Med Health Care and Philos (2013) 16:225230

DOI 10.1007/s11019-011-9365-5

SCIENTIFIC CONTRIBUTION

Autonomy-based arguments against physician-assisted suicide

and euthanasia: a critique
Manne Sjostrand Gert Helgesson
Stefan Eriksson Niklas Juth

Published online: 8 December 2011

 Springer Science+Business Media B.V. 2011

Abstract Respect for autonomy is typically considered a

key reason for allowing physician assisted suicide and
euthanasia. However, several recent papers have claimed
this to be grounded in a misconception of the normative
relevance of autonomy. It has been argued that autonomy is
properly conceived of as a value, and that this makes assisted
suicide as well as euthanasia wrong, since they destroy the
autonomy of the patient. This paper evaluates this line of
reasoning by investigating the conception of valuable
autonomy. Starting off from the current debate in end-of-life
care, two different interpretations of how autonomy is
valuable is discussed. According to one interpretation,
autonomy is a personal prudential value, which may provide
a reason why euthanasia and assisted suicide might be
against a patients best interests. According to a second
interpretation, inspired by Kantian ethics, being autonomous
is unconditionally valuable, which may imply a duty to
preserve autonomy. We argue that both lines of reasoning
have limitations when it comes to situations relevant for endof life care. It is concluded that neither way of reasoning can
be used to show that assisted suicide or euthanasia always is
impermissible.
Keywords Autonomy
Bioethics
Assisted suicide

Euthanasia
Palliative care
Palliative sedation

Paternalism
Ethical theory
M. Sjostrand (&)
G. Helgesson
N. Juth
Centre for Healthcare Ethics, Department of Learning,
Informatics, Management and Ethics, Karolinska Institutet,
Berzelius vag 3, 171 77 Stockholm, Sweden
e-mail: [email protected]
S. Eriksson
Centre for Research Ethics and Bioethics, Uppsala University,
Husargatan 3, 751 22 Uppsala, Sweden

Introduction
Respect for autonomy is usually considered one of the most
important reasons in favour of legalising euthanasia.
However, in recent debate this has been challenged by
arguments claiming that autonomy is primarily a value that
needs to be promoted or protected. This may imply, or so it
has been argued, that euthanasia and physician-assisted
suicide (PAS) are impermissible since they destroy the
autonomy of the patient (Materstvedt 2003). Accordingly,
it has been maintained that considerations of autonomy
cannot be used as a reason in favour of euthanasia or PAS
and that such arguments are self-contradictory (Doerflinger
1989; Gordijn and Janssens 2000). The idea of autonomy
as a value has also been taken as a reason not to offer
palliative, continuous deep sedation in end-of-life care
(Eckerdal 2004). The question of whether respect for
autonomy may support a right to euthanasia has been
labelled as one of the central topics in palliative care ethics
(Hurst and Mauron 2006).
The aim of the present paper is to investigate the
rationale behind the claim that respect for autonomy is
incompatible with euthanasia and assisted suicide. The
argument deserves attention for two reasons. First, it has
become influential in palliative care guidelines and policy
documents, and it has been put forth by leading theorists in
the field. Second, it is theoretically interesting since it
supposes quite a different normative relevance of autonomy than the standard bioethical conception of autonomy
as a ground for a right to self-determination (including the
right to decide when to end ones life).
The outline of our paper is as follows: starting with
some general remarks about the concept of autonomy as it
is used in bioethical debate, we will go on to present the
above-mentioned arguments as they have been propounded

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in current discussions. After that, we will present two

different interpretations of the idea that autonomy is
valuable: autonomy conceived of as a personal prudential
valuesomething that benefits us in that it makes our lives
betteror as an unconditional value in a Kantian sense. In
doing this, we will argue that autonomy as a value, however interpreted, cannot provide a reasonable ground for
the position that euthanasia or assisted suicide is always
wrong.

