Introduction to Ethics
Dr. Syed Nizar
1
Lecture - 8
EUTHANASIA
2
Reading
Materials
Mackinnon & Fiala(2014), Ethics: Theory and Contemporary
Issues, London: Cengage Learning. pp. 199 - 229
Lecture Outline
• History
• Meaning
• Types of Euthanasia
• Arguments for and against Euthanasia
• Ethical Theories with Regard to Physician- Assisted Suicide
History
Euthanasia has been a topic under debate within our world for many
centuries; but with medicine advancing quicker every day, euthanasia is
becoming more of a concern with society and the medical community as
well. The debate on end-of-life issues became pertinent in the late 20th
century.
In the Netherlands, euthanasia has been legal since 2002. The law in the
Netherlands stipulates that physicians must exercise “due care” in
assisting in suicide or when terminating life on request. In May 2013,
Vermont became the fourth state in the United States to permit
physician-assisted suicide, joining Washington, Montana, and Oregon—
although legal challenges remain in Montana, and the courts are still
working out the details.
In Europe, active euthanasia—where instead of simply prescribing lethal
medication, the doctor administers the lethal injection—is legal in the
Netherlands, Belgium, Luxembourg, and Switzerland. Active euthanasia is
not legal in the United States. It is considered illegal in the United
Kingdom.
Meaning
• Etymologically the word euthanasia comes from the words eu – meaning good, and
thánatos – meaning death, and it was originally defined as a calm and easy death. In
the course of time, the meaning of the term gained the connotation of ‘mercy killing’.
The Oxford Advanced Learner’s Dictionary also defines euthanasia as
‘the practice of killing without pain of a person who is suffering from
an incurable and painful disease’.
American Medical Association’s Council on Ethical and Judicial Affairs defines it as
‘the act of bringing about the death of a hopelessly ill and suffering
person in a relatively quick and painless way for reasons of mercy’.
Meaning and Aim
The meaning of the word euthanasia is this – hastening the death of those people who are
incurably/terminally ill and who experience excruciating pain or torment for the sole
purpose of alleviating the patients’ physical suffering and agony.
The motive behind euthanasia is the ultimate benefit, i.e. welfare of the patient.
Key value in assessing the morality of euthanasia: autonomy of thinking and decision-
making.
Types of Euthanasia
Criteria for differentiating different types of euthanasia:
(1) First criterion entails the expressed will of the person, i.e., this criterion is based on the consent
given on behalf of the person over whom euthanasia is to be performed.
(I) Voluntary,
(II) Non-voluntary and
(III) Involuntary euthanasia.
(2) The second criterion with respect to differentiating various types of euthanasia is based on the
distinction between killing someone and letting someone die.
(I) Active euthanasia
(II) Passive euthanasia
Types of Euthanasia
1. Voluntary euthanasia
Voluntary euthanasia is performed at the request of a patient who voluntarily expresses a
wish to die. Euthanasia is also regarded as voluntary if a person is unable to express his/her
wish to die, but who nevertheless expresses this wish.
While a person is still in good health, he/she can make a written request for euthanasia,
should he/she become incapable of expressing his/her decision to die, as well as in the
situation when he/she feels pain, or no longer possesses mental abilities, while at the same
time there is no reasonable hope of making a recovery.
Types of Euthanasia
2. Non-voluntary euthanasia
Non-voluntary euthanasia means ending the patient’s life without his/her expressed will
or permission. This happens when the patient’s consent is not available for ‘performance’
of euthanasia.
People who cannot/are not able to give their own consent include infants, who are
incurably ill or have a severe disability, as well as those people who have permanently lost
the ability to understand the decision behind euthanasia either because of an accident,
illness or old age, and also if they previously failed to requested or refused euthanasia in
such circumstances.
Non-voluntary euthanasia is also conducted when the patient’s consent arises from the
hypothetical will of that individual or from his family members. Therefore, in case of non-
voluntary euthanasia, there is no direct request for euthanasia, but the decision to
conduct/perform euthanasia is based on the assumption that this should be done.
Types of Euthanasia
2. Involuntary euthanasia
Involuntary euthanasia is performed when an individual is able to give his/her consent, but
the consent is not given – a patient is able to give the consent for his/her death, but he/she
does not give it, either because they are not even asked, or simply because they choose to
continue to live irrespective of the agonizing circumstances.
Thus, killing someone who failed to agree to be deprived of one’s own life can be regarded as
euthanasia only if the motive for killing that person is to prevent his/her unbearable
suffering.
