I. Preliminaries
A. Death: the primary criteria used to determine whether a person is alive is to determine
whether there is any detectable brain function; if so, then the person is not dead; if there is no
detectable brain function, the person is dead.
-even if there is some slight non-conscious brain function, the person is to be considered
living.
-lack of blood circulation for five to ten minutes will end brain- functioning, thereby ending
the life of the person.
B. Permanent Vegetative State (PVS):
(1) loss of all cerebral cortex function (where higher- level nervous activity takes place, e.g.
cognition)
(2) not dead because of retention of good brain stem function (e.g. respiratory and heart rate,
facial reflexes and muscle control, gag reflex, swallowing ability)
(3) not conscious and never will be.
(4) Because the person is not conscious, he or she cannot feel pain.
(5) Goes through sleeping and waking cycles in which eyes open and close; said to be awake but
not conscious.
C. Coma :
(1) only brain activity is poor brain stem function; so not dead.
(2) not conscious and asleep.
(3) tend not to live as long as PVS cases, because of poor brain-stem function.
II. Important Distinctions
A. Active vs. Passive Euthanasia: Killing vs. Letting Die
(1) Active: When a patient is killed, usually by lethal injection.
(2) Passive: When treatment is stopped (or simply not started) allowing a person to die. (A
common medical practice carried our by ~96% of doctors.)
B. Voluntary vs. Non- voluntary Euthanasia
(1) Voluntary: The person whose life is at issue knowingly and freely decides to either be killed
or to be left to die by the withholding treatment.
(2) Non- voluntary: When a patient is unable to request her own death and the decision is made
by others. (e.g. infants, small children, comatose patients, patients in permanent vegetative states,
mentally incompetent patients such as those with Alzheimer's).
C. Withholding Ordinary Measures vs. Withholding Extraordinary Measures
(1) Withholding ordinary measures: when treatment that has good potential to benefit the patient
is withheld; such treatment has a reasonable chance to cure or ameliorate a life-threatening
condition.
(2) Withholding extraordinary measures: when treatment that has little or no prospect of
benefitting the patient is withheld; such treatment is considered ineffective and excessively
burdensome.
III. The Combinations
A. Types of Voluntary Euthanasia
(1) active, voluntary euthanasia: when a competent patient requests to be killed by a doctor.
(2) passive, voluntary euthanasia by withholding extraordinary measures: when a patient requests
that a treatment which has little or no prospect of benefitting her be withheld so that she may die
without needlessly wasting resources.
(3) passive, voluntary euthanasia by withholding ordinary measures: when a patient requests that
a treatment which has good prospects of improving or prolonging life is withheld so that she may
die.
B. Types of non-voluntary Euthanasia
(1) active, non-voluntary euthanasia : when a patient who cannot choose death herself is killed at
the bequest of others, most often family.
(2) passive, non-voluntary euthanasia by withholding extraordinary measures: when a patient
who cannot choose death herself is withheld treatment with little or no hope of improving her
condition so that she may die.
(3) passive, non-voluntary euthanasia by withholding ordinary measures: when a patient who
cannot choose death herself is withheld treatment that has good prospects of improving her
condition so that she may die.
IV. Physician Assisted Suicide and the Principle of Double-Effect
Physician Assisted Suicide: When the doctor provides the means by which a patient will commit
suicide with full knowledge of the patient’s intentions. Technically, not a form of euthanasia.
This is taken by proponents to be a good solution to the debate on active euthanasia. Since one
person is not killing another, there is no issue of murder. Proponents argue that since terminally
ill patients have a right to end their own suffering, they can enlist the help of their doctors to do
so. Opponents argue that patients do not have a right to take their own lives and assisting such an
activity is not the role of a doctor. Dr. Jack Kevorkian is the most famous practitioner of
physician assisted suicide. Kevorkian was charged with two counts of murder but was
subsequently acquitted. He was even acquitted when he was prosecuted for violating state laws
banning physician assisted suicide. It was only when Kevorkian actively euthanized a patient that
he was convicted in a court, this time for second-degree murder.
The Relevancy of the Principle of Double-Effect: It is not considered physician assisted suicide
if the doctor provides pain medication with the intention of easing pain, but the patient dies or
uses the medication to commit suicide, even if the doctor foresees such possible consequences.
Whether such an action is morally permissible depends upon whether the principle of double
effect is a legitimate principle. According to this principle, if one administers a pain killer while
intending to produce a good effect, such as relieving pain, then one has not done something
morally impermissible, even though one is fully aware that a bad effect, such as death or abuse,
may also be the consequence of one’s actions.