The concept of autonomy in bioethics

Autonomy is a central concept in bioethics. The core of the
concept as it is understood in this context concerns personal self-governance: being in control of oneself and
choosing ones own way (Dworkin 1988). Most theories
about personal autonomy acknowledge that it presupposes
a capacity for intentional action on the basis of ones own
rational deliberations as well as freedom from controlling
instances. Sometimes a distinction is made between freedom and autonomy, with freedom specifically referring
to the absence of external hindrances (Tannsjo 1998).
Freedom in this sense corresponds to Isaiah Berlins notion
of negative liberty (Berlin 2002). The term freedom is also
used in the sense of positive liberty, which is a broader
notion concerning the actual presence of self-governance.
Both aspects of liberty are highly relevant to autonomy as
the concept is understood in contemporary bioethics
(Beauchamp and Childress 2001).
Another distinct question is what normative relevance
autonomy has, i.e. in what way autonomy is important. Its
relevance can be understood in terms of a right to be
respected, (Beauchamp and Childress 2001) and in terms of
a valuable end to be promoted (Juth 2005). In Kantian
ethics, autonomy is a fundamental moral value and the
basis of our moral obligations towards ourselves as well as
towards other persons, and thus gives rise to duties and not
primarily to rights (ONeill 2002).
The central question for this paper is whether there is a
reasonable interpretation of the normative relevance of
autonomy that can back up the claim that euthanasia or
PAS is always wrong, or that considerations of autonomy
cannot be a reason for complying with a patients request
for PAS or euthanasia.

Autonomy-based arguments against PAS

and euthanasia
The idea that autonomy is incompatible with euthanasia
emanates from the presumption that autonomy is valuable,
and therefore needs to be protected. This reasoning has

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been put forth in several different contexts. Gordijn and

Janssens (2000) maintain that respect for autonomy in
palliative care implies negative as well as positive obligations for healthcare personnel. They argue that healthcare personnel may be obliged to enhance or restore
patients autonomy, but they have no obligation to act if
their actions lead to loss of autonomy. Since death means
that the necessary conditions for autonomy are lost, respect
for autonomy can therefore not be a reason in favour of
complying with a patients request for euthanasia (Gordijn
and Janssens 2000). The European Association of Palliative Care (EAPC) similarly argues that respect for autonomy in palliative care primarily is about strengthening
and restoring autonomy [] not to destroy it (Materstvedt
et al. 2003). According to Materstvedt, the chair of the
EAPC ethics task force on palliative care and euthanasia,
the value of autonomy means that euthanasia and PAS are
unjustifiable since they damage autonomy in the most
fundamental way (Materstvedt 2003). Doerflinger develops a similar argument in the paper Assisted Suicide: ProChoice or Anti-Life (1989). In this paper, Doerflinger
argues that there cannot be an autonomy-based right to
PAS (which is the subject he discusses), since death means
total loss of future freedom. He concludes that options in
healthcare must be limited in order to safeguard freedom
itself.
An analogous argument has also been put forth in the
discussion concerning continuous deep sedation (CDS).
CDS means that the consciousness of the patient is reduced
without any intention to restore it, in order to avoid intolerable suffering (Morita et al. 2002). Although practised in
many European countries (Cherny and Radbruch 2009), the
procedure is controversial.1 Although there are important
differences between the practices of CDS, PAS, and
euthanasia, similar arguments have been used both for and
against these practices. It has, for instance, been argued
that since autonomy is valuable and sedation leads to loss
of autonomy, it is wrong to sedate competent patients
during their last phase in life (Eckerdal 2004). We will
return to this discussion in the subsequent sections.
This reasoning implies that physicians have obligations
to preserve and promote patients autonomy and that these,
in some situations, have priority over patients wishes
about how to end their lives. Thus, autonomy is seen as a
value to protect and promote rather than a right for individuals to decide about their care.
The arguments presented above can be questioned on
several grounds. In this paper, we will neither discuss
whether autonomy is valuable in itself, nor how the alleged
value of autonomy is to be balanced against other
1

CDS has been called slow euthanasia by critical debaters (Billings

and Block 1996).

Autonomy-based arguments against PAS

potentially valuable things, such as wellbeing or absence of

suffering. In the following we will assume that autonomy is
valuable in itself, in order to focus on the question of
whether death through euthanasia or PAS necessarily
means an unacceptable loss of autonomy for the person in
question.
In order to investigate this we need to achieve a better
understanding of the ways in which autonomy can be
considered valuable. We will examine what we believe are
the two most plausible interpretations of autonomy as a
value in healthcare. As we shall see, neither interpretation
gives a compelling reason for holding every instance of
euthanasia to be wrong. On the contrary, we will argue that
autonomy, also conceived of as a value, may serve as a
well-founded reason in favour of these practices. This does
not mean that requests for euthanasia or PAS always
should be respected, nor do we believe this to be a sufficient reason for legislative or regulatory changes in Europe
or elsewhere. The aim of the paper is merely to show that
autonomy-based arguments against euthanasia, PAS, or
CDS cannot establish that these practices always and
necessarily are wrong.

