EUTHANASIA OR PHYSICIAN-ASSISTED SUICIDE

Euthanasia has been a topic under debate within our world for many centuries; but with medicine
advancing quicker every day, euthanasia is becoming more of a concern with society and the
medical community as well. The debate on end-of-life issues became pertinent in the late 20th
century. Although there is unavoidable overlap between suicide and euthanasia, the debate on
them became separated along with their subject matter and arguments. As a result, the nature of
euthanasia is more pertinent to the medical profession and the debate over rights of patients and
duties of clinicians. Thus broadly, euthanasia becomes interdisciplinary as the issue is being
discussed by philosophers, physicians, religious bodies, academics and human rights activists,
among others. It has been a topic of concern that many different ethical theories have tried to
tackle over the years, but remains just as controversial, if not more, today.
In the Netherlands, euthanasia has been legal since 2002, when the Termination of Life
on Request and Assisted Suicide (Review Procedures) Act took effect. The law in the
Netherlands stipulates that physicians must exercise “due care” in assisting in suicide or when
terminating life on request. In May 2013, Vermont became the fourth state in the United States to
permit physician-assisted suicide, joining Washington, Montana, and Oregon—although legal
challenges remain in Montana, and the courts are still working out the details. According to
physician-assisted suicide laws in Oregon—which has become the model for such laws—a
patient who has fewer than six months to live, according to the judgment of two independent
doctors, may receive a prescription for a lethal dose of a drug to be taken orally. The patient must
be competent; must have a clear and continuing request, made orally and in writing; and must be
able to take the drug without assistance. In Europe, active euthanasia—where instead of simply
prescribing lethal medication, the doctor administers the lethal injection—is legal in the
Netherlands, Belgium, Luxembourg, and Switzerland. Active euthanasia is not legal in the
United States. It is considered illegal in the United Kingdom.
Etymologically the word euthanasia comes from the words eu – meaning good, and
thánatos – meaning death, and it was originally defined as a calm and easy death. In the course
of time, the meaning of the term gained the connotation of ‘mercy killing’. The common
synonym for euthanasia, therefore, in the lay and professional vocabularies has been mercy
killing. Merriam-Webster’s dictionary defines euthanasia as ‘an easy and painless death, or, an
act or method of causing death painlessly so as to end suffering: advocated by some as a way to
deal with victims of incurable disease’. The Oxford Advanced Learner’s Dictionary also defines
euthanasia as ‘the practice of killing without pain of a person who is suffering from an incurable
and painful disease’. The Euthanasia Society of America that was founded in 1938 defines
euthanasia as the ‘termination of human life by painless means for the purpose of ending severe
physical suffering’. And the American Medical Association’s Council on Ethical and Judicial
Affairs defines it as ‘the act of bringing about the death of a hopelessly ill and suffering person in
a relatively quick and painless way for reasons of mercy’.
So, euthanasia is the practice of ending or depriving somebody of his/her own life, which
leads to peaceful and painless death. The meaning of the word euthanasia is this – hastening the
death of those people who are incurably/terminally ill and who experience excruciating pain or
torment for the sole purpose of alleviating the patients’ physical suffering and agony. It is
important to lay stress on the fact that the motive behind euthanasia is the ultimate benefit, i.e.
welfare of the patient. This particular motivation is very significant, in addition to the

