## 1. Introduction



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



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



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



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



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



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



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



A similar legal position to that in Montana has obtained in the nation
of Colombia since the late 1990s as a result of a majority ruling by
its Constitutional Court in favor of the legality of
physician-assisted suicide. In 2021, Spain legalized voluntary
euthanasia. In Austria and Germany courts have authorised
physician-assisted suicide but no legislative backing for the practice
has been introduced, while in Italy legislation for voluntary
medically assisted death has been passed in one house of the bicameral
parliament and in Portugal there is legislation in place for
physician-assisted suicide which is currently under review for its
constitutionality. 



In Canada, the province of Quebec introduced legislation permitting
medical aid in dying in 2014. The legislation came into effect in 2016
at around the same time that the Canadian National Parliament passed
legislation permitting both physician-assisted suicide and voluntary
euthanasia throughout all of the Canadian federation. (For a brief
account of events leading up to the enactment of the various pieces of
legislation in the United States and in Canada see Sumner 2017.)



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



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


## 2. Five Conditions Often Proposed as Necessary for Candidacy for Voluntary Euthanasia



Advocates of voluntary euthanasia typically contend that if a
person


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



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



It should be acknowledged that these conditions are quite restrictive,
indeed more restrictive than many think appropriate. In particular,
the first condition restricts access to voluntary euthanasia to those
who are *terminally ill*. While that expression is not free of
all ambiguity, for present purposes it can be agreed that it does not
include those who are rendered quadriplegic as a result of accidents,
or sufferers from motor neurone disease, or individuals who succumb to
forms of dementia like Alzheimer's Disease, to say nothing of
those afflicted by 'existential suffering'. Those who
consider that cases like these show the first condition to be too
restrictive (e.g., Varelius 2014) may, nonetheless, agree that
including them as candidates for legalized voluntary euthanasia is
likely to make it far harder in many jurisdictions to gain sufficient
support for legalization (and so to make it harder to help those
terminally ill persons who wish to die). Even so, they believe that
voluntary euthanasia should be permitted for those who consider their
lives no longer worth living, not just for for the terminally ill. The
fifth condition further restricts access to voluntary euthanasia by
excluding those capable of ending their own lives, and so may be
thought unduly restrictive by those who would wish to discourage
terminally ill patients from attempting suicide. There will be yet
others who consider this condition to be too restrictive because
competent patients can always refuse nutrition and hydration (see,
e.g., Bernat, et al., 1993; Savulescu 2014). Though this is true, many
competent dying persons still wish to have access to legalized
medically assisted death, rather than having to rely on refusing
nutrition and hydration, so that they may retain control over the
timing of their deaths and avoid needlessly prolonging the process of
dying.



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



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



A final preliminary point is that the fourth condition requires that
the choice to die not only be uncoerced and competent but that it be
enduring. The choice is one that will require time for reflection,
and, almost certainly, discussion with others, so should not be
settled in a moment. Nonetheless, as with other decisions affecting
matters of importance, adults are presumed to choose voluntarily and
to be competent unless the presence of defeating considerations can be
established. (See the entry on
 decision-making capacity.)
 The burden of proof of establishing lack of voluntariness, or lack of
competence, is on those who refuse to accept an adult person's
choice. There is no need to deny that this burden can sometimes be met
(e.g., by pointing to the person's being in a state of clinical
depression). The claim is only that the onus falls on those who assert
that an adult's choice is not competent.



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


## 3. A Moral Case for Voluntary Euthanasia



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



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



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



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



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



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


## 4. Five Objections to the Moral Permissibility of Voluntary Euthanasia


### 4.1 Objection 1



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



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


### 4.2 Objection 2



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



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



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



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


### 4.3 Objection 3



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


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



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



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



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


### 4.4 Objection 4



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



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



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



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



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



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


### 4.5 Objection 5



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



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



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



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



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



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



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



Since the publication of the Remmelink Report in 1991 into the medical
practice of euthanasia in The Netherlands, it has frequently been said
that the Dutch experience shows that legally protecting voluntary
euthanasia is impossible without also affording shelter to the
non-voluntary euthanasia that will follow in its train (see, e.g.,
Keown 2002). In the period since that report there have been a further
four national studies of the practice of euthanasia in The
Netherlands. These studies were carried out in 1995, 2001, 2005 and
2010 respectively (see, e.g., Rietjens, et al. 2009;
Onwuteaka-Philipsen, et al. 2012). The findings from these national
studies have consistently shown that there is no evidence for the
existence of such a slippery slope. Among the specific findings the
following are worth mentioning: of those terminally ill persons who
have been assisted to die about sixty per cent have clearly been cases
of voluntary euthanasia as it has been characterised in this entry; of
the remainder, the vast majority of cases were of patients who at the
time of their medically assisted deaths were no longer competent. It
might be thought that these deaths ought to be regarded as instances
of non-voluntary euthanasia. But, in fact, it would be inappropriate
to regard them as such. Here is why. For the overwhelming majority of
these cases, the decisions to end life were taken only after
consultation between the attending doctor(s) and close family members,
and so can legitimately be thought of as involving substituted
judgements. Moreover, according to the researchers, the overwhelming
majority of these cases fit within either of two common practices that
occur in countries where voluntary euthanasia has not been legalized,
namely, that of terminal sedation of dying patients, and that of
giving large doses of opioids to relieve pain while foreseeing that
this will also end life. In a very few cases, there was no
consultation with relatives, though in those cases there were
consultations with other medical personnel. The researchers contend
that these instances are best explained by the fact that families in
The Netherlands strictly have no final legal authority to act as
surrogate decision-makers for incompetent persons. For these reasons
the researchers maintain that non-voluntary euthanasia is not widely
practised in The Netherlands.



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



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



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



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