V. Euthanasia and the Law
A. The United States: Active euthanasia is currently illegal in the USA, but physician assisted
suicide is currently legal in Oregon (though Dr. Kervorkian was exonerated on three occasions in
Michigan). The Supreme Court, while not acknowledging a constitutional right to die, have made
euthanasia an issue for the states.
-Often times, people who commit mercy killings are sentenced very lightly or simply not
convicted. (e.g. A man shot to death his terminally ill and suffering wife in a Chicago hospital
but the jury at his murder trial refused to convict him of anything even though it should have
been an open and shut case).
-Passive voluntary and involuntary euthanasia are common and largely uncontroversial medical
practices.
B. The Netherlands: Active Euthanasia is legal in the Netherlands provided the following
conditions are met:
(1) Voluntariness: The request of the patient must be made entirely of the patient’s own free will
without any pressure from others.
(2) Informed and competent : The patient must be informed of all the alternatives and be capable
of contemplating them.
(3) Certainty: The patient must have a lasting longing for death; requests made on impulse or
based on temporary depression are not considered.
(4) Unacceptable Suffering: The patient must experience suffering as perpetual, unbearable and
hopeless.
(5) Consultation: The doctor must consult another physician who has faced at least one case of
euthanasia before.
VI. Euthanasia and Religion
A. Monotheistic Religions: Islam, Judaism, and Christianity have for the most part been
traditionally opposed to active euthanasia, though there has been a significant number of
traditional and contemporary Christian theologians and philosophers who advocate it (St.
Thomas More, R.M. Hare and Daniel Maguire)
B. The Sixth Commandment and the Golden Rule: an argument from James Rachels
-James Rachels observes that Theologians generally agree that the Sixth Commandment is to be
interpreted as “Thou shalt not murder” not as “Thou shalt not kill”. So while no one would
question whether active euthanasia is killing, one would need to argue that it is murder or a
wrongful killing. Hence the Sixth Commandment alone cannot rule out active euthanasia. But,
Rachels continues, if the golden rule has any validity, euthanasia ought to be considered
permissible on occasion to Christians. For example, if a physician, while witnessing the
unremitting pain of a patient, thinks to himself “I would want to die if I were in that position”,
then it would seem to follow from the golden rule that it would be permissible for the physician
to euthanize the patient if the patient requested it. This is bolstered, says Rachels, particularly if
we keep in mind the Bible’s exhortations to Mercy.
C. Others: Buddhists, Shintos, and Confucians believe, as did Ancient Greeks and Romans, that
active euthanasia is morally permissible.
VII. Other Facts
A. Doctors
-The AMA and the hippocratic oath both prohibit active euthanasia and physician assisted
suicide.
-61% of the general public are in favor of physician assisted suicide.
-46% of oncologists agree with physician assisted suicide in cases of unremitting pain
VIII. Utilitarianism, Kantianism and Euthanasia
A. Voluntariness: concerns about voluntariness with regard to euthanasia are concerns about how
much freedom and control a patient should have over his or her own death. Those who
emphasize patient voluntariness want patients to have at least some say in deciding how they
want to die; those who are not concerned with patient voluntariness believe that the patient’s
own desires about they want to die are irrelevant with regard to how his or her life will actually
end.
1) Utlilitarianism and Voluntariness: voluntariness matters morally only to the extent that it
affects human happiness and welfare.
a) act utilitarianism: a patient’s voluntariness should probably be limited if he or she is
ignorant of the availability of services, support and money that is, in fact, available. For example,
if a patient learns that she has cancer and immediately wants to be euthanized, her voluntariness
should probably be overridden if treatment would give her a good chance of survival.
Presumably, successfully treating a curable type of cancer would maximize the happiness of the
patient and her family in the long run.
b) rule utilitarianism: rule utilitarians would have to determine which policy regarding
patient voluntariness would maximize happiness if implemented in society at large. Presumably,
a policy of giving a patient free reign over how she wants to die would not maximize happiness,
since such a policy would always undermine the opinion of physicians or those who are most
informed about the prospects of survival and the success of treatment. On the other hand, it
seems highly unlikely that a policy whereby patients never had a say in whether they wanted to
be euthanized would maximize happiness. A moderate position, in which patient choices could
be overridden by medical experts when they decide that euthanasia would not be in the patient’s
best interest, would seem to be most likely to pass muster on a rule utilitarian analysis.
