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Article Contents

The implication of a medicalized dying process, the historical case against physicians assisting suicide, the medical cloak, collaborators in euthanasia, healing and euthanasia, recent developments, is euthanasia medical treatment, acknowledgements.

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Euthanasia is not medical treatment

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J. Donald Boudreau, Margaret A. Somerville, Euthanasia is not medical treatment, British Medical Bulletin , Volume 106, Issue 1, June 2013, Pages 45–66, https://doi.org/10.1093/bmb/ldt010

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The public assumes that if euthanasia and assisted suicide were to be legalized they would be carried out by physicians.

In furthering critical analysis, we supplement the discourse in the ethics and palliative care literature with that from medical education and evolving jurisprudence.

Both proponents and opponents agree that the values of respect for human life and for individuals' autonomy are relevant to the debate.

Advocates of euthanasia and assisted suicide give priority to the right to personal autonomy and avoid discussions of harmful impacts of these practices on medicine, law and society. Opponents give priority to respect for life and identify such harmful effects. These both require euthanasia to remain legally prohibited.

Proposals are emerging that if society legalizes euthanasia it should not be mandated to physicians.

The impact of characterizing euthanasia as ‘medical treatment’ on physicians' professional identity and on the institutions of medicine and law should be examined in jurisdictions where assisted suicide and euthanasia have been de-criminalized.

….tha'll nivver feel it, tha'll be out of existence i' two minutes

James Billington

Physician-assisted suicide (PAS) and euthanasia are among the most contentious issues faced by the medical profession. Numerous scholars have argued in favor of 1 or against 2 ‘assisted death’, as these interventions are euphemistically called. These debates generally take it for granted that the person carrying out euthanasia will be a physician. That assumption has been questioned, most recently, by two ethicists from the Harvard Medical School who propose a limited role for physicians in assisted dying. 3 We discuss their proposal shortly. The possibility of deleting the physician from the equation has certainly not been salient in professional discourse.

In this article we will examine factors, highlighting historical contexts and the influence of language, which have helped campaigners who aim to sanitize ‘assisted dying’ by associating it with medicine. We broach the issue of whether euthanasia can be considered medical treatment by focusing on the irreconcilability of euthanasia with medicine's mandate to heal.

In the remainder of this text, we use the word euthanasia to include PAS, unless the contrary is indicated. We do so in accordance with the fact that both procedures raise the same ethical and legal considerations with respect to many of the issues discussed in this article. In PAS and euthanasia, physicians and society are complicit in helping persons to commit suicide or giving them a lethal injection, respectively. Moreover, whether or not a society will alter its laws to allow ‘medically induced death’ is a binary decision.

Are medical doctors, by being responsible for the prolongation of the dying process, blameworthy for the existence of conditions that elicit a desire for hastened death? The profession has indeed created circumstances, through overly aggressive technical interventions, whereby persons' illness narratives have included chapters with alienating, depersonalizing and dehumanizing plots and characters. The following trajectory of a hypothetical patient with amyotrophic lateral sclerosis is all too common: first, non-invasive nocturnal ventilation enters the scenario; next, a wheelchair; then a Dobhof feeding tube, promptly replaced by a jejunostomy; innumerable venous punctures and catheterizations; intervening urinary tract infections; recurrent aspiration pneumonias, followed by invasive ventilation, eventually necessitating a tracheostomy; accompanied by unremitting despondency; and finally, progressive somnolence and terminal sepsis. Too many patients find themselves in a sickroom in such a state, one of spent physical resources and suspended hope or even total despair. Some would add that this metaphoric dwelling is also inhabited by a crushed spirituality.

Pro-euthanasia advocates sometimes present such scenarios to support their views that the profession is, in some measure, responsible for the condition in which a patient may conceive of no escape or redress other than self-willed death. A comment such as, ‘I'd rather die than slog on with deformity, disfigurement and disability', is not infrequently heard and, when expressed, often denounces a sequence of medical interventions rather than the original illness. In dire situations, one of the few avenues that can seem to offer a sense of comfort is that of personal control. Control, usually packaged in a discursive frame of politico-judicial personal autonomy, can be manifest as a desire to manage the ultimate mode of exit from life, that is, for patients to select the method, place and hour of their death. Moreover, some may want this stance to be legitimized by societal approval and even see it as a heroic act and as furthering a common cause, by promoting shared values and ideologies. 4

It would, however, be an overstatement to attribute all changes in the nature of death to the health professions. Improvements in general socioeconomic conditions have decreased the incidence of death from catastrophic accidents, trauma and obstetrical mishaps and have lessened the impact of previously deadly infectious diseases. Undeniably, the shift in prevalence from acute and preventable conditions to chronic degenerative diseases, as well as many cancers, is a consequence of a prolongation of life resulting from improvements in public health, universal literacy and preventive interventions. Nonetheless, there is a kernel of truth in the notion, expressed in commentaries dating from Hellenistic to modern times, that physicians have invented ‘lingering’ death. 5 We believe that some of the profession's approaches in responding to illness in modern society may have fueled the clamour for radical solutions such as euthanasia.

The process has been abetted by those who espouse so-called ‘progressive values’, in what are often referred to as the ‘culture wars’, and who often manifest a pervasive questioning of authority. 6 A desire for unfettered individual decision-making powers—seeing ‘radical autonomy’ as always being the overriding value—and the demotion of established religions as influential voices in the public square are also important factors in the rise in demands to legalize euthanasia. We consider euthanasia a misguided solution to a complex socio-cultural transformation. It is reasonable that the medical profession not deny its contributions to the situation; but, it would be perverse if it allows itself to be co-opted by a perceived need for atonement. It must be vigilant to avoid over-compensating by endorsing society-sanctioned euthanasia.

The profession must not disown its ethical tradition or abandon its basic precepts. The potential harm is not only to individuals, but also to the institutions of medicine and law and the roles they play in society, especially in secular societies, where they are the primary carriers of the value of respect for human life, at the level of both the individual person and society. Ironically, they are more important in this regard now than when religion was the main carrier of the value of respect for life. 4 Therefore, the degrees of freedom, in terms of legitimate actions and behaviours available to physicians confronted with a dying patient are, and must remain, clearly and strictly limited.

The injunction against physician involvement in hastening death has recurred throughout recorded history, the Hippocratic Oath providing the following emblematic statement: ‘I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect’. 7 This unambiguous prohibition has oriented medical practice towards specific ends and means and away from certain others for over 2400 years. Its enduring impact was apparent in early-modern Western society. Euthanasia was discussed by the lawyer Casper Questel in a book entitled ‘De pulvinari morientibus non subtrahendo’. 8 Translated as ‘On the pillow of which the dying should not be deprived’, it described common practices that were thought to hasten death. These popular practices included removing pillows from dying persons so that, with their bodies completely supine, ventilatory capacity would be constricted and death accelerated. Another strategy was to transfer dying persons from their beds to the ground. Perhaps the latter operated through a tacit understanding that the bodily cold thereby induced would bring dying persons closer to their natural demise. Regardless of the underlying pathophysiologic mechanism, it is highly probable that symbolism (for example, facilitating passage of the soul from the shell of the dying body to life eternal) was at play. We note that it was natural death that was sought, not terminating the life of the person.

An intriguing and noteworthy feature of this ancient text is that such practices were popular amongst the general public. They were not acts delegated by society to a particular group and certainly not restricted to medical doctors. Questel was aware of undesirable ramifications if they were practiced by physicians. Physicians risked losing trust should they be discovered to have intentionally shortened the lives of dying patients. Trust is of paramount importance to a successful doctor–patient encounter and is indispensable to the implicit moral contract between the profession and society. 9 Maintaining the trust of individual patients and of society is a sine qua non for the maintenance of professional status. Participating in euthanasia carries the risk of vitiating trustworthiness.

Constraints on physician complicity in euthanasia are to be found throughout history. An 1826 Latin manuscript by a physician, Carl Friedrich Marx, referred to medical euthanasia as the skillful alleviation of suffering. 10 He absolutely forbade physicians from engaging in any attempt at accelerating death, stating : ‘ … and least of all should he be permitted, prompted either by other people's request or his own sense of mercy, to end the patient's pitiful condition by purposefully and deliberately hastening death’. Examples of more recent statements of such prohibitions include the defeat in the House of Lords in 1932 of the ‘Voluntary Euthanasia Bill’ 11 and the Canadian parliament's clear rejection in 2010, by a vote of 228 to 59, of Bill C-384, a private member's bill that would have permitted PAS and euthanasia. 12

Certain jurisdictions, notably the Netherlands and Belgium, have legalized euthanasia. In America, Oregon's ‘Death with Dignity Act’, which permits PAS, came into force in 1997 and Washington state followed suit in 2008. However, on 6 November 2012, Massachusetts voters defeated a ballot that would have allowed assisted suicide, 51–49%. There have been discussions, debates and proposed legislation in many other American states and other countries in the recent past. Generally, these have reaffirmed the ban on medical assistance in killing (whether in the context of end-of-life or, in the USA, physicians' involvement in carrying out capital punishment through lethal injections). The Benelux and a few American states represent the exception to the rule. ‘Do not kill’ has been considered a moral absolute for most physicians for millennia, and remains so for physicians even in jurisdictions where the public has looked favorably on legislative change. That medicine has all to do with healing, and nothing to do with the purposeful ending of life, has been a reverberating imperative throughout history.

The pro-euthanasia lobby derives advantages by aligning itself tightly with medicine and physicians. The history of physician involvement in capital punishment is illustrative of this strategy. Juries in the USA, who had seen horrific footage of convicted murderers being executed in the ‘electric chair’, became reluctant to convict persons accused of capital offences or to vote for a death sentence for felons convicted of a capital offence. Most physicians and the American Medical Association adamantly opposed medicine's involvement in administering capital punishment by lethal injections. Nevertheless, some physicians participated. By virtue of their involvement and in concocting a method of execution that makes a convicted criminal appear serene during final moments, enhanced acceptability was conferred on the procedure. It has been suggested that ‘the law turned to medicine to rescue the death penalty’. 13

It is germane to point out that the word ‘doctor’ is linked etymologically to ‘teacher’. The Oxford English dictionary's definition is: ‘one who gives instruction in some branch of knowledge, or inculcates opinions or principles’. 14 Medical doctors can influence public opinion, much as teachers contribute to the socialization of their pupils. The recruitment of doctors, both as a collectivity and as individuals, to undertake a procedure, can greatly modify the public's view of that procedure.

Language is critically important in not only reflecting, but also creating reality. For example, the field testing conducted prior to the passage of the Oregon Death with Dignity Act demonstrated that when the intervention was described as ‘suicide’ or ‘euthanasia’, popular support declined by 10–12%. 15 The phrase ‘death with dignity’, by avoiding the negative connotations of suicide, was perceived as less alarming. It was able to create a halo of benignity and to generate greater support for and muted opposition to the proposed law. For similar reasons, the euphemism ‘physician assistance in a dignified death’ is reassuring. It would be rare indeed for an individual to wish explicitly for a gruesome death or want to banish a benevolent healer from the sickroom. Research shows that emotions, 16 which we would qualify as ‘examined emotions’, and we would add, moral intuition, are important in making good ethical decisions. Choice of language affects both these human ways of knowing what is morally right and morally wrong. 17

Jill Dierterle, a member of the Department of History and Philosophy at Eastern Michigan University, denigrates the validity and power of words in order to claim that none of the anti-PAS arguments hold merit and concludes that ‘we have no reason not to legalize it’. 18 She turns a blind eye to any potential harm and conveniently overlooks the lacuna in current data-gathering procedures or impact assessments. This stance flies in the face of the golden rule of medicine: primum non nocere. Hence, it is anathema to the vast majority of practicing physicians. Few of us, presented with a new and relatively untested therapeutic instrument, would conclude, ‘we have no reason to doubt its safety; let's forge ahead’. Her nonchalant dismissal borders on the offensive. Note how she handles an important deontological argument against PAS: ‘ … if PAS is wrong, its wrongness cannot be constituted by its conflict with the Hippocratic Oath. After all, the Hippocratic Oath itself is just a bunch of words’. 18 With the phrase ‘just a bunch of words’ Diertele implies that the oath is hollow and meaningless. But ethical precepts and laws are also just a ‘bunch of words’, yet they establish our metaphysical reality—what can be called our metaphysical ecosystem—which, depending on its nature, determines whether or not we have a society in which reasonable people would want to live.

It is critical to the euthanasia debate to consider what role, if any, physicians may, should or must not play. It is not a ‘given’ that, were euthanasia to be legalized, it would be inextricable from the medical mandate. We propose that it is in the best interests of individuals and society to remove the medical cloak from euthanasia in order to lay bare fundamental arguments against it. The stakes are too high to have the veneer of doctoring obscure the essential core of what is involved and its potential harms and risks.

