EUTHANASIA
From Moral Issues that Divide us, by James Fieser
Home: https://storage.googleapis.com/jfieser/160/Index.html
2008, updated 9/1/2024, CC BY-NC-ND 4.0
CONTENTS
Introduction
Background
Distinctions
Three Definitions of Death
What People Think
Ethical Issues
Obligations to God in End-Of-Life Situations
Obligations to Oneself in End-Of-Life Situations
Obligations to Society in End-Of-Life Situations
The Active-Passive Distinction
Active Euthanasia and the Doctrine of Double Effect
Passive Euthanasia and Ordinary vs. Extraordinary Care
Public Policy Issues
The Legal Status of Euthanasia
Who Decides
Living Wills
The Hospice and Palliative Care Alternative
Conclusion
Study Questions
INTRODUCTION
A man named Jeff was diagnosed with stomach cancer and initially managed his illness successfully. However, after three years, the disease took a severe turn, and treatments became ineffective. In his final months, Jeff endured extreme suffering: he vomited blood, lost about half his body weight, became unable to walk, and experienced pain beyond anything he had ever known. While he was hospitalized at times, Jeff preferred to spend his remaining days at home, where his wife took on the responsibility of caring for his basic needs as he lay bedridden. A meticulous planner, Jeff anticipated the possibility of a grim end and took measures to avoid prolonged suffering. He stockpiled a lethal dose of medication and kept a loaded gun by his bed as a backup. Despite being on painkillers, his suffering became unbearable. Jeff resolved to end his life but was by then too weak to take the medication or even lift the gun. He asked his wife for help, but she couldn't bring herself to do it. Desperate, he turned to family members, friends, or anyone visiting, but they all refused, many fearing legal repercussions. In the end, Jeff died painfully at home in his bed.
Most of us hope to live long and stay healthy throughout our lives, and we might wish to die painlessly at 100 years old while still in good health. The reality of death, however, is often far less peaceful, and many people, like Jeff, die in prolonged agony from lingering illnesses. Throughout history, societies have struggled with how to address such deaths. Inevitably, the question arises: Are we morally justified in ending the lives of those suffering so intensely as a means of mercy? In recent times, this debate has centered on concepts like "the right to die" and "death with dignity." In this chapter, we will explore the options surrounding this issue and their potential moral justifications.
BACKGROUND
Moral controversies about death in situations like Jeff's usually involve three conditions: the person seeking death (1) is terminally ill, (2) is in intense pain, and (3) voluntarily chooses to end his life to escape prolonged suffering. For brevity, in the discussion below we will use the expression "end-of-life situations" to refer to cases in which these three conditions apply.
Distinctions
There are different ways to bring about the death of someone in an end-of-life situation. The first is suicide, defined as self-killing. People commit suicide for various reasons, often due to mental health issues. However, the type of suicide relevant to our discussion is one that occurs under the three end-of-life conditions mentioned earlier. If Jeff had successfully taken a lethal dose of drugs or shot himself, it would have been considered this type of suicide. There are several obstacles to this approach. One, as seen with Jeff, is that some people may lack the physical ability to carry out a death-causing act. Others may not know how to commit suicide or have access to the necessary drugs. There s also the issue of courage: overcoming the survival instinct is one of the most challenging tasks a human can face, and the mental resolve required for end-of-life suicides may be beyond some people s capacity. Some who have attempted end-of-life suicide and failed report that while they wished they had succeeded, they doubt they could find the courage to try again.
A second method is assisted death, sometimes called "assisted suicide." This involves a third party providing the resources for a person to end their own life. For example, it would have been an assisted death if Jeff's wife had handed him the pills or the loaded gun, and Jeff had used them to kill himself. The key aspect of assisted death is that the third party only supplies the means, while the person seeking death performs the act themselves. However, spouses and family members may not always be the best third parties to assist in death. Conflicts of interest can arise such as if Jeff's wife, exhausted from caregiving, wished to expedite the situation. Ideally, assisted death would occur under the supervision of a physician, who would be impartial, knowledgeable about the patient's condition, and capable of prescribing the most effective death-causing medication. This practice is sometimes called "medical aid in dying."
A third method is euthanasia, which literally means "good death" and is often defined as "mercy killing." In euthanasia, a third party directly performs the act that causes death, rather than the person seeking to die. For example, if Jeff's wife had taken his gun and shot him or injected him with a lethal dose of drugs, that would be considered euthanasia. Euthanasia can be further categorized into different types, leading to additional distinctions. The first is between active and passive euthanasia. Active euthanasia occurs when a third party deliberately takes action to cause the person's death, such as if Jeff's wife had shot him herself. In a clinical setting, a doctor might perform active euthanasia by administering a lethal dose of drugs through pills or an injection.
In contrast, passive euthanasia involves allowing the patient to die by either (1) withholding treatment entirely or (2) discontinuing treatment when it becomes futile. An example of the first type would be if Jeff, dehydrating due to his stomach cancer, was not given intravenous fluids by his physicians and consequently died. An example of the second type would be if Jeff were initially given fluids intravenously, but the treatment was later withdrawn when it proved futile, leading to his death. The first scenario represents straightforward non-intervention, while the second involves retroactive non-intervention, where physicians attempt to return the patient to their previous state by stopping the treatment. Passive euthanasia can become more complex when physicians choose not to treat a secondary illness in the patient. For instance, suppose Jeff contracted an infection that could be easily cured with antibiotics. If he took the antibiotic, he would live out his remaining weeks in pain from the cancer. However, if he did not take the antibiotic, the infection would cause his death within days due to his already weakened condition. In such a case, Jeff's doctor might hasten his death by either withholding the antibiotic treatment or discontinuing it once started.
Another distinction in euthanasia is between voluntary and non-voluntary euthanasia. Voluntary euthanasia occurs when a competent adult requests or gives informed consent for a specific death-causing action to be performed on themselves. This is the scenario we've assumed in Jeff's case: he is conscious, rational, and mentally capable of making a willful request. However, many people lack the mental competence to make these decisions, such as when they are unconscious, delirious, or suffering from dementia. In these situations, euthanasia would be non-voluntary if a third party makes the decision on behalf of the person who is to die. For instance, if Jeff had fallen into a coma, his wife might have decided to end his life. It's important to note that "non-voluntary" is not the same as "involuntary." An involuntary act is one imposed on a person against their will, such as if Jeff did not want to die and his physician gave him a lethal injection anyway. This would be a case of murder, not mercy killing. In contrast, non-voluntary euthanasia involves a patient who is unable to make a decision, and a third party steps in as a surrogate to make the choice in the patient's best interests.
Three Definitions of Death
Another crucial issue in end-of-life situations is defining death. In many non-voluntary euthanasia cases, patients are not only mentally incompetent but also so severely brain-damaged that it raises questions about whether the person is already dead. The bodies of comatose individuals can be kept alive for decades through artificial life-sustaining treatment, which seems pointless if they have crossed the line between life and death. But what exactly is that line? There are three main theories about when death occurs. The first and most widely accepted today is the neurological theory, which asserts that brain death constitutes the true death of the person. According to this view, death occurs when a person is no longer able to engage with the surrounding world, and brain death signals that this state has been reached. Individuals we consider "living" must be receptive to stimuli from their environment and capable of acting to obtain what they need. When the brain can no longer sustain these functions, we presume that the person is dead.
