Billede: Det Etiske Råds logo

"End of life – Euthanasia"

3. Arguments for and against euthanasia

The following sections set out the most important and most frequently adduced arguments for and against euthanasia. Each section takes as its basis one aspect of the debate (for example, autonomy in 3.1 and the inviolability of life in 3.2), describing how it is possible to argue both for and against euthanasia, respectively, on the basis of the same aspect. The account will include such arguments as take a positive point of reference in the individual concept as well as some that take critical issue with it (section 3.1, for instance, describes arguments that home in on the incompatibility of euthanasia with autonomy, whereas among other things section 3.2 contains arguments that are based on a critique of the actual concept of the sanctity of life).

3.1 Autonomy

People's autonomy or self-determination is an important concept in the debate on legalizing euthanasia. Proponents argue that the ban on euthanasia imposes too great a limit on the individual's scope for controlling the end of his or her life and what shape death will take. Opponents, on the other hand, argue that self-determination would be false autonomy with respect to euthanasia, or that self-determination regarding euthanasia should not weigh more heavily than the principle of not killing.

The debate presupposes that people entertain some notions of what self-determination and autonomy can mean. The word autonomy is a compound made up of the ancient Greek words for `self' (autos) and `law' (nomos). In one sense of the word, then, autonomy is about the person who is autonomous granting himself his own determination. Underlying the idea of autonomy, therefore, is the notion that the individual himself should have the freedom to define the parameters that determine his life and choose his ideals regarding the way life ought to be lived. That does not necessarily mean that everything is perceived as being equally good and equally acceptable, as long as it is the individual himself who has made that determination, because regard for the individual's autonomy does not exclude the relevance of observing other considerations too, such as regard for others' lives and lifestyles and regard for the values of the community. But if it is felt that the individual ought basically to be treated as an autonomous being, it is because relatively great weight is attached to humankind's ability and responsibility to choose how to determine or plan its own life conduct.[7] It should be noted that this concept of autonomy does not rule out an autonomous person continually choosing throughout life to base his life conduct on a set of values and standards from a religious persuasion, a political party or suchlike. Anyone who does advocate autonomy simply needs to recognize the value of the individual himself having the possibility of relating to his values and choosing them freely, or choosing whether they should still be the same.

There is good reason to stress the above meaning of autonomy or self-determination, because for the purposes of the debate on euthanasia self-determination is otherwise often used to describe only freedom of choice. Promoting the individual's scope for self-determination, in this sense, means extending the field of actions that others may carry out on one's behalf if so asked. If the possibility of being self-determining is associated primarily with the extent of legal options, there will not be the same degree of focus on the independent value of autonomy as above, but rather on the value of the course of action under review. In other words, one can argue from the baseline that personal autonomy per se is something to be aspired to, or one can imply that autonomy chiefly signifies freedom of choice and is thus a tool for achieving a goal worthy of aspiring to, which in the case of euthanasia is to die.

3.1.1 Arguments in favour of euthanasia based on self-determination and autonomy

Self-determination as a positive or a negative right?

Adherents of euthanasia advocate the legalization of killing on request in carefully circumscribed situations. However, the choice is not merely one of whether euthanasia should be legal or illegal. There is also a need to create some clarity about the way in which it is wished to legalize euthanasia. It is important to distinguish whether the reasoning argues for a positive or a negative right of self-determination regarding euthanasia. A positive right of self-determination implies that a person can demand to have euthanasia carried out, providing the criteria for being able to request euthanasia are otherwise met. A positive right of self-determination regarding euthanasia, therefore, implies that the duty to perform euthanasia is imposed on someone. A negative right does not, however, imply any entitlement to demand that euthanasia be carried out. Legalization here would merely mean that euthanasia is an action that is not illegal. No one is obliged to comply with the request for euthanasia, but it is legal to carry out euthanasia if the individual meets the qualifying criteria for having euthanasia carried out. If arguing for the legalization of euthanasia as a negative right, the practical implementation of euthanasia will depend on there being some people among those able/entitled to carry out killing on request under such a law who are willing to do so. If arguing for the legalization of euthanasia as a positive right, a legitimate request for euthanasia will result in individuals or institutions being obliged to accommodate that request. But the positive right can be graduated in terms of the authorities or persons in whom that obligation is vested. In one radical variant, it is possible to envisage all doctors being obliged to carry out euthanasia. A less restrictive variant might mean that the health services as such were obliged to arrange for euthanasia to be carried out, while leaving the individual doctor free to choose whether he or she wishes to perform euthanasia.

Apart from the variety of practical consequences, whether one is a supporter of a positive or a negative right of self-determination regarding euthanasia is significant in principle. A positive right of self-determination regarding euthanasia cannot be introduced without simultaneously acknowledging that, in certain cases provided for in law, society is duty-bound to take the life of a human being. A negative right of self-determination regarding euthanasia, on the other hand, can be introduced on the grounds that euthanasia, under certain circumstances provided for in law, is a matter for the judgement and conscience of the individual. The fundamental difference is that the first form of legalization, more so than the second, turns euthanasia into a communal, general matter, which must be acknowledged by society as a whole as being worthy of aspiring to ethically.

Autonomy as a value worth protecting

For some adherents, the prime purpose of legalizing euthanasia would be to promote autonomy or at least eliminate unnecessary barriers to it, given that they perceive autonomy as an essential value of human society worth protecting. These adherents of euthanasia will often base their views and arguments on the first meaning of autonomy (cf. the introduction to this section of the publication), which is all about the individual himself having the freedom to define the framework of his life and choosing his ideals as regards how that life should be lived and ended. Justifying their views will involve two different tasks. Firstly, it will be necessary to explain how euthanasia is essential to human autonomy. Secondly, they will have to argue against the legalization of euthanasia having detrimental side-effects that might outweigh the benefit they see in promoting autonomy in the above sense.

If these adherents advocate self-determination regarding euthanasia, but do not feel that euthanasia should be a duty that has to be performed, their defence of the legalization of euthanasia can be formulated thus: In some (enactable) cases, it is not unconscionable to take the life of a human being. Therefore, it must not be illegal to perform euthanasia in those cases. In the following, only the adherents' positive reasoning for saying that euthanasia is important for personal autonomy will be set out.

The positive reasoning for legalizing euthanasia is that euthanasia is perceived as a good action. For adherents, the good thing about taking a suffering person's life on that person's request lies particularly in promoting the person's scope for self-determination and hence their own control over events of vital, critical significance to the person's identity and life history.

In that sense, personal autonomy is about the individual's scope for shaping his or her life and imparting sense and meaning to it. The way people die is of great importance to individuals' overall perception and understanding of their existence. Adherents of euthanasia are therefore able to point to the particular importance of being able to influence the circumstances surrounding one's own death in societies that generally attempt to create a framework for individuals' freedom to define their lives themselves and choose their own values. For a supporter of personal autonomy in the above sense, the wish to die can be made understandable if the way the person dies, or the way the person can look forward to dying, is fundamentally at odds with the framework and values around which the person has built his or her life.

Even adopting this point of view as an adherent of euthanasia, there is still scope for graduating one's views as to who is entitled to have euthanasia performed. Thus the attitude towards autonomy can be supplemented by acknowledging that euthanasia involves some person who has to carry out euthanasia. That person has a responsibility of his or her own, for which reason the action may be subject to some restrictions that do not apply either to suicide or to the patient's right to interrupt or refuse life-prolonging treatment. In addition, it can be pointed out that euthanasia is an action which, unlike interrupting life-sustaining treatment, leads per se to death. To a greater extent, therefore, the action involves the doctor's responsibility, and it is an action that cannot be regretted or undone. If the emphasis is placed on these considerations as well as autonomy, it may make sense to confine euthanasia to an option for the dying and not, therefore, for people (totally paralyzed patients, for example) who may be enduring unbearable suffering but are not dying.

