A case for justified non-voluntary active euthanasia: exploring the ethics of the Groningen Protocol

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  • 1 Arizona State University, West Campus, 4701 West Thunderbird Road, Phoenix, AZ 85069, USA. [email protected]
  • PMID: 17074822
  • PMCID: PMC2563300
  • DOI: 10.1136/jme.2005.014845

One of the most recent controversies to arise in the field of bioethics concerns the ethics for the Groningen Protocol: the guidelines proposed by the Groningen Academic Hospital in The Netherlands, which would permit doctors to actively euthanise terminally ill infants who are suffering. The Groningen Protocol has been met with an intense amount of criticism, some even calling it a relapse into a Hitleresque style of eugenics, where people with disabilities are killed solely because of their handicaps. The purpose of this paper is threefold. First, the paper will attempt to disabuse readers of this erroneous understanding of the Groningen Protocol by showing how such a policy does not aim at making quality-of-life judgements, given that it restricts euthanasia to suffering and terminally ill infants. Second, the paper illustrates that what the Groningen Protocol proposes to do is both ethical and also the most humane alternative for these suffering and dying infants. Lastly, responses are given to some of the worries expressed by ethicists on the practice of any type of non-voluntary active euthanasia.

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  • Attitude to Health
  • Euthanasia, Active / ethics*
  • Medical Futility
  • Netherlands
  • Pain, Intractable
  • Practice Guidelines as Topic*
  • Quality of Life
  • Right to Die
  • Terminally Ill*
  • Value of Life
  • Withholding Treatment / ethics

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  • B A Manninen
  • Correspondence to:
 B A Manninen
 Arizona State University, West Campus, 4701 West Thunderbird Road, Phoenix, A2 85 069; bertha.manninen{at}asu.edu

One of the most recent controversies to arise in the field of bioethics concerns the ethics for the Groningen Protocol: the guidelines proposed by the Groningen Academic Hospital in The Netherlands, which would permit doctors to actively euthanise terminally ill infants who are suffering. The Groningen Protocol has been met with an intense amount of criticism, some even calling it a relapse into a Hitleresque style of eugenics, where people with disabilities are killed solely because of their handicaps. The purpose of this paper is threefold. First, the paper will attempt to disabuse readers of this erroneous understanding of the Groningen Protocol by showing how such a policy does not aim at making quality-of-life judgements, given that it restricts euthanasia to suffering and terminally ill infants. Second, the paper illustrates that what the Groningen Protocol proposes to do is both ethical and also the most humane alternative for these suffering and dying infants. Lastly, responses are given to some of the worries expressed by ethicists on the practice of any type of non-voluntary active euthanasia.

https://doi.org/10.1136/jme.2005.014845

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It is a rather disturbing trend when the general public fails to take the time to educate itself about a certain controversial issue before criticising or condemning it. This does a disservice to all by conveying a faulty view of the actual issue, thereby precluding the possibility of discussing its ethical implications intelligently or accurately. In my opinion, this has been the prevailing trend when it comes to the debate about the Groningen Protocol, the guidelines proposed in December 2004 by the Groningen Academic Hospital in Amsterdam, The Netherlands, which permits doctors to actively euthanise terminally ill infants who are deemed to be in a state of unbearable pain. 1 Given that infants cannot consent to their deaths, approval of the protocol would establish a legal framework permitting non-voluntary active euthanasia (not involuntary active euthanasia, as I have heard some describe it, for the infants are not requesting to be spared from death, but are put to death nevertheless). The protocol was officially introduced across The Netherlands in July 2005.

This request on behalf of the doctors from the University Medical Center Groningen has met with a considerable amount of backlash. The protocol has been labelled by some to be a Hitleresque type of eugenics programme.


 This chilling, horrific development is as appalling a story as occurs but also not surprising. So complete is the devaluing of life and the idea of soul that we have come in 60 swift years back to the gates of Auschwitz. 2 
 Were he attempting to escape allied justice today, Dr. Joseph Mengele, the Nazi “Angel of Death,” would not have to make his way to the jungles of Brazil; the Netherlands would probably welcome him with open arms … Hey, if we can get rid of society’s “deadwood,” why let niceties of law or morality get in the way? I have no doubt that if the Groningen Protocol becomes official, parents who don’t want to contend with raising a disabled child will have their baby or young child euthanized, even if the baby has a fighting chance at a meaningful life. 3

Such straw man arguments detract from discussing the actual proposed protocol, which is not in any way an attempt to kill infants because they are “inconvenient”, “disabled” or considered to be “deadwood”. The Groningen Protocol, if adopted, would not entail the killing of infants because they are disabled; indeed, the protocol makes no mention of justifying the deaths of infants owing to any cognitive disabilities per se. Most infants who would be killed under the guidelines will be disabled—indeed terminally disabled—but it is their terminal prognosis that grounds their eligibility for active euthanasia. Consequently, the protocol would probably not lead to a slippery slope that would entail the deaths of infants simply because they have some minor defect—for example, if they are missing a limb—because such defects are not usually terminal in nature. We will return to the slippery slope concern later in the paper.

Nevertheless, if the Groningen Protocol is adopted, it would indeed change the face of active euthanasia in The Netherlands and it may lead to other countries adopting similar practices. Thus, it is necessary to explore what exactly the Groningen Protocol entails and whether what it purports to do is ethical.

UNDERSTANDING THE GRONINGEN PROTOCOL

To morally assess the protocol as accurately and fairly as possible, it is imperative to look at exactly what its guidelines are proposing. An infant must meet the following five criteria to be eligible for active euthanasia under the protocol 1 :

The suffering must be so severe that the infant has no prospects for a future.

There is no possibility that the infant can be cured or alleviated of her affliction with medication or surgery.

The parents must give their consent.

A second opinion must be provided by an independent doctor who has not been involved with the child’s treatment.

The deliberate ending of life must be meticulously carried out with the emphasis on aftercare.

Notice what the first condition does not say. It does not say that the infants must have such a severe affliction that they have no prospects of enjoying a future of a certain kind—that is, the condition does not make a quality-of-life judgement pertaining to the future of these children. Instead, what the first condition states is that the infants must be so severely afflicted that they face no future at all—that is, the infants must be terminally ill. The second condition reaffirms this requirement and the fourth condition mandates that the infant’s prognosis be evaluated by a doctor who has had no previous exposure to the neonate, to ensure that the bleak prognosis is accurately diagnosed. Moreover, according to the third condition, parental consent is required, so that there will never be a case in which the parents are opposed to euthanasia, but the child would nevertheless be euthanised. For example, parents are often opposed to active (although not passive) euthanasia as a result of religious convictions, and the third condition will serve as a guarantee that a child’s life will never be taken without a parent’s explicit consent. Again, the protocol is not advising that all infants who are disabled be euthanised. The infants who will be eligible for euthanasia if the protocol is approved will most likely be disabled, but what grounds their killing is that the disability has made them terminally ill; it is their terminal prognosis that makes them candidates for active euthanasia. If a child was born disabled, but not terminally ill (eg, with Down’s syndrome), then he or she would not be considered a candidate for active euthanasia under the Groningen Protocol.

Now that I hope to have clarified some of the misunderstandings surrounding the protocol, I will analyse the guideline itself and argue that, as it stands, what the Groningen Protocol is advocating is not unethical. Indeed, I will argue that it is the most humane course of action that can be taken, given the prognosis of these infants and the fact that any life that they face will be one of intense pain, with not even a single moment of respite from their suffering lest they be terminally sedated. A possible objection against the practice of actively euthanising these terminally ill infants who are suffering is that, rather than giving a lethal injection, it would perhaps be better to terminally sedate them. In the case of terminal sedation, the subject is deliberately rendered unconscious with an overdose of analgesics and sedative drugs to relieve intractable physical pain or mental suffering. An essential aspect of terminal sedation is the cessation of all forms of treatment, nourishment and hydration to hasten death. In other words, terminal sedation is a method of painless passive euthanasia; the practice essentially drugs the patients into unconsciousness until they finally die, rather than giving a lethal injection that would kill them relatively instantly. I have no objections to this procedure being used if the infants are indeed completely unaware of their suffering and the slow process of dehydration and starvation that they are then exposed to. My only problem with this option is that it is often presented as a morally acceptable alternative to active euthanasia, because whereas in active euthanasia the doctor directly hastens death, terminal sedation is an attempt to relieve pain, with death occurring as a foreseen, but unintentional, consequence. In this paper, I will not deal with the famous doctrine of double effect that this distinction appeals to, but I will say that such a distinction, at least in the case of terminal sedation, seems rather implausible, given that an essential aspect of the procedure is the withdrawal of even basic treatment and sustenance. These actions do indeed strike me as a blatant attempt to hasten death; indeed, why else would they be undertaken? If the appeal to terminal sedation is thought to be morally superior to active euthanasia, it is only because of its passive rather than active nature, because it means “letting die” and not actively killing. No morally relevant difference exists between the two forms of euthanasia, however, and doctors are equally causally and morally culpable in both instances of euthanasia. If parents prefer the terminal sedation of their infants to active euthanasia that is, of course, their prerogative; it is morally acceptable as long as the infant does not suffer. I, however, reject the notion that terminal sedation is morally superior to active euthanasia, given that it is based on the passive/active distinction, a distinction that strikes me as being morally untenable. As the protocol does indeed widen the door concerning who may be euthanised by allowing for a form of non-voluntary active euthanasia, I will argue that careful steps need to be taken to ensure that the protocol does not lead to abuse and the death of others who may have lived to see valuable futures or to the betrayal of the wishes of people who may not have wanted euthanasia as a way of ending their lives, but who can no longer express such a sentiment.

WHEN DEATH MAY CONSTITUTE A BENEFIT

To avoid controversy, I will confine my arguments to considering the best interests of the infant who would be euthanised. I want to show that if properly construed and regulated, the Groningen Protocol can serve the best interests of a terminally ill infant. In arguing for this, it is necessary to first understand what an interest is and then consider whether prolonged existence is in the best interests of an infant who would be eligible for euthanasia under the protocol.

I will appeal mainly to the conception of interests as defined by Joel Feinberg in his book Harm to others and how he subsequently relates it to a proper understanding of harm and benefit. According to Feinberg, 4 to have an interest in x is to have a stake in x’s well-being, and a person has a stake in x “when he stands to gain or lose depending on the nature or the condition of x”. A person’s collection of interests “consists in all of those things in which one has a stake … what promotes them is to his advantage or in his interest ; what thwarts them is to his detriment or against his interest ”. 4 When a person’s interest in x is advanced or promoted, this constitutes a benefit for that person; subsequently, when an interest is thwarted, this constitutes a harm. An interest in continued existence is, of course, the most fundamental interest a person can possess, for if we are deprived of continued existence, we are deprived of all other interests life has to offer. Given its primacy, Feinberg 4 refers to the interest in continued existence as the most basic welfare interest a person can have, and welfare interests “cry out for protection, for without their fulfillment, a person is lost … an invasion of a welfare interest is the most serious … harm a person can sustain”.

Whereas the interest in continued existence is usually the most fundamental interest a person can possess, there are instances in which it is actually death itself that serves a person’s best interests. It is not that any type of life, even a life consisting of nothing more than intense pain, is better than no life at all. Indeed, because of the strong conviction that there are times when death is preferable to life, many people choose to cease life-sustaining treatment either for themselves or as a proxy for someone else. For the purposes of this paper, I will concentrate on the selective non-treatment of certain newborns and whether doing so in certain situations is ethical. I will compare two cases: one in which an infant was not treated for a certain affliction that was terminal if left untreated, and thus was passively euthanised, and another in which an infant was treated rather aggressively, against her parents’ request, only to die shortly thereafter.

In April 1982, a baby boy with Down’s syndrome, dubbed Baby Doe, was born in Bloomington, Indiana, USA, with trachea-oesophageal fistula—a condition that prevented the infant from being nourished as no food reached his stomach. The affliction, if left untreated, was of course terminal, but it could have easily been rectified by a routine operation. But because the infant was also afflicted with Down’s syndrome, the parents issued a directive that the operation correcting the trachea-oesophageal fistula should not be performed. The Indiana Supreme Court let this decision stand, although many families offered to adopt Baby Doe, and he died of pneumonia, starvation and dehydration on 15 April 1982. 5 Although Baby Doe could have had his affliction rectified, and although he could have gone on to live a fruitful life with adoptive parents who would have wanted him and loved him, he was instead passively euthanised. It is imperative to note that Baby Doe would not be considered a proper candidate for active euthanasia under the Groningen Protocol because he did not meet the second condition. His trachea-oesophageal fistula was treatable by surgery and after a successful surgery he would no longer be terminally ill and so would not have met the first criterion, although he was disabled.