The second approach is the two deaths theory, which suggests that the death of a person's conscious processes is distinct from the death of their body. Essentially, this means that your brain could die while your body remains fully alive. The problem with this approach is that it is too unconventional; we do not typically think of people as going through two deaths. Throughout human history, death has been understood as a single event. While it can be challenging to define the boundary between life and death, these challenges do not justify creating a dual notion of death. The third theory is the bodily integration theory, which holds that the overall integrity of the body, rather than the condition of the brain, determines whether a person is dead. Even in brain-dead individuals, many biological functions remain active, such as maintaining body temperature, healing wounds, and fighting infections. Brain-dead individuals can grow, age, and reach sexual maturity. Given these ongoing functions, it is argued that we should err on the side of caution when considering whether a comatose person is truly dead. According to this theory, the sign of life is whether a person's body functions in an integrated way. A criticism of this theory is that mere ongoing biological activity in various cells or tissues is not sufficient to signify the presence of a living person. As the neurological theory argues, some level of interactive engagement with the outside world is necessary to designate human life.
What People Think
As a whole, the U.S. population is sympathetic to both passive euthanasia and assisted death, as reflected in three national surveys:
"Please tell me whether you personally believe that in general it is morally acceptable or morally wrong. How about Doctor-assisted suicide?" (Gallup, May 2024)
Morally acceptable: 53
Morally wrong: 40
"When a person has a disease that cannot be cured, do you think doctors should be allowed by law to end the patient's life by some painless means if the patient and his or her family request it? (Gallup, May 10, 1018)
Yes: 72
No: 27
"Which comes closest to your view? In all circumstances, doctors and nurses should do everything possible to save the life of a patient. Sometimes there are circumstances where a patient should be allowed to die." (Associated Press, 5/24/2007)
Always Try To Save Life: 30
Sometimes Allow to Die: 68
"Do you think a person has a moral right to end his or her own life under any of the following circumstances?" (Pew, 11/9-27/05)
"When this person has a disease that is incurable"
Yes: 53%
No: 39%
"When this person is suffering great pain and has no hope of improvement"
Yes: 60%
No: 34%
"When this person is an extremely heavy burden on his or her family"
Yes: 29%
No: 62%
"When this person is ready to die because living has become a burden"
Yes: 33%
No: 58%
Note the discrepancy between the first two questions, where the first asks a moral question and the second a legal question on the same issue of assisted death. In the first, there is a significant degree of moral ambivalence among the public concerning doctor-assisted suicide. While a slight majority finds it morally acceptable, a substantial minority still views it as morally wrong. This split implies differing personal convictions regarding the sanctity of life and the autonomy of individuals in making end-of-life decisions. However, in the second question, the question shifts from general moral beliefs to specific legal scenarios, such as whether doctors should be allowed by law to end a patient s life at the patient s and their family's request. Here support increases significantly. This suggests that while the concept of assisted suicide may be contentious in abstract moral terms, people are more supportive when considering practical situations where the patient is suffering from an incurable disease.
The data also shows that a strong majority believes there are circumstances where a patient should be allowed to die, rather than pursuing every possible life-saving measure. This reflects a broader acceptance of the idea that prolonging life at all costs is not always desirable, especially in cases where quality of life is severely compromised. However, public opinion diverges sharply when considering the circumstances under which a person might have the moral right to end their own life. While there is substantial support for allowing individuals to end their lives when facing incurable diseases or unbearable pain, there is far less support for suicide in situations where a person feels they are a burden or simply wishes to die because life has become too difficult. This indicates that while the public may sympathize with those in severe physical distress, they are less comfortable with the idea of ending life due to psychological or social pressures, such as feeling like a burden.
ETHICAL ISSUES
Since ancient times philosophers have discussed voluntary death, but usually did so with the focus on suicide, rather than euthanasia as we do today. A good example is Stoic philosophy, which defended suicide as a "reasonable departure" from this life. They argued that there are five good reasons for voluntarily ending life, which parallel five good reasons for leaving a party. As the analogy goes, party guests may depart because of the following:
1. A sudden need such as the arrival of a friend (i.e., a call to sacrifice oneself for their country).
2. Party crashers breaking in and shouting obscenities (i.e., tyrants doing them violence).
3. The food turning bad (i.e., disease obstructing the use of their body).
4. The food being eaten up (i.e., poverty).
5. The company being drunk (i.e., insanity, which is drunkenness of the soul).
[Arnim, Stoicorum, 3.768]
Of these five justifications, it is the third that pertains specifically to the end-of-life situations that concern us in this chapter, namely, disease obstructing the use of someone's body. The founder of Stoicism explicitly stated that it is reasonable to end one's life if we "suffer intolerable pain, mutilation, or incurable disease" (Diogenes, Lives, 7.1)." While Stoic philosophers typically thought of a chronically ill person ending their life entirely by their own hand, this third justification easily extends to assisted death and even euthanasia. We begin this section by considering the arguments of several classic moral philosophers on this topic. Like the Stoics, they discuss a range of reasons for suicide, but we will confine their positions to end-of-life situations where assisted death and euthanasia might also be options.
Philosophers of the past often analyzed end-of-life situations by considering whether suicide or euthanasia would violate one of three fundamental moral obligations: those to God, those to oneself, or those to other people. We begin with moral obligations to God.
Obligations to God in End-Of-Life Situations
The standard position on obligations to God in end-of-life situations was expressed 2,500 years ago by Pythagoras, the Greek philosopher and mathematician, who stated: "we are forbidden to abandon our station or post of life without the orders of our commander, that is of God" (Cicero, On Old Age). That is, like soldiers, we are duty-bound to the life that God has assigned to us, and are not permitted to depart by taking our own lives. Plato echoes this view using the metaphor of a prisoner:
There is a doctrine of the mystics that we are in a kind of prison and must not free ourselves from it and escape. This is a great mystery which I do not quite understand. Yet I too believe that the gods are our guardians, and that we are a possession of theirs. . . . [Plato, Phaedo, 62b]
Like prisoners, we are confined by the life that the gods assign us, and are not free to depart from it through voluntary death. With yet another metaphor concerning property ownership, Plato asks us to imagine that one of our possessions, such as an ox or donkey, took the liberty of ending its life without our permission. Surely, he argues, we would be angry at the animal and would want to punish it if we could. By analogy, we are the property of the gods and they would be unhappy if we intentionally ended our lives. We find one more metaphor in Thomas Aquinas (1225-1274) who holds the same view: "whoever takes his own life sins against God, just as he who kills another's slave sins against that slave's master. . . for it belongs to God alone to pronounce the sentence of death and life" (ST 2.2.65.5). Of these various metaphors, it is the one of the duty-bound soldier that has resonated through the millennia, and is used in debates even today. But whether we view God as our commanding officer, prison warden, owner, or master, the point is the same: my life does not belong to me but rather to God, and what I can do with my life is subject to his special authority. God assigns particular tasks and obligations to me that I must carry out, where some are pleasant and others unpleasant. But at no point am I authorized to end my own life, regardless of how unpleasant things get, since that decision rests with God alone.
