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PHI 2604 Format for Moral Argumentation

 

The format for argumentation that you will use to write the essay and you must label the parts of your essay accordingly:
 
1.
Thesis Paragraph
: Introduce the topic, explain the scenario and the ethical dilemma.
2.
Defensible Moral Standards (Pro

Argument)
: Present an argument for the side of the ethical dilemma you are taking by appealing to one or more moral standards as basis for your argument.  [i.e., Aristotle’s formal principle for justice, Mill on injustice, the principle of no-harm, etc.]
3. Then present data and/or others’ arguments that support your position (use references, data, etc.).
4.
Con-Arguments (arguments that challenge the moral standards you are appealing to)
: Recite arguments (with reasons and data) that are against your position, that is against what you are arguing for. Be careful of straw man arguments.
5.
Refutation of Con

Arguments
: Using data and providing reasons, pick apart those arguments that are against what you are arguing for. Show why or how these arguments fail or are inaccurate (e.g., false premise[s], invalid reasoning, counterexamples exist).
6.
Summary/Conclusion (Passage of moral judgment)
: Summarize your argument and state why it is the fair and moral/just answer to the ethical dilemma.
 
Using this format you will have more than ample opportunity to express your grounded opinion throughout the essay.
 
This is a formal college essay, therefore avoid: colloquialisms (e.g., slang expressions), and remember that unclear writing signifies unclear thinking. Maintain clarity of thought, provide relevant premises, and proofread for proper grammar and syntax.
 
Directions (follow closely to not lose points): Write a college-level essay in which you argue your position on abortion. You will be graded on your ability to construct a sustained argument using outside sources, data, ethical theories we covered in class, as well as proper usage of grammar and syntax. a.) You are required to label each part of your argument using the format for moral argumentation sheet. b.)  Use chapter nine on abortion for definition, sources and data and document source by putting “textbook p.__”. c.) Use at least one independent (non-textbook)  source and document it. d.) Use no more than two lines of quotation for textbook or outside source(s) e.) avoided in pro-argument and pointed out in con-argument logical fallacies.
 
 
 
Answer            
–used format for moral argumentation sheet & labeled argument accordingly
 
–used and documented sources from chapter nine
 
–utilized and documented at least one independent source
 
–used no more than two lines of direct quotation
 
–used ethical theory (-ies)
 
–demonstrated knowledge of proper argumentation
 
–avoided logical fallacies
 
–used proper grammar and syntax

285

C H A P T E R 1 0

‘’
Euthanasia and Physician- Assisted Suicide

For fifteen years, Terri Schiavo existed between life
and death in that shadow land called a persistent
vegetative state, a place where she was wakeful but
without awareness or any purposeful behavior.
Severe brain damage had left her there, with vir-
tually no chance of recovery. And all the while, a
storm of caustic debate swirled around her, reach-
ing its greatest strength in the last few days before
her death on March 31, 2005. In 1990 her heart had
stopped briefly because of a chemical imbalance,
leaving her in that twilight state, kept alive by a
feeding tube. She had left no living will, no written
record of her wishes should she become indefinitely
incapacitated. Her husband, Michael Schiavo,
insisted that Terri had told him once that she would
prefer death to being kept alive with machines. Her
parents rejected his claim and demanded that Terri
be kept alive, holding out hope that with proper
care she might recover.

The battle between Michael Schiavo and Terri’s
parents raged on in the courts for years. Again and
again, state and federal courts sided with the hus-
band, while the U.S. Supreme Court repeatedly
refused to hear the case. In the final days before
Terri died, President George W. Bush, the U.S. Con-
gress, the governor of Florida (where she lived), and
Florida legislators weighed in on the controversy,
supporting Terri’s parents.

Finally, a judge allowed the feeding tube to be
removed, and Terri Schiavo, age forty- one, died
thirteen days later. The parents called the removal
“judicial homicide.” A Vatican official called it “an
attack against God.”1

So it goes with all public debates on the moral
permissibility of euthanasia. Passions rise, claims
and counterclaims collide, and stakes are high. In
the balance are issues of life and death, science and
religion, murder and mercy. The tragic end of Terri
Schiavo is only the most dramatic (and dramatized)
case in a series of tragic ends that turned into widely
publicized moral battlegrounds (see the box “The
Death of Karen Ann Quinlan”). The moral ques-
tions it incited are typical of such cases: Was remov-
ing Terri Schiavo’s feeding tube really a case of
murder? Or was it a morally permissible act allow-
ing her to die with dignity and escape her bleak
condition? What if instead of stopping the tube
feeding, her doctors had never started it because
they deemed her situation hopeless? Would that
have been murder— or a permissible act of mercy?
Or suppose that soon after Schiavo collapsed, her
doctors had decided to give her a lethal injection?
Would such an act have been morally wrong? What
if Schiavo had left a living will that clearly specified
that she did not want to be kept alive by any means
if she fell into a persistent vegetative state? Would
withdrawing the feeding tube or giving her a lethal
injection then have been morally acceptable?

Of course, in every instance of euthanasia there
are plenty of nonmoral questions too— primarily
legal, judicial, medical, scientific, and political.
(In the Schiavo case, for example, the moral ques-
tions arose side by side with what most informed
observers saw as the real issue: Who, if anyone,
had the legal right to decide for Schiavo what was
to become of her?) But these nonmoral concerns

285

286 Á  PART 4: ETHICAL ISSUES

preserved in the Greek roots of euthanasia, which
literally means “easy death.” Euthanasia makes
sense to many people because they believe that a
quick and painless death would be preferable to a
slow and painful dying (such as the kind that some
terminal cancer patients endure) or a long, vegeta-
tive sleep without a chance for a meaningful life.

As you might expect, the moral permissibility
of euthanasia depends heavily on the consent of
the patient (the person whose death is being con-
sidered). Moral philosophers therefore distinguish
between euthanasia that is voluntary, nonvolun-
tary, and involuntary. In voluntary euthanasia,
the patient requests or agrees to the act. She may
make the request in person or leave instructions to
be followed in case she becomes incapacitated. Such
instructions are usually in the form of an advance
directive (for example, a living will), a legal docu-
ment allowing physicians to withhold or withdraw
treatments if a patient becomes terminally ill and
unable to express her wishes. For any voluntary
euthanasia request to be valid, the patient at the
time of the request must be competent— that is,
capable of making an informed, rational choice. In
nonvoluntary euthanasia, others besides the
patient (family or physicians, for example) choose
euthanasia for her because she is not competent
(due to illness or injury) and has left no instruc-
tions regarding her end- of- life preferences. Eutha-
nasia performed on infants and small children is, of
course, nonvoluntary. In involuntary euthana-
sia, the act is carried out against the wishes of the
patient and is therefore illegal and widely regarded
as immoral.

People also draw a distinction between active
and passive euthanasia. Active euthanasia is
taking a direct action to kill someone, to carry out
a “mercy killing.” A doctor who gives a patient a
lethal injection is performing active euthanasia,
and so is a man who suffocates his dying brother
to spare him from an unbearably painful pass-
ing. Passive euthanasia is allowing someone
to die by not doing something— by withholding

are intertwined with the moral concerns. Our task
here is to apply moral reasoning to try to unravel
the knot.

ISSUE FILE: BACKGROUND

Euthanasia is directly or indirectly bringing
about the death of another person for that person’s
sake.2 It is thought to provide a benefit or a good for
the person by ending a life deemed no longer worth
living— a situation that typically arises when some-
one has an incurable or terminal disease that causes
great suffering or when someone experiences an
irreversible loss of consciousness (as in the Schiavo
case). This notion of dying as a kind of blessing is

’The Death of Karen Ann Quinlan
Like nothing else before it, the case of Karen
Ann Quinlan focused the world’s attention on
the medical truths, the legal complexities, and
the moral problems of euthanasia. She was just
twenty- one years old when she sustained acute
brain damage after imbibing alcohol along with
a tranquilizer. She was left in a persistent vege-
tative state, kept alive by a feeding tube and a
respirator, a machine that maintained her breath-
ing mechanically. After several months, members
of her family came to accept that her recovery
was hopeless and sought permission from the
courts to unplug the respirator to allow her to
die. Finally in 1976 the New Jersey Supreme Court
granted their request. But to everyone’s surprise,
she continued to breathe without the respirator
until 1985, ten years after she slipped into the
vegetative state. She died on June 11.*

*See “Famous Cases: Karen Ann Quinlan,” CBC News
Online, March 22, 2005, http://www.cbc.ca/news2
/back ground/schiavo/vegetative_state.html (January
20, 2015); Barran H. Lerner, “Planning for the Long
Goodbye,” New York Times, June 18, 2004.

http://www.cbc.ca/news2/background/schiavo/vegetative_state.html

http://www.cbc.ca/news2/background/schiavo/vegetative_state.html

CHAPTER 10: EUTHAnASIA And PHySICIAn- ASSISTEd SUICIdE Á  287

the agent who ultimately causes the death in active
voluntary euthanasia is the physician, whereas the
ultimate causal agent in physician- assisted suicide is
the patient. In the former, the physician is primarily
responsible for the killing; in the latter, the patient
is. In most cases, the physician provides help by pre-
scribing a lethal dose of drugs, which the patient
then administers to himself.

In the United States, physician- assisted suicide is
legal in six states— Oregon, Washington, Montana,
Colorado, Vermont, and California— and in the
District of Columbia. U.S. Supreme Court rul-
ings allow each state to decide for itself whether
to legalize assisted suicide. The official position
of the American Medical Association (AMA), the
main professional group for American physicians,
is that “ physician- assisted suicide is fundamentally
incompatible with the physician’s role as healer,
would be difficult or impossible to control, and
would pose serious societal risks.”3

A factor that can complicate all the foregoing
issues is the concept of death itself. One prob-
lem is that thanks to modern medical technol-
ogy, determining when a person is dead is not
so straightforward as it once seemed. Death has
become more difficult to define. Years ago the pre-
vailing notion was that a person is dead when his
breathing and blood flow stop (no respiration and
no heartbeat). But nowadays machines can keep
an individual’s heart and lungs functioning long
after the brain permanently and completely shuts
down. Thus we can have an individual whose
organs are mechanically operated while he is in
a coma or persistent vegetative state— for years.
By the traditional definition of death, such an
individual would still be alive, but many people
would insist that he is no longer there: he is dead.
So the conventional notion of death seems to be
inadequate.

Why does correctly defining death matter at
all? Say an individual is in the kind of state just
described. If we judge him to be dead and thus no
longer a person, then perhaps it would be morally

or withdrawing measures necessary for sustaining
life. A doctor, then, would be performing passive
euthanasia if she removed a patient’s respirator, did
not administer antibiotics to halt a life- threatening
infection, or withdrew hydration and nutrition
(fluids and nutrients).

Many believe that this active- passive distinc-
tion is essential to understanding the moral permis-
sibility of euthanasia. It allows them to maintain
that whereas active euthanasia is always wrong, in
some cases passive euthanasia may be permissible.
This view is widespread among physicians and fits
with the popular notion that killing people is mor-
ally worse than letting them die. Others, however,
argue that there is no moral difference between
killing and letting die: in both active and passive
euthanasia the patient’s death is caused, and they
are therefore morally equivalent.

Taking into account the categories of voluntary,
nonvoluntary, active, and passive (and disregarding
involuntary), we can identify four kinds of euthana-
sia: (1) active voluntary (mercy killing at the patient’s
request), (2) active nonvoluntary (mercy killing with-
out the patient’s consent or request), (3) passive
voluntary (letting the patient die at her request),
and (4) passive nonvoluntary (letting the patient
die without his consent or request). Generally, the
law forbids active euthanasia (either voluntary or
nonvoluntary), and the medical profession is offi-
cially opposed to it (though the views of individual
physicians vary). Passive voluntary euthanasia is
legal; by law, competent patients have the right to
refuse any kind of medical treatment. Passive non-
voluntary euthanasia may be legal provided that
someone (a family member, for example) can be des-
ignated to make decisions on behalf of the patient.

Related to, but distinct from, active voluntary
euthanasia is physician- assisted suicide— the
killing of a person by the person’s own hand with
the help of a physician. Like active voluntary eutha-
nasia, physician- assisted suicide is requested by the
patient, and the intended outcome is the patient’s
death for the relief of pain and suffering. But

288 Á  PART 4: ETHICAL ISSUES

permissible to disconnect him from the machines,
or administer a fatal drug overdose, or remove his
feeding tube, or even harvest his organs for trans-
plant into another person. Or would it? If we deem
him alive and still a person, perhaps we are not jus-
tified in doing any of the above. Maybe taking any
one of these actions is to commit murder. Depend-
ing on the concept of death accepted by the legal
system, killing him or allowing him to die could
have serious legal consequences.

To overcome the drawbacks of the traditional
definition of death, alternative definitions have

been suggested. According to the whole- brain defi-
nition of death, an individual is dead when all
brain functions (including those performed in
the brain stem) permanently stop. It has become
the primary standard in both medicine and the
law for determining death. Critics of the whole-
brain standard, though, have pointed out that it
is based on a faulty assumption: that the brain is
the control center for all physiological functions.
Yet some functions (such as respiration) are par-
tially independent of brain activity. In addition,
by the whole- brain standard, individuals in an


In the past five decades, U.S. courts have several
times weighed in on the controversial issues of
euthanasia and physician- assisted suicide. The fol-
lowing are some of the more far- reaching rulings:

• 1976 The New Jersey Supreme Court ruled that
a life- sustaining respirator could be legally dis-
connected from Karen Ann Quinlan, a young
woman who had lapsed into a persistent vegeta-
tive state. After it was removed, she remained
comatose and lived for another ten years, finally
dying in June 1985.

• 1990 The U.S. Supreme Court (in Cruzan v. Direc-
tor, Missouri Department of Health) ruled that
a feeding tube could be removed from Nancy
Cruzan, a woman in a persistent vegetative state
due to an automobile accident, if “clear and
convincing evidence” shows that she would have
approved of the withdrawal. The ruling recog-
nized the legitimacy of living wills, surrogates to
act for incapacitated individuals, and a qualified
“right to die.”

• 1997 The U.S. Supreme Court (in Washington
v. Glucksberg) ruled that a Washington State
prohibition of physician- assisted suicide did not
violate the due process clause of the Fourteenth
Amendment.

• 1997 The U.S. Supreme Court (in Vacco v. Quill)
ruled that a New York State prohibition of physi-
cian- assisted suicide did not violate the equal pro-
tection clause of the Fourteenth Amendment. The
Court acknowledged a crucial distinction between
withdrawing life- sustaining treatment and assisted
suicide. People may refuse life- sustaining treat-
ment, but assisted suicide is prohibited.

• 2006 In a 6–3 decision in Gonzales v. Oregon, the
U.S. Supreme Court ruled that the U.S. attorney
general is not authorized to ban controlled sub-
stances used in physician- assisted suicide. The
decision had the effect of upholding Oregon’s
Death with Dignity Act.

• 2009 In a 4–3 decision in Baxter v. State of Mon-
tana, the Montana Supreme Court ruled that
physician- assisted suicide is not “against public
policy.” The decision applied only to Montana.
The court also ruled that doctors who help
terminally ill patients commit suicide cannot be
prosecuted under Montana state law.

