essay about legalizing euthanasia

Euthanasia – For Legalizing

There are many arguments for and against legalizing euthanasia. It has ethical benefits as well as downsides. Should euthanasia be legalized? Essay samples like this one will help you understand the issue.

Introduction

There is no respect for autonomy, justice is denied, sympathy for the suffering of others, individual liberty vs. state interest, the voice of the u.s. public.

The legality issue of Euthanasia has been a subject of heated debate since long. On the global scene, the Netherlands was the first country to legalize Euthanasia in April 2002, followed a month later by Belgium.

Switzerland legalized the practice in December 2005 (Reuters U.K). In the U.K where public support for legalization of Euthanasia rose from 69% in 1976 to 82% in 2004, it is widely expected that Parliament will soon legalize the practice (News-medical.net).

In the U.S, many states have been debating the legality issue of Euthanasia but only Oregon has legalized it since 1997 (Reuters U.K). It is my contention that Euthanasia should be legalized all over the country.

The word ‘Euthanasia’ comes from the Greek word ‘Euthanatos’ meaning ‘good health.’ Euthanasia is defined as the deliberate ending of a person’s life by anther person at the specific request of the former. Euthanasia is not the same as other practices such as Physician-Assisted Suicide, Terminal Sedation or Withholding/Withdrawing Life-Sustaining Treatments.

Physician-Assisted Suicide takes place when a physician, responding to specific request from patients, gives information {for example, a prescription for a fatal dose of sleeping pills}, and/or the means {such as a supply of carbon monoxide gas} of committing suicide to patients so that they can easily hasten their death (Religious tolerance.org).

Terminal Sedation occurs in cases where the physician administers sufficient sedatives to cause a terminally ill, competent patient to become unconscious, then permitting the patient to die of starvation, dehydration and the disease which has been contracted (Braddock et al.).

Withholding/Withdrawing Life-Sustaining Treatments takes place where a competent patient refuses to continue taking on-going life-sustaining treatment (Braddock et al.) such as the use of ventilators, dialysis, intravenous fluids and feeding tubes.

There are 3 kinds of Euthanasia. Active Euthanasia takes place when a person is put to death as a direct consequence of a request from him or her.

A famous example is the 1998 case involving Jack Kevorkian who caused the death {by lethal injection} of a patient suffering from ALS {Lou Gehrig’s Disease} who begged for a swift and painless death. Passive Euthanasia occurs when the death of a person is speeded up by changing some type of life-support being administered to him or her, thereby paving the way for nature to take its own course.

Examples of Passive Euthanasia include unplugging a respirator, ceasing administration of medications or not performing CPR {cardio-pulmonary resuscitation} on a person whose heart has ceased functioning. Involuntary Euthanasia involves putting to death persons who have not specifically asked for assistance in dying.

This usually occurs in case of those who have slipped into a Persistent Vegetative State and will in all likelihood never regain consciousness (Religioustolerance.org).

Taking decisions about the time and method of one’s death is considered very personal and confidential. Persons who are terminally ill patients with deadly diseases like ALS, AIDS, Alzheimer’s or Multiple Sclerosis know they will soon die and simply want to exercise control over the process. They cannot tolerate the loss of personal dignity as they are no longer self-sufficient, but have to constantly depend on others for care (Religioustolerance.org).

Secondly, such terminally ill persons do not wish to reduce their financial assets by having to constantly pay massive hospital bills as their death draws nearer; they would prefer to die quickly so that their inheritors of their assets will benefit to a greater degree by way of savings of such heavy hospital expenses.

Heavily underlying these reasons is the inescapable fact that they are living in excessive, chronic pain fully knowing that there is no cure for their ailment and that death is inevitable (Religioustolerance.org).

The Constitution of the country dictates that all persons have the freedom of choice. The freedom of choice in this case refers to the right of all persons – whether in good health, slightly ill or terminally ill – to choose if they want to go on living or if they are restrained so heavily by circumstances such as terminal illness to take the decision that they do not want to continue living and that they would be better off dead.

By not legalizing Euthanasia, terminally ill patients are denied the right to court speedier death by taking matters into their own hands. For some of them, death does not come as speedily as they wish, with the result that they have only one option left – death (Braddock et al.). By denying them the right to escape a life of pain that will anyway end in nothing by death, the State is denying terminally ill persons their Constitutional right

Some illnesses, besides causing intense physical suffering, also cause unbearable psychological burdens to patients (Braddock et al.). A classic example is AIDS. Sufferers of this disease endure horrific suffering as the disease progresses. Their bodily resistance steadily deteriorates, weakness sets in and they literally wither away to death.

Their physical anguish is accompanied by extreme mental suffering as they know that even with the best treatment, their burden of physical and metal suffering will at the most be slight, and that too temporarily, relieved but the onset of death is inevitable.

If these patients may request Euthanasia hasten death, do their loved ones not have the moral duty to end their physical and metal suffering? The key word in this scenario is ‘inevitability.’

The persons who have been entrusted by the patient to administer Euthanasia knows that death is inevitable, therefore, if such death is allowed to come in earlier than scheduled, it is a matter of showing sympathy for the suffering of the patient. In this context, Euthanasia is seen as a compassionate reaction to intense suffering.

There is no doubt that the State has a strong interest in preserving the life of its citizens. It is understandable and widely expected as a sign of a well-run State because such interest stems from the responsibility entrusted to the State.

Therefore when the State takes precautionary measures to safeguard its citizens such as apprehending thieves and muggers, or interning drug dealers and human smugglers, or punishing rapists and wife batterers, or sentencing serial killers to life imprisonment or capital punishment, these actions are viewed as signs of a government correctly doing the job that it was elected to do.

However, when it turns into a matter of private {as opposed to the above various forms of public safeguards}, the intensity of such State interest does not match the interest of terminally ill individuals who opt for death to end life. This lopsided {against the State} level of interest, if strengthened by prohibition by the State, is seen as an infringement on the personal liberty of the individual (Braddock et al.).

Perhaps the greatest U.S President of all time, Abraham Lincoln, described democracy as a rule “by the people, of the people and for the people.” It therefore follows that in this great democracy called the United States of America, it is the voice of the people that is paramount.

It also therefore follows that the voice of the people in case of legalizing Euthanasia should be treated with the greatest of importance. The voice of the people states that Euthanasia should be legalized.

While almost all the U.S states may have been intimated by the 1997 U.S Supreme Court landmark ruling against Euthanasia, the U.S public certainly has not been similarly affected. A 2005 Harris Poll involving 1,010 adults in the U.S discovered that as many as 64% of them disagreed with the 1997 Supreme Court ruling.

It was therefore not surprising that the same poll also found that 70% of them were in favor of legalizing Euthanasia. The greatest support was reserved for Involuntary Euthanasia with an overwhelming 72% of respondents declaring that they would go to the extent of expressly authorizing the administration of Euthanasia against themselves in their last wills and testaments (Taylor).

In addition to the above cited arguments, hard facts show that the most potent argument against legalizing Euthanasia {that it will increase the number of deaths of terminally ill persons} has been soundly refuted. Data from areas that have legalized Euthanasia do not show any marked changes as a result of this action. A good example is the U.S state of Oregon.

Ever since the passing of the Death with Dignity Act, the number of Euthanasia cases has hardly registered any noticeable change as compared to data of previous years. But what did change however, in Oregon as well as all those nations that have legalized Euthanasia, is the great relief that was made available to terminally ill patients – much needed relief that was cruelly denied to them before such legalization.

Their relief has been well articulated by Professor Torbjorn Tannsjo: “They [terminally ill patients] would know that, if, when their turn comes, and things turn out to be terrible, they have a way out” (News-medical.net).

Braddock C.H. & Tonelli M.R. “Physician-Assisted Suicide.” University of Washington. 2008.

“ British Medical Journal Publishes Euthanasia Opinions .” News-medical.net. 2005.

“ Euthanasia & Physician-Assisted Suicide .” Religioustolerance.org. 2002.

“ FACTBOX – Legal Status of Euthanasia around the World .” Reuters U.K. 2007.

Taylor, H. “Poll: U.S Adults Favor Euthanasia & Physician Assisted Suicide.” Death with Dignity National Center. 2005.

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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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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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Should assisted dying be legalised?

• Thomas D G Frost 1 ,
• Devan Sinha 2 &
• Barnabas J Gilbert 3  

Philosophy, Ethics, and Humanities in Medicine volume  9 , Article number:  3 ( 2014 ) Cite this article

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When an individual facing intractable pain is given an estimate of a few months to live, does hastening death become a viable and legitimate alternative for willing patients? Has the time come for physicians to do away with the traditional notion of healthcare as maintaining or improving physical and mental health, and instead accept their own limitations by facilitating death when requested? The Universities of Oxford and Cambridge held the 2013 Varsity Medical Debate on the motion “This House Would Legalise Assisted Dying”. This article summarises the key arguments developed over the course of the debate. We will explore how assisted dying can affect both the patient and doctor; the nature of consent and limits of autonomy; the effects on society; the viability of a proposed model; and, perhaps most importantly, the potential need for the practice within our current medico-legal framework.

Introduction

Over the past two centuries, the United Kingdom has experienced rapid population growth associated with a substantial decline in mortality from acute infectious diseases and poor nutrition [ 1 ]. As the average life expectancy has increased, so too have the rates of debilitating chronic illness – particularly coronary artery disease and cancers [ 2 ]. These diseases require years of treatment instead of the mere days to weeks that medicine once operated within [ 2 ]. Although healthcare systems have sought to adapt to such changes, aiming to prevent and treat such disease wherever possible, debate has arisen regarding those patients in the latter stages of chronic, incurable, terminal conditions [ 3 , 4 ]. Moreover, there is increasing recognition that the patient must be at the centre of health care decision-making, such that outcomes must be tailored to their individual needs and views. By extension, assisted dying might seem a logical step to help achieve these goals within the realm of end-of-life decision making [ 5 ]. Several jurisdictions, notably Oregon (1997) and the Netherlands (2001) have already legalised assisted dying in some form. These factors have contributed to ongoing legislative discussions within Parliaments for almost a decade, with current opinion polling suggesting a majority of medical practitioners and the public in favour of physician-assisted suicide [ 6 ].

Viability of assisted dying in practice

In the UK, a model for assisted dying has been developed from the legal structure found within the Assisted Dying Bill introduced by Lord Falconer in the House of Lords in 2013 [ 7 ]. Assisted dying could only be considered under circumstances in which a patient of legal age is diagnosed with a progressive disease that is irreversible by treatment and is “reasonably expected to die within six months” [ 7 ]. Registered medical practitioners would make such decisions for patients with terminal illnesses. Addressing the technicalities of ‘assisted dying’ requires distinction between ‘physician-assisted suicide’ (offering patients medical actions or cessation of actions by which they can end their own life) and ‘euthanasia’ (whereby the medical practitioner actively induces death). In light of the strong hostility of the medical profession towards active euthanasia, this proposed model, as with previous attempts to legalise assisted dying, permitted only the former [ 8 – 10 ].

However, there is concern that such distinction may be unrealistic in practice because medical practitioners could find themselves with a patient who had failed to successfully end their own life and was subsequently left in a state of greater suffering. Were such a patient no longer able to give consent, a heavy burden would then be placed on the physician regarding how to proceed. Moreover, the practice of physician-assisted suicide might be deemed discriminatory, for example by giving only patients with good mobility control over their own method of death.

The Assisted Dying Bill 2013 included the provision that any terminal prognosis must be confirmed and attested by a second registered practitioner. The strictness of such criteria has parallels to a similar double-physician requirement when procuring a legal abortion under the 1967 Abortion Act. The stated aims of the provision in both cases are as follows: first, to check the accuracy of the prognosis upon which the decision was being made; second, to ensure that the situation meets the required criteria; and third, to check that such a decision was taken by the patient after full consideration of all available options [ 11 , 12 ]. By having a second independent doctor, the legislation ensures that all three checks are met without prejudice or mistake.

Problematic for any protocol for assisted dying is the fact that estimates of life expectancy in terminal prognoses are erroneous in 80.3% of cases [ 13 ]. Furthermore, the accuracy of such prognoses deteriorates with increased length of clinical predicted survival. Forecasts of survival times are based largely on past clinical experience, and the inherent variability between patients makes this more of an art than a science. This brings to concern both the accuracy of any prognosis meeting the six-month threshold and the validity of requests for assisted dying based partly or wholly on predicted survival times. Whilst the majority of errors in life expectancy forecasts are a matter of over-optimism and hence would not affect either of those two concerns, many cases remain unaccounted for. Overly pessimistic forecasts occur in 17.3% of prognoses; hence we must decide whether the one in six patients making a decision based on an inaccurate prognosis is too high a cost to justify the use of this system. Patients requesting an assisted death often cite future expectations of dependency, loss of dignity, or pain [ 14 ]. If the hypothetical point at which the progression of their illness means they would consider life to be not worth living is not, as informed, mere weeks away but in fact many more months, then this information would have resulted in a different decision outcome and potentiated unnecessary loss of life.

Whilst the presence of a second doctor would be expected to mitigate such forecasting errors, the anchoring bias of the initial prediction may be enough to similarly reduce the accuracy of the second estimate. It is prudent to question the true independence of a second medical practitioner, and whether this second consultation could become more of a formality, as has now become the case with abortion [ 15 ].

Another challenge for an assisted dying system would be to recognise whether patients requesting death were legally competent to make that decision. Consider that any request for suicide from a patient with clinical depression is generally categorised as a manifestation of that mental disorder, thereby lacking capacity. It is arguably impossible to separate out the natural reactions to terminal illness and clinical depression. Indeed, there is evidence that major depressive disorders afflict between 25% and 77% of patients with terminal illness [ 16 , 17 ]. Any protocol for assisted dying must first determine what qualifies as a ‘fit mental state’ for a terminal patient.

