Bioethics ISSN 0269-9702 (print); 1467-8519 (online)

Volume 17 Numbers 5–6 2003

VOLUNTARY EUTHANASIA:
A UTILITARIAN PERSPECTIVE
PETER SINGER

ABSTRACT
Belgium legalised voluntary euthanasia in 2002, thus ending the long
isolation of the Netherlands as the only country in which doctors could
openly give lethal injections to patients who have requested help in dying.
Meanwhile in Oregon, in the United States, doctors may prescribe drugs
for terminally ill patients, who can use them to end their life – if they are
able to swallow and digest them. But despite President Bush’s oft-repeated
statements that his philosophy is to ‘trust individuals to make the right
decisions’ and his opposition to ‘distant bureaucracies’, his administra-
tion is doing its best to prevent Oregonians acting in accordance with a
law that its voters have twice ratified. The situation regarding voluntary
euthanasia around the world is therefore very much in flux.
This essay reviews ethical arguments regarding voluntary euthanasia
and physician-assisted suicide from a utilitarian perspective. I shall begin
by asking why it is normally wrong to kill an innocent person, and whether
these reasons apply to aiding a person who, when rational and competent,
asks to be killed or given the means to commit suicide. Then I shall con-
sider more specific utilitarian arguments for and against permitting vol-
untary euthanasia.

UTILITARIANISM
There is, of course, no single ‘utilitarian perspective’, for there
are several versions of utilitarianism and they differ on some
aspects of euthanasia. Utilitarianism is a form of consequential-
ism. According to act-utilitarianism, the right action is the one that,
of all the actions open to the agent, has consequences that are
better than, or at least no worse than, any other action open to
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and 350 Main Street, Malden, MA 02148, USA.
 VOLUNTARY EUTHANASIA 527

the agent. So the act-utilitarian judges the ethics of each act inde-
pendently. According to rule-utilitarianism, the right action is the
one that is in accordance with the rule that, if generally followed,
would have consequences that are better than, or at least no worse
than, any other rule that might be generally followed in the
relevant situation. But if we are talking about changing laws to
permit voluntary euthanasia, rather than about individual deci-
sions to help someone to die, this distinction is not so relevant.
Both act- and rule-utilitarians will base their judgements on
whether changing the law will have better consequences than not
changing it.
What consequences do we take into account? Here there are
two possible views. Classical, or hedonistic, utilitarianism counts
only pleasure and pain, or happiness and suffering, as intrinsically
significant. Other goods are, for the hedonistic utilitarian, sig-
nificant only in so far as they affect the happiness and suffering
of sentient beings. That pleasure or happiness are good things
and much desired, while pain and suffering are bad things that
we want to avoid, is generally accepted. But are these the only
things that are of intrinsic value? That is a more difficult claim to
defend. Many people prefer to live a life with less happiness or
pleasure in it, and perhaps even more pain and suffering, if they
can thereby fulfil other important preferences. For example, they
may choose to strive for excellence in art, or literature, or sport,
even though they know that they are unlikely to achieve it, and
may experience pain and suffering in the attempt. We could
simply say that these people are making a mistake, if there is an
alternative future open to them that would be likely to bring them
a happier life. But on what grounds can we tell another person
that her considered, well-informed, reflective choice is mistaken,
even when she is in possession of all the same facts as we are? The
difficulty of satisfactorily answering this question is one reason
why I favour preference utilitarianism, rather than hedonistic util-
itarianism. The right act is the one that will, in the long run, satisfy
more preferences than it will thwart, when we weigh the prefer-
ences according to their importance for the person holding them.
There is of course a lot more to be said about questions inter-
nal to utilitarianism. But that is perhaps enough to provide a basis
for our next topic.

WHEN KILLING IS, AND IS NOT, WRONG

Undoubtedly, the major objection to voluntary euthanasia is
the rule that it is always wrong to kill an innocent human being.