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autonomy of thinking and decision-making, because it is one of the key values when assessing
the morality of euthanasia.
There are two main criteria that need to be considered when differentiating types of
euthanasia. The first criterion entails the expressed will of the person, i.e., this criterion is based
on the consent given on behalf of the person over whom euthanasia is to be performed.
Therefore, we can distinguish between voluntary, non-voluntary and involuntary euthanasia.
Voluntary euthanasia is performed at the request of a patient who voluntarily expresses a wish
to die. Euthanasia is also regarded as voluntary if a person is unable to express his/her wish to
die, but who nevertheless expresses this wish. While a person is still in good health, he/she can
make a written request for euthanasia, should he/she become incapable of expressing his/her
decision to die, as well as in the situation when he/she feels pain, or no longer possesses mental
abilities, while at the same time there is no reasonable hope of making a recovery. Non-
voluntary euthanasia means ending the patient’s life without his/her expressed will or
permission. This happens when the patient’s consent is not available for ‘performance’ of
euthanasia. People who cannot/are not able to give their own consent include infants, who are
incurably ill or have a severe disability, as well as those people who have permanently lost the
ability to understand the decision behind euthanasia either because of an accident, illness or old
age, and also if they previously failed to requested or refused euthanasia in such circumstances.
Non-voluntary euthanasia is also conducted when the patient’s consent arises from the
hypothetical will of that individual or from his family members. Therefore, in case of non-
voluntary euthanasia, there is no direct request for euthanasia, but the decision to
conduct/perform euthanasia is based on the assumption that this should be done. Involuntary
euthanasia is performed when an individual is able to give his/her consent, but the consent is not
given – a patient is able to give the consent for his/her death, but he/she does not give it, either
because they are not even asked, or simply because they choose to continue to live irrespective
of the agonizing circumstances. Thus, killing someone who failed to agree to be deprived of
one’s own life can be regarded as euthanasia only if the motive for killing that person is to
prevent his/her unbearable suffering.
The second criterion with respect to differentiating various types of euthanasia is based
on the distinction between killing someone and letting someone die. This factor defines moral
weight as the basic difference between doing and not doing, between actions and omissions or
lack of action. Active euthanasia is someone’s active help in the process of dying, while passive
euthanasia refers to allowing a person to die. The essential difference between these two types
of euthanasia can be explained in this example - it is entirely one thing to switch off a person’s
life-sustaining medical devices, as opposed to unplugging devices when they are already
switched off. Furthermore, when action is taken towards ending a person – such as
discontinuation of life-sustaining treatments, then this is considered to be active euthanasia,
whereas in case when no actions is taken to end a patient’s then this is regarded as passive
euthanasia. Passive euthanasia can only include the lack of treatment needed to sustain life.

Passive euthanasia: Stopping (or not starting) some treatment, which allows
the person to die. The person’s condition causes his or her death.
Active euthanasia: Doing something such as administering a lethal drug or
using other means that cause the person’s death.
Voluntary euthanasia: Causing death with the patient’s consent, knowingly
and freely given.

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 Involuntary euthanasia: Causing death in violation of the patient’s consent.
Non-voluntary euthanasia: Causing the death of a patient who is unable to
consent.
Involuntary active euthanasia is the patient being injected with a lethal
dosage of drugs by a physician without having the patient’s consent.
Involuntary passive euthanasia is the withholding or withdrawing of
medical care to a patient without consent.
Voluntary passive euthanasia is where the patient actively consents for the
physician to withhold or withdraw medical treatment in order to allow the
patient to die.
Voluntary active euthanasia or Physician-assisted suicide is the patient’s
consent given to a physician in order to inject a lethal dosage of drugs to cause
his or her death.

So, what is physician-assisted suicide and how is it related to voluntary active

euthanasia? In physician-assisted suicide, the physician plays an important role in enabling the
death of a patient. Although the patient has given the physician consent to help aid with the
process by prescribing the lethal dosage of medicine, the patient is actually the one who will
administer it in order for himself or herself to die (typically by ingesting a lethal dosage of
drugs). Therefore, physician-assisted suicide is a type of voluntary active euthanasia.

Arguments For and Against Physician-Assisted Suicide

So why is there such controversy over the concept of physician-assisted suicide and why
is it not widely accepted by everyone? The debate over euthanasia and physician-assisted suicide
pits arguments about autonomy and about relief of pain and suffering on the ‘for’ side, versus
arguments about the intrinsic wrongness of killing, threats to the integrity of medical profession,
and potentially damaging social effects on the ‘against’ side.

