thesis against euthanasia

Euthanasia: Every For and Against Essay (Article Review)

Euthanasia or physician-assisted suicide is a highly debated issue. This issue is outlawed in almost all major countries. Proponents for euthanasia advocate the ending of pain for those who cannot otherwise survive any terminal disease (eHow). On the other hand, the opponents to euthanasia view it as a rejection of human life. The following are some of the articles for and against euthanasia.

• Jane L Givens and Susan L Mitchell “Concerns about End-of-Life Care and Support for Euthanasia” Journal of Pain and Symptom Management Article in Press – FOR

The authors state socio-demographic characteristics of the people are the main reason for popular support. Using data from a 1988 General Social Survey, found various reasons for people supporting euthanasia like concerns about the emotional burden of end-of-life decision making family members and worry about lack of money or insurance will result in poor end-of-life care (Givens & Mitchell, 2009).

• Isis Kearney “What Does Euthanasia Mean” found available on NHS Exposed website – FOR

In this article, the author describes the different categories of euthanasia like voluntary euthanasia, involuntary euthanasia, active euthanasia and passive euthanasia. The author states that euthanasia is to be considered as a pro-choice decision and when legalized the government should implement stricter laws so that there is no abuse of euthanasia by physicians (Kearney).

• Dr. Gregor Wolbring “Why Disability Rights Movements Do Not Support Euthanasia:

Safeguards Broken Beyond Repair” found in Bioethics and Disability website – FOR

This article provides a descriptive analysis of euthanasia from different angles. The article deals with the grounds on which the terminally ill cancer patients may decide to opt for euthanasia. The author provides detailed explanation on terms like ‘terminal condition’, ‘physical pain’, ‘consent and competent adult’ and ‘self-determination’. The author cites a British study supporting voluntary and involuntary euthanasia by 80% people (Wolbrnig).

• Euthnasia.com “Arguments against Euthanasia” available online – AGAINST

This article defends each of the arguments, which support euthanasia citing valid arguments of them. This article argues that when euthanasia is legalized there is a distinct possibility that the physicians may become greedy and look only for their financial well-being, when a disabled person chooses to die (Euthnasia.com).

• Nicholas Beale and Prof. Stuart Horner “Non-Religious Arguments against ‘Voluntary Euthanasia’” available on starcourse website – AGAINST

Beale and Horner enumerate the potential problems or issues that may arise when euthanasia is legalized. For instance, the authors are of the view that legalizing voluntary euthanasia might result in a large scale of the practice of advising the patients. They argue that bad cases do not make good law since no system of safeguards could ever be foolproof and therefore, legalizing voluntary euthanasia would lead to legalizing involuntary euthanasia (Beale & Horner).

• Dr. Robert Pollnitz “The Case Against Euthanasia” available online at hcic.org website – AGAINST

The author defines euthanasia extensively and provides arguments against euthanasia. The article provides statistics on involuntary euthanasia. There is a descriptive discourse on euthanasia and palliative care. Some of the arguments are also religion-based which talks against euthanasia (Pollinitz).

Beale, N., & Horner, P. (n.d.). Non-Religious Arguments against ‘Voluntary Euthanasia’ . Web.

eHow. (n.d.). How to Debate in Support of Euthansia . Web.

Euthnasia.com. (n.d.). Arguments against Euthansia . Web.

Givens, J. L., & Mitchell, S. L. (2009). Concerns about End-of-Life Care and Support for Euthanasia .

Kearney, I. (n.d.). What doe Euthanasia Mean?

Pollinitz, D. (n.d.). The Case against Euthanasia .

Wolbrnig, D. G. (n.d.). Why Disability Rights Movements Do Not Support Euthanasia:Safeguards Broken Beyond Repair .

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IvyPanda. (2022, March 6). Euthanasia: Every For and Against. https://ivypanda.com/essays/euthanasia-articles-for-and-against/

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IvyPanda . (2022) 'Euthanasia: Every For and Against'. 6 March.

IvyPanda . 2022. "Euthanasia: Every For and Against." March 6, 2022. https://ivypanda.com/essays/euthanasia-articles-for-and-against/.

1. IvyPanda . "Euthanasia: Every For and Against." March 6, 2022. https://ivypanda.com/essays/euthanasia-articles-for-and-against/.

Bibliography

IvyPanda . "Euthanasia: Every For and Against." March 6, 2022. https://ivypanda.com/essays/euthanasia-articles-for-and-against/.

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Euthanasia and the Law: The Rise of Euthanasia and Relationship With Palliative Healthcare

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Ethical perspectives regarding Euthanasia, including in the context of adult psychiatry: a qualitative interview study among healthcare workers in Belgium

• Monica Verhofstadt 1 ,
• Loïc Moureau 2 ,
• Koen Pardon 1 &
• Axel Liégeois 2 , 3  

BMC Medical Ethics volume  25 , Article number:  60 ( 2024 ) Cite this article

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Introduction

Previous research has explored euthanasia’s ethical dimensions, primarily focusing on general practice and, to a lesser extent, psychiatry, mainly from the viewpoints of physicians and nurses. However, a gap exists in understanding the comprehensive value-based perspectives of other professionals involved in both somatic and psychiatric euthanasia. This paper aims to analyze the interplay among legal, medical, and ethical factors to clarify how foundational values shape the ethical discourse surrounding euthanasia in both somatic and psychiatric contexts. It seeks to explore these dynamics among all healthcare professionals and volunteers in Belgium.

Semi-structured interviews were conducted with 30 Dutch-speaking healthcare workers who had encountered patients requesting euthanasia for psychiatric conditions, in Belgium, from August 2019 to August 2020. Qualitative thematic analysis was applied to the interview transcripts.

Participants identified three pivotal values and virtues: religious values, professional values, and fundamental medical values encompassing autonomy, beneficence, and non-maleficence, linked to compassion, quality care, and justice. These values interwove across four tiers: the patient, the patient’s inner circle, the medical realm, and society at large. Irrespective of their euthanasia stance, participants generally displayed a blend of ethical values across these tiers. Their euthanasia perspective was primarily shaped by value interpretation, significance allocation to key components, and tier weighting. Explicit mention of varying ethical values, potentially indicating distinct stances in favor of or against euthanasia, was infrequent.

The study underscores ethical discourse’s central role in navigating euthanasia’s intricate landscape. Fostering inclusive dialogue, bridging diverse values, supports informed decision-making, nurturing justice, and empathy. Tailored end-of-life healthcare in psychiatry is essential, acknowledging all involved actors’ needs. The study calls for interdisciplinary research to comprehensively grasp euthanasia’s multifaceted dimensions, and guiding policy evolution. While contextualized in Belgium, the implications extend to the broader euthanasia discourse, suggesting avenues for further inquiry and cross-cultural exploration.

Peer Review reports

Medical assistance in dying is allowed in 27 jurisdictions in the world and if so, it is mainly restricted to the terminally ill (see BOX 1 in OSF) [ 1 ]. Medical assistance in dying entails that a patient’s death request can be granted via euthanasia , defined as the intentional termination of life by a physician at the patient’s explicit request, which is currently decriminalised in Australia, Belgium, Canada, Colombia, Luxembourg, the Netherlands, Spain, and New Zealand. In addition, it can be granted by means of assisted suicide , also defined as the intentional termination of life by a physician at the patient’s explicit request, but in these cases, the lethal drugs are provided by a physician and self-administered by the patient at a time of the latter’s own choosing (e.g., Australia, Austria, Switzerland, United States). In some countries, not only a physician, but also a nurse practitioner can be involved in the procedure (e.g., Canada, New Zealand).

Euthanasia has been legal in Belgium since 2002, positioning the country as a pioneer in this field with two decades of euthanasia practice [ 2 ]. According to Belgian legislation, individuals can be deemed eligible for euthanasia when they are, among other criteria, in a medically futile state characterized by constant and unbearable physical or psychological suffering resulting from a serious and incurable disorder caused by accident or illness [ 2 ]. Belgium is one of the few countries that does not exclude people from assisted dying who suffer predominantly from irremediable psychiatric conditions (see BOX 2 in OSF for all legal criteria in Belgium). As regards prevalence, euthanasia accounted for up to 3.1% of all registered deaths in 2023 in Belgium [ 3 ]. Whereas most registered euthanasia deaths concerned the terminally ill (approximately 84%), predominantly suffering from cancer, only 48 or 1.4% of euthanasia deaths concerned non-terminally ill adults predominantly suffering from psychiatric conditions. Since euthanasia was legalised, in total 457 such euthanasia cases have been reported, less than 1.5% of all registered euthanasia cases in Belgium [ 3 , 4 , 5 , 6 , 7 , 8 , 9 ].

However, this is only the tip of the iceberg, as there is reason to believe that the total number of requests for euthanasia in Belgium (regardless of outcome), is at least 10 times higher. For instance, recent annual reports from Vonkel, an end-of-life consultation centre in Belgium, revealed around 100 unique patients per year applying for euthanasia for psychiatric reasons. Less than 10% of those euthanasia requests were reported to be carried out [ 10 , 11 , 12 ]. Moreover, a recent survey among psychiatrists working in Flanders, Belgium, revealed that 8 out of 10 respondents had been confronted at least once throughout their career with patients requesting euthanasia for psychiatric reasons [ 13 ]. The survey also showed that, although three-quarters are supportive of not excluding the option of euthanasia for this specific patient group [ 14 ], the majority is hesitant to be actively engaged in a euthanasia procedure [ 13 , 14 ]. The literature ascribed the reluctance to the complexity of euthanasia assessment in this patient group, inherently high in professional and emotional demands [ 15 , 16 , 17 , 18 , 19 ]. The complexity was for a large part described in terms of the practical considerations surrounding euthanasia requests and assessment, e.g., whether and when these patients can meet the legal criteria.

There is thus reason to believe that healthcare workers’ overarching ethical considerations influence their attitudes on euthanasia in general and in the context of psychiatry specifically, and their practice. As empirical in-depth studies are lacking, this area is largely understudied. To date, only two recent qualitative studies among Dutch physicians emphasised the value-based reasons for euthanasia decision-making, but did not [ 20 ] or only summarily [ 21 ] scratch the specific context of psychiatry. Another recent qualitative study among Dutch physicians, including psychiatrists, emphasized the value-based reasons for supportive attitudes towards euthanasia, e.g. the value of self-determination, compassion, fairness, and suicide prevention, versus the value-based reasons for not supporting euthanasia, e.g. the mission of medicine of hope and healing [ 22 ]. Furthermore, a recent systematic review described the main ethical challenges surrounding the euthanasia practice in the context of psychiatry [ 23 ]. However, this ethical debate was mainly concentrated on the permissibility and implementation of euthanasia from a practical-clinical point of view, e.g. whether euthanasia in the context of psychiatry should be permitted, and why the legal requirements can (not) be adequately embedded in the field of psychiatric medicine. How practically and juridically relevant these considerations may be, they remain the outcome of ethical values being weighed up, which means that no single consideration can be considered ethically irrelevant, neutral, or value-free. Moreover, the review was based on articles that have been selected in a timeframe in which sound empirical data regarding euthanasia in the context of psychiatry were largely lacking.

Also, the overarching value-based views of other professionals involved in psychiatric euthanasia practice have not yet been studied. This is striking, as a recent Belgian survey study revealed that that half of the psychiatric nurses (53%) are frequently and directly confronted with such euthanasia requests [ 24 ], but in-depth insights into their value-based views are lacking. Furthermore, there are many more formal caregivers, other than psychiatric nurses, involved in euthanasia assessment procedures. End-of-life centres employ e.g., paramedical personnel such as psychologists, psychiatric nurses for intake and registration purposes, and well-trained volunteer personnel such as buddies, entrusted with the task to help these patients to cope with the euthanasia procedure. In addition, rehabilitation-oriented support groups (REAKIRO) were established to help these patients (and their relatives) in walking the tightrope of life and death [ 25 ]. All of these caregivers may also have an unacknowledged but influential role in these euthanasia assessment procedures, and therefore, an interesting perspective to reflect on euthanasia legislation and practice. Gaining insight into healthcare workers’ ethical considerations related to euthanasia in psychiatry will lay bare the ethical foundations underlying current practice and is important to inform and spark further debate around this extremely thorny issue, and to promote sound ethical analysis.

Hence, the purpose of this research is to explore healthcare workers’ ethical considerations regarding euthanasia in general and euthanasia concerning adults suffering predominantly from psychiatric conditions in particular.

Theoretical research framework

Our research was guided by the framework of ‘critical social constructionism’ [ 26 ], providing a nuanced perspective that diverges from the acknowledgment of an objective reality. This approach intricately examines the interplay of personal, social, and societal dimensions within the phenomena under study. It necessitates an acknowledgment of the layered complexities influencing our understanding of phenomena such as euthanasia, a notion supported by both our prior research [ 27 ] and additional studies [ 23 , 28 ].

Our interpretation of the data was informed by social constructionism, which recognizes the role of internalized societal norms in shaping individuals’ perceptions of reality over time. Furthermore, we embraced a contextualist epistemology [ 29 ], acknowledging the contextual influence on knowledge formation among both researchers and participants. This methodological approach aimed to capture diverse lived experiences (e.g., diversity in clinical and euthanasia trajectories) and perspectives, including varied attitudes toward euthanasia based on specific relationships (e.g., professional healthcare worker or volunteer). Consequently, we maintained a reflexive stance regarding the potential impact of our individual experiences and identities on our analyses and interpretations, as elaborated in the Ethical Considerations section.

Study design

The qualitative research design consisted of semi-structured face-to-face interviews with healthcare workers in Flanders and Brussels, Belgium.

Participants

All participants were Dutch-speaking and had at least one concrete experience with euthanasia requests and procedures concerning adults with psychiatric conditions in the period 2016–2020, either as professional or volunteer healthcare workers. We adopted a broad recruitment approach, with a particular focus on all healthcare providers directly involved in medical practice rather than in managerial or policy-making roles. No further exclusion criteria were employed.

Recruitment and interview procedure

Purposive sampling was used to ensure diversity and heterogeneity in terms of: participants’ affiliation with institutions holding different stances on ‘euthanasia and psychiatry’; being to a different extent confronted with these euthanasia procedures as regards the amount of experiences (sporadically versus regularly); the nature of the experiences (e.g. confronted with or engaged in euthanasia procedures that were still under review or that had been rejected, granted, performed or withdrawn); and their specific role as professional or volunteer healthcare worker.

Participants were recruited via assistance of our contact persons at: (1) the end-of-life consultation centre Vonkel; (2) the Brothers of Charity; (3) the rehabilitation-oriented centre REAKIRO in Louvain; and (4) the Review Belgian Euthanasia Law for psychological suffering (REBEL) group, a group of Belgian physicians (e.g. psychiatrists), therapists (e.g. psychologists) as well as academics who express their concern on euthanasia in the context of psychiatry via the media. Participants were also recruited via a notice on the sites, newsflashes and/or in the online newsletters of LEIF (Life End Information Forum), Recht op Waardig Sterven (the Flemish Right to Die with Dignity Society) and Vlaamse Vereniging voor Psychiatrie (Flemish Psychiatric Association).

Potential participants contacted MV or a study assistant by phone or mail. The patients were then given an information letter and informed consent form that consisted of 2 main parts. All interviews were conducted by MV or a study assistant, who both have experience in conducting interviews on end-of-life topics. Interviews were held at the participant’s location of choice, except for five interviews which were held online via video call by Whereby 14 due to the Covid-19 crisis lockdown regulations. Interviews lasted between 55 min and 2 h, and were audio recorded (the online video interviews were recorded by Whereby’s software and immediately transferred in an mp.3 format).

Measurements

The interview guide (see OSF) contained the following consecutive questions of importance to the present report: (1) What is your personal stance regarding euthanasia as a legalised medical end-of-life option? and (2) What is your personal stance regarding euthanasia in the context of psychiatry?

Data management and analysis

We used a model of sampling-based saturation, namely inductive thematic saturation, that relates to the emergence of new themes (defined as 7 consecutive interviews without new themes) [ 30 ]. We continued to recruit and conduct interviews so that the sample would be heterogenous in terms of socio-demographics, clinical profile, and clinical setting. In particular, our focus was on recruiting individuals with the following profiles: psychologists, male psychiatric nurses and moral consultants/spiritual caregivers employed in residential psychiatric settings ( n  = 5).

All interviews were then transcribed verbatim and de-identified by the interviewers.

We made use of hybrid inductive and deductive coding and theme development by means of a 2-staged process. Stage 1 consisted of an inductive data-driven thematic coding procedure.

We made use of these four phases; (1) identification and coding of all transcripts; (2) the placing of the codes in subthemes, i.e., arguments in favour versus critical concerns; (3) the placing of these subthemes in overarching main themes, i.e., different stakeholders (patient/medicine/society); (4) the comparison and discussion of the findings (with all co-authors). In addition to the inductive approach, we also used a deductive, theory-driven template approach during stage 2. We made use of these four phases; 1) the development of an ethical interpretation framework (see OSF). The framework consists of four key concepts, each involving a multitude of ethical concepts: (a) ethical theories and methodologies, (b) ethical values, (c) basic ethical virtues, and (d) dialogue/decision making ethics; 2) the identification of codes that fit the ethical framework and the theory-driven renaming of these codes; 3) the placing of some of the subthemes in an additional main theme; and 4) the comparison and discussion of the findings (with all co-authors).

Ethical considerations

The research team comprised two experienced clinical psychologists, one specializing in euthanasia within the cancer patient population and the other skilled in conducting interviews on this sensitive topic within the adult psychiatric context. Additionally, two ethicists with expertise in assisted dying, including euthanasia, were part of the team. Some authors also have backgrounds in psychiatric practice, including outpatient and residential settings, while others bring expertise through personal experiences. Furthermore, all contributing authors have personal and/or professional connections with individuals navigating death ideation, offering diverse perspectives on euthanasia. Additionally, some authors hold religious beliefs, while others maintain a more agnostic stance. These perspectives vary depending on the predominant viewpoints adopted—whether that of the patient, a close relation, a clinician, an ethicist, or policy stances. To mitigate potential undue influence on data interpretation, three team assemblies were convened. These sessions served to share firsthand encounters from interviews and their outcomes, fostering reflection and deliberation among team members. This proactive measure was implemented to prevent both personal and professional biases from affecting the interpretation of the data.

