The Right to Die with Dignity:
An Argument in Ethics and Policy
Raphael Cohen-Almagor
April 13, 2015
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The Dilemma
A person suffers a great pain and wants to die.
 Those who believe that life is intrinsically
valuable object to taking action on the person’s
desire.
 But their objection ignores the autonomy of the
agent concerned.
 Can life be intrinsically valuable independently of
the interests of the individual? Do these persons
(or the state) have the right to impose their will
over the will of the individual?

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Key concepts
Liberty
 Autonomy
 Dignity
 Respect
 Concern
 Suffering
 Quality of Life
 Physician’s Role

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Key concepts
Ethics v. Policy Making
 Fear of Abuse
 Control Mechanisms

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Liberty

Liberty is required in order to enable
people to discover, from the open
confrontation of the ideas that are
cherished in their society, their own views,
their beliefs, and their future life plans.
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Liberty
Liberty enables autonomy, self-rule, and
self-direction.
 Accordingly, the view is that individuals
should be left to govern their affairs
without being overwhelmingly subject to
external forces.
 Patients should be at liberty to end their
lives if they so choose.

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Autonomy
The central idea of autonomy is of selfrule, or self-direction.
 People are autonomous when they see
themselves as sovereign in deciding what
to believe in and in weighing competing
reasons for action.

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Dignity
 To
have dignity means to look at oneself
with self-respect, with some sort of
satisfaction.
 Timing of death: people should be allowed,
whenever possible, to choose the time of
their departure; and
 the way people die: with the help of medical
professionals, people should be able to
control the process of dying, maintaining
autonomy at the end of life, not being
humiliated, and perceiving themselves with
honor.
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Dignity
Life qua life is not that important but
rather what one does with one’s life. Life
in earnest is important, not just the
mechanical processes that define life in
the superficial meaning of the term.
 That one’s heart is beating and that one is
able to breath are not sufficient reasons to
maintain life.

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Dignity

We must strive to reconcile the duty of
keeping a person alive with her right to
keep her dignity, which may also be
considered as an intrinsic value.
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Respect for Others

The objection to the ‘sanctity of life’ model
is accompanied by support for the
Respect for Others Argument.
This argument is derived from the Kantian
deontological school that accords all
people equal respect.
 Respect for a person means seeing the
other as an end rather than as a means to
something.

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Kant
As Immanuel Kant explains, persons are not
merely subjective ends, whose existence as an
effect of our actions has a value for us, but such
beings are objective ends, i.e., they exist as
ends in themselves.
 Such an end, Kant maintains, “is one for which
there can be substituted no other end to which
such beings should serve merely as means, for
otherwise nothing at all of absolute value would
be found anywhere.”

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Rawls
We should give equal consideration to the
interests of others and should grant equal
respect to the others’ life projects so long as
these do not deliberately undermine the
interests of others by interfering in a
disrespectful manner.
 As John Rawls asserts, “the public culture of a
democratic society” is committed to seeking
forms of social cooperation that can be pursued
on a basis of mutual respect between free and
equal persons.”

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Concern
This line of reasoning should be
supplemented by our emphasis on the
notion of concern.
 The notion of ‘concern’ signals the value
of well-being: we ought to show equal
concern for each individual’s good, to
acknowledge that human beings are not
only rational creators but also emotional
creatures.

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Concern
Treating people with concern means
treating them with empathy, viewing
people as human beings who may be
furious and frustrated, who are capable of
smiling and crying, of careful-decision
making and of impulsive reactions.
 ‘Concern’ means giving equal weight to a
person’s life and autonomy.
 Mind, body, communication.

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Suffering
Subjective
 Life of suffering is not worth living
 Makes death attractive
 Palliative care

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Palliative Care
Until 2000, palliative care was underdeveloped in both Belgium and the
Netherlands.
 Palliation seemed to be opposed to
euthanasia.
 Both countries preferred to develop the
practice of euthanasia.

