not surprised by these low numbers – in my experience, those facing death are more likely to want more time, not less.

We do need to respect autonomy, but as one of many relevant factors, not as a preeminent stand-alone factor.  People are more than autonomous entities. The argument from autonomy is based on a view of human beings which is too shallow, and devoid of the inevitable social context.

Moreover, in practice, some will lose autonomy whichever legal path is chosen: if euthanasia is legalised, precedent shows that legally unprotected persons too often have their autonomy to choose life undermined; if it remains illegal, Persons genuinely desiring euthanasia lose their autonomy to choose death. Either the right of the vulnerable to protection, or the right of the sufferer to end their suffering is compromised. Surely it is the responsibility of our society to care for those who cannot care for themselves.

In view of the very small number of people demanding autonomy, I believe that we must err on the side of justice and the responsibility of our society to care for those who cannot care for themselves. Those demanding euthanasia will not have what they want and that is terrible for them, but we must protect the frail and vulnerable who want to live. This is the conclusion of government-sponsored enquiries in England, Canada, the USA and Australia. [xix]

Proponents of euthanasia bills will reject this reasoning . They keep saying that it only affects patients and their carers, but this is just not true.  It can’t be.  Legalisation of euthanasia must affect society as a whole because in legalising euthanasia we are changing one of the most basic tenets of our society.  That is, that we do not kill each other, even for reasons of mercy and compassion.

Christian ethical response

Ethical choices involve motivation, action and consequences. So far the arguments we have looked at for and against euthanasia judge right and wrong on the basis of the consequences believed to ensue if euthanasia were legalised. Christians have another moral compass: the Bible. The Bible teaches that in ethical decision-making, motivations, actions and consequences all matter. [xx]

The most common motivation for those on both sides of the euthanasia debate is compassion for those who suffer. Motivation prompts us to act but does not inform the content of our actions, so common motivation may lead to different actions. Euthanasia is an inappropriate response for Christians because there are some actions we must never do, whatever the motivation or consequences. The Bible is very clear on euthanasia: the intentional killing of an innocent human being is wrong (Ex 20:16).

In addition, Christians recognise that all humans are made in the image of God and thus have value that is not dependent on our state of health or abilities. It also means that we are creatures, and so our autonomy will operate within the parameters given to us by our creator, God. Our bodies are not our own (1 Cor 6:19-20).

These arguments against euthanasia may seem inadequate in the face of the suffering we have identified as central to the debate.  God calls us to be salt and light – salt to preserve the good in the world, light to illuminate the truth as we influence the cultural drift. What does it mean to say no to euthanasia? What do we have to say to those who suffer?

We say that life is a gift from God, and acknowledge that sometimes it takes less courage to die than to continue living. We say that while we do not always understand why suffering occurs, we are willing to walk with them because God in his mercy created us to carry each other’s burdens, and when we are suffering, we are comforted by human presence. This is the challenge for the church: to stay with the dying.

When Job’s friends first saw him, they sat on the ground with him for seven days and seven nights.  No-one said a word to him, because they saw how great his suffering was.  And as Job learnt, it is only God who can give meaning to our suffering.

The euthanasia debate is an expression of a society that is struggling to find meaning in life, and so finds no meaning in death.  It is desperately trying to control death any way it can.  But the true answer to our plight as we struggle on in this broken, fallen world is not legalisation of euthanasia but the good news that Jesus came to give us new life, new bodies, better bodies in the world to come (1 Cor 15:44). In the next world there will be no more death or mourning or crying or pain (Rev 21:4).  Euthanasia is not the solution to suffering.  In the end, the only thing that can wipe our tears from our eyes is the hand of God.

E N D N O T E S

[i] P. D. Good et al ., (2005). Effects of opioids and sedatives on survival in an Australian inpatient palliative care population. Intern Med J , Vol.35(9) , pp512–517.

[ii] Palliative Care Australia. (2009). EOL, Vol.1(2).  

[iii] World Health Organization. (1996). Cancer pain relief (2nd ed.). (Geneva: WHO, 1996).

[iv] F. D. J. Roy & C. H. Rapin et al ., (1994). Regarding euthanasia. European Journal of Palliative Care, Vol.1(1), pp1-4.

[v] Medische Beslissingen Rond Het Levenseinde – Rapport van de Commissie Onderzoek Medische Praktijk insake Euthanasie. (The Hague, The Netherlands: Sdu Uitgeverij, 1991).

[vi] H. Jochemsen & J. Keown, ‘ Voluntary euthanasia under control? Further empirical evidence from The Netherlands’. Journal of Medical Ethics , Vol. 25(1), 1999, pp 16 - 21 .

[vii] A. van der Heide et al ., ‘End-of-life practices in the Netherlands under the Euthanasia Act’. The New England Journal of Medicine , Vol.356 (19), 2007, pp1957-65.

[viii] R. J. Lifton, The Nazi Doctors: Medical Killing and the Psychology of Genocide. (New York: Basic Books, 1986).

[ix] Y. Sheldon, Dutch argue that mental torment justifies euthanasia. BMJ , Vol.308, 1994, pp431-432.

[x] Dutch News.nl. 09-02-2010. Tired of life? Group calls for assisted suicide.

[xi] P. Verhagen & P. J. Sauer, The Groningen Protocol — Euthanasia in Severely Ill Newborns. NEJM, Vol.352(10),  2005, pp959-962.

