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Why euthanasia should not be legalised

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Why active euthanasia and physician assisted suicide should be legalised

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In response to the editorial regarding the legalisation of active euthanasia and physician-assisted suicide,1 I present the following arguments against the legalisation of active euthanasia.

Active euthanasia is unnecessary because alternative treatments exist

It is widely believed that there are only two options for patients with terminal illness: either they die suffering or receive euthanasia. Recent research in palliative medicine has shown that virtually all unpleasant symptoms experienced in terminal illness can be relieved or alleviated by existing techniques.

Requests for active euthanasia are rarely free and active.

A person with terminal illness is vulnerable, lacking the skills and knowledge to alleviate their symptoms. It is very difficult for him to be entirely objective about his own situation. Their capacity for decision-making may equally be affected by confusion, dementia or symptoms, which could be relieved with appropriate treatment. Patients who on admission say "let me die" usually after effective treatment are grateful that their request was not acceded to.

Active euthanasia gives too much power to doctors

Ironically, active euthanasia legislation makes doctors less accountable and gives them more power. Patients generally decide in favour of euthanasia on the basis of information given to them by doctors. If a doctor confidently suggests a certain course of action, it can be difficult for a patient to resist. However, diagnoses may be mistaken and prognoses may be widely misjudged. Active euthanasia gives the medical practitioner power, which in turn can be abused.

Active euthanasia leads inevitably to involuntary euthanasia

When active euthanasia has been previously accepted and legalised, it has led inevitably to inactive euthanasia.

Holland is moving rapidly down the slippery slope with the public conscience changing quickly to accept such action as acceptable. The Royal Dutch Medical Association has recommended that the termination of the lives of patients suffering from dementia is acceptable under certain conditions. Case reports include a woman killed at her own request for reasons of "mental suffering".[2]

Such a progression requires only four accelerating factors: favourable public opinion, willing doctors, economic pressure and a law allowing it. In most Western countries the first three ingredients are present already. When legislation comes into effect and political and economic interests are brought to bear, the generated momentum inevitably follows.

Dr Liz Croton SHO A&E City Hospital NHS Trust, Dudley Rd,Birmingham B18 7QH [email protected]

1. Doyle L, Doyle L. Why active euthanasia and physician assisted suicide should be legalised. BMJ 2001:323;1079-80.

Competing interests: No competing interests

Home — Essay Samples — Social Issues — Euthanasia — Why Euthanasia Should Not Be Legal: Ethical and Practical Reasons

Why Euthanasia Should not Be Legal: Ethical and Practical Reasons

• Categories: Assisted Suicide Euthanasia

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Published: Sep 7, 2023

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Introduction, ethical concerns and sanctity of life, euthanasia as assisted suicide, practical considerations and unintended consequences.

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• Why We Should Not Legalize Euthanasia

The Foundational Ethical Principle Obliging Us To Protect Life Must Be Translated Into a Concrete Norm

Fr. Place is research theologian for the Curia and counsel for policy development, Archdiocese of Chicago. This article is based on his talk at the 1992 Frank M. Norfleet Forum for the Advancement of Health, Memphis.

The euthanasia debate is really the backdrop for a discussion within our society about the very nature of human life and meaning. Because the origin of life is in God, human beings do not have dominion over life but are stewards of life.

The powerful combination of sanctity and stewardship is expressed in the foundational ethical principle. This principle says that no person has the right to directly take innocent human life and in fact there is a positive obligation to nurture and protect life.

In our secular society there is a need to develop a "natural" metaphysic of sacredness. Such a metaphysic can serve as bedrock from which a foundational principle can be developed and then applied in concrete moral norms. It can show that life contributes to the full dignity of the human person. For this perspective to be effective in countering the movement to legalize euthanasia, this sense of integral wholeness of human personhood must be demonstrated in a convincing manner. It can be because a dualistic philosophical bias has been found wanting by Western culture.

We must arrive at what ethicists would call concrete norms that guide individual choices. At issue is how we translate our foundational principle—Do not directly attack innocent human life—into a concrete norm when confronted with the possibility of death.

Some persons question whether the concrete norm opposing euthanasia should be a matter of public morality. To answer this question, we must turn to our foundational principle. As a society, we must ask ourselves, How "sacred" is life? Will that natural sense of awe about life, that natural desire not to be vulnerable, be enhanced or threatened by making euthanasia legal?

Euthanasia has become the ethical issue of the 1990s and the focus of some of our most controversial public policy questions. I oppose the legalization of euthanasia. But we must do more than simply disagree with its proponents. It is possible, using the belief structures of the Judeo-Christian tradition and other reflections, to develop a persuasive understanding of human life that can serve as the foundation for an ethic that would oppose the legalization of euthanasia.

Although voters in California and Washington State have rejected assisted-suicide initiatives, the euthanasia debate will continue. Religion serves a vital role in this public policy discussion. But I see the euthanasia debate as symptomatic of a much more profound cultural discussion on the nature and meaning of human life. Certain foundational principles, which can be formulated in both religious and secular terms, can guide the opposition to euthanasia.

Religion and Public Policy Persons involved in the euthanasia debate are often concerned about the role of religion. Many people are concerned that participation by religious leaders is an inappropriate attempt to impose a particular religion's morality on society. But the constitution protects our nation's religious pluralism and ensures that a person who practices a religion or a person who practices no religion will not be excluded from participating in public policy development. Such participation, however, is based on two distinctions:

• The distinction between civil law and morality. Although our legal tradition is rooted in moral principles, "the scope of law is more limited and its purpose is not the moralization of society." 1 Everything that people of good will consider to be morally wrong need not be made illegal. This should only happen when the mutually agreed-on demands of the public good or the public order require it.
• The distinction between public moral questions and private moral questions. Something is a matter of public morality if it affects the public order of society. Catholic thinker John Courtney Murray defined public order as encompassing three goods: public peace, essential protection of human rights, and commonly accepted standards of moral behavior in a community. As a general principle, the domain of law and public policy is public morality, not private morality.

Thus religious leaders must be circumspect when they speak outside their congregations. Some areas of religious belief and practice are not appropriate matter for legislation. Religious leaders should speak out, however, on matters pertaining to public morality. In a pluralistic society religious leaders are as free as other citizens to participate in the public discussion that seeks to build consensus on what constitutes public morality. Card. Joseph Bernardin of Chicago has suggested that when religious leaders do participate in such public dialogue, they must translate their religious beliefs or philosophical assumptions "into commonly agreed upon language, arguments and categories before they can become the moral or ethical foundations for key public policy choices." 2 He adds:

A rationally persuasive case must be made that an action violates the rights of another or that the consequences of actions on a given issue are so important to society that the authority of the state ought to be invoked through public policy or civil statute, to govern personal and group behavior. Obviously, in a pluralistic society, arriving at a consensus on what pertains to public policy is never easy. But we have been able to achieve such consensus in the past by a process of dialogue, decision making and review of our decisions.