2) Kantianism and voluntariness: the Kantia n respects the capacity of a person to govern his
own life and make his own decisions. Hence, the Kantian would respect the wishes of a fully
informed, mentally competent patient who wanted to be euthanized. Clearly, though, if a patient
does not know all of her options, her capacity to exercise her autonomy is limited; in such a case,
if the person wants to be euthanized, her own choice should be overridden until she is fully
informed. Overriding the choice, here, would not be undermining her autonomy but would be an
attempt to further it by making sure she has all the relevant information. Moreover, if a patient
with a good chance of survival still wants to be euthanized, she most likely would not be
considered mentally competent, in which case her own well-being should be placed into the
hands of others. (We do something similar with children, the mentally retarded, Alzheimer's
patients etc.)
B. Active and Passive Euthanasia: Is there any moral difference between active and passive
euthanasia? Is active euthanasia more morally problematic than passive euthanasia? If so, why?
If not, why not?
1. Utilitarianism
a) act utilitarianism: only looks at the consequences of the action, not the nature of the
action itself. Hence, the utilitarian will be unfazed by the claim that active euthanasia is wrong
because it is killing, whereas passive euthanasia is okay because it is merely letting someone die.
Indeed, if passively euthanizing a patient by withholding a life-prolonging treatment leads to
more overall suffering than would actively euthanizing the patient, killing the patient at his
request would be the morally obligatory action, while letting someone die would be
impermissible. In general, if passively or actively euthanizing a patient does not make a
difference in terms of the total amount of happiness, then it would not matter whether death was
caused by lethal injection or simply by terminating a life-prolonging treatment.
b) rule utilitarianism: would look at the consequences of implementing a policy of active
euthanasia. Would a policy that allowed active euthanasia in all terminal cases maximize
happiness? Or in some cases but not others? Or only in rare cases? Or never? Of concern would
be how much abuse would follow from a policy that allowed active euthanasia, and how well the
authorities could curb such abuse. For example, would it ever come about that some patients
were non-voluntarily euthanized? If so, would such occurrences outweigh the reduction of
overall suffering that a policy allowing active euthanasia in some cases would accomplish? The
matter of abuse is an empirical matter. It is not enough to say “I’ll bet abuse would happen” or to
simply ask “What if abuses happen?”. For the most part, utilitarianism would seem to support
active euthanasia in some--or perhaps many--cases, since it would clearly reduce the suffering of
patients and the families who watch them suffer. Hence, the burden of proof is on the opponent
to show that abuses do or are very likely to occur, and the harm of such abuses would outweigh
the good of a policy allowing active euthanasia.
2. Kantianism: a Kantian might argue that respecting a person’s right to die should make
irrelevant some of the potential abuse of implementing a policy of active euthanasia that worried
the utilitarian. Clearly, if such abuse involved actively euthanizing the patient against the
patient’s wishes, then the Kantian would be opposed (since that would be a violation of the
patient’s autonomy). But the Kantian, since he is concerned with patient autonomy, would be
able to justify voluntary active euthanasia even if the patient’s physician, family or community
would be strongly opposed. Or take for example the extremely unlikely but conceivable case
where a medical breakthrough occurs after we actively euthanize someone, but most likely
before they would have died if we never had actively euthanized them. One might be able to
argue, on utilitarian grounds, that actively euthanizing the patient was the wrong choice, since
continuing treatment would have ultimately maximized happiness. The Kantian could object by
claiming that the overriding consideration here is the respect of the patient’s autonomy, not the
consequences of the actions.
IX. Cases
A. A paradigmatic case of voluntary, active euthanasia
Albert A., a hospital patient, was dying of cancer which had spread throughout his body. The
intense pain could no longer be controlled. Every four hours he would be given a painkiller to
which he had built up a tolerance that would alleviate his pain for a matter of minutes. Albert
knew he was going to die anyway, for the cancer could not be cured. He did not want to linger in
agony, so he asked his doctor to give him a lethal injection to end his life without further
suffering. Albert’s family supported this request.
(1) The act utilitarian must ask: would administering the drug maximize the happiness, or
minimize the unhappiness, of those affected by the action?
-abstracting away from all legal cosequences for the doctor and the hospital, this would be an
easy case for the utilitarian: Albert’s doctor would minimize unhappiness by euthanizing Albert.
The only thing that might prevent the utilitarian from concluding this would be if we situated the
action in a forbidding legal context in which Albert’s physician would be tried for murder and
his hospital is sued. But this really misses the point: that there is no in principle act- utilitarian
objection to active euthanasia.
