voluntary euthanasia case study

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Personal Health

When Patients Choose to End Their Lives

For some, the decision to die is more complicated than a wish to reduce pain.

By Jane E. Brody

At a time when so many are dying against their will, it may seem out of sync to discuss the option of having a doctor help people end their lives when they face intolerable suffering that no treatment can relieve.

It’s less a question of uncontrollable physical pain, which prompts only a minority of requests for medical aid in dying, than it is a loss of autonomy, a loss of dignity, a loss of quality of life and an inability to engage in what makes people’s lives meaningful.

Intractable suffering is defined by patients, not doctors. Patients who choose medical aid in dying want to control when they die and die peacefully, remaining conscious almost to the very end, surrounded by loved ones and able to say goodbye.

Currently, nine states and the District of Columbia allow doctors to help patients who meet well-defined criteria and are on the threshold of dying choose when and how to end their lives. The laws are modeled after the first Death with Dignity Act , passed in Oregon in 1997.

A similar law has been introduced repeatedly, and again this January, in New York . Last year, Maryland came within one vote of joining states that permit medical aid in dying. Diane Rehm, the retired National Public Radio talk show host, says in a new film on the subject , “Each of us is just one bad death away from supporting these laws.”

Most people who seek medical aid in dying would prefer to live but have an illness that has in effect stripped their lives of meaning. Though often — and, proponents say, unfortunately — described as “assisted suicide,” the laws hardly give carte blanche for doctors to give people medication that would end their lives quickly and painlessly. The patient has to be terminally ill (usually with a life expectancy of less than six months), professionally certified as of sound mind, and able to self-administer the lethal medication without assistance. That can leave out people with advanced dementia or, in some cases, people with severe physical disabilities like those with amyotrophic lateral sclerosis (A.L.S., or Lou Gehrig’s disease).

A desire to broaden access to medical aid in dying prompted Joe Fab, a director and writer, to create the film “When My Time Comes,” to air on public television starting April 8. (A free livestream of the film preview and discussion will be available on April 8, at 12:45 p.m. Eastern, at weta.org/WhenMyTimeComesFilm .) The film follows the 2020 publication of Ms. Rehm’s companion book of the same title, subtitled “Conversations About Whether Those Who Are Dying Should Have the Right to Determine When Life Should End.” Both the book and film were inspired by the protracted death in 2014 from Parkinson’s disease of John Rehm, her first husband, to whom she was married for 54 years.

Mr. Rehm, then living in Maryland, could no longer stand, feed or toilet himself, but his doctors could not legally grant his plea to help him die quickly. Instead, the only recourse he was given was to refuse all food, liquid and medication, which ended his life 10 days later.

This is still the only option doctors can legally “prescribe” for the overwhelming majority of Americans who live in the 41 states that have yet to pass a medical aid-in-dying law. The approach does indeed work, but it’s not an acceptable choice for many dying patients and their families.

Ms. Rehm said her goal is that no patient should have to suffer the indignity her husband experienced at the end of his life. She described his death as “excruciating to witness,” even though after about two days the absence of food and water is usually quite tolerable for the patient.

Dr. Jessica Nutik Zitter, a palliative care physician at Highland Hospital in Oakland, Calif., said in an interview, “The concept of medical aid in dying is gaining acceptance, but it takes a while for people to be comfortable with it. Doctors are trained to just keep adding technology to patient care regardless of the outcome, and withdrawing technology is anathema to what we’re taught.”

As a result, doctors may convince dying patients and their families to accept treatments “that result in terrible suffering,” said Dr. Zitter, author of the book “Extreme Measures: Finding a Better Path to the End of Life.” In her experience, a fear of losing control is the main reason patients request medical aid in dying, but when they have access to good palliative care, that fear often dissipates.

A third of patients who qualify for medical aid in dying do not end up using the life-ending drugs they get, she said, explaining that once given the option, they regain a sense of autonomy and no longer fear losing control. In a study of 3,368 prescriptions for lethal medications written under the laws in Oregon and Washington state, the most common reasons for pursuing medical aid in dying were loss of autonomy (87.4 percent); impaired quality of life (86.1 percent), and loss of dignity (68.6 percent).

Of course, many doctors consider medical aid in dying contrary to their training, religious beliefs or philosophy of life. Dr. Joanne Lynn, a geriatrician in Washington, D.C., who is not a supporter, said the emphasis should be on providing better care for people who are very sick, disabled or elderly.

“We should resist medical aid in dying until we can offer a real choice of a well-supported, meaningful and comfortable existence to people who would have chosen a medically assisted death,” Dr. Lynn said. “There’s currently no strong push for decency in long-term care. It’s not a real choice if a person’s alternative is living in misery or impoverishing the family.”

Barbara Coombs Lee, president emerita of Compassion & Choices, a nonprofit organization in Portland, Ore., that seeks to expand end-of-life options, said, “The core principle of medical aid in dying is self-determination for someone who is terminally ill.”

Still, Ms. Lee, the author of “Finish Strong: Putting Your Priorities First at Life’s End,” said that there are options for the majority of dying patients who still lack access to an aid-in-dying law. In addition to voluntarily refusing to eat and drink, everyone has the right to create an advance directive that stipulates the medical circumstances under which they would want no further treatment.

For example, people in the early stages of Alzheimer’s disease could specify that when they reach a certain stage — perhaps when they no longer know who they are or recognize close relatives — they do not want to be treated if they develop a life-threatening infection.

Leaving such instructions when a person is still able to give them “is a gift to the family, relieving loved ones of uncertainty,” Ms. Lee said. She suggested consulting the website compassionandchoices.org for tools that can help families who want to plan ahead.

Jane Brody is the Personal Health columnist, a position she has held since 1976. She has written more than a dozen books including the best sellers “Jane Brody’s Nutrition Book” and “Jane Brody’s Good Food Book.” More about Jane E. Brody

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• v.46(2); 2017 Feb

An Ethical Review of Euthanasia and Physician-assisted Suicide

Božidar banoviĆ.

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

Veljko TURANJANIN

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

Anđela MILORADOVIĆ

3. Seniorenzentrum Röweland, Hamburg, Germany

Background:

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

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

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

Conclusion:

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

Introduction

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

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

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

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

Materials and Methods

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

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

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

Is ADE ethically acceptable?

Is PAS ethically acceptable?

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

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

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

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

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

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

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

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

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

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

Ethical considerations

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

Acknowledgments

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

Voluntary Euthanasia

The entry sets out five individually necessary conditions for anyone to be a candidate for legalized voluntary euthanasia (or, in some usages, physician-assisted suicide), outlines the moral case advanced by those in favour of legalizing voluntary euthanasia, and discusses five of the more important objections made by those opposed to the legalization of voluntary euthanasia.

1. Introduction

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

When a person carries out an act of euthanasia, he brings about the death of another person because he believes the latter's present existence is so bad that she would be better off dead, or believes that unless he intervenes and ends her life, it will become so bad that she would be better off dead. The motive of the person who commits an act of euthanasia is to benefit the one whose death is brought about. (Though what was just said also holds for many instances of physician-assisted suicide, some wish to restrict the use of the latter term to forms of assistance which stop short of the physician ‘bringing about the death’ of the patient, such as those involving mechanical means that have to be activated by the patient.)

Our concern will be with voluntary euthanasia — that is, with those instances of euthanasia in which a clearly competent person makes a voluntary and enduring request to be helped to die. There will be occasion to mention non-voluntary euthanasia -- instances of euthanasia where a person is either not competent to, or unable to, express a wish about euthanasia and there is no one authorised to make a substituted judgment (in which case a proxy tries to choose as the no-longer-competent patient would have chosen had she remained competent) — in the context of considering the claim that permitting voluntary euthanasia will lead via a slippery slope to permitting non-voluntary euthanasia. Nothing will be said here about involuntary euthanasia , where a competent person's life is brought to an end despite an explicit expression of opposition to euthanasia, beyond saying that, no matter how honourable the perpetrator's motive, such a death is, and ought to be, unlawful.