The second case is that of a baby girl who was born with a variety of congenital defects, including


 meningomyelocele (spina bifida), hydrocephalus, and paralysis and deformities of her legs. No satisfactory treatment exists for this set of conditions … even with costly and repeated surgery, more than half of these infants would be expected to die. Crippling disabilities, retardation, and shortened lifespan were common among the survivors. The mother, supported by the father, refused to consent to surgery, but a court order was secured for a series of operations … the child’s brain was damaged [the infant died at 10 months of age] 6 (emphasis mine).

It seems as though the respective decisions on proper treatment were inverted in these two situations. Clearly, Baby Doe ought not to have been allowed to die, especially given that many families offered to adopt this little boy in full knowledge of his disability. To allow Baby Doe to die was morally wrong, a flagrant expression of chauvinism for a certain type of cognitive existence. Many people with Down’s syndrome, depending on the severity of the affliction, go on to lead fruitful lives that are of great worth to them and to the loved ones who surround them. Baby Doe could have continued to live a normal span of human years and although his cognitive abilities were impaired, they probably were not impaired enough to preclude a worthwhile existence. Continued existence would have thus benefited Baby Doe and hence the operation would have been in his best interests. In other words, in the Baby Doe case “treatment [would have been a] benefit and, thus, since the physician has an obligation to benefit the patient, that obligation here entails the obligation to secure life”. 6 In passively euthanising Baby Doe, the medical staff violated his most basic welfare interest and one of the primary moral tenants of medicine: to do no harm.

I am doubtful that the same could be said about the baby girl in the second case. Her condition was very close to being terminal in nature and the short existence that she did experience was one fraught with invasive procedures and extreme pain and suffering. Interestingly, although death seems to have been in this girl’s best interests, she would nevertheless still not have been eligible for active euthanasia under the Groningen Protocol. Although the infant’s prognosis was very bleak and she was close to being terminally ill, she did have a small chance at survival, and thus did not meet the Protocol’s second condition. In her situation, “the prognosis was poor and the interventions burdensome”. In this case, the odds were strongly against the possibility that she would have survived the invasive procedures and any prolongation of her life contained nothing but pain and suffering; nothing positive was added to her life. Continued existence for her was pointless, not because she would have been disabled if she had survived, but because she probably would not have survived at all and whatever time she was given was full of nothing but suffering. My thesis thus is less ambitious than that promoted by Kipnis and Williamson. 6 They do, eventually, make an assertion on quality of life in their article (although they also admit that letting Baby Doe die was morally wrong because Baby Doe’s life could indeed have had some “subjective value” to him). In the end, they conclude: “Where life-sustaining treatment and the resulting burdensome existence can be expected to have negative value to the patient, there is an obligation to withhold or discontinue the treatment”. 6 I do not disagree with them on this point. I think that there can be some forms of human existence that are so impaired as to make life not worth living. But this is a controversial statement, and one that entails delineating the necessary and sufficient conditions for when a person has crossed the threshold into a comparatively valueless state of existence, which I admit is difficult, given that it is hard to assess the subjective experiences of others (but so is the problem of other minds). My main interest in this article is defending the Groningen Protocol and, despite what some have argued, the protocol does not make judgements on quality of life but is rather very clear that the infant in question must be terminally ill—that is, the infant must have no prospects, not an impaired prospect, for a valuable future life. In this situation, the pain that the infant went through added injury to her already bleak diagnosis. Continued existence arguably constituted a harm for her. 6

But isn’t any life better than no life at all? Couldn’t someone argue that despite being in an intense amount of pain, the possibility of being given a few more days to share with loved ones is worth the pain and suffering that we may endure? The answer to this question, of course, depends on each patient’s priorities. Some patients may be willing to endure days of extreme agony to experience some goods—for example, the good of kissing a spouse or child for the last time, saying goodbye to loved ones, watching one last sunrise and sunset, and reading excerpts from a favourite book over again. Indeed, the very act of looking forward to these prospects may make enduring the pain worthwhile. But infants are not these sorts of creatures. All infants lack the cognitive ability to look forward to anything, to anticipate a future activity, to take comfort in the fact that tomorrow they will be able to see their loved ones and spend more time with them. Infants are the types of beings that are locked in a perpetual state of present emotions and desires. The life of an infant in agony is nothing but perpetual existence in that agony. For infants who are suffering and terminally ill, extending their lives is nothing but extending their agony. It is hard to see how this can fail to constitute a harm for them. Their interests lie not in continued existence but, rather, in death. Given that infants eligible for active euthanasia under the Groningen Protocol face a similar diagnosis, continued existence constitutes a harm for them as well.

This is why not all cases of withholding or withdrawing life-sustaining treatment from infants are morally problematic. It is imperative that medical decisions are made, first and foremost, with the best interests of the patient in mind. Continued existence is usually in a patient’s best interests; indeed, as stated earlier, it is usually the most important and basic interest any person can possess. But when patients are terminally ill, and when the remainder of their lives will be spent in a chronic state of nothing but pain and suffering, then it is hard to see how continued existence constitutes a benefit for them, given that prolonging their lives means just prolonging their suffering. In these cases, the basic moral imperative to do no harm may entail that terminally ill infants not be treated, that their pain not be needlessly prolonged.

FROM PASSIVE TO ACTIVE EUTHANASIA

The above section shows that passively euthanising terminally ill infants who are suffering is a better way to ensure that the best interests of the infants are honoured than fruitlessly prolonging their lives. I will assume that this is a rather uncontroversial claim. The controversy ensues when we make the transition from passive to passive euthanasia. Although neither voluntary nor non-voluntary passive euthanasia is without its critics, these are generally accepted practices. Yet, if death is beneficial to the patient rather than harmful, then active euthanasia brings about a beneficial state of affairs sooner; it is more advantageous for the patient than passive euthanasia. Indeed, by allowing terminally ill infants who are in pain to die passively, we do not add to their suffering by artificially prolonging their life, but we do add to their suffering by allowing the dying process to be prolonged naturally. It may take days, even weeks, for an infant to die by passive means, and the infant experiences those days or weeks in an agonising and atrocious manner. It seems, then, that it would be more humane to actively euthanise terminally ill infants who are suffering and bring their suffering to an end rather than to allow that suffering to be prolonged for the days or weeks it may take them to die. In this, I must agree wholeheartedly with James Rachels 7 : “The doctrine that says that a baby may be allowed to dehydrate and wither, but may not be given an injection that would end its life without suffering, seems so patently cruel as to require no further refutation.”

And yet, there remains refutation. So much so that the doctors at the Groningen Hospital are referred to as Nazis or murderers for bringing the life of terminally ill, suffering infants to an end. I am sure that this would not be the general public’s reaction if these infants were either aggressively treated to prolong their inevitably doomed lives for a few short days or allowed to die owing to convulsions, dehydration or starvation. It is this that puzzles me the most: how can the two options that are ultimately the cruellest for the infant (although passive euthanasia is less cruel than prolonging the infant’s life, and subsequent suffering, artificially) be deemed the most moral and most in the infant’s interest?

I can offer very little new material in this area, for this is simply rehashing the old ethical question on whether there is a major moral difference between active and passive euthanasia. However, I want to reiterate a point that has been emphasised before by previous ethicists but which nevertheless often remains ignored when discussing this controversial issue: the fact that doctors do indeed have a causal role in passive euthanasia in addition to active euthanasia, and thus that passive euthanasia may very well be considered an instance of killing rather than merely “allowing to die”.

In her book The Sanctity-of-Life Doctrine in Medicine , Helga Kuhse uses John Mackie’s analysis of an inus condition, defined by Mackie as “an insufficient but non-redundant part of an unnecessary but sufficient condition”, 8 to argue that the causal role of a doctor in both passive and active euthanasia is causally, and therefore morally, equivalent. When discussing the issue of selective non-treatment of infants affected with spina bifida, Kuhse argues that a doctor who fails to treat the afflicted infant is causally responsible for the infant’s death, particularly because the doctor’s omission classifies as an inus condition towards the death. That is, the doctor’s failure to treat the infant is an insufficient condition towards the infant’s death in so far as other factors also contribute to the death (eg, being afflicted with spina bifida or contracting a case of pneumonia that doctors deliberately fail to treat). The doctor’s failure to treat was also a non-redundant condition, however, for without this omission the infant would not have died. As the omission, the failure to treat, is an inus condition, it “is a cause in the correct sense of the word” 9 and thus the failure to treat the infant can well be viewed as an integral causal factor leading to the infant’s death.


 If it can be shown that what differentiates those situations in which death occurs (or would have occurred) from other situations in which death does not occur (or would not have occurred) is the doctor’s failure to treat, then the doctor’s omission is the causal factor that allows us to distinguish those situations in which death occurs from those in which it does not, and the doctor’s failure to treat is identified as the causal factor that made, or would have made, the difference between an infant’s dying or not dying. Hence, the doctor’s failure to treat is the cause of death. 9

Kuhse argues that killing a patient by lethal injection also classifies as an inus condition towards the death of the patient, thus bringing about the death of a patient by either passive or active means “cannot be distinguished in terms of causal efficacy or in terms of causal agency … [b]oth killing and letting die are inus conditions in two different minimally sufficient conditions for death”. 9 Kuhse also maintains that a doctor who brings about death by passive means (such as deliberately refraining from treating a patient) is “just as accountable or morally responsible as she would be had she brought it about by a deliberate positive action”. 9

The following example offered by Brock 11 illustrates this last point excellently.


 Consider the case of a patient terminally ill with ALS [amyotrophic lateral sclerosis] disease. She is completely respirator dependent with no hope of ever being weaned. She is unquestionably competent but finds her condition intolerable and persistently requests to be removed from the respirator and allowed to die. Most people and physicians should respect the patient’s wishes and remove her from the respirator, though this will certainly cause the patient’s death … suppose the patient has a greedy and hostile son who mistakenly believes that his mother will never decide to stop her life-sustaining treatment and that even if she did her physician would not remove the respirator. Afraid that his inheritance will be dissipated by a long and expensive hospitalization, he enters his mother’s room while she is sedated, extubates her, and she dies. Shortly thereafter the medical staff discovers what he has done and confronts the son. He replies, “I didn’t kill her, I merely allowed her to die. It was the ALS [amyotrophic lateral sclerosis] disease that caused her death.” I think this would rightly be dismissed as transparent sophistry—the son went into his mother’s room and deliberately killed her. But, of course, the son performed just the same physical actions, did just the same thing, that the physician would have done.

As this example shows, removing life-sustaining treatment can indeed be considered a form of killing that is morally impermissible—that is, it can be considered a form of murder. The patient’s greedy son is just as guilty in the death of his mother as he would have been had he given her a lethal injection. Yet, I suspect that few of us would argue that the mother’s doctor would have committed murder had he taken the same physical action the greedy son did. This means that the same physical action of removing life-sustaining treatment may be considered morally justifiable in some cases and morally impermissible in other cases. The following example really drives this point home.


 Samuel Linares, an infant, swallowed a small object that stuck in his windpipe, causing a loss of oxygen to the brain. [Particularly, Samuel asphyxiated on a blue latex balloon at a birthday party on August 2, 1988.] He was admitted to a Chicago hospital in a coma and placed on a respirator. Eight months later he was still comatose, still on the respirator, and the hospital was planning to move Samuel to a long-term care unit. Shortly before the move, Samuel’s parents visited him in the hospital. His mother left the room, while his father produced a pistol and told the nurse to keep away. He then disconnected Samuel from the respirator, and cradled the baby in his arms until he died. When he was sure Samuel was dead, he gave up his pistol and surrendered to police. He was charged with murder, but the grand jury refused to issue a homicide indictment, and he subsequently received a suspended sentence on a minor charge arising from the use of the pistol. 12

Samuel’s father took exactly the same physical action that the greedy son did: he removed his baby’s life-sustaining treatment and allowed him to die. If the greedy son’s action constituted killing his mother, then Samuel’s father killed his son as well (as did the doctor in the earlier example). In all these examples, the removal of life-sustaining treatment classified as an inus condition: the respective deaths would not have occurred without the removal of the treatment, although the removals were not, in themselves, sufficient for causing the deaths. All three people, the greedy son, the doctor and Samuel’s father, were causally, and morally, responsible for the deaths that resulted from their removal of treatment. The reason most of us, I think, would only impugn the greedy son as performing a morally unjustifiable act is because of his murderous, selfish and callous intent. Samuel’s father and the doctor, however, did not have these morally appalling intentions, and so their respective instances of killing may indeed be justifiable ones. What all this drives at is that passive euthanasia is indeed a form of killing, which may or may not be morally permissible, and hence may or may not be considered an instance of murder. One thing seems rather clear, however: in all the examples cited, there is certainly some degree of causal agency that can be attributed to each of the people who removed life-sustaining treatment.