Against this argument, David Hume suggested an alternative view of what the divine being expects of us. God is not our commanding officer, but instead takes a completely hands-off approach to governing the world, and does not micromanage anything that happens in our lives. God established general laws of nature to regulate the physical events of the world, and left it to us to navigate our way through life with the use of our human minds. Our normal human activity involves imposing our own purposes on the physical world, such as when we alter the flow of a river. Now, according to Hume, suicide is just another situation in which we alter the physical world for our own purpose, specifically our physical bodies. He writes, "It would be no crime in me to divert the Nile or Danube from its course, were I able to effect such purposes. Where then is the crime of turning a few ounces of blood from their natural channel?" ("Of Suicide"). We might think that taking our own lives is different than changing the flow of a river, and God has reserved the former right especially for himself. But, Hume argues, if determining the time of death is entirely up to God, then it would also be wrong to lengthen our lives, such as through medicine: "it would be equally criminal to act for the preservation of life as for its destruction." Further, he argues, the causes of human death are seemingly arbitrary and insignificant: the most trivial thing can end our lives, such as a hair or fly that carries a disease. It is absurd to say that through our own human choice we cannot rightfully "dispose of what depends on such insignificant causes". Thus, for Hume, we do not violate any obligation to God by ending our own lives.
So, who is right, Pythagoras or Hume? That is, does God have ownership of our lives and command what we do, or did God hand over authority of our lives and actions to us? This question cannot be answered impartially, but depends on one's faith tradition. Hume himself was not a religious believer, and his conception of a hands-off God does not match up with any traditional religious system. For traditional believers, it is Pythagoras's view of divine authority that makes sense, which means that suicide, assisted death and active euthanasia are morally impermissible.
But what about passive euthanasia, which is less controversial than active euthanasia: might that practice be permissible under the traditional Pythagorean view? American legal scholar Simeon E. Baldwin argued that it is. Baldwin accepts that each person is placed on earth just as a soldier is at a post of duty until relieved by his commanding officer. Accordingly, suicide is impermissible, regardless of how empty and burdensome life may have become. If a recovery is possible, he argues, all means to that end should be exhausted. However, if it is not possible, then to keep the suffering person alive through medical means "is simply to prolong a useless struggle at the cost of misery to the patient, and to the profit of no one but the doctor and the nurse." The dying person is not "bound by any rule of religion or law of conduct" to take such action, and the will of God is expressed through the direction that nature has taken: "The call has come. The sentry is to be relieved". Baldwin's reference to the "sentry" makes it clear that he is specifically referring to the Pythagorean metaphor of God as our commanding officer. Baldwin also makes it clear that he is referring only to people in hopeless conditions:
I am thinking of the victim of a cancer which has pursued its way to the verge of some vital organ; of the sufferer from consumption [i.e., tuberculosis], worn to a shadow of his former self; of him whom, as we say, the doctors have "given up," and who is simply lingering on the brink of a kindly grave . . . . [H]e has, it seems to me, the right to reject such aids to the continuance a little longer of a life that has no remaining value. ["The Natural Right to a Natural Death," Journal of Social Science, 1899, 37]
He argues further that this same rationale applies to newborns with severe defects who, without medical intervention would live only a few days or weeks, and, with intervention, would be condemned to a life of misery. If the child himself could "be consulted, he would surely say, 'Leave me to my God'."
Thus, for Baldwin, passive euthanasia with both adults and infants is consistent with our obligation to God. Whether Baldwin is correct is again a question for one's faith tradition. But, unlike Hume, Baldwin holds to a conception of God that is actively involved in human affairs and authorizes when each of our lives should end. This will appeal more to traditional believers than Hume's view.
Obligations to Oneself in End-Of-Life Situations
We next consider whether voluntarily ending one's life violates our obligation to ourselves. Today we do not often think in terms of moral obligations that I might have to myself, irrespective of any obligations that I might have to God or other humans. In past centuries, though, this was an integral part of morality, and moral theories commonly held that I have obligations to myself to increase my knowledge and develop skills. The question now is whether voluntarily ending my life violates a similar obligation to myself. Aquinas argues that it is indeed wrong since it is contrary to self-preservation and the natural life asserting purpose embedded in human nature. Morality, for Aquinas, is grounded in "that which we naturally seek after", and we look to our natural human inclinations to see exactly what that is. We have, for example, natural inclinations to shun ignorance and educate our offspring, and, consequently, these become our moral obligations. At the top of the list of our fundamental natural inclinations is self-preservation:
every substance seeks the preservation of its own being, according to its nature. Because of this inclination, whatever is a means of preserving human life, and of warding off its obstacles, belongs to the natural law [Summa Theologica, 2.1.94.2]
Aquinas describes this drive for self-preservation as a type of self-love by which we resist deterioration and annihilation as much as possible. Suicide, then, is contrary to the natural inclination that "every man should love himself" (Summa Theologica, 2.2.65.5).
Immanuel Kant (1724-1824) offers another self-preservation argument against suicide. While Aquinas links self-preservation with natural law, Kant sees it as a necessary consequence of our inherent value as rational beings. Unlike animals which are driven by mere instinct, I as a human have the capacity to make rational free choices, and by doing so I can fashion the world around me in creative and beneficial ways. In Kant's words, I am an "end in itself", and not a mere means to an and like some object or animal. In this manner, my human life is a "holy trust" that I cannot violate. If I kill myself, I am abandoning my humanity and turn myself into a mere object to be used and abused. "The rule of morality," Kant says, "does not allow suicide under any condition because it degrades human nature below the level of animal nature and so destroys it" (Lectures on Ethics). As such, self-preservation is our highest obligation, and that must govern the way we treat our bodies. If my injured foot threatens my life, I can have it amputated and preserve my life by doing so. In that situation, I have the right of disposal over parts of my body. But if I end my life, I am robbing myself of my person, not preserving it. Even in end-of-life situations where I am in great misery, I still cannot abandon my humanity and the holy trust of my life. Kant writes,
If someone destroys himself in order to escape from painful circumstances, he uses a person merely as a mean to maintain a tolerable condition up to the end of life. But a man is not a thing, that is to say, something which can be used merely as means, but must in all his actions be always considered as an end in himself. [Groundwork, 2]
Hume again objects to these types of arguments against suicide from obligations to oneself. Many suicides, he maintains, are done for good personal reasons that are consistent with moral obligations to oneself: "age, sickness, or misfortune may render life a burden, and make it worse even than annihilation" ("Of Suicide"). Yes, the instinct to survive is incredibly strong, and, following Kant, so too is our sense of the inherent value of human life. But, as Hume argues, this only shows that in some situations the motivation to die is so powerful that it overcomes the natural fear of death. People just do not throw away their lives while they are worth keeping, especially in end-of-life situations. Our natural horror of death is so great that "small motives will never be able to reconcile us to it." In end-of-life situations, my desire to die may very well overpower my natural instinct to survive and sense of inherent value, and my obligation to myself may rest with ending my misery. Thus, for Hume, in at least some situations suicide does not violate a moral obligation to oneself.