Debate about the morality and legality of voluntary euthanasia has been, for the most part, a phenomenon of the second half of the twentieth century and the beginning of the twenty first century. Certainly, the ancient Greeks and Romans did not believe that life needed to be preserved at any cost and were, in consequence, tolerant of suicide in cases where no relief could be offered to the dying or, in the case of the Stoics and Epicureans, where a person no longer cared for his life. In the sixteenth century, Thomas More, in describing a utopian community, envisaged such a community as one that would facilitate the death of those whose lives had become burdensome as a result of ‘torturing and lingering pain’. But it has only been in the last hundred years that there have been concerted efforts to make legal provision for voluntary euthanasia. Until quite recently, there had been no success in obtaining such legal provision (though assisted suicide has been legally tolerated in Switzerland for many years). However, in the 1970s and 80s a series of court cases in The Netherlands culminated in an agreement between the legal and medical authorities to ensure that no physician would be prosecuted for assisting a patient to die as long as certain guidelines were strictly adhered to (see Griffiths, et al. 1998) In brief, the guidelines were established to permit physicians to practise voluntary euthanasia in those instances in which a competent patient had made a voluntary and informed decision to die, the patient's suffering was unbearable, there was no way of making that suffering bearable that was acceptable to the patient, and the physician's judgements as to diagnosis and prognosis were confirmed after consultation with another physician. In the 1990s, the first legislative approval for voluntary euthanasia was achieved with the passage of a bill in the parliament of Australia's Northern Territory to enable physicians to practise voluntary euthanasia. Subsequent to the Act's proclamation in 1996, it faced a series of legal challenges from opponents of voluntary euthanasia. In 1997 the challenges culminated in the Australian National Parliament overturning the legislation when it prohibited Australian Territories (the Australian Capital Territory and the Northern Territory) from enacting legislation to permit euthanasia. In Oregon in the United States, legislation was introduced in 1997 to permit physician-assisted suicide after a second referendum clearly endorsed the proposed legislation. Later in 1997, the Supreme Court of the United States ruled that there is no constitutional right to physician-assisted suicide; however, the Court did not preclude individual states from legislating in favor of physician-assisted suicide. The Oregon legislation has, in consequence, remained operative and has been successfully utilised by a number of people. In November 2000, The Netherlands passed legislation to legalize the practice of voluntary euthanasia. The legislation passed through all the parliamentary stages early in 2001 and so became law. The Belgian parliament passed similar legislation in May 2002. (For a very helpful comparative study of relevant legislation see Lewis, 2007.)

With that brief sketch of the historical background in place, we now proceed to set out the conditions that those who have advocated making voluntary euthanasia legally permissible have wished to insist should be satisfied. The conditions are stated with some care so as to give focus to the moral debate about legalization. Second, we shall go on to outline the positive moral case underpinning the push to make voluntary euthanasia legally permissible. Third, we shall then consider the more important of the morally grounded objections that have been advanced by those opposed to the legalization of voluntary euthanasia.

Advocates of voluntary euthanasia contend that if a person

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

then there should be legal and medical provision to enable her to be allowed to die or assisted to die.

It should be acknowledged that these conditions are quite restrictive, indeed more restrictive than some would think appropriate. In particular, the conditions concern access to voluntary euthanasia only for those who are terminally ill . While that expression is not free of all ambiguity, for present purposes it can be agreed that it does not include the bringing about of the death of, say, victims of accidents who are rendered quadriplegic or victims of early Alzheimer's Disease. Those who consider that such cases show the first condition to be too restrictive may nonetheless accept that including them would, at least for the time being, make it far harder to obtain legal protection for helping those terminally ill persons who wish to die. The fifth condition further restricts access to voluntary euthanasia by excluding those capable of ending their own lives, and so will not only be thought unduly restrictive by those who think physician-assisted suicide a better course to follow, but will be considered morally much harder to justify by those who think health care practitioners may never justifiably kill their patients. More on this anon.

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

The third condition recognises what many who oppose the legalization of voluntary euthanasia do not, namely, that it is not only release from pain that leads people to want to be helped to die. In The Netherlands, for example, it has been found to be a less significant reason for requesting assistance with dying than other forms of suffering and frustration with loss of independence. Sufferers from some terminal conditions may have their pain relieved but have to endure side effects that for them make life unbearable. Others may not have to cope with pain but instead be incapable, as with motor neurone disease, of living without forms of life support that simultaneously rob their lives of quality.

A final preliminary point is that the fourth condition requires that the choice to die not only be voluntary but that it be made in an enduring (not merely a one-off) way and be competent. The choice is one that will require discussion and time for reflection and so should not be settled in a moment. As in other decisions affecting matters of importance, normal adults are presumed to choose voluntarily unless the presence of defeating considerations can be established. The burden of proof of establishing lack of voluntariness or lack of competence is on those who refuse to accept the person's choice. There is no need to deny that this burden can sometimes be met (e.g. by pointing to the person's being in a state of clinical depression). The claim is only that the onus falls on those who assert that a normal adult's choice is not competent.

The central ethical argument for voluntary euthanasia — that respect for persons demands respect for their autonomous choices as long as those choices do not result in harm to others — is directly connected with this issue of competence (cp. Brock, 1992) because autonomy presupposes competence. People have an interest in making important decisions about their lives in accordance with their own conception of how they want their lives to go. 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. Many people are concerned about what the last phase of their lives will be like, not merely because of fears that their dying might involve them in great suffering, but also because of the desire to retain their dignity and as much control over their lives as possible during this phase.

The technological interventions of modern medicine have had the effect of stretching out the time it takes for many people to die. Sometimes the added life this brings is an occasion for rejoicing; sometimes it drags out the period of significant physical and intellectual decline that a person undergoes in burdensome ways so that life becomes, to them, no longer worth living. There is no single, objectively correct answer as to when, if at all, life becomes a burden and unwanted. But that simply points up the importance of individuals being able to decide autonomously for themselves whether their own lives retain sufficient quality and dignity to make life worth living. Given that a critically ill person is typically in a severely compromised and debilitated state, it is, other things being equal, the patient's own judgement of whether continued life is a benefit that must carry the greatest weight, provided always that the patient is competent.

Suppose it is agreed that we should respect the autonomous choices of other people. If medical assistance is to be provided to help a person achieve her autonomously chosen goal of an easeful death (because she cannot end her own life), the autonomy of any professional who lends assistance also has to be respected. The value (or right) of self-determination does not entitle a patient to compel a medical professional to act contrary to her own moral or professional values. Hence, if voluntary euthanasia is to be legally permitted, it must be against a backdrop of respect for professional autonomy. Similarly, if a doctor's view of her moral or professional responsibilities is at odds with her patient's request for euthanasia, provision must be made for the transfer of the patient to the care of a doctor who faces no such conflict.

Opponents of voluntary euthanasia have endeavoured to counter this very straightforward moral case for the practice in a variety of ways (see, for example, Keown, 2002 and Foley .et al. , 2002). Some of the counter-arguments are concerned only with whether the moral case warrants making the practice of voluntary euthanasia legal, others are concerned with trying to undermine the moral case itself. In what follows, consideration will be given to the six most important of the counter-arguments. (For more comprehensive discussions of the ethics of medically assisted death see Keown, 2002; Biggar, 2004; and Young, 2007.)

