Voluntary euthanasia: a utilitarian perspective

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 administration 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 consider more specific utilitarian arguments for and against permitting voluntary euthanasia.     

Euthanasia.

The principles of self-determination and individual well-being support the use of voluntary euthanasia by those who do not have moral or professional objections to it. Opponents of this posture cite the ethical wrongness of the act itself and the folly of any public or legal policy permitting euthanasia. Positive consequences of making euthanasia legally permissible respect the autonomy of competent patients desiring it, expand the population of patients who can choose the option, and release the dying patient from otherwise prolonged suffering and agony. Potentially bad consequences of permitting euthanasia include the undermining of the "moral center" of medicine by allowing physicians to kill, the weakening of society's commitment to provide optimal care for dying patients, and, of greatest concern, the "slippery slope" argument. The evaluation of the arguments leads to support for euthanasia, with its performance not incompatible with a physician's professional commitment.     

Legal Standards for Brain Death and Undue Influence in Euthanasia Laws

A major appellate court decision from the United States seriously questions the legal sufficiency of prevailing medical criteria for the determination of death by neurological criteria. There may be a mismatch between legal and medical standards for brain death, requiring the amendment of either or both. In South Australia, a Bill seeks to establish a legal right for a defined category of persons suffering unbearably to request voluntary euthanasia. However, an essential criterion of a voluntary decision is that it is not tainted by undue influence, and this Bill falls short of providing adequate guidance to assess for undue influence.     

Managing intentions: the end-of-life administration of analgesics and sedatives, and the possibility of slow euthanasia

There has been much debate regarding the 'double-effect' of sedatives and analgesics administered at the end-of-life, and the possibility that health professionals using these drugs are performing 'slow euthanasia.' On the one hand analgesics and sedatives can do much to relieve suffering in the terminally ill. On the other hand, they can hasten death. According to a standard view, the administration of analgesics and sedatives amounts to euthanasia when the drugs are given with an intention to hasten death. In this paper we report a small qualitative study based on interviews with 8 Australian general physicians regarding their understanding of intention in the context of questions about voluntary euthanasia, assisted suicide and particularly the use of analgesic and sedative infusions (including the possibility of voluntary or non-voluntary 'slow euthanasia'). We found a striking ambiguity and uncertainty regarding intentions amongst doctors interviewed. Some were explicit in describing a 'grey' area between palliation and euthanasia, or a continuum between the two. Not one of the respondents was consistent in distinguishing between a foreseen death and an intended death. A major theme was that 'slow euthanasia' may be more psychologically acceptable to doctors than active voluntary euthanasia by bolus injection, partly because the former would usually only result in a small loss of 'time' for patients already very close to death, but also because of the desirable ambiguities surrounding causation and intention when an infusion of analgesics and sedatives is used. The empirical and philosophical implications of these findings are discussed.     

A GOOD DEATH: WHO BEST TO BRING IT?*

The author supports the right of persons to terminate their lives when it would be in their "best interests" to do so. He considers cases in which persons are unable to kill themselves and request euthanasia or have requested it beforehand in a living will. Crisp rejects relatives, friends, and most physicians as the agents to carry out the request because of the emotional trauma to the agents and the damage to the image of physicians as savers of lives. He proposes that the practice of euthanasia be part of "telostrics," an area of medical specialization in the care of the terminally ill, and that these "telostricians" should perform voluntary euthanasia.     

LIVING TO THE BITTER END? A PERSONALIST APPROACH TO EUTHANASIA IN PERSONS WITH SEVERE DEMENTIA

The number of people suffering from dementia will rise considerably in the years to come. This will have important implications for society. People suffering from dementia have to rely on relatives and professional caregivers when their disorder progresses. Some people want to determine for themselves their moment of death, if they should become demented. They think that the decline in personality caused by severe dementia is shocking and unacceptable. In this context, some people consider euthanasia as a way to avoid total deterioration. In this article, we discuss some practical and ethical dilemmas regarding euthanasia in persons with severe dementia based on an advance euthanasia directive. We are using a personalist approach in dealing with these ethical dilemmas.     