The commentary previously mentioned, ‘Redefining Physicians’ Role in Assisted Dying’, suggests that a non-physician group could be made responsible for the ‘active’ role in euthanasia. 3 The label ‘thanatologist’ has been suggested for such a group. 11 The possibility that a new discipline might emerge raises a set of intriguing questions: What would be the scope of practice of thanatologists? Where would one draw the line between ‘active’ and ‘passive’ roles? Of what might their education consist? We want to make it clear that we believe euthanasia is inherently wrong and, therefore, should never be undertaken, but, it is important to consider what such a proposal could involve if it were put into practice.

It is reasonable to speculate that the training could be offered in a program at a technical level and that the duration of training period would be modest. The act of terminating someone's life is thought to be fairly straightforward—at least, the execution of it is not overly complicated. The experience in the UK of recruiting and training hangmen can provide useful clues. 19 Executioners were trained in the late 19th to mid-20th century with a 5-day course that included lectures, a practical component—‘applicants to pass pinioning in the presence of the Governor’—and ended with a written examination that included simple algebra—the applicant was required to calculate the length of drop (i.e. stretch of the rope) for men of varying weights. Given the complexity of drug-based protocols used in euthanasia, 5 days of instruction would likely be insufficient. A program in the order of 24 weeks, as is the case for cadet training in many police academies, might allow for core objectives to be adequately covered and relevant abilities to be tested and credentialed.

A provocative essay on the topic suggests that lawyers could be trained in euthanasia, practicing a new specialty called legistrothanatry. 20 Although admittedly implausible, the proposal serves to foreground pragmatic issues relevant to the debate. It rests on two fundamental assumptions: (i) that lawyers are trained to interpret laws and regulations accurately, to apply them strictly and to act on the basis of implementing patients' values and (ii) that carrying out the required tasks does not require sophisticated technical expertise. The authors state, ‘Attorneys who wish to provide this service would require only a small amount of additional training’. 20 An appropriate educational blueprint could include the following cognitive base: the physiology of dying, basic pharmacology and an overview of the historical, ethical and legal aspects of natural and requested/assisted death. The toolkit of required skills would likely include: communication, verification of decision-making capacity and informed consent, securing of intravenous access, supplying and/or administering of lethal drugs, management of complications, accurate recognition of death and completion of death certificates. The desired attitudinal substrate would include: personal resolve (that is, stick-with-it-ness), respect for individuals' rights to autonomy and self-determination, and, ideally, a calm demeanour.

Although the tone of the previous discussion may be—and should be—rather ‘chilling’, the substance it addresses has clearly gained a foothold in the current medical literature. A description of procedures for successful euthanasia has been published; one is entitled ‘Euthanasia: medications and medical procedures’. 21 It includes protocols for dealing with terminal dyspnea or agitation in the terminal phase, euthanasia, and the induction of ‘controlled sedation’. Controlled sedation is placed in inverted commas by the author, presumably because he feels that it needs qualification; in his opinion, it represent a hypocritical response to suffering and is undertaken with the aim of muzzling the patient while he dies. We note, but will not discuss here, the ethical issues raised by ‘palliative sedation’, sometimes called ‘terminal sedation’, in which the dying patient is sedated in order to relieve otherwise unrelievable suffering. We suggest that the former term should be used when sedation is the only reasonable, medically indicated, way to relieve the patient's suffering (when it is not euthanasia); the latter term is appropriate when those conditions are not fulfilled and the doctor's intention is to hasten the patient's death (when it is euthanasia).

The epigram to the euthanasia guidelines cited above is fascinating. It states: ‘One summer evening, Mr J-M L, suffering from Charcot's Disease, passed away peacefully after having asked for and obtained the assistance of a physician. Upon leaving the home, the latter did not ponder: ‘What did I do?’ but rather, ‘Did I do it well?’ (Translation by author JDB) 21 This formulation reveals a unique mindset. The affective and moral stance expressed in that quote is closely aligned to a technical perspective, one where the emphasis is on accomplishing tasks with self-efficacy as opposed to one embellished with critical reflection. Meta-reflection is an important aspect of doctoring. What we do and the conversations we routinely engage in forge who we become; they become a habitus. Even the clothing we wear can influence our thought processes. For example, a recent article documents the impacts on cognition of donning a lab coat. 22 If the simple habitual act of wearing a white lab coat can affect thinking and action, one can easily imagine the harmful impacts of regular discussions of euthanasia as they insinuate themselves into the ethos of medical care.

‘The Executioner's Bible’, a story of England's executioners in the 20th century, describes the work of the hangman as a ‘cold, clinical operation’. 19 The epigram we have chosen for our essay, extracted from that textbook, is a quote from James Billington, the UK's Chief Executioner from 1891 to 1901. It is intended to evoke calculated efficiency. The author of ‘Euthanasia: medications and medical procedures’ is similarly categorical, prescriptive and unrestrained by self-doubt. For example, he advises the physician not to propose suicide without medical assistance; to do so is considered incompatible with the role of the physician. He warns the physician against using ‘violent options’ (such as injecting potassium chloride) as this is considered contrary to medical ethics. Leaving aside a disregard for the value of respect for life, the punctilious euthanizer can be seen as behaving with professional dignity and serenity, within a priori defined limits. As the Home Office stated in 1926, when describing the work of hangman William Willis, ‘ … .even an executioner can remain humane and decorous’. 19 Our purpose in making this historical link is not to denigrate advocates of euthanasia. Rather, through this analogy we are endeavoring to focus on the act itself and not just the actor. The latter is often well meaning.

Thanatologists, given the narrow focus of their field of expertise would, over time, almost certainly develop clinical practice guidelines; these might be tailored to different illness categories, for instance, neurodegenerative diseases and the various cancers with poor prognosis. This process seems to be well underway. For example, a recent paper explores euthanasia requests and practices in a highly particularized context, namely, patients in Belgium dying of lung cancer. 23 If euthanasia is accepted as integral to ‘medical care’, this sort of disease-specific focus will surely expand. One can envisage the emergence of guidelines delineating the complementary roles of physicians and thanatologists. Most physicians (we hope) would eschew any involvement in euthanasia and confine themselves to traditional roles such as diagnosing, estimating prognosis and providing supportive care and symptom control, that is, excellent palliative care—which does not include euthanasia, as some advocates argue it should.

The extent to which principled opponents of euthanasia would be legally ‘excused’ from participating in the steps leading up to fulfilling a patient's request for assisted death is a contentious aspect of the debate. How would the profession balance the requirement for individual physicians to fulfill specific social roles and the need to respect the freedom of conscience of those who, on moral grounds, reject certain options? Physician–philosopher Edmund Pellegrino argues that physicians can refrain from entering into professional relationships that have the potential to erode their moral integrity; he offers strategies to assist the physician in navigating potential conflicts. 24

Psychiatrists and medical ethicists who do not reject euthanasia would be expected to focus on soliciting patient perspectives, exploring options and assessing comprehension, competence and voluntariness—that in making her decision, the patient is free from coercion, duress or undue influence, assuming this is possible. The profession has begun to equip itself with tools to deal with this incipient new clinical reality in jurisdictions which allow euthanasia. Physicians in the USA have been provided with an eight-step algorithm to assist them in discussing assisted suicide with patients who request it. 25 These guidelines were developed immediately after the legalization of PAS in Oregon. It is reasonable to expect that additional decision-making tools will emerge should the practice gain wider societal acceptance. Also, the possible consequences on undergraduate medical education, should it have to include protocols for ending patients' lives, have been explored. 26

Again, we note that the above discussion is included for the sake of comprehensive coverage of the issue of physicians' involvement in euthanasia, were it to be legalized, and whether it could be ethically acceptable ‘medical treatment’ or even ‘therapy’. It is not meant to signal that we see euthanasia as ethically acceptable.

It has been repeatedly found that of all separately identified groups in Western societies, physicians are among the most opposed to involvement in euthanasia. There is substantial indirect evidence to support this claim, even in jurisdictions in which doctor-assisted death is legal. For example, in Oregon, there is a suggestion that some patients have to resort to ‘doctor shopping’ to obtain their lethal medications. The Oregon Public Health Division's annual report for 2011 shows that one physician was responsible for 14 of the requisite prescriptions out of a total of 114 that year. 27 Also, the Netherlands recently approved the launching of mobile euthanasia clinics. A stated reason for this development was that patients' goals in self-determination were being thwarted by physician resistance to providing euthanasia. Not all physicians, including many Dutch colleagues, are on-side with having euthanasia become a medical act.

A questionnaire-based study comparing the opinions of the Dutch general public with that of physicians revealed some marked differences. With respect to the active ending of life for patients with dementia, the level of acceptance was 63% for the public and 6% for physicians. 28 With respect to terminally ill cancer patients, the figures were much higher and less divergent; this may be a consequence of the prolonged experience of euthanasia in cases of terminal illness in the Netherlands. Or, it might be that often survey questions are phrased as, ‘If a person is in terrible pain, should they be given access to euthanasia?’ The respondent must choose between leaving the person in pain and euthanizing them. But this choice is wrongly constructed. The person should be able to choose fully adequate pain management—that is, the ‘death’ of the pain—without having to endorse the intentional infliction of death on the patient. 29 Despite high levels of acceptance by physicians of euthanasia for cancer patients in the Netherlands, recent reports reveal persistent ethical concerns. 30 It is also noteworthy that physicians involved in palliative care, including in Britain, appear to be particularly concerned about legalizing euthanasia. 31

What underlies the medical profession's reluctance to accept euthanasia? There are multiple explanations. Aside from ethical, moral and religious beliefs, one of the most salient and compelling has to do with one's conception of the medical mandate, especially as it relates to healing. Healing is a challenging term to define. Many in our institution (the Faculty of Medicine, McGill University) consider it to be ‘a relational process involving movement towards an experience of integrity and wholeness’. 32 It has been operationally defined as ‘the personal experience of the transcendence of suffering’. 33 A feature of healing important to our thesis is the notion that healing does not require biological integrity. Although it may seem counter intuitive at first glance, it has been pointed out that if a sick person is able to construct new meaning and is able to achieve a greater sense of wholeness, that individual may ‘die healed’. 32 It is undeniably a vastly different concept than curing, although they are not in opposition one to the other. Most physicians accept the healer role as a fundamental and enduring characteristic of the profession. 34 In our undergraduate medical program, this concept is taught using the term ‘physicianship’; it refers to the dual and complementary roles of the physician—the physician as healer and professional. 35 It could be argued that one can remain ‘professional’ even while serving as a collaborator in requested death. On the contrary, many commentators—the American Medical Association is a prime example 36 —believe that it is impossible to do so as a ‘healer’, one who is focused on accompanying the patient on a transformational journey towards personal integrity that transcends the embodied self.

The process of healing in the doctor–patient relationship is poorly understood. We do not have a complete picture of how it is initiated or which clinical skills or abilities are essential in fostering a healing relationship. The literature suggests that healing resides in the quality of interpersonal connections and that it requires a deep respect for the agency of the physician in the therapeutic process. 37 An appreciation of the placebo effect, or in more poetic terms, the ‘doctor as the medicine’, is required. 38 , 39 It is almost certainly linked to the phenomena of transference and counter-transference and it may utilize the power differential for salutary purposes, even if these phenomena operate largely at a covert level.

The patient–doctor relationship is marked by intense ambivalence. Any physician who has initiated a discussion with a patient on the issue of resuscitation or desired level of technical intervention will realize how easily it can be misinterpreted, how quickly it can catalyze existential angst and how thoroughly it can overwhelm hopeful sentiments. Affective turmoil and cognitive dissonance can rapidly ensue. These sorts of cross-purpose exchanges would surely be magnified in the context of discussions regarding euthanasia. Although there may be a productive ‘meeting of the minds’ in any specific doctor–patient dyad, the risks of emotional derailment, self-effacing dependency and irremediable miscommunication should not be minimized. It is inconceivable to us that deep layers of existential suffering would not be activated and exposed by such a discussion. A healing space that can support patients would be unnecessarily deflated. Admittedly, this belief is based on incomplete understandings of the clinical encounter, yet the axiomatic foundation of that encounter is anchored in a 2400-year old tradition. We must consider why we have so jealously guarded that tradition. We could always have abandoned it by accepting euthanasia. Unlike many other current medical–ethical dilemmas, neither death nor euthanasia is a novel issue presented by new technoscience.