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528 PETER SINGER

Anyone interested in an ethics that is free of religious commit-

ments should be ready to ask sceptical questions about this view.
Rule-utilitarians will not accept this rule without being persuaded
that it will have better consequences than any other rule. Act-
utilitarians will need to be assured that it will have the best con-
sequences to follow the rule in every instance in which it applies.
The idea that it is always wrong to kill an innocent human being
gains its strongest support from religious doctrines that draw
a sharp distinction between human beings and other sentient
beings. Without such religious ideas, it is difficult to think of
any morally relevant properties that separate human beings with
severe brain damage or other major intellectual disabilities from
other beings at a similar mental level. For why should the fact that
a being is a member of our species make it worse to kill that being
than it is to kill a member of another species, if the two individ-
uals have similar intellectual abilities, or if the non-human has
superior intellectual abilities?
My claim that the wrongness of killing cannot rest on mere
species membership is compatible with, but need not be based
on, utilitarianism. Consider, for instance, the Kantian principle
that it is always wrong to use someone merely as a means, and not
as an end. Who is to count as ‘someone’ for the purposes of ap-
plying such a principle? Kant’s own argument in support of this
principle depends on autonomy, and our autonomy, for Kant,
depends on our ability to reason.1 Hence, it is fallacious to treat
Kant’s principle as equivalent to: ‘Never use a human being as
means to an end.’ It would be better to read it as: ‘Never use an
autonomous being merely as a means.’
I can think of only one non-religious reason that has any plau-
sibility at all, as a defence of the view that the boundary of our
species also marks the boundary of those who it is wrong to kill.
This is a utilitarian argument, to the effect that the species bound-
ary is sharp and clear, and if we allow it to be transgressed, we will
slide down a slippery slope to widespread and unjustified killing.
I will consider slippery slope arguments against allowing volun-
tary euthanasia towards the end of this paper. Here it is sufficient
to note that this argument effectively admits that there is no
intrinsic reason against attributing similar rights to life to humans
and non-humans with similar intellectual capacities, but warns
against the likely consequences of doing so. For our present
inquiry into the underlying reasons against killing human beings,

1 See: I. Kant. Groundwork of the Metaphysics of Morals. First published 1785.

Various editions: Part II.

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 VOLUNTARY EUTHANASIA 529

this is enough to show that one cannot simply assume that to be

human is to give one a right to life. We need to ask, not: what is
wrong with killing a human being; but rather, what makes it wrong
to kill any being? A consequentialist might initially answer: what-
ever goods life holds, killing ends them. So if happiness is a good,
as classical hedonistic utilitarians hold, then killing is bad because
when one is dead one is no longer happy. Or if it is the satisfac-
tion of preferences that is good, as modern preference utilitar-
ians hold, then when one is dead, one’s preferences can no longer
be satisfied.
These answers suggest their own limits. First, if the future life
of the being killed would hold more negative elements than posi-
tive ones – more unhappiness than happiness, more frustration
of preferences than satisfaction of them – then we have a reason
for killing, rather than against killing. Needless to say, this is
highly relevant to the question of euthanasia.
At this point, however, some further questions arise that suggest
the relevance of higher intellectual capacities. Among these ques-
tions are: who is to decide when a being’s life contains, or is likely
to contain, more positive characteristics than negative ones? And
what further impact will the killing of a being have on the lives of
others?
Regarding the first of these questions, the nineteenth century
utilitarian John Stuart Mill argued that individuals are, ultimately,
the best judges and guardians of their own interests. So, in a
famous example, he said that if you see people about to cross a
bridge you know to be unsafe, you may forcibly stop them in order
to inform them of the risk that the bridge may collapse under
them, but if they decide to continue, you must stand aside and let
them cross, for only they know the importance to them of cross-
ing, and only they know how to balance that against the possible
loss of their lives.2 Mill’s example presupposes, of course, that
we are dealing with beings who are capable of taking in informa-
tion, reflecting and choosing. So here is the first point on which
intellectual abilities are relevant. If beings are capable of making
choices, we should, other things being equal, allow them to
decide whether or not their lives are worth living. If they are not
capable of making such choices, then someone else must make
the decision for them, if the question should arise. (Since this
paper focuses on voluntary euthanasia, I shall not go into details
regarding life-and-death decisions for those who are not capable