The need for assisted dying

It could be argued that a doctor’s fundamental duty is to alleviate forms of suffering in the best interests of the patient. The avoidance of physical pain, as an obvious manifestation of suffering, might explain why assisted dying would be both necessary and within the duties of a doctor to provide. The evolving principle in common law known as the ‘Doctrine of Double Effect’ offers a solution to this problem [ 18 ]. This legal judgement stated that “[a doctor] is entitled to do all that is proper and necessary to relieve pain even if the measures he takes may incidentally shorten life”. This entails that a protocol already exists for patients searching for an escape from chronic pain. Furthermore, numerous retrospective studies have revealed very little correlation between opioid dose and mean survival times: one study of over 700 opioid-treated patients found that the variation in survival time from high-dose opioid treatment is less than 10% [ 19 – 21 ]. It can therefore be said that pain alone, if appropriately managed, should never be cause for considering assisted dying as an alternative.

By contrast, the ‘Doctrine of Double Effect’ might be seen as a subjective interpretation that has been applied unequally due to a lack of specialist training or knowledge [ 22 ]. Despite this, the principle can be easily understood and poor awareness can be remedied by improvements in medical education and standardisation of protocols. Moreover, should we choose to accept arguments for assisted dying that are based upon inadequate administration of pain medication, we set a precedent for conceding shortcomings in palliative care and other end-of-life treatments. Offering hastened death could become an alternative to actively seeking to improve such failings.

Whilst much has been made of the ‘pain argument’ here, the call for assisted dying is rarely this simple. Many patients also suffer a loss of dignity, often due to their lack of mobility – the inability to relieve oneself without help is a potent example. Beyond this are additional fears of further debilitation and the emotional costs of dealing with chronic illness, both for the patient and for their relatives and friends. A study of terminal patients in Oregon showed that these were the most significant reasons behind requests for assisted suicide, the next commonest reason being the perception of themselves as a ‘burden’ [ 14 ]. Clearly, we could seek to provide balanced, compassionate medical care for these patients, and still fail to address these points.

Developments in healthcare and technology may reduce this emotional burden, but remain an imperfect solution.

Rights of patients and limitations of their autonomy

J.S. Mill’s pithy dictum describes autonomy as follows: “over himself, over his own body and mind, the individual is sovereign” [ 23 ]. Not only has the sanctity of bodily autonomy profoundly influenced the development of liberal democracies, it has also provoked a holistic shift in making our healthcare systems more patient-centred – “care that meets and responds to patients’ wants, needs and preferences and where patients are autonomous and able to decide for themselves” [ 5 ]. The ethical principle of controlling the fate of one’s own body is inherently relevant to the debate on assisted dying. It is difficult to reconcile that citizens may have the right to do almost anything to and with their own bodies– from participating in extreme sports to having elective plastic surgery – yet a terminal patient cannot choose to avoid experiencing additional months of discomfort or loss of dignity in their final months of life.

Expectation of individual liberty has been codified in law. The right to bodily autonomy has been interpreted to be included under Article 8 - the right to privacy - of the European Convention on Human Rights (ECHR) and subsequently the Human Rights Act (HRA) [ 24 , 25 ]. Moreover, the ECHR underpins the right of individuals to ‘inherent dignity’ [ 26 ]. Hence, if an individual feels that dignity is unattainable due to the progression of a terminal illness, then taking recourse though assisted dying ought to be a legitimate option.

Conversely, there are two notable oversights in this interpretation of a right to assisted dying as an extension of the principles of bodily autonomy:

First, it would be wrong to view individual liberty as absolute. The HRA allows for exceptions to Article 8 on grounds of ‘health or morals’ [ 25 ]. The principle of autonomy is not inviolable. Governments have limited such privileges for the protection of individuals and society, for example by criminalizing the use of recreational drugs or the selling of one’s own organs. The preservation of life by denying assisted dying could fall within this category.

Second, the right of autonomy is not necessarily intrinsic to human beings but, as Kant argued, is dependent on our ‘rational nature’ [ 27 ]. This concept sees autonomy as an exercise of ‘evaluative choice’ [ 27 ], requiring rationality on the part of individuals to appreciate the nature of options and their consequences. To achieve true autonomy, there must be sufficient information to make those rational decisions; this is the basis of informed consent and why it is a fundamental duty of a doctor to offer a patient an informed series of treatment options [ 28 ]. The logistical issue is that doctors are unable to advise patients regarding the point at which their situation becomes less preferable to being dead. No doctor (or individual) has any knowledge or experience of what ‘death’ may be like. Hence, in this case, the idea of exercising true autonomy through informed consent might be considered meaningless.

Legalising assisted dying by attempting to establish an absolute right to bodily autonomy may undermine other individual and group rights. Vulnerable patients may feel pressured into assisted dying because of social, emotional, or financial strains placed on family and/or friends. This is exemplified by the trend showing that the proportion of patients stating ‘relief of burden’ on others as the reason for requesting assisted dying has risen from 17% to 25% in Oregon since legalisation [ 29 ]. One could even consider the risk of assisted dying becoming an expected choice rather than a free one. Thus, assisted dying may erode the elemental right to life of terminal patients as the value of their life becomes tied to relative costs to society and to those around them.

Moreover, by creating one class of individuals for whom life is expendable, that particular view may be extended by society to all groups possessing such attributes (e.g. the permanently disabled). There would be a definite risk to the rights of these vulnerable groups in the form of society being less willing to provide for their health and social care.

It is often raised that the limited legalisation of assisted dying would inevitably become extended in scope, but this is not necessarily a flaw. Even if the right to determine the manner of death were later extended to a wider group of people, posterity may reflect positively on such a change, just as extending the franchise to women ultimately led to legislation demanding equal pay.

Effect on health professionals and their role

‘To act in the best interest of the patient’ is often cited as a central duty of the doctor [ 28 ]. This concept of ‘best interest’ guiding the doctor’s action has seen the development of two important ethical principles: beneficence and non-maleficence. Beneficence mandates that the actions of the doctor must be aimed to bring about benefit (clinical improvement) for the patient, usually measured in terms of reduced morbidity or mortality; non-maleficence requires that the doctor not carry out treatment that is likely to cause overall harm the patient [ 30 ]. These traditional ethical imperatives on a doctor both conflict with intentionally hastening the death of a patient, and a resolution of this tension would require redefining what constitutes ‘acting in the best interest’.

A further dimension is the potential reluctance of health professionals to engage in a practice that contravenes their own ethical beliefs, particularly as this would affect doctors who never entered training in the knowledge that assisting patients to die would be an expected duty. This is certainly no argument against the introduction of assisted dying; indeed, a recent survey of a cohort of NHS doctors found that 46% would seriously consider requests from patients to undertake steps to hasten death [ 31 ]. It merely expresses the point that any early model would have to account for the fact that an initial 54% of the doctors in the NHS would be required to advise qualifying patients of assisted dying as a legitimate option, despite disagreeing with it in principle.

Furthermore, doctors who agree ethically with this practice may find themselves facing conflicts of interest. It is expensive to treat chronically ill patients, particularly in the final months of life [ 32 ]. Moreover, it would be difficult for commissioners to ignore the fact that the sustained treatment of one individual could deprive many others from access to surgery or access to novel drugs. Such an argument does not suggest that doctors or any other hospital staff would treat this practice without appropriate respect or care; rather it acknowledges the need for appropriate rationing of care and questions the intentions of service providers. The perception of an ulterior motive could negatively impact patient trust. One survey showed that a reasonable minority of patients (27%) – and particularly particularly the elderly – believe that legalising assisted dying would lessen their trust in their personal physician [ 33 ]. The costs of weakened trust in the doctor-patient relationship could far outweigh the benefits of assisted dying, particularly given the importance of trust when treating a chronic patient for an extended period of time.

There is no doubt that assisted dying would empower some patients to maximise control over the timing and manner of their own death. Such expression of autonomy would surely solidify moves towards a patient-centred approach to healthcare. However, the capacity for such consensual requests remains in doubt. Clinically, the patient’s state of mind and the reliability of diagnostic predictions are of issue; philosophically, the idea of informed consent for death is contradictory. The implications for patients, physicians and society have been weighed extensively within this article. The central tenet throughout has been the balancing of an individual’s right to escape a circumstance that they find intolerable, alongside the consequential changes to their other rights, and the rights and responsibilities of third parties. Ultimately, the challenge is for us as a society to decide where this balance lies.

About the debate

The Varsity Medical Debate was started in 2008 with the aim of allowing students, professors and members of the polis, to engage in discussion about ethics and policy within healthcare. Utilising the age-old rivalry between the two Universities, the debate encourages medical students from both Oxford and Cambridge to consider and articulate the arguments behind topics that will feature heavily in their future careers.

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Acknowledgements

For Cambridge University: Hilmi Bayri (Trinity), Alistair Bolger (Jesus), Casey Swerner (St Johns).

For Oxford University: Devan Sinha (Brasenose), Thomas Frost (Lincoln), Collis Tahzib (Lincoln).

Martin Farrell (Cambridge).

Baroness Finlay: Professor of Palliative Care Medicine and former President of the Royal Society of Medicine.

Dr. Roger Armour: Vascular Surgeon and Inventor of the Lens Free Ophthalmoscope.

Mr. Robert Preston: Director of Living and Dying Well.

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Frost, T.D.G., Sinha, D. & Gilbert, B.J. Should assisted dying be legalised?. Philos Ethics Humanit Med 9 , 3 (2014). https://doi.org/10.1186/1747-5341-9-3

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Medical Perspectives on Death and Dying

Several states have begun to consider legislation that would legalize active voluntary euthanasia.

Several states have begun to consider legislation that would legalize active voluntary euthanasia. To address some of the ethical issues raised by such legislation, the Center for Applied Ethics sponsored a symposium entitled Legalizing Euthanasia: Ethical Perspectives on Medicine and Dying . Principal speakers were Derek Humphry, founder and president of the Hemlock Society, and author of the current best-seller, Final Exit , a suicide manual for the terminally ill; and Richard Gula, S.S., Ph.D., a professor of moral theology at St. Patrick's Seminary in Menlo Park, California. The symposium was funded in part by the California Council for the Humanities, a state program of the National Endowment for the Humanities. The following excerpts highlight the remarks of Mr. Humphry and Father Gula.

Derek Humphry Let me explain how I became involved with the subject of euthanasia. In 1974 my first wife, Jean, was dying of bone cancer. Thrombosis had set in, her bones were cracking and she was losing control of her bowels. One day, after a very close brush with death, she sat up in her hospital bed and said to me, "Will you help me die?" That is when I first encountered the issue of euthanasia; from across my late wife's hospital bed.

After she made her request, I asked myself, "What if I were sitting in that hospital bed? What if I had had two years of pain and agony? What if I faced an imminent death? What if I was losing control of my bowels and my bones were cracking and so-forth?" I realized then that I would be asking her to help me to die. That, ladies and gentlemen, is my simple reason for what I did. It was an act of love.

Jean had been a good wife to me for 22 years. She stood by me in good times and bad. And when she was experiencing a bad time, I felt it was my duty to support her in her decision. I am not a Christian. I am an atheist. So, for me there was no question of consulting any god. It was a matter of situational ethics.

In 1980, five years after Jean's death, I helped to establish the Hemlock Society. This organization seeks to change certain laws regarding suicide. We want the government to decriminalize the actions taken by physicians in the assisted suicides of terminally ill patients.

We believe that a mentally competent adult who is dying should be able to submit a written request to their doctor that would state, "I've had all I can take. The pain and suffering are too much. I wish to die. Help me."

The physician, according to the Hemlock movement's prepared law, would have to obtain the opinion of a second doctor. They would both have to agree that the person is dying. The first doctor could then end the life of the patient with an oral or intravenous drug overdose, without the threat of prosecution or lawsuit. Our laws also state that the doctor could elect not to assist the patient with such an action.

There are those who agree with what the Hemlock movement is saying at the present time, but are fearful that such an ideology would result in a system of euthanasia similar to that used by Nazi forces. It is true that the Nazis introduced a program which they called euthanasia. They murdered about 100,000 people who were physically or mentally handicapped. No senior citizens or terminally ill people were allowed to voluntarily end their own lives.

But how can you say to a person who is dying of throat cancer today that they cannot have voluntary euthanasia because of what the Germans did in 1940 and 1942? I think that the person would respond, "It's not relevant. It's me. It's my body. It's my liberty. It's my life. And it's my death. Let me have control."

I would claim that this is the ultimate civil liberty. If we cannot go to our deaths in the manner of our own choosing, what liberty do we have?

Richard Gula Most of the focus on euthanasia so far has been dominated by what I'm going to call the paradigm of individual case analysis. My position is that euthanasia is not primarily an individual issue; it's a societal one. So discussion about euthanasia should not be governed primarily by individual case ethics, but by societal ethics.

The sanctity of life principle is probably the common ground principle. There are two extreme positions that can give sanctity of life as a principle a bad name. One extreme is what I call vitalism, and that is the extreme that tries to absolutize physical life making an idol out of biological existence. This principle says no cost is too great to keep this biological life going. The other extreme interpretation leads to what I'm calling a utilitarian perspective, which values life for its usefulness. This is the interpretation that says only the strongest and the fittest ought to survive. The danger here is the abuse of undertreatment.

I want to think about the sanctity of life from the middle position. This is the interpretation of the principle that recognizes we have limited dominion over life. It's the interpretation that says we are stewards of life, that we ought to care for life and promote it and enhance it in order to allow our lives to flourish and to achieve our potential. This is the interpretation that wants to respect life in all its forms and in all its stages. Interpreting sanctity of life in this way entails two obligations: a positive one--to nurture and support life„and a negative obligation not to harm life. Therefore, to appeal to sanctity of life in a discussion of euthanasia is to create a presumption in favor of life.

The second principle is the principle against the prohibition of killing. I want to look at three ways of interpreting this principle. The first says there is no moral difference between killing and allowing to die -- that once you decide that life no longer needs to be sustained, because the use of treatment would be futile, then it makes no difference whether you actively intervene or simply withhold or withdraw treatment.

The second interpretation is that there is a qualified moral difference. That qualified moral difference is that the distinction holds but gives way at a certain point. Some will say when the person has gone beyond the reach of human care, when there is no longer the capacity to receive love, or to receive comfort, then the distinction dissolves. Others will say when the person is in intractable pain and there's nothing more that can be done to relieve the pain, then the distinction between killing and allowing to die dissolves. Others would say when the patient is overtaken by the dying process -- that is to say, once you have decided that nothing more needs to be done, that life has reached its limits, then it makes no difference whether you withhold treatment or intervene, because in that condition, you are not usurping the dominion that is not yours. Then there's the third position that says the distinction holds all the way through.