Hume does not explicitly state that we have a moral "right to die" in end-of-life situations; that expression did not emerge until long after his time. One of the first occurrences of the term was in a poem by African American poet Paul Laurance Dunbar titled "The Right to Die". In this he argues that human beings "who plot and plan and scheme and calculate with such shrewd wit" are sufficiently clever "to know when they have lived enough" (Lyrics of the Hearthside, 1899). In more recent times, contemporary American philosopher Joel Feinberg argues explicitly that the right to die is embedded in our fundamental right to life. He writes,
Just as we have rights to come or go as we choose, to read or not read, to speak or not speak, to worship or not worship, to buy, sell, or sit tight, as we please, so we have a right, within the boundaries of our own autonomy, to live or die, as we choose. The right to die is simply the other side of the coin of the right to live. ["Euthanasia and the Inalienable Right to Life", Philosophy and Public Affairs, 1978, 7]
According to Feinberg, then, the right to life includes my liberty to both choose to live, and choose to die if I deem that best for me. In end-of-life situations, I am morally permitted to end my life if I so choose. If my illness incapacitates me so that I cannot perform the death causing act myself, I can still waive my right to life which would in essence be "releasing at least one other person from his obligation not to kill me." In this way, the right to life entails my right to die through either suicide or voluntary euthanasia. A potential problem with Feinberg's defense of the right to die is that, if life truly is a liberty right to exercise one way or the other as we see fit, then we would be morally justified in ending our lives for temporary reasons. If I have a few exceptionally bad weeks of physical or emotional suffering and decide that life is not worth it, not only would my suicide be morally justifiable, but I could voluntarily release someone from their obligation to not kill me, and she would not be morally accountable for my death. The scope of the right to die as Feinberg presents it is thus too sweeping.
But there may be a way to salvage the right to die, and limit it to a more acceptable level by carefully examining the concept of "moral obligations to oneself" and precisely who that "self" is. Philosophers often speak about the problem of personal identity over time, and how, as the years go by, my life changes so radically that I cannot find any permanent characteristics that make me the same person at different stages. My body, my memories, my personality all change. Rather than just being one person, it seems that I am many persons over time, with one progressively morphing into the next. While we cannot solve this philosophical problem here, let's assume that, morally speaking, I am not just one person, but instead a collection of several moral persons spread over time. Thus, in the same way that I have a moral obligation to you and other people that I come in contact with, I similarly have a moral obligation to my future selves. For example, I have an obligation to become educated, work hard at my job, and stay out of jail, not just because of how these benefit me now, but also how they will benefit my future selves. For similar reasons, I should not kill myself even if life is currently bad for me, since I would also be depriving my future selves of their lives without their consent. I cannot assume that the desperation that I feel now will also be felt by my future selves, and I would be robbing them of their right to life. The situation is different, though, in end-of-life situations: if I am terminally ill, then there are no more future selves and I speak only for myself. In this circumstance, I can exercise my right to die without violating another self's right to life, and, similarly, waive someone of his obligation not to kill me. Consequently, the right to life might reasonably include the right to die, but only in end-of-life situations.
Obligations to Society in End-Of-Life Situations
We lastly consider whether suicide and euthanasia violate our obligation to society. Unlike obligations to oneself, we are much more familiar with obligations to society and other people, and this is often precisely what we mean by the term "morality". So, does voluntarily ending one's life violate our obligation to society? Again, Aquinas argues that they do. Every person is a member of the community, and not just an isolated individual existing on one's own. We each have our own jobs and social roles that we fill, the combination of which makes up our society. In a sense, each person belongs to the community and, thus, "by killing himself a person injures the community" (Summa Theologica, 2.2.65.5). Later philosophers, particularly utilitarian ones, similarly focused on the specific harms to society caused by ending one's life. This is especially clear with British philosopher William Godwin who directly links utilitarian reasoning with a prohibition against suicide:
In common with every branch of morality, it is a topic of calculation, as to the balance of good and evil to result from its employment in any individual instance. . . . We should consider that, though the pain to be suffered by ourselves is by no means to be overlooked, we are but one, and the persons nearly or remotely interested in our possible usefulness innumerable. Each man is but the part of a great system, and all that he has is so much wealth to be put to the account of the general stock. [Enquiry, 2.2]
According to Godwin, since the morality of an action is determined by weighing its good and bad consequences, even if I am suffering, it is wrong to end my life since my life has a larger social benefit to others. William Paley argues further on utilitarian grounds that, even if my particular situation appears to justify ending my life, we need to consider the negative impact that suicide as a general rule has on society (Principles, 4.3). Further, as a rule, the misery that I experience through my continued existence is outweighed by the sorrow that others would experience by my premature death. Adam Sidgwick argues further that, as a rule, permitting suicide in end-of-life situation has negative consequences on society by encouraging suicidal impulse in others and making secret murder easier (Methods, 3.11.7)
But Hume, who was also a utilitarian, has a response to this reasoning. Yes, we do have obligations to society, but they all have limits. For example, my community cannot demand that I do volunteer work every waking hour of the day, regardless of the social good that it might do. In Hume's words, "I am not obliged to do a small good to society at the expense of a great harm to myself" ("Of Suicide") That being so, he asks "why then should I prolong a miserable existence, because of some frivolous advantage which the public may perhaps receive from me?" If I am in an end-of-life situation, the good that I can do to society is very minimal. In fact, to tend to the endless complications of my terminal illness, I must resign all my social activities. "Why may I not cut short these miseries at once by an action which is no more prejudicial to society?" Thus, in end-of-life situations, the interest I have in ending my misery outweighs the few remaining obligations that I have to society. Suppose further that my end-of-life situation is so horrible that I become a burden to others by draining financial resources and requiring around the clock attention. In such situations, my decision to end my life is not only morally permissible, but it may be morally praiseworthy. In Hume's words, "my resignation of life must not only be innocent but laudable." Hume is not suggesting that I would be morally required to kill myself in this circumstance, but, rather, that it would be an act of kindness towards others that I should place in the balance when making my decision.
What can we conclude about whether suicide violates obligations to God, oneself or others? In each case the question involves the range of freedom that we rightfully have. With obligations to God, the issue is whether God has reserved for himself the decision to end my life, or, instead, has granted me the freedom to make that choice. This, we have seen, is a matter of one's faith tradition, but, following Baldwin, passive euthanasia may still be permissible. With obligations to oneself, the issue is whether I have the freedom to determine for myself the value of my own life, or whether I am constrained by some special feature of human nature, such as a natural instinct to survive or the inherent value of human life. Following Feinberg, we have seen that the right to life may entail a right to die in end-of-life situations. Lastly, with obligations to others, the key question is whether my obligation to society is more compelling than my freedom to choose my own destiny. Hume appears to have the stronger argument here, namely, that, by remaining alive in end-of-life situations, society's gain may be trivial while my loss may be potentially great.
The Active-Passive Distinction
We turn next to questions about the moral permissibility of active euthanasia, which is the most controversial of all the options in end-of-life situations. Active euthanasia is doubly controversial, since, first, it is debatable whether the patient even has the right to end his own life, and, second, a different person is now stepping in to perform the death-causing action. The distinction between active and passive euthanasia is accepted by most health care practitioners and has become the cornerstone of many debates on the morality of euthanasia. The general assumption is that actively killing someone is morally worse than passively letting someone die, and this is reflected in the amount of guilt that we might feel in each case: we would feel worse by actively killing someone rather than just allowing someone to die. But, in an influential article titled "Active and Passive Euthanasia" (1975), author James Rachels challenges this reasoning. From a strictly moral standpoint, he argues, there is no difference between the two, and since we accept passive euthanasia, we should also accept active euthanasia which is more merciful. For Rachels, the outcome of both active and passive euthanasia is ultimately the same: the death of the patient on humanitarian grounds. The difference between the two is often played up because we frequently hear of terrible cases of active killings, but not of passive killings.