2
John Stuart Mill. On Liberty. First published 1869. Various editions:
Chapter 5.

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530 PETER SINGER

of exercising a choice. But to those who think that, in the absence

of choice, the decision should always be ‘for life’, I would add that
even those who are most strongly against killing rarely insist on
the use of every possible means of life-support, to draw life out to
the last possible minute. In allowing life to end earlier than it
might, they are effectively deciding for those who are not capable
of making such decisions, and against life, not for it.3)
The conclusion we can draw from this is as follows: if the
goods that life holds are, in general, reasons against killing,
those reasons lose all their force when it is clear that those
killed will not have such goods, or that the goods they have
will be outweighed by bad things that will happen to them. When
we apply this reasoning to the case of someone who is capable
of judging the matter, and we add Mill’s view that individuals are
the best judges of their own interests, we can conclude that
this reason against killing does not apply to a person who, with
unimpaired capacities for judgement, comes to the conclusion
that his or her future is so clouded that it would be better to die
than to continue to live. Indeed, the reason against killing is
turned into its opposite, a reason for acceding to that person’s
request.
Now let us consider the second question: what impact does
killing a being have on the lives of other beings? The answer
will range from ‘none’ to ‘devastating’, depending on the par-
ticular circumstances. Even in the case of beings who are unable
to comprehend the concept of death, there can be a great
sense of loss, when a child or a parent, for example, is killed.
But putting aside such cases of close relationship, there will
be a difference between beings who are capable of feeling
threatened by the deaths of others in circumstances similar to
their own, and those who are not. This will provide an additional
reason to think it wrong – normally – to kill those who can under-
stand when their lives are at risk, that is, beings with higher intel-
lectual capacities.
Once again, however, the fact that killing can lead to fear and
insecurity in those who learn of the risk to their own lives, is trans-
formed into a reason in favour of permitting killing, when people
are killed only on their request. For then killing poses no threat.
On the contrary, the possibility of receiving expert assistance
when one wants to die relieves the fear that many elderly and ill

3 For further discussion see: Peter Singer. 1993. Practical Ethics. Second
edition. Cambridge. Cambridge University Press. Peter Singer. 1995. Rethinking
Life and Death. New York. St Martin’s Press.

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people have, of dying in unrelieved pain and distress, or in cir-

cumstances that they regard as undignified and do not wish to
live through.
Thus the usual utilitarian reasons against killing are turned
around in the case of killing in the circumstances that apply in
the case of voluntary euthanasia. But it is not only with utilitarian
reasons that this happens. It is also true of the Kantian argument
that to kill autonomous beings against their will shows a failure
to respect them as autonomous beings. This is true, obviously,
when they do not want to be killed; and it is equally obviously false
when they have autonomously decided to hasten their death.
In these circumstances, it is preventing others from assisting
them in carrying out their considered desire that violates their
autonomy. That Kant himself took the opposite view only shows
that he was influenced more by the conventional Christian moral-
ity of his day than by a thorough-going application of his own
fundamental principles.4
What of an argument based on a right to life? Here everything
will depend on whether the right is treated as most other rights
are, that is, as an option that one can choose to exercise or to give
up, or if it is seen as ‘inalienable’, as something that cannot be
given up. I suggest that all rights should be seen as options. An
‘inalienable right’ is not a right at all, but a duty. Hence the idea
of a right to life does not provide a basis for opposing voluntary
euthanasia. Just as my right to give you a book I own is the flip
side of my right to keep my property if I choose to retain it, so
here too, the right to end one’s life, or to seek assistance in doing
so, is the flip side of the right to life, that is, my right not to have
my life taken against my will.
Against this, it will be said that we do not allow people to sell
themselves into slavery. If, in a free society, people are not allowed
to give up their freedom, why should they be able to give up their
lives, which of course also ends their freedom?
It is true that the denial of the right of competent adults to sell
themselves, after full consideration, into slavery creates a paradox
for liberal theory. Can this denial be justified? There are two pos-
sible ways of justifying it, neither of which implies a denial of vol-
untary euthanasia. First, we might believe that to sell oneself into
slavery – irrevocably to hand over control of your life to someone
else – is such a crazy thing to do that the intention to do it creates
an irrebutable presumption that the person wishing to do it is not