The next principle is the principle of autonomy, which is probably going to be at the core of this discussion of whether euthanasia ought to be legalized. In our culture, we interpret autonomy as the right to self determination. The prevailing interpretation of autonomy in our culture is that autonomy is there to maximize self-interest. That means that we are able to pursue our own goals and life plans without external constraints. When we interpret autonomy this way, we answer the question "whose life is it anyway?" in favor of the one whose life is in question. This is solid ground for supporting euthanasia.

Can the principle of autonomy be used to challenge euthanasia? Some argue that the very interpretation of autonomy that says that you have the freedom to have another person intervene to take your life is a contradiction of what autonomy means -- that actually what you're doing is giving away your freedom. The other way of looking at it is to say that euthanasia is not primarily a private affair. It's a public or societal action that involves others, and therefore it is something that ought to be treated as a form of public action.

The third principle is the principle of the common good. To show that euthanasia ought to be sanctioned as a public practice, we need to be able to show that we can justify it in more than the individual case. This is the principle that says that when we establish a policy, we are sanctioning actions as a common practice. When we apply that principle to euthanasia, we need to ask, "how does the goal of my own private killing contribute towards making society the context in which human life can flourish?"

Now let's turn to the perspective of virtue. Virtue asks whether or not a policy on euthanasia creates the right kind of relationship between the physician and the patient, and would a policy on euthanasia create the right kind of community in which health care is delivered. The perspective of virtue asks that the physician deliver compassionate care within the limits of the physician's role. The trust that we extend to the medical profession to heal and protect life is something that we would want to sustain and the perspective of virtue asks whether that kind of trusting relationship would be enhanced or hindered if euthanasia became part of the options that are available to the physician. The perspective of virtue looks on ourselves as a community of interdependents in which we are partners to one another. It sustains the community of trust and care by promising not to abandon anyone, and it tries to be realistic about accepting the limits about what it means to be human. We recognize that life will not be free of suffering, that life will be burdensome, and there will be tragedy. The perspective of virtue tries to be realistic about accepting that. It encourages us to construct structures of support which will enable us to raise those who suffer into the network of the supportive, caring community.

Ultimately we cannot convert individual cases into public policy without having something remaining. The common good resists the temptation. How do the burdens to one individual compare to the burdens and the benefit on society as a whole? I think all of this ultimately is going to turn not on the basis of principles we argue with, but on the kind of people we are. Are we a virtuous people that creates a community of caring or are we going to compromise that in the way we allow euthanasia to become a practice in our healing society?

Videotapes of the symposium are available for $16.50 by writing to the Center for Applied Ethics, Santa Clara University, Santa Clara, CA 95053.

This article was originally published in Issues in Ethics - V. 5, N. 2 Fall 1991

The Legalisation of Euthanasia

• Policy and Ethics
• Ethical Issues
• Essays and articles

Brian Pollard MB BS, FANZCA, Grad Cert Bioeth. Sydney, Australia

The legalisation of euthanasia is a constantly recurring topic for debate, in which the chief themes include the status of good medical and nursing care for the dying, its morality, legal detail and human rights, especially respect for personal autonomy and perhaps privacy, and the role of public opinion. Since there are deep divisions in society on all those issues, it is not surprising that the debate seems to rotate endlessly about them, without any reasonable prospect of consensus. Those for and those against the proposal are both unwilling to yield on what they see as immutable positions of principle.

If progress is to be made, a way needs to be found whereby personal views about the medico-social role of euthanasia can be excluded, while the subject is discussed on neutral grounds, capable of objective examination.

It is apparent now that such a neutral way has been discovered, though perhaps by chance, it has already been used several times and the results of that use have been published. I refer to the reports of the large government-supported committees of inquiry held in recent years, on four different continents, devoted to the consideration of the consequences of legalising euthanasia.

In sharp contrast to the usual lack of resolution on debate on this topic, every one of these committees independently reached the same conclusion, namely that legalisation would be unwise and dangerous public policy, because unpreventable abuses could not be eliminated. More astonishingly, when it is difficult to find at random even a small number of people who can agree on almost any aspect of euthanasia, three of these four committees reached this conclusion unanimously, though they all included individuals who held opposing personal views about euthanasia.

The committees and their reports were:

- Select Committee on Medical Ethics, House of Lords, January 1994.(1)

- New York State Task Force on Life and the Law, titled Euthanasia and Assisted Suicide in the Medical Context, May, 1994. (2)

- Senate of Canada, June, 1995, titled Of Life and Death.(3)

- Community Development Committee, parliament of Tasmania, titled The Need or Legislation on Voluntary Euthanasia, 1998.(4)

Of the fourteen members of the House of Lords Committee, it can safely be assumed that some of the Peers were for, and some against, the legalisation of euthanasia when they commenced their deliberations and began to hear evidence. When it visited Holland, the Committee learned there of an alarming number of patient deaths without patient consent, and were openly told by Dutch advocates of euthanasia that effective safeguards against abuse had proved impossible to devise (5).

The Committee of the New York State Task Force had 25 members, including some who thought that euthanasia and assisted suicide were sometimes ethical and compatible with good medical practice. This Committee issued a unanimous report rejecting legalisation, a most valuable compendium of important information.

In early 1997, the Tasmanian parliament established a committee to examine the need for legislation on voluntary euthanasia in that State. When she released the final report of this Committee in 1998, the Chairperson revealed that of its five MP members, four, including herself, had originally been in favour of euthanasia. This Committee unanimously found that 'it would be impossible to frame a law that included all the vital safeguards to protect the vulnerable, weak and disabled' (6).

These reports, taken together, constitute an unexpected and valuable body of expert findings, all pointing in the same direction. Thus, any future proposal for the legalisation of voluntary euthanasia (VE) could reasonably be regarded as incomplete and inadequate unless it displayed familiarity with the arguments contained in those reports, and included effective solutions to the many difficulties they uncovered.

Regarding laws on killing, the House of Lords Report said 'The product of an adequate, legal framework should be public confidence that the law protects life...there can be no more important area in which the law's protection should be complete and transparent than where individual's lives are at stake'.

For a law to be unsafe, it does not have to be shown that it will be abused, merely that it is clearly open to abuse. The more open it is, the greater the likelihood that it will be abused.

A good deal of the reasoning in the reports may be summarised in this extract from the report of the New York State Task Force: 'For purposes of public debate, one can describe cases in which all the recommended safeguards would be satisfied. But positing an 'ideal' or 'good' case is not sufficient for public policy, if it bears little relation to prevalent social and medical practices. No matter how carefully any guidelines are framed, (assisted suicide and) euthanasia will be practised through the prism of social inequality and bias that characterises the services in all segments of our society, including health care. The practices will pose the greatest threats to those who are poor, elderly, members of a minority group or without access to good medical care'.

This paper cannot do justice to the whole of the content of the cited reports which need to be read in full, because they cover an extensive range of subjects. It will include:

- discussion of the essential incompatibility of any euthanasia law with the objectives of sound criminal law

- some discussion of the human rights thought relevant to euthanasia

- the role of public opinion in law making, and

- some of the medical factors that would make any such law unsafe.

Incompatibility of legalised euthanasia with existing criminal law.

Since euthanasia is the intentional taking of innocent human life, it is a form of homicide, and even if it were legalised, it would be legalised homicide. The basic aims of criminal law are to provide equal justice for every citizen and to protect the weak. Additionally, the consent of the victim is by legal tradition no defence to a crime.

Equal. The criminal law of every nation holds that all innocent human life is inviolable, innocent persons being those who pose no threat, or have done no harm, to others. The value placed equally by law on each life is such that its intentional destruction is the greatest of crimes, deserving of the greatest penalty. Euthanasia law would provide the first exception to the prevailing universal protection of innocent life, by creating a category of persons whose lives may be taken intentionally, under certain conditions. It would thus constitute a precedent for repeating the process later to further enlarge the scope of the new principle, where no such precedent had previously existed. The concept of equality before the law would have been abandoned.

Justice. For a law to be just, it should be grounded in sound ethical principle capable of receiving general acceptance; its definitions and provisions should be set out in clear terms so they can be interpreted in the same way by all who read them. This would constitute a particular problem with euthanasia, since many of the phenomena associated with death are difficult to define with such precision; its provisions, particularly those intended to act as safeguards, must be capable of being realised and of being monitored, and it must contain no obvious avenues for abuse. If any of its important elements relied for their observance on opinion rather than fact, that would introduce arbitrariness and would be incompatible with justice.

A patient who requested euthanasia would have concluded that his/her life was no longer worth living, and a doctor who agreed to the request would have reached the same conclusion, by an independent but arbitrary judgment. In the same circumstances, different patients and different doctors would have come to different conclusions, depending on their personal values. Thus, under a euthanasia law that simply accepted these personal choices as grounds for lawful killing, the result would represent a kind of lottery of life, whereby a subjective request was met with a subjective response, and neither would be, or could be, objectively validated. The idea that legally taking life may be made dependent on the untestable choice or opinion of persons is at odds with any mature notion of justice.

Protection of the weak. The lives of individuals or groups who are unable to participate fully in the life of the community are especially protected by the current law, because it allows of no exceptions. These groups include the poor, the aged and the very sick, and those who make heavy demands on the community's time or resources, such as physically or intellectually handicapped, or permanently unconscious, people. Once it had been decided in law that the equal right to life may be waived on account of a low quality of that life, it would seem, to some at least, that individuals in the above categories would be the most logical for the extension of that principle, should other circumstances seem to justify it.

Mutual consent. Voluntary euthanasia involves one person asking and another agreeing to the taking of life. Though, in criminal law, consent is no defence to a breach of any of its provisions, with lawful euthanasia both parties would have acted in defiance of that principle.

It is instructive that the statute laws on killing in the Netherlands are much the same as elsewhere, and that the Dutch have to date preferred to try to justify their expanding euthanasia practices by case law or precedent, not by statute. They have wanted to have euthanasia regarded as an arguable exception to the legal principle that they see as vital to maintain, namely that innocent life should be regarded as inviolable. Most of those who promote lawful euthanasia elsewhere fail to see that the retention of this principle is needed to sustain the credibility and strength of the rest of the criminal law, for a person must at least be alive in order to be subject to its provisions.

Human rights and the law.

As outlined above, any proposal to legalise VE would constitute, not only an attempt to change the present laws, but to overturn them. If the proposal appealed to any human rights for its justification, they would have to be acknowledged natural rights, those derived from considerations of the nature of mankind. That right would also need to be properly defined and understood in the same way by all who discuss it.

Natural rights were originally conceived as the entitlements of citizens that would protect them against injustices. Respect for autonomy can be argued to be a genuine natural right, and as such, it would oblige its acceptance by others. Autonomy is the right of every person to decide freely the course of his/her own life, within the limits set by the competing genuine rights of others, and it will oblige compliance when it respects those rights. That is, autonomy involves both the privilege of choice and the duty to restrain one's choice, when that is required. Difficulties arise in relation to VE when (a) autonomy is not defined or not correctly defined, since clarity is essential when discussing such a contentious and emotional subject, and (b) when it is commonly discussed as though it were no more than a welfare right. Autonomy is now commonly presented as, and often thought to be, merely an individual's expression of preference, which is never claimed to be binding on others.

Welfare rights have a well deserved reputation for being divisive and confronting, because they tend to favour one individual above others. Natural rights, which place equal emphasis on furthering the well-being of both the individual and of society, promote harmony and friendship. The facts that rights are so often incorrectly understood and unequally applied led one observer to comment 'when rights come in, love goes out the door'.

Though any proposal to take innocent life has unarguably high moral content, any suggestion that this merits close examination is apt to be met with accusations of 'religious bigotry' or the like, as though secular morality did not hold similar claims to fundamental importance. However that may be, a common practice now is simply to ignore any discussion of it. When absolute morality is rejected, traditional ways of deciding morality become diluted, without any consistent ethic found to replace them. Questions of right and wrong can then be transformed into questions about individual rights, so that 'What is right?' becomes 'What are the rights?', an entirely different topic.

Autonomy is misunderstood or misrepresented when it is assumed to apply to whatever an individual may happen to want sincerely, or when it is assumed that the significance of the consensual killing of VE is a private matter, with no harmful consequences for others. Both assumptions are wrong. Further, it is widely but incorrectly assumed that choice itself is the essence of autonomy, not what is chosen. Individuals have no entitlement at all to be given what they happen to want--that would be nearer to self-indulgence than self-determination.

Depicting euthanasia as no more than a private matter is dangerously naive, ignoring the fact that euthanasia law would set new and lower standards of respect for human life, because in the eyes of many, making a matter legal signifies it has the approval of authority. VE would then become one of the options that may be put to all vulnerable sick patients, and it would be proper to promote and encourage it. In light of the gross imbalance in power between doctors and their patients, some patients would than be powerfully and unfairly influenced. This would place an unnecessary burden on dying patients when they may already be seriously taxed and confused by so many aspects of their illness.

If the right to request death were a genuine right, it would oblige compliance, though VE supporters are careful always to point out that that is not their aim. A human right cannot be claimed at the same time to be genuine and yet only permitted to be exercised arbitrarily. To be consistent, if the right were genuine, VE should then be available to all who ask, sick or not, at any time, for any or no given reason. The young who now commit suicide in alarming numbers should no longer distress us, but be congratulated for showing how to take control of one's dying, as a matter of right.

Further, to depict VE as no more than an individual patient's wish is to ignore the presence of the person asked, the doctor. This second person is an independent moral agent who must make his/her independent and separate autonomous response, be required to justify it when asked, and take due responsibility for it.

The sum of these deficiencies in the common understanding of autonomy to justify VE means that the argument is distorted. No matter how often or how vehemently it is asserted that an individual's wish binds others to comply, just because that is what he/she sincerely wants, the mere expression of a wish is not autonomy. The wish, and all that may flow from it, must be closely examined within the context of its social and medical setting, and in this paper, some of those factors are discussed.

A different form of distortion, in the opposite direction, is the virtual exclusion from the debate of the right of every innocent person to his/her life, the genuine natural right on which the criminal law is founded. Not only must this right be included, logically it should be first.