[xii] P. Hudson et al ., Desire for hastened death in patients with advanced disease and the evidence base of clinical guildelines: a systematic review. Palliative Medicine , Vol.20, 2006, pp693-701.

[xiii] H. Chochinov et al ., Will to live in the terminally ill. Lancet , Vol.354, 1999, pp 816–19.

[xiv] Hudson, op. cit.  p697.

[xv] S. D. Passik, M. V. McDonald, W. M. Dugan Jr, S. Edgerton  & A. J. Roth, Depression in Cancer Patients: Recognition and Treatment. Medscape Psychiatry & Mental Health eJournal, Vol.2(3), 1997.

[xvi] L. Ganzini, E. R. Goy & S. K. Dobscha, Prevalence of depression and anxiety in patients requesting physicians’ aid in dying: cross sectional survey.   BMJ, Vol.337, 2008,  p1682.

[xvii] News poll (2009) Voluntary Euthanasia Study. Prepared for Dying with Dignity NSW. Available at: http://www.dwdv.org.au/DOCS/Newspollsurvey2009.pdf   (accessed March 3, 2010).

[xviii] P. A. Glare, The euthanasia controversy. Decision-making in extreme cases. MJA, Vol.163 , 1995, p558.

[xix] U K Select Committee on Medical Ethics, House of Lords. (1994). (Unanimous); New York State Task Force on Life and the Law, Euthanasia and Assisted Suicide in the Medical Context, ( 1994). (Unanimous); Senate of Canada, (1995) Of Life and Death ; Community Development Committee, Parliament of Tasmania, The Need for Legislation on Voluntary Euthanasia, ( 1998). (Unanimous);

Social Development Committee, Parliament of South Australia. Report of the Inquiry into the Voluntary Euthanasia Bill 1996 . (1999).

[xx] E.g. Matt 5-7; Rom 3:8.

2 Responses

October 18, 2017

Yes, the oldest surviving code of medical ethics, the Hippocratic Oath (500 BC) says ‘Neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course.’ In more modern times, the World Medical Association states ‘Euthanasia, that is the act of deliberately ending the life of a patient, even at the patient’s own request or at the request of close relatives, is unethical’ (WMA Resolution on Euthanasia 2013).

Isimar Zorrilla

September 29, 2017

Does euthanasia by any means go against any any of points established in the medical code of ethics?

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What is euthanasia.

Euthanasia is the practice of ending the life of a patient to limit the patient’s suffering.  The patient in question would typically be terminally ill or experiencing great pain and suffering.

The word “euthanasia” itself comes from the Greek words “ eu ” (good) and “ thanatos ” (death).  The idea is that instead of condemning someone to a slow, painful, or undignified death, euthanasia would allow the patient to experience a relatively “good death.”

Types of euthanasia

Different practices fall under the label “euthanasia.”  Here are some distinctions demarcating different versions.

Active euthanasia : killing a patient by active means, for example, injecting a patient with a lethal dose of a drug.  Sometimes called “aggressive” euthanasia. Passive euthanasia : intentionally letting a patient die by withholding artificial life support such as a ventilator or feeding tube.  Some ethicists distinguish between  withholding  life support and  withdrawing  life support (the patient is on life support but then removed from it). Voluntary euthanasia : with the consent of the patient. Involuntary euthanasia : without the consent of the patient, for example, if the patient is unconscious and his or her wishes are unknown..  Some ethicists distinguish between “involuntary” (against the patient’s wishes) and “nonvoluntary” (without the patient’s consent but wishes are unknown) forms. Self-administered euthanasia : the patient administers the means of death. Other-administered euthanasia : a person other than the patient administers the means of death. Assisted : the patient administers the means of death but with the assistance of another person, such as a physician.

There are many possible combinations of the above types, and many types of euthanasia are morally controversial.  Some types of euthanasia, such as assisted voluntary forms, are legal in some countries.

Mercy-killing:  The term “mercy-killing” usually refers to active, involuntary or nonvoluntary, other-administered euthanasia.  In other words, someone kills a patient without their explicit consent to end the patient’s suffering.  Some ethicists think that

Physician-assisted suicide:  The phrase “physician-assisted suicide” refers to active, voluntary, assisted euthanasia where a physician assists the patient.  A physician provides the patient with a means, such as sufficient medication, for the patient to kill him or herself.

Some instances of euthanasia are relatively uncontroversial.  Killing a patient against their will (involuntary, aggressive/active, other-administered), for instance, is almost universally condemned.  During the late 1930’s and early 1940’s, in Germany, Adolf Hitler carried out a program to exterminate children with disabilities (with or without their parent’s permission) under the guise of improving the Aryan “race” and reducing costs to society.  Everyone now thinks this kind of euthanasia in the service of a eugenics program was clearly morally wrong.

What are key disputes in the controversy over euthanasia?

Advocates of active euthanasia typically argue that killing the patients in question is not worse than letting them die.  Advocates of voluntary euthanasia often claim that patients should have the right to do what they want with their own lives.  Advocates of mercy killing argue that for patients who are in vegetative states with no prospect of recovery, letting them die prevents future needless and futile treatment efforts.  If they are suffering then killing them prevents further suffering.  Advocates of physician-assisted suicide argue that a physician assisting a terminally ill or suffering patient is merely helping the patient who wishes to die with dignity.