• 2015 In a 2–1 ruling, the New Mexico Court of
Appeals struck down a lower court ruling legal-
izing physician- assisted suicide, concluding that
“aid in dying is not a fundamental liberty inter-
est under the New Mexico Constitution.”

Landmark Court Rulings

CHAPTER 10: EUTHAnASIA And PHySICIAn- ASSISTEd SUICIdE Á  289

disappeared is no longer a person and is therefore
rightly considered dead. By the higher- brain stan-
dard, individuals in a persistent vegetative state
(who continue to breathe and have a heartbeat)
but whose higher brain functions have ceased are
thought to be dead— also a result that some people
find counterintuitive.

MORAL THEORIES

Utilitarianism, Kant’s ethics, and natural law the-
ory lead to divergent conclusions on the issue of
euthanasia. An act- utilitarian would certainly try
to take into account how much overall happiness
various possible actions could bring about, every-
one considered. But she could make this calcula-
tion in different ways. The basic approach would
be to consider the patient’s suffering (as well as
that of others involved, such as family members)
and the likely success of any treatments and try to
determine how much overall happiness would be
generated by different actions, including bring-
ing about the patient’s death. If the patient’s situ-
ation were hopeless and his suffering great, an
act- utilitarian could decide that the greatest net
happiness would result from killing the patient
or letting him die. The patient’s consent to eutha-
nasia might or might not be a primary concern,
depending on how his consent would affect overall
happiness. On the other hand, the act- utilitarian
might say that euthanasia is contrary to the goal
of maximizing happiness because killing a person
rules out any possibility of his experiencing hap-
piness in the future. Happiness does not occur in
a vacuum; it exists only when persons experience
it. So eliminating a person eliminates potential
happiness.

Some people— even those who are not thor-
oughgoing utilitarians— argue against euthanasia
on what amounts to rule- utilitarian grounds or
something close to it. They contend that regard-
less of the moral permissibility of euthanasia in

irreversible persistent vegetative state (who have
some detectable brain activity) are thought to be
alive— a result that some regard as counterintui-
tive or puzzling.

The higher- brain definition of death says
that an individual is dead when higher brain
functions— those that give rise to consciousness—
permanently stop. Some have maintained that
because consciousness is necessary for personhood,
an individual whose higher brain functions have

’ QUICK REVIEW
euthanasia— Directly or indirectly bringing about

the death of another person for that person’s
sake.

voluntary euthanasia— Euthanasia performed on
a person with his or her permission.

advance directive— A legal document allowing
physicians to withhold or withdraw treatments
if a patient becomes terminally ill and unable
to express his or her wishes.

nonvoluntary euthanasia— Euthanasia performed
on a person who is not competent to decide the
issue and has left no instructions regarding end-
of- life preferences. In such cases, family or physi-
cians usually make the decision.

involuntary euthanasia— Euthanasia performed
on a person against his or her wishes.

active euthanasia— Euthanasia performed by tak-
ing a direct action to cause someone’s death;
“mercy killing.”

passive euthanasia— Euthanasia performed by
withholding or withdrawing measures neces-
sary for sustaining life.

physician- assisted suicide— The killing of a per-
son by that person’s own hand with the help
of a physician.

290 Á  PART 4: ETHICAL ISSUES

who have slipped from waking life into a coma or
a vegetative state? Are they still persons with full
moral rights? If they are persons, then performing
euthanasia on them would be immoral. If they are
not persons, then euthanasia might be morally
acceptable. In fact, a Kantian might argue that
performing euthanasia on individuals in comas or
vegetative states may be morally permissible pre-
cisely because persons have intrinsic worth and
dignity. The bioethicist Ronald Munson explains
this view well:

It may be more in keeping with our freedom and dig-
nity for us to instruct others either to put us to death
or to take no steps to keep us alive should we ever be in
such a state. Voluntary euthanasia may be compatible
with (if not required by) Kant’s ethics.

By a similar line of reasoning, it may be that
nonvoluntary euthanasia might be seen as a duty
that we have to others. We might argue that by put-
ting to death a comatose and hopeless person we
are recognizing the dignity that person possessed
in his or her previous state.5

According to the dominant reading of natural
law theory, euthanasia is wrong in almost every
instance. It is wrong because we have a moral duty
to preserve life. So intentionally performing any
kind of euthanasia, active or passive, is impermis-
sible. The doctrine of double effect, however, allows
one exception to this rule. Recall that this doctrine
makes a distinction between (1) performing a good
action that happens to have a bad effect and (2) per-
forming a bad action to achieve a good effect. The
former may be permissible, but the latter is not. In
the case of euthanasia, the doctrine implies that
giving a pain- racked patient a large dose of mor-
phine to end her life (a practice known as terminal
sedation) is never morally acceptable. But giving
her a large dose of morphine with the intention of
easing her pain— an act that has the side effect of
expediting her death— is permissible. The hasten-
ing of the patient’s death is permissible because
even though it was foreseen, it was not intended.

specific cases, a general rule (that is, a social policy
or law) permitting some types of euthanasia would
cause more harm than good. They offer slippery
slope arguments such as the following: Passing a
law (making a rule) permitting active voluntary
euthanasia would inevitably lead to abuses such as
more frequent use of nonvoluntary euthanasia and
unnecessary killing; therefore, no such law should
be passed. Similarly, some argue that a general rule
allowing physician- assisted suicide would destroy
the “moral center” of the medical profession; if
physicians are allowed to kill patients, they will
violate their pledge to protect life and to heal, caus-
ing patients to distrust them. Of course, it is also
possible to argue for euthanasia on rule- utilitarian
grounds. (Whether such arguments are sound is
another matter.) A rule- utilitarian could devise a
rule that he thinks would result in a maximization
of happiness for everyone if the rule were consis-
tently followed.

Like the utilitarian, the Kantian theorist could
also take several different positions on euthana-
sia, consistent with Kantian principles. She could
argue that euthanasia is never permissible because
it would entail treating persons as mere disposable
things. Kant underscores this view in his discus-
sion of suicide. He maintains that “suicide is in
no circumstances permissible” because it robs
individuals of their personhood, which is the very
foundation of all moral values. Furthermore, it
treats persons as if they had no more value than
a beast. As Kant puts it, “But the rule of moral-
ity does not admit of [suicide] under any condi-
tion because it degrades human nature below the
level of animal nature and so destroys it.”4 This
stern prohibition against suicide may or may not
apply equally well to euthanasia— depending on
whether those considered for euthanasia are to
be regarded as persons. Certainly those who are
competent (coherent and rational) are persons
and therefore should not be killed or allowed to
die. But what would Kant say about individuals

CHAPTER 10: EUTHAnASIA And PHySICIAn- ASSISTEd SUICIdE Á  291

is morally permissible and that it should not be
legalized— or vice versa. We might plausibly argue
that in some cases, performing active voluntary
euthanasia is the right thing to do but that legal-
izing it would have terrible consequences. Legal-
ization could, say, lead doctors to practice active
nonvoluntary euthanasia or encourage them to care
less about preserving life or cause patients to fear
or mistrust doctors. To mix up these two kinds of
issues— moral and legal— is to invite confusion.

We begin by examining arguments for active
voluntary euthanasia. The strongest of these are
built on two fundamental moral principles: per-
sons have (1) a right of self- determination and
(2) an obligation to help someone in serious dis-
tress or peril (if they are in a position to help with-
out great risk to themselves). Principle 1 refers
to the patient’s right of self- determination, and
Principle 2 to other persons who might be able to
benefit her. Principle 1 assumes that persons have
autonomy— the capacity, as Kant would have it,
to use reason to guide their own actions and make
their own decisions. It asserts that persons have the

In the doctrine of double effect, intention makes all
the difference.

MORAL ARGUMENTS

Most plausible euthanasia arguments are about
active euthanasia (mercy killing, as opposed to let-
ting the patient die). As suggested earlier, passive
euthanasia (both voluntary and nonvoluntary)
is legal, provided certain conditions are met, and
both forms of it are widely believed to be morally
acceptable. So let us confine our evaluation here
to moral arguments for and against active voluntary
euthanasia (mercy killing at the patient’s request).
The question these arguments address, then, is
straightforward: Is active voluntary euthanasia mor-
ally permissible?

As we proceed, we must keep an important dis-
tinction in mind: moral permissibility is not the
same thing as legal permissibility. Whether eutha-
nasia is morally acceptable is a separate issue from
whether it should be legalized. It is possible that we
could be justified in believing both that euthanasia


Dr. Jack Kevorkian was known as a champion of the
right- to- die movement, having helped many incur-
ably ill people commit suicide. He was also known
as “Dr. Death,” the physician who helped desper-
ate people kill themselves. After many unsuccessful
tries, prosecutors finally won a conviction against
him for murder: in 1999, he was sentenced to ten
to twenty- five years in prison. The New York Times
reported that the sentence was handed down
“despite emotional courtroom pleas on his behalf
from the widow and brother of the terminally ill
man he was convicted of killing.”*

Do you agree with the verdict in this case? Why
or why not? If you do not agree, would your opinion
change if you knew that many of Dr. Kevorkian’s sui-
cide patients were not mentally competent at the
time of their deaths (because of depression), as some
people allege? If so, why? If you were terminally ill
and in horrendous pain with no hope of relief, might
you think it morally permissible to use the services of
someone like Dr. Kevorkian? If not, why not?

*Dirk Johnson, “Kevorkian Sentenced to 10 to 25
Years in Prison,” New York Times, April 14, 1999.

CRITICAL THOUGHT: Dr. Kevorkian and Physician- Assisted Suicide

292 Á  PART 4: ETHICAL ISSUES

patient is in agony and asks to be put out of her
misery (active voluntary euthanasia), rejecting her
plea for mercy would be both cruel and wicked.
They also insist that merely withholding treatment
from her to hasten her death (passive euthanasia)
would only prolong her suffering.

Here is one way to incorporate both Principles
1 and 2 into a single argument for active voluntary
euthanasia:

1. Competent persons have a right of self-
determination (as long as exercising this right
does not violate others’ rights).

2. The right of self- determination includes the
right of competent persons to decide the man-
ner of their dying and to choose active (volun-
tary) euthanasia.

3. We have an obligation to help others in serious
distress or peril (if we are in a position to help
without great risk to ourselves).

4. This duty of beneficence includes the duty,
under appropriate conditions, to ease the pain
and suffering of competent dying persons by
performing active (voluntary) euthanasia.

5. Therefore, active voluntary euthanasia for com-
petent dying persons is permissible.

The central idea behind this argument is that
if competent dying persons have a right to choose
active euthanasia, and if the duty of beneficence
includes performing active voluntary euthanasia,
then active voluntary euthanasia is morally permis-
sible. But does the conclusion follow from the prem-
ises, and are the premises true? The answer to the
first part of this question is yes. The answer to the
second part is more complicated. Look at Premises 1
and 3; they articulate the two basic moral principles
we began with. These principles qualify as consid-
ered moral judgments and are accepted by virtually
all parties to the euthanasia debate. We have good
reason, then, to say that Premises 1 and 3 are true.

Premises 2 and 4, however, are controversial.
Critics of Premise 2 would say that we do indeed

right to exercise this power to direct their lives as
they see fit (with the proviso that their actions not
violate the rights of others). Many who appeal to
this principle argue that if it applies to how persons
live, then it surely applies to how they die, because
their dying is part of their life. This is how the bio-
ethicist Dan W. Brock explains the importance of
this end- of- life self- determination:

Most people are very concerned about the nature of
the last stage of their lives. This reflects not just a fear
of experiencing substantial suffering when dying,
but also a desire to retain dignity and control dur-
ing this last period of life. Death is today increasingly
preceded by a long period of significant physical and
mental decline, due in part to the technological inter-
ventions of modern medicine. Many people adjust to
these disabilities and find meaning and value in new
activities and ways. Others find the impairments and
burdens in the last stage of their lives at some point
sufficiently great to make life no longer worth living.
For many patients near death, maintaining the qual-
ity of one’s life, avoiding great suffering, maintaining
one’s dignity, and insuring that others remember us
as we wish them to become of paramount importance
and outweigh merely extending one’s life. But there
is no single, objectively correct answer for everyone
as to when, if at all, one’s life becomes all things con-
sidered a burden and unwanted. If self- determination
is a fundamental value, then the great variability
among people on this question makes it especially
important that individuals control the manner, cir-
cumstances, and timing of their dying and death.6

Principle 2 is a duty of beneficence (a duty
to benefit others). Applied to euthanasia, it says
that if we are in a position to ease the agony of
another, and we can do so without excessive cost
to ourselves, we should try to render aid. This tenet
applies to persons generally, but it carries extra
weight for people with a special relationship with
the suffering person, such as family members, close
friends, and doctors. Physicians have an explicit
obligation to try to relieve the misery of their
patients— especially dying patients who often must
endure horrific pain and suffering. Many advocates
of euthanasia contend that if a competent dying

CHAPTER 10: EUTHAnASIA And PHySICIAn- ASSISTEd SUICIdE Á  293

escape her agony. Modern medicine is better than
ever at alleviating pain— even very intense pain.
Spinal blocks, drug combinations, new ways to
deliver powerful analgesics (drugs that ease pain)—
these options and others can offer dying patients
unprecedented levels of pain relief. So euthanasia is
uncalled for. If this claim is correct, then opponents
can argue that contrary to Premise 4, active eutha-
nasia will actually harm patients by cutting their
lives short unnecessarily and thus depriving them
of the benefits that may accrue in their remain-
ing days— benefits such as profoundly meaningful
moments spent with their families, the chance to
come to terms with their dying, and even the pos-
sibility of a newfound cure for their disease.7 Pro-
ponents of active euthanasia, however, charge that
this upbeat view of pain management is not accu-
rate. They point to several unpleasant facts: though
it is possible to manage even severe pain well, too
often pain is not well managed (for a variety of
reasons, including the reluctance of health care
workers to administer large doses of pain- relieving
drugs); the side effects of the best pain medications
(especially when used over the long term) often
add to the suffering of the patient; and many dying
patients endure not physical pain, but psychologi-
cal suffering that is unbearable and untreatable by
any medication.

Proponents can put forth another kind of argu-
ment for active voluntary euthanasia, this one
based on the moral significance of killing (active
euthanasia) and letting die (passive euthanasia). As
we saw earlier, active euthanasia is taking a direct
action to kill someone, while passive euthanasia is
allowing someone to die by withholding or with-
drawing measures necessary for sustaining life. Pas-
sive euthanasia is legal (competent patients have
the right to refuse treatment) and widely believed
to be morally permissible. Active euthanasia is gen-
erally illegal, and debate continues over its moral
permissibility. Opponents of active euthanasia
generally think that there is a profound moral dif-
ference between killing and letting die: killing is

have a right of self- determination but that this
right does not include the right to opt for active vol-
untary euthanasia. The reason is that active eutha-
nasia is killing, and killing is always wrong. We may
have all sorts of rights, but killing is still killing.