Rachels explains that a common argument in favor of the active-passive distinction is that, with passive euthanasia, the doctor does not have to do anything: he just allows nature to take its course. However, Rachels responds, letting the patient die is an action that the doctor performs by not performing other actions. It is parallel to insulting someone by not shaking their hand. Suppose, for example, that a doctor let an otherwise healthy patient die who was suffering from a routinely curable illness; this would count as an intentional killing, even though it was done passively. He writes,
If a doctor lets a patient die, for humane reasons, he is in the same moral position as if he had given the patient a lethal injection for humane reasons. If his decision was wrong -- if, for example, the patient's illness was in fact curable -- the decision would be equally regrettable no matter which method was used to carry it out. And if the doctor's decision was the right one, the method used is not in itself important.
According to Rachels, not only is there no real moral distinction between active and passive euthanasia, but, by improperly creating such a distinction, we do more harm than good. Techniques of passive euthanasia prolong the suffering of the patient, since it takes longer to passively allow the patient to die than it would if active measures were taken. In the meantime, the patient is in unbearable pain. Since in either case the decision has been made to bring on an early death, it is cruel to adopt the longer procedure.
Finally, Rachels argues, the active-passive euthanasia distinction encourages physicians to make life and death decisions on irrelevant grounds. For example, Down's Syndrome infants sometimes have correctable secondary medical problems, such as having an intestinal obstruction. But decisions are made to forego corrective surgery (and thus let the infant die) simply because the parents do not want the burden of having a Down's Syndrome child. Rachels writes,
But notice that this situation is absurd, no matter what view one takes of the lives and potentials of such babies. If the life of such an infant is worth preserving, what does it matter if it needs a simple operation? Or, if one thinks it better that such a baby should not live on, what difference does it make that it happens to have an unobstructed intestinal tract? In either case, the matter of life and death is being decided on irrelevant grounds. It is the Down's syndrome, and not the intestines, that is the issue. The matter should be decided, if at all, on that basis, and not be allowed to depend on the essentially irrelevant question of whether the intestinal tract is blocked.
The active-passive euthanasia distinction merely encourages these groundless decisions. Again, Rachels's central point is that society should accept active euthanasia since we already accept so called passive approaches, and there is no legitimate moral difference between the two.
Is Rachels correct about the lack of a moral distinction between the two types of euthanasia? Maybe not, for we can think of other scenarios in which there is a noticeable moral difference between passive and active approaches to conduct. Suppose that I passively watch someone accidentally step into a mud puddle, and do nothing about it. That would be insensitive, but not malicious. Suppose instead that I actively push him into the puddle; that would be malicious, and the person would be morally entitled to sue me or have me arrested. We can think of parallel situations: A security guard passively watches someone shoplift from a store vs. actively helps him do it. A police officer passively watches an addict buy illegal drugs without arresting him vs. actively gives the addict the drugs. A teacher passively watches a student cheat on an exam vs. actively helps him cheat. These are situations in which both the passive and active conducts are morally wrong, but the active is worse. We can also think of scenarios in which the passive and active conducts are morally right, but the active conduct is in fact morally superior. For example, it is good for me to passively allow someone to borrow my tools to fix his car, but it is even better if I actively help him with the repair.
None of these examples perfectly parallel the cases of passive and active euthanasia, but they show that our moral judgments often differ based on the degree of direct involvement that we exercise in a situation. Like these examples, active euthanasia involves more direct involvement than passive euthanasia. Sometimes active involvement may make a euthanasia situation morally worse. Suppose, for example, that a newborn has a defect that if untreated would result in its death, but if treated would result in a relatively normal life. It may be wrong to passively allow it to die, but it would be worse to actively kill it. But other times active involvement may make a euthanasia situation morally better, such as by actively killing a terminally ill person whose pain cannot be adequately suppressed with drugs. This would be more merciful than having him linger in agony with a more passive approach. In a perfect world, it would be best to assess each end-of-life situation on its own merits and determine whether active euthanasia is morally preferable to passive. But in an imperfect world where we need quick rules to guide us through complex decisions, it may be best to err on the side of caution in matters of life and death, and give a default moral preference to passive euthanasia.
Active Euthanasia and the Doctrine of Double Effect
Critics of active euthanasia sometimes defend what they believe is a more blame-free way of bringing on a patient's death, and one particularly popular approach is based on the doctrine of double effect. According to this doctrine, an act of killing is justified if the death is only a side effect (or an unintended consequence that one could foresee), but is not the primary intended consequence of one's act. For example, I am justified in killing someone in self-defense since my primary aim is to protect my life, while the unfortunate yet foreseeable side effect is the death of the attacker. Thomas Aquinas, the originator of the doctrine of double effect, describes it here:
Nothing hinders one act from having two effects, only one of which is intended, while the other is distinct from the intention. . . . Accordingly, the act of self-defense may have two effects, one is the saving of one's life, the other is the slaying of the aggressor. Therefore this act, since one's intention is to save one's own life, is not unlawful, seeing that it is natural to everything to keep itself in "being," as far as possible. [Summa Theologica, 2-2, Q. 64, A. 7]
Similarly, in cases of war, an advocate of the doctrine of double effect could argue that I am justified in bombing an enemy city since my primary aim is to destroy a military base there, while the unfortunate yet foreseeable side effect is the death of some innocent civilians. Applied to the euthanasia situation, a physician is justified in administering an overdose of some pain medication to a patient if the primary aim is to relieve some ailment, while the secondary side effect is the death of the patient. The point is that, even though the physician knows with 100% certainty that the patient will die from the pain medication overdose, the act is morally justifiable since the doctor is intending only to alleviate the patient's pain, and not to kill the patient. The doctrine of double effect involves three specific conditions:
1. The act itself must be good, or at least morally neutral, independent of its consequences.
2. The agent must intend only the good effect. The bad effect can be foreseen, tolerated, and permitted, but it must not be intended.
3. The good effect outweighs the bad effect in circumstances sufficiently grave to justify causing the bad effect.
Physician Walter R. Hunter graphically describes how he applied the doctrine of double effect with the mercy killing of an AIDS patient. The patient was having difficulty breathing, and, to slow down his respiratory rate, Hunter gave him a small injection of morphine. When this had no effect, he gave him another injection, then another until his breathing reached a normal rate. However, the patient's breathing continued to drop until after several minutes he stopped breathing altogether and died. Hunter writes,
I knew that there was a slight risk of lethal side effects to the medications. But I knew that I might have to risk them, tolerate them in part or in totality if I were to attempt to ease his breathing. I did not intend for him to die, but I did intend to make his breathing easier. Had I intended the side effect of cessation of breathing, I would not have given incremental doses of medicine over time and observed his clinical response with each dose. I would have given a very large dose all at once to stop the breathing. [ "Pain Relief Promotion Act," U.S. Senate Judiciary Committee Hearing, 2000]
Accordingly, Hunter does not view this as a case of active euthanasia, but rather considers it a therapeutic treatment with the unintended (but foreseen) side effect of causing death.