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‘Quality of Life’

Positive connotations, for example, in
rehabilitation, cosmetic treatments,
psychiatry, and psychology
‘Quality of Life’

However, when dealing with end of life
issues, ethicists who support euthanasia
use the term ‘quality of life’ in a negative
sense more often than in a positive one,
meaning that they do not seek to improve
the patient’s life but to end it.
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Quality of Life

A subjective concept, meaning that one’s
quality of life is determined by one’s
personal life circumstances
Physician’s Role
To heal
 To reduce suffering
 To improve quality of life
 To help patients find meaning in life
 To kill?
 “Why us?”
 “Philosopher’s assisted suicide”

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Role of Physicians

In both Belgium and the Netherlands, the
physician is required to devote energies in
the patient and her loved ones, to consult
with other specialists, to spend time and
better the communication between all
people concerned.
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Ethics v. Policy Making
Difference between morally principled
views and policy-making
 Difference between case-by-case decisionmaking and creating a general framework

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Euthanasia v. PAS
One way to address this issue of abuse is
to advance physician-assisted suicide for
all patients who are able to swallow oral
medication.
 However, in Belgium and in the
Netherlands there is a tradition of doctors
administering lethal drugs.
 In addition, there is also the issue of
taking responsibility. Physicians in both
countries like to have control over the
process.

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Euthanasia v. PAS
Consequently, in Belgium and the
Netherlands there are relatively few cases
of PAS.
 I suggest putting this issue on public
agenda, speaking openly as people in
Belgium like and appreciate about the
findings and the fear of abuse, and
suggest PAS as an alternative to
euthanasia.

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Reporting
In both Belgium and the Netherlands,
problems with reporting.
 Why?
 Importance of reporting

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Consultation
 In
both countries, the physician
practicing euthanasia is required to
consult an independent colleague in
regard to (a) the hopeless condition
of the patient, and (b) the
voluntariness of the request.
 In both Belgium and the Netherlands,
the independency requirement has
been compromised.
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Consultation
Studies showed, unsurprisingly, that almost all
consultants regarded the request of the patient
to be well-considered and persistent, conceded
that there were no further alternative treatment
options, and agreed with the intention to
perform euthanasia or assisted suicide.
 In general, the GPs did not need to change their
views or plans following the consultation.
 My own study (1999) showed that the
consultants often were not independent from
the physician who was asking for their opinion.

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Consultation
Since 2000, SCEN in the Netherlands.
Since 2003, LEIFartsen in Belgium.
In Belgium, there are no rules regarding who
decides the identity of the consultant.
 The only rule is that the consultant needs to be
independent.
 Probably doctors approach like-minded
physicians.
 Unclear what happens if there is disagreement
between doctors. This issue deserves attention
and probing.



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Suggestions for Improvement
Physician-assisted suicide, not
euthanasia, to ensure better control
that at least in the Netherlands is
lacking.
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Guideline 1
 The
physician should not suggest
assisted suicide to the patient.
Instead, it is the patient who should
have the option to ask for such
assistance.
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Guideline 2
The request for physician-assisted suicide of an
adult, competent patient who suffers from an
intractable, incurable and irreversible disease
must be voluntary. The decision is that of the
patient who asks to die without pressure,
because life appears to be the worst alternative
in the current situation. The patient should state
this wish repeatedly over a period of time.
 These requirements appear in the abolished
Northern Territory law in Australia, the Oregon
Death with Dignity Act, as well as in the Dutch
and Belgian Guidelines.

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Guideline 3


At times, the patient’s decision might be
influenced by severe pain. The role of palliative
care can be crucial .
The Belgian law as well as the Oregon Death
with Dignity Act require the attending physician
to inform the patient of all feasible alternatives,
including comfort care, hospice care and pain
control.
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Guideline 4
The patient must be informed of the
situation and the prognosis for recovery or
escalation of the disease, with the
suffering that it may involve. There must
be an exchange of information between
doctors and patients.
 The Belgian law and the Oregon Death
with Dignity Act require this.