This reply, though, is based on a superficial
understanding of prohibitions against killing. Some
kinds of killing are considered by most people to
be morally permissible— for example, killing in
self- defense and killing in war. These are regarded
as justified killings; unjustified killings are known
as murder. So even though all killing may be regret-
table, not all killing is immoral. Active euthanasia
may in fact be a form of acceptable killing.

The opponent of active euthanasia can make a
stronger reply along the same lines. He can say that
the problem with active euthanasia is not that it is
a type of killing, but that it is a type of unwarranted
killing. A dying patient in the grip of unimagina-
ble pain, for example, does not have to be killed to

’Public Opinion and Euthanasia
Many opinion polls have shown that most people
favor some form of euthanasia or physician assis-
tance in dying. A 2016 Gallup poll of 1,025 adults
aged eighteen and over echoed these findings:

• 69 percent of Americans approve of doctor-
assisted suicide.

• 51 percent of Americans say they would con-
sider ending their own lives by some painless
means if they had an incurable disease and
they were in severe pain.

• 53 percent of Americans say they believe
doctor- assisted suicide is morally acceptable.*

*“Euthanasia Still Acceptable to Solid Majority
in U.S.,” Gallup Poll, May 4–6, 2016, http://www
. gallup.com/poll/193082/euthanasia-acceptable-solid
-majority.aspx.

http://www.gallup.com/poll/193082/euthanasia-acceptable-solid-majority.aspx

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294 Á  PART 4: ETHICAL ISSUES

morally, then we would judge one man’s action
(either Smith’s or Jones’s) to be more blamewor-
thy than that of the other. But our judgment is
the same for both, so there must be no moral
difference.

Some reject this argument and insist that
there is in fact a moral difference between killing
and letting die but that the distinction is often
obscured in thought experiments like the Smith-
Jones story. One critic claims, for example, that
in this scenario the two men are equally repre-
hensible and the two actions appear to be morally
equivalent simply because both men were prepared
to kill. Remove this common factor, and the moral
difference between killing and letting die will be
apparent.9

Some of the strongest arguments against active
voluntary euthanasia take a slippery slope approach.
The gist of most of them is that lifting a moral or
legal prohibition against this kind of mercy killing
will dilute respect for life and encourage a slow slide
from active voluntary euthanasia to active nonvol-
untary euthanasia and then perhaps to involuntary
euthanasia. This argument is therefore consequen-
tialist: active voluntary euthanasia is wrong because
it leads to bad consequences. (The argument is also
sometimes lodged against legalizing this form of
euthanasia.) Here is how one bioethicist describes
the descent down the slope:

A person apparently hopelessly ill may be allowed
to take his own life. Then he may be permit-
ted to deputize others to do it for him should he
no longer be able to act. The judgment of others
then becomes the ruling factor. Already at this
point euthanasia is not personal and voluntary,
for others are acting “on behalf of” the patient
as they see fit. This may well incline them to act
on behalf of other patients who have not autho-
rized them to exercise their judgment. It is only a
short step, then, from voluntary euthanasia ( self-
inflicted or authorized), to directed euthanasia
administered to a patient who has given no autho-
rization, to involuntary euthanasia conducted as
part of a social policy.10

far worse than letting die; in fact, killing is morally
wrong while letting die is permissible. But propo-
nents of active voluntary euthanasia assert that
the two are morally equivalent. Using this alleged
moral equivalence, proponents can construct an
argument like this:

1. Passive euthanasia is morally permissible.

2. If passive euthanasia is morally equivalent to
active euthanasia, active euthanasia is also
morally permissible.

3. Passive euthanasia is morally equivalent to
active euthanasia.

4. Therefore, active (voluntary) euthanasia is mor-
ally permissible.

The conclusion follows from the premises, and
Premises 1 and 2 are uncontroversial. The crux of
the matter is Premise 3. What reasons are there for
thinking that it is true? Here is an argument for
Premise 3 in the form of a classic thought experi-
ment. Suppose Smith will inherit a fortune if his
six- year- old cousin dies. So he decides to take mat-
ters into his own hands. He slips into the bathroom
while his little cousin is taking a bath and drowns
him. He makes the whole thing look like an acci-
dent and leaves undetected. Now consider Jones,
who also will inherit a fortune if his six- year- old
cousin dies. He too decides to kill the child, and he
too slips into the bathroom while the boy is bath-
ing. But before Jones has a chance to commit the
deed, the boy slips in the tub, gets knocked uncon-
scious, and will surely drown unless Jones rescues
him. Jones is happy to do nothing and lets the
boy drown on his own— a simple “accident.” Now
which man behaves better morally? If there is a sig-
nificant moral difference between killing and let-
ting die, we would want to say that Jones’s actions
are less blameworthy than Smith’s. But this distinc-
tion doesn’t seem correct. The motives and aims of
both men are the same.8

The line taken here is that if the difference
between killing and letting die really is important

CHAPTER 10: EUTHAnASIA And PHySICIAn- ASSISTEd SUICIdE Á  295

possible slippery slope worry could have been raised
to securing competent patients’ rights to decide about
life support, but recent history shows such a worry
would have been unfounded.11

CHAPTER REVIEW

SUMMARY

Euthanasia is directly or indirectly bringing about the
death of another person for that person’s sake. Its moral
status depends in large measure on the consent of the
patient. In voluntary euthanasia, the patient agrees to
the act. In nonvoluntary euthanasia, others besides
the patient decide on euthanasia because he or she is
incompetent and has left no statement about end- of-
life preferences. In involuntary euthanasia, the act is
performed against the patient’s wishes. Active euthana-
sia is taking direct action to kill someone (administer-
ing a lethal injection, for example); passive euthanasia
is allowing the patient to die by withholding or with-
drawing life- sustaining measures.

The traditional notion of death as the cessation
of breathing and heartbeat has been revised in light
of new developments in medical technology. Accord-
ing to the whole- brain view of death, the individual is
dead when all brain functions permanently stop. The
higher- brain view of death says that an individual is
dead when higher brain functions permanently stop.

An act- utilitarian might see euthanasia as morally
permissible because it results in the greatest happi-
ness for all concerned. She could also consistently say
that euthanasia is contrary to the goal of maximizing
happiness because killing an individual rules out any
possibility of that person’s future happiness. A rule-
utilitarian might say that a general rule permitting
some kinds of euthanasia would do more harm than
good— or that such a rule would maximize happiness
in the long run. A Kantian theorist could consistently
reject euthanasia because it entails treating persons as
disposable things. Or he could consistently maintain

We can formulate a version of the argument
thus:

1. If the general acceptance or approval of active
voluntary euthanasia leads to widespread abuses
(unjustified killing), then the practice is mor-
ally wrong.

2. The general acceptance or approval of active
voluntary euthanasia will lead to widespread
abuses (unjustified killing).

3. Therefore, active voluntary euthanasia is morally
wrong.

This is a valid argument, an instance of modus
ponens, so we need to focus only on the truth or
falsity of the premises. Probably most people who
have thought carefully about this kind of argu-
ment accept Premise 1 or a variation of it. Premise
2 is the sticking point. Because of a lack of solid
evidence on the subject, the social consequences
of a general acceptance of active euthanasia are
difficult to ascertain. For example, to prove their
case, some opponents of euthanasia cite reports
on the Dutch experience with physician- assisted
suicide. Proponents point to the same reports to
undermine that case. The difficulty is that the
research is not robust enough to lend unequivo-
cal support to one side or the other. It therefore
does not show that Premise 2 is true. Many of the
arguments for Premise 2 are arguments by analogy
or inferences based on observations concerning
human behavior. Generally, these arguments, too,
are weak and conjectural.

Those who are skeptical of Premise 2 often sim-
ply point out that no good reasons have been pro-
vided to support it. At best, they say, arguments for
Premise 2 show only that dreadful consequences
from widespread use of active euthanasia are pos-
sible. As one skeptic puts it,

Now it cannot be denied that it is possible that per-
mitting euthanasia could have these fateful con-
sequences, but that cannot be enough to warrant
prohibiting it if it is otherwise justified. A similar

296 Á  PART 4: ETHICAL ISSUES

8. What is the American Medical Association’s
official view of physician- assisted suicide?
(p. 287)

9. What is an advance directive? (p. 286)
10. What is the higher- brain definition of death?

(p. 289)

Discussion Questions

1. Do you think voluntary active euthanasia is
morally permissible in some cases? Why or why
not?

2. Critique the Terri Schiavo case. Who was right
in their view of what should be done for Terri?
Was the participation of politicians in the case
helpful? Distracting? Wrong?

3. Was removing Terri Schiavo’s feeding tube a case
of murder? If not, what was it?

4. What actions (or lack of actions) should have
been performed in her case?

5. Would you consider her a person in her brain-
damaged state? Why or why not?

6. Do you consider Dr. Kevorkian’s practice of
physician- assisted suicide morally acceptable?
Why or why not?

7. Is there a moral difference between killing and
letting die? Give reasons for your answer.

8. How might an act- utilitarian argue for
physician- assisted suicide? Critique this
argument.

9. How might a Kantian argue against physician-
assisted suicide?

10. Is the use of terminal sedation ever morally
permissible? If so, in what situations?

FURTHER READING
Tom L. Beauchamp, ed., Intending Death: The Ethics of

Assisted Suicide and Euthanasia (Englewood Cliffs, NJ:
Prentice Hall, 1995).

R. B. Brandt, “The Morality and Rationality of Suicide,” in
A Handbook for the Study of Suicide, ed. Seymour Perlin
(New York: Oxford University Press, 1975).

Lonnie R. Bristow, President of the American Medical
Association, statement on physician- assisted suicide
to the U.S. House of Representatives Committee on the

that individuals in comas or persistent vegetative
states are no longer persons, and therefore euthanasia
is morally acceptable.

Arguments in favor of active voluntary euthanasia
are often based on a right of self- determination and
a duty to help others in distress. Some arguments for
euthanasia, however, depend on the alleged equiva-
lence between active and passive euthanasia. Some
of the strongest arguments against euthanasia are of
the slippery slope type: active voluntary euthanasia is
wrong because it leads to bad consequences, such as
an increased risk of unjustified killings.

KEY TERMS
euthanasia (p. 286)
voluntary euthanasia (p. 286)
advance directive (p. 286)
nonvoluntary euthanasia (p. 286)
involuntary euthanasia (p. 286)
active euthanasia (p. 286)
passive euthanasia (p. 286)
physician- assisted suicide (p. 287)

EXERCISES
Review Questions

1. What is euthanasia? What is physician- assisted
suicide? (p. 286)

2. What is the difference between voluntary
euthanasia and nonvoluntary euthanasia?
(p. 286)

3. What is the difference between active and
passive euthanasia? (p. 286)

4. Who was Terri Schiavo and what are the
main medical and legal facts of her case?
(p. 285)

5. Who was Dr. Kevorkian and what role did
he play in the debate over physician- assisted
suicide? (p. 291)

6. What percentage of American adults
think physician- assisted suicide is morally
permissible? (p. 293)

7. In what states is physician- assisted suicide legal?
(p. 287)

CHAPTER 10: EUTHAnASIA And PHySICIAn- ASSISTEd SUICIdE Á  297

Medical Ethics, ed. Ronald Munson, 7th ed. (Belmont,
CA: Wadsworth, 2004).

Jeffrey Olen and Vincent Barry, “Euthanasia,” in Apply-
ing Ethics: A Text with Readings, 6th ed. (Belmont, CA:
Wadsworth, 1999).

The President’s Commission for the Study of Ethical Prob-
lems in Medicine and Biomedical and Behavioral Research
(Washington, DC: Government Printing Office, 1983).

Bonnie Steinbock and Alastair Norcross, eds., Killing and
Letting Die, 2nd ed. (New York: Fordham University
Press, 1994).

Thomas D. Sullivan, “Active and Passive Euthanasia: An
Impertinent Distinction?” Human Life Review 3, no. 3
(1977): 40–46.

Robert Young, “Voluntary Euthanasia,” in Stanford Ency-
clopedia of Philosophy, Summer 2005 ed., ed. Edward
N. Zalta, http://plato.stanford.edu/archives/sum2005/
entries/ euthanasia- voluntary/ (March 1, 2015).

Judiciary, Subcommittee on the Constitution, 104th
Cong., 2nd sess., Congressional Record 142 (April 29,
1996).

Dan W. Brock, “Medical Decisions at the End of Life,” in
A Companion to Bioethics, ed. Helga Kuhse and Peter
Singer (1998; reprint, Malden, MA: Blackwell, 2001).

Daniel Callahan, “When Self- Determination Runs Amok,”
Hastings Center Report 22, no. 2 (March/April 1992):
52–55.

Philippa Foot, “Euthanasia,” Philosophy & Public Affairs 6,
no. 2 (1977): 85–112.

Walter Glannon, “Medical Decisions at the End of Life,”
in Biomedical Ethics (New York: Oxford University Press,
2005).

John Lachs, “When Abstract Moralizing Runs Amok,”
Journal of Clinical Ethics 5, no. 1 (1994): 10–13.

Ronald Munson, “Euthanasia and Physician- Assisted
Suicide,” in Intervention and Reflection: Basic Issues in

E T H I C A L d I L E M M A S

1. Assisted Suicide or Murder?

One of the more bizarre cases of assisted suicide in recent times came to its con-
clusion on September 29, 2014, when New Yorker Kenneth Minor was convicted of
manslaughter after stabbing a Long Island motivational speaker. Minor claimed that
the man wished to die and had paid him to help him do so.

Minor received a sentence of twelve years when he accepted the prosecutors’
plea deal and pled guilty to first- degree manslaughter.

However, Minor’s lawyer claims, “We will be back again . . . Our hope is the
appellate division will once again reverse this case.”

Minor’s lawyer, Daniel J. Gotlin, hopes to overturn the conviction by bringing the
case to an appeals court. Gotlin argues that the verdict should be thrown out based
on procedural grounds. Minor’s indictment includes murder charges and assisted
suicide charges, which Gotlin claims are mutually exclusive.

Minor has been incarcerated for more than five years, and, according to Gotlin,
accepted the plea deal because “he wants finality; he wants this to be over.” If
Minor is unsuccessful in his appeal, he will have to serve five more years before he
is eligible to be released.

Moments before Minor entered his plea, Justice Laura A. Ward of the New York
Supreme Court in Manhattan denied Gotlin’s request to dismiss the case, stating that
a man can be charged for both murder and assisted suicide. However, she did not
refute that Minor had a right to appeal her ruling, and said, “Perhaps we will get
a definite ruling from the appellate division.”

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298 Á  PART 4: ETHICAL ISSUES

The man who Minor admits to killing, Jeffrey Locker, was found tied up in his
car in East Harlem in July 2009. Multiple stab wounds were found on his chest.

Minor claims that Locker, a middle- aged father who had fallen deeply into debt,
had hired him to assist in his suicide plan. Minor says he held a knife to a steering
wheel while Locker flung himself against it multiple times. Minor’s prosecutors found
his story incredible and brought a murder charge against him instead of a charge
of assisting suicide.

