Assisted Voluntary Euthanasia
The main arguments
This a systematic survey of the arguments and counterarguments that are most commonly in play when considering the ethical rights and wrong of euthanasia and whether it should be legally permitted.
By ‘assisted dying’ I shall mean primarily voluntary euthanasia (where a person is in a position to confirm or deny that they wish their life ended), but the expression may be taken to extend to albeit difficult cases of non-voluntary euthanasia (where a person is a position where they can neither confirm or deny that they wish their life ended), cases that are complicated by the possibility of the expression of prior wishes. This, of course, contrasts with involuntary euthanasia where a person’s life is ended against their wishes.
I assume that any validly supported conclusion as to the desirability or otherwise of euthanasia must be based on arguments, and a mere statement of belief, no matter how sincerely or dogmatically it is held, or how venerable such a belief may be, is insufficient to count as establishing or refuting the conclusion.
Arguments on euthanasia (assisted dying) divide into those based on rights and those grounded in utilitarianism, here termed consequentialism, the latter judging the rightness or wrongness of action not by its obeying or breaking absolute rules, but by the goodness or badness of the supposed consequences.
Roughly speaking the strongest arguments for euthanasia are rights-based and the strongest arguments against euthanasia utilitarianism-based. The consequentialist opposed to euthanasia will usually try to undercut the rights argument for it by denying the existence of absolute rights. Since it is hard for them to find a reason to rule out rights (or all absolute moral rules) altogether, as certain cases seem to demand them — no child torture, for example — it is hard for them to find an argument that singles out the right to decide when one dies.
However, I shall argue that even consequentialist arguments against euthanasia, usually taken to be the best grounds for opposing euthanasia, are not as strong as they are sometimes supposed. Indeed, as will be shown, many of the arguments of the consequentialist against euthanasia, just because of their tendency to deny absolute rules, may be found to cut both ways, and may be used to argue for euthanasia by plausibly inverting the supposed consequences.
One argument which tries to reverse a rights argument — one that usually on the grounds of personal autonomy argues that people should have the right to determine their own death — is where it is contended that it is not permissible for us to hand over our right to life and give to another permission to kill us.
The best reply here is that we think it is morally permissible to hand over all sorts of rights (as in the case of surgery, where the actions of the doctor could otherwise be construed as assault) if we think the consequences are good. (In fact, in an emergency a doctor is entitled to act without consent on a person incapable of consenting.)
If bringing about our own death in a certain way under certain circumstance can constitute a good, as surely plausibly it can, then there is no reason why we should be forbidden from granting permission to another to bring that death about. As an extreme example think of the example of a driver trapped hopelessly in a lorry involved in an accident who is burning to death and you standing by happen to have a gun that would cease their prolonged agony. This shows, at least, that it can be the case that assisting someone to die may not be wrong.
It is often argued that legalising euthanasia would undermine the doctor-patient relationship, for it would erode the trust that the primary concern of the doctor is our best interests. This simply begs the question as to our best interests. For it assumes that in facilitating our death according to our wishes the doctor would not be acting in our best interests, and in not doing so he always would be acting in our best interests. Which is the case cannot be universalised and will vary from case to case. This conclusion is perfectly compatible with a doctor permissibly assisting death. Indeed, doctors would often be better offering euthanasia than offering, as they do now for want of anything positive to offer, the cruel false hope of treatment that is in fact futile.
Moreover, this problem can be circumvented. There is no reason to suppose that the assistance to die must be dealt with by doctors — although it would be surprising if they were not involved at all. One could imagine a specially licensed group of people primarily engaging in these acts, thought of as — although the suggestion may seem a little gruesome from our present perspective — the mirror-image of midwives.
It is often overlooked how the possibility of assisted dying may not only be a comfort to those in their final years, but paradoxically, so it may seem, prolong life. This is so because individuals might be more likely to persevere in what may be a difficult life if they know that there is some well-worked-out reliable escape from what might ensue, including mental and physical incapacity as well as suffering — otherwise they may be inclined to take precipitate action to end their life earlier than they otherwise would.