The main characteristics of the 30 participants are listed in Table  1 . The sample consisted of 16 physicians, 7 other care professionals (ranging from psychiatric nurses to mobile support teams), and 7 volunteers, all of whom were engaged in one or more euthanasia procedures predominantly based on psychiatric conditions.

The participating physicians held various roles regarding the handling of euthanasia requests:

1 physician refused to discuss the request with the patient on principle grounds.

7 physicians managed the clarification of euthanasia requests from their own patients or referred them to colleagues for further clarification.

10 physicians provided one of the two legally required formal advices or an additional advice on the euthanasia request.

5 physicians performed the act of euthanasia.

3 physicians held a more normative, dissuasive stance against euthanasia in the context of psychiatry but were willing to explore and discuss the euthanasia request with the patient.

The sample further included 14 non-physicians, among them members holding one or more roles:

2 members were part of mobile teams providing psychiatric care and support in the patient’s home setting.

3 were psychiatric nurses working either in a general hospital or in a psychiatric residential setting.

2 were Experts by Experience, individuals with a history of mental distress trained to provide support for individuals new to the euthanasia procedure and/or rehabilitation approaches.

3 were buddies, individuals entrusted with assisting and supporting the patient throughout the euthanasia procedure.

3 were moral consultants/spiritual caregiver, tasked with offering various forms of existential guidance and support to patients considering euthanasia, including religious, moral, and/or other perspectives.

5 were consultants at end-of-life information and/or consultation centers responsible for patient intake.

Participants’ ethical considerations regarding euthanasia, in the broadest context of medicine

As can be seen from the coding structure in Table  2 , we ordered coding categories on the level of 1) the individual patient, 2) the patient’s social inner circle, 3) the (para)medical field, and 4) the society. Note that words used verbatim by the interviewees (often interview fragments instead of quotes, as to better illuminate the complexities and nuances of interviewees’ first-hand lived experiences) from the transcribed interviews are incorporated that provide both additional insightful details and reveal the at times interwoven nature of the analysed codes.”

The level of the individual patient

On the level of the individual patient, the following five ethical considerations were distinguished: (1) autonomy, (2) dignity, (3) quality of life, (4) compassion, and (5) the meaning and transformative value of suffering.

First, Autonomy was a recurrent theme in all the interviews. Some participants expressly valued individual autonomy , and more specifically its following two underpinning characteristics: (1) self-determination in terms of the fundamental right for each individual to direct the course of one’s own life, which also includes ‘taking control over the timing and circumstances of one’s end-of-life’, and (2) freedom of choice , as they strongly believed that individuals are free to choose what meaning and purpose they assign to their lives. According to them, as each individual should be enabled ‘to live according to one’s own value system’, so should the ending of one’s life also be congruent with one’s own value system. Hence, in their opinion, euthanasia should remain ‘one of the many options to die’.

Other participants called this individualistic approach of autonomy ‘unrealistic’ or even ‘delusional’, as it shies away from: (1) the relational account of autonomy, in which a true autonomous decision was seen as the outcome of a decision-making process which is shaped by individual, social and contextual components, and (2) the internalised downside of autonomy, as the feeling underpinning many euthanasia requests, namely ‘not wanting to be a burden to others’ may lead to ‘self-sacrifice’ and ‘the duty to die’ under the false pretence of autonomy. In addition, some pointed to the power of susceptibility and subliminality, as human beings are subliminal creatures whose behaviour is continuously influenced on both a subconscious and even conscious level. Consequently, internalised pressure cannot be excluded when a patient requests euthanasia. One psychiatrist even stated that ‘ there exists no such thing as a free will, as human beings are always manipulated in many areas of human life and functioning’ .

“I believe that that there should still be places in society where you could die without considering euthanasia. While many people today are facing dementia, and you almost must…. Interviewer: Yes. “Yes, like how should I deal with it? Should I exit life before it becomes inevitable dementia or something similar? Because I think that in a neo-liberal society, many people internalize the idea that at some point, it becomes a moral duty to step aside. They feel obliged to eliminate themselves. Self-elimination. In a neo-liberal model, as long as you can keep up and contribute, everything is fine. But if you can’t keep up, well, if you cannot fully exercise autonomy, then… Essentially, you should hold your honour and step aside.” (spiritual caregiver)

Second, participants mentioned euthanasia as an option to die with dignity . For those in favour of the Law, euthanasia is considered (1) a ‘dignified way of dying’ when everything that leads up to death, including individual, medical, and social needs and expectations, is consistent with one’s own sense of integrity, belief-system and lifestyle, and (2) a ‘good death’, when referring to the literal meaning of the concept ‘euthanasia’, namely ‘a soft and gentle passing’. Other participants raised concerns on the reference to euthanasia and dignified dying in the same breath, as if “ other ways of dying are not or less dignified ”.

Third, the value of quality of life underpinned the arguments made in favour of the Law on Euthanasia, as (1) life itself should not be prolonged unnecessarily, (2) meaningless suffering should be prevented, and (3) a good life should pertain to all stages in life, from the very beginning until the very end, which is feasible if quality of dying circumstances can be guaranteed. As one buddy stated: “ Living a full and good life implies dying a good death ”. Other participants made use of this value underpinning their argument against euthanasia, based on (1) the “protect-worthiness” of life itself and (2) the suffering that must be considered an inherent feature of the human condition.

Fourth, and seamlessly fitting with the former value, divergent courses also emerged regarding the aspect of how to deal with suffering . Some participants were in favour of euthanasia out of compassion in terms of (1) bringing a kind of relief to the patient when providing her the prospect of an end to the suffering and (2) ending the suffering once it has become ‘useless and meaningless’ and ‘disclosing the limits of the carrying capacity of the self’. Some participants referred to the insufficient degree of quality of life in some patients and valued euthanasia as sort of ‘ compensation for a life gone wrong’.

Others considered the option of euthanasia as compromising patients’ ability to accept, bear and cope with suffering experiences by offering the opportunity ‘to quickly resign from it’.

Some participants referred to the dynamic features and hence, the potential enriching value of suffering. They believed that one can and must revolt against the perception of pointless suffering, as suffering may offer unique opportunities to achieve personal growth through the realisation of self-actualising tendencies amidst the suffering and though all kinds of hardship and adversity in life. Therefore, the real challenge is to support the sufferer to (re)gain the ability to transform the suffering by means of redefining, accepting, and making sense of it. One psychiatrist referred to the Myth of Sisyphus and stated:

A rock that must be pushed up the mountain, which is terrible, and then Sisyphus lets the rock fall back down, and he must start all over again. And what is the purpose of that suffering? Pushing the rock up? It’s absurd, really, but still. I find it so vital, human, uh, yes. That is something that inspires me enormously and often makes me, well, yes, vitality and suffering, suffering is inherent to being, of course, and one can suffer, of course, that is very serious suffering, terrible suffering. I know that. But well, accept suffering, right? I’m not glorifying suffering, no, I don’t belong to that category. Some Catholics do that; the suffering of Christ, we must… No, not at all. Suffering is inherent to life. Interviewer: It’s just more bearable for some than for others. Interviewee: Then it’s our task to make it more bearable. Yes. (…) Look, that sets a dynamic in motion. By dynamic, I also mean movement. A euthanasia request is often rigid. I am for movement. That’s what Eastern philosophy teaches us too, that everything moves, and we must keep that movement and that the question may change or that people may also discover things. Or indeed, a suffering that is even more exposed, but on which one can then work. There is still much to do, yes, before the ultimate and final act of euthanasia, by a doctor for all sakes, should be considered. (psychiatrist)

The level of the patient’s inner circle

On the level of the social inner circle, the following three ethical considerations were distinguished: (1) involvement, (2) connectedness, and (3) attentiveness.

Some participants stressed that euthanasia can only be a soft and thus ‘good’ way of dying, if the patient’s social inner circle can be involved in the euthanasia procedure and if sufficient support to them can be provided. All participants in favour of the legal framework on euthanasia echoed the importance of the social circle being involved in an early stage of the euthanasia procedure, as the prospect of the end of life may challenge a patient’s ability of staying and feeling connected . If the euthanasia request is to be carried out, it offers a unique opportunity for both the patient and her social inner circle of consciously being present and sharing goodbyes. Other participants considered this reasoning as potentially deceiving, as concern was raised regarding the trap of false assumptions, in terms of words being left unspoken and the bottling up of one’s own needs for the sake of the other.

As the third doctor, I was asked to provide advice about someone, and the [adult child] was present, a charming [adult child]. The [adult child] was also very friendly but didn’t say much. The man explained why he himself wanted euthanasia and so on. To be honest, at first, I thought, “Well, this won’t take long,” because there were many arguments and reports I had received, but as the conversation went on, I started to feel something different. It turned into a very long conversation, during which the [adult child] also had their say. In short, the father believed that he couldn’t burden his children. He was a kind man who knew what he wanted, and his children were inclined to follow his idea, to follow his vision. However, the children thought, “Yes, we are actually going to agree with our father, and we’ll allow it,” but deep down, they still wanted to take good care of him. The father didn’t want them to take care of him, and there were many other things, but after that long conversation with the [adult child] and the father, and everything else, like, “We’ll still celebrate Christmas together,” there was a complete turnaround. The other physicians involved accepted this very well, and they said, “Okay, for us, it wasn’t clear. (physician)

In addition, concern was raised regarding the inner circle’s respect of individual patient autonomy and freedom of choice outweighing their r esponsibility and accountabilit y to take care for one another and to act according to all these subjects’ best interest.

Consequently, divergent discourses on the virtue of attentiveness emerged. Whereas for some, the euthanasia procedure may offer a unique opportunity for both the patient and her relatives to be better prepared for death and for the bereaved to better cope with grief, others pointed to the inner circle’s continued grappling with unresolved feelings and perceived helplessness after such a fast-track to death.

Yes, and sometimes I also see people, family members after such euthanasia, yeah, I’ve experienced it several times. They say things like, “Yes, I supported it, but I didn’t know it would affect me like this,” you know? They try to convince themselves, saying, “It was good, it was good, and I stand behind it.” Yeah, you are hardly allowed to do otherwise, but you feel that inner struggle in them, you know? Like, “Was it really okay?” But you can’t question it because you think, “Poor them,” but you still feel it, like, “How sad, how sad. (psychiatrist)

The level of medicine

The following five ethical considerations were distinguished: (1) professional duties, (2) responsibility to alleviate suffering, (3) subsidiarity, (4) professional integrity, and (5) monologic versus dialogic approaches.

First and as regards professional duties, it was (only) reported by some physicians that the physician’s duty is “ to provide good care, which includes good end-of-life care ”. Hence, physicians are the ones who should have euthanasia “as a tool in their end-of-life toolbox”. Others held a different stance and referred to Hippocrates’ Oath when stating that the physician’s duty is to save life at all costs.

Second, all the participants agreed that clinicians have the responsibility to alleviate the patient’s suffering . Whereas some welcomed the option of euthanasia due to the experienced limits of palliative care, that in some cases is deemed an insufficient response to intractable suffering, others stated that euthanasia is not needed as physicians have proper palliative care in their toolbox to alleviate all kinds and degrees of suffering.

Third and as regards the subsidiarity principle , opinions differed on the use of a palliative filter, i.e., whether a consultation with specialist palliative care units should precede euthanasia.

Fourth and as regards professional integrity , some participants relativized the physicians’ executive autonomy. As one psychiatrist stated “because in the end, we do not decide whether someone might die or not. We only decide whether we want to be of help and assist in it.” All the ones in favour of the current legal framework echoed that as physicians are the ones that have better access to the lethal drugs and the technical expertise to end the patient’s life in more efficacious ways than non-physicians, they should remain entrusted with euthanasia assessment procedures. Others (only physicians) criticized the Belgian legislator for placing too much power in the physicians’ hands so that the latter “ can play for God instead of using their pharmacological and technical know-how to save lives ”.

Fifth, and as regards the decision-making process, most participants valued the ethical principle of shared decision-making between the patient and her physicians, and some even preferred a triadic dialogue in which the patient, her relevant health carers and her social inner circle is involved in euthanasia assessment procedures. For most of them, this type of extended or relational autonomy is considered as best clinical euthanasia practice, especially when death is not foreseeable. According to some non-physicians, a strict dyadic patient-physician approach is to be preferred when death is reasonably foreseeable in a patient with sufficient mental competence. In this event, no intermediary should be tolerated as the medical secret is considered ‘sacred’. One participant elaborated further on this strict dyadic approach and said:

“ But actually, in my opinion, the request for euthanasia is something between two people. So…. Interviewer: The singular dialogue? “So, a relationship between the patient and the doctor, yes. That’s what I think. And I do understand that the legislation exists, primarily to protect the doctor against misuse or accusations, because euthanasia used to happen before too, but in secret. But for me as a doctor, it would be enough if a patient whom I’ve known for years, followed for years, maybe 20 years, 30 years, 40 years, and who is terminally ill, asks me in private, ‘I want it.’ For me, it doesn’t need to be more than that for me to say, ‘yes.’ So, there’s no need for a whole set of legislation, except of course to protect myself, maybe from the heirs who might have a different idea about it, yes, but I find it beautiful. And they say, you know, our legislation is such that you can write your euthanasia request on the back of a beer coaster and that’s enough, you know? But how it used to be, euthanasia happened just as well, that’s what I heard from my older colleagues. But it was done in private. Actually, that is the most beautiful sign of trust between a doctor and a patient. ” (Physician and consultant)

Others, all physicians without a favourable stance on euthanasia, considered medical paternalism morally justified in the end-of-life context, as (1) physicians have more intimate knowledge of the patient and are thus best placed to act in the patient’s best interests, (2) only the independent evaluation from well-trained and experienced physicians may rule out external or internalized pressure from the patient’s social inner circle, and (3) some patients may show impaired decision-making capacity when confronted with the end of life.

The level of society

As regards the origins and impact of euthanasia legislation on the level of society, the following four ethical themes emerged: (1) protection, (2) dignified dying, (3) solidarity, and (4) distributive justice.

First and as regards protection , some participants valued the existence of a legal framework for an ‘underground’ practice before 2002. According to them, this framework was highly needed to protect the patient against malicious practices and the physician against being charged for murder when ensuring herself that all the legal requirements are met.

So, I believe that it should be well-regulated in a state. In a country, it should be well-regulated. You can either be in favour of it, have reservations, or question it, but when it happens and many people want it or think it’s okay, then it should be regulated. And those, like me, who may be against it, have doubts about it, or wonder, “Is this really necessary?” I would say, or “Does it align with our purpose?” the existential comments that you can make about it, we must accept it because it would be terrible if it, well, it would be even worse if it happened in the underground, like before those laws were established, that’s, yeah. So, I think the laws should exist. Whether I would have made those laws is a different question, or whether I would vote for the parties in parliament that, you know, that support it, that’s another question, but apparently, here in North-western Europe, the need for those practices exists, and it should be regulated properly. And yes, it shouldn’t be left to amateurs or something like that, that’s not the intention. Yes, well, it serves to protect, both in terms of health and to ensure that it doesn’t become a business, of course. I’d prefer it to be integrated into the healthcare system rather than turning it into a profit-driven and exploitative affair for some others. So, that’s…. (psychiatric nurse)

Critical concerns were raised on the lack of protection of the most vulnerable people, i.e., the mentally ill and the elderly. Some of them referred to the amended Law in 2014, that also allowed minors to die by means of euthanasia – be it under more strict circumstances, inter alia, when based on unbearable physical suffering resulting from a medically terminal condition – and feared that the Law will be amended again, so it would no longer exclude the people suffering from dementia or for groups without serious incurable illness, e.g., the elderly with a perceived ‘completed life’.

Second, a major societal shift in thoughts regarding what constitutes dignified dying was reported. For some, the Law on Euthanasia reflects a nascent movement of death revivalism, in terms of people reclaiming control over their dying process. In this respect, euthanasia is deemed a counterreaction to the former dominant paternalistic attitude in Western society to systematically marginalise conversations on death and dying, e.g., due to the mechanisms of denial, avoidance, and postponement, and with the line between life and death increasingly held in physician’s hands, which has left many people ill-equipped to deal with dying and death. The current broad public support for euthanasia is seen as the individual patient taking back the decision-making process of dying and death in her own hands. They further considered euthanasia as a logical consequence of living an artificially prolonged life due to e.g., advances in medicine, that have not necessarily enhanced the quality of life.

“ One thing I also consider is that a part of our lives is artificially prolonged, you know. We don’t live longer because we are healthier, but because we have good pills or better surgical procedures, so we can afford to buy our health. So that part of life is still valuable to me, it’s not less valuable, but it’s artificially extended. So, I think we should keep that in mind, that we can prolong something artificially and maybe even go beyond a point where it no longer works. Interviewer: Beyond the expiration date? That’s what I was looking for (laughs). So, in that sense, I believe we should keep in mind that we can artificially extend something and then maybe, even if it’s just that artificial part, stop or be allowed to stop when the person no longer wants to, I think that makes perfect sense. ” (psychiatrist)

Others provided arguments against the increased death revivalism, referring to euthanasia as a ‘fast-track to death’ resulting in ‘the trivialisation of death’ in the face of formerly known and experienced Art of Dying. For instance, the current societal tendency to avoid suffering and the fear of dying may lead to patients (too quickly) resigning from a slow track to death, in which there is time to e.g., hold a wake.