In 2011, Minor was tried and convicted of second- degree murder by a jury. The
judge gave him twenty years to life in prison, but the verdict was invalidated two
years later by an appellate panel. They concluded that the trial judge had given the
jury an incorrect definition of assisted suicide.

Minor was given another trial in January. This time, a charge of assisting suicide
was added to his indictment at the request of Cyrus R. Vance Jr., Manhattan district
attorney. A jury could now convict him of a lesser charge.

During Minor’s first trial, the defense and the prosecution agreed that Minor
had participated in Locker’s suicide at the request of the deceased, who wished
to make his death look like a murder so that his family could claim life insurance.

However, prosecutors argued that it was a case of murder for hire, not assisted
suicide, as Minor was still the cause of Locker’s death. According to a medical
expert, Minor did not simply hold a knife to a steering wheel, but stabbed Locker
as he lay in his car. He then used Locker’s credit card to withdraw money from
an ATM.*

Suppose Minor killed Locker at Locker’s request.
Would the killing then be morally permissible? Is
there a moral difference between physician- assisted
suicide and Locker’s murder when both actions are
taken at the victim’s request? What is the differ-
ence, if any, between murder and assisted suicide?

Suppose Locker’s motive for asking Minor for aid in
dying, and for making the death look like murder,
was that Locker’s life insurance money would pay
for the only medical treatment that could save his
daughter’s life. How would these facts change your
moral judgment about the killing?

*Based on James C. McKinley Jr., “Harlem Man Pleads Guilty to Assisting 2009 Death,” New York Times, September
29, 2014, http://www.nytimes.com/2014/09/30/nyregion/- harlem- man-pleads-guilty-to-assisting-2009-death.
html?_r=0 (March 23, 2015).

2. Euthanasia for Newborns

Imagine the unimaginable: Your newborn baby is born with a severe, deadly birth
defect or contracts a fatal illness. The baby will die and is in tremendous pain. In
this case, is it justified, perhaps even humane, to euthanize the child?

In Holland, some doctors and parents say the answer is yes. Back in 2005, the
Netherlands adopted the Groningen Protocol, which is designed to help doctors
end the suffering of very sick newborns through euthanasia. The rule requires that
five criteria must be met before taking the decision to end the child’s life: beyond-

CHAPTER 10: EUTHAnASIA And PHySICIAn- ASSISTEd SUICIdE Á  299

a- doubt diagnosis; presence of unbearable suffering; a second expert medical
opinion to verify the child’s condition; consent of both parents; and compliance
with medical standards.

Some critics feared that this would create a “slippery slope” of infanticide, but
new research published in the Journal of Medical Ethics contends that that has
not been the case. The authors reviewed all reported cases of infant euthanasia
between 2001 and 2010 (doctors sometimes covertly practiced infanticide before the
protocol was passed) and found that in 95 percent of cases the mode of euthanasia
was withholding or withdrawing treatment. In 60 percent of those cases, this was
because the infant would soon die from an incurable disease. For the remaining
40 percent, quality of life prompted the decision.

However, since 2007, doctors reported euthanizing just two babies. The authors
of the new paper suspect that an increase in abortions when fatal problems are
detected in the womb may explain this. Alternatively, doctors may be confused about
what constitutes euthanasia– such as withholding treatment, food or water— and may
be underreporting it. Either way, the authors write, there has not been a detectable
snowballing of euthanized babies in Holland as a result of the new protocol.†

Provide reasons for your answers to the follow-
ing questions. Under the circumstances described
(severe pain, terminal illness), would child eutha-
nasia ever be morally permissible? Would child
euthanasia be permissible if the newborn was not

terminal, but in an unalterable vegetative state?
Would it be permissible if the newborn suffered
from a severe birth defect such as Down syndrome,
which causes severe disabilities but does not rule
out a worthwhile life?

† Rachel Nuwer, “Is It Ever OK to Euthanize a Baby?” Smithsonianmag.com, May 3, 2013. Copyright 2013 Smith-
sonian Institution. Reprinted with permission from Smithsonian Enterprises. All rights reserved. Reproduction in
any medium is strictly prohibited without permission from Smithsonian Institution.

3. The Suicide of Admiral Nimitz

The name of Chester W. Nimitz is legendary in the annals of naval warfare. In
June 1942, Admiral Nimitz commanded the U.S. forces assigned to block a Japanese
invasion of Midway.

In the Battle of Midway, Nimitz’s fighter- bombers caught the Japanese fleet off
guard, as its carrier aircraft were being refueled on deck. His pilots swooped in and
sent to the bottom four of the Japanese carriers— Hiryu, Soryu, Akagi and Kaga—
that had led the attack on Pearl Harbor. Midway broke the back of Japanese naval
power and was among the most decisive battles in all of history.

Nimitz’s son and namesake, Chester W. Nimitz Jr., would rise to the same rank
of admiral and become a hero of the Pacific war— a submarine commander who
would sink a Japanese destroyer bearing down on his boat by firing torpedoes
directly into its bow.

http://www.Smithsonianmag.com

300 Á  PART 4: ETHICAL ISSUES

But Chester W. Nimitz Jr. achieved another kind of fame on Jan. 2. In a suicide
pact with his 89- year- old wife, the 86- year- old hero ended his life with an overdose
of sleeping pills.

Having lost 30 pounds from a stomach disorder, suffering from congestive heart
failure and in constant back pain, the admiral had been determined to dictate the
hour of his death. His wife, who suffered from osteoporosis so severe her bones
were breaking, had gone blind. She had no desire to live without her husband.

So, as the devoted couple had spent their lives together, they decided to end
their lives together. The admiral’s final order read: “Our decision was made over a
considerable period of time and was not carried out in acute desperation. Nor is it
the expression of a mental illness. We have consciously, rationally, deliberately and
of our own free will taken measures to end our lives today because of the physical
limitations on our quality of life placed upon us by age, failing vision, osteoporosis,
back and painful orthopedic problems.”

According to The New York Times obituary, “The Nimitzes did not believe in any
afterlife or God, and embraced no religion. But one of Mr. Nimitz’s three surviving
sisters, Mary Aquinas, 70, is a Catholic nun. . . . Sister Mary said that she could not
condone her brother’s decision to end his life, but that she felt sympathetic. ‘If you
cannot see any value to suffering for yourself or others,’ she said, ‘Then maybe it
does make sense to end your life.’”‡

Provide reasons for your answers: Was Admiral
Nimitz justified in his decision to commit suicide?
Is suicide morally wrong in all circumstances? Is

suicide a matter of personal choice, morally per-
missible if a person freely opts to end her life for
whatever reason?

‡Patrick J. Buchanan, “The Sad Suicide of Admiral Nimitz,” World Net Daily, January 18, 2002. Reprinted by per-
mission of Patrick J. Buchanan and Creators Syndicate, Inc.

The distinction between active and passive eutha-
nasia is thought to be crucial for medical ethics. The
idea is that it is permissible, at least in some cases, to
withhold treatment and allow a patient to die, but it

is never permissible to take any direct action designed
to kill the patient. This doctrine seems to be accepted
by most doctors, and it is endorsed in a statement
adopted by the House of Delegates of the American
Medical Association on December 4, 1973:

The intentional termination of the life of one human
being by another— mercy killing— is contrary to that
for which the medical profession stands and is contrary
to the policy of the American Medical Association.

R E A d I n G S

Active and Passive Euthanasia
James R achels

James Rachels, excerpts from “Active and Passive Euthana-
sia,” from The New England Journal of Medicine, Vol. 292, No. 2,
pp. 78–80. Copyright © 1975 Massachusetts Medical Society.
Reprinted with permission from Massachusetts Medical Society.

CHAPTER 10: EUTHAnASIA And PHySICIAn- ASSISTEd SUICIdE Á  301

The cessation of the employment of extraordinary
means to prolong the life of the body when there is irre-
futable evidence that biological death is imminent is
the decision of the patient and/or his immediate fam-
ily. The advice and judgment of the physician should
be freely available to the patient and/or his immediate
family.

However, a strong case can be made against this doc-
trine. In what follows I will set out some of the relevant
arguments, and urge doctors to reconsider their views
on this matter.

To begin with a familiar type of situation, a patient
who is dying of incurable cancer of the throat is in ter-
rible pain, which can no longer be satisfactorily alle-
viated. He is certain to die within a few days, even if
present treatment is continued, but he does not want
to go on living for those days since the pain is unbear-
able. So he asks the doctor for an end to it, and his fam-
ily joins in the request.

Suppose the doctor agrees to withhold treatment,
as the conventional doctrine says he may. The justifi-
cation for his doing so is that the patient is in terrible
agony, and since he is going to die anyway, it would
be wrong to prolong his suffering needlessly. But now
notice this. If one simply withholds treatment, it may
take the patient longer to die, and so he may suffer
more than he would if more direct action were taken
and a lethal injection given. This fact provides strong
reason for thinking that, once the initial decision not
to prolong his agony has been made, active euthana-
sia is actually preferable to passive euthanasia, rather
than the reverse. To say otherwise is to endorse the
option that leads to more suffering rather than less, and
is contrary to the humanitarian impulse that prompts
the decision not to prolong his life in the first place.

Part of my point is that the process of being
“allowed to die” can be relatively slow and painful,
whereas being given a lethal injection is relatively
quick and painless. Let me give a different sort of
example. In the United States about one in 600 babies
is born with [Down] syndrome. Most of these babies
are otherwise healthy— that is, with only the usual
pediatric care, they will proceed to an otherwise nor-
mal infancy. Some, however, are born with congeni-
tal defects such as intestinal obstructions that require

operations if they are to live. Sometimes, the parents
and the doctor will decide not to operate, and let the
infant die. Anthony Shaw describes what happens
then:

. . . When surgery is denied [the doctor] must try to
keep the infant from suffering while natural forces sap
the baby’s life away. As a surgeon whose natural incli-
nation is to use the scalpel to fight off death, standing
by and watching a salvageable baby die is the most
emotionally exhausting experience I know. It is easy at
a conference, in a theoretical discussion, to decide that
such infants should be allowed to die. It is altogether
different to stand by in the nursery and watch as dehy-
dration and infection wither a tiny being over hours
and days. This is a terrible ordeal for me and the hospi-
tal staff— much more so than for the parents who never
set foot in the nursery.1

I can understand why some people are opposed to
all euthanasia, and insist that such infants must be
allowed to live. I think I can also understand why
other people favor destroying these babies quickly and
painlessly. But why should anyone favor letting “dehy-
dration and infection wither a tiny being over hours
and days”? The doctrine that says that a baby may be
allowed to dehydrate and wither, but may not be given
an injection that would end its life without suffering,
seems so patently cruel as to require no further refu-
tation. The strong language is not intended to offend,
but only to put the point in the clearest possible way.

My second argument is that the conventional
doctrine leads to decisions concerning life and death
made on irrelevant grounds.

Consider again the case of the infants with [Down]
syndrome who need operations for congenital defects
unrelated to the syndrome to live. Sometimes, there
is no operation, and the baby dies, but when there is
no such defect, the baby lives on. Now, an operation
such as that to remove an intestinal obstruction is not
prohibitively difficult. The reason why such opera-
tions are not performed in these cases is, clearly, that
the child has [Down] syndrome and the parents and
doctor judge that because of that fact it is better for the
child to die.

But notice that this situation is absurd, no matter
what view one takes of the lives and potentials of such

302 Á  PART 4: ETHICAL ISSUES

push the child’s head back under if it is necessary, but
it is not necessary. With only a little thrashing about,
the child drowns all by himself, “accidentally,” as
Jones watches and does nothing.

Now Smith killed the child, whereas Jones
“merely” let the child die. That is the only difference
between them. Did either man behave better, from
a moral point of view? If the difference between kill-
ing and letting die were in itself a morally important
matter, one should say that Jones’s behavior was less
reprehensible than Smith’s. But does one really want
to say that? I think not. In the first place, both men
acted from the same motive, personal gain, and both
had exactly the same end in view when they acted.
It may be inferred from Smith’s conduct that he is a
bad man, although that judgment may be withdrawn
or modified if certain further facts are learned about
him— for example, that he is mentally deranged. But
would not the very same thing be inferred about Jones
from his conduct? And would not the same further
considerations also be relevant to any modification of
this judgment? Moreover, suppose Jones pleaded, in
his own defense, “After all, I didn’t do anything except
just stand there and watch the child drown. I didn’t
kill him: I only let him die.” Again, if letting die were
in itself less bad than killing, this defense should have
at least some weight. But it does not. Such a “defense”
can only be regarded as a grotesque perversion of
moral reasoning. Morally speaking, it is no defense
at all.

Now, it may be pointed out, quite properly, that
the cases of euthanasia with which doctors are con-
cerned are not like this at all. They do not involve
personal gain or the destruction of normal healthy
children. Doctors are concerned only with cases in
which the patient’s life is of no further use to him,
or in which the patient’s life has become or will soon
become a terrible burden. However, the point is the
same in these cases: the bare difference between killing
and letting die does not, in itself, make a moral differ-
ence. If a doctor lets a patient die, for humane reasons,
he is in the same moral position as if he had given the
patient a lethal injection for humane reasons. If his
decision was wrong— if, for example, the patient’s
illness was in fact curable— the decision would be

babies. If the life of such an infant is worth preserv-
ing, what does it matter if it needs a simple operation?
Or, if one thinks it better that such a baby should not
live on, what difference does it make that it happens
to have an unobstructed intestinal tract? In either
case, the matter of life and death is being decided on
irrelevant grounds. It is the [Down] syndrome, and
not the intestines, that is the issue. The matter should
be decided, if at all, on that basis, and not be allowed
to depend on the essentially irrelevant question of
whether the intestinal tract is blocked.

What makes this situation possible, of course, is
the idea that when there is an intestinal blockage, one
can “let the baby die,” but when there is no such defect
there is nothing that can be done, for one must not
“kill” it. The fact that this idea leads to such results as
deciding life or death on irrelevant grounds is another
good reason why the doctrine should be rejected.

One reason why so many people think that there
is an important moral difference between active and
passive euthanasia is that they think killing someone
is morally worse than letting someone die. But is it?
Is killing, in itself, worse than letting die? To investi-
gate this issue, two cases may be considered that are
exactly alike except that one involves killing whereas
the other involves letting someone die. Then, it can be
asked whether this difference makes any difference to
the moral assessments. It is important that the cases
be exactly alike, except for this one difference, since
otherwise one cannot be confident that it is this dif-
ference and not some other that accounts for any
variation in the assessments of the two cases. So, let us
consider this pair of cases:

In the first, Smith stands to gain a large inheri-
tance if anything should happen to his six- year- old
cousin. One evening while the child is taking his
bath, Smith sneaks into the bathroom and drowns the
child, and then arranges things so that it will look like
an accident.

In the second, Jones also stands to gain if anything
should happen to his six- year- old cousin. Like Smith,
Jones sneaks in planning to drown the child in his
bath. However, just as he enters the bathroom Jones
sees the child slip and hit his head, and fall face down
in the water. Jones is delighted; he stands by, ready to

CHAPTER 10: EUTHAnASIA And PHySICIAn- ASSISTEd SUICIdE Á  303

however, the doctor does something to bring about
the patient’s death: he kills him. The doctor who gives
the patient with cancer a lethal injection has himself
caused his patient’s death: whereas if he merely ceases
treatment, the cancer is the cause of the death.”