A criticism of the doctrine of double effect is that a doctor cannot meaningfully separate in his mind what he "intends" from what he merely "foresees". Attempting to do so as Hunter does appears to be just verbal trickery for the purpose of making himself feel better about his action. Let's grant that Hunter intended to regulate his patient's breathing through the morphine injection. Let's also grant that he did not hope for his patient to die. Nevertheless, by foreseeing the likelihood of his death through cumulative injections, his mental state might better be described as having a regretful intention of killing the patient. That is, once he foresaw the outcome and acted on it anyway, that act of "foreseeing" transformed into an intention, albeit a regretful one. Recall the common saying that if it walks like a duck and quacks like a duck then it is a duck. Hunter's mental state and conduct bears all the indicators of active euthanasia, and an implausible distinction between "intending" and "foreseeing" does not change that fact.
Passive Euthanasia and Ordinary vs. Extraordinary Care
Let's set aside the issue of active euthanasia for the moment and focus just on passive euthanasia. We have seen that there are a variety of end-of-life situations that might involve withholding treatment. The question now is whether it is permissible to withhold any type of treatment, or whether some should never be withheld in any circumstance whatever. For example, if a person is in the final stages of cancer, is it morally permissible to withhold beverages from him and let him dehydrate to death? A common way of answering this involves distinguishing between ordinary care and extraordinary care. Generally speaking, ordinary care involves medical procedures that offer a reasonable hope of benefit to the patient but do not involve excessive pain, expense, or other inconveniences. The conservative position on this is that ordinary care should never be denied a dying patient. This is typically associated with food and water, which any patient would expect when staying in a hospital. By implication, a food tube should never be removed from a dying patient, even if the patient is in an irreversible coma.
By contrast, extraordinary care consists of procedures that are unusual, extremely difficult, dangerous, inordinately expensive, or have no reasonable hope of benefit to the patient. Because of these negative features, it may be morally permissible for physicians to forego or withdraw such procedures from dying patients. An artificial heart is a good example of this since it is accompanied with all these negative features. Thus, the distinction between ordinary and extraordinary care might serve as a practical guide to determine when passive euthanasia might be permitted.
The ordinary-extraordinary care distinction is a helpful one, but a problem with it is that it may not be easy to determine whether a given medical procedure falls into one category or the other. Artificial hearts may be an obvious example of extraordinary care, but what about respirators, dialysis machines, blood transfusions, or experimental drugs? None of these come with labels marking them as "ordinary" or "extraordinary," and with medical technology always advancing the problem of deciding is ongoing. Further, the removal of a food tube with dying patients is becoming a more common practice, and this compromises the value of the ordinary-extraordinary care distinction as a practical guide with even the most basic medical procedures. Physicians may seek guidance on these procedures from their specific hospital, but that hospital's decision would not be morally binding on similar cases in other hospitals. Thus, while the ordinary-extraordinary care distinction might offer a quick rule of thumb for morally justifying passive euthanasia, it is a relativistic one that patients, family members and physicians should recognize. That is, it is relative to the current state of technology, the procedure's current availability and expense, and the end-of -life practices of a given hospital.
PUBLIC POLICY ISSUES
Many times, our laws line up perfectly well with our moral values. Stealing is immoral, and it is also illegal. Playing tennis is morally permissible, and it is also legal. End-of-life situations, though, often involve a tension between our moral convictions and what we might want enacted into law. Many people feel that, generally speaking, active euthanasia and assisted death are morally permissible. However, because of the challenges of crafting safe public policies, these same people may feel that active euthanasia and assisted death should not be legalized, at least not yet. Thus, the political debate about end-of-life situations often focuses on the practical problems with implementing death-causing procedures.
The Legal Status of Euthanasia
In the U.S., individual states enact their own laws regarding murder and homicide, and, accordingly, it is for each state to decide for itself how to handle end-of-life situations. Passive euthanasia is legal in all states, where the medical profession itself establishes some guidelines for what types of treatment can be withheld from dying patients. As of now, though, no state permits active euthanasia, and only ten states permit assisted death, namely, California, Colorado, Hawaii, Montana, Maine, New Jersey, New Mexico, Oregon, Vermont, and Washington. Oregon was the first, and because of its uniqueness, other states look to it as a test case for what the effects of such a policy might be elsewhere. Enacted in 1994, the specific guidelines of Oregon's "Death With Dignity Act" are strict, and include the following conditions: (1) the person must be suffering from a terminal disease (with less than six months to live) and voluntarily express orally in writing his or her wish to die; (2) the person's decision must be an informed one regarding his or her prognosis and the alternatives to assisted death; (3) after the patient's initial request he or she must wait 15 days before receiving a prescription for the death-causing medication, and at that time the physician will offer the patient an opportunity to rescind the request.
Oregon keeps detailed records of the patients who avail themselves of the "Death with Dignity Act", and an annual report notes the following:
During 2023, 560 people received prescriptions for lethal doses of medications under the provisions of the Oregon DWDA, compared to 433 reported during 2022 (Figure 1). As of January 26, 2024, OHA had received reports of 367 people who died during 2023 from ingesting the medications prescribed under the DWDA, an increase from 304 in 2022. Since the law was passed in 1997, a total of 4,274 people have received prescriptions under the DWDA and 2,847 people (67%) have died from ingesting the medications. During 2023, DWDA deaths accounted for an estimated 0.8% of total deaths in Oregon. [Oregon's Death with Dignity Act: 2023 Data Summary]
Notice in the above that many people who receive prescriptions for lethal medication do not actually take it. According to the Oregon report, most patients were well-educated, insured, and enrolled in a hospice program. Among their end-of-life concerns, most indicated loss of autonomy, loss of ability to engage in enjoyable activities, and loss of dignity. About half also indicated concerns about losing control of bodily functions, and burden on family, and about a quarter noted inadequacy of pain control.
The U.S. Supreme Court addressed the issue of assisted death in two important cases. First, in Vacco v. Quill (1997), a group of physicians in New York argued that assisted death should be legally permitted throughout the country. They maintained that assisted death is essentially the same as withholding life-saving treatment (i.e., passive euthanasia), which is already legal in all states. The central issue was whether assisted death was different enough from withholding life-sustaining treatment to justify different laws. The physicians maintained that they were sufficiently similar, and, thus, current bans on assisted death were arbitrarily discriminatory. The Supreme Court disagreed and argued that the two procedures are distinct in two important ways. First, the causes of death are distinct from each other: "when a patient refuses life sustaining medical treatment, he dies from an underlying fatal disease or pathology; but if a patient ingests lethal medication prescribed by a physician, he is killed by that medication." Second, the physician's intentions differ in the two procedures: when withholding life sustaining treatment, the intention is "to cease doing useless and futile or degrading things to the patient," but with assisted death, the intention is to end the patient's life. Thus, there are no grounds for legalizing assisted death nationwide based on any supposed similarities with passive euthanasia.
In the second case, Washington v. Glucksberg (1997), a different group of physicians argued that the ban on assisted death in the state of Washington violated a patient's Constitutionally protected liberty rights. The Supreme Court concluded that the U.S. Constitution's conception of liberty does not include the right to assisted death. First, they argued, there is a long history of prohibiting assisted death: "The history of the law's treatment of assisted suicide in this country has been and continues to be one of the rejection of nearly all efforts to permit it." Further, they argued, individual states have legitimate interests in preserving human life and "protecting the integrity and ethics of the medical profession," which assisted death threatens. Finally, states have an interest in "protecting vulnerable groups including the poor, the elderly, and disabled persons from abuse, neglect, and mistakes." The upshot of both of these cases is that individual states can legalize assisted death within their own borders if they so choose, just as Oregon did. However, the U.S. Constitution does not require that states do this.