Arguments for ‘for’ side:

(1) The argument from autonomy

Just as a person has the right to determine as much as possible the course of his or her own life,
a person also has the right to determine as much as possible the course of his or her dying. If a
terminally ill person seeks assistance in suicide from a physician freely and rationally, the
physician ought to be permitted to provide it.
This argument appeals to the fundamental principle of autonomy as the central value. In
the context of end-of-life medical care, respecting autonomy for the dying patient not only means
honouring as far as possible that person’s choices concerning therapeutic and palliative care,
including life prolonging care if it is desired, but could also mean refraining from intervening to
prevent that person’s informed, voluntary, self-willed choice of suicide in preference to a slow,
painful death, or even providing assistance in realizing that choice.

(2) The argument from Relief of Pain and Suffering

No person should have to endure pointless terminal suffering. If the physician is unable to
relieve the patient’s suffering in other ways acceptable to the patient and the only way to avoid
such suffering is by death, then as a matter of mercy death may be brought about.

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 Allowing patients to try to avoid pain and suffering, proponents argued, would in some
cases mean allowing physician-assisted suicide, and a few also argued, allowing euthanasia as
well, at least euthanasia in its root sense, eu-thanatos, Greek for ‘good death’. The Netherlands
provide a relevant example: In the Netherlands, euthanasia and physician-assisted suicide were
coming to be legally tolerated for a person facing intolerable suffering, where that suffering
could not be relieved by any method acceptable to the patient (a patient with amyotrophic lateral
sclerosis (ALS), or Lou Gherig’s disease, could not be forced onto a respirator, for example): the
avoidance of suffering was what was central. What counted as intolerable suffering was to be
defined by the patient: there were no objective criteria for this.
Those who opposed physician-assisted suicide do not generally deny the value of
autonomy and the relief of suffering. Many, but not all, even concede that in particular cases a
physician would be justified in providing a patient with the knowledge or means for them to take
their own life. Yale Kamisar, for example, a strong opponent of legalizing physician-assisted
suicide, said that if he were convinced that someone was terminally ill, suffering from intolerable
pain that could not be relieved, were competent, and requested death, he would ‘hate to have to
argue that the hand of death should be stayed’ ("Some Non-Religious Views against Proposed Mercy-
Killing Legislation" (1958). Minnesota Law Review. https://scholarship.law.umn.edu/mlr/2588). But opponents
believe that there are a number of different considerations, usually of a consequentialist nature,
that lead to the conclusion that, important as the values of autonomy and relief of suffering are,
they cannot justify the institutionalization or legalization of physician-assisted suicide. These
considerations include the possibility of discovery of cures, the dangers of mistaken diagnosis,
the difficulties of knowing when requesters are rational, the dangers of patients being coerced or
pressured by relatives or by their physicians, and the effects of legalization on the doctor–patient
relationship.

Arguments for ‘against’ side:

(1) Argument from Intrinsic Wrongness of Killing

The taking of human life is simply wrong (witness the commandment ‘Thou shall not kill’; since
suicide is killing, suicide is also wrong.
Killing is understood as morally wrong in virtually all cultures and religious systems.
Judaism, Christianity, Islam, Hinduism, Buddhism, Confucianism, and many other religious
traditions prohibit killing; so do the moral and legal codes of virtually all social systems. Since
suicide is a form of killing, this argument observes, suicide – and with it assisted-suicide – is
wrong (‘sinful’, ‘taboo’, ‘reviled by God’, and so on) as well. However, although this view is
shared by all the major world traditions, it has been Roman Catholicism that has been more
active in the political debate over physician-assisted suicide in Europe and the USA.
Proponents of physician-assisted suicide pointed out that, while killing is morally and
legally regarded as wrong in general, in some exceptional circumstances – for instance, in war,
self-defence, and (though now more controversially) capital punishment – it is accepted as
morally permissible. The objection goes, if killing could be morally acceptable in some or all of
those circumstances like war, self-defence and capital punishment, why not self-killing or self-
directed killing in painful terminal illness, when the killing would be for good reason and any
assistance offered in performing it occurs at the express request of the ‘victim’? There is a
counter objection to this objection: In self-defence, war and capital punishment, the person killed
is guilty; in assisted-suicide, the person killed is innocent.

