Voluntary Active Euthanasia

Voluntary Active Euthanasia
Author(s): Dan W. Brock

Source: The Hastings Center Report , Mar. - Apr., 1992, Vol. 22, No. 2 (Mar. - Apr.,
1992), pp. 10-22
Published by: The Hastings Center
Stable URL: https://www.jstor.org/stable/3562560
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Hastings Center Report, March-April 1992
vided by a physician for that purpose. A

paradigm case of voluntary active eu-
thanasia is a physician's administering
Voluntary Active Euthanasia the lethal dose, often because the

patient is unable to do so. The only
difference that need exist between the
by Dan W. Brock two is the person who actually adminis-
ters the lethal dose-the physician or
the patient. In each, the physician plays
an active and necessary causal role.
In physician-assisted suicide the
ince the case of Karen Quin-
question of whether it should be made patient acts last (for example,Janet Ad-
lan first seized public atten-
legally permissible on the ballot in Cal- kins herself pushed the button after Dr.
tion fifteen years ago, no ifornia. In November 1991 voters in the Kevorkian hooked her up to his suicide
issue in biomedical ethics state of Washington defeated a widely machine), whereas in euthanasia the
has been more prominent than publicized
the referendum proposal to le- physician acts last by performing the
debate about forgoing life-sustaining
galize both voluntary active euthanasia physical equivalent of pushing the but-
treatment. Controversy continues and physician-assisted suicide. Finally, ton. In both cases, however, the choice
regarding some aspects of that debate, some cases of this kind, such as "It's rests fully with the patient. In both the
such as forgoing life-sustaining nutri- Over, Debbie," described in the Journal patient acts last in the sense of retaining
tion and hydration, and relevant of law
the Ameican Medical Association, the the right to change his or her mind
varies some from state to state. Never- "suicide machine" of Dr. Jack Kevor- until the point at which the lethal
theless, I believe it is possible to identifykian, and the cancer patient "Diane" of process becomes irreversible. How
an emerging consensus that competent Dr. Timothy Quill, have captured wide could there be a substantial moral
patients, or the surrogates of incom- public and professional attention.3 Un- difference between the two based only
petent patients, should be permitted tofortunately, the first two of these cases on this small difference in the par
weigh the benefits and burdens of alter- were sufficiently problematic that even played by the physician in the causal
native tr-eatments, including the alter-most supporters of euthanasia or as- process resulting in death? Of course, i
native of no treatment, according to the sisted suicide did not defend the physi- might be held that the moral difference
patient'svalues, and either to refuse anycians' actions in them. As a result, the
is clear and important-in euthanasi
treatment or to select from among subsequent debate they spawned has the physician kills the patient whereas
available alternative treatments. This
often shed more heat than light. My in physician-assisted suicide the patient
consensus is reflected in bioethicsaim is to increase the light, and perhaps kills him- or herself. But this is mislead-
as well to reduce the heat, on this im- ing at best. In assisted suicide the physi-
scholarship, in reports of prestigious
bodies such as the President's Commis- portant subject by formulating and cian and patient together kill th
sion for the Study of Ethical Problems evaluating the central ethical argu- patient. To see this, suppose a physician
in Medicine, The Hastings Center, and ments for and against voluntary active supplied a lethal dose to a patient with
the American Medical Association, in a euthanasia and physician-assisted sui- the knowledge and intent that the
large body ofjudicial decisions in courts cide. My evaluation of the arguments patient will wrongfully administer it t
around the country, and finally in the leads me, with reservations to be noted, another. We would have no difficulty in
beliefs and practices of health care to support permitting both practices. morality or the law recognizing this as a
professionals who care for dying My primary aim, however, is not to case ofjoint action to kill for which both
patients. argue for euthanasia, but to identify are responsible.
More recently, significant public and confusions in some common argu- If there is no significant, intrinsic
professional attention has shifted from ments, and problematic assumptions moral difference between the two, it i
life-sustaining treatment to eutha- and claims that need more defense or
also difficult to see why public or lega
nasia-more specifically, voluntary ac- data in others. The issues are consider-
policy should permit one but not the
tive euthanasia-and to physician-as- ably more complex than either sup- other; worries about abuse or about
sisted suicide. Several factors have con- porters or opponents often make out; giving anyone dominion over the lives
tributed to the increased interest in eu- my hope is to advance the debate by of others apply equally to either. As a
thanasia. In the Netherlands, it has focusing attention on what I believe the result, I will take the arguments eval-
been openly practiced by physicians for real issues under discussion should be. uated below to apply to both and will
several years with the acceptance of the In the recent bioethics literature focus on euthanasia.
country's highest court. In 1988 there some have endorsed physician-assisted My concern here will be with volun-
was an unsuccessful attempt to get the suicide but not euthanasia.4 Are theytary euthanasia only-that is, with the
case in which a clearly competent
sufficiently different that the moral ar-
guments for one often do not apply patient
to makes afullyvoluntary and per-
Dan W. Brock is professor ofphilosphy and the other? A paradigm case of physi- sistent request for aid in dying. Involun-
biomedical ethics and director of the Centercian-assisted suicide is a patient's tary euthanasia, in which a competent
for Biomedical Ethics, Brown University, ending his or her life with a lethal dose patient explicitly refuses or opposes re-
Providence, RI. of a medication requested of and pro- ceiving euthanasia, and nonvoluntary
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euthanasia, in which a patient is incom- termination presupposes some min- is no longer considered a benefit by
petent and unable to express his or her imum of decisionmaking capacities or the patient, but has now become a bur-
wishes about euthanasia, will be con- competence, which thus limits the den. The same judgment underlies a
sidered here only as potential un- scope of euthanasia supported by self- request for euthanasia: continued life
wanted side-effects of permitting volun- determination; it cannot justifiably be is seen by the patient as no longer a
tary euthanasia. I emphasize as well that administered, for example, in cases of benefit, but now a burden. Especially
I am concerned with active euthanasia, serious dementia or treatable clinical in the often severely compromised
not withholding or withdrawing life-sus- depression. and debilitated states of many criti-
taining treatment, which some com- Does the value of individual self-de-
cally ill or dying patients, there is no
mentators characterize as "passive eu- termination extend to the time and objective standard, but only the com-
thanasia." Finally, I will be concerned manner of one's death? Most people petent patient'sjudgment of whether
with euthanasia where the motive of are very concerned about the nature continued
of life is no longer a benefit.
those who perform it is to respect the the last stage of their lives. This reflectsOf course, sometimes there are con-
wishes of the patient and to provide the notjust a fear of experiencing substan- ditions, such as clinical depression, that
patient with a "good death," though tial suffering when dying, but also call a into question whether the patient
one important issue is whetherdesire a to retain dignity and control has made a competent choice, either to
change in legal policy could restrict the during this last period of life. Deathforgo is life-sustaining treatment or to
performance of euthanasia to only today increasingly preceded by a long seek euthanasia, and then the patient's
those cases. period of significant physical and men- choice need not be evidence that con-
A last introductory point is that I will tal decline, due in part to the techno- tinued life is no longer a benefit for him
be examining only secular arguments logical interventions of modern medi- or her.Just as with decisions about treat-
about euthanasia, though of course cine. Many people adjust to these disa- ment, a determination of incom-
many people's attitudes to it are inextri- bilities and find meaning and value petencein can warrant not honoring the
cable from their religious views. The new activities and ways. Others find the patient's choice; in the case of treat-
policy issue is only whether euthanasia impairments and burdens in the last ment, we then transfer decisional
should be permissible, and no one who stage of their lives at some point suffi- authority to a surrogate, though in the
has religious objections to it should be ciently great to make life no longer case of voluntary active euthanasia a
required to take any part in it, though worth living. For many patients near determination that the patient is in-
of course this would not fully satisfy death, maintaining the quality of one's competent means that choice is not
some opponents. life, avoiding great suffering, maintain- possible.
ing one's dignity, and insuring that The value or right of self-determina-
others remember us as we wish them to
The Central Ethical Argument for tion does not entitle patients to compel
Voluntary Active Euthanasia become of paramount importance and physicians to act contrary to their own
outweigh merely extending one's life. moral or professional values. Physicians
The central ethical argument for eu- But there is no single, objectively cor- are moral and professional agents
thanasia is familiar. It is that the very rect answer for everyone as to when, if whose own self-determination or integ-
same two fundamental ethical values
at all, one's life becomes all things con- rity should be respected as well. If per-
supporting the consensus on patient's sidered a burden and unwanted. If self- forming euthanasia became legally per-
rights to decide about life-sustainingdetermination is a fundamental value, missible, but conflicted with a particular
treatment also support the ethical per- then the great variability among people physician's reasonable understanding
missibility of euthanasia. These values on this question makes it especially im- of his or her moral or professional re-
are individual self-determination or au-
portant that individuals control the sponsibilities, the care of a patient who
tonomy and individual well-being. By manner, circumstances, and timing of requested euthanasia should be trans-
self-determination as it bears on eutha- ferred to another.
their dying and death.
nasia, I mean people's interest in The other main value that supports Most opponents do not deny that
making important decisions about euthanasia is individual well-being. It there are some cases in which the values
their lives for themselves according to might seem that individual well-being of patient self-determination and well-
their own values or conceptions of a conflicts with a person's self-determi- being support euthanasia. Instead, they
good life, and in being left free to act on nation when the person requests eu- commonly offer two kinds of argu-
those decisions. Self-determination is
thanasia. Life itself is commonly taken" ments against it that on their view out-
valuable because it permits people to to be a central good for persons, often weigh or override this support. The first
form and live in accordance with their valued for its own sake, as well as nec- kind of argument is that in any in-
own conception of a good life, at least essary for pursuit of all other goods dividual case where considerations of
within the bounds of justice and con- within a life. But when a competent the patient's self-determination and
sistent with others doing so as well. In patient decides to forgo all further well-being do support euthanasia, it is
exercising self-determination people life-sustaining treatment then the nevertheless always ethically wrong or
take responsibility for their lives and for patient, either explicitly or implicitly, impermissible. The second kind of ar-
the kinds of persons they become. A commonly decides that the best life gument grants that in some individual
central aspect of human dignity lies in possible for him or her with treatment cases euthanasia may not be ethically
people's capacity to direct their lives in is of sufficiently poor quality that it is wrong, but maintains nonetheless that
this way. The value of exercising self-de- worse than no further life at all. Life public and legal policy should never
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permit it. The first kind of argument