In accepting Card. Bernardin's challenge, I will explain why the legalization of euthanasia would violate the public order of our society and therefore should not be allowed. Persons who propose the legalization of euthanasia must be held to the same standard: They must demonstrate how such a change of public policy would not adversely affect public order.

The Cultural Context Although euthanasia is not new in Western culture, it is evident that euthanasia has not been acceptable practice within U.S. culture or our civil laws. Only in the past few years has euthanasia become a matter of public discussion and concern. The reasons for this growing openness to euthanasia are many, including the advancements of medical technology that have made it possible to maintain and extend human life as never before. Clearly, the sense of powerlessness and the fear of needless pain often associated with such advanced forms of treatment have been practical reasons for the advancement of the euthanasia movement. However, deeper reasons exist for this euthanasia phenomenon—reasons that are cultural or philosophical.

Underlying Assumptions Harvard's Arthur J. Dyck has identified what he considers to be the underlying presuppositions of an ethic of euthanasia. They are as follows:

• That an individual's life belongs to the individual to dispose of entirely as he or she wishes;
• That the dignity that attaches to personhood by reason of the freedom to make moral choices demands also the freedom to take one's life;
• That there is such a thing as a life not worth living, whether by reason of distress, illness, physical or mental handicaps, or even sheer despair for whatever reason;
• That what is sacred or supreme in value is the "human dignity" that resides in man's own rational capacity to choose and control life and death. 3

Obviously, one might disagree with some of Dyck's characterizations, but I suggest that he has captured, in a general sense , the presuppositions of the euthanasia movement. And there is much to be said for these presuppositions. For example, they make us aware that values exist beyond those of physical survival. Similarly, they force us to realize that death is not the greatest harm which can befall a person.

Assumptions' Weaknesses Nevertheless, weaknesses are inherent in these assumptions. Rev. Richard M. Gula, SS, identifies three:

• They are arbitrary in that they identify a few values to define the significance of human life and fail to put them in the context of a full spectrum of human values and their consequences.
• Taken as a freestanding composite, they are too risky. It is not self-evident why their application could not be extended to the most vulnerable members of society such as the elderly and the handicapped.
• They erode the "character of a helping community of trust and care." 4

Disagreements regarding the end of life choices open to dying persons reflect non-moral assumptions about the source of meaning and good in human life; the significance of suffering and death in human experience; the relation between dependency, dignity and control; the moral character of caring relationships; and the nature of the human self. 5

The euthanasia debate is really the backdrop for a discussion within American society about the very nature of human life and meaning. Although societies seldom choose to engage such fundamental questions in their abstract form, we must not lose sight of the fact that we are discussing more than whether euthanasia should be legalized.

Argument Against Euthanasia For Catholics (indeed for many Christians), at the center of such a discussion on the nature of human life and meaning is the question of the sanctity of human life. For the believer, God is the origin of all life and the sustainer of all life. For that reason human life has a dignity greater than the sum of life's parts. In a sense this dignity is not intrinsic to the human person. Human dignity is not conferred by one's actions, by the judgments of others, or by the fiat of law. Rather, it is conferred by God. Intimately associated with the concept of sanctity is an awareness that, because the origin of life is in God, human beings do not have dominion over life but are the stewards of life, which is a gift from another.

The Foundational Ethical Principle The powerful combination of sanctity and stewardship is expressed in the foundational ethical principle. This principle says that no person has the right to directly take innocent human life and, in fact, we have a positive obligation to nurture and protect life. This same ethical principle inspired religious leaders and the faithful to participate in the civil rights movement of the 1950s and 1960s, raised citizens' concern about the morality of nuclear warfare, enlightened the discussions on the manner in which the war against Iraq was conducted, and now motivates the drive against the legalization of euthanasia. This foundational ethical principle is the keystone, if you will, of a consistent ethic of life.

Many persons might suggest that this perspective on the sacredness of life is no longer valid for a large number of Americans. They argue that traditional Judeo-Christian symbols and values are no longer adequate to serve as a substratum for the development of a consensus or vision to guide the evaluation of the needs of public order. Some Americans believe we should replace that substratum with one similar to Dyck's presuppositions. If this were to happen, the legalization of euthanasia would be easily justified.

As a committed Christian, I disagree with such a contention. But it is not enough to simply disagree. As Card. Bernardin has proposed, we must offer a positive vision that opposes euthanasia, one secular America will heed.

A Positive Vision Several persons have attempted to develop such a vision. One of the more persuasive contributions is that of Edward Shils. Shils proposes a natural metaphysic that supports the sacredness of life. Sacredness for him is not rooted in a transcendent creator but "in the primordial experience of being alive, in the fear of extinction, in the spontaneous revulsion to contrived interventions and unnatural destruction of human life, and in the sense of awe one feels before one's own vitality and that of the species." 6

For Shils, sanctity of life does not come from outside life but from the experience of life itself. On a pragmatic level, Shils and others argue that unless sacredness of life is acknowledged, the entire structure of human values and rights will collapse. This natural metaphysic of sacredness, much as the Christian understanding, serves as bedrock from which a foundational principle must be developed and then applied in concrete moral norms. The process of developing such a principle is complex, and there is room for disagreement. For example, one could hold to a natural understanding of the sacredness of life and still support euthanasia.

Developing a Foundational Principle Instrumental Good To develop a foundational principle, it is necessary to discuss the question, Is human life and its natural sacredness only an instrumental good necessary for personal fulfillment? Or is it something more? Many euthanasia supporters view life as an instrumental good. In other words, the living body is a means to achieve the true end or purpose of being, which is personal activity. Bodily life provides the wherewithal for personal fulfillment. And when the personal component (the ability to control life through rational choice) is missing, the person has no obligation to continue living. Bodily living has lost its purpose.

The Body-Person Distinction In response to this dualistic distinction between body and person, Fr. Gula proposes an anthropology that "regards the human being as one. . . . Bodily life participates in the integrity of the human person as a substantive good of human life, and human life is the life of a personal being." 7 In other words, life is not only a condition necessary for a person to achieve other values, it is intrinsic to being human, and it contributes to the full dignity of the human person. This sense of an integral wholeness to personhood must be demonstrated in a convincing manner. And I believe it can be, because a dualistic philosophical bias has been found wanting by Western culture.