But I won’t just grab a syringe, fill it up, and administer a lethal injection, you know? I follow the symptoms. And if they become uncomfortable, then I’ll increase the dosage so they can rest peacefully and not have to suffer. That’s what I call a dignified death. And if the family can be present, sometimes it takes a while for them to arrive, and they’ll say, “Come on, even a dog is not allowed to suffer that long.” Meanwhile, the person is just lying peacefully. But that too. Everything should, even that, should progress, and there isn’t much time left for vigil and, yes, I don’t want to romanticize it, but sometimes you see so much happening between families. There’re all kinds of things happening in those rooms, with the family, reconciliations being made. Memories being shared. “Oh, I didn’t know that about our father.“, an aunt walking in and telling a story. Well, so much still happens. I don’t want to romanticize it, but to say that all that time is useless, that’s not true either. And at the farewell, there’s always, the time, you think there’s time for it, but people are still taken aback when an infusion is given, that it can happen within a minute, even if they’re behind it and have been informed beforehand. Just a minute… and it’s done. The banality of death, it’s almost like that. (psychiatrist)

These and other participants also criticised ‘the romanticised image of euthanasia’, that masks the economics of the death system, taking financial advantage of ‘patients not wanting to be a burden to society’.

Third and consequently, divergent discourses on the value of solidarity emerged. For some, decades of civic engagement pointed to the need of death revivalism and patient empowerment, that resulted in the current legal framework. Others strongly criticised the lack of solidarity underpinning the legal framework on the following three counts: 1) the emphasis on patient autonomy is deemed a ’societal negligence in disguise’, as citizens are no longer urged to take care of others, 2) equating autonomy and dignity in euthanasia debates leads to the trap of viewing the ill or the elderly as having ‘undignified’ lives, and 3) wealth over health has become the credo of the current neoliberal society, as the Law on Euthanasia discourages further investments in health care but settles on the ‘commodification’ of health care.

“ I believe that we should take care of each other and especially care for the most vulnerable in our society. We shouldn’t just leave them to fend for themselves. I don’t think the motto should be all about autonomy, autonomy, and then the flip side, saying, “figure it out on your own.” That’s not acceptable. We have a responsibility to take care of each other. We are meant to care for one another. In biblical terms, we are each other’s keeper, right? “Am I my brother’s keeper?” Yes, I am my brother’s keeper. I must take care of each other, take care of others. So, I think in the long term, speaking maybe 100 years from now, people might say, “Sorry, that was a real mistake in the way they approached things.” I don’t know, but that’s looking at it from a meta-level, as historians call it, “longue durée,” and combining it with a neoliberal model, right? Neoliberalism and euthanasia thinking, it would be interesting to do a doctoral thesis on how they fit together perfectly. How they fit together perfectly… They are no longer patients, they are no longer clients, and I also don’t like the word ‘clients.’ They have become ‘users’. Sorry, but that’s our Dutch translation of the English word ‘consumers’ right? It’s like buying Dash detergent or a car; you buy care, just like the Personal Budget for people with disabilities. You buy your care, sorry, this goes against the very essence of what care fundamentally is. Care is a relationship between people; it’s not something you buy. It’s not something you say, “It’s a contract, and I want that.” It doesn’t work like that. [raising voice] The burden is on society. [end of raising voice] And when the money runs out, you have nothing left. If you can’t buy it, then it doesn’t come. “Here’s your little package,” that’s how it’s translated, and it’s always a hidden cost-cutting operation, let’s be very honest about it, a nice story, but it’s always a hidden cost-saving measure. I see right through that story, but well, big stories are always told, and they are always about saving money. [raising voice] It doesn’t bring anything, right? [end of raising voice] People’s self-reliance, they must stay at home, etc. How many people would benefit from going to a care centre, not at the end of their lives, but just because they feel totally lonely at home, but they can’t get in because nobody wants them there, as they don’t bring any profit. ” (spiritual caregiver)

Fourth, critical concerns were expressed concerning the lack of (distributive) justice due to the many existing misperceptions and misconceptions regarding medical end-of-life options that need to be uncovered. For instance, many people would be unaware of euthanasia and palliative sedation can both be dignified ways of dying, with euthanasia functioning as a fast-track and palliative sedation functioning as slow track to death. Also, the evolution of death literacy was contested: there was a sense that patients did not become more death literate, as many of them have insufficient knowledge of the content of the many end-of-life documents in circulation.

Yeah, I mean, you see, and I hear many people saying, “My papers are in order.” I won’t say every day, but I hear it almost every day, “My papers are in order.” That’s also something. It’s an illusion of control, right? Because what papers are they talking about? “My papers are in order.” When you ask them about it, they themselves don’t really know what that means, some kind of ‘living will’, ‘an advance care plan’, but yeah, with all… A living will or advance care plan is not that simple either, and then they think, “Oh, if I get dementia and I don’t recognize anyone anymore, they will give me an injection.” Ah yes, but then we are in a different domain, and that’s a whole other… But yeah, people are not well-informed, I find. They have totally wrong ideas and sometimes fear the wrong things, don’t know what is possible and what is not, and they also let themselves believe all kinds of things. Well, there are many misconceptions out there. (psychiatrist)

Participants’ ethical considerations regarding the additional procedural criteria for people with a non-terminal illness

As can be seen from the coding structure in Table  3 , participants made use of the principle justice to motivate their stance on additional (procedural) criteria that people with a non-terminal illness must meet before euthanasia can be carried out, in comparison with people with terminal illness. Those in favour of the additional procedural criteria referred to the differences between the terminally ill and the non-terminally ill regarding the aspect of content (i.e., the difference between general life expectancy and healthy life expectancy) and the aspect of time (i.e., the probability verging on certainty concerning the terminally ill versus the rough estimation concerning the non-terminally ill). Some of them also referred to the legal proceedings and stated that the Law was meant only for people with terminal illnesses to die by means of euthanasia. Others were of the opinion that it concerns only an arbitrary difference due to 1) the vagueness of the concept ‘naturally foreseeable’, i.e., suffering from a terminal illness, and the subjectivity of the calculated course and prognosis of e.g., degenerative somatic illnesses and dementia. A few participants said that this is beside the question, as one’s individual carrying capacity trumps the course and prognosis of an illness.

Participants’ ethical considerations regarding adults with psychiatric conditions

As can be seen from the coding structure in Table  4 , when asked about participants’ stances on euthanasia in the context of psychiatry, we distinguished value-based themes at the level of (1) the patient, (2) the field of psychiatry, and (3) society in general.

The level of the patient

Justice was the main value-based principle that emerged at the level of the patient. Participants in favour of not legally amending additional procedural criteria in the context of psychiatry stated that every patient with a non-terminal illness should receive equal end-of-life care options. The main counterargument given concerned the differences in patient profile, as some questioned whether the mentally ill can meet the legal criteria or stated that extreme caution is needed and thus additional criteria are in place due to the factor of e.g., ambiguity, impulsivity, and manipulation in the mentally ill.

“I find, the way the procedure is conducted for psychiatric suffering, I find it only natural that they handle it more cautiously because it’s indeed less… It’s not so easy to determine everything, is there really no other option left? And then I understand somewhere that time must be taken to investigate all of that. Because some of these people can be very impulsive, and that impulsivity needs to be addressed somewhere, of course. You also have people who can use their setbacks in the sense of, ‘I’ve been through all that, so I deserve euthanasia.’ And those are the people you need to single out because that’s just… I think those are also people who, with the necessary guidance, can still get out of it. Do you understand? It’s a form of self-pity, in a way. I think there might be resilience there, but they haven’t tapped into it themselves yet; it’s a kind of deflection or something. People with a history of, who say ‘I’ve experienced this and that, so I don’t need it anymore, just give me euthanasia, I deserve that. I’ve been through all that.’ While maybe, if they see, that’s still worth something to me, who knows, maybe that can still happen. They’re people who give up a little too quickly.” (Moral consultant)

Regarding the field of medicine, the following four value-based considerations emerged: (1) justice, (2) responsiveness to suffering, (3) protection, and (4) proportionality.

First, and as regards the principle of justice , participants in favour of equal procedural criteria for all non-terminally ill pointed to the indissociable unity of soma and psyche. A few physicians went one step further and reported that some psychiatric conditions can be considered terminal, e.g., suicidality, or predominantly of somatic nature, e.g., anorexia. The main counterarguments in this respect were (1) the firm belief in the inexistence of irremediableness in psychiatry (only mentioned by some physicians) or (2) that more caution is needed due to the higher level of subjectivity in terms of diagnostics, prognosis, and outcome.

Second, arguments against the distinction between the somatically versus the mentally ill were based on the attitude of responsiveness to the extreme extent and duration of mental suffering that can also render the mentally ill in a medically futile situation and the field of psychiatry empty-handed.

And many of the psychiatric patients I see suffer more than the average ALS patient who has to endure it for three years. In my experience, we’re less advanced in psychiatry compared to most other medical fields. You can easily say “we don’t know” in other areas of medicine and people will understand, but when it comes to psychiatric conditions, it’s different. Doctors might admit “it’s not working” or “there’s no trust,” and they might refer patients elsewhere or even refuse further appointments. I’ve even told a judge during a forced admission, “There’s simply no treatment available.” Yes, sometimes it’s just over and society must accept that there’s no solution. I’m not saying euthanasia is the solution for everyone, but I think it can be an option for some people. (Psychiatrist)

Other participants were not blind to the deep suffering, but strongly believed in the ground principle and core strength of psychiatry, namely the beneficial effect of hope. In addition, they pointed to the differences in the nature and course of somatic versus psychiatric illnesses when stating that considerably more time is needed in psychiatry, with inclusion of the therapeutic effect of hope to become effective.

“And I also believe that collectively, within psychiatry, we can and must provide additional support to endure profound despair. So, even in the face of seemingly endless hopelessness, we must maintain hope, look towards the future with trust, and continuously offer encouragement to those who feel hopeless. Our unwavering optimism and support convey the message that together, we can overcome. Because individuals who suffer from severe mental illness are treatable, I consider myself to be a genuinely optimistic psychiatrist. I have witnessed individuals who have harbored feelings of hopelessness and despair for extended periods, sometimes even decades, undergo profound transformations and experience significant improvement, and in some cases, complete recovery.” (Psychiatrist)

Third, participants in favour of the current legal framework reported that allowing euthanasia for the mentally ill was needed in the light of protection , as it might protect the patient against brutal suicides and also against therapeutic tenacity that more often occurs in psychiatry. Other participants in favour of, as well as participants against the current framework held a different stance on the following two counts: (1) allowing euthanasia conflicts with the aim of psychiatry to prevent suicide at all costs, and (2) the mentally ill are insufficiently protected by the Law as there are insufficient built-in safeguards against therapeutic negligence.

But usually with a psychiatric condition, death isn’t imminent. That’s the tricky part, you know? How many suicides do we have here? But anyway, I have an issue with that, using euthanasia as a kind of antidote against, well, against suicide, that’s a completely different matter. But death and psychiatry, why do we have all those government programs against suicide then? Isn’t that dying as a result of a psychiatric condition? (Psychiatrist, supportive of maintaining euthanasia option in psychiatric settings)

Fourth and as regards proportionality , a few participants with a normative stance against euthanasia in the context of psychiatry argued that psychiatric patients may not be allowed to die by means of euthanasia for as long as the field of psychiatry is under-resourced. They pointed to e.g., the lack of sufficient crisis shelters with a 24/7 availability and the lack of palliative approaches in the field of psychiatry. Instead of allowing euthanasia, they argue ‘to jolt the Belgian government’s conscience on mental health policies’. As a revolution to defeat the built-up inequalities in the field of medicine and knowing that palliative and rehabilitation initiatives in psychiatry require time.

“I oppose euthanasia in psychiatry. Compared to somatic medicine, psychiatry lags behind by 50 years. While physical pain can be managed with medication, there’s insufficient research on treatments for psychological suffering. Promising options like psilocybin and ketamine show potential in easing existential mental struggles. Magnetic stimulation can also alleviate depression, yet access remains limited. Unfortunately, these treatments are underused and under-researched. Many patients aren’t informed about these alternatives to euthanasia. It’s frustrating to see reluctance in exploring these options, especially when they offer hope to long-suffering patients. Utilizing these methods in psychiatric settings carries no risk of addiction. However, current restrictions impede access to these treatments, depriving patients of viable alternatives.” (Shortened excerpt from an interview with a psychiatrist)

When taking a societal perspective, no new arguments emerged from the respondents strongly in favour of the current euthanasia legislation, other than the main value of justice described in the subsection above. According to some, the current Law on Euthanasia busts some myths on the malleability of life and medical omnipotence, and even on psychiatric illnesses as a ‘Western phenomenon’, with e.g., depression and suicidality as a consequence of material wealth instead of a neurologic issue in the brain (only reported by some non-physicians).

There are quite a few people who consider the whole issue of the unbearable nature of psychological suffering a luxury problem, you know? They say something like, “Yeah, where are the suicide rates, to put it in equivalent terms, the lowest in the world? In Africa, because they obviously don’t have the luxury to concern themselves with that. They are already happy if they have a potato on their plate every day.” This is a viewpoint held by many, right? They call it a luxury problem, a modern, typical Western luxury problem. And perhaps there is some truth to it, right? But there are other causes of mortality there, which are much higher, such as child mortality, for example. (non-physician)

Counterarguments were also given and pointed to the value of (distributive) Justice. First, euthanasia was considered as ‘a logical but perverse consequence of systemic societal inequities’ on the one hand and the ‘further evolution towards the commodification or commercialisation of health care in individualised Western societies’ on the other. This would then lead to another vicious circle, with a rapidly growing ‘perception of vulnerable patient groups as irremediable’ and hence less likely to receive potentially beneficial treatment or other interventions. Some took a more radical stance against euthanasia in psychiatry, as they were convinced that euthanasia is nothing but ‘a perverse means to cover societal failures’. In addition, some participants with permissive stances on euthanasia in the context of psychiatry pointed to gender disparities in euthanasia requestors. This was based on the evidence that in the context of psychiatry, many more females request and die by means of euthanasia than males, and proportionally more female patient suffering from psychiatric disorders request and die by means of euthanasia compared to their fellow peers suffering from life-limiting or predominantly somatic conditions.

Finally, some respondents said that they could understand and, in some cases, even support euthanasia in some individual cases, but felt uncomfortable with its impact on the societal level. They pointed to the vicious circle of stigma and self-stigma that may impede the mentally ill to fully participate in societal encounters. In the long run, this type of societal disability may lead to vulnerable patients no longer wanting to perceive themselves a burden to society or to remain ‘socially dead’.

While considering their ethical perspectives towards euthanasia, participants weigh up various values related to and intertwining with the following levels: (1) the patient, (2) the patient’s inner circle, (3) the field of medicine, and (4) society in general. Overall, the participants shared an amalgam of ethical values on each of these four levels, regardless of their stance on euthanasia. It was mainly the interpretation of some values, the emphasis they placed on the key components underpinning each value and the importance they attach to each of the four levels, that determined their stance towards euthanasia. It was uncommon for different ethical values to be explicitly mentioned, which could distinguish distinct stances for or against euthanasia.

As regards euthanasia in the context of psychiatry, the focus has primarily been on arguments for and against euthanasia [ 23 ]. However, our study takes a more comprehensive approach, exploring the issue from a wider range of perspectives. This approach allowed us to uncover more complex insights that may have been overlooked if we had only considered it as a black-and-white issue.

Both the systematic review of Nicolini et al. [ 23 ] and our study emphasized fundamental ethical domains such as autonomy, professional duties, and the broader implications of euthanasia on mental healthcare. While our findings aligned with those of the systematic review, our inquiry delved deeper into psychiatry-specific considerations, including the influence of sudden impulses and feelings of hopelessness. This underscores the importance of healthcare professionals carefully assessing the timing and contextual aspects of such decisions within psychiatric contexts, ensuring individuals receive timely and tailored support and interventions.

Furthermore, our study extended beyond the boundaries of medical discourse, addressing broader societal ramifications. Participants engaged in discussions about ‘social death,’ a phenomenon that describes the marginalization of individuals despite their physical existence. This discussion highlighted entrenched structural inequities and societal attitudes perpetuating social alienation, particularly affecting marginalized demographics, including individuals grappling with mental health issues. Advocating for societal inclusivity and supportive measures, our study strongly emphasized the need to foster a sense of unity and respect for everyone’s worth, regardless of their circumstances.

Interpretation of the main findings

We make explicit and discuss the values corresponding to the four classical principles of biomedical ethics, in particular beneficence, non-maleficence, respect for autonomy and justice [ 31 ]. We place these values in the context of different ethical approaches, such as religious, professional, emancipatory, social, societal, and virtue-oriented approaches (see the ethical interpretation framework in OSF).

In the discussion section, therefore, the following main values and virtues are addressed: (1) the values of beneficence and non-maleficence in a religious perspective, (2) those same values in the professional context, (3) the value of autonomy in the contemporary emancipation paradigm, (4) the virtue of compassion stemming from virtue ethics theory, (5) the value of quality care in a social approach, and (6) the value of justice in societal policy contexts.

Beneficence and non-maleficence: religious perspective

In the realm of euthanasia debates, the interplay of religious beliefs and the values of ‘beneficence’ (the act of doing good) and ‘non-maleficence’ (do no harm) has emerged as a pivotal point of contention, often giving rise to divergent perspectives on this complex ethical issue [ 32 , 33 ]. Some religious traditions staunchly oppose medical end-of-life decisions, including euthanasia and abortion, viewing them as morally wrong and as disruptive to the natural order of life and death. The principle of ‘sanctity of life’ forms the bedrock of their belief system, underscoring the significance they attach to preserving life at all costs, as an embodiment of beneficence [ 34 , 35 ]. Conversely, those who argue for the ethical consideration of euthanasia emphasize the concept of beneficence in alleviating suffering and granting autonomy to individuals in their final moments. However, intriguingly, our examination of the topic has revealed a nuanced relationship between religious beliefs and attitudes toward euthanasia. While some individuals in our sample expressed strong religious convictions ( n  = 5) and even considered themselves as practicing Catholics, they did not necessarily adopt a firm normative stance against euthanasia, signifying a complex balancing of beneficence and possible maleficence within their belief system. Conversely, certain participants who held steadfastly against euthanasia ( n  = 3) did not identify with any religious belief system, yet their position was firmly grounded in their perception of potential maleficence associated with medical intervention in life and death decisions. This observation aligns with recent studies highlighting the intricate and multifaceted nature of religiosity, where individuals within various religious frameworks may hold diverse beliefs and values surrounding beneficence and non-maleficence [ 36 , 37 ]. Moreover, it underscores the powerful influence of societal culture on shaping personal perspectives on euthanasia, and how these views are entwined with the values of beneficence and non-maleficence [ 36 , 37 ].