4
See Kant’s discussion of the ‘first example’ in Part II of the Groundwork of
the Metaphysics of Morals.

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532 PETER SINGER

a competent rational being. In contrast, ending one’s life when

one is terminally or incurably ill is not crazy at all.
A second distinction between selling yourself into slavery and
committing suicide can be appreciated by considering another
apparently irrational distinction in a different situation. Interna-
tional law recognises a duty on nations to give asylum to genuine
refugees who reach the nation’s territory and claim asylum.
Although the recent increase in asylum seekers has strained this
duty, as yet no nation has openly rejected it. Instead, they seek to
prevent refugees crossing their borders or landing on their
shores.5 Yet since the plight of the refugees is likely to be equally
desperate, whether they succeed in setting foot on the nation’s
territory or not, this distinction seems arbitrary and morally
untenable. The most plausible explanation is that it is abhorrent
to forcibly send refugees back to a country that will persecute
them. Preventing them from entering is slightly less abhorrent.
Similarly, a law recognising a right to sell oneself into slavery
would require an equivalent of America’s notorious fugitive slave
law; that is, those who sold themselves into slavery, and later,
regretting their decision, ran away, would have to be forced to
return to their ‘owners.’ The repugnance of doing this may be
enough explanation for the refusal to permit people to sell them-
selves into slavery. Obviously, since no one changes their mind
after voluntary euthanasia has been carried out, it could not lead
to the state becoming involved in any similarly repugnant enforce-
ment procedures.
Some will think that the fact that one cannot change one’s
mind after voluntary euthanasia is precisely the problem: if
people might make mistakes about selling themselves into slavery,
then they might also make mistakes about ending their lives. That
has to be admitted. If voluntary euthanasia is permitted then
some people will die who, if they had not opted for euthanasia,
might have come to consider the remainder of their life worth-
while. But this has to be balanced against the presumably much
larger number of people who, had voluntary euthanasia not been
permitted, would have remained alive, in pain or distress and
wishing that they had been able to die earlier. In such matters,
there is no course of action that entirely excludes the possibility
of a serious mistake. But should competent patients not be able
5 This distinction lies behind the deplorable The Tampa incident, in which
the Australian government forcibly prevented refugees who had been picked up
at sea by the Norwegian freighter The Tampa from landing in Australia. See:
Refugees Stranded at Sea. The Age August 21, 2001. Available at:
http://www.theage.com.au/news/national/2001/08/28/FFX7ISRBVQC.html.

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to make their own judgements and decide what risks they prefer
to take?

COMPETENCE, MENTAL ILLNESS AND OTHER GROUNDS

FOR TAKING LIFE
We have seen that Mill thought that individuals are the best judges
and guardians of their own interests, and that this underlies his
insistence that the state should not interfere with individuals for
their own good, but only to prevent them harming others. This
claim is not an implication of utilitarianism, and a utilitarian
might disagree with it. But those who, whether for utilitarian or
other reasons, support individual liberty, will be reluctant to inter-
fere with individual freedom unless the case for doing so is very
clear.
It is sometimes claimed that patients who are terminally ill
cannot rationally or autonomously choose euthanasia, because
they are liable to be depressed. The American writer Nat Hentoff,
for example, has claimed that many physicians ‘are unable to
recognize clinical depression, which, when treated successfully,
removes the wish for death.’6 Even if this statement is true, it is
not an argument against legalising voluntary euthanasia, but an
argument for including in any legislation authorising voluntary
euthanasia, a requirement that a psychiatrist, or someone else
trained in recognising clinical depression, should examine any
patient requesting voluntary euthanasia and certify that the
patient is not suffering from a treatable form of clinical depres-
sion. Such a proposal is perfectly practicable, and when voluntary
euthanasia was briefly legalised in Australia’s Northern Territory
a few years ago, the law did require that someone with a psy-
chiatric qualification must certify that the patient was mentally
competent to make the decision. Whether such a provision is nec-
essary will depend on whether Hentoff’s claim about the inabil-
ity of physicians to recognise this condition is true.
In any case, not all clinical depression is susceptible to treat-
ment. This leads to a different question, whether doctors should
act on requests for euthanasia from patients who wish to die
because they are suffering from clinical depression that has,
over many years, proven unresponsive to treatment. This issue
was raised in the Netherlands in 1991, when a psychiatrist,
Dr Boudewijn Chabot, provided assistance in dying to a 50-year-
old woman who was severely depressed, but suffered from no
6 Nat Hentoff. Challenging Singer. Free Inquiry 2002; 22: 1.