(2) The rule utilitarian
Would the practice of euthanizing a terminally ill and suffering patient upon that patient’s
request maximize happiness within a society?
---rule (1): Euthanize terminally ill and suffering patients upon request when loved ones are
supportive.
-Might there be too much abuse if such a policy were implemented? Would we slide down a
slippery slope? Might family members begin pressuring ill patients to opt for euthanasia to avoid
paying expenses of treatment-- and if so, would this be negative?
---rule (2): Do not euthanize terminally ill and suffering patients upon request, even when loved
ones are supportive.
-Patients would continue to suffer miserably until death, and family members would continue to
watch in utter horror and despair.
(3) The Kantian
*Kant himself seemed to think suicide would be wrong, but does is system really rule out
euthanasia?
--(a) The first formulation of the categorical imperative
--Would willing as universal law that terminally ill patients be euthanized upon request be
contradictory or undermine the physician’s ability to euthanize the patient in this case? ---> I
don’t see why.
--(b) The second formulation: would a physician’s euthanizing a terminally ill patient be
disregarding the patients own interests, goals and desires in favor of his own interests, goals and
desires? Most definitely not--> active euthanasia is morally permissible.
--(c) Might it be an imperfect or meritorious duty?
--Try willing this universally: Never contribute to the well-being of another or assist her when in
need.
-Unlike the maxim “make false promises” we could imagine a world where people followed
this maxim; however, one could not will this as a universal law because it would contradict one’s
own will to have others assist him at times. Hence, contributing to the well-being of another and
assisting others in need is an imperfect duty. We are not required to act out of this duty at all
times, as we would the duty not to make false promises, but we are required to make some
contribution to the well-being of others and assist them when in need.
-Now, try willing this universally: always refuse a terminally ill patient’s request for
euthanasia. If the physician were terminally ill and in a constant and unbearable state of
suffering, would his will contradict the universal law just willed? Most likely, yes. If so, then the
duty to euthanize the patient is meritorious, or one that is deserving of honor and esteem-- it
would be a morally praiseworthy act.
B. Other cases of active voluntary euthanasia
Barbara B. was a multiple amputee and diabetic in constant pain who was told that she could live
for only a few more months. She begged her husband to kill her, and he did, by electrocution.
The husband was charged with murder and was convicted. On sentencing day the judge wept.
Mr. B. never wavered in his opinion that he had done the right thing, and he said that his act was
an act of love.
The driver of a gas truck was in an accident in which his tanker overturned and immediately
caught fire. He was trapped in the cab and could not be freed. He therefore besought one of the
bystanders who had a gun to kill him by shooting him in the head so that he would not roast to
death. The bystander obliged.
X. Brandt on Killing and Killing Injuriously
A. Killing vs. Killing Injuriously: Richard Brandt (1910-) argues that we should not accept the
principle that we should not to kill an innocent human being except in justifiable self-defense.
Rather, he thinks that there is a more fundamental duty of not causing injury, and that one can
kill without causing injury. Predictably, for Brandt, active euthanasia, if carried out according to
basic restrictions, is a case of killing without injury and is therefore morally permissible.
According to Brandt, one is not causing another injury if he is treating that person in a way in
which that person would rationally want to be treated.
1. Cases of killing without injury
(a) if someone is roasting to death and has made clear that he wants to die, then shooting
him, according to Brandt, is not causing him injury. It is not causing injury precisely because he
is relieving pain. Presumably he is thereby treating the person dying in a way that he would
rationally want to be treated.
(b) if someone is unconscious and it is known that he will never regain consciousness, then,
according to Brandt, if we have good reason to believe that this person would want to be
euthanized, then we could kill him. This would again be killing without injury because the
person is in a condition that exempts him from or “places him beyond” injury.
B. The Moral Force of Patient Request: suppose a terminally ill patient who is suffering
tremendously but is being given treatment that extend his life requests that such treatment be
continued even though he will prolong unnecessary and unbearable suffering. Most, if not all, of
us would respect such a request, even though we might not understand it and consider it to be
irrational. Brandt asks why the patient’s expressed wishes should carry moral force in this case-when he is behaving irrationally and causing himself needless suffering-- but would carry no
moral force when a patient asks to be actively euthanized in a rational and comprehensible effort
to end his pain.
-According to Brandt, since the expressed wishes of a patient carry moral force, and killing in
this case would non-injurious, we are permitted to actively euthanize tha patient.