Autonomy as a prudential value

The first notion of the value of autonomy that seems relevant for the way the argument has been presented is the
idea of autonomy as a personal prudential valuesomething that benefits us and makes our lives better. Such a
notion of the value of autonomy can be found in J. S. Mills
classical writings on liberty (Mill 1982).2 In recent years
the idea has been elaborated by Lindley (1986) as well as in
contemporary bioethics (Beauchamp and Childress 2001;
Juth 2005). The value of autonomy here resembles the
value that usually is ascribed to wellbeing or preference
satisfaction in consequentialist ethical theories. If the value
of autonomy is seen in this way, the question of whether or
not to respect a patients wish for euthanasia or PAS boils
down to concerns for the patients overall prudential
interests (welfare in a very broad sense). If we look at the
argument against PAS and euthanasia from this perspective, it must lend credence to the view that it is in the
patients own best interests to remain autonomous, rather
than to die or lose consciousness.
There are two ways of understanding such a position.
One possible interpretation is that capacity for autonomy is
what is valuable (Husted 1997), whereas another view

227

would rather stress the value of exercising ones autonomy

(Lindley 1986). Let us start with the first assumption, that
merely capacity and not exercise constitutes the value of
autonomy. If capacity is valuable without relating it to
actual exercise, the complete infringement of a persons
actual abilities to act autonomously is unproblematic from
the point of view of autonomy as long as the mere capacity
for autonomous acting is maintained. But if it is in a persons interest to be autonomous, then it is reasonable to
assume that it must also be of some interest for that person
to actually exercise their capacity. It seems strange to hold
the capacity for autonomy as highly valuable and not
ascribe any value to the exercise of it. Such a position may
be coherent but is, in our view, not very plausible.
However, if we would adhere to the idea that the exercise of autonomy (also) is valuable (which of course presupposes capacity), there does not seem to be a simple
clear-cut answer on how to respect autonomy when persons
decide to end their lives. Rather the value of respecting a
certain autonomous wish must be weighed against the
value of future autonomy.3 In order to take a closer look
at how to balance the different aspects of the value of
autonomy, we will turn to the argument presented by
Doerflinger (1989).
Doerflinger writes that patients who are capable of
choosing to end their lives are also capable of making
many other important decisions. The problem with suicide
is that it removes the possibility of making all these other
choices.4 Doerflinger argues by way of analogy by referring to the well-known discussion of whether a right to
freedom entails a right to give up ones freedom and
become a slave. Doerflingers answer is no, the freedom of
the individuals must be protected against their own decisions. He then compares the situation of a slave with that of
a corpse and argues that, in terms of freedom, the slave is
better off, since he at least is free to choose which attitude
to take towards his predicament whereas the corpse cannot
think at all. Therefore, or so it can be argued, if one holds
that there is no autonomy-related right to voluntary slavery,
one must come to the same conclusion regarding assisted
suicide.
Appealing as this analogy may seem at first, it rests on a
quite problematic assumption. It seems to assume that we
can compare the freedom of a corpse with that of a living
person. This is absurd; corpses are neither free nor unfree,
the predicate free cannot be accurately applied to a
corpse. When comparing the freedom of a slave with a free
3

Mill does not use the term autonomy, but liberty. His conception of
liberty, though, is quite close to the common interpretation of
autonomy in bioethics, which is being able to do as one chooses. Kant
on the other hand has a much stricter view, where autonomy consists
in doing what one ideally ought to do.

We could for instance assume that every infringement of autonomy

has some negative value, but that this could be balanced against other
valuable things such as preference satisfaction, pleasure or autonomous self-realisation.
4
See also ten Haves discussion in the paper Euthanasia: moral
paradoxes (2001).

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M. Sjostrand et al.