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Guideline 5
 It must be ensured that the patient’s
decision is not a result of familial and
environmental pressures.
 It is the task of social workers to
examine patients’ motives and to see
to what extent they are affected by
various external pressures.
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Guideline 6
The decision-making process should
include a second opinion in order to verify
the diagnosis and minimize the chances of
misdiagnosis, as well as to allow the
discovery of other medical options.
 A specialist, who is not dependent on the
first doctor, either professionally or
otherwise, should provide the second
opinion.

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Guideline 7
It is advisable for the identity of the
consultant to be determined by a
small committee of specialists (like
the Dutch SCEN), who will review the
requests for physician-assisted
suicide.
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Guideline 8

Some time prior to the performance of
physician-assisted suicide, a doctor and a
psychiatrist are required to visit and examine the
patient so as to verify that this is the genuine
wish of a person of sound mind who is not being
coerced or influenced by a third party. The
conversation between the doctors and the
patient should be held without the presence of
family members in the room in order to avoid
familial pressure. A date for the procedure is
then agreed upon.
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Guideline 9
The patient can rescind at any time and in any
manner.
This provision was granted under the abolished
Australian Northern Territory Act and under the
Oregon Death with Dignity Act.
The Belgian Euthanasia Law holds that patients
can withdraw or adjust their euthanasia
declaration at any time.
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Guideline 10
Physician-assisted suicide may be performed
only by a doctor and in the presence of another
doctor.
 The decision-making team should include at
least two doctors and a lawyer, who will
examine the legal aspects involved. Insisting on
this protocol would serve as a safety valve
against possible abuse. Perhaps a public
representative should also be present during the
entire procedure, including the decision-making
process and the performance of the act.

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Guideline 11
Physician-assisted suicide may be conducted in
one of three ways, all of them discussed openly
and decided upon by the physician and the patient
together: (1) oral medication; (2) self-administered,
lethal intravenous infusion; (3) self-administered
lethal injection.
Oral medication may be difficult or impossible for
many patients to ingest because of nausea or
other side effects of their illnesses. In the event
that oral medication is provided and the dying
process is lingering on for long hours, the
physician is allowed to administer a lethal
injection.
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Guideline 12

Doctors may not demand a special fee
for the performance of assisted suicide.
The motive for physician-assisted suicide
is humane, so there must be no financial
incentive and no special payment that
might cause commercialization and
promotion of such procedures.
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Guideline 13

There must be extensive documentation in the
patient’s medical file, including the following:
diagnosis and prognosis of the disease by the
attending and the consulting physicians;
attempted treatments; the patient’s reasons for
seeking physician-assisted suicide; the patient’s
request in writing or documented on a video
recording; documentation of conversations with
the patient; the physician’s offer to the patient to
rescind his or her request; documentation of
discussions with the patient’s loved ones; and a
psychological report confirming the patient’s
condition.
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Guideline 14
Pharmacists should
also be required to
report all
prescriptions for lethal
medication, thus
providing a further
check on physicians’
reporting.
 This is not the case
now in both
countries.

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Guideline 15
• Doctors must not be coerced into taking
actions that contradict their heart and
conscience, or their understanding of their
role.
• This was provided under the Northern
Territory Act.
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Guideline 16

The local medical association should
establish a committee, whose role will be
not only to investigate the underlying facts
that were reported but also to investigate
whether there are “mercy” cases that were
not reported and/or that did not comply
with the Guidelines.
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Guideline 17


Licensing sanctions will be taken to punish those
health care professionals who violated the
Guidelines, failed to consult or to file reports,
engaged in involuntary euthanasia without the
patient’s consent or with patients lacking proper
decision-making capacity.
Physicians who failed to comply with the above
Guidelines will be charged and procedures to
sanction them will be brought by the Disciplinary
Tribunal of the Medical Association. Sanctions
should be significant.
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Thank you
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