Objection 1

It is often said that it is not necessary nowadays for anyone to die while suffering from intolerable or overwhelming pain. We are getting better at providing effective palliative care, and hospice care is more widely available. Given these considerations, some have urged that voluntary euthanasia is unnecessary.

There are several flaws in this counter-argument. First, while both good palliative care and hospice care make important contributions to the care of the dying, neither is a panacea. To get the best palliative care for an individual involves trial and error, with some consequent suffering in the process. Far more importantly, even high quality palliative care commonly exacts a price in the form of side effects such as nausea, incontinence, loss of awareness because of semi-permanent drowsiness, and so on. A rosy picture is often painted as to how palliative care can transform the plight of the dying. Such a picture is misleading according to those who have closely observed the effect of extended courses of treatment with drugs such as morphine, a point acknowledged by many skilled palliative care specialists. Second, though the sort of care provided through hospices is to be applauded, it is care that is available to only a small proportion of the terminally ill and then usually only in the very last stages of the illness (typically a matter of a few weeks). Third, and of greatest significance, not everyone wishes to avail themselves of palliative or hospice care. For those who prefer to die on their own terms and in their own time, neither option may be attractive. For many dying patients, the major source of distress is having their autonomous wishes frustrated. Fourth, as indicated earlier, the suffering that occasions a wish to end life is not always due to the pain occasioned by illness. For some, what is intolerable is their dependence on others or on machinery; for these patients, the availability of effective pain control will be quite irrelevant.

Objection 2

A second, related objection to permitting the legalization of voluntary euthanasia argues that we can never have sufficient evidence to be justified in believing that a dying person's request to be helped to die is competent, enduring and genuinely voluntary.

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

But, it might be said, what if a person is racked with pain, or mentally confused because of the measures taken to relieve her pain, and so not able to think clearly and rationally about the alternatives? It has to be agreed that a person in those circumstances who wants to die should not be assumed to have a competent, enduring and genuinely voluntary desire to die. However, there are at least two important points to make about those in such circumstances. First, they do not account for all of the terminally ill, so even if it is acknowledged that such people are incapable of agreeing to voluntary euthanasia that does not show that no one can ever voluntarily request help to die. Second, it is possible for a person to indicate, in advance of losing the capacity to give competent, enduring and voluntary consent, how she would wish to be treated should she become terminally ill and suffer intolerable pain or loss of control over her life. ‘Living wills’ or ‘advance declarations’ are legally useful instruments for giving voice to people's wishes while they are capable of giving competent, enduring and voluntary consent, including to their wanting help to die. As long as they are easily revocable in the event of a change of mind (just as ordinary wills are), they should be respected as evidence of a well thought out conviction. It should be noted, though, that any request for voluntary euthanasia or physician-assisted suicide will not at present be able lawfully to be implemented outside of The Netherlands, Belgium and Oregon.

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

Objection 3

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

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

According to the doctrine of double effect, it is, for example, permissible to alleviate pain by administering drugs such as morphine, knowing that doing so will shorten life, but impermissible to give an overdose or injection with the direct intention of terminating a patient's life (whether at her request or not). This is not the appropriate forum to give full consideration to this doctrine. However, there is one vital criticism to be made of the doctrine concerning its relevance to the issue of voluntary euthanasia.

On one plausible reading, the doctrine of double effect can be relevant only where a person's death is an evil or, to put it another way, a harm . Sometimes the notion of ‘harm’ is understood simply as damage to a person's interest whether consented to or not. At other times, it is understood, more strictly, as damage that has been wrongfully inflicted. On either account, if the death of a person who wishes to die is not harmful (because from that person's standpoint it is, in fact, beneficial), the doctrine of double effect can have no relevance to the debate about the permissibility of voluntary euthanasia. (For an extended discussion of the doctrine of double effect and its bearing on the moral permissibility of voluntary euthanasia see McIntyre, 2001.)

Objection 4

There is a widespread belief that passive (voluntary) euthanasia, in which life-sustaining or life-prolonging measures are withdrawn or withheld, is morally acceptable because steps are simply not taken which could preserve or prolong life (and so a patient is allowed to die), whereas active (voluntary) euthanasia is not, because it requires an act of killing. The distinction, despite its widespread popularity, is very unclear. (For a fuller, and very helpful, discussion, see McMahan, 2002.) Whether behaviour is described in terms of acts or omissions (a distinction which underpins the alleged difference between active and passive voluntary euthanasia), is generally a matter of pragmatics rather than anything of deeper importance. Consider, for instance, the practice (once common in hospitals) of deliberately proceeding slowly to a ward in response to a request to provide assistance for a patient subject to a ‘not for resuscitation’ code. Or consider ‘pulling the plug’ on an oxygen machine keeping an otherwise dying patient alive as against not replacing the tank when it runs out. Are these acts or omissions; are these cases of passive euthanasia or active euthanasia?

Further, the distinction between killing and letting die is unclear. Consider the case of a patient suffering from motor neurone disease who is completely respirator dependent, finds her condition intolerable, and competently and persistently requests to be removed from the respirator so that she may die. Even the Catholic Church in recent times has been prepared to agree that it is permissible, in cases like this, to turn off the respirator. But it seems odd to think that a case like this is best described as one in which the patient is allowed to die.

In rejoinder, it is sometimes said that the difference is found in the provider's intention: if someone's life is intentionally terminated she has been killed, whereas if she is no longer being aggressively treated, we can attribute her death to the underlying disease. But this is often implausible. In many cases, the most plausible interpretation of the physician's intention in withdrawing life-sustaining measures is to end the person's life. Consider the growing practice of withholding artificial nutrition and hydration when a decision has been made to cease aggressive treatment, and then see if we can generalise to cases like those of motor neurone sufferers (cf. Winkler, 1995). Many physicians would say that their intention in withholding life-sustaining artificial nutrition is simply to respect the patient's wishes. This is plausible in those instances where the patient is still able competently to ask that such treatment no longer be given (or the patient's proxy makes the request); in the absence of such a request, though, the best explanation of the physician's behaviour seems to be that the physician intends thereby to end the life of the patient. Permanently withdrawing nutrition from someone in, say, a persistent vegetative state, does not seem merely to be a matter of foreseeing that death will ensue, but, rather, one of intending their death. What could be the point of the action, the goal aimed at, the intended outcome, if not to end the patient's life? No sense can be made of the action as being intended to serve to palliate the disease, or to keep the patient comfortable, or even, in the case of a person in a permanently vegetative state, of allowing the underlying disease to carry the person off. The loss of brain activity is not going to kill the person: what is going to kill the patient is the act of starving her to death.

Similarly, giving massive doses of morphine far beyond what is needed to control pain, or removing a respirator from a sufferer from motor neurone disease would seem, by parallel reasoning, to amount to the intentional bringing about of the death of the person being cared for. To be sure, there are circumstances in which doctors can truthfully say that the actions they perform, or omissions they make, lead to the deaths of their patients without them intending that those patients should die. If, for instance, a patient refuses life-prolonging medical treatment because she considers it useless, it might reasonably be said that the doctor's intention in complying is simply to respect the patient's wishes. The point is that there are many other circumstances in which it seems highly stilted to claim, as some doctors do, that the intention is anything other than the intention to bring about death — and hence, by an intention-based definition of killing, that the acts and ommissions in question count as killings.

This itself is a problem only if killing, in medical contexts, is always morally unjustified — a premise that underwrites much of the debate surrounding this fourth objection. But this underlying assumption is open to challenge (and has been challenged in e.g. Rachels, 1986, chs. 7, 8; Kuhse, 1987). For one thing, there may well be cases in which killing, where requested, is morally better than allowing a death — namely, where the latter would serve only to prolong the person's suffering. Further, despite the longstanding legal doctrine that no one can justifiably consent to be killed (on which more later), it surely is relevant to the justification of an act of killing that the person killed has autonomously decided that he would be better off dead.

