should euthanasia be legalized in philippines essay

Legalizing Voluntary & Non-Voluntary Euthanasia in the Philippines: A Utilitarian Perspective

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Mercy killing: yes, no, and why?

Possibly the first in the history of the Congress of the Philippines, a  voluntary euthanasia or mercy killing and “living will-related” proposal known as Senate Bill No. 1887 or the Natural Death Act was filed by Senator Miriam Defensor-Santiago. The bill seeks to recognize the fundamental right of adult persons to decide their own health care, including the decision to have life-sustaining treatment withheld or withdrawn in instances of a terminal condition or permanent unconscious condition.

Over the past two decades, an end-of-life policy unfolded quietly in some parts of the world. In the US, the Death With Dignity Act (1994) in Oregon allows doctors to write legal prescriptions for terminally ill patients who want to control the time and place of their death. To qualify under the law, the patient should be fully conscious and able to administer his own overdose. In Europe, Belgium is set to be the second country after The Netherlands to allow terminally ill children over 12 years old facing unbearable physical suffering and repeatedly makes the request to be officially killed. Belgium and Switzerland have legalized euthanasia for many years but only for people over the age of 18. The Netherlands have legalized euthanasia for adults and children over 12 years for the past twelve years.

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Home — Essay Samples — Social Issues — Euthanasia — Why Euthanasia Should Be Legal: Analysis of Arguments and Counterarguments

Why Euthanasia Should Be Legal: Analysis of Arguments and Counterarguments

• Categories: Assisted Suicide Euthanasia Right to Die

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Introduction, why euthanasia should be legal, works cited, counterarguments.

• Corder, Mike. “Dutch Euthanasia Center Sees 22% Rise in Requests in 2019.” WAVY.com, 7 Feb. 2020, www.wavy.com/news/health/dutch-euthanasia-center-sees-22-rise-in-requests-in-2019/. Accessed 10 March 2020.
• Davis, Jacky. “Kevin Davis Deserved Choice.” Dignity in Dying, www.dignityindying.org.uk/story/kevin-davis/. Accessed 13 March 2020.
• De La Torre, Esther B. The Right to Assisted Suicide , www.lonestar.edu/rightto-assist-suicide.htm. Accessed 19 March 2020.
• “Euthanasia Laws - Information on the Law about Euthanasia.” Information on the Law about Euthanasia - Suicide, Life, Act, and Mercy - JRank Articles, law.jrank.org/pages/11858/Euthanasia.html. Accessed 10 March 2020.

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• Published: 15 January 2014

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.

The debate was judged on the logic, coherence, and evidence in arguments, as well as flair in presentation. Although the debaters may not have necessarily agreed with their allocated side, the debate format required them to acknowledge a particular school of thought and present the key arguments behind it. Oxford, who opposed the motion, was awarded the victory in the debate; however, this does not mean that the judges believe that position ought to become public policy.

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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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Santiago bill seeks terminally ill person’s right to die

Senator Miriam Defensor-Santiago. INQUIRER FILE PHOTO

MANILA, Philippines—Senator Miriam Defensor-Santiago has filed a bill that will allow  a patient with a terminal condition or “permanent unconscious condition” to refuse medical treatment and allow the “natural process of dying.”

Senate Bill 1887 also known as the “Natural Death Act” filed by Santiago provides that  any person of legal age and sound mind may execute a written instruction, “directing the witholding or withdrawal of life-sustaining treatment in a terminal condition or permanent unconscious condition.”

The directive should be signed by the patient in the presence of two witnesses.

But the witnesses, the bill said, should not be related to the declarer, should not  be entitled to any portion of the estate of the declarer upon his or her demise, and should not be the attending physician of the declarer or an employee of the physician or  a hospital in which the declarer is a patient.

In the “health care directive,” the patient may “wilfully” and “voluntarily make known” his  desire that his  dying should not be “artificially prolonged” if he was diagnosed for example to be in a terminal condition by the attending physician or in a permanent unconscious condition.

“If at anytime I should be diagnosed in writing to be in a terminal condition by the attending physician or in a permanent unconscious condition by two physicians, and the where the application of life-sustaining treatment would serve only to artificially prolong the process of my dying, I direct that such treatment be withheld or withdrawn, and that I be permitted to die naturally…” said the proposed directive.

The directive may also state that in the absence of the patient’s  ability to give directions regarding the use of such life-sustaining treatment, “It is my intention that this directive shall be honored by my family and physician (s) as the final expression of my legal right to refuse medical or surgical treatment and I accept the consequences of such refusal.”

The directive, under the bill, should be notarized and should be made part of the patient’s medical records.

“If a qualified patient capable of making health care decision indicates his or her desire to die at home, the patient shall be discharged as soon as reasonably possible,” it also said.

Section 10 of the proposed measure though clarified  that “Nothing in this Act shall be construed to condone, authorize, or approve mercy killing or physician-assisted suicide or to permit any affirmative or deliberate act or omission to end life other than to permit the natural process of dying.”

The bill also exempts any physician or health care provider from any legal liability.

“Any physician or health care provider acting under the direction of a physician or health facility and its personnel, who participate in good faith in the withholding or withdrawal of life-sustaining treatment from a qualified patient in accordance with the requirements of this chapter, shall be immune from legal liability, including civil, criminal or professional conduct sanctions unless otherwise negligent,” the bill said.

In filing the bill, Santiago acknowledged the fundamental right of adult persons to decide their own health care, including the decision to have life-sustaining treatment withheld or withdrawn in instances of a terminal condition or permanent unconscious decision.

“Modern medical technology has made possible the artificial prolongation of human life beyond natural limits. Such prolongation of the process of dying for persons with a terminal condition or permanent unconscious condition may cause loss of patient dignity, and unnecessary pain and suffering, while providing nothing medically necessary or beneficial to the patient,” she said in her explanatory note of the bill.

“In the interest of protecting individual autonomy, and in recognition of the dignity and privacy which patients have a right to expect, our laws should recognize the right of an adult person to make a written directive instructing such  person’s physician to withhold or withdraw life-sustaining treatment in the event of a terminal condition or permanent unconscious condition,” Santiago added.

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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

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Mercy killing debate: should euthanasia be legalized?

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Many new cases of physician-assisted suicide or mercy killing are emerging in Western countries. Some of them have regulated it. Do you think euthanasia  should be legalized? Under what circumstances? Do we have the right to die as we choose?

Mercy Killing Debate

Euthanasia or physician- assisted suicide , also know as mercy killing , is becoming a prominent public debate . The implications of legalizing assisted suicide are wide-ranging from a  medical , legal, political and ethical point of view. 

The term euthanasia means "good death" in Greek. With the progress of medicine in multiple domains (e.g. anesthesiology, pain medicine) came the problem of the decision of death. Some countries, like for instance Belgium, The Netherlands, and some states in the USA, including New Mexico, Montana, Oregon and Vermont, have passed laws allowing voluntary euthanasia. But the legality of choosing the moment of death is an extremely controversial subject because it appeals to personal views on ethics and morality and is highly emotional and linked to religious beliefs. Most countries still consider euthanasia a crime . Some people consider allowing euthanasia to risk opening a slippery slope where killing may become more common, and risk the killing of people misinformed or against their will. These people also worry about the risk of killing any person with some sort of suffering (e.g. mental disability, physical handicap). Supporters of euthanasia claim it is an individual right to decide when to die, to keep control of their fate when it is still possible.

Types of euthanasia

There are different types of euthanasia according to whether the will of the patient has been expressed.

• Voluntary euthanasia : to intentionally end the life of someone who asked for it to relieve physical pain and psychological suffering. It can be considered as assisted suicide. Patient gives informed consent. An official signed document in which one declares one wants to be euthanized.
• Non-voluntary euthanasia : consent of the patient is unavailable. Usually family members are asked about the possible will of the patient as well as their own wish.
• Involuntary euthanasia is against the patient’s will and is illegal, considered as murder, in most countries. 

Euthanasia can also be divided into:

• Passive euthanasia:  when the family or medical staff withhold life support (e.g. medication, respiratory machine, feeding or liquids) from the patient.
• Active euthanasia: when the patient is administered (e.g. injected) a lethal dose of any chemical substance to end her/life. 

And you? Do you support  mercy killing ?   Should euthanasia be legalized? Before voting and commenting you may want to consider the pros and cons of legalizing physician-assisted suicide (see below).

Watch this video on the mercy killing debate

Euthanasia pros and cons

• Dying with dignity: some people are deeply sick, postrated and unable to do even the most basic human actions, such as eating, changing clothes, washing themselves or using the toilets. They often find their state degrading and humilliating and may prefer to die with dignity and stop being a burden to those around them.
• End to human suffering: people with terminal illness and no chance of recovery often suffer great physical pain and emotional distress. Ending their lives, if they wish so, can spare them from an unnecessary suffering.
• Legal certainty: according to research conducted in the Netherlands, regulating euthanasia has improved legal certainty and has contributed to the carefulness of assisted suicide.
• Healthcare spending: keeping alive terminal patients who are suffering and not able to recover is also very expensive and detracts medical resources from other patients who could heal or need treatments. Families of the patients who want to end their lives may also face bills which can very negatively affect their finances.
• Autonomy and self-determination: opposing to someone's will of ending her/his life goes against that person freedom and right of deciding on their future.
• Moral and ethical problems: physician assisted death clashes with religious beliefs. Many religions state that human life end should not be decided by people but by God. 
• Misunderstandings and errors: there are cases in which doctors have wrongfully diagnosed a terminal disease or have thought that a patient is without hope of recovery. However, medicine evolves and cures may be found. Some new treatments may become effective were others failed. So terminating someone's life even with her/his consent may be a mistake.
• Legalizing murder: regulating euthanasia for some extreme cases may mean crossing a line. It has been argued that this could be a slippery slope which could end up with the legalization of an increasing number of cases for ending a life for utilitarian reasons.
• Abuse: if euthanasia is legal, there may be an incentive to exaggerate the negative condition of patients so that the family decides to "disconnect" them so that the hospital or insurance company saves money.
• Complexity: even if countries decide to legalize euthanasia, there may be great difficulties in agreeing with the cases and situations in which these mercy killings are acceptable and with the legal procedures that should be respected.

Taking all these pros and cons into consideration and the experience in the territories where it has been legalized, what would you recommend doing?