Therefore, in any instance of passive euthanasia, the doctor does indeed have a direct causal role in the death of the patient. The doctor initiates a state of affairs that directly leads to the patient’s death: withholding or withdrawing life-sustaining treatment that, had it been given, would have resulted in a patient’s continued existence. The doctor has a causal role in the patient’s death by withholding or withdrawing treatment, and the passivity comes only after this initial action. The doctor takes active measures to withhold or withdraw life-sustaining treatment and then passively stands by and allows the patient to die. Indeed, it is precisely because of this initial active and causal role in his mother’s death that the greedy son cannot justify his actions by arguing “I didn’t kill her, the underlying ALS [amyotrophic lateral sclerosis] killed her, I simply stood by and let it happen”.

Yet, as unacceptable as this defence would be for the greedy son, it is exactly this logic that is used to exonerate doctors of their causal role when they participate in passive euthanasia. The American Medical Association’s 13 official stance on the ethics of euthanasia incorporates this very defence:


 When a life-sustaining treatment is declined, the patient dies because of an underlying disease. The illness is simply allowed to take its natural course. With assisted suicide however [or any instance of active euthanasia], death is hastened by the taking of a lethal drug or other agent.

Some philosophers also incorporate this distinction. For example, Fiona Randall, 14 a consultant in palliative care with a background in philosophy and medical ethics, argues that in cases of patients in a persistent vegetative state who die as a result of the withdrawal of treatment,


 … surely the patient’s death is caused by the underlying severe pathological condition of the PVS [persistent vegetative state], which renders the patient incapable of survival without constant life-prolonging treatment, including artificial hydration and nutrition. The fundamental cause of death is the patient’s condition, not the withdrawal of treatment, which should be regarded as incidental.

As Kuhse’s argument shows, however, the withdrawal of treatment, or refraining from treatment by a physician, is not merely incidental, but is rather a non-redundant condition for the patient’s death; the patient would not have otherwise died at that time had it not been for the withdrawal of or refraining from treatment. If the argument proposed by the American Medical Association and Randall were a sound one, then the greedy son would be exonerated for his actions, given that he can argue that he merely withdrew treatment, that his action was incidental, and thus that he merely “let his mother die”. Yet every single moral fibre in our body prevents us from accepting this consequence. The mother’s death at the hands of her greedy son (and Baby Doe’s death) was an unjustifiable instance of killing by withdrawing or withholding some kind of life support, and there were people who played causal roles in these deaths, who may be morally impugned for their actions. On the other hand, Samuel’s death, or the death of the mother at the hands of the doctor, were justifiable instances of killing by removing life support, as would have been the death of the baby girl born with the congenital defects or the death of any terminally ill infant who is suffering intolerably.

But does it matter how a person is killed? If the killing of a patient is sometimes morally permissible, can the method of killing be morally problematic? I am hard pressed to see why there is a major moral difference between the causal role a doctor has when removing life support and the role the doctor has when injecting a patient with a lethal chemical that causes death (indeed, according to Kuhse, there is no such moral difference, for both are inus conditions and thus causes of death in the proper sense). If the greedy son cannot take refuge in passivity, then a doctor cannot do so either. In passive euthanasia, the doctor takes steps to ensure a patient’s death (either by removing existing life support or by declining to initiate any type of life support), and then stands by while the patient dies, when the patient otherwise would have continued to live, as a result of the lack of life-sustaining treatment. In active euthanasia, the doctor injects the patient with a chemical that leads to the patient’s death. In both cases, the doctor takes the first step in a causal chain that leads to the patient’s death. If the death is unjustifiable, then the doctor, being the initiator of such a causal chain, would be equally guilty of murder, whether by active or passive means. For instance, if a doctor were to refrain from giving a simple drug to an infant who has a mild case of pneumonia, resulting in the infant’s untimely death, the doctor is causally, and morally, responsible for the infant’s death, as responsible as he or she would have been had he given the infant a lethal injection. As Kuhse 10 argues, “[I]f a doctor deliberately refrained from preventing an infant’s death, we would say that it is the doctor’s failure to treat that was the cause of that infant’s death.” The doctor would most likely be brought up on murder charges, although his actions constituted passive, not active, euthanasia. Indeed, those people who called the death of Terri Schiavo a form of murder, although her death was an instance of passive, not active, euthanasia, illustrated this very point in their moral condemnation of Michael Schiavo and those doctors who removed Terri’s feeding tube. Not one single person who thought the death of Terri Schiavo was unjustified argued that it was not a form of killing, but merely “allowing to die”, because it was an instance of passive euthanasia, or “allowing nature to take its course”. For those who thought the death was unjustifiable, it was murder no matter what method of euthanasia, active or passive, was used. An unjustifiable death is unjustifiable, no matter how the death occurs.

It should follow, then, that a justifiable death is justifiable, no matter how the death occurs. If the death of a particular infant is justifiable, then the doctor should be equally exonerated in instances of either active or passive euthanasia, just as he should be equally impugned if the death is unjustifiable. In both cases, the doctor remains causally and morally responsible for the death of the patient, but if the death has already been deemed justifiable, then the doctor should be absolved of any wrongdoing when performing active or passive euthanasia. Therefore, if doctors from the Groningen Medical Center are not to be morally impugned for passively euthanising an infant who is terminally ill and suffering, given that continued existence is not in the infant’s best interests, they ought not to be morally impugned for actively bringing about this beneficial state of affairs sooner rather than later by active euthanasia, especially when letting the infant die passively only adds to the infant’s suffering.

Nevertheless, many ethicists argue with just as much conviction that there is a moral difference between these two methods of killing. I would now like to consider some pressing concerns that have led them to the conclusion that killing actively is worse than killing passively.

RESPONDING TO SOME WORRIES

In his article “‘Aid-in-dying’: the social dimensions”, Daniel Callahan 15 argues that allowing for voluntary active euthanasia results in an inequality of power by putting the life and death of one person, the patient, completely in the hands of another, the doctor, resulting in a violation of human dignity:


 To allow another person to kill us is the most radical relinquishment of sovereignty imaginable, not just one more way of exercising it. Our life belongs no longer to us, but to the person into whose power we give it. No person should have that kind of power over another, freely gained or not.

I am not sure why Callahan thinks that this instance of relinquishing control over a person’s life to a doctor is more problematic than relinquishing such control when a doctor is asked to perform passive euthanasia by removing or withholding life-sustaining treatment. In both voluntary passive and active euthanasia, the life of the patient is handed over to the doctor; the patient has the final and decisive word on whether the patient lives or dies, but the doctor has a causal role that leads to the patient’s death. It seems that the control handed over to the doctor in both instances of euthanasia is equally strong, and if such control is not deemed sufficiently morally problematic in instances of passive euthanasia and prevents its practice, I do not see why it should be sufficiently morally problematic in instances of passive euthanasia to prevent its practice.

Callahan 15 also makes another noteworthy argument against active euthanasia:


 Traditionally, only three circumstances have been acceptable for the taking of life: killing in self-defense or to protect another life, killing in the course of just war, and, in the case of capital punishment, killing by agents of the state … the proposal for “aid-in-dying” is nothing less than a proposal to add a new category of acceptable killing to those already socially accepted. To do so would be to reverse the long-developing trend to limit the occasions of legally sanctioned killing.

I agree with Callahan that as a society we should implement strict conditions detailing when it is acceptable to kill other human beings, and that we should sincerely ask ourselves whether a particular instance of killing another human being should be advocated on moral grounds. Killing in self-defence seems to me the least morally problematic of the above three cases to justify. Killing as a form of punishment or societal vengeance for wrongful killings is more problematic, as is killing in the course of a just war, which claims the lives of soldiers and innocent civilians in the name of “collateral damage”. Indeed, the justification given in defence of the latter two instances of permissible killing seems more morally dubious to me than the reasons the doctors from the Groningen Medical Center have given for allowing terminally ill and suffering infants to be killed. They advocate the premature killing of these infants, who will die soon no matter what actions they undertake, in the name of mercy; in the name of sparing, primarily, the infants’ atrocious pain and suffering and, secondarily, ending the resulting parental suffering upon seeing their terminally ill children in such a state.


 It’s time to be honest about the unbearable suffering endured by newborns with no hope of a future ... A lot of disquiet has arisen around this issue, especially when the Vatican expressed concern. But these children face a life of agonizing pain. For example, we’re talking about newborns with hydrocephalus and no brain. Another example may be a child with spina bifida with a sack of brain fluid attached where all the nerves are floating around. This child is barely able to breathe, and would have to undergo at least sixty operations in the course of a year to temporarily alleviate its problems. These operations would not ease the pain. Moreover, the child would suffer such unbearable pain that it has to be constantly anaesthetized. The parents watch this in tears and beg the doctor to bring an end to such suffering. 16 [My emphasis to highlight that the infants in question are indeed terminally ill, and thus to reaffirm that the Groningen Protocol is not making quality-of-life judgements when it comes to these infants.]

Such a justification strikes me as being much less morally problematic than the reasons we, as a society, allow for the death penalty (which fails to serve as a deterrent to prevent future murders, which is a justification that I would find less morally problematic if it were true): killing for punishment or revenge. Such a focus on mercy is also morally less problematic than killing in the name of collateral damage in war; perhaps it is indeed true that it is necessary to bomb a whole village to kill a few terrorists, yet I find it dubious whether such a consideration justifies the death of innocent people, including infants and children, who, unlike the infants of the Groningen Protocol, are not terminally ill.

In other words, we should pay close attention to what types of killing we permit in society, but I am at a loss about why we sanction the above instances of killing, for morally dubious reasons, but do not sanction killing for what seems to be an altruistic interest in preventing suffering for terminally ill infants and their families. Unless we want to be rid of all instances of approved killing in a society, we ought only to allow for those instances of killing that ground its basis on morally sound reasons for doing so. The justification for killing offered in the Groningen Protocol does not validate the death of these infants to rid their families of children who are mentally disabled, despite what some critics maintain (the Baby Doe case, on the other hand, did justify the death of the infant, ultimately, on such grounds and, ironically enough, this harmful death did not take place in The Netherlands, but in the US). Rather, it justifies the premature death of these terminal infants in the interest of sparing them pain and suffering throughout their short, inevitably doomed, lives. I can think of few other morally sound reasons for killing than this one.

Perhaps the strongest objection against the Groningen Protocol pertains to the ethics of non-voluntary euthanasia in general and whether establishing a legal framework for its practice on any occasion may lead to the killing of people who cannot give their consent for euthanasia, but who ought not to have been killed because they would have objected to it had they been able. Given this possibility, it is not advisable to make such acts of killing into a general rule, even if certain individual acts of killing may be morally justified. This concern is voiced by Beauchamp and Childress 17 when they write, “although particular acts of killing may be humane or compassionate, a policy or practice that authorizes killing in medicine—in even a few cases—might create a grave risk of harm in many cases and a risk that we find it unjustified to assume”. Brock, 11 an advocate of voluntary active euthanasia, expresses similar worries:


 Making nonvoluntary active euthanasia legally permissible, however, would greatly enlarge the number of patients on whom it might be performed and substantially enlarge the potential for misuse and abuse. As noted above, frail and debilitated elderly people, often unable to defend and assert their own interests, may be especially vulnerable to unwanted euthanasia.

These concerns are perhaps reflective of what most people fear may happen if non-voluntary active euthanasia is made legal—that is, it would result in a type of involuntary euthanasia, where people who do not want to be killed, but who cannot express such a desire, are nevertheless killed. One thing to note right away, however, is that this is not a problem confined to non-voluntary active euthanasia; this problem also applies to non-voluntary passive euthanasia, and so I caution readers against unfairly impugning active euthanasia with a whole host of problems that apply equally strongly to passive euthanasia, but do not lead to its moral or legal proscription. If a person does not want to die, but is too incompetent to express such a wish (eg, being in a temporary coma), killing the patient by active or passive means violates the patient’s wishes equally.

The worry may remain, however, that even if the Groningen Protocol itself does not allow for this type of misuse, permitting any general guidelines that allow for non-voluntary euthanasia would establish a precedence that would make it easier to kill other people who may not have wanted to die. Certainly we do not want patients being terrified that if they slip into temporary unconsciousness they may be euthanised by the consent of a proxy. Although the Groningen Protocol itself does not leave room for such a possibility, could this not be construed as the first step in a terrifying slippery slope? If so, as Beauchamp and Childress argue, no matter how heart-breaking the particular cases of terminal and suffering infants may be, we simply cannot afford to start down this road, and so we cannot, as a rule, allow for non-voluntary active euthanasia in any situation.

