euthanasia philosophy essay

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Voluntary Euthanasia

The entry sets out five conditions often said to be necessary for anyone to be a candidate for legalized voluntary euthanasia (and, with appropriate qualifications, physician-assisted suicide), outlines the moral case advanced by those in favor of legalizing voluntary euthanasia, and discusses the five most important objections made by those who deny that voluntary euthanasia is morally permissible and who are, in consequence, opposed to its being legalized.

1. Introduction

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

When a person performs an act of euthanasia, she brings about the death of another person because she believes the latter’s present existence is so bad that he would be better off dead, or believes that unless she intervenes and ends his life, his life will very soon become so bad that he would be better off dead. Accordingly, the motive of the person who performs an act of euthanasia is to benefit the one whose death is brought about. (This also holds for many instances of physician-assisted suicide, but use of the latter term is usually restricted to forms of assistance which stop short of the physician ‘bringing about the death’ of the patient, for example, those involving means that have to be activated by the patient.)

It is important to emphasize the motive of benefiting the person who is assisted to die because well-being is a key value in relation to the morality of euthanasia (see Section 3 below). Nonetheless, the defensibility of the contention that someone can be better off dead has been the subject of extensive philosophical deliberation. Those who claim that a person can be better off dead believe this to be true when the life that remains in prospect for that person has no positive value for her (a possibility which is discussed by e.g., Foot, 1977; McMahan 2002; Bradley 2009), whereas some of those who hold that a person’s life is inviolable deny that a person can ever be better off dead (e.g., Keown in Jackson and Keown 2012). A Kant-inspired variant on this latter position has been advanced by Velleman (1999). He considers that a person’s well-being can only matter if she is of intrinsic value and so that it is impermissible to violate a person’s rational nature (the source of her intrinsic value) for the sake of her well-being. Accordingly, he holds that it is impermissible to assist someone to die who judges that she would be better off dead and competently requests assistance with dying. The only exception is when a person’s life is so degraded as to call into question her rational nature, albeit he thinks it unlikely that anyone in that position will remain competent to request assistance with dying. This position appears to be at odds with the well-established right of a competent patient to refuse life-prolonging medical treatment, at least when further treatment is refused because she considers that her life no longer has value for her and further treatment will not restore its value to her. (For further reasons to reject arguments for the inviolability of the life of a person, including Velleman’s, see e.g., McMahan 2002; Young 2007; Sumner 2011, 2017.)

Because our concern will be with voluntary euthanasia – that is, with those instances of euthanasia in which a clearly competent person makes a voluntary and enduring request to be helped to die (or, by extension, when an authorised proxy makes a substituted judgment by choosing in the manner the no-longer-competent person would have chosen had he remained competent) – a second key value is the competence of the person requesting assistance with dying. There will be occasion to mention non-voluntary euthanasia – instances of euthanasia where a person lacks the competence at the time when a decision is to be made to request euthanasia and has not previously competently declared a preference for it via an advance directive (see the entry on advance directives ) – only when consideration is given to the claim that permitting voluntary euthanasia will lead via a slippery slope to permitting non-voluntary euthanasia. Nothing will be said here about involuntary euthanasia , where a competent person’s life is brought to an end despite an explicit expression of opposition to euthanasia, beyond saying that, no matter how honorable the perpetrator’s motive, such a death is, and ought to be, unlawful.

Debate about the morality and legality of voluntary euthanasia has been, for the most part, a phenomenon of the second half of the twentieth century and the beginning of the twenty first century. Certainly, the ancient Greeks and Romans did not believe that life needed to be preserved at any cost and were, in consequence, tolerant of suicide when no relief could be offered to a dying person or, in the case of the Stoics and Epicureans, when a person no longer cared for his life. In the sixteenth century, Thomas More, in describing a utopian community, envisaged such a community as one that would facilitate the death of those whose lives had become burdensome as a result of ‘torturing and lingering pain’. But it has only been in the last hundred years that there have been concerted efforts to make legal provision for voluntary euthanasia. Until quite recently there had been no success in obtaining such legal provision (though assisted suicide, including, but not limited to, physician-assisted suicide, has been legally tolerated in Switzerland for a number of decades). However, the outlook changed dramatically in the 1970s and 80s because of a series of court cases in the Netherlands which culminated in an agreement between the legal and medical authorities to ensure that no physician would be prosecuted for assisting a patient to die as long as certain guidelines were strictly adhered to (see Griffiths, et al., 1998). In brief, the guidelines were established to permit physicians to practise voluntary euthanasia in those instances in which a competent patient had made a voluntary and informed request to be helped to die, the patient’s suffering was unbearable, there was no way of making that suffering bearable that was acceptable to the patient, and the physician’s judgements as to diagnosis and prognosis were confirmed after consultation with another physician.

The first legislative approval for voluntary euthanasia was achieved with the passage in the parliament of Australia’s Northern Territory of a bill enabling physicians to practise voluntary euthanasia. Subsequent to the Act’s proclamation in 1996, it faced a series of legal challenges from opponents of voluntary euthanasia. In 1997 the challenges culminated in the Australian National Parliament overturning the legislation when it prohibited Australian territories from enacting legislation to permit voluntary euthanasia on constitutional grounds. Australia is a federation consisting of six states and two territories. Unlike the territories, the states do have the constitutional right to enact such legislation and in 2017 the state of Victoria did just that. The legislation came into effect in 2019. In 2019, a second state, Western Australia, enacted legislation to enable voluntary medically assisted death. The legislation became effective in 2021. In 2021 three further states, Tasmania, South Australia and Queensland enacted legislation to enable voluntary medically assisted death which came into force in 2022 for the first two, and 2023 for the third. Finally, in 2022 NSW enacted legislation which came into force in 2023 resulting in voluntary medically assisted death being available in each of the states. Attempts are currently being made in both the Australian Capital Territory and the Northern Territory to introduce legislation in favor of voluntary medically assisted death that will avoid being vetoed by the federal parliament.

In November 2000, the Netherlands passed legislation to legalize the practice of voluntary euthanasia. The legislation passed through all the parliamentary stages early in 2001. The Belgian parliament passed similar legislation in 2002 and Luxembourg followed suit in 2009. (For a very helpful comparative study of relevant legislation see Lewis 2007. See also Griffiths, et al. 2008.)

In Oregon in the United States, legislation was introduced in 1997 to permit physician-assisted suicide after a referendum strongly endorsed the proposed legislation. Later in 1997 the Supreme Court of the United States ruled that there is no constitutional right to physician-assisted suicide; however, the Court did not preclude individual states from legislating in favor of physician-assisted suicide (so the Oregon legislation was unaffected). Since that time the Oregon legislation has been successfully utilised by a significant number of people and similar legislation has been passed in the state of Washington in 2009, in Vermont in 2013, and more recently still in California, Colorado, Florida, Hawaii, Iowa, Maine, Maryland, Massachusetts, Minnesota, New Jersey, New Mexico and the District of Columbia. A series of judicial decisions in the state of Montana in 2008 and 2009 established that the state could not prohibit physician-assisted suicide but legislation has not yet been introduced to codify the legal situation. A number of the remaining states are currently considering physician-assisted suicide bills.

A similar legal position to that in Montana obtained in the nation of Colombia from the late 1990s as a result of a majority ruling by its Constitutional Court in favor of the legality of physician-assisted suicide but legislative provision was finally made only quite recently. In 2021, Spain legalized voluntary euthanasia. In Austria and Germany courts have authorised physician-assisted suicide but no legislative backing for the practice has been introduced, while in Italy legislation for voluntary medically assisted death has been passed in one house of the bicameral parliament. In Portugal legislation for physician-assisted suicide was passed but was subsequently rejected by the Constitutional Court.

In Canada, the province of Quebec introduced legislation permitting medical aid in dying in 2014. The legislation came into effect in 2016 at around the same time that the Canadian National Parliament passed legislation permitting both physician-assisted suicide and voluntary euthanasia throughout all of the Canadian federation. (For a brief account of events leading up to the enactment of the various pieces of legislation in Canada see Downie and Schuklenk 2021.)

New Zealand held a referendum in 2019 which resulted in approval for the introduction of legislation for voluntary medically assisted death. The legislation came into effect late in 2021.

In the following countries legislative proposals for voluntary medically assisted death are presently under review: the Czech Republic, France, Ireland, the Isle of Man, Japan, Jersey, South Korea, the Philippines, Slovenia and the United Kingdom.

With that brief sketch of the historical background in place, we will proceed first to consider the conditions that those who have advocated making voluntary medically assisted death legally permissible have typically insisted should be satisfied. Consideration of the proposed conditions will establish a framework for the moral interrogation that will follow in Sections 3 and 4. Section 3 will outline the positive moral case put forward by those who want voluntary euthanasia and physician-assisted suicide to be legally permissible. Section 4 will be devoted to scrutinising the most important of the objections that have been levelled against that case by those opposed to the legalization of voluntary euthanasia and physician-assisted suicide.

Advocates of voluntary euthanasia typically contend that if a person

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

there should be legal and medical provision to facilitate her being allowed to die or assisted to die.

It should be acknowledged that these conditions are quite restrictive, indeed more restrictive than many think appropriate. In particular, the first condition restricts access to voluntary euthanasia to those who are terminally ill . While that expression is not free of all ambiguity, for present purposes it can be agreed that it does not include those who are rendered quadriplegic as a result of accidents, or sufferers from chronic diseases, or individuals who succumb to forms of dementia like Alzheimer’s Disease, to say nothing of those afflicted by ‘existential suffering’. Those who consider that cases like these show the first condition to be too restrictive (e.g., Varelius 2014, Braun, 2023) may, nonetheless, agree that including them as candidates for legalized voluntary euthanasia is likely to make it far harder in many jurisdictions to gain sufficient support for legalization (and so to make it harder to help those terminally ill persons who wish to die). Even so, they believe that voluntary euthanasia should be permitted for those who consider their lives no longer worth living, not just for for the terminally ill. Whether those who judge that their lives are no longer worth living, and so believe their lives are in that sense ‘complete’, should be afforded medical assistance with dying, has recently become a pressing concern in Belgium and the Netherlands. Several court cases have affirmed that such assistance may sometimes be provided for individuals in the former category even though the question remains as to whether it is properly a medical responsibility to render assistance with dying to someone who believes her life is complete despite her not suffering from a terminal medical condition (see, e.g., Young 2017). Relatedly, the issues of whether those suffering from a disability which will not reasonably foreseeably lead to death and those suffering because of a mental illness should be able to access medical assistance with dying have recently been the subject of intense debate in Canada. The debate culminated in disabled individuals, whose conditions are the cause of enduring, intolerable and irremediable suffering, being given access to medical assistance with dying as long as they are capable of making a competent request for that assistance. An intention to make a similar arrangement for those whose sole underlying condition is a mental illness was flagged for introduction in 2024, but has been temporarily shelved until further research has been conducted on the issue. It seems likely that the changes that have been made, or mooted, in these jurisdictions to the eligibility conditions for medical assistance with dying will lead to an expansion of the eligibility conditions for voluntary medically assisted death in other jurisdictions.

The fifth condition further restricts access to voluntary euthanasia by excluding those capable of ending their own lives, and so may be thought unduly restrictive by those who would wish to discourage terminally ill patients from attempting suicide. There will be yet others who consider this condition to be too restrictive because competent patients can always refuse nutrition and hydration (see, e.g., Bernat, et al. 1993; Savulescu 2014). Though this is true, many competent dying persons still wish to have access to legalized medically assisted death, rather than having to rely on refusing nutrition and hydration, so that they may retain control over the timing of their deaths and avoid needlessly prolonging the process of dying.

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

The third condition recognises what many who oppose the legalization of voluntary euthanasia do not, namely, that it is not only a desire to be released from pain that leads people to request help with dying. In the Netherlands, for example, pain has been found to be a less significant reason for requesting assistance with dying than other forms of suffering like frustration over loss of independence (see e.g., Marquet, et al. 2003; Onwuteaka-Philipsen, et al. 2012; Emanuel, et al. 2016). Sufferers from some terminal conditions may have their pain relieved but have to endure side effects that, for them, make life unbearable. Others may not have to cope with pain but, instead, with having to rely on forms of life support that simultaneously rob their lives of quality (as with, e.g., motor neurone disease). Yet others struggle with psychological distress and various psychiatric conditions and believe these conditions ought to be counted among the forms of suffering that qualify competent individuals to access medical assistance with dying. There has been greater recognition of, and support for, this position in those jurisdictions that make the role of unbearable suffering central to the determination of the eligibility of competent individuals for medical assistance with dying (see the discussion above of the first condition). Even so, inclusion of these forms of suffering highlights legitimate issues to do with the competence of at least some of those who suffer from them. (For a helpful recent study of the handling of requests for assistance with dying by psychiatric patients in the Netherlands see Kim, et al. 2016.)

A final preliminary point is that the fourth condition requires that the choice to die not only be uncoerced and competent but that it be enduring. The choice is one that will require time for reflection, and, almost certainly, discussion with others, so should not be settled in a moment. Nonetheless, as with other decisions affecting matters of importance, adults are presumed to choose voluntarily and to be competent unless the presence of defeating considerations can be established. (See the entry on decision-making capacity .) The burden of proof of establishing lack of voluntariness, or lack of competence, is on those who refuse to accept an adult person’s choice. There is no need to deny that this burden can sometimes be met (e.g., by pointing to the person’s being in a state of clinical depression). The claim is only that the onus falls on those who assert that an adult’s choice is not competent. (There are different issues to be faced when the competence of at least some older children and adolescents is at issue. In the Netherlands, for example, those aged twelve and older have sometimes been found to be competent to make end-of-life decisions for themselves. However, the topic will not be pursued further here because the focus of the entry is on competent adults.)

Clearly the five conditions set out above are likely to require some refinement if complete agreement is to be reached but there is sufficient agreement for us to proceed without further ado to consideration of the cases for and against legalization of voluntary euthanasia. (However, for a fuller discussion of issues concerning the definition of ‘euthanasia’ see, e.g., Beauchamp and Davidson 1979.)

One central ethical contention in support of voluntary euthanasia is that respect for persons demands respect for their autonomous choices as long as those choices do not result in harm to others. Respect for people’s autonomous choices is directly connected with the requirement for competence because autonomy presupposes competence (cf., Brock 1992). People have an interest in making important decisions about their lives in accordance with their own conception of how they want to live. In exercising autonomy, or self-determination, individuals take responsibility for their lives; since dying is a part of life, choices about the manner of their dying and the timing of their death are, for many people, part of what is involved in taking responsibility for their lives. Many are concerned about what the last phase of their lives will be like, not merely because of fears that their dying might involve them in great suffering, but also because of the desire to retain their dignity, and as much control over their lives as possible, during this phase. A second contention in support of voluntary euthanasia was mentioned at the beginning of this entry, namely the importance of promoting the well-being of persons. When someone is suffering intolerable pain or only has available a life that is unacceptably burdensome (see the third condition above), and he competently requests medical assistance with dying, his well-being may best be promoted by affording him that assistance. When harnessed together, the value to individuals of making autonomous choices, and the value to those individuals who make such choices of promoting their own well-being, provide the moral foundation for requests for voluntary euthanasia. Each consideration is necessary for moral justification of the practice, but taken in isolation neither suffices (see, e.g., Young 2007, 2017; Sumner 2011, 2017).