You may also want to participate in our debates on the legalization of  cannabis , prostitution , and  same sex marriage .

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• > Journals
• > Cambridge Quarterly of Healthcare Ethics
• > Volume 32 Issue 1
• > Existential Suffering as a Legitimization of Euthanasia

Article contents

Introduction, the right to euthanasia, the meaning of life and the meaning of “life”, the individual suffering, existential suffering as a legitimization of euthanasia.

Published online by Cambridge University Press:  04 November 2022

Several countries have legalized euthanasia on the basis of medically diagnosable suffering over the last decennial; the criteria to which they adhere differ. The topic of this article is euthanasia on the basis of existential suffering. This article presents a recent proposal to legalize euthanasia for people who experience such suffering and then discusses the issue of what the value of life may be, and whether the standard that life is normally something positive should be accepted. This provides the foundation to answer the question of whether euthanasia on the basis of existential suffering should be allowed.

The controversial nature of the issue of whether it should be legal to perform euthanasia or assist in another’s suicide has waned, and several countries have legalized these options, but it would not be realistic to expect a universally accepted perspective to be forthcoming. While this observation may be made with respect to the issue in general (i.e., whether euthanasia or assisted suicide should be accepted at all ), I will focus on a specific aspect and presume that euthanasia Footnote 1 as such is acceptable in certain cases of suffering whose cause may be medically diagnosed. I say “certain cases” since those who accept that euthanasia should in principle be allowed in cases of medically diagnosable suffering may differ amongst themselves with respect to the criteria that should be in place, and the countries referred to above do not adhere to (precisely) the same criteria. This is not the topic of the present inquiry, which is rather focused on answering the question of whether it should be allowed to perform euthanasia in cases where medically diagnosable suffering is absent.

A recent proposal in the Netherlands to allow euthanasia in such cases is presented in section “The Right to Euthanasia.” The basis for euthanasia in terms of a natural right is examined in order to determine whether a right to euthanasia may be defended on such a basis. I do not start from the premise that an inalienable right to euthanasia exists and should be acknowledged, nor would I base such a right on moral considerations, on account of the fact that no compelling reasons exist to conclude that either of such foundations must be acknowledged to exist and it is not clear, even if this were the case, that such a right must cogently be derived from one of them or both.

I will rather limit myself to considering the interests that are at stake and inquiring how they may best be served. The word “best” is problematic, however, especially in light of what has just been said. I will not, however, attribute a special meaning to this word and hold that no absolute standard is to be adhered to. It is not clear what this standard should be (or which of the existing candidates that are presented, from different perspectives, should be opted, in favor of its alternatives, foregoing the issue here of whether it might exist , waiting to be discovered, in the first place). An additional problem is that the freedom of someone who would not accept that standard would be curtailed, since the standard would be forced on such an individual.

What I present as an answer to the main question presented above is, accordingly, simply a reflection of what policy is most desirable , at least according to me, for which I present arguments in the hopes of convincing those who read this article. Before presenting that position in the section “The Individual Suffering,” I will analyze what the value of life might be and how this may be determined. This is what is undertaken in the section “The Meaning of Life and the Meaning of ‘Life.’” The question of whether life is worth living is one of the most challenging ones with which may be confronted. I have tried to do justice to the complexity of this question without losing sight of the practical, concrete issues those who are confronted with it in the darkest moments of their existence face.

When addressing the issue of whether it is desirable to legalize euthanasia and, if so, under what conditions, it is important to acknowledge that different interests are at stake and that the issue may be approached from different perspectives. Important considerations will be addressed in the following sections. The present section is focused on representative legislation, so as to provide a relevant context. The Netherlands is a pioneering country in legalizing euthanasia and if a recent bill is passed, a new category—to which specific criteria apply—in which euthanasia is allowed will be introduced; Dutch legislation and jurisprudence will, accordingly, feature prominently here.

In order to perform euthanasia legally in the Netherlands, a number of criteria must be met. Those that are relevant for the purposes of this article are that it must be performed by a physician, who must hold the conviction that the patient’s suffering is unbearable, with no prospect of improvement. Footnote 2 (“With no prospect of improvement” is the translation of the Dutch word “uitzichtloos,” which may alternatively, more dramatically but arguably also more accurately, be rendered as “prospectlessness.”) The suffering may be physical or have a psychiatric disorder as its cause. Footnote 3 From a practical point of view, the limits of what medicine can accomplish, in some cases, must be acknowledged, Footnote 4 while principally it is justified to say that “If there are no logical differences between mental and physical disorders, there is a strong prima facie case for the possibility and acceptability of psychiatric active voluntary euthanasia (AVE) and physician-assisted suicide (PAS).” Footnote 5 The assessment of a request made by someone with a psychiatric disorder does bring with it specific difficulties for physicians. Footnote 6

Importantly—irrespective of the cause of the suffering—it must be determined what “with no prospect of improvement” and “unbearable” mean. Insofar as the absence of a prospect of improvement is concerned, the possibility of improvement is decisive: “The medical judgment is decisive in ascertaining the absence of a prospect of improvement of the suffering. It must be certain, according to medical expertise, that the patient’s situation will deteriorate and cannot be relieved. The absence of a prospect of improvement is thus objectified.” Footnote 7 A medical standard is thus decisive in determining whether the suffering must be deemed to be without a prospect of improvement or not. The same standard is used for the criterion “unbearable,” but the patient’s perspective is decisive here: “The unbearableness of the suffering must also be determined in order to decide the issue whether euthanasia may be performed, but it is, in contradistinction to the absence of a prospect of improvement of the suffering, a factor that is highly subjective and difficult to objectify.” Footnote 8

It is justified to point to the subjective nature of unbearableness (and the modifier “highly” might have been omitted), but that means that the very justification of the necessity of the criterion becomes debatable. After all, if “unbearableness” is qualified as the point at which the patient’s suffering is such that he feels the need to request euthanasia, no one who requests euthanasia may be said to fail to meet the criterion. (A—secondary—point to consider is that the suffering cannot truly be unbearable, for if it were, the patient would not be able to endure the suffering and—presumably—die as a result, rendering the issue moot.)

Being tired of life is not a sufficient condition for euthanasia, Footnote 9 nor is the conviction that one’s life is completed. Footnote 10 A bill proposed by Pia Dijkstra, a member of the House of Representatives for political party Democrats 66, aims to address this issue by legalizing assisted suicide (but not euthanasia in the strict sense) for those who consider their lives completed and are at least 75 years old. Footnote 11 The suffering the bill addresses is “suffering from life,” resulting from the experience of a completed life. Footnote 12 So-called “end-of-life supporters” (who must have completed special training) rather than (as in the case of euthanasia in the strict sense) physicians are to provide the means to make the suicide possible; the general practitioner of the person who has made the request will be consulted, provided that person consents. Procedures will be in place to prevent requests being made based on “outside pressure.” Footnote 13

The age limit of 75 years is defended in the bill on account of the consideration that young persons will usually have a long life before them, in the course of which problematic circumstances may take a turn for the better, for example, by means of medical treatments yet to be developed. Footnote 14 Is legalizing euthanasia (or assisted suicide) in such cases desirable? One may hold that such legislation is too radical, but it may, conversely, be argued that it is not radical enough. I will present my perspective in the final section, in the wake of the present section and the section “The Meaning of Life and the Meaning of ‘Life.’”

One may argue that (some cases of) euthanasia should be allowed by appealing to a human right, where “human rights” may be defined as follows: “At their most fundamental, core human rights are considered as the transcendental moral principles on which positive law is founded.” Footnote 15 Specifically, one may, insofar as the jurisdiction of a member state of the Council of Europe is concerned, appeal to articles 2 and 8 of the European Convention on Human Rights (ECHR). In Pretty v. United Kingdom , Footnote 16 the European Court of Human Rights (ECtHR) rightly ruled that the rights guaranteed in those articles (namely, the right to life and the right to respect for private and family life) do not confer the right to die. The rights in question are negative rights and thus require the absence of government interference; an interpretation of the articles according to which they would confer a right to die is incompatible with the nature of these rights.

A yet more relevant case for the present discussion is Haas v. Switzerland , Footnote 17 in which the ECtHR, while holding that the right to decide by what means and when one ends one’s life is an aspect of article 8 ECHR, this must be distinguished from a right to obtain the means to end one’s life. Footnote 18 Specifically, it might have been possible, under Swiss law, to obtain such means, but the applicant in this case would have to undergo a psychiatric assessment so that it could be ruled out that his desire to commit suicide was a symptom of mental illness; the ECtHR ruled that the restrictions were legitimate and necessary. Footnote 19

Alternatively, one may appeal to substantive due process, invoking fundamental rights that may not be restricted. This was the central issue, with respect to the right to assisted suicide, in Washington v. Glucksberg. Footnote 20 The Supreme Court ruled that the right could not be invoked on that basis, referring to the rejection in the past of the legalization of assisted suicide. Footnote 21 What is problematic here is that the possibility to invoke the right depends on a—presumably—contingent tradition, which means that it is not truly a fundamental right. Should one, by contrast, hold that a natural right, in isolation from the circumstances as they have developed in a specific country, be at issue, another difficulty presents itself, namely, what, if anything, a natural right might mean. This is a general issue in philosophy; with respect to the topic at hand, I remark that even if one should accept the existence of natural rights, it would need to be made clear whether or not a right to euthanasia, in particular, would exist, so that those defending such a right would be confronted with a twofold burden of proof.

Chemerinsky raises the question: “[…] is the right to physician-assisted suicide so fundamental to autonomy that it should be deemed a fundamental right? Put another way, is it sufficiently analogous in its importance to the privacy rights which the Court has previously protected that the right should be worthy of being deemed a fundamental right?” Footnote 22 He argues against an originalist interpretation of the Constitution, pointing out that other rights than the right to PAS have been acknowledged by the Supreme Court to be fundamental without appealing to the original text of the Constitution. Yet that does not mean that those rights are indeed fundamental rights, but only that the Supreme Court considers certain rights to be fundamental. So the crucial question still remains to be answered, namely, what, if anything, are “fundamental rights”?

Chemerinsky approaches the issue by focusing on autonomy, thus presupposing autonomy to be a guiding principle, not indicating why it should be respected. He may be correct in saying “If any aspect of autonomy is to be deemed fundamental, surely it is the right to choose to die,” Footnote 23 but even apart from the fact that autonomy is not the only relevant factor to consider, an appeal to its importance takes away nothing from the burden of proof if such an appeal is made in the context of “fundamental rights.”