Critics of the euthanasia typically argue that killing is always wrong, that nonvoluntary or involuntary euthanasia violates patient rights, or that physician-assisted suicide violates an obligation to do no harm.

Killing vs. letting die : There is dispute over whether killing a patient is really any worse than letting the patient die if both result in the same outcome.

Commonsense morality usually thinks that letting a person die is not as bad as killing a person.  We sometimes condemn letting an innocent person die and sometimes not, but we always condemn killing an innocent person.

Consider different instances of “letting die.”  One might claim that it is wrong to let our neighbor die of an accident if we could easily have saved his or her life by calling an ambulance.  On the other hand, we let starving people in poor countries die without condemning ourselves for failing to save them, because we think they have no right to demand we prevent their deaths.  But if someone killed a neighbor or starving people we would think that wrong.

Likewise, we would condemn a healthcare professional who kills a patient.  But we might accept the healthcare professional who at patient and family request withholds artificial life support to allow a suffering, terminally ill patient to die.

The distinction between killing and letting die is controversial in healthcare because critics charge there is no proper moral basis for the distinction.  They say that killing the above patient brings about the same end as letting the patient die.  Others object to this and claim that the nature of the act of killing is different than letting die in ways that make it morally wrong.

Ordinary vs. extraordinary treatment :  Ordinary medical treatment includes stopping bleeding, administering pain killers and antibiotics, and setting fractures.  But using a mechanical ventilator to keep a patient breathing is sometimes considered extraordinary treatment or care.  Some ethicists believe letting a patient die by withholding or withdrawing artificial treatment or care is acceptable but withholding or withdrawing ordinary treatment or care is not.  This view is controversial.  Some claim the distinction between ordinary and extraordinary treatment is artificial, contrived, vague, or constantly changing as technology progresses

Death intended vs. anticipated : Some ethicists believe that if a suffering, terminally-ill patient dies because of intentionally receiving pain-relieving medications, it makes a difference whether the death itself was intended or merely anticipated.  If the death was intended it is wrong but if the death was anticipated it might be morally acceptable.  This reasoning relies on the moral principle called the principle of double effect.

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The Morality of Euthanasia Essay

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Those who do not advocate for euthanasia frequently pose the debate that it would be recommended to allow a patient in a vegetative state to die rather than to actively take them out of life.

Morally, physicians are allowed to voluntarily cut off patients’ drinking, eating and drugs taking or sedating the patient and leaving the rest to nature, but it is not permissible in morality terms to facilitate a patient’s means of committing suicide or administer hastening measures for death.

This is a complicated and very demanding issue to get a definite stand. The purpose of this paper is to address the issue of whether from this point of view Euthanasia is morally acceptable (Daniel, 1999).

For this discussion to be feasible there is need to know how to determine morally permissible actions. That is, some of the factors which make such actions different in moral grounds.

All actions according to general knowledge are composed of intent and aftermaths, and it is this part that goes further to determine whether an action is moral or not. There are varied philosophical conventions which prefer either intent or consequences, while others are proponents of totally separate factors.

Conversely, there is no intention of moving further to through the demanding role of assessing this issue from all philosophical perspectives, which would rather be not feasible (Ashley & O’Rourke, 2001).

Most probably majority of individuals have went through experiences with relatives and friends who physically and psychologically suffered before death occurred. In other instances, some people are at the moment undergoing the grievous moment with may be a friend or a relative suffering terminal disease.

This is mostly in the last stages of such diseases as Cancer, AIDS and Diabetes where the victim is normally in a vegetative state with chances of recovering scaling at zero. These terminally ill individual are often forced to endure vital and inexorable pain and suffering. Modern medicine can only reach a certain limit in the attempt to alleviate the pain (Moreland, 2009).

Any individual who may come across and hear or see such an anguish in reality with someone dear to him or her to some extent shares the pain and suffering both emotionally and psychologically which makes one even desperately wishes it to stop.

In the meantime the medication and the doctors are not trivial anymore in stopping the pain and the victim despite all the sufferings, he or she is in a vegetative state and there is nothing she or he can contribute even to the society (Rachels, 2009).

In respect to this, some terminally ill patients may willingly wish to terminate their lives, but since they are in critical stages when even speaking is an issue it becomes very hard or rather impossible to it by themselves.

In this kind of a situation, some close people may be willing to assist the terminally ill patient commit suicide, because by doing so they feel that suffering will finally come to an end. The problem comes when the moral concern of whether doing so would be acceptable in moral terms (Sullivan, 1999).

Irrefutably it is very natural for an individual to wish well for another one and this would drive to assisting one dear to from such unnecessary suffering and pain and anguish. To force a terminally ill patient to go on living until nature takes its course would contradict human dignity since at the same time the patient is being forced to endure constant pain and suffering from the disease and other medical procedures.

The term euthanasia implies “good death” as it is supposed to act as a means through which a terminally ill person whose recovery chances are nonexistent dies with dignity.

All the same, to some people’s view it will be morally wrong to use euthanasia to terminate somebody’s life even in whichever condition (Moreland, 2000).

To these opponents of mercy killing, the problem arises because the approach focuses on happiness versus suffering and puts them at the forefront of life itself. Claims favoring mercy killing seems to mean that unhappy life is not worthy living.

This is a hedonistic point of view to life where it is believed that in the analysis, if the situation produces more of pain, suffering and anguish than it produces joy, serenity and happiness, then it is not good. This is because in such a situation there will be of evil than good being produced as a result (Moreland, 2009).