The technological interventions of modern medicine have had the effect of stretching out the time it takes for many people to die. Sometimes the added life this brings is an occasion for rejoicing; sometimes it drags out the period of significant physical and intellectual decline that a person undergoes with the result that life becomes no longer worth living. Many believe there is no single, objectively correct answer as to when, if at all, a person’s life becomes a burden and hence unwanted. If they are right, that simply points up the importance of individuals being able to decide autonomously for themselves whether their own lives retain sufficient quality and dignity to make life worth living. Others maintain that individuals can be in error about whether their lives continue to be worth living (cf., Foot 1977). The conditions outlined above in Section 2 are intended by those who propose them to serve, among other purposes, to safeguard against such error. But it is worth adding that in the event that a person who considers that she satisfies those conditions is judged by her medical attendants to be in error about whether it would be worth her continuing to live, the likely outcome is that those attendants will refuse to provide medical assistance with dying. (Evidence that will be mentioned below shows that this happens more frequently than might be predicted in jurisdictions in which medically assisted dying has been legalized. (There are discussions of the principles at stake in such matters in Young 2007; Wicclair 2011; Sumner 2020.) Unless a patient is able to be transferred to the care of other medical professionals who accept her assessment, she will have to rely on her own resources (e.g., by refusing nutrition and hydration). Even so, other things being equal, as long as a critically ill person is competent, her own judgement of whether continued life is a benefit to her ought to carry the greatest weight in any end-of-life decision making regardless of whether she is in a severely compromised and debilitated state. The idea that a competent individual’s autonomous judgment of the value to her of continued life should trump an assessment by others of her well-being should not be thought surprising because precisely the same happens when a competent patient refuses life-prolonging treatment.

Suppose, for the sake of argument, that it is agreed that we should respect a person’s competent request for medical assistance with dying (e.g., so as to enable her to achieve her autonomously chosen goal of an easeful death). It might be thought that in such an eventuality different moral concerns will be introduced from those that arise in connection with competent refusals. After all, while competent patients are entitled to refuse any form of medical treatment, they are not entitled to insist on the administration of forms of medical treatment that have no prospect of conferring a medical benefit or are not being provided because of a scarcity of medical resources or their affordability. While each of these points is sound, it remains the case that medical personnel have a duty to relieve suffering when that is within their capacity. Accordingly, doctors who regard medical assistance with dying as an element of appropriate medical care will consider it morally permissible to agree to a request for assistance with dying by a competent dying patient who wishes to avoid unbearable suffering. The reason for claiming only that this is morally permissible rather than morally obligatory will be explained in a subsequent paragraph. (For further reflections on the issue of responses to requests for medical assistance see, for instance, Dworkin 1998; Sumner 2011, 2017, 2020; Young 2007, 2017.)

Notwithstanding this response, as was seen earlier, at least some proponents of voluntary medically assisted dying wish to question why medical assistance with dying should be restricted to those covered by, in particular, the first three conditions set out above in Section 2. If people’s competent requests for medically assisted death should be respected why impose any restrictions at all on who may have access to medically assisted death? Why, for example, should those suffering from depression, or forms of dementia, not be eligible for medically assisted dying? Most proponents of voluntary medically assisted dying hold that there are at least two reasons for restricting access to it to those who satisfy the conditions set out earlier (or, a modified set that takes account of the concerns canvassed in the discussion of those proposed conditions). First, they contend that there are political grounds for doing so, namely, that because legalizing medically assisted dying for competent individuals is politically contested, the best hope for its legalization lies in focusing on those forms of suffering most likely to effect law reform. That is why some proponents deny the eligibility even of sufferers from conditions like ‘locked-in’ syndrome, motor neurone disease, and multiple sclerosis for voluntary medically assisted dying since, strictly, they are not terminally ill, and reliance has to be placed in consequence on their claim to be suffering unbearably. Second, and relatedly, most proponents of the legalization of medical assistance with dying have been cautious about supporting medically assisted death for those suffering from, for example, depression and dementia, because not only are they not terminally ill, but their competence to request assistance with dying is apt to be called into question, particularly in instances where they have given no prior indication of their preference for such assistance. Restricting access to medical assistance with dying to those whose suffering is less likely to be disputed avoids becoming embroiled in controversy. As was noted earlier, some critics of the restrictive approach (e.g., Varelius 2014) take a harder line and claim that it should not even be necessary for a person to be suffering from a medical condition to be eligible for medical assistance with dying; it should be enough to be ‘tired of life’. Only in a few jurisdictions, viz., Switzerland, the Netherlands and Belgium, has this issue been seriously broached. Regardless of what may happen in those jurisdictions, those seeking the legal provision of medical assistance with dying in other jurisdictions seem likely to maintain that if such assistance is to be seen as a legitimate form of medical care it has to be provided in response to a medical condition (rather than because someone is ‘tired of life’), and, indeed, restricted to those who satisfy the conditions outlined earlier in Section 2 (or some similar set of conditions). In short, these latter hold that making an autonomous request for assistance with dying is necessary, but should not be sufficient, for triggering such assistance.

There is one final matter of relevance to the moral case for voluntary medically assisted death on which comment must be made. The comment concerns a point foreshadowed in a previous paragraph, but it is also linked with the remark just made about the insufficiency of an autonomous request for assistance with dying to trigger that assistance. It is important to make the point that respect has to be shown not only for the dying person’s autonomy but also for the professional autonomy of any medical personnel asked to lend assistance with dying. The value (or, as some would prefer, the right) of self-determination does not entitle a patient to try to compel medical professionals to act contrary to their own moral or professional values. Hence, if voluntary euthanasia is to be legally permitted, it must be against a backdrop of respect for professional autonomy. Similarly, if a doctor’s view of her moral or professional responsibilities is at odds with her patient’s competent request for euthanasia, she should make provision, where it is feasible to do so, for the transfer of the patient to the care of a doctor who faces no such conflict. Given that, to date, those who contend that no scope should be permitted for conscientious objection within medical practice have garnered very little support for that view, making use of referrals and transfers remains the most effective means of resolving such disagreements.

Opponents of voluntary euthanasia have endeavored in a variety of ways to counter the very straightforward moral case that has been laid out above for its legalization (see, for example, Keown 2002; Foley, et al. 2002; Biggar 2004; Gorsuch 2006). Some of the counter-arguments are concerned only with whether the moral case warrants making the practice of voluntary euthanasia legal, whereas others are concerned with trying to undermine the moral case itself. In what follows, consideration will be given to the five most important counter-arguments. (For more comprehensive discussions of the morality and legality of medically assisted death see Biggar 2004; Gorsuch 2006; Young 2007; Sumner 2011, 2017; Keown 2018).

4.1 Objection 1

It is sometimes said (e.g., Emanuel 1999; Keown in Jackson and Keown 2012) that it is not necessary nowadays for people to die while suffering from intolerable or overwhelming pain because the provision of effective palliative care has improved steadily, and hospice care is more widely available. Some have urged, in consequence, that voluntary euthanasia is unnecessary.

There are several flaws in this contention. First, while both good palliative care and hospice care make important contributions to the care of the dying, neither is a panacea. To get the best palliative care for an individual involves trial and error, with some consequent suffering in the process; moreover, even the best care fails to relieve all pain and suffering. Perhaps even more importantly, high quality palliative care commonly exacts a price in the form of side-effects such as nausea, incontinence, loss of awareness because of semi-permanent drowsiness, and so on. A rosy picture is often painted as to how palliative care can transform the plight of the dying. Such a picture is misleading according to those who have closely observed the effect of extended courses of treatment with drugs like morphine. For these reasons many skilled palliative care specialists acknowledge that palliative care does not enable an easeful death for every patient. Second, even though the sort of care provided through hospices is to be applauded, it is care that is available to only a small proportion of the terminally ill and then usually only in the very last stages of the illness (typically a matter of a few weeks). Notwithstanding that only relatively few of the dying have access to hospice care it is worth drawing attention to the fact that in, Oregon, to cite one example, a high proportion of those who have sought physician-assisted suicide were in hospice care. Third, and of greatest significance for present purposes, not everyone wishes to avail themselves of palliative or hospice care. For those who prefer to die on their own terms and in their own time, neither option may be attractive. As previously mentioned, a major source of distress for many dying patients is the frustration that comes with being unable to satisfy their autonomous wishes. Fourth, as also indicated earlier, the suffering that occasions a desire to end life is not always traceable to pain caused by illness. For some, what is intolerable is their forced dependence on others or on life-supporting machinery; for these patients, the availability of effective pain control is not the primary concern. (In relation to the preceding matters see Rietjens, et al. 2009 and Onwuteaka-Philipsen et al. 2012 for findings for the Netherlands; and, for Oregon, Ganzini, et al. 2009.)

4.2 Objection 2

A second, related objection to the moral and legal permissibility of voluntary euthanasia turns on the claim that we can never have sufficient evidence to be justified in believing that a dying person’s request to be helped to die is competent, enduring and genuinely voluntary.

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

But, it might be asked, what if a person is racked with pain, or mentally confused because of the measures taken to relieve her pain, and is, in consequence, unable to think clearly and rationally about the alternatives? It has to be agreed that a person in those circumstances who wants to die should not be assumed to have a truly voluntary and enduring desire to die. However, there are at least two important points to make about those in such circumstances. First, they do not account for all of the terminally ill, so even if it is acknowledged that such people are incapable of agreeing to voluntary euthanasia that does not show that no one can ever voluntarily request help to die. Second, it is possible in at least some jurisdictions for a person to indicate, in advance of losing the capacity to give competent consent, how she would wish to be treated should she become terminally ill and suffer either intolerable pain or an unacceptable loss of control over her life (cf., for instance, Dworkin 1993). ‘Living wills’ or ‘advance directives’ are legal instruments for giving voice to people’s wishes while they are capable of giving competent, enduring and voluntary consent, including to their wanting help to die. As long as they are easily revocable in the event of a change of mind (just as civil wills are), they should be respected as evidence of a well thought-out conviction. (For more detailed consideration of these instruments see the entry on advance directives .)

Perhaps, though, what is really at issue in this objection is whether anyone can ever form a competent, enduring and voluntary judgement about being better off dead, rather than continuing to suffer from an illness, prior to suffering such an illness (cf., Keown in Jackson and Keown 2012). If this is what underlies the objection it is surely too paternalistic to be acceptable. Why is it not possible for a person to have sufficient inductive evidence (e.g., based on the experience of the deaths of friends or family) to know her own mind, and act accordingly, without having had direct experience of such suffering?

4.3 Objection 3

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

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

Hence, it is permissible, according to the doctrine of double effect, to, for example, alleviate pain (a good effect) by administering a drug, knowing that doing so will shorten life, but impermissible to administer the same drug with the direct intention of terminating a patient’s life (a bad effect). This latter claim is said to apply regardless of whether the drug is given at the person’s request.

This is not the appropriate forum for a full consideration of the doctrine, for which see the entry on the doctrine of double effect . However, there is one very important criticism to be made of the application of the doctrine that has direct relevance to the issue of voluntary euthanasia.

On the most plausible reading, the doctrine of double effect can be relevant to the permissibility of voluntary euthanasia only when a person’s death is bad for her or, to put it another way, a harm to her. Sometimes the notion of ‘harm’ is understood simply as damage to a person’s interests whether consented to or not. At other times, it is understood, more strictly, as damage that has been wrongfully inflicted. On either understanding of harm, there can be instances in which death for a person does not constitute a harm for her because it will either render her better off, or, as some would insist, no worse off, when compared with remaining alive. Accordingly, in those instances, the doctrine of double effect can have no relevance to the debate about the permissibility of voluntary euthanasia. (For extended discussions of the doctrine of double effect and its bearing on the moral permissibility of voluntary euthanasia see, e.g., McIntyre 2001; Woodward 2001; Cavanaugh 2006; Young 2007; Sumner 2011, 2017.)

4.4 Objection 4

As was noted earlier in Section 3, there is a widespread belief that so-called passive (voluntary) euthanasia, wherein life-sustaining or life-prolonging measures are withdrawn or withheld in response to a competent patient’s request, is morally permissible. The reason why passive (voluntary) euthanasia is said to be morally permissible is that the patient is simply allowed to die because steps are not taken to preserve or prolong life. This happens, for example, when a dying patient requests the withdrawal or the withholding of measures whose administration would be medically futile, or unacceptably burdensome. By contrast, active (voluntary) euthanasia is said to be morally impermissible because it is claimed to require an unjustifiable intentional act of killing to satisfy the patient’s request (cf., for example, Finnis, 1995; Keown in Jackson and Keown 2012; Keown 2018).

Despite its popularity and widespread use, the distinction between passive and active euthanasia is neither particularly clear nor morally helpful. (For a fuller discussion, see McMahan 2002.) Whether behavior is described in terms of acts or omissions (a distinction which underpins the alleged difference between active and passive voluntary euthanasia and that between killing a person and letting her die), is often a matter of pragmatics rather than anything of deeper moral importance. Consider, for instance, the practice (once common in hospitals) of deliberately proceeding slowly to a ward in response to a request to provide assistance for a patient who has been assigned a ‘not for resuscitation’ code. Or, consider ‘pulling the plug’ on a respirator keeping an otherwise dying patient alive, as against not replacing the oxygen supply when it runs out. Are these acts or omissions? If the answers turn on merely pragmatic considerations the supposed distinction between passive euthanasia and active euthanasia will be hard to sustain.

Even supposing that the distinction between acts and omissions, and the associated distinction between killing and letting die, can be satisfactorily clarified (on which see the entry doing v. allowing harm ), there remains the issue of whether these distinctions have moral significance in every circumstance. Consider a case of a patient suffering from motor neurone disease who is completely respirator dependent, finds her condition intolerable, and competently and persistently requests to be removed from the respirator so that she may die. Even the Catholic Church in recent times has been prepared to agree that it is permissible, in a case like this, to turn off the respirator. No doubt this has been because the Catholic Church considers such a patient is only being allowed to die. Even were it to be agreed, for the sake of argument, that such a death should be regarded as an instance of letting die, this concession would not show that it would have been morally worse had the patient been killed at her request (active voluntary euthanasia) rather than being allowed to die (passive voluntary euthanasia). Indeed, supporters of voluntary medically assisted death maintain that since death is beneficial in such an instance (or, at the very least, leaves the dying person no worse off), actively bringing about the death is morally to be preferred to just allowing it to happen because the desired benefit is achieved sooner and thus with less suffering.

Opponents of voluntary euthanasia claim, however, that the difference between active and passive euthanasia is to be found in the agent’s intention: if someone’s life is intentionally terminated she has been killed, whereas if she is just no longer being aggressively treated, her death should be attributed to the underlying disease. Many physicians would say that their intention in withholding or withdrawing life-sustaining medical treatment in such circumstances is simply to respect the patient’s wishes. This is plausible in those instances where the patient competently requests that aggressive treatment no longer be given (or, the patient’s proxy makes such a request). But it will often be implausible. In many cases the most plausible interpretation of a physician’s intention in withholding or withdrawing life-sustaining measures is that it is to end the patient’s life. Consider the palliative care practice of ‘terminally sedating’ a patient after a decision has been made to cease aggressive treatment. Suppose (as sometimes happens) that this is then followed by withholding artificially supplied nutrition. In these latter instances the best explanation of the physician’s behavior is that the physician intends thereby to end the life of the patient. What could be the point of the action, the goal aimed at, the intended outcome, if not to end the patient’s life? (Cf. Winkler 1995.) No sense can be made of the action as being intended to palliate the patient’s diseased condition, or to keep the patient comfortable. Nor is it appropriate to claim that what kills the patient is the underlying disease. What kills the patient is the act of depriving her of nutrition (i.e., of starving her to death). The point can be generalized to cover many more instances involving either the withdrawal or the withholding of life-sustaining medical treatment. In short, there is no good reason to think that whereas so-called passive voluntary euthanasia is morally acceptable active voluntary euthanasia never can be.

But we can go further. Giving titrated doses of morphine that reach levels beyond those needed to control pain, or removing a respirator from a sufferer from motor neurone disease, seem to many of us to amount to intentionally bringing about the death of the person being cared for. To be sure, as was acknowledged above, there are circumstances in which doctors can truthfully say that the actions they perform, or omissions they make, will bring about the deaths of their patients even though it was not their intention that those patients would die. So, for instance, if a patient refuses life-prolonging medical treatment because she considers it futile, it can be reasonable to say that her doctor’s intention in complying with the request was simply to respect her wishes. Nevertheless, as we have seen, there are other circumstances in which it is highly stilted to claim, as some doctors continue to do, that they had no intention of bringing about death.