Many of the arguments against the legalisation of euthanasia centre around the consequences of its being legalised, while failing to realise that these consequences only follow if at all in circumstances where it has not been legal. The very illegality of euthanasia means that the formal and informal mechanisms — openness, legal process, social support and public visibility — which would act against its abuse cannot grow up in the way that they have in the cases of, say, marriage, birth and parenthood. In fact, one may conclude that the secrecy consequent on euthanasia’s illegality makes dubious cases of euthanasia more likely not less.
It is argued against euthanasia that legalisation allowing it would pressure people into choosing to die. This argument cuts both ways. It ignores the fact that its illegality — along with social stigma and related psychological trauma for relatives and friends involved — means that people feel pressured to go on living when they would rather die. The illegality of euthanasia is what in fact produces many of the bad consequences that are thought to follow from its legality, as the arguer for illegality ignores the fact that making it legal would itself change the circumstances in which it takes place. To be concrete, one can imagine euthanasia being discussed by family members and friends, as well as with the doctor, in a way that is impossible in a state where it is illegal.
It is said that euthanasia is uniquely objectionable because unlike other decisions it is, if successful, something we cannot change our minds about. This is both false and confused. Many decisions — becoming a parent, for example — are irreversible. Many decisions are unidirectional. I cannot now decide anymore — as I may once have decided against and so chose a different path — to become a concert violinist as I am simply too old. There’s no going back on the many decisions we make. Choosing to die, and successfully doing so, is indeed something we cannot change our mind about — but as the seat of the decision ceases to exist it is pointless and misleading to suggest that the person might regret it and wish to change their minds later.
This only makes sense from another perspective. So, the decision looks definitively less prone to a later desire to do otherwise than a vast array of other decisions. The argument also cuts both ways. The decision not to demand euthanasia, and to die some other way, is just as irreversible after death as the decision to die by euthanasia. If regret were per impossibile to occur after death, it could just as well be the decision not to die by euthanasia as to die from it. The hidden assumption here, giving the opposer of euthanasia the appearance of plausibility, is that the decision for euthanasia is seen as having purely negative qualities (no life) rather than it having positive qualities (dying with dignity, or for the person involved in a timely fashion) against the negative qualities such as the pain, humiliation or misery of continuing to live.
Next may be slippery slope objection. This divides into the logical and factual slippery slope.
The logical slippery slope says that allowing euthanasia entails normatively permitting acts that are morally objectionable, whether or not they actually happen. The factual slippery slope says that allowing euthanasia would as a matter of fact lead to morally objectionable acts whether they are normatively permissibly entailed or not.
The logical slippery slope objection is weak. It either illegitimately makes a matter of degree a matter of a difference of kind, or simply confuses one kind of thing with another. There is no more reason why permitting euthanasia should entail, say, permitting murder, than permitting sexual relations should entail permitting rape.
The first reply to the factual slippery slope is again that it cuts both ways. Just as there may be cases where it is supposed that someone might connive another’s death under the cover of euthanasia in order to gain some advantage (say, a rich inheritance), so there might be cases where someone connives to keep another alive under the cover of the illegality of euthanasia against their wishes to gain some advantage (say, denying a rich inheritance to another). It’s not clear that the former would outnumber the latter.
It is said that permitting euthanasia would weaken the prohibition on taking life in other areas by some sort of change in the moral ethos of a community. I know of no empirical evidence that this is so — the evidence would point the other way — where what we are dealing with is voluntary euthanasia. This argument often relies on confuses voluntary and involuntary euthanasia, and falls foul of the refutation of the logical slippery slope argument.
Moreover, the introduction of euthanasia, rather than weakening the value we place on the life of individuals, may be said to generally affirm it by placing value on its quality and obeying the individual’s wishes and will during a person’s life time. This might be said to be in accordance with Kant’s ‘Respect for Persons’, Categorical Imperative: to never treat people as a mere means but also as ends in themselves — without which it is tantamount to treating someone as a mere thing. With it one always takes account of the willed wishes of people acknowledging thereby that they and they alone are the locus of all values and of supreme value. The proponent of the factual slippery slope would in their speculation have to show why one should think that legalising euthanasia would lead to an increase of immoral illegal acts such as murder, anymore that one should think that legalised surgery leads to an increase in knife assault attacks.
