Euthanasia. In this lecture… General overview Arguments for voluntary euthanasia A right to die? Arguments against voluntary euthanasia The

Euthanasia

In this lecture…

General overview Arguments for voluntary euthanasia A right to die? Arguments against voluntary

euthanasia The slippery-slope argument Non-voluntary and involuntary

euthanasia Active vs. Passive euthanasia Physician-assisted suicide End-of-life care

General overview

In earlier periods of human history, physicians could do little to stave off death. Today, improvements in public sanitation, the development of immunization, the development of antibiotics, and the many technologies of modern medicine have combined to lengthen the human lifespan, particularly in the developed world.

General overview

In the developed world, with its sophisticated healthcare systems, the majority of the population dies at comparatively advanced ages of degenerative diseases –cancer, stroke, heart disease, etc. – with characteristically long downhill courses, marked by a terminal phase of dying.

General overview

The developments in medical technology and treatments, which prolong and sustain life of a patient, mean that more patients stay alive for longer.

However, this extension of life is often associated with severe pain as well as intense and burdensome treatments for the terminally ill patients.

General overview

At the same time, there has been progress in the legal acknowledgement of patients’ rights.

In many developed nations, patients have the right to refuse unwanted treatment or to discontinue it once it has been started.

General overview

Euthanasia is the termination of a very sick person’s life in order to relieve them of their suffering. The following are some related terms and definitions:

Voluntary euthanasia – death is brought about or hastened at the patient’s request.

General overview

Non-voluntary euthanasia – euthanasia conducted where the explicit consent of the individual concerned is unavailable.

Involuntary euthanasia – euthanasia performed on a person who is able to provide informed consent, but does not, either because he or she does not choose to die, or because he or she was not asked.

General overview

Active euthanasia – hastening death by the use of drugs or other means, with a doctor’s direct assistance.

Passive euthanasia – hastening death by withholding or withdrawing life-sustaining treatment.

Physician-assisted suicide – the practice of a doctor providing the means for a patient to end his own life.

General overview

Can life become so burdensome, so filled with pain and suffering, that it loses all meaning and value?

Should life be preserved at the cost of continuous suffering when modern medicine makes this possible?

General overview

An accident or illness may bring people to an extreme of pain, disability, distress or dependency, so that their lives become intolerable.

If there is no reasonable prospect of substantial improvement, perhaps hastening the end of life is the only way to relieve suffering.

General overview

While most people think unbearable pain is the main reason people seek euthanasia, some surveys in the USA and the Netherlands showed that less than a third of requests for euthanasia were because of severe pain.

General overview

Terminally ill people can have their quality of life severely damaged by physical conditions such as incontinence, nausea and vomiting, breathlessness, paralysis and difficulty in swallowing.

General overview

Psychological factors that cause people to think of euthanasia include depression, fearing loss of control or dignity, feeling a burden, or dislike of being dependent.

Arguments for voluntary euthanasia

Three main arguments for voluntary euthanasia:

1. the argument from autonomy (or self-determination)

2. the argument from the relief of pain and suffering

3. the argument from the right to die


‘Autonomy’ or ‘self-determination’ refers to people’s right to making important decisions about their lives for themselves according to their own values or conceptions of a good life, and the right to be left free to act on those decisions.


In exercising autonomy or self-determination, people take responsibility for their lives.

Since dying is a part of life, choices about the manner of their dying and the timing of their death are, for many people, part of what is involved in taking responsibility for their lives.


Proponents of euthanasia argue that human beings are free and autonomous and have a right to self-determination in end-of-life decisions.

They believe that individuals should have the right to control the circumstances of their own death and to determine how much suffering is too much.


Patient autonomy includes the right to full information concerning the nature and development of the terminal illness.

Any decision about how to die must be made on the basis of ‘informed consent.’


Generally speaking, informed consent exists when patients can understand what they are agreeing to and voluntarily choose it.

People should be informed of their diagnosis, their prognosis, their options in responding to their condition and all other relevant information.


Counterargument [1]: For a decision about death to be voluntary, the individual must give explicit consent. Patients in an indefinite coma or persistent vegetative state are not candidates for euthanasia. Nor can euthanasia be justifiably administered in cases of serious dementia or clinical depression.


Counterargument [2]: We can never be absolutely sure that we have voluntary and informed consent. The pain and drugs may prevent patients from making a fully rational decision.


Another argument for euthanasia is based upon compassion, mercy and beneficence.

In cases of intractable suffering and inevitable death, a spirit of mercy and compassion is supposed to be the correct response to a patient’s desire to die.


According to this view, life is devoid of quality and of meaning to patients subject to severe and unremitting physical or mental suffering.

These patients should have the option of a quick and painless relief.


Thus, doctors have a duty to do everything within their power to relieve that suffering, even to the point of hastening death if there are no realistic alternatives acceptable to the patients.