Beneficence and non-maleficence: professional values

Second, a profound division arises between proponents and opponents, particularly in the field of medicine, where interpretations of the Oath of Hippocrates play a central role. At its core, the Oath emphasizes the deontological values of beneficence and non-maleficence, as physicians are bound by a prohibition against administering a deadly drug to ‘anyone,’ even at their explicit request, highlighting the reverence for the sanctity of life inherent in medical practice. This interpretation has led some to perceive active euthanasia as contrary to these sacred principles of preserving life. The notion of beneficence, understood as promoting the well-being of patients, appears to be in tension with the act of intentionally ending a life. Critics argue that euthanasia undermines the fundamental duty of physicians to protect and preserve life. Additionally, the principle of ‘non-maleficence,’ which entails not harming the patient or their life, is seen by some as being in accordance with the ‘sanctity of life’. However, the Oath also recognizes the significance of alleviating relentless suffering, opening the door to a nuanced debate on how these timeless principles align with the modern concept of euthanasia. As the discourse unfolds, perspectives emerge, with some viewing euthanasia as a compassionate form of care, that respects the autonomy and dignity of patients facing terminal illness or unbearable suffering. Advocates argue that euthanasia can be an act of beneficence, providing relief from pain and allowing individuals to die with dignity and control over their own fate. On the other hand, opponents of euthanasia steadfastly uphold the sanctity of life principle, viewing it as an ethical imperative that must not be compromised. They argue that intentionally ending a life, even in the context of relieving suffering, undermines the fundamental values of medical ethics and the intrinsic worth of every human life. For these individuals, euthanasia represents a profound ethical dilemma that conflicts with the near sanctity of medical ethics and the value of preserving life [ 38 , 39 , 40 ].

Autonomy: contemporary emancipation paradigm

The principle of autonomy emerges as one of the most prominent and contentious values in our contemporary emancipation paradigm. Autonomy, grounded in the belief in individual self-governance, is often cited as a foundational ethical principle in euthanasia legislation, emphasizing the significance of an individual’s capacity to make choices aligned with their own personal values and desires [ 31 ]. However, the discussion on autonomy extends beyond pure individualism, with considerations for relational autonomy, recognizing that individuals are not isolated entities but are shaped by their relationships, communities, and broader societal structures [ 41 ]. Within the context of euthanasia, the complexities of autonomy become evident as participants in the debate strived to find a delicate balance. On one hand, they stress the importance of respecting a patient’s individual autonomy in end-of-life decisions, ensuring that their choices are honoured and upheld. Simultaneously, they acknowledge the necessity of accounting for the patient’s social context and broader community when considering euthanasia as a compassionate option. Nevertheless, concerns are raised by some about the potential risks posed by euthanasia legislation, particularly for the most vulnerable individuals, such as the elderly and the mentally ill. These concerns centre on the negative consequences that may arise when individual autonomy is exercised without consideration for others or for societal well-being, and the concept of “social death,” which refers to the marginalization and exclusion of individuals from social relationships and networks due to illness or disability [ 42 , 43 ].

Amidst these complexities, the ethical value of autonomy stands as a paramount consideration. However, its application necessitates thoughtful consideration and balance with other values, including justice, equality, and societal responsibility. Recent reflections on “relational autonomy” have prompted critical evaluations of the idea of pure autonomy, emphasizing the need to delve deeper into the micro, meso, and macro levels that underpin autonomy and address potential conflicts between individual and relational autonomy [ 44 ]. Further, it highlights the imperative to take the broader societal context into account when grappling with the ethical challenges associated with euthanasia [ 45 ].

Compassion: virtue ethics

Our study confirms that while the value of autonomy holds importance, it is not the sole determinant in the ethical considerations surrounding euthanasia [ 46 ]. In this complex discourse, numerous other ethical values and virtues come to the fore, including the significance of compassion towards suffering individuals and the imperative of alleviating their distress. Notably, compassion is not merely a singular principle, but rather a profound ground attitude or virtue that motivates individuals to empathize with the pain of others and take actions to provide relief.

As revealed in our research, participants who opposed euthanasia did not invoke religious frameworks; instead, they explored diverse philosophical approaches to comprehend suffering and compassion. Among these, non-Western philosophies emphasized embracing suffering as an intrinsic aspect of life, acknowledging the impermanence of all things, including suffering. Additionally, the existentialist perspective of Albert Camus underscored suffering’s innate connection to human existence, leading to deeper self-understanding and comprehension of the world.

These philosophical viewpoints find relevance in the realm of ethics as well. Virtue ethics, in particular, highlights the significance of cultivating virtues such as courage and resilience, while narrative ethics emphasizes storytelling as a means to gain profound insight and reflection on experiences of suffering [ 47 , 48 ]. Such narratives foster empathy and create a shared sense of experience and community.

Our results show that, for some, suffering may hold positive value in various ways. The nature and intensity of suffering, alongside an individual’s values and virtues, beliefs, and coping capacity, significantly influence the ethics of euthanasia decision-making. An intricate approach that recognizes the multifaceted impacts of suffering becomes essential, acknowledging that various factors could potentially influence the experience of suffering as well as the interpretation of the consequences of the suffering experience. It’s possible that this approach doesn’t solely depend on the quantity of suffering or even its nature. Instead, it could be related to the delicate balance between one’s ability to endure suffering, the burden it places on them, and the (ir)remediableness of this burden, which can vary greatly among individuals as well as it might change over time. Such an approach aims to alleviate relentless suffering and, in certain cases, relieve unnecessary and enduring distress without consistently imposing interpretations upon it. Thus, acknowledging that, experiences of suffering are inherent to life and might act as drivers for personal development, fostering resilience, empathy, and a deeper apprehension of life’s essence, while it also might represent something irremediable, underscores the significance of a broader meaning of the concept of compassion as guiding principle in euthanasia discussions. These discussions further extend to the recognition of the dynamic trajectory inherent to the burden of suffering, as well as its potential for temporal evolution within the individual experiences of the afflicted. Such recognition not only fosters a more intricate understanding of the complex interplay between suffering and resilience but also highlights the acknowledgment that there may be moments when suffering becomes unendurable, surpassing the individual’s capacity to cope. This dimension introduces a layer of intricacy to the ethical considerations inherent in these discussions, thus necessitating a nuanced approach that contemplates the potentialities as well as the constraints of human endurance and the associated ethical ramifications.

Quality care: social approach

Examining euthanasia debates from a sociological perspective sheds light on the influence of societal inequalities in healthcare access and quality on the practice of euthanasia, and how it can shape personal, relational, and societal values, leading to the normalization or culturalization of euthanasia [ 49 ]. A noteworthy finding in this context is the contrasting perspectives on the evolving process of dying, transitioning from being perceived as in God’s hands to a more medical realm, where proponents of euthanasia view medicine as a catalyst for granting individuals greater control over the timing, manner, and circumstances of their own deaths. They envision the opportunity to be surrounded by loved ones and maintain consciousness while embracing the option of euthanasia, which they believe improves the quality of life at the end.

Proponents also emphasize additional benefits, such as enhanced transparency and regulation, ensuring ethical conduct through regulatory measures. They express concerns about a cultural environment where certain physicians adopt paternalistic attitudes and resist accepting death, prioritizing the extension of life as a moral imperative. In contrast, critical voices argue that death and dying have become increasingly medicalized, leading to their institutionalization. Some critics further contend that this medicalization has devalued the dying process and commodified life itself, leading patients, and families to increasingly rely on medical interventions at life’s end.

Moreover, as shared by some of the interviewees, the growing acceptance of medical assistance in dying may raise concerns. It’s conceivable that this evolving attitude could contribute to a perception of death undergoing a shift in seriousness, resulting in decisions about one’s life conclusion being made with less comprehensive thought and insufficient reflection. Consequently, this scenario could potentially lead individuals who are more susceptible to experiencing feelings of life’s insignificance, weariness, or sense of being ‘through with life’, to lean towards considering euthanasia. However, this inclination might also be driven by a lack of sufficient access to the necessary, long-term quality mental health care that would otherwise facilitate the pursuit of a life imbued with adequate significance, comfort, and dignity, achievable through appropriate (mental) healthcare.

Earlier research indicates that Belgium’s psychiatric care system has been grappling with underfunding and fragmentation, leading to individuals falling through the gaps in the mental health safety net [ 50 ]. One critical aspect is, e.g., the inadequate investment in long-term, intensive care, which is precisely the kind of support that individuals grappling with such existential questions may require.

Hence, in the context of euthanasia debates, the value of quality care emerges, encompassing the principle of beneficence, which emphasizes the obligation to provide good care and enhance the overall well-being of individuals. Ethical considerations go beyond the individual’s right to autonomy, extending to societal factors that influence healthcare practices and attitudes towards euthanasia. Addressing the impact of healthcare disparities and the medicalization of dying becomes imperative to ensure ethical and compassionate decision-making that upholds the true value of quality care and respect for human dignity.

Justice: societal policy contexts

In the context of euthanasia in somatic versus psychiatric medicine, ethical considerations regarding euthanasia often revolve around the fundamental value of justice [ 23 , 51 , 52 ]. Some respondents in our study emphasized the need for parity between somatic and psychiatric illnesses, recognizing that there should be no distinction between patients suffering from either. They argued that upholding the principle of justice demands equal treatment and recognition of the suffering experienced by individuals with psychiatric illnesses.

However, for others, achieving justice requires acknowledging and addressing the unique challenges faced by patients predominantly suffering from psychiatric illnesses. A comprehensive and integrated healthcare approach is proposed, where mental health is regarded as an integral part of overall health. This approach involves allocating the same level of attention and resources to psychiatric medicine as given to somatic illnesses, aiming to combat stigma and discrimination towards individuals with psychiatric conditions. Equitable treatment during life and at the end of life becomes the focus.

Yet, the Belgian context of psychiatry presents significant challenges. The field is characterized by underfunding and fragmented care, particularly for individuals with longstanding and complex psychiatric problems [ 53 ]. Additionally, the end-of-life care for psychiatric patients is still underdeveloped, and palliative psychiatry is in its early stages, lacking a uniformly agreed-upon definition or clear implementation guidelines [ 54 ]. In response, Belgium is exploring the “Oyster Care” model, designed to provide flexible, personalized care for individuals with severe and persistent mental illness who may be at risk of neglect or overburdened by psychiatric services [ 55 ]. This model aims to create a safe “exoskeleton” or supportive environment for patients, recognizing that recovery, reintegration, and resocialization might not be attainable for everyone with certain psychiatric conditions [ 55 ].

However, the integration of Oyster Care in today’s psychiatric practice is still limited and requires further development. Emphasizing the value of justice calls for continued efforts to enhance and refine psychiatric care, ensuring that individuals with psychiatric illnesses receive equitable treatment throughout their lives, including end-of-life care decisions [ 55 , 56 ].

Implications for future research, policy, and practice

In terms of policy and practice, our findings indicate that the discourse surrounding euthanasia extends beyond legal or medical considerations and encompasses fundamental ethical values that underpin our society. These values may not always be aligned and can create ethical dilemmas that are challenging to address. A value-centred approach to the euthanasia debate necessitates a constructive ethical dialogue among various actors involved, including patients, healthcare practitioners, and the wider community. This conversation should strive to comprehend the diverse values involved and endeavour to achieve a balance between these values. Additionally, ethical dialogue might encourage individuals to reflect on their own assumptions and beliefs, leading to more informed and thoughtful decision-making on ethical and moral issues. Ultimately, ethical dialogue can promote a more just and equitable society that prioritizes empathy, understanding, and mutual respect.

It is also crucial to acknowledge that patients with somatic illnesses and those with psychiatric illnesses may have different needs and expectations regarding the end of life. Hence, end-of life healthcare must be sensitive to the unique needs of each group. This recognition of differences does not justify unequal treatment or discrimination based on the type of illness. Instead, it involves addressing the different needs and expectations of each patient group while ensuring equitable and high-quality care for all.

As regards research, most articles on euthanasia legislation to date placed the emphasis on what other countries and states can learn from the Belgian and Dutch euthanasia practice. In addition, what can be learned is mainly restricted to the evidence and reflections on factual issues from a global practical-clinical perspective. Consequently, one of the main ethical, clinical, and societal issues remains unrequited, namely the impact of legislation and its consequences on an intrapersonal, interpersonal, medical, social, and societal level. Although cultural diversity is recently put high on the research agenda concerning general health care and mental health care, it is largely understudied in the context of end-of-life decisions and largely ignored in the context of psychiatry. Fewer articles have focused on what the latter countries may learn from those not implementing or not considering euthanasia legislation. In an increasingly diverse society, rapidly evolving in terms of fluidity and multi-ethnicity, cross-cultural research can help us learn from one another. To address the many dimensions of euthanasia, there is a need for input from a variety of academic fields, including sociology, anthropology, communication studies, and history. Further interdisciplinary research in all these areas could help inform policy and practice related to euthanasia.

Strengths and limitations

This is the first empirical in-depth interview study that uncovered the underlying ethical considerations of a variety and relatively large sample of health care professionals and volunteers in Belgium, a country with one of the most permissive legislative frameworks regarding euthanasia, as – unlike in some other countries – it does not exclude adults with psychiatric conditions per definition. Belgium is also one of the pioneering countries with such a legislative framework and can boast on two decades of euthanasia legislation and implementation.

We succeeded in providing a unique and representative sample of participants, varying in gender, work setting and expertise, and stances regarding euthanasia. Finally, and unlike former scientific studies that focused on either the somatic or psychiatric context, we now gauged for participants’ ethical perspectives on euthanasia in both fields of medicine.

There are also several limitations to our study. We may have experienced selection bias, as our sample of non-physicians had varying ages, but the sample of physicians was mostly older than 60. In addition, some interviews had to be postponed or cancelled due to COVID-19 restrictions and, potentially, due to legal and emotional concerns surrounding a high-profile euthanasia case being brought to court. Additionally, our sample exhibited heterogeneity regarding worldview (religious or non-religious), but possibly not regarding other culture-sensitive aspects, like migration background. As our qualitative research focused on exploring themes, narratives, and shared experiences rather than on ensuring high participation rates for statistical generalizability, drawing definitive conclusions regarding the prevalence of each opinion (pro/ambivalent/critical/against), the level of experience, or perspective across the entire spectrum of euthanasia practice is beyond the scope of our study.

Finally, although there is a growing number of countries and states around the globe with a legislative framework on euthanasia, all the legal frameworks differ from one another, so the results of our study cannot be generalized to the specific euthanasia context in e.g., Switzerland or Canada.

Our study illuminates the foundational values guiding perceptions of euthanasia, including autonomy, compassion, quality care, and justice, which permeate through four interconnected tiers: the patient, their inner circle, the medical community, and society at large. Despite varied stances on euthanasia, participants demonstrated a convergence of ethical principles across these tiers, shaped by nuanced interpretations and considerations. While explicit discussions of distinct ethical values were infrequent, their profound impact on euthanasia perspectives underscores the importance of ethical discourse in navigating this complex issue. By fostering inclusive dialogue and reconciling diverse values, we can promote informed decision-making, justice, and empathy in end-of-life care, particularly in psychiatric settings. Interdisciplinary research is essential for a comprehensive understanding of euthanasia’s dimensions and to inform policy development. While our study is rooted in Belgium, its implications extend to the broader euthanasia discourse, suggesting avenues for further exploration and cross-cultural understanding.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due reasons of privacy and anonymity, but are available from the corresponding author on reasonable request, following procedures from all 3 Medical Ethics Committees involved. To access the supplementary materials, see the Open Science Framework repository at https://osf.io/26gez/?view_only=af42caddb2554acfb7d1d5aabd4dec7a . Upon publication of this paper, the repository will be made public, and a shorter link will be provided.

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Acknowledgements

The authors wish to thank prof. dr. Kenneth Chambaere and prof. dr. Kurt Audenaert for their preliminary advice regarding the ethics of the research methodology, dr. Steven Vanderstichelen for his help with the interviews (i.e., conducting and transcribing) and all the participants for sharing their professional and in some cases also personal experiences during the interview. We’d also like to thank prof. dr. Kenneth Chambaere for the supervision during the conducting of the interviews and his feedback on the ‘near to final’ draft.

MV is funded by the Research Foundation Flanders via research project (G017818N) and PhD fellowship (1162618 N).

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The article has been developed with the following authors’ contributions: MV was responsible for the study methodology and managed ethical approval; MV conducted most of the interviews and wrote the main manuscript texts. AL drafted the ethical interpretation framework. MV, LM, KP and AL were responsible for the coding structure and data interpretation and performed a critical review and revision of the final manuscript.

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This research project was performed in accordance with the Declaration of Helsinki and the European rules of the General Data Protection Regulation. It received ethical approval from the Medical Ethics Committee of the Brussels University Hospital with reference BUN 143201939499, from the Medical Ethics Committee of Ghent University Hospital with reference 2019/0456, and from the Medical Ethics Committee of the Brothers of Charity with reference OG054-2019-20. The interviews were held after obtaining informed consent from all the participants.

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Verhofstadt, M., Moureau, L., Pardon, K. et al. Ethical perspectives regarding Euthanasia, including in the context of adult psychiatry: a qualitative interview study among healthcare workers in Belgium. BMC Med Ethics 25 , 60 (2024). https://doi.org/10.1186/s12910-024-01063-7

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To Die or Not to Die: A Kantian Perspective on Euthanasia

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The paper attempts to explore the implications of Kant's moral criticism of suicide in the case of euthanasia. The paper argues that since Kant's criticism of suicide is essentially directed towards rational beings who are in full control of their rational faculty. It would hence not be applicable in case of individuals who are suffering from dementia and who have expressed a prior desire to be euthanized in such a scenario.

