THE ETHICS OF

EUTHANASIA
 The Four Fears of Dying

1. We are afraid that we will die sooner

than we should want to.

2. We are afraid that we will be forced

to live, miserably, in pain, and longer than
we want.
3. We fear that we might be abandoned,
misused or scorned by those near to us.

4. We fear that we might be a burden to

those near to us.
 The term euthanasia has its etymology
in the Greek word eu, meaning good,
and thanatos, meaning death.

Although the term euthanasia is

commonly applied to cases of so-called
“mercy killing,” in the ethical and legal
literature, it is applied to a wide variety of cases.
The Type of euthanasia can be defined by
the intersection of 3 factors:

1. the mental state of the patient.

2. the patient’s desires or wishes.
3. the manner in which euthanasia is
performed.
THE MENTAL STATE OF THE PATIENT:
competent, patient is of sound mind sufficient to
make medical decisions;
incompetent, patient is incapable of making medical
decisions.
PATIENT’S WISHES OR DESIRES
voluntary= the patient is competent and consents
to a medical action;
involuntary, the patient is competent but has not
consented to a medical action;
non-voluntary, patient has not made wishes known
or is incompetent to make a decision.
THE KIND OF ACT INVOLVED:
Active. commission of an intervention that is
intended to end the life of the patient with a terminal
or debilitative illness; it is an act that would cause the
person to die whether they are terminally ill or not.

Passive. Omission of an intervention that would

prolong the life of someone with a terminal or
debilitative illness.

Deactive. decomission—or withdrawal, the removal

of interventions that are prolonging the life of a
patient with a terminal or debilitative illness; the
removal will likely cause the patient to die.
the intersection of mental state, consent and
kind of action defines 9 types of standard
cases of euthanasia:

voluntary active
voluntary passive
voluntary deactive
nonvoluntary active
nonvoluntary passive
nonvoluntary deactive
involuntary active
involuntary passive
involuntary deactive
The intersection of mental state, consent creates nine
basic types of euthanasia:

voluntary active: physician-assisted suicide, as permitted

in Oregon, Vermont, Washington and California, and is
currently being considered in New York.

Voluntary passive: cases of DNR (Do Not Resuscitate),

where competent patient has made a request through a
living will or power of attorney.

Voluntary deactive: cases of removing a

ventilator; withdrawing a G-tube from competent
patients by their request or through a living will or
power of attorney.
Types, cont’d
Nonvoluntary active: various cases where
incompetent patient is actively euthanized.

Nonvoluntary passive: choices made by

family, physicians or courts to not
resuscitate or treat an incompetent patient.

Nonvoluntary deactive: choices made by

family, physicians or courts to withdraw
existing treatments for an incompetent
patient. Classic cases: Karen Ann Quinlan, Nancy
Cruzan, Terri Schiavo.
Involuntary active: as practiced in
Nazi Germany death camps.

Involuntary passive: triage in battlefield

hospitals or emergency situations (Italy
during the 2020 Covid pandemic).
Involuntary deactive: triage in battlefield
hospitals or emergency situations. (Italy
during the 2020 Covid pandemic).
Why is involuntary euthanasia in all its
forms, considered to be morally wrong?
 Ethical Principles Involved:
Contractualist Based principles

Consent and Autonomy:

the core of liberty rights;

the right of bodily self-determination is the

manifestation of liberty rights;

the right to prevent harm against one’s body by another;

basis of laws against battery, assault and rape

 categorical imperative

always treat people as ends-in-themselves,

that is, we cannot do to another what they
would not will for themselves.

categorical imperative would align with

contractual theories in this regard.
Advantages of Consent-Based Ethics:

1. Places the decision-making in the hands

of the person most affected by the decision.

2. Protects against the abuse of an individual

or a minority for some collective good, or
abusive family members or uncaring medical
staff .
Disadvantages of consent-based ethics:

1. It is not very useful in the case of incompetent

patients, or cases where we do not know the wishes of
the patient .
2. It may lead to decisions that are medically irrational,
based on beliefs or wishes of the patient.