The 1948 United Nations‚ Universal Declaration of Human Rights is the most widely acclaimed and accepted statement of human rights. It was compiled at a time when member states of the UN, horrified by their discovery of the then recent extent of the abuse of natural rights, were resolved to ensure that this should never happen again. It describes the right of each person to his/her life as equal, inherent, inviolable, inalienable and deserving of the protection of law. This means that the right is not to be made dependent on its quality at a particular time, there are no exceptions and the right may neither taken away nor given away.

There is an urgent necessity for full consideration of this natural right to be reintroduced whenever the legalisation of euthanasia is being discussed, if the proper role of law in the governance of society is to retained.

The doctrine of personhood is a relatively recently added plank in the platform for VE, and is now receiving broad assent. While it may not directly be connected with human rights, the concept is a denial of the right of every person to his/her life, and is therefore an attack on the ethical basis of law. 'Personhood' claims that the value and dignity of a person, which are the reasons that entitle every individual to be treated with equal justice, are said to depend on the prior development of certain currently usable psychological abilities. This raises questions as to which abilities there must be and how developed they must be. Since there are no standards by which every observer could reach the same conclusions, such questions can be answered only by choosing the criteria that will lead to the conclusion one wants. Thus, this will always be an arbitrary exercise, reliant on the values of the observer, and cannot be just.

If it were asked 'What benefits does this new idea confer on society in order to justify the displacement of the traditional understandings of who may be regarded as a person?', the answer can only be 'None, that do not permit and rely on the taking of the lives of certain individuals who are already unwanted by society, for other reasons, without their knowledge'. Those individuals will be some of the disabled, the senile, the seriously ill and the unconscious, whose lives are at present protected by law, and whose specific human rights are proclaimed in various declarations. When the malignant intention of personhood is realised, with its inherent disregard for both law and rights, its advocates‚ real lack of concern for all human life is exposed, to which is added duplicity when they also purport to appeal to other human rights.

The role of public opinion in law making.

One reason given for wanting the laws on killing changed is that a majority of the community have declared, via opinion polls, that that is what they want.

Opinion polls were developed to test views about political issues, but VE is clearly a moral issue, secular or otherwise. When an issue is as complex in almost every respect as VE is, no valid conclusions can be drawn from polls when the respondents' real understanding of them is both unknown and unknowable. To use such results as an argument to change part of the criminal law would be foolish and dangerous. This would be self evident if it were proposed to change other parts of the law, using the same mechanism.

Morgan opinion polls have been asking the following question in Australia since 1962: 'If a hopelessly ill patient, in great pain, with absolutely no chance of recovering, asks for a lethal dose, so as not to wake again, should the doctor be allowed to give the lethal dose?' The proportion of respondents answering 'yes' has increased from about 50% at first to nearly 80% now. As one commentator noted, it would be hard for an uninformed person to say 'no' without feeling negligent, dogmatic or insensitive.

But when the current ability of good palliative care to relieve the severe pain of terminal illness is known, though it is also known that such care is still not sufficiently available for many, the same question could be more accurately phrased 'If a doctor is so negligent as to leave a terminally ill patient in severe pain, severe enough to drive him/her to ask to be killed, should the doctor be able to compound that negligence by killing the patient, instead of seeking expert help?' The question is really about appropriate standards of medical care, not euthanasia.

It cannot be doubted that most of the community's information and opinions on VE have been obtained from the media which, almost without exception, give an emotionally charged and partial, if not distorted, account. When opinion polls claim to show that most people are in favour of VE, the media, which have created this opinion by their advocacy and lack of balance, then cite these figures as evidence of the need to change the law to allow it! Such behaviour is self-serving and lacking in both truth and justice.

If such issues could really be settled satisfactorily by opinion polls or referenda, parliaments could largely be dispensed with, in favour of endless polling.

Some of the medical reasons why any VE law would be unsafe.

Draft VE laws easily become intellectual constructs within an idealised context, with a false appearance of safety, unless the medical environment in which they will operate is well understood. One of the most tragic medical facts, tragic because it is so remediable, is that, while palliative care is now able to mitigate most of the distresses of dying persons, large numbers of these patients still receive substandard treatment because doctors are uninformed about its practices and/or do not refer their patients to those who are more expert, when they have reached the limit of their own abilities.

The following points are to be found in the cited reports:

1. Necessity for adequate disclosure of medical detail.

Since it would clearly be wrong to allow VE for dying patients with unrelieved symptoms that could be treated by good palliative care, but who had not received such care, information about the quality of their medical care should be an essential requirement before approval could be given for the taking of their lives. No draft euthanasia law in Australia (or elsewhere, as far as the author can discover) has required these facts to be available for scrutiny - it is usual to find only a requirement for medical certificates. These concern opinions, not facts. Thus, the doctor's actions would be unsupervised at the time and could not be reviewed later. Only open, expert scrutiny of a patient's medical care, before euthanasia was carried out, could satisfy the community's need to be assured of a doctor's good judgment and probity.

The community at present properly demands the highest standards of supervision, even when the state has the power to take life. Open hearings, legal representation, avenues of appeal and mechanisms for review are supplied before permitting any legal taking of life, even when deciding the fate of convicted criminals, such as serial killers. In contrast, draft euthanasia bills fail to offer more than token protection for the seriously sick. When examined, their only really effective safeguards are found to be those that protect doctors from civil or criminal action, after euthanasia.

2. Pain and suffering cannot safely be made the basis for taking life because they cannot be measured or compared.

Although palliative care doctors insist that it is not necessary to take life in order to relieve pain, a common reason given by other doctors for wanting VE is to relieve pain. It must be presumed that some doctors take life that could have been relieved by experts, but who are not consulted. Even many advocates of VE now concede that unrelieved pain is probably no longer sufficient justification for taking life. Among the reasons given for euthanasia in the Netherlands, the relief of pain is not prominent.

If pain were a genuine reason to take life, it could not rationally be restricted to the pain of terminal illness, since many other causes of pain are equally distressing.

The mental anguish or suffering associated with life-threatening illness requires different strategies for its management, but it too usually responds to good emotional support. Suffering is evident in a wide range of human conditions, since it is an existential problem, not a medical problem. It has many causes, only some of which are of medical origin, even in those with terminal illness. Most of the causes of suffering are social, requiring understanding of the underlying social, relational and cultural factors.

If suffering were a genuine reason to take life, it could not be restricted to those with terminal illness, since many others causes of suffering are equally distressing. To do so would not only be discriminatory, it would be tragic and a gross abuse to empower doctors to take life for what would commonly be chiefly social reasons.

Neither pain nor suffering can be objectively measured or compared between persons, and so, neither could be subject to the objective standards on which sustainable, just public policy would need to be based. What one person can bear, another finds intolerable. Everything would have come down to the opinion of the patient, based on his/her personal characteristics.

If VE were legalised while the prevailing standards of palliative care were as patchy and unpredictable as they are at present, it would be inevitable that some lives would be taken on account of the medical ignorance of the doctor, even though effective treatment was available. The conclusion is inescapable that such a situation is the probable cause of at least some of the known instances of illegal euthanasia at present, and this would not change, even though the law was changed, in the absence of a widespread correction of the present medical deficiencies in palliative care training and practice.

3. A right to involve another person in one's intentional killing does not exist.

Autonomy has already been discussed, including the point that personal autonomy cannot be extended to others. A right to ask another person to take one's life is not found in any code of ethics or the law or in any statement of human rights. Despite this, such a right is often confidently asserted, even claimed to be 'sovereign' or 'supreme', entirely without warrant. The fact that it is not more often challenged is a reflection of how little is commonly known about rights. Failing its validation by argument, this putative right must continue to be seen for what it is - no more than a wish.

Nor is there a 'right to die', if by that one means a 'right to have one's life taken on request'. There is however a genuine right to die, by which dying persons are entitled to expect that they will be afforded every comfort in their dying, and when it is in their interest to die, not to have their dying unnecessarily impeded.

VE is sometimes said to be permissible as an expression of a claim to privacy, as though it were a matter only of importance between patient and doctor. If a doctor agreed to perform euthanasia, it could only be because he/she had concluded that that life had lost sufficient value - nobody would destroy a life they valued. But if a doctor became comfortable with the idea that it was acceptable for him/her to assign low value to certain patients‚ lives, backed by law, that could be fateful for others of his patients who were in a similar state, but who had not asked to die. He/she would be entitled to interpret any discussion of euthanasia in positive terms, ignoring the evidence that many such discussions are initiated by patients in their desperate need to have their lives affirmed, not rejected. It is well known that to-day's medical systems increasingly depersonalise patients.

3. It would never be certain that a request to be killed was voluntary.

There are no criteria for detecting undue influence on another person, and doctors are no better able to do so than other people. When considering euthanasia in 1982, the Canadian Law Reform Commission observed that coercion would be 'an ever present possibility' (7). The report of the House of Lords declared 'It would be next to impossible to ensure that all acts of euthanasia were truly voluntary, and that any liberalisation of laws would not be abused'. Coercion, particularly if it were subtle, would be very difficult to detect with certainty, and would be impossible if concealment was really wanted.

But would it be likely? After a long inquiry into mental health, a former Australian Human Rights Commissioner said he had discovered that the sick were already 'the most systematically abused, and the most likely to be coerced' (8).

To be seriously ill has been described as being in the 'quintessential state of vulnerability'. Doctors can act coercively even without intending it. Regarding the sexual abuse of patients by doctors, a newspaper editorial claimed 'Even apparent consent is coerced by the power of the professional person in whom the client has placed his or her trust'. The imbalance in power between patient and doctor is far greater than is usually supposed. Just as a doctor's response can forestall suicide, a doctor's ready acceptance of a patient's request to be killed can encourage that outcome, and make the patient feel abandoned.

In such an environment, a patient's request for euthanasia could never be guaranteed to be voluntary.

5. It would never be certain that a request was informed.

Although a draft VE law may require a doctor to inform the patient of the different treatment options, their effects and their likely chances of success, this information will be given in private. Unless an independent, informed observer was present on every occasion, it could never be known whether the information was adequate, correct, unbiased and/or non-coercive. If anyone wished later to check, the only other witness would not be available. Many doctors do not know enough about palliative care-how could they give adequate information about it?

Doctors are often subject to significant stress in dealing with terminally ill patients and their families, arising from frustration at being unable to cure, from uncertainty when faced with difficult problems for which they have not been prepared by their training, and subject to competing and perhaps unfair pressures from distracted patient and family. To suppose that all doctors will behave rationally in these emotionally charged situations is itself irrational, and it would be dangerous to presume it.

6. Even in terminally ill patients, a persistent wish to die is abnormal, while the diagnosis of the underlying psychological disturbance is hard to make and is often missed in those already under medical care.

The true nature of a sustained wish to die, even in the dying, is widely misunderstood, too often being accepted as a natural response to the threat of death. Many persons with terminal illness have suicidal ideation at some time, but never attempt or commit suicide. The great power of fear was revealed in a study that found that more people over 50 committed suicide in the mistaken belief that they had cancer than among those who actually had cancer and committed suicide.

Factors that are consistently found to be strongly associated with a sustained wish to die include: unrelieved severe distress due to pain or other symptoms, previous psychiatric disorder or history of suicide attempt, and the presence of depression or despair. Depression is widely under-diagnosed and under-treated in the elderly, being mistaken for a natural response to aging or dementia. Treatment for depression can remove suicidal ideation in up to 90% of these patients.

The significance of these facts is only half grasped when it is supposed that having a psychiatrist see the patient will provide an effective safeguard. In a recent poll of psychiatrists, only 6% thought they could properly assess mental status in a single consultation. More importantly, only those psychiatrists with training with terminally ill patients will be able to make these diagnoses with confidence in these circumstances.

One experienced Professor of Psychiatry maintains that if these patients were always seen by a psychiatrist with the appropriate training, 'euthanasia would virtually never take place' (9). The scope for abuse in this area would be extraordinary.

Nor are doctors immune to the high emotional content of their patients' situation. A committee of psychiatrists, established in the Netherlands to assist and counsel doctors faced with requests for euthanasia, reported that 'without such consultation, the professionals would often have assisted suicide, even though viable treatment alternatives were available, because of an emotional involvement with the patients'. This caused an American psychiatrist, an expert on suicide, to comment: 'One suspects that those doctors who are most emotionally involved in euthanasia, and most interested in performing it, may be those who whose own needs in the matter should disqualify them' (10).

This important point was emphasised by the comment of a forensic psychiatrist: 'I have, on more occasions than I care to recall, failed professionally to recognise depression because I have been caught up in, and dazzled by, the tragedy of my patient's life. I have accepted their wish for death as a rational and proper desire only to see these desires melt away with their depression when...less involved colleagues treated the process in which the patients were trapped' (11).

7. Progression from voluntary to non-voluntary euthanasia would be simply logical.

Non-voluntary euthanasia (NVE) is discussed more fully in a separate paper, but the core of the message in this title may be simply stated. While VE is regarded by many as a compassionate act, it is assumed that taking life without a patient's expressed wish or consent could only be motivated by some degree of malice. How then could the known incidence of NVE in the Netherlands, United States and Australia be explained, since doctors are not malicious people?

It is because such life taking is seen by its practitioners as an exercise in beneficence. Once taking life on request is regarded as a benefit for that person, it can be thought unfair and discriminatory to withhold that benefit from others who are in a similar plight, just because they cannot ask. That view is logical, if taking life truly supplies a benefit.

No arguments have prevailed to prevent the spread of one practice to the other, and no guarantee could be given that such extension would not occur wherever and whenever VE was introduced. Lawmakers can never guarantee that the law they make will not be modified, perhaps in ways which they could not foresee and would oppose, by subsequent lawmakers. In fact, by making the first exception to the principle of universal protection for innocent human life, they would have created the first precedent for change.

It is sometimes heard that it would be better to have a law to regulate euthanasia practice, even though that law may not be perfect, than to persist with the present position, where euthanasia is practised in secret, without control. That raises several points.

First, there is currently a law to regulate euthanasia-it is the criminal code, which forbids euthanasia as a form of murder, though that law is not commonly invoked. This is because hard evidence is not easy to obtain and the community properly sees a distinction between mercy and malice, even though motive is not taken into account by the law. Thus, euthanasia is presently practised by lawbreakers, who put their own view of their duty above the law, while other practitioners find their duty in the same circumstances fulfilled by different means, such as good palliative care. The former respond to the patient's demands, while the latter look to the demands of the patient's illness.