The ethics of euthanasia: advocates' perspectives

The Netherlands is currently the only country in the world in which euthanasia is legally permissible. More specifically, Dutch law (briefly explained) allows that a doctor terminates the life of a patient of hers on his voluntary, well-considered and sustained request, if he is suffering unbearably and hopelessly. The aim of this paper is to reconstruct the Dutch debate on the moral permissibility of euthanasia so as to clarify and strengthen the various views that can be advanced in support of euthanasia. On the one view, The Pure Autonomy View (TPAV), the justification of euthanasia rests solely on the principle of respect for autonomy. That is, the reason for performing and permitting euthanasia is the patient's voluntary, well-considered and sustained, in one word: autonomous, request for euthanasia. On the alternative view, The Joint View (TJV), the principle of respect for autonomy and the principle of beneficence morally justify euthanasia together . That is, euthanasia is ethical if and partly because, since the patient is suffering unbearably and hopelessly, euthanasia is in his interest. According to this paper, there is no easy argument for one of these views rather than the other. Instead, as yet both TPAV and TJV seem inherently problematic. TPAV is unable to give a doctor a reason for performing euthanasia that appeals to her in her capacity as a doctor, such as relief of suffering. And TJV begs the question – for example, if a state were to legalize euthanasia on grounds of TJV, it would force the view upon its citizens that it may be in a person's interest to die.     

Hastening death and respect for dignity: Kantianism at the end of life

Suppose that a young athlete has just become quadriplegic. He expects to live several more decades, but out of self‐interest he autonomously chooses to engage in physician‐assisted suicide (PAS) or voluntary active euthanasia (VAE). Some of us are unsure whether he or his physician would be acting rightly in ending his life. One basis for such doubt is the notion that persons have dignity in a Kantian sense. This paper probes responses that David Velleman and Frances Kamm have suggested to the question of whether participating in PAS or VAE to benefit oneself, as the young man might, respects the dignity of persons, specified in an orthodox Kantian way. Velleman claims that it does not, while Kamm insists that, in certain circumstances, it does. I argue against Kamm's position. I go on to contend that while orthodox Kantianism might provide a basis for moral concern regarding the case of the young quadriplegic, it suffers from two serious shortcomings. First, it implies that terminally ill patients are wrong to request VAE or engage in PAS to avoid intense suffering, at least when this suffering has not yet overwhelmed their reason. Second, orthodox Kantianism implies that it is wrong for physicians to withdraw such patients from life‐sustaining treatments, even if they request it. To remedy these shortcomings, I sketch an unorthodox Kantian account of respect for the dignity of persons. This account promises to capture the idea that it would be morally problematic for doctors to help the young quadriplegic to die, but to avoid the shortcomings of an orthodox Kantian account.     

Active and Passive Physician‐Assisted Dying and the Terminal Disease Requirement

The view that voluntary active euthanasia and physician‐assisted suicide should be made available for terminal patients only is typically warranted by reference to the risks that the procedures are seen to involve. Though they would appear to involve similar risks, the commonly endorsed end‐of‐life practices referred to as passive euthanasia are available also for non‐terminal patients. In this article, I assess whether there is good reason to believe that the risks in question would be bigger in the case of voluntary active euthanasia and physician‐assisted suicide than in that of passive euthanasia. I propose that there is not. On that basis, I suggest that limiting access to voluntary active euthanasia and physician‐assisted suicide to terminal patients only is not consistent with accepting the existing practices of passive euthanasia.     

‘SETTING A PRINCIPLED BOUNDARY’? EUTHANASIA AS A RESPONSE TO ‘LIFE FATIGUE’

The Dutch case of Brongersma presents novel challenges to the definition and evaluation of voluntary euthanasia since it involved a doctor assisting the suicide of an individual who was (merely?) ‘tired of life’. Legal officials had called on the courts to ‘set a principled boundary’, excluding such cases from the scope of permissible voluntary euthanasia, but they arguably failed. This failure is explicable, however, since the case seems justifiable by reference to the two major principles in favour of that practice, respect for autonomy and beneficence. Ultimately, it will be argued that those proponents of voluntary euthanasia who are wary of its use in such circumstances may need to draw upon ‘practical’ objections, in order to erect an otherwise arbitrary perimeter. Furthermore, it will be suggested that the issues raised by the case are not peculiarly Dutch in nature and that, therefore, there are lessons here for other jurisdictions too.     