Types of Euthanasia
Based on the criterion between the difference between killing someone and letting someone die or
between doing and not doing, between actions and omissions or lack of action, we can distinguish
between:
(I) active euthanasia
(II) passive euthanasia
(I) active euthanasia
Active euthanasia is someone’s active help in the process of dying. When action is taken towards
ending a person’s life – such as discontinuation of life-sustaining treatments, then this is
considered to be active euthanasia
(II) passive euthanasia
passive euthanasia refers to allowing a person to die. When no actions is taken to end a patient’s
then this is regarded as passive euthanasia. Passive euthanasia can only include the lack of
treatment needed to sustain life.
Difference: It is entirely one thing to switch off a person’s life-sustaining medical devices, as
opposed to unplugging devices when they are already switched off.
Types of Euthanasia (Table)
Passive euthanasia: Stopping (or not Involuntary active euthanasia is the patient being
starting) some treatment, which allows the injected with a lethal dosage of drugs by a physician
without having the patient’s consent.
person to die. The person’s condition causes
his or her death.
Active euthanasia: Doing something such Involuntary passive euthanasia is the withholding
or withdrawing of medical care to a patient without
as administering a lethal drug or using other
consent.
means that cause the person’s death.
Voluntary passive euthanasia is where the patient
Voluntary euthanasia: Causing death with actively consents for the physician to withhold or
the patient’s consent, knowingly and freely withdraw medical treatment in order to allow the
given. patient to die.
Involuntary euthanasia: Causing death in Voluntary active euthanasia or Physician-assisted
violation of the patient’s consent. suicide is the patient’s consent given to a physician
Non-voluntary euthanasia: Causing the in order to inject a lethal dosage of drugs to cause
death of a patient who is unable to consent. his or her death.
Voluntary active euthanasia or Physician-
assisted suicide: Arguments For
(1) The argument from the fundamental principle of autonomy
• Just as a person has the right to determine as much as possible the course of
his or her own life, a person also has the right to determine as much as
possible the course of his or her dying. If a terminally ill person seeks
assistance in suicide from a physician freely and rationally, the physician
ought to be permitted to provide it.
• In the context of end-of-life medical care, respecting autonomy for the dying
patient not only means honouring as far as possible that person’s choices
concerning therapeutic and palliative care, including life prolonging care if it
is desired, but could also mean refraining from intervening to prevent that
person’s informed, voluntary, self-willed choice of suicide in preference to a
slow, painful death, or even providing assistance in realizing that choice.
Arguments For Physician-
assisted suicide
(2) The argument from Relief of Pain and Suffering
• No person should have to endure pointless terminal suffering. If the physician is unable
to relieve the patient’s suffering in other ways acceptable to the patient and the only
way to avoid such suffering is by death, then as a matter of mercy death may be
brought about.
• Allowing patients to try to avoid pain and suffering, proponents argued, would in
some cases mean allowing physician-assisted suicide, and a few also argued, allowing
euthanasia as well, at least euthanasia in its root sense, eu-thanatos, Greek for ‘good
death’.
• In the Netherlands, euthanasia and physician-assisted suicide were coming to be
legally tolerated for a person facing intolerable suffering, where that suffering could
not be relieved by any method acceptable to the patient.
Physician-Assisted Suicide
Those who opposed physician-assisted suicide do not generally deny the value
of autonomy and the relief of suffering. Many, but not all, even concede that in
particular cases a physician would be justified in providing a patient with the
knowledge or means for them to take their own life.
But opponents believe that there are a number of different considerations,
usually of a consequentialist nature, that lead to the conclusion that,
important as the values of autonomy and relief of suffering are, they cannot
justify the institutionalization or legalization of physician-assisted suicide.
These considerations include the possibility of discovery of cures, the dangers
of mistaken diagnosis, the difficulties of knowing when requesters are rational,
the dangers of patients being coerced or pressured by relatives or by their
physicians, and the effects of legalization on the doctor–patient relationship.
Argument Against Physician-Assisted Suicide
(1) Argument from Intrinsic Wrongness of Killing
• The taking of human life is simply wrong (witness the commandment ‘Thou
shall not kill’); since suicide is killing, suicide is also wrong.
• Killing is understood as morally wrong in virtually all cultures and religious
systems. Judaism, Christianity, Islam, and many other religious traditions
prohibit killing; so do the moral and legal codes of virtually all social
systems.
• Since suicide is a form of killing, this argument observes, suicide – and with
it assisted-suicide – is wrong (‘sinful’, ‘taboo’, ‘reviled by God’, and so on) as
well. However, although this view is shared by all the major world
traditions, it has been Roman Catholicism that has been more active in the
political debate over physician-assisted suicide in Europe and the USA.