Counterargument: Suffering is almost always relievable without killing the person. Thanks to techniques of pain management and better end-of-life care, it is possible to treat virtually all pain and to relieve all suffering.

A right to die?

Many people think that each person has the right to control his or her life and so should be able to determine at what time, in what way and by whose hand he or she will die.

They believe that human beings should be as free as possible, and that unnecessary restraints on human freedom are morally unjustifiable.

A right to die?

Most countries that put a value on individual liberty allow competent adults to refuse medical treatment even if such treatment is life-saving.

Besides, people have the right to die in the sense that they can commit suicide – attempted suicide is decriminalized nearly everywhere in the world.

A right to die?

Some people, however, invoke the right to life to justify banning suicide and euthanasia.

According to this view, if we have the right to life, we owe ourselves the duty to keep ourselves alive under any circumstances.

A right to die?

Kantians, in particular, believe that persons must be treated as ends in themselves and never merely as means.

Suicide, in Kant’s view, uses oneself merely as a means (by giving up one’s own life) to avoid pain and suffering. This, in his view, debases one’s humanity.

A right to die?

Do you think that the terminally ill should have a right to die? Do you think that an individual who has no hope of recovery should have the right to decide how and when to end his or her life?

A right to die?

It can be argued that the right to die is an integral part of our right to control our own lives.

However, euthanasia is not a completely autonomous act or personal decision; it requires the assistance of another person.

A right to die?

We may have a right to do whatever we like, including ending our own lives.

However, even if we have a right to die, it does not mean that doctors have a duty to kill us (or help us to commit suicide) – no doctors can be forced to help patients who want euthanasia.

A right to die?

Apart from that, the decision to die by euthanasia will affect other people such as our family and friends, and we must balance the consequences for them against our rights.

Arguments against voluntary euthanasia

The main arguments against voluntary euthanasia are:

1. the argument from the intrinsic wrongness of killing

2. the argument from the integrity of the medical profession

3. the argument from potential abuse (i.e. the slippery-slope argument)


One objection to euthanasia invokes the ‘sanctity of life’ principle which argues that all killing is morally wrong.

Human life is sacred and valuable intrinsically because it is a gift from God. Deliberately shortening life is against God’s will. Only God should determine the time of death.


The deliberate taking of human life should be prohibited except in self-defense or the legitimate defense of others.

‘Thou shalt not kill’ and ‘Man should not play God’ are typical objections to euthanasia based on religious faith.


Counterargument [1]: In a free, democratic society, we do not use the law to enforce the religious views held by some people on others who do not share these views. A government which respects the right of its citizens to choose their own religious values cannot use the law to enforce such views.


Counterargument [2]: For those who believe that all matters of life and death must be decided by God, to use medicine to keep a sick person from dying is playing God. If playing God simply means doing what will affect the chances of life and death, then a lot of responsible social action does exactly that (e.g. giving aid to starving children).


Counterargument [3]: In the euthanasia debate, the use of the term ‘killing’ should be avoided because it usually refers to taking a person’s life against his or her will. But as far as voluntary euthanasia is concerned, this is clearly not the case.


Counterargument [4]: The trouble with the sanctity of life principle is that it implies that every human being should be kept alive as long as possible, and that is a proposition few thoughtful people would accept. Most would agree, for example, that it is pointless to keep alive patients in an irreversible coma or a persistent vegetative state.


Opponents to euthanasia point out that depression is very often a contributing factor in the desire for hastened death.

Clearly, if a patient is depressed or suffering from a mental disturbance, therapy and counseling – not euthanasia – should be recommended.


There is also the justifiable fear that some elderly patients might be pressured by family, friends, government, health care providers, social workers or by the example of other terminally ill patients, to choose euthanasia.


For the elderly, the right to die may become a duty to die.

The old and ill often feel themselves to be an unwelcome burden on their children. If euthanasia has become a widely accepted option, they may feel under pressure to ask for it.


Counterargument: It is a mistake to think that if euthanasia is strictly prohibited no such tragedies will occur. The sick will continue occasionally to attempt suicide in ways which are neither painless to themselves or others.


Another objection to euthanasia is that there is always the possibility of an incorrect diagnosis or the discovery of a treatment that will permit either survival or recovery.


Allowing euthanasia undermines the commitment of doctors and nurses to saving lives and discourage the search for new cures and treatments for the terminally ill.


Besides, asking doctors to abandon their duty to preserve human life could damage the doctor-patient relationship.

Patients could become distrustful of their doctors’ efforts and intentions, thinking their doctors would rather ‘kill them off’ than take responsibility for them.


Counterargument: If euthanasia is restricted to cases in which it is truly voluntary, then no patient should fear getting it unless he or she has voluntarily requested it. Patients’ trust of their physicians could be increased, not eroded, by knowledge that physicians will provide aid in dying only when they ask for it.