A Community of Trust and Care Another area that must be addressed is the nature of the community in which human life is situated. As Fr. Gula notes, "If we focused our attention solely on the dying patient and extended our vision no further, then perhaps we might be able to make a case for euthanasia. But if we are socially conscious so that our vision encompasses the caring community as well, then we can make a better case against euthanasia." 8

In this context Stanley Hauerwas has argued that an essential aspect of human experience is the need and the desire to trust the community in which one lives. If life is sacred, then that community of necessity will be a community of trust and care. Euthanasia would be unacceptable because it means the community has abandoned its responsibility to care and comfort. Euthanasia fails to show to dying persons what Hauerwas calls "the continuing trustworthiness of their existence." 9

In a similar fashion one must evaluate euthanasia's effect on the life of the community. Because we are social by nature, we are connected to others. Our individual choices have an impact on others. We must keep in mind that:

Actions reflect and give expression to certain values and beliefs. The more people perform a certain action and the more frequently they perform it, the more those values and beliefs are expressed. The effect is cumulative and eventually influences the moral tone and character of a society. . . . [And] as a result, we need to be concerned not only with individual welfare but also with societal welfare. 10

Clearly, as Robert Bellah and others have demonstrated, the relationship between individual and community is an issue of fundamental importance to our society. 11 An increased sense of isolation and alienation affects many in our midst because we have allowed the individual to be separated from community. In a sense euthanasia can be seen as the logical conclusion of the existential angst of the person alienated from self and community.

Setting Concrete Ethical Norms If we are able as human beings and as a society to agree on this foundational principle, it is then necessary to apply it to concrete ethical issues. We must arrive at what ethicists would call concrete, or material, norms that guide individual choices.

Historically, we have done this. For example, we believe it is wrong to take the life of another person except in self-defense. In simple, straightforward terms we say it is wrong to murder. As a society, we accept this concrete norm as true whether its source is the decalogue or a secular ethic of human sacredness. And we affirm this concrete norm with such conviction that we teach it to our young and expect them to make it part of their code of personal or private morality. We are offended or frightened when we see it violated, especially in senseless or wanton killing.

We also have come to the conclusion that the consequences of the violation of this concrete norm are so great that they threaten the well-being of society. In other words, murder threatens the good of the public order. The public peace is shattered, and the protection of human rights compromised. For these reasons the concrete norm "Do not murder" has been translated into public law. It is understood to be part of the public morality.

At issue, then, is how we translate our foundational principle—Do not directly attack innocent human life—into a concrete norm when confronted with the possibility of death. I could argue that the earlier discussion about the natural "sacredness" of life, the integrity of personhood, and the trustworthiness necessary to sustain human community can be drawn together to support a concrete moral norm saying that it would be wrong to directly take or assist in the taking of human life to relieve pain or suffering. Although originally grounded in a Christian foundational principle, this concrete norm opposing euthanasia now has a nonsectarian basis, like the concrete norm regarding murder. It can, if you will, be called a human or a natural norm.

Although many persons might agree this is a worthy concrete norm to guide the development of personal morality, they would question whether it is so exceptionless, or the consequences of its violation so significant, as to also make it a matter of public morality. For this reason, some are questioning the validity of the existing societal presumption—namely, they question whether the concrete norm opposing euthanasia should be a matter of public morality.

To answer this question, we must return to the grounding for our foundational principle. As a society, we must ask ourselves, How "sacred" is life? Will that natural sense of awe about life, that natural desire not to be vulnerable or at risk, be enhanced or threatened by making euthanasia legal? Are enough protections available in the human community, in light of human foibles and limitations, to ensure that this practice will not make individuals more vulnerable to outside attack? In other words, will the "safe harbor" that laws against murder and euthanasia have created for human existence be enhanced or diminished? We must consider whether, as a society, we want to say that human life is but another "thing" to be used and discarded at will, like a broken toy. Is this the understanding of life we wish to celebrate as a civil society? We must ask whether we are happy living as lone rangers on the frontier of life or whether community is essential to our well-being. And if it is, what are the mutual commitments of trust necessary to support and sustain such community? Will the legalization of euthanasia enhance these commitments or detract?

Meeting the Challenge All too often the euthanasia discussion has not addressed these more fundamental issues. The image of persons dying needlessly painful deaths controlled by insensitive medical technology dominates the discussion. And I suspect many persons who might vote to legalize euthanasia are doing so out of desperation. Ironically, they view their votes as the only way to preserve the sacredness of life and community. What they fail to see is how in fact euthanasia compromises what they most deeply believe.

Card. Bernardin addressed this reality in the following terms:

It is important for us to address the sense of powerlessness which many people experience in regard to the contemporary practice of medicine. While the catch phrase "patient as person" is a helpful guide in this matter, we have to extend this concept more aggressively into the world of critical and terminal illness where the patient is the frailest and most vulnerable. We must also face our own fear of death and learn to provide for those who are dying or critically ill in a way that preserves their dignity and ennobles them. . . . In this way we can eliminate many of the legitimate concerns that may motivate people to consider euthanasia—which otherwise would be unacceptable to them and to society. 12

I agree with the cardinal. The reasoned and sophisticated arguments against the legalization of euthanasia will never be heard and the real discussion will not take place unless, as individuals and providers of healthcare, we first meet this critical challenge.

• Joseph Bernardin, "Address: Consistent Ethic of Life Conference," Consistent Ethic of Life , Sheed & Ward, Kansas City, MO, 1988, pp. 86-95.
• Joseph Bernardin, "Euthanasia: Ethical and Legal Challenges," Origins , June 9, 1988, p. 52.
• Arthur J. Dyck, "An Alternative to the Ethics of Euthanasia," as cited in Richard M. Gula, What Are They Saying about Euthanasia? Paulist Press, Mahwah, NJ, 1986, p. 169. These reflections are deeply indebted to Fr. Gula's masterful analysis of this important subject.
• Gula, p. 70.
• Courtney S. Campbell, "Religious Ethics and Active Euthanasia in a Pluralistic Society," Kennedy Institute of Ethics Journal , vol. 2, 1992, pp. 253-284.
• Edward Shils, "The Sanctity of Life," in Daniel H. Labby, ed., Life or Death: Ethics and Options , University of Washington Press, Seattle, 1968, p. 12.
• Gula, p. 97.
• Gula, p. 71.
• Ron Hamel and Edwin DuBose, "Views of Major Faith Traditions," in Ron Hamel, ed., Active Euthanasia, Religion and the Public Debate , Park Ridge Center, Chicago, 1991.
• Robert N. Bellah, Habits of the Heart: Individualism and Commitment in American Life , HarperCollins, New York City, 1986.
• Bernardin, "Euthanasia," p. 56.

HOW THE CATHOLIC TRADITION VIEWS EUTHANASIA

In the Catholic tradition euthanasia is understood "as an action or omission which of itself or by intention causes death in order that all suffering may in this way be eliminated" (Congregation for the Doctrine of the Faith, "Declaration on Euthanasia," Origins , vol. 10, 1980, pp. 154-157). Euthanasia may be voluntary or involuntary. The difference is found in the patient's intention. Voluntary euthanasia is when a patient ends his or her own life with the assistance of a care giver, or when a care giver does it at a patient's request. Involuntary euthanasia occurs when a care giver ends a patient's life without the patient's consent.

Also, euthanasia may be either active or passive. Active euthanasia occurs when death is induced through an external method, such as Dr. Jack Kevorkian's machine. Passive euthanasia occurs "if the cause of death is present within one's body, but is not resisted when there is a moral obligation to do so" (Kevin O'Rourke, "Assisted Suicide: An Evaluation," Journal of Pain and Symptom Management , vol. 6, 1991, p. 2).