Two ways of responding to this genuine and serious concern exist. One is to point out, once again, that this danger lies also in permitting non-voluntary passive euthanasia, which the US itself pervasively practises and which was unjustly practised in the Baby Doe case. As mentioned earlier, an unjustifiable death remains unjustifiable, and a harm to the patient, whether it occurs by passive or active means. It seems simply unfair for this concern to count decisively against non-voluntary active euthanasia when it does not do so for non-voluntary passive euthanasia. It is a concern, and it is a concern that must be guarded against. But surely, if we allow for non-voluntary passive euthanasia despite these concerns, there is no reason not to allow for non-voluntary active euthanasia as well, as long as we are mindful not to perform any type of euthanasia, active or passive, if we have the least bit of an indication that the patient may not have wanted to be euthanised.

The second is to try as much as possible to safeguard against these concerns by making any protocol specific to certain types of cases to prevent abuse (which I believe the Groningen Protocol successfully achieves, given its five criteria). Indeed, in all the cases that morality and the law allow for killing, there is the possibility of abuse that can lead to the unjustifiable deaths of innocent people. McMahan 18 responds to this concern quite aptly when it comes to the sanctioning of killing in self-defence:


 Our acceptance of the permissibility of killing in self-defense offers significant opportunities for people to perpetrate wrongful killings under the guise of self-defense—for example, by provoking a person to violence and claiming that killing him was necessary to save oneself, or by killing, in a secluded spot, a person with a known history of violent aggression and then claiming that one killed in self-defense. Although we are aware of these possibilities of abuse, we do not respond by forbidding killing in self-defense. Instead we erect safeguards against the abuse.

Similarly, there are questions on the danger of executing innocent people who were unjustly convicted to death row, yet this worry alone has not been sufficient for eradicating the death penalty (although some have argued that it should be). There will always be dangers, and we should always remain vigilant about these dangers. But, when it comes to the issue at hand, providing a careful analysis on which infants are eligible for euthanasia under the Groningen Protocol can safeguard against these dangers. Indeed, bringing the euthanasia of these infants out in the open and under the watchful eye of the government of The Netherlands and public will aid in creating these safeguards and help prevent another Baby Doe from dying needlessly. Indeed, there has been an increase in the reporting of euthanasia in The Netherlands by doctors. In 1999, 2216 cases of euthanasia were reported, which was a clear increase from the 1466 cases reported in 1994. 19 As of this writing, a doctor in The Netherlands must report any death that results from active euthanasia to the municipal corner in adherence to the relevant procedural requirements in the Burial and Cremation Act.

Is there a certain amount of unwarranted optimism on my behalf? Is such a slippery slope inevitable even with strict guidelines legally in place? Keown would certainly think so. Indeed, he would perhaps argue that the very fact that the doctors in The Netherlands are proposing these guidelines, and that I am writing a paper defending these guidelines, is evidence that the slippery slope has already occurred. In various publications, Keown expresses worry that the Dutch guidelines allowing for voluntary active euthanasia have already resulted in illicit instances of non-voluntary active euthanasia despite the strict guidelines delineated by several Dutch lower courts, which require that a patient’s euthanasia request “must come only from the patient and must be entirely free and voluntary … [in addition] the patient’s request must be well-considered, durable, and persistent”. 19, 20 According to Keown, however, the empirical evidence suggests that many instances of euthanasia in The Netherlands do not adhere to these two very pivotal rules, and it is adherence to these rules that renders a particular act of euthanasia truly voluntary, rather than non-voluntary or involuntary. Using the Remmelink Commission Report and the van der Maas survey as evidence, Keown 20 concludes that “non-voluntary euthanasia is in fact more common than voluntarily euthanasia” (p 278) in The Netherlands, and he defends his claim by citing the number of instances where doctors in The Netherlands have performed passive or active euthanasia, with the precise intention of ending a patient’s life, without the patient’s explicit consent. His conclusion is that “cardinal safeguards—requiring a request which is free and voluntary; well-informed; and durable and persistent—have been widely disregarded” (p 278). As a result, the slide from voluntary to non-voluntary active euthanasia is rather evident in The Netherlands and “[t]here is little sense in which it can be said, in any of its forms, to be under control”. 21

As mentioned earlier, the concern with permitting any legalisation of non-voluntary active euthanasia is that it will result in a slide towards involuntary euthanasia. The concern is not that people will be euthanised “for their own good” while actively begging not to be killed. (I cannot begin to imagine that this is even a viable possibility.) Rather, the concern is that people will be killed “for their own good” when they are too incompetent to express their wishes: wishes that would have revealed their desire not to be euthanised. This is a very important concern, but one that I do not think the Groningen Protocol is in danger of resulting in, given that the subjects of euthanasia in this case—infants—possess no will to be defied (this concern would be an issue, however, if the Protocol were ever expanded to include people who do have wills and preferences on the matter—for example, older children, adults and elderly people). A more realistic danger, as I see it, is that, over time, the first two conditions of the Groningen Protocol, requiring that the infants in question be terminally ill with no prospects for a future, would be relaxed to include infants who may not survive or to infants who would survive, but whose prospects for a valuable future would be severely impaired.

I will admit that this possibility worries me. Although there are cases where it is uncontested that a child’s life would be so devastating and full of suffering that it is not worth living, these assessments reach a grey area rather quickly and as a result there may be more Baby Does who will fall through the cracks, infants who may have survived and would perhaps have led fruitful lives. I have argued that the Groningen Protocol does not make quality-of-life judgements, and it is because of this very important requirement that the protocol strikes me as humane and morally permissible, for it seems utterly vicious to extend the life of a suffering infant with no prospects for a future. If the infant did have a possible future ahead, I would be more hesitant to condone a legal practice that begins to make quality-of-life judgements, for such judgements can be, and have been, subject to error. Consider, for example, the case of the Danville conjoined twins. Jeff and Scott Mueller were born on 5 May 1981 at Lakeview Hospital in Danville, Illinois, USA. The brothers were joined at the waist and the spine and shared a lower digestive system, bowels and a leg. At first, the twins were not expected to live through the night, but the next day they were still very much alive. After a battle with the courts on whether the decision to deprive the infants of nourishment and hydration was attempted murder, the parents of the Mueller twins were allowed to take them home. Despite preliminary assessments, the brothers had reached a healthy year when they underwent separation surgery on 15 July 1981. Scott died in 1985, having lived four more years than originally expected. Jeff is still alive and is a testament to the error that can occur when doctors engage in quality-of-life judgements. Perhaps we ought to restrict all instances of both passive and active non-voluntary euthanasia to patients with no prospects for a future—for example, people in confirmed persistent vegetative states or infants who would currently be eligible for euthanasia under the Groningen Protocol. Therefore, I am willing to defend the protocol only in so far as it strictly adheres to the first two conditions. A marked difference exists between guidelines that make quality-of-life judgements, which entails doctors “playing the odds” with the life of an infant despite the medical profession’s reputation for miscalculating those odds, and those guidelines that do not engage in these types of judgements, as the Groningen Protocol carefully seems to avoid doing. Therefore, the first two conditions of the protocol are of pivotal importance in assessing its moral and legal permissibility, and to ensure that they are strictly enforced, I suggest that in addition to having another doctor offer a second opinion on the infant’s diagnoses (according to the fourth requirement), ethics boards should be formed with the adoption of the Groningen Protocol, which will extensively review each case before the infant is euthanised to ensure that each infant is in fact terminally ill and that the infant’s prospects for a future are truly naught.

In this paper, I have argued that the current debate on the Groningen Protocol is highly misdirected and deserves fair and unbiased attention. The doctors at the Groningen Medical Center are not Nazis. They are not advocating a type of eugenics programme for ridding The Netherlands of infants with disability and they certainly are not making quality-of-life decisions about who is worthy of continued existence. These infants are terminally ill; modern medicine can do nothing to save them. The remainder of their short lives will be fraught with intense pain and suffering—the simple act of breathing may fill an infant with nothing but agony. These infants cannot take psychological refuge the way adults can by remembering a pleasurable past experience or by looking forward to a desirable experience in the future. The life of these infants consists of nothing more than perpetual suffering. Continued existence is of no benefit to them; rather, death is often looked upon as a much prayed for blessing. In these tragic cases, death is what constitutes the best interests of the infant and it is on the basis of this realisation that we recognise that passive euthanasia is what the primary moral principle of medicine—to do no harm—calls for. Needlessly prolonging the lives of these infants counts against their interests, and so we concede to their deaths and allow them to occur. Yet, when the time it takes the infant to die is also full of suffering, inducing death by active euthanasia does nothing but bring about a beneficial state of affairs sooner, and this works more for the interests of the infant than killing him by passive means. In these cases, the duty to do no harm may entail the positive duty of hastening death. As such, the Groningen Protocol, as it stands, is morally permissible. The five criteria the hospital has offered, strictly enforced, will serve to safeguard against the possibility of abuse and ensure that the best interests of the infant are never compromised.

As a society, we must be careful not to wantonly allow for the killing of innocent people, infants included. We must respect life and build medicine around the ethics of preserving life as much as possible. Yet, when a fatal tragedy befalls infants, if we truly care about their best interests, we will deliver them from their suffering sooner rather than later. This strikes me as being much more morally justifiable than tucking them away into the corner of a hospital while they slowly die in agony, as was done with Baby Doe, which seems to me to add insult to his already tragic injury.

Acknowledgments

I thank the two external reviewers for the Journal of Medical Ethics who provided helpful comments on earlier drafts of the paper, and the board of editors for the Journal of Medical Ethics for publishing this paper. I also thank Dr Paul Thompson from Michigan State University and Dr Robert Weir from the University of Iowa for their helpful comments in the very early stages of the paper. A personal note of gratitude goes to my husband, Tuomas Manninen, for always reading over my papers and giving helpful comments, and to my family and friends for their undying support and love. Finally, I would like to take a moment to remember all the families of terminally ill, impaired or suffering infants. Your strength is an example to us all, and may the souls of your children forever rest in peace.

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Competing interests: None.

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The Complexity of Non-Voluntary Euthanasia

Dr Howard Martin has been in the news recently for having told the Telegraph that he intentionally shortened the life of a number of his patients.  On the face of it, his actions seem to be fairly straightforward, and to lend some kind of support to the fears of those who think that any easing of the law on assisted dying will put (at least some) patients in danger.  In his interview, he said that he

hastened the final moments of some of his patients. “I just promised people that they could die free from pain and with dignity[.  ]Most times patients and relatives were of an accord and wanted the patient to be free from pain and have dignity. In that scenario, I would take control by keeping people asleep until they had passed over.
“I twice helped people die, not because they wanted to die but because they had such dreadful suffering. Everyone else wanted to [die] – they could make that choice.”

There is something slightly… oh, I don’t know… not exactly sinister about his words, but… well, somewhere between “sinister” and “iffy” – and, as I said, I can see how they could be taken to lend evidence to the fears of the anti-Assisted Dying (AD) lobby.  Not that I’m accusing Martin of acting in anything but good faith – a couple of shills have already started mentioning Shipman in this case, and we’re a million miles from there.  Nevertheless, people can, in good faith, make all kinds of moral blunders, and there’s part of me that worries that this is what Martin may have done.

I’ve not been exactly reticent on these pages in publicising my views on voluntary euthanasia and assisted dying.  There’s no need to rehearse them here.  Having said that, we should note that Martin’s actions tell us no more about the wisdom of legalising AD than did Shipman’s.  Given that the law plainly didn’t stop either of them doing what they did, altering the law won’t obviously change things for the worse – unless you think, bizarrely, that there’s a cohort of medics out there dying to go on a killing spree if only it weren’t for that pesky illegality.  I don’t believe that there is any such person who exists.

Nor is there really any need to say much about “involuntary euthanasia” – I put that in scare-quotes simply because there’s no such thing: euthanasia implies, at the very least, a killing that is motivated by a concern for the best interests of the person killed – and if a person is saying that, really, they’d really rather not be killed, then that looks pretty much like a deal-breaker.  If they evaluate their life as being worth living, then it is worth living; to kill them is not, in this case, euthanasia.  Bluntly, involuntary euthanasia ought not to attract the attention of ethicists any more than seven-sided triangles ought to attract the attention of mathematicians.

Things are a bit more complicated when it comes to non-voluntary euthanasia (NVE).  For the sake of clarification, this is deliberate and beneficent killing that is neither wholly for nor wholly against the patient’s wishes – perhaps because the patient is not in a position to have any wishes on the matter.