A number of points need to be made here. The
first is that it is not exactly correct to say that in pas-
sive euthanasia the doctor does nothing, for he does
do one thing that is very important: he lets the patient
die. “Letting someone die” is certainly different, in
some respects, from other types of action— mainly in
that it is a kind of action that one may perform by way
of not performing certain other actions. For example,
one may let a patient die by way of not giving medi-
cation, just as one may insult someone by way of not
shaking his hand. But for any purpose of moral assess-
ment, it is a type of action nonetheless. The decision
to let a patient die is subject to moral appraisal in the
same way that a decision to kill him would be subject
to moral appraisal: it may be assessed as wise or unwise,
compassionate or sadistic, right or wrong. If a doctor
deliberately let a patient die who was suffering from a
routinely curable illness, the doctor would certainly be
to blame for what he had done, just as he would be to
blame if he had needlessly killed the patient. Charges
against him would then be appropriate. If so, it would
be no defense at all for him to insist that he didn’t “do
anything.” He would have done something very seri-
ous indeed, for he let his patient die.

Fixing the cause of death may be very impor-
tant from a legal point of view, for it may determine
whether criminal charges are brought against the doc-
tor. But I do not think that this notion can be used to
show a moral difference between active and passive
euthanasia. The reason why it is considered bad to be
the cause of someone’s death is that death is regarded
as a great evil— and so it is. However, if it has been
decided that euthanasia— even passive euthanasia— is
desirable in a given case, it has also been decided that
in this instance death is no greater an evil than the
patient’s continued existence. And if this is true, the
usual reason for not wanting to be the cause of some-
one’s death simply does not apply.

Finally, doctors may think that all of this is only of
academic interest— the sort of thing that philosophers

equally regrettable no matter which method was used
to carry it out. And if the doctor’s decision was the
right one, the method used is not in itself important.

The AMA policy statement isolates the crucial
issue very well: the crucial issue is “the intentional ter-
mination of the life of one human being by another.”
But after identifying this issue, and forbidding “mercy
killing,” the statement goes on to deny that the ces-
sation of treatment is the intentional termination of
a life. This is where the mistake comes in, for what is
the cessation of treatment, in these circumstances, if
it is not “the intentional termination of the life of one
human being by another”? Of course it is exactly that,
and if it were not, there would be no point to it.

Many people will find this judgment hard to
accept. One reason, I think, is that it is very easy to
conflate the question of whether killing is, in itself,
worse than letting die, with the very different ques-
tion of whether most actual cases of killing are more
reprehensible than most actual cases of letting die.
Most actual cases of killing are clearly terrible (think,
for example, of all the murders reported in the news-
papers), and one hears of such cases every day. On the
other hand, one hardly ever hears of a case of letting
die, except for the actions of doctors who are moti-
vated by humanitarian reasons. So one learns to think
of killing in a much worse light than of letting die.
But this does not mean that there is something about
killing that makes it in itself worse than letting die,
for it is not the bare difference between killing and
letting die that makes the difference in these cases.
Rather, the other factors— the murderer’s motive of
personal gain, for example, contrasted with the doc-
tor’s humanitarian motivation— account for different
reactions to the different cases.

I have argued that killing is not in itself any worse
than letting die: if my contention is right, it follows
that active euthanasia is not any worse than passive
euthanasia. What arguments can be given on the other
side? The most common, I believe, is the following:

“The important difference between active and pas-
sive euthanasia is that, in passive euthanasia, the doc-
tor does not do anything to bring about the patient’s
death. The doctor does nothing, and the patient dies
of whatever ills already afflict him. In active euthanasia,

304 Á  PART 4: ETHICAL ISSUES

However, the preceding considerations suggest that
there is really no moral difference between the two,
considered in themselves (there may be important
moral differences in some cases in their consequences,
but, as I pointed out, these differences may make active
euthanasia, and not passive euthanasia, the morally
preferable option). So, whereas doctors may have to
discriminate between active and passive euthanasia to
satisfy the law, they should not do any more than that.
In particular, they should not give the distinction any
added authority and weight by writing it into official
statements of medical ethics.

NOTE

1. Anthony Shaw, “Doctor, Do We Have a Choice?” New York
Times Magazine, 30 January 1972, 54.

may worry about but that has no practical bearing on
their own work. After all, doctors must be concerned
about the legal consequences of what they do, and
active euthanasia is clearly forbidden by the law.
But even so, doctors should also be concerned with
the fact that the law is forcing upon them a moral
doctrine that may well be indefensible, and has a
considerable effect on their practices. Of course, most
doctors are not now in the position of being coerced
in this matter, for they do not regard themselves as
merely going along with what the law requires. Rather,
in statements such as the AMA policy statement that
I have quoted, they are endorsing this doctrine as a
central point of medical ethics. In that statement,
active euthanasia is condemned not merely as illegal
but as “contrary to that for which the medical profes-
sion stands,” whereas passive euthanasia is approved.

The Wrongfulness of Euthanasia
J. Gay- Williams

conclusion is wrong. I want to show that euthanasia
is wrong. It is inherently wrong, but it is also wrong
judged from the standpoints of self- interest and of
practical effects.

Before presenting my arguments to support this
claim, it would be well to define “euthanasia.” An
essential aspect of euthanasia is that it involves tak-
ing a human life, either one’s own or that of another.
Also, the person whose life is taken must be someone
who is believed to be suffering from some disease or
injury from which recovery cannot reasonably be
expected. Finally, the action must be deliberate and
intentional. Thus, euthanasia is intentionally taking
the life of a presumably hopeless person. Whether the
life is one’s own or that of another, the taking of it is
still euthanasia.

It is important to be clear about the deliberate and
intentional aspect of the killing. If a hopeless person
is given an injection of the wrong drug by mistake
and this causes his death, this is wrongful killing but
not euthanasia. The killing cannot be the result of

My impression is that euthanasia— the idea, if not
the practice— is slowly gaining acceptance within our
society. Cynics might attribute this to an increasing
tendency to devalue human life, but I do not believe
this is the major factor. The acceptance is much more
likely to be the result of unthinking sympathy and
benevolence. Well- publicized, tragic stories like that of
Karen Quinlan elicit from us deep feelings of compas-
sion. We think to ourselves, “She and her family would
be better off if she were dead.” It is an easy step from
this very human response to the view that if someone
(and others) would be better off dead, then it might
be all right to kill that person. Although I respect the
compassion that leads to this conclusion, I believe the

J. Gay- Williams, “The Wrongfulness of Euthanasia.” Copy-
right © 1979 by Ronald Munson. Published from Ronald
Munson, Intervention and Reflection: Basic Issues in Medical
Ethics, 4th Edition. Wadsworth Publishing Company: Belmont,
California. Reprinted with permission.

CHAPTER 10: EUTHAnASIA And PHySICIAn- ASSISTEd SUICIdE Á  305

bacteria, antibodies are produced to fight against the
alien organisms, and their remains are swept out of the
body by special cells designed for clean- up work.

Euthanasia does violence to this natural goal of
survival. It is literally acting against nature because
all the processes of nature are bent towards the end of
bodily survival. Euthanasia defeats these subtle mech-
anisms in a way that, in a particular case, disease and
injury might not.

It is possible, but not necessary, to make an appeal
to revealed religion in this connection. Man as trustee
of his body acts against God, its rightful possessor,
when he takes his own life. He also violates the com-
mandment to hold life sacred and never to take it
without just and compelling cause. But since this
appeal will persuade only those who are prepared to
accept that religion has access to revealed truths, I
shall not employ this line of argument.

It is enough, I believe, to recognize that the organiza-
tion of the human body and our patterns of behavioral
responses make the continuation of life a natural goal.
By reason alone, then, we can recognize that euthanasia
sets us against our own nature. Furthermore, in doing
so, euthanasia does violence to our dignity. Our dignity
comes from seeking our ends. When one of our goals
is survival, and actions are taken that eliminate that
goal, then our natural dignity suffers. Unlike animals,
we are conscious through reason of our nature and our
ends. Euthanasia involves acting as if this dual nature—
inclination towards survival and awareness of this as an
end— did not exist. Thus, euthanasia denies our basic
human character and requires that we regard ourselves
or others as something less than fully human.

2. THE ARGUMENT FROM SELF- INTEREST

The above arguments are, I believe, sufficient to show
that euthanasia is inherently wrong. But there are rea-
sons for considering it wrong when judged by stan-
dards other than reason. Because death is final and
irreversible, euthanasia contains within it the possi-
bility that we will work against our own interest if we
practice it or allow it to be practiced on us.

Contemporary medicine has high standards of
excellence and a proven record of accomplishment,

accident. Furthermore, if the person is given an injec-
tion of a drug that is believed to be necessary to treat
his disease or better his condition and the person dies
as a result, then this is neither wrongful killing nor
euthanasia. The intention was to make the patient
well, not kill him. Similarly, when a patient’s condi-
tion is such that it is not reasonable to hope that any
medical procedures or treatments will save his life, a
failure to implement the procedures or treatments
is not euthanasia. If the person dies, this will be as a
result of his injuries or disease and not because of his
failure to receive treatment.

The failure to continue treatment after it has been
realized that the patient has little chance of benefit-
ing from it has been characterized by some as “passive
euthanasia.” This phrase is misleading and mistaken.
In such cases, the person involved is not killed (the
first essential aspect of euthanasia), nor is the death of
the person intended by the withholding of additional
treatment (the third essential aspect of euthanasia).
The aim may be to spare the person additional and
unjustifiable pain, to save him from the indignities of
hopeless manipulations, and to avoid increasing the
financial and emotional burden on his family. When
I buy a pencil it is so that I can use it to write, not to
contribute to an increase in the gross national prod-
uct. This may be the unintended consequence of my
action, but it is not the aim of my action. So it is with
failing to continue the treatment of a dying person. I
intend his death no more than I intend to reduce the
GNP by not using medical supplies. His is an unin-
tended dying, and so- called “passive euthanasia” is
not euthanasia at all.

1. THE ARGUMENT FROM NATURE

Every human being has a natural inclination to con-
tinue living. Our reflexes and responses fit us to fight
attackers, flee wild animals, and dodge out of the way
of trucks. In our daily lives we exercise the caution and
care necessary to protect ourselves. Our bodies are sim-
ilarly structured for survival right down to the molecu-
lar level. When we are cut, our capillaries seal shut, our
blood clots, and fibrogen is produced to start the pro-
cess of healing the wound. When we are invaded by

306 Á  PART 4: ETHICAL ISSUES

enough to save the patient. They might decide that
the patient would simply be “better off dead” and take
the steps necessary to make that come about. This
attitude could then carry over to their dealings with
patients less seriously ill. The result would be an over-
all decline in the quality of medical care.

Finally, euthanasia as a policy is a slippery slope.
A person apparently hopelessly ill may be allowed to
take his own life. Then he may be permitted to depu-
tize others to do it for him should he no longer be able
to act. The judgment of others then becomes the rul-
ing factor. Already at this point euthanasia is not per-
sonal and voluntary, for others are acting “on behalf
of” the patient as they see fit. This may well incline
them to act on behalf of other patients who have not
authorized them to exercise their judgment. It is only
a short step, then, from voluntary euthanasia ( self-
inflicted or authorized), to directed euthanasia admin-
istered to a patient who has given no authorization, to
involuntary euthanasia conducted as part of a social
policy. Recently many psychiatrists and sociologists
have argued that we define as “mental illness” those
forms of behavior that we disapprove of. This gives us
license then to lock up those who display the behav-
ior. The category of the “hopelessly ill” provides the
possibility of even worse abuse. Embedded in a social
policy, it would give society or its representatives the
authority to eliminate all those who might be con-
sidered too “ill” to function normally any longer. The
dangers of euthanasia are too great to all to run the
risk of approving it in any form. The first slippery step
may well lead to a serious and harmful fall.

I hope that I have succeeded in showing why the
benevolence that inclines us to give approval of eutha-
nasia is misplaced. Euthanasia is inherently wrong
because it violates the nature and dignity of human
beings. But even those who are not convinced by this
must be persuaded that the potential personal and
social dangers inherent in euthanasia are sufficient to
forbid our approving it either as a personal practice or
as a public policy.

Suffering is surely a terrible thing, and we have a
clear duty to comfort those in need and to ease their
suffering when we can. But suffering is also a natural
part of life with values for the individual and for others

but it does not possess perfect and complete knowl-
edge. A mistaken diagnosis is possible, and so is a mis-
taken prognosis. Consequently, we may believe that
we are dying of a disease when, as a matter of fact, we
may not be. We may think that we have no hope of
recovery when, as a matter of fact, our chances are
quite good. In such circumstances, if euthanasia were
permitted, we would die needlessly. Death is final and
the chance of error too great to approve the practice of
euthanasia.

Also, there is always the possibility that an experi-
mental procedure or a hitherto untried technique will
pull us through. We should at least keep this option
open, but euthanasia closes it off. Furthermore, spon-
taneous remission does occur in many cases. For no
apparent reason, a patient simply recovers when those
all around him, including his physicians, expected
him to die. Euthanasia would just guarantee their
expectations and leave no room for the “miraculous”
recoveries that frequently occur.

Finally, knowing that we can take our life at any
time (or ask another to take it) might well incline us
to give up too easily. The will to live is strong in all of
us, but it can be weakened by pain and suffering and
feelings of hopelessness. If during a bad time we allow
ourselves to be killed, we never have a chance to recon-
sider. Recovery from a serious illness requires that we
fight for it, and anything that weakens our determi-
nation by suggesting that there is an easy way out is
ultimately against our own interest. Also, we may be
inclined towards euthanasia because of our concern
for others. If we see our sickness and suffering as an
emotional and financial burden on our family, we may
feel that to leave our life is to make their lives easier.
The very presence of the possibility of euthanasia may
keep us from surviving when we might.

3. THE ARGUMENT FROM PRACTICAL EFFECTS

Doctors and nurses are, for the most part, totally com-
mitted to saving lives. A life lost is, for them, almost
a personal failure, an insult to their skills and knowl-
edge. Euthanasia as a practice might well alter this. It
could have a corrupting influence so that in any case
that is severe doctors and nurses might not try hard

CHAPTER 10: EUTHAnASIA And PHySICIAn- ASSISTEd SUICIdE Á  307

NOTE

1. Arthur Dyck, “Beneficent Euthanasia and Benemortasia,”
in Beneficent Euthanasia, ed. Marvin Kohl (Buffalo, NY: Pro-
metheus Books, 1975), 117–29.

that we should not overlook. We may legitimately
seek for others and for ourselves an easeful death, as
Arthur Dyck has pointed out.1 Euthanasia, however, is
not just an easeful death. It is a wrongful death. Eutha-
nasia is not just dying. It is killing.

From Voluntary Active Euthanasia
Dan W. Brock

administered, for example, in cases of serious dementia
or treatable clinical depression.

