The topic of euthanasia is one that is shrouded with much ethical debate and ambiguity. Various types of euthanasia are recognised, with active voluntary euthanasia, assisted suicide and physicianassisted suicide eliciting the most controversy.  Broadly speaking, these terms are used to describe the termination of a person’s life to end their suffering, usually through the administration of drugs. Euthanasia is currently illegal in all Australian states, refl ecting the status quo of most countries, although, there are a handful of countries and states where acts of euthanasia are legally permitted under certain conditions.
Advocates of euthanasia argue that people have a right to make their own decisions regarding death, and that euthanasia is intended to alleviate pain and suffering, hence being ascribed the term “mercy killing.” They hold the view that active euthanasia is not morally worse than the withdrawal or withholding of medical treatment, and erroneously describe this practice as “passive euthanasia.” Such views are contested by opponents of euthanasia who raise the argument of the sanctity of human life and that euthanasia is equal to murder, and moreover, abuses autonomy and human rights. Furthermore, it is said that good palliative care can provide relief from suffering to patients and unlike euthanasia, should be the answer in modern medicine. This article will define several terms relating to euthanasia in order to frame the key arguments used by proponents and opponents of euthanasia. It will also outline the legal situation of euthanasia in Australia and countries abroad.
The term “euthanasia” is derived from Greek, literally meaning “good death”.  Taken in its common usage however, euthanasia refers to the termination of a person’s life, to end their suffering, usually from an incurable or terminal condition.  It is for this reason that euthanasia was also coined the name “mercy killing”.
Various types of euthanasia are recognised. Active euthanasia refers to the deliberate act, usually through the intentional administration of lethal drugs, to end an incurably or terminally ill patient’s life.  On the other hand, supporters of euthanasia use another term, “passive euthanasia” to describe the deliberate withholding or withdrawal of life-prolonging medical treatment resulting in the patient’s death.  Unsurprisingly, the term “passive euthanasia” has been described as a misnomer. In Australia and most countries around the world, this practice is not considered as euthanasia at all. Indeed, according to Bartels and Otlowski  withholding or withdrawing life-prolonging treatment, either at the request of the patient or when it is considered to be in the best interests of the patient, “has become an established part of medical practice and is relatively uncontroversial.”
Acts of euthanasia are further categorised as “voluntary”, “involuntary” and “non-voluntary.” Voluntary euthanasia refers to euthanasia performed at the request of the patient.  Involuntary euthanasia is the term used to describe the situation where euthanasia is performed when the patient does not request it, with the intent of relieving their suffering – which, in effect, amounts to murder.  Non-voluntary euthanasia relates to a situation where euthanasia is performed when the patient is incapable of consenting.  The term that is relevant to the euthanasia debate is “active voluntary euthanasia”, which collectively refers to the deliberate act to end an incurable or terminally ill patient’s life, usually through the administration of lethal drugs at his or her request. The main difference between active voluntary euthanasia and assisted suicide is that in assisted suicide and physician-assisted suicide, the patient performs the killing act.  Assisted suicide is when a person intentionally assists a patient, at their request, to terminate his or her life.  Physician-assisted suicide refers to a situation where a physician intentionally assists a patient, at their request, to end his or her life, for example, by the provision of information and drugs. 
Another concept that is linked to end-of-life decisions and should be differentiated from euthanasia is the doctrine of double effect. The doctrine of double effect excuses the death of the patient that may result, as a secondary effect, from an action taken with the primary intention of alleviating pain.  Supporters of euthanasia may describe this as indirect euthanasia, but again, this term should be discarded when considering the euthanasia debate. 
Legal situation of active voluntary euthanasia and assisted suicide
In Australia, active voluntary euthanasia, assisted suicide and physician-assisted suicide are illegal (see Table 1).  In general, across all Australian states and territories, any deliberate act resulting in the death of another person is defined as murder.  The prohibition of euthanasia and assisted suicide is established in the criminal legislation of each Australian state, as well as the common law in the common law states of New South Wales, South Australia and Victoria. 
The prohibition of euthanasia and assisted suicide in Australia has been the status quo for many years now. However, there was a period when the Northern Territory permitted euthanasia and physician-assisted suicide under the Rights of Terminally Ill Act (1995). The Act came into effect in 1996 and made the Northern Territory the first place in the world to legally permit active voluntary euthanasia and physicianassisted suicide. Under this Act, competent terminally ill adults who were aged 18 or over, were able to request a physician to help them in dying. This Act was short-lived however, after the Federal Government overturned it in 1997 with the Euthanasia Laws Act 1997. [1,2] The Euthanasia Laws Act 1997 denied states the power to legislate to permit euthanasia or assisted suicide.  There have been a number of attempts in various Australian states, over the past decade and more recently, to legislate for euthanasia and assisted suicide, but all have failed to date, owing to a majority consensus against euthanasia. 