3. It views the individual as separate from family, and

doesn’t take into consideration how they might be
affected.
 The Utilitarian Principle

Choose that action which creates

the greatest good for the greatest
number.
 Advantages of the Utilitarian Principle

1. It can take into consideration the overall good or

harm of euthanasia practices on society; e.g.,
health care costs, or the values of a society.

2. It provides a decision-making model in

the case of incompetent patients.
 Disadvantages of the utilitarian principle:

1. the collective good may be realized at

price of a minority or a set of individuals;
it could tolerate worsening the condition of a
few for the benefit of the many.

2. It lends itself to bureaucratic decision-

making without the participation of those
who are primarily affected by the decisions.

3. it could lead to abuse of patients

by family or medical staff.
 Consent-based ethics of Euthanasia:

The principle would seem to justify passive,

deactive and even active euthanasia, so long as the
patient was competent and truly consented to it.
The legal system appears to support consent-based
ethics up to a point.
Satz v. Perlmutter, 379 So. 2d 359
(Fla. 1980) Florida Supreme Court
Abe Perlmutter, 73 years old, with
advanced ALS
sought to remove respirator

Court decision have noted a right to withdrawal

medical treatment in the case of unavoidable,
imminent death.
Courts have also validated a right to withdrawal
treatment in the case of unavoidable, but non-
imminent death.

Bartling v Superior Court 1984.Civ. No.

B007907. Court of Appeals of California,
Second Appellate District, Division Five.
December 27, 1984

70 year old, suffering from cancer, emphysema,

chronic respiratory failure, arteriosclerosis, and an
abdominal aneurism.

sought to be removed from ventilator.

Courts have validated a right to refuse medical
treatment in the case of fatal but salvageable conditions:

Randolph v. City of New York 117 A.D.2d 44 (N.Y.

App. Div. 1986)

45 year old woman with three children; a Jehovah

Witness who refused blood transfusion despite risk
of hemorrhage in Caesarian procedure.

also Lane v. Candura 6 Mass. App. Ct. 377 (1978)

376 N.E.2d 1232

77 year old woman sought stay from amputation.

Legislation which confirms competent
patient’s right to withdrawal or refuse medical
treatment:

The Patient Self-Determination Act. 42.

USC Sects 1395cc and 1396 (1990).

requires all federally funded hospitals and

nursing facilities to give every patient, on
admission, written information about their
right to refuse treatment under existing state law.
The Patient Self-Determination Act. 42.
USC Sects 1395cc and 1396

Gave sanction to a number of living will

legislations found at the state level.

Another vehicle of confirmation of this

position is the Durable Power of Attorney,
present in all 50 states.
 from New York State template

1. Would you want your doctor to withhold or withdraw

medical treatment, if that medical treatment will only prolong
dying?
2. Would you want cardiopulmonary
resuscitation (CPR) to restore stopped breathing and/or
heartbeat?
3. Would you want to continue mechanical respiration, i.e. use
machines to keep you breathing?
4. Would you want tube or intravenous feeding and water?
5. Would you want maximum pain relief even if it hastens
your death?
6. Would you want to donate your organs and/or tissues?
The second issue is what to do
in the case of an incompetent
person . In principle, we
cannot get their consent.
Incompetency can be defined in 3 different
senses:

1. the inability to exercise judgment (as in

cases of being comatose; or in the case of
neonates).

2. the inability to form judgments (as in the

case of young children, the developmentally
disabled, or the mentally debilitated)

3. the inability to make sound judgments

in principle (as in the case of mental illness,
clinical depression, addiction).
Criteria used for incompetent patients:

Best interests: implicit consent on the

basis of what a reasonable, competent
and informed agent would do.

Substituted judgment (Based on Consent-

based ethics): implicit consent based on what
one believes the patient in question would
choose.
 Problems with best interests:

often such medical decisions involve

values and religious beliefs that are not
reducible to decision-making on the basis of
rational medical choices of cost-benefit.

it may leave the family and those

nearest the patient out of the decision-
making process.
 Problems with substituted judgment

the reconstruction of a patient’s wishes

can be subject to the bias of the decision-
maker.