Second, there is already a proven incidence of secret NVE at the hands of doctors who also carry out VE, because, as stated, they believe it to be compassionate also. Because they include NVE in their concept of duty to certain patients, there could be no guarantee that a law that allowed only VE would not also be disregarded by them. In fact, it would be foolish not to expect it.

Third, given the common finding by inquiries that the lives of other vulnerable sick people could not be protected by any VE law, the House of Lords Committee thought that more lives could be put at risk by such a law than is the case at present. Because abuse would be undetectable, often if not usually, it could then appear to observers that matters had improved, when they had actually deteriorated. To expose the most vulnerable patients to this risk should be seen as unacceptable.

Conclusion.

A number of important factors, hitherto ignored or misunderstood in the debate about the legalisation of VE, have now been revealed in several large studies. They concluded that no such law could be guaranteed to be free of the possibility, if not the likelihood, of abuse, chiefly centred on the lives of other sick persons who did not want their lives taken. An especially dangerous aspect is that such abuse may be easily made undetectable. Thus, impartial observers may believe that a particular law was safe, while many or even every one of its subjects were in fact victims of abuse.

The medical loopholes listed above would alone have justified the common finding of the inquiries, that legalisation would be dangerous. Rather than seek recourse to medical life-taking, all doctors with responsibility for the care of terminally ill patients should accept their duty to deliver this care at the known best standards, as they are legally obliged to do in other branches of medical practice. That means they will familiarise themselves with the principles and practices of palliative care, at the standard required of their peer group, and when for any reason they cannot do that, they will refer their patients to others who can. If they have remaining doubts about the evidence regarding the abuse of euthanasia law, they should acquaint themselves with the contents of the reports listed in this paper, before supporting further attempts to legalise VE.

References.

1. Select Committee on Medical Ethics. House of Lords. January, 1994.

2. When Death Is Sought - Assisted Suicide and Euthanasia in the Medical Context. The New York State Task Force on Life and the Law. May, 1994.

3. Of Life and Death. Report of the Special Senate Committee on Euthanasia and Assisted Suicide. Senate of Canada. June 1995.

4. Report on the Need for Legislation on Voluntary Euthanasia. Community Development Committee, Parliament of Tasmania. June 1998.

5. Gormally L. Why the Select Committee on Medical Ethics of the House of Lords Unanimously Rejected the Legalization of Euthanasia. Proceedings of a Seminar held at St Vincent's Hospital, Sydney. 10 November 1995.

6. Jackson J. Hobart Mercury. 5 June 1998.

7. Working Paper 21, Euthanasia, Assisting Suicide and Cessation of Treatment. Law Reform Commission of Canada. 1982.

8. Burdekin B. Sydney Morning Herald. 21 October 1993.

9. Varghese F. The Australian. 6 June 1995.

10. Hendin H. Seduced by Death: Doctors, Patients and the Dutch Cure. Issues Law Med. 1994. 10; 123-168.

11. Zalcberg JR, Buchanan JD. Clinical Issues in Euthanasia. Med J Aust. 1997. 166: 150-152.

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Legalizing euthanasia or assisted suicide: the illusion of safeguards and controls

Euthanasia or assisted suicide—and sometimes both—have been legalized in a small number of countries and states. In all jurisdictions, laws and safeguards were put in place to prevent abuse and misuse of these practices. Prevention measures have included, among others, explicit consent by the person requesting euthanasia, mandatory reporting of all cases, administration only by physicians (with the exception of Switzerland), and consultation by a second physician.

The present paper provides evidence that these laws and safeguards are regularly ignored and transgressed in all the jurisdictions and that transgressions are not prosecuted. For example, about 900 people annually are administered lethal substances without having given explicit consent, and in one jurisdiction, almost 50% of cases of euthanasia are not reported. Increased tolerance of transgressions in societies with such laws represents a social “slippery slope,” as do changes to the laws and criteria that followed legalization. Although the initial intent was to limit euthanasia and assisted suicide to a last-resort option for a very small number of terminally ill people, some jurisdictions now extend the practice to newborns, children, and people with dementia. A terminal illness is no longer a prerequisite. In the Netherlands, euthanasia for anyone over the age of 70 who is “tired of living” is now being considered. Legalizing euthanasia and assisted suicide therefore places many people at risk, affects the values of society over time, and does not provide controls and safeguards.

1. INTRODUCTION

Euthanasia is generally defined as the act, undertaken only by a physician, that intentionally ends the life of a person at his or her request 1 , 2 . The physician therefore administers the lethal substance. In physician-assisted suicide ( pas ) on the other hand, a person self-administers a lethal substance prescribed by a physician.

To date, the Netherlands, Belgium, and Luxembourg have legalized euthanasia 1 , 2 . The laws in the Netherlands and Luxembourg also allow pas . In the United States, the states of Oregon and Washington legalized pas in 1997 and 1999 respectively, but euthanasia remains illegal 3 . The situation in the state of Montana is currently unclear; a bill legalizing pas was passed by the state legislature in 2010, but was recently defeated by the state’s Senate Judiciary Committee.

In the Netherlands, euthanasia and pas were formally legalized in 2001 after about 30 years of public debate 1 . Since the 1980s, guidelines and procedures for performing and controlling euthanasia have been developed and adapted several times by the Royal Dutch Medical Association in collaboration with that country’s judicial system. Despite opposition, including that from the Belgian Medical Association, Belgium legalized euthanasia in 2002 after about 3 years of public discourse that included government commissions. The law was guided by the Netherlands and Oregon experiences, and the public was assured that any defects in the Dutch law would be addressed in the Belgian law. Luxembourg legalized euthanasia and pas in 2009. Switzerland is an exception, in that assisted suicide, although not formally legalized, is tolerated as a result of a loophole in a law dating back to the early 1900s that decriminalizes suicide. Euthanasia, however, is illegal 4 . A person committing suicide may do so with assistance as long as the assistant has no selfish motives and does not stand to gain personally from the death. Unlike other jurisdictions that require euthanasia or assisted suicide to be performed only by physicians, Switzerland allows non-physicians to assist suicide.

In all these jurisdictions, safeguards, criteria, and procedures were put in place to control the practices, to ensure societal oversight, and to prevent euthanasia and pas from being abused or misused 5 . Some criteria and procedures are common across the jurisdictions; others vary from country to country 5 , 6 . The extent to which these controls and safeguards have been able to control the practices and to avoid abuse merits closer inspection, particularly by jurisdictions contemplating the legalization of euthanasia and pas . The present paper explores the effectiveness of the safeguards and the “slippery slope” phenomenon.

2. SAFEGUARDS AND THEIR EFFECTIVENESS

2.1. voluntary, written consent.

In all jurisdictions, the request for euthanasia or pas has to be voluntary, well-considered, informed, and persistent over time. The requesting person must provide explicit written consent and must be competent at the time the request is made. Despite those safeguards, more than 500 people in the Netherlands are euthanized involuntarily every year. In 2005, a total of 2410 deaths by euthanasia or pas were reported, representing 1.7% of all deaths in the Netherlands. More than 560 people (0.4% of all deaths) were administered lethal substances without having given explicit consent 7 . For every 5 people euthanized, 1 is euthanized without having given explicit consent. Attempts at bringing those cases to trial have failed, providing evidence that the judicial system has become more tolerant over time of such transgressions 5 .

In Belgium, the rate of involuntary and non-voluntary euthanasia deaths (that is, without explicit consent) is 3 times higher than it is in the Netherlands 8 , 9 . (“Involuntary euthanasia” refers to a situation in which a person possesses the capacity but has not provided consent, and “non-voluntary euthanasia,” to a situation in which a person is unable to provide consent for reasons such as severe dementia or coma). A recent study found that in the Flemish part of Belgium, 66 of 208 cases of “euthanasia” (32%) occurred in the absence of request or consent 10 . The reasons for not discussing the decision to end the person’s life and not obtaining consent were that patients were comatose (70% of cases) or had dementia (21% of cases). In 17% of cases, the physicians proceeded without consent because they felt that euthanasia was “clearly in the patient’s best interest” and, in 8% of cases, that discussing it with the patient would have been harmful to that patient. Those findings accord with the results of a previous study in which 25 of 1644 non-sudden deaths had been the result of euthanasia without explicit consent 8 .

Some proponents of euthanasia contend that the foregoing figures are misrepresentative, because many people may have at some time in their lives expressed a wish for or support of euthanasia, albeit not formally. The counterargument is that the legal requirement of explicit written consent is important if abuse and misuse are to be avoided. After all, written consent has become essential in medical research when participants are to be subjected to an intervention, many of which pose far lesser mortality risks. Recent history is replete with examples of abuse of medical research in the absence of explicit informed consent.

2.2. Mandatory Reporting

Reporting is mandatory in all the jurisdictions, but this requirement is often ignored 11 , 12 . In Belgium, nearly half of all cases of euthanasia are not reported to the Federal Control and Evaluation Committee 13 . Legal requirements were more frequently not met in unreported cases than in reported cases: a written request for euthanasia was more often absent (88% vs. 18%), physicians specialized in palliative care were consulted less often (55% vs. 98%), and the drugs were more often administered by a nurse (41% vs. 0%). Most of the unreported cases (92%) involved acts of euthanasia, but were not perceived to be “euthanasia” by the physician. In the Netherlands, at least 20% of cases of euthanasia go unreported 7 . That number is probably conservative because it represents only cases that can be traced; the actual number may be as high as 40% 14 . Although reporting rates have increased from pre-legalization in 2001, 20% represents several hundred people annually.

2.3. Only by Physicians

The involvement of nurses gives cause for concern because all the jurisdictions, with the exception of Switzerland, require that the acts be performed only by physicians. In a recent study in Flanders, 120 nurses reported having cared for a patient who received life-ending drugs without explicit request 15 . Nurses performed the euthanasia in 12% of the cases and in 45% of the cases without explicit consent. In many instances, the physicians were absent. Factors significantly associated with a nurse administering the life-ending drugs included the nurse being a male working in a hospital and the patient being over 80 years of age.

2.4. Second Opinion and Consultation

All jurisdictions except for Switzerland require a consultation by a second physician to ensure that all criteria have been met before proceeding with euthanasia or pas . In Belgium, a third physician has to review the case if the person’s condition is deemed to be non-terminal. The consultant must be independent (not connected with the care of the patient or with the care provider) and must provide an objective assessment. However, there is evidence from Belgium, the Netherlands, and Oregon that this process is not universally applied 10 , 13 . In the Netherlands, for example, a consultation was not sought in 35% of cases of involuntary euthanasia 7 . In 1998 in the Netherlands, 25% of patients requesting euthanasia received psychiatric consultation; in 2010 none did 16 . Moreover, non-reporting seems to be associated with a lack of consultation by a second doctor 14 .

In Oregon, a physician member of a pro-assisted-suicide lobby group provided the consultation in 58 of 61 consecutive cases of patients receiving pas in Oregon 17 . This raises concerns about the objectivity of the process and the safety of the patients, and raises questions about the influence of bias on the part of these physicians on the process.

Networks of physicians trained to provide the consultation role when euthanasia is sought have been established in the Netherlands (Support and Consultation on Euthanasia in the Netherlands) and Belgium [Life End Information Forum ( leif )] 18 . Their role includes ensuring that the person is informed of all options, including palliative care. However, most leif physicians have simply followed a 24-hour theoretical course, of which only 3 hours are related to palliative care, hardly sufficient to enable a leif member to provide adequate advice on complex palliative care needs 19 . The development of expertise in palliative care, as in any other specialty, requires a considerable amount of time. In the United Kingdom, it involves a 4-year residency program, and in Australia and the United States, 3 years.

Oregon requires that a patient be referred to a psychiatrist or psychologist for treatment if the prescribing or consulting physician is concerned that the patient’s judgment is impaired by a mental disorder such as depression. In 2007, none of the people who died by lethal ingestion in Oregon had been evaluated by a psychiatrist or a psychologist 20 , despite considerable evidence that, compared with non-depressed patients, patients who are depressed are more likely to request euthanasia and that treatment for depression will often result in the patient rescinding the request 21 – 23 . In a study of 200 terminally ill cancer patients, for example, the prevalence of depressive syndromes was 59% among patients with a pervasive desire to die, but only 8% among patients without such a desire 21 . Despite that finding, many health professionals and family members of patients in Oregon who pursue pas generally do not believe that depression influences the choice for hastened death 24 .

A recent Oregon-based study demonstrated that some depressed patients are slipping through the cracks 25 . Among terminally ill patients who received a prescription for a lethal drug, 1 in 6 had clinical depression. Of the 18 patients in the study who received a prescription for the lethal drug, 3 had major depression, and all of them went on to die by lethal ingestion, but had been assessed by a mental health specialist.

There is evidence, therefore, that safeguards are ineffective and that many people who should not be euthanized or receive pas are dying by those means. Of concern, too, is the fact that transgressions of the laws are not prosecuted and that the tolerance level for transgressions of the laws has increased. Moreover, as the next section will explore, the boundaries of what constitutes “good” practices with respect to euthanasia and pas continue to change, and some of the current practices would just a few decades ago have been considered unacceptable in those jurisdictions that have legalized the practices.

3. THE “SLIPPERY SLOPE” ARGUMENT

The “slippery slope” argument, a complex legal and philosophical concept, generally asserts that one exception to a law is followed by more exceptions until a point is reached that would initially have been unacceptable. The “slippery slope” argument has, however, several interpretations 26 , some of which are not germane to the euthanasia discussion. The interpretations proposed by Keown in 2002 27 appear very relevant, however. He refers to these collectively as a “practical slippery slope,” although the term “social slippery slope” may be more applicable. The first interpretation postulates that acceptance of one sort of euthanasia will lead to other, even less acceptable, forms of euthanasia. The second contends that euthanasia and pas , which originally would be regulated as a last-resort option in only very select situations, could, over time, become less of a last resort and be sought more quickly, even becoming a first choice in some cases.