A number of countries and states around the world have permitted euthanasia and/or assisted suicide in some form; however this is often under specific conditions (see Table 2).
Arguments for and against euthanasia
There are many arguments that have been put forward for and against euthanasia. A few of the main arguments for and against euthanasia are outlined below.
Advocates of euthanasia argue that a patient has the right to make the decision about when and how they should die, based on the principles of autonomy and self-determination. [1, 5] Autonomy is the concept that a patient has the right to make decisions relating to their life so long as it causes no harm to others.  They relate the notion of autonomy to the right of an individual to control their own body, and should have the right to make their own decisions concerning how and when they will die. Furthermore, it is argued that as part of our human rights, there is a right to make our own decisions and a right to a dignified death. 
It is said that relieving a patient from their pain and suffering by performing euthanasia will do more good than harm.  Advocates of euthanasia express the view that the fundamental moral values of society, compassion and mercy, require that no patient be allowed to suffer unbearably, and mercy killing should be permissible. 
The difference between active euthanasia and passive euthanasia
Supporters of euthanasia claim that active euthanasia is not morally worse than passive euthanasia – the withdrawal or withholding of medical treatments that result in a patient’s death. In line with this view, it is argued that active euthanasia should be permitted just as passive euthanasia is allowed.
James Rachels  is a well-known proponent of euthanasia who advocates this view. He states that there is no moral difference between killing and letting die, as the intention is usually similar based on a utilitarian argument. He illustrates this argument by making use of two hypothetical scenarios. In the first scenario, Smith anticipates an inheritance should anything happen to his six-year-old cousin, and ventures to drown the child while he takes his bath. In a similar scenario, Jones stands to inherit a fortune should anything happen to his six-year-old cousin, and upon intending to drown his cousin, he witnesses his cousin drown on his own by accident and lets him die. Callahan  highlights the fact that Rachels uses a hypothetical case where both parties are morally culpable, which fails to support Rachels’ argument.
Another of his arguments is that active euthanasia is more humane than passive euthanasia as it is “a quick and painless” lethal injection whereas the latter can result in “a relatively slow and painful death.” 
Opponents of euthanasia argue that there is a clear moral distinction between actively terminating a patient’s life and withdrawing or withholding treatment which ends a patient’s life. Letting a patient die from an incurable disease may be seen as allowing the disease to be the natural cause of death without moral culpability.  Life-support treatment merely postpones death and when interventions are withdrawn, the patient’s death is caused by the underlying disease. 
Indeed, it is this view that is strongly endorsed by the Australian Medical Association, who are opposed to voluntary active euthanasia and physician-assisted suicide, but does not consider the withdrawal or withholding of treatment that result in a patient’s death as euthanasia or physician-assisted suicide. 
The sanctity of life
Central to the argument against euthanasia is society’s view of the sanctity of life, and this can have both a secular and a religious basis.  The underlying ethos is that human life must be respected and preserved. 
The Christian view sees life as a gif offerrom God, who ought not to be off ended by the taking of that life.  Similarly the Islamic faith says that “it is the sole prerogative of God to bestow life and to cause death.”  The withholding or withdrawal of treatment is permitted when it is futile, as this is seen as allowing the natural course of death. 
Euthanasia as murder
Society views an action which has a primary intention of killing another person as inherently wrong, in spite of the patient’s consent.  Callahan  describes the practice of active voluntary euthanasia as “consenting adult killing.”
Abuse of autonomy and human rights
While autonomy is used by advocates for euthanasia, it also features in the argument against euthanasia. Kant and Mill  believe that the principle of autonomy forbids the voluntary ending of the conditions necessary for autonomy, which would occur by ending one’s life.
It has also been argued that patients’ requests for euthanasia are rarely autonomous, as most terminally ill patients may not be of a sound or rational mind. 
Callahan  argues that the notion of self-determination requires that the right to lead our own lives is conditioned by the good of the community, and therefore we must consider risk of harm to the common good.
In relation to human rights, some critics of euthanasia argue that the act of euthanasia contravenes the “right to life”. The Universal Declaration of Human Rights highlights the importance that, “Everyone has the right to life.”  Right to life advocates dismiss claims there is a right to die, which makes suicide virtually justifi able in any case. 