Many proponents of euthanasia like to claim that opponents rely on two types of unsound arguments: one based on empirical data and the other anchored in axiology. In the first instance, they allege that the outcomes data available from jurisdictions where euthanasia or assisted suicide has been legalized, suggest that our fears of potential abuse are groundless. They deny that there is a ‘logical’ slippery slope—that the situations in which euthanasia will be available will expand over time—or a ‘practical’ slippery slope—that euthanasia will be used abusively. Pro-euthanasia advocates claim that evolving legislation does not pose a threat to persons with a disability, does not lead to euthanasia without consent, does not invite extension of the practice to vulnerable populations—in short, that it has not become a ‘run-away train’. They usually express satisfaction with individual clinicians' professional restraint and integrity as well as with administrative safe guards. Some suggest that the acceptance of euthanasia results in improvements in traditional palliative care. This belief that it represents a positive force for changing prevailing clinical practices is not based on robust evidence. Moreover, the evidence for the existence of a practical slippery slope is very convincing. This was very recently affirmed by the High Court of Ireland, in a judgment we discuss shortly, in deciding whether prohibiting assisted suicide contravened the Irish Constitution, which it held it did not. 40

A recent dramatic example of the logical slope's gravitational pull is the euthanizing, in December 2012, of 45-year-old twins in Belgium. Deaf since childhood, Marc and Eddy Verbessem were facing the additional disability of blindness. Accepting that they were irremediably suffering, their physician euthanized them. 41 Euthanizing patients with non-terminal conditions, even though it can be legal in Belgium, will surely meet with the disapproval of most physicians. Even within the pro-euthanasia movement, this development may be considered an aberration. Nonetheless, there are increasing numbers of commentators who subscribe to the following philosophy: ‘If a patient is mentally competent and wants to die, his body itself constitutes unwarranted life-support unfairly prolonging his or her mental life’. 42

There are two arguments, both warranting careful scrutiny, frequently advanced in support of physician involvement in euthanasia. The first is that physicians have privileged access to information about their patients' unique perspectives and circumstances, including personal resources and frailties, as well as complex family dynamics. That argument has been undermined by evolving practices. The ‘Oregon Public Health Divisions’ report for 2011 reveals that the median length of the doctor–patient relationship for those who died by PAS was merely 12 weeks (with a range of 1–1379 weeks). 27 It is highly unlikely that a physician would have acquired a sophisticated understanding of a person's values, hopes and fears in the matter of a few weeks. It is even less plausible in the case of the mobile euthanasia units currently being deployed in the Netherlands. The second argument is that physicians are inclined, by temperament and experience, to accompany their patients throughout the illness trajectory, including death. That too is not defensible on the known facts. For example, in Oregon, in the first 3 years of the administration of Oregon's ‘Death with Dignity Act’, physicians were present at approximately half of assisted deaths. By 2005, it was 23%. In 2011, it was a mere 9%. 27 The behaviour of these prescribing physicians is not congruent with the image of physicians represented in that iconic painting by Sir Luke Fildes, bearing the title ‘The Doctor’, and often used to portray empathic witnessing. Pro-euthanasia advocates can come across as rather intrepid in their defense of personal autonomy. Autonomy is the overriding principle that is used to buttress arguments in favor of euthanasia; indeed, it generally runs roughshod over all other considerations. Many pro-euthanasia commentators are disposed to brush off concerns about the impact of accepting ‘radical autonomy’ as always being the overriding value—especially concerns about the risks and harms to vulnerable people and to important shared values, in particular, respect for life at the societal level. A 2012 case in British Columbia manifests all these issues; it involved vulnerable persons, values conflicts and shows the preferencing by the court of the value of individual autonomy in relation to euthanasia. The case originates in a challenge to the Canadian Criminal Code's current prohibition of assisted suicide. 43

Gloria Taylor, a plaintiff in the case, Carter v Canada (Attorney General) 44 , was a person with ALS who requested assisted suicide arguing that as her illness progressed she would be incapable of committing suicide, unaided, due to her physical disability. The judge, Justice Lynn Smith, ruled in the plaintiff's favour on the basis that the prohibition was unconstitutional on the grounds that it contravened both Ms Taylor's constitutional ‘right to life, liberty and security of the person’ (under section 7 of the Canadian Charter of Rights and Freedoms) 45 and her right not to be discriminated against as a physically disabled person (under section 15 of the Charter ); and that the prohibition could not be saved (under section 1 of the Charter ), as a reasonable limit on constitutionally protected rights. Consequently, the judge held that the law prohibiting assistance in suicide was not applicable with respect to preventing Ms Taylor and other people in similar circumstances from having such assistance. The judgment is very long and legally complex and is now on appeal. Read as a whole, it strongly supports legalizing PAS and euthanasia.

In that case, the Canadian court reviewed the available evidence from other jurisdictions with liberalised legislation and concluded that there was no evidence of abuse. This Court also reviewed the same evidence and has drawn exactly the opposite conclusions. The medical literature documents specific examples of abuse which, even if exceptional, are nonetheless deeply disturbing. Moreover, contrary to the views of the Canadian court, there is evidence from this literature that certain groups (such as disabled neonates and disabled or demented elderly persons) are vulnerable to abuse. Above all, the fact that the number of LAWER (‘life-ending acts without explicit request’) cases remains strikingly high in jurisdictions which have liberalised their law on assisted suicide (Switzerland, Netherlands and Belgium) – ranging from 0.4% to over 1% of all deaths in these jurisdictions according to the latest figures – without any obvious official response speaks for itself as to the risks involved’. 40

One can also question Justice Smith's conclusions that PAS is not inherently unethical; that individuals' right to autonomy takes priority over the value of respect for life; that sanctity of life is only a religious value; that there is no relevant ethical or moral difference between refusals of life-support treatment that result in the death of the patient and euthanasia; and, that the availability of legalized PAS is necessary ‘medical treatment’ for some.

Justice Smith's justification for allowing euthanasia is largely based on a selective application of Canadian Charter of Rights and Freedoms jurisprudence 45 and depends upon her being able to distinguish the binding precedent set by the Supreme Court of Canada in the Rodriguez case. 46 The latter held, in a four to three split among the judges, that the Canadian Criminal Code's prohibition on assisted suicide 43 was constitutionally valid.

Invoking the Canadian Charter of Rights and Freedoms , Justice Smith ruled that Ms Taylor's right to life was infringed by the prohibition of assisted suicide because she might conclude that ‘she needs to take her own life while physically able to do so, at an earlier date than she would find necessary if she could be assisted’. 44 We believe that this would strike many as a straw man argument. It is to convert a right to life to a right to assisted suicide, by accepting as a breach of a right to life that a person will commit suicide sooner, if not given access to assisted suicide. But validating assistance in committing suicide hardly upholds a right to life.

Like everybody else, Ms Taylor has a right to refuse treatment even if that means she will die sooner than she otherwise would. Justice Smith accepts the plaintiffs' argument that there is no ethical or moral difference between euthanasia and refusals of life-support treatment that result in death and, therefore, both should be legal. But a right to refuse treatment is based in a right to inviolability—a right not to be touched, including by treatment, without one's informed consent. It is not a right to die or a right to be killed. At most, people have a negative content right to be allowed to die, not any right to positive assistance to achieve that outcome. A person with Ms Taylor's illness trajectory will surely die—even more precipitously if they decline many of the interventions described in the hypothetical patient with ALS we introduced earlier on. (Subsequent to the judgment, Ms Taylor died a natural death from an infection). It is also important to underline that current medical practices enable physicians to attenuate much of the suffering that may accompany the progressive loss of function and well-being in advanced ALS.

The judge appears also to accept the argument that legalizing euthanasia enhances palliative care. This goes some way towards treating euthanasia, as some have termed it, ‘the last act of good palliative care’. 47 It is also consistent with the ‘no-difference-between-them approach’ to a spectrum of end-of-life medical interventions. Euthanasia is confused with interventions, such as pain management and rights to refuse treatment, which are ethically and legally acceptable, and an argument is thus set up that, if we are to act consistently, euthanasia must also be ethically and legally acceptable. It is tantamount to legalizing euthanasia through confusion. 48

In the policy, ‘palliative care’ is defined as ‘a qualified medical practitioner, or a person acting under the general supervision of a qualified medical practitioner, administering medication or other treatment to a terminally ill patient with the intention of relieving pain or suffering, even though this may hasten death’. The policy states that that conduct, ‘when provided or administered according to accepted ethical medical standards, is not subject to criminal prosecution’. 44

In other words, the policy's definition of palliative care can be expansively interpreted to place euthanasia in same category as other end-of-life interventions which may hasten death.

For the sake of exploration of the issue, let us assume momentarily that euthanasia is medical treatment. What might flow from this?

Classifying euthanasia as medical treatment would affect the scope of disclosure of information necessary to obtain informed consent. A physician must disclose to the patient all reasonably indicated medical treatments as well as their risks and benefits. It would now have to include euthanasia. Even most pro-euthanasia advocates regard it as unethical for a physician to introduce the possibility of euthanasia. Currently, it is generally accepted that any discussion of it must be initiated by the patient.

It would also mean that to obtain informed consent to euthanasia, all reasonably indicated treatments would need to be offered and they would certainly include all necessary palliative care, in particular, fully adequate pain management. Many of those advocating for euthanasia posit euthanasia and palliative care as alternatives, but informed consent to euthanasia could not be obtained unless good palliative care was available. This is not available to a majority of people who die in Canada; it has been estimated that less than 30% have access to even the most minimal form of palliative care. 49

As well, Canadian psychiatrist Dr Harvey Max Chochinov, who specializes in psychiatric treatment for dying people, has shown that there are significant fluctuations in the will to live, even as death is imminent. 50 The impact of these findings, as well as conditions such as depression, on the possibility of obtaining valid informed consent to euthanasia would need to be fully addressed.

Another crucially important issue is that, if PAS and euthanasia are ‘medical treatment’, then surrogate decision-makers have the authority to consent to them for the patient. Their decisions must be based on either their knowledge of what the patient would have wanted or, if those wishes are unknown, their belief that these interventions are in the ‘best interests’ of the patient. Would mentally incompetent people and those with dementia or disabled newborn babies, as is now the case in the Netherlands under the Groningen protocol, be eligible for ‘therapeutic homicide’? 51

Yet another issue is what would be the indications for euthanasia as medical treatment and who could access it if were legalized? Justice Smith, citing an expert witness for the plaintiffs, refers to ‘the end-of-life population’. 44 This is a term used in the Royal Society of Canada Expert Panel Report on End of Life Decision - Making. 52 In the report, this population is defined as those persons on a continuum beginning with any serious diagnosis or injury. This represents an expansion of a term, ‘end-of-life’, traditionally used for those inevitably in the last days of life, to all people with serious chronic conditions, resulting from illness or injury, that may be fatal in the course of time. And, of course, it is notoriously difficult to predict with any certainty the timing of even obviously terminal illnesses. It is precisely the type of ‘slippery slope’ that we fear emerging from the ‘limited’ exception, as defined by Justice Smith. It will likely culminate in more decisions similar to that taken in the case of the Verbessem brothers in Belgium.

It is also pertinent to point out that Canada continues to fund and promote programs that aim to prevent suicide. If suicide is conferred the status of a right or is held to be acceptable medical treatment it would be difficult to reconcile this situation with the presence of programs that aim to actively thwart it. Some resolve this dilemma by trying to banish the word ‘suicide’ from the debate, in favor of the phrase ‘assisted dying’. Marcia Angell, erstwhile editor of the NEJM and a fervent proponent of PAS, endorses the notion that ‘assisted dying’ can be distinguished from ‘typical suicide’. The latter is described as being undertaken by someone with a normal life expectancy, whereas the former is carried out in someone ‘who is near death from natural causes anyway’. 53 They are going to die anyway, so what does it matter?! We believe that this reasoning is rather disingenuous and that it can result in a dishonouring of that segment remaining in someone's life, whether this is measured in minutes or months, and could deprive them of something as ephemeral as dreams and hopes. It certainly negates the idea of dying as our last great act of living. 54

Finally, a decision classifying euthanasia as medical treatment could have impact far outside the context of issues directly related to death and dying. For example, in Canada, the federal and provincial governments' respective powers are allocated under the Canadian Constitution. The criminal law power belongs to the federal parliament and the power to govern health and social services to the provincial legislatures. If euthanasia was defined as medical treatment, the federal parliament's prohibition of it in the Criminal Code could be invalid by reason of its trespassing on the provincial jurisdiction to govern health and social services. That is one reason that the Quebec College of Physicians and Surgeons, which supports legalizing euthanasia, argues that it is medical treatment. Likewise, the Quebec Legislative Assembly committee, which issued a report, ‘Dying with Dignity’, 55 adopts the same argument. From past experience, we expect that Quebec might challenge the constitutional validity of the Criminal Code prohibition on this basis. However, a legal committee, set up by the Quebec government, has proposed another approach. It has just reported on how Quebec could operationalize giving doctors legal immunity for carrying out euthanasia, including by the Attorney General of Quebec instructing Crown Prosecutors not to prosecute them under the Criminal Code for doing so, provided they comply with certain guidelines. 56 In either case we could see Quebec becoming ‘separate’ from the rest of Canada on this critically important issue.