Within the Catholic theological tradition, no moral distinction is made between active and passive euthanasia. Both are described as causing the death of a person who is ill when there is a moral obligation to prolong that person's life.

Key to this ethical analysis is the assumption that there is a moral obligation to preserve and protect human life. The existence of such an obligation is relevant because, according to the Catholic theological tradition, there are times when no moral obligation exists to prolong life—namely, when the care or treatment would be futile or disproportionately burdensome. Consequently, when there is no such obligation and a person is allowed to die from a fatal pathological condition, "then the act by which one is allowed to die is not euthanasia" (O'Rourke).

This is an important point. Catholic tradition does not require that persons who are dying be kept alive needlessly. Rather, it opposes reversing a centuries-old tradition enshrined in our civil law saying that no one should directly take the life of another innocent person or assist in the taking of that life even if that person is dying or is seriously ill.

Copyright © 1993 by the Catholic Health Association of the United States For reprint permission, contact Betty Crosby or call (314) 253-3477.

Copyright © 1993 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.

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• Published: 15 January 2014

Should assisted dying be legalised?

• Thomas D G Frost 1 ,
• Devan Sinha 2 &
• Barnabas J Gilbert 3  

Philosophy, Ethics, and Humanities in Medicine volume  9 , Article number:  3 ( 2014 ) Cite this article

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When an individual facing intractable pain is given an estimate of a few months to live, does hastening death become a viable and legitimate alternative for willing patients? Has the time come for physicians to do away with the traditional notion of healthcare as maintaining or improving physical and mental health, and instead accept their own limitations by facilitating death when requested? The Universities of Oxford and Cambridge held the 2013 Varsity Medical Debate on the motion “This House Would Legalise Assisted Dying”. This article summarises the key arguments developed over the course of the debate. We will explore how assisted dying can affect both the patient and doctor; the nature of consent and limits of autonomy; the effects on society; the viability of a proposed model; and, perhaps most importantly, the potential need for the practice within our current medico-legal framework.

Introduction

Over the past two centuries, the United Kingdom has experienced rapid population growth associated with a substantial decline in mortality from acute infectious diseases and poor nutrition [ 1 ]. As the average life expectancy has increased, so too have the rates of debilitating chronic illness – particularly coronary artery disease and cancers [ 2 ]. These diseases require years of treatment instead of the mere days to weeks that medicine once operated within [ 2 ]. Although healthcare systems have sought to adapt to such changes, aiming to prevent and treat such disease wherever possible, debate has arisen regarding those patients in the latter stages of chronic, incurable, terminal conditions [ 3 , 4 ]. Moreover, there is increasing recognition that the patient must be at the centre of health care decision-making, such that outcomes must be tailored to their individual needs and views. By extension, assisted dying might seem a logical step to help achieve these goals within the realm of end-of-life decision making [ 5 ]. Several jurisdictions, notably Oregon (1997) and the Netherlands (2001) have already legalised assisted dying in some form. These factors have contributed to ongoing legislative discussions within Parliaments for almost a decade, with current opinion polling suggesting a majority of medical practitioners and the public in favour of physician-assisted suicide [ 6 ].

Viability of assisted dying in practice

In the UK, a model for assisted dying has been developed from the legal structure found within the Assisted Dying Bill introduced by Lord Falconer in the House of Lords in 2013 [ 7 ]. Assisted dying could only be considered under circumstances in which a patient of legal age is diagnosed with a progressive disease that is irreversible by treatment and is “reasonably expected to die within six months” [ 7 ]. Registered medical practitioners would make such decisions for patients with terminal illnesses. Addressing the technicalities of ‘assisted dying’ requires distinction between ‘physician-assisted suicide’ (offering patients medical actions or cessation of actions by which they can end their own life) and ‘euthanasia’ (whereby the medical practitioner actively induces death). In light of the strong hostility of the medical profession towards active euthanasia, this proposed model, as with previous attempts to legalise assisted dying, permitted only the former [ 8 – 10 ].

However, there is concern that such distinction may be unrealistic in practice because medical practitioners could find themselves with a patient who had failed to successfully end their own life and was subsequently left in a state of greater suffering. Were such a patient no longer able to give consent, a heavy burden would then be placed on the physician regarding how to proceed. Moreover, the practice of physician-assisted suicide might be deemed discriminatory, for example by giving only patients with good mobility control over their own method of death.

The Assisted Dying Bill 2013 included the provision that any terminal prognosis must be confirmed and attested by a second registered practitioner. The strictness of such criteria has parallels to a similar double-physician requirement when procuring a legal abortion under the 1967 Abortion Act. The stated aims of the provision in both cases are as follows: first, to check the accuracy of the prognosis upon which the decision was being made; second, to ensure that the situation meets the required criteria; and third, to check that such a decision was taken by the patient after full consideration of all available options [ 11 , 12 ]. By having a second independent doctor, the legislation ensures that all three checks are met without prejudice or mistake.

Problematic for any protocol for assisted dying is the fact that estimates of life expectancy in terminal prognoses are erroneous in 80.3% of cases [ 13 ]. Furthermore, the accuracy of such prognoses deteriorates with increased length of clinical predicted survival. Forecasts of survival times are based largely on past clinical experience, and the inherent variability between patients makes this more of an art than a science. This brings to concern both the accuracy of any prognosis meeting the six-month threshold and the validity of requests for assisted dying based partly or wholly on predicted survival times. Whilst the majority of errors in life expectancy forecasts are a matter of over-optimism and hence would not affect either of those two concerns, many cases remain unaccounted for. Overly pessimistic forecasts occur in 17.3% of prognoses; hence we must decide whether the one in six patients making a decision based on an inaccurate prognosis is too high a cost to justify the use of this system. Patients requesting an assisted death often cite future expectations of dependency, loss of dignity, or pain [ 14 ]. If the hypothetical point at which the progression of their illness means they would consider life to be not worth living is not, as informed, mere weeks away but in fact many more months, then this information would have resulted in a different decision outcome and potentiated unnecessary loss of life.

Whilst the presence of a second doctor would be expected to mitigate such forecasting errors, the anchoring bias of the initial prediction may be enough to similarly reduce the accuracy of the second estimate. It is prudent to question the true independence of a second medical practitioner, and whether this second consultation could become more of a formality, as has now become the case with abortion [ 15 ].

Another challenge for an assisted dying system would be to recognise whether patients requesting death were legally competent to make that decision. Consider that any request for suicide from a patient with clinical depression is generally categorised as a manifestation of that mental disorder, thereby lacking capacity. It is arguably impossible to separate out the natural reactions to terminal illness and clinical depression. Indeed, there is evidence that major depressive disorders afflict between 25% and 77% of patients with terminal illness [ 16 , 17 ]. Any protocol for assisted dying must first determine what qualifies as a ‘fit mental state’ for a terminal patient.