Most commonly perhaps it is argued that euthanasia is unnecessary because the death of an individual can be managed successfully by palliative methods including loving care and pain-relieving medicines.
The lack of necessity for euthanasia alone in no way entails that euthanasia should not be permitted, anymore than the lack of the necessity to climb to the summit of high dangerous mountains entails that we should not do so, unless one also shows that the benefits out weigh the advantages — but that is what is in dispute.
Moreover, it is not clear that an overall answer is legitimate; rather, because of this, such decisions should be left to the individual according to their values. What counts as an undesirable or intolerable (or desirable and not intolerable) state to be in is not something that one can plausibly claim to provide a definitive answer to valid for all individuals.
It is not even only that people’s tolerance of pain is reasonably said to be a personally defined matter. Rather one might find oneself in a position one finds intolerable and would wish to be out of, that no palliative care by necessity can ameliorate. This might arise where what a person finds intolerable is the very fact of being dependent under the palliative care of another and more of the same however delivered is not going to make any difference to the mere fact of it.
In addition, the contrast between what they once were and what they have become may easily and understandably be sufficient to make a person’s life an intolerable lived-hell for them. The twists and turns as to what constitutes an intolerable state to be in for a particular individual are extremely complex and subtle, and it may be argued that it is utterly presumptive to decide this matter for another. But it is very hard to see how any such view could be legitimately gainsaid by another. The intolerable nature of their lives may be the mere perception of the fact of their condition, and no palliation can affect this fact for otherwise, necessarily, the palliation would not be required. Even where the physical aspect of palliative care is the issue, there are some physical features of our condition that it cannot reach. Pain is by no means the only issue. The intolerability of death by asphyxiation is not a function of pain. In other conditions where people are left mentally or physically crippled, it is quite likely that neither pain relief — no pain may be involved — nor any other treatment can relieve the debilitated, immobile, or trapped ghastliness of the condition for the individual who experiences it.
It is sometimes said that legalising assisted dying, perhaps assisted by doctors, would put doctors in a position that we have no right to demand of them. But this objection is easily answered.
First, if they are obliged to act in our best interest, and if euthanasia is in our best interest, then we do have a right to demand their assistance, just as we do with other procedures we undergo in our best interest.
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Second, legalising euthanasia would not entail the demand that all doctors engage in it. Doctors could volunteer for it, and others may refuse, just as now some agree and some refuse to do abortions. There could be a register of doctors — or other specialists — that one could call upon, just as there are specialist in other fields, such as now there are doctors that do post mortems (autopsies). Thus, consideration of assisted dying involving others is not an objection to the legalisation of voluntary euthanasia, for the assistance could be equally voluntary.
It’s worth bearing in mind that assisted voluntary euthanasia without the assistance is in fact suicide, and that has long been in most countries legal and a right — though sometimes drawing to it moral complexities — and it is now legally and mostly morally highly objectionable that it should be otherwise. Reflecting on this might lead one to wonder why the assistance part makes as big a legal and moral difference as some suppose.
In this piece I have tried to give the weight to the arguments as they justify it. There is much to consider, but on balance, I think it reasonable — without going into the details of the legal framework and criteria — to think assisted voluntary euthanasia may be morally justified in some circumstances.
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Dr John Shand is a Visiting Fellow in Philosophy at the Open University. He studied philosophy at the University of Manchester and King’s College, University of Cambridge. He has taught at Cambridge, Manchester and the Open University. The author of numerous articles, reviews, and edited books, his own books include, Arguing Well (London: Routledge, 2000) and Philosophy and Philosophers: An Introduction to Western Philosophy, 2nd edition (London: Routledge, 2014).
- Dr John Shand, The Open University, Walton Hall, Milton Keynes, Buckinghamshire, MK7 6AA, United Kingdom.
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