The truth is that in life everyone suffers and the ability to endure such sufferings is present through focus and thinking positive. It thus follows that, those who come out to assist others or to commit suicide probably do focus much on the suffering side and ignores the inherent capability of the mind to tolerate suffering and come up with implication that goes beyond any feeling that is intrinsically negative (Sidney, 2001).

To die is a reality that every one will eventually experience, and this unfortunately comes sooner for those individuals who contracts terminal diseases.

Even if one in such a condition endures the pain and suffering with an implication that it will be feasible if remains focused and with the meaning of life at the forefront, the bottom line remains that such an individual still remembers that soon he or she will meet death and thus little can he or she decide of the future (Sidney, 2001).

The future becomes determined by the disease. However those who are forced to tolerate suffering and pain should be able to seek their own self-respect without recourse to circumstances with any one claiming to be a beloved one being willing and able to do so too.

No one in the family members or those dear to the victim wishes death to come soon, actually they never wish them to die so as to terminate the suffering claimed but instead they celebrate their lives and always be thoughtful that inherent treasure of life that is incomparably more non trivial than suffering and happiness. This means that life has immeasurable treasure or value which also means that life is sacred (Plato, 2000).

If individuals in the society decide stupidly that the life value should be fully considered with reference to the level of suffering and happiness that people go through, then it as well can be taken to mean that those languishing in absolute poverty should be permitted to die since they endure constant suffering and pain.

As a matter of fact, very few individuals will seem to entertain such a nonsensical claim or notion which will sounds abhorrent to many people.

Conversely, the truth then follows from the fact that, we should ground our society morals on strong and sensible ground, otherwise there will be much immorality creeping in the society deceiving our worldviews (Joanne, 2006).

Societies should be of the claim that life is inherently valuable no matter what extent of pain and suffering one might go through. By this, humanity will possibly be opening up to deeds that recently sound inhumane but might sound usual to pleasant to more than expected individuals in the near future (Joanne, 2006).

The intent for patients being helped to commit suicide and those willingly and actively volunteer to use euthanasia to shorten their suffering and painful and “useless” life is similar to the aforementioned alternatives; it call for intentional life taking of the ill patient.

By its very definition, PAS permits the physician to terminate lives of terminally ill patients using the death booster for those patients willing to die.

The physician is said to be conveyed in intentional killing by embracing this approach to hasten death of a terminally ill person who wills to die (Bowie, Michaels and Solomon, 2006).

To recapitulate, it is noteworthy to say that life is sacred and human beings should always seek to protect ad preserve it which then leads us to the notion that people should be allowed to live until nature does it role.

If human beings become thoughtful of the sanctity of life, then there should always be personal dignity n life regardless of tough circumstances people face.

Therefore, since both seem to mean the same thing, there is no significant difference between killing a patient in reality and using euthanasia or allowing him or her to die because they are both intentional in essence.

Reference List

Ashley, B. and O’Rourke, K. 2001. Health Care Ethics . South Bend: University of Notre Dame Press.

Bowie, L., Michaels, M, & Solomon, C.2006. Twenty questions: an Introduction to philosophy . Fort Worth: Harcourt Brace College Publishers.

Daniel, C. 1999. Minimalistic Ethics. Hastings Center Report 1 (11), Pp.19-25.

Joanne, L. 2006. By No Extraordinary Means . Bloomington: Indiana University Press.

Moreland, J. 2009. Review of The End of Life. The Thomist. 53(1), Pp.714-22.

Moreland, J. 2000. The Life and Death Debate . Westport, CT: Praeger Books. 4(2), Pp. 12.

Plato. 2000. The death of Socrates’ in Bowie, GL, Michaels, MW & Solomon, RC, Twenty questions: an introduction to philosophy . Fort Worth: Harcourt Brace College Publishers.

Rachels, J. 2009. The End of Life . Oxford: Oxford University Press.

Sidney, H., W. 2001. The Physicians Responsibility toward Hopelessly Ill Patients: A Second Look. The New England Journal of Medicine. 3(2), Pp. 844-49.

Sullivan, D. 1999. Active and Passive Euthanasia: An Important Distinction . New York: McGraw- Hill Press.

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Ethics guide

Ethical problems of euthanasia

Pinpointing the ethical problems and questions around euthanasia. This article sets out the current legal position in the UK.

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Does an individual who has no hope of recovery have the right to decide how and when to end their life?

Why euthanasia should be allowed

Those in favour of euthanasia argue that a civilised society should allow people to die in dignity and without pain, and should allow others to help them do so if they cannot manage it on their own.

They say that our bodies are our own, and we should be allowed to do what we want with them. So it's wrong to make anyone live longer than they want. In fact making people go on living when they don't want to violates their personal freedom and human rights.It's immoral, they say to force people to continue living in suffering and pain.

They add that as suicide is not a crime, euthanasia should not be a crime.

Why euthanasia should be forbidden

Religious opponents of euthanasia believe that life is given by God, and only God should decide when to end it.

Other opponents fear that if euthanasia was made legal, the laws regulating it would be abused, and people would be killed who didn't really want to die .

The legal position

Euthanasia is illegal in most countries, although doctors do sometimes carry out euthanasia even where it is illegal.

Euthanasia is illegal in Britain. To kill another person deliberately is murder or manslaughter, even if the other person asks you to kill them. Anyone doing so could potentially face 14 years in prison.