3.1.2 Arguments against euthanasia based on self-determination and autonomy

Opponents of euthanasia can criticize adherents' arguments about autonomy by questioning whether the legalization of euthanasia would promote the individual's scope for practising self-determination. This criticism can be put forward despite the consensus-inprinciple that autonomy in the above sense is a benefit and a value central to a person's life. [8]

Some argue (a) that a decision about one's own death is something fundamentally different from other life decisions and life choices, and therefore that a person's own death cannot meaningfully be said to be the subject of a free and autonomous choice. Others argue (b) that the concrete circumstances surrounding the choice scenario in the form of the role played by the doctor, society and the next-of-kin mean that the request for euthanasia will have arisen partly or wholly out of a situation in which autonomy cannot be practised, either because the person is not competent or because of direct or indirect pressure from their surroundings.

a. Autonomy and euthanasia make odd bedfellows

Although people are actually in a position to choose to commit suicide of their own accord or to ask to be killed, the idea is that the very choice of death cannot be the sort that involves making a serious and lucid decision beforehand which brings that choice into line with one's integrity as a human being. That view is predicated on a basic assumption that human life is lived on certain unavoidable terms, which include birth and death. In light of this, choosing to die can be said to be a choice that denies the basic conditions of humanity, and hence an essential part of the individual's general identity as a person. Any choice that seeks to improve life by doing away with it completely is irrational, according to this view, because that choice is made to look absurd when held up against the basic human condition.

Another aspect of this criticism that can be highlighted is the lack of scope for regretting or undoing euthanasia. Regret can lead to a reversal of that choice or, where this is not possible, to evaluation and possibly even remorse. Both can be perceived as essential parts of autonomy. Some also emphasize that choosing one's own death is a choice like no other, because it intrinsically results in the person who is doing the choosing becoming no one.

b. Euthanasia is incompatible with autonomy as a result of the circumstances surrounding the choice scenario

This view focuses on the institutional framework within the health services, with which the legalization of euthanasia is most often associated. The critique includes three different points, all of which have to do with the circumstances surrounding the choice scenario.

Firstly, it may be claimed that a law on self-determination pertaining to euthanasia in the health services will invariably lead to euthanasia becoming an offer that severe sufferers and dying patients cannot avoid having to take a stance on. Even if euthanasia is not mandatory, the choice scenario surrounding euthanasia will be forced on patients, solely because the possibility is provided.

Secondly, it is worth pointing out that, given the choice scenario, patients who already find themselves in a very difficult situation are saddled with an excessive burden of responsibility. Many factors will be taken on board as the patient weighs up the issue—for instance, regard for next-of-kin and a decision based on the doctor's advice. The gist of these misgivings is that, in a highly fraught situation, this complex deliberation does not provide the proper circumstances for making an autonomous decision, for which reason patients should not even be given the option at all. The possibility of exercising autonomy will often not be present, as the patient may be in a noncompetent state due to fear, desperation, a feeling of futility and a sense of being superfluous—a state that can be psychosis-like.

Thirdly, people may be sceptical about the terms of autonomy because there is always the danger that euthanasia will appear to be the best alternative in an environment where palliative efforts may be anything but adequate. Thus a patient can be pressured into viewing euthanasia as the proper action as a result of care and medical initiatives in the home or at hospital not being up to standard. The mere risk of such a situation being able to occur will weigh heavily in the anti-euthanasiasts' deliberations of the merits and demerits of legalizing euthanasia. Legalizing euthanasia may result in there being less focus on existential support and palliative treatment. For the individual it can result in less security and more uncertainty as to what he or she may be subjected to at the conclusion of life. Such uncertainty may also be perceivable as a lessening of autonomy, because lack of confidence in society's readiness to provide care itself engenders a poorer setting for personally coping with changes in living conditions.

Logically, the attitude underlying these criticisms implies scepticism about the possibility that legalizing euthanasia—even as a right that cannot be demanded—can ensure that the choice scenario is not forced upon doctors or patients. In a health service, consent is obtained on the basis of information about treatment options. It may be thought, then, that such information will invariably open up the choice scenario for the patient, however neutral the information dispensed. Moreover, it is worth pointing out that the mere awareness of the possibility of choice will be present, whatever happens, despite the patient not being informed directly before requesting euthanasia of his or her own accord.

3.2 The inviolability of human life

The fundamental conception that it is wrong to kill another human being is one of the weightiest reasons why euthanasia poses a dilemma: Why discuss the reasonableness of taking the life of a person at his or her request unless there were something rudimentarily understandable about the ban on intentional killing? Most people, on the contrary, can agree that taking the life of another human being belongs to those actions that are morally reprehensible in the highest degree. At the heart of such general consensus is a distinction between people's life, which has value in its own right, and physical objects, which have no value in their own right but roughly speaking only by reason of whatever use people find for them. The feeling that people's life has value in its own right leads to the view that people's life should not be violated or destroyed. Physical things can be destroyed if they no longer serve their purpose and everyone agrees that they are of no value to anyone. But when it comes to a human being, the idea is that the being is always its own end, too, and that destroying life with reference to the worthlessness of life is a violation, because a person's life cannot be worthless.

How exactly people interpret the sanctity-of-human-life principle and make up their minds about it is tightly bound up with the way they perceive the special value or dignity associated with humankind. In the debate on euthanasia, widely divergent views of this are represented. Naturally enough, adherents and opponents disagree as to what the sanctity-of-human-life principle involves. But also internally, among the ranks of opponents of euthanasia, there are different readings of the principle.

3.2.1 Arguments against euthanasia based on the inviolability of life

For opponents of euthanasia the principle of the inviolability of life can be put forward on either a humanist [9] or a religious footing. That is to say: in the humanist variant, the special value of human life can be viewed as a result of human qualities or as a result of humane recognition of this value; and in the religious variant the special value of human life can be viewed as being rooted in a divinity and hence in an authority outside the human world. Religious points of view will often differ from humanistically oriented ones in as far as killing is not merely perceived as a crime, but the individual also has an obligation to live, which is not due solely to any obligation to oneself or other people.

a. The inviolability of life from a religious point of view

Viewed from any one person's own angle, the principle of the inviolability of life is easy to empathize with. The fact that the principle is virtually a moral intuition, whichever approach to life one endorses, is certainly due above all to it being about protecting the innocent person's right to live. Religious and humanist conceptions of the principle have this element in common. But for a Christian viewpoint, for example, the sanctity-of-life principle functions not `just' as another formulation of the prohibition on killing. Life, according to Christianity, is something God-given, and something which everyone therefore has a duty to cherish.[10] This also means that the privileged status of human life cannot be derived from human qualities or from historical developments of interhuman standards. Human life, by contrast, possesses a special value, one worth preserving, ultimately because man is created in God's image and thus forms part of a suprahuman semantic context.[11] Therefore, resistance to euthanasia, founded on a Christian interpretation of the inviolability of life, can assume a more restrictive and dutiful form than resistance based on a secular interpretation of the sanctity of life. In such a religious outlook on life, the focus will not be just on regard for the individual's right to life but also on protecting the sanctity of life as such.