In pondering medicine's possible involvement in euthanasia, we must foreground those aspects of the medical mandate that are immutable and eternally relevant. We believe these to be the constant nature of ‘illness’, changeless across time, place and culture, and the resultant obligations of the healer. It is important to appreciate how illness affects persons in all spheres of their lives. Patients become intensely vulnerable, impressionable and open to abuse. Pellegrino has summarized the nature of the clinical encounter eloquently as ‘a peculiar constellation of urgency, intimacy, unavoidability, unpredictability and extraordinary vulnerability within which trust must be given’. 57 This vulnerability sets up an intense and enduring obligation of physicians; they must respond to the wounded person with authenticity, compassion and moral agency. The latter demands that physicians harness and deploy their unique influences and persuasive powers in a particular manner. The essential nature of physicianship has evolved over time in a direction that recognizes the extraordinary vulnerability of patients and guards ferociously against their exploitation. In part, this has been achieved by imposing inviolable limits on the physician's terrain of action. Moreover, we believe that, even if one accepted that euthanasia was ethically acceptable—which we do not—it opens up too many doors for abuse.

The medical profession has arrived at a crossroad; it must choose whether to embrace euthanasia as medical treatment, as a logical extension of end-of-life care, or it can reject the redefinition of its healing mandate that this would entail. We believe, that looking back in the future, the euthanasia events of the present time will be seen as a turning point, not only for the profession of medicine, but also for societies. Crossing the line in the sand articulated by Hippocrates, that as a physician ‘I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect’, would result in the ‘doctor as healer’ becoming the ‘doctor as executioner’. In short, healing and euthanizing are simply not miscible and euthanasia can never be considered ‘medical treatment’.

Donald Boudreau was an Arnold P. Gold Foundation Associate Professor of Medicine when this manuscript was written and submitted. He is grateful for the financial support the foundation has provided in the past and requests that readers appreciate the opinions expressed herein are his personal views and not necessarily reflective of the perspectives of the Foundation, its staff, affiliates or benefactors.

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We have a right to die with dignity. The medical profession has a duty to assist

Distinguished Professor of Philosophy and Director: Centre for Applied Ethics, Stellenbosch University

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Anton van Niekerk is director of the Centre for Applied Ethics and Head of the Unit for Bioethics in that Centre. The Unit receives an annual contribution from Mediclinic, but that is not for the exclusive use of Anton van Niekerk.

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Euthanasia represents one of the oldest issues in medical ethics. It is forbidden in the original Hippocratic Oath, and has consistently been opposed by most religious traditions since antiquity – other than, incidentally, abortion, which has only been formally banned by the Catholic Church since the middle of the 19th century.

Euthanasia is a wide topic with many dimensions. I will limit myself in this article to the issue of assisted death, which seems to me to be one of the most pressing issues of our time.

Desmond Tutu, emeritus archbishop of Cape Town, raised it again on his 85th birthday in an article in the Washington Post. He wrote:

I have prepared for my death and have made it clear that I do not wish to be kept alive at all costs. I hope I am treated with compassion and allowed to pass onto the next phase of life’s journey in the manner of my choice.

Assisted death can take the form of physician assisted suicide (PAS) . Here a suffering and terminal patient is assisted by a physician to gain access to a lethal substance which the patient himself or herself takes or administers. If incapable of doing so, the physician – on request of the patient – administers the lethal substance which terminates the patient’s life.

The latter procedure is also referred to as “voluntary active euthanasia” (VAE). I will not deal with the issue of involuntary euthanasia –where the suffering patient’s life is terminated without their explicit consent -– a procedure which, to my mind, is ethically much more problematic.

Passive form of euthanasia

The term “voluntary active euthanasia” suggests that there also is a passive form of euthanasia. It is passive in the sense that nothing is “actively” done to kill the patient, but that nothing is done to deter the process of dying either, and that the termination of life-support which is clearly futile, is permitted.

However, the moral significance of the distinction between “active” and “passive” euthanasia is increasingly questioned by ethicists. The reason simply is the credibility of arguing that administering a lethal agent is “active”, but terminating life support (for example switching off a ventilator) is “passive”. Both clearly are observable and describable actions, and both are the direct causes of the patient’s death.

There are a number of reasons for the opposition to physician assisted suicide or voluntary active euthanasia. The value bestowed on human life in all religious traditions and almost all cultures, such as the prohibition on murder is so pervasive that it is an element of common, and not statutory, law.

Objections from the medical profession to being seen or utilised as “killers” rather than saviours of human life, as well as the sometimes well-founded fear of the possible abuse of physician assisted suicide or voluntary active euthanasia, is a further reason. The main victims of such possible abuse could well be the most vulnerable and indigent members of society: the poor, the disabled and the like. Those who cannot pay for prolonged accommodation in expensive health care facilities and intensive care units.

Death with dignity

In support of physician assisted suicide or voluntary active euthanasia, the argument is often made that, as people have the right to live with dignity, they also have the right to die with dignity. Some medical conditions are simply so painful and unnecessarily prolonged that the capability of the medical profession to alleviate suffering by means of palliative care is surpassed.

Intractable terminal suffering robs the victims of most of their dignity. In addition, medical science and practice is currently capable of an unprecedented prolongation of human life. It can be a prolongation that too often results in a concomitant prolongation of unnecessary and pointless suffering.

Enormous pressure is placed upon both families and the health care system to spend time and very costly resources on patients that have little or no chance of recovery and are irrevocably destined to die. It is, so the argument goes, not inhumane or irreverent to assist such patients – particularly if they clearly and repeatedly so request – to bring their lives to an end.

I am personally much more in favour of the pro-PAS and pro-VAE positions, although the arguments against do raise issues that need to be addressed. Most of those issues (for example the danger of the exploitation of vulnerable patients) I believe, can be satisfactorily dealt with by regulation.

Argument in favour of assisted suicide

The most compelling argument in favour of physician assisted suicide or voluntary active euthanasia is the argument in support of committing suicide in a democracy. The right to commit suicide is, as far as I am concerned, simply one of the prices we have to be willing to pay as citizens of a democracy.

We do not have the right, and we play no discernible role, in coming into existence. But we do have the right to decide how long we remain in existence. The fact that we have the right to suicide, does not mean that it is always (morally) right to execute that right.

It is hard to deny the right of an 85-year-old with terminal cancer of the pancreas and almost no family and friends left, to commit suicide or ask for assisted death. In this case, he or she both has the right, and will be in the right if exercising that right.

Compare that with the situation of a 40-year-old man, a husband and father of three young children, who has embezzled company funds and now has to face the music in court. He, also, has the right to commit suicide. But, I would argue, it would not be morally right for him to do so, given the dire consequences for his family. To have a right, does not imply that it is always right to execute that right.

My argument in favour of physician assisted suicide or voluntary active euthanasia is thus grounded in the right to suicide, which I think is fundamental to a democracy.

Take the case of a competent person who is terminally ill, who will die within the next six months and has no prospect of relief or cure. This person suffers intolerably and/or intractably, often because of an irreversible dependence on life-support. This patient repeatedly, say at least twice a week, requests that his/her life be terminated. I am convinced that to perform physician assisted suicide or voluntary active euthanasia in this situation is not only the humane and respectful, but the morally justified way to go.

The primary task of the medical profession is not to prolong life or to promote health, but to relieve suffering. We have a right to die with dignity, and the medical profession has a duty to assist in that regard.

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Home — Essay Samples — Social Issues — Euthanasia — The Ethics of Euthanasia

The Ethics of Euthanasia

• Categories: Euthanasia

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Published: Jan 30, 2024

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Table of contents

Introduction, advantages of euthanasia, disadvantages of euthanasia, counterarguments and rebuttals, relieving pain and suffering, autonomy and personal choice, reducing medical costs, moral and ethical implications, the risk of abuse, impact on medical professionals, ethical considerations and alternatives, safeguards against abuse and potential solutions.

• New England Journal of Medicine. https://www.nejm.org/doi/full/10.1056/NEJMp0804651
• Journal of Medical Ethics. https://jme.bmj.com/content/early/2013/05/15/medethics-2012-101093

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Arguments for and Against Physician-Assisted Suicide

The right to legally end your own life is a heavily debated issue..

Posted September 16, 2020 | Reviewed by Gary Drevitch

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Although September is designated National Suicide Awareness Month, there are those who think about suicide 12 months of the year. They may be survivors of suicide loss—the family and friends of those who have taken their own lives—or they may be people who often contemplate suicide or have already made attempts. Articles and anecdotes of suicide published during the month of September and at other times most often focus on prevention. But there’s another side to the story.

Many people believe that ending one’s own life is a human right, particularly for those who are terminally ill and suffering from indescribable pain or impairment. In the United States, however, it is only a right for those in the nine places where physician-assisted death is now legal when strict guidelines are followed. In Oregon, Washington, Vermont, Maine, Hawaii, California, Colorado, New Jersey, or the District of Columbia, eligible, terminally ill patients can legally seek medical assistance in dying from a licensed physician. In all of these places, a physician can decide whether or not to provide that assistance. At the same time, other states—Alabama, Arizona, Georgia, Idaho, Louisiana, New Mexico, Ohio, South Dakota, and Utah—have, in recent years, strengthened their laws against assisted suicide. In 2018, for instance, Utah amended its manslaughter statute to include assisted suicide.

In a nutshell, it works like this: The patient orally requests legal medical assistance in dying from a qualified physician. That physician must assess and confirm the patient’s eligibility and also inform the patient of alternative treatments that provide pain relief or hospice care. At that point, a second physician must confirm the patient’s diagnosis and mental competence to make such a decision. If deemed necessary, either physician can require the patient to undergo a psychological evaluation. The patient must then make a second oral request for assistance. Once approved, the original physician writes a prescription for lethal medication (usually a high-dose barbiturate powder that must be mixed with water) that the patient can self-administer when and where they choose, as long as it is not in a public place. Some people never fill the prescription or fill the prescription but never take the medication. Those who do generally fall asleep within minutes and die peacefully within a few hours.

Several organizations have been formed to both support and oppose physician-assisted dying for moral, ethical, and legal reasons. Groups such as Death with Dignity and Compassion and Choices are in favor of what they call “medical aid in dying” and work to provide assistance and lobbying efforts to initiate legal “right to die” programs in every state. They support patient autonomy and choice, particularly in the case of terminal illness. To these groups and their supporters, most of whom come to this side of the issue as a result of agonizing personal experience, death with dignity is a human rights issue and those who are suffering are entitled to a peaceful death.

On the other side of the debate, groups like the Patients Rights Council and Choice Is an Illusion work to tighten laws against euthanasia and medical aid in dying. They fear a complete lack of oversight at the moment of death, as well as normalization of the process to the degree that patients will feel they must relieve their families of the burden they are inflicting by living with their illness. They are concerned that decisions will be made by others on behalf of those too ill to speak for themselves. These groups believe the job of a physician is to find ways to eliminate patients’ suffering, not the patients themselves. They do not believe a physician is qualified to make the decision to assist in ending a life.

In the end, no group really wants assisted suicide to be the final answer, but those who favor medical aid in dying see little recourse for those living with unbearable chronic pain , who are terminally ill, and who have no hope of improving the quality of their lives because medical science has not yet caught up with our modern potential for longevity.

Compassion and Choices: https://compassionandchoices.org/

Death with Dignity: https://www.deathwithdignity.org/

Patients Rights Council: http://www.patientsrightscouncil.org/site/

Choice is An Illusion: https://www.choiceillusion.org/2019/04/in-last-ten-years-at-least-nine-…

Susan McQuillan is a food, health, and lifestyle writer.

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Voluntary euthanasia: A utilitarian perspective

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

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• Health Policy

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• Utilitarian Keyphrases 100%
• Humane Euthanasia Keyphrases 100%
• Belgium Social Sciences 100%
• Assisted Suicide Social Sciences 100%
• Law Keyphrases 20%
• United States Keyphrases 20%
• Suicide Keyphrases 20%
• President Bush Keyphrases 20%

T1 - Voluntary euthanasia

T2 - A utilitarian perspective

AU - Singer, Peter

PY - 2003/10

Y1 - 2003/10

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

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

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The Morality of Euthanasia Essay

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Those who do not advocate for euthanasia frequently pose the debate that it would be recommended to allow a patient in a vegetative state to die rather than to actively take them out of life.

Morally, physicians are allowed to voluntarily cut off patients’ drinking, eating and drugs taking or sedating the patient and leaving the rest to nature, but it is not permissible in morality terms to facilitate a patient’s means of committing suicide or administer hastening measures for death.