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“You Got Me Into This…”: Procreative Responsibility and Its Implications for Suicide and Euthanasia

“You Got Me Into This …”: Procreative Responsibility and Its Implications for Suicide and Euthanasia

Suicide and Homicide: Symmetries and Asymmetries in Kant’s Ethics

https://www.ama-assn.org/delivering-care/ethics/euthanasia visited on 08/04/20.

Marina Budic, ‘Suicide Euthanasia and the Duty to Die: A Kantian Approach to Euthanasia’, ( 2017 ) Philosophy and Society 29, 89. Also see generally, Hazel Biggs, Death with Dignity and the Law, (Hart Publishing 2001 ), Michael Cholbi (ed), Euthanasia and Assisted Suicide: Global Views on Choosing to End Life (Praeger, 2017 ), Helga Kushe, Udo Schuklenk and others (ed), Bioethics an Anthology (3rd ed, Wiley Blackwell, 2016 ); Ora O’Neil, Autonomy and Trust in Bioethics, (CUP, 2002 ).

Robert Young, Voluntary Euthanasia, Stanford Encyclopaedia of Philosophy (Spring 2020 Edition) Edward N Zalta (ed) at https://plato.stanford.edu/archives/spr2020/entries/voluntary/ visited on 08/04/20.

cf Budic (note 2) 90.

For example, in India, there were two forms of altruistic suicide- Jauhar and Sati. Jauhar or mass suicide, was practiced by women when their male counterparts were defeated in battle. Suicide in such situation was undertaken to avoid rape, enslavement and other retributions against them. In Sati, the wife would immolate herself on the funeral pyre of her husband. While sati is often justified on religious grounds, there is a possible economic angle to it as well. See generally, Lakshmi Vijay Kumar, “Altruistic Suicide in India’, 2010 Arch Suicide Res 8, 73–80.

The ‘sanctity of life” theory as a prohibition against suicide can be found in the works of classical thinkers like Plato and Socrates. For Plato, the act of suicide represented the act of releasing our soul from our bodies. Suicide under religious heads were regarded as sins. For example, early and medieval Christianity also used religious precepts to prohibit suicide. For, example the often-quoted command from the Old Testament, “Thou shall not kill’, was taken to be forbidding self-destruction. Similar views can be found in Islam, Hinduism and Buddhism. See generally, Michael Cholbi, Suicide, The Stanford Encyclopaedia of Philosophy (Fall 2017 Edition) Edward N Zalta (ed) at https://plato.stanford.edu/artchives/fall2017/entries/suicide/ visited on 08/04/2020.

The Greek philosopher Seneca believed that it was better to kill oneself than to live with failing capacities. For example in one of his works he observed “I will not abandon old age, if old age preserves me intact as regards the better part of myself; but if old age begins to shatter my mind, and to pull its various faculties to pieces, if it leaves me not life, but only the breath of life”. Seneca, “58th Letter to Lucilius,” trans. R. M. Gummere, in T. E. Page et al. (eds.).

Mark Timmons, Moral Theory an Introduction (2nd edn, Rowman and Littlefield Publishers, 2004 ) 2010.

Young (note 5).

Andrews Reath, Kant’s Conception of the Autonomy of the Will, in Oliver Sensen (eds), Kant on Moral Autonomy (Cambridge 2013) 33.

Timmons (n 10) 207.

The idea that dignity consist of the inherent worth of an individual is also commonly associated with the idea of human rights. All international human rights instruments endorse directly or indirectly the “inherent dignity’ of an individual as the source of human rights. However, for a contrary opinion see Oliver Sensen, who argues that Kantian dignity is based on the concept of dignity by which he means that it is not a distinct metaphysical property, that itself dignity is not a source of rights, and dignity is primarily about duties to oneself. Oliver Sensen, Kant on Human Dignity ( 2011 Deutsche Nationalbibliothek) 161.

Christopher McCrudden, ‘Human Dignity and Judicial Interpretation of Human Rights’( 2008 ) 19 EJIL 655, 659.

See generally, Rachel Bayefsky, Dignity, Honour, and Human Rights: Kant's Perspective , ( 2013 ) 41 Political Theory 809, 816.

Jeniffer. E. Bulcock, ‘How Kant would Chose to Die’ (Master’s Thesis, University of New Hampshire Durham, 2006 ).

By hypothetical imperative Kant refers to all those external forces of causality that derives its validity as an object of desire, and therefore is of a conditional nature.

Immanuel Kant, Lectures on Ethics, ed. Peter Heath and J.B. Schneewind. (New York: Cambridge University Press, 1997), 148.

Kerstein Samuel, Treating Persons as Means’, The Stanford Encyclopedia of Philosophy (Summer 2019 Edition), Edward N. Zalta (ed.), URL =  <  https://plato.stanford.edu/archives/sum2019/entries/persons-means/  > . Accessed on 22/09/20.

For example, Kant observes “There is thus lodged in man an unlimited capacity that can be determined to operate in his nature through himself alone, and not through anything else in nature. This is freedom, and through it we may recognize the duty of self-preservation” Lectures (note 24) 144.

Rachel (note 21) 814.

Rachel (note 21) 816–819.

Lectures (n 24) 147.

Yost, Benjamin S. “Kant’s Justification of the Death Penalty Reconsidered”, 2020 Kantian Review 15.

Sharp, Robert, “The Dangers of Euthanasia and Dementia: How Kantian Thinking Might be used to Support non-voluntary euthanasia in cases of extreme dementia”, 2012 Bioethics 26, 231–235.

Questions regarding capacity and consent and also those for determining at a what particular stage a person lose the capacity to make decisions for himself are mostly empirical enquiries. Existing laws on mental capacity presumes that a patient has the capacity to make decisions and that decisions taken by him with regard to his treatment (stopping) are taken in full understanding of the consequences. However, existing literature suggests this might not always be the case. See, Colin Gavaghan, Capacity and Assisted Dying in Michael Cholbi (ed), Euthanasia and Assisted Suicide: Global Views on Choosing to End Life ( 2017 Praeger); S Natalie Banner, “Can Procedural and Substantive Elements of Decision- Making be Reconciled in Assessments of Mental Capacity?”( 2013 ) International Journal of Law in Context 9, 71–86.

Brassington Iain “Killing people: what Kant could have said about suicide and euthanasia but did not”, 2006 Journal of Medical Ethics 32, 571–574.; Dennis Cooley, “A Kantian Moral Duty for the Soon-to-be Demented to Commit Suicide”, ( 2007 ) AJOB 7, 37–44; Sharp, Robert, “The dangers of euthanasia and dementia: how Kantian thinking might be used to support non-voluntary euthanasia in cases of extreme dementia”, (Sharp 2012 ) Bioethics 26, 231– 235.

Dennis Cooley, “A Kantian Moral Duty for the Soon-to-be Demented to Commit Suicide”, ( 2007 ) AJOB 7, 37–44.

Sharp (note 50) 232.

Cooley (note 54) 37–44.

Sharp (note 50) 234. For similar claims see Joshua Beckler, ‘Kantian Ethics: A Support for Euthanasia with Extreme Dementia’, 2012 CedarEthics Online 16.

Sharp (note 50) 234. Kant’s duty of beneficence flows from his duty to others regarding their happiness. Kant regards such duties as imperfect duties or duties of commission. It includes the duty to cultivate the virtues of beneficence, gratitude and sympathy.

Ibid 235–245.

Cholbi, Michael ( 2014 ), “Kant on Euthanasia and the Duty to Die: Clearing the Air”, Journal of Medical Ethics, 2014 Bioethics 41, 607–610.

Sharp (note 50) 234.

See Cholbi’s criticism against this line of thought. Cholbi (note 62) 609.

Ibid 607. Cholbi claims (in a footnote) that Cooley’s assumption of Kantian duty to die is also based on an erroneous reading of Kant. He argues that while Kant considers it heroic for someone to sacrifice herself to save her honor, the act still violates her humanity. Thus, disallowing the possibility of a duty to die.

Rachel (note 27) 824, 25.

Bayefsky, R. (2013). Dignity, honour, and human rights: Kant’s perspective. Political Theory, 41 , 809–816.

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Beckler, J. (2012). Kantian ethics: A support for euthanasia with extreme dementia. Cedar Ethics , 16 , 1–7.

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Brassington, I. (2006). Killing people: What Kant could have said about suicide and euthanasia but did not. Journal of Medical Ethics, 32 , 571–574.

Budic, M. (2017). Suicide euthanasia and the duty to die: A Kantian approach to Euthanasia. Philosophy and Society, 29 , 88–114.

Bulcock, J. E. (2006). How Kant would chose to die . Master’s Thesis, University of New Hampshire Durham.

Cholbi, M. (2014). Kant on Euthanasia and the duty to die: Clearing the air. Journal of Medical Ethics, Bioethics, 41 , 607–610.

Cholbi, M. (Ed.). (2017). Euthanasia and Assisted Suicide: Global Views on Choosing to End Life . Praeger.

Cholbi, M. Suicide, The Stanford Encyclopaedia of Philosophy (Fall 2017 Edition) E. N Zalta (Ed.). Visited on 08/04/2020. https://plato.stanford.edu/artchives/fall2017/entries/suicide/

Christopher, M. (2008). Human dignity and judicial interpretation of human rights. EJIL, 19 , 655–659.

Colin, G. (2017). Capacity and assisted dying. In M. Cholbi (Ed.), Euthanasia and assisted suicide: Global views on choosing to end life. Praeger.

Dennis, C. (2007). A Kantian moral duty for the soon-to-be demented to commit suicide. AJOB, 7 , 37–44.

Hazel, B. (2001). Death with dignity and the law . Hart Publishing.

Helga, K., Schuklenk, U., et al. (ed). (2016). Bioethics an anthology (3rd ed.). Wiley Blackwell.

Natalie Banner, S. (2013). Can procedural and substantive elements of decision-making be reconciled in assessments of mental capacity? International Journal of Law in Context, 9 , 71–86.

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Timmons, M. (2013). Moral Theory an Introduction (2nd ed.). Rowman and Littlefield Publishers.

Vijay Kumar, L. (2004). Altruistic suicide in India. Archives of Suicide Research, 8 , 73–80.

Yost, B. S. (2010). Kant’s justification of the death penalty reconsidered. Kantian Review, 15 , 1–27.

Young, R. Voluntary Euthanasia, Stanford Encyclopaedia of Philosophy (Spring 2020 Edition). In E. N. Zalta (Ed). Visited on 08/04/20. https://plato.stanford.edu/archives/spr2020/entries/voluntary/ 〹

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Sinha, N. To Die or Not to Die: A Kantian Perspective on Euthanasia. J. Indian Counc. Philos. Res. 39 , 13–24 (2022). https://doi.org/10.1007/s40961-021-00265-3

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Moral dimensions

A utilitarian argument against euthanasia.

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Tannsjo is correct to observe that the same philosophical starting points can be used to arrive at very different outlooks. For example, I can use utilitarianism to oppose euthanasia.

Utilitarianism is an ethical approach that attempts to maximise happiness for society or humanity. Its founder, Jeremy Bentham, claimed that “nature has placed mankind under the governance of two sovereign masters, pain and pleasure. It is for them alone to point out what we ought to do, as well as to determine what we shall do. On the one hand the standard of right and wrong, on the other the chain of causes and effects, are fastened to their throne. They govern us in all we do, in all we say, in all we think.” (1) He deveolped the proposition thus: “it is the greatest happiness of the greatest number that is the measure of right and wrong.” However, his subsequent reflection that “it is vain to talk of the interest of the community without understanding what is the interest of the individual” supposedly threw his model into confusion. Which had become more important to him: the individual or the greatest number?

I believe he still favoured community happiness over individual happiness. After all, he believed that the role of law was to delimit autonomy, and that the creation of rights destroyed all notion of liberty. For example, in Anarchial Fallacies (2) he wrote: “The great enemies of public peace are the selfish and dissocial passions, necessary as they are, the one to the very existence of each individual, the other to his security. On the part of these affections, a deficiency in point of strength is never to be apprehended: all that is to be apprehended in respect of them, is to be apprehended on the side of their excess. Society is held together only by the sacrifices that men can be induced to make of the gratifications they demand: to obtain these sacrifices is the great difficulty, the great task of government. What has been the object, the perpetual and palpable object, of this declaration of pretended rights? To add as much force as possible to these passions, already but too strong, - - to burst the cords that hold them in, -- to say to the selfish passions, there - everywhere -- is your prey! -- to the angry passions, there - everywhere -- is your enemy.”

How might Bentham have applied these ideas to the legalisation of euthanasia? Firstly, euthanasia might eliminate physical and existential pain in the person wishing to be euthanased. It might also provide some comfort to anyone who believed that the person would be better off dead, although this sense of comfort would presumably be counterbalanced by the grief of bereavement. It would actually create emotional pain in those opposed to euthanasia, either through intimate involvement with a particular case or through a general objection to the whole principle. Secondly, a euthanased person cannot be confidently described as being in a state of pleasure. Even third parties who thought that death was the best option could hardly be described as pleased after the death: unless malicious, they would probably express regret that euthanasia seemed the most appropriate choice. Those opposed to the act from the outset would definitely be displeased. Therefore, I suggest that a chain of causes and effect that both eliminates and creates pain whilst pleasing nobody is unlikely to measure up favourably to the utilitarian standard of right and wrong as understood by Bentham. Euthanasia would not have featured as part of his delimited autonomy, and he rejected the notion of rights.

Philosophy often has a superficial softness to it, but I often find it very harsh for the simple reason that its objectivity can trivialise something very important: human feeling. For example, Bentham once said: “The question is not, "Can they reason?" nor, "Can they talk?" but rather, "Can they suffer?"” I suspect that he was not afraid of answering in the affirmative, particularly when rights, which in his eyes were misconceived notions, potentially threatened the greatest happiness of the greatest number. Whatever the outcome of the parliamentary debate on assisted dying, there will still be pain and there will still be pleasure. We must only hope that the whole process will help generate the greatest happiness of the greatest number.

(1) Bentham J. The Principles of Morals and Legislation, 1781

(2) Bentham J. Critique of the Doctrine of Inalienable, Natural Rights. From Jeremy Bentham, Anarchical Fallacies, vol. 2 of Bowring (ed.), Works, 1843.

Competing interests: No competing interests

Tips on How to Write a Euthanasia Argumentative Essay

Abortion, birth control, death sentencing, legalization of medical marijuana, and gender reassignment surgery remain the most controversial medical issues in contemporary society.  Euthanasia is also among the controversial topics in the medical field. It draws arguments from philosophy, ethics, and religious points of view.

By definition derives from a Greek term that means good death, and it is the practice where an experienced medical practitioner or a physician intentionally ends an individual's life to end pain and suffering. The names mercy killing or physician-assisted suicide also knows it.

Different countries have different laws as regards euthanasia. In the UK, physician-assisted suicide is illegal and can earn a medical practitioner 14 years imprisonment. All over the world, there is a fierce debate as regards mercy killing.

Like any other controversial topic, there are arguments for and against euthanasia. Thus, there are two sides to the debate. The proponents or those for euthanasia believe it is a personal choice issue, even when death is involved.

On the other hand, those against euthanasia or the opponents believe that physicians must only assist patients when the patients are sound to make such a decision. That is where the debate centers.

This article explores some of the important basics to follow when writing an exposition, argumentative, persuasive, or informative essay on euthanasia.

Steps in Writing a Paper on Euthanasia

When assigned homework on writing a research paper or essay on euthanasia, follow these steps to make it perfect.

1. Read the Prompt

The essay or research paper prompt always have instructions to follow when writing any academic work. Students, therefore, should read it to pick up the mind of the professor or teaching assistant on the assigned academic task. When reading the prompt, be keen to understand what approach the professor prefers. Besides, it should also tell you the type of essay you are required to write and the scope.

2. Choose a Captivating Topic

After reading the prompt, you are required to frame your euthanasia essay title. Make sure that the title you choose is captivating enough as it invites the audience to read your essay. The title of your essay must not divert from the topic, but make it catchy enough to lure and keep readers. An original and well-structured essay title on euthanasia should give an idea of what to expect in the body paragraphs. It simply gives them a reason to read your essay.

3. Decide on the Best Thesis Statement for your Euthanasia Essay

Creating a thesis statement for a euthanasia essay does not deviate from the conventions of essay writing. The same is consistent when writing a thesis statement for a euthanasia research paper. The thesis statement can be a sentence or two at the end of the introduction that sums up your stance on the topic of euthanasia. It should be brief, well crafted, straight to the point, and outstanding. Right from the start, it should flow with the rest of the essay and each preceding paragraph should support the thesis statement.

4. Write an Outline

An outline gives you a roadmap of what to write in each part of the essay, including the essay hook, introduction, thesis statement, body paragraphs, and the conclusion. We have provided a sample euthanasia essay outline in this article, be sure to look at it.

5. Write the First Draft

With all ingredients in place, it is now time to write your euthanasia essay by piecing up all the different parts. Begin with an essay hook, then the background information on the topic, then the thesis statement in the introduction. The body paragraphs should each contain an idea that is well supported with facts from books, journals, articles, and other scholarly sources. Be sure to follow the MLA, APA, Harvard, or Chicago formatting conventions when writing the paper as advised in the essay prompt.

6. Proofread and Edit the Essay

You have succeeded in skinning the elephant, and it is now time to cut the pieces and consume. Failure to proofread and edit an essay can be dangerous for your grade. There is always an illusion that you wrote it well after all. However, if you take some time off and come to it later, you will notice some mistakes. If you want somebody to proofread your euthanasia essay, you can use our essay editing service . All the same, proofreading an essay is necessary before turning the essay in.