Argument Against Physician-Assisted Suicide
Counter-argument:
• Proponents of physician-assisted suicide pointed out that, while killing is morally and legally
regarded as wrong in general, in some exceptional circumstances – for instance, in war, self-
defence, and (though now more controversially) capital punishment – it is accepted as
morally permissible.
• The objection goes, if killing could be morally acceptable in some or all of those
circumstances like war, self-defence and capital punishment, why not self-killing or self-
directed killing in painful terminal illness, when the killing would be for good reason and
any assistance offered in performing it occurs at the express request of the ‘victim’?
There is a counter objection to this objection: In self-defence, war and capital punishment,
the person killed is guilty; in assisted-suicide, the person killed is innocent.
Argument Against Physician-Assisted Suicide
(2) The Argument from the Integrity of the Profession.
• Doctors should not kill; this is prohibited by the Hippocratic Oath. The
Physician is bound to save life, not take it.
• Hippocratic Oath (c. 400 BC) is an ethical code attributed to the ancient
Greek physician Hippocrates, adopted as a guide to conduct by the medical
profession throughout the ages and still used in the graduation ceremonies
of many medical schools.
• The oath dictates the obligations of the physician to students of medicine
and the duties of pupil to teacher. In the oath, the physician pledges to
prescribe only beneficial treatments, according to his abilities and
judgment; to refrain from causing harm or hurt; and to live an exemplary
personal and professional life.
Hippocratic Oath
I swear by Apollo the physician, and Aesculapius, and Health, and All-heal, and all the gods and
goddesses, that, according to my ability and judgment, I will keep this Oath and this stipulation—to reckon
him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve
his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach
them this Art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and
every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my
teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none
others. I will follow that system of regimen which, according to my ability and judgment, I consider for the
benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly
medicine to any one if asked, nor suggest any such counsel; and in like manner I will not give to a woman a
pessary to produce abortion. With purity and with holiness I will pass my life and practice my Art. I will not
cut persons laboring under the stone, but will leave this to be done by men who are practitioners of
this work. Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from
every voluntary act of mischief and corruption; and, further from the seduction of females or males, of
freemen and slaves. Whatever, in connection with my professional practice or not, in connection with it, I
see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that
all such should be kept secret. While I continue to keep this Oath unviolated, may it be granted to me to
enjoy life and the practice of the art, respected by all men, in all times! But should I trespass and violate
this Oath, may the reverse be my lot!
Counter-argument
• Against this argument, some may raise an objection: In its original
version the Hippocratic Oath also prohibits doctors from performing
surgery, providing abortifacients, and taking fees for teaching
medicines.
• If the Oath can be modified to permit these practices, why not
assistance in suicide, where the patient is dying anyway and seeks the
physician’s help?
• Then there is the counter objection: To permit physicians to kill patients
would undermine the patient’s trust in the physician.
• But an objection to this counter objection is that patients trust their
physicians more when they know that their physicians will help them,
not desert them as they die.
Argument Against Physician-Assisted Suicide
(3) The Argument from Potential Abuse: The Slippery Slope Argument
Permitting physicians to assist in suicide, even in sympathetic cases, may lead to
situations in which patients are killed against their will. Once we permit any active
voluntary euthanasia we have started down the slippery slope towards allowing
other, unacceptable acts of euthanasia.
Patients will opt for assisted-suicide because of pressure from relatives, motivated
by a desire to save money; or requests will be prompted by feelings that they lack
worth, or manifest a protest against inadequate care.
It has to be admitted that the legalisation and open practice of active euthanasia
might have bad effects on our attitudes to the dying and the elderly, attitudes which
are not induced by the current practice of passive euthanasia.
The legalisation of active euthanasia might make us lose our grip on the value of life,
to see sick, elderly or disabled people as nuisances which we would be well rid of.
Physicians might end up regarding the taking of life as a small matter, something
which doesn't necessarily require the informed consent of the patient, for example.
Ethical Theories with Regard to Physician- Assisted
Suicide: Kantian Deontology
• Immanuel Kant famously condemned suicide in the Fundamental Principles of the
Metaphysic of Morals. He held that it violated the categorical imperative, since the
maxim of suicide was not universalizable.
• If the maxim of suicide were universalized, we’d end up saying that everyone
should kill themselves, which Kant rejects as an impossible law of nature.
Furthermore, if one commits suicide out of a self-interested motive (say to avoid
misfortune), then there is a contradiction. Self-interest—what Kant calls self-love—
contradicts itself when it leads to the killing of the self.
• Furthermore, suicide was disrespectful of personhood, in violation of the second
form of the categorical imperative. If a person destroys himself in order to escape
painful circumstances, he uses his own life as a means to an end.
Kantian Deontology
• Suicide (Physician-assisted) violated three duties of the formula of humanity: “perfect
duties to others,” “perfect duties to self,” and “imperfect duties to others”.