The circumvention of safeguards and laws, with little if any prosecution, provides some evidence of the social slippery slope phenomenon described by Keown 5 , 28 . Till now, no cases of euthanasia have been sent to the judicial authorities for further investigation in Belgium. In the Netherlands, 16 cases (0.21% of all notified cases) were sent to the judicial authorities in the first 4 years after the euthanasia law came into effect; few were investigated, and none were prosecuted 5 . In one case, a counsellor who provided advice to a non-terminally ill person on how to commit suicide was acquitted 29 . There has therefore been an increasing tolerance toward transgressions of the law, indicating a change in societal values after legalization of euthanasia and assisted suicide.

In the 1987 preamble to its guidelines for euthanasia, the Royal Dutch Medical Association had written “If there is no request from the patient, then proceeding with the termination of his life is [juristically] a matter of murder or killing, and not of euthanasia.” By 2001, the association was supportive of the new law in which a written wish in an advance directive for euthanasia would be acceptable, and it is tolerant of non-voluntary and involuntary euthanasia 7 , 30 , 31 . However, basing a request on an advance directive or living will may be ethically problematic because the request is not contemporaneous with the act and may not be evidence of the will of the patient at the time euthanasia is carried out.

Initially, in the 1970s and 1980s, euthanasia and pas advocates in the Netherlands made the case that these acts would be limited to a small number of terminally ill patients experiencing intolerable suffering and that the practices would be considered last-resort options only. By 2002, euthanasia laws in neither Belgium nor the Netherlands limited euthanasia to persons with a terminal disease (recognizing that the concept of “terminal” is in itself open to interpretation and errors). The Dutch law requires only that a person be “suffering hopelessly and unbearably.” “Suffering” is defined as both physical and psychological, which includes people with depression. In Belgium, the law ambiguously states that the person “must be in a hopeless medical situation and be constantly suffering physically or psychologically.” By 2006, the Royal Dutch Medical Association had declared that “being over the age of 70 and tired of living” should be an acceptable reason for requesting euthanasia 32 . That change is most concerning in light of evidence of elder abuse in many societies, including Canada 33 , and evidence that a large number of frail elderly people and terminally ill patients already feel a sense of being burden on their families and society, and a sense of isolation. The concern that these people may feel obliged to access euthanasia or pas if it were to become available is therefore not unreasonable, although evidence to verify that concern is not currently available.

In Oregon, although a terminal illness with a prognosis of less than 6 months to live has to be present, intolerable suffering that cannot be relieved is not a basic requirement (again recognizing that the concept of “intolerable suffering” is in itself ambiguous). This definition enables physicians to assist in suicide without inquiring into the source of the medical, psychological, social, and existential concerns that usually underlie requests for assisted suicide. Physicians are required to indicate that palliative care is a feasible alternative, but are not required to be knowledgeable about how to relieve physical or emotional suffering.

Until 2001, the Netherlands allowed only adults access to euthanasia or pas . However, the 2001 law allowed for children aged 12–16 years to be euthanized if consent is provided by their parents, even though this age group is generally not considered capable of making such decisions 5 . The law even allows physicians to proceed with euthanasia if there is disagreement between the parents. By 2005, the Groningen Protocol, which allows euthanasia of newborns and younger children who are expected to have “no hope of a good quality of life,” was implemented 34 , 35 . In 2006, legislators in Belgium announced their intention to change the euthanasia law to include infants, teenagers, and people with dementia or Alzheimer disease 36 .

In Belgium, some critical care specialists have opted to ignore the requirement that, in the case of non-terminally-ill patients, an interval of 1 month is required from the time of a first request until the time that euthanasia is performed. One specialist reported that, in his unit, the average time from admission until euthanasia was performed for patients that seemed to be in a “hopeless” situation was about 3.5 days 37 . Beneficence, this specialist argued, was the overriding principle.

Initially, euthanasia in the Netherlands was to be a last-resort option in the absence of other treatment options. Surprisingly, however, palliative care consultations are not mandatory in the jurisdictions that allow euthanasia or assisted suicide, even though uncontrolled pain and symptoms remain among the reasons for requesting euthanasia or pas 38 . Requests by the Belgian palliative care community to include an obligatory palliative care consultation (“palliative filter”) were denied 19 . From 2002 to 2007 in Belgium, a palliative care physician was consulted (second opinion) in only 12% of all cases of euthanasia 31 . Palliative care physicians and teams were not involved in the care of more than 65% of cases receiving euthanasia. Moreover, the rates of palliative care involvement have been decreasing. In 2002, palliative care teams were consulted in 19% of euthanasia cases, but by 2007 such involvement had declined to 9% of cases. That finding contradicts claims that in Belgium, legalization has been accompanied by significant improvements in palliative care in the country 39 . Other studies have reported even lower palliative care involvement 8 , 13 . It must be noted that legalization of euthanasia or pas has not been required in other countries such as the United Kingdom, Australia, Ireland, France, and Spain, in which palliative care has developed more than it has in Belgium and the Netherlands.

The usefulness of a single palliative care assessment has been challenged—even when it is an obligatory requirement, as is the case at the University Hospital of the Canton of Vaud, Lausanne, Switzerland (the first hospital to allow, in 2005, assisted suicide in Switzerland 40 ) 41 . Among U.K. palliative care physicians, 63% feel that a single assessment is insufficient to fully evaluate and address the needs of a person requesting euthanasia or pas 42 . A similar number of U.K. psychiatrists have expressed similar concerns 43 , 44 , and only 6% of Oregon psychiatrists are comfortable providing consultations for patients requesting pas 45 .

Originally, it was the view of the Supreme Court of the Netherlands, the Royal Dutch Medical Association, and the ministers of Justice and Health that euthanasia would not be an option in situations in which alternative treatments were available but the patient had refused them. When this view conflicted with the accepted ethical principle that patients are allowed to refuse a treatment option, the law was altered to allow access to euthanasia even if the person refused another available option such as palliative or psychiatric care. One consequence of the change is that, the appropriateness of suicide prevention programs may begin to be questioned, because people wanting to commit suicide should, on the basis of autonomy and choice, have the same rights as those requesting euthanasia.

There are other examples that a “social slippery slope” phenomenon does indeed exist. In Switzerland in 2006, the university hospital in Geneva reduced its already limited palliative care staff (to 1.5 from 2 full-time physicians) after a hospital decision to allow assisted suicide; the community-based palliative care service was also closed (JP. Unpublished data). Of physicians in the Netherlands, 15% have expressed concern that economic pressures may prompt them to consider euthanasia for some of their patients; a case has already been cited of a dying patient who was euthanized to free a hospital bed 46 . There is evidence that attracting doctors to train in and provide palliative care was made more difficult because of access to euthanasia and pas , perceived by some to present easier solutions, because providing palliative care requires competencies and emotional and time commitments on the part of the clinician 47 , 48 . At the United Kingdom’s parliamentary hearings on euthanasia a few years ago, one Dutch physician asserted that “We don’t need palliative medicine, we practice euthanasia” 49 . Compared with euthanasia cases, cases without an explicit request were more likely to have a shorter length of treatment of the terminal illness 10 .

Advocates of euthanasia have largely ignored these concerns about the “social slippery slope” and have opted to refute the “slippery slope” argument on the basis that legalizing euthanasia and pas has not led to exponential increases in cases of euthanasia or pas or in a disproportionate number of vulnerable persons being euthanized 7 , 26 , 30 . However, there is evidence that challenges those assertion.

The number of deaths by euthanasia in Flanders has doubled since 1998 30 . Of the total deaths in this Flemish-speaking part of Belgium (population 6 million), 1.1%, 0.3%, and 1.9% occurred by euthanasia in 1998, 2001, and 2007 respectively 30 (about 620, 500, and 1040 people respectively in those years). The requirement of the law to report euthanasia cases (aided by laxity in prosecuting cases that fall outside the requirement) may explain some, but not all, of the increase 31 . Chambaere et al. 10 reported in the Canadian Medical Association Journal that in Belgium, euthanasia without consent had decreased from 3.2% in 1998 to 1.8% in 2007. But a closer review of the original study shows that the rate had declined to 1.5% in 2001 and then increased again to 1.8% in 2007 30 .

In Holland, the overall rate of euthanasia was 1.7% of all deaths in 2005, down from 2.4% and 2.6% in 2001 and 1995 respectively, but no different from 1990 when the rate was 1.7% 7 . However, the Dutch government’s official statistics indicate a rise of 13% in 2009 compared with 2008; euthanasia now accounts for 2% of all deaths. Given the increasing numbers, interest in developing facilities that provide euthanasia (similar to those of the Swiss pro–assisted suicide group Dignitas) has recently been increasing. In Oregon, although the number of cases of pas remain very small relative to the population, the rate has been increasing: 24 prescriptions were written in 1998 (16 of which led to deaths by pas ), 67 prescriptions in 2003 (43 of which led to deaths by pas ), and 89 in 2007 50 .

In Belgium, the rates of involuntary and non-voluntary euthanasia have decreased; together they accounted for 3.2%, 1.5%, and 1.8% of all deaths in 1998, 2001, and 2007 respectively (1800, 840, and, 990 people respectively in those years) 30 . In the Netherlands, the rate decreased from 0.7% in 2001 to 0.4% in 2005 7 . The actual rate is probably higher, given the large number of unreported cases. Notwithstanding the decrease, the rates are perturbing.

Battin et al. 51 examined data from Oregon and the Netherlands and concluded, as have others 30 , that there was no evidence that vulnerable people, except for people with aids , are euthanized disproportionately more. “Vulnerable” was defined in that study as individuals who are elderly, female, uninsured, of low educational status, poor, physically disabled or chronically ill, younger than the age of majority, affected with psychiatric illnesses including depression, or of a racial or ethnic minority. Finlay and George challenged the study on the basis that vulnerability to pas or euthanasia cannot be categorized simply by reference to race, sex, or other socioeconomic status. Other characteristics, such as emotional state, reaction to loss, personality type, and the sense of being a burden are also important 52 . Patients are also vulnerable to the level of training and experience that their physicians have in palliative care and to the personal views of their physicians about the topic. For example, one study showed that the more physicians know about palliative care, the less they favour euthanasia and pas 53 .

Two recent studies further contradict the findings by Battin and colleagues. Chambaere et al. found that voluntary and involuntary euthanasia occurred predominantly among patients 80 years of age or older who were in a coma or who had dementia 10 . According to them, these patients “fit the description of vulnerable patient groups at risk of life-ending without request.” They concluded that “attention should therefore be paid to protecting these patient groups from such practices.” In another study, two of the factors significantly associated with a nurse administering life-ending drugs were the absence of an explicit request from the patient and the patient being 80 years of age or older 15 .

4. THE RESPONSE

What can be done, then, when the best of palliative care is unable to address suffering?

Zylicz, a palliative care specialist who has worked extensively in the Netherlands with people requesting euthanasia and pas , provides a taxonomy to understand the reasons underlying the requests and provides stepping stones for addressing the requests. The requests can be classified into five categories (summarized by the abbreviation abcde ) 54 :

• Being afraid of what the future may hold
• Experiencing burnout from unrelenting disease
• Having the wish and need for control
• Experiencing depression
• Experiencing extremes of suffering, including refractory pain and other symptoms

Strategies are available to begin to address severe refractory symptoms, to treat depression, and to deal with the fear that some people have of what the future with a terminal disease may hold. Approximately 10%–15% of pain and other physical symptoms (such as dyspnea and agitated delirium) cannot be controlled with first- and second-line approaches and become refractory. For these symptoms, there is the option of palliative sedation. Palliative sedation is defined as “the monitored use of medications intended to induce a state of decreased or absent awareness (unconsciousness) in order to relieve the burden of otherwise intractable suffering in a manner that is ethically acceptable to the patient, family and health-care providers in patients that are imminently dying” 55 . Its intent is not to hasten death, which differentiates it from euthanasia. The goal is to achieve comfort at the lowest dose of sedative possible (usually with midazolam infusion, not with opioids) and at the lightest level of sedation. Some patients therefore achieve comfort at light levels of sedation, allowing them to continue interacting with family; in others, comfort is achieved only at deep levels of sedation.

Studies have shown that losing a sense of dignity and hope and taking on a sense of burden prompt some people to seek euthanasia and pas 21 – 23 , 56 . Strategies to improve the sense of dignity, based on empirical studies that have explored the concept of dignity within palliative care, have been shown to work 57 . Similar strategies need to be developed in the areas of hope and burden.

Given effective palliation, including palliative sedation for patients with refractory symptoms, the only remaining issue is that of legalizing “on-demand” euthanasia and pas when there is no terminal disease or when the person is tired of living or has a mental illness. Legalizing euthanasia and assisted suicide in these circumstances is most concerning and would have major implications over time, including changing a society’s values and making suicide prevention programs redundant because people wishing to commit suicide would then be entitled to do so.

In 30 years, the Netherlands has moved from euthanasia of people who are terminally ill, to euthanasia of those who are chronically ill; from euthanasia for physical illness, to euthanasia for mental illness; from euthanasia for mental illness, to euthanasia for psychological distress or mental suffering—and now to euthanasia simply if a person is over the age of 70 and “tired of living.” Dutch euthanasia protocols have also moved from conscious patients providing explicit consent, to unconscious patients unable to provide consent. Denying euthanasia or pas in the Netherlands is now considered a form of discrimination against people with chronic illness, whether the illness be physical or psychological, because those people will be forced to “suffer” longer than those who are terminally ill. Non-voluntary euthanasia is now being justified by appealing to the social duty of citizens and the ethical pillar of beneficence. In the Netherlands, euthanasia has moved from being a measure of last resort to being one of early intervention. Belgium has followed suit 37 , and troubling evidence is emerging from Oregon specifically with respect to the protection of people with depression and the objectivity of the process.

The United Nations has found that the euthanasia law in the Netherlands is in violation of its Universal Declaration of Human Rights because of the risk it poses to the rights of safety and integrity for every person’s life. The UN has also expressed concern that the system may fail to detect and to prevent situations in which people could be subjected to undue pressure to access or to provide euthanasia and could circumvent the safeguards that are in place.

Autonomy and choice are important values in any society, but they are not without limits. Our democratic societies have many laws that limit individual autonomy and choice so as to protect the larger community. These include, among many others, limits on excessive driving speeds and the obligation to contribute by way of personal and corporate income taxes. Why then should different standards on autonomy and choice apply in the case of euthanasia and pas ?