Under the 1961 Suicide Act, it is also a criminal offence in Britain, punishable by 14 years' imprisonment, to assist, aid or counsel somebody in relation to taking their own life.

Nevertheless, the authorities may decide not to prosecute in cases of euthanasia after taking into account the circumstances of the death.

In September 2009 the Director of Public Prosecutions was forced by an appeal to the House of Lords to make public the criteria that influence whether a person is prosecuted. The factors put a large emphasis on the suspect knowing the person who died and on the death being a one-off occurrence in order to avoid a prosecution.

(Legal position stated at September 2009 )

Changing attitudes

The Times (24 January 2007) reported that, according to the 2007 British Social Attitudes survey, 80% of the public said they wanted the law changed to give terminally ill patients the right to die with a doctor's help.

In the same survey, 45% supported giving patients with non-terminal illnesses the option of euthanasia. "A majority" was opposed to relatives being involved in a patient's death.

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• v.46(2); 2017 Feb

An Ethical Review of Euthanasia and Physician-assisted Suicide

Božidar banoviĆ.

1. Faculty of Security Studies, University at Belgrade, Belgrade, Serbia

Veljko TURANJANIN

2. Faculty of Law, University at Kragujevac, Kragujevac, Serbia

Anđela MILORADOVIĆ

3. Seniorenzentrum Röweland, Hamburg, Germany

Background:

In the majority of countries, active direct euthanasia is a forbidden way of the deprivation of the patients’ life, while its passive form is commonly accepted. This distinction between active and passive euthanasia has no justification, viewed through the prism of morality and ethics. Therefore, we focused on attention on the moral and ethical implications of the aforementioned medical procedures.

Data were obtained from the Clinical Hospital Center in Kragujevac, collected during the first half of the 2015. The research included 88 physicians: 57 male physicians (representing 77% of the sample) and 31 female physicians (23% of the sample). Due to the nature, subject and hypothesis of the research, the authors used descriptive method and the method of the theoretical content analysis.

A slight majority of the physicians (56, 8%) believe that active euthanasia is ethically unacceptable, while 43, 2% is for another solution (35, 2% took a viewpoint that it is completely ethically acceptable, while the remaining 8% considered it ethically acceptable in certain cases). From the other side, 56, 8% of respondents answered negatively on the ethical acceptability of the physician-assisted suicide, while 33% of them opted for a completely ethic viewpoint of this procedure. Out of the remaining 10, 2% opted for the ethical acceptability in certain cases.

Conclusion:

Physicians in Serbia are divided on this issue, but a group that considers active euthanasia and physician-assisted suicide as ethically unacceptable is a bit more numerous.

Introduction

Does a man, in addition to the right to live, have a right to die? More specifically, does he have a right to a dignified death? Is a deprivation of life from the mercy reasons a crime or unpunishable act? The answer to these questions varies from country to country. On the one hand, if a state decides to legalize this form of the deprivation of life, the key question is what are the reasons for it? On the other hand, in a case when legislator takes an opposite view, we have the same question ( 1 ). Therefore, euthanasia, and in recent time physician-assisted suicide, are inexhaustible topics for reflection and observation of the different aspects of medicine, law, sociology, philosophy, religion and morality (according to some authors, this debate is one of the ten hotly moral issues ( 2 ), but also one of the major problems in the national and international health limits. By bypassing defining these two very famous terms at this point in time, we will just point out that the direct active euthanasia is a medical act directed to the deprivation of life (hereinafter: ADE), while a physician-assisted suicide is an act of the physician where he provides to the patient a medicament for taking life (hereinafter: PAS).

It is not clear when the man for the first time came to the idea of euthanasia ( 3 ). There have been many discussions in the United States and United Kingdom, culminated in 1906, when Ohio attempted to pass a law to legalize euthanasia ( 4 ). Movements to the legalization of the ADE and PAS have marked the last few decades, but we can notice that legislators across the world more easily decriminalize PAS, as a milder form of the deprivation of life. This is primarily evident on the American continent, where a few states decriminalized PAS, although the Supreme Court held that there is no constitutional right to ADE and PAS, nor the ban on the mentioned acts. Parallel to this process, there are strict criticisms of such actions, which have the ultimate aim of eliminating criminal penalties for persons who assist in the deprivation of the life of the patient, who is terminally ill at his request ( 5 ). If we take the example of England, the constant change of the attitudes of the British Medical Association and Royal College of Physicians, that varies from the strict opposition to the neutral position and vice versa, shows that is hard for them to accept any attitude regarding taking one’s life and to take any constant attitude whatsoever ( 6 ).

Different viewpoints in some countries caused a different approach to the legislative treatment of these two issues ( 7 , 8 ), but their solutions are, due to the many activities in this area, constantly reviewed ( 9 ). For example, Belgium in 2014 went far ahead when approved ADE for children, considering them as competent for such decision ( 10 , 11 ). Both procedures are in the majority of countries in the world illegal, but they exist everywhere ( 12 ).

However, in this paper, we will mainly deal with the observation of the ADE and PAS from ethical point of view, where we devote due attention to the criticism of a different regulation of ADE and passive euthanasia (hereinafter: PE), which is inexhaustible field for everyone who seriously takes this matter. In order to contribute to existed theoretical and practical considerations, we conducted a survey among physicians in Serbia on this topic.