ATTITUDES TOWARDS EUTHANASIA AND ASSISTED SUICIDE: A COMPARISON BETWEEN PSYCHIATRISTS AND OTHER PHYSICIANS

Euthanasia and physician assisted‐suicide are terms used to describe the process in which a doctor of a sick or disabled individual engages in an activity which directly or indirectly leads to their death. This behavior is engaged by the healthcare provider based on their humanistic desire to end suffering and pain. The psychiatrist's involvement may be requested in several distinct situations including evaluation of patient capacity when an appeal for euthanasia is requested on grounds of terminal somatic illness or when the patient is requesting euthanasia due to mental suffering. We compare attitudes of 49 psychiatrists towards euthanasia and assisted suicide with a group of 54 other physicians by means of a questionnaire describing different patients, who either requested physician‐assisted suicide or in whom euthanasia as a treatment option was considered, followed by a set of questions relating to euthanasia implementation. When controlled for religious practice, psychiatrists expressed more conservative views regarding euthanasia than did physicians from other medical specialties. Similarly female physicians and orthodox physicians indicated more conservative views. Differences may be due to factors inherent in subspecialty education. We suggest that in light of the unique complexity and context of patient euthanasia requests, based on their training and professional expertise psychiatrists are well suited to take a prominent role in evaluating such requests to die and making a decision as to the relative importance of competing variables.     

A Survey of Veterinarians’ Attitudes toward Euthanasia of Companion Animals in Japan

This study investigated veterinarians’ attitudes toward euthanasia of companion animals in Japan. A nationwide survey was conducted with 932 veterinarians in small animal practices. It examined the number of times they administered euthanasia, their moral criteria for choosing euthanasia for animals, and their behavioral criteria for suggesting euthanasia to owners. According to the data analyses, on average the veterinarians administered euthanasia 2.48 times a year. For many veterinarians, two conditions were necessary to justify euthanasia for animals: “the animals are incurable and suffering” and “the owners request to euthanize the animals.” In the absence of either condition, the veterinarians were inclined to disapprove of choosing euthanasia. If the owners requested further treatment, 67% showed clear disapproval of choosing euthanasia for animals with serious medical conditions. Meanwhile, more than 76% showed clear disapproval of euthanizing healthy animals when the owners requested it. These results indicate that the owners’ request takes precedence over the animals’ condition for suffering animals, but not for healthy animals. For animals with serious medical conditions, 56% of the veterinarians answered that they would or might suggest euthanasia to the owners even though the owners requested further treatment. In this situation, for some veterinarians, the animals’ condition rather than the owners’ request might become a determinant in suggesting euthanasia to owners, even if their moral judgments were against choosing euthanasia for the animals. A decrease in the owners’ or the animals’ quality of life and the owners’ inability to pay were not primary factors in choosing or suggesting euthanasia. Having an experience of euthanizing their own animals was a key factor for the veterinarians which increased not only the number of times they administered euthanasia but also the degree of their moral approval of choosing euthanasia and their behavioral willingness to suggest it to owners.     

THE DEAD DONOR RULE,VOLUNTARY ACTIVE EUTHANASIA,AND CAPITAL PUNISHMENT

We argue that the dead donor rule, which states that multiple vital organs should only be taken from dead patients, is justified neither in principle nor in practice. We use a thought experiment and a guiding assumption in the literature about the justification of moral principles to undermine the theoretical justification for the rule. We then offer two real world analogues to this thought experiment, voluntary active euthanasia and capital punishment, and argue that the moral permissibility of terminating any patient through the removal of vital organs cannot turn on whether or not the practice violates the dead donor rule. Next, we consider practical justifications for the dead donor rule. Specifically, we consider whether there are compelling reasons to promulgate the rule even though its corresponding moral principle is not theoretically justified. We argue that there are no such reasons. In fact, we argue that promulgating the rule may actually decrease public trust in organ procurement procedures and medical institutions generally – even in states that do not permit capital punishment or voluntary active euthanasia. Finally, we examine our case against the dead donor rule in the light of common arguments for it. We find that these arguments are often misplaced – they do not support the dead donor rule. Instead, they support the quite different rule that patients should not be killed for their vital organs.     

The impact of reporting cases of euthanasia in Holland: a patient and family perspective

In 1991 the Dutch government released the results of the first national investigation into the nature and extent of decisions concerning end of life including euthanasia. A significant finding was that most cases of euthanasia were not reported. This prompted us to ask what effect, if any, not reporting caused. More specifically, we asked whether reporting has a positive or negative impact on the experiences of friends or relatives of patients who have received euthanasia. In cases of euthanasia, complications of both process and experience can deter from a minimally complicated death. These difficulties arise when either the family or physician does not perceive the freedom to disclose euthanasia openly. On the basis of interviews with family members and patients, we illustrate that they generally benefit from reporting. Our premise is that reporting fosters open discussion of euthanasia. We further suggest physicians and society benefit from a milieu of openness initiated by reporting cases of euthanasia.     