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534 PETER SINGER

physical illness. When prosecuted, Chabot contended that the

woman was suffering intolerably, and that several years of
treatment had failed to alleviate her distress. He thus sought to
bring the case under the then-accepted guidelines for volun-
tary euthanasia in the Netherlands. He was convicted, but only
because no other doctor had examined the patient, as the guide-
lines required. The Supreme Court of the Netherlands accepted
the more important claim that unbearable mental suffering
could, if it was impossible to relieve by any other means, consti-
tute a ground for acceptable voluntary euthanasia, and that a
person suffering from this condition could be competent.7
From a utilitarian perspective, Chabot and the Dutch courts
were correct. For the hedonistic utilitarian, what matters is not
whether the suffering is physical or psychological, but how bad
it is, whether it can be relieved, and – so that others will not
be fearful of being killed when they want to live – whether the
patient has clearly expressed a desire to die. Whether preference
utilitarians would reach the same conclusion would depend on
whether they are concerned with the satisfaction of actual pref-
erences, or with the satisfaction of those preferences that people
would have if they were thinking rationally and in a psychologi-
cally normal state of mind. It is easy to say: ‘If you were not
depressed, you would not want to die.’ But why should we base
our decision on the preferences a person would have if in a psy-
chologically normal state of mind, even when it is extremely
unlikely that the person in question will ever be in a psychologi-
cally normal state of mind?
Some cases of depression are episodic. A person can be
depressed at times, and at other times normal. But if, having expe-
rienced many periods of depression, she knows how bad these
periods are, and knows that they are very likely to recur, she may,
while in a normal state of mind, desire to die rather than go
through another period of depression. That could be a rational
choice and one that a preference utilitarian should accept as pro-
viding a basis for assisted suicide or voluntary euthanasia. Given
this, it seems possible to be rational about one’s choice to die,
even when depressed. The problem for the physician lies in recog-
nising that the choice is one that would persist, even if the person
were, temporarily, not depressed, but able to see that he would

7 See: Arjan Schippers. How the Courts Allowed Euthanasia.

http://www.rnw.nl/society/html/courts010723.html; and: Euthanasia in the

Netherlands: Evidence of the Slippery Slope.
http://www.nrlc.org/news/1999/NRL999/slope.html

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again become depressed. If this can be ascertained, a preference

utilitarian should not dismiss such a preference.
The application of this view is probably more frequent than
we realise. The World Health Organization estimates that there
are about a million suicides a year and that depression or other
forms of mental illness, including substance abuse, are involved
in 90% of them. Moreover, the number of suicide attempts is
said to be up to 20 times greater than the number of successful
suicides.8 The WHO and many other organisations focus on
suicide prevention, and if by this is meant prevention of the causes
that lead people to try to end their lives, then this focus is entirely
sound. But if by ‘suicide prevention’ is meant simply preventing
people from succeeding in killing themselves, irrespective of
whether it is possible to change the conditions that lead them to
wish to kill themselves, then suicide prevention is not always
the right thing to do. It is possible that in a significant number
of cases, suicide is the only way of escaping from unbearable
and unrelievable suffering due to mental illness, and is in accor-
dance with the rational preferences of the person committing
suicide.9
Richard Doerflinger has argued that those who invoke auton-
omy in order to argue for voluntary euthanasia or physician-
assisted suicide are not being entirely straightforward, because
they defend the autonomy of terminally ill or incurably ill
patients, but not of people who are just bored with life.10 A recent
Dutch case raised that issue. Edward Brongersma, an 86-year-old
former senator in the Dutch parliament, committed suicide with
the assistance of a doctor, simply because he was elderly and tired
of life. The doctor who assisted him was initially acquitted, but
the Dutch Ministry of Justice appealed against the acquittal. This
led to the doctor’s conviction, on the grounds that what he did
was outside the existing rules. Nevertheless, since the court recog-
nised that the doctor had acted out of compassion, it did not

8 World Health Organization. Updated April 2002. Prevention of Suicidal

Behaviors: A Task for All.
http://www5.who.int/mental_health/main.cfm?p=0000000140
9
Relevant to this topic are: J.H. Groenewoud et al. Physician-Assisted Death
in Psychiatric Practice in the Netherlands. New England Journal of Medicine 1997;
336: 1795–1801; V.G. Hardcastle & R.W. Stewart. Supporting Irrational Suicide.
Bioethics 2002; 16; and J. Young. Morals, Suicide and Psychiatry: A View from
Japan. Bioethics 2002; 16.
10 Richard Doerflinger. 2000. Assisted Suicide: Pro-Choice or Anti-Life. In

Contemporary Moral Issues. Second edition. Lawrence Hinman, ed. Upper Saddle
River, NJ. Prentice-Hall: 169–70.