These considerations should settle matters but do not do so for those who maintain that killing, in medical contexts, is always morally unjustified – a premise that underwrites much of the debate surrounding this fourth objection. But this underlying assumption is open to challenge and has been challenged by, for instance, Rachels 1986 and McMahan 2002. One of the reasons the challengers have given is that there are cases in which killing a competent dying person when she requests assistance with dying, is morally preferable to allowing her to die, namely, when taking the latter option would serve only to prolong her suffering against her wishes. Further, despite the longstanding legal doctrine that no one can justifiably consent to be killed (on which more later), it surely is relevant to the justification of an act of killing that the person killed has autonomously decided that she would be better off dead and so asks to be helped to die.

4.5 Objection 5

It is sometimes said that if society allows voluntary euthanasia to be legalized, we will then have set foot on a slippery slope that will lead us eventually to support other forms of euthanasia, including, in particular, non-voluntary euthanasia. Whereas it was once the common refrain that that was precisely what happened in Hitler’s Germany, in recent decades the tendency has been to claim that experience with legalized euthanasia in the Netherlands and Belgium, in particular, has confirmed the reality of the slippery slope.

Slippery slope arguments come in various versions. One (but not the only) way of classifying them has been to refer to logical, psychological and arbitrary line versions. The common feature of the different forms is the contention that once the first step is taken on a slippery slope the subsequent steps follow inexorably, whether for logical reasons, psychological reasons, or to avoid arbitrariness in ‘drawing a line’ between a person’s actions. (For further discussion see, e.g., Rachels 1986; Brock 1992; Walton 1992.)

We need first to consider whether, at the theoretical level, any of these forms of argument is powerful enough to refute the case for the legalization of voluntary euthanasia. We will then be in a position to comment on the alleged empirical support from the experiences of Hitler’s Germany and, more recently, of legalized euthanasia in the Netherlands and elsewhere, for the existence of a slippery slope that supposedly comes into being with the legalization of voluntary euthanasia.

To begin with, there is nothing logically inconsistent in supporting voluntary euthanasia while maintaining the moral inappropriateness of non-voluntary euthanasia. (However, for an attempt to press the charge that there is such an inconsistency see, e.g., Keown 2022.) Undoubtedly, some advocates of voluntary euthanasia wish also to lend their support to some acts of non-voluntary euthanasia, for example, for those in persistent vegetative states who have never indicated their wishes about being helped to die, or for certain severely disabled infants for whom the outlook is hopeless. (See, e.g., Kuhse and Singer 1985; Singer 1994; Stingl 2010; Sumner 2017.) Others believe that the consent of the patient is strictly required if euthanasia is appropriately to be legalized. The difference is not a matter of logical acumen; it is to be explained by reference to the importance placed on key values by the respective supporters. Thus, for example, those who insist on the necessity for a competent request by a patient for medical assistance with dying typically believe that such a request is the paramount consideration in end-of-life decision making (even when it is harnessed to the value of individual well-being), whereas those who consider a person’s best interests to be the paramount consideration are more likely to believe in the justifiability of instances of non-voluntary euthanasia like those mentioned above.

Next, it is hard to see why moving from voluntary to non-voluntary euthanasia is supposed to be psychologically inevitable. Why should those who support the legalization of voluntary euthanasia, because they value the autonomy of the individual, find it psychologically easier, in consequence, to endorse the killing of those who are not able competently to request assistance with dying? What reason is there to believe that they will, as a result of their support for voluntary euthanasia, be psychologically driven to endorse a practice of non-voluntary euthanasia?

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

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

Since the publication of the Remmelink Report in 1991 into the medical practice of euthanasia in the Netherlands, it has frequently been said that the Dutch experience shows that legally protecting voluntary euthanasia is impossible without also affording shelter to the non-voluntary euthanasia that will follow in its train (see, e.g., Keown 2018). In the period since that report there have been regular national studies of the practice of euthanasia in the Netherlands (see, e.g., Rietjens, et al. 2009; Onwuteaka-Philipsen, et al. 2012; van der Heide, et al. 2017). The findings from these national studies have consistently shown that there is no evidence for the existence of such a slippery slope. Among the specific findings the following are worth mentioning: of those terminally ill persons who have been assisted to die about sixty per cent have clearly been cases of voluntary euthanasia as it has been characterised in this entry; of the remainder, the vast majority of cases were of patients who at the time of their medically assisted deaths were no longer competent. It might be thought that these deaths ought to be regarded as instances of non-voluntary euthanasia. But, in fact, it would be inappropriate to regard them as such. Here is why. For the overwhelming majority of these cases, the decisions to end life were taken only after consultation between the attending doctor(s) and close family members, and so can legitimately be thought of as involving substituted judgements. Moreover, according to the researchers, the overwhelming majority of these cases fit within either of two common practices that occur in countries where voluntary euthanasia has not been legalized, namely, that of terminal sedation of dying patients, and that of giving large doses of opioids to relieve pain while foreseeing that this will also end life. In a very few cases, there was no consultation with relatives, though in those cases there were consultations with other medical personnel. The researchers contend that these instances are best explained by the fact that families in the Netherlands strictly have no final legal authority to act as surrogate decision-makers for incompetent persons. For these reasons the researchers maintain that non-voluntary euthanasia is not widely practised in the Netherlands.

That there have only been a handful of prosecutions of Dutch doctors for failing to follow agreed procedures (Griffiths, et al. 1998; Asscher and van de Vathorst 2020), that none of the doctors prosecuted has had a significant penalty imposed, that a significant proportion of requests for medical assistance with dying are rejected as unjustifiable, and that the Dutch public have regularly reaffirmed their support for the agreed procedures suggests that, contrary to the claims of some critics, the legalization of voluntary euthanasia has not increased the incidence of non-voluntary euthanasia. A similar picture to the one in the Netherlands has emerged from studies of the operation of the law concerning physician-assisted suicide in Oregon. Indeed, in a recent wide-ranging study of attitudes and practices of voluntary euthanasia and physician-assisted suicide covering two continents, a prominent critic of these practices has concluded (in agreement with his co-authors) that little evidence exists of abuse, particularly of the vulnerable (see Emanuel, et al., 2016). Unfortunately, insufficient time has elapsed for appropriate studies to be conducted in the other jurisdictions that have legalized either voluntary euthanasia or physician-assisted suicide (but for some relevant evidence see e.g., White, et al. 2022). Finally, some commentators have pointed out that there may, in reality, be more danger of the line between voluntary and non-voluntary euthanasia being blurred if euthanasia is practised in the absence of legal recognition, since there will, in those circumstances, be neither transparency nor monitoring (which cannot be said of the Netherlands, Belgium, Oregon and so on).

None of this is to suggest that it is not necessary to ensure the presence of safeguards against potential abuse of legally protected voluntary euthanasia. This is particularly important for the protection of those who have become incompetent by the time decisions need to be taken about whether to assist them to die. Furthermore, it is, of course, possible that the reform of any law may have unintended effects. However, if the arguments outlined above are sound (and the experience in the Netherlands, Belgium and Luxembourg, along with the more limited experience in several states in the United States and in Canada, is, for the present, not only the best evidence we have that they are sound, but the only relevant evidence), that does not seem very likely.

It is now well-established in many jurisdictions that competent patients are entitled to make their own decisions about life-sustaining medical treatment. That is why they can refuse such treatment even when doing so is tantamount to deciding to end their life. It is plausible to think that the fundamental basis of the right to decide about life-sustaining treatment – respect for a person’s autonomy and her assessment of what will best serve her well-being – has direct relevance to the legalization of voluntary euthanasia (see, e.g., Dworkin 1998; Young 2007, 2017; Sumner 2011, 2017). In consequence, extending the right of self-determination to cover cases of voluntary euthanasia does not require a dramatic shift in legal policy. Nor do any novel legal values or principles need to be invoked. Indeed, the fact that suicide and attempted suicide are no longer criminal offences in many jurisdictions indicates that the central importance of individual self-determination in a closely analogous context has been accepted. The fact that voluntary euthanasia and physician-assisted suicide have not been more widely decriminalized is perhaps best explained along a similar line to the one that has frequently been offered for excluding the consent of the victim as a justification for an act of killing, namely the difficulties thought to exist in establishing the genuineness of the consent. But, the establishment of suitable procedures for giving consent to voluntary euthanasia and physician-assisted suicide is surely no harder than establishing procedures for competently refusing burdensome or otherwise unwanted medical treatment. The latter has already been accomplished in many jurisdictions, so the former should be achievable as well.

Suppose that the moral case for legalizing voluntary euthanasia and physician-assisted suicide does come to be judged more widely as stronger than the case against legalization, and they are made legally permissible in more jurisdictions than at present. Should doctors take part in the practice? Should only doctors perform voluntary euthanasia? These questions ought to be answered in light of the best understanding of what it is to provide medical care. The proper administration of medical care should promote the welfare of patients while respecting their individual self-determination. It is these twin values that should guide medical care, not the preservation of life at all costs, or the preservation of life without regard to whether patients want their lives prolonged should they judge that life is no longer of benefit or value to them. Many doctors in those jurisdictions where medically assisted death has been legalized and, to judge from available survey evidence, in other liberal democracies as well, see the practice of voluntary euthanasia and physician-assisted suicide as not only compatible with their professional commitments but also with their conception of the best medical care for the dying. That being so, doctors of the same conviction in jurisdictions in which voluntary medically assisted death is currently illegal should no longer be prohibited by law from lending their professional assistance to competent terminally ill persons who request assistance with dying because of irremediable suffering or because their lives no longer have value for them.

• Asscher, E. and S. van de Vathorst, 2020, “First Prosecution of a Dutch Doctor Since the Euthanasia Act of 2002: What Does It Mean?”, Journal of Medical Ethics , 46: 71–75.
• Beauchamp, T. and A. Davidson, 1979, “The Definition of Euthanasia”, The Journal of Medicine and Philosophy , 4: 294–312.
• Bernat, J., B. Gert, and R. Mognielnicki, 1993, “Patient Refusal of Hydration and Nutrition: An Alternative to Physician Assisted Suicide or Voluntary Euthanasia”, Archives of Internal Medicine , 153: 2723–2728.
• Biggar, N., 2004, Aiming to Kill: The Ethics of Suicide and Euthanasia , London: Darton, Longman and Todd.
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• Brock, D., 1993, “Voluntary Active Euthanasia”, Hastings Center Report , 22(2): 10–22.
• Burleigh, M., 1994, Death and Deliverance: Euthanasia in Germany c. 1900–1945 , Cambridge: Cambridge University Press.
• Cavanaugh, T., 2006, Double-Effect Reasoning: Doing Good and Avoiding Evil , Oxford: Clarendon Press.
• Commission on the Study of Medical Practice Concerning Euthanasia: Medical Decisions Concerning the End of Life , The Hague: SdU, 1991. (This is known as ‘The Remmelink Report’.)
• Downie, J. and U. Schuklenk, 2021, “Social determinants of health and slippery slopes in assisted dying debates: lessons from Canada”, Journal of Medical Ethics , 47: 662–669.
• Dworkin, R., 1993, Life’s Dominion: An Argument About Abortion, Euthanasia, and Individual Freedom , New York: Random House.
• Dworkin, G., 1998, “Public Policy and Physician-Assisted Suicide”, in Dworkin, Frey, & Bok 1998, pp. 64–80.
• Dworkin, G., R. Frey, and S. Bok, 1998, Euthanasia and Physician-Assisted Suicide: For and Against , Cambridge: Cambridge University Press.
• Emanuel, E., 1999, “What Is the Great Benefit of Legalizing Euthanasia or Physician-Assisted Suicide?”, Ethics , 109: 629–642.
• Emanuel, E., B. Onwuteaka-Philipsen, J. Urwin and J. Cohen, 2016, “Attitudes and Practices of Euthanasia and Physician-Assisted Suicide in the United States, Canada and Europe”, Journal of the American Medical Association , 316: 79–90.
• Finnis, J., 1995, “A Philosophical Case Against Euthanasia” in J. Keown (ed.), Euthanasia Examined: Ethical, Clinical and Legal Perspectives , Cambridge: Cambridge University Press.
• Foley, K. and H. Hendin (eds.), 2002, The Case Against Assisted Suicide: For the Right to End-of-Life Care , Baltimore: The Johns Hopkins University Press.
• Foot, P., 1977, “Euthanasia”, Philosophy and Public Affairs , 6: 85–112.
• Ganzini, L., E. Goy and S. Dobscha, 2009, “Oregonians’ Reasons for Requesting Physician Aid in Dying”, Archives of Internal Medicine , 169: 489–492.
• Gorsuch, N., 2006, The Future of Assisted Suicide and Euthanasia , Princeton, New Jersey: Princeton University Press.
• Griffiths, J., A. Bood, and H. Weyers, 1998, Euthanasia and Law in the Netherlands , Amsterdam: Amsterdam University Press.
• Griffiths, J., H. Weyers and M. Adams, 2008, Euthanasia and Law in Europe , Oxford: Hart Publishing.
• Jackson, E. and J. Keown, 2012, Debating Euthanasia , Oxford: Hart Publishing.
• Keown, J., 2018, Euthanasia, Ethics and Public Policy: an argument against legalization , 2nd edition, New York: Cambridge University Press.
• –––, 2022, “The Logical Link Between Voluntary and Non-Voluntary Euthanasia”, Cambridge Law Journal , 81: 84–108.
• Kim, S., R. De Vries and J. Peteet, 2016, “Euthanasia and Assisted Suicide of Patients with Psychiatric Disorders in the Netherlands 2011 to 2014”, Journal of the American Medical Association Psychiatry , 73: 362–368.
• Kuhse, H. and P. Singer, 1985, Should the Baby Live?: The Problem of Handicapped Infants , Oxford: Oxford University Press.
• Lewis, P., 2007, Assisted Dying and Legal Change , Oxford: Oxford University Press.
• Marquet, R., A. Bartelds, G. Visser, P. Spreeuwenberg and L. Peters, 2003, “Twenty Five Years of Requests for Euthanasia and Physician Assisted Suicide in Dutch General Practice: Trend Analysis”, British Medical Journal , 327: 201–202.
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• McMahan, J., 2002, The Ethics of Killing: Problems at the Margins of Life , New York: Oxford University Press.
• Onwuteaka-Philipsen, B., A. Brinkman-Stoppelenburg, C. Penning, G. Jong-Krul, J. van Delden and A. van der Heide, 2012, “Trends in end-of-life practices before and after the enactment of the euthanasia law in the Netherlands from 1990–2010: A repeated cross-sectional survey”, The Lancet , 380: 908–915.
• Rachels, J., 1986, The End of Life: Euthanasia and Morality , Oxford: Oxford University Press.
• Rietjens, J., P. van der Maas, B. Onwuteaka-Philipsen, J. van Delden and A. van der Heide, 2009, “Two Decades of Research on Euthanasia from the Netherlands: What Have We Learnt and What Questions Remain?”, Journal of Bioethical Inquiry , 6: 271–283.
• Savulescu, J., 2014, “A Simple Solution to the Puzzles of End of Life? Voluntary Palliated Starvation”, Journal of Medical Ethics , 40: 110–113.
• Singer, P. 1994, Rethinking Life and Death: The Collapse of Our Traditional Ethics , Melbourne: Text Publishing.
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• Sumner, L., 2011, Assisted Death: A Study in Ethics and Law , Oxford: Oxford University Press.
• –––, 2017, Physician-Assisted Death: What Everyone Needs to Know , New York: Oxford University Press.
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• –––, 2017, “An Argument in Favor of the Morality of Voluntary Medically Assisted Death”, in M. Cholbi (ed.), Euthanasia and Assisted Suicide: Global Views on Choosing to End Life , Santa Barbara: Praeger.

How to cite this entry . Preview the PDF version of this entry at the Friends of the SEP Society . Look up topics and thinkers related to this entry at the Internet Philosophy Ontology Project (InPhO). Enhanced bibliography for this entry at PhilPapers , with links to its database.

• Medically Assisted Dying , an annotated bibliography authored by Robert Young (La Trobe University)
• Eight Reasons Not to Legalize Physician Assisted Suicide , by David Albert Jones, online resource at the Anscombe Bioethics Centre website.