A clear example of this is found in the Catholic Church's approach to euthanasia. According to this, suicide (and hence being euthanized on request) should be regarded as murder, even though it is acknowledged that suicide sometimes takes place under the influence of psychological factors that can diminish responsibility or even eliminate it completely on the part of the suicide candidate.[12] The authority responsible for judging the value of life is not deemed to be the actual person, therefore—neither the one living the life in question nor others viewing it “from without”. Human life has an inalienable value; and whatever happens, taking the life of an innocent person will be a crime, and caring for life a duty. This attitude does not necessarily involve a heroic approach to modern medical methods of prolonging life, but it may do so. Furthermore, such a conviction will logically result in some scepticism towards the perception of autonomy presented in the previous section. The ideal here is not that people

b. The inviolability of life from a humanist point of view

There are a number of secular views as to what the inviolability of life means. Only two main types will be mentioned here, both of which may of necessity entail human beings being said to have an inalienable right to live and a duty not to kill—a right and a duty so valued that it would normally be morally unacceptable to legalize or perform euthanasia.

One main type of view might be called regulative, because the prohibition on killing and the inalienable right to live are perceived as principles that have a highly regulative and hence instrumental value in facilitating communal life between people. These principles can be claimed to belong to the basic conditions or possibility conditions governing sociability and should be valued as such. Within this point of view it is quite possible to opine that euthanasia in some instances would benefit the party requesting it while simultaneously insisting that euthanasia ought not to be carried out. The rationale is that the framework we humans decide to adopt for the sake of our social lives would suffer irreparable damage from doing so. [13]

The other main type of view is not based on the assumption that the sanctity-of-human-life principle has regulative value only. On the contrary: here it is maintained that the principle is valuable because people's life per se is actually characterized by being worthy of preservation, a fact that cannot be explained exhaustively on the basis of regard for the individual and the personal value life holds for that person. The result here is the same deference for the inherent value of life as arrived at via the religious point of view. But in one way the perception of human life's self-validity is more radical than in the Christian religious tradition, where the special status of human life is explained on the basis of a binding dependence on a suprahuman authority, the very result of which is ultimately to cancel out the intrinsic validity of that person's life. What is meant by the intrinsic value of life in secular traditions can only be hinted at with examples.

For instance, one might ask: Is most people's idea that we ought to do whatever we can to prevent the human race becoming extinct in a couple of hundred years' time based on some regard for those who do not yet exist? No, that description does not seem to pinpoint the moral intuition or feeling nearly as well as if we merely assumed that life per se is worthy of preservation. The same mental exercise can be performed in relation to euthanasia: Is the idea that something is lost by taking a person's life explicable solely in terms of the value that life possesses for the individual and his or her nearest and dearest? No, some will say, because the individual's life must be protected on the strength of that life having an inalienable value in its own right. However, it must be said that this humanist intuition about the inviolability of human life is less conclusive in relation to euthanasia than the religious variant described: a more open-ended question would be whether the individual can assume responsibility for pondering and ignoring the inviolability of life, for instance if life no longer has any personal value for the individual.

3.2.2 Arguments in favour or euthanasia as a critique of the inviolability-of-life principle

Critics of the inviolability-of-human-life principle do not say that the prohibition on killing is irrelevant. However, they do suppose that regard for the inviolability of human life hinges on regard for the individual, who has no interest in being killed, under normal circumstances. This can therefore be said to be a general rule that does not apply in the absolute sense but should be observed in all situations where the rule serves to safeguard the individual's interest in continuing to live. If the prohibition on killing is primarily and chiefly about protecting the value vested in the individual by virtue of being alive, that prohibition can no longer apply unless the person requesting euthanasia associates being alive with some positive value. The view is as follows: It is morally wrong to kill because it will deprive the individual of a specific number of years of life, complete with the positive value associated with those years. But as one of the champions of this view states: “The problem of the inviolability-ofhuman-life principle in the context of euthanasia is precisely that the person desirous of assisted dying is able to signal that he has no desire to carry on living, since he has anything but good years ahead of him to live” (Holtug, Niels & Kappel, Klemens (1993), p. 59. Translated by The Danish Council of Ethics). According to critics of the inviolability-of-human-life principle, it makes no sense to talk about life having a value besides its personal value as perceived by the individual. Such an outlook is bound to have absurd consequences in the form of life having to be preserved at all costs, wherever possible, regardless of the degree of suffering involved for the person living it: “but even if it were possible to defend the view that life always has some value, it would affect not only active, assisted, but also passive suicide. If life were always valuable, no matter how bad, presumably there would also be something problematic about omitting to administer treatment if a life were curtailed in the process” (Holtug, Niels & Kappel, Klemens (1993) p. 60. Translated by The Danish Council of Ethics.). Of course, it is also possible to feel that although the general principle of the sanctity of human life should be a weighty one for regulative reasons (see above), it should not weigh more heavily than regard for those people for whom death is purportedly better—owing to unbearable suffering—than continuing to live.

3.3 Killing and allowing to die

In the debate on euthanasia, there is major disagreement over what constitutes the ethically crucial difference between killing and allowing to die. The discussion arises because the majority of opponents of euthanasia are simultaneously willing to accept the interruption or omission of life-sustaining measures for the dying or patients in a persistent vegetative state (PVS)[14] who cannot give consent for such themselves. The “crunch factor” will be that life-sustaining treatment is considered futile. In addition, there is general consensus that “a terminally ill patient can receive whatever palliative, sedative or similar agents are needed to alleviate the patient's condition, even if this may result in hastening the time of death” (Danish Act on the Legal Status of Patients, Section 16, subs. 3). Advocates of euthanasia stress that the ethical assessment must be identical for euthanasia and for the end-of-life medical decisions mentioned. Conversely, many opponents of euthanasia will insist that there is a clear ethical difference in typical euthanasia scenarios between the doctor allowing the patient to die as a result of the patient's condition and the doctor taking the life of the patient by actively intervening.

3.3.1 Equating euthanasia with avoiding life-prolonging treatment in ethical terms

Most people will feel that refraining from sustaining a person's life is less challengeable in moral terms than killing a person. The philosopher James Rachels, however, elaborated on the issues surrounding this view in an article on so-called active and passive euthanasia from 1975.[15] The article is constructed around a supposition made for the sake of argument, which has since become a much-used tool in the pro-euthanasiasts' battery of arguments. It should be noted from the outset that this intellectual experiment revolves around allowing to die and killing in a completely different context than the one applicable to euthanasia or cessation of treatment. The situations are not parallel, therefore. However, the object of this experiment is to test what constitutes the ethically relevant difference between actions usually classed as killing and those usually classed as allowing to die. Rachels' point is that it is not the actual killing that is ethically more problematic than the allowing to die. Rather, the intention behind the action is what counts. According to Rachels, then, the fact that killing is normally more objectionable ethically than allowing to die is due to the incidental aspect that the intention of killing is usually more problematic. This point is then transferred to the debate on euthanasia to demonstrate that euthanasia (based on comparable intentions) should be equated with avoiding life-prolonging treatment.

In the article, James Rachels asks whether it is worse, per se, to kill than to allow to die. He answers the question by imagining two situations that are completely identical except that a person in one situation kills another person, whereas a person in the other situation allows another person to die without intervening: in one situation Smith drowns his six-year-old cousin in the bathtub, because he will inherit a fortune in the process. In the other situation Jones sneaks into the bathroom with the same intent and motive towards his six-year-old cousin, but Jones is `lucky' and is able to observe his cousin accidentally slipping, hitting his head, falling down into the bathtub and drowning. In this instance it is obvious to anyone that Jones failing to intervene is just as objectionable as Smith killing his cousin, even though Jones's action is not the direct cause of the cousin's death. Rachels acknowledges that the intellectual experiment does not have much in common with the doctor-patient situation in which the problematic issue of euthanasia is set. He is merely using the example to highlight the fact that neither the active action nor avoidance per se makes a moral difference, but rather the intention underlying the action as well as the act of omission.