focuses on features of any individual
'I Gave Him All the Morphine ... in case of euthanasia, while the second
My Bag. It Wasn't Easy.' kind focuses on social or legal policy. In
the next section I consider the first kind
of argument.
"I've never shared this with anyone," says the retired internist,
who looks like the subject of an Andrew Wyeth painting. "Not with
the patient's family, not with anyone else. I've never even told my Euthanasia Is the Deliberate Killing
of an Innocent Person
wife about this one. This was probably the toughest one."
The patient was a retired business executive and attorney in his The claim that any individual in-
early 70s, whose attention to physical fitness could only be described stance of euthanasia is a case of de-
as a fetish and for whom control was the dominant element in his
liberate killing of an innocent person is,
life. He was used to doing things his way, including leaving home with only minor qualifications, correct.
and business for up to two months a year to travel the globe in Unlike forgoing life-sustaining treat-
search of high adventure. ment, commonly understood as allow-
"He developed colon cancer and had some problems with intes- ing to die, euthanasia is dearly killing,
tinal obstruction and was clearly headed for a kind of miserable defined as depriving of life or causing
end, not just pain, but obstruction and vomiting, a demeaning the death of a living being. While pro-
thing that he just could not think of facing." viding morphine for pain relief at doses
Not unexpectedly, having so controlled his life, the patient where the risk of respiratory depression
wanted to control his death. The physician agreed and gave him a and an earlier death may be a foreseen
hypodermic of morphine to keep in ajar in his bedroom. but unintended side effect of treating
But as often happens in such cases, as the cancer spread the the patient's pain, in a case of eutha-
patient was given ever increasing doses of morphine with a home IV nasia the patient's death is deliberate or
pump, and he developed a tolerance for the drug. Clearly, the physi- intended even if in both the physician's
cian thought, the single syringe was not going to do the job. ultimate end may be respecting the
patient'swishes. If the deliberate killing
"I didn't want to go through the scenario I did with another
of an innocent person is wrong, eu-
patient, where he'd taken something and not have it work. I knew
thanasia would be nearly always imper-
that the morphine would never do it--on the other hand I never missible.
carry anything in my bag that's adequate to resolve the problem.
In the context of medicine, the ethi-
But I had thought that probably two full, 20cc, ampules of mor-
cal prohibition against deliberately kill-
phine would be sufficient So I went up and talked with him," says
ing the innocent derives some of its
the physician, and the patient told him he wanted out.
plausibility from the belief that nothing
"He said, 'I don't want to get you in any legal trouble,' and I said, in the currently accepted practice of
'No, that's my problem'-he didn't want me tojeopardize myself. I medicine is deliberate killing. Thus, in
didn't make him sign anything, or make him say ... [what he commenting on the "It's Over, Debbie"
wanted] in so many words, but we had a clear understanding that case, four prominent physicians and
this was it. The family waited in the dining room, the son and the
bioethicists could entitle their paper
mother. They didn't know what I was doing and they never asked. "Doctors Must Not Kill.'"5 The belief
"I gave him all the morphine and all the atropine I had in my bag. that doctors do not in fact kill requires
It wasn't easy. It's the only time I've ever done this, but I felt in his the corollary belief that forgoing life-
case that it was extraordinary. He never felt anything and it worked sustaining treatment, whether by not
all right. I think his wife knows and is very grateful, but I've never starting or by stopping treatment, is
discussed it."
allowing to die, not killing. Common
The physician is convinced he did the right thing in killing his though this view is, I shall argue that it
patient of many years, yet the act does not sit easily. "It'sjust the un- is confused and mistaken.
comfortable feeling that you are the actual mechanism. It's a step Why is the common view mistaken?
that we normally take when we say, 'I'm not going to give antibiotics Consider the case of a patient termi-
for this bout of pneumonia in this person who's comatose.' nally ill with ALS disease. She is
"It's the only time I've ever done anything that direct. It's not part completely respirator dependent with
of your training, it's not part of the Hippocratic oath, it's not part of no hope of ever being weaned. She is
anything that's justified. And yet, I felt that there was no other solu- unquestionably competent but finds
tion to the situation, and when you take on medicine you put your- her condition intolerable and persist-
self through uncomfortable situations, hopefully for the benefit of ently requests to be removed from the
your patients." respirator and allowed to die. Most
From "Death m Request"by B. D. Colen people and physicians would agree that
the patient's physician should respect
ANewsday rtide
Neusdaxy, Inc pted by peiio
1991. the patient's wishes and remove her
from the respirator, though this will
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certainly cause the patient's death. The both kill. One reason this conclusion is The characterization as allowing to die
common understanding is that the resisted is that on a different under- is meant to shift felt responsibility away
physician thereby allows the patient to standing of the distinction between kill-from the agent-the physician-and to
die. But is that correct? ing and allowing to die, what the physi-the lethal disease process. Other lan-
Suppose the patient has a greedy and cian does is allow to die. In this account,
guage common in death and dying con-
hostile son who mistakenly believes that the mother's ALS is a lethal disease texts plays a similar role; 'letting nature
his mother will never decide to stop her take its course" or "stopping prolonging
whose normal progression is being held
life-sustaining treatment and that even back or blocked by the life-sustaining
the dying process" both seem to shift
if she did her physician would not re- respirator treatment Removing this responsibility
ar- from the physician who
move her from the respirator. Afraid
that his inheritance will be dissipated by
a long and expensive hospitalization,
he enters his mother's room while she
is sedated, extubates her, and she dies. Killing patients is not understood to be part of physicians'
Shortly thereafter the medical staff dis- job description, but some killings are ethically justified
covers what he has done and confronts including many instances of stopping life support.
the son. He replies, "I didn't kill her, I
merely allowed her to die. It was her
ALS disease that caused her death." I
think this would rightly be dismissed astificial intervention is then viewed as
stops life support to the fatal disease
transparent sophistry--the son went
standing aside and allowing the patient process. However psychologically help-
into his mother's room and deliberately
to die of her underlying disease. I have ful these conceptualizations may be in
killed her. But, of course, the son per-
argued elsewhere that this alternative making the difficult responsibility of a
formed just the same physical actions,
account is deeply problematic, in part physician's role in the patient's death
did just the same thing, that the physi-
because it commits us to accepting that bearable, they nevertheless are confu-
cian would have done. If that is so, then
what the greedy son does is to allow to sions. Both physicians and family mem-
doesn't the physician also kill the die, not kill.7 Here, I want to note two bers can instead be helped to under-
patient when he extubates her?
other reasons why the conclusion that stand that it is the patient's decision and
I underline immediately that there
stopping life support is killing is re- consent to stopping treatment that
are important ethical differences be-sisted.
limits their responsibility for the
tween what the physician and the
The first reason is that killing is often patient's death and that shifts that re-
greedy son do. First, the physician acts
understood, especially within medi- sponsibility to the patient.
with the patient's consent whereas the
cine, as unjustified causing of death; in Many who accept the difference be-
son does not. Second, the physician acts
medicine it is thought to be done only tween killing and allowing to die as the
with a good motive-to respect the distinction between acts and omissions
accidentally or negligently. It is also in-
patient's wishes and self-determina-
tion-whereas the son acts with a bad creasingly widely accepted that a physi- resulting in death have gone on to
cian is ethicallyjustified in stopping life argue that killing is not in itself morally
motive-to protect his own inheri-
support in a case like that of the ALS different from allowing to die.8 In this
tance. Third, the physician acts in a
patient. But if these two beliefs are cor- account, very roughly, one kills when
social role through which he is legally
rect, then what the physician does can- one performs an action that causes the
authorized to carry out the patient's
not be killing, and so must be allowing death of a person (we are in a boat, you
wishes regarding treatment whereas
the son has no such authorization. to die. Killing patients is not, to put it cannot swim, I push you overboard,
flippantly, understood to be part of and you drown), and one allows to die
These and perhaps other ethically im-
physicians'job description. What is mis- when one has the ability and opportu-
portant differences show that what the
taken in this line of reasoning is the nity to prevent the death of another,
physician did was morally justified
assumption that all killings are un- knows this, and omits doing so, with the
whereas what the son did was morally
justifiedcausings of death. Instead, some result that the person dies (we are in a
wrong. What they do notshow, however,
killings are ethicallyjustified, including boat, you cannot swim, you fall over-
is that the son killed while the physician
allowed to die. One can either kill or many instances of stopping life support. board, I don't throwyou an available life
Another reason for resisting the con- ring, and you drown). Those who see
allow to die with or without consent,
clusion that stopping life support is no moral difference between killing
with a good or bad motive, within or
outside of a social role that authorizes often killing is that it is psychologically and allowing to die typically employ the
one to do so. uncomfortable. Suppose the physician strategy of comparing cases that differ
had stopped the ALS patient's respira- in these and no other potentially
The difference between killing and
tor and had made the son's claim, '1 morally important respects. This will
allowing to die that I have been impli-
didn't kill her, I merely allowed her to allow people to consider whether the
citly appealing to here is roughly thatdie. It was her ALS disease that caused mere difference that one is a case of
between acts and omissions resulting in
her death." The clue to the psychologi-killing and the other of allowing to die
death." Both the physician and the
cal role here is how naturally the matters morally, or whether instead it is
greedy son act in a manner intended to other features that make most cases of
"merely" modifies "allowed her to die."
cause death, do cause death, and so
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killing worse than most instances of these plans and desires as well. In a also no single, well-specified policy pro-
allowing to die. Here is such a pair of nutshell, wrongful killing deprives a posal for legalizing euthanasia on
cases: person of a valued future, and of all the which policy assessments can focus. But
personiswanted and planned to do in without such specification, and espe-
Case 1. A very gravely ill patient
that future. cially without explicit procedures for
brought to a hospital emergency
room and sent up to the ICU. TheA natural expression of this account protecting against well-intentioned
patient begins to develop of the wrongness of killing is that misuse and ill-intentioned abuse, the
respiratory failure that is likely to people have a moral right not to be consequences for policy are largely
require intubation very soon. At killed.9 But in this account of the wrong- speculative. Despite these difficulties, a
that point the patient's family ness of killing, the right not to be killed, preliminary account of the main likely
members and long-standing like other rights, should be waivable good and bad consequences is possible.
physician arrive at the ICU and when the person makes a competent This should help clarify where better
decision that continued life is no longer
inform the ICU staff that there had data or more moral analysis and argu-
been extensive discussion about wanted or a good, but is instead worse ment are needed, as well as where
than no further life at all. In this view, policy safeguards must be developed.
future care with the patient when
he was unquestionably competent. euthanasia is properly understood as a Potential Good Consequences of
Given his grave and terminal ill-case of a person having waived his or Permitting Euthanasia. What are the
ness, as well as his state of debilita-her right not to be killed. likely good consequences? First, if
tion, the patient had firmly This rights view of the wrongness of euthanasia were permitted it would be
rejected being placed on a killing is not, of course, universally possible to respect the self-determina-
respirator under any circumstan- shared. Many people's moral views tion of competent patients who want it,
ces, and the family and physician about killing have their origins in re- but now cannot get it because of its
produce the patient's advance ligious views that human life comes illegality. We simply do not know how
directive to that effect. The ICU from God and cannot be justifiably de- many such patients and people there
staff do not intubate the patient, stroyed or taken away, either by the are. In the Netherlands, with a popula-
who dies of respiratory failure. person whose life it is or by another. But tion of about 14.5 million (in 1987),
in a pluralistic society like our own with estimates in a recent study were that
Case 2. The same as Case 1 except
a strong commitment to freedom of about 1,900 cases of voluntary active
that the family and physician are
religion, public policy should not be euthanasia or physician-assisted suicide
slightly delayed in traffic and arrive
grounded in religious beliefs which occur annually. No straightforward ex-
shortly after the patient has been
many in that society reject I turn now trapolation to the United States is
intubated and placed on the
to the general evaluation of public possible for many reasons, among
respirator. The ICU staff extubate
policy on euthanasia. them, that we do not know how many
the patient, who dies of respiratory
failure. people here who want euthanasia now
Would the Bad Consequences of get it, despite its illegality. Even with
In Case 1 the patient is allowed to die, better data on the number of persons
Euthanasia Outweigh the Good?
in Case 2 he is killed, but it is hard to see who want euthanasia but cannot get it,
why what is done in Case 2 is signifi- The argument against euthanasia at significant moral disagreement would
cantly different morally than what isthe policy level is stronger than at the remain about how much weight should
done in Case 1. It must be other factors level of individual cases, though even be given to any instance of failure to
that make most killings worse than most here I believe the case is ultimately un- respect a person's self-determination in
allowings to die, and if so, euthanasia persuasive, or at best indecisive. The this way.
cannot be wrong simply because it is policy level is the place where the main One important factor substantially af-
killing instead of allowing to die. issues lie, however, and where moral fecting the number of persons who
Suppose both my arguments are mis- considerations that might override ar- would seek euthanasia is the extent to
taken. Suppose that killing is worse than guments in favor of euthanasia will be which an alternative is available. The
allowing to die and that withdrawing found, if they are found anywhere. It is widespread acceptance in the law, social
life support is not killing, although eu- important to note two kinds ofdisagree- policy, and medical practice of the right
thanasia is. Euthanasia still need not for
ment about the consequences for pub- of a competent patient to forgo life-
that reason be morally wrong. To see lic policy of permitting euthanasia. sustaining treatment suggests that the
this, we need to determine the basic First, there is empirical or factual dis- number of competent persons in the
principle for the moral evaluation of agreement about what the con- United States who would want
killing persons. What is it that makes sequences would be. This disagree- euthanasia if it were permitted is p
paradigm cases of wrongful killing ment is greatly exacerbated by the lack ably relatively small.
wrongful? One very plausible answer is of firm data on the issue. Second, since A second good consequence
that killing denies the victim something on any reasonable assessment there making euthanasia legally permiss
that he or she values greatly--con- would be both good and bad conse- benefits a much larger group. P
tinued life or a future. Moreover, since
quences, there are moral disagree- have shown that a majority of the A
continued life is necessary for pursuing ments about the relative importance of ican public believes that people sh
any of a person's plans and purposes, different effects. In addition to these
have a right to obtain euthanasia if
killing brings the frustration of all of two sources of disagreement, there is want it. No doubt the vast majori
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those who support this right to eutha-