This view is not to be equated with the idea that it is simply desirable that the right to PAS should exist; such an alternative has the benefit of being relieved from the burden of proof just mentioned, but admittedly faces the issue of relativism, since it raises the question of whose perspective should be decisive in determining what is “desirable.” This should in a democratic state presumably be that of the majority of the people, whose preferences and convictions may gradually change; an appeal to tradition is possible, such as in Washington v. Glucksberg , but this raises the question—if the perspective thus found differs from the present perspective—why ideas that prevailed in the past should dictate how one should act or think in the present.

Incidentally, when Chemerinsky appeals to the majority position when he argues that the issue should be left to “the political process,” he also points to the importance of interpreting the Constitution as including a fundamental right to PAS, Footnote 24 apparently expressing a belief that the majority view will (continue to) correspond with such an interpretation.

An appeal to “(human) dignity” is no less problematic. Even if this is presumed to have a meaning, it is clear that defenders of “dignity” do not agree on what this is, which results in different positions: one may associate “dignity” with the protection of life, with the corollary that one’s life should not end prematurely—leaving the issue here what “prematurely” means, since this depends on what is understood by a “natural” life (which depends, inter alia, on whether one considers the accomplishments of modern medicine that lead to a prolonging of the lives of some individuals something natural, or not)—or, conversely, with respect for the freedom to decide for oneself when the time has come to die, Footnote 25 if necessary or desirable by means of euthanasia. Footnote 26 In addition, one may defend the idea of a person as no mere means to advance society’s ends Footnote 27 ; in this case, the difficulty presents itself at another point in the argumentation, namely, at the point it must become clear why this directive should be accepted. Footnote 28

Biggs concedes that “dignity” is not easy to grasp, but maintains: “[…] in spite of its susceptibility to misinterpretation and sophistry, dignity clearly does play a valuable role in contextualizing people’s perceptions of death and dying, especially as it appears to embody a spirit of self-determination that advocates of voluntary euthanasia crave.” Footnote 29 Incorporating an idea into one’s perceptions must be distinguished, though, from justifying an appeal to that idea. As Singer remarks, “‘Death with dignity’ can mean almost anything, depending on what one considers a dignified way to die.” Footnote 30

There is, then, no fundamental right to euthanasia or it is at least not clear what the basis of such a right would be. This state of affairs must not be confused with the issue of the desirability of realizing such a right. It is ultimately the legislature that decides on the matter of legalizing euthanasia. In a democratic state, the majority of the people supposedly—indirectly—support the law. A people is composed of individuals whose votes (should) be decided individually, and I have a particular view I deem most desirable; as I said above, this will be expounded in the final section. That does not mean, though, that I consider my view to be an expression of a natural right, and by saying “most desirable” rather than “right” or “just,” I express a relativistic stance. It is difficult for me to say on what basis I have come to accept this particular viewpoint rather than another, since I cannot go back in time and create an alternative reality in which I would exchange one or more factors that may or may not have decided my viewpoint for one or more other factors and I accept, accordingly, what I hold as tentative. It is always wise to analyze legal matters carefully, but a radical skeptical stance, on the basis of which suspension of judgment is accomplished, is not possible lest no legislation be realized at all.

The question of why it is a problem if a life is terminated prematurely is rarely raised in euthanasia debates, which is surprising, given the existential perspective that is at issue, besides the medical perspective.

Aristotle considers death the most fearful thing, since nothing can be good or bad for someone who is dead. Footnote 31 “Bad” is mentioned here as well as “good,” but this may be explained by the fact that Aristotle defines an active life in accordance with virtue as the function of man and a necessary condition for his happiness. Footnote 32 By contrast, Lucretius, following Epicurus, maintains that death does not concern human beings Footnote 33 since one’s soul, given that it does not remain as a separate substance after death, is mortal. Footnote 34 Which of these views (if any) one is willing to accept depends on one’s metaphysical bent and it seems too hopeful to expect a definitive answer to the question which of these views may be true to be forthcoming anytime soon.

A similar metaphysical perspective may be said to support the idea of an “intrinsically valuable” life that is often presented: “[…] while life is instrumentally valuable to us as we pursue other goods, it is also intrinsically valuable. Something X has intrinsic value to the extent that the value of X is due to what X fundamentally is, apart from X’s relations to other things.” Footnote 35 In accordance with such a viewpoint, one may hold that “[…] life demands from us levels of commitment directed toward its maintenance and furtherance that are in broad accord with a reasonable life narrative and ground projects […].” Footnote 36 One may, accordingly, maintain: “We believe that it is intrinsically regrettable when human life, once begun, ends prematurely. We believe, in other words, that a premature death is bad in itself, even when it is not bad for any particular person.” Footnote 37

Still, does it make sense to speak of something being intrinsic? An evaluator always seems necessary in order to determine whether something is valuable, and to what degree. It is conceivable that something is valuable according to every or even every possible evaluator, that is, everyone now existing and everyone who will exist and anyone that might have existed, but that would (merely) mean that it has an objective value. An objective value differs from an intrinsic value: if all evaluators would cease to exist (and thus cease to value anything), no objective value would remain, while what had an intrinsic value (whatever this might mean) before would—supposedly—not lose this. This is difficult to grasp.

A more promising approach might consist in listing the values that are actually at issue. This is what Bullock does. Given that one may question whether self-determination provides a proper basis for the patient’s well-being, Bullock presents a list of purportedly objective interests, Footnote 38 so as to identify “[…] the substantive goods that contribute to the well-being of an individual and holds that they are good for the individual independently of that individual’s preferences.” Footnote 39

Bullock rightly observes: “[…] the concept of ‘autonomy’ is vague and has various meanings in different contexts.” Footnote 40 Autonomy may be used in two senses: first, the fundamental—and literal—sense of imposing a law (and specifically a putative “moral” law) on oneself, associated with the notion of “free will,” and, second, the sense of legal autonomy, that is, the liberty of citizens, at least those “of sound mind,” to perform legal acts.

Autonomy in the second sense, notwithstanding the objections raised by Bullock, may be defended (if one refrains from also appealing to autonomy in the first sense); suspension of judgment or even denial with respect to the existence (or even meaning) of the former is compatible with acceptance of the latter, an issue to will I return below. For completeness, it must be added that Bullock’s stance on autonomy is nuanced: she promotes “autonomy as a side-constraint on action,” which serves as a type of failsafe: even if one acts in accordance with the individual’s objective interests, his withholding consent must be respected. Footnote 41

Among the objective interests are listed (inter alia): “life, consciousness, and activity,” “pleasures and satisfactions of all or certain kinds,” “happiness, beatitude, contentment, etc.,” “morally good dispositions or virtues,” “just distribution of goods and evils,” and “freedom.” Footnote 42 It is not clear, however, why (all of) these would be objective. Life is, after all, only an interest for those who want to (continue to) live. “Pleasures” will presumably be desired by everyone, but which pleasures are desired depends on the individual, so that speaking of generic pleasures is little illuminating; the same applies to “happiness.” As for “morally good dispositions or virtues,” this may be specified in various ways, presuming that it has a meaning at all; the same applies to “just distribution of goods and evils.”

As for “freedom”: this is precisely what is under discussion, and whether autonomy as a side-constraint suffices may be doubted. Notwithstanding the empirical analyses to which the author, arguably justifiably, refers, Footnote 43 if the absence of self-determination—in accordance with the second sense of “autonomy” outlined above, suspending judgment, incidentally, with respect to what “self” might mean—is a reason to substitute “objective interests” for individual preferences, there is no principled reason to distinguish between end-of-life decisions and certain other types of decisions. End-of-life decisions have a far-reaching effect, but so does buying a house or marrying someone, with respect to which people are normally allowed to act in accordance with their preferences.

It may be objected that what has been said is unjustifiably flippant, if only because carrying out an end-of-life decision is irrevocable. One may imagine someone who requests euthanasia but reverses his decision before the euthanasia is performed; if the euthanasia had been performed, he would have died. Similarly, euthanasia may have been performed on people who, likewise, would have reversed their decision if the period between the request and the act had been longer. It is of course not possible to determine whether this is the case since any relevant response would have to be provided by people who have already died. How much weight does the fact that a hypothetical person would in time—in hindsight—come to reconsider his request, given the irrevocability of the act, carry?

First of all, euthanasia is only possible if strict procedures are adhered to, ensuring that a lasting desire to die exists, and the individual’s request is voluntary and well-considered. Footnote 44 That does not exclude the possibility that euthanasia is performed on people who would have revoked their decision but merely reduces the likelihood that such cases occur, and presumably no procedure is foolproof, but the alternative is that no one should be granted euthanasia, Footnote 45 which would come at the expense of all those who suffer without ever wishing to revoke their decision, who would either have to keep suffering until they die of natural causes or resort to alternative, possibly gruesome, means to end their lives without assistance. The prolonged suffering such people experience—before ultimately dying from another cause than euthanasia—is no less irrevocable than the pleasures of which those who might have come to regret their decision are deprived.

What is important to consider here is that—however harsh this formulation may come across—all euthanasia means, as far as can be assessed without taking a conception of the afterlife into consideration, is that life is shortened by a certain amount of time. One may object that the possibility of an afterlife does have to be taken into consideration, but there is no consensus with respect to whether an afterlife exists and, if so, what this might look like, nor do I have anything to contribute here myself to provide clarity on the matter.

Still, one may hold that an entity (specifically, a deity) may exist that judges and punishes those who commit suicide or invoke the aid of others to let their life end. It is difficult to ascertain what the basis of such a deity’s judgment would be, apart from the preliminary issue of the difficulty of ascertaining that it exists in the first place. Barring the ability to determine that the tenets of a specific religion are true, the individual is left to his own devices. One may resort to Pascal’s wager: by wagering that He exists, one presumably either has nothing to lose (or gain)—namely, if He does not exist—or everything (an eternity of life and happiness) to win —namely, if He does exist—whereas wagering that He does not exist will either—if He indeed does not exist—result in the first situation (so that one will neither gain nor lose anything) or in the outcome that one has everything to lose. Footnote 46 Several objections have—rightly—been levelled against this line of thought, which do not have to be discussed here. I add to them the following consideration, which is relevant for the present theme.