Rachels' intellectual experiment shows that the presence of moral responsibility is not absolutely dependent on a person causing the death of another directly through his actions in the physical sense. In other words, if a person's active deed is the cause of another person's death (and that deed is performed deliberately, with insight into its likely consequences), the agent will always have a moral responsibility, but conversely it cannot be inferred that a person who does not cause the death of another through his or her active deed never has a moral responsibility for that person's death.

The ethically significant difference between euthanasia and avoidance of life-prolonging treatment cannot be comprised of “allowing to die” as one action with “taking the life of” being the other. The extent to which an action whose consequence is another person's death is morally acceptable must be explained on the basis of other differences, for example the difference in intent. If it is maintained that the intent of euthanasia—like accepted medical interventions at the conclusion of life—is to avoid unbearable suffering, then that which advocates such interventions must also advocate euthanasia. In other words, it is not acknowledged that the intent of euthanasia is to take the life of the patient, whereas the intent of avoiding life-prolonging treatment is only to avoid futile treatment or undue pain. On the contrary, it is maintained that the intent of both is to avoid undue suffering, and that the actual consequence—of the patient dying—is in both instances something that is not desired per se.

By way of experiment, then, it can now be admitted that it is the intent, not the nature, of the action of “allowing to die” or “taking the life of” that is ethically crucial. Accordingly, as an opponent of euthanasia, one can object to the intent of euthanasia actually being to take the patient's life, whereas the intent of avoiding life-prolonging treatment is to avoid undue suffering or to grant a possibly legally competent patient's right to exert control over his treatment. But even accepting this difference of intent, an argumentational challenge arises for opponents of euthanasia who advocate doctors being able to interrupt life-prolonging treatment of PVS patients. Continuing to be alive does not cause the patient any pain, so avoiding treatment cannot be said to be palliative by nature. The patient is not legally competent, so avoiding treatment cannot be justified on the basis of the patient's right to determine himself whether legal treatments are to be continued or interrupted. The only thing that would seem to be left is the considered view that dying is at least no worse than living for a person in PVS. Adherents of euthanasia can therefore aver that no good reason for interrupting this type of patient's treatment is given that would not be an equally good reason for performing euthanasia.

3.3.2 Criticism of equating euthanasia with avoiding life-prolonging treatment in ethical terms

Many opponents of euthanasia will assert that the difference between “allowing to die” and “taking the life of” has sound and well-founded ethical significance for precisely the sort of situation most often encountered in discussing euthanasia, i.e. the incurably ill, suffering and possibly dying, because these people are already in an unavoidably progressive state, which is no one's choice, simply one of life's vicissitudes. In this situation, then, there is a marked difference between allowing the person to die—whether it be by opting out of further treatment or by interrupting treatment already initiated—and taking the person's life. [16], [17]

Permitting a person to die in these situations is an action that allows something already in progress to happen which, even then, is the result of something unmerited and inevitable in the form of severe disease or injury. The taking-away of life-sustaining treatment is different from euthanasia in as much as the action is not the only condition necessary for the decease of the patient. If the patient were not in a critical state to start with, taking away that life-sustaining treatment would not lead to the patient's death.[18] It is different with euthanasia. This action leads to the death of the other person, regardless of the condition that person is in. It can thus be ascertained that there actually is an essential difference between allowing a person to die and taking a person's life.

So what if, as an opponent of euthanasia, one acknowledges that the rationale for avoiding life-prolonging treatment in certain cases is very much akin to the reasoning for euthanasia (i.e. acknowledgement that life is no longer preferable to death)? Here it can be argued that therapeutic intentions cannot be merely postulated—they must also be able to be gleaned from the types of action initiated. The ethically vital difference between allowing death and curtailing life in contexts where a patient is suffering from an incurable disease is that euthanasia as an action will suffice to bring about death, whereas avoiding life-prolonging treatment is not sufficient per se to bring about death. In conjunction with PVS patients, for example, treatment can be said to originally have been initiated for the purpose of improving the patient's condition. Discontinuing life-prolonging treatment is subsequently justified by reasoning that the treatment is not serving the purpose for which it was originally initiated. Euthanasia, on the other hand, is not an action that relates to whether or not previous treatment was successful but is a new action with a purpose all of its own.

3.4 Unbearable suffering and compassion

When debating euthanasia, it is not primarily objectives and motivations that are up for discussion. Thus proponents and opponents of euthanasia seldom disagree that preventing or assuaging people's suffering is a commendable deed in medical and humane terms, and that the feeling of compassion is generally a valued emotion. Disagreements and differences of opinion are more to do with the extent to which the end justifies the means, i.e. to what extent eliminating pain and suffering can justify performing and/or legalizing euthanasia. Furthermore, the appeal for compassion for people who are suffering unbearably is particularly germane to the question of the role and practice of medicine in the context of euthanasia, for alleviation of suffering ranks among the most ancient objectives of medical practice, in as much as it was obviously possible to allay suffering associated with disease and sickness long before it became more widely possible to cure disease.
In the discussion about suffering it is particularly important to relate to the questions:
What human conditions does the concept of suffering cover?
What states of suffering are so severe that they can allegedly justify the desire for and possibly even the right to euthanasia?
It is important to examine possible meanings of the concept of suffering, because existing euthanasia laws in the Netherlands and Belgium (see Appendix) determine that the patient must be going through unbearable suffering in order to qualify for euthanasia. Moreover, the problem is already hinted at by an important difference between the two laws: In the Netherlands the law merely mentions unbearable suffering, whereas the Belgian law talks about unbearable physical or mental suffering. The provision in these laws on unbearable suffering is also an expression of a general consensus among proponents of euthanasia that euthanasia should not be an option open to just anyone asking for it. The debate rarely sets out the reasoning for not arguing in favour of completely free access to euthanasia. This is probably due to agreement that suffering as a criterion for access to euthanasia is based on an approach that is taken for granted and regarded as self-evident. It is an approach shared with many opponents of euthanasia: The ethical acceptability of one person taking the life of another at the latter's request and based on a feeling of compassion will depend, as a minimum, on the situation involved being one of extraordinary suffering and agony that cannot be relieved. The approach, in other words, is that euthanasia is not a straightforward panacea that can be offered to everyone. On the contrary, existing euthanasia laws and the trend-setting arguments in the domestic debate reflect a realization that euthanasia is a measure prompted by necessity—a “last resort” reserved for people for whom life is so full of suffering that death appears to be the kinder of two evils.

But what does suffering mean? Firstly, it must be noted that suffering is not identical with the experience of pain caused by physicalities. Some bioethicists will think that suffering and physically caused pain are two essentially different phenomena, whereas others will assert that physically caused pain is merely one of many ways of suffering.