nasia will never in fact come to want
euthanasia for themselves. Neverthe-
'She Wanted Out Now'
less, making it legally permissible would
reassure many people that if they ever An internist, who three times in twenty-seven years has provided termi-
do want euthanasia they would be able nally ill patients with the means to kill themselves, recalls when he provided
to obtain it. This reassurance would aid-in-dying to a patient he barely knew.
supplement the broader control over A woman in her fifties, who was dying of breast cancer that had metasta-
the process of dying given by the rightsized throughout her body, "somehow or other knew that I was interested
to decide about life-sustaining treat-in this subject of the dying patient, so she called me up on the phone one
ment. Having fire insurance on one'sday," the physician recalls. "She lived in a neighboring town, five or six
house benefits all who have it, notjustmiles away, and asked if she could come see me about a very important mat-
those whose houses actually burnter concerning her final illness."
down, by reassuring them that in the When the woman arrived in the physician's office it turned out that what
unlikely event of their house burning"she wanted was to have me assist her in dying with a prescription for pills,
down, they will receive the moneybecause her physician would not She'd been a patient of some physicians
needed to rebuild it. Likewise, the legal-at a cancer center and had had beautiful care. They'd done quite well by
ization of euthanasia can be thought ofher. But at this point she had absolutely run out of options and there was
as a kind of insurance policy againstnothing more that could be done. And she was miserable. She had a tightly
being forced to endure a protracteddistended abdomen, was highly uncomfortable and in moderately severe
dying process that one has come to findpain and just was generally miserable. And she wanted out She wanted out
burdensome and unwanted, especially nOW. now.
when there is no life-sustaining treat-