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impose any penalty.11 A utilitarian should not find anything

wrong in the doctor’s action, either because the desire to die was
Brongersma’s considered preference, or because no one was in a
better position than Brongersma to decide whether his life con-
tains a positive or negative balance of experiences. Of course, it
is relevant that Brongersma was 86-years old, and his life was
unlikely to improve. We do not have to say the same about the
situation of the lovesick teenager who thinks that without the girl
he loves life can never again be worth living. Such cases are more
akin to a temporary mental illness, or period of delusion. Neither
a preference nor a hedonistic utilitarian would justify assisting a
person in that state to end his life.
The reason that the focus of debate has been on people who are
terminally or incurably ill, rather than on people who are simply
tired of life, may just be political. Advocates of voluntary euthana-
sia and physician-assisted suicide find it difficult enough to per-
suade legislators or the public to change the law to allow doctors
to help people who are terminally or incurably ill. To broaden the
conditions still further would make the task impossible, in the
present climate of opinion. Moreover, where terminally or incur-
ably ill patients who want to die are concerned, both respect for
the autonomy of the patients and a more objective standard of
rational decision-making point in the same direction. If permissi-
ble assistance in dying is extended beyond this group it becomes
more difficult to say whether a person’s choice is persistent and
based on good reasons, or would change over time. From a utili-
tarian perspective, this is a ground for saying, not that it is neces-
sarily wrong to help those who are not terminally or incurably ill
and yet want to die, but that it is more difficult to decide when the
circumstances justify such assistance. This may be a ground against
changing the law to allow assistance in those cases.

PALLIATIVE CARE
I return now to another of Nat Hentoff’s objections to the legal-
isation of voluntary euthanasia and physician-assisted suicide.
Hentoff thinks that many physicians are not only unable to recog-
nise depression, but also not good at treating pain, and that some-
times good pain relief can remove the desire for euthanasia. That
is also true, but most specialists in palliative care admit that there

11 Arjan Schippers. How the Courts Allowed Euthanasia.

http://www.rnw.nl/society/html/courts010723.html

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is a small number of cases in which pain cannot be adequately

relieved, short of making patients unconscious and keeping them
that way until death ensues a few days later. That alternative –
known as ‘terminal sedation’ – is sometimes practised. Some ethi-
cists, even non-religious ones, do not consider it equivalent to
euthanasia, despite the fact that, since terminally sedated patients
are not tube-fed, death always does ensue within a few days.12
From a utilitarian perspective, it is hard to see that terminal
sedation offers any advantages over euthanasia. Since the uncon-
scious patient has no experiences at all, and does not recover
consciousness before dying, the hedonistic utilitarian will judge
terminal sedation as identical, from the point of view of the
patient, to euthanasia at the moment when the patient becomes
unconscious. Nor will the preference utilitarian be able to find a
difference between the two states, unless the patient has, while
still conscious, a preference for one rather than the other. Since
additional resources are involved in caring for the terminally
sedated patient, and the family is unable to begin the grieving
process until death finally takes place, it seems that, other things
being equal, voluntary euthanasia is better than voluntary termi-
nal sedation.
But to return to the issue of whether better pain relief would
eliminate the desire for euthanasia, there is again an obvious
solution: ensure that candidates for euthanasia see a palliative
care specialist. If every patient then ceases to ask for euthanasia,
both proponents and opponents of voluntary euthanasia will
be pleased. But that seems unlikely. Some patients who want
euthanasia are not in pain at all. They want to die because they
are weak, constantly tired, nauseous, or breathless. Or perhaps
they just find the whole process of slowly wasting away undigni-
fied. These are reasonable grounds for wanting to die.
It is curious that those who argue against voluntary euthanasia
on the grounds that terminally ill patients are often depressed, or
have not received good palliative care, do not also argue against
the right of terminally ill patients to refuse life-sustaining treat-
ment or to receive pain relief that is liable to shorten life. Gen-
erally, they go out of their way to stress that they do not wish
to interfere with the rights of patients to refuse life-sustaining
treatment or to receive pain relief that is liable to shorten life.
But the patients who make these decisions are also terminally

12 See: Törbjörn Tännsjo. Terminal Sedation – A Compromise in the

Euthanasia Debate? Bulletin of Medical Ethics 2000; 163: 13–22.