The role of palliative care
It is often argued that pain and suffering experienced by patients can be relieved by administering appropriate palliative care, making euthanasia a futile measure.  According to Norval and Gwynther  “requests for euthanasia are rarely sustained after good palliative care is established.”
The rights of vulnerable patients
If euthanasia were to become an accepted practice, it may give rise to situations that undermine the rights of vulnerable patients.  These include coercion of patients receiving costly treatments to accept euthanasia or physician-assisted suicide.
The doctor-patient relationship and the physician’s role
Active voluntary euthanasia and physician-assisted suicide undermine the doctor-patient relationship, destroying the trust and confi dence built in such a relationship. A doctor’s role is to help and save lives, not end them. Casting doctors in the role of administering euthanasia “would undermine and compromise the objectives of the medical profession.” 
It can be seen that euthanasia is indeed a contentious issue, with the heart of the debate lying at active voluntary euthanasia and physicianassisted suicide. Its legal status in Australia is that of a criminal off ence, conferring murder or manslaughter charges according to the criminal legislation and/or common law across Australian states. Australia’s prohibition and criminalisation of the practice of euthanasia and assisted suicide refl ects the legal status quo that is present in most other countries around the world. In contrast, there are only a few countries and states that have legalised acts of euthanasia and/or assisted suicide. The many arguments that have been put forward for and against euthanasia, and the handful that have been outlined provide only a glimpse into the ethical debate and controversy surrounding the topic of euthanasia.
Conflicts of interest
N Ebrahimi: email@example.com
 Bartels L, Otlowski M. A right to die? Euthanasia and the law in Australia. J Law Med. 2010 Feb;17(4):532-55.
 Walsh D, Caraceni AT, Fainsinger R, Foley K, Glare P, Goh C, et al. Palliative medicine. 1st ed. Canada: Saunders; 2009. Chapter 22, Euthanasia and physician-assisted suicide; p.110-5.
 Goldman L, Schafer AI, editors. Goldman’s Cecil Medicine. 23rd ed. USA: Saunders; 2008. Chapter 2, Bioethics in the practice of medicine; p.4-9.
 Norval D, Gwyther E. Ethical decisions in end-of-life care. CME. 2003 May;21(5):267-72.
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 Callahan D. When self-determination runs amok. Hastings Cent Rep. 1992 Mar- Apr;22(2):52-55.
 Patterson R, George K. Euthanasia and assisted suicide: A liberal approach versus the traditional moral view. J Law Med. 2005 May;12(4):494-510.
 George R J, Finlay IG, Jeff rey D. Legalised euthanasia will violate the rights of vulnerable patients. BMJ. 2005 Sep 24;331(7518):684-5.
 Rachels J. Active and passive euthanasia. N Engl J Med. 1975 Jan 9;292(2):78-80.
The Ethics of Euthanasia (Part Two)
This post is the second in a short series on the ethics of euthanasia. The series follows the pair of essays in the book Contemporary Debates in Applied Ethics. Right now, I am looking at Michael Tooley’s “pro” euthanasia essay. In part one, I outlined, in some detail, Tooley’s basic argument. In this part, I’ll consider Tooley’s second argument, as well as his views on the legalisation of euthanasia.
1. From Passive to Active Euthanasia
To understand Tooley’s second argument we need to bear in mind the different forms of euthanasia. As you recall from part one, particular instances of euthanasia can vary along two dimensions: (i) the voluntary-involuntary dimension; and (ii) the active-passive dimension. The first of these dimensions is concerned with the attitudes of the person being euthanised to their death (did they consent to it or not?), while the second is concerned with the type of assistance offered to that person (does a third party act to bring about their demise or is their demise brought about through omission?).
The most ethically contentious form of euthanasia is the voluntary active one. This form of euthanasia arises whenever a person A performs some action which has as its direct intention the killing of another person B, and B consents to this. Contrariwise, the voluntary passive form of euthanasia is relatively uncontentious. Most people seem to think it would be okay for B, in certain circumstances, to forego life-preserving treatments. The asymmetrical reactions to these forms of euthanasia opens up an intriguing possibility: if we can convince people that there are no morally significant differences between the active and passive forms of voluntary euthanasia, then perhaps we can convince them that euthanasia is morally permissible.
This is exactly what Tooley’s second argument attempts to do. It tries to show that there are no good grounds for thinking that two cases are ethically different. Let’s see how he makes his case.
2. The Difference between Killing and Letting Die
Tooley starts by offering the following argument:
- (1) Voluntary passive euthanasia is not morally wrong in itself.