• The perfect duties to others include respecting others. Examples include not killing
innocent people, keeping promises, and not lying. There is no exception in breaking
these duties.
• With “perfect duties to self,” you are not to disrespect yourself either. Kant believes
that this includes suicide, and that suicide is not acceptable under any situation. Killing
oneself is seen to go against Kant’s moral principle of the categorical imperative, and,
therefore, is never to be broken.
• The duty of beneficence is an “imperfect duty to others” - we are not only to treat
people with respect but we are to further the happiness of others as well, but never at
the expense of a perfect duty.
Kant with Regards to Physician-assisted Suicide
• With regards to physician-assisted suicide, based on Kant’s duties as
explained above, it would seem that Kant would believe that there is no
justification for this particular action.
• Since Kant’s perfect duties to others and self seem to say that no matter
the situation killing is wrong, it would seem that Kant would not ever be in
agreement with physician-assisted suicide.
• However, through the duty of beneficence, the physician would be
creating happiness for the patient who wants to die. This, however, still
goes against Kant’s categories of “perfect duties to others” and “perfect
duties to self”, which are to never be broken according Kant’s belief in the
categorical imperative.
Physician-assisted Suicide: Rule Utilitarianism
Example: Consider a patient who is terminally ill and in a lot of pain. He or she wants a
physician to help speed up his or her death by prescribing a lethal dosage of drugs.
Rule-utilitarianism believes an individual action is morally correct when it sides with
the rules or codes that were already made on a utilitarian basis. It says that a person
should act in agreement with the rule that brings about the largest balance of good
over evil for everyone involved within the situation.
A rule-utilitarian, in this situation, would consider raising the possibility of a justified
exception to the rule of “do not kill.” In most rule-utilitarian’s eyes, killing in self-
defence is seen to be a justifiable exception to the rule of “do not kill.”
Therefore, the rule-utilitarian that advocates for physician-assisted suicide believes that
if the terminally ill patient would be able to escape a prolonged painful death, others
involved would benefit as well. The hospital and physicians would benefit from not
using unnecessary money that could go to another patient who would ultimately live.
The family involved would benefit by not watching their loved one suffer anymore.
Physician-assisted Suicide: Act Utilitarianism
• Act-utilitarianism is sometimes referred to as a type of situational ethics. This
means that a certain kind of action can be wrong within one setting but right
within another. This situation is either right or wrong considering which side
brings the greatest amount of good for everyone involved.
• The act-utilitarians would agree with the rule-utilitarians on this matter as well.
They agree that “do not kill” is a moral rule that should be followed, but if the
terminally ill patient is in terrible pain, wishes to die, and everyone else who is
involved would benefit as well, then physician-assisted suicide is justifiable.
• An act-utilitarian would feel that the killing rule is better to be broken in order to
bring about the better consequences for everyone involved.
• When applying both of these categories of utilitarianism, we see that, more than
likely, most people who find that they agree with both theories agree with
physician-assisted suicide.
Conclusion
• The controversial issue of euthanasia or physician-assisted suicide cannot be totally resolved; we did
not see any middle ground.
• We have noticed that people who argue for the use of physician-assisted suicide believe in the
fundamental principle of autonomy. This allows for the patient to have the right to choose what is
best for his or her life. In this case, it is whether he or she should live or die. Advocates for
physician-assisted suicide also believe that no one should have to live through terminal suffering,
and that if the physician cannot alleviate the pain any other way, then aiding in death is acceptable.
• On the contrary, people who are against the actions of physician-assisted suicide believe that it is
not in the physician’s job description to decide the fate of the patient, even if patient consent is
given; they also believe that killing is intrinsically wrong.
Conclusion
• On the ethical side we also noticed two different sides of the issue in question: On the
one hand, there is Kantian deontology which speaks against any kind of killing, including
physician-assisted suicide. As a non- supporter of suicide Kant remarks are worth
mentioning here:
• “The suicide deprives him/herself of his/her person. This is contrary to the highest duty we have towards
ourselves, for it annuls the conditions with respect to all the other duties. Destroying the subject of morality in
one’s own person is the same as rooting out morality itself from the world, which is a purpose in itself; to
dispose of a person as a mere means for some other purpose, means humiliating humanity in one’s own
person.” (Fundamental Principles of the Metaphysic of Morals.)
• On the other hand, the both forms of utilitarianism seem to support physician-assisted
suicide. Although they agree that “do not kill” is a moral rule that should be followed,
their argument is that if the terminally ill patient is in terrible pain, wishes to die, and
everyone else who is involved would benefit as well, then physician-assisted suicide is
justifiable.