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1000-Word Philosophy: An Introductory Anthology

Philosophy, One Thousand Words at a Time

Euthanasia, or Mercy Killing

Author: Nathan Nobis Category: Ethics Word count: 1000

Listen here

Sadly, there are people in very bad medical conditions who want to die. They are in pain, they are suffering, and they no longer find their quality of life to be at an acceptable level anymore.

When people like this are kept alive by machines or other medical treatments, can it be morally permissible to let them die ?

Advocates of “passive euthanasia” argue that it can be. Their reasons, however, suggest that it can sometimes be not wrong to actively kill some patients, i.e., that “active euthanasia” can be permissible also. [1] This essay reviews these arguments.

1. Passive Euthanasia

Denying that passive euthanasia is ever morally permissible suggests that we must always do everything we can to try to keep someone alive, even if they are miserable, want to die, and say so. To many, that’s just cruel. [2]

Passive euthanasia can be directly supported by both consequentialist (or utilitarian) and Kantian ethics. [3]

For the consequentialist, the patient being out of their misery is a better consequence for them , and overall, than their staying alive: this decreases the total amount of pain and unhappiness in the world, and no other choice would produce more good, for them or overall.

For a Kantian, letting them die respects their autonomy or decisions about matters that profoundly affect their own lives: this respects them as “ends in themselves,” whereas forcing them to live treats them as a “mere means” toward our ends, not their own.

Passive euthanasia can also be supported by stating conditions when it can be OK to let someone die. We begin with an ‘if’ and develop a principle:

(a) someone is dying, and (b) is in horrible pain and suffering, and (c) that pain and suffering cannot be relieved, and (d) that person wants to die and says so, and (e) informed, thoughtful and caring people agree that the person would be better off no longer living . . ,

then it can be permissible to let that person die. [4]

Passive euthanasia, then, can be justified in a variety of ways.

2. Active Euthanasia

To see why active euthanasia might be permissible, we begin by reflecting on why passive euthanasia might be OK: it gets people out of their misery and respects what they want for their own lives.

We then observe that these goals can often be pursued more directly and immediately by, say, giving them an overdose of pain-killing medications. Letting people die can take a long time, and that time might be full of unwanted suffering. Killing people, when they want to be killed, achieves their goals, more quickly.

So, it seems that if passive euthanasia can be permissible, so can active.

3. Objections

There are many objections to this reasoning. Some concern euthanasia in general.

3.1. Some claim that pain can always be controlled and so there is never a need to euthanize anyone. However, this insistence that pain can always be made bearable is, sadly, not true.

3.2. Some argue that “miracles” are possible – there’s always a chance that someone recovers – and so euthanasia is wrong. But making important decisions on very unlikely chances is often unwise. Most interestingly though, euthanasia would never prevent a miracle, especially one of divine origins.

Further objections claim there are important differences between active and passive euthanasia, making passive permissible but active wrong.

3.3. Some argue that it’s always wrong to intentionally kill someone, so active euthanasia is wrong. In reply, while it’s, at least, nearly always wrong to kill people, this is arguably because people usually want to live and do not have lives full of pain. Perhaps killing can be justified when this is not the case. [5]

3.4. Some argue that allowing active euthanasia might put us on a “slippery slope” to murdering people who want to live. But this hasn’t happened where active euthanasia is allowed, since we do and would have safeguards to lessen this possibility, as we do with other things that might lead to bad results if misused.

3.5. Some argue that there are important moral differences between allowing something to happen and doing something or because killing someone and letting them die are profoundly different, and so passive and active euthanasia should be judged differently. But consider this case:

An aunt will inherit lots of money if her five-year-old nephew dies. She plans to drown him in the bathtub and make it look like an accident. He just started his bath; she’s on her way to the bathroom to drown him. She opens the bathroom door and is delighted to see that he has slipped in the bathtub and is drowning. She watches, ready to push him under if he steadies himself and saves his own life. But, as her luck would have it, he drowns; she never touches him throughout the ordeal. She inherits the money. [6]

If she claimed that she didn’t “do anything,” she did : she stood there, and doing nothing is doing something . And letting someone die can be as bad , or nearly as bad , and perhaps sometimes even worse than killing someone [7] : indeed, a way to kill someone is to let them die. So these distinctions are, at least, not clear.

3.6. A final concern is that especially if active euthanasia were allowed, some people could be wrongfully killed. This is possible: some people might wrongfully break (potentially good) rules. But we cannot ignore that if euthanasia is not allowed, it might be that some people could be wrongly kept alive. Which wrong is more likely? Which wrong is worse?

4. Conclusion

While death is, arguably, usually bad for the person who dies, the goal of euthanasia is to make this less bad: the word euthanasia means a “good death.” These issues are important, and not just for people currently facing hard choices about death. None of us knows what will happen to us: at any time, an accident or illness might force these issues upon us, and so we should engage them more deeply, now. [8]

[1] The discussion and arguments here are largely based on James Rachels ’ (1941-2003) famous and widely-reprinted article “ Active and Passive Euthanasia,” New England Journal of Medicine 1975; 292: 78-80 .

[2] The discussion here concerns what’s called voluntary euthanasia, where a person wants to die and says so. There are other types of euthanasia though. Non-voluntary euthanasia involves an individual who neither wants to die nor wants to live, e.g., someone who has been unconscious for a long time, say in a coma, and we have good reason to believe that consciousness will never return: they currently don’t literally want anything and we usually don’t know what they would have wanted , since people usually don’t discuss this. What is sometimes called involuntary “euthanasia” involves someone who wants to live and says so . If such a person is let die or killed, this is not euthanasia: in all or nearly all cases, this is murder or wrongful killing , and so won’t be discussed further here.

These definitions cover most actual cases of euthanasia, but they aren’t perfect. First, it could happen that someone said that, if they were to fall into a permanent coma, they would very much want their body to be kept alive for as long as possible, but nobody knows this is what they wanted: if they are euthanized, is that in voluntary or non -voluntary? It could also happen that someone wants to die, but has no way of communicating that (suppose they have an extreme form of “ locked-in syndrome ,” with eye paralysis too, so they cannot even blink out messages): if they are euthanized, is that voluntary or non-voluntary? These cases are unclear, given the characterizations above, as are further possibilities of someone who wants to die but nobody knows that and someone who wants to live but nobody can tell .

Non-human animals who are judged to have a poor quality of life due to serious health problems are often (actively) euthanized: is this best considered a form of non-voluntary euthanasia, or potentially a different type of voluntary euthanasia? These animals have some current wants or desires, unlike a coma patient, but probably don’t have a specific want or desire to die, unlike in typical voluntary euthanasia cases. 

[3] Consequentialism and Kantianism can be used to support euthanasia (although Kant himself might have opposed it: Kant’s own judgments on many moral issues and the positions on moral issues that his theories arguably support sometimes diverge). But these theories do urge us to be very cautious about bringing about someone’s death, including our own.

Consequentialists would, and should, urge especially anyone who doesn’t have a challenging medical condition but wishes to die to seek counseling and assistance to help find happiness and fulfillment: in most cases, this would be better than death for that person and for promoting overall happiness. “ It gets better ,” the saying goes: it’s possible for someone to be euthanized (passively or actively), or commit suicide (if someone euthanizes themselves, this is a type of suicide; if they need assistance to do this, this is assisted suicide ), whose death is not in their own best interest or contributes to the greatest overall good. Indeed, some people have wished to die, have been prevented from ending their own life, come to appreciate their own life later, and then have been glad that they had not ended their life when they wanted to do so earlier. (However, it’s also sometimes true that people want to die, they live, and are eventually able to live what they report to be fulfilling lives, yet they still they wish they had died: Dax Cowart is a well-known case perhaps like this).

And Kantians don’t think that autonomy is unrestricted or limitless: just because we want something for ourselves doesn’t mean we should get it. Kantians firmly reject an attitude of “It’s your life, so do whatever you want with it,” since we have obligations to respect ourselves (and our future selves), given our value as persons, and this respect for ourselves could rule out some cases of euthanasia and suicide.

[4] The details of a principle like this, however, take us to harder questions about euthanasia, harder than those that arise in most circumstances: for examples, what if someone wants to die now but isn’t currently in horrible pain and suffering, or is expecting to die, but many years later after a very slow decline? Should anyone else have “say” over your own life or judge whether some pain and suffering is “horrible enough” for you to reasonably wish to die? If so, who? What if someone isn’t dying and doesn’t even have a bad medical condition but just finds their life not worth living and so wants to die (and so, say, plans to starve themselves to death or do other things that will result in their death)? These harder questions, and others, would need to be addressed for a complete defense of this or similar principles and any arguments based on them.

[5] Some might claim that their intention in any euthanasia is not to kill anyone: killing is an unintended consequence of their real intention, which might be to make the patient comfortable. If this makes sense, they might claim that they are not engaged in any intentional killing, so they aren’t violating any moral principle against intentional killing. This type of reasoning is related to what’s called the “Doctrine of Double Effect.”

[6] This case is from James Rachels. Here is another example that addresses the distinction between doing something versus allowing something to happen :

In a deep forest, hiking alone, Adam finds someone who has fallen into a deep pit. They ask him to throw them a rope so they can climb out. Adam doesn’t and they eventually starve to death. Adam learns of this on the news but feels fine since, he tells himself, “I didn’t do anything there. I did nothing wrong.”

To most, Adam clearly did something  –  he didn’t just allow something to happen – and he did something wrong: what he did , standing there not throwing the rope, was wrong.

[7] For tragic reflections that letting someone die can be worse than killing them, see Gary Comstock, “You Should Not Have Let Your Baby Die,” The New York Times , July 12, 2017 .

[8] Thanks to Zach Blaesi, Taylor Cyr, Chelsea Haramia, Dan Lowe, Travis Rodgers and Dan Peterson for comments on and discussion of this essay.

Gary Comstock, “You Should Not Have Let Your Baby Die,” The New York Times , July 12, 2017 .

James Rachels, “Active and Passive Euthanasia,” New England Journal of Medicine 1975; 292: 78-80.

For Further Reading

Young, Robert, “Voluntary Euthanasia”, The Stanford Encyclopedia of Philosophy (Spring 2019 Edition), Edward N. Zalta .

Cholbi, Michael, “Suicide”, The Stanford Encyclopedia of Philosophy (Fall 2017 Edition), Edward N. Zalta (ed.) .

Woollard, Fiona and Howard-Snyder, Frances, “Doing vs. Allowing Harm”, The Stanford Encyclopedia of Philosophy (Winter 2016 Edition), Edward N. Zalta (ed.) .

McIntyre, Alison, “Doctrine of Double Effect”, The Stanford Encyclopedia of Philosophy (Spring 2019 Edition), Edward N. Zalta (ed.) .

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Acknowledgments 

This essay is an abbreviated version of a longer chapter of the same title published in Noah Levin, ed.,  Introduction to Ethics: An Open Educational Resource (NGE Press, 2019) .  Nathan is grateful to Noah Levin for the occasion and inspiration to write these essays. 

About the Author

Nathan Nobis is a Professor of Philosophy at Morehouse College, Atlanta, GA. He is the author of Animals & Ethics 101 , co-author of  Thinking Critically About Abortion , a co-author of  Chimpanzee Rights , and author or co-author of many other articles, chapters, and reviews in philosophy and ethics. www.NathanNobis.com

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Euthanasia and assisted dying: the illusion of autonomy—an essay by Ole Hartling

Read our coverage of the assisted dying debate.

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• Ole Hartling , former chairman
• Danish Council of Ethics, Denmark
• hartling{at}dadlnet.dk

As a medical doctor I have, with some worry, followed the assisted dying debate that regularly hits headlines in many parts of the world. The main arguments for legalisation are respecting self-determination and alleviating suffering. Since those arguments appear self-evident, my book Euthanasia and the Ethics of a Doctor’s Decisions—An Argument Against Assisted Dying 1 aimed to contribute to the international debate on this matter.

I found it worthwhile to look into the arguments for legalisation more closely, with the hope of sowing a little doubt in the minds of those who exhibit absolute certainty in the matter. This essay focuses on one point: the concept of “autonomy.”

(While there are several definitions of voluntary, involuntary, and non-voluntary euthanasia as well as assisted dying, assisted suicide, and physician assisted suicide, for the purposes of brevity in this essay, I use “assisted dying” throughout.)

Currently, in richer countries, arguments for legalising assisted dying frequently refer to the right to self-determination—or autonomy and free will. Our ability to self-determine seems to be unlimited and our right to it inviolable. The public’s response to opinion poll questions on voluntary euthanasia show that people can scarcely imagine not being able to make up their own minds, nor can they imagine not having the choice. Moreover, a healthy person answering a poll may have difficulty imagining being in a predicament where they simply would not wish to be given the choice.

I question whether self-determination is genuinely possible when choosing your own death. In my book, I explain that the choice will always be made in the context of a non-autonomous assessment of your quality of life—that is, an assessment outside your control. 1

All essential decisions that we make are made in relation to other people. Our decisions are affected by other people, and they affect other people. Although healthy people find it difficult to imagine themselves in situations where they do not decide freely, it is also true that all of us are vulnerable and dependent on others.

Yet autonomy in relation to assisted dying is often viewed in the same way as our fundamental right to choose our own course in life. If we are able to control our lives, then surely we can also control our death. Autonomy with respect to your own death, however, is already halved: you can choose to die if you don’t want to live, but you cannot choose to live if you are about to die.

Decisions about your own death are not made in normal day-to-day contexts. The wish to die arises against a backdrop: of desperation, a feeling of hopelessness, possibly a feeling of being superfluous. Otherwise, the wish would not be there. Thus, it is under these circumstances that the right to self-determination is exercised and the decision is made. Such a situation is a fragile basis for autonomy and an even more fragile basis for decision making. The choice regarding your own death is therefore completely different from most other choices usually associated with the concept of autonomy.

Here are just some of the critical matters that would arise if assisted dying were legalised.

A duty to die

The possibility of choosing to die would inhabit everyone’s consciousness—the patient, the doctor, the relatives, and the care staff—even if not formulated as an out-and-out offer. But if a law on assisted dying gives the patient a right to die, that right may turn into a duty to die. How autonomously can the weakest people act when the world around them deems their ill, dependent, and pained quality of life as beyond recovery?

Patients can find themselves directly or indirectly under duress to choose that option if they consider themselves sufficiently pained and their quality of life sufficiently low. Patients must be at liberty to choose assisted dying freely, of course—that is how it is presented—but the point is that the patient cannot get out of having to choose. It has been called the “prison of freedom.”

Internalised external pressure

Pressure on the patient does not have to be direct or articulated. As pointed out by the US professor of biomedical ethics Daniel Sulmasy it may exist as an “internalised external pressure.” 2 Likewise, the French bioethicist Emmanuel Hirsch states that individual autonomy can be an illusion. The theologian Nigel Biggar quotes Hirsch saying that a patient “may truly want to die, but this desire is not the fruit of his freedom alone, it may be—and most often is—the translation of the attitude of those around him, if not of society as a whole which no longer believes in the value of his life and signals this to him in all sorts of ways. Here we have a supreme paradox: someone is cast out of the land of the living and then thinks that he, personally, wants to die.” 3

The end of autonomy

An inherent problem of autonomy in connection with assisted dying is that a person who uses his or her presumed right to self-determination to choose death definitively precludes himself or herself from deciding or choosing anything. Where death is concerned, your right to self- determination can be exerted only by disposing of it for good. By your autonomy, in other words, you opt to no longer have autonomy. And those around must respect the right to self-determination. The respect refers to a person who is respected, but this is precisely the person who disappears.

Danish philosopher Johannes Sløk, who supported legalisation, said, “The actual concept of death has no content, for death is the same as nothing, and one cannot choose between life and nothing. Rather, therefore, one must speak of opting out; one opts out of life, without thereby choosing anything else. Death is not ‘something other’ than life; it is the cessation or annihilation of life.”

Autonomy is a consistent principle running through the care and management of patients and is enshrined in law. However, a patient’s autonomy means that he or she has the right to decline any treatment. It does not entail a right to have any treatment the patient might wish for. Patients do not have the right to demand treatment that signifies another’s duty to fulfil that right. If that were so, autonomy would be the same as “autocracy”—rule of the self over others. Even though patients have the right to reject any intervention, they do not have the right to demand any intervention. Rejecting any claim that the person might make is not a violation of a patient’s self- determination—for example, there may be sound medical reasons for not complying with a demand. The doctor also has autonomy, allowing him or her to say no. Refusing to kill a person or assist in killing cannot be a violation of that person’s autonomy.