If faith is decisive, nothing can be said of God by means of reason. This is in line with what Pascal observes: “If there is a God, He is infinitely incomprehensible, because, having neither parts nor limits, He does not stand in any relationship to us; consequently, we are incapable to know either what He is or whether He exists.” Footnote 47 Taking seriously the meaning of faith means that nothing can be said of God’s ideas of what is right and wrong without appealing to faith, and there is no reason to presuppose that God (in this sense) would consider suicide or euthanasia something “wrong.” Indeed, He may be of such a nature as to think ending one’s life or having it ended something “right,” rewarding those who let their lives end prematurely with an eternity of life and happiness.

This consideration is of course only relevant if the individual contemplating euthanasia believes in such an entity, unless it would be deemed acceptable to resort to paternalistically forcing a view on individuals. Those who do not subscribe to a religious worldview would merely consider the pains and pleasures that are to be expected if they continue to live; since they opt for euthanasia, they apparently expect to experience more pain than pleasure if they continue to live. (I admit that this is a simplistic analysis compared to what is actually at stake, if only because “pleasure” and “pain” may be defined in various ways and, related to that issue, it may be difficult to balance them. I have not explored these issues since it is not relevant to present a general account here: in line with what will be argued in the final paragraph, the individual’s judgment is decisive in this respect.)

The positive and purposive nature of life, with the corollary that it should in principle be preserved is not proven, and is perhaps unprovable. It may be a heritage of a mix of Christian Footnote 48 and Aristotelian tenets. By contrast, a negative appreciation of life is promulgated in Hinduism, Buddhism, and Jainism, where the goal to be achieved is extinction (ceasing to exist), so that one does not reincarnate. Suicide or euthanasia would express a desire (namely, the desire to end one’s suffering), on the basis of which reincarnation would follow, so that this goal would not be reached.

One may oppose legalizing euthanasia without appealing to religious ideas, but such a position does mean that one has adopted—explicitly or implicitly—a positive outlook on life. Importantly, such an outlook is nonneutral. All that may be said of life in a neutral sense is that it exists , manifested by someone’s beating heart and breathing (forgoing here cases in which someone is kept alive by means of life support). Footnote 49

The question that presents itself is who should decide whether life is something positive or negative. There is no compelling reason for the state (or society) to decide this for the individual, so that the individual’s judgment is decisive. Footnote 50 One may hold that defining life in terms of pain and pleasure is (too) reductionist, or that pain itself has a certain meaning, and even attempt to persuade someone of the positive nature of life, but forcing a worldview on someone would be unacceptable. Having a worldview does not, of course, in and of itself result in anything. Once a request for euthanasia is made, however, the issue is no longer theoretical. If physicians decline such a request on the basis of other considerations than procedural ones (legitimate concerns existing when, e.g., there is doubt whether the individual making the request is competent), they evidence nonneutrality (or even paternalism). Incidentally, it may be defended that physicians whose worldview is incompatible with performing euthanasia should have the right to decline a request on that basis; whether a physician may invoke his worldview in such a case depends on whether the tasks a physician may normally be expected to perform include euthanasia.

Should one hold that “Physicians should help patients at the end of their lives find the ‘why’ they have lost to enable them to endure their abhorrent ‘how’ if they so desire and not resort to physician-assisted suicide and euthanasia,” Footnote 51 a “why” (i.e., a meaning of life) is presupposed to begin with, in accordance with which something worthwhile for which to keep living supposedly exists. Relieving the individual’s suffering without resorting to euthanasia may be an alternative, Footnote 52 but if this option is available, the issue may be moot and, besides, it should not be used as a means to dodge the main question who is to decide whether the individual’s suffering is truly relieved.

The foregoing is not sufficient, however, to determine whether performing euthanasia should be allowed in cases where no medically diagnosable suffering is involved (irrespective of whether one accepts “unbearableness” and “absence of a prospect of improvement” as qualifiers), for some important matters are still to be considered. These will be addressed in the next section.

I have argued that the perspective of the individual should be decisive in assessing the value of life rather than a prevailing worldview (implicit or explicit). The theoretical question of what view on life an individual may have immediately leads to the practical question whether and, if so, in which cases individuals should have the right to euthanasia. Now that the necessary background has been presented, the present section can focus on the remaining issues.

If euthanasia is legal in (certain) cases where the individual suffers from a medically diagnosable cause, it seems difficult not to allow it in (certain) cases where the suffering has another cause. After all, the individual seems to be the proper judge to decide whether the suffering is so grave that ending one’s life is the most desirable outcome. It is unclear why the cause of the suffering should be a relevant issue. If there is a reason to think it may more easily be relieved without resorting to euthanasia in one type of case than in the other, Footnote 53 there is a reason to ensure that the individual requesting euthanasia is informed about possible alternatives (which should, incidentally, be—and presumably already is—part and parcel of any procedure following a request, so irrespective of the cause of suffering), but even if it is supposed that the suffering could in similar cases (disregarding, arguendo , the difficulty of comparing different cases of existential suffering) be relieved, it is still the individual who is to decide whether such information is relevant, and whether he would thus (nonetheless) resort to euthanasia.

Schmidt speaks, in this respect, of the “Argument from Arbitrary Difference”: “The central argument for CLE [completed life euthanasia] is what I call the Argument from Arbitrary Difference : if a concern for people’s autonomy and well-being justifies medical euthanasia, it also justifies CLE. Drawing a distinction between the two is morally arbitrary.” Footnote 54 In addition to that principal argument, one may point to the pragmatic considerations that medical cases may be difficult to demarcate from nonmedical ones Footnote 55 and that the domain of “medicine” is not clearly demarcated. Footnote 56

One may argue, then, that since physicians may face their patients’ existential suffering, which does not significantly differ from the suffering they are trained to address, if euthanasia is allowed on the basis of medically diagnosable suffering, it would be inconsistent not to allow euthanasia on the basis of existential suffering. Footnote 57 This position is defensible, but physicians do not have specific expertise to address this issue. It is for this reason that the Dutch Supreme Court ruled that a physician should not try to help people who experience such suffering, and should instead seek others who could assist in finding a meaning in one’s existence. Footnote 58

The Court fails to indicate, however, whom those others might be; this will presumably depend on the circumstances, and a priest, rabbi, imam, or humanistic therapist, amongst others, are conceivable options. More importantly, though, should none of such counselors—for whatever reason—be able to provide a solution for the individual’s suffering, no (further) recourse appears available. The introduction of end-of-life supporters has, as was mentioned in the section “The Right to Euthanasia,” been proposed in the Netherlands; they may, for individuals who are resolved that no means exist to end their suffering save those an end-of-life supporter may provide, provide those means. Footnote 59

Importantly, though, if what was argued in the section “The Meaning of Life and the Meaning of ‘Life’” is accepted, there is no reason to use the proposed age limit. If individuals’ own judgments in assessing whether they suffer existentially or whether their life has value are decisive, the age limit could instead be 18 years, 21 years, or somewhere in between; this might be a difficult delimitation issue. The idea of a “completed life” is thus fully individualized by separating it from the notion that there is normally (whatever that may be taken to mean) something to complete, which an age limit of 75 years suggests.

The reader is reminded here that end-of-life supporters will not be allowed to perform euthanasia in the strict sense, which will remain a task reserved for physicians, and will only be involved in assisted suicide. If suicide itself is not illegal (so that the corpse of a self-murderer is not treated irreverently as a form of punishment, presumably in the guise of some sort of [vicarious] atonement, and someone who attempts to commit suicide and fails is not punished), then assisted suicide should not be illegal, either. After all, the individual who ends his life is the same in the first case as in the second, the only variable being the means that are provided by the person who assists. Footnote 60 The suicide of someone who acquires a rope and hangs himself is assisted, in a sense, by the storekeeper who sells it, which is not thereby punishable. The phrase “in a sense” is apt, for there is no assisted suicide if the storekeeper does not know what it is intended to be used for (or if he is lied to, and is told it is to be used for something legal), while his action is punishable if he knows the rope’s purpose and sells it nonetheless, thus willingly facilitating the suicide.

A final issue to consider is the danger of a “slippery slope”: if euthanasia (and in the case under discussion assisted suicide) is not just allowed in cases of medically diagnosable suffering and the only criterion is the individual’s assessment of his own life (i.e., whether he experiences suffering sufficient—by his own standards—to request euthanasia or considers his life completed, based on a subjective definition of “suffering” or “completed life”), some people may feel pressured to make a request they do not truly want to make.

This concern should not be dismissed, but, first, it may also be expressed in the case of medically diagnosable suffering, so that it could be used as an argument not to legalize euthanasia for any situation, an outcome that seems too severe, unless one already thinks that euthanasia (and specifically assisted suicide) should not just not be extended to cases where nonmedically diagnosable suffering is involved but should not be allowed under any circumstances, and, second, I remind the reader here that precautions are in place to ensure that the request expresses a genuine desire to die.

This does not mean, though, that a critical stance is unacceptable, and one may legitimately question whether implementing a procedure that seems sound might have unforeseen effects. It is difficult to assess whether and, if so, to what extent such effects have already manifested themselves. On the one hand, one may point to historical examples of accepted killings in exceptional contexts and circumstances that have not resulted in a general devaluation of human life, Footnote 61 and maintain that the Nazi euthanasia program is an irrelevant example since nonvoluntary euthanasia was allowed from the start, Footnote 62 while, on the other hand, data appear to suggest that the permissibility of voluntary euthanasia has led to nonvoluntary euthanasia. Footnote 63

In any event, given the (dire) position of those whose suffering can only be relieved by the radical means discussed here, the best course of action would be to focus on improving the procedures, if necessary. Only then may the interests of everyone involved be said to be taken seriously.

Whether being alive is something positive or negative must be determined by the living. If “the living” is interpreted collectively and life is deemed something positive, with the outcome that euthanasia is forbidden or only allowed in cases of medically diagnosable suffering, an individual whose assessment of (his own) life differs from the assessment of the majority has no right to euthanasia, unless this assessment has a medically diagnosable cause. I have argued that existential suffering should also be acknowledged as a reason to perform euthanasia (or, specifically, to assist in another’s suicide). Only thus may the imposition of the idea that life is something positive, with the corollary that one should in principle (continue to) live, on individuals be forestalled.