This is a complicated and very demanding issue to get a definite stand. The purpose of this paper is to address the issue of whether from this point of view Euthanasia is morally acceptable (Daniel, 1999).

For this discussion to be feasible there is need to know how to determine morally permissible actions. That is, some of the factors which make such actions different in moral grounds.

All actions according to general knowledge are composed of intent and aftermaths, and it is this part that goes further to determine whether an action is moral or not. There are varied philosophical conventions which prefer either intent or consequences, while others are proponents of totally separate factors.

Conversely, there is no intention of moving further to through the demanding role of assessing this issue from all philosophical perspectives, which would rather be not feasible (Ashley & O’Rourke, 2001).

Most probably majority of individuals have went through experiences with relatives and friends who physically and psychologically suffered before death occurred. In other instances, some people are at the moment undergoing the grievous moment with may be a friend or a relative suffering terminal disease.

This is mostly in the last stages of such diseases as Cancer, AIDS and Diabetes where the victim is normally in a vegetative state with chances of recovering scaling at zero. These terminally ill individual are often forced to endure vital and inexorable pain and suffering. Modern medicine can only reach a certain limit in the attempt to alleviate the pain (Moreland, 2009).

Any individual who may come across and hear or see such an anguish in reality with someone dear to him or her to some extent shares the pain and suffering both emotionally and psychologically which makes one even desperately wishes it to stop.

In the meantime the medication and the doctors are not trivial anymore in stopping the pain and the victim despite all the sufferings, he or she is in a vegetative state and there is nothing she or he can contribute even to the society (Rachels, 2009).

In respect to this, some terminally ill patients may willingly wish to terminate their lives, but since they are in critical stages when even speaking is an issue it becomes very hard or rather impossible to it by themselves.

In this kind of a situation, some close people may be willing to assist the terminally ill patient commit suicide, because by doing so they feel that suffering will finally come to an end. The problem comes when the moral concern of whether doing so would be acceptable in moral terms (Sullivan, 1999).

Irrefutably it is very natural for an individual to wish well for another one and this would drive to assisting one dear to from such unnecessary suffering and pain and anguish. To force a terminally ill patient to go on living until nature takes its course would contradict human dignity since at the same time the patient is being forced to endure constant pain and suffering from the disease and other medical procedures.

The term euthanasia implies “good death” as it is supposed to act as a means through which a terminally ill person whose recovery chances are nonexistent dies with dignity.

All the same, to some people’s view it will be morally wrong to use euthanasia to terminate somebody’s life even in whichever condition (Moreland, 2000).

To these opponents of mercy killing, the problem arises because the approach focuses on happiness versus suffering and puts them at the forefront of life itself. Claims favoring mercy killing seems to mean that unhappy life is not worthy living.

This is a hedonistic point of view to life where it is believed that in the analysis, if the situation produces more of pain, suffering and anguish than it produces joy, serenity and happiness, then it is not good. This is because in such a situation there will be of evil than good being produced as a result (Moreland, 2009).

The truth is that in life everyone suffers and the ability to endure such sufferings is present through focus and thinking positive. It thus follows that, those who come out to assist others or to commit suicide probably do focus much on the suffering side and ignores the inherent capability of the mind to tolerate suffering and come up with implication that goes beyond any feeling that is intrinsically negative (Sidney, 2001).

To die is a reality that every one will eventually experience, and this unfortunately comes sooner for those individuals who contracts terminal diseases.

Even if one in such a condition endures the pain and suffering with an implication that it will be feasible if remains focused and with the meaning of life at the forefront, the bottom line remains that such an individual still remembers that soon he or she will meet death and thus little can he or she decide of the future (Sidney, 2001).

The future becomes determined by the disease. However those who are forced to tolerate suffering and pain should be able to seek their own self-respect without recourse to circumstances with any one claiming to be a beloved one being willing and able to do so too.

No one in the family members or those dear to the victim wishes death to come soon, actually they never wish them to die so as to terminate the suffering claimed but instead they celebrate their lives and always be thoughtful that inherent treasure of life that is incomparably more non trivial than suffering and happiness. This means that life has immeasurable treasure or value which also means that life is sacred (Plato, 2000).

If individuals in the society decide stupidly that the life value should be fully considered with reference to the level of suffering and happiness that people go through, then it as well can be taken to mean that those languishing in absolute poverty should be permitted to die since they endure constant suffering and pain.

As a matter of fact, very few individuals will seem to entertain such a nonsensical claim or notion which will sounds abhorrent to many people.

Conversely, the truth then follows from the fact that, we should ground our society morals on strong and sensible ground, otherwise there will be much immorality creeping in the society deceiving our worldviews (Joanne, 2006).

Societies should be of the claim that life is inherently valuable no matter what extent of pain and suffering one might go through. By this, humanity will possibly be opening up to deeds that recently sound inhumane but might sound usual to pleasant to more than expected individuals in the near future (Joanne, 2006).

The intent for patients being helped to commit suicide and those willingly and actively volunteer to use euthanasia to shorten their suffering and painful and “useless” life is similar to the aforementioned alternatives; it call for intentional life taking of the ill patient.

By its very definition, PAS permits the physician to terminate lives of terminally ill patients using the death booster for those patients willing to die.

The physician is said to be conveyed in intentional killing by embracing this approach to hasten death of a terminally ill person who wills to die (Bowie, Michaels and Solomon, 2006).

To recapitulate, it is noteworthy to say that life is sacred and human beings should always seek to protect ad preserve it which then leads us to the notion that people should be allowed to live until nature does it role.

If human beings become thoughtful of the sanctity of life, then there should always be personal dignity n life regardless of tough circumstances people face.

Therefore, since both seem to mean the same thing, there is no significant difference between killing a patient in reality and using euthanasia or allowing him or her to die because they are both intentional in essence.

Reference List

Ashley, B. and O’Rourke, K. 2001. Health Care Ethics . South Bend: University of Notre Dame Press.

Bowie, L., Michaels, M, & Solomon, C.2006. Twenty questions: an Introduction to philosophy . Fort Worth: Harcourt Brace College Publishers.

Daniel, C. 1999. Minimalistic Ethics. Hastings Center Report 1 (11), Pp.19-25.

Joanne, L. 2006. By No Extraordinary Means . Bloomington: Indiana University Press.

Moreland, J. 2009. Review of The End of Life. The Thomist. 53(1), Pp.714-22.

Moreland, J. 2000. The Life and Death Debate . Westport, CT: Praeger Books. 4(2), Pp. 12.

Plato. 2000. The death of Socrates’ in Bowie, GL, Michaels, MW & Solomon, RC, Twenty questions: an introduction to philosophy . Fort Worth: Harcourt Brace College Publishers.

Rachels, J. 2009. The End of Life . Oxford: Oxford University Press.

Sidney, H., W. 2001. The Physicians Responsibility toward Hopelessly Ill Patients: A Second Look. The New England Journal of Medicine. 3(2), Pp. 844-49.

Sullivan, D. 1999. Active and Passive Euthanasia: An Important Distinction . New York: McGraw- Hill Press.

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Why is the ethics of euthanasia wrong?

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• 1 Vytautas Magnus University, Gimnazijos g. 7, LT-3000 Kaunas, Lithuania.
• PMID: 16294446

Human beings are made in the image and likeness of God and are therefore of intrinsic worth or value, beyond all prices. Almost all Christian pro-life arguments spring from the fountain of personal dignity. Euthanasia would make moral sense only if it were possible to say, morally, that this dignity had vanished. To commit euthanasia is to act with the specific intention that somebody should be nobody. This is the fundamental error of all immorality in human relations. To commit euthanasia is to fail to see the intrinsic worth or dignity of the person. The judgement that what has worth, intrinsically, somehow does not have worth, is both logically and morally wrong. The ethics of euthanasia is based on dualistic anthropology and wrong moral presuppositions underlying the defence of euthanasia, namely, proportionalism and consequentialism. The basic claim of proponents of the ethics of euthanasia is that human persons are consciously experiencing subjects whose dignity consists of their ability to made choices and to determine their own lives. Bodily life, according to them, is a condition for personal life because without bodily life one cannot be a consciously experiencing subject. It means that bodily life is distinct from personal life. Thus, the body and bodily life are instrumental goods, goods for the person, not goods of the person. It thus follows that there can be such a thing as a life not worth living--one can judge that bodily life itself is useless or burdensome, and when it is, the person, i.e., the consciously experiencing subject, is at liberty to free himself of this useless burden. Today a key in fighting euthanasia and assisted suicide is better care for the sick and dying. The dignity of the sick cannot be erased by illness and suffering. Such procedures are not private decisions; they affect the whole society. Death with dignity, in the end, is the realisation that human beings are also spiritual beings. We have to promote the way of caring for the dying in which mercy is extended to the patients without inducing death.

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4 Non-Religious Reasons Why Euthanasia is Wrong

You are a member of the first generation of doctors in the history of medicine to turn their backs on the oath of Hippocrates and kill millions of old useless people, unborn children, born malformed children, for the good of mankind ― and to do so without a single murmur from the august New England Journal of Medicine . And do you know what you’re going to end up doing? You, a graduate of Harvard and a reader of the New York Times and a member of the Ford Foundation’s Program for the Third World? Do you know what is going to happen to you? You’re going to end up killing Jews. ― Walker Percy , The Thanatos Syndrome .

It is one thing to speak of the sanctity of life and of human life being created in the image and likeness of God . But what does one s ay when it comes to end-of life issues, and the question of euthanasia comes up? What does one do when a loved one is in immense suffering?  

When people talk about whether euthanasia is right or wrong, two questions will inevitably come up:  

• Why is euthanasia right (or wrong)?  
• Should we not be able to determine the ultimate disposition of our own bodies?  

Even from a non-religious standpoint, euthanasia is wrong for 4 reasons:  

• Humans have great dignity.  
• Voluntary euthanasia is a slippery slope.  
• It puts pressure on “burdensome” individuals.  
• It makes true palliative care worse.  

We will review each of these reasons in detail.  

Reason #1: Humans Have Greater Dignity

Some say that if one euthanizes their pets when they are old and suffering, the same should be true for humans. Some go so far as to say that, if humans are unable to choose euthanasia, their pets have more “rights” than they do.  

The pain of watching a loved one suffer immensely, particularly in their final days, is indescribable. Understandably, we often wish to do anything to alleviate their suffering.

The fundamental problem with euthanasia is that it violates human dignity.

Human dignity doesn’t come from ability, wealth, mental state, or any other changeable factor. It comes directly from our humanity. This inherent and immutable dignity gives every human life value. Human dignity and the intrinsic value of human life are the bedrock of any sane structure of social ethics.  

When we let anyone decide that a life is no longer valuable, even if it’s the individual making that decision, we are treating human dignity like a subjective opinion instead of an immutable reality. The attitude that human dignity is subjective is an essential ingredient to any kind of human rights abuse.  

Even in a person’s final moments, even with immense suffering, everyone deserves to die a natural death. Humans have an intrinsic and unique value and worth, and hastening one’s death violates this worth.

In their final days, humans should opt for comfort care – or palliative care, as we will discuss below – while accepting a natural death. What is a “natural death?”  

Natural death is when an individual allows their ailments to claim their life versus hastening their death or using physician-assisted suicide. By dying a natural death, one is not hastening their death through drugs or lack of food, for example. Instead, they are accepting their end as it comes naturally and living their final moments in the best comfort possible.  

Reason #2: Voluntary Euthanasia is a Slippery Slope

Voluntary euthanasia is a slippery slope to involuntary euthanasia. Involuntary euthanasia involves killing a person when they either do not consent or are unable to consent (such as while in a coma).  

If we allow individuals to choose physician-assisted suicide when they are suffering, what’s to stop the family of a patient from choosing euthanasia when their loved one is unconscious?

The Netherlands legalized euthanasia of newborns who are “defective,” which includes being “severely handicapped.” Killing newborns is not voluntary euthanasia. The newborn lacks the ability to consent.  

Indeed, allowing voluntary euthanasia and expecting involuntary euthanasia to still be opposed is dangerous. Involuntary euthanasia can easily go under the radar , especially in the case of newborns and the elderly.

Many oppose the “slippery slope” argument, saying there is no evidence that allowing voluntary euthanasia would lead to involuntary euthanasia. They further argue that creating laws that draw a hard line between voluntary and involuntary euthanasia would prevent the slippery slope fear, that society can support the voluntary while strongly rejecting the involuntary.

However, allowing voluntary euthanasia and expecting involuntary euthanasia to be opposed in all cases is dangerous. A 2022 project concluded that legalized euthanasia presents too great a risk to vulnerable communities, namely, the disabled and terminally ill.