"After listening to her and talking with her and her husband, I said
ment to forgo. The strong concern
unwilling to do anything for her unless she was my patient," the phys
about losing control of their care ex-
recalls, stressing both that he had to convince himself of the woman's
pressed by many people who face seri-
cal need, and protect himself against possible legal repercussions.
ous illness likely to end in death suggests
that they give substantial importance to The woman and the internist each spoke by phone with the woman
the legalization of euthanasia as acialist, explaining that she wanted to be cared for by the internist, and
means of maintaining this control. records were transferred to him. The following day, the internist says
A third good consequence of the had her come back and did a complete physical and history and wrote
legalization of euthanasia concerns down so it was thoroughly documented that this was a patient of mine
patients whose dying is filled with severe '"Then I gave her husband a prescription for sleeping pills in his na
and unrelievable pain or suffering.and I gave her one. Her husband took them to two different drug sto
When there is a life-sustaining treat- and within a day or two she took the pills. He called me up early one
ment that, if forgone, will lead relativelying and said she had died overnight He was aware when she took the
quickly to death, then doing so can and helped her with this. Then he went to another part of the house
bring an end to these patients' suffering returned a few hours later and she had died. That was good.
without recourse to euthanasia. For
"This was all relatively compressed in time; from the time I first met
patients receiving no such treatment,
until she took the pills and died was a matter of a week," he acknowle
however, euthanasia may be the only
'"In this instance I felt perfectly okay about it because I was so convin
release from their otherwise prolonged
her disease was so far progressed. And her husband was highly suppor
suffering and agony. This argument
and after this he continued to be my patient and on a number of occa
from mercy has always been the expressed his gratitude for what I had done.
strongest argument for euthanasia in
"I think you draw the line at your own sense of comfort about it," the
those cases to which it applies.'1
The importance ofrelieving pain and ternist says. "Each of the instances that I've had anything to do with, e
withdrawing
suffering is less controversial than is the treatment or assisting in suicide, they've all been instanc
frequency with which patients are I have felt perfectly okay about The situation has been so bad, clearly
forced to undergo untreatable agony bad, that I didn't have a problem with it in my own mind. Now this se
that only euthanasia could relieve. Ifwe up as the judge, and I don't claim to be all knowing. But in the instan
focus first on suffering caused by physi-where it was really needed, it seemed to me to be so clear cut, and th
was no alternative.
cal pain, it is crucial to distinguish pain
that could be adequately relieved with "It's not a matter of killing patients. There's a difference between
modern methods of pain control, euthanasia and assisted suicide. The physician is involved in helping fa
tate, yes, but the patient does the final act, and there is a difference t
though it in fact is not, from pain that is
relievable only by death.12 For a variety
of reasons, including some physicians' From "ah Request" by B. D. Colen
fear of hastening the patient's death, as A Newsda i'de rpntby permisio
well as the lack of a publicly accessible Nesd Iizc 199.
means for assessing the amount of the
15