Materials and Methods

The data for the current analysis have been derived from the broader research project whose aim was to identify occurrence, distribution, and opinions of the physicians about euthanasia and physician-assisted suicide. In this paper, we analyzed part of the obtained data. Research is primarily based on quantitative research approach, and data were collected using a short survey, created specifically for the purpose of this study. In the civilized countries, physicians are increasingly faced with demands to assist patients in committing suicide or to apply euthanasia ( 13 , 14 ). Therefore, we conducted a survey among the physicians from Clinical Hospital Center in Kragujevac (Serbia) in 2015. Data were collected during the first half of the mentioned year. We analyzed the segments of dataset which concern to two questions: Which of them is acceptable: ADE ethically or PAS ethically? To both questions, we offered three answers: yes , no , and yes, in some cases .

The scope of the tested population, gender structure of the respondents, as well as the diversity of the health departments in participants employed, gives us possibility of a wider generalization of the findings to the physicians’ populations across the whole country. The initial sample plan was to try to conduct a survey of all employees in this medical institution. Of 100 physicians, 88 expressed their willingness to be participants. The final sample included 88 physicians: 57 male physicians (representing 64, 77% of the sample) and 31 female physicians (35, 23% of the sample). The study was divided into three parts: in the Ambulance, in the Emergency Room, while the third, the most numerous sample, and included physicians from the departments of Surgery, Transfusion, and Cardiology. The initial hypothesis was that the physicians who work in the Emergency Room are prone to saving lives, and will be exclusively against ADE and PAS. The same situation is expected in the Ambulance, while in the remaining sample, physicians will be divided by their opinions. We analyzed total data as well as data by departments.

The sample included 88 physicians, who declared on ethical acceptability of ADE and PAS. In Table 1 are total data for the ADE, while in the Table 2 are results located by departments; in the Table 3 are total data for the ethical acceptability for the PAS, and in the Table 4 are located data by departments for this question.

Is ADE ethically acceptable?

Is PAS ethically acceptable?

The issue of the right to death with dignity is inevitably linked with ethics and morals. The law and moral in some cases does not stand in the necessary pervasive connection, due to the brutal features of some legal systems, although such phenomena should be as rare as possible ( 15 ).

In the literature, we can find another significant question: could the moral and ethical conduct be illegal, but the act to be in accordance with the law to be immoral ( 16 )? If we start from the basic rule that the law is only a minimum of morality, thus the moral rules are at the higher level then legal. Based on this, when a legislator regulates ADE and PE, he should not make distinction between them, because they are equal in weight. In the numerous issues raised in the area of euthanasia, the existence or non-existence of moral differences between killing and letting to die a patient from the effects of the disease, and between ADE and PAS stands out ( 17 ).

The supporters of this attitude (most commonly in the sphere of philosophy and religion ( 18 )) found one of the main reasons for the immorality of ADE in the assertion that human life is sacred (although this term usually belongs to the religion -“traditional ethical principle” ( 19 , 20 ) that one cannot and must not take. They bypass a debate about the reasons that led to killing by using ADE. They do not put an accent on the quality and content of life. At the same time, these authors are divided into two fractions: radical and moderate. The supporters of moderate direction reject possibility of the moral justification and legal regulation of ADE, while the authors who hold the radical position are absolutely against any form of euthanasia and taking of human life. Human life is sacred and it is the work of the God ( 21 – 23 ). However, human life has a meaning only in a case when the brain is operational ( 24 ), and from the times of Confucius, we have had philosophical thought that biological life has not more value of the man ( 25 ). The supporters of ADE and PAS do not believe that these actions are immoral per se , especially in the situations where the patient is suffering from great pain ( 26 ). In the medical practice, we have such conditions of the patient in which their pain cannot be controlled or reduced. According to the specific research, in the best scenario, 97% of all pain can be brought under control, but 3% of pains remain and that can be unbearable and cannot be controlled ( 27 ). We have noted just one of the many examples of unreasonableness of the observation of euthanasia as an immoral procedure ( 28 ). Simply, the interests and the will of the patient should be above the wishes of doctors, and even legislators. According to some authors, respect for human being involves four dimensions: concern for his well-being, respect for his wishes, respect of the core values of his life and respect of his interests ( 29 ).

When a physician determines that the patient suffers from an incurable disease, death becomes the inevitable outcome, and therefore, we cannot seek the cause of death in the medical treatment, but in the natural reasons. Regardless of the fact that determines the patient’s life by his active engagement, his act cannot be considered as a direct cause of the patient’s death. This removes the doctor’s responsibility, legal and moral ( 30 ). The fact that lies in the basic of the ADE and PE is the intention to terminate a patient’s life, elaborated in the acting/omission doctrine. Some authors assert this view, stating that a big difference exists between deprivations of life and letting someone to die, citing the example of the hunger in the poor regions of the world. If we accept a view that there are no differences between ADE and PE, and arguing that persons who die from the hunger did not die from poverty and shortages of the food, and in that case, we are all killers ( 31 ). This attitude is unacceptable for the obvious reasons. It is very important difference between occurrence of a death as an effect of the direct physicians’ act and its occurrence as a side effect of the drug given with the aim of relieving pain ( 32 ). Obviously, it gives moral justifications primarily to the active indirect euthanasia, while ADE remains in every sense morally prohibited, which is the unsustainable structure. Here, it is also unacceptable to set up possibility of comparing these two modes of death, especially from the patient’s point of view. After the occurrence of death, the patient is indifferent about this issue ( 33 ).