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(2) The Argument from the Integrity of the Profession.
Doctors should not kill; this is prohibited by the Hippocratic Oath. The Physician is bound to
save life, not take it.
Hippocratic Oath (c. 400 BC) is an ethical code attributed to the ancient Greek physician
Hippocrates, adopted as a guide to conduct by the medical profession throughout the ages and
still used in the graduation ceremonies of many medical schools. Although little is known of the
life of Hippocrates—or, indeed, if he was the only practitioner of the time using this name—a
body of manuscripts, called the Hippocratic Collection (Corpus Hippocraticum), survived until
modern times. In addition to containing information on medical matters, the collection embodied
a code of principles for the teachers of medicine and for their students. The oath dictates the
obligations of the physician to students of medicine and the duties of pupil to teacher. In the
oath, the physician pledges to prescribe only beneficial treatments, according to his abilities
and judgment; to refrain from causing harm or hurt; and to live an exemplary personal and
professional life.
Classic Version of Hippocratic Oath

I swear by Apollo the physician, and Aesculapius, and Health, and All-heal, and all the gods
and goddesses, that, according to my ability and judgment, I will keep this Oath and this stipulation—to
reckon him who taught me this Art equally dear to me as my parents, to share my substance with him,
and relieve his necessities if required; to look upon his offspring in the same footing as my own
brothers, and to teach them this Art, if they shall wish to learn it, without fee or stipulation; and that by
precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own
sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of
medicine, but to none others. I will follow that system of regimen which, according to my ability and
judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and
mischievous. I will give no deadly medicine to any one if asked, nor suggest any such counsel; and in
like manner I will not give to a woman a pessary to produce abortion. With purity and with holiness I
will pass my life and practice my Art. I will not cut persons laboring under the stone, but will leave this
to be done by men who are practitioners of this work. Into whatever houses I enter, I will go into them
for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and,
further from the seduction of females or males, of freemen and slaves. Whatever, in connection with my
professional practice or not, in connection with it, I see or hear, in the life of men, which ought not to
be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret. While I
continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the art,
respected by all men, in all times! But should I trespass and violate this Oath, may the reverse be my
lot!

Against this argument, some may raise an objection: In its original version the
Hippocratic Oath also prohibits doctors from performing surgery, providing abortifacients (Mf©cvZ
Kiv), and taking fees for teaching medicines. If the Oath can be modified to permit these
practices, why not assistance in suicide, where the patient is dying anyway and seeks the
physician’s help? Then there is the counter objection: To permit physicians to kill patients would
undermine the patient’s trust in the physician. But an objection to this counter objection is that
patients trust their physicians more when they know that their physicians will help them, not
desert them as they die.

(3) The Argument from Potential Abuse: The Slippery Slope Argument
Permitting physicians to assist in suicide, even in sympathetic cases, may lead to situations in
which patients are killed against their will.
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 Once we permit any active voluntary euthanasia we have started down the slippery slope
towards allowing other, unacceptable acts of euthanasia. Patients will opt for assisted-suicide
because of pressure from relatives, motivated by a desire to save money; or requests will be
prompted by feelings that they lack worth, or manifest a protest against inadequate care. It has to
be admitted that the legalisation and open practice of active euthanasia might have bad effects on
our attitudes to the dying and the elderly, attitudes which are not induced by the current practice
of passive euthanasia. The legalisation of active euthanasia might make us lose our grip on the
value of life, to see sick, elderly or disabled people as nuisances which we would be well rid of.
Family members might bring pressure to bear on their elderly or sick, because of the debilitating
financial and emotional costs of caring for them. Physicians might end up regarding the taking of
life as a small matter, something which doesn't necessarily require the informed consent of the
patient, for example. It might be much easier to take people’s lives without obtaining the consent
of any of the relevant parties.
Consider the following argument from George and Porth:

What sort of society would creation of a right to assisted suicide help us to become … [I]t
would be likely to lead to moral deterioration and a slide from acceptance of suicide as a
'rational' and legitimate choice to acceptance of 'mercy killing' with or without the victim's
consent and even to the disposal of those who desire to cling to life but whose desire is
deemed selfish or irrational. ... [T]he slope becomes very slippery very fast as soon as a
society begins acting on the proposition that some people are better off dead … [O)nly
sentimentality stands in the way of embracing the concept of "lebensunswertes Leben" - "life
unworthy of life". (R George and W Porth, "Death, be not Proud" National Review June 26,
1995, 52.)

So, the conclusion for those who oppose physician-assisted suicide is: Given that the
number of patients who need assistance in dying and who meet the usual conditions (terminal,
non-relievable suffering, competence, wishing to die) is small, and given the seriousness of the
dangers, physician-assisted suicide should not be legalized.

Ethical Theories with Regard to Physician- Assisted Suicide

Ethical theories help shape a person’s morality and their behavior and actions in regards
to their moral views. In order to understand how many people would determine their position on
physician-assisted suicide, we must examine some of these ethical theories and determine their
positions.
Kantian Deontology
There are a number of ethical issues related to suicide. Immanuel Kant famously condemned
suicide in the Fundamental Principles of the Metaphysic of Morals. He held that it violated the
categorical imperative, since the maxim of suicide was not universalizable. If the maxim of
suicide were universalized, we’d end up saying that everyone should kill themselves, which Kant
rejects as an impossible law of nature. Furthermore, if one commits suicide out of a self-
interested motive (say to avoid misfortune), then there is a contradiction. Self-interest—what
Kant calls self-love—contradicts itself when it leads to the killing of the self. Kant says, “…a
system of nature by whose law the very same feeling whose function is to stimulate the
furtherance of life should actually destroy life would contradict itself and consequently could not
subsist as a system of nature.” Kant also held that suicide was disrespectful of personhood, in
violation of the second form of the categorical imperative. The problem is that if a person

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destroys himself in order to escape painful circumstances, he uses his own life as a means to an
end.
Kant believes that the categorical imperative is the fundamental principle that is the basis
of all moral responsibilities. One of the most important formulations that are relevant here is the
second formulation, which says, “…treat humanity... never merely as a means, but always at the
same time as an end.” Kant furthers this formulation by breaking it down into four different
duties. Of the four duties, “perfect duties to others,” “perfect duties to self,” and “imperfect
duties to others” are the three that are relevant to our topic of physician-assisted suicide. The
perfect duties to others include respecting others. Examples include not killing innocent people,
keeping promises, and not lying. There is no exception in breaking these duties. They are simply
off limits. With “perfect duties to self,” you are not to disrespect yourself either. Kant believes
that this includes suicide, and that suicide is not acceptable under any situation. Killing oneself is
seen to go against Kant’s moral principle of the categorical imperative, and, therefore, is never to
be broken. Kant deontology also expresses the duty of beneficence, which lies within the
“imperfect duty to others” category. He believes that we are not only to treat people with respect
but we are to further the happiness of others as well, but never at the expense of a perfect duty.
Kant with Regards to Physician-assisted Suicide
With regards to physician-assisted suicide, based on Kant’s duties as explained above, it would
seem that Kant would believe that there is no justification for this particular action. Since Kant’s
perfect duties to others and self seem to say that no matter the situation killing is wrong, it would
seem that Kant would not ever be in agreement with physician-assisted suicide. However,
through the duty of beneficence, the physician would be creating happiness for the patient who
wants to die. This, however, still goes against Kant’s categories of “perfect duties to others” and
“perfect duties to self”, which are to never be broken according Kant’s belief in the categorical
imperative.