49.144.229.78 on Tue, 01 Jun 2021 12:01:00 UTC
patient's pain, many patients suffer loved ones and might otherwise expect If permitting physicians to kill would
pain that could be, but is not, relieved. for themselves. undermine the very "moral center" of
Specialists in pain control, as for ex- Some opponents of euthanasia chal- medicine, then almost certainly physi-
ample the pain of terminally ill cancer lenge how much importance should cians should not be permitted to per-
patients, argue that there are very few be given to any of these good con- form euthanasia. But how persuasive is
patients whose pain could not be ade- sequences of permitting it, or even this claim? Patients should not fear, as a
quately controlled, though sometimes whether some would be good con- consequence of permitting voluntary
at the cost of so sedating them that they sequences at all. But more frequently, active euthanasia, that their physicians
are effectively unable to interact with opponents cite a number of bad con- will substitute a lethal injection for what
other people or their environment. sequences that permitting euthanasia patients want and believe is part of their
Thus, the argument from mercy in would or could produce, and it is to care. If active euthanasia is restricted to
cases of physical pain can probably be their assessment that I now turn. cases in which it is truly voluntary, then
met in a large majority of cases by pro- Potential Bad Consequences of Per- no patient should fear getting it unless
viding adequate measures ofpain relief. mitting Euthanasia. Some of the argu- she or he has voluntarily requested it.
This should be a high priority, whatever ments against permitting euthanasia (The fear that we might in time also
our legal policy on euthanasia-the re- are aimed specifically against physi- come to accept nonvoluntary, or even
lief of pain and suffering has long been, cians, while others are aimed against involuntary, active euthanasia is a
quite properly, one of the central goals anyone being permitted to perform it. slippery slope worry I address below.)
of medicine. Those cases in which pain I shall first consider one argument of Patients' trust of their physicians could
could be effectively relieved, but in fact the former sort. Permitting physicians be increased, not eroded, by knowledge
is not, should only count significantly in to perform euthanasia, it is said, would that physicians will provide aid in dying
favor of legalizing euthanasia if all rea- be incompatible with their fundamen- when patients seek it.
sonable efforts to change pain manage- tal moral and professional commit- Might Gaylin and his colleagues
ment techniques have been tried and ment as healers to care for patients and nevertheless be correct in their claim
have failed. to protect life. Moreover, if euthanasia that the moral center of medicine
Dying patients often undergo sub- by physicians became common, would collapse if physicians were to be-
stantial psychological suffering that is come killers? This question raises what
patients would come to fear that a med-
not fully or even principally the result ication was intended not to treat or at the deepest level should be the guid-
of physical pain.1 The knowledge care, but instead to kill, and would thus ing aims of medicine, a question that
about how to relieve this suffering is obviously cannot be fully explored
lose trust in their physicians. This posi-
much more limited than in the case of tion was forcefully stated in a paper by here. But I do want to say enough to
relieving pain, and efforts to do so are Willard Gaylin and his colleagues: indicate the direction that I believe an
probably more often unsuccessful. If The very soul of medicine is on trial appropriate response to this challenge
the argument from mercy is extended . .. This issue touches medicine at should take. In spelling out above what
to patients experiencing great and un- its moral center; if this moral cen- I called the positive argumentforvolun-
relievable psychological suffering, the ter collapses, if physicians become tary active euthanasia, I suggested that
numbers of patients to which it applies killers or are even licensed to kill, two principal values-respecting
are much greater. the profession-and, therewith, patients' self-determination and pro-
One last good consequence of legal- each physician--will never again moting their well-being-underlie the
izing euthanasia is that once death has be worthy of trust and respect as consensus that competent patients, or
been accepted, itis often more humane healer and comforter and protec- the surrogates of incompetent patients,
to end life quickly and peacefully, when tor of life in all its frailty. are entitled to refuse any life-sustaining
that is what the patient wants. Such a treatment and to choose from among
death will often be seen as better than These authors go on to make clear available alternative treatments. It is the
that, while they oppose permitting any- commitment to these two values in
a more prolonged one. People who
one to perform euthanasia, their
suffer a sudden and unexpected death, guiding physicians' actions as healers,
special concern is with physicians doing
for example by dying quickly or in their SO: comforters, and protectors of their
sleep from a heart attack or stroke, are patients' lives that should be at the
often considered lucky to have died in We call on fellow physicians to say "moral center" of medicine, and these
this way. We care about how we die in that they will not deliberately kill. two values support physicians' adminis-
part because we care about how others We must also say to each of our tering euthanasia when their patients
remember us, and we hope they will fellow physicians that we will not make competent requests for it.
remember us as we were in "good tolerate killing of patients and that What should not be at that moral
times" with them and not as we might we shall take disciplinary action center is a commitment to preserving
be when disease has robbed us of our against doctors who kill. And we patients' lives as such, without regard to
dignity as human beings. As with much must say to the broader com- whether those patients want their lives
in the treatment and care of the dying, munity that if it insists on tolerat- preserved orjudge their preservation a
people's concerns differ in this respect, ing or legalizing active euthanasia, benefit to them. Vitalism has been re-
but for at least some people, euthanasia itwill have to find nonphysicians to jected by most physicians, and despite
will be a more humane death than what do its killing.'4 some statements that suggest it, is al-
they have often experienced with other most certainly not what Gaylin and col-
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leagues intended. One of them, Leon occur from euthanasia if it were per- Most agree, however, that increased in-
Kass, has elaborated elsewhere the view mitted. In the Netherlands, where eu- volvement of the courts in these deci-
that medicine is a moral profession thanasia under specified circumstances sions would be undesirable, as it would
whose proper aim is "the naturally is permitted by the courts, though not make sound decisionmaking more
given end of health," understood as the authorized by statute, the best estimate cumbersome and difficultwithout suffi-
wholeness and well-working of the of the proportion of overall deaths that cient compensating benefits.
human being; "for the physician, at result from it is about 2 percent.'6 Thus,As with the second potential bad con-
least, human life in living bodies com- the vast majority of critically ill and sequence of permitting euthanasia, this
mands respect and reverence-by its dying patients will not request it, and third
so consideration too is speculative
very nature." Kass continues, "the deep- will still have to be cared for by physi- and difficult to assess. The feared ero-
est ethical principle restraining the phy- cians, families, and others. Permitting sion of patients' or surrogates' rights to
sician's power is not the autonomy or euthanasia should not diminish decide about life-sustaining treatment,
freedom of the patient; neither is it his people's commitment and concern to with greater court involve-
together
own compassion or good intention. maintain and improve the care of ment
thesein those decisions, are both
Rather, it is the dignity and mysterious patients. possible. However, I believe there is rea-
power of human life itself.'"5 I believe A third possible bad consequence of son to discount this general worry. The
Kass is in the end mistaken about the permitting euthanasia (or even a public legal rights of competent patients and,
proper account of the aims of medicine discourse in which strong support for to a lesser degree, surrogates of incom-
and the limits on physicians' power, but euthanasia is evident) is to threaten the petent patients to decide about treat-
this difficult issue will certainly be one progress made in securing the rights of ment are very firmly embedded in a
of the central themes in the continuing patients or their surrogates to decide long line of informed consent and life-
debate about euthanasia. about and to refuse life-sustaining treat- sustaining treatment cases, and are not
A second bad consequence that ment1'7 This progress has been made likely to be eroded by a debate over, or
some foresee is that permitting eu- against the backdrop of a clear and firm even acceptance of, euthanasia. It will
thanasia would weaken society's com-legal prohibition of euthanasia, which not be accepted without safeguards that
mitment to provide optimal care for has provided a relatively bright line lim- reassure the public about abuse, and if
iting the dominion of others over
dying patients. We live at a time in that debate shows the need for similar
which the control of health care costs patients' lives. It has therefore been an safeguards for some life-sustaining
has become, and is likely to continue important reassurance to concerns treatment decisions they should be
to be, the dominant focus of health about how the authority to take steps adopted there as well. In neither case
care policy. If euthanasia is seen as a ending life might be misused, abused, are the only possible safeguards greater
cheaper alternative to adequate care or wrongly extended. court involvement, as the recent growth
and treatment, then we might become
less scrupulous about providing some-
times costly support and other services
to dying patients. Particularly if our
society comes to embrace deeper and The legal rights of competent patients to decide about
more explicit rationing of health care, treatment are very firmly embedded in a long line of
frail, elderly, and dying patients will informed consent and life-sustaining treatment cases, and
need to be strong and effective advo-
cates for their own health care and are not likely to be eroded by a debate over euthanasia.
other needs, although they are hardly
in a position to do this. We should do
nothing to weaken their ability to ob-
tain adequate care and services. Many supporters of the right of of institutional ethics committees
patients or their surrogates to refuse shows.
This second worry is difficult to assess
because there is little firm evidence treatment strongly oppose euthanasia, The fourth potential bad conse-
about the likelihood of the feared ero-and if forced to choose might well with- quence of permitting euthanasia has
sion in the care of dying patients. There
draw their support of the right to refuse been developed by David Velleman and
are at least two reasons, however, for treatment rather than accept euthana- turns on the subtle point that making a
skepticism about this argument The sia. Public policy in the last fifteen years new option or choice available to
first is that the same worry could havehas generally let life-sustaining treat- people can sometimes make them
been directed at recognizing patients' ment decisions be made in health care worse off, even if once they have the
settings between physicians and
or surrogates' rights to forgo life-sus- choice the8 go on to choose what is best
taining treatment, yet there is no per-patients or their surrogates, and for them. Ordinarily, people's con-
suasive evidence that recognizing the without the involvement of the courts. tinued existence is viewed by them as
right to refuse treatment has causedHowever,
a if euthanasia is made legally given, a fixed condition with which they
serious erosion in the quality of care permissible
of greater involvement of the must cope. Making euthanasia available
dying patients. The second reason for courts is likely, which could in turn ex- to people as an option denies them the
tend to a greater court involvement in
skepticism about this worry is that only alternative of staying alive by default. If
avery small proportion ofdeathswould life-sustaining treatment decisions. people are offered the option of eutha-
17