There’s also the concern that involuntary euthanasia will be used for those whose lives are not deemed “worth living,” such as deformed or disabled children, or for those with treatable conditions.

Canada is a Warning for Our Future

Canada’s “progressive” euthanasia and physician-assisted suicide laws are further down the slippery slope than our own. It can serve as a stark, real-life example of the slippery slope argument.  

A Canadian veteran was offered euthanasia as the ideal solution when she couldn’t secure a stairlift for her home.  

Another veteran was reportedly seeking treatment for PTSD injuries and had been improving when his VA counselor suggested physician-assisted suicide as the best option. What’s the point of having healthcare, if the go-to is euthanasia when someone is suffering?  

Canada has expanded their euthanasia laws to include individuals with chronic conditions, even if those conditions are not life-threatening . But the expansion doesn’t stop there. There has been a push to legalize euthanasia for individuals suffering solely from a mental illness, such as depression. This expansion was set to take place in March 2023, but they extended the date to March 2024.  

What the future may reap with such policies is bleak. Canada has government-funded healthcare. If euthanasia becomes the norm for illnesses and conditions, will the government stop funding many sectors in healthcare, with the assumption that individuals will choose euthanasia?  

A Forbes article addresses concerns felt by doctors:

“Dr. Ramona Coelho, a Canadian family physician told the Associated Press, ‘The whole premise of the legislation is built on a discriminatory approach to people with disabilities. … Most Canadians think that this is a service of compassion offered for people who have nothing left to be offered and are being offered death as a way out. When, in fact, the system is being applied so liberally and so easily in such a short time period that people are dying who would’ve recovered with greater care and resources to live.’ It is a view echoed by Marie-Claude Landry head of the country’s human rights commission who said that euthanasia ‘cannot be a default for Canada to fulfill its human rights obligations.’ Addressing the notion that, when patients are presented with treatment options by doctors, they are likely to be viewing their future life with disability through the lens of economic deprivation, Landry said, “In an era where we recognize the right to die with dignity, we must do more to guarantee the right to live with dignity.”

Related:  Is Euthanasia Ever Justified?

Reason #3: Allowing Euthanasia Puts Pressure on “Burdensome” Individuals

Related to Reason #2, if euthanasia is allowed, it indicates that there are individuals in society who we are unwilling to help and care for. Society should be sensitive and caring to those who have more challenges.  

Normalized and encouraged euthanasia further puts pressure on these individuals to take their own lives to make life “easier” for the society who spurns them. Such individuals would include disabled, elderly, mentally challenged, or even those who suffer from mental illnesses such as anxiety or depression (such as we are seeing in Canada).  

Professor Theo Boer is a leading expert in the ethics of euthanasia. He is a member of a review committee that receives information regarding every euthanasia case in the Netherlands. He expressed concern regarding the pressure that normalized euthanasia puts on “burdensome” individuals.  

Further, a poll by the disability charity Scope found that 64% of disabled respondents would be concerned with a relaxation of the laws surrounding assisted suicide. They fear that, by having broader assisted suicide services, disabled individuals will be pressured to choose this option.  

An article on The Guardian on how disabled individuals are pressured to choose assisted suicide:

“Some 5% of people in Oregon dying by assisted suicide cited financial pressures as a cause. Meanwhile, the number citing being a ‘burden on family/friends/caregivers’ increased from 13% in 1998 to 55% in 2017 . This tallies with Scope’s research that the majority of people with disabilities are concerned that legalising assisted suicide might lead to disabled people choosing it in order not to be a burden on others. Under austerity people who are disabled, ill or elderly are constantly taught that  funding our health  and social care  is a burden – that we are inherently a burden.”

Society should never shrug off the responsibility of taking ca re of its members, particularly those who need it the most. There is no limit to how far the ugly arms of euthanasia could reach. But these individuals are loved and valued human beings with intrinsic worth. They should receive the same respect, honor, and kindness as the rest of society.  

Indeed, those who choose euthanasia may well be choosing it out of a fear of being “burdensome” to their loved ones. Instead, th ese individuals should be reassured that their lives are worth living and that they have dignity. They are worthy of care, support, comfort, and compassion in their final days. Palliative care is a worthy alternative to euthanasia. It honors the patient’s dignity and gives them comfort as they prepare for their final day.  

Which brings us to the final reason euthanasia is wrong.

Reason #4: Allowing Euthanasia Makes True Palliative Care Worse

Euthanasia is, by its nature and definition, in complete opposi tion to the principle of “do no harm.” Thus, euthanasia and palliative care are completely incompatible . Palliative care seeks to provide dignity, comfort, and compassion in a person’s final days. It seeks to minimize or eliminate pain and to give comfort to the patient. Palliative care is thus in perfect accord with the m edical principle of “do no harm.” Not only does it make euthanasia obsolete, but it also makes it unthinkable.

It also can be said that palliative care affords an understanding of one’s own worthiness and dignity, even in the midst of suffering. A 2018 study found that 86% of patients who received palliative care did not request euthanasia. Euthanasia, meanwhile, is the ultimate despair, the la st-ditch effort to make things “easier” for the patient’s family and loved ones. In reality, a family should know their own individual dignity and worth and honor themselves and their family members.

If euthanasia is pushed and normalized, palliative car e is impossible. Having euthanasia as the norm makes it expected, so palliative care becomes unexpected and neglected. Those who do not choose euthanasia may be seen as a burden on the healthcare system. Those who do not have access to needed care may also be pushed towards euthanasia, as seen in Canada with the two veterans. Indeed, we’ve seen assisted suicide suggested for fin ancial reasons .

Dr. Madeline Li, a Canadian psychiatrist who’s helped hundreds of patients with physician-assisted suicide, expressed concern over where Canada is heading with its euthanasia expansions: “Making death too ready a solution disadvantages the most vulnerable people, and actually lets society off the hook. I don’t think death should be society’s solutions for its own failures.”  

In countries where the government funds healthcare (thus providing universal healthcare), normalized and pushed euthanasia would encourage the government to limit or even halt funding of end-of-life healthcare beyond euthanasia. In other words, in such countries, the government does not have an interest in paying for palliative services, assuming or wanting the patient to choose euthanasia as the cheaper option.  

Allowing and normalizing euthanasia takes away from the dignity and worth that palliative care encourages and emphasizes.

Final Thoughts

Humans deserve more than hastening their death in the painful final days. Instead of euthanasia, we should be pushing for improved palliative care to give comfort to individuals in their final days in accordance with their worth and dignity.

This article was originally published in July 2020 by Dr. Brian Clowes and was most recently updated in June 2023 by Marisa Cantu.

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Brian Clowes, PhD

Dr. Brian Clowes has been HLI’s director of research since 1995 and is one of the most accomplished and respected intellectuals in the international pro-life movement. Best known as author of the most exhaustive pro-life informational resource volume The Facts of Life , and for his Pro-Life Basic Training Course , Brian is the author of nine books and over 500 scholarly and popular articles, and has traveled to 70 countries on six continents as a pro-life speaker, educator and trainer.

Marisa Cantu

Marisa Cantu has a master's in political science and international affairs and a bachelor's in political science. She has also studied international studies and French. She has a strong background in nonprofit work, research, writing, and policy proposal and analysis.

Everything you said sounds extremely biased. Not everyone is religious, and as an athiest, I can easily make several of these arguments; I totally agree that under absolutely NO circumstances, should euthanasia be actively encouraged; let alone should it ever be used on a non-consenting human.

I have the same belief for humans as I do for animals: No creature should be forced to surrender their lives, or their organs or anything else, for others “convenience”.

However, I can see where your argument falls apart at the seams: you repeatedly, and emphatically, turn into a “strawman”, as well as a “slippery slope”, and you overemphasize every single time your argument is “proven”, while willfully ignoring anything that could be used as evidence against this.

If laws were put in place to protect all minors, and laws put in place that those seeking euthanasia for non-lethal reasons (including poverty and mental illness) would automatically have to go through various programs that would give their lives dignity (one point I agree with wholeheartedly); and that no matter what, every person would be granted the right to live, and the right to all needed healthcare free of charge; thus protectong all other forms of healthcare, including pallative care (which could, ideally, coexist with patient requested euthanasia, in extremely painful circumstamces); And if we were to simply apply similar to pets as well (pets may receive pallative care, we stop euthanizing healthy individuals no matter the reason, etc); Then we could have a much more friendly, bearable world, that is still quite safe for the living, without being a trap of torture.

The issue I have with your opinion piece is that it is quite intentionally selective in the examples used. They are of the “Supposed brain-dead comatose patient surprises evil doctors and gets up to pick up a puppy” variety.

I’m literally in the middle of experiencing a quite different situation. I am the caregiver for a great friend I’ll call Fred. Fred is an 80-year-old Marine…the “tough as nails” type who never showed a moment of physical pain. He also smoked for over 60 years. He knew that his hacking cough probably meant a bad outcome, so he ignored it for years.

When his body started aching to the point of unbearable pain, he finally agreed to let me take him for a visit to the doctor. It’s now six weeks later. Stage 4 lung cancer, with the pain being caused by the cancer spreading to his bones. I watched as the radiologist showed the CT and PET scans, along with Fred. The technology is amazing. The results were close to horrifying. The computer display took a path that started at Fred’s jawline, and travelled to knee level. The radiologist would pause at each of the affected bones. By “affected”, I mean each area with a mass that was actively eating away at his bones. Fred’s right shoulder blade was missing one-third of it’s bone. The same with both pelvic bones, a few ribs, and quite a few more bones. He had a fracture in his right mid-humerus. The doctor said that, given the fragility of his bones, the fracture could easily have been caused by a sneeze.

Fred is going to die today, tomorrow, likely no more than three days from now. He’s not going to miraculously rise up and pick up a granddaughter or a puppy. I’ll tell you what he IS going to do, and what he’s been doing for five days now: He is going to agonize in a state of semiconciousness while breakthrough pain causes his body to twitch uncontrollably. This tough-as-nails Marine screams every two or three minutes….a long, desperate scream that even makes his nurses cringe. How do I know this? Because I’ve spent hours at his bedside, his hand in mine, praying silently that his body finally succumbs. I wonder how many of the commenters to this article, who opine so stridently and with such conviction, even sat and watched a loved one suffer so brutally.

And the “But in this day and age, with modern pain medications, no one needs to suffer before dying” contention? I speak from first hand observation: It was bull**** 20 years ago when my mother died a very painful cancer death, and it remains so today. Why? Because when you see your loved one in agony, and try to have the pain meds increased, the response is today what it was 20 years ago: “If we give him any more medication, we run the risk of stopping his heart. We aren’t allowed to do that.” And to give you an idea of just how effective those end-of-life drugs are: Fred is receiving a strong dose of morphine EVERY HOUR, along with a daily fentenyl patch. Two of the strongest medications available. His screams of agony as he lies in a fetal position shows just how effective they are. There’s a reason it’s called “breakthrough pain”.

So forgive me if I find your article disingenuous at best, and intentionally misleading at worst. You cite examples of people in comas, while intentionally overlooking that there are some patients who will NOT rise up miraculously. The discussion is one of great nuance, but you paint with a broad brush. I suspect that your mind won’t be changed unless and until you have to hold that loved one’s hand and watch him in agony. You might then realize that your claims that the moment of a person’s death should be “God’s will” ring hollow. To subscribe such mercilessness on God is sacrilegious in and of itself. I also suspect that you will delete this post, as it doesn’t fit easily into your simplistic rationale.

One last thing: I pray that you never suffer as Fred suffers at this moment, and I pray that you never see what I’ve seen.

Peter, We are so very sorry for Fred’s suffering. It is no easy thing to accompany a loved one in his final days, even less so when great suffering is involved. Our sympathy goes out to you both and to all who are dear to Fred and will feel his loss. Fred’s life, and indeed all human life, is a gift from God. I humbly offer my prayers and the following resource to better explain the redemptive power of suffering: https://www.hli.org/resources/slippery-slope-euthanasia/

Peter: 1) I’m so very sorry that you’ve had to endure watching a loved one leave this world like that. While I do not 100% know your pain, I empathize with you very deeply… my mother passed away in 2020 while I was in bootcamp from Stage 4 uterine cancer that, by the time it was discovered, had spread to most of her body. This was about a few years after a very successful surgery that removed a malignant glioblastoma in her brain. 2) I’m very glad you decided to post your comment (and that it remained up), as I found this article left an exceedingly bad taste in my mouth, as well. As you cited, the medical examples used are extremely narrow and all follow one “genre.” I actually couldn’t believe what I was reading, and I could not finish the article, as such. 3) I hope you have the love and support that YOU need after going through such an ordeal with your dear friend.