Rule and Act-utilitarianism

Rule-utilitarianism believes an individual action is morally correct when it sides with the rules or
codes that were already made on a utilitarian basis. It says that a person should act in agreement
with the rule that brings about the largest balance of good over evil for everyone involved within
the situation. Act-utilitarianism is sometimes referred to as a type of situational ethics. This
means that a certain kind of action can be wrong within one setting but right within another. This
situation is either right or wrong considering which side brings the greatest amount of good for
everyone involved.
Rule and Act-Utilitarianism in Regards to Physician-assisted Suicide
Consider a patient who is terminally ill and in a lot of pain. He or she wants a physician to help
speed up his or her death by prescribing a lethal dosage of drugs. A rule-utilitarian, in this
situation, would consider raising the possibility of a justified exception to the rule of “do not
kill.” In most rule-utilitarian’s eyes, killing in self-defence is seen to be a justifiable exception to
the rule of “do not kill.” Therefore, the rule-utilitarian that advocates for physician-assisted
suicide believes that if the terminally ill patient would be able to escape a prolonged painful
death, others involved would benefit as well. The hospital and physicians would benefit from not
using unnecessary money that could go to another patient who would ultimately live. The family
involved would benefit by not watching their loved one suffer anymore. The patient should be
allowed to be the administration of the lethal dosage of a drug since the consequences will bring
about the greatest balance of good over evil.

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 The act-utilitarian would agree with the rule-utilitarian on this matter as well. They agree
that “do not kill” is a moral rule that should be followed, but if the terminally ill patient is in
terrible pain, wishes to die, and everyone else who is involved would benefit as well, then
physician-assisted suicide is justifiable. An act-utilitarian would feel that the killing rule is better
to be broken in order to bring about the better consequences for everyone involved. When
applying both of these categories of utilitarianism, we see that, more than likely, most people
who find that they agree with both theories agree with physician-assisted suicide.

Conclusion
What emerged from the above discussion is that the controversial issue of euthanasia or
physician-assisted suicide cannot be totally resolved; we did not see any middle ground. We
have noticed that people who argue for the use of physician-assisted suicide believe in the
fundamental principle of autonomy. This allows for the patient to have the right to choose what
is best for his or her life. In this case, it is whether he or she should live or die. Advocates for
physician-assisted suicide also believe that no one should have to live through terminal suffering,
and that if the physician cannot alleviate the pain any other way, then aiding in death is
acceptable. On the contrary, people who are against the actions of physician-assisted suicide
believe that it is not in the physician’s job description to decide the fate of the patient, even if
patient consent is given; they also believe that killing is intrinsically wrong.
On the ethical side we also noticed two different sides of the issue in question: On the
one hand, there is Kantian deontology which speaks against any kind of killing, including
physician-assisted suicide. As a non- supporter of suicide Kant remarks are worth mentioning
here:
The suicide deprives him/herself of his/her person. This is contrary to the highest duty we
have towards ourselves, for it annuls the conditions with respect to all the other duties.
Destroying the subject of morality in one’s own person is the same as rooting out morality
itself from the world, which is a purpose in itself; to dispose of a person as a mere means for
some other purpose, means humiliating humanity in one’s own person. (Fundamental
Principles of the Metaphysic of Morals.)

On the other hand, the utilitarians, both forms, seem to support physician-assisted suicide.
Although they agree that “do not kill” is a moral rule that should be followed, their argument is
that if the terminally ill patient is in terrible pain, wishes to die, and everyone else who is
involved would benefit as well, then physician-assisted suicide is justifiable.

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