49.144.229.78 on Tue, 01 Jun 2021 12:01:00 UTC
Death Wish Honored, Despite Doubts
That an action is legal does not necessarily make it any many months wanted to be there, so in essence itwas done
less gut-wrenching, as a physician learned when he parti- with the whole family there.
cipated in what might be termed court-sanctioned "She was lying in her bed. She said her final goodbyes to
euthanasia. everybody, kissing them and crying. It wasn't enormously
As he vividly recalls the incident, a woman in her fortiesdemonstrative at this point, but it had been going on for
awoke from a neurosurgical attempt to remove a slow-years and she had been saying goodbye forweeks. I remem-
growing, malignant brain tumor, only to find herself ber a one of the nurses was just fed up and wanted to get it
respirator-dependent quadriplegic. A vital, independentover with."
woman used to controlling all aspects of her life, she 'I'd sort of bitten the bullet at that point," says the
attempted in her last year to adjust. physician, to whom dying and death were old companions,
'"When I saw her I think she'd been on a respirator for'"but I was scared. I was worried that something might go
wrong with the medicine, I worried that I'd botch it I'd
about two-and-a-halfyears," says the physician. "She'd gone
gotten some advice, and I'd had backups, but... I put in
through a lot of physical therapy and was seen by a lot of
doctors, and after a year began asking much morean intravenous line and gave her opioids and barbiturates
vigorously for the respirator to be turned off. But sheto put her to sleep. She was deeply asleep and unresponsive
couldn't find anybody who would do it---which kind of to pain and we turned off the respirator," he says, pausing
surprises me because this was only a couple of years ago."
and sighing deeply.
The woman decided to take her case to court, and the "She continued to breathe for another ten, fifteen,
physician, an expert on the care of the dying, was asked minutes
to and we kind ofwatched her slowly stop breathing.
evaluate her. "She was being cared for by a couple of nursesIt was a very painful experience. My head knew ... felt...
in a hospice program, and they thought Iwouldjust come that this was what she wanted and it was the right thing,
in that day and turn off the respirator. But I did a fairly
and everybody had agreed to it. But it was sort of awful to
prolonged evaluation on her that took weeks, and had her watch somebody who I basically felt was viable and able to
seen by other people." Despite that, and despite speaking lead a meaningful life from my viewpoint, to see her die.
to the physicians who had cared for her over the two years, It was pretty ugly and pretty much made me decide not to
the physician says he couldn't understand the woman's do that again. I had distasteful feelings and a gut reaction
reasons for wanting to end her life. that this was not something I wanted to do."
"I'm not sure I ever had a good feeling for why she felt The physician says that ethical terms and distinctions are
this way, but she just felt life was not worth living if youuseful, but he recognizes that the woman's case blurred
couldn't be independent, that it was not enough to talkthem. "You could say that we just withdrew treatment and
and eat and move around and get out in her van. She lived gave her something to make her comfortable, or you could
mostly in a wheelchair, was really independent at home. say that we took her life. But I don't think it matters. What
But there was just a strong sense that life was not worth matters to me is this is what she wanted.
living." 'She'd been given everything to lead a happier life. She
The judge who heard the woman's case agreed that she was not depressed; that was the conclusion reached by
had a right to refuse life-sustaining treatment, and he three sets of competent psychiatrists. She'd even been
issued an order protecting any medical personnel who medicated with the presumption that she might be de-
turned off the machine. pressed and that might help her. She wasn't physically
The physician agreed to help the woman, but had suffering. There was no financial incentive. Her family
problems. 'In the first place, I didn't know how to turn off seemed happy to have her around. This was her choice
a respirator and have her comfortable, and I didn't know ultimately, and something that had been her wish for a year,
how to find out about it either--that's not something one or two years or three years was not going to change, as far
learns how to do in medical school. I had to make some as I could see. I guess the other side is she felt like it was a
phone calls that I felt very uncomfortable about, to people living hell."
who I thought would know aboutit, but itwasn't like I could However, he adds, while he believes he did the right
just read about it or pick up a book. One of the problems thing, "it really goes against the grain to kill somebody, to
is even if you're going to do it, how do you do it without do something of this sort. There's a real potential to tarnish
harming people?" one's image, something that's important ... if patients
He continues: 'There were lots of discussions about how think you can turn against them and kill them."
to do it, who was going to be in the room, and so on and
so forth, and the family decided they wanted to be outside Fmm "Death on Request"by B. D. Cdes
the room--she was in her bedroom and theywanted to be
A Newsday c-tide sprinted by prmisioan.
in the living room, although as it turns out, they all came Nenu~ a Inc. 01991.
in. And the two nurses who had been caring for her for
18

49.144.229.78 on Tue, 01 Jun 2021 12:01:00 UTC
nasia, their continued existence is now would be to deny it to most who would worries about this weakening can be
a choice for which they can be held want it. captured in the final potential bad con-
responsible and which they can be A fifth potential bad consequence of sequence, to which I will now turn.
asked by others to justify. We care, and making euthanasia legally permissible This final potential bad consequence
are right to care, about being able to is that it mightweaken the general legal is the central concern of many op-
justify ourselves to others. To the extent prohibition of homicide. This prohibi- ponents of euthanasia and, I believe, is
that our society is unsympathetic to tion is so fundamental to civilized the most serious objection to a legal
justifying a severely dependent or im- society, it is argued, that we should do permitting it. According to this
policy
paired existence, a heavy psychological nothing that erodes it. If most cases of
"slippery slope" worry, although active
burden of proof may be placed on stopping life support are killing, as I
euthanasia may be morally permissible
patients who think their terminal illness have already argued, then the court
in cases in which it is unequivocally
or chronic infirmity is not a sufficient cases permitting such killing havevoluntary
al- and the patient finds his or
reason for dying. Even if they otherwise ready in effect weakened this prohibi-
her condition unbearable, alegal policy
view their life as worth living, the opin- tion. However, neither the courts permitting
nor euthanasia would inevitably
ion of others around them that it is not most people have seen these cases as to active euthanasia being per-
lead
can threaten their reason for living and killing and so as challenging the prohi-
formed in many other cases in which it
bition of homicide. The courts have
make euthanasia a rational choice. would be morally wrong. To prevent
Thus the existence of the option be- grounded patients' or their sur-
usually those other wrongful cases of euthana-
comes a subtle pressure to request rogates'
it. sia we should not permit even morally
rights to refuse life-sustaining
This argument correctly identifies treatment in rights to privacy, liberty,
justified performance of it.
the reason why offering some patientsself-determination, or bodily integrity, Slippery slope arguments of this
the option of euthanasia wouldnot notin exceptions to homicide laws. form are problematic and difficult to
benefit them. Velleman takes it not as Legal
a permission for physicians or evaluate.' From one perspective, they
reason for opposing all euthanasia,others
but to perform euthanasia could not are the last refuge of conservative
be grounded in patients' rights to de-
for restricting it to circumstances where defenders of the status quo. When all
there are "unmistakable and over- cide about medical treatment. Permit- the opponent's objections to the
powering reasons for persons to want ting euthanasia would require qualify- wrongness of euthanasia itself have
the option of euthanasia," and for denying, at least in effect, the legal prohibi- been met, the opponent then shifts
ing the option in all other cases. tion Butagainst homicide, a prohibition ground and acknowledges both that it
there are at least three reasons why that suchin general does not allow the con- is not in itself wrong and that a legal
restriction may not be warranted. First, sent of the victim tojustify or excuse the policy which resulted only in its being
polls and other evidence support that act. Nevertheless, the very same fuimn- performed would not be bad.
most Americans believe euthanasia damental basis of the right to decide Nevertheless, the opponent maintains,
should be permitted (though theabout re- life-sustaining treatment-re- it should still not be permitted because
cent defeat of the referendum to per- specting a person's self-determina- doing so would result in its being per-
mit it in the state of Washington raises tion--does support euthanasia as well. formed in other cases in which it is not
some doubt about this support). Thus, Individual self-determination has long voluntary and would be wrong. In this
many more people seem to wantbeen theawell-entrenched and fundamen- argument's most extreme form, per-
choice than would be made worse off tal value in the law, and so extending it mitting euthanasia is the first and fate-
by getting it. Second, if giving peopleto euthanasia would not require appeal ful step down the slippery slope to
the option of ending their life really to novel legal values or principles. That Nazism. Once on the slope we will be
makes them worse off, then we shouldsuicide or attempted suicide is no unable to get off.
not only prohibit euthanasia, but also longer a criminal offense in virtually all Now it cannot be denied that it is
take back from people the right they states indicates an acceptance of in- possible that permitting euthanasia
now have to decide aboutlife-sustainingdividual self-determination in the could have these fateful consequences,
treatment. The feared harmful effect taking of one's own life analogous but to that cannot be enough to warrant
should already have occurred from se-that required forvoluntary active eutha- prohibiting it if it is otherwise justified.
curing people's right to refuse life-sus- nasia. The legal prohibition (in most A similar possible slippery slope worry
taining treatment, yet there is no evi- states) of assisting in suicide and thecould have been raised to securing
dence of any such widespread harm orrefusal in the law to accept the consent competent patients' rights to decide
any broad public desire to rescind that of the victim as a possiblejustification aboutof life support, but recent history
right. Third, since there is a wide rangehomicide are both arguably a result shows of such a worry would have been
of conditions in which reasonable difficulties in the legal process ofestab- unfounded. It must be relevant how
people can and do disagree about lishing the consent of the victim after likely it is that we will end with hor-
whether they would want continued the fact. If procedures can be designed rendous consequences and an un-
that clearly establish the voluntariness
life, it is not possible to restrict the per- justified practice of euthanasia. How
missibility of euthanasia as narrowly ofasthe person's request for euthanasia, likely and widespread would the abuses
Velleman suggests without thereby it would under those procedures repre- and unwarranted extensions of permit-
denying it to most persons who would sent a carefully circumscribed qualifica- ting it be? By abuses, I mean the per-
want it; to permit it only in cases in on the legal prohibition of homi-
tion formance of euthanasia that fails to
which virtually everyone would want cide.
it Nevertheless, some remaining satisfy the conditions required for vol-
19