Objection 5

It is often said that if society allows voluntary euthanasia to be legally permitted, then we will have set foot on a slippery slope that will lead us to support other forms of euthanasia, including non-voluntary euthanasia. Whereas it was once the common refrain that that was precisely what happened in Hitler's Germany, in recent decades the tendency has been to claim that experience in The Netherlands has confirmed the reality of the slippery slope. Slippery slope arguments come in various versions. One (but not the only) way of classifying them has been to refer to logical, psychological and arbitrary line versions. The common feature of the different forms is the contention that once the first step is taken on a slippery slope the subsequent steps follow inexorably, whether for logical reasons, psychological reasons, or to avoid arbitrariness in ‘drawing a line’ between a person's actions. (For further discussion see e.g. Rachels, 1986, ch. 10; Brock, 1992, pp. 19ff; Walton, 1992).

We first consider why, at the theoretical level, none of these forms of argument appears powerful enough to trouble an advocate of the legalization of voluntary euthanasia. We then comment on the alleged empirical support from the experiences of Hitler's Germany and The Netherlands of today for the existence of a slippery slope beginning from the legalization of voluntary euthanasia.

There is nothing logically inconsistent in supporting voluntary euthanasia while rejecting non-voluntary euthanasia as morally inappropriate. Some advocates of voluntary euthanasia, to be sure, will wish also to lend their support to some acts of non-voluntary euthanasia (e.g. for those in persistent vegetative states who have never indicated their wishes about being helped to die, or for certain severely disabled infants for whom the outlook is hopeless). Others will think that what may be done with the consent of the patient sets a strict limit on the practice of euthanasia. The difference is not one of logical acumen; it has to be located in the respective values of the different supporters (e.g. whether a person's self-determination or her best interests should prevail).

It is also difficult to see the alleged psychological inevitability of moving from voluntary to non-voluntary euthanasia. Why should it be supposed that those who value the autonomy of the individual and so support provision for voluntary euthanasia will, as a result, find it psychologically easier to kill patients who are not able competently to request assistance with dying? What reason is there to believe that they will, as a result of their support for voluntary euthanasia, be psychologically driven to practise non-voluntary euthanasia?

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

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

Since the publication of the Remmelink Report in 1991 into the medical practice of euthanasia in The Netherlands, it has frequently been said that the Dutch experience shows that legally protecting voluntary euthanasia is impossible without also affording protection to the non-voluntary euthanasia that will come in its train. Serious studies carried out by van der Maas, et al., 1991, and van der Wal, et al., 1992a and 1992b, seem to indicate, though, that the worry is unfounded; more recently, a second nation-wide investigation of physician-assisted dying in the Netherlands carried out in 1995 found no evidence of a descent down a slippery slope toward ignoring people's voluntary choices to be assisted to die (see van der Maas, et al., 1996; van der Wal, et al., 1996; Griffiths, et al., 1998). A third study, which confirmed the earlier results, was reported in 2003 (see Onwuteaka-Philipsen, et al., 2003). More specifically, of those terminally ill persons assisted to die (initially under the agreement between the legal and medical authorities and subsequently under legislation), a little over one-half were clearly cases of voluntary euthanasia as it has been characterised in this article; of the remainder, the vast majority of cases were of patients who at the time of the assisted death were no longer competent. For the overwhelming majority of the latter group, the decision to end life was taken only after consultation between the doctor(s) and family members; further, according to the researchers, most of the cases should be seen as fitting the practice, common in other countries where voluntary euthanasia is not legally tolerated, of giving large doses of opioids to relieve pain in the knowledge that this will also end life. It is true that in a very few cases, there was consultation only with other medical personnel, rather than with relatives; the researchers point out that this was due to the fact that families in The Netherlands strictly have no final authority to act as surrogate decision-makers for incompetent persons.

That there have only been a handful of prosecutions of Dutch doctors for failing to follow agreed procedures (Griffiths, et al., 1998), that none of the doctors prosecuted has had a significant penalty imposed, and that the Dutch public have regularly reaffirmed their support for those agreed procedures suggests that, contrary to the claims of some critics, the legalization of voluntary euthanasia has not increased the incidence of non-voluntary euthanasia. Indeed, such studies as have been published about what happens in other countries, like Australia (see Kuhse, et al. , 1997), where no legal protection is in place, suggest that the pattern in The Netherlands and elsewhere is quite similar. Some have argued, further, that there may be more danger of the line between voluntary and non-voluntary euthanasia being blurred if euthanasia is practised in the absence of legal recognition, since there will be no transparency or monitoring.

None of this is to suggest that there is no need to put in place safeguards against potential abuse of legally protected voluntary euthanasia. This is particularly important for those who have become incompetent by the time decisions need to be taken about whether to assist them to die. Further, it is, of course, possible that the reform of any law may have unintended effects. However, if the arguments given above are sound (and the Dutch experience, along with the more limited experience in the State of Oregon and in Belgium, is not only the best evidence we have that they are sound, but the only relevant evidence), that does not seem very likely.

Moreover, it is plausible to think that the fundamental basis of the right to decide about life-sustaining treatment -- respect for a person's autonomy — has direct relevance to voluntary euthanasia as well. Extending the right of self-determination to cover cases of voluntary euthanasia would not, therefore, amount to a dramatic shift in legal policy. No novel legal values or principles need to be invoked. Indeed, the fact that suicide and attempted suicide are no longer criminal offences in many jurisdictions indicates that the central importance of individual self-determination in a closely analogous setting has been accepted. The fact that assisted suicide and voluntary euthanasia have not yet been widely decriminalised is perhaps best explained along the lines that have frequently been offered for excluding consent of the victim as a justification for an act of killing, namely the difficulties thought to exist in establishing the genuineness of the consent. But, the establishment of suitable procedures for giving consent to assisted suicide and voluntary euthanasia would seem to be no harder than establishing procedures for competently refusing burdensome or otherwise unwanted medical treatment. The latter has already been accomplished in many jurisdictions, so the former should be achievable as well.

Suppose that the moral case for legalizing voluntary euthanasia does come to be judged as stronger than the case against legalization and voluntary euthanasia is made legally permissible. Should doctors take part in the practice? Should only doctors perform voluntary euthanasia? The proper administration of medical care is not at odds with an understanding of it that both promotes patients' welfare interests and respects their self-determination. It is these twin values that should guide medical care, not a commitment to preserving life at all costs, or preserving life without regard to whether patients want their lives prolonged when they judge that life is no longer of benefit or value to themselves. Many doctors in The Netherlands and, to judge from available survey evidence, in other Western countries as well, see the practice of voluntary euthanasia as not only compatible with their professional commitments but also with their conception of the best medical care for the dying. That being so, they should not be prohibited by law from lending their professional assistance to those competent, terminally ill persons for whom no cure is possible and who wish for an easy death.