The need for assisted dying

It could be argued that a doctor’s fundamental duty is to alleviate forms of suffering in the best interests of the patient. The avoidance of physical pain, as an obvious manifestation of suffering, might explain why assisted dying would be both necessary and within the duties of a doctor to provide. The evolving principle in common law known as the ‘Doctrine of Double Effect’ offers a solution to this problem [ 18 ]. This legal judgement stated that “[a doctor] is entitled to do all that is proper and necessary to relieve pain even if the measures he takes may incidentally shorten life”. This entails that a protocol already exists for patients searching for an escape from chronic pain. Furthermore, numerous retrospective studies have revealed very little correlation between opioid dose and mean survival times: one study of over 700 opioid-treated patients found that the variation in survival time from high-dose opioid treatment is less than 10% [ 19 – 21 ]. It can therefore be said that pain alone, if appropriately managed, should never be cause for considering assisted dying as an alternative.

By contrast, the ‘Doctrine of Double Effect’ might be seen as a subjective interpretation that has been applied unequally due to a lack of specialist training or knowledge [ 22 ]. Despite this, the principle can be easily understood and poor awareness can be remedied by improvements in medical education and standardisation of protocols. Moreover, should we choose to accept arguments for assisted dying that are based upon inadequate administration of pain medication, we set a precedent for conceding shortcomings in palliative care and other end-of-life treatments. Offering hastened death could become an alternative to actively seeking to improve such failings.

Whilst much has been made of the ‘pain argument’ here, the call for assisted dying is rarely this simple. Many patients also suffer a loss of dignity, often due to their lack of mobility – the inability to relieve oneself without help is a potent example. Beyond this are additional fears of further debilitation and the emotional costs of dealing with chronic illness, both for the patient and for their relatives and friends. A study of terminal patients in Oregon showed that these were the most significant reasons behind requests for assisted suicide, the next commonest reason being the perception of themselves as a ‘burden’ [ 14 ]. Clearly, we could seek to provide balanced, compassionate medical care for these patients, and still fail to address these points.

Developments in healthcare and technology may reduce this emotional burden, but remain an imperfect solution.

Rights of patients and limitations of their autonomy

J.S. Mill’s pithy dictum describes autonomy as follows: “over himself, over his own body and mind, the individual is sovereign” [ 23 ]. Not only has the sanctity of bodily autonomy profoundly influenced the development of liberal democracies, it has also provoked a holistic shift in making our healthcare systems more patient-centred – “care that meets and responds to patients’ wants, needs and preferences and where patients are autonomous and able to decide for themselves” [ 5 ]. The ethical principle of controlling the fate of one’s own body is inherently relevant to the debate on assisted dying. It is difficult to reconcile that citizens may have the right to do almost anything to and with their own bodies– from participating in extreme sports to having elective plastic surgery – yet a terminal patient cannot choose to avoid experiencing additional months of discomfort or loss of dignity in their final months of life.

Expectation of individual liberty has been codified in law. The right to bodily autonomy has been interpreted to be included under Article 8 - the right to privacy - of the European Convention on Human Rights (ECHR) and subsequently the Human Rights Act (HRA) [ 24 , 25 ]. Moreover, the ECHR underpins the right of individuals to ‘inherent dignity’ [ 26 ]. Hence, if an individual feels that dignity is unattainable due to the progression of a terminal illness, then taking recourse though assisted dying ought to be a legitimate option.

Conversely, there are two notable oversights in this interpretation of a right to assisted dying as an extension of the principles of bodily autonomy:

First, it would be wrong to view individual liberty as absolute. The HRA allows for exceptions to Article 8 on grounds of ‘health or morals’ [ 25 ]. The principle of autonomy is not inviolable. Governments have limited such privileges for the protection of individuals and society, for example by criminalizing the use of recreational drugs or the selling of one’s own organs. The preservation of life by denying assisted dying could fall within this category.

Second, the right of autonomy is not necessarily intrinsic to human beings but, as Kant argued, is dependent on our ‘rational nature’ [ 27 ]. This concept sees autonomy as an exercise of ‘evaluative choice’ [ 27 ], requiring rationality on the part of individuals to appreciate the nature of options and their consequences. To achieve true autonomy, there must be sufficient information to make those rational decisions; this is the basis of informed consent and why it is a fundamental duty of a doctor to offer a patient an informed series of treatment options [ 28 ]. The logistical issue is that doctors are unable to advise patients regarding the point at which their situation becomes less preferable to being dead. No doctor (or individual) has any knowledge or experience of what ‘death’ may be like. Hence, in this case, the idea of exercising true autonomy through informed consent might be considered meaningless.

Legalising assisted dying by attempting to establish an absolute right to bodily autonomy may undermine other individual and group rights. Vulnerable patients may feel pressured into assisted dying because of social, emotional, or financial strains placed on family and/or friends. This is exemplified by the trend showing that the proportion of patients stating ‘relief of burden’ on others as the reason for requesting assisted dying has risen from 17% to 25% in Oregon since legalisation [ 29 ]. One could even consider the risk of assisted dying becoming an expected choice rather than a free one. Thus, assisted dying may erode the elemental right to life of terminal patients as the value of their life becomes tied to relative costs to society and to those around them.

Moreover, by creating one class of individuals for whom life is expendable, that particular view may be extended by society to all groups possessing such attributes (e.g. the permanently disabled). There would be a definite risk to the rights of these vulnerable groups in the form of society being less willing to provide for their health and social care.

It is often raised that the limited legalisation of assisted dying would inevitably become extended in scope, but this is not necessarily a flaw. Even if the right to determine the manner of death were later extended to a wider group of people, posterity may reflect positively on such a change, just as extending the franchise to women ultimately led to legislation demanding equal pay.

Effect on health professionals and their role

‘To act in the best interest of the patient’ is often cited as a central duty of the doctor [ 28 ]. This concept of ‘best interest’ guiding the doctor’s action has seen the development of two important ethical principles: beneficence and non-maleficence. Beneficence mandates that the actions of the doctor must be aimed to bring about benefit (clinical improvement) for the patient, usually measured in terms of reduced morbidity or mortality; non-maleficence requires that the doctor not carry out treatment that is likely to cause overall harm the patient [ 30 ]. These traditional ethical imperatives on a doctor both conflict with intentionally hastening the death of a patient, and a resolution of this tension would require redefining what constitutes ‘acting in the best interest’.

A further dimension is the potential reluctance of health professionals to engage in a practice that contravenes their own ethical beliefs, particularly as this would affect doctors who never entered training in the knowledge that assisting patients to die would be an expected duty. This is certainly no argument against the introduction of assisted dying; indeed, a recent survey of a cohort of NHS doctors found that 46% would seriously consider requests from patients to undertake steps to hasten death [ 31 ]. It merely expresses the point that any early model would have to account for the fact that an initial 54% of the doctors in the NHS would be required to advise qualifying patients of assisted dying as a legitimate option, despite disagreeing with it in principle.