The issue is not whether there is a right to die, but whether there is a duty (to continue) to live. The onus is not, then, on the individual who wants to die to prove that he has such a right, but, conversely, on those who keep him from dying by means of euthanasia to prove that he has a duty to live. This given does not preclude the justification of using a procedure to ensure that the individual’s request to have his life ended or receive aid to do so himself is voluntary and well-considered, and that there is a lasting desire to die.

The foregoing is not taken to mean that an absolute right (a “natural” right) to die exists and that legislation that conflicts with the acknowledgement of such a right is therefore invalidated. I have not argued that such a right exists, if only because I would not even know where to begin if it were my intention to do so. I have rather expressed what situation I deem most desirable, having no recourse to a superior standard to make my case. This does not take away anything from the importance of the issue of taking existential suffering seriously.

1. “Euthanasia”—as a working definition—here refers to both euthanasia in the strict sense (i.e., a person’s voluntary death by means of little or no pain, brought about by another than that person) and assisted suicide (i.e., a person’s suicide that is brought about with the aid of another than that person), unless otherwise indicated. Incidentally, “euthanasia” is thus equated with “voluntary euthanasia,” not because “nonvoluntary euthanasia” would not qualify as euthanasia but because nonvoluntary euthanasia is not an issue in the present inquiry; for the same reason, “euthanasia” is equated with “active euthanasia.” “Euthanasia” in the literal sense has a very broad sense, but this will not explored here in order not to needlessly complicate matters; as I just indicated, I will use a working definition here.

2. The relevant legislation where these and the other criteria are listed is the Termination of Life on Request and Assisted Suicide Act. Euthanasia is illegal on the basis of articles 293 and 294 of the Dutch Criminal Code, but euthanasia performed by physicians is not punishable as long as they adhere to the criteria specified in said Act.

3. Dutch Supreme Court , June 6, 1994, at 5.2.

4. Berghmans , R , Widdershoven , G , Widdershoven-Heerding , I. Physician-assisted suicide in psychiatry and loss of hope . International Journal of Law and Psychiatry 2013 ; 36 ( 5/6 ): 436 –43 CrossRef Google Scholar PubMed , at 442.

5. Parker , M. Defending the indefensible? Psychiatry, assisted suicide and human freedom . International Journal of Law and Psychiatry 2013 ; 36 ( 5/6 ): 485 –97 CrossRef Google Scholar PubMed , at 487.

6. For example, Hatherley , JJ . Is the exclusion of psychiatric patients from access to physician-assisted suicide discriminatory? Journal of Medical Ethics 2019 ; 45 ( 12 ): 817 –20 CrossRef Google Scholar PubMed , at 818.

7. Parliamentary Documents: House of Representatives, 1993/1994:23877, no. 1, at 4. The original text reads: “Voor de uitzichtloosheid van het lijden is het medisch oordeel bepalend. Naar medisch vakkundig oordeel moet vaststaan dat de situatie van de patiënt verergert en niet te verbeteren is. Aldus wordt de uitzichtloosheid geobjectiveerd.”

8. Parliamentary Documents: House of Representatives, 1993/1994:23877, no. 1, at 5. The original text reads: “De ondraaglijkheid van het lijden dient voor de vraag of euthanasie mag worden toegepast evenzeer te worden vastgesteld, maar is, in tegenstelling tot de uitzichtloosheid van het lijden, een in hoge mate subjectieve, en moeilijk te objectiveren factor.”

9. Parliamentary Documents: House of Representatives, 1999/2000:26691, no. 6, at 30; 1999/2000:26691, no. 6, at 70; and 2007/2008:31036, no. 3, at 5, 6.

10. Parliamentary Documents: House of Representatives, 2007/2008:31036, no. 8, at 3.

11. Parliamentary Documents: House of Representatives, 2019/2020:35534, no. 2, at 1–10.

12. Parliamentary Documents: House of Representatives, 2019/2020:35534, no. 3, at 2.

13. Parliamentary Documents: House of Representatives, 2019/2020:35534, no. 3, at 23, 36.

14. Parliamentary Documents: House of Representatives, 2019/2020:35534, no. 3, at 20.

15. Tiensuu , P. Whose right to what life? Assisted suicide and the right to life as a fundamental right . Human Rights Law Review 2015 ; 15 ( 2 ): 251 –81 CrossRef Google Scholar , at 252.

16. ECtHR, Pretty v. United Kingdom (Apr. 29, 2002), Application No. 2346/02.

17. ECtHR, Haas v. Switzerland (Jan. 29, 2011), Application No. 31322/07.

18. ECtHR, Haas v. Switzerland (Jan. 29, 2011), at 51, 52.

19. ECtHR, Haas v. Switzerland (Jan. 29, 2011), at 56–8.

20. Washington v. Glucksberg , 521 U.S. 702 (1997), at 720, 721.

21. Washington v. Glucksberg , 521 U.S. 702 (1997), at 728.

22. , Chemerinsky E. Washington v. Glucksberg was tragically wrong . Michigan Law Review 2008 ; 106 ( 8 ): 1501 –16 Google Scholar , at 1506.

23. See note 22 , Chemerinsky 2008, at 1507.

24. See note 22 , Chemerinsky 2008, at 1515.

25. For example, Euthanasia , Biggs H. , Death with Dignity and the Law . Oxford : Hart ; 2001 Google Scholar , at 15, 29; Neeley , GS . The constitutional right to suicide, the quality of life, and the “slippery-slope”: An explicit reply to lingering concerns . Akron Law Review 1994 ; 28 ( 1 ): 53 – 77 Google Scholar PubMed , at 76.

26. See Doomen J. Dignity in life and death. In: Doomen J, Van Schaik M, eds. Religious Ideas in Liberal Democratic States. Lanham, MD: Lexington Books (Rowman & Littlefield); 2021:85–104, at 90–2 for an overview.

27. See note 25 , Neeley 1994, at 65–7.

28. The author does not refer to Kant, but his perspective does come to mind. A discussion of Kant’s ideas would unwarrantably diverge from the discussion at hand; I refer the reader to Doomen J. Beyond dignity. Archiv für Begriffsgeschichte 2016;57:57–72, at 59–61.

29. See note 25 , Biggs 2001, at 157.

30. Singer P. Practical Ethics. Cambridge: Cambridge University Press; 2011, at 156.

31. Aristotle, Ethica Nicomachea. Opera, Vol. 2. Darmstadt: Wissenschaftliche Buchgesellschaft; 1831[±350BC], at 1115a.

32. See note 31 , Aristotle 1831, at 1098a, 1098b.

33. Lucretius. De Rerum Natura. Berlin: Georg Reimer; 1871[±60BC], Book 3, 830, 831, at 105.

34. See note 33 , Lucretius 1871, Book 3, 798, 799, at 105; and 830, 831, at 105.

35. Paterson C. Assisted Suicide and Euthanasia. A Natural Law Ethics Approach. Aldershot: Ashgate; 2008, at 51. Similarly, Dworkin states: “Something is intrinsically valuable […] if its value is independent of what people happen to enjoy or want or need or what is good for them.” Dworkin R. Life’s Dominion. New York, NY: Alfred Knopf; 1993, at 71. The idea of “(human) dignity,” discussed in the previous section, is associated with the idea of an intrinsic value (see note 25 , Biggs 2001, at 145) and with the inherent value of one’s own life (Dworkin 1993, at 238).

36. See note 35 , Paterson 2008, at 78.

37. See note 35 , Dworkin 1993, at 68, 69.

38. Bullock , E. Assisted dying and the proper role of patient autonomy . In: Cholbi , M , Varelius , J , eds. New Directions in the Ethics of Assisted Suicide and Euthanasia . New York, NY : Springer ; 2015 : 11 – 25 CrossRef Google Scholar , at 17, 18.

39. See note 38 , Bullock 2015, at 17.

40. See note 38 , Bullock 2015, at 13.

41. See note 38 , Bullock 2015, at 20–2.

42. See note 38 , Bullock 2015, at 17, 18.

43. See note 38 , Bullock 2015, at 14–6.

44. “Lasting” (the translation of the term “duurzaam,” which is used in the bill) (Parliamentary Documents: House of Representatives, 2019/2020:35534, no. 2, at 2) must be differentiated from “absence of a prospect of improvement” of medically diagnosable suffering (see note 2 ). In the case of medically diagnosable suffering, the suffering is expected to be such that no prospect of improvement exists as a result of a lack of medical means to alleviate it, while “lasting” in the present sense refers to the fact that the person making the request has a lasting desire to die.

45. In line with what Sudarshan argues ( Sudarshan , S. The irrevocability of capital punishment and active voluntary euthanasia . Journal of Applied Philosophy 2021 ; 18 ( 3 ): 431 –43 CrossRef Google Scholar , at 436, 437).

46. Pascal B. Pensées. Œuvres Complètes, Vol. 1. Paris: Librairie de L. Hachette et Cie; 1869 [1669], Article X, at 303–5.

47. See note 46 , Pascal 1869, Article X, at 303. The original text (with the original spelling) reads: “S’il y a un Dieu, il est infiniment incompréhensible, puisque, n’ayant ni parties ni bornes, il n’a nul rapport à nous: nous sommes donc incapables de connoître ni ce qu’il est, ni s’il est.”

48. Compare Simmons , K. Suicide and death with dignity . Journal of Law and the Biosciences 2018 ; 5 ( 2 ): 436 –9, at 439 CrossRef Google Scholar PubMed .

49. It is in this sense that Marcus Aurelius speaks of life. Seeking to consider things as they are in themselves (Marcus Aurelius Antonius. Ta Eis Heauton. Leipzig: B.G. Teubner; 1903 [180AD], Book Δ, ιά, at 34), he indeed identifies life with such physical elements (Book Ζ, ιέ, at 67).

50. Compare Schramme T. Rational suicide, assisted suicide, and indirect legal paternalism. International Journal of Law and Psychiatry 2013;36(5/6):477–84, at 480, 482, and the dissenting opinion of Justice Brennan in Cruzan v. Director, Missouri Department of Health, 497U.S. 261 (1990): “[…] the State has no legitimate general interest in someone’s life, completely abstracted from the interest of the person living that life, that could outweigh the person’s choice to avoid medical treatment.”