The authors who argue about admissibility of legalization ADE and on its complete immorality and deny the possibility of the deletion of legal and moral dividing line, when presenting counter-arguments do not take into account, or they mention it only cursory, without deeper analysis, a crucial fact without no treatment applied – the will of the patient ( 31 ). Here, we bypass theories about autonomy of the will from the John Stuart Mill and Immanuel Kant, although some authors believe that the right to self-determination derives only from the teaching of Kant ( 2 ). Autonomy of the will is the basis of dignity of human nature and the every mind nature ( 34 ). However, the authors who are deeply involved in the studying of the individual autonomy of the will bring into the question the ability of the patient to express his will to ADE, because they are under the pressure to agree with such act ( 35 ). As a counter-argument, there is a possibility of abuse, but this is a case with every procedure in the world.

The main argument for the removal of the status of immorality from the ADE lies in the patient’s autonomy of the will, and not bypassed. Therefore, we ought once again to remind Dworkin’s thesis that the grossest form of the tyranny is allowing the death of the person in a manner that another people justify ( 27 ). At the same time, we have to bear in mind the best interest of the patient, not limited only to the perception of his physician ( 36 ). Based on that, we can assess the patient’s best interest, because, there are situations in life in which a patient wants shortening of his life despite the real possibilities of his healing, where one should restrict his autonomy of the will. In addition, a patient wants to continue his medical treatment, even though the doctor diagnosed that death is inevitable. In such cases, the autonomy of patient’s will have a dominant character. The application of the euthanasia on that patient would mean a violation of the all ethical principles that exist. The men who simply do not want to accelerate his death despite serious medical condition, either for religious or from nonreligious reasons, thus expressing their will that must be respected and their life must not be shortened by applying ADE. Nobody has a moral right to decide for another person whether his life is worth living or not, because, for one person his pain can be unbearable to the point that his life is of no value, while for others pain cannot be compared with the values of life. Any decision that patiently brings is morally acceptable for him. It must be the same for everyone else. Overall, from the Table 1 , we can see that physicians were divided regarding the issue of the ethical acceptability of ADE. A slight majority, 56.8% believe that this method is ethically unacceptable, while 43.2% opted for another solution. In addition, 35.2% took a viewpoint that it is completely ethically acceptable, while the remaining 8% considered it ethically acceptable in certain cases. Respondents who viewed ADE ethically acceptable in certain situations could not deny its acceptability because they are aware of the fact that patient’s condition could be extremely difficult. This confirms initial hypothesis and we got expected results, not only here but also almost through the remaining results. Namely, in the region of Kragujevac, and also in the most part of Serbia, physicians did not yet meet with the ADE in practice, and therefore, their basic view on it and its ethical acceptability is mostly negative. Orthodox Church in the region contributes to such a view because it regards ADE and PAS as murders.

Our starting hypothesis is proved through the next, Table 2 . The highest percentage of the respondents who declared themselves in favor of ethics ADE is among respondents in the third, the largest part of the sample. Of the 19 physicians in the Ambulance, six consider that this practice is ethically acceptable, while just one considered that it is ethically acceptable in some cases. Twelve physicians opted for the opposite response. In the Emergency Room, on the other hand, almost no one of the respondents did vote in favor of ethics, except one, who sees ADE as ethically acceptable in some cases. The results show the correctness of the assumption that the physicians who are in the first place turned to saving lives will be against ADE, and that physicians in the Ambulance with majority will be against ADE. Another part of the sample with the mild majority voted in favor of ADE - we expected that because this part of the sample is not on the front line of the struggle for the life of the patients. Precisely because of this group of respondents, the percentage of the physicians who are against the ethical acceptability of ADE does not deviate much from the supporters.

The following question tried to establish ethical acceptability of the PAS and results are shown in Table 3 . What surprised us a bit is a greater support, even in a minuscule percentage, to the ADE in the relation to the PAS. As we can see, 56.8% of respondents answered negatively on the ethical acceptability of the PAS, while 33% of them opted for a completely ethic viewpoint of this procedure. Out of the remaining 10.2% opted for the ethical acceptability in certain cases. Although there are no excessive variations in relation to ADE, we assumed that a greater percentage of respondents would consider PAS more acceptable than ADE, since in this procedure physicians do not represent the main cause of the patient’s death. In PAS, they represent just accomplices, who will provide a necessary aid to the patients. In addition, physicians in some cases consider that they should not abandon their patients and that they should take responsibility for their death.

Results almost identically to the ADE are with PAS when we have a look at the distribution by departments in Table 4 . The only difference is reflected in the fact that the number of respondents who believe that these procedures are ethical to have fallen from 25 to 23, while two respondents increased the number of those who believe that PAS is ethically acceptable in some cases. Moreover, we can assume that these are two same respondents. Therefore, if we compare the percentage of the subjects in the ADE and PAS tables in the relation to the Emergency Room, we have identical data. Simply, respondents are absolutely against these procedures, except for the one, who believes that in some cases PAS would be ethically acceptable. Absolute orientation to saving lives contributes their denial of the justification of any form of the deprivation of life.