The killing ban

Assisted dying requires the doctor’s moral and physical help. It is a binding agreement between two people: the one who is to be killed and the one who is to kill or assist in killing. But our society does not condone killing as a relationship between two legally competent, consenting people. Exemptions from the killing ban involve war or self-defence and are not justified on the grounds that the killing is done for the “benefit” of someone else.

Valuation of a life

If the action is to be decriminalised, as some people wish, it means the doctor will have to enter into deliberations and arguments for and against a request for assisted dying each time. That is, whether he or she is willing to grant it. The alternative would be to refer the patient to another doctor who might be willing to help—that doctor would still have to assess whether the patient’s life was worth preserving.

Thus, autonomy is not the only factor or even always the key factor when deciding whether assisted dying can be granted. It is not only the patient’s own evaluation that is crucial. The value of the patient’s life must also be assessed as sufficiently low. This demonstrates the limitation of the patient’s self-determination.

Relieving suffering

If a competent and legally capable person must have the option of voluntarily choosing assisted dying in the event of unbearable suffering, why does suffering have to be a requirement? The answer is straightforward: our concepts of assisted dying imply that compassion must form a crucial aspect of the decision—mercy killing and compassionate killing are synonyms. But this leads instantly to the question of why we should not also perform assisted dying on people who are not in a position to ask for it themselves but are also suffering.

Some people find the reasoning unproblematic. It stands to reason that relieving suffering is a duty after all. But in this context it is not unproblematic, because it effectively shifts the focus from the autonomy claimed. According to prevailing ideas about autonomy, patients initially evaluate their quality of life themselves, but ultimately it is those around them who end up gauging that quality and the value of their life. That is to say, the justification for assisted dying is borne on the premise that certain lives are not worth living rather than the presence of a request. The whole point is that in the process, respect for the right to self-determination becomes relative.

Autonomy is largely an illusion in the case of assisted dying. 1 A patient overwhelmed by suffering may be more in need of compassion, care, and love than of a kind offer to help end his or her life. It is not a question of whether people have a right to say that they are unworthy. It is a question of whether they have a right to be believed when saying it.

Ole Hartling is a physician of over 30 years standing, doctor of medical sciences at the University of Copenhagen, professor of health promotion at the University of Roskilde, and an author and co-author of several books and scientific articles published mainly in Scandinavia. Between 2000 and 2007 he was a member of the Danish Council of Ethics and its chair for five years. During this time, the council extensively debated the ethics of euthanasia and assisted dying.

Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

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Belgium legalised voluntary euthanasia in 2002, thus ending the long isolation of the Netherlands as the only country in which doctors could openly give lethal injections to patients who have requested help in dying. Meanwhile in Oregon, in the United States, doctors may prescribe drugs for terminally ill patients, who can use them to end their life - if they are able to swallow and digest them. But despite President Bush's oft-repeated statements that his philosophy is to 'trust individuals to make the right decisions' and his opposition to 'distant bureaucracies', his administration is doing its best to prevent Oregonians acting in accordance with a law that its voters have twice ratified. The situation regarding voluntary euthanasia around the world is therefore very much in flux. This essay reviews ethical arguments regarding voluntary euthanasia and physician-assisted suicide from a utilitarian perspective. I shall begin by asking why it is normally wrong to kill an innocent person, and whether these reasons apply to aiding a person who, when rational and competent, asks to be killed or given the means to commit suicide. Then I shall consider more specific utilitarian arguments for and against permitting voluntary euthanasia.

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• Euthanasia Arts & Humanities 90%
• euthanasia Social Sciences 66%
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T1 - Voluntary euthanasia

T2 - A utilitarian perspective

AU - Singer, Peter

PY - 2003/10

Y1 - 2003/10

N2 - Belgium legalised voluntary euthanasia in 2002, thus ending the long isolation of the Netherlands as the only country in which doctors could openly give lethal injections to patients who have requested help in dying. Meanwhile in Oregon, in the United States, doctors may prescribe drugs for terminally ill patients, who can use them to end their life - if they are able to swallow and digest them. But despite President Bush's oft-repeated statements that his philosophy is to 'trust individuals to make the right decisions' and his opposition to 'distant bureaucracies', his administration is doing its best to prevent Oregonians acting in accordance with a law that its voters have twice ratified. The situation regarding voluntary euthanasia around the world is therefore very much in flux. This essay reviews ethical arguments regarding voluntary euthanasia and physician-assisted suicide from a utilitarian perspective. I shall begin by asking why it is normally wrong to kill an innocent person, and whether these reasons apply to aiding a person who, when rational and competent, asks to be killed or given the means to commit suicide. Then I shall consider more specific utilitarian arguments for and against permitting voluntary euthanasia.

AB - Belgium legalised voluntary euthanasia in 2002, thus ending the long isolation of the Netherlands as the only country in which doctors could openly give lethal injections to patients who have requested help in dying. Meanwhile in Oregon, in the United States, doctors may prescribe drugs for terminally ill patients, who can use them to end their life - if they are able to swallow and digest them. But despite President Bush's oft-repeated statements that his philosophy is to 'trust individuals to make the right decisions' and his opposition to 'distant bureaucracies', his administration is doing its best to prevent Oregonians acting in accordance with a law that its voters have twice ratified. The situation regarding voluntary euthanasia around the world is therefore very much in flux. This essay reviews ethical arguments regarding voluntary euthanasia and physician-assisted suicide from a utilitarian perspective. I shall begin by asking why it is normally wrong to kill an innocent person, and whether these reasons apply to aiding a person who, when rational and competent, asks to be killed or given the means to commit suicide. Then I shall consider more specific utilitarian arguments for and against permitting voluntary euthanasia.

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

• Published: 07 November 2021
• Volume 39 , pages 13–24, ( 2022 )

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• Navin Sinha   ORCID: orcid.org/0000-0003-3086-3504 1  

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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

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

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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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• Published: 15 January 2014

Should assisted dying be legalised?

• Thomas D G Frost 1 ,
• Devan Sinha 2 &
• Barnabas J Gilbert 3  

Philosophy, Ethics, and Humanities in Medicine volume  9 , Article number:  3 ( 2014 ) Cite this article

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When an individual facing intractable pain is given an estimate of a few months to live, does hastening death become a viable and legitimate alternative for willing patients? Has the time come for physicians to do away with the traditional notion of healthcare as maintaining or improving physical and mental health, and instead accept their own limitations by facilitating death when requested? The Universities of Oxford and Cambridge held the 2013 Varsity Medical Debate on the motion “This House Would Legalise Assisted Dying”. This article summarises the key arguments developed over the course of the debate. We will explore how assisted dying can affect both the patient and doctor; the nature of consent and limits of autonomy; the effects on society; the viability of a proposed model; and, perhaps most importantly, the potential need for the practice within our current medico-legal framework.

Introduction

Over the past two centuries, the United Kingdom has experienced rapid population growth associated with a substantial decline in mortality from acute infectious diseases and poor nutrition [ 1 ]. As the average life expectancy has increased, so too have the rates of debilitating chronic illness – particularly coronary artery disease and cancers [ 2 ]. These diseases require years of treatment instead of the mere days to weeks that medicine once operated within [ 2 ]. Although healthcare systems have sought to adapt to such changes, aiming to prevent and treat such disease wherever possible, debate has arisen regarding those patients in the latter stages of chronic, incurable, terminal conditions [ 3 , 4 ]. Moreover, there is increasing recognition that the patient must be at the centre of health care decision-making, such that outcomes must be tailored to their individual needs and views. By extension, assisted dying might seem a logical step to help achieve these goals within the realm of end-of-life decision making [ 5 ]. Several jurisdictions, notably Oregon (1997) and the Netherlands (2001) have already legalised assisted dying in some form. These factors have contributed to ongoing legislative discussions within Parliaments for almost a decade, with current opinion polling suggesting a majority of medical practitioners and the public in favour of physician-assisted suicide [ 6 ].

Viability of assisted dying in practice

In the UK, a model for assisted dying has been developed from the legal structure found within the Assisted Dying Bill introduced by Lord Falconer in the House of Lords in 2013 [ 7 ]. Assisted dying could only be considered under circumstances in which a patient of legal age is diagnosed with a progressive disease that is irreversible by treatment and is “reasonably expected to die within six months” [ 7 ]. Registered medical practitioners would make such decisions for patients with terminal illnesses. Addressing the technicalities of ‘assisted dying’ requires distinction between ‘physician-assisted suicide’ (offering patients medical actions or cessation of actions by which they can end their own life) and ‘euthanasia’ (whereby the medical practitioner actively induces death). In light of the strong hostility of the medical profession towards active euthanasia, this proposed model, as with previous attempts to legalise assisted dying, permitted only the former [ 8 – 10 ].

However, there is concern that such distinction may be unrealistic in practice because medical practitioners could find themselves with a patient who had failed to successfully end their own life and was subsequently left in a state of greater suffering. Were such a patient no longer able to give consent, a heavy burden would then be placed on the physician regarding how to proceed. Moreover, the practice of physician-assisted suicide might be deemed discriminatory, for example by giving only patients with good mobility control over their own method of death.

The Assisted Dying Bill 2013 included the provision that any terminal prognosis must be confirmed and attested by a second registered practitioner. The strictness of such criteria has parallels to a similar double-physician requirement when procuring a legal abortion under the 1967 Abortion Act. The stated aims of the provision in both cases are as follows: first, to check the accuracy of the prognosis upon which the decision was being made; second, to ensure that the situation meets the required criteria; and third, to check that such a decision was taken by the patient after full consideration of all available options [ 11 , 12 ]. By having a second independent doctor, the legislation ensures that all three checks are met without prejudice or mistake.

Problematic for any protocol for assisted dying is the fact that estimates of life expectancy in terminal prognoses are erroneous in 80.3% of cases [ 13 ]. Furthermore, the accuracy of such prognoses deteriorates with increased length of clinical predicted survival. Forecasts of survival times are based largely on past clinical experience, and the inherent variability between patients makes this more of an art than a science. This brings to concern both the accuracy of any prognosis meeting the six-month threshold and the validity of requests for assisted dying based partly or wholly on predicted survival times. Whilst the majority of errors in life expectancy forecasts are a matter of over-optimism and hence would not affect either of those two concerns, many cases remain unaccounted for. Overly pessimistic forecasts occur in 17.3% of prognoses; hence we must decide whether the one in six patients making a decision based on an inaccurate prognosis is too high a cost to justify the use of this system. Patients requesting an assisted death often cite future expectations of dependency, loss of dignity, or pain [ 14 ]. If the hypothetical point at which the progression of their illness means they would consider life to be not worth living is not, as informed, mere weeks away but in fact many more months, then this information would have resulted in a different decision outcome and potentiated unnecessary loss of life.

Whilst the presence of a second doctor would be expected to mitigate such forecasting errors, the anchoring bias of the initial prediction may be enough to similarly reduce the accuracy of the second estimate. It is prudent to question the true independence of a second medical practitioner, and whether this second consultation could become more of a formality, as has now become the case with abortion [ 15 ].

Another challenge for an assisted dying system would be to recognise whether patients requesting death were legally competent to make that decision. Consider that any request for suicide from a patient with clinical depression is generally categorised as a manifestation of that mental disorder, thereby lacking capacity. It is arguably impossible to separate out the natural reactions to terminal illness and clinical depression. Indeed, there is evidence that major depressive disorders afflict between 25% and 77% of patients with terminal illness [ 16 , 17 ]. Any protocol for assisted dying must first determine what qualifies as a ‘fit mental state’ for a terminal patient.

The need for assisted dying

It could be argued that a doctor’s fundamental duty is to alleviate forms of suffering in the best interests of the patient. The avoidance of physical pain, as an obvious manifestation of suffering, might explain why assisted dying would be both necessary and within the duties of a doctor to provide. The evolving principle in common law known as the ‘Doctrine of Double Effect’ offers a solution to this problem [ 18 ]. This legal judgement stated that “[a doctor] is entitled to do all that is proper and necessary to relieve pain even if the measures he takes may incidentally shorten life”. This entails that a protocol already exists for patients searching for an escape from chronic pain. Furthermore, numerous retrospective studies have revealed very little correlation between opioid dose and mean survival times: one study of over 700 opioid-treated patients found that the variation in survival time from high-dose opioid treatment is less than 10% [ 19 – 21 ]. It can therefore be said that pain alone, if appropriately managed, should never be cause for considering assisted dying as an alternative.

By contrast, the ‘Doctrine of Double Effect’ might be seen as a subjective interpretation that has been applied unequally due to a lack of specialist training or knowledge [ 22 ]. Despite this, the principle can be easily understood and poor awareness can be remedied by improvements in medical education and standardisation of protocols. Moreover, should we choose to accept arguments for assisted dying that are based upon inadequate administration of pain medication, we set a precedent for conceding shortcomings in palliative care and other end-of-life treatments. Offering hastened death could become an alternative to actively seeking to improve such failings.

Whilst much has been made of the ‘pain argument’ here, the call for assisted dying is rarely this simple. Many patients also suffer a loss of dignity, often due to their lack of mobility – the inability to relieve oneself without help is a potent example. Beyond this are additional fears of further debilitation and the emotional costs of dealing with chronic illness, both for the patient and for their relatives and friends. A study of terminal patients in Oregon showed that these were the most significant reasons behind requests for assisted suicide, the next commonest reason being the perception of themselves as a ‘burden’ [ 14 ]. Clearly, we could seek to provide balanced, compassionate medical care for these patients, and still fail to address these points.

Developments in healthcare and technology may reduce this emotional burden, but remain an imperfect solution.

Rights of patients and limitations of their autonomy

J.S. Mill’s pithy dictum describes autonomy as follows: “over himself, over his own body and mind, the individual is sovereign” [ 23 ]. Not only has the sanctity of bodily autonomy profoundly influenced the development of liberal democracies, it has also provoked a holistic shift in making our healthcare systems more patient-centred – “care that meets and responds to patients’ wants, needs and preferences and where patients are autonomous and able to decide for themselves” [ 5 ]. The ethical principle of controlling the fate of one’s own body is inherently relevant to the debate on assisted dying. It is difficult to reconcile that citizens may have the right to do almost anything to and with their own bodies– from participating in extreme sports to having elective plastic surgery – yet a terminal patient cannot choose to avoid experiencing additional months of discomfort or loss of dignity in their final months of life.

Expectation of individual liberty has been codified in law. The right to bodily autonomy has been interpreted to be included under Article 8 - the right to privacy - of the European Convention on Human Rights (ECHR) and subsequently the Human Rights Act (HRA) [ 24 , 25 ]. Moreover, the ECHR underpins the right of individuals to ‘inherent dignity’ [ 26 ]. Hence, if an individual feels that dignity is unattainable due to the progression of a terminal illness, then taking recourse though assisted dying ought to be a legitimate option.

Conversely, there are two notable oversights in this interpretation of a right to assisted dying as an extension of the principles of bodily autonomy:

First, it would be wrong to view individual liberty as absolute. The HRA allows for exceptions to Article 8 on grounds of ‘health or morals’ [ 25 ]. The principle of autonomy is not inviolable. Governments have limited such privileges for the protection of individuals and society, for example by criminalizing the use of recreational drugs or the selling of one’s own organs. The preservation of life by denying assisted dying could fall within this category.

Second, the right of autonomy is not necessarily intrinsic to human beings but, as Kant argued, is dependent on our ‘rational nature’ [ 27 ]. This concept sees autonomy as an exercise of ‘evaluative choice’ [ 27 ], requiring rationality on the part of individuals to appreciate the nature of options and their consequences. To achieve true autonomy, there must be sufficient information to make those rational decisions; this is the basis of informed consent and why it is a fundamental duty of a doctor to offer a patient an informed series of treatment options [ 28 ]. The logistical issue is that doctors are unable to advise patients regarding the point at which their situation becomes less preferable to being dead. No doctor (or individual) has any knowledge or experience of what ‘death’ may be like. Hence, in this case, the idea of exercising true autonomy through informed consent might be considered meaningless.