51. Sprung , C , Somerville , M , Radbruch , L , Collet , NS , Duttge , G , Piva , J , et al. Physician-assisted suicide and euthanasia: Emerging issues from a global perspective . Journal of Palliative Care 2018 ; 33 ( 4 ): 197 – 203 CrossRef Google Scholar PubMed , at 199.

52. See note 51 , Sprung et al. 2018, at 200.

53. In addition, “[…] what is diagnosed is the condition and not the suffering; physical conditions are objectively diagnosable while physical suffering is not or less so.” Raus , K , Sterckx , S. Euthanasia for mental suffering . In: Cholbi , M , Varelius , J , eds. New Directions in the Ethics of Assisted Suicide and Euthanasia . New York, NY : Springer ; 2015 : 79 – 96 CrossRef Google Scholar , at 89.

54. Schmidt , A. Should we extend voluntary euthanasia to non-medical cases? Solidarity and the social context of elderly suffering . Journal of Moral Philosophy 2020 ; 17 ( 2 ): 129 –62 CrossRef Google Scholar , at 132.

55. See note 54 , Schmidt 2020, at 134, and see note 53 , Raus, Sterckx 2015, at 89.

56. See note 53 , Raus, Sterckx 2015, at 89.

57. Varelius , J. Medical expertise, existential suffering and ending life . Journal of Medical Ethics 2014 ; 40 ( 2 ): 104 –7 CrossRef Google Scholar PubMed , at 106.

58. Dutch Supreme Court , Dec. 24, 2002, at 5.

59. Complementing what he argues, Varelius points to such an alternative: persons with a special expertise on existential questions may, provided that they meet the same standards as physicians insofar as the procedural requirements are concerned, be preferable to physicians (see note 57 , Varelius 2014, at 107).

60. Compare note 50 , Schramme 2013, at 484.

61. See note 25 , Neeley 1994, at 60, 61.

62. Lesser , H. Should it be legal to assist suicide? Journal of Evaluation in Clinical Practice 2010 ; 16 ( 2 ): 330 –4 CrossRef Google Scholar PubMed , at 332.

63. See note 51 , Sprung et al. 2018, at 198.

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• Volume 32, Issue 1
• Jasper Doomen (a1)
• DOI: https://doi.org/10.1017/S0963180122000020

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Social and Legal Aspects of Eutanasia Regulation: International Experience

2021, Medico Legal Update

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The Ethical and Legal Implications of Euthanasia

Generally, the topic of euthanasia has resulted in hot debates among all stakeholders, including healthcare professionals and legal experts, due to the ethical and legal issues associated with the topic. It affects both patients and their healthcare providers. Over the years, the debate on euthanasia has focused on suffering patients with terminal illnesses. However, the topic has extended to include even patients with mental illnesses like depression. Therefore, it is appropriate to look at the controversy surrounding euthanasia in a recent case study. Euthanasia is a controversial topic that requires further inquiry to fully understand different opinions offered by the opposing sides and the ethical implications associated with it.

Recent Case Study

The case published in the Catholic Herald involves a 29-year-old woman who underwent euthanasia following a series of mental illnesses. According to the author, despite being physically fit, the woman was given a lethal injection, having been granted her wish to die by the court after eight years of legal battles. In her argument, the woman claimed she had experienced extreme bouts of depression that had made her life intolerable. The case raised concerns among various stakeholders, including politicians who lamented how dangerous euthanasia could be.

Ethical Issues Involved in the Case Study

Generally, the case study raises various ethical dilemmas related to euthanasia, including when it is justifiable to end one’s life. In addition, the topic also opens up a whole discussion on the limitations of patients’ autonomy and the ethical responsibilities of healthcare professionals, as highlighted in the bioethical principles of beneficence and maleficence. Concerning autonomy, questions are raised regarding the patient’s capability to understand the decision that she was making. With superior knowledge and training, the physician is best positioned to help make an ethical decision that is in the patient’s best interest to protect patients from irresponsible choices. For patients to make an autonomous decision, they should be mentally capable of comprehending the information of the decision. In the case study, the patient has a mental health condition. Hence, her ability to make rational decisions is in question.

The Context of Euthanasia

The case study highlights euthanasia, particularly among patients with mental conditions such as depression. Historically, numerous attempts have been made to legalize euthanasia, but minimal success has occurred. The euthanasia discussion in psychiatry was awakened after the Nazi Holocaust when thousands of psychiatric patients were gassed or poisoned to death under the ‘euthanasia program’. According to Felder, the Nazi euthanasia program was used by scientists, mainly physicians, to conduct medical experiments. It is out of the scientific experiments of the Nazi physicians that ‘The Nuremberg Code’ was established to guide future experiments on human subjects.

Additionally, politicians have had their hand in the matter by sponsoring bills to legalize the act, with some opposing such attempts and publicly making their views known. From a social perspective, euthanasia has continued to be controversial, with many societies coming up to air their opinion. In the traditional Christian context and culture, euthanasia is viewed as morally unacceptable due to human life’s sacred nature. However, other social groups support euthanasia with the thought of extending dignity to death, such as the Voluntary Euthanasia Society. As such, there is no single available societal perspective regarding the issue of euthanasia. Hence, it is important to society as it touches on the critical matters of life and death.

The Differing Perspectives on Euthanasia

The individuals and societies in support of euthanasia have always centered their opinion on patient suffering. They argue that patients in the terminal stages of illness experience excruciating pain and have poor wound healing, poor social interactions, and many other aspects of physical suffering. According to the proponents, euthanasia is a more merciful response to relieve this suffering, especially where the quality of life is jeopardized. Among the patients with mental illnesses, the proponents argue that some mental conditions, including severe depression, induce intense suffering and are unresponsive to treatment. Additionally, the proponents note that since the patients request most cases of euthanasia, it is a way for physicians to show respect for personal autonomy. Thus, to the proponents, euthanasia relieves undue suffering and is in harmony with respect for autonomy and the individual’s right to a dignified death.

Contrary to the proponents’ arguments, the opponents base their argument on the intrinsic wrongness of killing, professional integrity, and the possibility of potential abuse. According to Naga and Mrayyan, willingly ending one’s life is inconsistent with human rights, and alternatives should be sought to relieve the patient’s suffering and improve their quality of life. Furthermore, Naga and Mrayyan note that administering lethal substances by physicians to end life is unethical according to guiding medical ethical practices, especially the Hippocratic Oath that restricts physicians from administering such substances to their patients or aiding their patients to die. They also note that legalizing euthanasia could lead to its potential abuse and a slippery slope where individuals will use it to escape chronic but manageable medical conditions.

Evaluation of the Arguments and Their Ethical Implications

The arguments presented by both the proponents and the opponents seem to be entirely influenced by one’s culture, moral philosophy, and personal experiences. Those opposed to euthanasia seem to be influenced by their religious cultures. Specifically, Christian teachings view life as sacred and state it should not be terminated prematurely at any cost. On the other hand, the proponents seem to subscribe to the Stoic philosophy that has always defended suicide as a reasonable departure from life, especially when intense suffering is involved. Anecdotal evidence also suggests that personal life experiences with suffering may make one choose to end one’s life. For example, seeing a cancer patient suffer may make individuals consider euthanasia if diagnosed with a similar terminal disease, as they will not want to experience the same ordeal.

While both the proponents and those opposed to euthanasia have valid arguments, myriads of ethical issues surround each side’s perspective. It is indeed true that certain illnesses, including mental conditions, lead to severe suffering and reduced quality of life. However, ethical issues arise regarding the ability of the patients requesting euthanasia to make autonomous decisions. For example, Appelbaum notes that it is common for depressed patients to reject treatment and even request death, yet change their decision once the depression is resolved. Accordingly, this raises the ethical question concerning the impact of the mental illness itself on the patient’s decision-making. It has also been observed that most patients are only resistant to one form of treatment and that other options should be tried to relieve their suffering.

Furthermore, it is noted that the right to autonomy is not always absolute and that physicians have the legal and ethical responsibility to override the patient’s decisions and continue pursuing alternative treatment in response to the patient’s symptoms and request a dignified death. Thus, the argument regarding patients’ autonomy to end their lives is weak. On the other hand, the opponents’ unethical medical practice mainly touches on physicians’ ethical responsibilities to act in good faith and protect their patients from harm. In line with non-maleficence and beneficence principles, physicians cannot administer lethal dosages to their patients as it causes more harm than good. Additionally, the claim of potential abuse if euthanasia is legalized, holds grounds owing to several reported cases, including ones with mental illnesses, where euthanasia has been performed without following due process in countries where it is legalized. Thus, the ethical questions raised by those opposed to euthanasia regarding non-maleficence, benevolence, and potential abuse are strongly supported by evidence.

Personal Perspective on Euthanasia

The issue of euthanasia among depressed patients will continue to dominate medical discussions. Subjectively, the opponents of euthanasia seem to offer a strong argument. Notably, depression can be treated just like other mental conditions, and symptoms can be controlled where treatment is impossible. Patient autonomy among psychiatric patients is in question. Mental illnesses tend to affect one’s way of thinking, and suicidal ideations are common phenomena among depressed patients. I have dealt with patients who have changed their stance on ‘mercy killing’ after a series of professional counseling sessions and continued treatment. Thinking about these experiences concerning my patients and the ethical dilemmas related to euthanasia makes me view it as an undesirable event in medical practice that I will not want to engage in.

The topic of euthanasia is controversial based on the numerous arguments aired by those in its support and those who are against it. The case study published in the Catholic Herald offers a good scenario through which the effects of euthanasia can be accessed and its ethical implications reviewed. While the Pro-euthanasia argument is based on the need to relieve undue suffering, respect autonomy, and grant the right to a dignified death, the opponents have emphasized the intrinsic wrongness of killing, professional integrity, and the possibility of a “slippery slope”. Overall, the ethical issues addressed autonomy, beneficence, and non-maleficence. Subjectively, the ethical questions touching upon professional integrity, especially the need to observe non-maleficence and doing good, are strong enough to make me offer my support against euthanasia.