• Biggar, N., 2004, Aiming to Kill: The Ethics of Suicide and Euthanasia , London: Darton, Longman and Todd.
• Brock, D., 1993, “Voluntary Active Euthanasia”, Hastings Center Report , 22/2: 10-22.
• Burleigh, M., 1994, Death and Deliverance: Euthanasia in Germany c. 1900-1945 , Cambridge: Cambridge University Press.
• Commission on the Study of Medical Practice Concerning Euthanasia: Medical Decisions Concerning the End of Life , The Hague: SdU, 1991. (This is known as ‘The Remmelink Report’.)
• Foley, K. and H. Hendin, (eds.), 2002, The Case Against Assisted Suicide: For the Right to End-of-Life Care , Baltimore: The Johns Hopkins University Press.
• Griffiths, J., A. Bood, and H. Weyers, 1998, Euthanasia and Law in The Netherlands , Amsterdam: Amsterdam University Press.
• Keown, J., 2002, Euthanasia, ethics and public policy: an argument against legalization , New York: Cambridge University Press.
• Kuhse, H., 1987, The Sanctity-of-Life Doctrine in Medicine: A Critique , Oxford: Clarendon Press.
• Kuhse, H., P. Singer, P. Baume, A. Clark, and M. Rickard, 1997, “End-of-Life Decisions in Australian Medical Practice”, The Medical Journal of Australia , 166: 191-196.
• Lewis, P., 2007, Assisted Dying and Legal Change , Oxford: Oxford University Press.
• McIntyre, A., 2001, “Doing Away With Double Effect”, Ethics , 111: 219-255.
• McMahan, J., 2002, The Ethics of Killing: Problems at the Margins of Life , New York: Oxford University Press.
• Onwuteaka-Philipsen, B.D., A. van der Heide, D. Koper, I. Keij-Deerenberg, J.A.C. Rietjens, M.L. Rurup, A.M. Vrakking, J.J. Georges, M.T. Muller, G. van der Wal and P.J. van der Maas, 2003, “Euthanasia and Other End-of-Life Decisions in The Netherlands in 1990, 1995 and 2001”, The Lancet , 362: 395-399.
• Rachels, J., 1986, The End of Life: Euthanasia and Morality , Oxford: Oxford University Press.
• van der Maas, P.J., J.J.M. van Delden, L. Pijnenborg, C.W.N. Looman, 1991, “Euthanasia and other Medical Decisions Concerning the End of Life”, The Lancet , 338: 669-674.
• van der Maas, P.J., G. van der Wal, I. Haverkate, C.L.M. de Graaf, J.G.C. Kester, B.D. Onwuteaka-Philipsen, A. van der Heide, J.M. Bosma and D.L. Willems, 1996, “Euthanasia, Physician-Assisted Suicide, and other Medical Practices Involving the End of Life in the Netherlands, 1990-1995”, The New England Journal of Medicine , 335: 1699-1705.
• van der Wal, G., J.Th.M. van Eijk, H.J.J. Leenen, C. Spreeuwenberg, 1992a, “Euthanasia and Assisted Suicide, I: How Often is it Practised by Family Doctors in the Netherlands?”, Family Practice , 9: 130-134.
• van der Wal, G., J.Th.M. van Eijk, H.J.J. Leenen, C. Spreeuwenberg, 1992b, “Euthanasia and Assisted Suicide, II: Do Dutch Family Doctors Act Prudently?”, Family Practice , 9: 135-140.
• van der Wal, G., P.J. van der Maas, J.M. Bosma, B.D. Onwuteaka-Philipsen, D.L. Willems, I. Haverkate and P.J. Kostense, 1996, “Evaluation of the Notification Procedure for Physician-Assisted Death in the Netherlands”, The New England Journal of Medicine , 335: 1706-1711.
• Winkler, E., 1995, “Reflections on the State of Current Debate Over Physician-Assisted Suicide and Euthanasia”, Bioethics , 9: 313-326.
• Young, R., 2007, Medically Assisted Death , Cambridge: Cambridge University Press.
• Euthanasia and Assisted Suicide: Seven Reasons Why They Should Not Be Legalized , authored by Luke Gormally (Linacre Centre for Healthcare Ethics)
• Voluntary Euthanasia Society of the Netherlands
• Euthanasia and End-of-Life Decisions (Ethics Updates, L. Hinman, University of San Diego)

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Euthanasia and the case of Daniel James

October 18, 2008.

The case of Daniel James raises important issues concerning the right to die.  What are the ethical principles we might invoke in this case? And should Daniel’s parents be prosecuted for assisting him? Go to the CASE STUDIES section under TOPICS for a powerpoint case study of this case.

On September 12 th Daniel James, aged 23, travelled to Switzerland with his parents and killed himself by lethal injection in a suicide clinic run by Dignitas, an organisation that exists to facilitate voluntary euthanasia .

 Daniel was the youngest British person of the 100 people who have taken their own life by this route.

 In March 2007, during a practice session at Nuneaton Rugby Club, the U-16 England International was paralysed from the chest downwards when a scrum collapsed on top of him, breaking his neck.  His mother explained: “he couldn’t walk, had no hand function, and had constant pain in his fingers.  He was incontinent, suffered uncontrollable spasms in his legs and upper body, and needed 24-hour care”.

His parents supported his decision to die: “Daniel continually expressed his wish to die and was determined to achieve this.  He was not prepared to live a second-class existence…his death was, no doubt, a welcome relief from the prison his body had become and the day-to-day fear and loathing of his living existence”.

 Although no-one has ever been successfully prosecuted for assisting suicide in the UK, the police investigated the case and sent a file to the Crown Prosecution Service.  Did the parents do the right thing in assisting Daniel to die?

A Utilitarian  might argue that they did.  Utilitarians seek to maximise happiness or pleasure or preferences of individuals.  Daniel clearly chose to die: no-one forced him.  His life had become intolerable, we are told.  And parents and friends were consulted, and so presumably, though sad, were happy that his wishes were fulfilled or they would not have driven him to Switzerland.

And yet something about this case leaves us uneasy.  Even from the Utilitarian standpoint, can we be sure Daniel’s life wouldn’t have improved?  Part of the problem with Utilitarian ethics is that we cannot be sure of the consequences. We aren’t God: we cannot precisely predict the future.   Daniel’s physiotherapist expressed deep shock: “I was totally shocked.  Daniel was improving and still had the use of his arms and hands.  He could feed and dress himself…most paralysed people do improve over time…perhaps two or three years after the accident. It was early days for Daniel”.  So not only are we uncertain of the future consequences, in this case Daniel’s closest carer suggests he would have improved.  How can we be sure he wasn’t simply suffering from depression, which might have lifted as his condition improved?

 To a natural law theorist (like Aquinas) suicide is an absolute wrong because it breaks the intrinisic relationship between the primary good of self-preservation and the sanctity or sacredness of life.  If you are a Christian  natural law theorist, you might go further: God knit us together in our mother’s womb (Psalm139:13) and his gift of life is something only God can take away.  It is our job to minimise suffering, not to take the role of God in ending life.  Such an action is to repeat the sin of Eden, where Adam and Eve usurped the power of God by eating of the tree of the knowledge of good and evil.

  Kantian ethics would seem to provide a more complex answer.  Kantian ethics has three  main strengths.  It is reasonable because decisions should be universalisable.  It promotes equality because the individual is seen as morally autonomous (ie can take his or her own decisions), and it is consensual , because laws should go through a moral parliament where most people should agree.

Kant himself argued in Metaphysics of Morals   that suicide was self-contradictory as it violated the second formulation of the categorical imperative : treat people not just as a means but as an end in themselves.

“Firstly, under the head of necessary duty to oneself: He who contemplates suicide should ask himself whether his action can be consistent with the idea of humanity as an end in itself. If he destroys himself in order to escape from painful circumstances, he uses a person merely as a mean to maintain a tolerable condition up to the end of life. But a man is not a thing, that is to say, something which can be used merely as means, but must in all his actions be always considered as an end in himself. I cannot, therefore, dispose in any way of a man in my own person so as to mutilate him, to damage or kill him”.