Does the value of individual self- determination
extend to the time and manner of one’s death? Most
people are very concerned about the nature of the last
stage of their lives. This reflects not just a fear of expe-
riencing substantial suffering when dying, but also a
desire to retain dignity and control during this last
period of life. Death is today increasingly preceded
by a long period of significant physical and mental
decline, due in part to the technological interven-
tions of modern medicine. Many people adjust to
these disabilities and find meaning and value in new
activities and ways. Others find the impairments and
burdens in the last stage of their lives at some point
sufficiently great to make life no longer worth living.
For many patients near death, maintaining the qual-
ity of one’s life, avoiding great suffering, maintaining
one’s dignity, and insuring that others remember us
as we wish them to become of paramount impor-
tance and outweigh merely extending one’s life.
But there is no single, objectively correct answer for
everyone as to when, if at all, one’s life becomes all
things considered a burden and unwanted. If self-
determination is a fundamental value, then the great
variability among people on this question makes it
especially important that individuals control the
manner, circumstances, and timing of their dying
and death.

The other main value that supports euthanasia is
individual well- being. It might seem that individual
well- being conflicts with a person’s self- determination
when the person requests euthanasia. Life itself is

* * *

THE CENTRAL ETHICAL ARGUMENT FOR
VOLUNTARY ACTIVE EUTHANASIA

The central ethical argument for euthanasia is familiar.
It is that the very same two fundamental ethical values
supporting the consensus on patient’s rights to decide
about life- sustaining treatment also support the ethical
permissibility of euthanasia. These values are individual
self- determination or autonomy and individual well-
being. By self- determination as it bears on euthanasia,
I mean people’s interest in making important decisions
about their lives for themselves according to their own
values or conceptions of a good life, and in being left
free to act on those decisions. Self- determination is valu-
able because it permits people to form and live in accor-
dance with their own conception of a good life, at least
within the bounds of justice and consistent with others
doing so as well. In exercising self- determination people
take responsibility for their lives and for the kinds of
persons they become. A central aspect of human dig-
nity lies in people’s capacity to direct their lives in this
way. The value of exercising self- determination presup-
poses some minimum of decision making capacities or
competence, which thus limits the scope of euthanasia
supported by self- determination; it cannot justifiably be

Dan W. Brock, excerpts from “Voluntary Active Euthanasia”
from Hastings Center Report 22(2): 10–22. Copyright © 1992 The
Hastings Center. Reproduced with permission of John Wiley &
Sons, Inc.

308 Á  PART 4: ETHICAL ISSUES

against it that on their view outweigh or override this
support. The first kind of argument is that in any indi-
vidual case where considerations of the patient’s self-
determination and well- being do support euthanasia,
it is nevertheless always ethically wrong or impermis-
sible. The second kind of argument grants that in
some individual cases euthanasia may not be ethi-
cally wrong, but maintains nonetheless that public
and legal policy should never permit it. The first kind
of argument focuses on features of any individual case
of euthanasia, while the second kind focuses on social
or legal policy. In the next section I consider the first
kind of argument.

* * *

WOULD THE BAD CONSEQUENCES OF
EUTHANASIA OUTWEIGH THE GOOD?

The argument against euthanasia at the policy level is
stronger than at the level of individual cases, though
even here I believe the case is ultimately unpersua-
sive, or at best indecisive. The policy level is the place
where the main issues lie, however, and where moral
considerations that might override arguments in
favor of euthanasia will be found, if they are found
anywhere. It is important to note two kinds of dis-
agreement about the consequences for public policy
of permitting euthanasia. First, there is empirical or
factual disagreement about what the consequences
would be. This disagreement is greatly exacerbated
by the lack of firm data on the issue. Second, since
on any reasonable assessment there would be both
good and bad consequences, there are moral dis-
agreements about the relative importance of dif-
ferent effects. In addition to these two sources of
disagreement, there is also no single, well- specified
policy proposal for legalizing euthanasia on which
policy assessments can focus. But without such
specification, and especially without explicit proce-
dures for protecting against well- intentioned mis-
use and ill- intentioned abuse, the consequences for
policy are largely speculative. Despite these difficul-
ties, a preliminary account of the main likely good
and bad consequences is possible. This should help
clarify where better data or more moral analysis and

commonly taken to be a central good for persons,
often valued for its own sake, as well as necessary for
pursuit of all other goods within a life. But when a
competent patient decides to forgo all further life-
sustaining treatment then the patient, either explic-
itly or implicitly, commonly decides that the best life
possible for him or her with treatment is of sufficiently
poor quality that it is worse than no further life at all.
Life is no longer considered a benefit by the patient,
but has now become a burden. The same judgment
underlies a request for euthanasia: continued life is
seen by the patient as no longer a benefit, but now a
burden. Especially in the often severely compromised
and debilitated states of many critically ill or dying
patients, there is no objective standard, but only the
competent patient’s judgment of whether continued
life is no longer a benefit.

Of course, sometimes there are conditions, such
as clinical depression, that call into question whether
the patient has made a competent choice, either to
forgo life- sustaining treatment or to seek euthanasia,
and then the patient’s choice need not be evidence
that continued life is no longer a benefit for him or
her. Just as with decisions about treatment, a deter-
mination of incompetence can warrant not honoring
the patient’s choice: in the case of treatment, we then
transfer decisional authority to a surrogate, though
in the case of voluntary active euthanasia a determi-
nation that the patient is incompetent means that
choice is not possible.

The value or right of self- determination does not
entitle patients to compel physicians to act contrary
to their own moral or professional values. Physi-
cians are moral and professional agents whose own
self- determination or integrity should be respected
as well. If performing euthanasia became legally
permissible, but conflicted with a particular physi-
cian’s reasonable understanding of his or her moral
or professional responsibilities, the care of a patient
who requested euthanasia should be transferred to
another.

Most opponents do not deny that there are
some cases in which the values of patient self-
determination and well- being support euthanasia.
Instead, they commonly offer two kinds of arguments

CHAPTER 10: EUTHAnASIA And PHySICIAn- ASSISTEd SUICIdE Á  309

who have it, not just those whose houses actually burn
down, by reassuring them that in the unlikely event
of their house burning down, they will receive the
money needed to rebuild it. Likewise, the legalization
of euthanasia can be thought of as a kind of insurance
policy against being forced to endure a protracted dying
process that one has come to find burdensome and
unwanted, especially when there is no life- sustaining
treatment to forgo. The strong concern about losing
control of their care expressed by many people who
face serious illness likely to end in death suggests that
they give substantial importance to the legalization of
euthanasia as a means of maintaining this control.

A third good consequence of the legalization of
euthanasia concerns patients whose dying is filled
with severe and unrelievable pain or suffering. When
there is a life- sustaining treatment that, if forgone,
will lead relatively quickly to death, then doing so
can bring an end to these patients’ suffering with-
out recourse to euthanasia. For patients receiving no
such treatment, however, euthanasia may be the only
release from their otherwise prolonged suffering and
agony. This argument from mercy has always been the
strongest argument for euthanasia in those cases to
which it applies.

The importance of relieving pain and suffering is
less controversial than is the frequency with which
patients are forced to undergo untreatable agony
that only euthanasia could relieve. If we focus first on
suffering caused by physical pain, it is crucial to dis-
tinguish pain that could be adequately relieved with
modern methods of pain control, though it in fact is
not, from pain that is relievable only by death. For a
variety of reasons, including some physicians’ fear of
hastening the patient’s death, as well as the lack of a
publicly accessible means for assessing the amount
of the patient’s pain, many patients suffer pain that
could be, but is not, relieved.

Specialists in pain control, as for example the
pain of terminally ill cancer patients, argue that
there are very few patients whose pain could not be
adequately controlled, though sometimes at the cost
of so sedating them that they are effectively unable
to interact with other people or their environment.
Thus, the argument from mercy in cases of physical

argument are needed, as well as where policy safe-
guards must be developed.

Potential Good Consequences of
Permitting Euthanasia

What are the likely good consequences? First, if eutha-
nasia were permitted it would be possible to respect
the self- determination of competent patients who
want it, but now cannot get it because of its illegality.
We simply do not know how many such patients and
people there are. In the Netherlands, with a popula-
tion of about 14.5 million (in 1987), estimates in a
recent study were that about 1,900 cases of voluntary
active euthanasia or physician- assisted suicide occur
annually. No straightforward extrapolation to the
United States is possible for many reasons, among
them, that we do not know how many people here
who want euthanasia now get it, despite its illegality.
Even with better data on the number of persons who
want euthanasia but cannot get it, significant moral
disagreement would remain about how much weight
should be given to any instance of failure to respect a
person’s self- determination in this way.

One important factor substantially affecting the
number of persons who would seek euthanasia is the
extent to which an alternative is available. The wide-
spread acceptance in the law, social policy, and medi-
cal practice of the right of a competent patient to forgo
life- sustaining treatment suggests that the number of
competent persons in the United States who would
want euthanasia if it were permitted is probably rela-
tively small.

A second good consequence of making euthana-
sia legally permissible benefits a much larger group.
Polls have shown that a majority of the American pub-
lic believes that people should have a right to obtain
euthanasia if they want.1 No doubt the vast majority of
those who support this right to euthanasia will never
in fact come to want euthanasia for themselves. Nev-
ertheless, making it legally permissible would reassure
many people that if they ever do want euthanasia they
would be able to obtain it. This reassurance would sup-
plement the broader control over the process of dying
given by the right to decide about life- sustaining treat-
ment. Having fire insurance on one’s house benefits all

310 Á  PART 4: ETHICAL ISSUES

Potential Bad Consequences of
Permitting Euthanasia

Some of the arguments against permitting euthanasia
are aimed specifically against physicians, while others
are aimed against anyone being permitted to perform
it. I shall first consider one argument of the former
sort. Permitting physicians to perform euthanasia, it
is said, would be incompatible with their fundamental
moral and professional commitment as healers to care
for patients and to protect life. Moreover, if euthanasia
by physicians became common, patients would come
to fear that a medication was intended not to treat or
care, but instead to kill, and would thus lose trust in
their physicians. This position was forcefully stated in
a paper by Willard Gaylin and his colleagues:

The very soul of medicine is on trial. . . . This issue touches
medicine at its moral center; if this moral center col-
lapses, if physicians become killers or are even licensed
to kill, the profession— and, therewith, each physician—
will never again be worthy of trust and respect as healer
and comforter and protector of life in all its frailty.

These authors go on to make clear that, while they
oppose permitting anyone to perform euthanasia,
their special concern is with physicians doing so:

We call on fellow physicians to say that they will not
deliberately kill. We must also say to each of our fellow
physicians that we will not tolerate killing of patients
and that we shall take disciplinary action against doctors
who kill. And we must say to the broader community
that if it insists on tolerating or legalizing active eutha-
nasia, it will have to find nonphysicians to do its killing.2

If permitting physicians to kill would undermine
the very “moral center” of medicine, then almost cer-
tainly physicians should not be permitted to perform
euthanasia. But how persuasive is this claim? Patients
should not fear, as a consequence of permitting vol-
untary active euthanasia, that their physicians will
substitute a lethal injection for what patients want
and believe is part of their care. If active euthanasia is
restricted to cases in which it is truly voluntary, then
no patient should fear getting it unless she or he has
voluntarily requested it. (The fear that we might in
time also come to accept nonvoluntary, or even invol-
untary, active euthanasia is a slippery slope worry

pain can probably be met in a large majority of cases
by providing adequate measures of pain relief. This
should be a high priority, whatever our legal policy on
euthanasia— the relief of pain and suffering has long
been, quite properly, one of the central goals of medi-
cine. Those cases in which pain could be effectively
relieved, but in fact is not, should only count signifi-
cantly in favor of legalizing euthanasia if all reason-
able efforts to change pain management techniques
have been tried and have failed.

Dying patients often undergo substantial psycho-
logical suffering that is not fully or even principally
the result of physical pain. The knowledge about how
to relieve this suffering is much more limited than in
the case of relieving pain, and efforts to do so are prob-
ably more often unsuccessful. If the argument from
mercy is extended to patients experiencing great and
unrelievable psychological suffering, the numbers of
patients to which it applies are much greater.

One last good consequence of legalizing eutha-
nasia is that once death has been accepted, it is often
more humane to end life quickly and peacefully,
when that is what the patient wants. Such a death will
often be seen as better than a more prolonged one.
People who suffer a sudden and unexpected death,
for example by dying quickly or in their sleep from
a heart attack or stroke, are often considered lucky
to have died in this way. We care about how we die
in part because we care about how others remember
us, and we hope they will remember us as we were in
“good times” with them and not as we might be when
disease has robbed us of our dignity as human beings.
As with much in the treatment and care of the dying,
people’s concerns differ in this respect, but for at
least some people, euthanasia will be a more humane
death than what they have often experienced with
other loved ones and might otherwise expect for
themselves.

Some opponents of euthanasia challenge how
much importance should be given to any of these
good consequences of permitting it, or even whether
some would be good consequences at all. But more
frequently, opponents cite a number of bad conse-
quences that permitting euthanasia would or could
produce, and it is to their assessment that I now turn.

CHAPTER 10: EUTHAnASIA And PHySICIAn- ASSISTEd SUICIdE Á  311

surrogates’ rights to forgo life- sustaining treatment, yet
there is no persuasive evidence that recognizing the
right to refuse treatment has caused a serious erosion in
the quality of care of dying patients. The second reason
for skepticism about this worry is that only a very small
proportion of deaths would occur from euthanasia if
it were permitted. In the Netherlands, where eutha-
nasia under specified circumstances is permitted by
the courts, though not authorized by statute, the best
estimate of the proportion of overall deaths that result
from it is about 2 percent.3 Thus, the vast majority of
critically ill and dying patients will not request it, and
so will still have to be cared for by physicians, families,
and others. Permitting euthanasia should not dimin-
ish people’s commitment and concern to maintain
and improve the care of these patients.

A third possible bad consequence of permitting
euthanasia (or even a public discourse in which strong
support for euthanasia is evident) is to threaten the
progress made in securing the rights of patients or their
surrogates to decide about and to refuse life- sustaining
treatment. This progress has been made against the
backdrop of a clear and firm legal prohibition of eutha-
nasia, which has provided a relatively bright line limit-
ing the dominion of others over patients’ lives. It has
therefore been an important reassurance to concerns
about how the authority to take steps ending life might
be misused, abused, or wrongly extended.

Many supporters of the right of patients or their
surrogates to refuse treatment strongly oppose eutha-
nasia, and if forced to choose might well withdraw
their support of the right to refuse treatment rather
than accept euthanasia. Public policy in the last fif-
teen years has generally let life- sustaining treatment
decisions be made in health care settings between
physicians and patients or their surrogates, and with-
out the involvement of the courts. However, if eutha-
nasia is made legally permissible greater involvement
of the courts is likely, which could in turn extend to
a greater court involvement in life- sustaining treat-
ment decisions. Most agree, however, that increased
involvement of the courts in these decisions would
be undesirable, as it would make sound decisionmak-
ing more cumbersome and difficult without sufficient
compensating benefits.

I address below.) Patients’ trust of their physicians
could be increased, not eroded, by knowledge that
physicians will provide aid in dying when patients
seek it.