Legalising assisted dying by attempting to establish an absolute right to bodily autonomy may undermine other individual and group rights. Vulnerable patients may feel pressured into assisted dying because of social, emotional, or financial strains placed on family and/or friends. This is exemplified by the trend showing that the proportion of patients stating ‘relief of burden’ on others as the reason for requesting assisted dying has risen from 17% to 25% in Oregon since legalisation [ 29 ]. One could even consider the risk of assisted dying becoming an expected choice rather than a free one. Thus, assisted dying may erode the elemental right to life of terminal patients as the value of their life becomes tied to relative costs to society and to those around them.

Moreover, by creating one class of individuals for whom life is expendable, that particular view may be extended by society to all groups possessing such attributes (e.g. the permanently disabled). There would be a definite risk to the rights of these vulnerable groups in the form of society being less willing to provide for their health and social care.

It is often raised that the limited legalisation of assisted dying would inevitably become extended in scope, but this is not necessarily a flaw. Even if the right to determine the manner of death were later extended to a wider group of people, posterity may reflect positively on such a change, just as extending the franchise to women ultimately led to legislation demanding equal pay.

Effect on health professionals and their role

‘To act in the best interest of the patient’ is often cited as a central duty of the doctor [ 28 ]. This concept of ‘best interest’ guiding the doctor’s action has seen the development of two important ethical principles: beneficence and non-maleficence. Beneficence mandates that the actions of the doctor must be aimed to bring about benefit (clinical improvement) for the patient, usually measured in terms of reduced morbidity or mortality; non-maleficence requires that the doctor not carry out treatment that is likely to cause overall harm the patient [ 30 ]. These traditional ethical imperatives on a doctor both conflict with intentionally hastening the death of a patient, and a resolution of this tension would require redefining what constitutes ‘acting in the best interest’.

A further dimension is the potential reluctance of health professionals to engage in a practice that contravenes their own ethical beliefs, particularly as this would affect doctors who never entered training in the knowledge that assisting patients to die would be an expected duty. This is certainly no argument against the introduction of assisted dying; indeed, a recent survey of a cohort of NHS doctors found that 46% would seriously consider requests from patients to undertake steps to hasten death [ 31 ]. It merely expresses the point that any early model would have to account for the fact that an initial 54% of the doctors in the NHS would be required to advise qualifying patients of assisted dying as a legitimate option, despite disagreeing with it in principle.

Furthermore, doctors who agree ethically with this practice may find themselves facing conflicts of interest. It is expensive to treat chronically ill patients, particularly in the final months of life [ 32 ]. Moreover, it would be difficult for commissioners to ignore the fact that the sustained treatment of one individual could deprive many others from access to surgery or access to novel drugs. Such an argument does not suggest that doctors or any other hospital staff would treat this practice without appropriate respect or care; rather it acknowledges the need for appropriate rationing of care and questions the intentions of service providers. The perception of an ulterior motive could negatively impact patient trust. One survey showed that a reasonable minority of patients (27%) – and particularly particularly the elderly – believe that legalising assisted dying would lessen their trust in their personal physician [ 33 ]. The costs of weakened trust in the doctor-patient relationship could far outweigh the benefits of assisted dying, particularly given the importance of trust when treating a chronic patient for an extended period of time.

There is no doubt that assisted dying would empower some patients to maximise control over the timing and manner of their own death. Such expression of autonomy would surely solidify moves towards a patient-centred approach to healthcare. However, the capacity for such consensual requests remains in doubt. Clinically, the patient’s state of mind and the reliability of diagnostic predictions are of issue; philosophically, the idea of informed consent for death is contradictory. The implications for patients, physicians and society have been weighed extensively within this article. The central tenet throughout has been the balancing of an individual’s right to escape a circumstance that they find intolerable, alongside the consequential changes to their other rights, and the rights and responsibilities of third parties. Ultimately, the challenge is for us as a society to decide where this balance lies.

About the debate

The Varsity Medical Debate was started in 2008 with the aim of allowing students, professors and members of the polis, to engage in discussion about ethics and policy within healthcare. Utilising the age-old rivalry between the two Universities, the debate encourages medical students from both Oxford and Cambridge to consider and articulate the arguments behind topics that will feature heavily in their future careers.

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

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Acknowledgements

For Cambridge University: Hilmi Bayri (Trinity), Alistair Bolger (Jesus), Casey Swerner (St Johns).

For Oxford University: Devan Sinha (Brasenose), Thomas Frost (Lincoln), Collis Tahzib (Lincoln).

Martin Farrell (Cambridge).

Baroness Finlay: Professor of Palliative Care Medicine and former President of the Royal Society of Medicine.

Dr. Roger Armour: Vascular Surgeon and Inventor of the Lens Free Ophthalmoscope.

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Euthanasia in Kant's Ethics

Does Kantian Ethics Permit Euthanasia?

Euthanasia has been a controversial topic for centuries. Kantian ethics, focusing on the concepts of autonomy and dignity, offers a unique moral assessment.

By Baran Barlas , MA Political Studies, BA Philosophy

Kantian ethics is one of the most influential moral theories in the history of philosophy. Two fundamental concepts – autonomy and dignity – emerge in an intertwined relationship in Kant’s moral theory. These two concepts are also frequently highlighted in debates about the morality of euthanasia. A careful examination of Kant’s philosophy leads us to an intriguing discussion about the moral permissibility of euthanasia.

Kantian Ethics: A Deontological Theory of Right Conduct

With its systematic approach and solid argument structure, Immanuel Kant’s (1724 – 1804) moral philosophy is extremely thought-provoking. Three major works outline the famous German philosopher’s ethical thought: Groundwork of the Metaphysics of Morals , Critique of Practical Reason , and The Metaphysics of Morals .

A leading notion in Kantian ethics is that moral principles can only be derived from reason. Kant argued that moral obligation was rooted in the rationality of human beings. Reason, as one’s capacity for deliberation and free choice, is what enables individuals to act morally. The duty not to lie thus applies to all rational agents, not just to a particular individual for achieving a particular goal. If reason leads us to a principle of moral action, then, it is our duty to follow it. Hence Kant’s moral theory falls within the domain of deontology ; a normative theory of duties. That’s why principles of human action are called imperatives in Kantian terminology: because they constitute commands addressed to individuals.

The two types of imperatives discussed in Kant’s moral philosophy , the categorical imperative and hypothetical imperatives , are in contrast. The unconditional and universal nature of moral requirements makes them categorical . For Kant, a moral principle must categorically hold for everyone. The defining aspect of the categorical imperative is that it is based on universal principles, while the demands of hypothetical imperatives depend on one’s desires. For example, one ought to take Logic 101 course to succeed in analytical philosophy. This is a non-moral requirement based on an individual’s personal goals, therefore not universalizable. The duty to take care of a sick human being, on the other hand, holds universally valid because it is not dependent on one’s own ends.

But what exactly is the special significance of human beings in Kantian ethics?

The Categorical Imperative in Kantian Ethics: Humanity as an End in Itself

There are two types of ends in Kant’s moral theory: Ends that are brought through action, and ends that exist unconditionally. Former types of ends are objects of desire, while the latter ones are ends in themselves. The example of a student’s goal of passing the Logic 101 course constituted an end that is an object of desire. However, the source of morality in Kantian ethics must be unconditional. Kant puts forward humanity as the main example for existent ends , claiming that human beings have absolute inner worth.

Kant defined the categorical imperative in terms of humanity in Groundwork of the Metaphysics of Morals :

“ So act that you use humanity, whether in your own person or in the person of any other, always at the same time as an end, never merely as a means. ” (Kant, 1996, 38)

This formulation provides a moral criterion for decision-making. But what exactly makes human beings end in themselves for Kant? His reasoning for reaching this formulation is explained as follows:

As rational agents, we can determine our actions independently of desires and external effects.

This means that we possess autonomy .

As autonomous beings, we are ends in ourselves because we are uniquely capable of forming universal principles, comprehending them, and acting accordingly.

As an end in itself, every human being has an absolute intrinsic value called dignity .

It’s crucial to understand that Kant’s formulation only rules out treating humanity as mere means in our actions. In fact, we have to regularly use other people as means for our own goals in daily life. We may treat a taxi driver as a means of our own transportation. But the categorical imperative states that we should always treat the taxi driver’s humanity as an end in itself at the same time. This forms the basis of Kant’s duties for promoting humanity in ourselves and others.

The Categorical Imperative: Universalizability of Maxims

The other famous formulation of the categorical imperative states that moral principles must be universalizable . This formulation is a formal statement that expresses the rationality of action rather than its moral content. Kant expresses this “universal law” formulation again in the Groundwork of the Metaphysics of Morals :

“ Act as if the maxim of your action were to become by your will a universal law of nature. ” (Kant, 1996, 31)

A maxim forms the principle of action in an individual’s thought process. A simple example of a maxim is: “I will avoid helping others when they ask for help.” According to Kant, a maxim has to pass the tests of “contradiction in conception” and “contradiction in will” to have moral significance. The “contradiction in conception” test asks whether a world in which the agent’s maxim becomes a universal law can be consistently conceived. Our case passes this test, as a world in which everyone refrains from helping others can be consistently conceived.

However, it fails at the “contradiction in will” test. Because a world in which every other person acts upon this maxim wouldn’t be desirable by the agent. Every rational individual naturally wants to be able to get the help of others when needed. The agent cannot consistently will this maxim to become a universal law. Therefore, this maxim fails to constitute a universal principle.

Through this second formulation, Kant sets the objective condition of the categorical imperative as universality . The first formulation had already set the subjective condition, stating that humanity is an end in itself and shouldn’t be treated as a mere means. Having set the criteria for both the content and the form, the outline of Kantian moral assessment becomes clear: Our actions must derive from universalizable principles, while not interfering with other human beings. These formulations allow us to apply Kant’s philosophy to a specific topic, euthanasia in our case.

Euthanasia: The History of “Good Death”

Euthanasia in its modern sense is the intentional practice of ending one’s life to relieve pain. The term euthanasia derives from the Greek words eu , meaning good, and thanatos , meaning death . So the literal meaning of the word is “good death”. In its earlier use, the term meant supporting someone who was on the verge of dying. In that sense, it implied a practice that eased death for the dying to relieve suffering.

Only after the mid-19th century did the term euthanasia come to be understood in its modern interpretation. The emergence of morphine usage in treating the pains of dying patients led to the idea of hastening the death of terminally ill people. This sparked the beginning of the debate over euthanasia as the “right to die”. As of 2022, euthanasia is legal in different forms in several countries around the world. However, due to ongoing campaigns for and against it, the legality of the practice changes quite often in some countries.

The discussions on euthanasia in bioethics focus on different forms of the practice. Voluntary and non-voluntary euthanasia are two main types of practice, while these types are further divided into categories of active and passive euthanasia. Voluntary euthanasia is carried out with the consent of the patient. This usually involves a patient dying with the assistance of a physician. Hence it is often called “assisted suicide”. Non-voluntary euthanasia is usually conducted with the consent of a relative since this practice is performed when the patient’s consent is unavailable.

The further division into active and passive euthanasia indicates whether the action is directly aimed at killing the patient. The most common example of active euthanasia is the injection of a lethal drug. Passive euthanasia, often called “pulling the plug”, usually involves the termination of treatment or life support that keeps the patient alive.

Whether and to what extent these different types of euthanasia differ in moral significance poses a deep philosophical question.

The Controversy Surrounding Euthanasia

The opposing sides of the debate on euthanasia focus on two different key concerns. The paramount concern for the proponents of the practice is the autonomy of patients as self-governance. However, this argument only holds for voluntary euthanasia since non-voluntary euthanasia doesn’t involve the patient’s autonomy. In the case of non-voluntary euthanasia, the proponents put forward another argument. In this case, the idea is that letting the patient die might be the better option than keeping her suffering.

A major argument asserted by opponents of euthanasia is that it destroys a being with absolute inner worth. Opponents with religious standpoints share this view, while they also see euthanasia as a disrespect to the creator since it involves killing his creations. As this understanding is based on an inner value of human beings, it also holds for non-voluntary euthanasia.

The Doctrine of Double Effect

An important principle for the Christian-based critiques of active euthanasia, which was first articulated by Saint Thomas Aquinas , is the doctrine of double effect . This principle suggests that under certain conditions, an intended action is morally permissible even if it causes a foreseen bad effect. Applying the doctrine of double effect to the case of euthanasia reveals a moral difference between passive and active euthanasia. Active euthanasia is considered morally wrong since it involves directly killing the patient. In passive euthanasia, the action of terminating the treatment or administration of drugs in dangerous doses may be permissible if the main intention is not to kill, but to relieve pain.

The doctrine of double effect has become a commonly referred principle in medicine, especially in cases of abortion and passive euthanasia. The Supreme Court of the United States has supported the principle for certain medical cases.

The main criticism of this intention-focused reasoning comes from consequentialist perspectives. Consequentialist assessments assert that there’s no moral difference between passive, active, voluntary, or non-voluntary euthanasia. That’s simply because they have the same consequences; the death of the patient.

Suicide in Immanuel Kant’s Philosophy

Kant didn’t write explicitly on euthanasia, as it was not even an openly debated topic during his time. He did, however, discuss suicide. Unsurprisingly, he deliberated about an action aimed directly at destroying a rational agent:

“ If he destroys himself in order to escape from a trying condition he makes use of a person merely as a means to maintain a tolerable condition up to the end of life. ” (Kant, 1996, 38)

Kant claimed that an individual attempting suicide treats humanity as a mere means to escape pain. Accordingly, one cannot rationally choose to commit suicide because it aims to destroy the autonomous nature which enables one to make choices. But can’t suicide also be understood as the realization of personal autonomy as an act in which individuals determine their fate?

Inevitably, this examination of suicide reveals the hidden tension between the notions of personal autonomy and human dignity in Kantian ethics. The two notions are intertwined in Kant’s philosophy: The source of human beings’ dignity is their autonomous and rational capacities. What makes the case of suicide unique for Kantian ethics is that the two notions seem to come into conflict.

It is important to keep in mind that Kant criticized the generic notion of suicide. Extending the discussion to euthanasia, however, brings up new aspects for consideration. Kant’s main argument against suicide stemmed from his humanity-based formulation. It is therefore reasonable to continue the examination by applying this formulation to euthanasia. Is it possible for someone to end their own life while respecting humanity?

Euthanasia and the Categorical Imperative

Firstly, let’s consider a situation in which a patient gradually loses the ability to think rationally. For example, Alzheimer’s disease starts slowly but worsens as the disease progresses. Eventually, the patient becomes unable to act like a rational human being due to a loss of brain functions. Another example could be a bodily condition affecting the mind. The physical pain, drug effects, or the mental burden of the condition may be so tense that it impairs the patient’s ability to think rationally.

Such a person wouldn’t be considered human by Kantian moral standards. It’s not human beings per se , but the humanity in them that we are required to treat as an end in itself. Therefore, a person who lacks the essential features of humanity wouldn’t possess dignity to be respected. There is no apparent ethical reason forbidding the choice to end the life of a person who is losing her autonomy and rationality.

One research covering 1905 patients revealed that loss of autonomy and loss of dignity were among the top three reasons for wanting to die, and not pain as Kant assumed. Then in the case of euthanasia, some empirical data suggest that loss of dignity and autonomy is sometimes the cause, not the result, of the decision to die.

Certain conditions must be met for euthanasia to be morally permissible in this case:

The diagnosis must be made with absolute certainty that the patient will gradually lose her human abilities and cannot be cured.

The patient must make a choice about the future for herself while she is still able to think rationally.

It is compatible with Kant’s humanity-based formulation that one ends their life after losing what makes them essentially human and part of the moral domain. Testing euthanasia with Kant’s universalizability formulation will take us one step closer to understanding what the moral status of euthanasia should be.