There are times, for example, when killing could be preferable to letting die, and NVE might present itself as a morally desirable option.  Imagine that someone is universally agreed to be irreversibly and severely brain-damaged, and is being kept alive with a ventilator.  There is some evidence of responsiveness to physical stimuli, but no evidence of any higher brain functions, sense of self or anything like that.  Something goes wrong with the machinery, and the ventilation tube has to be withdrawn.  It is apparent that the tube cannot be reinserted without causing great distress – perhaps not without surgery – and reinsertion would be very dangerous anyway; it is also clear that, without it, the patient will die of asphyxiation.

So the medics have an unenviable dilemma: do they attempt to save a life – a life that some would say is merely and irreversibly biological rather than biographical at this stage – for a short time, and in doing so run the risk of causing significant harm, at least some of which will be directly experienced by the patient?  Or do they withhold further intervention?  Current law would allow for the second option.

But it so happens that the medics have nearby a syringe full of a powerful neurotoxin that will kill the patient painlessly within a couple of seconds.  There’s a good number of people who’d argue that they ought to administer it: that there’s something morally perverse about allowing a person to die of asphyxiation but not killing them more quickly.  This would be non-voluntary euthanasia, and plausibly defensible.

Slightly more graphically, we might imagine someone who is trapped in a burning vehicle, and who cannot be cut out before being burned to death – you know this for sure.  It so happens that this person is currently unconscious, though may not remain so, and that you have a loaded pistol.  Here, again, I think that there’d be a good case to be made that you either could or ought to kill the motorist to save him from a worse death.  Again, NVE.

Now, let’s go back to Martin, and the penultimate and peripenultimate sentence of the quotation above.  Here they are again:

I would take control by keeping people asleep until they had passed over.  I twice helped people die, not because they wanted to die but because they had such dreadful suffering.

I’m going to assume that this is a case of NVE.  But it seems different from the examples I just gave.

The first possibility for explaining the difference is that there’s something starkly paternalist about it: the claim seems to be not that Martin couldn’t understand how someone would find such-and-such a life tolerable, but that he took it upon himself to ensure that the patients in question wouldn’t have even to make that kind of judgement.  The moral attention here would be on the usurpation of choice in patients who may or may not have agreed that their life was intolerable, but who never got the chance.

The second possibility goes something like this: there are situations in which the future life to be lived can reasonably be expected to be worse than death.  In those circumstances, I think that NVE might be permissible – that’s why it’s OK to shoot the driver in the burning vehicle.  Of course, we have to be careful with the decision, but the principle stands.  (Moreover, , any indication that the person who stands to die is actually willing to take his chances after all is enough to turn NVE into involuntary “euthanasia”.)

But there are other situations in which we cannot reasonably expect the future life to be worse than counterfactual death – at least, not with any certainty.  In that case, to kill someone non-voluntarily is to deprive them of a future; and I can see how one might mount an argument about the wrongness of this.  It’s tricky, though: the dead don’t know that they no longer have a future, so it looks as though the emphasis has to be on the practitioner – we need to be able to generate an a priori rule with the required normative clout.  I guess that there are versions of deontology and virtue ethics that might be able to provide what’s needed here.  Maybe rule-consequentialism, too, if we can stop it collapsing into non-consequentialism.

Now, the future that patients would otherwise have is likely to be richest in those with more-than-minimal consciousness; and for those with no consciousness and no prospect of it, we could perhaps say that they have no future at all – we might say that there’s not much point to a life that’s all biology and no biography.  But even if there is no point to such a life, it doesn’t follow that there’s a reason to end it.  (I’m leaving aside considerations like resource drain, the strain on families, and so on, for the sake of simplicity.)  If a patient is utterly insensible, there’s no reason to live – but to kill involves a positive intervention, and there’s no reason for that, either.  Hence to kill looks to be arbitrary.  But there’s something morally iffy about arbitrary actions – so we ought not to kill by NVE here.

(Perhaps the reasoning in this case is a bit Kantian – a bit like his argument against cruelty to animals or inanimate nature in The Doctrine of Virtue .  I’ve never been wholly happy with that – it seems a bit slippery-slopey – but there you go…)

Anyway: the point of this rather rambling post is this: NVE is a lot more complex than it seems at first.  It might even be the case that there’re several kinds of NVE, each of which needs independent moral consideration.  It’s only on the basis of such careful consideration that there’s any chance of bringing clarity to the AD debate.

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BMJ Journals

Non-Voluntary Euthanasia

  • Policy and Ethics
  • Ethical Issues
  • Essays and articles

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

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

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

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

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

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

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

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

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

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

The Netherlands.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

United States of America.

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

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

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

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

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

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

Conclusion.

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

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

References.

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

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

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

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

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

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

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

8. Do. p 230.

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

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

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

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

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

14. Do. p 170.

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

16. Washington vs Glucksberg, 117 SCt 2303.

17. Op cit 8. p 165.

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

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

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Applied Ethics in the Fractured State

ISBN : 978-1-78769-600-6 , eISBN : 978-1-78769-599-3

Publication date: 12 November 2018

Natural Law philosophy asserts that there are universally binding and universally evident principles that can be determined to guide the actions of persons. Moreover, many of these principles have been enshrined in both statute and common law, thus ensuring their saliency for staff and institutions charged with palliative care. The authors examine the often emotive and politicized matter of (non-voluntary) euthanasia – acts or omissions made with the intent of causing or hastening death – with reference to Natural Law philosophy. This leads us to propose a number of important public policy remedies to ensure dignity in dying for the patient, and their associates.

  • Palliative care
  • Natural Law
  • Principle of double effect
  • Non-voluntary euthanasia
  • Doctrine of double effect

Drew, J. and Grant, B. (2018), "Natural Law, Non-Voluntary Euthanasia, and Public Policy", Grant, B. , Drew, J. and Christensen, H.E. (Ed.) Applied Ethics in the Fractured State ( Research in Ethical Issues in Organizations, Vol. 20 ), Emerald Publishing Limited, Leeds, pp. 67-82. https://doi.org/10.1108/S1529-209620180000020006

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Dutch law requires doctors in euthanasia cases to seek an independent second opinion. Picture posed by models.

Three euthanasia cases face investigation in Netherlands

Inquiries confirmed following controversy over death of anorexic teenager

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Nursing and euthanasia: A narrative review of the nursing ethics literature

Sally thorne.

The University of British Columbia, Canada

Janet Storch

University of Victoria, Canada

Michael Burgess

University of British Columbia, Canada

Carol Tishelman

Karolinska Institutet, Sweden

Kenneth Chambaere

Vrije Universiteit Brussel; Belgium Ghent University, Belgium

Robert Janke

Associated data.

Supplemental Material, NEJ845127_SUPPLEMENTAL_MATERIAL_CLN for Nursing and euthanasia: A narrative review of the nursing ethics literature by Barbara Pesut, Madeleine Greig, Sally Thorne, Janet Storch, Michael Burgess, Carol Tishelman, Kenneth Chambaere and Robert Janke in Nursing Ethics

Background:

Medical Assistance in Dying, also known as euthanasia or assisted suicide, is expanding internationally. Canada is the first country to permit Nurse Practitioners to provide euthanasia. These developments highlight the need for nurses to reflect upon the moral and ethical issues that euthanasia presents for nursing practice.

The purpose of this article is to provide a narrative review of the ethical arguments surrounding euthanasia in relationship to nursing practice.

Systematic search and narrative review. Nine electronic databases were searched using vocabulary developed from a stage 1 search of Medline and CINAHL. Articles that analysed a focused ethical question related to euthanasia in the context of nursing practice were included. Articles were synthesized to provide an overview of the literature of nursing ethics and euthanasia.

Ethical Considerations:

This review was conducted as per established scientific guidelines. We have tried to be fair and respectful to the authors discussed.

Forty-three articles were identified and arranged inductively into four themes: arguments from the nature of nursing; arguments from ethical principles, concepts and theories; arguments for moral consistency; and arguments from the nature of the social good. Key considerations included nursing’s moral ontology, the nurse–patient relationship, potential impact on the profession, ethical principles and theories, moral culpability for acts versus omissions, the role of intention and the nature of the society in which euthanasia would be enacted. In many cases, the same assumptions, values, principles and theories were used to argue both for and against euthanasia.

Discussion:

The review identified a relative paucity of literature in light of the expansion of euthanasia internationally. However, the literature provided a fulsome range of positions for nurses to consider as they reflect on their own participation in euthanasia. Many of the arguments reviewed were not nursing-specific, but rather are relevant across healthcare disciplines. Arguments explicitly grounded within the nature of nursing and nurse–patient relationships warrant further exploration.

Medical assistance in dying

Medical Assistance in Dying was legalized in Canada in 2016 by an amendment to the Criminal Code that removed its prohibition. This legalization, which allows Nurse Practitioners to be both assessors and providers of Medical Assistance in Dying, was the catalyst for the current review. Under the Canadian legislation, two actions to medically aide the dying are permissible: (1) administering a substance to a person at their request that causes their death (commonly referred to as euthanasia) or (2) prescribing or providing a substance to a person at their request so that they may self-administer the substance and in so doing cause their own death (commonly referred to as assisted suicide). 1 To date, seven countries around the world offer a type of euthanasia. 2 As in Canada, the Netherlands, Belgium, Columbia and some US states have adopted assistance in dying into law. In others (i.e. Switzerland, Luxembourg), medical procedures that aid-in-dying have been decriminalized or are allowable under certain, predetermined circumstances. 2

In Canada, the term Medical Assistance in Dying was chosen carefully to reflect Canadian context and values. However, terminology around the world varies to reflect the specific practices in that country. For example, physician-euthanasia is the terminology used in the United States, a term which reflects the limits of a client-administered death. Euthanasia is the term used most commonly in the international context. Specifically, euthanasia is defined as an ‘active and intentional act of putting to death, in a relatively painless way, of persons suffering severely from medical conditions that are incurable, untreatable, or irreversible…at that person’s explicit request’ (para. 1). 3 In this article, the term euthanasia will be used to represent euthanasia, medical assistance in dying and assisted suicide or physician-euthanasia.

Euthanasia in relationship to nursing practice

The legalization of euthanasia has presented regulated nurses with a complex array of ethical and moral decisions as they relate to determining one’s level of involvement in this new care option. At one end of the spectrum is full conscientious objection, whereby nurses choose to be relieved of all care for reasons related to preserving moral integrity. At the other end of the spectrum is full involvement in the euthanasia process. In between are levels of involvement in care which may, or may not, be directly related to the actual provision of euthanasia (e.g. ongoing care for persons receiving euthanasia and bereavement support for family). 4 Although the right for nurses to conscientiously object is enshrined in Canadian law, 1 regulatory policies specify that this act cannot be taken lightly. For example, the regulatory document for nurses in Manitoba suggests that a position of conscientious objection should only be taken based upon long and deeply held values and beliefs. 5 Furthermore, nurses have a commitment to proactively inform employers of their conscientious objection, preferably prior to the start of a new employment contract. 4 In Canada, health region policies may require nurses to remain involved in euthanasia in non-related care even if they do conscientiously object to euthanasia. This requires nurses to engage in thoughtful and dedicated periods of reflection about their ability to participate, or not, in euthanasia.

Evidence from nurses’ experiences with euthanasia in countries outside of Canada suggests that this can be a rewarding, albeit morally complex, ambiguous and emotionally laden experience. 6 A recent publication detailing nurses’ involvement with euthanasia in the first 6 months of its implementation in the Canadian context offered similar findings. 7 In light of the moral and ethical complexity of this act, a number of authors have encouraged nurses to engage in discussions around euthanasia. 8 , 9 To do so, nurses require knowledge of the issues they should be considering, time to reflect on the breadth of the issues at hand and a substantive body of literature to draw upon to stimulate reflection. The most recent review of the ethical literature we could locate was published in 2009. This was an arguments-based review of the ethical literature and nurses’ involvement in euthanasia (1987–2007). 10 Our article provides a narrative review of the ethical arguments surrounding euthanasia in relationship to nursing practice which includes papers published up to 2018.