49.144.229.78 on Tue, 01 Jun 2021 12:01:00 UTC
untary active euthanasia, for example, determination. Such additional restric- ture, in the courts since Quinlan, and
if the patient has been subtly pressured tions might, however, be justified by in norms of medical practice, that right
to accept it. By unwarranted extensions concern for limiting potential harms has been extended to incompetent
of policy; I mean later changes in legal from abuse. At the same time, it is im- patients and exercised by a surrogate
policy to permit not just voluntary eu- portant not to impose procedural or who is to decide as the patient would
thanasia, but also euthanasia in cases in substantive safeguards so restrictive as have decided in the circumstances if
which, for example, it need not be fully to make euthanasia impermissible or competent.22 It has been held unrea-
voluntary. Opponents of voluntary eu- practically infeasible in a wide range of sonable to continue life-sustaining
thanasia on slippery slope grounds justified cases. treatment that the patient would not
have wanted just because the patient
now lacks the capacity to tell us that.
Life-sustaining treatment for incom-
petent patients is today frequently for-
The very same logic that has extended the right to refuse gone on the basis of a surrogate's deci-
life-sustaining treatment from a competent patient to the sion, or less frequently on the basis of
surrogate of an incompetent patient may well extend the an advance directive executed by the
patient while still competent. The very
scope of active euthanasia.
same logic that has extended the right
to refuse life-sustaining treatment from
a competent patient to the surrogate of
an incompetent patient (acting with or
have not provided the data or evidence These examples of procedural safe- without a formal advance directive
necessary to turn their speculative con- guards make clear that it is possible to from the patient) may well extend the
cerns into well-grounded likelihoods. substantially reduce, though not to scope of active euthanasia. The argu-
It is at least clear, however, that both eliminate, the potential for abuse of a ment will be, Why continue to force
the character and likelihood of abuses policy permitting voluntary active eu- unwanted life on patients just because
of a legal policy permitting euthanasiathanasia. Any legalization of the prac- they have now lost the capacity to re-
depend in significant part on the pro-tice should be accompanied by a well- quest euthanasia from us?
cedures put in place to protect againstconsidered set of procedural A related phenomenon may rein-
them. I will not try to detail fully what safeguards together with an ongoingforce this slippery slope concern. In the
such procedures might be, but will justevaluation of its use. Introducing eutha-Netherlands, what the courts have sanc-
give some examples of what they mightnasia into only a few states could be a tioned has been clearly restricted to
include: form of carefully limited and controlled voluntary euthanasia. In itself, this
1. The patient should be provided social experiment that would give usserves as some evidence that permitting
with all relevant information about his evidence about the benefits and harms it need not lead to permitting the non-
or her medical condition, current prog- of the practice. Even then firm and voluntary variety. There is some indica-
nosis, axailable alternative treatments, uncontroversial data may remain elu- tion, however, that for many Dutch phy-
and the prognosis of each. sive, as the continuing controversy over sicians euthanasia is no longer viewed
2. Procedures should ensure that the what has taken place in the Netherlands as a special action, set apart from their
patient's request for euthanasia is stable in recent years indicates.21 usual practice and restricted only to
or enduring (a brief waiting period The Slip into Nonvoluntary Active competent persons.2 Instead, it is seen
could be required) and fully voluntary Euthanasia. While I believe slippery as one end of a spectrum of caring for
(an advocate for the patient might be slope worries can largely be limited by dying patients. When viewed in this way
appointed to ensure this). making necessary distinctions both in it will be difficult to deny euthanasia
3. All reasonable alternatives must principle and in practice, one slippery to a patient for whom it is seen as the
have been explored for improving the slope concern is legitimate. There is best or most appropriate form of care
reason to expect that legalization of simply because that patient is now in-
patient's quality of life and relieving any
pain or suffering. voluntary active euthanasia might soon competent and cannot request it.
4. A psychiatric evaluation should en- be followed by strong pressure to legal- Even if voluntary active euthanasia
sure that the patient's request is not theize some nonvoluntary euthanasia of should slip into nonvoluntary active eu-
incompetent patients unable to express thanasia, with surrogates acting for in-
result of a treatable psychological im-
pairment such as depression. their own wishes. Respecting a person's competent patients, the ethical evalua-
These examples of proceduralself-determination and recognizing tion is more complex than many op-
safeguards are all designed to ensure
that continued life is not always of value ponents of euthanasia allow. Just as in
that the patient's choice is fully in-
to a person can support not only volun- the case of surrogates' decisions to
formed, voluntary, and competent, and tary active euthanasia, but some non- forgo life-sustaining treatment for in-
so a true exercise of self-determination. voluntary euthanasia as well. These are competent patients, so also surrogates'
Other proposals for euthanasia would the same values that ground competent decisions to request euthanasia for in-
restrict its permissibility further-for patients' right to refuse life-sustaining competent persons would often accu-
example, to the terminally ill-a restric- treatment. Recent history here is in- rately reflectwhat the incompetent per-
tion that cannot be supported by self- structive. In the medical ethics litera- son would have wanted and would deny
20