Family members with a history of

unfriendly relations with the patient may
exploit this process to their advantage.
In the courts, and in legislation, the best
interests argument seems to have prevailed:

Two prominent cases:

The Baby Doe case and the regulations

that were consequent to it (1985)

The Nancy Cruzan case (1990)

Baby Doe was a neonate born with
Down syndrome and esophagus
malformation.

The decision of the parents was

not to treat.

The hospital in Bloomington, Indiana appointed a

guardian ad litem; court concurred with parents
decision and the Indiana Supreme court refused to
hear the case.

This led to national attention in the 1980s, and a

series of court cases, and eventually national
legislation.
 As a reaction to this and other cases, the government
issued the so-called Baby Doe regulations (1985).
they specifed criteria of when neonates should or
should not be treated:
there should be a presumption of treatment
(including nutrition and hydration) except:
1. neonate is chronically comatose.
2. treatment would prolong dying.
3. treatment would not be effective in
fixing all the life-threatening conditions.
4. the treatment is futile.

5. the treatment is inhumane.

The rules were struck down by the courts on two
grounds:

1. U.S. Supreme court: parental decisions

not subject to Section 504 (DHHS
Rehabilitation Act). Bowen v. American
Hospital Association

2. U.S. District Court: seizure of hospital

files is an invasion of privacy.

The current Baby Doe Law has been revised to

require all federally funded hospitals to have
procedures for reporting of medical neglect of infants
with disabilities.
Nancy Cruzan, 25, was in an auto
accident in 1983, and remained in
a persistently vegetative state.

in 1988, after 5 years in a

vegetative state, her parents
requested the removal
of a G-tube.

The hospital refused.

The Missouri courts generally agreed with
the hospital:

It ruled that “no one may refuse treatment for another person,
absent an adequate living will "or the clear and convincing,
inherently reliable evidence absent here."
U.S. Supreme Court Case
Cruzan v Director, Missouri Department of Health
(497 US 261 (1990).

the lawyer for Cruzan’s family argued that

the issues is whether a state can order a
person to receive invasive medical treatment,
contrary to the wishes of the family.

In a split 5-4 decision, the Court found in favor of the

Missouri Department of Health and ruled that nothing in
the Constitution prevents the state of Missouri from
requiring "clear and convincing evidence" before
terminating life-supporting treatment.
what’s interesting about these two cases, Baby
Doe and Cruzan, is that the courts allowed
best interests or substituted judgment in the
one, but not in the other.

parents could make benevolent decisions

for their immature children, since they
do that as a matter of course as parents.

But not for their adult children, since the

adult child is autonomous.
 The Cruzan case (1990)

Presented an argument against the

substituted judgment of the family.

1.benevolence, even the benevolence of parent

for adult child can’t be used as a basis for end-
of-life decisions.

2. even if parents or other kin are benevolent,

they may be partial to their own interests
and beliefs.

3. since some patients may not have living

parents, then substituted judgment depends on
having living parents .
Eventually information about Nancy Cruzan’s
wishes became known and the hospital permitted
the removal of the G-tube.
The Cruzan opinion established the right of
a competent patient to refuse medical
treatment, including life-sustaining
treatment, but denied the use of substituted
judgment as a viable alternative to decision-
making for incompetent patients who have
not made their wishes clear.
Active Euthanasia is considered to
be one of the more morally
controversial acts of euthanasia
 Probably one of the most controversial figures
in the movement to legalize voluntary active
euthanasia was Dr. Jack Kevorkian

assisted in over 130 active

euthanasia when it was illegal
in any state.

he was arrested and convicted

in 1999 of second degree
murder and served 8 years of a
10 to 25 year prison sentence
Does consent-based ethics justify active euthanasia?

the argument against: there is a difference in moral

kind between committing an act that will end a life,
and one in which one refuses (omits) an act.

therefore, even if a patient consents to active

euthanasia, it’s wrong, because it permits the doctor
to kill another human being.
it would be equivalent to killing someone who wants
to commit suicide.

a doctor who considers it murder, should

not be forced to do what the patient wants
 James Rachels argues for the morality of
active euthanasia for competent patients.