- (2) Intentionally killing a person and intentionally letting a person die are, in themselves, morally on a par.
- (3) The only intrinsic difference between voluntary active euthanasia and voluntary passive euthanasia is that the former is a case of killing, and the latter a case of letting die.
- (4) Therefore, voluntary active euthanasia is not morally wrong in itself.
Premise (1) is likely to be accepted by most people, and premise (3) is just an implication of the definitions of active and passive euthanasia. This means that premise (2) is where the controversy might be thought to lie.
Is it really true to say that intentional killing and intentional “letting die” are morally equivalent?
Some philosophers are likely to argue that there are important moral differences between the two cases. In making their argument, they might appeal to the famous thought experiments involving organ donation. For instance, consider the following. You are doctor in a hospital with two patients, both of whom need organ transplants to survive (say one needs a kidney and the other needs a heart). As luck would have it, a healthy person who is a perfect match for both patients walks into your hospital ward. If you kill the healthy person and harvest their organs, you can save your two patients. Should you do it? Most people say “no” but this is puzzling if there’s no moral difference between killing and letting die. After all, if there were no moral difference then surely letting two patients die would be worse than directly killing another?
Tooley thinks we can skirt these difficulties by first acknowledging the following asymmetry principle which, presumably, motivates the objection to premise (2):
(A) The property of killing a person and the property of allowing a person to die are, other things being equal, wrong-making properties of actions, but the former is a weightier wrong-making property than the latter.
See what we’ve done here? We’ve acknowledged that killing and letting die are morally undesirable, but we’ve also accepted that the former is worse than the latter. This can account for our reaction to the organ donation case.
But this asymmetry principle is problematic in the present context. As David Boonin argues, if principle (A) is true, then the following more general principle ought to be true:
(B) Both the property of intentionally causing a harm, and the property of intentionally allowing a harm to occur are wrong-making properties of actions, but the former is a weightier wrong-making property than the latter.
Principle (A) would actually be derivable from (B) since (B) expresses the more general rule that harming is morally bad. The problem this creates is the following: in the euthanasia case the claim is that killing a person is not actually a harm to them but is, in fact, a benefit. This is why I included the clause “other things being equal” in my formulation of principle (A): the point being that in euthanasia cases “other things” (namely, the relationship between death and harm) are not equal.
We can go further with this line of thought by noting that (B) would seem to have an obvious corrollary:
(C) Both the property of intentionally causing a benefit and the property of intentionally allowing a benefit to occur are right-making properties of actions, but the former is a weightier right-making property than the latter (or, at a minimum, is at least as weighty a right-making property as the latter).
From which could be derived the following revised version of premise (2):
- (2*) Both the property of killing a person, when the killing benefits the person, and the property of allowing the person to die, when allowing the person to die benefits the person, are right-making properties of actions, and the former is at least as weighty a right-making property as the latter.
When plugged back into the argument given above, (2*) allows us to reach the same conclusion. But is it any less objectionable than the original version?
3. The Revised Form of Premise 2
Tooley thinks there is one plausible line of objection to the revised version of premise (2). This line of objection holds that the property of killing a person, even when the killing benefits them, cannot be a right-making property of an action since the direct killing of an (innocent) person is always morally wrong in and of itself. The “innocent”-caveat here is a concession to those who think that under certain conditions it is morally good to inflict capital punishment on a guilty person.
To those who mount this objection to (2*) we must ask: what basis is there for thinking that killing innocent persons is morally wrong in and of itself? There are two possibilities here (according to Tooley). Appealing to axiology, we could argue that the existence of innocent persons always makes the world a better place than it would be if they failed to exist (2.1). Or, appealing to the notion of rights, we could argue that all innocent persons have a right to life and so any violation of that right would be morally wrong (2.2).
The appeal to axiology faces two objections. First, if it is true, then intentionally refraining from bringing persons into existence is also morally wrong in the exact same degree. This is implausible (2.3). Second, looking at cases of people suffering considerable pain due to incurable illness, the proponent of the axiological appeal must believe that their continued existence is a net benefit to the world. But then should they not also hold that the failure to bring into existence a person who will live a life of considerable pain is morally bad? Again, this seems very implausible (2.4).
The appeal to rights is also problematic. For starters, people can, in general, waive their rights (2.5). What’s more, the claim that the death of those who are suffering considerable pain due to incurable illness violates their rights is likely to be false. Why is this? Well, consider that there are two plausible theoretical bases for rights, either (a) rights protect individual interests or (b) rights protect freedom of choice. But in the voluntary euthanasia case, the claim is that death is either (i) in the person’s interests or (ii) something they desire for themselves. Therefore, on neither account is voluntary euthanasia a violation of individual rights (2.6).