Creating a Euthanasia Essay or Research Paper Outline

Like any other academic paper, having a blueprint of the entire essay on euthanasia makes it easy to write. Writing an outline is preceded by choosing a great topic. In your outline or structure of argumentative essay on euthanasia, you should highlight the main ideas such as the thesis statement, essay hook, introduction, topic sentences for the body paragraphs and supporting facts, and the concluding remarks. Here is a sample outline for a euthanasia argumentative essay.

This is a skeleton for your euthanasia essay:

Introduction

• Hook sentence/ attention grabber
• Thesis statement
• Background statement (history of euthanasia and definition)
• Transition to Main Body
• The legal landscape of euthanasia globally
• How euthanasia affects physician-patient relationships
• Biblical stance on euthanasia
• Consequences of illegal euthanasia
• Ethical and moral issues of euthanasia
• Philosophical stance on euthanasia
• Transition to Conclusion
• Restated thesis statement
• Unexpected twist or a final argument
• Food for thought

Sample Euthanasia Essay Outline

Title: Euthanasia is not justified

Essay hook - It is there on TV, but did you know that a situation could prompt a doctor to bring to an end suffering and pain to a terminally ill patient? There is more than meets the eye on euthanasia.

Thesis statement : despite the arguments for and against euthanasia, it is legally and morally wrong to kill any person, as it is disregard of the right to life of an individual and the value of human life.

Paragraph 1: Euthanasia should be condemned as it ends the sacred lives of human beings.

• Only God gives life and has the authority to take it and not humans.
• The bible says, Thou shalt not kill.
• The Quran states, "Whoever killed a Mujahid (a person who is granted the pledge of protection by the Muslims) shall not smell the fragrance of Paradise though its fragrance can be smelt at a distance of forty years (of traveling).

Paragraph 2: Euthanasia gives physicians the power to determine who lives and who dies.

• Doctors end up playing the role of God.
• It could be worse when doctors make mistakes or advance their self-interests to make money. They can liaise with family members to kill for the execution of a will.

Paragraph 3: it destroys the patient-physician relationship

• Patients trust the doctors for healing
• When performed on other patients, the remaining patients lose trust in the same doctor of the facility.
• Under the Hippocratic Oath, doctors are supposed to alleviate pain, end suffering, and protect life, not eliminate it.

Paragraph 4: euthanasia is a form of murder

• Life is lost in the end.
• There are chances that when tried with other therapeutic and non-therapeutic approaches, terminally ill patients can always get better.
• It is selfish to kill a patient based on a medical report, which in itself could be erratic.
• Patients respond well to advanced care approaches.

Paragraph 5: ( Counterargument) euthanasia proponents argue based on relieving suffering and pain as well as reducing the escalating cost of healthcare.

• Euthanasia helps families avoid spending much on treating a patient who might not get well.
• It is the wish of the patients who have made peace with the fact that they might not recover.

  Conclusion

In sum, advancement in technology in the medical field and the existence of palliative care are evidence enough that there is no need for mercy killing. Even though there are claims that it ends pain and suffering, it involves killing a patient who maybe could respond to novel approaches to treatment.

Abohaimed, S., Matar, B., Al-Shimali, H., Al-Thalji, K., Al-Othman, O., Zurba, Y., & Shah, N. (2019). Attitudes of Physicians towards Different Types of Euthanasia in Kuwait.  Medical Principles and Practice ,  28 (3), 199-207.

Attell, B. K. (2017). Changing attitudes toward euthanasia and suicide for terminally ill persons, 1977 to 2016: an age-period-cohort analysis.  OMEGA-Journal of Death and Dying , 0030222817729612.

Barone, S., & Unguru, Y. (2017). Should Euthanasia Be Considered Iatrogenic? AMA journal of ethics, 19(8), 802-814.

Emanuel, E. (2017). Euthanasia and physician-assisted suicide: focus on the data.  The Medical Journal of Australia ,  206 (8), 1-2e1.

Inbadas, H., Zaman, S., Whitelaw, S., & Clark, D. (2017). Declarations on euthanasia and assisted dying.  Death Studies, 41 (9), 574-584.

Jacobs, R. K., & Hendricks, M. (2018). Medical students' perspectives on euthanasia and physician-assisted suicide and their views on legalising these practices in South Africa.  South African Medical Journal ,  108 (6), 484-489.

Math, S. B., & Chaturvedi, S. K. (2012). Euthanasia: the right to life vs right to die.  The Indian journal of medical research, 136 (6), 899.

Reichlin, M. (2001). Euthanasia in the Netherlands.  KOS , (193), 22-29.

Saul, H. (2014, November 5). The Vatican Condemns Brittany Maynard's Decision to end her Life as �Absurd'.

Sulmasy, D. P., Travaline, J. M., & Louise, M. A. (2016). Non-faith-based arguments against physician-assisted suicide and euthanasia.  The Linacre Quarterly, 83 (3), 246-257.

Euthanasia Essay Introduction Ideas

An introduction is a gate into the compound of your well-reasoned thoughts, ideas, and opinions in an essay. As such, the introduction should be well structured in a manner that catches the attention of the readers from the onset.

While it seems the hardest thing to do, writing an introduction should never give you the fear of stress, blank page, or induce a writer's block. Instead, it should flow right from the essay hook to the thesis statement.

Given that you can access statistics, legal variations, and individual stories based on personal experiences with euthanasia online, writing a euthanasia essay introduction should be a walk in the park.

Ensure that the introduction to the essay is catchy, appealing, and informative. Here are some ideas to use:

• Rights of humans to life
• How euthanasia is carried out
• When euthanasia is legally allowed
• Stories from those with experience in euthanasia
• The stance of doctors on euthanasia
• Definition of euthanasia
• Countries that allow euthanasia
• Statistics of physicians assisted suicide in a given state, locality, or continent.
• Perception of the public given the diversity of culture

There are tons of ideas on how to start an essay on euthanasia.  You need to research, immerse yourself in the topic, and scoop the best evidence. Presenting facts in an argumentative essay on euthanasia will help convince the readers to argue for or against euthanasia. Based on your stance, make statements in favor of euthanasia or statements against euthanasia known from the onset through the strong thesis statement.

Essay Topics and Ideas on Euthanasia

• Should Euthanasia be legal?
• What are the different types of euthanasia?
• Is euthanasia morally justified?
• Cross-cultural comparison of attitudes and beliefs on euthanasia
• The history of euthanasia
• Euthanasia from a Patient's Point of View
• Should euthanasia be considered Iatrogenic?
• Does euthanasia epitomize failed medical approaches?
• How does euthanasia work?
• Should Physician-Assisted Suicide be legal?
• Sociology of Death and Dying
• Arguments for and against euthanasia and assisted suicide
• Euthanasia is a moral dilemma
• The euthanasia debate
• It Is Much Better to Die with Dignity Than to Live with Pain Essay
• Euthanasia Is a Moral, Ethical, and Proper
• Euthanasia Law of Euthanasia in California and New York
• Effect of Euthanasia on Special Population
• Euthanasia is inhuman
• Role of nurses in Euthanasia
• Are family and relative decisions considered during the euthanasia
• The biblical stance on euthanasia

Related Articles:

• Argumentative essay topics and Ideas
• Topics and ideas for informative essays

Get Help with Writing Euthanasia Argumentative Essay for School

We have covered the tips of writing an argumentative essay on euthanasia. Besides, we have also presented a sample euthanasia essay outline, which can help you write your essay. However, sometimes you might lack the motivation to write an essay on euthanasia, even when you have access to argumentative essay examples on euthanasia. 

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How To Write A Vivid Euthanasia Argumentative Essay?

Table of Contents

Euthanasia (good death from Greek) is the practice of intentional life ending aiming to relieve patients’ pain and suffering. The topic of its use is fiercely debated all over the world.

People have divided into two camps: some say Euthanasia is the matter of choice, even when it comes to choosing death. Another group claims that doctors mustn’t be empowered to offer death to people who may not even realize the decision they make.

Every country where Euthanasia is legal has its own specific legislative base of its use. Nevertheless, there is one aspect of this topic that unites all the people together: the issue is considered from the moral and ethical perspective.

Euthanasia argumentative essay: the basics

The topics for an argumentative essay writing are usually two-sided: voting for or against the topic, agree or disagree with the statement, choose one option or another.

Writing any argumentative assay requires highlighting both possible points of view, no matter what is your own. Remember, you should explain both sides equally correct and impartial.

So let’s take a closer look into the details…

How to write a Euthanasia thesis statement?

Before writing an essay on Euthanasia you have to think about your own attitude towards the topic. It will help you write a good thesis statement.

…Why you need it?

The thesis is the representation of the essay’s main idea. You’ll have to clarify both sides of the topic, sure. Still, you also need to express your own point of view. And that is made with the thesis statement in the first place.

You may clearly state your opinion in the thesis, like:

“Injecting a medication to a hopeless patient is a murder.”

“Taking life from a person who wants to end up sufferings is mercy.”

Also, you can try to intrigue your readers and present your thesis as a question with no answer provided right away. Like:

“Helping people die: is it murder or mercy?”

“Would you personally use your right for euthanasia if there was no chance to get better?”

Variations are welcomed.

Euthanasia essay introduction: general recommendations

Most professional essay writing services agree that writing an introduction is always the hardest thing. You get the fear of the blank paper, writer’s block, and the stress from remembering all the requirements you should ideally follow.

… Sounds familiar?

There are no reasons to be that stressed, actually. The web is full of info, interesting statistics, law variations, and personal stories.

A combination of those would be both, catchy and informative, that’s all you need for a perfect intro.

Start with some background information to help your reader understand the subject better.

What kind of info would be relevant?

• A brief definition of Euthanasia.
• When it might be allowed.
• Laws of the countries where it is permitted.
• Personal stories of friends/relatives.
• Stories of doctors and nurses.

All of that can be easily found online. Your goal here would rewrite it in your style, make it appealing to read and combined logically. End your introduction with the thesis statement. You already know how it’s done.

Specifics of Euthanasia essay main body

The main body for an argumentative essay should consist of two parts, one for each point of view. Once you express your point of view in the introduction, then it would be logical to start the main body from it.

Still, it is far from being obligatory. You may start with whatever you find more comfortable.

Like, f.e., you decide to start by talking about the positive aspects of Euthanasia. List the statements using words “firstly,” “secondly,” “moreover,” etc. Begin with the weakest argument and move up to the most solid one you have.

Provide the reader with some positive examples, including personal stories, if they fit in, try to find shreds of evidence of euthanasia practice in your country.

Here are some ideas for statements in favor of Euthanasia:

• A patient’s life can be worse than death.
• It is better to die from Euthanasia than from suicide.
• Euthanasia can help in saving budget funds. Saved money may help somebody else.
• Some people don’t want to see how their relatives suffer hopelessly.
• Death from Euthanasia can be more humane than natural.

Once you finish with the arguments for the first part, go on representing the opposite point of view. A good idea to begin the second paragraph with phrases like “on the other hand,” “the other side of the coin is,” “however,” etc.

List a couple of statements against Euthanasia. You may also search for some scandals including the illegal activity of doctors who made such decision without consulting the patient’s relatives.

Here are several ideas that might be helpful.

• Life is the primary integral right and can’t be taken away.
• If there are many organizations and measures to prevent suicides, why should we offer death to someone?
• Each aspect of Euthanasia can’t be foreseen in the law.
• It’s impossible to define who may/may not be offered the Euthanasia.
• What if the person who chose Euthanasia could recover and live the life to its fullest?

What to write in Euthanasia essay conclusion?

In conclusion, you sum up all the ideas highlighted in your essay, without adding new ones. Start with phrases like “to sum up,” “to conclude,” “in conclusion,” “on balance,” “in a nutshell,” etc.

Here you should also express your point of view and paraphrase the thesis you used in the introduction. For uttering your point, use inputs like “my point of view is,” “I strongly believe,” “I am convinced,” “to tell you the truth,” and so on.

How to create a Euthanasia essay outline?

An outline is a brief sketch of your essay. If you need to write it, select the main ideas of your work and write them down in a couple of sentences.

The sketch outline for an essay on Euthanasia may be like:

“Th work is about the problem of Euthanasia. I highlight some statements for and against the use of Euthanasia and support them with top examples. In conclusion, I explain my personal position on this question.”

The full version of an outline would look something like this…

Introduction

• Hook sentence
• Thesis statement
• Transition to Main Body
• History of Euthanasia
• Euthanasia statistics in countries where it is legal
• Impact of legal Euthanasia on people’s life
• Negative consequences of illegal Euthanasia
• Transition to Conclusion
• Unexpected twist or a final argument
• Food for thought

The use of Euthanasia argumentative essay example

This topic is pretty vast. It can be both good and bad for you. Due to the variety of topics within the issue of Euthanasia, it might be easy to find something you are genuinely interested in.

On the other hand, there are dozens of various materials, thousands of articles, and billions of opinions you should consider before writing. Sometimes it might be difficult for you to get a full picture.

Therefore, a sample of the essay on this topic is presented here. It follows all the standards of an argumentative essay and shows you how this type of work may be completed.

On balance…

I’d say that it’s great to work with such an ambiguous topic. You’ll definitely benefit from training your persuasive and analytical skills while working on this essay.

Hope you’ve found some inspiration here, good luck!

Not excited to write an essay on euthanasia? Buy argumentative essay instead! Luckily, we’ve got dozens of writers, who are 100% fit for the job. Order an essay and save time for yourself!

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Perspectives of Major World Religions regarding Euthanasia and Assisted Suicide: A Comparative Analysis

Graham grove.

1 QLD Specialist Palliative Rural Telehealth Service, Robina Hospital, Robina, QLD 4226 Australia

2 Bond University, Robina, QLD 4226 Australia

3 School of Medicine, Griffith University, Southport, QLD 4222 Australia

4 University of Sydney, Camperdown, NSW 2050 Australia

5 Renew Church Gold Coast, Gold Coast, QLD 4213 Australia

Melanie Lovell

6 HammondCare Palliative Care Services, Greenwich, NSW 2065 Australia

7 University of Sydney, Camperdown, NSW 2050 Australia

8 Institute for Ethics and Society, University of Notre Dame, Chippendale, NSW 2007 Australia

Associated Data

Not applicable.

Euthanasia and physician-assisted suicide (EPAS) are important contemporary societal issues and religious faiths offer valuable insights into any discussion on this topic. This paper explores perspectives on EPAS of the four major world religions, Christianity, Islam, Hinduism and Buddhism, through analysis of their primary texts. A literature search of the American Theological Library Association database revealed 41 relevant secondary texts from which pertinent primary texts were extracted and exegeted. These texts demonstrate an opposition to EPAS based on themes common to all four religions: an external locus of morality and the personal hope for a better future after death that transcends current suffering. Given that these religions play a significant role in the lives of billions of adherents worldwide, it is important that lawmakers consider these views along with conscientious objection in jurisdictions where legal EPAS occurs. This will not only allow healthcare professionals and institutions opposed to EPAS to avoid engagement, but also provide options for members of the public who prefer an EPAS-free treatment environment.

Introduction

Euthanasia and physician-assisted suicide (EPAS) is an important issue in contemporary societies, increasingly discussed in medical, legal and religious organisations. The topic often elicits strong opinions, with some in favour and others against the legalisation of EPAS. Several jurisdictions have legalised EPAS in one form or another in the last three decades, including the Netherlands, Belgium, Switzerland, Canada, Spain and various states of the USA and Australia (Table ​ (Table1 1 ).

Countries with some form of legal EPAS and their religious make-up

Lists countries and states that have some form of legal EPAS with details of their religious make-up. Victorian figures from the Australian Bureau of Statistics 2016. All other data from the Pew Research Center 2015 and 2018

Although understandings of EPAS vary, a widely accepted definition of voluntary euthanasia is the administration of a medication by a health professional to actively end a person's life at the competent individual's voluntary request and with their informed consent (Materstvedt et al., 2003 ). Physician-assisted suicide is the closely related concept of the prescription of a medication that, when ingested, will result in the person dying (Materstvedt et al., 2003 ). The more recently introduced terms “voluntary assisted dying” or “medical assistance in dying” describe both active voluntary euthanasia and physician-assisted suicide. Discussions about EPAS are often contextualised to people with terminal medical conditions suffering from pain and distress. Where legal, rules about who can access EPAS vary, ranging from strict criteria related to terminal illness and suffering to those with minimal regulations other than patient autonomy and capacity.

Although not the sole reason, beliefs about the ethics of EPAS are often closely connected to religious beliefs (Sharp, 2018 ). Many studies have confirmed religiosity to be one of the critical factors associated with people's opposition to the legalisation of EPAS (Chakraborty et al., 2017 ). A cursory glance at jurisdictions where EPAS has been legalised confirms that these tend towards a greater degree of secularity and atheism than the average (Table ​ (Table1). 1 ). Furthermore, in these jurisdictions, among people affiliated with a religion, a lower proportion consider their religious faith important when compared to their counterparts in other parts of the world (Hackett et al., 2018 ).

Given religious faith appears to play a significant role in defining individuals' beliefs about the ethics of EPAS, it is helpful to understand the official teachings of major religions on EPAS (Eckersley, 2007 ). The opinions of adherents of any religion may vary significantly between individuals and may sometimes be inconsistent with their religion’s specific official teachings. Likewise, views on the role of pastoral ministry and the beliefs of chaplains and spiritual care workers also vary (Carey et al., 2009 ; Newell & Carey, 2001 ). Despite this, a religious organisation's formal theological teachings do influence societal beliefs, often unconsciously, in any given society where that faith predominates (Sandu & Huidu, 2020 ). A secular Western mindset might presume that the underlying "culture" influences the religious doctrines and beliefs (Eckersley, 2007 ). However, the reverse is possibly true, i.e. cultural beliefs (both conscious and unconscious) might be influenced by the underlying majority religion (Abdulla, 2018 ). Therefore, understanding official religious teachings related to life, suffering and death will give significant insight into common and prevailing opinions on the morality of EPAS.