 Daniel’s action might be universalisable, however, according to the first formulation of the categorical imperative: act in such a way as you action could be willed as a universal law.  Would you or I want the right to do the same thing in similar situations?  Or would our moral parliament decide that we need to be protected from our depressed self in such situations, and so pass a law saying it was absolutely wrong to assist a suicide?

 Peter Baron October 18 th 2008 to make a comment please go to the front page and click on Peter Baron.  You can send me an email, and I’ll publish your comments!

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Three euthanasia cases face investigation in Netherlands

Inquiries confirmed following controversy over death of anorexic teenager

Three euthanasia cases involving women with psychiatric conditions and dementia are under investigation in the Netherlands , the Observer can reveal.

Prosecutors confirmed that the deaths, in 2017 and 2018, were being investigated for potentially breaching strict conditions in the 2002 law that allows people in the Netherlands to ask a doctor to help them die.

The confirmation comes two weeks after news organisations around the world incorrectly reported that Noa Pothoven , a 17-year-old Dutch girl with anorexia, who had been sexually abused as a child, had died through euthanasia – with even the pope tweeting that the practice was “a defeat for us all”.

Separately, in August, a Dutch doctor will be the first prosecuted for failings, in a 2016 case , in which sedatives were put in a dementia patient’s coffee and her family asked to hold her down when she struggled against the euthanasia injection.

Dutch euthanasia law requires patients to be experiencing unbearable suffering, with no prospect of improvement, and to have a voluntary, sustained wish to die; doctors must also seek a second independent opinion.

The latest report by the Dutch Regional Euthanasia Committees – which examine legal compliance in every case – shows prosecutors are investigating a doctor for failing to treat the case of a woman with “due diligence” last year. According to the report, a woman in her 70s with depression had been operated on for abdominal problems when surgeons found evidence of lung cancer. She approached her doctor, saying she was experiencing unbearable psychological suffering and wanted euthanasia. Her doctor’s colleague took on the case, but, the review committee said, failed to obtain a second opinion from an independent psychiatrist, as is required.

The two other cases, from 2017, involve a woman in her 60s with Alzheimer’s whom an independent consultant did not judge to be suffering badly enough, and another in her 80s with osteoarthritis and other problems who refused other treatment.

The investigations have raised alarm, according to Dick Bosscher of the NVVE , the organisation that campaigned for the euthanasia law. “We think doctors are holding back more, although we can’t prove it,” he said. “Last year, for the first time in years, there were fewer euthanasia cases in the Netherlands. Whether things are clear for doctors is a difficult question, as unbearable suffering is different from one person to another.”

The issue has divided doctors: last year, 450 put their names to a full-page advertisement saying they would not give a deadly injection to an incapacitated patient. One ethicist,

Berna van Baarsen, resigned from a regional euthanasia committee in protest at the growing role of advance directives for people unable to express their wishes.

Cases involving psychiatric suffering and dementia are, however, relatively rare. In 2018 there were 6,126 cases of euthanasia (compared to 6,585 in 2017): 1% involved psychiatric conditions, and 2.4% dementia. Two-thirds were requested by people with terminal cancer.

A staff member for the review committees – who did not want to be directly quoted – pointed out that a teenager with anorexia cannot simply ask for and receive euthanasia, each case is extremely nuanced, and the committees have issued detailed guidelines to doctors. In 2015, the committees reported that euthanasia accounted for 4.6% of 147,000 Dutch deaths, while 18% of people who died had palliative sedation – such as morphine – as they died.

“Euthanasia law is a constant matter of debate, and individual cases involve complex consideration,” said Axel Dees, spokesman for the health ministry, which has just launched a campaign OnAbout Palliative Care to encourage people to plan for the end of their lives. He said the government is researching a 2016 euthanasia proposal for those ineligible under current euthanasia law, but who feel their lives are “complete” – something that one member of the governing coalition, the ChristenUnie, opposes.

The debate on “complete lifers” is expected to be fierce, but pro-euthanasia campaigners say psychiatric reasons are as valid as physical ones – arguing that otherwise, people would commit suicide, as Pothoven effectively did by refusing food and drink.

Elke Swart, a spokeswoman for the End of Life Clinic – which Pothoven said refused her request for euthanasia last year – said that its focus is preserving life. “Patients say: I don’t want to die, but I cannot live,” she said. “Less than a third of euthanasia requests are granted. Most don’t fulfil the legal criteria or people see during the process – which is very intensive and can take years – reasons to stay alive. This is of course the best result.”

Swart added: “Euthanasia is the ultimate cry for mercy from someone in extreme need, and every request deserves careful consideration.”

I n the UK, Samaritans can be contacted on 116 123. In Australia, the crisis support service Lifeline is on 13 11 14. In the US, the suicide prevention lifeline is 1-800-273-8255. Other international helplines can be found at www.befrienders.org

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Non-Voluntary Euthanasia

• Policy and Ethics
• Ethical Issues
• Essays and articles

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

Advocates of legalised euthanasia usually insist that they only want voluntary euthanasia (VE) - they say they are as opposed to the taking of life without the subject's knowledge or consent, that is, non-voluntary euthanasia (NVE), as anyone else. Some do extend their advocacy to some examples of NVE, such as seriously deformed newborns (1), where consent would not be possible, but this is not usual. It is widely accepted that sufficient protection against the unwanted extension of VE to NVE would be ensured by the inclusion of legal provisions to guarantee this.

As safeguards, clauses are proposed that would require the doctor to be satisfied that the patient's request was freely made and sufficiently informed, that there was no psychological abnormality such as depression, and possibly by requiring psychiatric consultation, that more than one doctor be involved in the decision that it was medically appropriate to take life in the circumstances, and that there be adequate documentation. It is also common to find lawyers who declare that such laws would be feasible to devise, though it is less common to find actual draft laws published for discussion. In one sense, those lawyers are correct when they say such law would be possible - but they stop short of addressing the question of whether they would be safe, in practice. It is uncommon to find any analysis that assesses the effectiveness of the so-called safeguards.

By contrast, overwhelming evidence is now available in the published reports of a number of independent committees of inquiry into the consequences of legalising VE, which all concluded that NO such law could be guaranteed to be safe against the likelihood of abuse. In fact, no committee set up for this purpose has ever reached any conclusion other than prohibition of legalisation. To discover the many reasons why these committees all reached the same conclusion, in three instances unanimously, that every such law would be flawed, the author's paper on the matter may be consulted (2).

Though the first of these reports appeared in 1994 and the last in 1998, their arguments are so compelling that no criticism of them has ever been published. Until and unless it can be shown that their common conclusion is unwarranted, they must be regarded as having established the truth.

This seems to some to be such an unexpected development, and so contrary to what is confidently often asserted, that it barely seems credible. The commonest and most serious form of abuse of any euthanasia law would be the endangering or the actual taking of the lives of some of the other terminally ill or disadvantaged groups of the sick or disabled who did not want their lives taken. That is, the apparently strict control over the practice of VE would be illusory, and in the worst case, acceptance of VE would lead to the practise of NVE. Additionally, since concealment would be easy to carry out, and hence correspondingly difficult to discover, a truly compassionate society must rate the risk as too high to be acceptable.

This common finding by each committee is consistent with what had already been predicted many times, namely that NVE is such a logical extension of VE that its occurrence should be regarded more as a fulfilled expectation than a matter for surprise. The arguments for VE already encompass the rationale for NVE.

That progression would be logical because, once it had been decided that taking life provided a benefit to one whose quality of life had led him/her to ask for death, it could then be thought discriminatory and unfair to withhold that supposed benefit from others in a similar plight, just because they did not, or could not, ask. NVE, like VE, is also thought by its practitioners to be compassionate and benevolent, not malicious or malevolent.