Euthanasia, regarded as deprivation of life with compassion, as well as PAS, is complex issues that cause and raise numerous questions. A particular problem is breaking euthanasia on ADE and PE, and then their different regulation. Morally and ethically, they are equal. In any case, autonomy of the will of the patient should be an essential moment. Physicians in Serbia are divided on this issue, but a group that considers ADE and PAS as ethically unacceptable is a bit more numerous. However, for the better view of their attitudes we should research on a much wider area.

Ethical considerations

Ethical issues (Including plagiarism, Informed Consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc) have been completely observed by the authors.

Acknowledgments

This work was supported by Faculty of Law, University of Kragujevac. The authors declare that there is no conflict of interest.

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12  Euthanasia

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• Published: March 2006
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This chapter discusses why euthanasia presents a moral dilemma for physicians. It shows that trying to distinguish between active and passive euthanasia in any of the following four ways: (1) acts versus omissions, (2) withholding versus withdrawing, (3) ordinary care versus extraordinary care, or (4) whether death is due to natural causes, does not work. It then shows that using the distinction between patient requests and patient refusals does provide an adequate way to make this distinction. It provides an analysis of killing and discusses the Supreme Court decision concerning assisted suicide.

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The New York Times

Advertisement

The Opinion Pages

Doctor-assisted suicide is unethical and dangerous.

Ira Byock , a professor at Dartmouth's Geisel School of Medicine, is chief medical officer of the Institute for Human Caring of Providence Health and Services and the author of "Dying Well" and "The Best Care Possible."

Updated September 4, 2015, 2:25 PM

American health care is undergoing tumultuous changes and showing signs of strain. A recent Institute of Medicine report attests to persistent deficiencies in care and social support that seriously ill people and their families experience. Witnessing the suffering of our relatives, friends and, for clinicians, our patients, gives rise to moral distress.

It is not surprising that support for physician-assisted suicide is also rising. The age-old dictum that doctors must not kill patients can appear antiquated, out of touch with hard realities, and even heartless.

Holland shows how such measures get out of control. While the state of dying in America is outrageous, two wrongs don't make a right.

On the contrary, this is when such principles are most important. Principles are the I-beams of civilization’s architecture, designed to withstand the forces of social upheaval. Prohibitions on medical practice protect vulnerable patients and the public from the power that doctors wield due to their specialized knowledge and skills. People who are poor, or old and frail, or simply have long-standing disabilities, may worry that when they become acutely ill, doctors might see their lives as not worth living and compassionately act to end their supposed misery.

When doctor-induced death becomes an accepted response to the suffering of dying people, logical extensions grease the slippery slope. Last year in Holland, where voluntary euthanasia is permitted, over 40 people sought and received euthanasia for depression or other mental illness. Even the psychiatrist who began this practice in the 90's recently declared the situation had gone “off the rails.” In April, a 47-year-old Dutch mother of two was granted her wish to die because of long-standing tinnitus (ringing of the ears). In late 2012, 45-year-old congenitally deaf twins were euthanized in Belgium rather than face the prospect of losing their sight.

Proponents of Oregon’s law claim that such excesses couldn’t happen in the United States. Really? Holland and Belgium are sophisticated countries with universal health care. In America patients are commonly pauperized by a profit-driven health care system, doctors are often inadequately trained in basic palliative skills, and nursing homes are understaffed, leaving people to feel uncomfortable, unwanted and undignified.

Even today, people with advanced cancer, heart disease or neurological disorders in Montana, Oregon, Vermont and Washington may qualify for physician-assisted suicide, but be deemed ineligible for hospice under Medicare and Medicaid, either because they are too healthy or still want treatment for their terminal condition.

Moral outrage is appropriate and needed to fix the sorry state of dying in America. Legalizing assisted suicide fixes nothing. The principle that doctors must not kill patients stands. Two moral wrongs don’t make a right.

Join Opinion on Facebook and follow updates on twitter.com/roomfordebate .

Topics: assisted suicide , disabled , elderly , medical ethics , right to die

Oregon Shows That It Can Work Sensibly and Fairly

Everyone Deserves to Die With Dignity

Expanding the right to die, it violates medical principles and is dangerous, too many questions remain.

Denying Someone a Peaceful Death Can Be Unethical

Limit Agressive Treatments for the Sickest and Oldest

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Choosing death: autonomy, ethics, and the controversy of euthanasia, advocating for end-of-life rights.

Gael MacLean

“If I cannot give consent to my own death, whose body is this? Who owns my life?” — Sue Rodriguez

Winter kill. That’s what they call it around here when, come spring, not everyone has emerged from their cocoons in the backcountry. “Hey, have you seen Travis?” Winter kill. Those two words tell you that Travis has taken his own life due to health or age. Folks here are tough and independent. They will not spend the last of their time on this planet in assisted living or a hospital—not when they have spent their lifetime in glorious nature, free and autonomous.

Winter kill. It’s no secret how it’s done. You mix a bottle of your favorite alcohol with a thermos of coffee and grab a seat under the stars in below 0 degrees temps. Both the coffee and the alcohol push your body heat out your pores. It doesn’t take long. And if you can’t wait for winter? There is always a Plan B. It’s just messier.

Before Christianity

Euthanasia, or mercy killing, was practiced in many ancient civilizations. Common in the times of the Greeks and Romans it was viewed as an…

Written by Gael MacLean

Award-winning creator bringing a fearless approach to exploring new creative worlds across multiple disciplines. Portfolio - https://www.gaelmac.com

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