Pain and suffering are two different phenomena, and suffering is a personal phenomenon

Suffering can be perceived as a subjectively experienced reaction to critical changes of life—in connection with illness, for example. Physical symptoms may be the source of suffering, but the treatment of that illness, the isolation in relation to normal social life and the fear in terms of the illness developing, for example, can also be sources of suffering.[19] Physically caused pain, then, is one of just many possible sources of suffering—a fact recognizable to most people because it is possible to envisage being in an agonizing condition without experiencing physically caused pain. But the difference in nature between suffering and pain is also seen in the experience of severe physical pain not being simultaneously perceived as actual suffering in some people, whereas the experience of less severe physical pain in others largely gives rise to suffering. Doctor and bioethicist Eric J. Cassell has established the model of a person-centric view of suffering, and as an example of the dependence of suffering on personal factors states the following:

One patient, who said he was not suffering, had metastatic cancer of the stomach from which he knew he would shortly die. On the other hand, a woman who felt her suffering bitterly was waiting in the hospital for her blood count to return to normal after it had been long depressed by chemotherapy. Aside from some weakness, she was otherwise well and would remain so. (Cassell, Eric J. (1991), p. 31)

Cassell thus perceives suffering as something quintessentially ascertainable only by asking the patient. He highlights the challenge for the medical profession posed by the subjectivity of suffering. In tandem with healing disease, alleviating suffering is a central objective of medical therapy, yet at the same time suffering is a phenomenon that cannot be reduced to biomedical scientificality, as a matter of principle. Suffering, unlike the physical symptoms, is not accessible per se to a third-person perspective. To a large degree, however, Cassell views it as the medical profession's purpose to address and allay suffering, including suffering that is not linked directly to physical symptoms but typically arises nevertheless as a result of severe states of ill health. Based on his own medical experience, he defines this suffering as a “state of severe distress associated with events that threaten the intactness of person”. This problem complex has a bearing on the discussion of whether an evaluation of suffering can be included in justifying a patient's entitlement to euthanasia. Discussion of this is continued in sections 3.4.1 and 3.4.2.

Pain is one of many other forms of suffering, and suffering is an objective phenomenon

A slightly different yet related description of suffering is found in the Dutch bioethicist Stan van Hooft. According to this description, different types of suffering exist, and objectively they can be described as suffering, without the personal perception of such always being crucial. Van Hooft's point of departure is that the fulfilment of specific aspects of human existence may be universally perceived as units of measurement that determine whether a person is complete and therefore preserves his or her integrity. He highlights four central areas (drawing inspiration from Aristotle's science of the soul): “[1] people's biological functions, [2] their emotional and volitional functions, [3] their practical and rational life, and [4] their feeling of meaning to their existence”. Van Hooft consequently perceives suffering as “prevention of the tendency to fulfil these various aspects of our life”[20]. For example, he views disease, handicap and physical injuries as suffering in the objective sense—i.e. without regard for what people who have been subject to such states think about it. Disease is primarily suffering in the sense that it works counter to people's biological and bodily function. That is to day: disease, by definition, is a disruption to a human's biological functions. In addition, however, disease will generally result in some degree of suffering in relation to the person's senses and emotional make-up. Disease brings with it a change in one's relationship with one's body, just as debilities not necessarily serious in themselves (for instance, fever, nausea and so on) involve a change in a person's sensuous relationship with the outside world, a change representing the source of discomfort and suffering in van Hooft's sense.[21] Furthermore, disease can result in suffering in relation to a person's life conduct, but that will depend on the objectives the individual has, and on the way the individual is capable of adjusting his objectives while keeping his contentment intact—hence the disappointments that person will experience in terms of his courses of action being thwarted. Finally, it is possible, but not certain, that disease will lead to suffering in the form of the person's sense of meaning to life changing and becoming uncertain.

Although, according to this model, suffering is suffering, no matter how it is perceived by the individual, the difference between this model and Cassell's description is not very great. The greatest difference lies in van Hooft's description, which implies the slightly contra-intuitive aspect that PVS patients, for instance, can be said to suffer even though they do not experience anything. Furthermore, that perception will imply that disabled people suffer, regardless of their own thoughts on the subject. The latter consideration is mostly hair-splitting, however, since on the basis of the “objective model” disabled people might be said to have a disorder, but not necessarily to suffer from it, because despite the biological functional suffering, they do not perceive suffering on the other functional levels (in their emotional life, in their life conduct and in the dimension that deals with the view of the meaning of life).

3.4.1 Reasoning in favour of euthanasia based on the regard for alleviating suffering

As previously mentioned, any argument in favour of legalizing euthanasia based on the regard for alleviating suffering must address the fact that any evaluation of suffering, and to a great extent any evaluation of unbearable suffering, will vary according to who is in the condition described. At the same time, if the suffering criterion that qualifies people for euthanasia is to play an independent part, the job of evaluating such suffering clearly cannot be left solely to the person requesting euthanasia. In that case the criterion would no longer be a constraint on access to euthanasia and self-determination would be the only crucial requirement. The argument only makes sense, therefore, if the patient's affirmation of unbearable suffering is a necessary but not a sufficient condition of the patient's eligibility for euthanasia. In other words, it must be a minimum requirement that certain objective and highlightable aspects of the patient's condition must have been met before the patient's statement about unbearable suffering and the request to have euthanasia performed can actually result in the doctor accommodating the patient. If suffering is perceived as something other or more than physical pain, the argument further presupposes that the purpose of medicine is partly acknowledged as preventing or alleviating suffering bound up with the patient's self-perception, integrity and spiritual dimension.[22] As described in section 1.3, the pro-euthanasiasts' assertion that people have a right to a dignified death is all about promoting such an end. Although such an end for the medical profession would enjoy widespread recognition, it is only fair to mention that acknowledging it is not a matter of course. For example, van Hooft, mentioned above, is an exponent of the view that it is not within the medical profession's power to prevent or alleviate this form of suffering, though doctors and others would naturally be obliged to ensure that treating patients resulted as little as possible in such suffering.[23]

Euthanasia as an ethically defensible means of preventing unbearable suffering

As mentioned, most adherents of euthanasia do acknowledge that euthanasia must be a last resort. That is to say that the suffering must be truly unbearable and considered as incapable of being allayed in any other way. It is possible to conceive of different angles of approach to unbearable suffering as justification for euthanasia.

One line of argument can take as its basis Cassell's above-mentioned definition of suffering: “A state of severe distress associated with events that threaten the intactness of person”.[24] Furthermore, it is worth emphasizing that severe disease, injuries and bodily decay will very often constitute events that threaten the person's intactness and self-perception. Although the degree of appreciable suffering caused by physical pain and other frustrations brought on by disease depends on the individual, some factors relating to pain associated with severe disease can be highlighted that will generally lead to an appreciable degree of suffering. Cassell himself lists certain points that indicate when pain is a source of suffering: if the pain is overwhelming; if there is no hope or faith that the pain can be brought under control; if the pain is constant and unavoidable; and if the painful symptoms are alien and unexplained to the patient.[25] The subjective component of suffering and its many different forms are arguably justification for making the doctor, in collaboration with the patient, the one to assess whether the suffering is unbearable, just as the doctor must assess whether enough has been done to allay the suffering in other ways (for example, by explaining what the symptoms are due to). This presupposes trust in the doctor's ability—for example, with the above or similar criteria in mind—to assess whether the patient is suffering unbearably and whether the suffering has been caused by the disease interfering with his or her life.

The approach described here involves partly foregrounding features of the backdrop to pathologically determined suffering that are not random, and partly highlighting trust in proper medical judgement and good communications between doctor and patient. A slightly different approach would be to recognize to a greater degree that suffering in the above sense (Cassell's definition) is subjective and existential, and in return to introduce a restriction that constitutes a safeguard against any random assessments of unbearable suffering playing too crucial a role. One such restriction on entitlement to euthanasia may be that euthanasia is only one option for terminally ill patients. As a supplement to the self-determination and unbearable-suffering requirement, this eligibility criterion can be viewed as a safety device for ensuring that the damage connected with any random evaluation of unbearable suffering is contained. But it can also be rooted in a notion that dying people, being close to death, run a particular risk of suffering unbearably as a result of the fear of becoming estranged from their own lives during their final days, owing to a lack of mobility, pain and invasive treatments. It is thereby possible to argue that, of all people, the dying have a special need to be able to request euthanasia. As a euthanasia supporter, then, one may feel in principle that everyone (including the non-dying) risks suffering appreciably from crippling disease and the prospect of living a life and even dying a death at odds with one's overall life story and philosophy of life. At the same time, for pragmatic reasons, one may wish to restrict euthanasia to being an option for the terminally ill. For the attitude may be that it would be considerably more difficult for the non-dying to dismiss hopes that the patient's current situation will cease to be full of unbearable suffering. This applies equally to people with chronic and incurable pain or disability, because hope in the cessation of suffering is not just hope in the cessation of physical pain, but also hope that physical pain and infirmity will gradually become bearable and liveable-with—that is, a hope in new meaning and existential stability.