The sources we have drawn on for this article are part of a broader systematic search of the literature focused on the policy, practice and ethical implications of euthanasia for nursing. This broader search was conducted following the principles for systematic reviews developed by the Joanna Briggs Institute. 11 Nine electronic databases ( Table 1 ) were searched by an information scientist (R.J.) using strategies developed through consulting team members and previously published reviews on this subject. 12 , 13 Before being finalized, the strategies were refined through a stage 1 search of Medline and CINAHL and peer reviewed using the PRESS Checklist. 14 A copy of the final strategy used in Medline is available in the supplementary material. A total of 6715 articles were retrieved and loaded into EPPI-Reviewer where duplicates were identified and removed leaving 3352 unique articles for review. To be included in the broader review, articles had to address policy, practice or ethical implication of euthanasia for nursing. No date restrictions were set. Non-English language articles were excluded, although a count of the non-English language articles was kept to evaluate the degree of bias inherent in the review (see Figure 1 for a PRISMA flow diagram).

List of electronic databases searched (31 August 2017).

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PRISMA flow diagram for broader systematic search of the literature.

a Screening of the ethics literature was conducted at the same time as the broader review (which included a focus on the policy, practice and ethical implications of euthanasia for nursing).

This article focuses on the sub-set of literature that discussed the ethical implications of euthanasia for nursing. To be eligible for this review of the ethical literature, the article had to (1) answer a focused ethical inquiry in relation to euthanasia and (2) make explicit application to nursing practice. For example, if an author simply provided an overview of some of the ethical issues related to euthanasia, it was excluded. On the contrary, if an author provided a robust analysis of the ethical implications of euthanasia in relation to nursing, even if the author did not argue to a particular conclusion, it was included. To ensure the reliability of the screening in accordance with these criteria, articles were screened by two investigators after establishing an inter-rater reliability rating of 90%.

Articles were then analysed using the process of narrative review. Narrative reviews seek to map complex bodies of literature for the purposes of conveying not only the depth and breadth of a field of study, but also the ‘reasons why it has been studied in a particular way, the interpretations that have been made with respect to what we know about it, and the nature of the knowledge base that informs or might inform clinical practice’ (p. 3). 15 Unlike argument-based reviews designed to ask and answer focussed ethical questions based upon the quality of the arguments, 16 the goal of a narrative review is to provide a map of the scholarly work, alongside interpretation and critique. 15 As such, our focus in this review was on better understanding how nursing ethical discourse has chosen to approach the subject of euthanasia by surveying the arguments put forward rather than by directly answering the question of whether euthanasia is an ethical good in the context of nursing practice.

Forty articles focusing on ethical issues related to euthanasia in the context of nursing practice were identified and formed the basis of this narrative review. An additional three articles were identified through backward and forward searching and through the process of hand searching tables of contents of relevant journals (e.g. Nursing Ethics ). A data extraction table (see supplementary material) was created that included authors, date, country, definition of euthanasia used and the focused ethical question addressed. The next step of this narrative review was to do a critical analysis of these articles to determine the current knowledge around nursing ethics and euthanasia. These articles were thematically categorized based upon the nature of the questions and the arguments used to address those questions. This process took the form of a qualitative inductive analysis. To begin, questions and arguments contained within the included articles were extracted by two investigators (M.G. and B.P.). Extracted data were then placed on an analysis map to look for commonalities within and between the ethical questions and arguments. Once the data were grouped within categories that shared common features, descriptors were assigned to the groupings to construct the thematic categories. Articles that contained ethical questions and arguments that overlapped categories were assigned to multiple themes.

Of the 43 articles identified, the majority originated from the United States (see Table 2 ) and were published between 1995 and 1998 (see Figure 2 ). Relatively few articles were published within the last decade. The findings will be presented using the four thematic categories developed as a result of the analysis: the nature of nursing; ethical principles, concepts and theories; moral consistency; and the nature of the social good. Here, in keeping with the intent of narrative review methodology, we provide an overview of the kinds of arguments that were raised within the body of literature in relation to each thematic category. 15

Countries of studies’ origins (N = 43).

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Frequency of publications (by year).

a Increase in publications between the years of 1995 and 1999 may be attributed, in part, to the legalization of assisted suicide in Oregon, USA (Death with Dignity Act, 1997).

Nature of nursing

Twenty-three articles provided ethical arguments for and against euthanasia based upon the nature of nursing. Of these 23 articles, 14 focused exclusively on a nursing standpoint and nine discussed the nursing standpoint alongside other arguments (e.g. principle-based, societal consequences). Eleven articles did not take a position in relation to euthanasia, nine argued against and three argued for. Three assumptions about the nature of nursing were used to position arguments related to euthanasia: the nature of nursing’s moral ontology; nurses’ unique relational space with patients; and the consequence of euthanasia on nurses’ personhood and nursing as a profession.

The first set of assumptions concerned the nature of nursing’s moral ontology. As Mathes 17 asked, ‘is there something intrinsic to the nursing role that makes it ethically impermissible for a nurse to aid a patient in committing suicide even if the suicide itself were ethically acceptable?’ (p. 262). For example, in arguing against euthanasia, Ferrell and Rivera (citing Coyle) 18 appealed to nursing’s tacit values of alleviating suffering, preserving dignity, addressing meaningfulness, guarding sanctity of life and acting with compassion. 19 Compassion was commonly cited as a foundational and enduring nursing value that could be used to argue both for and against euthanasia. 20 – 22 This ontological morality of nursing was further described as altruistic beneficence in which the nurse’s goal is to work on behalf of the good of their patients and to avoid doing harm; again an argument that could be used to support positions both for and against euthanasia. 20 , 23 These values were accompanied by moral goals of practice that included improving patient quality of life; 19 , 22 healing; 17 , 22 , 24 – 26 and preserving, protecting and respecting life. 24 , 27 , 28 Those against euthanasia argued that euthanasia, as the act of killing, is a violation of this ontological morality and so nurses should not take part. In taking part, nursing as a discipline would be perceived as killers rather than healers resulting in the erosion of public trust. 20 , 27 , 29 , 30

However, in defence of euthanasia, White 31 argued that this ontological morality is subject to interpretation. She stated that there is justified harm in the context of nursing practice, that nursing’s social trust might include euthanasia if the public sees it to be in its best interest and that euthanasia could be viewed as relieving pain and suffering. As such, White argued that, although there may be an ontological morality, how that morality works itself out in practice is subject to interpretation. This argument was revealed in the way that authors used common concepts, such as compassion, to argue for different end points.

Likewise, Newham 32 argued against an ‘internal morality’ (p. 109) of nursing on the basis that there is no agreed upon outcome or ‘end of nursing’ (p. 115). Without a definitive end of nursing, it is impossible to have an internal morality robust enough to address challenging ethical problems. Rather, he suggested that any claim to an internal morality is most useful as a ‘heuristic for people entering the profession of nursing’ (p. 115). Ultimately, he argued that the ‘moral agent is and must be one person’ (p. 115).

Others questioned whether the moral ontology of nursing remains stable or should respond to social change. For example, in arguing against euthanasia, McCabe 25 suggested that nurses must resist a social contract in which nursing becomes nothing more than a profession which adheres to patient wishes in the guise of autonomy. Without explicitly arguing a position in regard to euthanasia, Thiele and Dunsford 26 argued that nursing’s ontology needs to be fluid in response to a changing world.

A second set of assumptions that had implications for nurses’ ethical relationship to euthanasia was the nature of the nurse–patient relationship. Several authors opposing euthanasia argued that nurses have a unique relationship with patients because of the intense and continuing nature of their interaction. This relationship was characterized as genuine, caring, founded on mutual respect and inclusive of family as the unit of care. 19 Exemplary relationships are characterized by nurses’ abilities to see patients as persons, by the ability to generate meaning for both patients and nurses, 33 and by a duty of promise-keeping or faithfulness. 34 Without coming to a position, Wurzbach discussed the implications of nurses being the ones who ‘stay with patients’ 35 during the dying process. Furthermore, nurses are viewed as ‘chief witnesses’ 19 in that they can understand the context within which patients make medical decisions 19 , 36 and so can advocate on behalf of their patients to the larger team. 19 , 36 However, this unique relationship was seen to have unique challenges in the context of euthanasia. Young, 37 citing Jameton, 38 described this as the ‘nurse in the middle’ (p. 12) phenomenon whereby nurses have a responsibility for care that does not match their power to influence decisions about care. In the context of euthanasia, she acknowledged the paradox that although nurses do not order medication for symptom management, they are in the position of delivering and titrating that medication to alleviate suffering. A nurse in the middle may be the ‘chief witness’ 19 to suffering without the means to relieve that suffering. As such, euthanasia may have unique moral implications for nurses. The acknowledgement of this special relationship between nurses and patients was used to argue both for 30 , 36 and against 19 , 33 euthanasia.

The third assumption in this body of literature was the potential impact that engaging in euthanasia could have on the nursing profession and on nurses’ personhood. In her argument for euthanasia, Young 37 suggested that a nurse’s integrity is an essential part of professional practice. As such, nurses must do the difficult work of examining ‘competing demands carefully and making decisions that are congruent with their personal beliefs and within professional guidelines’ (p. 12). Beyond that, she argued that professional integrity must support patient self-determination and hence, requests for euthanasia. In contrast, Zimbelman and McCabe 39 argued that professionalism means much more than simply supporting autonomy through state-enacted legislation. Arguing against euthanasia, Zimbelman suggested that nursing is a social institution whose ‘power, status, [and] role’ (p. 164) in society must transcend both individual interests of its practitioners and private choices of patients. 40 Without arguing a position in relation to euthanasia, other authors suggested that euthanasia may have consequences that could exacerbate the sense of failure and loss that nurses often feel after a patient death, 41 or harm nurses if their values and beliefs are challenged or ignored, 21 which in turn, can affect the nature of the nurse–patient relationship.

Ethical principles, concepts and theories

Eighteen articles drew upon ethical principles, concepts and theories to provide arguments for or against the ethical permissibility of euthanasia in the context of nursing practice. The majority of articles grounded ethical arguments and discussions in one or more of the four main tenets of biomedical ethics: autonomy, beneficence, nonmaleficence and justice. 42 Four authors argued in support of euthanasia, six were in opposition and the remaining eight authors took no position. Articles that provided a descriptive overview will be addressed first, followed by articles that argued using principle-based ethics and finally, articles that drew upon ethical theories, such as consequentialism, virtue ethics, relational ethics and care ethics.

Four articles addressed focused ethical questions by providing a descriptive landscape of the ethical principles, concepts and theories that are being discussed in the existing literature on euthanasia in the context of nursing practice. 43 – 46 Interestingly, the majority of arguments raised within this body of literature presented what Snelling 47 would call ‘intuitive arguments’; opinions related to ‘feelings’, such as mercy, ‘understanding that sometimes death is preferable to life’ (p. 352), respecting autonomy, and, conversely, ‘the feeling that it is wrong to kill’ (p. 352). All four articles incorporated – to varying degrees – Beauchamp and Childress’ 42 principles for biomedical ethics into their respective discussions on euthanasia from a nursing perspective. In two of the four articles, the main tenets of biomedical ethics were presented in a way that elucidated the tension and malleability that exists within and between the principles. 43 , 46 For instance, Benedict et al. 43 highlighted the tension that exists between respecting an individual’s autonomous decision to request euthanasia and upholding one’s professional duty to prevent harm. Other ethical issues raised included arguments related to ethical concepts, such as the sanctity of life, quality of life, suffering, pain management and the ‘slippery slope’. i , 44 , 45

Nine articles drew upon principles of biomedical ethics to construct arguments for and against the justification of euthanasia in the context of nursing practice. Most often, arguments in favour of euthanasia were grounded in rights-based language; for example, the ‘right to die’, the ‘right to self-determination’, 48 or the ‘right to die with dignity’. 49 A number of authors argued that upholding an individual’s right to die fosters human flourishing and in turn, facilitates a dignified and autonomous death. 21 , 48 , 50 , 51 These arguments can be summarized by the perspective that respect for persons requires respect for individuals’ autonomous decision-making. 21 Such arguments are predicated on the belief that individuals’ ‘own’ their death, just as they have ‘owned’ their life. 21 , 50 , 51 For instance, Farsides 51 argued that requests for euthanasia are not an indication of failure of healthcare professionals’ abilities to provide care, but rather an expression of autonomy or the right of an individual to make a ‘choice that they consider consistent with the person that they are and the life that they have led’ (p. 104). However, despite a firm commitment to upholding patient autonomy, a number of authors acknowledged and indeed emphasized, that the principle of autonomy ought not to be considered in isolation, such that it is seen without any limits. 21 , 50 For example, Begley, 50 as well as Kopala and Kennedy, 21 emphasized that, in upholding a patient’s autonomous decision to participate in euthanasia, the autonomy of the healthcare provider who is involved in caring for that patient must also be respected. As Begley 50 stated, ‘…consenting adults should not be prevented from availing themselves of beneficent voluntary active euthanasia if another consenting [emphasis added] adult (a medical doctor) is available and capable of carrying out their wishes’ (p. 224). This perspective takes into consideration that the involvement of at least one other person is required should an individual seek to end his or her life through euthanasia. 52