📎 References:

1. Appelbaum, P. S. (2017). Should mental disorders be a basis for physician-assisted death? Law & Psychiatry, 68(4), 315-317. https://doi.org/10.1176/appi.ps.201700013 2. Beauchamp, T. L. (2016) Principlism in bioethics. In P. Serna & J. A. Seoane (Eds.), Bioethical decision making and argumentation (pp. 1-16). New York, NY: Springer. 3. Caldwell, S. (2018, February 1). Dutch doctors euthanize a 29-year old woman with depression. Catholic Herald. 4. Felder, B. M. (2013). “Euthanasia,” human experiments, and psychiatry in Nazi-occupied Lithuania, 1941-1944. Holocaust and Genocide Studies, 27(2), 242-275. https://doi.org/10.1093/hgs/dct025 5. Kim, S. Y., De Vries, R. G., & Peteet, J. R. (2016). Euthanasia and assisted suicide of patients with psychiatric disorders in the Netherlands 2011 to 2014. JAMA Psychiatry, 73(4), 362-368. https://doi.org/10.1001/jamapsychiatry.2015.2887 6. Naga, B. S. B., & Mrayyan, M. T. (2013). Legal and ethical issues of euthanasia: Argumentative essay. Middle East Journal of Nursing, 7(5), 31-39. https://doi.org/10.5742/MEJN.2013.75330 7. Nunes R., & Rego, G. (2016.) Euthanasia: A challenge to medical ethics. Journal of Clinical Research & Bioethics, 7(4), 1-5. https://doi.org/10.4172/2155-9627.1000282 8. Tomasini, F. (2014). Stoic defence of physician-assisted suicide. Acta Bioethica, 20(1), 99-108. Retrieved from https://scielo.conicyt.cl/pdf/abioeth/v20n1/art11.pdf

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Why euthanasia should not be legalised

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Why active euthanasia and physician assisted suicide should be legalised

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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

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• Why We Should Not Legalize Euthanasia

The Foundational Ethical Principle Obliging Us To Protect Life Must Be Translated Into a Concrete Norm

Fr. Place is research theologian for the Curia and counsel for policy development, Archdiocese of Chicago. This article is based on his talk at the 1992 Frank M. Norfleet Forum for the Advancement of Health, Memphis.

The euthanasia debate is really the backdrop for a discussion within our society about the very nature of human life and meaning. Because the origin of life is in God, human beings do not have dominion over life but are stewards of life.

The powerful combination of sanctity and stewardship is expressed in the foundational ethical principle. This principle says that no person has the right to directly take innocent human life and in fact there is a positive obligation to nurture and protect life.

In our secular society there is a need to develop a "natural" metaphysic of sacredness. Such a metaphysic can serve as bedrock from which a foundational principle can be developed and then applied in concrete moral norms. It can show that life contributes to the full dignity of the human person. For this perspective to be effective in countering the movement to legalize euthanasia, this sense of integral wholeness of human personhood must be demonstrated in a convincing manner. It can be because a dualistic philosophical bias has been found wanting by Western culture.

We must arrive at what ethicists would call concrete norms that guide individual choices. At issue is how we translate our foundational principle—Do not directly attack innocent human life—into a concrete norm when confronted with the possibility of death.

Some persons question whether the concrete norm opposing euthanasia should be a matter of public morality. To answer this question, we must turn to our foundational principle. As a society, we must ask ourselves, How "sacred" is life? Will that natural sense of awe about life, that natural desire not to be vulnerable, be enhanced or threatened by making euthanasia legal?

Euthanasia has become the ethical issue of the 1990s and the focus of some of our most controversial public policy questions. I oppose the legalization of euthanasia. But we must do more than simply disagree with its proponents. It is possible, using the belief structures of the Judeo-Christian tradition and other reflections, to develop a persuasive understanding of human life that can serve as the foundation for an ethic that would oppose the legalization of euthanasia.

Although voters in California and Washington State have rejected assisted-suicide initiatives, the euthanasia debate will continue. Religion serves a vital role in this public policy discussion. But I see the euthanasia debate as symptomatic of a much more profound cultural discussion on the nature and meaning of human life. Certain foundational principles, which can be formulated in both religious and secular terms, can guide the opposition to euthanasia.

Religion and Public Policy Persons involved in the euthanasia debate are often concerned about the role of religion. Many people are concerned that participation by religious leaders is an inappropriate attempt to impose a particular religion's morality on society. But the constitution protects our nation's religious pluralism and ensures that a person who practices a religion or a person who practices no religion will not be excluded from participating in public policy development. Such participation, however, is based on two distinctions:

• The distinction between civil law and morality. Although our legal tradition is rooted in moral principles, "the scope of law is more limited and its purpose is not the moralization of society." 1 Everything that people of good will consider to be morally wrong need not be made illegal. This should only happen when the mutually agreed-on demands of the public good or the public order require it.
• The distinction between public moral questions and private moral questions. Something is a matter of public morality if it affects the public order of society. Catholic thinker John Courtney Murray defined public order as encompassing three goods: public peace, essential protection of human rights, and commonly accepted standards of moral behavior in a community. As a general principle, the domain of law and public policy is public morality, not private morality.

Thus religious leaders must be circumspect when they speak outside their congregations. Some areas of religious belief and practice are not appropriate matter for legislation. Religious leaders should speak out, however, on matters pertaining to public morality. In a pluralistic society religious leaders are as free as other citizens to participate in the public discussion that seeks to build consensus on what constitutes public morality. Card. Joseph Bernardin of Chicago has suggested that when religious leaders do participate in such public dialogue, they must translate their religious beliefs or philosophical assumptions "into commonly agreed upon language, arguments and categories before they can become the moral or ethical foundations for key public policy choices." 2 He adds:

A rationally persuasive case must be made that an action violates the rights of another or that the consequences of actions on a given issue are so important to society that the authority of the state ought to be invoked through public policy or civil statute, to govern personal and group behavior. Obviously, in a pluralistic society, arriving at a consensus on what pertains to public policy is never easy. But we have been able to achieve such consensus in the past by a process of dialogue, decision making and review of our decisions.

In accepting Card. Bernardin's challenge, I will explain why the legalization of euthanasia would violate the public order of our society and therefore should not be allowed. Persons who propose the legalization of euthanasia must be held to the same standard: They must demonstrate how such a change of public policy would not adversely affect public order.

The Cultural Context Although euthanasia is not new in Western culture, it is evident that euthanasia has not been acceptable practice within U.S. culture or our civil laws. Only in the past few years has euthanasia become a matter of public discussion and concern. The reasons for this growing openness to euthanasia are many, including the advancements of medical technology that have made it possible to maintain and extend human life as never before. Clearly, the sense of powerlessness and the fear of needless pain often associated with such advanced forms of treatment have been practical reasons for the advancement of the euthanasia movement. However, deeper reasons exist for this euthanasia phenomenon—reasons that are cultural or philosophical.

Underlying Assumptions Harvard's Arthur J. Dyck has identified what he considers to be the underlying presuppositions of an ethic of euthanasia. They are as follows:

• That an individual's life belongs to the individual to dispose of entirely as he or she wishes;
• That the dignity that attaches to personhood by reason of the freedom to make moral choices demands also the freedom to take one's life;
• That there is such a thing as a life not worth living, whether by reason of distress, illness, physical or mental handicaps, or even sheer despair for whatever reason;
• That what is sacred or supreme in value is the "human dignity" that resides in man's own rational capacity to choose and control life and death. 3

Obviously, one might disagree with some of Dyck's characterizations, but I suggest that he has captured, in a general sense , the presuppositions of the euthanasia movement. And there is much to be said for these presuppositions. For example, they make us aware that values exist beyond those of physical survival. Similarly, they force us to realize that death is not the greatest harm which can befall a person.

Assumptions' Weaknesses Nevertheless, weaknesses are inherent in these assumptions. Rev. Richard M. Gula, SS, identifies three:

• They are arbitrary in that they identify a few values to define the significance of human life and fail to put them in the context of a full spectrum of human values and their consequences.
• Taken as a freestanding composite, they are too risky. It is not self-evident why their application could not be extended to the most vulnerable members of society such as the elderly and the handicapped.
• They erode the "character of a helping community of trust and care." 4

Disagreements regarding the end of life choices open to dying persons reflect non-moral assumptions about the source of meaning and good in human life; the significance of suffering and death in human experience; the relation between dependency, dignity and control; the moral character of caring relationships; and the nature of the human self. 5

The euthanasia debate is really the backdrop for a discussion within American society about the very nature of human life and meaning. Although societies seldom choose to engage such fundamental questions in their abstract form, we must not lose sight of the fact that we are discussing more than whether euthanasia should be legalized.

Argument Against Euthanasia For Catholics (indeed for many Christians), at the center of such a discussion on the nature of human life and meaning is the question of the sanctity of human life. For the believer, God is the origin of all life and the sustainer of all life. For that reason human life has a dignity greater than the sum of life's parts. In a sense this dignity is not intrinsic to the human person. Human dignity is not conferred by one's actions, by the judgments of others, or by the fiat of law. Rather, it is conferred by God. Intimately associated with the concept of sanctity is an awareness that, because the origin of life is in God, human beings do not have dominion over life but are the stewards of life, which is a gift from another.

The Foundational Ethical Principle The powerful combination of sanctity and stewardship is expressed in the foundational ethical principle. This principle says that no person has the right to directly take innocent human life and, in fact, we have a positive obligation to nurture and protect life. This same ethical principle inspired religious leaders and the faithful to participate in the civil rights movement of the 1950s and 1960s, raised citizens' concern about the morality of nuclear warfare, enlightened the discussions on the manner in which the war against Iraq was conducted, and now motivates the drive against the legalization of euthanasia. This foundational ethical principle is the keystone, if you will, of a consistent ethic of life.

Many persons might suggest that this perspective on the sacredness of life is no longer valid for a large number of Americans. They argue that traditional Judeo-Christian symbols and values are no longer adequate to serve as a substratum for the development of a consensus or vision to guide the evaluation of the needs of public order. Some Americans believe we should replace that substratum with one similar to Dyck's presuppositions. If this were to happen, the legalization of euthanasia would be easily justified.

As a committed Christian, I disagree with such a contention. But it is not enough to simply disagree. As Card. Bernardin has proposed, we must offer a positive vision that opposes euthanasia, one secular America will heed.