. . . In spelling out above what I called the posi-
tive argument for voluntary active euthanasia, I sug-
gested that two principal values— respective patients’
self- determination and promoting their well- being—
underlie the consensus that competent patients, or
the surrogates of incompetent patients, are entitled
to refuse any life- sustaining treatment and to choose
from among available alternative treatments. It is the
commitment to these two values in guiding physi-
cians’ actions as healers, comforters, and protectors of
their patients’ lives that should be at the “moral cen-
ter” of medicine, and these two values support physi-
cians’ administering euthanasia when their patients
make competent requests for it.

What should not be at that moral center is a com-
mitment to preserving patients’ lives as such, without
regard to whether those patients want their lives pre-
served or judge their preservation a benefit to them. . . .

A second bad consequence that some foresee
is that permitting euthanasia would weaken soci-
ety’s commitment to provide optimal care for dying
patients. We live at a time in which the control of
health care costs has become, and is likely to continue
to be, the dominant focus of health care policy. If
euthanasia is seen as a cheaper alternative to adequate
care and treatment, then we might become less scru-
pulous about providing sometimes costly support and
other services to dying patients. Particularly if our
society comes to embrace deeper and more explicit
rationing of health care, frail, elderly, and dying
patients will need to be strong and effective advocates
for their own health care and other needs, although
they are hardly in a position to do this. We should do
nothing to weaken their ability to obtain adequate
care and services.

This second worry is difficult to assess because
there is little firm evidence about the likelihood
of the feared erosion in the care of dying patients.
There are at least two reasons, however, for skepticism
about this argument. The first is that the same worry
could have been directed at recognizing patients’ or

312 Á  PART 4: ETHICAL ISSUES

This argument correctly identifies the reason why
offering some patients the option of euthanasia would
not benefit them. [David] Velleman takes it not as a
reason for opposing all euthanasia, but for restricting
it to circumstances where there are “unmistakable and
overpowering reasons for persons to want the option
of euthanasia,”4 and for denying the option in all
other cases. But there are at least three reasons why
such restriction may not be warranted. First, polls and
other evidence support that most Americans believe
euthanasia should be permitted (though the recent
defeat of the referendum to permit it in the state of
Washington raises some doubt about this support).
Thus, many more people seem to want the choice
than would be made worse off by getting it. Second,
if giving people the option of ending their life really
makes them worse off, then we should not only pro-
hibit euthanasia, but also take back from people the
right they now have to decide about life- sustaining
treatment. The feared harmful effect should already
have occurred from securing people’s right to refuse
life- sustaining treatment, yet there is no evidence of
any such widespread harm or any broad public desire
to rescind that right. Third, since there is a wide range
of conditions in which reasonable people can and do
disagree about whether they would want continued
life, it is not possible to restrict the permissibility of
euthanasia as narrowly as Velleman suggests without
thereby denying it to most persons who would want it;
to permit it only in cases in which virtually everyone
would want it would be to deny it to most who would
want it.

A fifth potential bad consequence of making
euthanasia legally permissible is that it might weaken
the general legal prohibition of homicide. This pro-
hibition is so fundamental to civilized society, it is
argued, that we should do nothing that erodes it. If
most cases of stopping life support are killing, as I have
already argued, then the court cases permitting such
killing have already in effect weakened this prohibi-
tion. However, neither the courts nor most people
have seen these cases as killing and so as challenging
the prohibition of homicide. The courts have usually
grounded patients’ or their surrogates’ rights to refuse
life- sustaining treatment in rights to privacy, liberty,

As with the second potential bad consequence
of permitting euthanasia, this third consideration
too is speculative and difficult to assess. The feared
erosion of patients’ or surrogates’ rights to decide
about life- sustaining treatment, together with greater
court involvement in those decisions, are both pos-
sible. However, I believe there is reason to discount
this generally worry. The legal rights of competent
patients and, to a lesser degree, surrogates of incom-
petent patients to decide about treatment are very
firmly embedded in a long line of informed consent
and life- sustaining treatment cases, and are not likely
to be eroded by a debate over, or even acceptance
of, euthanasia. It will not be accepted without safe-
guards that reassure the public about abuse, and if
that debate shows the need for similar safeguards for
some life- sustaining treatment decisions they should
be adopted there as well. In neither case are the only
possible safeguards greater court involvement, as
the recent growth of institutional ethics committees
shows.

The fourth potential bad consequence of permit-
ting euthanasia . . . turns on the subtle point that
making a new option or choice available to people
can sometimes make them worse off, even if once
they have the choice they go on to choose what is best
for them. Ordinarily, people’s continued existence is
viewed by them as given, a fixed condition with which
they must cope. Making euthanasia available to peo-
ple as an option denies them the alternative of stay-
ing alive by default. If people are offered the option of
euthanasia, their continued existence is now a choice
for which they can be held responsible and which
they can be asked by others to justify. We care, and are
right to care, about being able to justify ourselves to
others. To the extent that our society is unsympathetic
to justifying a severely dependent or impaired exis-
tence, a heavy psychological burden of proof may be
placed on patients who think their terminal illness or
chronic infirmity is not a sufficient reason for dying.
Even if they otherwise view their life as worth living,
the opinion of others around them that it is not can
threaten their reason for living and make euthanasia
a rational choice. Thus the existence of the option
becomes a subtle pressure to request it.

CHAPTER 10: EUTHAnASIA And PHySICIAn- ASSISTEd SUICIdE Á  313

cases of euthanasia we should not permit even mor-
ally justified performance of it.

Slippery slope arguments of this form are prob-
lematic and difficult to evaluate. From one per-
spective, they are the last refuge of conservative
defenders of the status quo. When all the opponent’s
objections to the wrongness of euthanasia itself have
been met, the opponent then shifts ground and
acknowledges both that it is not in itself wrong and
that a legal policy which resulted only in its being
performed would not be bad. Nevertheless, the
opponent maintains, it should still not be permitted
because doing so would result in its being performed
in other cases in which it is not voluntary and would
be wrong. In this argument’s most extreme form,
permitting euthanasia is the first and fateful step
down the slippery slope to Nazism. Once on the
slope we will be unable to get off.

Now it cannot be denied that it is possible that
permitting euthanasia could have these fateful con-
sequences, but that cannot be enough to warrant pro-
hibiting it if it is otherwise justified. A similar possible
slippery slope worry could have been raised to secur-
ing competent patients’ rights to decide about life
support, but recent history shows such a worry would
have been unfounded. It must be relevant how likely
it is that we will end with horrendous consequences
and an unjustified practice of euthanasia. How like,
and widespread would the abuses and unwarranted
extensions of permitting it be? By abuses, I mean the
performance of euthanasia that fails to satisfy the
conditions required for voluntary active euthanasia,
for example, if the patient has been subtly pressured
to accept it. By unwarranted extensions of policy,
I mean later changes in legal policy to permit not just
voluntary euthanasia, but also euthanasia in cases in
which, for example, it need not be fully voluntary.
Opponents of voluntary euthanasia on slippery slope
grounds have not provided the data or evidence nec-
essary to turn their speculative concerns into well-
grounded likelihoods.

It is at least clear, however, that both the charac-
ter and likelihood of abuses of a legal policy permit-
ting euthanasia depend in significant part on the
procedures put in place to protect against them. I will

self- determination, or bodily integrity, not in excep-
tions to homicide laws.

Legal permission for physicians or others to per-
form euthanasia could not be grounded in patients’
rights to decide about medical treatment. Permit-
ting euthanasia would require qualifying, at least in
effect, the legal prohibition against homicide, a pro-
hibition that in general does not allow the consent
of the victim to justify or excuse the act. Neverthe-
less, the very same fundamental basis of the right to
decide about life- sustaining treatment— respecting
a person’s self- determination— does support eutha-
nasia as well. Individual self- determination has long
been a well- entrenched and fundamental value in
the law, and so extending it to euthanasia would
not require appeal to novel legal values or princi-
ples. That suicide or attempted suicide is no longer
a criminal offense in virtually all states indicates an
acceptance of individual self- determination in the
taking of one’s own life analogous to that required
for voluntary active euthanasia. The legal prohibi-
tion (in most states) of assisting in suicide and the
refusal in the law to accept the consent of the vic-
tim as a possible justification of homicide are both
arguably a result of difficulties in the legal process
of establishing the consent of the victim after the
fact. If procedures can be designed that clearly estab-
lish the voluntariness of the person’s request for
euthanasia it would under those procedures repre-
sent a carefully circumscribed qualification on the
legal prohibition of homicide. Nevertheless, some
remaining worries about this weakening can be
captured in the final potential bad consequence, to
which I will now turn.

This final potential bad consequence is the cen-
tral concern of many opponents of euthanasia and,
I believe, is the most serious objection to a legal pol-
icy permitting it. According to this “slippery slope”
worry, although active euthanasia may be morally
permissible in cases in which it is unequivocally
voluntary and the patient finds his or her condi-
tion unbearable, a legal policy permitting euthana-
sia would inevitably lead to active euthanasia being
performed in many other cases in which it would
be morally wrong. To prevent those other wrongful

314 Á  PART 4: ETHICAL ISSUES

THE ROLE OF PHYSICIANS

If euthanasia is made legally permissible, should physi-
cians take part in it? Should only physicians be permit-
ted to perform it, as is the case in the Netherlands? In
discussing whether euthanasia is incompatible with
medicine’s commitment to curing, caring for, and
comforting patients, I argued that it is not at odds with
a proper understanding of the aims of medicine, and so
need not undermine patients’ trust in their physicians.
If that argument is correct, then physicians probably
should not be prohibited, either by law or by profes-
sional norms, from taking part in a legally permissible
practice of euthanasia (nor, of course, should they be
compelled to do so if their personal or professional
scruples forbid it). Most physicians in the Netherlands
appear not to understand euthanasia to be incompat-
ible with their professional commitments.

Sometimes patients who would be able to end
their lives on their own nevertheless seek the assis-
tance of physicians. Physician involvement in such
cases may have important benefits to patients and oth-
ers beyond simply assuring the use of effective means.
Historically, in the United States suicide has carried
a strong negative stigma that many today believe
unwarranted. Seeking a physician’s assistance, or what
can almost seem a physician’s blessing, may be a way
of trying to remove that stigma and show others that
the decision for suicide was made with due seriousness
and was justified under the circumstances. The physi-
cian’s involvement provides a kind of social approval,
or more accurately helps counter what would other-
wise be unwarranted social disapproval.

There are also at least two reasons for restricting
the practice of euthanasia to physicians only. First,
physicians would inevitably be involved in some of
the important procedural safeguards necessary to a
defensible practice, such as seeing to it that the patient
is well- informed about his or her condition, prognosis,
and possible treatments, and ensuring that all reason-
able means have been taken to improve the quality of
the patient’s life. Second, and probably more impor-
tant, one necessary protection against abuse of the
practice is to limit the persons given authority to per-
form it, so that they can be held accountable for their

not try to detail fully what such procedures might be,
but will just give some examples of what they might
include:

1. The patient should be provided with all relevant
information about his or her medical condition,
current prognosis, available alternative treat-
ments, and the prognosis of each.

2. Procedures should ensure that the patient’s request
for euthanasia is stable or enduring (a brief wait-
ing period could be required) and fully voluntary
(an advocate for the patient might be appointed to
ensure this).

3. All reasonable alternatives must have been explored
for improving the patient’s quality of life and reliev-
ing any pain or suffering.

4. A psychiatric evaluation should ensure that the
patient’s request is not the result of a treatable
psychological impairment such as depression.

These examples of procedural safeguards are all designed
to ensure that the patient’s choice is fully informed,
voluntary, and competent, and so a true exercise of self-
determination. Other proposals for euthanasia would
restrict its permissibility further— for example, to the
terminally ill— a restriction that cannot be supported by
self- determination. Such additional restrictions might,
however, be justified by concern for limiting potential
harms from abuse. At the same time, it is important
not to impose procedural or substantive safeguards so
restrictive as to make euthanasia impermissible or prac-
tically infeasible in a wide range of justified cases.

These examples of procedural safeguards make
clear that it is possible to substantially reduce, though
not to eliminate, the potential for abuse of a policy
permitting voluntary active euthanasia. Any legaliza-
tion of the practice should be accompanied by a well-
considered set of procedural safeguards together with an
ongoing evaluation of its use. Introducing euthanasia
into only a few states could be a form of carefully limited
and controlled social experiment that would give us evi-
dence about the benefits and harms of the practice. Even
then firm and uncontroversial data may remain elusive,
as the continuing controversy over what has taken place
in the Netherlands in recent years indicates.5

* * *

CHAPTER 10: EUTHAnASIA And PHySICIAn- ASSISTEd SUICIdE Á  315

2. Willard Gaylin, Leon R. Kass, Edmund D. Pellegrino, and
Mark Siegler, “Doctors Must Not Kill,” Journal of the American
Medical Association 259 (1988): 2139–40.

3. Paul J. Van der Maas et al., “Euthanasia and Other Medi-
cal Decisions Concerning the End of Life,” Lancet 338 (1991):
669–74.

4. David Velleman commented on an earlier version of the
paper delivered at the American Philosophical Association
Central Division meetings.

5. Richard Fenigsen, “A Case against Dutch Euthanasia,”
Special Supplement, Hastings Center Report 19, no. 1 (1989):
22–30.

exercise of that authority. Physicians, whose training
and professional norms give some assurance that they
would perform euthanasia responsibly, are an appro-
priate group of persons to whom the practice may be
restricted.

* * *

NOTES

1. P. Painton and E. Taylor, “Love or Let Die,” Time, 19
March 1990, 62–71; Boston Globe/Harvard University Poll,
Boston Globe, 3 November 1991.

Euthanasia
Philippa Foot

Under this program, planned before the War but
brought into full operation by a decree of 1 Septem-
ber 1939, some 275,000 people were gassed in centers
which were to be a model for those in which Jews were
later exterminated. Anyone in a state institution could
be sent to the gas chambers if it was considered that he
could not be “rehabilitated” for useful work. As Dr. Leo
Alexander reports, relying on the testimony of a neu-
ropathologist who received 500 brains from one of the
killing centers,

In Germany the exterminations included the mentally
defective, psychotics (particularly schizophrenics), epi-
leptics and patients suffering from infirmities of old age
and from various organic neurological disorders such as
infantile paralysis, Parkinsonism, multiple sclerosis and
brain tumors. . . . In truth, all those unable to work and
considered nonrehabilitable were killed.1

These people were killed because they were “useless”
and “a burden on society”; only the manner of their
deaths could be thought of as relatively easy and quiet.

Let us insist, then, that when we talk about eutha-
nasia we are talking about a death understood as a good
or happy event for the one who dies. This stipulation
follows etymology, but is itself not exactly in line with

The widely used Shorter Oxford English Dictionary gives
three meanings for the word “euthanasia”: the first, “a
quiet and easy death”; the second, “the means of pro-
curing this”; and the third, “the action of inducing a
quiet and easy death.” It is a curious fact that no one of
the three gives an adequate definition of the word as it
is usually understood. For “euthanasia” means much
more than a quiet and easy death, or the means of pro-
curing it, or the action of inducing it. The definition
species only the manner of the death, and if this were
all that was implied a murderer, careful to drug his vic-
tim, could claim that his act was an act of euthanasia.
We find this ridiculous because we take it for granted
that in euthanasia it is death itself, not just the man-
ner of death, that must be kind to the one who dies.