Conversely, a number of authors provided arguments in opposition to euthanasia, using the principle of autonomy to highlight their view that other biomedical principles, such as nonmaleficence and beneficence, 21 , 53 , 54 can outweigh an individual’s claim to self-determination. For instance, in an argument against the absolutism of autonomy, and in particular, against obligations to always fulfil autonomous requests, Friend 53 argued,

[i]ndividual autonomy is not a supreme ethical doctrine and does not deserve to be weighted more heavily than the physician’s duty to ‘above all do no harm’. Although respect for patient self-determination is important, especially when deciding to withhold and withdraw life-sustaining treatments, it does not mandate a right that others help them end their lives. (p. 115)

As reflected in the passage above, arguments against the absolutism of autonomy were often grounded in the assumption that individuals exist, and indeed, thrive, within a constellation of relationships. 21 , 53 , 55 Following this line of reasoning, an individual’s decision to pursue an euthanasia significantly affects those around them and, as such, ‘…cannot be a purely private decision’ (p. 23). 21

Kopala and Kennedy, 21 Kowalski, 29 and King and Jordan-Welch 54 put forth arguments which refuted the claim that requests for euthanasia are part of a truly autonomous and rational decision-making process. For example, instead of seeing requests for euthanasia as extensions of a patient’s right to self-determination, King and Jordan-Welch argued that an individual’s true autonomy is upheld when nurses help patients to find meaning in life even in times of suffering and when nurses explore questions such as ‘why is the patient asking for assistance in dying?’ (p. 52). 54

Five articles drew upon ethical theories to discuss euthanasia in the context of nursing practice. Two authors raised consequentialist arguments. 47 , 56 Snelling 47 discussed the contradictory nature of absolute deontological positions (i.e. referring to the law in the United Kingdom), which claim that consideration of consequences cannot justify killing in the form of euthanasia because it is always morally wrong to kill an innocent life. In particular, he contended that the credibility of the prohibition against euthanasia depends on distinguishing it from other legally and morally sanctioned end-of-life care practices (i.e. omissions, refusal of extraordinary measures or letting die). These distinctions depend on consequentialist considerations so it is inconsistent to claim that the prohibition on euthanasia cannot consider consequences. Snelling 47 argued that just as increased doses of opioids (at levels that are potentially life-shortening) can be morally and legally acceptable under certain conditions, so might be an injection of potassium chloride (i.e. a lethal injection). In each circumstance, the consequences have been weighed, a thoughtful decision to shorten the individual’s life has been reached, and in the end ‘the consequences are the same’ (p. 356). 47 In contrast, Praskwiecz 55 focused on the sub-category of assisted suicide, which she defines as requiring ‘both patient request and patient action’ (p. 37), to contrast to some forms of euthanasia. She 55 contended that some moral justification for assisted suicide might be provided by act utilitarianism – a consequentialist theory whereby the consequences of an action are weighed in the context of a particular situation. Praskwiecz 55 argued that, because the consequences of legalized assisted suicide are difficult to fully understand and predict, rule utilitarian analysis cannot determine whether legalization would lead to ‘maximum balance of good over evil’ (p. 38) 54 , 55 and, thus is ethically unjustified from a rule utilitarian perspective. Praskwiecz 55 further argued that assisted suicide could not be justified by Kantian or natural law theories, and concluded that nurses should focus on other approaches to improving end-of-life care.

From another ethical perspective, Begley 57 suggested that, in comparison to a strictly principled approach to analysis, a virtue ethics approach to analysing euthanasia widens the field of moral appraisal. Indeed, she argued that in virtue terms, euthanasia facilitates ‘eudaimonia (living well, flourishing) because dying is a life event, and not dying well frustrates the goal of flourishing and well-being for both client and professional’ (p. 441). 57 In a different, albeit not entirely unrelated argument, Rich and Butts 58 suggested that coherence in ethical positions opposing and supporting euthanasia can be achieved through an ethic of care. In opposition to a more legalistic approach inherent in absolutist principles, an ethic of care invites nurses and other healthcare providers to consider ‘where boundaries lie in the imposition of one’s morality on others’ (p. 275) 58 when we ‘care’ for another person. For instance, if the act of caring involves ‘feeling with’ the other (Noddings, 59 as cited in Rich and Butts), 58 euthanasia can be ethically justified if the actions of the individual requesting aid in dying are rational and do not infringe on the rights of others. 58 Finally, in an application of the four core elements of relational ethics – mutual respect, engagement, environment and embodiment – Thiele and Dunsford 26 argued not about the ethical or moral permissibility of euthanasia, but rather, how relational ethics can provide nurses and nurse leaders with a framework for thinking through the moral complexity that has accompanied the legalization of euthanasia in Canada. 24

Moral consistency

Seven articles examined the ethical permissibility of euthanasia from the perspective of moral consistency across acts. Such arguments sought to elucidate the moral difference, if any, between one practice and another related practice. Five authors sought to clarify the moral distinction between a ‘passive’ and ‘active’ euthanasia through an examination of the role of causation, and more specifically, the philosophic differences between ‘killing’ and ‘letting die’, 41 , 47 and in some cases, using the acts and omissions doctrine. 47 , 52 , 60 , 61 In addition, a number of authors examined the role of intention – either in isolation or alongside other arguments. 47 , 52 , 56 , 61 From the standpoint of consistency (i.e. if one type of euthanasia is ethically justified, then why isn’t the other), five of the seven authors argued in support of euthanasia, one author argued against and another author did not take a position on the topic.

Several articles sought to elucidate the moral difference between ‘killing’ versus ‘letting die’ 47 , 62 , 41 or, as Dines 60 refers to it, ‘killing’ versus ‘going along with nature’. Such arguments often centred on the ambiguous nature of what ‘letting die’ or ‘going along with nature’ entailed, and in particular, how it is morally distinct from an act that also causes death, albeit in a more direct way. For instance, Dines 60 argued that the moral distinction between causing death and ‘going along with nature’ is not a ‘water tight barometer of moral acceptability’ (p. 914), and that if it were, then many attempts to redress suffering (i.e. pain and symptom management) would be immoral as a result of their unnatural interference with the dying, or indeed living, process. Kuhse 62 argued to a similar position; however, she arrived at more of a direct conclusion,

you may refuse treatment and then ‘nature’ will look after the rest – you will be dead in a few hours, a few days, or at the very latest in a few weeks, [this] is an approach unfit for a humane and rational society. It imposes on those patients a mode of dying that they find unacceptable, much unnecessary suffering, and all that for no good reason. (p. 12)

Several authors situated the ‘killing’ versus ‘letting die’ argument within the acts and omissions doctrine. 63 Central to this doctrine is the belief that sometimes we are morally less responsible for our omissions – our failures to take action – than we are for our actions. 64 Central to this debate is the question of if you consider an action and do not act, is that then an omission or an action? Four authors examined the validity of the ethical and moral arguments inherent in the acts and omissions doctrine. 47 , 52 , 60 , 61 For instance, through the evaluation of three different approaches to one case-based scenario, Begley 50 questioned whether there is a morally significant difference between an act and an omission. She argued, much to the same conclusion as Dines 60 and Moody, 61 that if the initial and end states of the patient are the same (i.e. they are dying (initial); they are dead (end)) and that the actions or inactions of the healthcare provider are what rendered the patient into that end state, then what is the morally significant difference between an act and an omission? The argument here is that because the beginning and end states are the same, and the healthcare provider is the agent involved in the intervening performance, then the healthcare provider is the ethically responsible agent. Begley, 50 Dines, 60 and Moody 61 all argued that the acts and omissions doctrine does little to clarify a moral distinction between an act and an omission, thereby failing to distinguish a morally significant difference between passive euthanasia and active euthanasia on the sole basis of causation. This conclusion was later echoed by Snelling, 47 who, like Moody, 61 argued that in practice it may also be difficult to differentiate between acts and omissions. For instance, Snelling 47 illustrated how the removal of a feeding tube can be regarded as both a case of passive euthanasia (i.e. withdrawing care; ‘letting die’) and a case of active euthanasia (i.e. ‘killing’). This would lend further support to the need for moral consistency across practices for, as Moody 61 pointed out,

it is apparent that omissions can be just as effective as actions in terms of bringing about change…(t)he fact that one response was passive and the other active seems to have little bearing on the moral assessment of the situation. (p. 913)

Indeed, should a moral distinction exist, additional factors, such as the role of intention, must be taken into consideration.

Four authors examined the role of direct versus indirect intention, and more specifically, the doctrine of double effect. 47 , 52 , 56 , 61 The doctrine of double effect seeks to describe the circumstances in which harmful actions (or omissions) are permitted ‘in the overall pursuit of good’ (p. 355). 47 However, in order to satisfy these requirements – so as to justify the ‘two effects of one act (or omission)’ (p. 870) 52 – the following conditions must be met:

1. The action itself must not be intrinsically bad; 2. The good effect must not be a direct consequence of the bad effect; 3. The good effect must be ‘directly intended’; the bad effect only ‘indirectly intended’, or ‘tolerated’; 4. The good effect must be equal to or greater than the bad effect. (p. 85) 65

This would be exemplified by the nurse who provides large doses of opioids to manage pain, but through that act unintentionally hastens death. In the context of this body of literature, Goodman 56 argued that the intent to kill inherent in euthanasia is not only what makes it a morally unacceptable choice but also what makes it morally distinct from actions sanctioned under the doctrine of double effect. However, Begley, 50 Moody, 61 and Snelling, 47 argued that the morally significant difference between direct and indirect intention is not easily identifiable if both acts lead to death. In defence of moral congruence, Snelling 47 suggested that the doctrine of double effect ‘allows us to deflect moral criticism and legal redress by arguing that we did not intend the death’ (p. 355), thus encouraging a particular type of hypocrisy. The argument that there is no morally significant distinction between direct and indirect intention or causation is a rejection of the doctrine of double effect as a valid ethical principle.

Nature of the social good

Six articles raised ethical questions in relation to the possible impact that the legalization of euthanasia might have on society more broadly. By ‘social good’, we are referring to what is perhaps more commonly known as ‘the common good’: ‘those facilities – whether material, cultural or institutional – that the members of a community provide to all members in order to fulfill a relational obligation they all have to care for certain interests that they have in common’ (para. 1). 66 Four of the six articles argued against euthanasia based upon the nature of the social good, while two articles did not take a position on the topic.

Articles in this theme focused on questions such as ‘does assisted suicide harm society?’ (p. 22). 21 Central to many of these arguments was an exploration of the existing social context upon which euthanasia would be layered. For instance, authors examined how existing social fragilities, such as vulnerable populations, 21 , 27 , 46 , 67 fragmented healthcare teams, 67 threats of cost containment, 18 , 21 , 27 , 67 poor public understanding of euthanasia, 67 and perceptions of burden at the end-of-life, 21 , 27 , 67 would be affected should euthanasia be legalized. A number of articles examined the intersection of such concerns. For instance, Ericksen et al. 67 argued that in an era of cost containment, euthanasia policies put vulnerable groups, such as the disabled, women, older people and the impoverished, at an ever-heightened risk for exploitation and harm. The authors stated, ‘there is a very real danger that patients and their family members will opt for euthanasia because of inadequate resources for care rather than because of well-informed, autonomous decision-making’ (p. 32). 67 This concern for resources was echoed by Goodman 56 who situated her argument within the good of palliative care. She questioned the rightness of alleviating suffering through euthanasia when many patients and families do not have access to high-quality palliative care or understand its goal of improving quality of life. Throughout these articles, there was a recognition of the complexity of interacting factors that would ultimately influence the goodness of euthanasia in a social context.

In this narrative review, we have analysed the ethical arguments surrounding euthanasia in relationship to nursing practice based upon the nature of nursing; ethical principles, concepts and theories; moral consistency; and the nature of the social good. In the literature reviewed, arguments based within the first three categories were used to argue both for and against euthanasia. The latter category of the nature of the social good contained only arguments against or reflecting no opinion towards euthanasia.

Several limitations characterize this review. In that this was a review of published papers that asked and answered a focussed ethical question, there was no attempt to formally evaluate the overall robustness of this body of literature, although papers without a focussed ethical question were excluded from the review from the outset. Furthermore, only English language literature was reviewed. Another limitation of this review stems from our decision to not differentiate in the analysis between articles that addressed physician-assisted suicide from those that addressed euthanasia. One could argue that the ethical issues surrounding a clinician-administered death (euthanasia) might be quite different than a client-administered death (assisted suicide). To aid the reader in deciding whether this is relevant, we have included relevant definitions in the data extraction table. Interestingly, we were unable to locate any articles originating from the Netherlands, Belgium or Luxembourg. This may have been related to our search strategy that included only articles that had an explicit nursing focus.