I would like a printable copy of your this article to share with the Drs who are trying to euthanize my father. We’re fighting for his life and trying to to get him to a safe place out of secular hospitals. We have a very short window to do so. We need to find a pro-life neurologist in CA and a compassionate healthcare facility willing to take him and rescue a living person from the tyranny of wanna-be-god doctors and empowered by corrupt laws.

Thanks for your interest. When viewing this article on the HLI website, you should see a “bar” of icons: Facebook, Instagram, Twitter, etc., and a Printer Friendly icon. Clicking that printer icon will allow you to print the article in PDF format.

I have got so many facts from this article to my debate “Euthanasia should be banned”. Thank you so much !!!

God bless you. Every life soul matters.

Dear Mr. Clowes,

I enjoyed your article. Well written. Thanks.

Derek Simpson

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• v.75; 2022 Mar

Euthanasia and assisted suicide: An in-depth review of relevant historical aspects

Yelson alejandro picón-jaimes.

a Medical and Surgical Research Center, Future Surgeons Chapter, Colombian Surgery Association, Bogotá, Colombia

Ivan David Lozada-Martinez

b Grupo Prometheus y Biomedicina Aplicada a las Ciencias Clínicas, School of Medicine, Universidad de Cartagena, Cartagena, Colombia

Javier Esteban Orozco-Chinome

c Department of Medicine, RedSalud, Santiago de Chile, Chile

Lina María Montaña-Gómez

d Department of Medicine, Keralty Salud, Bogotá, Colombia

María Paz Bolaño-Romero

Luis rafael moscote-salazar.

e Colombian Clinical Research Group in Neurocritical Care, Latin American Council of Neurocritical Care, Bogotá, Colombia

Tariq Janjua

f Department of Intensive Care, Regions Hospital, Minnesota, USA

Sabrina Rahman

g Independent University, Dhaka, Bangladesh

End-of-life care is an increasingly relevant topic due to advances in biomedical research and the establishment of new disciplines in evidence-based medicine and bioethics. Euthanasia and assisted suicide are two terms widely discussed in medicine, which cause displeasure on many occasions and cause relief on others. The evolution of these terms and the events associated with their study have allowed the evaluation of cases that have established useful definitions for the legal regulation of palliative care and public policies in the different health systems. However, there are still many aspects to be elucidated and defined. Based on the above, this review aimed to compile relevant historical aspects on the evolution of euthanasia and assisted suicide, which will allow understanding the use and research of these terms.

• • The history of euthanasia and assisted suicide has been traumatic.
• • The church and research have been decisive in the definition of euthanasia.
• • The legal framework on the use of euthanasia and assisted suicide has been strengthened.

1. Introduction

Euthanasia and assisted suicide are two topics discussed throughout history, mainly because they fall within the scope of life as a human right, which has been universally defended for many years [ 1 ]. However, the mean of the word euthanasia as good death generates conflicts at social, moral, and ethical levels. Mainly because death is a loss, it is difficult to understand it as something positive and; additionally, several historical events such as the Nazi experiments related the term euthanasia more to murder than to a kind and compassionate act [ 1 ]. More current texts mention that euthanasia is the process in which, through the use or abstention of clinical measures, the death of a patient in an incurable or terminal condition can be hastened to avoid excessive suffering [ 2 ].

The difference between euthanasia and assisted suicide is that in the latter, the patient takes the final action; however, both practices can be combined in the term assisted death [ 2 ]. At present, several countries authorize assisted death, including Holland, Luxembourg, and Canada [ 3 ]. Belgium and Colombia have regulations that decriminalize only euthanasia; other places where assisted suicide is legal are Switzerland and five states of the United America states, specifically Oregon, Vermont, Washington, California, and Montana [ 2 , 3 ]. Spain recently joined the list of countries that have legislated on euthanasia through the organic law March 2021 of March 24 that regulates euthanasia in that state in both public and private institutions [ 4 ]. The fact that more and more countries were joining the legislation on euthanasia and assisted suicide has brought to light the opinion of thinkers, politicians, philosophers, and physicians. Several nations have initiated discussions on the matter in their governmental systems. Latin America is trying to advance powerfully in this medical-philosophical field. Currently, in Chile, the “Muerte digna y cuidados paliativos” law, which seeks to regulate the issue of euthanasia and assisted suicide in the country, is being debated in Congress [ 5 ].

It is essential to know the point of view of physicians on euthanasia and assisted suicide, especially taking into account that these professionals who provide care and accompany patients during this moment, which, if approved, would involve the medical community in both public and private health systems. Although it seems easy to think that physicians have a position in favor of the act of euthanasia because they are in direct and continuous contact with end-of-life situations, such as palliative care, terminally ill, and critically ill patients. It is important to remember that the Hippocratic medical oaths taken at the time of graduation of professionals are mostly categorical in mentioning the rejection of euthanasia and assisted suicide [ 6 ]. Furthermore, it is also important to note that many of the oldest universities in the Western world originated through the Catholic Church; and just this creed condemns the practice of euthanasia and continues to condemn it to this day. This situation generates that many medical students in these schools have behaviors based on humanist principles under the protection of faith and religion and therefore reject the possibility of euthanasia [ 7 , 8 ].

The relevance of the topic and the extensive discussion that it has had in recent months due to the COVID-19 pandemic added to the particular interest of bioethics in this topic and the need to know the point of view of doctors and other health professionals on euthanasia and assisted suicide.

2. Origin and meaning of the term euthanasia

The word euthanasia derives from the Greek word “eu” which means good, and the word “thanatos” which means death; therefore, the etymological meaning of this word is “good death”. Over time the evolution of the meaning has varied; even as we will see below was considered a form of eradication of people categorized under the designation of leading a less dignified life. Assisted suicide is a condition in which the patient is the one who carries out the action that ends his life through the ingestion of a lethal drug but has been dispensed in the context of health care and therefore called assisted. This care is provided by a physician trained in the area. However, it requires the prior coordination of a multidisciplinary team and even the assessment by an ethics committee to determine that the patient is exercising full autonomy, free from coercion by the situation he/she is living and free from the fatalistic desires of a psychiatric illness [ 9 ]. In a more literary sense, the word euthanasia meaning of “giving death to a person who freely requests it in order to free himself from suffering that is irreversible and that the person himself considers intolerable” [ 9 ].

Some authors go deeper into the definition and consider that for the meaning of euthanasia, are necessary to consider elements that are essential in the word itself; such as the fact that it is an act that seeks to provoke death and that carried out to eliminate the suffering in the person who is dying. Other elements with a secondary character in the definition are the patient's consent (which must be granted respecting autonomy and freedom in the positive and negative sense; that means the fact must be not be coerced in any way). Another element is the terminal nature of the disease, with an irreversible outcome that generates precariousness and a loss of dignity. The third secondary element is the absence of pain of the death through the use of drugs such as high-potency analgesics, including opioids, high-potency muscle relaxants, and even anesthetic drugs. Finally, the last element is the health context in which the action is performed (essential in some legislations to be considered euthanasia) [ 10 ]. According to the World Health Organization, the union of these two components is the current definition of euthanasia, which describes as “the action performed by a person to cause the painless death of another subject, or not preventing death in case of terminal illness or irreversible coma. Furthermore, with the explicit condition that the patient must be suffering physical, emotional, or spiritual and that affliction is uncontrollable with conventional measures such as medical treatments, analgesics, among others; then the objective of euthanasia is to alleviate this suffering” [ 11 ]. Unfortunately, the term euthanasia has been misused over the years, and other practices have been named with this word. An example of this situation occurred during the Nazi tyranny when the word euthanasia concerned the murder of people with disabilities, mental disorders, low social status, or gay people. At that time, euthanasia was even a simultaneous practice to the Jewish genocide [ 11 ].

Not only has the term been misused; also exists an enormous variability of terms to refer to euthanasia. For example, the laws created to regulate euthanasia have different names around the world; in the Netherlands (Holland), the law that regulates this practice is known as the law of termination of life; in Belgium, it is called euthanasia law, in France, it is called euthanasia law too. In Oregon (USA), it is called the death with dignity act; in California, it is the end of life option act. In Canada is called the medical assistance in dying act. Victoria (Australia) is the voluntary assisted dying bill, but all these denominations refer to the already well-known term euthanasia [ 11 ].

3. Evolution of euthanasia and assisted suicide: digging into historical events

To understand the evolution and relevance of these concepts should analyze the history of euthanasia and assisted suicide; from the emergence of the term, going through its first manifestations in antiquity; mentioning the conceptions of great thinkers such as Plato and Hippocrates; going through the role of the Catholic Church; mainly in the Middle Age, where following the thought of St. Thomas Aquinas, self-induced death or death contemplated by own will, was condemned. Later, with the renaissance age and the resurgence of science, technology, and the arts, the term euthanasia made a transition to a form similar to what we know today from thinkers such as Thomas More and Francis Bacon. Finally, the first signs of eugenics were known in London, Sweden, Germany, and the United States in the twentieth century. There was a relationship with the term euthanasia that was later used interchangeably, especially in the Nazi regime, to denote a form of systemic murder that sought to eradicate those who were not worthy of living a life.

Since the sixties, with emblematic cases, the path towards the decriminalization of euthanasia began in some countries, especially concerning the cessation of extreme support measures in cases of irreversible illness or a terminal condition. The practice has progressed to the appearance of laws on euthanasia in several countries.

4. Euthanasia and assisted suicide in ancient times

In book III of Plato's “The Republic”, the author stated that those who live their lives amidst illnesses and medicines or who were not physically healthy should be left to die; implying that it was thought that people in these conditions suffered so much that their quality of life diminished, which seemed understandable to these thinkers. However, other authors such as Hippocrates and his famous Hippocratic oath sought the protection of the patient's life through medicine, especially in vulnerable health conditions prone to fatal outcomes. This Hippocratic oath is the same oath that permeates our times and constitutes an argument among those who mark their position against euthanasia and assisted suicide [ 12 , 13 ].

Other texts that collect thoughts of Socrates and his disciple Plato point out that it was possible and well understood to think of ceasing to live in the face of a severe illness; to consider death to avoid a long and torturous agony. This fact is compatible with the conception of current euthanasia since this is the end of this health care procedure [ 13 ].

In The Republic, the text by Plato, the physician Heroditus is also condemned for inventing a way to prolong death and over manage the symptoms of serious illnesses, which is currently known as distanasia or excessive treatment prolongs life. This kind of excessive treatment prolongs the sick person's suffering, even leading him to maintain biological signs present but in a state of alienation and absolute dependence on medical equipment such as ventilators and artificial feeding [ 13 ]. However, the strongest indication that Euthanasic suicide was encouraged in Greece lies in other thinkers such as the Pythagoreans, Aristotelians, and Epicureans who strongly condemned this practice, which suggests that it was carried out repeatedly as a method and was therefore condemned by these thinkers [ 12 , 13 ]. According to stoicism, the pain that exceeded the limits of what was humanly bearable was one of the causes for which the wise man separates himself from life. Referring to one of the nuances that euthanasia touches today, that is, at a point of elevated suffering, the dignity and essence of the person are lost, persisting only the biological part but in the absence of the person's well-being as a being. In this sense, Lucius Seneca said that a person should not love life too much or hate it; but that person should have a middle ground and end their life when they ceased to perceive life as a good, worthy, and longed-for event [ 1 , 12 ].

During the Roman Empire and in the territories under its rule, it was believed that the terminally ill who commit suicide had sufficient reasons to do so; so since suicide caused by impatience and lack of resolution to pain or illness was accepted, when there was no access to medicines. In addition, there was little development in medicine during that time, and many of the sick died without treatment [ 12 ]. This situation changed later with the emergence of the Catholic church; in this age, who attempted against own life, was deprived of burial in the ground. Saint Augustine said that the suicide was an abominable and detestable act; from 693 AD, anyone who attempted against his physical integrity was excommunicated. Rejecting to the individuals and their lineage, depriving them of the possibility of attending the funeral and even expelled from cities and stripped of the properties they owned [ 12 , 13 ].

4.1. Euthanasia and assisted suicide in the Middle Age

During the Middle Age, Catholicism governed the sciences, arts, and medicine; the sciences fell asleep. Due to this solid religious tendency and the persistence of Augustinian thought, suicide was not well seen. It was not allowed to administer a lethal substance to a person to end the suffering of a severe or terminal illness [ 9 , 12 ]. People who took their own lives at this time could not be buried “Christianly”; therefore, they did not have access to a funeral, nor to the accompaniment of their family in a religious rite. Physical suffering and pain were then seen as a path to glorification. Suffering was extolled as the form that god purified the sin, similar to the suffering that Jesus endured during his Calvary days. However, a contrary situation was experienced in battles; a sort of short dagger-like weapon was often used to finish off badly wounded enemies and thus reduce their suffering, thus depriving them of the possibility of healing and was called “mercy killing” [ 12 ].