3.4.2 Criticism of euthanasia as a means of alleviating suffering

Criticism of justifying euthanasia on the grounds of alleviating unbearable suffering is naturally based on the impossibility of measuring suffering and hence the impossibility of setting even tolerably clear bounds to determine when a person might meaningfully be said to be suffering so unbearably and so unavoidably that euthanasia is the best choice. The introduction to this section shows how many different forms of suffering can be brought about by severe illness or disease. Surely, then, it is only natural to enquire what forms of suffering euthanasia should be able to be used to eliminate?

Because apart from the question of whether there are other options less serious than euthanasia in a specific situation, the physician will also need to be clear as to whether only physical pain needs to be evaluated, or also the suffering that arises as a result of becoming more dependent on help and no longer being able to perform the most basic bodily functions.

On the one hand it might be thought safest if suffering were taken to mean physical pain only. On the other hand it seems to be ill-founded to say that the very suffering that arises as a result of physical pain should entitle people to euthanasia while other suffering, which can be just as unbearable, if not more so, is insufficient justification. Furthermore, criticism of the pro-euthanasia suffering argument can focus on the unsuitability, in very general terms, of euthanasia as a means of preventing pathologically determined suffering. In relation to the argument that euthanasia is only for the dying and for patients with unbearable suffering, it may be stated that the appropriate way of relieving existential suffering associated with death is spiritual care, not euthanasia. It can be said that regard for preserving the integrity and self-perception of a dying person should not result in the manner of dying being tailored to the patient's former way of living (level of activity, self-control etc.). If anything, it should lead to health professionals taking into account the patient's life story and basic value set in their endeavours to help the patient live with the more or less pronounced loss of meaning and control.

3.5 Euthanasia and slippery slope arguments

For some opponents of euthanasia, arguments that legalizing euthanasia will have adverse knock-on effects are more important and more central than arguments rejecting euthanasia on the principle of the inviolability of life. That is to say that someone opposed to legalizing euthanasia may feel that these effects make it ethically unacceptable to legalize euthanasia. At the same time, it may be felt without any contradiction that euthanasia per se is not an unethical action under all circumstances. Opponents who place the greatest stress on the adverse knock-on effects of legalization or institutionalization may even concede that, in certain particular instances, unbearable suffering in the terminally ill constitutes the very circumstance that renders the actual action of euthanasia ethically acceptable. They will merely maintain that the negative effects of turning euthanasia into a legitimate action are greater than the ethical benefits achieved by accommodating the request for euthanasia in those who are suffering unbearably, may even be dying and cannot be helped further with palliative care. An important element of this argument is the general agreement that there are relatively few people in Denmark who will be in the situation described.

As a rule, when up against this type of argument, adherents of euthanasia will seek to demonstrate that the fear of negative effects is ungrounded. They cling to the fact that the legislators and health services will be able to keep practice within the object intended by proponents of euthanasia: to help people suffering unbearably and possibly dying to die when they so request, and when the palliative treatment options have been exhausted.

3.5.1 Slippery slope arguments against legalizing euthanasia

The slippery slope argument occurs in two different variants. Firstly, an ethical justification of euthanasia may be thought to entail the justification of other actions by a process of logic, for example euthanasia without the patient's request. The logical correlation asserted (which is amplified below) between euthanasia and euthanasia without request can thus be stated as the reasoning for the supposition that future practice will follow on the heels of the logic that underpins the desire to legalize euthanasia but also justifies euthanasia without request as a result. This variant of the slippery slope argument can be called the logical slippery slope argument. Secondly, one may feel that in practice there will be great difficulty interpreting and complying with provisions stipulating who can request euthanasia, i.e.: whether they are suffering unbearably, whether their request is autonomous and intended seriously, and possibly whether they are terminally ill. Here, then, the focus is on the framework for performing euthanasia, and it is asserted that the scope for judgement and interpretation is too great to be able to guarantee the patient's autonomy and ensure that he or she is the kind of person whom the law grants the option of requesting euthanasia. This variant of the slippery slope argument can be called the practice-oriented slippery slope argument. In the following account, the main emphasis is on the logical slippery slope argument.

a. The logical slippery slope argument

At bottom this argument is about demonstrating that there is a special correlation between three typical components of proposals to legalize euthanasia: (1) the requirement concerning the patient's autonomous decision, (2) the requirement that the patient be suffering unbearably and (3) the requirement that a medical assessment be made to this effect and hence that euthanasia must be indicated medically. The doctor's assessment of whether euthanasia is beneficial to the patient in a specific case means that, logically speaking, pro-euthanasia arguments with the constraints outlined must be pro-euthanasia arguments without the constraints outlined. The conclusion will then be that the key argument actually in favour of euthanasia is not respect for the patient's self-determination but regard for the benefit of the patient who, according to the doctor's judgement, is suffering to such a degree that dying is better than continuing to live. Logically, then, euthanasia is a boon for anyone for whom it is indicated, not merely for those capable of requesting it. With time, therefore—so the argument goes—euthanasia will be accepted for patients who are dying and suffering unbearably, even if they are incapable of requesting it.[26] A brief account is given below of the steps in the argument that lead to this conclusion.

The first step in the argument is to ascertain that euthanasia is an option for those who are medically assessed to be suffering unbearably and possibly even dying.[27] The doctor assesses whether euthanasia is indicated for the individual patient, the point of this assessment being not primarily autonomy. Rather, it must be said that the autonomous request for euthanasia is regarded as a necessary proviso for the doctor to even be able to begin assessing whether the patient is otherwise in a state qualifying him or her for euthanasia according to the provisions set out. The decision of the doctor (and any consulting physician) concerning indication for euthanasia is based on an assessment of whether the patient is suffering unbearably and on whether all other possibilities for alleviating the patient's suffering have been exhausted.

The next step in the argument emphasizes that this assessment is reminiscent of the assessment already being made as part of good clinical practice before a doctor omits or interrupts life-prolonging treatment for terminally ill patients who are not legally competent. Similarly, the assessment recalls the deliberations any doctor has to go through before deciding to administer palliative medicine, a side-effect of which is to risk shortening the patient's life, or before deciding to administer palliative sedation.[28] Although there may be a difference between the intent of euthanasia and pain-relief therapy at the conclusion of life, most people will surely agree that the doctor's assessment in either case is about the degree of suffering and whether to provide other, less serious therapeutic options that can benefit the patient.

The third and conclusive step in the argument indicates that, in the situation described above, euthanasia without request in dying patients will become just as acceptable as avoiding life-prolonging treatment is today, since the important thing about any medical assessment of the indication for euthanasia is whether euthanasia really is in the patient's interest; and if it patently is no longer in the patient's interest to live (for which reason avoiding life-prolonging treatment is acceptable), euthanasia will also be perceived as being in the patient's interest. The autonomy requirement will therefore recede into the background in cases where the patient is terminally ill and the suffering is so great that living that short while longer will be of no benefit to the patient. An additional opening will perhaps appear when the autonomy requirement in some cases recedes into the background, when unbearable suffering will generally play a greater role as a criterion. But unbearable suffering is difficult to define, so that in the even longer term some people may fear that euthanasia without request will not occur `only' in the same instances where it is currently good clinical practice for a doctor to avoid life-prolonging treatment for a terminally ill person.