Furthermore, doctors who agree ethically with this practice may find themselves facing conflicts of interest. It is expensive to treat chronically ill patients, particularly in the final months of life [ 32 ]. Moreover, it would be difficult for commissioners to ignore the fact that the sustained treatment of one individual could deprive many others from access to surgery or access to novel drugs. Such an argument does not suggest that doctors or any other hospital staff would treat this practice without appropriate respect or care; rather it acknowledges the need for appropriate rationing of care and questions the intentions of service providers. The perception of an ulterior motive could negatively impact patient trust. One survey showed that a reasonable minority of patients (27%) – and particularly particularly the elderly – believe that legalising assisted dying would lessen their trust in their personal physician [ 33 ]. The costs of weakened trust in the doctor-patient relationship could far outweigh the benefits of assisted dying, particularly given the importance of trust when treating a chronic patient for an extended period of time.

There is no doubt that assisted dying would empower some patients to maximise control over the timing and manner of their own death. Such expression of autonomy would surely solidify moves towards a patient-centred approach to healthcare. However, the capacity for such consensual requests remains in doubt. Clinically, the patient’s state of mind and the reliability of diagnostic predictions are of issue; philosophically, the idea of informed consent for death is contradictory. The implications for patients, physicians and society have been weighed extensively within this article. The central tenet throughout has been the balancing of an individual’s right to escape a circumstance that they find intolerable, alongside the consequential changes to their other rights, and the rights and responsibilities of third parties. Ultimately, the challenge is for us as a society to decide where this balance lies.

About the debate

The Varsity Medical Debate was started in 2008 with the aim of allowing students, professors and members of the polis, to engage in discussion about ethics and policy within healthcare. Utilising the age-old rivalry between the two Universities, the debate encourages medical students from both Oxford and Cambridge to consider and articulate the arguments behind topics that will feature heavily in their future careers.

The debate was judged on the logic, coherence, and evidence in arguments, as well as flair in presentation. Although the debaters may not have necessarily agreed with their allocated side, the debate format required them to acknowledge a particular school of thought and present the key arguments behind it. Oxford, who opposed the motion, was awarded the victory in the debate; however, this does not mean that the judges believe that position ought to become public policy.

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Acknowledgements

For Cambridge University: Hilmi Bayri (Trinity), Alistair Bolger (Jesus), Casey Swerner (St Johns).

For Oxford University: Devan Sinha (Brasenose), Thomas Frost (Lincoln), Collis Tahzib (Lincoln).

Martin Farrell (Cambridge).

Baroness Finlay: Professor of Palliative Care Medicine and former President of the Royal Society of Medicine.

Dr. Roger Armour: Vascular Surgeon and Inventor of the Lens Free Ophthalmoscope.

Mr. Robert Preston: Director of Living and Dying Well.

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Frost, T.D.G., Sinha, D. & Gilbert, B.J. Should assisted dying be legalised?. Philos Ethics Humanit Med 9 , 3 (2014). https://doi.org/10.1186/1747-5341-9-3

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Arguments for and against assisted suicide and euthanasia

Assisted suicide is where a doctor helps a patient to kill themselves by prescribing a lethal drug for the patient to take. This becomes euthanasia when the doctor administers the drug directly. There has been much debate in the UK in recent years over issues concerning the end of life. Here we briefly outline the main arguments for and against assisted suicide and euthanasia, and outline CARE's perspective on the issue. Below you will also find resources and further reading.

The Argu­ments For Assisted Sui­cide &  Euthanasia

“We have no control over how we arrive in the world but at the end of life we should have control over how we leave it.”

1 . We need it

This is 'the compassion argument'. Supporters of assisted suicide believe that allowing people to ‘die with dignity’ is kinder than forcing them to continue their lives with suffering.

2 . We want it

This is known as 'the autonomy argument'. Some believe that every patient has a right to choose when to die.

3 . We can con­trol it

This is 'the public policy argument'. Proponents believe that assisted suicide can be safely regulated by government legislation.

The Argu­ments Against Assisted Sui­cide &  Euthanasia

“The exper­i­ence of death is going to get more and more pain­ful, con­trary to what many people believe. The forth­com­ing euthanas­ia will make it more rather than less pain­ful because it will put the emphas­is on per­son­al decision in a way which was bliss­fully ali­en to the whole prob­lem of dying in former times. It will make death even more sub­ject­ively intol­er­able, for people will feel respons­ible for their own deaths and mor­ally oblig­ated to rid their rel­at­ives of their unwanted pres­ence. Euthanas­ia will fur­ther intensi­fy all the prob­lems its advoc­ates think it will solve.”

1 . Altern­at­ive treat­ments are available

Alternative treatments are available, such as palliative care and hospices. We do not have to kill the patient to kill the symptoms. Nearly all pain can be relieved.

2 . There is no ​ ‘ right’ to be killed and the slip­pery slope of assisted sui­cide is real

Opening the doors to voluntary euthanasia and assisted suicide could lead to non-voluntary and involuntary euthanasia, by giving doctors the power to decide when a patient’s life is not worth living. In the Netherlands in 1990 around 1,000 patients were killed without their request.

3 . We could nev­er truly con­trol it.

Reports from the Netherlands, where euthanasia and physician-assisted suicide are legal, reveal that doctors do not always report it.

4 . The assump­tion that patients should have a right to die would impose on doc­tors a duty to kill

The assumption that patients should have a right to die would impose on doctors a duty to kill, thus restricting the autonomy of the doctor. Also, a ‘right to die’ for some people might well become a ‘duty to die’ by others, particularly those who are vulnerable or dependent upon others.

CARE’s Per­spect­ive: Why say no to euthanas­ia and assisted suicide?

What about per­son­al choice.

The pro-euthanasia and assisted suicide lobby emphasise the importance of personal choice and autonomy. Shouldn’t patients have the right to end their lives? Dignity in Dying patron, Sir Patrick Stewart has argued “We have no control over how we arrive in the world but at the end of life we should have control over how we leave it.”

Surely however the debate is not about the right to die; it is about the right to help patients kill themselves. Instead of giving freedom to patients, euthanasia and assisted suicide is about giving other people the legal power to end another person’s life.

Assisted suicide is not a private act. Nobody chooses assisted suicide in isolation. Euthanasia and assisted suicide are matters of public concern because they involve one person facilitating the death of another. Friends, relatives, healthcare staff and society are hugely affected by the wider ramifications of the process.

Journalist and author George Pitcher has said that any change in the law would have “profound adverse affects on the social fabric of our society, on our attitudes towards each other’s deaths and illnesses, on our attitudes towards those who are ill and have disabilities .”

Increased autonomy would apply only if you met all the criteria to be eligible. If you had a disease where the prognosis is not straightforward, dementia or a chronic but not terminal disease, then you would not meet the criteria; attempts to extend the law further would be almost inevitable. Assisted suicide is not a private act and there is a real risk that a ‘right to die’ may soon become a ‘duty to die’.