Opponents to euthanasia also draw attention to the extraordinary development of palliative care and pain control in recent years as a more positive and safer response to patients’ suffering.


Counterargument: There are indeed drugs which, if properly administered, can control pain. But there are other forms of distress such as the terror of breathlessness, uncontrollable vomiting, paralysis, incontinence, inability to swallow and sheer weakness and helplessness which cannot always be adequately controlled.

The slippery-slope argument One of the main arguments

against legalizing euthanasia is the ‘slippery slope’ argument.

Critics of euthanasia claim that legalizing voluntary euthanasia will lead to a slippery slope effect, resulting eventually in non-voluntary or even involuntary euthanasia.

The slippery-slope argument They argue that if we allow

voluntary euthanasia, then we will be authorizing doctors and nurses to sometimes kill their patients.

Once medical professionals are making decisions about whose life is worth living and whose life is not, then over time our commitment to protecting innocent life will inevitably weaken.

The slippery-slope argument In other words, permitting

voluntary euthanasia would weaken society’s prohibition of intentional killing, and thereby undermine the safeguards against non-voluntary or involuntary euthanasia.

Thus, in order to prevent these undesirable practices from occurring, we need to resist taking the first step.

The slippery-slope argument

Slippery slope arguments have been used by conservatives and traditionalists to oppose all sorts of social change.

But is there sufficient evidence for the slippery-slope argument against euthanasia?

The slippery-slope argument Some people think that

euthanasia should not be allowed because it could be abused and used as a cover for the murder of innocent people.

For example, the horrors that characterized the Nazi regime’s attempt to weed out the unfit had given euthanasia a bad name.


The Nazi practice of ‘euthanasia’ – the killing about 100,000 disabled people on the grounds that they had ‘lives not worth living’ – has been regarded by some as an example of how the removal of restrictions against killing can result in mass murder.


Counterargument [1]: In Nazi German, doctors took the lives of tens of thousands of their fellow citizens on orders from the government. These unfortunate people were neither terminally ill nor in pain. The murder of these people was thinly disguised as ‘euthanasia’.


Counterargument [2]: The Nazi program of ‘euthanasia’ was neither voluntary nor based on compassion; it was, rather, motivated by the desire to preserve the purity of the German race, and hence was the result of a vicious and racist ideology.


For a contemporary example, many scholars focus their attention on the Netherlands, where the criteria of legalized euthanasia had been formalized since the 1980s.

Some of them see the Dutch experience as evidence for the slippery slope effect.


Statistics showed that in the Netherlands, families requested euthanasia more often than patients; and some studies there too showed that some elderly people feared their lives would be ended without their consent.

The slippery-slope argument However, more recent studies in the

Netherlands found no evidence that legalizing voluntary euthanasia has had any serious bad consequences.

Researchers conclude that, generally speaking, [1] abuse of the Dutch euthanasia system is rare, and [2] no slippery slope effect has occurred.


Suppose slippery-slope evidence did suggest that some patients would be abused, how should this weigh against the freedoms of other patients to make specific end-of-life choices?

The slippery-slope argument Just because a practice can be

abused does not entail that it should not be used at all. Knives, cars, and drugs can be abused, but that does not mean they should be outlawed.

The abuses envisioned in slippery-slope arguments can be prevented by strict legal guidelines, like those currently used in the Netherlands.


The legal guidelines for euthanasia in the Netherlands include:

1.The patient must face a future of unbearable, interminable suffering.

2.The request to die must be voluntary and well-considered.


3. The doctor and patient must be convinced there is no other solution.

4. A second medical opinion must be obtained and life must be ended in a medically appropriated way.

Non-voluntary and involuntary euthanasia A non-voluntary decision about

death refers to cases in which the decision is not made by the person who is to die. Such cases would include situations where, because of age, mental impairment, or unconsciousness, patients are not competent to give informed consent to life-or-death decisions and where others make the decision for them.

Non-voluntary and involuntary euthanasia

In those instances where the patient is not able to communicate wishes, medical staff and family are faced with a dilemma.

For example, this may happen when a patient has entered a persistent vegetative state without having expressed their intentions concerning end-of-life treatment.


The family may seek to exercise ‘substituted judgment’ and, on the basis of statements the dying person made in the past, request the withdrawal of life support.

Otherwise, such a person may be kept alive by medications and gastric tube feeding for many years.


In these cases, family members or relatives try to make a decision for the patient according to what the patient would choose or in the best interest of the patient.

Some hospitals have established ‘ethics committees’ to provide guidance on such matters.


Involuntary euthanasia occurs when patients are killed against their will or without their consent.

This kind of euthanasia is almost always considered wrong and is rarely debated.


Most people tend to equate involuntary euthanasia with murder, but is it possible to conceive of cases where the killing would count as being for the benefit of the person who dies?