Finally, we found a relative paucity of literature that addressed the ethical issues surrounding euthanasia in the context of nursing practice, a disproportionate number of articles published from the United States, and a surprising paucity of recent publications. These findings could be related to the perception that nursing has been viewed as having a limited role in euthanasia and, hence, the idea that debating the moral permissibility of the act is outside of the concern of nurses. However, evidence of the importance of the nursing role, particularly in dealing with those preliminary requests for euthanasia, has been well documented in the literature. 7 , 68 – 71 The disproportionate ethical debate generated out of the United States may also be related to the American Nurses Association’s definitive stance against euthanasia. 72 It is understandable that this definitive stance would have generated substantial ethical debate, considering client-administered euthanasia has been legal in a number of states for many years and is currently under consideration for legalization in others. The somewhat dated nature of many of these articles may not necessarily reflect current debates, particularly as it relates to the social good, which is largely context dependent.

The apparent lack of ethical debate from a Canadian perspective is more intriguing. Public advocacy in favour of euthanasia had been developing within Canada for many years prior to the 2016 legalization of euthanasia. However, early Canadian literature focusing on euthanasia was largely physician-centric and thus, nurses may not have been alerted to the implications for nursing practice. Therefore, nurses may not have fully considered the practical, ethical and philosophic implications of their role in this new practice. More recently, however, it was widely anticipated that Nurse Practitioners would play a key role, not only in assessing for eligibility but also in providing the means for clients to pursue an euthanasia. This unique role for Canadian nurses will likely generate more debate in the upcoming years.

Our goal in this article was to synthesize literature that specifically focused on the discipline of nursing in relation to euthanasia. This naturally leads to the question of how much of this literature is delineating ethical and moral issues that would be considered unique to nursing. Arguments based upon ethical principles, concepts and theories; moral consistency; and the nature of the social good are likely to be relevant across practice-related healthcare disciplines. Furthermore, the arguments put forward in relation to euthanasia are ones that apply to many healthcare situations encountered by nurses. But what about those arguments based upon the nature of nursing? One might argue that assumptions about nursing’s moral ontology could be applied to any discipline that might hold similar values (e.g. compassion, dignity). Likewise, arguments related to the impact that engaging in euthanasia could have on nursing and nurses could be applied just as well to medicine. However, the nature of the nurse–patient relationship may raise unique issues. For instance, nurses bear the responsibility of being the care providers who are closest to patients, witnessing the day-to-day experiences, and at times, suffering, of their patients. Yet, they often hold little power to influence the care decisions that shape these experiences. Particularly in the context of euthanasia, where suffering is a key concern, this places nurses in a unique social location. As such, we can expect that ethical and moral concerns of special interest to the discipline may arise. Further study of these concerns is important.

In conclusion, despite the relatively small volume of nursing-specific literature identified, the breadth of perspectives in argumentation was impressive. Disciplinary philosophical arguments, ethical principles, concepts and theories, as well as social justice arguments were all used to explore the ethical and moral implications of euthanasia for nursing. Likewise, the relative balance between supportive, opposed and no opinion provided diverse viewpoints upon which nurses can reflect. Taken together, this literature provides a fulsome range of positions for nurses to consider as they reflect on their role, both as individuals and as a discipline, in relation to euthanasia. While not neglecting traditional biomedical ethics, these articles challenged nurses to look beyond biomedical ethics to other questions relevant to the discipline of nursing. Is there something about the relationship between nurses and their patients that influences the moral acceptability of euthanasia? How does nursing’s location in an institutional and social hierarchy, and the social privilege accorded to nursing in our society, influence nurses’ considerations of social good beyond autonomy? From an individual perspective, does these articles support nurses to become morally consistent in our end-of-life nursing practices? In a related paper, we discuss some of the factors for nurses to consider as they engage with questions about their participation in euthanasia, factors such as their intuitional responses, the relational impacts of their decisions and their moral coherence with similar end-of-life decisions. 73 Wrestling with questions such as these will provide important intellectual substance for nursing’s ongoing dialogue around its particular relationship with euthanasia. Articles identified within this review provide a range of arguments from a variety of perspectives for nurses to consider as the development of euthanasia continues to unfold within the international context.

Supplemental material

i ‘Slippery slope arguments, which are regularly invoked in a variety of practical ethics contexts, make the claim that if some specific kind of action (such as euthanasia) is permitted, then society will be inexorably led (“down the slippery slope”) to permitting other actions that are morally wrong’ (Benatar, 2011, p. 206).

Authors’ note: Carol Tishelman is also affiliated with the Centre for Rural Medicine, Storuman Sweden and Stockholm Health Care Services, Stockholm Sweden.

Conflict of interest: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project is supported by a Canadian Institutes for Health Research Project Grant PJT-376065. Barbara Pesut is supported, in part, through the Canada Research Chairs Program.

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Supplemental material: Supplemental material for this article is available online.

Contributor Information

Sally Thorne, The University of British Columbia, Canada.

Janet Storch, University of Victoria, Canada.

Michael Burgess, University of British Columbia, Canada.

Carol Tishelman, Karolinska Institutet, Sweden.

Kenneth Chambaere, Vrije Universiteit Brussel; Belgium Ghent University, Belgium.

Robert Janke, University of British Columbia, Canada.

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

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  4. Euthanasia Case Studies and Corresponding Worksheet for Medical Ethics

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COMMENTS

  1. A case for justified non‐voluntary active euthanasia: exploring the ethics of the Groningen Protocol

    First, the paper will attempt to disabuse readers of this erroneous understanding of the Groningen Protocol by showing how such a policy does not aim at making quality‐of‐life judgements, given that it restricts euthanasia to suffering and terminally ill infants.

  2. The Logical Link Between Voluntary and Non-voluntary Euthanasia

    I. Introduction Voluntary euthanasia (VE) is the intentional shortening of a patient's life by a doctor at the patient's request in order to end the patient's suffering. Physician-assisted suicide (PAS) is the intentional assistance by a physician in a patient's suicide in order to confer the same benefit.

  3. Legalizing euthanasia or assisted suicide: the illusion of safeguards

    1. INTRODUCTION Euthanasia is generally defined as the act, undertaken only by a physician, that intentionally ends the life of a person at his or her request 1, 2. The physician therefore administers the lethal substance. In physician-assisted suicide ( pas) on the other hand, a person self-administers a lethal substance prescribed by a physician.

  4. A case for justified non-voluntary active euthanasia: exploring the

    Abstract One of the most recent controversies to arise in the field of bioethics concerns the ethics for the Groningen Protocol: the guidelines proposed by the Groningen Academic Hospital in The Netherlands, which would permit doctors to actively euthanise terminally ill infants who are suffering.

  5. A case for justified non-voluntary active euthanasia: exploring the

    Abstract One of the most recent controversies to arise in the field of bioethics concerns the ethics for the Groningen Protocol: the guidelines proposed by the Groningen Academic Hospital in The Netherlands, which would permit doctors to actively euthanise terminally ill infants who are suffering.

  6. Non-voluntary euthanasia

    Non-voluntary euthanasia is euthanasia conducted when the explicit consent of the individual concerned is unavailable, such as when the person is in a persistent vegetative state, or in the case of young children. [citation needed] It contrasts with involuntary euthanasia, when euthanasia is performed against the will of the patient.The different possible situations considered non-voluntary ...

  7. Euthanasia: Murder or Not: A Comparative Approach

    Introduction Euthanasia, i.e. mercy killing is both historical and contemporary problem of medicine, law, ethics and religion, which is reflected in the multitude of interwoven concepts and different legislative solutions of that question all over the world.

  8. The Complexity of Non-Voluntary Euthanasia

    Things are a bit more complicated when it comes to non-voluntary euthanasia (NVE). For the sake of clarification, this is deliberate and beneficent killing that is neither wholly for nor wholly against the patient's wishes - perhaps because the patient is not in a position to have any wishes on the matter.

  9. PDF The Logical Link Between Voluntary and Non-voluntary Euthanasia

    THE LOGICAL LINK BETWEEN VOLUNTARY AND NON-VOLUNTARY EUTHANASIA JOHN KEOWN* ABSTRACT. The logical "slippery slope" argument is of key relevance to ... Study in Ethics and Law (Oxford 2011), 120-27. ... The Case Against Physician-assisted Suicide: For the Right to End-of-life Care (Baltimore 2002), 17. 13 Keown, Euthanasia,67-89.

  10. The troubled 29-year-old helped to die by Dutch doctors

    Ronald Hissink/De Stentor In January a young Dutch woman drank poison supplied by a doctor and lay down to die. Euthanasia and doctor-assisted suicide are legal in the Netherlands, so hers was a...

  11. Non-Voluntary Euthanasia

    Sydney, Australia Advocates of legalised euthanasia usually insist that they only want voluntary euthanasia (VE) - they say they are as opposed to the taking of life without the subject's knowledge or consent, that is, non-voluntary euthanasia (NVE), as anyone else.

  12. Two Decades of Research on Euthanasia from the Netherlands. What Have

    Because the legalization of euthanasia in the Netherlands is the result of decades of debates, an overview is provided of the history of the Dutch debate on euthanasia, including the highlighting of some specific aspects of Dutch culture that contributed to the legalization of euthanasia.

  13. Natural Law, Non-Voluntary Euthanasia, and Public Policy

    Our case study demonstrates tha t non-voluntary euthanasia does occur and it seems that it is such a commonplace event tha t the Coroner didn' t trouble them- selves to investiga te the matter ...

  14. What people close to death say about euthanasia and assisted suicide: a

    In the UK, the issue of euthanasia has been widely debated since the 1870s, 1 and many argue that the question of the right to die has become one of the most important in contemporary ethics. 2 A House of Lords select committee recently produced a report on Joel Joffe's Assisted Dying for the Terminally Ill Bill, and recommended that, in future,...

  15. The patient suicide attempt

    In Mr Green's case, the choice of keeping secret can be classified into assisted dying. Sneesby [13] pointed that "the ethical principle of autonomy is not upheld in law regarding euthanasia and assisted suicide, 'as people do not have the right to be assisted to die at any time they choose' " (p. 456). Therefore, although Mr Green's ...

  16. Natural Law, Non-Voluntary Euthanasia, and Public Policy

    The authors examine the often emotive and politicized matter of (non-voluntary) euthanasia - acts or omissions made with the intent of causing or hastening death - with reference to Natural Law philosophy. This leads us to propose a number of important public policy remedies to ensure dignity in dying for the patient, and their associates.

  17. Involuntary Euthanasia

    Medical Ethics: Euthanasia and Assisted Suicide. J.J.Z. Polaris, L.S. Lehmann, in Encyclopedia of Forensic and Legal Medicine (Second Edition), 2016 Shifting social norms. Embedded within arguments about the sanctity of life and the risk of abuse is a concern about the 'slippery slope,' the fear that legalizing one controversial practice will eventually lead to other, more problematic ...

  18. Three euthanasia cases face investigation in Netherlands

    Senay Boztas in Amsterdam. Sun 23 Jun 2019 04.00 EDT. Three euthanasia cases involving women with psychiatric conditions and dementia are under investigation in the Netherlands, the Observer can ...

  19. PDF Euthanasia

    Case 1: Tony Bland, 1989 When doctors at Airedale Hospital in Yorkshire asked the High Court for permission to withdraw artificial nutrition and hydration from Hillsborough victim Tony Bland, his family supported the application. After the Hillsborough stadium tragedy, Tony was left in a persistent vegetative state - and hence was not legally dead.

  20. (PDF) Legalizing Voluntary & Non-Voluntary Euthanasia in the

    Non-voluntary euthanasia is when the person is unconscious or unable to decide whether one is in a coma or if one is a baby with congenital disabilities. The two types of euthanasia is practiced ...

  21. Euthanasia and assisted suicide: An in-depth review of relevant

    1. Introduction Euthanasia and assisted suicide are two topics discussed throughout history, mainly because they fall within the scope of life as a human right, which has been universally defended for many years [ 1 ]. However, the mean of the word euthanasia as good death generates conflicts at social, moral, and ethical levels.

  22. Nursing and euthanasia: A narrative review of the nursing ethics

    To be eligible for this review of the ethical literature, the article had to (1) answer a focused ethical inquiry in relation to euthanasia and (2) make explicit application to nursing practice. For example, if an author simply provided an overview of some of the ethical issues related to euthanasia, it was excluded.

  23. Euthanasia

    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.