A Universalizable Principle of Euthanasia

Kant claimed that suicide indicated the following maxim:

“ From self-love I make it my principle to shorten my life when its longer duration threatens more troubles than it promises agreeableness. ” (Kant, 1996, 32)

In addition to treating humanity as a means to escape pain, this maxim contains another wrongness in terms of Kantian ethics. It implies happiness as the main goal of a person based on the measurement of satisfaction and harm. Happiness is a utilitarian concern and has no moral value in Kant’s ethical thought. Furthermore, Kant stated that this maxim failed at the “contradiction in conception” test.

This is not the only possible maxim for suicide in the context of euthanasia. Based on the case of euthanasia examined in the previous section, a new maxim can be constructed: “If I begin to incurably lose my ability to think rationally, I want my life ended.” This maxim reflects the specific euthanasia case which doesn’t violate Kant’s humanity-based formulation of the categorical imperative.

Applying the “contradiction in conception” test reveals that one can consistently conceive a world in which this second maxim becomes a universal law. The maxim is in accordance with the two conditions stated above. We can conceive a world in which people seek euthanasia only on the verge of losing their human capacities. One might even argue that this maxim is already actualized in the countries where euthanasia is legal.

The maxim also passes the “contradiction in will” test, as euthanasia contains only a decision about one’s self. Every other agent who adopts this principle would act individually on this principle without affecting other people. Therefore, the creator of the maxim will not encounter a contradiction when everyone acts on this maxim. As a result, all cases seem to fit Kant’s formulation of universalizability.

Kantian Ethics on Euthanasia: The Verdict

The case of euthanasia is a special challenge for Kantian ethics mainly for two reasons. Firstly, the debates on the permissibility of euthanasia revolve around the concepts of autonomy and dignity. These two concepts also play central roles in Kant’s ethical thought. Secondly, Kant’s discussion about suicide seems to reveal a tension between the two key concepts. However, applying the two formulations of the categorical imperative reveal that in specific cases, euthanasia can be compatible with the Kantian line of thought.

Many scholars today argue that Kantian ethics permits euthanasia. However, especially due to Kant’s own opposition to suicide, it remains an open debate.

By Baran Barlas MA Political Studies, BA Philosophy Baran is a writer and translator from Istanbul. He holds a BA in Philosophy and an MA in Political Studies. His main areas of interest are political philosophy, ethics, and the intersection of the two. He has recently been focusing on the ethical aspects of Marx's philosophy and looks forward to starting a PhD in philosophy. He's passionate about gastronomy, history of music, and football.

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• Nov 20, 2021

Philosophy 101: Euthanasia - A Complicated Affair

In the last of the philosophy 101 series, the examination into whether or not euthanasia - the legal right given by the state to allow people the right to die - should be granted. It follows on from the last series questioning the rights of defendants in cases of a sexual nature over anonymity. There are many arguments for and against euthanasia, including; it is expensive to keep people alive when there is no cure for their illness. Euthanasia would release precious resources to treat people who could live and it would lead to worse care for the terminally ill, though I will highlight the main three arguments for, and outline the counter-arguments. The main three arguments are The Compassion argument, The autonomy argument, and The public policy argument.

“We have no control over how we arrive in the world but at the end of life we should have control over how we leave it.” Patrick Stuart - Patron of Dignity in Dying

Euthanasia or assisted dying is a very divisive topic amongst many. For some, the notion that one has a right to take a life should not even be up for debate. Staunch believers in God, for instance, argue that no one has the right to play God, and only God himself should decide over matters of life and death. While others argue that it is cruel to keep someone alive who may be suffering from a terminal illness. When people's pets are in great pain and suffering it is understood that the right course of action to take is to have the animal put to sleep. Society generally accepts that this is the right action to take. But when it comes to humans, society takes a very different view. Some argue that People can make unexpected recoveries or some may change their mind about euthanasia and be unable to tell anyone. There are countries that have legalized euthanasia; Belgium, Luxembourg, the Netherlands, Canada, Colombia, and most recently Spain. This is a delicate subject that one needs to understand the main arguments across all sides of the debate.

The compassion argument - this is an extension to the aforementioned example of someone living with a terminal illness. People view that giving someone the right to die in dignity is kinder than forcing them to live a life of suffering and pain. The argument against this is that surely it is more compassionate to love and care for someone who is nearing the end of life to demonstrate just how valuable and beautiful life is regardless of age or abilities. However, on the other hand, family and friends would be spared the pain of seeing their loved one suffer a long-drawn-out death if they had that legal right to choose. This point also highlights that this sad dilemma affects not just the person concerned, but all who are connected with the patient.

Warnand, J. (11 Feb 2014). Acti vists of the collective Yellow Safety Jacket protest against the proposed statutory amendment legalizing the euthanasia of young children, in Brussels [ Photograph]. Time.Com. https://time.com/7565/belgium-euthanasia-law-children-assisted-suicide/

The autonomy argument - this argument, touched on above is simply saying that every human being should have the right to choose when to die if one is living a life of misery, pain, and suffering. Also, death is a private matter and the state should not interfere with the individual's right to die. The counter-argument is why should dying be a 'right' at all. Similar to the religious view, this line of thinking is to say that nature should decide when a person dies. It is not a necessary right for human beings. Another argument against euthanasia is that it does not really give people the right to die, merely the right for patients to kill themselves or it puts the legal power in the hands of others, like doctors, friends, and family to end a person's life. Moreover, questions over advancements in medication and technology can allow for a greater quality of life. Patients no longer have to live in abject pain and misery with good palliative care. Again, all very understandable arguments only go to show just how complex this debate is.

For anyone unsure of where to fall on this debate, sometimes just listening or reading personal stories can help to make one's own mind up. Or muddle it further! In 2016 in the Netherlands - where euthanasia is legal - Mark Langedijk was granted life-ending treatment after years of suffering from alcoholism, depression, and anxiety. "For me, it's very important to make sure that everyone knows we did everything and some people just aren't curable," his brother, Marcel, told the BBC. However, on the other side of the coin, the BBC, in April 2016 reported that Dutch authorities brought a case against a doctor who euthanized a 74-year old Alzheimer's patient. The decision was taken after a regional euthanasia review board found she had "overstepped the mark" in euthanizing the 74-year-old Alzheimer's patient. Prosecutors allege the patient's will was "unclear and contradictory" when it came to her final wishes. The doctor, who has not been named, says she acted cautiously in the case.

Bowden, E. (19 Jun 2019). Australian state legalizes voluntary euthanasia for terminally ill. (n.d.). [Photograph]. Nytimes.Com. https://nypost.com/2019/06/19/australian-state-legalizes-voluntary-euthanasia-for-terminally-ill/

The case highlighted above brings into focus the final argument for euthanasia: The public policy argument - this is the idea that governments can safely regulate and control assisted suicide. According to the Australian philosopher, Peter Singer, "We can draw on decades of experience with medical assistance in dying from other countries". They have been carefully studied and there has been no slippery slope to disaster - 2017. So essentially, Singer argues that there has not been a major concern of malpractice in countries where euthanasia is legal. His philosophy is simple. Singer believes that humans have an obligation to reduce what he calls 'pointless suffering'. People argue that governments could not truly control this type of legislation. There have been other cases in the Netherlands where physician-assisted suicides go unreported.

If one is still confused about how to think or feel about this debate then the following argument for the anti-euthanasia team might help to clarify one’s thoughts. What about the protection of the vulnerable? This is, personally speaking, the best argument that this side has. The elderly or mentally ill could be exploited for personal or financial gain. Sure, there could be protocols in place to prevent the likelihood of this happening, but people always find a way around the rules. Where there is a will there is a way! (no pun intended). But, even if there is no coercion by family members who are due a healthy inheritance from their loved one, there could be untold pressure on the patient to take their own life. The unimaginable guilt for merely staying alive could cause a kind of tacit resentment. The philosopher Rene Girade makes the salient point, “The exper­i­ence of death is going to get more and more pain­ful, con­trary to what many people believe. The forth­com­ing euthanas­ia will make it more rather than less pain­ful because it will put the emphas­is on per­son­al decision in a way which was bliss­fully ali­en to the whole prob­lem of dying in former times. It will make death even more sub­ject­ively intol­er­able, for people will feel respons­ible for their own deaths and mor­ally oblig­ated to rid their rel­at­ives of their unwanted pres­ence. Euthanas­ia will fur­ther intensi­fy all the prob­lems its advoc­ates think it will solve.”

BBC News, (8 Feb 2019). What's the difference between assisted suicide and euthanasia?. BBC News. https://www.bbc.co.uk/news/uk-47158287 .

BBC News, (9 Nov 2018). First euthanasia prosecution launched in the Netherlands. BBC News. https://www.bbc.co.uk/news/world-europe-46154180

Singer, P. (18 Sep 2017). We should end the suffering of patients who know they are dying and want to do so peacefully. The Guardian . https://www.theguardian.com//2017/sep/18/we-should-end-the-suffering-of-patients-who-know-they-are-dying-and-want-to-do-so-peacefully

Rosman, A. (5 Nov 2014). Girard: Assisted Suicide and the Further Intensification of Problem. Patheos. https://www.patheos.com/blogs/cosmostheinlost/2014/11/05/girard-suicide-problems

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1 comentario

I think its a loop hole topic.

You don't want to live in medical life support system but also the question emerges '' What if they will find a cure to my disease in 10 years question…'' It's all creates paradox that the one can not find solution. How terrifying.

Peter Terrence

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A Level Philosophy & Religious Studies

This page: full notes      A* summary notes       C/B summary notes

Theories on the value of life.

Euthanasia being morally acceptable or not will depend on which view of the value of life is correct and, if relevant to the theory, on the particular type of euthanasia or situation involved.

The Sanctity of life

The conservative, sometimes also called the ‘strong’ sanctity of life view, claims that because God created human life, only God has the right to end it. Humans were created in God’s image, further suggesting that human life is especially valuable

Both conservative Catholics and protestants believe that the strong sanctity of life principle is justified by the Bible. Catholics would also think that Natural Law ethics provides justification for the conservative sanctity of life principle.

The sixth of the ten commandments is “thou shalt not murder”

“Your body is a temple of the holy spirit, who lives in you and was given to you by God. You do not belong to yourself” (1 Corinthians 6:19).

This quote clearly shows there is something sacred about the body such that destroying it would be like destroying a temple. It was given to us by God, implying a gift, and then very straightforwardly and clearly states that we do not belong to ourselves. We essentially do not have the right to take our own life.

“Whoever sheds human blood, by humans shall their blood be shed; for in the image of God has God made mankind.” Genesis 9:6.

This quote shows that the ultimate penalty is deserved for those who take life. The value of life is explained through its link to our being created in God’s image.

The weak sanctity of life view. Proponents of the weak sanctity of life principle criticise the strong version by pointing out that although the sanctity of life is found in the Bible, it is only one of many biblical principles and themes. So, although sanctity of life is important in judging the value of life, there are other principles that should also be included, such as Jesus’ emphasis on compassion. The problem with the strong sanctity of life view is that it allows unnecessary suffering and is uncompassionate, seeming to ignore the demands of compassion. In some cases, then, compassion for the quality of life might outweigh the sanctity of life.

However, although the Bible does have the theme of compassion, that doesn’t mean it can be used to overrule the sanctity of life. The Bible clearly is against killing. There is no exception mentioned for the sake of compassion. Although the Bible says to be compassionate, it doesn’t follow that it is Biblical to go against the sanctity of life when it would be compassionate to do so.

Quality of life

Quality of life refers to how happy or unhappy a life is. Proponents of the quality of life in relation to euthanasia regard it as a valid ethical consideration because they think that life has to be of a certain quality in order for it to count as worth living.

Peter Singer believes the quality of life to be an important factor in euthanasia. He goes as far as recommending non-voluntary euthanasia for babies whose potential quality of life is low, such as due to being born with an incurable condition like spine abifida.

Peter Singer’s criteria for personhood are rationality and self-consciousness. He distinguishes between ‘humans’ (members of our species) and ‘persons’ (rational self-conscious beings). Not all humans are persons. Singer argued that belief in the sanctity of life of members of our species (humans) was based on ‘Christian domination of European thought’, especially belief in an afterlife and that God had ownership of us, his creation. He proposes that since Christian theological tenants are no longer accepted, we should re-evaluate Christian ethical precepts too.

Singer argues that if we think about what we find wrong with killing someone, it is that it deprives them of the life they want to continue live. A consequence is that if euthanasia is voluntarily asked for by a competent adult, then it would not be wrong because they don’t want to continue living their life. In the case of non-voluntary euthanasia for babies or patients in a vegetative state, they have no sense or conception of their life, let alone their life continuing. So, it’s not morally wrong to kill them because it doesn’t deprive them of anything that they are able to have a preference to not be deprived of.

The slippery slope & effect on vulnerable people.   Archbishop Anthony Fisher makes the slippery slope argument against the quality-of-life view, arguing that wherever euthanasia is legalised, it is extended to more and more people. He points out that in Holland euthanasia was legalised for the terminally ill but 10 year later was legalised for babies in cases of severe illness.

Fisher further argues that if Euthanasia is allowed for quality of life, then some elderly or otherwise vulnerable people might be tempted to die because they feel like a burden. Western culture values success, self-sufficiency, productivity and beauty. Those who fall short can feel miserable as a result. If we allow euthanasia, such people might feel encouraged to die because they feel like failures.

Adding to Fisher’s argument, In 2022 in Canada there was a controversy over two high profile cases of people with medical conditions for which they received insufficient financial support applying for euthanasia. One called Denise saying they have applied for euthanasia “because of abject poverty”.

The valid ethical approach would be changing our society, not allowing euthanasia. Those who advocate for euthanasia think they stand for compassion, not realising they are the unwitting executioners for our merciless success-driven society.

Singer responds that people who receive euthanasia in Oregon are disproportionately white, educated and not particularly elderly, so euthanasia does not especially target vulnerable people.

Singer adds that there is no creep of euthanasia becoming more widespread. He points out how in Oregon only one in three thousand deaths are by euthanasia. Genetic screening allowing mothers to know if their baby has a condition before its born and aborting it meant the post-birth non-voluntary euthanasia numbers dropped from 15 in 2005 to 2 in 2010.

We can conclude that Fisher’s points are not criticisms of euthanasia per se . They highlight the problem with allowing euthanasia in a society which lacks proper support for those who need it. Arguably it at most suggests that euthanasia must be combined with proper support for the vulnerable, not that euthanasia cannot be justified.

Autonomy is the freedom of people to make their own choices. This isn’t directly a view on the value of life, but it is the view that the decision about whether a life is valuable ought morally to be up to the individual whose life it is. There are two approaches to autonomy: deontological and consequentialist.

The deontological (absolutist) view of autonomy. Nozick is a libertarian, meaning he thinks people have an absolute right to do whatever they want, so long as they are not harming others, no matter the situation. He argued for the principle of ‘self-ownership’, meaning we essentially have property rights over our own lives and bodies. This results in a deontological view of autonomy regarding euthanasia. If a person wants to die and receive help from others (making it euthanasia) then that is their right.

However, Nozick’s approach seems to have enormous downsides. People will choose euthanasia for short-sighted reasons such as when in the temporary grip of negative emotion. Singer takes a more consequentialist view of the value of autonomy. He’s not an absolutist about autonomy as he says he doesn’t want to make it easy for people to end their lives when they have a treatable condition or when they might easily recover. He gives the example of a young person wanting euthanasia due to depression over relationship issues. Singer argues we can ‘safely predict’ that they will come to view their life as worth living again and the value of that ‘overrides’ the temporary violation of their autonomy when denying them euthanasia.

The consequentialist view of autonomy. Singer’s consequentialist approach to autonomy was influenced by Mill. Mill did not comment on euthanasia directly, but his philosophy formed the basis for justifying the autonomy principle. Mill developed political liberalism. Before the enlightenment, religion told people what to do. Mill thought that people would be happier if granted individual freedom. Individual people are in the best position to judge what is best for them and have the greatest motivation to ensure they live the best lives possible. This shows that euthanasia should be left to the autonomy of a competent adult.