Active vs. passive euthanasia

In active euthanasia, death is brought about by a physician’s act, for example, when a person is killed by a lethal injection.

In passive euthanasia, death is the result of withholding or withdrawal of treatment.

Active vs. passive euthanasia In active euthanasia, the proximate

cause of death is the physician’s act. But in passive euthanasia, the proximate cause of death is the patient’s disease, not the physician’s act.

Some regard the difference as one between killing as an act of commission, and letting die as an act of omission.


The distinction between active and passive euthanasia is an important one because some people who reject active euthanasia do accept passive euthanasia as a practice that provides benefits to the dying person without violating ethical standards or religious values.

Active vs. passive euthanasia Opponents to active euthanasia

think that the practice is wrong because they believe that taking a person’s life under all circumstances is morally impermissible.

On the other hand, it is believed that no one has to take direct responsibility for a person’s death in the case of passive euthanasia.


James Rachels, however, argues that there is no moral difference between active and passive euthanasia.

He uses the example of Smith and Jones to prove this point.


Smith stands to gain a large inheritance if anything should happen to his 6-year-old cousin. One evening while the child is taking his bath, Smith sneaks into the bathroom and drowns the child, and then arranges things so that it will look like an accident.

Active vs. passive euthanasia Jones also stands to gain if anything

should happen to his 6-year-old cousin. Like Smith, Jones sneaks in planning to drown the child in his bath. But as he enters the bathroom Jones sees the child slip, hit his head, and fall face-down in the water. Jones watches all this happen without doing anything, and the child drowns all by himself accidentally.


Is Jones’ behavior, Rachels asks, any less reprehensible than Smith’s?

If the answer is ‘no’, then we must conclude that the difference between killing and letting die does not really make a moral difference.


Rachels: “If one simply withholds treatment, it may take the patient longer to die, and so he may suffer more than he would if more direct action were taken and a lethal injection given.”


“…once the initial decision not to prolong his agony has been made, active euthanasia is actually preferable to passive euthanasia, rather than the reverse… the process of being ‘allow to die’ can be relatively slow and painful, whereas being given a lethal injection is relatively quick and painless.”

Active vs. passive euthanasia If death is the inevitable outcome,

there are no morally relevant differences between not providing the treatment and taking active steps to end life.

Taking active steps to end a patient’s life in a quick and painless manner may be the morally right thing to do because unnecessary suffering can be avoided.


The reason why killing is normally a great wrong is that dying is normally a great harm. But if it is in the best interest of a patient to die now rather than suffer a prolonged and painful dying process, then killing is no longer a wrong.

Physician-assisted suicide Assisted suicide usually refers to cases

where people who want to die need help to kill themselves and ask for it.

In physician-assisted suicide, the physician does not directly cause the patient’s death but enables the patient to choose the time and circumstances of his or her own death, usually by prescribing a lethal dose of drugs.

Physician-assisted suicide

The main difference between physician-assisted suicide and euthanasia lies in who performs the last causal act leading to death.

In the case of physician-assisted suicide it is the patient; in the case of euthanasia it is the physician.

Physician-assisted suicide Without the assistance of their

doctors, patients can choose to die by refusing food and water. They will die more slowly than with physician-assisted suicide but die they will.

Advocates of physician-assisted suicide argue that alternatives should be provided so that patients need not choose this unpleasant way of dying.


Arguments against physician-assisted suicide include considerations such as the possibility of discovery of cures, the dangers of mistaken diagnosis, the difficulties of knowing whether the patient asking for it is rational, the dangers of patients being coerced by others, and so on.


Is it morally wrong to help another person commit suicide?

End-of-life care

We are getting better at providing effective palliative care, and hospice care is more widely available.

Because of advances in palliative care and mental health treatment, there is no reason any person should ever feel they are suffering intolerably, whether it is physical or mental suffering or both.

End-of-life care

Palliative care is physical, emotional and spiritual care for a dying person when cure is not possible. It provides relief from pain and suffering and thereby offers an alternative to euthanasia.

Good palliative or hospice care has the goal of helping the patient to live each day as well as possible.

End-of-life care

Advocates of palliative and hospice care emphasize the importance of reducing human suffering.

Palliative management of suffering is believed to substantially decrease the number of requests for both euthanasia and physician-assisted suicide.

End-of-life care

According to this view, palliative and hospice care – including excellent pain and symptom management and psychosocial support for patients and families – should be part of the standard of care for all severely ill patients.

End-of-life care

A major study in cancer patients found that people who receive early palliative care choose less chemotherapy, spend less time in hospital, and start hospice care earlier.

As a result, they have less suffering, lower cost, and they live 25 percent longer on average.

Documents

Euthanasia. In this lecture… General overview Arguments for voluntary euthanasia A right to die? Arguments against voluntary euthanasia The