Although atheism is becoming more common in many Western countries, there still tends to remain a majority of citizens who identify as belonging to a particular religion (Hackett et al., 2015 ). However, in many instances, this affiliation may be nominal without a strong personal connection (Hackett et al., 2018 ). Outside the West, the situation is even more apparent, with the vast majority of people worldwide identifying with a specific religion. In much of Africa and Asia, religion is playing an increasingly important role in many people’s lives (Hackett et al., 2015 ).

Of all world religions, four stand out in terms of sheer numbers of adherents: Christianity, Islam, Hinduism and Buddhism (Hackett et al., 2015 ). Within these four religions, there are then numerous branches or denominations that vary in their specific beliefs and practices.

This article aims to review the official teachings on EPAS of these four major world religions and their principal branches by examining their primary sources of doctrine (with the translated text of the sources quoted in Table ​ Table2), 2 ), using secondary sources to aid this interpretation. Common theological threads that overlap the four religions and influence their teaching on EPAS will then be sought. Finally, the implications of these teachings for ongoing debate and any future implementation of legal EPAS will be explored.

Primary source [translated] texts that were referred to in the article

A literature review was conducted to identify published secondary texts that examined understandings and interpretations of primary texts of one or more of the branches of the four identified world religions. Articles on Judaism were included in this screening process as the Hebrew scriptures, or Old Testament, is also part of the Christian canon of scripture. Primary texts were defined as both translated ancient holy texts and theological statements published by recognised leaders or official leaderships bodies.

An American Theological Library Association (ATLA) database search for “euthanasia” was performed. Inclusion criteria were: academic publication; written in English; outcome of interest (articles that specifically explored the ethics of euthanasia from the perspective of at least one of the major world religions identified above). One author assessed all abstracts against inclusion criteria. Relevant articles were obtained in full text format. These were assessed for eligibility according to the same criteria and ineligible papers were excluded. The following data were extracted: relevant primary texts and data relevant to the research questions. English translations of each primary text were obtained. Extracted data from primary texts were then analysed primarily using a grammatical–historical approach to exegesis (Surburg, 1974 ) in addition to understanding them through any lens of the interpretation described in the identified secondary sources.

Results and Discussion

The ATLA search for “euthanasia” revealed 1,183 articles. Abstract screening identified that 44 articles explored the ethics of euthanasia from the perspective of at least one of the major world religions; a small number of articles examined the topic from the perspective of two or more of these world religions. Publication dates ranged from 1984 to 2020 with half of all articles published within the last 10 years. Twenty-five of the articles related to Christian perspectives on euthanasia (10 specific to Catholicism, 4 to Protestantism and 4 to Orthodoxy), 9 on Islamic viewpoints (3 specific to Shia and 1 to Sunni Islam), 7 on Jewish understandings, 5 on Hindu perspectives and 4 on Buddhist (Fig.  1 ).

Number of relevant articles identified by religion. Note: Fig. 1 shows the number of articles that explored the ethics of euthanasia from the perspective of at least one of the major world religions identified through an ATLA search for “euthanasia”. Some articles examined more than one religion and are therefore represented more than once in the chart

Primary texts identified from these 44 articles included the ancient, scriptural texts of the Bible, the Quran, the Vedic texts and the Pali Canon. Further non-scriptural primary texts identified included Gaudium et Spes (The Second Vatican Council, 1965 ), the Sacred Congregation for the Doctrine of the Faith’s Declaration on Euthanasia (1980), resolutions from the Lambeth Conference ( 1998 ) and the Southern Baptist Convention ( 1992 ), documents from the Assemblies of God General Presbytery in Session ( 2010 ), Sahih Al Bukhari (ca. 846 C.E./1997), the Islamic Code of Medical Ethics Kuwait Document (International Organization for Islamic Medicine, 1981), Ayatollah Sayyid Ali Khamenei’s Islamic Rulings (2007) and the Collected Works of Mahatma Gandhi (Mahatma Gandhi, 1926 ).

Christianity

Christianity is the world’s largest religion in terms of the number of professing adherents (Hackett et al., 2015 ). It contains various distinct branches that, although divided by historical separations and contemporary leadership structures, mutually recognise each other as part of the worldwide Christian faith. Principal branches include the Catholic Church (and more specifically, Roman Catholicism), Eastern Orthodoxy (which includes the Russian and Greek Orthodox Churches) and the Protestant denominations. Of the many Protestant churches, two distinct themes of Protestantism have emerged in contemporary society, the evangelical, or conservative, Protestant churches and the progressive, or liberal, Protestant churches. In both practice and theology, these two themes are more relevant than denomination when it comes to understanding beliefs (Bauder et al., 2011 ). For example, an evangelical Anglican church shares closer theological ties with an evangelical Baptist church than it does with a liberal Anglican church.

In this article, the doctrines of the three most populous branches of Christianity worldwide will be analysed: Catholicism, Eastern Orthodoxy and Evangelical Protestantism (which includes many Pentecostal churches). The most important primary source for each of these is the Bible. Other written documents may also be considered primary texts of official church doctrine, although they are less authoritative than the Bible. These include the creedal formulae of church councils in all three branches, and, in the Roman Catholic Church, Papal Encyclicals and the Catechism of the Catholic Church. In more recent decades, denominations have also released specific officially authorised documents about EPAS.

Biblical Analysis of Themes that Speak on the Topic of EPAS

Although allusions to euthanasia are found in the literature from the Ancient Near East and the Greco-Roman world (Erdemir & Elcioglu, 2001 ), the Bible itself is silent on EPAS. However, several themes are spoken about within the Bible that shed light on Christian thinking regarding euthanasia, including creation, human life, suffering and hope.

The Bible views the universe through the monotheistic lens of a creator God who, although able to enter into the universe, exists outside of space–time. From the Old Testament’s first sentence (Genesis 1:1), a picture emerges of a creator who spoke the universe into existence. This creation theme continues throughout the Bible, including into the New Testament, which describes God as the creator of all things (John 1:1–4). Furthermore, although creation within the Bible is spoken of in terms of an event, there is also a theme of ongoing sustaining of the creation by God himself (Colossians 1:17; Hebrews 1:3).

God as the sole creator and sustainer of the universe is an important theological concept, producing a sense of human limitation regarding issues of life and death (Matthew 6:27). The ability of life to be self-sustaining, of the heart to beat and the lungs to breathe, is not merely a natural phenomenon in Biblical terms; rather, this is under God’s control. As such, any human interference with hastening the end of life must be very carefully considered and cautiously approached.

Human Value

In the Biblical narrative, humans are seen to be part of the sphere of creation. However, humans have a special place within creation and are especially valuable because they are created in the image of God (Genesis 1:27).

The meaning of “God’s image” is complex and nuanced. However, even without exploring the depth of this, it can be seen, from the Bible’s perspective, that humans are unique. There are many allusions scattered throughout the Bible of this unique value, including from the words of Jesus in the Gospels (Matthew 6:26).

The importance of this view of human value is particularly seen in Biblical passages that describe the consequences of judgement that God anticipates upon those who do not value human life. Direct instructions from God prohibiting murder, mandating its punishment and ensuring justice, occur in several passages such as Exodus 20:13, Genesis 9:6 and Proverbs 24:11–12.

This prohibition on taking life relates intimately to both the value of humans and God’s nature as creator and sustainer. The prohibition against taking life is not absolute, however, as can be seen by the implicit support for capital punishment from Genesis 9:6. Nonetheless, the taking of life is restricted to only distinct circumstances. Furthermore, the framework of God as sustainer indicates that the deliberate action of killing should only ever occur at God’s command. Consequently, there is an implied prohibition of EPAS in Biblical theology. To argue against a Biblical ban on EPAS, it becomes necessary to understand EPAS in one of the two ways. Either EPAS does not involve deliberate killing but is merely facilitating the dying process, or, although EPAS does involve deliberate killing, it is a compassionate representation of love relieving suffering. However, neither argument is strong in overcoming the straightforward scriptural mandate that disallows killing except in the framework of the creator’s direct instruction.

Suffering, Death, Hope and Resurrection

Although Genesis’ creation account describes a good creation, the Bible develops a theodicy and theology of suffering very early on. It describes the entrance of suffering into the world through the concept of sin, the act of deliberately turning away from God and his instructions. In the narrative of Genesis 3, the first man and woman make the deliberate choice to ignore God’s instruction to them, and the result is a separation from everlasting life sustained by God (Genesis 3:17–19).

Although suffering and death entered the universe because of sin, the Bible also demonstrates that we are often unable to explain the suffering of an individual. Jesus himself referred to this a number of times in the Gospels (e.g. John 9:2) and the Old Testament book of Job finishes with verses that emphasise the impossibility of humans ever truly understanding the mystery of suffering (Job 42:3).

In offering these two contrasting views of suffering—that it is through human sin that suffering occurs, yet, that suffering cannot be understood fully—the Bible also describes two responses of God to our suffering. Firstly, God cares about human suffering, and secondly, God himself suffers. In many places, the Old Testament describes God’s care for his people Israel and his desire to comfort them in their suffering (e.g. Isaiah 66:13). Likewise, in the New Testament, a picture of Jesus as a comforter emerges. For example, in Matthew 5:4 Jesus is recorded as saying “Blessed are those who mourn for they will be comforted”. The Epistles also share this image of God as a comforter (2 Corinthians 1:3–4).

God is not only portrayed as one who cares and comforts; he is also portrayed as the God who suffers, especially in the person of Jesus, God the Son (Isaiah 53:3).

The suffering that God endured not only places God in a position to understand our suffering but is part of God’s redemptive plan for humanity. The book of Revelation describes the future of humanity as one without suffering. God himself wipes every tear away from his resurrected people who have received eternal life (Revelation 21:4). The redemption is inaugurated in the suffering of Jesus on the Cross (Ephesians 1:7). In other words, God does not delight in human suffering but instead is in the process of bringing suffering and death to an end. At the same time, the Bible acknowledges suffering and death are realities that will be part of the lives of all people in this world.

This Biblical description of suffering and death immersed in hope is complex. Humans, in imitating God’s love and care for his creation, aim to bring relief of suffering and hope to the world. In this sense, this could be extrapolated as Biblical acceptance of EPAS; however, suffering in this life is inevitable according to the Bible, and suffering is not presented as the ultimate of evils as it is transient and temporary. Instead the Bible explains that this life, with its associated suffering and death, occurs along the path to a better future of eternal life without suffering. In this theological framework, living right in this life, following the path set out by God and being obedient to his rules, is of more importance than avoiding temporary suffering (Matthew 5:30). As such, there is a strongly implied theological opposition to EPAS throughout the Bible. Consistent with this, Roman Catholic, Eastern Orthodox and most evangelical Protestant churches present a unified official stance in opposition to EPAS.

An Analysis of Roman Catholic Teachings

The Roman Catholic Church has developed official statements and documents consistent with the Biblical analysis on EPAS already described. These documents, including the Second Vatican Council’s Pastoral Constitution Gaudium et Spes (1965), the Church’s Declaration on Euthanasia (Sacred Congregation for the Doctrine of the Faith, 1980 ) and Pope John Paul’s Evangelium Vitae (1995), explore themes of God as Creator, the intrinsic value of all human life and the sinfulness of deliberately destroying human life. In 1965, the Second Vatican Council made a strong comment on the sanctity of life and expressly condemned euthanasia ( Pastoral Constitution Gaudium et Spes , Number 27, 1.17).

Catholic doctrine on EPAS is further clarified in its Declaration on Euthanasia (Sacred Congregation for the Doctrine of the Faith, 1980 ), where life is described as a gift from God. Although death is unavoidable, it is the pathway to immortal life. Medical staff are instructed to never neglect their care for the dying and to seek to bring comfort to the ill. Euthanasia, specifically defined as an action undertaken with the express intention of causing death in order to alleviate all suffering, is described as sinful (Sacred Congregation for the Doctrine of the Faith, 1980 ).

An Analysis of Eastern Orthodoxy Teachings

The Orthodox churches have less church-wide official documents that speak about EPAS when compared with Roman Catholicism. However, there is widespread understanding of its leaders of the inherent sinfulness of EPAS. For example, Orthodox priests and, to a lesser extent, parishioners almost universally recognise the Church’s prohibition on euthanasia (Sandu & Huidu, 2020 ; Verulava et al., 2019 ) even if they themselves do not specifically agree with it. In standing opposed to the practice of EPAS (Sandu & Huidu, 2020 ), Eastern Orthodoxy sees a direct link between mercy and salvation as being fundamentally in contradiction with euthanasia (Guroian, 1993 ). Furthermore, God’s sovereignty is a strong theme of Orthodox theology. As such, an acceptance of illnesses that God has allowed in our lives is an important part of faithful living and opens the Orthodox Christian to spiritual growth (Sandu & Huidu, 2020 ).

An Analysis of Evangelical Protestantism

The Protestant Christian churches present a less unified view on EPAS than do the Catholic and Orthodox churches. Within the evangelical theme of Protestant Christianity, there is a strong emphasis on Biblical authority on matters of faith. These churches therefore naturally tend towards opposing EPAS.

The Anglican Church, one of the largest branches of the Protestant church, although not monolithically evangelical, confirmed a resolution against euthanasia during its 1998 Lambeth Conference of worldwide bishops. This statement affirmed the intrinsic value of all life, explicitly opposing EPAS (Lambeth Conference, Resolution I.14).

Although self-identifying as individually autonomous local churches, Baptist churches have also released numerous statements through their various voluntarily connected associations. For example, the Southern Baptist churches released a Resolution on Euthanasia and Assisted Suicide , confirming its belief in the connection between humans created in God’s image and the sacredness of human life being incompatible with EPAS (Southern Baptist Convention, 1992 ).

The world’s largest association of Pentecostal churches, the Assemblies of God, has also released specific documents that discuss the issue of EPAS and confirm its opposition to the practice. In an analysis of the subject from a Biblical standpoint, the 2010 General Presbytery in Session adopted a Sanctity on Human Life Position Paper noting that the philosophy favouring EPAS was “mistaken, deceptive and evil”. In this document, EPAS is described through the lenses of humankind’s dignity, God’s authority and hope for suffering humanity. Despite recognising the sinful nature of EPAS, the document concludes with themes of mercy and grace, as defining elements of the Christian faith (e.g. John 1:17 and 2 John 1:3).

Islam, the world’s second-largest religion, has two major branches, Sunni and Shia (Hackett et al., 2015 ). Both consider the Quran as God’s message and the primary source for determining religious beliefs. In addition to the Quran, Muslims rely on Hadith or records of the words of Islam’s major prophet, Muhammad and Ijma or expert reasoning and consensus (Avci, 2019 ). Sunni Islam, accounting for almost 80% of Muslims, consists of several distinct schools of interpretation, including Shafi, Hanbali, Hanafi and Maliki. These schools broadly agree on matters of doctrine. Shia Islam, the second-largest branch of Islam, accounting for almost 20% of Muslims, also consists of various similarly minded sub-branches, including the Zaidis, Ismailis and Ithna Asharis.

No Muslim-predominant nations have legalised EPAS. Furthermore, in most Muslim-predominant countries, the degree of secularity and atheism is less than in the West’s traditionally Christian nations, where EPAS has risen to prominence (Hackett & Grim, 2012 ). Therefore, broader Islamic theological discussions about EPAS have not naturally occurred to the same degree as in Christian denominations. Nonetheless, there has been increasing consideration by contemporary Sunni and Shia scholars of the topic.

Quranic Analysis of Themes Related to EPAS

The Quran has minimal direct discussion on the topic of EPAS (Avci, 2019 ), but it does contain passages about Allah’s authority, human dignity, life, perseverance, death and paradise. These passages give guidance towards an Islamic interpretation that, in general, strongly opposes EPAS in any context (Avci, 2019 ), considering it to be a form of murder (Sobotkova, 2019 ).

Allah’s Authority

In the Quran, all existence is explained as having come into being through one God, Allah, who is the creator of all life. As the creator, Allah is understood as the trustee over everything in existence (Quran 39:62). He has sole authority over life (Quran 3:145) and death (Quran 16:61), which includes determining the timing of every person’s death. From an Islamic perspective, recognising this truth is an essential part of being a good servant of God (Avci, 2019 ).

In addition to Allah’s complete authority over life and death, human life is presented as having special value in I slam and is considered sacred. This is a particular honour given to humanity over all other creatures and is connected with the ability to learn (Quran 17:70) and receive faith (Quran 33:72). Consistent with these axioms of human value and Allah’s authority, murder or the deliberate taking of life outside the context of justice is forbidden (Quran 17:33). In other words, there are certain times when the taking of life is allowable in I slam, but the Quran is explicit that this can occur only when it represents justice for crimes committed or on the instruction of Allah. This prohibition on the taking of life also extends to suicide (Quran 4:29).

Suffering, Perseverance, Comfort and Paradise

The Quran’s view of human value extends to a philosophy towards saving life (Sobotkova, 2019 ). Even in hardships and suffering, there is a command to persevere in I slam (Quran 31:17), which includes patiently bearing through the suffering of illness, either experienced personally or by a loved one.

The need for obedience to Allah’s authority is a central theme in Islam (Avci, 2019 ). Through choices of obedience to Allah and belief in his instructions, the Muslim travels the road to heaven, or paradise, after a resurrection and day of judgement for all people. In contrast, actions performed in disobedience to Allah and rejection of Quranic teaching result in a judgement of guilt and entry to hell (Quran 84:25). Through obedience to Allah and perseverance in illness, the believing Muslim may have comfort and hope of resurrected life in paradise (Quran 13:24).

Although the Quran speaks particularly of a distant future of resurrection and paradise, it also promises comfort for those suffering in this life. Allah is called gracious and merciful, and comfort is promised in hardship (Quran 94:5). Associated with this is a recognition that a Muslim can, and should, seek spiritual and emotional support to help soften their pain (Avci, 2019 ). There is also some comfort offered in the Quran’s representation of Allah’s omnipotence with the teaching that Allah understands our hardships but that sometimes these occur for our good (Quran 2:216).