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538 PETER SINGER

ill, and are making choices that will, or may, end their lives earlier
than they would have ended if the patient had chosen differently.
To support the right of patients to make these decisions, but
deny they should be allowed to choose physician-assisted suicide
or voluntary euthanasia, is to assume that a patient can rationally
refuse treatment (and that doctors ought, other things being
equal, to co-operate with this decision) but that the patient
cannot rationally choose voluntary euthanasia. This is implaus-
ible. There is no reason to believe that patients refusing life-
sustaining treatment or receiving pain relief that will foreseeably
shorten their lives, are less likely to be depressed, or clouded
by medication, or receiving poor treatment for their pain, than
patients who choose physician-assisted suicide or voluntary
euthanasia. The question is whether a patient can rationally
choose an earlier death over a later one (and whether doctors
ought to co-operate with these kinds of end-of-life decisions), and
that choice is made in either case. If patients can rationally opt
for an earlier death by refusing life-supporting treatment or by
accepting life-shortening palliative care, they must also be ratio-
nal enough to opt for an earlier death by physician-assisted
suicide or voluntary euthanasia.

THE SLIPPERY SLOPE ARGUMENT

Undoubtedly the most widely invoked secular argument against
the legalisation of voluntary euthanasia is the slippery slope
argument that legalising physician-assisted suicide or voluntary
euthanasia will lead to vulnerable patients being pressured into
consenting to physician-assisted suicide or voluntary euthanasia
when they do not really want it. Or perhaps, as another version
of the argument goes, they will simply be killed without their
consent because they are a nuisance to their families, or because
their healthcare provider wants to save money.
What evidence is there to support or oppose the slippery slope
argument when applied to voluntary euthanasia? A decade ago,
this argument was largely speculative. Now, however, we can draw
on evidence from two jurisdictions where for several years it has
been possible for doctors to practice voluntary euthanasia or
physician-assisted suicide without fear of prosecution. These juris-
dictions are Oregon and the Netherlands. According to Oregon
officials, between 1997, when a law permitting physician-assisted
suicide took effect, and 2001, 141 lethal prescriptions were issued,
according to state records, and 91 patients used their prescrip-
tions to end their lives. There are about 30 000 deaths in Oregon

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annually.13 There have been no reports of the law being used to

coerce patients to commit suicide against their will, and from all
the evidence that is available, this does not appear to be a situa-
tion in which the law is being abused.
Opponents of voluntary euthanasia do contend, on the
other hand, that the open practice of voluntary euthanasia in
the Netherlands has led to abuse. In the early days of non-
prosecution of doctors who carried out voluntary euthanasia,
before full legalisation, a government-initiated study known as the
Remmelink Report indicated that physicians occasionally – in
roughly 1000 cases a year, or about 0.8% of all deaths – termi-
nated the lives of their patients without their consent. This was,
almost invariably, when the patients were very close to death and
no longer capable of giving consent.14 Nevertheless, the report
gave some grounds for concern. What it did not, and could not,
have shown, however, is that the introduction of voluntary
euthanasia has led to abuse. To show this one would need either
two studies of the Netherlands, made some years apart and
showing an increase in unjustified killings, or a comparison
between the Netherlands and a similar country in which doctors
practising voluntary euthanasia are liable to be prosecuted.
Such studies have become available since the publication
of the Remmelink report. First, there was a second Dutch survey,
carried out five years after the original one. It did not show any
significant increase in the amount of non-voluntary euthanasia
happening in the Netherlands, and thus dispelled fears that that
country was sliding down a slippery slope.15
In addition, studies have been carried out in Australia and
in Belgium to discover whether there was more abuse in the
Netherlands than in other comparable countries where euthana-
sia was illegal and could not be practised openly. The Australian
study used English translations of the survey questions in the
Dutch studies to ask doctors about decisions involving both
direct euthanasia and foregoing medical treatment (for example,

13 Oregon Reporting 15 Deaths in 1998 under Suicide Law. New York Times

February 18, 1999.