Legislators in several countries and jurisdictions have, in just the last year, voted against legalizing euthanasia and pas in part because of the concerns and evidence described in this paper. Those jurisdictions include France, Scotland, England, South Australia, and New Hampshire. They have opted to improve palliative care services and to educate health professionals and the public.

6. CONFLICT OF INTEREST DISCLOSURES

The author has no financial conflict of interest to declare.

7. REFERENCES

158 Euthanasia Topics & Essay Examples

If you’re writing a euthanasia essay, questions and topics on the subject can be tricky to find. Not with our list!

• 📑 Aspects to Cover in a Euthanasia Essay

🏆 Best Euthanasia Essay Examples & Topics

💡 clever euthanasia titles, 🎓 simple & easy euthanasia essay titles, ✅ most interesting euthanasia topics to write about, ❓ euthanasia essay questions.

Our experts have prepared a variety of ideas for your paper or speech. In the article below, find original euthanasia research questions and essay titles. And good luck with your assignment!

📑 Aspects to Cover in an Euthanasia Essay

Euthanasia is the process of intentional life ending. Its goal is to stop patients’ suffering and pain. In today’s world, euthanasia is a debatable topic, and there are many questions about it.

Euthanasia essays can help students to raise awareness of the process and its aspects. That is why it is crucial to research this issue and write papers on it.

You can discuss various problems in your essay on euthanasia, as there is a broad variety of related issues. You can choose the one you are the most concerned about, search for euthanasia essay questions online or consult your professor.

Here are some examples of euthanasia essay topics and titles we can suggest:

• The benefits and disadvantages of a physician-assisted suicide
• Ethical dilemmas associated with euthanasia
• An individual’s right to die
• Euthanasia as one of the most debatable topics in today’s society
• The ethical dilemma around euthanasia
• The ethics associated with voluntary euthanasia
• Can euthanasia be considered murder?
• Euthanasia debate: Should the government legalize this procedure?
• The legality of physician-assisted suicide in today’s society

Once you have selected one of the euthanasia essay titles, you can start working on your paper. Here are some important aspects to cover:

Start from developing a solid euthanasia essay thesis. You should state the main idea of your paper and your primary argument clearly. A thesis statement can look like this: Euthanasia is beneficial for patients because it prevents them from suffering. Euthanasia can be equal to murder.

• Remember to include a definition of euthanasia and related terms, such as physician-assisted suicide. Your audience should understand what you are talking about in the essay.
• Do not forget to include the existing evidence on the issue. For instance, you can research euthanasia in different countries, the debates around its legalization, and all other aspects related to the problem. Support your claims with facts and cite your sources correctly.
• Legal and ethical questions are some of the most significant aspects you should cover in the essay. Discuss the potential benefits and disadvantages of the procedure, as well as its impact on patients’ families and medical professionals.
• If you are writing an opinion paper, do not forget to state your opinion clearly. Include relevant experience, if possible (for example, if you work at a hospital and patients have asked you about the procedure). Have you met people who could have benefited from euthanasia? Include their stories, if applicable.
• Do not forget to cover the legal aspects of euthanasia in your state. Is it legal to perform some form of euthanasia where you live or work? Do you think it is beneficial for the patients?
• Remember to look at the grading rubric to see what other aspects you should cover in your paper. For example, your professor may want you to state a counter-argument and include a refutation paragraph. Make sure that you follow all of your instructor’s requirements.
• If you are not sure that you have covered all the necessary questions related to your issue, check out related articles and analyze the authors’ arguments. Avoid copying other people’s work and only use it as an inspiration.

Please find our free samples below with the best ideas for your work!