228

person it seems obvious that a life of slavery is likely to

involve less freedom than a life of freedom. But this does
not prove that a person would live a less free life if they
were to have a request for assisted suicide respected at the
end of their life than if such a wish on their part were not to
be respected. Thus, the analogy loses force. If we assume
(as the argument presupposes) that we can measure
autonomy, not only the sheer quantity of autonomous
decisions seems relevant but also their relative importance
to the person. It seems unreasonable to claim that persons
are better off just because they make, or are able to make,
many choices, if these choices do not matter to them, or if
they are made possible at the cost of disrespecting more
important decisions.
Although a person in slavery may be free in some
respects, their freedom could be infringed in so many
substantial ways that a life of slavery would be highly
unlikely to benefit their overall autonomy. In fact, if it is
possible to ascribe a negative value to every infringement
of a persons autonomy, it is possible that a slave will end
up with a negative balance. In order to make the analogous
argument that it is better for a patient to remain autonomous than to be assisted in dying, one must make a case for
the negative value of disrespecting the patients choice
being outweighed by the positive value of future autonomy.
This claim may hold in some cases, as when persons with
relatively long and healthy lives ahead of them want to end
their lives, as in the case of a temporarily depressed and
suicidal teenager. But, for instance, in situations where
patients are suffering from end-stage terminal illnesses, the
claim seems much less compelling.
Imagine a case where after careful consideration a
patient decides that they want to end their life in order to
escape suffering at the very final stage of an incurable
illness. Would disrespecting their wish to die be more
beneficial to their autonomy than actually helping them to
end their life the way they want to? We believe that, from
the point of view of autonomy as a prudential value, it is
unreasonable to claim that any amount of future autonomous action, no matter how small, is of greater value to a
person than having a central wish respected towards the
end of life. If the value of autonomy is to be conceived of
also in terms of actually exercising ones autonomy, having
control over how to end ones life is a plausible candidate
for valuable exercise of ones autonomy.

for concluding that all acts of euthanasia, PAS, or CDS are

wrong. But there is another way of interpreting the
autonomy argument against PAS and euthanasia, namely
one which rests on Kantian ethics and the idea of autonomy
as an absolute, unconditional value.5 This is a completely
different notion of the value of autonomy from the idea of a
prudential value outlined above. According to this view,
autonomy is not good because it is good for us, and not
something that should be promoted because more is better.
As Velleman (1999) argues, there is an important difference between what is good for a person and the value of the
person himself. This latter value is a fundamental value
which all prudential values depend on. Thus, on this view
autonomy is intrinsically linked to our dignity as human
beings and the absolute value of personhood.
Velleman, like Doerflinger, takes the case of slavery as
an example. Velleman argues that people have no right to
sell themselves into slavery, not because slavery harms
them (or is prudentially bad for them), but because slavery
violates personhood. And the same reasoning could,
according to Velleman, be applied to suicide. Suicide is
wrong, not because it is prudentially bad for us but because
it is a violation of the value of personhood. Many contemporary Kantians similarly argue that PAS and euthanasia are impermissible for this very reason. However, in
the following we will argue that considerations of autonomy also gives Kantian ethics a possible reason to accept at
least some instances of suicide as well as euthanasia.
Kantian ethics is built on the notion of a categorical
imperative, which comes in three different formulations.
The first formulation of the categorical imperative says:
Act only in accordance with the maxim through which you
can at the same time will that it become a universal law
(Kant 2002: 37). According to Kantianism, this rules out
practices that would be inconsistent in terms of universal
practice (for instance, if everyone were to lie, there would
be no trust, and with no trust there can be no liestherefore
the practice of lying is inconsistent with the categorical
imperative). Kant argued that suicide cannot be universalised and is therefore wrong. However, it is questionable
whether it is inconsistent in such a strict sense so that the
maxim cannot be universalised.6 Let us assume that a person in terrible suffering and with little time left to live takes
his life. There does not seem to be any logical inconsistency
with a world just like ours where people in such predicaments choose to end their lives (Nell 1975: 79f).

The Kantian argument; autonomy

as an unconditional value

As argued above, the idea of autonomy as a prudential

value may rule out certain acts of assisted suicide or
euthanasia. It does not, however, provide us with a reason

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Materstvedt (2003) writes that Kant held suicide to be irrational as

well as immoral, and Doerflinger uses a Kantian rhetoric in denoting
suicide as the ultimate self-contradiction of freedom.
6
Many contemporary Kant scholars argue that suicide may be
compatible with the categorical imperative (see for instance Anderberg 1989; Brassington 2006; Nell 1975; Rhodes 2007; Velleman
1999). See also Vong (2008).