Just as Oregon has become a test case for assisted death, the country of the Netherlands is being closely scrutinized for its practice of legalized active euthanasia. Famous for its liberal social policies, such as legalized prostitution and drug use, the Dutch have turned a blind eye towards euthanasia since 1973, and finally legalized it in 2002. Like Oregon's "Death with Dignity Act," Dutch laws also have a checklist of requirements that must be fulfilled before physicians can directly administer a lethal dose of a drug to their patients. The Dutch government has issued reports on the practice of euthanasia in their country, which indicate that some abuses have taken place. Most notably, some patients were euthanized or assisted in death when their suffering was only emotional, but not physical. Critics of active euthanasia in the U.S. have seen this as a warning for what might occur if the U.S. follows Dutch policies.
While the Netherlands was the first European country to allow active euthanasia, they've been joined by a few others. Belgium is one such country, and their active euthanasia laws are more lenient than those of the Netherlands. In one case, two twin brothers of 45 years old, who were born deaf, were progressively becoming blind, and they opted to be euthanized to avoid living in a condition of being both deaf and blind. In this case, while their decision was voluntary, they were not terminally ill, and their pain was emotional, not physical. Some other European countries don't go as far as permitting active euthanasia, but have legalized physician assisted death. Switzerland is the only one of these that allows outsiders to participate in the program, and this has led to a phenomenon in that country called "suicide tourism". That is, people in end-of-life situations travel to that country specifically to have a physician there assist them in suicide.
Who Decides to Pull the Plug?
Consider the earlier case of Jeff, who has fallen into a coma and been placed on life support and feeding tubes. There is no realistic hope of him recovering from the coma, and he is expected to die from stomach cancer within a few months. In this scenario, passive euthanasia could be a reasonable option, but Jeff himself would be unable to voice his preference about discontinuing the life-sustaining treatment, essentially "pulling the plug." The key question is: who should be empowered to make this decision on Jeff's behalf?
In this type of situation, the first consideration would be involving Jeff's family members, as they have the most at stake. However, they should likely not be the sole decision-makers, as their judgment could be impaired by factors like mounting medical costs and other family demands. Their desire to discontinue treatment may be colored by these practical concerns, while conversely, an unrealistic hope for Jeff's miraculous recovery could lead them to prolong treatment unnecessarily. The hospital staff and Jeff's physician would also have a voice in the decision-making process. But their judgments could also be skewed by their own agendas - for instance, a desire to free up hospital beds by hastening Jeff's death, or alternatively, an impulse to provide every possible treatment to avoid potential malpractice liability.
In cases where the family members and medical institution cannot reach an agreement, a judge may need to intervene and make the ultimate decision, either siding with the family or the hospital. The high-profile case of Terri Schiavo is a compelling illustration of this. Terri Schiavo had been in a persistent vegetative state for eight years when her husband obtained a court order to have her feeding tube removed. However, Terri's parents insisted that she was still conscious, and with the support of advocacy groups and sympathetic politicians, they fought to block the court's order. This resulted in a seven-year legal battle, until the original order to remove Terri's feeding tube was finally carried out, leading to her death.
The issue of who has the authority to make end-of-life decisions is particularly pertinent in cases involving infants born with severe deformities that offer them little to no hope of a normal, pain-free existence. For example, anencephalic infants are missing a significant portion of their brain and are often born blind, deaf, and unconscious. Decisions about withholding treatment, effectively allowing these infants to die, typically hinge on assessments of their likely quality of life. The more dismal the projected quality of life, the stronger the case for withholding treatment. However, with certain congenital conditions, it can be challenging to accurately predict the infant's ultimate quality of life. Children with Down syndrome, for instance, exhibit a wide range of cognitive abilities, from a nearly vegetative state to functionality close to normal. This variability makes it difficult to presume in advance how severely the infant's quality of life may be impacted.
In the U.S., state laws and policies vary regarding end-of-life decisions and proxy decisions. The American Medical Association (AMA) provides guidelines emphasizing the importance of patient autonomy and informed consent, advocating for clear advance directives and durable powers of attorney to guide these decisions. Hospitals typically have ethics committees or policies to assist in resolving disputes and ensuring decisions are made in the patient s best interests, adhering to both legal and ethical standards.
Living Wills
I, John Doe, hereby give these advance instructions on how I want to be treated by my doctors and other health care providers when I can no longer make those treatment decisions myself.
Agent: I want the following person to make health care decisions for me: [space provided for name, relation, and contact information].
Alternate Agent: If the person named above is unable or unwilling to make health care decisions for me, I appoint as alternate: [space provided for name, relation, and contact information]
Quality of Life: I want my doctors to help me maintain an acceptable quality of life including adequate pain management. A quality of life that is unacceptable to me means when I have any of the following conditions (you can check as many of these items as you want):
Permanent Unconscious Condition: I become totally unaware of people or surroundings with little chance of ever waking up from the coma.
Permanent Confusion: I become unable to remember, understand or make decisions. I do not recognize loved ones or cannot have a clear conversation with them.
Dependent in all Activities of Daily Living: I am no longer able to talk clearly or move by myself. I depend on others for feeding, bathing, dressing and walking. Rehabilitation or any other restorative treatment will not help.
End-Stage Illnesses: I have an illness that has reached its final stages in spite of full treatment. Examples: Widespread cancer that does not respond anymore to treatment; chronic and/or damaged heart and lungs, where oxygen needed most of the time and activities are limited due to the feeling of suffocation.
Treatment: If my quality of life becomes unacceptable to me and my condition is irreversible (that is, it will not improve), I direct that medically appropriate treatment be provided as follows. Checking "yes" means I WANT the treatment. Checking "no" means I DO NOT want the treatment.
Yes/No. CPR (Cardiopulmonary Resuscitation): To make the heart beat again and restore breathing after it has stopped. Usually this involves electric shock, chest compressions, and breathing assistance.
Yes/No. Life Support / Other Artificial Support: Continuous use of breathing machine, IV fluids, medications, and other equipment that helps the lungs, heart, kidneys and other organs to continue to work.
Yes/No. Treatment of New Conditions: Use of surgery, blood transfusions, or antibiotics that will deal with a new condition but will not help the main illness.
Yes/No. Tube feeding/IV fluids: Use of tubes to deliver food and water to patient's stomach or use of IV fluids into a vein which would include artificially delivered nutrition and hydration.
Other instructions, such as burial arrangements, hospice care, etc.:
[space provided for instructions]
Organ donation (optional): Upon my death, I wish to make the following anatomical gift (please mark one):
Any organ/tissue My entire body Only the following organs/tissues: [space provided for instructions]
The above living will is a detailed one, which in many states is a necessity rather than a luxury. A Supreme Court ruling Cruzan v. Director, Missouri Department of Health (1990), established that individual states are within their rights to require that patients have clearly articulated living wills before life-sustaining treatment can be withheld. A patient's mere verbal statement to a family member would not be sufficient. The justification for such strict standards is that we cannot assume that family members will always act to protect the patient, and, thus, "a State is entitled to guard against potential abuses in such situations."