14
See: Ministry of Justice and Ministry of Welfare, Public Health and
Culture. 1991. Report of the Committee to Investigate Medical Practice Concerning
Euthanasia. Medical Decisions about the End of Life (The ‘Remmelink Report’). The
Hague; P.J. van der Maas et al. 1992. Euthanasia and Other Decisions Concerning
the End of Life. Amsterdam. Elsevier Science Publishers.
15 P.J. van der Maas, G. van der Waal et al. Euthanasia, Physician-

Assisted Suicide, and other Medical Practices involving the End of Life in the
Netherlands, 1990–1995. New England Journal of Medicine 1996; 335: 1699–1705.

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540 PETER SINGER

withholding antibiotics or withdrawing artificial ventilation).16 Its

findings suggest that while the rate of active voluntary euthanasia
in Australia is slightly lower than that shown in the most recent
Dutch study (1.8% as against 2.3%), the rate of explicit non-
voluntary euthanasia in Australia is, at 3.5%, much higher than
the Dutch rate of 0.8%. Rates of other end-of-life decisions, such
as withdrawing life-support or giving pain relief that was foreseen
to be life shortening, were also higher than in the Netherlands.17
The Belgian study, which examined deaths in the country’s
northern, Flemish-speaking region, came to broadly similar con-
clusions. The rate of voluntary euthanasia was, at 1.3% of all
deaths, again lower than in the Netherlands, but the proportion
of patients given a lethal injection without having requested it was,
at 3% of all deaths, similar to the Australian rate and like it, much
higher than the rate in the Netherlands. The authors of the
Belgian study, reflecting on their own findings and those of the
Australian and Dutch study, concluded:
Perhaps less attention is given to the requirements of careful
end-of-life practice in a society with a restrictive approach than
in one with an open approach that tolerates and regulates
euthanasia and PAS (Physician Assisted Suicide).18
These two studies discredit assertions that the open practice of
active voluntary euthanasia in the Netherlands had led to an
increase in non-voluntary euthanasia. There is no evidence to
support the claim that laws against physician-assisted suicide or
voluntary euthanasia prevent harm to vulnerable people. It is
equally possible that legalising physician-assisted suicide or vol-
untary euthanasia will bring the issue out into the open, and thus
make it easier to scrutinise what is actually happening, and to
prevent harm to the vulnerable. If the burden of proof lies on
those who defend a law that restricts individual liberty, then in
the case of laws against physician-assisted suicide or voluntary
euthanasia, that burden has not been discharged.

16 Helga Kuhse, Peter Singer, Maurice Richard, Malcolm Clark & Peter

Baume. End-of-Life Decisions in Australian Medical Practice. Medical Journal of

Australia 1997; 166: 191–196.
17 For further evidence of the practice of illegal, and therefore uncontrolled,

euthanasia in Australia, as well as in the United States, see: Roger Magnusson.

2002. Angels of Death: Exploring the Euthanasia Underground. Melbourne.
Melbourne University Press.
18 L. Deliens, F. Mortier et.al. End of Life Decisions in Medical Practice in

Flanders, Belgium: A Nationwide Survey. The Lancet 200; 356: 1806–1811; see also:
http://europe.cnn.com/2000/WORLD/europe/11/24/brussels.euthanasia

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Those who, despite the studies cited, still seek to paint the sit-
uation in the Netherlands in dark colours, now need to explain
the fact that its neighbour, Belgium, has chosen to follow that
country’s lead. The Belgian parliament voted, by large margins in
both the upper and lower houses, to allow doctors to act on a
patient’s request for assistance in dying. The majority of Belgium’s
citizens are Flemish-speaking, and Flemish is so close to Dutch
that they have no difficulty in reading Dutch newspapers and
books, or watching Dutch television. If voluntary euthanasia in
the Netherlands really was rife with abuses, why would the country
that is better placed than all others to know what goes on in the
Netherlands be keen to pass a similar law?

CONCLUSION
The utilitarian case for allowing patients to choose euthanasia,
under specified conditions and safeguards, is strong. The slippery
slope argument attempts to combat this case on utilitarian
grounds. The outcomes of the open practice of voluntary
euthanasia in the Netherlands, and of physician-assisted suicide
in Oregon, do not, however, support the idea that allowing
patients to choose euthanasia or physician-assisted suicide leads
to a slippery slope. Hence it seems that, on utilitarian grounds,
the legalisation of voluntary euthanasia or physician-assisted
suicide would be a desirable reform.

Peter Singer
5 Ivy Lane
Princeton, NJ 08544
USA
psinger@princeton.edu

© Blackwell Publishing Ltd. 2003