Autonomy-based arguments against PAS

Even if one would reject the argument that purposively

shortening ones life is not universalisable according to the
first version of the categorical imperative, there could
nevertheless be reasons why it would be acceptable
according to Kantian ethics. According to the second formulation of the categorical imperative, we should always
act in such a way that we treat humanity, whether in ourselves or in others, as an end, and never merely as a means
to an end (Kant 2002: 46f). In order to respect our own
dignity, there are constraints on what actions are permissible for us. Suicide could then be seen as being wrong,
since it means that we use ourselves (our autonomy) as a
means and not as an end. We cannot justifiably trade an
absolute value (autonomy or dignity) against interest-relative goods such as pain relief, since this would mean our
prioritising what is valuable to us over the value we carry
in ourselves (Velleman 1999).
Velleman nevertheless argues that there is a Kantian
argument in favour of at least some instances of PAS and
euthanasia. He argues that the Kantian objection to suicide
applies to cases where suicide is committed in order to
obtain benefits or escape harm, and that this leaves open
the possibility of suicide being justified for other reasons,
namely when it is committed out of concern and respect for
our dignity. Velleman writes that it sometimes is justifiable
to destroy objects of value if they would otherwise deteriorate in ways that would offend that very value. Similarly, patients who are about to lose autonomy and dignity
due to suffering and distress caused by terminal and
incurable illness may be justified in ending their lives in
order to die with dignity.7 If we accept this line of reasoning, the Kantian argument can be used as a reason
against PAS or euthanasia that is motivated by concern for
suffering but not by concern for loss of autonomy and
dignity. This would mean that an absolute ban on assisted
suicide and euthanasia cannot be maintained on this reading of the autonomy-argument against PAS and euthanasia.

Kantian autonomy and the noumenal self

The Kantian argument may be interpreted in yet another
way as a basis for rejecting PAS or euthanasia. Materstvedt
and Bosshard (2009) develop such an argument when
7

Other writers, such as Anderberg (1989: 179192) and Rhodes

(2007), have advanced similar arguments. Rhodes writes that
biological human life and dignified life in the Kantian sense are not
coextensive. A person who is about to lose her autonomy, for instance
due to dementia, could thus will to end her life in accordance with a
maxim such as: In order to avoid degenerating into a thing that
cannot act from the autocracy of the human mind, agents should show
respect for their humanity by sacrificing their physical life (Rhodes
2007:46).

229

discussing the relationship between CDS on the one hand

and PAS and euthanasia on the other. They argue that
permanently removing a persons consciousness, as in
CDS, means a loss of valuable autonomy but also that this
does not necessarily make CDS wrong. If loss of autonomy
comes after autonomous consent has been given, the value
of autonomy is properly respected. However, this does not
apply to PAS or euthanasia. Materstvedt and Bosshard
argue that even though there is no important difference
from the point of view of the patient between being permanently unconscious and dead, there is still an ethically
relevant difference which they account for by the Kantian
notion of personhood. According to Kant, the world is
divided into an empirical realm and a noumenal realm. The
empirical realm concerns the world as it appears to us; it is
a contingent world governed by the laws of nature. The
noumenal world, on the other hand, is outside of time and
is governed by reason, not by causation. Human beings
have a part in the noumenal world, which makes it possible
for us to act autonomously. Materstvedt and Bosshard write
that CDS only affects the empirical person (the body), and
although it makes autonomous action impossible, it does
not take away the basic capacity for autonomy and thus
leaves the patients noumenal self intact.
Interesting as this idea may be, it entails two main
problems. First, the metaphysical assumption of two separate realms and two separate selves is metaphysically
extravagant and quite difficult to make congruent with
modern science. We believe it to be quite problematic to
base normative assumptions on this kind of speculative
metaphysics. Second, and more importantly, respect for
autonomy here seems to imply that the important autonomy
to respect is the autonomy of our noumenal self, not that of
our empirical self. As Berlin (2002) points out, this does
not necessarily imply respect for our actual wishes and
desires. If our noumenal self is causally independent of our
empirical self, how can it be threatened by anything we do
to the empirical person? However, autonomy as it is usually understood in bioethics concerns our actual, not ideal,
wishes and desires. It does not concern something located
in another realm. It seems highly counterintuitive to claim
that a person is free in a morally relevant sense if they
would be deprived of all actual, empirical freedom. The
question for anyone relying on such a notion of personhood
is what respect for autonomy actually means, if it means
anything at all.

Conclusions
Respect for autonomy is typically considered a central
reason for allowing physician-assisted suicide and euthanasia. However, according to certain interpretations of the

123

230

normative relevance of autonomy, these practices are

unacceptable. According to one interpretation, autonomy is
a prudential value to be promoted and protected. According
to another, Kantian, interpretation, autonomy is an
unconditional value, which leaves us with a duty to remain
autonomous. Both these interpretations of autonomy give
ground for claiming that PAS or euthanasia may be wrong
in some cases, but not all but not all. If we suppose that
autonomy is a prudential value, respecting current autonomous decisions must be weighed against the value of
future autonomy. In a Kantian approach, reasons against
PAS or euthanasia motivated by concern for suffering can
be complemented by pro-arguments based on respect for
autonomy and dignity. We conclude that neither of the two
interpretations of the value of autonomy that we have
discussed can be used to show that all cases of assisted
suicide or euthanasia are wrong.

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