Since nobody would take a life they valued, in each instance of VE or NVE the ultimate justification is that the particular life no longer has sufficient value to mandate its continuance. Such reasoning would be incompatible with recognising the equal, inherent dignity of every person, as that dignity is declared in statements of human rights to attach to every life, without exception. That view of human dignity is also the one that provides the basis in criminal law for the provision of universal protection for every innocent human life, without exception. Hence, both practices are radically incompatible both with what needs to be acknowledged if we are to live well and peaceably with each other and with the very notion of justice in society, since justice is founded on and exists to respect equal dignity.

It may be objected that these arguments are theoretical and do not necessarily apply to the actual decision-making required in medical practice at or near the end of life. Thus, it is said doctors are not monsters who would suddenly begin to take life indiscriminately, and the risk of extension of one euthanasia practice to the other is overstated and no more than scare mongering, for which, in any case, there is no evidence. The difficulty with that position is that the evidence for NVE at present is readily found, even though it is carried out in secret and to an unknown extent.

The Netherlands.

Dutch euthanasia has been known to be commonly practised since 1973, when a court determined that a doctor, who had killed her mother who was dying and had requested euthanasia, was guilty but that her action was justified. At her trial, evidence was given on her behalf that she was doing no more than what was already common but unpublicised. The court also described circumstances in which it thought that doctors may be excused after euthanasia.

There ensued many years during which the Dutch maintained that euthanasia was closely supervised and controlled by the authorities, while some well informed outsiders maintained that this was certainly not the case, and that abuse was already common and extended as far as medical life-taking without the patient's consent.

During this period, even though VE was the only practice publicly discussed, official support for NVE could be readily found in the Netherlands. The State Commission on Euthanasia in 1987 had recommended that NVE should not be an offence, if carried out in the context of 'careful medical practice', though that term was not defined (3). In 1988, a Royal Dutch Medical Association (KNMG) working party condoned euthanasia for deformed infants, in some instances thinking it might be compulsory (3). In 1991, a KNMG committee condoned the killing of patients in persistent coma (3).

Dutch euthanasia practices were first officially examined in the Remmelink Report of 1991 which was based on medical practice throughout 1990 (4), for which the statistical study was done by van der Maas and others (5). This study was later repeated and its findings were reported in 1996 (6).

In 1991, by adopting the narrow definition of euthanasia only as 'active termination of life upon the patient's request', there were 2,300 instances of euthanasia in the year of the study, or 1.8% of all deaths. When, however, to these are added instances of life-taking without request and intentionally shortening the lives of both conscious and unconscious patients, the figures for which are found in the statistical study, the conclusions are dramatically altered.

They now become: 2,300 instances of euthanasia on request; 400 of assisted suicide; 1,000 instances of life-ending actions without patient request; 8,750 patients in whom life-sustaining treatment was withdrawn or withheld without request, 'partly with the purpose' (4,750) or 'with the explicit purpose' (4,000) of shortening life; 8,100 cases of morphine overdose 'partly with the purpose' (6,750) or 'with the explicit purpose' (1,350) of shortening life; 5,800 cases of withdrawing or withholding treatment on explicit request 'partly with the purpose' (4,292) or 'with the explicit purpose' (1,508) of shortening life (6). Thus, there were up to 23,359 instances of doctors intending, by act or omission, to shorten life. The true incidence of euthanasia could have been as high as 20% of all deaths in the year.

Although the Report stated that the 1,000 instances of 'life ending actions without request' were carried out on incompetent persons 'in their death agony', on the doctors' testimony at interview as described in the Survey, 14% of these patients were competent and 11% were partly so. According to that part of the Survey known as the death certificate study, 36% were competent. While NVE is generally thought of, and defined, as taking the life of an incompetent patient who could not choose at the time, these figures include another and unexpected category of NVE as killing practised on persons who were competent - those who could have been consulted, but were not.

One observer who has closely studied Dutch euthanasia estimated that the Dutch statistics allow for the possibility that there were 'about five thousand cases in which physicians made decisions that might or were intended to end the lives of competent patients without consulting them'. When he tried to obtain a possible explanation for this astonishing practice while he was visiting the Netherlands, he could get none. He was left to conjecture that when a doctor already thought it was appropriate to end the patient's life, he might think it safer not to seek consent, since if it was refused, to proceed would evidently be murder (9).

In the preamble to its Guidelines for Euthanasia in 1987, the KNMG had written: 'If there is no request from the patient, then proceeding with the termination of his life is juridically a matter of murder or killing, and not of euthanasia' (10). Using their own society's definition, Dutch doctors were carrying out medical murder in 1991, and have continued to do so ever since.

There followed a period of official inactivity because some of the findings were so unexpected, and because euthanasia was well supported by the community. Euthanasia activists lobbied to have it formally legalised, but without success. In particular, NVE presented a semantic problem because by the official definition, it was not any form of euthanasia. To meet this difficulty, the authorities abandoned their candour of 1987 in favour of an innocuous-sounding acronym, LAWER, 'life-terminating acts without explicit request' (11). The topic could now be openly discussed as though it were morally, medically and socially neutral, and it was soon to become just another medical alternative available to doctors and the community.

In 1993, authors from the department of Public Health at the Erasmus University could write: 'But is it not true that once one accepts euthanasia and assisted suicide, the principle of universalizability forces one to accept termination of life without explicit request, at least sometimes, as well? In our view, the answer to this question must be in the affirmative' (12).

In February 1993, new regulations about the medical reporting of euthanasia were issued (13), but they had little impact, either on reporting or on the practices themselves. The new rules required the reporting of both VE and NVE on the same form. This had the effect of confirming in many doctors the view that both were equally acceptable to the authorities. Indeed, in 1993 the Secretary of Health, referring to these practices, said: 'For a physician, the considerations in these two cases are not essentially different; from the moral point of view, the two actions are not of an essentially different kind' (14).

In the official 1996 review of developments since 1991, it was concluded that 'euthanasia seems to have increased in incidence since 1990, and the ending of life without the patient's explicit request seems to have decreased slightly' (5). Later in this paper, the matter of a possible 'slippery slope' associated with euthanasia is discussed, and it is mentioned that some euthanasia supporters insist there is no evidence that it has ever happened or would even be likely to happen. The reader's attention is therefore drawn again to the last quote above, where the Dutch can say simply, in essence, that medical murder (their own term) seems to have decreased slightly in the five years since it was first officially detected. The Dutch have reached the position where medical murder is now entrenched, and is not seen by their authorities as anything that might represent a deterioration in standards or call for correction. Not only have the Dutch become unwilling or unable to recognise the corruption of medicine and law attributable to their acceptance of any form of euthanasia, it seems that neither have some of the Australian supporters.

In 1995, two separate Dutch courts upheld the actions of doctors who had deliberately ended the lives of handicapped neonates with lethal injections, thus providing the first legal endorsement of NVE. In one case, the judge said 'In the decision of active ending of life, Dr Kadjik had acted with scientific responsible insight and in accordance with the medical ethic and accepted norms and in due consideration of due care resulting therefrom; he is entitled to an appeal of force majeure' (15). To justify what is admittedly an offence, courts in the Netherlands are allowed to decide that it is lawful for a doctor, faced with the alternative of leaving a patient in pain or of giving relief by taking life, to take the 'compassionate' option, by taking life. The doctor is said to be acting under a higher duty.

Most jurisdictions elsewhere regard this so-called dilemma as a fiction, on account of the proven effectiveness of palliative care to control such pain. This was specifically referred to by the US Supreme Court in its historic judgment of November 1996, when Justice O'Connor noted: 'A patient who is...experiencing great pain has no legal barriers to obtaining medication from qualified physicians to alleviate that suffering, even to the point of causing unconsciousness and hastening death (16).