The slippery slope vs consequentialist autonomy. Archbishop Anthony Fisher argues that allowing euthanasia for the reason of autonomy is vulnerable to the slippery slope issue. There is no logically coherent way to restrict the principle of “freedom to die” to the cases where it seems most applicable. If we grant that people have the autonomous freedom to die, how can we then avoid extending it to all cases where someone wishes to die, no matter how short-sighted their reason?

Fisher is arguing that it’s not logically consistent to take a consequentialist approach to autonomy. It’s only possible to coherently believe in absolute autonomy like Nozick. Since that has such morally terrible downsides, it’s better to not adopt autonomy as a principle at all regarding euthanasia.

However, there is a way to coherently adopt a consequentialist view of autonomy, which is to pair it with rationality.

Following Singer and Mill’s arguments, the individual who is in the best position to judge what is best for them and whether the potential value of their future life is of sufficient worth to make continuing to live the best choice for them. However, sometimes people can make irrational choices, not taking their actual long term self-interest into account.

To ensure that autonomy avoids ethical issues, we can therefore add the condition of rationality. The young love-sick person is clearly not making a rational calculation, for example. This position is not susceptible to the slippery slope argument. It would not allow euthanasia for short-sighted unthinking reasons since that would not be rational. This is a logically coherent way of avoiding extending autonomy absolutely.

Situation ethics on Euthansia

Fletcher’s rejection of legalism in the Bible including the sanctity of life. Fletcher’s liberal view of the Bible. Fletcher argued that the Bible is not a legalistic ‘rules book’ but an ‘editorial collection of scattered sayings’ which at most offers us ‘some paradigms or suggestions’. We can’t take the Bible literally, nor can we figure out which interpretation is correct. The best approach is to follow the general themes of the Bible, the most important of which is agape. This approach allows Fletcher to reject the sanctity of life principle.

Application to euthanasia. Situation ethics would judge that euthanasia can be morally good, in situation where it maximises agape. In situations where it would maximise agape to avoid euthanasia, it would be wrong, however. For example, if someone has a very low quality of life and an autonomous wish to die, it seems that Fletcher would accept euthanasia. However if someone is pressured into euthanasia by their family who are greedy for inheritance or by society making them feel like a failure or a burden, or if they have a short-term issue like Singer’s example of a lovesick teenager, Fletcher would think it wrong to allow euthanasia in such cases.

The issue that love is subjective applied to euthanasia

Situation ethics claims that love is the basis for ethical judgement. However, what counts as loving is subjective, meaning a matter of opinion. The Nazis had a forced euthanasia program against terminally ill patients and also babies they deemed disabled. Love is too subjective a thing to provide a stable basis for ethics.

Defence of Fletcher: love might be subjective, but agape is not. Agape is more than just love – it involves selfless love of your neighbour; loving your neighbour as yourself. A person would not want to be pressured into euthanasia themselves, so it cannot be agape to pressure your neighbour into it.

Optional further evaluation: However, what if someone genuinely thought that they would actually want to be euthanised if they were in the circumstance their neighbour was in. Many Nazis would probably genuinely feel like they would hope someone would have euthanised them If they were born with what the deemed to be a disability. So in a grotesque sense they would technically be ‘loving their neighbour as themselves’. The problem with loving your neighbour as yourself is that it depends on whether you love yourself in an ethical way.

W. Barclay’s criticism applied to euthanasia

People are not perfectly loving so if given the power to judge what is good or bad, people will do selfish or even cruel things. People’s loving nature can be corrupted by power. Someone might find it loving to manipulate/pressure someone into or out of euthanasia, perhaps if they will get inheritance to pay for their children’s food or something. Some might find it loving to end their life because they feel like a burden.

Fletcher and Robinson argue (influenced by Bonhoeffer) that humanity has ‘come of age’, however. This means that humanity has become more mature. In medieval and ancient time, when humanity had not come of age, people in general were less educated and less self-controlling. This meant that they needed fixed ridged clear rules to follow, because they could not be trusted to understand and act on the nuances and complexities in how a rule could justifiably be bent or broken if the situation called for it. However, now people are more civilised, to the point that granting them more autonomy will increase love without risking the stability of society.

Barclay disagrees however, and thinks that although people might appear improved, if granted the freedom (and thus power) to do what they want, they won’t choose the loving thing they will choose the selfish or even the cruel thing. This is essentially the classic argument that power corrupts. It also echoes the debate about the extent to which human nature is corrupt, such as by original sin. Also relevant is psychology like the Stanford prison experiment and literature like lord of the flies. It is a well-known feature of human psychology that power is corrupting. The freedom to decide what is good or bad without external supervision of legalistic laws grants humans more power and thereby corrupts them.

Natural law and the Catholic church on Euthanasia

Natural law ethics claims that we should follow the Bible teachings, which Aquinas calls the ‘divine law’. It claims there is also another law, the ‘natural law’ which also comes from God. God has given reason to human nature and designed it to be able to intuitively know the primary precepts of natural law.

Application to Euthanasia. Euthanasia violates the primary precept to protect and preserve human life. 

Violating the sanctity of life, such as by allowing euthanasia, also violates the primary precept of maintaining an orderly society. Natural law is the idea that God designed all things, including humans, with the potential to be in harmony if they follow God’s natural law, such as the preservation of human life. Failure to follow this will therefore cause disharmony. Our society will break down because living contrary to God’s design is unnatural and thus leads to immorality and social disorder.

Mother Theresa summed up this kind of argument well during her speech upon receiving the noble peace prize. She claimed “the greatest threat to world peace is abortion. If a mother can kill her own child in her own womb, what is left to stop us from killing one another?”

It is dangerous for human beings to give themselves the right to judge when it is ok to kill people. We are unworthy of that power because we would be corrupted by it. If we stop believing life is sacred, we reduce the value our society places on life and thus will treat it as less valuable. That will endanger the order of society. No human is good enough to wield that power responsibly.

The Catholic Church on euthanasia & the sanctity of life  

The Catholic Church uses the double effect to claim that sometimes doctors can stop or withdraw treatment (passive euthanasia) or even administer pain medication which could speed up death. So long as the intention is not to kill, the double effect would suggest such actions can be morally acceptable.  

The Catechism of the Catholic Church on euthanasia:

‘Direct’ (active) euthanasia is never justified, but passive euthanasia, whether voluntary or non-voluntary, can be justified through the double effect.

“Whatever its motives and means, direct euthanasia consists in putting an end to the lives of handicapped, sick, or dying persons. It is morally unacceptable … Discontinuing medical procedures that are burdensome, dangerous, extraordinary, or disproportionate to the expected outcome can be legitimate … Here one does not will to cause death; one’s inability to impede it is merely accepted.” – Catechism of the catholic church.  

Interestingly, the Catechism does allow for administering high doses of pain killers even if it risks killing them, so long as death is foreseen but besides the intention:  

“The use of painkillers to alleviate the sufferings of the dying, even at the risk of shortening their days, can be morally in conformity with human dignity if death is not willed as either an end or a means, but only foreseen and tolerated as inevitable. ” – Catechism of the catholic church.

Peter Singer criticises the way that the sanctity of life principle is applied by the Catholic Church – claiming that “they do not really act as if they believe it”. He points out that the Catholic Church allows for passive euthanasia – the withdrawal of life support machines from patients who are in a coma or vegetative state. The Church claim that this is because they have no obligation to provide “burdsonsome or disproportionate treatment”. However, there are cases of patients in comas who the Church have allowed passive euthanasia for (e.g. Karen Ann Quinlan). Singer points out that since such patients are in a coma, it’s impossible to see how keeping them alive on life-support machines could have imposed a ‘burden’, since unconscious people cannot experience burden. Singer concludes that the only logical way to think it good to remove treatment is if you believe that life must have some “positive quality” in order to be valuable, i.e. the quality of life view.

Whether Natural law ethics and the sanctity of life is outdated

Weakness: Aquinas’ Natural law ethics and the sanctity of life principle are increasingly seen as outdated. Sociologically, we could claim these ethical principles were created to be useful in the socio-economic conditions of their time. Ancient and Medieval society was more chaotic, strict rules were important to hold society together and because people were not educated nor civilised enough to be trusted with the freedom to interpret their application. It made sense to create strict absolutist ethical principles to prevent society from falling apart. This would explain the primary precepts. They served a useful function in medieval society.

Applied to euthanasia, we can argue it was useful to simply ban all killing in medieval times, because violence and killing was much more common and therefore needed to be strongly restricted. People were less self-controlling and less educated, so they needed clear simple rules to follow.

The issue clearly is that all of these socio-economic conditions have changed. So, the primary precepts are no longer useful. They were designed for a different time and are now increasingly outdated. Society can now afford to gradually relax the inflexibility of its rules and think about how they might be reinterpreted to better fit modern society.

Evaluation: Aquinas could be defended that this doesn’t actually make his theory wrong. The fact that mainstream culture has moved on from natural law ethics doesn’t mean it was right to. If Hitler had won WW2 and enslaved humanity, then democracy might have been viewed as ‘outdated’, but that wouldn’t make it wrong. Calling an ethical theory outdated is not an argument against its actual truth.

Counter-evaluation: A better version of the ‘outdated’ critique is to argue that Aquinas’ theory was actually a reaction to his socio-economic context and since that has changed, Natural law is no longer relevant.

Aquinas thought that he discovered the primary precepts through human reason, as God designed. However, arguably it’s a simpler explanation that Aquinas was simply intuiting what was good for people in his socio-economic condition. The idea that the resulting principles actually came from God was only in his imagination.

The great strength of religion as a form of social organisation is also its greatest weakness. By telling people that its ethical precepts (such as the primary precepts or sanctity of life) come from God it creates a strong motivation to follow them. Yet, because those precepts are imagined to come from an eternal being, they become inflexible and painstakingly difficult to progress. This makes them increasingly outdated.

Types of euthanasia which the theories on the value of life will have judgements on:

Terminal illness.

Terminal illness is the most common reason for euthanasia as the person is going to die anyway often after a period of suffering.

Incurable physical illness

incurable physical illness such as cluster headaches are simply extremely painful and have no cure, reducing quality of life. Other incurable physical illness such as locked in syndrome almost completely paralyse a person which make them incapable of committing suicide even if they wanted to.

Incurable mental illness

incurable mental illness raises the issue of whether there is a kind and degree of mental illness which sufficiently impinges on the mind such that a rational choice to die cannot be made. Someone might be suffering considerable from an incurable mental illness, but if their ability to make informed rational choices is undermined by their illness, pro-autonomists would argue they shouldn’t be given euthanasia, while quality of life advocates might decide they should be.

In Belgium euthanasia is legal for people who don’t have a terminal illness but have an incurable and severe mental illness. Even young people in their 20s have been euthanized for this reason. If they have tried everything including every medication available, euthanasia is seen as a last resort.

Active & passive

Active euthanasia is when the person is killed by some positive action such as lethal injection, usually by a Doctor. Passive euthanasia is when no one performs an action which results in the death of the person but they are left to die by natural means, either by the result of their illness if they have one or simply by removing life-support machine equipment or even stopping giving them food. The death takes longer and unless they are unconscious in a coma or braindead, is more painful. However, the moral difference is that no one performed an action of killing them.

Situation ethics would likely regard active euthanasia as morally better than passive euthanasia, since it is quicker which can mean less suffering, which seems the more loving option.

The sanctity of life view would regard active and passive euthanasia as equally wrong since all life is sacred and must therefore be preserved.

The Catholic Church’s use of Natural law regards passive euthanasia as being potentially justifiable in certain circumstances under the double effect, so long as the intention is to accept ‘one’s inability to impede’ death.

Voluntary & non-voluntary

Voluntary euthanasia is when a person has the mental capacity to choose euthanasia.

Non-voluntary euthanasia is when someone does not have the mental capacity to choose euthanasia. If they are in a coma for example, or a persistant vegitative state,

This also applies to the euthanasia of babies. When a baby is born with a terrible terminal condition that will cause them significant pain before killing them in a few months anyway, many argue that non-voluntary euthanasia would be justified.

Case study: Alfie Evans. A particularly difficult case because the (apparently religious) parents wanted medical treatment to continue but the High Court of the UK ruled that the decision should be taken away from them as continued treatment of Alfie would be unkind and inhumane, due to it pointlessly delaying inevitable death and causing pain to Alfie in the process. It’s tempting to think that the parents should have the right to decide in cases like this, but what about the rights of the child not to suffer unnecessarily?

Possible exam questions for Euthanasia

Easy Assess whether natural law is helpful for dealing with the issue of euthanasia Assess whether situation ethics is helpful for dealing with the issue of euthanasia ‘euthanasia can be the loving choice in some situations’ – Discuss. ‘euthanasia goes against God’ – How far do you agree? Can euthanasia ever be justified? To what extent is euthanasia morally good?

Medium Should a person have complete autonomy to choose euthanasia? Is quality of life a basis on which euthanasia might be justified? ‘Life should never be ended because it is sacred’ – Discuss.

Hard ‘The religious concept of sanctity of life has no meaning in twenty-first century medical ethics’ – How far do you agree? Critically compare sanctity of life with autonomy as principles for judging the issue of euthanasia Is there a moral difference between active and passive euthanasia? Critically compare the morality of voluntary with non-voluntary euthanasia

Quick links

Year 12 ethics topics: Natural Law. Situation ethics. Kantian ethics. Utilitarianism. Euthanasia. Business ethics. 

Year 13 ethics topics: Meta-ethics. Conscience. Sexual ethics. 

OCR Philosophy OCR Christianity OCR essay structure OCR list of possible exam questions

My Teaching Philosophy Statement

This essay about a teaching philosophy emphasizes innovation, empathy, and empowerment as foundational elements for a dynamic learning environment. It advocates for active student participation, diversity, and the practical application of knowledge. The approach promotes critical thinking, a growth mindset, and meaningful feedback, aiming to develop lifelong learners and compassionate leaders. The philosophy embodies collaboration, inclusivity, and engagement with the wider world as key components.

How it works

In my educational approach, I blend the art of teaching with the science of inspiration, weaving together elements of innovation, empathy, and empowerment to create a dynamic tapestry of learning experiences where each student can truly flourish. Rather than simply delivering information, I see myself as a catalyst for intellectual and personal growth, igniting the flames of curiosity within each learner.

At the heart of my pedagogy lies a deep commitment to fostering student agency. I recognize that every student brings a rich diversity of backgrounds and perspectives to the classroom, and I strive to create an environment where they are active participants in their own educational journey.

Through collaborative projects, spirited discussions, and immersive activities, I aim to cultivate a culture of inquiry and exploration, where questions are celebrated and curiosity is nurtured.

Equally essential to my philosophy is the promotion of inclusivity and belonging. I firmly believe that diversity is not only a strength but a fundamental aspect of our humanity, and I work tirelessly to create a space where every voice is heard and every identity is respected. By fostering empathy, understanding, and open dialogue, I seek to build a community where students feel empowered to express themselves authentically and engage with one another in meaningful ways.

Moreover, I am deeply passionate about bridging the gap between theory and practice. I firmly believe that education should extend beyond the walls of the classroom, and I strive to integrate real-world relevance into my teachings. Whether through hands-on experiences, real-life case studies, or project-based learning, I aim to inspire students to see the connections between their studies and the world around them, motivating them to become proactive agents of change in their communities.

Furthermore, I am committed to nurturing critical thinking skills and fostering a growth mindset. In an age inundated with information, the ability to analyze, synthesize, and evaluate is more important than ever. Through thought-provoking discussions, challenging assignments, and opportunities for reflection, I aim to instill in my students a deep sense of intellectual curiosity and a willingness to explore new ideas, equipping them with the skills they need to thrive in an ever-changing world.

Finally, I believe in the transformative power of feedback and assessment as tools for growth and development. Rather than viewing assessment as a mere judgment, I see it as an opportunity for learning and improvement. By providing timely and constructive feedback, I empower my students to reflect on their progress, identify areas for growth, and set meaningful goals for their continued development.

In essence, my teaching philosophy is a mosaic of collaboration, inclusivity, relevance, critical thinking, and growth. By creating an environment where students are encouraged to take ownership of their learning, embrace diversity, and engage with the world around them, I hope to inspire a lifelong love of learning, compassionate leadership, and global citizenship.

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