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the person nothing that he or she public and professional debate about essary to a defensible practice, such as
would have considered worth having. seeing to it that the patient is well-in-
whether, all things considered, permit-
Making nonvoluntary active euthanasia ting euthanasia would be desirable orformed about his or her condition,
legally permissible, however, would undesirable reflects these disagree- prognosis, and possible treatments, and
greatly enlarge the number of patients ments. While my own view is that the ensuring that all reasonable means
on whom it might be performed and balance of considerations supports per-
have been taken to improve the quality
substantially enlarge the potential for of the patient's life. Second, and prob-
mitting the practice, my principal pur-
misuse and abuse. As noted above, frail pose here has been to clarify the mainably more important, one necessary
and debilitated elderly people, often issues. protection against abuse of the practice
demented or otherwise incompetent is to limit the persons given authority to
and thereby unable to defend and The Role of Physicians perform it, so that they can be held
assert their own interests, may be espe- accountable for their exercise of that
cially vulnerable to unwanted eutha- If euthanasia is made legally permis-authority. Physicians, whose training
nasia. sible, should physicians take part in it?and professional norms give some as-
For some people, this risk is more Should only physicians be permitted to surance that theywould perform eutha-
than sufficient reason to oppose the perform it, as is the case in the Nether-nasia responsibly, are an appropriate
legalization of voluntary euthanasia. lands? In discussing whether eutha-group of persons to whom the practice
But while we should in general be cau- nasia is incompatible with medicine's
may be restricted.
tious about inferring much from the commitment to curing, caring for, and
Adm kdgmentmis
experience in the Netherlands to what comforting patients, I argued that it is
our own experience in the United not at odds with a proper under- Earlier versions of this paper were
States might be, there may be one im- standing of the aims of medicine, and presented at the American Philosophical
portant lesson that we can learn from so need not undermine patients' trust Association Central Division meetings (at
them. One commentator has noted in their physicians. If that argument which
is David Velleman provided extremely
that in the Netherlands families of in- helpful comments), Massachusetts General
correct, then physicians probably
Hospital, Yale University School of
competent patients have less authority should not be prohibited, either by law
Medicine, Princeton University, Brown
than do families in the United States to or by professional norms, from taking
University, and as the Brin Lecture at The
act as surrogates for incompetent part in a legally permissible practice of Johns Hopkins School of Medicine. I am
patients in making decisions to forgo euthanasia (nor, of course, should they grateful to the audiences on each of these
life-sustaining treatment24 From the be compelled to do so if their personal occasions, to several anonymous reviewers,
Dutch perspective, it may be we in the or professional scruples forbid it). Mostand to Norman Daniels for helpful com-
United States who are already on the physicians in the Netherlands appear ments. The paper was completed while I was
not to understand euthanasia to be in- a Fellow in the Program in Ethics and the
slippery slope in having given suirro-
gates broad authority to forgo life- compatible with their professional Professions at Harvard University.
commitments.
sustaining treatment for incompetent References
persons. In this view, the more impor- Sometimes patients who would be
able to end their lives on their own 1. President's Commission for the Study
tant moral divide, and the more impor-
of Ethical Problems in Medicine and
tant with regard to potential for abuse, nevertheless seek the assistance of phy-
Biomedical and Behavioral Research,
is not between forgoing life-sustaining sicians. Physician involvement in such
Deciding to Forego Life-Sustaining Treatment
treatment and euthanasia, but instead cases may have important benefits to
(Washington, D.C.: U.S. Government
between voluntary and nonvoluntary patients and others beyond simply as-
Printing Office, 1983); The Hastings Cen-
performance of either. If this is correct, suring the use of effective means. His-
ter, Guidelines on the Termination of Life-
then the more important issue is ensur- torically, in the United States suicide has
Sustaining Treatment and Care of theDying
ing the appropriate principles and pro- carried a strong negative stigma that (Bloomington: Indiana University Press,
cedural safeguards for the exercise of many today believe unwarranted. Seek- 1987); Current Opinions of the Council on
decisionmaking authority by surrogates ing a physician's assistance, or what can
Ethical and Judicial Affairs of the American
for incompetentpersons in alldecisions almost seem a physician's blessing, may Medical Association-1989: Withholding or
be a way of trying to remove that stigmaWithdrawing Life-Prolonging Treatment
at the end of life. This may be the
and show others that the decision for (Chicago: American Medical Association,
correct response to slippery slope wor-
ries about euthanasia. suicide was made with due seriousness 1989); George Annas and Leonard
Glantz, "The Right of Elderly Patients to
I have cited both good and bad con- and was justified under the circum-Refuse Life-Sustaining Treatment,"
sequences that have been thoughtstances. The physician's involvementMillbank Memorial Quarterly 64, suppl. 2
likely from a policy change permittingprovides a kind of social approval, or (1986): 95-162; Robert F. Weir, Abating
voluntary active euthanasia, and have more accurately helps counter whatTreatment with Critically Ill Patients (New
tried to evaluate their likelihood and would otherwise be unwarranted social York: Oxford University Press, 1989); Sid-
relative importance. Nevertheless, as disapproval.
I ney J. Wanzer et al. "The Physician's
noted earlier, reasonable disagreement
There are also at least two reasons for Responsibility toward Hopelessly Ill
remains both about the consequences restricting the practice of euthanasia to Patients," NEJM 310 (1984): 955-59.
2. M.A.M. de Wachter, "Active Euthana-
of permitting euthanasia and about physicians only. First, physicians would
sia in the Netherlands,"JAMA 262, no. 23
which of these consequences are moreinevitably be involved in some of the (1989): 3315-19.
important. The depth and strength of important procedural safeguards nec-
21

49.144.229.78 on Tue, 01 Jun 2021 12:01:00 UTC
3. Anonymous, "It's Over, Debbie," 10. P. Painton and E. Taylor, "Love orCentral Division meetings; a similar point
JAMA 269 (1988): 272; Timothy E. Quill, Let Die," Time, 19 March 1990, pp. 62-71;was made to me by Elisha Milgram in
"Death and Dignity," NEJM 322 (1990): discussion on another occasion. For more
Boston Globe/Harvard University Poll, Bos-
1881-83. ton Globe, 3 November 1991. general development of the point see
4. Wanzer et al., "The Physician's Thomas Schelling, The Strategy of Conflict
11. James Rachels, The End of Life (Ox-
Responsibility toward Hopelessly Ill ford: Oxford University Press, 1986). (Cambridge, Mass.: Harvard University
Patients: A Second Look," NE]M 320 12. Marcia Angell, "The Quality ofPress, 1960); and Gerald Dworkin, "Is
(1989): 844-49. Mercy," NEJM 306 (1982): 98-99; M.More Choice Better Than Less?" in The
5. Willard Gaylin, Leon R Kass, Ed- Donovan, P. Dillon, and L. Mcguire, "In-Theory and Practice of Autonomy
mund D. Pellegrino, and Mark Siegler,cidence and Characteristics of Pain in a (Cambridge: Cambridge University Press,
"Doctors Must Not Kill," JAMA 259Sample of Medical-Surgical Inpatients," 1988).
(1988): 213940. Pain 30 (1987): 69-78. 19. Frederick Schauer, "Slippery
6. Bonnie Steinbock, ed., Killing and 13. Eric Cassell, The Nature of Suffering Slopes," Harvard Law Review 99 (1985):
Allowing to Die (Englewood Cliffs, N.J.: and the Goals of Medicine (New York: Ox- 361-83; Wibren van der Burg, "The Slip-
Prentice Hall, 1980'). ford University Press, 1991). pery Slope Argument," Ethics 102 (Oc-
7. Dan W. Brock, "Forgoing Food and 14. Gaylin et al., "Doctors Must Not tober 1991): 42-65.
Water: Is It Killing?" in By No ExtraordinaryKill." 20. There is evidence that physicians
Means: The Choice to Forgo Life-Sustaining 15. Leon R. Kass, "Neither for Love Nor commonly fail to diagnose depression.
Food and Wate;, ed. Joanne Lynn Money: Why Doctors Must Not Kill," The See Robert I. Misbin, "Physicians Aid in
(Bloomington: Indiana University Press, Public Interest 94 (1989): 25-46; cf. also his
Dying," NEJM325 (1991): 1304-7.
1986), pp. 117-31. Toward a More Natural Science: Biology and21. Richard Fenigsen, "A Case against
8. James Rachels, "Active and PassiveHuman Affairs (New York: The Free Press, Dutch Euthanasia," Special Supplement,
Euthanasia," NEJM 292 (1975): 78-80; 1985), chs. 6-9. Hastings Center Report 19, no. 1 (1989):
Michael Tooley, Abortion and Infanticide 16. PaulJ. Van der Maas et al., "Eutha- 22-30.
(Oxford: Oxford University Press, 1983).nasia and Other Medical Decisions Con- 22. Allen E. Buchanan and Dan W.
In my paper, "Taking Human Life," Ethics cerning the End of Life," Lancet 338 Brock, Decidingfor Others: The Ethics of Sur-
95 (1985): 851-65, 1 argue in more detail(1991): 669-74. rogate Decisionmaking (Cambridge: Cam-
that killing in itself is not morally different 17. Susan M. Wolf, "Holding the Line bridge University Press, 1989).
from allowing to die and defend the on Euthanasia," Special Supplement,23. Van der Maas et al., "Euthanasia and
strategy of argument employed in this and Hastings Center Report 19, no. 1 (1989):Other Medical Decisions."
the succeeding two paragraphs in the text.13-15. 24. Margaret P. Battin, "Seven Caveats
9. Dan W. Brock, "Moral Rights and 18. My formulation of this argument Concerning the Discussion of Euthanasia
Permissible Killing," in Ethical Issues Relat-derives from David Velleman's statement in Holland," American PhilosophicalAssocia-
ing to Life and Death, ed. John Ladd (New of it in his commentary on an earlier tion Newsletter on Philosophy and Medicine 89,
York: Oxford University Press, 1979), pp. version of this paper delivered at the no. 2 (1990).
94-117. American Philosophical Association
22

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Voluntary Active Euthanasia

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