The significance of NVE in the Netherlands has now been reduced almost to the point where discussion about it relates only to its detail, while the fact that it is still a major criminal offence by Dutch statute law, as it is elsewhere throughout the world, is no longer given special mention. That its incidence hardly fell between 1991 and 1995, or that it occurs at all, elicits no critical comment. An American psychiatrist estimated that, if NVE had been practised in the US at the same rate as prevailed in the Netherlands in 1990, the figure would have exceeded the 'combined total of all deaths from suicides and homicides' in that year (17).

In all Australian states, euthanasia is the crime of murder. In a study by sociologists in South Australia reported in 1994, using an anonymous questionnaire sent to 10% of the medical practitioners in that state, a significant incidence of NVE was discovered (18). The authors had seeded linked questions in different parts of their questionnaire, so that their association would be less evident to the respondents. 19% of doctors surveyed admitted they had ended life deliberately, and on 49% of those occasions, the answers revealed they had done so without patient request.

This study has not been repeated in Australia, but it is known that there is a high incidence of illegal euthanasia among the gay communities in the large cities, and it is probable that this includes NVE also.

United States of America.

In 1998, the results were published of a national survey of the attitudes and practices, concerning assisted suicide and euthanasia, of physicians in the 10 specialties in which doctors are most likely to receive requests for euthanasia (19). 61% of the 3,102 physicians surveyed responded. Under the heading 'Characteristics of Patients Receiving Assistance‚ where a request for death had been met' it is reported that '54 per cent of the requests for a lethal injection were made by a family member or partner'. This brought no specific comment from the authors, though it reveals that slightly more than half the medical killing reported by some 1,800 doctors was NVE. Does this mean that, as in the Netherlands, NVE no longer causes surprise in the US, or did the authors not realise that they had uncovered a deeply disturbing state of affairs?

This paper went on: 'requests for a lethal injection were characterised as indirect rather than explicit in 79 per cent of cases. Five per cent of patients who received prescriptions and 7 per cent of those who received a lethal injection were described as "confused 50% or more of the time"'. Since all these events were carried out in private and therefore unsupervised, the figures give grounds for great concern about the potential for the uncontrolled extension of the euthanasia practices of some doctors. Because they are done in secret, not even a law to allow VE could hope to prevent such extension.

The opinion that there is no evidence for a 'slippery slope', by which is meant the progression of VE to NVE, is still commonly heard, even though evidence for it is available, as just discussed. When this is pointed out, the response has been that, though this may be so, there is no evidence that one has actually led to the other. This evasive answer fails to offer any explanation at all for the occurrence of NVE, which is, by any legal criterion, medical murder, and shows little concern that it is happening at all. It would seem that, to some, it is more important simply to deny the facts or to denigrate those who draw attention to them, than to lose face by condemning NVE.

Ready proof that the progression of VE to NVE has grounds in logic is available whenever euthanasia becomes a topic for public discussion following the media disclosure of some instance of mercy killing. At such times, radio talk-back programs quickly come round to discussing the plight of the senile, elderly people in nursing homes, how their lives are futile, how they, their families and the public purse would all experience great relief from their demise, and particularly singled out for comment are those who are irreversibly mentally incompetent. This is heard from those who, shortly before, professed to want only NVE, and who, I suspect, do not even realise they have made this subtle but significant mental shift.

Two dangerous ideas lie just below the surface of awareness in an unknown number of people in the community, though they are not usually thought proper to be voiced openly: that there are groups of unfortunate people whom society could well do without, and that they cost a lot of money that could be better spent. These ideas are rejected by the usual advocates of VE, as they should be, but those who hold them would constitute a significant problem were legalisation of VE to be voted on. They would cast a vote in favour, but they would not forever be satisfied with VE only, and would be likely to push for its extension to NVE. And if that vote were made reliant on compassion, even though it may be misplaced compassion, these disadvantaged people would often seem to be the most deserving of compassionate release.

It is impossible for those who would have VE legalised to guarantee that such law could or would remain unaltered in the future. When legalised VE had in time caused a lowering of the community's respect for all human life, as it undoubtedly would, and when health costs had escalated to what were seen to be unsustainable levels, as they undoubtedly will, a precedent for the further erosion of protection for human life would already exist, having been created when VE was legalised.

Conclusion.

As long as notions of life-taking without consent are simplistically thought to be only associated with some degree of malicious intent, it can be considered insulting to suggest that NVE might also be practised, if VE were legally permitted. Especially if such a suggestion thought to reflect adversely on doctors, who, while they are often criticised on other grounds, are not generally thought to be unprincipled or malicious. But when the actual motivation for NVE, in its practitioners' estimation, is that it is an act of kindness, the risk to the lives of some of the more vulnerable in society then becomes more apparent.

The prospect of NVE then changes from being repugnant and rare to an act that can be thought to be desirable and beneficial, in some circumstances. So regarded, NVE could be confidently predicted to be, in time, virtually inevitable. Any instance of NVE is a case in practice of 'the tendency of a principle to expand itself to the limits of its logic'.

References.

1. Kuhse H, Singer P. Should the Baby Live? Oxford; Oxford University Press. 1985. p v.

2. Pollard B. The Legalisation of Euthanasia. 1999.[ On this website]

3. Keown J. The Law and Practice of Euthanasia in the Netherlands. Law Q Rev 1992; 108: 51-78.

4. Report of the Committee to Investigate Medical Practice Concerning Euthanasia. Medical Decisions about the End of Life. I. Remmelink Report. The Hague; Ministry of Justice and Ministry of Welfare, Public Health and Culture. 1991.

5. Van der Maas PJ et al. Euthanasia and Other Decisions Concerning the End of Life. Elsevier Science Publications, Amsterdam. 1992.

6. Van der Maas PJ, van ver Wal G, Haverkate I, de Graaf CML, Kester J et al. Euthanasia, Assisted Suicide and other Medical Practices Involving the End of Life in the Netherlands. 1990-1995. NEnglJMed 1996; 335: 1699-1705.

7. Keown J. Further Reflections of Euthanasia in the Netherlands in the Light of The Remmelink Report and the van der Maas Study. Chapter in Euthanasia, Clinical Practice and the Law. Ed Gormally L. The Linacre Centre 1994. p219-240.

8. Do. p 230.

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

10. Guidelines for Euthanasia (KNMG). trans Lagerwey W. Issues Law Med 1988; 3: 429-437.

11. Pijnenborg L, van der Maas PJ, van Delden JJM, Looman CWN. Life terminating acts without explicit request of patient. Lancet 1993; 341: 1196-1199.

12. Van Delden JJM, Pijnenborg L, van der Maas PJ. The Remmelink Report; Two Years Later. Hastings Center Report 1993; Nov/Dec 24-27.

13. Fenigsen R. The Netherlands; New Regulations Concerning Euthanasia. Issues Law Med 1993; 9: 167-171.

14. Do. p 170.

15. Brownstein EG. Neonatal Euthanasia Case Law in the Netherlands. Aust Law J 1997; 7: 54-58.

16. Washington vs Glucksberg, 117 SCt 2303.

17. Op cit 8. p 165.

18. Stevens C, Hassan R. Management of death, dying and euthanasia; attitudes and practices of medical practitioners in South Australia. J Med Ethics 1994; 20: 41-46.

19. Meier DE, Emmons CA, Wallenstein S, Quill T, Morrison RS, Cassel CK. A National Survey of Physician-Assisted Suicide and Euthanasia in the United States. NEnglJMed 1998; 338: 1193-1201.