Rates of euthanasia and adoption for dogs and cats in Michigan animal shelters

Estimates of canine and feline euthanasia at U.S. animal shelters—largely based on voluntary surveys with low response rates—make it difficult to estimate the population from which the euthanized animals derive. Estimates of euthanasia rates (animals euthanized per unit of population) have varied widely and been available only sporadically. This study used requirements of Michigan state law (Pet Shops, Dog Pounds, and Animal Shelters Act, 1969) for animal shelters to collect admission and discharge data for all 176 Michigan-licensed animal shelters. In 2003, Michigan shelters discharged 140,653 dogs: Of these, 56,972 (40%) were euthanized; 40,005 (28%) were adopted. This annual euthanasia rate is 2.6% of the estimated 2003 Michigan dog population. Michigan shelters discharged 134,405 cats in 2003: 76,321 (57%) by euthanasia and (24%) by adoption. The estimated ratio of euthanized cats to cats who had owners was 3.1%. Small shelters and privately owned shelters were associated with higher adoption rates. Comparison with historical information from the past 10 to 20 years suggests the number of companion animals being euthanized in shelters has decreased and that progress has been made in reducing the companion animal overpopulation problem.     

Bioethics and Political Ideology: The Case of Active Voluntary Euthanasia

In different countries responses to important bioethical issues are different, as exemplified by the attitudes towards the voluntary and active forms of medical euthanasia. But why is this the case? My suggestion is that the roots of the variety are, to a considerable degree, ideological.
The most important present-day political ideologies all have their roots in the prevailing doctrines of moral and social philosophy. In the paper these doctrines are outlined and the predicted response towards active voluntary euthanasia within each model is sketched. The conclusion reached is that while it would in some countries be dangerous to allow euthanasia in the prevailing circumstances, the solution is not to hinder the legalization process but to alter the circumstances.     

Bioethics and political ideology: the case of active voluntary euthanasia

In different countries responses to important bioethical issues are different, as exemplified by the attitudes towards the voluntary and active forms of medical euthanasia. But why is this the case? My suggestion is that the roots of the variety are, to be considerable degree, ideological. The most important present-day political ideologies all have their roots in the prevailing doctrines of moral and social philosophy. In the paper these doctrines are outlined and the predicted response towards active voluntary euthanasia within each model is sketched. The conclusion reached is that while it would in some countries be dangerous to allow euthanasia in the prevailing circumstances, the solution is not to hinder the legalization process but to alter the circumstances.     

Voluntary Health Insurance Coverage in California, 1961: A Report of the Bureau of Research and Planning, California Medical Association

Almost 7 out of every 10 of the estimated population of 16.2 million persons in California, were covered under some form of voluntary health insurance at the end of 1961. The forms of protection included hospital, surgical, regular medical and major medical expense benefits. The per cent of the civilian population of California covered for surgical benefits was slightly over 66 per cent, while 56 per cent were covered for regular medical expense benefits. Comparable percentages for the United States are approximately 74 per cent (hospital), 69 per cent (surgical), and 51 per cent (regular medical). While the percentage of the State's population covered for hospital and surgical expenses is below that for the United States, it is higher for regular medical expense benefits. The rate of increase in coverage for the different forms of health care protection in California exceeded the rate of population growth during the one-year period ending 1961. The foregoing summary and the information in the accompanying text, does not reflect the total number of persons in California who receive or are eligible for health care services. A large variety of government financed programs on local, state and federal levels either finance or provide such services to an estimated 40 to 50 per cent of the California population, which does not have voluntary health insurance coverage. No current data are available regarding the number of persons who do not desire voluntary health insurance coverage for a variety of personal or financial reasons.     

On the Moral Acceptability of Physician‐Assisted Dying for Non‐Autonomous Psychiatric Patients

Several authors have recently suggested that the suffering caused by mental illness could provide moral grounds for physician‐assisted dying. Yet they typically require that psychiatric‐assisted dying could come to question in the cases of autonomous, or rational, psychiatric patients only. Given that also non‐autonomous psychiatric patients can sometimes suffer unbearably, this limitation appears questionable. In this article, I maintain that restricting psychiatric‐assisted dying to autonomous, or rational, psychiatric patients would not be compatible with endorsing certain end‐of‐life practices commonly accepted in current medical ethics and law, practices often referred to as ‘passive euthanasia’.