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Centre Of Bioethical Research & Analysis (COBRA) Resources:
Cobra Issue Guides

Euthanasia

The COBRA Issue Guide on Euthanasia is intended as a brief introduction and not a comprehensive overview of the topic.  If you wish to learn more about the ethical theory and arguments involved in the issue of Euthanasia, we suggest you begin with our recommended readings below.

Definitions and Distinctions

Euthanasia: the intentional bringing about of the death of a patient, either by killing her, or by letting her die, for the patients own sake (i.e. to prevent further pain or suffering).  From the Greek, meaning 'good death'.

Active v. Passive Euthanasia

Active euthanasia is carried out through some ACT of killing, for example, administering a lethal injection.

Passive euthanasia is carried out by FAILING to perform some act that would, if performed, have extended the life of the patient.

While active euthanasia is illegal in most jurisdictions in most countries, passive euthanasia is permitted in some forms in most countries.  Active euthanasia is permitted in a limited form - as physician-assisted suicide - in Oregon, US under the Death with Dignity Act (2007) and - in a broader form - in the Netherlands under the Termination of Life on Request and Assisted Suicide (Review of Procedures) Act (2002). 

Both these forms of euthanasia that have been legislated for (in Oregon and the Netherlands) are voluntary.  See the next section for more on this aspect of euthanasia.

Voluntary, Involuntary and Non-voluntary Euthanasia

Voluntary euthanasia is where the patient is (a) sufficiently informed and competent to request or consent to it and (b) does in fact request or consent to it.

Involuntary euthanasia is where the patient is competent but does not request or consent to euthanasia. Either she refuses euthanasia and her views are overridden, or she doesn't express an opinion about it and is not consulted.

Non-voluntary euthanasia involves euthanasia of a patient who is either not in a position to have, or not in a position to express, any views on the matter.

The following arguments for and against euthanasia assume that euthanasia is always voluntary

Arguments for permitting euthanasia

• Autonomy: the idea that we should be able to exercise control over our own life and death.
  
  
• Beneficence: the idea that we should prevent suffering wherever we can.

The arguments for permitting to euthanasia can vary according to the type of euthanasia involved. We provide some general arguments here and recommend further reading for a more detailed understanding of the arguments.

Autonomy is a significant biomedical principle (as well as a philosophical concept), in which the patient is central in decision-making with regard to their care.  If we accept that competent individuals can make decisions about what treatment they will have, we must also accept that they can decide what treatment they will not have.  This allows for passive euthanasia, whereby the patient (through a DNR or other more expansive advance directive) can dictate what treatments they want or do not want.  The autonomous choice of the patient may not be sufficient alone to justify the active involvement of others (e.g. such as nurses or physicians) in their death, but the wishes of the patient should be taken very seriously.

Beneficence is another important biomedical principle, which requires health care professionals to always act in the best interests of patients, and minimise suffering to that end.  If the only way to minimise or alleviate serious suffering is to end life, should this not also be required of the health care professional?  Furthermore, if we concede that active euthanasia can be less cruel (i.e. quicker) than passive euthanasia, to be consistent we must hold either (a) that neither active nor passive euthanasia is ever permissible, or (b) that both active and passive euthanasia can sometimes be permissible.

Arguments against euthanasia

• Killing is an act that is wrong in itself.
  
  
• Slippery slope arguments: if we allow any type of euthanasia, all sorts of nasty things might follow, e.g. involuntary euthanasia, or 'ageism'. A related argument suggests that euthanasia undermines our commitment to improving the lives of the terminally ill.
  
  
• Professional Integrity: the ethical tradition of medicine is to 'do no harm' and often seen as committed to promoting life. As euthanasia can be interpreted as assisting death, it seems to contradict the nature of medicine itself.
  
  
• The fallibility of professionals poses risks to the lives of innocent and healthy patients if euthanasia is permitted, i.e. that physicians can and will make mistakes in diagnosis, prognosis and treatment that could undermine the valid justifications f or euthanasia.
  

Our society does not always view killing as an act that is wrong in itself.  If this were the case, killing would never be morally permissible but we hold that some acts of killing are morally justified, e.g. killing another human in self-defence, killing an animal that is suffering.  Could killing to ease the suffering of a terminally ill human being be seen as a legitimate exception to the prima facie (or generally accepted) principle that killing is morally wrong?

Slippery slope arguments arise whenever a new practice, that challenges our moral intuitions, is proposed.  However, they are not always justified often involving a 'non sequitur', whereby what is suggested does not logically follow.  It is not necessarily the case that permitting voluntary euthanasia will lead to involuntary euthanasia as a cost-saving measure in hospitals or a devaluing of life, the elderly or the terminally ill in society.

Similarly, the nature of the health care profession is not necessarily compromised by the practice of euthanasia.  A holistic view of care extends to limiting suffering in death as well as in life.

While physicians and other health care professionals are undoubtedly fallible, strict and appropriate regulation of the practice of voluntary euthanasia would prevent the death of healthy patients.  As such, the regulation and restrictions imposed on the practice of euthanasia are an ethical issue, but not necessarily an ethical problem.

Beauchamp and Childress

Beachamp and Childress argue that "We need to reconceive certain forms of assisting in dying as part of the responsibility of caring for a patient".

They believe that, if the following conditions are met, then physician assistance in dying can be justified:

1. A voluntary request by a competent patient.

2. An ongoing patient-physician relationship.

3. Mutual and informed decision-making by patient and physician.

4. A supportive, yet critical and probing environment of decision-making.

5. A considered rejection of alternatives.

6. Structured consultation with other parties in medicine.

7. A durable preference for death expressed by the patient.

8. Use of means that is as painless and comfortable as possible.

In principle, these conditions could be operative while everything was being done to ensure that requests for assistance were unnecessary.

 

Further Reading

Beachamp, T., & Childress, J., Principles of Biomedical Ethics, Oxford University Press, 1994. pp. 226-249.

Death with Dignity Act (2007), Oregon - Reports and surveys on implementation. All available on-line here.

Glover, J., Causing Death and Saving Lives, Penguin, 1990.

Rachels, J., "Active and Passive Euthanasia" in Singer, P., (ed), Applied Ethics, Oxford University Press, 1986.

Termination of Life on Request and Assisted Suicide Act (2002), the Netherlands - FAQs document available from the Ministry for Foreign Affairs here, and the Ministry of Health, Welfare and Sport has more general information here.

Documentary

Terry Pratchett: Choosing to Die: Covering the deep emotional insights into people's personal journey to the Dignitas Clinic in Switzerland to receive assisted deaths. Terry Pratchett was diagnosed with Alzheimer's in 2008, and investigates the procedures a person has to go through to end their own life through assisted death, as a possibility before his own illness gets worse. The documentary throws up a wide-range of personal, ethical, and societal questions and challenges about euthanasia.

    

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