James
Rachels
 If a decision (on utilitarian
principles) is made to withdraw or
withhold treatment for a
terminally ill patient because
prolonging life would create more
suffering, then active euthanasia
James
Rachels would create even less suffering.
 Many people argue that killing is
morally worse than letting people die.

Rachels argues that they are morally

James
Rachels equivalent, so that if one is justified,
than the other should be as well.
 killing and letting die a
distinction made famous by
James Rachels.
bathtub example:

killing someone by forcefully

submerging them in a bathtub full of
James water.
Rachels
vs. letting them die in the bathtub full
of water after they have fainted.

Rachels argues they are morally equivalent.

When a physician and family chooses not
to treat a dying patient that is morally
equivalent to killing the patient.

Thus, if passive euthanasia is

morally permitted, then so
should active euthanasia.
Daniel Callahan active euthanasia is a form of
suicide, and suicide is always a
sorrowful event.

it is not a sensible way to deal with

the tribulations of life.
it also corrupts and goes against the
values of the medical profession.

Life is full of tragedy and suffering and we ought to

encourage people to learn how to bear it, to be noble in
the face of it, rather than committing suicide.
Callahan wants to argue against the
standard arguments in favor of active
euthanasia.

1. bodily autonomy and self-determination

2. we owe each other out of charity or
beneficence to reduce the suffering of others
3. there is no moral distinction between active
and passive euthanasia
the bodily autonomy argument makes euthanasia
into a private act when, in fact, it is public and
requires doctors and institutions to participate in it.

in regard to the second argument, palliative care

has improved to the point where most end of life
suffering can be relieved satisfactorily.

there is an important difference between

asking a physician to actively end the life of a
patient and caring for them in their last days.

a small minority of people utilize the death with

dignity laws. should we affect the values of an
entire culture to cater to a minority of outliers?
The Slippery Slope Argument

The permission of an act which, although

considered morally tolerable, will have
the consequence of promoting or leading
to acts which are not as morally tolerable.

This will eventually snowball into acts

which are morally wrong.

Consequently,
the moral permission of the initial act
should not be given.
 The fears typically expressed by
the slippery slope argument:

1. euthanasia will come under State control.

2. voluntary, active euthanasia will lead to
the permission of nonvoluntary and
eventually involuntary, active euthanasia.

3. those who are subject to the prejudices

of society will be the most frequently
euthananized: sexism, ageism, and racism.

4. euthanasia will corrupt medical practice.

5. euthanasia will corrupt social values.
DEATH WITH DIGNITY LAWS
 Death-with-dignity laws are legal in:

Oregon (Oregon Death with Dignity Act; 1994/1997)

Washington (Washington Death with Dignity Act; 2008
Vermont (Patient Choice and Control at the End of Life Act;
2013)
California (End of Life Option Act; approved in 2015, in
effect from 2016)
Colorado (End of Life Options Act; 2016)
District of Columbia (Death with Dignity Act; 2016/2017)
Hawaii (Our Care, Our Choice Act; 2018/2019)
Maine ( Death With Dignity Act 2019)
New Jersey (Aid in Dying for the Terminally Ill Act, 2019)
 Oregon measure 16

Passed in 1994 by a slim margin.