That gives us the following completed argument map.
4. The Legalisation Debate
Through his two arguments, Tooley feels he has made the case for the moral permissibility of voluntary active euthanasia. But just because something is morally permissible does not entail that it should be legalised. For example, some people think that, under extreme circumstances, interrogative torture is morally permissible. But the same people do not necessarily think that the legal ban on torture should therefore be relaxed. Laws alter people’s incentives and these alterations may not be morally desirable. So before pronouncing on legal policy, Tooley considers three objections to the legalisation of voluntary active euthanasia.
The first objection comes from Yale Kamisar. He argues that if voluntary euthanasia is legalised, some people will consent to being killed in cases in which their death is actually contrary to their own interests. Tooley is pretty quick in his dismissal of this argument. He argues that, unless the person is emotionally or psychologically disordered, there no reason to think they will fail to appreciate good reasons for their continued existence if such reasons exist. Also, he argues that this objection fails to distinguish between the active and passive forms of voluntary euthanasia. So if it’s a good objection to legalising the active form, then it’s also a good objection to legalising the passive form. That’s a problem for Kamisar since, according to Tooley, he accepts the latter. So much the worse for Kamisar, I guess.
The second objection appeals to the notion of a slippery slope: if we legalise voluntary active euthanasia, what’s to stop us from legalising other undesirable things such as involuntary euthanasia? Kamisar also makes this argument. He justifies this by pointing out that advocates of voluntary active euthanasia often think that certain forms of non-voluntary euthanasia should be legalised. He also points to the historical experiences in Nazi Germany and suggests that some of the problems there were attributable to an initial acceptance of the proposition that there is such a thing as a life not worth living. And from there it was but a short slide down the slippery slope to racial extermination.
There are many things that could be said in response to this. We can start by pointing out that there is a distinction between non-voluntary and involuntary euthanasia and that acceptance of the former would not logically entail acceptance of the latter. Turning to the Nazi case, we become embroiled in a dispute over historical causality. The claim that there was a slippery slope from the acceptance of one proposition about the worth of life to policies of racial extermination is certainly debatable. Some would argue that the ideology of racial purity and supremacy predated the acceptance of the claim that some lives are not worth living. And that this is a more likely cause of the extermination policies. Whatever the case may be, it seems that the Nazi experience is likely to have multiple, historically contingent causes, most of which will not apply to modern societies.
Furthermore, in response to the slippery slope argument, we can point to empirical evidence suggesting that the slippery slope will not arise. The best set of evidence comes, of course, from the Netherlands which has legalised voluntary active euthanasia. The evidence from the Netherlands is controversial. Some (including Callahan, who we’ll talk about the next time) argue that the Dutch experience actually does provide evidence of a slippery slope because there have been cases of involuntary euthanasia there. Tooley disputes this, however, because it fails to contrast the situation in the Netherlands with the situation in countries which have not legalised voluntary euthanasia. He argues that when you contrast it with such a country (he uses the example of Australia) you find that there are more cases of involuntary euthanasia in the other countries.
I’m a little bit wary of this empirical evidence because Tooley only compares figures over the years 1995-1996 (and he’s basing this on analyses done by others). I haven’t read this evidence and I haven't read any countervailing evidence either. Nevertheless, there is an interesting point here: regulation of an activity can sometimes lead to fewer rights-violations than non-regulation because people are suddenly made accountable for decisions which were previously carried out under the radar of the law.
The third and final objection to legalisation is this: there is uncertainty about the form that legal regulation should take. Should there be complex and stringent guidelines for those who carry out voluntary euthanasia? Or should there just be some general principles? If we opt for the former, then some people who might benefit from euthanasia might be excluded. And if we opt for the latter, rights might fail to be protected.
Tooley’s proposal is this: First, we follow James Rachel’s suggestion and make voluntary active euthanasia a defence to a charge of murder or manslaughter (like self-defence). And second, we combine this with rather conservative and stringent regulation. The former would allow for a certain degree of flexibility, while the latter would protect against abuses.
I have no idea whether this dual regime would work. My preference would be for complex and stringent guidelines since, acknowledging that errors will be made, I think we should err on the side of preserving life rather than ending it.
This brings us to the end of Tooley's essay. In the next part, we'll look at the anti-euthanasia essay by Daniel Callahan.