• Euthanasia: Advantages and Disadvantages The most heavily criticized of all such similar actions is involuntary euthanasia which bears the brunt of all severe protests against the issue, with involuntary euthanasia being dubbed as the deprivation of an individual of […]
• Arguments in Favor of Euthanasia Due to the sensitivity of the issue, laws that will protect the rights of both the patient and the physicians who practice euthanasia should be put in place.
• Consequentialism: Euthanasia and Physician-Assisted Suicide People against euthanasia view the consequences of legalization as a gateway to other unethical practices being accepted, which is a slippery slope that could lead to adverse consequences to the fundamental principles and values of […]
• The Morality of Euthanasia 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 […]
• Euthanasia as Self-Termination Velleman believes that a person should not have the right to end their life as it can make other people suffer, but there is an objection to his opinion related to that person’s own pain.
• David Velleman’s Views on Euthanasia Velleman is correct in his conviction that in this case, the patient’s decision will be the outcome of a federal right to die; the situation with euthanasia is common to that of abortion with the […]
• Euthanasia: Right to Live or Right to Die Euthanasia or mercy killing as it is informally referred is the act of ending a person life if it is deemed to be the only way to help a person get out of their suffering.
• Why Active Euthanasia is Morally Wrong The issue of active euthanasia has come to the attention of the public over the past decades as more people demand for the right to be assisted to die.
• Euthanasia for Terminally Ill People: Pros & Cons Despite the fact that euthanasia causes a lot of controversy, every person should have the right to end suffering. Permission of euthanasia is the realization of a person’s right to dispose of their body.
• Euthanasia in Christian Spirituality and Ethics By examining Christian’s views on the fallenness of the world, the hope of resurrection, and the value of a person’s life, one can see that euthanasia is not a morally acceptable option for a Christian […]
• An Argument Against Euthanasia 5 Generally, it is contrary to the duty of the subject of euthanasia and that of those who intend to perform the mercy killing to take one’s life based on their own assessment of the […]
• The Problem of Euthanasia in Animal Shelters Animal shelters are forced to euthanize animals for a number of reasons which includes: Lack of funds to treat sick animals, overcrowding as a result of the increased number of animals brought in by owners […]
• Advantages and Disadvantages of Euthanasia in Modern Society In its turn, this points out to the fact that, in the field of health care, the notion of medicinal compassion organically derives out of the notion of scientific progress, and not out of the […]
• Euthanasia and Assisted Suicide The final act that results in the death of the person is however usually performed by the person intending to die after the provision of information, advice and even the ways through which he or […]
• The Death Definition and the Need for Euthanasia If the concept of the soul is to be believed in, then one’s death is simply a process that detaches the soul from the body.
• Euthanasia as a Polarizing Issue The example of a plethora of countries shows that the inclusion of assisted suicide is not detrimental to the broad society.
• Rachel’s Stance on Euthanasia: Passive and Active Killing Despite the appealing nature of Rachel’s argument, his claims of equity of killing and letting a person die are not ethically right. A major distinction between killing and witnessing death is the level of responsibility […]
• Analysis of Ethical Dilemma: Euthanasia One of these is the right to live, which includes much more than the ability to simply exist, and suggests an adherence to a minimum of quality and self-determination.
• Euthanasia-Related Ethical and Legal Issues There are no discussions about whether the person has the right to commit suicide or not because most individuals agree that it is the decision of the adult person who can dispose of their life.
• Euthanasia: Legal Prohibitions and Permits In addition, it is necessary to take into account the right of a suffering person to get rid of the suffering of loved ones.
• Euthanasia: Why Is It Such a Big Problem? Thus, according to the utilitarian viewpoint, there is no problem with euthanasia as along as it is better for the patient. Who is it to decide what is better for the patient?
• Euthanasia and Assisted Suicide as a Current Issue in Nursing Nowadays, even in nations where the procedure of euthanasia and assisted suicide has been legal for decades, this topic continues to be controversial due to ethical and policy issues. However, in the light of the […]
• Euthanasia and Its Main Advantages However, after realizing the condition is untreatable and having the consent of both the sick person and the relatives, undertaking assisted suicide will enable the patient to evade extreme suffering.
• Euthanasia: Nurses’ Attitudes Towards Death The weakest part of the article is that most of the participants did not clearly define the concept of euthanasia, which casts doubt on the reliability of the sampled data.
• Right to Die With Euthanasia Methods The possible answer is to develop the functionality of both ordinary public hospitals and hospices that are located in their departments. In addition, it is critical to specify the desirable methods of euthanasia.
• “Active and Passive Euthanasia” by James Rachels The second issue about euthanasia that Rachels raises is the difference between killing and allowing one to die. For Rachels, it is necessary to emphasize that killing is sometimes even more humane than allowing one […]
• Arguments Against Legalization of Euthanasia Although the PAS/E should be offered voluntarily to a patient, in some cases it is offered in secret by physicians to patients who are perceived to be dying.
• Euthanasia: The Terri Schiavo Case Analysis The long-term judicial resolution of the Terri Schiavo case was related to the bioethical problem of the humanity of euthanasia, which had many opponents and supporters.
• Can Euthanasia Be Considered Ethical Consequently, from this perspective, the act of euthanasia would be regarded as violence to someone else’s life. As a result, euthanasia is likely to be considered unethical from the point of view of any of […]
• “Active and Passive Euthanasia” and “Sexual Morality” According to Scruton, morality is a constraint upon reasons for action and a normal consequence of the possession of a first-person perspective. For Scruton, sexual morality includes the condemnation of lust and perversion that is, […]
• Nursing Role in Euthanasia Decision and Procedures The weakest point is the lack of analysis of other factors’ influence on the process of euthanasia. The researchers discovered that the role of nurses in euthanasia is underestimated.
• Aspects of Nursing and Euthanasia The subject of the research by Monteverde was to ask people who work in the medical sphere and face the necessity for euthanasia, whether they are for or against it, and why.
• Pros and Cons of Euthanasia from an Ethical Perspective Primarily, this is apparent on American soil, in which some states decriminalized euthanasia, although the supreme court maintained that there is no law that legalized the practice nor the ban of the mentioned act.
• Euthanasia in the Context of Christianity The questions addressed in the paper include the notions of fall and resurrection as means of interpreting suffering, the Christian stance on the value of human life and euthanasia, and the discussion of possible solutions […]
• Nursing Practice and Euthanasia’s Ethical Issues Effective healthcare management is the involvement of all stakeholders, such as CMS, and the federal government in the decision-making process to improve the sustainable growth in the effectiveness of Medicaid.
• Counseling on Euthanasia and End-of-Life Decision The immediate dynamic killing is a clinical demonstration coordinated to the hardship of life, while a doctor helped self-destruction is a demonstration of the doctor where he gives the patient a medicament for taking life.
• Euthanasia and Physician-Assisted Suicide Articles According to the methods of application, there are two main types of euthanasia: “active”, which consists in performing certain actions to accelerate the death of a hopelessly ill person, and “passive”, the meaning of which […]
• Legal and Ethical Issues of Euthanasia Davis argues that there exists a challenge on how to establish a consensus in the competing views regarding the desire for patients to have the choice to die with dignity while under pain and distress […]
• Debates on Euthanasia – Opposes the Use Therefore, the legal system should work hand in hand with healthcare shareholders in distinguishing the limits between the patients’ rights and the physicians’ accountability based on the possible life-limiting treatment choices.
• Active Euthanasia: Ethical Dilema In case of active euthanasia, it is the patient who requests the medical practitioner to end his or her life and the former abides by the wish.
• Euthanasia: Every For and Against Jane L Givens and Susan L Mitchell “Concerns about End-of-Life Care and Support for Euthanasia” Journal of Pain and Symptom Management Article in Press FOR The authors state socio-demographic characteristics of the people are the […]
• Pro Euthanasia in the United States The discussions of euthanasia implementation in the United States began in the early 19th century after the development of ether, which was applied to pain-relieving.
• Human Euthanasia Should Be Allowed It is stated that there is a shift in a social attitude towards human euthanasia, where people are beginning to realize that people’s lives are their rights.
• The Euthanasia in Humans The moral and ethical aspects of medical practice include not only the features of interaction with patients and other interested parties but also deeper nuances. In particular, one of the controversial and acute topics is euthanasia and its acceptability from different perspectives, including both patients’ and healthcare employees’ positions. In addition, religious issues are involved, […]
• Euthanasia: Philosophical Issues at Stake in Rodriguez I will argue that the prohibition of euthanasia contradicts utilitarianism and the principle of quality of life in particular, and can hardly be supported by paternalism since the ban does not benefit an individual’s life.
• “Euthanasia Reconsidered” by Deagle In more detail, there is a clearly discernible introduction that provides the background to the topic, introduces the thesis statement, and state the opinion of the author of the topic discussed.
• Euthanasia Movement in Modern America Euthanasia movements in modern America perfected the art of rhetoric in their communication and this worked for them in terms of winning the heart of the public.
• Euthanasia: The Issue of Medical Ethics In this respect, the position of a physician under the strain of extreme circumstances should be weighed about the value of compassion.
• The Dilemma of Euthanasia It is at this point, when it becomes a contention of professional ethics and moral considerations on the part of Jack and his wife on the one hand, and personal choice on the part of […]
• Euthanasia: Ethical Debates When a patient is in the final stage of life, sometimes, the disease or the conditions of the patient, cause a lot of physical and psychological suffering.
• Euthanasia Moral and Ethical Agitation If grandma were a dog, most all would agree that the only humane option would be to ‘put her to sleep.’ U.S.citizens are guaranteed certain rights but not the right to wouldie with dignity.’ This […]
• Life-Span Development: Terri Schiavo’s Euthanasia Case Euthanasia is the process of stopping the medical maintenance of a patient’s life when the patient/herself does not want to suffer anymore and the doctors are sure that no improvements in the patient’s condition are […]
• Euthanasia and Other Life Termination Options However, there is a strong case for helping terminally ill patients spend the remainder of their lives with care provided by the medical fraternity and with support from the state and insurance companies. And in […]
• The Problem of Euthanasia Nevertheless, we must recognize that the interruption of life, alone or with the help of doctors, is contrary to one of the basic tenets of Christianity: the more people suffer on earth, the easier it […]
• Euthanasia: Allow Them to Be Free From Body Euthanasia, the practice of deliberately bring about an easy, painless, and moderate death to a person who is in the last days of his life and can no more bear the pain of living, has […]
• Palliative Medicine Replacement for Euthanasia Euthanasia is not about helping ill and dying people to end their pain and bring comfort. Euthanasia undermines the core values of life and decreases the motivation to provide care for the dying.
• Euthanasia: A Legalized Right to Die Nothing could be further from the intent of those who favor a limited reconsideration of public policy in the areas of assisted suicide and voluntary active euthanasia.
• Euthanasia and Suicide Issues in Christian Ethics Based on the two perceptions of euthanasia, theological and professional, it is valid to say that assisted suicide is probably not the best way out.
• Euthanasia: Morals, Ethics, and the Value of Life James Rachels however disagrees with the position taken by doctors when it comes to active Euthanasia and argues that, given a case where the patient is in intolerable pain and is certain to die in […]
• Euthanasia. Arguments of Opponents The request of the patient to relieve them from Karma and sufferings that is clarification and healing, nobody gives the right to break life of a physical body.
• Attitudes Related to Euthanasia and Physician-Assisted Suicide Among Terminally Ill Patients Consequently, the outlined safeguard becomes the first line of defense in making sure that only the right individuals with chronic and incurable medical conditions benefit from assisted death.
• Active Euthanasia Legalization Controversy While many people present the notions of medical ethics, the right to life, and the availability of palliative care to oppose active euthanasia, there are those who support it since it is evidence-based in nature […]
• Dying With Dignity: Euthanasia Debate On the other hand, the supporters of the law claim that assisted death is not a suicide, and it allows more end-of-life options for terminally ill patients. The majority of people are concerned with control […]
• Euthanasia Legalization as an Unethical Practice The decision to legalize euthanasia is an idea that societies should ignore since it places many global citizens at risk, fails to provide adequate safeguards, diminishes social values, and undermines the teachings of Islam.
• The Ethics of Euthanasia In the analysis of the claims in favor and against euthanasia, the cause and effect relationships between the factors affecting the choice of euthanasia should be established.
• Today’s Moral Issues: Euthanasia To ensure that the right to life is respect, the law was amended to include assisted or aided suicide as a criminal offense.
• Controversial Issues of Euthanasia Decision We now had to make this difficult decision to end his life and relieve him of all the pain that he was undergoing.
• Confronting Physician-Assisted Suicide and Euthanasia It was because of that pain that led my mother and I to bring her to a Chinese holistic healer who treated her with some sort of secret Chinese medical injection.
• Assisted Suicide and Euthanasia Rights in Canada The article asserts that in the year 1993, Rodriquez petitioned in vain to the Supreme Court of Canada to allow her to undertake euthanasia. In the article, the author asserts that, in the year 1993, […]
• Euthanasia: “Being a Burden” by Martin Gunderson As it was implied in the Introduction, in his article, Gunderson argues in favor of the idea that it is utterly inappropriate to even consider the legalization of voluntary euthanasia, due to a number of […]
• Euthanasia: Fighting for the Right Cause Sommerville is a renowned Samuel Gale Professor of Law at the McGill University in Montreal, the Professor in the Faculty of Medicine, and the Founding Director of the Center for Medicine, Ethics, and Law. The […]
• Euthanasia as a Way of Painless Termination of Life The introduction of the Hippocratic School led to the abolishment of the practice. According to the approach, taking human life is unethical and violation of the core right to life.
• Euthanasia and Other Life-Destroying Procedures From this perspective, it is unethical to decide in favor of an end-of-life procedure on the condition that there are at least minimal chances for a patient’s survival.
• Ethics of Euthanasia and Pain-Relieving This leads to the historical argument that voluntary euthanasia is often the beginning of a slippery slope that gives rise to unintentional euthanasia and the murder of people who are unwanted in society.
• Euthanasia Legalization: Public Policy Debates The requirements of physicians to perform euthanasia and consideration of the second opinion eliminate the violation of legal and ethical stipulations, and thus, control the performance of euthanasia in health care environment. Opponents of euthanasia […]
• Euthanasia: Moral Rationalist View Human beings rely on the available evidence to generate beliefs about life and goals that should be attained, and thus the use of reason leads to success in these objectives.
• Euthanasia: Is It Worth the Fuss? In order to grasp the gist of the deliberations in this essay, it is important to first apprehend what the term euthanasia means and bring this meaning in the context of this essay.
• Active and Passive Euthanasia Analysis and Its Concept The issue of morality is one of the things that have to be mentioned when discussing the concept of euthanasia. In this instance, both the patient and the doctor know that there is no cure […]
• Euthanasia: Legalisation of a Mercy Killing The fact that the minority of countries and only several states in the US accept euthanasia proves that today people are still not ready to accept it as a mercy.
• Euthanasia in Today’s Society Euthanasia is the deliberate termination of life with the intention of relieving a patient from pain and suffering. If the prognosis of a patient is gloomy, medical care providers may find it more compassionate to […]
• When Ethics and Euthanasia Conflict? The main aim is to reduce the lifetime of a patient who is terminally ill. There is a deep mistrust of the motivations that fuel euthanasia.
• Religions Views on Euthanasia This essay highlights religious thoughts with regard to the whole issue of euthanasia, bringing into focus the extent to which our society has been influenced by courtesy of the Dr.
• Euthanasia as the Key Controversy of the XXI Century The fact that in the present-day society, human life is put at the top of the entire list of values is a major achievement of the civilization and the fact that the current society is […]
• Euthanasia: Is It the Best Solution? In twentieth century, various agencies erupted to address the practice of euthanasia such as Voluntary Euthanasia Legislation Society in 1935, which was advocating for its legalization in London and the National Society for the Legalization […]
• Legalizing Euthanasia The are supporters of the idea that only God has the right to take human’s life, on the other hand, the sufferings of the person may be unbearable and they may ask for euthanasia to […]
• A New Fight to Legalize Euthanasia Before settling down on the conclusion of the need to adopt the practice of euthanasia in our state, it is important to visit some basic aspects that are very key in the issue of euthanasia.
• The Ethics of Active Euthanasia In support of the euthanasia action, the argument is that there are circumstances when the rule of natural life can be violated.
• Is Euthanasia a Morally Wrong Choice for Terminal Patients? It is imperative to note that for both the opponents and proponents of euthanasia, the quality of life is usually the focal point, even though there is no agreement on the criteria of defining quality […]
• The Right to Life and Active Euthanasia The god of every individual should be the only one to bring death to a person and no person should have the authority to accept dying no matter the situation he/she is in.
• Singer’s Views on Voluntary Euthanasia, Non-voluntary Euthanasia, and Involuntary Euthanasia Hence, if a person consciously consents to die, there are no chances for recovery, and killing is the only way to deprive a patient from pain and suffering, euthanasia can be regarded as voluntary.
• Euthanasia Authorization Debate Euthanasia, which is equivalent to the termination of life, can be equated to a total breach of the principle of the sacredness of life, as well as the breach of the legal right of human […]
• Moral and Ethical Concerns of Euthanasia in Healthcare In the matter of euthanasia, professionals ought to decide between the overall good of the dying patient and that of other stakeholders.
• Good and Harm to Humanity of the Use a Euthanasia An Overview of Euthanasia The meaning of euthanasia has changed over the years from how it was originally construed to what it means to the contemporary world.
• Euthanasia and Meaning of Life The meaning of life is the most general aspect of judging about the requirements that must be set out by laws and people’s morals in regarding to the voluntary or involuntary taking of that life.
• Euthanasia: Your Right to Die? Although both positions can be supported with a lot of arguments, people should change their absolutely negative vision of euthanasia because the right to die with the help of physicians can be considered as one […]
• Euthanasia and Human’s Right to Die Trying to support human life with the help of modern equipment is a good idea, however, not in case there are no chances for a person to live without that equipment.
• Euthanasia Moral Permissibility Secondly, the application of voluntary euthanasia should not be regarded as the only way of reducing the pain that a patient can experience.
• Euthanasia (Mercy Killing) In some circumstances, the family and friends of the patient might request the hospital to terminate the life of the patient without necessarily informing the patient.
• Euthanasian Issues in Modern Society Is it possible to find the relief in the life which is full of pain and agony for those people who suffer from serious diseases and have only a little chance to get rid of […]
• Euthanasia From a Disciple of Jesus Christ in Today’s World Another form of euthanasia is that of Assisted Suicide where the person intending to end his/her life is provided with the necessary guidance, means as well as information as to how to go about the […]
• Euthanasia and Modern Society Towards this end Battin asserts that “the relief of pain of a patient is the least disputed and of the highest priority to the physician” in direct reference to sole and major reason of carrying […]
• Euthanasia: Moral Issues and Clinical Challenges Therefore, any law that rejects euthanasia is a bad one because it denies the patients the right and the liberty to die peacefully.
• Ethical Issues Surrounding the Choice of Euthanasia in the United States
• The Advantages and Disadvantages of the Legalization of Euthanasia
• Confronting Physician-Assisted Suicide and Euthanasia
• The Difference Between Active and Passive Euthanasia
• Euthanasia: Current Policy, Problems, and Solution
• The Permit and Legalization of Euthanasia for the Terminally Ill Patients
• Moral and Religious Differences Between Euthanasia and Suicide
• The Criticisms and Opposition of Euthanasia in Australia
• Assisted Suicide and Euthanasia It Is Not Murder, It Is Mercy
• The Factors That Influence the Legalization of Active and Passive Euthanasia in the United States
• Roman Catholic Church’s Teachings on Abortion and Euthanasia
• The Different Reasons Why People Are Against Euthanasia
• Religious and Ethical Arguments in Favour of Euthanasia
• The Moral and Ethical Views on the Goal of Euthanasia
• Euthanasia and the Role of Politics and Religion
• The Philosophical, Legal, and Medical Issues on Euthanasia
• General Information About Euthanasia and the Legality of Suicide in Australia
• The Nazi Euthanasia Programme Based on Racial Purity Theories
• Dr. Jack Kevorkian’s Role in Physician-Assisted Suicide and Euthanasia
• Utilitarian and Libertarian Views on Euthanasia
• The Moral and Religious Differences, if Any, Between Euthanasia and Suicide
• Biblical World View About the Euthanasia, Suicide, and Capital Punishment
• The Truth About Euthanasia and Assisted Suicide
• Tracing Back the Origins of the Practice of Euthanasia During the Greeks and Roman Times
• The Causes and Effects of Euthanasia and the Moral Right To Die
• The Arguments Against Euthanasia From a Standpoint of a Catholic Christian in the United States of America?
• Why Should Active Euthanasia and Physician-Assisted Suicide Be Legalized?
• What Are the Good and Bad Sides of Euthanasia?
• Do People Have To Commit Suicide by Euthanasia (Suicide by a Doctor)?
• What Is the Difference Between Passive and Active Euthanasia?
• What Are the Social Issues and Ethical Values of Euthanasia?
• What Is the Current Legal Situation Regarding Euthanasia?
• How Does Prohibition of Euthanasia Limit Our Rights?
• What Is the American Medical Association’s Attitude to Euthanasia?
• Can Hegelian Dialectics Justify Euthanasia?
• What Are the Viewpoints and Studies of the Legalization of Euthanasia in the United States?
• Why Does Parenting Make Euthanasia More Acceptable?
• What Are the Negative Arguments Against Euthanasia?
• Voluntary Euthanasia: What’s Right and Wrong?
• Why Can Christians not Accept Euthanasia?
• Can Euthanasia Help the Terminally Ill?
• What Are the Top Ten Reasons for Legalizing Euthanasia?
• Should Non Voluntary Euthanasia Be Legal?
• What Is the Difference Between Doctor-Assisted Suicide and Euthanasia?
• Why Should Euthanasia and Assisted Suicide Be Legalized?
• What’s Wrong With Involuntary Euthanasia?
• Why Are There So Different Views on Abortion and Euthanasia?
• How Would Christians Respond to the Issue of Abortion and Euthanasia?
• What Are the Objections To Legalizing Euthanasia in Hong Kong?
• How Does Euthanasia Devalue Human Life?
• What Are the Views and Arguments About Euthanasia?
• How May the Christian Faith Inform the Debate Over Euthanasia?
• What Does Euthanasia Mean to Society Today?
• What Are the Religious and Ethical Considerations to the Issue of Euthanasia?
• Euthanasia and Assisted Suicide – Who Wants It?
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In response to the editorial regarding the legalisation of active euthanasia and physician-assisted suicide,1 I present the following arguments against the legalisation of active euthanasia.

Active euthanasia is unnecessary because alternative treatments exist

It is widely believed that there are only two options for patients with terminal illness: either they die suffering or receive euthanasia. Recent research in palliative medicine has shown that virtually all unpleasant symptoms experienced in terminal illness can be relieved or alleviated by existing techniques.

Requests for active euthanasia are rarely free and active.

A person with terminal illness is vulnerable, lacking the skills and knowledge to alleviate their symptoms. It is very difficult for him to be entirely objective about his own situation. Their capacity for decision-making may equally be affected by confusion, dementia or symptoms, which could be relieved with appropriate treatment. Patients who on admission say "let me die" usually after effective treatment are grateful that their request was not acceded to.

Active euthanasia gives too much power to doctors

Ironically, active euthanasia legislation makes doctors less accountable and gives them more power. Patients generally decide in favour of euthanasia on the basis of information given to them by doctors. If a doctor confidently suggests a certain course of action, it can be difficult for a patient to resist. However, diagnoses may be mistaken and prognoses may be widely misjudged. Active euthanasia gives the medical practitioner power, which in turn can be abused.

Active euthanasia leads inevitably to involuntary euthanasia

When active euthanasia has been previously accepted and legalised, it has led inevitably to inactive euthanasia.

Holland is moving rapidly down the slippery slope with the public conscience changing quickly to accept such action as acceptable. The Royal Dutch Medical Association has recommended that the termination of the lives of patients suffering from dementia is acceptable under certain conditions. Case reports include a woman killed at her own request for reasons of "mental suffering".[2]

Such a progression requires only four accelerating factors: favourable public opinion, willing doctors, economic pressure and a law allowing it. In most Western countries the first three ingredients are present already. When legislation comes into effect and political and economic interests are brought to bear, the generated momentum inevitably follows.

Dr Liz Croton SHO A&E City Hospital NHS Trust, Dudley Rd,Birmingham B18 7QH [email protected]

1. Doyle L, Doyle L. Why active euthanasia and physician assisted suicide should be legalised. BMJ 2001:323;1079-80.

Competing interests: No competing interests

Home — Essay Samples — Social Issues — Euthanasia — Voluntary Euthanasia Persuasive Speech

Voluntary Euthanasia Persuasive Speech

• Categories: Euthanasia

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Words: 684 |

Published: Mar 20, 2024

Words: 684 | Pages: 2 | 4 min read

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