Empirical evidence for the logical slippery slope?

To some extent, euthanasia studies in the Netherlands can be said to provide support for the line of argument described. In 1990 and 1995 the Dutch authorities conducted in-depth studies into how and why euthanasia and other clinical end-of-life decisions are implemented. The study from 1990 (The Remmelink Report)[29] showed that doctors in the Netherlands had performed euthanasia in 1,000 cases where the patient was not capable of requesting it. Most cases involved terminally ill patients, where the majority would consider it reasonable to interrupt treatment or possibly administer palliative medicine, with the side-effect of that life being shortened. Indeed, John Keown, one of the foremost advocates of the slippery slope argument, has also stressed that the commission behind the report defended most of the 1,000 cases of unsolicited euthanasia by likening them to palliative treatment. In his book on the slippery slope argument, from 2002, he cites a quotation from the report, showing this:

The ultimate justification for the intervention is in both cases the patient's unbearable suffering. So, medically speaking, there is little difference between these situations [the majority of the 1,000 cases of euthanasia without request] and euthanasia [in the Netherlands `euthanasia' is consistently used about taking the life of a person at his or her request], because in both cases patients are involved who suffer terribly. The absence of a special request for the termination of life stems partly from the circumstances that the party in question is not (any longer) able to express his will because he is already in the terminal stage, and partly because the demand for an explicit request is not in order when the treatment of pain and symptoms is intensified. The degrading condition the patient is in confronts the doctor with a case of force majeure. According to the Commission, the intervention by the doctor can easily be regarded as an action that is justified by necessity, just like euthanasia.[30]

John Keown also makes a point of highlighting that the 1990 Remmelink Report provides evidence of far more cases of euthanasia without request than the 1,000 mentioned above if cases are included where doctors have interrupted or omitted life-prolonging treatment [31] and at the same time signalled that their express purpose in so doing was to shorten the patient's life. According to John Keown's reading of the study results, 5,450 patients were administered euthanasia without request if these cases are included. In a questionnaire survey in which doctors are asked to tick various ready-formulated reasons, there may naturally be some uncertainty as to how the individual doctor perceives the ability of such wordings to describe their actual intentions once they had resolved to go ahead. In other words, it is uncertain whether the doctor in all 5,450 cases would insist that the intention was to shorten the patient's life if he or she gave more careful consideration to the matter. But John Keown's reasoning is that, ethically speaking, avoiding life-prolonging treatment with the intention of shortening life must be judged in the same way as euthanasia. On the balance of probabilities, therefore, the extensive occurrence of these actions indicates a slippery slope towards actual euthanasia without request for patients in a similar condition.

Practice-oriented slippery slope

This argument takes as its basis the fact that any regulation and institutionalization of euthanasia will include a number of critical parameters that allow excessive room for interpretation and afford too great a risk of the competences and resources of those taking part (both the person on the receiving end and the one on the performing end) being insufficient to form the basis for so final a decision as euthanasia. The critical points are principally the following four: Firstly, there will always be uncertainty about the patient's diagnosis and prognosis. Albeit perhaps in very few instances, a patient occasionally lives considerably longer and may make a considerably better recovery than predicted by the medical prognosis. Secondly, assessments will vary as to when all the alternatives for relieving the patient's suffering have been exhausted, especially because this depends on the type of suffering (physical or existential suffering?) they are designed to alleviate. Here, in particular, it is a prerequisite that doctors have a high level of knowledge and skill in palliative care provision.[32] Thirdly, the definition of unbearable suffering, as previously mentioned, is largely open to interpretation. How does the patient's subjective evaluation of his or her suffering tally with the medical assessment, and what should count as qualifying a person for euthanasia?[33] Fourthly, it can be hard to assess when there is an explicit and sure-fire request for euthanasia from a patient whose powers of self-determination are intact. John Keown has summed up the argument as follows:

Surely, guidelines would end up granting considerable leeway to the opinion of the doctor as to whether the request was voluntary, and to the feelings of the patient as to whether the suffering was unbearable.

John Keown goes on to stress that the necessary confidentiality relationship between the practising doctor and patient regarding such assessments will in itself be a hindrance to successfully maintaining any effective control of euthanasia.

3.5.2 Criticism of slippery slope arguments about euthanasia

Euthanasia without request is ethically defensible in some cases

The most powerful objection to the logical variant of the slippery slope is that it is not at all about a slippery slope from something ethically less dubious to something ethically more dubious. The argument is powerful because it admits the premiss for the logical slippery slope argument: that euthanasia will be exercised chiefly to benefit the patient, and that the patient's ability to request euthanasia cannot therefore be said to be crucial in all cases. Based on this premiss, however, the opposite conclusion is drawn: that, precisely for this reason, it must be legal to exercise euthanasia not only at the patient's request, but also in certain cases where the patient is not in a position to request euthanasia. The ethical slide described by advocates of the slippery slope argument seems straightforward, of course, if one is of the conviction that euthanasia without request is ethically acceptable in cases logically included in the actual pro-euthanasia argument.[34]

This conviction bears some relation to a critical attitude towards the sanctity-of-life principle. As described in section 3.2.2, critics of the inviolability of human life perceive the prohibition on killing as a way of safeguarding the value vested in the individual by virtue of being alive. Consequently, the prohibition does not apply if the person whose life is taken attaches no positive value to being alive. According to that person, life cannot be said to have any value per se, only by virtue of the value the individual perceives life to have. Based on this view, it may be felt that a person who has irretrievably lost his or her consciousness no longer has an interest in living. In consequence, the conclusion can be drawn that euthanasia without request and avoiding life-prolonging treatment are both ethically acceptable actions when dealing with this type of patient. Moreover, it may be felt that a supposedly negatively perceived value (unbearable suffering) in incurable and possibly dying patients who are not legally competent justifies euthanasia without request in the same way. Some will therefore feel that euthanasia without request is ethically defensible in severely disabled infants, who may have to go through painful curative treatments in order to obtain what may turn out to be only a brief life with no or severely reduced ability to experience the world, function motorically and assimilate socially. Others will feel that euthanasia without request is also defensible in the case of severely demented people who express unbearable suffering without being capable of requesting euthanasia. In other words, acceptance of euthanasia without request need not tie in with a requirement for the patient to be terminally ill.

Euthanasia is particularly relevant for people who have the ability for self-determination

In a critique of the logical slippery slope argument, one may argue instead from the assumption that the premiss is wrong: The doctor's assessment of the patient's suffering is not the supreme criterion, and self-determination should not be viewed exclusively as the patient's ability to consider and request euthanasia. Instead, it can be asserted that the perceived, limited opportunity a modern health service offers for exerting influence over decisions regarding one's own death is an integral part of the actual suffering for many autonomous patients who are incurably ill or even dying. Against this backdrop it can be argued that euthanasia is an option that makes particular sense for patients with unbearable suffering who are concurrently in a state where their ability for self-determination is intact. By its very nature, euthanasia can be said to be a last resort that should be limited to those who have an altogether special need. Dying people who are suffering but have not decided and are currently unable to decide in favour of euthanasia may not have such a particular need. Their need is for pain relief and palliative care. If the patient has impaired consciousness and is on the brink of death, some will feel that the patient may not care if his or her life is terminated or his or her pain alleviated. Even in this case, however, it will be possible for euthanasia adherents to argue on the basis of the above that euthanasia—given the severity of the means—should only be administered where there is an altogether special need. This special need, it may be asserted, makes the minimum assumption that the patient is suffering unbearably and is simultaneously capable of making an autonomous decision. This precludes any acknowledgement that there is a logical link between the rationale for euthanasia and euthanasia without request.