5. Euthanasia in renaissance

With the awakening of science and philosophy, ancient philosophers' thoughts took up again, giving priority to man, the world, and nature, thus promoting medical and scientific development. In their discourse, Thomas More and Francis Bacon refer to euthanasia; however, they give a eugenic sense to the concept of euthanasia, similar to that professed in the book of Plato's Republic. It is precise with these phylosophers that the term euthanasia got its current focus, referring to the acceleration of the death of a seriously ill person who has no possibility of recovery [ 12 ]. In other words, it was during this period that euthanasia acquired its current meaning, and death began to be considered the last act of life. Therefore, it was necessary to help the dying person with all available resources to achieve a dignified death without suffering, closing the cycle of life that ends with death [ 13 , 14 ].

In his work titled “Utopia”, Thomas More affirmed that in the ideal nation should be given the necessary and supportive care to the dying. Furthermore, in case of extraordinary suffering, it can be recommended to end the suffering, but only if the patient agrees, through deprivation of food or with the administration of a lethal drug; this procedure must be known to the affected person and with the due permission of authorities and priests [ 12 , 13 ]. Later, in the 17th century, the theologian Johann Andreae, in his utopia “Christianopolis”, contradicts the arguments of Bacon and Moro, defending the right of the seriously ill and incurably ill to continue living, even if they are disturbed and alienated, advocating for the care based on support and indulgence [ 15 , 16 ]. Similarly, many physicians rejected the concepts of Plato, Moro, and Bacon. Instead, they focused on opposing euthanasia, most notably in the nineteenth century. For example, the physician Christoph Hufeland mentioned that the doctor's job was only to preserve life, whether it was a fate or a misfortune, or whether it was worth living [ 16 ].

5.1. Euthanasia in the 20th century

Before considering the relevant aspects of euthanasia in the 20th century, it is vital to highlight the manuscript by Licata et al. [ 17 ], which narrates two episodes of euthanasia in the 19th century. The first one happened in Sicily (Italy) in 1860, during the battle of Calatafimi, where two soldiers were in constant suffering, one because he had a serious leg fracture with gangrene, and the other with a gunshot wound. The two soldiers begged to be allowed to die, and how they were in a precarious place without medical supplies, they gave them an opium pill, which calmed them until they died [ 17 ]. The second episode reported by Licata et al. [ 17 ] was witnessed by a Swedish doctor named Alex Munthe; who evidenced the pain of many patients in a Parisian hospital. So he decided to start administering morphine to help people who had been seriously injured by wolves and had a poor prognosis; therefore, the purpose of opioid use was analgesia while death was occurring.

It is also important to highlight the manuscript entitled “Euthanasia” by S. Williams published in 1873 in “Popular Science Monthly”, a journal that published texts by Darwin, Edison, Pasteur, and Beecher. This text included the report for the active euthanasia of seriously ill patients without a cure, in which the physicians were advised to administer chloroform to these patients or another anesthetic agent to reduce the level of consciousness of the subject and speed up their death in a painless manner [ 16 ].

Understanding that euthanasia was already reported in the nineteenth century, years after, specifically in 1900, the influence of eugenics, utilitarianism, social Darwinism, and the new currents of thought in England and Germany; it began in various parts around the world, projects that considered the active termination of life, thus giving rise to euthanasia societies in which there were discussions between philosophers, theologians, lawyers, and medical doctors. Those societies discussed diverse cases, such as the tuberculous patient Roland Gerkan, who was considered unfit and therefore a candidate to be released from the world [ 16 ]. The scarcity of resources, famine, and wars were reasons to promote euthanasia as a form of elimination of subjects considered weak or unfit, as argued in texts such as Ernst Haeckel's. However, opponents to the practice, such as Binding and Hoche, defended the principle of free will in 1920 [ 16 ].

5.2. Euthanasia in the time of the Nazis

As mentioned above, the term euthanasia was misused during this period; approximately 275,000 subjects (as reported at the Nuremberg International Military Tribunal 1945–1946), who had some degree of physical or mental disability, were killed during Adolf Hitler's Euthanasia program [ 13 ]. However, the Nazis were not the first to practice a form of eugenics under the name of euthanasia, since the early 1900s in London had already begun the sterilization of the rejected, such as the blind, deaf, mentally retarded, people with epilepsy, criminals, and rapists. This practice spread to different countries like Sweden and the United States [ 13 , 16 ].

For the Nazis, euthanasia represented the systematic murder of those whose lives were unworthy of living [ 13 ]. The name given to this doctrine was “Aktion T4”. At first and by law, from 1939, the hospitals were obliged to account for all disabled newborns, which led to the execution of more than 5000 newborns utilizing food deprivation or lethal injection [ 12 , 18 ].

A year before that law, in 1938, one of the first known cases of euthanasia in children arose in Germany. That history called the story of child K, in which it was the father of the minor who asked Hitler in writing for euthanasia for his son because the child had a severe mental disability and critical morphic disorders. Hitler gave his consent to carry out the procedure on child K, and thus the program began to spread throughout the Aleman territory. Since then, physicians and nurses had been in charge of reporting the newborns with alterations, arising the “Kinderfachabteilugen” for the internment of children who would be sentenced to death after a committee's decision [ 12 , 18 , 19 ]. A list of diseases and conditions that were considered undesirable to be transmitted to Hitler's superior Aryan race was determined; thus, any child with idiocy, mongolism, blindness, deafness, hydrocephalus, paralysis, and spinal, head, and hip malformations were eligible for euthanasia [ 19 ].

Subsequently, the program was extended to adults with chronic illness, so those people were selected and transported by T4 personnel to psychiatric sanatoriums strategically located far away. There, the ill patients received the injection of barbiturate overdoses, and carbon monoxide poisoning was tested as a method of elimination, surging the widely known gas chamber of the concentration camp extermination; this situation occurred before 1940 [ 12 , 19 ]. Again, physicians and nurses were the ones who designated to the patients to receive those procedures; in this case, these health professionals supported Nazi exterminations. They took the patients to the sanatoriums, where psychiatrists evaluated them and designated with red color if they should die and with a blue color if they were allowed to live (this form of selection was similar in children) [ 12 , 13 , 19 ]. In this case, the pathologies considered as criteria for death were those generating disability such as schizophrenia, paralysis, syphilis with sequelae, epilepsy, chorea, patients with chronic diseases with many recent treatments, subjects of non-German origin and individuals of mixed blood [ 19 ]. Once in the sanatoriums, they were informed that they would undergo a physical evaluation and take a shower to disinfect themselves; instead, they were killed in gas chambers [ 12 , 13 ]. Despite the church's action in 1941 against Nazis and after achieving suspension of the Aktion T4 project; the Nazi supporters kept the practices secretly, resuming them in 1942, with the difference that the victims were killed by lethal injection, by an overdose of drugs, or left to starve to death, instead of the use of gas chambers. This new modified form of euthanasia, which did not include gas chambers, became known as “savage euthanasia” [ 12 , 13 , 19 ].

5.3. Euthanasia since the 1960s

In September 1945, trials began for crimes perpetrated by Nazi supporters; the victorious Allied forces conducted these trials at the end of the war. During these tribunals, cases of human experimentation were identified and the public exposure of the Nazi euthanasia program. After the Nuremberg trials and the abolition of Nazi experiments, a series of seven documents emerged, among which the Nuremberg code containing the ten basic principles for human research stood out [ 20 , 21 ].

After these judgments, biotechnology was accelerated, with the apparition of new techniques to intervene in the health-disease process. Additionally, the increase in life expectancy and the appearance of diseases that chronically compromise the state of health of people generated a change in the conception of the critically ill patient and the terminal state of life [ 20 , 21 ]. Cases such as Karen Ann Quinlan brought to the forefront the issue of euthanasia and precisely the control of extreme treatment measures. Karen, a young American woman, was left in a vegetative state due to severe neurological damage following alcohol and barbiturate intoxication. After six months in that state and under the guardianship of a Catholic priest, Karen's parents requested the removal of the artificial respirator, arguing that in her state of consciousness prior to the incident, she had stated that she disagreed with artificially maintaining life in comatose patients. The hospital refused to remove the ventilator, arguing the legal issues for the date, and the parents went to court, which in the first instance granted the hospital the right. Nevertheless, the New Jersey Supreme Court granted Karen Ann's right to die in peace and dignity. Despite the withdrawal of the artificial respirator, he continued to live until 1985, when he finally died [ [21] , [22] , [23] ].

Another important case was Paul Brophy, which also occurred in the United States. Paul was a firefighter in Massachusetts and went into a deep coma due to the rupture of a basilar artery aneurysm; initially, his family advocated for support measures but later requested the hospital to disconnect these means to allow death, as Paul had indicated when he was still conscious. The hospital refused to carry out this procedure, so the family went to court, where the removal of the support measures (gastrostomy) was initially denied. Hence, the family went to the state supreme court, achieving the transfer of Paul to another medical center where the gastrostomy was removed, leading to his death within a few days [ 23 ].

The case of Arthur Koestler, an influential English writer and activist diagnosed with Parkinson's disease and later with leukemia, who served as vice-president of the voluntary euthanasia society (Exit) and wrote a manual book with practical advice for euthanasia called “Guide to Self-Liberation”. He stood out because he applied one of his advice and ingested an overdose of barbiturates, causing his self-death. According to his writings, Koestler was not afraid of death but of the painful process of dying [ 23 ]. In this sense, it was a relevant case because it involved someone who held an important position in an association that advocated euthanasia, in addition to being the author of several works, which made him a recognized public figure [ 23 ].

Baby Doe was a case that also occurred in the United States; it was a small child with Down syndrome who had a tracheoesophageal fistula and esophageal atresia; in this case, surgery was necessary. On the advice of the obstetrician, the parents did not allow surgery, so the hospital managers took the case before a judge who ruled that parents could decide to perform or not the surgery. The case was appealed before a county judge who upheld the parents' power to make the decision, in the course of which the case became public and many families offered to take care of the child; however, before the case reached the supreme court, the child died at six days of age [ 23 ].

In the case of Ingrid Frank, a German woman who was in a quadriplegic state by a traffic accident, who initially sought rehabilitation but later insisted on being allowed to die; it was provided with a drink containing a cyanide solution that she drank. At the same time, she was filmed, which shows a kind of assisted suicide. For that reason, this is another case that deals with this issue and is important to know as background in the development of euthanasia and assisted suicide [ 22 , 23 ].

6. Current and future perspectives

The definition of brain death, the rational use of the concept of euthanasia and assisted suicide, and scientific literacy are the objectives of global bioethics to regulate euthanasia and assisted suicide, which can be accessible in all health systems [ [24] , [25] , [26] , [27] , [28] , [29] , [30] ]. End-of-life care will continue to be a subject of debate due to the struggle between biomedical principles, the different existing legal frameworks, and the general population's beliefs. Medical education and preparation in the perception of death, especially of a dignified death, seems to be the pillar of the understanding of the need to develop medical-legal tools that guarantee the integrity of humans until the end of their existence [ 31 , 32 ]. This is the reason why the new generations of physicians must be trained in bioethics to face these ethical conflicts during the development of their professional careers.

In addition, although the conception of bioethics belongs to the Western world, it is crucial to take into account the point of view of other cultures and creeds, for example, a study carried out in Turkey, where nursing students were questioned, found that many of them understood the reasons for performing euthanasia; however, they know that Islam prohibits it, as well as its legislation, and therefore they would not participate in this type of procedure [ 33 ]. Furthermore, Christianism and Islam prohibit euthanasia, but Judaism also prohibits it; in general, the so-called Abrahamic religions are contrary to any form of assisted death, whether it is active euthanasia, passive, or assisted suicide [ 34 ].

7. Conclusiones

The history and evolution of euthanasia and assisted suicide have been traumatic throughout human history. The church, politics, and biomedical research have been decisive in defining these concepts. Over the years, the legal framework and bioethical concepts on euthanasia have been strengthened. However, there is still much work to educate the general population and health professionals about end-of-life care and dignified death.

It is also important to remember that life is a concept that goes beyond biology. Currently, bioethics seeks to prioritize the concept of dignity, which must be linked to the very definition of life. Although the phrase is often heard that it is not necessary to move to be alive, what is important is that person feels worthy even if they have limited movement. The person's treatment must be individualized in bioethics since each individual is a unique unit. Therefore, medical paternalism must be abandoned. Instead, the subject must be more involved to understand their context and perception of life and dignity.

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All authors equally contributed to the analysis and writing of the manuscript.

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Sabrina Rahman. Independent University, Dhaka, Bangladesh. [email protected] .

Declaration of interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.