A Positive Vision Several persons have attempted to develop such a vision. One of the more persuasive contributions is that of Edward Shils. Shils proposes a natural metaphysic that supports the sacredness of life. Sacredness for him is not rooted in a transcendent creator but "in the primordial experience of being alive, in the fear of extinction, in the spontaneous revulsion to contrived interventions and unnatural destruction of human life, and in the sense of awe one feels before one's own vitality and that of the species." 6

For Shils, sanctity of life does not come from outside life but from the experience of life itself. On a pragmatic level, Shils and others argue that unless sacredness of life is acknowledged, the entire structure of human values and rights will collapse. This natural metaphysic of sacredness, much as the Christian understanding, serves as bedrock from which a foundational principle must be developed and then applied in concrete moral norms. The process of developing such a principle is complex, and there is room for disagreement. For example, one could hold to a natural understanding of the sacredness of life and still support euthanasia.

Developing a Foundational Principle Instrumental Good To develop a foundational principle, it is necessary to discuss the question, Is human life and its natural sacredness only an instrumental good necessary for personal fulfillment? Or is it something more? Many euthanasia supporters view life as an instrumental good. In other words, the living body is a means to achieve the true end or purpose of being, which is personal activity. Bodily life provides the wherewithal for personal fulfillment. And when the personal component (the ability to control life through rational choice) is missing, the person has no obligation to continue living. Bodily living has lost its purpose.

The Body-Person Distinction In response to this dualistic distinction between body and person, Fr. Gula proposes an anthropology that "regards the human being as one. . . . Bodily life participates in the integrity of the human person as a substantive good of human life, and human life is the life of a personal being." 7 In other words, life is not only a condition necessary for a person to achieve other values, it is intrinsic to being human, and it contributes to the full dignity of the human person. This sense of an integral wholeness to personhood must be demonstrated in a convincing manner. And I believe it can be, because a dualistic philosophical bias has been found wanting by Western culture.

A Community of Trust and Care Another area that must be addressed is the nature of the community in which human life is situated. As Fr. Gula notes, "If we focused our attention solely on the dying patient and extended our vision no further, then perhaps we might be able to make a case for euthanasia. But if we are socially conscious so that our vision encompasses the caring community as well, then we can make a better case against euthanasia." 8

In this context Stanley Hauerwas has argued that an essential aspect of human experience is the need and the desire to trust the community in which one lives. If life is sacred, then that community of necessity will be a community of trust and care. Euthanasia would be unacceptable because it means the community has abandoned its responsibility to care and comfort. Euthanasia fails to show to dying persons what Hauerwas calls "the continuing trustworthiness of their existence." 9

In a similar fashion one must evaluate euthanasia's effect on the life of the community. Because we are social by nature, we are connected to others. Our individual choices have an impact on others. We must keep in mind that:

Actions reflect and give expression to certain values and beliefs. The more people perform a certain action and the more frequently they perform it, the more those values and beliefs are expressed. The effect is cumulative and eventually influences the moral tone and character of a society. . . . [And] as a result, we need to be concerned not only with individual welfare but also with societal welfare. 10

Clearly, as Robert Bellah and others have demonstrated, the relationship between individual and community is an issue of fundamental importance to our society. 11 An increased sense of isolation and alienation affects many in our midst because we have allowed the individual to be separated from community. In a sense euthanasia can be seen as the logical conclusion of the existential angst of the person alienated from self and community.

Setting Concrete Ethical Norms If we are able as human beings and as a society to agree on this foundational principle, it is then necessary to apply it to concrete ethical issues. We must arrive at what ethicists would call concrete, or material, norms that guide individual choices.

Historically, we have done this. For example, we believe it is wrong to take the life of another person except in self-defense. In simple, straightforward terms we say it is wrong to murder. As a society, we accept this concrete norm as true whether its source is the decalogue or a secular ethic of human sacredness. And we affirm this concrete norm with such conviction that we teach it to our young and expect them to make it part of their code of personal or private morality. We are offended or frightened when we see it violated, especially in senseless or wanton killing.

We also have come to the conclusion that the consequences of the violation of this concrete norm are so great that they threaten the well-being of society. In other words, murder threatens the good of the public order. The public peace is shattered, and the protection of human rights compromised. For these reasons the concrete norm "Do not murder" has been translated into public law. It is understood to be part of the public morality.

At issue, then, is how we translate our foundational principle—Do not directly attack innocent human life—into a concrete norm when confronted with the possibility of death. I could argue that the earlier discussion about the natural "sacredness" of life, the integrity of personhood, and the trustworthiness necessary to sustain human community can be drawn together to support a concrete moral norm saying that it would be wrong to directly take or assist in the taking of human life to relieve pain or suffering. Although originally grounded in a Christian foundational principle, this concrete norm opposing euthanasia now has a nonsectarian basis, like the concrete norm regarding murder. It can, if you will, be called a human or a natural norm.

Although many persons might agree this is a worthy concrete norm to guide the development of personal morality, they would question whether it is so exceptionless, or the consequences of its violation so significant, as to also make it a matter of public morality. For this reason, some are questioning the validity of the existing societal presumption—namely, they question whether the concrete norm opposing euthanasia should be a matter of public morality.

To answer this question, we must return to the grounding for our foundational principle. As a society, we must ask ourselves, How "sacred" is life? Will that natural sense of awe about life, that natural desire not to be vulnerable or at risk, be enhanced or threatened by making euthanasia legal? Are enough protections available in the human community, in light of human foibles and limitations, to ensure that this practice will not make individuals more vulnerable to outside attack? In other words, will the "safe harbor" that laws against murder and euthanasia have created for human existence be enhanced or diminished? We must consider whether, as a society, we want to say that human life is but another "thing" to be used and discarded at will, like a broken toy. Is this the understanding of life we wish to celebrate as a civil society? We must ask whether we are happy living as lone rangers on the frontier of life or whether community is essential to our well-being. And if it is, what are the mutual commitments of trust necessary to support and sustain such community? Will the legalization of euthanasia enhance these commitments or detract?

Meeting the Challenge All too often the euthanasia discussion has not addressed these more fundamental issues. The image of persons dying needlessly painful deaths controlled by insensitive medical technology dominates the discussion. And I suspect many persons who might vote to legalize euthanasia are doing so out of desperation. Ironically, they view their votes as the only way to preserve the sacredness of life and community. What they fail to see is how in fact euthanasia compromises what they most deeply believe.

Card. Bernardin addressed this reality in the following terms:

It is important for us to address the sense of powerlessness which many people experience in regard to the contemporary practice of medicine. While the catch phrase "patient as person" is a helpful guide in this matter, we have to extend this concept more aggressively into the world of critical and terminal illness where the patient is the frailest and most vulnerable. We must also face our own fear of death and learn to provide for those who are dying or critically ill in a way that preserves their dignity and ennobles them. . . . In this way we can eliminate many of the legitimate concerns that may motivate people to consider euthanasia—which otherwise would be unacceptable to them and to society. 12

I agree with the cardinal. The reasoned and sophisticated arguments against the legalization of euthanasia will never be heard and the real discussion will not take place unless, as individuals and providers of healthcare, we first meet this critical challenge.

• Joseph Bernardin, "Address: Consistent Ethic of Life Conference," Consistent Ethic of Life , Sheed & Ward, Kansas City, MO, 1988, pp. 86-95.
• Joseph Bernardin, "Euthanasia: Ethical and Legal Challenges," Origins , June 9, 1988, p. 52.
• Arthur J. Dyck, "An Alternative to the Ethics of Euthanasia," as cited in Richard M. Gula, What Are They Saying about Euthanasia? Paulist Press, Mahwah, NJ, 1986, p. 169. These reflections are deeply indebted to Fr. Gula's masterful analysis of this important subject.
• Gula, p. 70.
• Courtney S. Campbell, "Religious Ethics and Active Euthanasia in a Pluralistic Society," Kennedy Institute of Ethics Journal , vol. 2, 1992, pp. 253-284.
• Edward Shils, "The Sanctity of Life," in Daniel H. Labby, ed., Life or Death: Ethics and Options , University of Washington Press, Seattle, 1968, p. 12.
• Gula, p. 97.
• Gula, p. 71.
• Ron Hamel and Edwin DuBose, "Views of Major Faith Traditions," in Ron Hamel, ed., Active Euthanasia, Religion and the Public Debate , Park Ridge Center, Chicago, 1991.
• Robert N. Bellah, Habits of the Heart: Individualism and Commitment in American Life , HarperCollins, New York City, 1986.
• Bernardin, "Euthanasia," p. 56.

HOW THE CATHOLIC TRADITION VIEWS EUTHANASIA

In the Catholic tradition euthanasia is understood "as an action or omission which of itself or by intention causes death in order that all suffering may in this way be eliminated" (Congregation for the Doctrine of the Faith, "Declaration on Euthanasia," Origins , vol. 10, 1980, pp. 154-157). Euthanasia may be voluntary or involuntary. The difference is found in the patient's intention. Voluntary euthanasia is when a patient ends his or her own life with the assistance of a care giver, or when a care giver does it at a patient's request. Involuntary euthanasia occurs when a care giver ends a patient's life without the patient's consent.

Also, euthanasia may be either active or passive. Active euthanasia occurs when death is induced through an external method, such as Dr. Jack Kevorkian's machine. Passive euthanasia occurs "if the cause of death is present within one's body, but is not resisted when there is a moral obligation to do so" (Kevin O'Rourke, "Assisted Suicide: An Evaluation," Journal of Pain and Symptom Management , vol. 6, 1991, p. 2).

Within the Catholic theological tradition, no moral distinction is made between active and passive euthanasia. Both are described as causing the death of a person who is ill when there is a moral obligation to prolong that person's life.

Key to this ethical analysis is the assumption that there is a moral obligation to preserve and protect human life. The existence of such an obligation is relevant because, according to the Catholic theological tradition, there are times when no moral obligation exists to prolong life—namely, when the care or treatment would be futile or disproportionately burdensome. Consequently, when there is no such obligation and a person is allowed to die from a fatal pathological condition, "then the act by which one is allowed to die is not euthanasia" (O'Rourke).

This is an important point. Catholic tradition does not require that persons who are dying be kept alive needlessly. Rather, it opposes reversing a centuries-old tradition enshrined in our civil law saying that no one should directly take the life of another innocent person or assist in the taking of that life even if that person is dying or is seriously ill.

Copyright © 1993 by the Catholic Health Association of the United States For reprint permission, contact Betty Crosby or call (314) 253-3477.

Copyright © 1993 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.

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Also in this Issue

• IDN Development: Issues to Resolve
• Primary Care Program Improves Reimbursement
• Mental Healthcare For Rural Seniors
• Care of the Dying: A Catholic Perspective

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