[7] Cf. Childress, James (2000), p. 149: “Autonomy does not imply that an individual’s life plan is his or her own creation and that it excludes interest in others. The first implication focuses on the source, the second on the object of autonomy. Neither implication holds. Autonomy simply means that a person chooses and acts freely and rationally out of her own life plan, however ill-defined. […] Thus, personal autonomy does not imply an asocial or ahistorical approach to life plans. It only means that whatever the life plan, and whatever its source, an individual takes it as his own”.

[8] A critical approach to euthanasia may also result from being sceptical about the ideal of human autonomy altogether. It may be felt that the ideal of autonomy values individual scope for action too highly and ignores interpersonal care. This critique of autonomy is not examined here but is represented in the Council’s arguments in section 2.4.1.

[9] The term ‘humanist’ is used here not in the sense of ‘human’ or ‘beneficent’, but of a philosophy of life that, unlike religious views, interprets life without reference to a superhuman reality.

[10] Cf. for instance the Declaration on Euthanasia, prepared by the Sacred Congregation for the Doctrine of the Faith (the Catholic Church): “Most people regard life as something sacred and hold that no one may dispose of it at will, but believers see in life something greater, namely a gift of God’s love, which they are called upon to preserve and make fruitful”. This view is more or less representative of the monotheistic religions in our part of the world (both within Christianity in the form of Protestantism and Catholicism, and within Islam and Judaism). Sacred Congregation of the Faith (1980).

[11] See e.g. Andersen, Svend (1999), p. 305: “The point of the prohibition on killing must be seen in the context of belief in Creation as the vital prerequisite to the biblical perception of human life. Belief in Creation means that human life is viewed in terms of some authority external to man, i.e. God as Creator. In keeping with belief in the Creation, the actual fundamental fact that a person exists is not due to that person him/herself, but is a blessing from the hand of the Creator.” [Translated by The Danish Council of Ethics]

[12] Cf. the Declaration on Euthanasia, prepared by the Sacred Congregation for the Doctrine of the Faith (the Catholic Church): “Intentionally causing one’s own death, or suicide, is therefore equally as wrong as murder; such an action on the part of a person is to be considered as a rejection of God’s sovereignty and loving plan. Furthermore, suicide is also often a refusal of love for self, the denial of a natural instinct to live, a flight from the duties of justice and charity owed to one’s neighbour, to various communities or to the whole of society—although, as is generally recognized, at times there are psychological factors present that can diminish responsibility or even completely remove it”. Sacred Congregation of the Faith (1980).

[13] Reasoning of this ilk is set out in a report from the British House of Lords’ Report of the Select Committee on Medical Ethics (1994), p. 49: “to create an exception to the general prohibition of intentional killing would inevitably open the way to its further erosion whether by design, by inadvertence, or by the human tendency to test the limits of any regulation. […] we believe that the message which society sends to vulnerable and disadvantaged people should not, however obliquely, encourage them to seek death, but should assure them of our care and support in life.”

[14] Patients in a persistent vegetative state are people who, as a result of irreversible damage to the brain, have permanently lost consciousness and all functions generally other than the most basic biological mechanisms, such as the cycle between waking and sleeping states. The patient can feel nothing and has no alertness, either to himself or to the surrounding world. See p. 66ff.

[15] Rachels, James (1975).

[16] Cf. Gesang, Bernward (2001), and Callahan, Daniel (1992).

[17] The difference can also be elucidated by referring to the arguments adduced by the defence for a person charged with murder in a case from the USA. With the aid of a respirator etc., doctors attempted to give the victim life-saving treatment. When it became clear that the treatment was futile, it was halted. It was now claimed by the defence attorneys that death had been caused not by the accused but by those who had stopped the treatment. This view was not reflected in the sentencing, however. Cf. Graves, F. A. (1989), pp. 976-7.

[18] Cf. Callahan, Daniel, 1992, p. 329: “A lethal injection will kill both a healthy person and a sick person. A physician’s omitted treatment will have no effect on a healthy person”.

[19] Cassell, Eric J. (1991), p. 32.

[20] Back translation from Danish, Hooft, Stan van (1998), p. 126.

[21] Cf. Hooft, Stan van (1998), p. 127: “Even the things that we normally enjoy doing, such as listening to music or conversing with friends, lose their lustre when we are ill. The world seems to have a pall cast over it and our relationship to it is vitiated. If the inherent goal of this aspect of our being is an inchoate form of enjoyment and rapport with the world, then malady destroys this relationship”.

[22] The implication here being that euthanasia is accepted as a means.

[23] Cf. Hooft, Stan van (1998), pp. 130-31.

[24] It should be noted that Cassell’s deliberations on the nature of suffering is not part of a debate on euthanasia.

[25] Cf. Cassell, 1991, p. 38: “That this is the relation of pain to suffering is strongly suggested by the fact that suffering can often be relieved in the presence of continued pain, by making the source of the pain known, changing its meaning, and demonstrating that it can be controlled and that an end is in sight”.

[26] See e.g. Keown, John (2002), p. 77: “Consequently, the real, rather than the rhetorical, justification for VAE [voluntary active euthanasia] is not the patient’s autonomous request but the doctor’s judgment that the request is justified because death would benefit the patient”.

[27] It should be noted that it is not crucial to this argument whether the choice of euthanasia acts as a negative or a positive right (see section 3.1.1).

[28] For more in-depth treatment of palliative sedation, see Treating the Dying – The Difficult Decisions, section 3.4.1. pp 77-80.

[29] Cf. Medische beslissingen rond het levenseinde. Rapport van de Commissie onderzoek medische praktijk inzake euthanasie (1991).

[30] Taken from the Remmelink Report (Outline Report of the Commission of Inquiry into Medical Practice with regard to Euthanasia) in: Keown, John (2002), p. 117.

[31] The implication here, of course, is that the patients were incapable of controlling their own treatment and that they were in a terminal phase.

[32] Dutch experience, for example, shows that doctors choose consulting colleagues to assess assisted suicide cases on the basis of convenience in terms of physical proximity rather than whether the doctor in question possesses expertise in palliative care (see Hendin, Herbert (2002), p. 104).

[33] A notorious case from the Netherlands demonstrates the fuzziness of unbearable suffering criteria. A psychiatrist, Dr Chabot, assisted a woman with suicide because she was grieving over her son’s death. That grief, according to Chabot, was incurable. Dr Chabot had written to a number of colleagues for their assessment. They all thought it was in order to help the woman accomplish suicide. No one felt it necessary to consult the woman themselves before submitting their assessment (Hendin, Herbert (2002), p. 110).

[34] Cf. Griffiths, John et al. (1998): “I put off for the moment one critical element of the slippery slope argument, namely that the repellent practices that are supposedly bound to follow from legalization of euthanasia are actually repellent. In fact, I think the Dutch case makes plain that on the whole this is not the case. If I am right, then however strong the association between legalization and these other practices might be, the slippery slope argument loses all force because there is nothing to be feared from sliding down it”.

Version 1.0 April 2006 • © The Danish Council of Ethics.
Published by The Danish Council of Ethics,
Publication produced according to the standard for electronic publication set by the Government