These Quranic descriptions regarding Allah, human life, obedience and paradise weigh against Islamic acceptance of EPAS. Therefore, there is widespread agreement among Islamic scholars and leaders, both Sunni and Shia, that EPAS is in contradiction to Allah’s will (Avci, 2019 ; Ayuba, 2016 ; Sobotkova, 2019 ).

An analysis of Sunni Thought

Sunni doctrine and shariah, or law, is strongly guided by the Sunnah and Hadith, in addition to the Quran (Avci, 2019 ). The Sahih Al Bukhari , one of the most trusted Hadith, is explicit in its condemnation of suicide, even when done because of pain ( Sahih Al Bukhari 3463, ca. 846 C.E./1997).

Throughout history, Islamic scholars have consistently interpreted the Quran and Hadith as prohibiting the act of suicide. From ancient Sunni scholars such as Al-Ghazali in the tenth century to Islamic bodies and statements of the twentieth century such as the Islamic Medical Code of Ethics (International Organization for Islamic Medicine, 1981), assisted suicide, and, more recently, euthanasia, remain condemned (Avci, 2019 ). Contemporary Sunni Islamic advisory and judicial bodies worldwide have issued fatwas, or non-binding legal guidance, prohibiting the practice of EPAS. These bodies include Dar al-Ifta al-Misriyyah in Egypt and the National Fatwa Committee of Malaysia (Malek et al., 2018 ).

Desire for relief and even praying for death may be acceptable in Islam, however, given Allah’s supremacy over life and death current Sunni thought insists that a higher value be placed on the sanctity of life than on a person’s quality of life (Avci, 2019 ). Nonetheless, Sunni scholars have recognised distinctions between murder, suicide and assisted suicide. However, all such differences relate to the severity of sin and the degree of punishment required, and EPAS is almost universally considered a form of murder. As such, EPAS remains haram, or prohibited, in Sunni praxis (Ayuba, 2016 ).

An Analysis of Shia Thought

Like Sunni Islam, Shia also determines doctrine by interpreting both the Quran and Hadith. Expert opinion from Shia religious jurists plays a significant role in determining doctrine and practice (Sobotkova, 2019 ). On bioethical issues, this expert opinion can be arrived at through reason in addition to an exploration of the Quran and Hadith (Dabbagh & Aramesh, 2009 ). These expert opinions are, at times, pronounced without explanation (Sobotkova, 2019 ). Although Shia religious jurists’ legal views do vary, the highest-ranking Shia clerics have consistently taught against the practice of EPAS. On this specific question, for example, the Ayatollah Sayyid Ali Khamenei of Iran has confirmed Shia’s prohibition on EPAS (Islamic Rulings: Medical Issues, Question 115, 2007).

Hinduism, India’s largest and the world’s third-largest religion, does not have a known founder or prophet, nor is there a single, authoritative scripture from which doctrine and belief stem (Avci, 2019 ). Likewise, no central authorities express conclusive Hindu doctrine. Despite this, strong cultural connections link Hindus, and in practice, the distinction between Indian culture and religion is ambiguous (Avci, 2019 ). In these shared cultural connections of Hindus are concepts such as atman, shared holy texts such as the Vedas and common rituals (Frazier, 2011). Hinduism is thus a connected yet diverse polytheistic, pantheistic or monistic belief and cultural system containing several loosely defined schools and branches. Sects such as Vaishnavism, Shaivism, Shaktism and Smartism are distinguished through their primary deity. Similarly, schools such as Purva Mimamsa, Yoga and Vedanta are demarcated by their philosophical and scriptural foci. Despite this extensive diversity in Hinduism and lack of centralised authority, the shared cultural, scriptural, ritual and conceptual connections allow for the development of Hindu philosophies for complex ethical issues, including for EPAS. There is less discussion of and uniformity of beliefs on the morality EPAS in Hinduism, however, compared to Christianity, Islam and Buddhism. For example, a recent systematic review on the beliefs regarding EPAS in major world religions did not identify any observational studies on the views of Hindus in the general population (Chakraborty et al., 2017 ). Furthermore, in the small amount of the published literature about EPAS and Hinduism, it is apparent that Hindu philosophies both against and in favour of EPAS coexist. Thus it is impossible to dogmatically state that Hinduism universally opposes or supports EPAS (Avci, 2019 ).

Hindu Themes Connected with EPAS

Hinduism has a rich history of exploring spiritual issues of atman, life and being, and of death, rebirth and ongoing existence. These are all significant themes that influence Hindu philosophies about EPAS. An additional specific underlying principle of profound importance is that of ahisma, the prohibition of killing.

Life and Death

In the Hindu worldview, a person consists of both a mortal physical body and an immortal atman, or soul. In this soul, thoughts and life experiences (Avci, 2019 ) are distinct from the mortal body. Although death will come to the physical body, the soul will continue its existence after death. Life then does not begin with birth and end with death, but rather exists eternally with the soul reincarnated or reborn into a new body, either human or animal, in a continuous and everlasting cycle of birth, death and rebirth (Ganga, 1994 ).

Dharma and Karma

The cycle of death and rebirth in Hinduism is associated with ideas of balance and justice, although not necessarily in the current life. Dharma is a word that describes the underlying cosmic law and moral force ordering the universe that is maintained through right obligations and behaviour (Avci, 2019 ; Frazier, 2011). Karma, an associated concept, relates to the moral aspect of a person’s day-to-day conduct (Avci, 2019 ). If a person lives righteously with good conduct, then there is good karma and a good future in a reborn life is being shaped; likewise, when people live with bad thoughts and actions, they suffer negative consequences in their future.

This idea of balance and justice extends to the circumstances around a person’s death. When a person dies at an old age, in a peaceful manner, in the right place and at the proper time, this is seen as a good death. Conversely, a bad death has occurred when a person dies prematurely, violently, in the wrong place or at the wrong time. Given this, EPAS becomes a problematic practice in Hinduism, with the person dying before the right time (Avci, 2019 ). However, the issue is not entirely straightforward, as there is some scope for religiously motivated suicide in Hinduism (Ganga, 1994 ). Historically, from the Hindu viewpoint, this has usually occurred in the context of right intentions and circumstances (Avci, 2019 ). This potential for religiously motivated suicide opens the door for appropriate EPAS within Hinduism for some; however, more conservative Hindus do not see EPAS as appropriate or desired because suffering is attributed to the law of karma. If one is destined to suffer, then one must fulfil that suffering in this lifetime; otherwise, it will be passed on to the next life (Ganga, 1994 ). There are allusions to this in various Hindu holy texts (e.g. Isha Upanishad verse 3).

Ahimsa and Killing

Hinduism has long maintained a philosophy of respect for all living things. It vigorously discourages the act of killing (Avci, 2019 ). This principle, known as ahimsa, is found in ancient Vedic texts and prayers such as the Riga Veda and Yajurveda (Walli, 1974 ) and is described as the highest virtue in the Sanskrit epics ( Mahabharata 13.117.37–41). Ahimsa remains strongly emphasised in Hindu thought and culture today. Mahatma Gandhi, for example, the highly influential Hindu thinker and Indian leader in the last century, was well known for his lifelong commitment of non-violence and ahimsa. This commitment against killing can be understood to speak powerfully against Hindu acceptance of euthanasia (Abbas et al., 2008 ). However, there is recognition within Hindu thought that, on occasions, a small sin may be committed to avoid greater sins or to demonstrate love (Gielen, 2012 ). For example, hastening the death through euthanasia of a person suffering intensely from a terminal illness may reflect compassion. Gandhi himself alluded to this at times suggesting that it is not relevant to apply the principle of non-violence to euthanasia where relief of suffering is the goal (Collected Works of Mahatma Gandhi, Volume 37, 1926).

Complex and nuanced threads of thought evidently infuse the Hindu understanding of EPAS. Atman and karma, balance and justice, and non-violence and ahimsa indicate EPAS is not acceptable within Hindu thought. However, an absolute exclusion of EPAS cannot fairly be made as Hinduism does allow scope for religiously motivated suicide and, possibly, for compassionately motivated EPAS. Despite this, contemporary Indian culture and its legal system is clear in its rejection of EPAS (Sinha & Sarkhel, 2012 ).

Almost 7% of the world’s people, primarily in Southern and Eastern Asia, identify as Buddhist, a religion founded by Siddhartha Gautama, also known as the Buddha. Texts believed to be records of his oral teachings, especially the Pali Canon collection, play a central role in Buddhist doctrine and are generally considered authoritative (Keown, 1998 ). Other religious texts are also often recognised as scripture, although it is difficult to define the limits of what constitutes scripture as views differ between the branches of Buddhism. Furthermore, there is no authoritative Buddhist council that speaks on behalf of the religion (Keown, 1998 ). Buddhism has also developed into several schools or branches with some differences in both practice and interpretation of the Buddha’s teachings. Significant branches include Theravada, Mahayana and Vajrayana, although there are many smaller branches.

Given the lack of a universally agreed corpus of scripture and absent contemporary central authority, along with the numerous branches of Buddhism, it is difficult to articulate a definitive Buddhist view on EPAS. However, specific themes within Buddhism provide a framework for understanding EPAS from a Buddhist perspective. These themes include concepts related to life, suffering, moral living and karma, death, rebirth and enlightenment.

Life and Suffering

Buddhist doctrine is built on the Four Noble Truths, which describe a philosophy of suffering. These truths are described in the Pali Canon and various other scriptures. The first of these truths contends that suffering is an innate aspect of life ( Samyutta Nikaya 56.11).

Buddhism presents suffering as an undeniable reality, explaining in the second noble truth that misplaced desire, ignorance and hatred are the root causes of all suffering. There is, however, potential for liberation of suffering in Buddhist philosophy and the way to discover the end of suffering is described in the third and fourth noble truths. The principle behind ending suffering, the third noble truth, involves removing all desires, and this is achieved through the eightfold path illustrated in the fourth noble truth (Keown, 1998 ). Thus, Buddhism has a highly developed philosophy of the reality and cause of suffering. The way to reach enlightenment and exist in a state without suffering is the central underlying premise permeating all Buddhist thought.

Karma and Rebirth

As in Hinduism, the ideas of karma’s balance and justice, and cyclical existence through rebirth are dominant themes within Buddhism. Karma is seen as an inherent part of the natural order (Keown, 2000 ) where intentional actions, thoughts and words influence future conditions in a reborn life. In other words, right and moral thoughts and actions, including preserving life, lead, at some point in time, to good rebirths ( Majjhima Nikaya 136.15). Likewise, wrong and immoral thoughts and behaviours, including killing, at some point in time, result in unhappy rebirths ( Majjhima Nikaya 136.17).

Karma is central to the Buddhist worldview and has a significant logical influence on the understanding of EPAS. As suffering is part of the universe’s natural order of balance and justice, EPAS is unable to alleviate suffering and will merely delay it to a subsequent life. The ending of a life is not the solution to suffering because life is seen through the prism of this cyclical existence of death and rebirth. And in fact, the desire for death sits squarely at odds with the Buddhist philosophy that calls for all desires to be extinguished (Keown, 1998 ). Rather than through death, Buddhism teaches that suffering is overcome through enlightenment which is reached through following the eightfold path of righteousness. This eightfold path includes cultivating a moral and right view, right intentions and right conduct, right speech, right conduct, a right livelihood, right effort, right mindfulness and right concentration. Through following the eightfold path, death and suffering cease, and liberation is attained ( Samyutta Nikaya 45.8). This path includes living morally through right action, which extends to avoiding killing, suicide and assisting suicide. Buddhist scriptures specifically tackle the question of assisted suicide ( Vinaya Piṭaka , Collection on Monastic Law), denying its rightness (Kawanda, 2016 ). Likewise, suicide is considered wrong except in the case of the Buddhist who has finally removed all desires and has completed their work and is ready to pass to Nirvana (Keown, 1998 ).

Buddhism aims for its adherents to find liberation from suffering, but not through death. In line with this, Buddhist teaching seeks to comfort those suffering with illness, helping them find peace that transcends their suffering.

Common Themes

Of particular interest is the observation that all four of the major world religions paint EPAS in a negative light. Their holy texts, scholars and official bodies consistently speak against the moral acceptability of EPAS. This contrasts with a secular and atheistic worldview where EPAS is frequently supported (DeCesare, 2000 ). The locus of morality of all four religions may play a role in this contrast. A secular or atheist worldview might contend that morality comes from within as an inherent, internal characteristic of each individual. Alternatively, this worldview may assume the need for a consequentialist ethic where outcome defines an action’s morality. In contrast, all four religions describe an external arbiter of morality in the form of deontological philosophy. In Christianity and Islam, this authority is God as revealed in either the Bible or Quran, and in Hinduism and Buddhism, the arbiter is the universal cosmic force or dharma. This inevitably leads practitioners of these religions to seek to understand morality not from within but instead in accordance with this external arbiter and as shown, all four religions develop a strong deontologically based position that it is inherently wrong to intentionally kill another human.

A second overlapping theme in these religions is the doctrine of life continuing after death. All four religions contend that life continues after death, either a resurrected life in heaven or hell in Christianity and Islam or a reborn life in this world in Hinduism and Buddhism. This ongoing existence may be good and with less or no suffering. Alternatively, it also may be worse with continued suffering. The afterlife state in which a person finds themselves is intimately related to the person’s actions in their previous life. Thus, the actions a person takes in this life have a very real consequence for their next life, so they must carefully consider all their deeds. As all four religions prohibit the taking of life and consider killing sinful, it follows that the hope of heaven or a better rebirth will lead to an antipathy to any action that intends to end a life. In other words, advocating for EPAS, even in the face of suffering, exposes a person to the risk of negative consequences in their next life.

Implications

The fundamental worldviews of the world’s four major religions are against the moral acceptability of EPAS. Not only do these beliefs represent thousands of years of combined human wisdom, but also the views of billions of people living today. There will thus be ongoing concern regarding the implementation of EPAS. Although this will be especially apparent in countries where religion officially plays a more direct role in government, it is also likely to be observed in any country with a high proportion of the population who identify as religious. Given this, lawmakers should ensure the views of those in leadership roles in the major religions remain part of any discussion regarding EPAS. The wide range of views on EPAS is recognised by governments in that politicians are usually allowed a conscience vote by their parties when it comes to EPAS legislation.

There is a need to genuinely consider the issue of conscientious objection, both at an individual level and at an institutional level, in jurisdictions that make a decision to legalise EPAS. At the individual level, clinicians who oppose the practice of EPAS, including many who adhere to one of these four religions, may experience distress if they feel compelled, by law or otherwise, to defy the teachings of their religion and take part in any aspect of the process of EPAS (Stevens, 2006 ). From a pragmatic perspective, safeguards against coercion to provide EPAS will reduce the risk of the loss of these clinicians who might otherwise resign from clinical practice, thereby depriving like-minded patients of access to the services of practitioners who share their moral views as well as being detrimental to the individuals concerned (Quinlan, 2016 ). At a more fundamental level, governments that legalise EPAS without ensuring provisions for clinicians to opt out will be violating the basic human right of clinicians to exercise their freedom of religious belief and practice as outlined in the Universal Declaration of Human Rights (United Nations, 1948 ).

“Everyone has the right to freedom of thought, conscience and religion; this right includes freedom to change his religion or belief, and freedom, either alone or in community with others and in public or private, to manifest his religion or belief in teaching, practice, worship and observance”. Universal Declaration of Human Rights, Article 18

In much of the world, hospitals, aged care facilities, healthcare services and health insurance providers are, to some degree, privately operated, often by religious organisations. For example, the Roman Catholic Church is the largest non-government worldwide provider of healthcare services (Agnew, 2010 ). As is the case for individual conscientious objection, legislating bodies should consider the issue of institutional conscientious objection. The idea of institutional conscientious objection is controversial given that institutions are not autonomous individuals and therefore, arguably, they lack the capacity to have a conscience (Bedford, 2016 ). Furthermore, when institutional conscientious objection is codified, there are potential occasions where individual clinicians are compelled to disregard the instructions of their own conscience in determining medical care in deference to institutional policies (Spencer, 2011 ), although prospective employees are made aware of institutional requirements and are asked to comply prior to commencing employment. It can also be argued that an institution relies on social agency where its actions occur through its members. This requires “socially coordinated behavior to enable each component part to pursue the institutional ends in harmony” (Bedford, 2016 ). Regardless of the theoretical position on institutional conscience taken, significant practical ramifications can be imagined in jurisdictions that legalise EPAS without allowing for institutional “opt outs”. These ramifications might include animosity between government and religious institutions, an impression of persecution of religious institutions by government, the collapse of private healthcare providers with subsequent economic and healthcare consequences and an increased burden on public healthcare systems. The existence of institutions not involved in EPAS would also allow like-minded patients to choose a healthcare provider that aligned to their values—such patients would not find themselves involved in unwanted discussions about EPAS with their clinicians. In this sense, removing provisions of conscientious objection would actually reduce rather than increase patient choice, which is often the purported goal of EPAS legislation.

Some commentators have suggested that the move to legalise EPAS, after it has been prohibited for millennia, despite a capacity to relieve pain better than ever before, is not due to a change in the situations of individuals who seek EPAS, but instead indicates profound changes in contemporary postmodern, secular, Western societies (Sommerville, 1996 ). These include the growth of individualism and the desire for autonomy, and the decline of religiosity with its vocabulary that allows for discussion around death and tolerance of mystery. Further research is required to explore whether religion might be a protective measure against annihilation of the self and the role of religion in generating hope in this context.

Conclusions

A review of the primary sources of the world’s four major religions demonstrates a near-universal opposition to the legalisation and practice of EPAS due to themes revolving around a common hope for a better life after death and a system of morality that is fundamentally deontological. Despite this opposition, there is increased discussion of and momentum towards state-sanctioned EPAS, particularly in Europe, North America and Australasia. Given these facts, it is especially important for legislators to explore and understand key religious viewpoints when considering legalising EPAS and enshrine the capacity for conscientious objection at an institutional and individual level.

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