Developed by physician Dr. Peter Goodwin

Permits physician to prescribe drugs, but

does not require physician to administer them.
1. allows terminally ill adult Oregon residents
voluntary informed choice to obtain physician’s
prescription for drugs to end life.
2. no criminal penalties for qualifying
physician or pharmacist.
3. applies when physician predicts patient’s death
within 6 months.
4. there must be a 15 day waiting period.
5. there must be two oral, and one written request by
terminally ill person.
6. there must be a second physician’s opinion.
7. counseling is required if either physician believes
that the patient has impaired judgment.
 Vermont law one of the most recent (2013)

To request a prescription for life-ending medication

in Vermont, the patient must be:

• at least 18 years old

• a Vermont resident
• mentally capable of making and communicating
health care decisions, and
• diagnosed with a terminal illness that will result in
death within six months.
A patient who meets the requirements above will be
prescribed aid-in-dying medication only if:

• The patient makes two verbal requests to their doctor,

at least 15 days apart.
• The patient gives a written request to the doctor, signed
in front of two qualified, adult witnesses.
• The prescribing doctor and one other doctor confirm
the patient’s diagnosis and prognosis.
• The prescribing doctor and one other doctor determine
that the patient is capable of making medical decisions.
• The patient has a psychological examination, if either
doctor feels the patient’s judgment is impaired.
• The prescribing doctor informs the patient of any
feasible alternatives to the medication, including care to
relieve pain and keep the patient comfortable.
• The prescribing doctor asks the patient to notify their
next of kin of the prescription request. (The doctor
cannot require the patient to notify anyone, however.)
• The prescribing doctor offers the patient an
opportunity to withdraw the request for aid-in-dying
medication before granting the prescription.

To use the medication, the patient must be able to take it

on their own. A doctor or other person who administers
lethal medication may face criminal charges.
New York State is now considering a similar law

the Medical Aid in Dying Act, (AB2383 in

the state assembly and SB3151 in the
senate) that would allow terminally ill
patients who meet certain requirements to
request life-ending medication.
Arguments Against Euthanasia
 Daniel Callahan
Argues against the three standard
justifications of euthanasia

1. bodily autonomy and self-determination;

2. duty to relieve suffering of others;
3. no moral difference between active and
passive euthanasia
euthanasia does not affect the person
alone, but involves the physician, family
and medical practice.

the medical practice has the values

of life-saving; killing others would
corrupt those values.

the family can also be affected by

people making decisions to
terminate their lives.
palliative care has been improved to the
point, where most suffering can be
attended to in the dying process.

it is more humane and caring to

relieve suffering and let the
person live, than to relieve
suffering by killing the person.
 Rachels’s argument against the moral
difference between active and passive
euthanasia is a false one.

this is based on a confusion

between the proximate
causes of death.

there is an important difference between

death due to the disease and a doctor
directly killing someone in anticipation of
death by the disease.
 Basic Terms
ACTIVE EUTHANASIA: The commission of an act
which is intended to:

(1) shorten the time it would normally take for a

person with a terminal or debilitative illness to die; or

The act is such that it would cause the death of

the person whether or not the person is terminally ill.
PASSIVE EUTHANASIA: The omission of an
act which would

(1) normally delay or prolong dying in a person

with terminal illness; or

(2) would support the life of a person in a severely

debilitated condition; or

(3) would allow a person with a fatal condition to

survive.
Is Voluntary Active Euthanasia a case
of suicide?

one significant difference is that in

almost all cases of voluntary active
euthanasia the person’s medical
condition is such that they will die
imminently.

In suicide, the person can be in good

physical health and the act of suicide
terminates the life.
DEACTIVE EUTHANASIA: the discontinuance
of a medical intervention which would

(1) normally delay or prolong dying in a person

with a terminal illness; or

(2) would support the life of a person in a severely

debilitative condition; or

(3) would allow a person with a fatal condition to

survive.
Voluntary euthanasia: The case where a patient who
is terminally ill, severely debilitated or suffers a fatal
condition, is competent and requests active, passive,
or deactive euthanasia.
Nonvoluntary euthanasia: the case where a patient
who is terminally ill, severely debilitated or suffers a
fatal condition, is incompetent, or the patient’s
wishes are not known. A decision is made on behalf of
the patient for active, passive, or deactive euthanasia.

Involuntary euthanasia: the case where a patient who is

terminally ill, severely debilitated or suffers a fatal
condition, is competent, but some form of
euthanasia is performed without the patient’s consent.