What about compassion?

The pro-euthanasia and assisted suicide lobby will often present the view that helping someone else to end their life is the most loving and compassionate thing to do. But surely the most compassionate thing to do is to care for a person at the end of their life and to show them that their life has tremendous value regardless of age or abilities.

Palliative care is an area of healthcare that focuses on relieving and preventing the suffering of patients. Britain is the only country in the world where palliative care is a recognised medical specialism . Further, in a recent survey by The Economist Britain was ranked first in the world for quality end-of-life care. The survey took in 40 OECD and non-OECD countries, including the USA, the Netherlands, Germany and France.

What about the most vulnerable?

Changing the law to allow euthanasia or assisted suicide will inevitably put pressure on vulnerable people to end their lives for fear of being a financial, emotional or care burden upon others. This would especially affect people who are disabled, elderly, sick or depressed. Some would face the added risk of coercion by others who might stand to gain from their deaths. Fear and anxiety would be promoted rather than Individual autonomy.

In its 1994 report The House of Lords Select Committee on Medical Ethics concluded:

“It was virtually impossible to ensure that all acts of euthanasia were truly voluntary and that any liberalisation of the law in the United Kingdom could not be abused. We were also concerned that vulnerable people – the elderly, lonely, sick or distressed – would feel pressure, whether real or imagined, to request early death.”

The law must protect the most vulnerable people in society. We must never let the depressed, the confused, those in terrible pain, the aged and the vulnerable feel that they should pursue the path of assisted suicide so as not to be a burden on others.

Dr Andrew Fergusson, of the Care Not Killing Alliance , has said “the simple truth is that the current law exists to protect those without a voice: the disabled, terminally ill and elderly, who might otherwise feel pressured into ending their lives”.

Studies concerning the euthanasia and assisted suicide law in countries that have legalised such measures make for troubling reading.

A study conducted in 2012 shows that 32% of the assisted deaths in Belgium are carried out without request and 47% of assisted deaths go unreported in the Flanders region of Belgium. Another recent study found that nurses are regularly euthanasing their patients in Belgium even though the laws prohibits it. Since euthanasia was legalised in 2002 there has not been one attempt to prosecute for abuses of the euthanasia law. In addition to this the study shows there was a 25% increase in the number of assisted deaths in Belgium in 2012.

In Oregon (where assisted suicide was legalised in 1997) the law has led to patients ‘doctor shopping’ for willing practitioners, using doctors who have minimal knowledge of their past. In 2008, 50 per cent of patients requesting suicide were assisted to die by a doctor who had been their physician for eight weeks or less .

Not all people who are ter­min­ally ill wish to end their life.

There have been tragic cases of people suffering terminable illness who want other people to help them end their life. It is important however that we do not lose sight of the large number of people who are terminally ill and have found richness and purpose in life despite the pain and hardship.

A survey published by the British Medical Journal in 2011 found that the majority of patients who are almost completely paralysed but fully conscious have said they are happy and do not want to die. The survey questioned 168 members of the French Association for Locked-in Syndrome.

Matthew Hampson was a promising young rugby player until a collapsing scrum left him paralysed from the neck down and requiring a ventilator to breathe. Matt divides his time between raising money for spinal care for UK charity Spinal Research, coaching youngsters at local schools and writing columns for rugby magazines. He has also written an autobiography. The Matt Hampson Foundation provides help, advice and for young people seriously injured through sport.

All life has pro­found human value.

We have to make clear that the value of life should not be determined by its benefit to others, or what it can contribute to society. The French biologist and philosopher Jean Rostand once said: “For my part I believe that there is no life so degraded, debased, deteriorated, or impoverished that it does not deserve respect and is not worth defending with zeal and conviction. ”

Assisted Suicide

Where assisted suicide is legal, it makes vulnerable people feel like a burden. CARE works to uphold laws that protect those people, and to assist them to live—not to commit suicide.

Some Useful Terms

Find out more what assisted suicide and euthanasia actually mean.

Assisted Suicide: What is the Christian perspective?

Explore biblical views on end of life issues.

Ten Ways to Pray for the End of Life

At CARE we believe it's better to care, not to kill. We want to pray for people approaching the end of their lives and for medical professionals who care for them. This resource will help you pray against euthanasia and for hospices and quality palliative care.

If you’ve enjoyed read­ing this art­icle, why not sign up to get more con­tent delivered straight into your inbox? Sign up today to Impact Dir­ect, and you’ll receive reg­u­lar updates on our work, free resources and art­icles, as well as invit­a­tions to events. We’d love you to become part of our act­ive and informed com­munity of supporters!

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Why Euthanasia Should not be Legalized

A Reflection on the Dutch Experiment

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The experience of the Netherlands continues to be cited as illustrative of the euthanasia debate that is going on in many countries. The parliamentary debates on the legalization of euthanasia (November 2000 in the Second Chamber and April 2001 First Chamber) have drawn a lot of international attention. But, before this legalization in the Penal Code this country had adopted a legal regulation of euthanasia and, before and after that, extensive surveys into the practice of euthanasia had been carried out. The fact that the Dutch example is cited both by those who favor the legislation of euthanasia and those who reject it demonstrates that empirical data in themselves do not settle an ethical or juridical issue.

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Jochemsen, H. (2001). Why Euthanasia Should not be Legalized. In: Weisstub, D.N., Thomasma, D.C., Gauthier, S., Tomossy, G.F. (eds) Aging: Decisions at the End of Life. International Library of Ethics, Law, and the New Medicine, vol 12. Springer, Dordrecht. https://doi.org/10.1007/978-94-015-9682-4_5

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Medical Perspectives on Death and Dying

Several states have begun to consider legislation that would legalize active voluntary euthanasia.

Several states have begun to consider legislation that would legalize active voluntary euthanasia. To address some of the ethical issues raised by such legislation, the Center for Applied Ethics sponsored a symposium entitled Legalizing Euthanasia: Ethical Perspectives on Medicine and Dying . Principal speakers were Derek Humphry, founder and president of the Hemlock Society, and author of the current best-seller, Final Exit , a suicide manual for the terminally ill; and Richard Gula, S.S., Ph.D., a professor of moral theology at St. Patrick's Seminary in Menlo Park, California. The symposium was funded in part by the California Council for the Humanities, a state program of the National Endowment for the Humanities. The following excerpts highlight the remarks of Mr. Humphry and Father Gula.

Derek Humphry Let me explain how I became involved with the subject of euthanasia. In 1974 my first wife, Jean, was dying of bone cancer. Thrombosis had set in, her bones were cracking and she was losing control of her bowels. One day, after a very close brush with death, she sat up in her hospital bed and said to me, "Will you help me die?" That is when I first encountered the issue of euthanasia; from across my late wife's hospital bed.