The Hospice and Palliative Care Alternative
Hospice programs are the least morally problematic way of dealing with end-of-life situations, more so than physician assisted death and euthanasia. The aim of hospice programs is to provide a caring environment that meets the physical and emotional needs of terminally ill people as they live out their final days. Hospice programs are associated with a type of medical treatment known as palliative care, which seeks to reduce the severity of a disease's symptoms, rather than curing the disease itself. This includes reducing the suffering of dying patients, typically through pain medication, once medical treatments such as chemotherapy are deemed ineffective. Hospice programs do not provide assisted death or active euthanasia, but instead focus on improving dying patients' quality of life during their final days, often within the patient's own home.
Ira R. Byock, a physician and advocate of hospice programs, argues that health care facilities today are not equipped to compassionately deal with the ever-growing number of terminally ill people. Pain medication is inadequate, patients' preferences are not honored, and families often lose life savings to cover medical costs. Hospice programs, he argues, are an important answer to the growing problem of the terminally ill, but they are plagued by intrusive government oversight which has the effect of discouraging people from using them. Despite decades of earnest efforts to improve end-of-life care, he argues, the crisis still persists, and "the legalizing of assisted suicide represents acquiescence to failed social policies, clinical practices and woeful deficiencies in personal care and social support." The expression "Death with Dignity" as used in assisted death advocacy, conveys the idea that for elderly or ill people to remain dignified, "they need to die before becoming senile or physically dependent." Byock believes better hospice and palliative care programs will reassert "basic human values and the right of each person we serve to feel wanted, worthy and dignified through the very end of life." ("We Must and Can do Better," Health Progress, 2014).
CONCLUSION
The conservative stance regarding end-of-life situations is that all active measures to cause death are wrong and should not be legalized, including suicide, assisted death and active euthanasia. Some more moderate or passive measures are permissible, though, when it is a matter of letting nature take its course. Here are common arguments against active measures in end-of-life situations, which also apply to suicide and assisted death: 1. The wrongness of intentional killing: active Euthanasia is wrong because it is deliberate killing, and societies throughout history have condemned killing others intentionally. 2. Slippery slope: euthanasia will lead to abuses, and ultimately result in actively euthanizing people against their wills. 3. Possible recovery: Euthanasia is wrong because we cannot tell for certain if a person's condition is really hopeless. 4. No assurance of voluntariness: even if patients appear to authorize euthanasia, we cannot be sure that their consent is truly voluntary.
The liberal view regarding end-of-life situations is that individuals should be morally and legally permitted to decide whether to terminate their lives by either active or passive means. Here are common arguments for active euthanasia, which, again, also apply to suicide and assisted death: 1. Exercising Autonomy: people have a right to control their lives and choose their own means of dying. 2. Dying with Dignity: people have a right to conduct their lives with dignity and, when possible, to choose a dignifying way of dying. 3. Showing Mercy: people in end-of-life situations are typically in great pain, and our obligation to be merciful and relieve suffering requires us to end their suffering through death if necessary. 4. The Golden Rule: active euthanasia is supported by the Golden Rule, that is, if I was in an end-of-life situation, I would want someone to kill me.
On both sides of the euthanasia debate, there is sympathy for people in end-of-life situations, and a shared conviction that artificially prolonging the lives of such people is not good. Hospice programs are widely available, and passive euthanasia policies are becoming more generous. Thus, there is already much middle ground on this issue, perhaps more so than with other controversial moral issues. The critical question, though, is how we should deal with the more aggressive measures of assisted death and active euthanasia. How far should the U.S. go? As a whole, the U.S. is more conservative than the Netherlands, and it is unlikely that Dutch policies regarding active euthanasia will be duplicated in the U.S. any time soon. Further, worries about potential abuses of legalized active euthanasia are at least somewhat justifiable. If the U.S. is to move in a more liberal direction, particularly with assisted death, which seems inevitable, it makes sense to first learn from the mistakes of places like the Netherlands.
Aquinas, Thomas. 1485. Summa Theologica.
Arnim, Stoicorum.
Baldwin, Simeon E. 1899. "The Natural Right to a Natural Death," Journal of Social Science 37.
Byock, Ira R. 2014. "We Must and we Can do Better," Health Progress.
Cicero, On Old Age.
Dunbar, Paul Laurance. 1899. "The Right to Die" in Lyrics of the Hearthside.
Feinberg, Joel. 1978. "Euthanasia and the Inalienable Right to Life", Philosophy and Public Affairs 7.
Godwin, William. 1793. Enquiry Concerning Political Justice and its Influence on Morals and Happiness.
Hume, David. 1783. "Of Suicide", in Essays Moral Political and Literary.
Hunter, Walter R. 2000. "Pain Relief Promotion Act." U.S. Senate Judiciary Committee Hearing.
Kant, Immanuel. 1775-1794. "Duties Towards Animals" in Lectures on Ethics.
Kant, Immanuel. 1785. Groundwork of the Metaphysics of Morals.
Oregon. 2023. Oregon's Death with Dignity Act: 2022 Data Summary.
Paley, William. 1785. Principles of Moral and Political Philosophy.
Plato, Phaedo.
Rachels, James. 1975. "Active and Passive Euthanasia". New England Journal of Medicine. 292:78-80.
Sidgwick, Adam. 1874. Methods of Ethics.
U.S. Supreme Court. 1997. Vacco v. Quill.
U.S. Supreme Court. 1997. Washington v. Glucksberg.
STUDY QUESTIONS
Please answer all of the following questions.
1. Define suicide, assisted death, active and passive euthanasia.
2. Explain the difference between voluntary euthanasia and nonvoluntary euthanasia.
3. Define the neurological theory of death, the two deaths theory, and the bodily integration theory.
4. What is Pythagoras's view regarding obligations to God in end-of-life situations, and what is Hume's criticism of it?
5. Explain Baldwin's view regarding obligations to God in end-of-life situations.
6. What are Aquinas's and Kant's positions regarding obligations to oneself in end-of-life situations?
7. What are Hume's and Feinberg's positions regarding obligations to oneself in end-of-life situations?
8. Explain Aquinas's position regarding obligations to society in end-of-life situations.
9. Explain the utilitarian position of Godwin, Paley and Sidgwick regarding obligations to others in end-of-life situations.
10. Explain Hume's criticism regarding obligations to others in end-of-life situations.
11. What is Rachels's critique of the active-passive distinction?
12. What are the criticisms of Rachels's critique of the active-passive distinction?
13. What are the three conditions of the doctrine of double effect and what is a criticism of it?
14. What is the distinction between ordinary and extraordinary care?
15. What are the criticisms of the distinction between ordinary and extraordinary care?
16. What are the three main stipulations in the Oregon "Death with Dignity Act"?
17. What were the central issues in the Supreme Court cases on assisted death, Vacco v. Quill (1997) and Washington v. Glucksberg (1997)?
18. Explain the euthanasia policy in the Netherlands.
19. What is a living will and what was the central issue on them in the Supreme Court case Cruzan v. Director, Missouri Department of Health (1990)?
20. What are hospice programs and palliative care?
[Short Essay]
21. Short essay: pick any one of the following views in this chapter and criticize it in a minimum of 100 words. The view of Pythagoras, Hume or Baldwin on obligations to God; the view of Aquinas, Kant, Hume or Feinberg on obligations to oneself; the view of Aquinas or Hume on duties to others; Rachels's critique of the active-passive distinction; the doctrine of double effect; the distinction between ordinary and extraordinary care; the ruling in one of the Supreme Court cases on end-of-life situations.