After she made her request, I asked myself, "What if I were sitting in that hospital bed? What if I had had two years of pain and agony? What if I faced an imminent death? What if I was losing control of my bowels and my bones were cracking and so-forth?" I realized then that I would be asking her to help me to die. That, ladies and gentlemen, is my simple reason for what I did. It was an act of love.

Jean had been a good wife to me for 22 years. She stood by me in good times and bad. And when she was experiencing a bad time, I felt it was my duty to support her in her decision. I am not a Christian. I am an atheist. So, for me there was no question of consulting any god. It was a matter of situational ethics.

In 1980, five years after Jean's death, I helped to establish the Hemlock Society. This organization seeks to change certain laws regarding suicide. We want the government to decriminalize the actions taken by physicians in the assisted suicides of terminally ill patients.

We believe that a mentally competent adult who is dying should be able to submit a written request to their doctor that would state, "I've had all I can take. The pain and suffering are too much. I wish to die. Help me."

The physician, according to the Hemlock movement's prepared law, would have to obtain the opinion of a second doctor. They would both have to agree that the person is dying. The first doctor could then end the life of the patient with an oral or intravenous drug overdose, without the threat of prosecution or lawsuit. Our laws also state that the doctor could elect not to assist the patient with such an action.

There are those who agree with what the Hemlock movement is saying at the present time, but are fearful that such an ideology would result in a system of euthanasia similar to that used by Nazi forces. It is true that the Nazis introduced a program which they called euthanasia. They murdered about 100,000 people who were physically or mentally handicapped. No senior citizens or terminally ill people were allowed to voluntarily end their own lives.

But how can you say to a person who is dying of throat cancer today that they cannot have voluntary euthanasia because of what the Germans did in 1940 and 1942? I think that the person would respond, "It's not relevant. It's me. It's my body. It's my liberty. It's my life. And it's my death. Let me have control."

I would claim that this is the ultimate civil liberty. If we cannot go to our deaths in the manner of our own choosing, what liberty do we have?

Richard Gula Most of the focus on euthanasia so far has been dominated by what I'm going to call the paradigm of individual case analysis. My position is that euthanasia is not primarily an individual issue; it's a societal one. So discussion about euthanasia should not be governed primarily by individual case ethics, but by societal ethics.

The sanctity of life principle is probably the common ground principle. There are two extreme positions that can give sanctity of life as a principle a bad name. One extreme is what I call vitalism, and that is the extreme that tries to absolutize physical life making an idol out of biological existence. This principle says no cost is too great to keep this biological life going. The other extreme interpretation leads to what I'm calling a utilitarian perspective, which values life for its usefulness. This is the interpretation that says only the strongest and the fittest ought to survive. The danger here is the abuse of undertreatment.

I want to think about the sanctity of life from the middle position. This is the interpretation of the principle that recognizes we have limited dominion over life. It's the interpretation that says we are stewards of life, that we ought to care for life and promote it and enhance it in order to allow our lives to flourish and to achieve our potential. This is the interpretation that wants to respect life in all its forms and in all its stages. Interpreting sanctity of life in this way entails two obligations: a positive one--to nurture and support life„and a negative obligation not to harm life. Therefore, to appeal to sanctity of life in a discussion of euthanasia is to create a presumption in favor of life.

The second principle is the principle against the prohibition of killing. I want to look at three ways of interpreting this principle. The first says there is no moral difference between killing and allowing to die -- that once you decide that life no longer needs to be sustained, because the use of treatment would be futile, then it makes no difference whether you actively intervene or simply withhold or withdraw treatment.

The second interpretation is that there is a qualified moral difference. That qualified moral difference is that the distinction holds but gives way at a certain point. Some will say when the person has gone beyond the reach of human care, when there is no longer the capacity to receive love, or to receive comfort, then the distinction dissolves. Others will say when the person is in intractable pain and there's nothing more that can be done to relieve the pain, then the distinction between killing and allowing to die dissolves. Others would say when the patient is overtaken by the dying process -- that is to say, once you have decided that nothing more needs to be done, that life has reached its limits, then it makes no difference whether you withhold treatment or intervene, because in that condition, you are not usurping the dominion that is not yours. Then there's the third position that says the distinction holds all the way through.

The next principle is the principle of autonomy, which is probably going to be at the core of this discussion of whether euthanasia ought to be legalized. In our culture, we interpret autonomy as the right to self determination. The prevailing interpretation of autonomy in our culture is that autonomy is there to maximize self-interest. That means that we are able to pursue our own goals and life plans without external constraints. When we interpret autonomy this way, we answer the question "whose life is it anyway?" in favor of the one whose life is in question. This is solid ground for supporting euthanasia.

Can the principle of autonomy be used to challenge euthanasia? Some argue that the very interpretation of autonomy that says that you have the freedom to have another person intervene to take your life is a contradiction of what autonomy means -- that actually what you're doing is giving away your freedom. The other way of looking at it is to say that euthanasia is not primarily a private affair. It's a public or societal action that involves others, and therefore it is something that ought to be treated as a form of public action.

The third principle is the principle of the common good. To show that euthanasia ought to be sanctioned as a public practice, we need to be able to show that we can justify it in more than the individual case. This is the principle that says that when we establish a policy, we are sanctioning actions as a common practice. When we apply that principle to euthanasia, we need to ask, "how does the goal of my own private killing contribute towards making society the context in which human life can flourish?"

Now let's turn to the perspective of virtue. Virtue asks whether or not a policy on euthanasia creates the right kind of relationship between the physician and the patient, and would a policy on euthanasia create the right kind of community in which health care is delivered. The perspective of virtue asks that the physician deliver compassionate care within the limits of the physician's role. The trust that we extend to the medical profession to heal and protect life is something that we would want to sustain and the perspective of virtue asks whether that kind of trusting relationship would be enhanced or hindered if euthanasia became part of the options that are available to the physician. The perspective of virtue looks on ourselves as a community of interdependents in which we are partners to one another. It sustains the community of trust and care by promising not to abandon anyone, and it tries to be realistic about accepting the limits about what it means to be human. We recognize that life will not be free of suffering, that life will be burdensome, and there will be tragedy. The perspective of virtue tries to be realistic about accepting that. It encourages us to construct structures of support which will enable us to raise those who suffer into the network of the supportive, caring community.

Ultimately we cannot convert individual cases into public policy without having something remaining. The common good resists the temptation. How do the burdens to one individual compare to the burdens and the benefit on society as a whole? I think all of this ultimately is going to turn not on the basis of principles we argue with, but on the kind of people we are. Are we a virtuous people that creates a community of caring or are we going to compromise that in the way we allow euthanasia to become a practice in our healing society?

Videotapes of the symposium are available for $16.50 by writing to the Center for Applied Ethics, Santa Clara University, Santa Clara, CA 95053.

This article was originally published in Issues in Ethics - V. 5, N. 2 Fall 1991

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Why Euthanasia Should Not Be Legal: Pros and Cons

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