To see how important it is that “euthanasia”
should not be used as the dictionary definition allows
it to be used, merely to signify that a death was quiet
and easy, one has only to remember that Hitler’s
“euthanasia” program traded on this ambiguity.

Philippa Foot, “Euthanasia” from Philosophy and Public Affairs 6(2):
85–112. Copyright © 1977 Blackwell Publishing Ltd. Reproduced
with permission of Blackwell Publishing Ltd.

316 Á  PART 4: ETHICAL ISSUES

But is it enough that he acts with this thought, or must
things actually be as he thinks them to be? If one man
kills another, or allows him to die, thinking that he is
in the last stages of a terrible disease, though in fact
he could have been cured, is this an act of euthanasia
or not? Nothing much seems to hang on our decision
about this. The same condition has got to enter into the
definition whether as an element in reality or only as an
element in the agent’s belief. And however we define an
act of euthanasia culpability or justifiability will be the
same: if a man acts through ignorance his ignorance
may be culpable or it may not.2

These are relatively easy problems to solve, but
one that is dauntingly difficult has been passed over
in this discussion of the definition, and must now be
faced. It is easy to say, as if this raised no problems,
that an act of euthanasia is by definition one aim-
ing at the good of the one whose death is in question,
and that it is for his sake that his death is desired. But
how is this to be explained? Presumably we are think-
ing of some evil already with him or to come on him
if he continues to live, and death is thought of as a
release from this evil. But this cannot be enough.
Most people’s lives contain evils such as grief or pain,
but we do not therefore think that death would be a
blessing to them. On the contrary life is generally sup-
posed to be a good even for someone who is unusu-
ally unhappy or frustrated. How is it that one can ever
wish for death for the sake of the one who is to die?
This difficult question is central to the discussion of
euthanasia, and we shall literally not know what we
are talking about if we ask whether acts of euthanasia
defined as we have defined them are ever morally per-
missible without first understanding better the reason
for saying that life is a good, and the possibility that it
is not always so.

If a man should save my life he would be my
benefactor. In normal circumstances this is plainly
true; but does one always benefit another in saving
his life? It seems certain that he does not. Suppose, for
instance, that a man were being tortured to death and
was given a drug that lengthened his sufferings; this
would not be a benefit but the reverse. Or suppose that
in a ghetto in Nazi Germany a doctor saved the life of
someone threatened by disease, but that the man once

current usage, which would be captured by the condi-
tion that the death should not be an evil rather than
that it should be a good. That this is how people talk is
shown by the fact that the case of Karen Ann Quinlan
and others in a state of permanent coma is often dis-
cussed under the heading of “euthanasia.” Perhaps it
is not too late to object to the use of the word “eutha-
nasia” in this sense. Apart from the break with the
Greek origins of the word there are other unfortunate
aspects of this extension of the term. For if we say that
the death must be supposed to be a good to the subject
we can also specify that it shall be for his sake that an
act of euthanasia is performed. If we say merely that
death shall not be an evil to him, we cannot stipulate
that benefiting him shall be the motive where eutha-
nasia is in question. Given the importance of the ques-
tion, For whose sake are we acting? it is good to have
a definition of euthanasia which brings under this
heading only cases of opting for death for the sake
of the one who dies. Perhaps what is most important
is to say either that euthanasia is to be for the good
of the subject or at least that death is to be no evil to
him, thus refusing to talk Hitler’s language. However,
in this paper it is the first condition that will be under-
stood, with the additional proviso that by an act of
euthanasia we mean one of inducing or otherwise opt-
ing for death for the sake of the one who is to die.

A few lesser points need to be cleared up. In the
first place it must be said that the word “act” is not to
be taken to exclude omission: we shall speak of an act
of euthanasia when someone is deliberately allowed
to die, for his own good, and not only when posi-
tive measures are taken to see that he does. The very
general idea we want is that of a choice of action or
inaction directed at another man’s death and causally
effective in the sense that, in conjunction with actual
circumstances, it is a sufficient condition of death. Of
complications such as overdetermination, it will not
be necessary to speak.

A second, and definitely minor, point about the
definition of an act of euthanasia concerns the question
of fact versus belief. It has already been implied that one
who performs an act of euthanasia thinks that death
will be merciful for the subject since we have said that
it is on account of this thought that the act is done.

CHAPTER 10: EUTHAnASIA And PHySICIAn- ASSISTEd SUICIdE Á  317

people have more evil than good in their lives; we do
not, however, conclude that we would do these people
no service by rescuing them from death.

To get around this last difficulty Thomas Nagel has
suggested that experience itself is a good which must
be brought in to balance accounts.

. . . life is worth living even when the bad elements of
experience are plentiful, and the good ones too meager
to outweigh the bad ones on their own. The additional
positive weight is supplied by experience itself, rather
than by any of its contents.4

This seems implausible because if experience itself
is a good it must be so even when what we experi-
ence is wholly bad, as in being tortured to death. How
should one decide how much to count for this experi-
encing; and why count anything at all?

Others have tried to solve the problem by arguing
that it is a man’s desire for life that makes us call life a
good: if he wants to live then anyone who prolongs his
life does him a benefit. Yet someone may cling to life
where we would say confidently that it would be better
for him if he died, and he may admit it too. Speaking
of those same conditions in which, as he said, a bullet
would have been merciful, Panin writes,

I should like to pass on my observations concerning the
absence of suicides under the extremely severe condi-
tions of our concentration camps. The more that life
became desperate, the more a prisoner seemed deter-
mined to hold onto it.5

One might try to explain this by saying that hope
was the ground of this wish to survive for further days
and months in the camp. But there is nothing unintel-
ligible in the idea that a man might cling to life though
he knew those facts about his future which would
make any charitable man wish that he might die.

The problem remains, and it is hard to know where
to look for a solution. Is there a conceptual connection
between life and good? Because life is not always a good
we are apt to reject this idea, and to think that it must
be a contingent fact that life is usually a good, as it is a
contingent matter that legacies are usually a benefit, if
they are. Yet it seems not to be a contingent matter that
to save someone’s life is ordinarily to benefit him. The
problem is to find where the conceptual connection lies.

cured was transported to an extermination camp; the
doctor might wish for the sake of the patient that he
had died of the disease. Nor would a longer stretch of
life always be a benefit to the person who was given
it. Comparing Hitler’s camps with those of Stalin,
Dmitri Panin observes that in the latter the method of
extermination was made worse by agonies that could
stretch out over months.

Death from a bullet would have been bliss compared
with what many millions had to endure while dying
of hunger. The kind of death to which they were
condemned has nothing to equal it in treachery and
sadism.3

These examples show that to save or prolong
a man’s life is not always to do him a service: it may
be better for him if he dies earlier rather than later. It
must therefore be agreed that while life is normally a
benefit to the one who has it, this is not always so.

The judgment is often fairly easy to make— that
life is or is not a good to someone— but the basis for it
is very hard to find. When life is said to be a benefit or a
good, on what grounds is the assertion made?

The difficulty is underestimated if it is supposed
that the problem arises from the fact that one who is
dead has nothing, so that the good someone gets from
being alive cannot be compared with the amount he
would otherwise have had. For why should this par-
ticular comparison be necessary? Surely it would be
enough if one could say whether or not someone
whose life was prolonged had more good than evil in
the extra stretch of time. Such estimates are not always
possible, but frequently they are; we say, for example,
“He was very happy in those last years,” or, “He had
little but unhappiness then.” If the balance of good
and evil determined whether life was a good to some-
one we would expect to find a correlation in the judg-
ments. In fact, of course, we find nothing of the kind.
First, a man who has no doubt that existence is a good
to him may have no idea about the balance of happi-
ness and unhappiness in his life, or of any other posi-
tive and negative factors that may be suggested. So the
supposed criteria are not always operating where the
judgment is made. And secondly the application of
the criteria gives an answer that is often wrong. Many

318 Á  PART 4: ETHICAL ISSUES

as that an animal is better or worse off for something
that happened, or that it was a good or bad thing for
it that it did happen. And new things count as benefit.
In the first place, there is comfort, which often is, but
need not be, related to health. When loosening a col-
lar which is too tight for a dog we can say, “That will
be better for it.” So we see that the words “better for
it” have two different meanings which we mark when
necessary by a difference of emphasis, saying “better
for it” when health is involved. And secondly an ani-
mal can be benefited by having its life saved. “Could
you do anything for it?” can be answered by, “Yes, I
managed to save its life.” Sometimes we may under-
stand this, just as we would for a plant, to mean that
we had checked some disease. But we can also do
something for an animal by scaring away its preda-
tor. If we do this, it is a good thing for the animal that
we did, unless of course it immediately meets a more
unpleasant end by some other means. Similarly, on
the bad side, an animal may be worse off for our inter-
vention, and this not because it pines or suffers but
simply because it gets killed.

The problem that vexes us when we think about
euthanasia comes on the scene at this point. For if we
can do something for an animal— can benefit it— by
relieving its suffering but also by saving its life, where
does the greater benefit come when only death will
end pain? It seemed that life was a good in its own
right; yet pain seemed to be an evil with equal status
and could therefore make life not a good after all. Is
it only life without pain that is a good when animals
are concerned? This does not seem a crazy suggestion
when we are thinking of animals, since unlike human
beings they do not have suffering as part of their nor-
mal life. But it is perhaps the idea of ordinary life that
matters here. We would not say that we had done
anything for an animal if we had merely kept it alive,
either in an unconscious state or in a condition where,
though conscious, it was unable to operate in an ordi-
nary way; and the fact is that animals in severe and
continuous pain simply do not operate normally. So
we do not, on the whole, have the option of doing the
animal good by saving its life though the life would
be a life of pain. No doubt there are borderline cases,
but that is no problem. We are not trying to make new

It may be good tactics to forget for a time that it is
euthanasia we are discussing and to see how life and
good are connected in the case of living beings other
than men. Even plants have things done to them that
are harmful or beneficial, and what does them good
must be related in some way to their living and dying.
Let us therefore consider plants and animals, and then
come back to human beings. At least we shall get away
from the temptation to think that the connection
between life and benefit must everywhere be a mat-
ter of happiness and unhappiness or of pleasure and
pain; the idea being absurd in the case of animals and
impossible even to formulate for plants.

In case anyone thinks that the concept of the ben-
eficial applies only in a secondary or analogical way
to plants, he should be reminded that we speak quite
straightforwardly in saying, for instance, that a certain
amount of sunlight is beneficial to most plants. What
is in question here is the habitat in which plants of
particular species flourish, but we can also talk, in a
slightly different way, of what does them good, where
there is some suggestion of improvement or remedy.
What has the beneficial to do with sustaining life? It
is tempting to answer, “everything,” thinking that a
healthy condition just is the one apt to secure survival.
In fact, however, what is beneficial to a plant may have
to do with reproduction rather than the survival of the
individual member of the species. Nevertheless there is
a plain connection between the beneficial and the life-
sustaining even for the individual plant; if something
makes it better able to survive in conditions normal for
that species it is ipso facto good for it. We need go no
further, and could go no further, in explaining why a
certain environment or treatment is good for a plant
than to show how it helps this plant to survive.6

This connection between the life- sustaining and
the beneficial is reasonably unproblematic, and there
is nothing fanciful or zoomorphic in speaking of ben-
efiting or doing good to plants. A connection with its
survival can make something beneficial to a plant. But
this is not, of course, to say that we count life as a good
to a plant. We may save its life by giving it what is ben-
eficial; we do not benefit it by saving its life.

A more ramified concept of benefit is used in
speaking of animal life. New things can be said, such

CHAPTER 10: EUTHAnASIA And PHySICIAn- ASSISTEd SUICIdE Á  319

a good to one permanently in the latter state, and we
must return to this topic later on.

When are we to say that life is a good or a benefit to
a man? The dilemma that faces us is this. If we say that
life as such is a good we find ourselves refuted by the
examples given at the beginning of this discussion. We
therefore incline to think that it is as bringing good
things that life is a good, where it is a good. But if life is
a good only because it is the condition of good things
why is it not equally an evil when it brings bad things?
And how can it be a good even when it brings more
evil than good?

It should be noted that the problem has here been
formulated in terms of the balance of good and evil,
not that of happiness and unhappiness, and that it
is not to be solved by the denial (which may be rea-
sonable enough) that unhappiness is the only evil or
happiness the only good. In this paper no view has
been expressed about the nature of goods other than
life itself. The point is that on any view of the goods
and evils that life can contain, it seems that a life with
more evil than good could still itself be a good.

It may be useful to review the judgments with
which our theory must square. Do we think that life
can be a good to one who suffers a lot of pain? Clearly
we do. What about severely handicapped people; can
life be a good to them? Clearly it can be, for even if
someone is almost completely paralyzed, perhaps liv-
ing in an iron lung, perhaps able to move things only
by means of a tube held between his lips, we do not
rule him out of order if he says that some benefactor
saved his life. Nor is it different with mental handicap.
There are many fairly severely handicapped people—
such as those with [Down] Syndrome (Mongolism)—
for whom a simple affectionate life is possible. What
about senility? Does this break the normal connection
between life and good? Here we must surely distin-
guish between forms of senility. Some forms leave a life
which we count someone as better off having than not
having, so that a doctor who prolonged it would ben-
efit the person concerned. With some kinds of senility
this is however no longer true. There are some in geri-
atric wards who are barely conscious, though they can
move a little and swallow food put into their mouths.
To prolong such a state, whether in the old or in the

judgments possible, but rather to find the principle
of the ones we do make.

When we reach human life the problems seem
even more troublesome. For now we must take quite
new things into account, such as the subject’s own
view of his life. It is arguable that this places extra
constraints on the solution: might it not be counted
as a necessary condition of life’s being a good to a
man that he should see it as such? Is there not some
difficulty about the idea that a benefit might be done
to him by the saving or prolonging of his life even
though he himself wished for death? Of course he
might have a quite mistaken view of his own pros-
pects, but let us ignore this and think only of cases
where it is life as he knows it that is in question. Can
we think that the prolonging of his life would be a
benefit to him even though he would rather have it
end than continue? It seems that this cannot be ruled
out. That there is no simple incompatibility between
life as a good and the wish for death is shown by the
possibility that a man should wish himself dead, not
for his own sake, but for the sake of someone else.
And if we try to amend the thesis to say that life can-
not be a good to one who wishes for his own sake that
he should die, we find the crucial concept slipping
through our fingers. As Bishop Butler pointed out
long ago not all ends are either benevolent or self-
interested. Does a man wish for death for his own
sake in the relevant sense if, for instance, he wishes
to revenge himself on another by his death? Or what
if he is proud and refuses to stomach dependence or
incapacity even though there are many good things
left in life for him? The truth seems to be that the
wish for death is sometimes compatible with life’s
being a good and sometimes not, which is possible
because the description “wishing for death” is one
covering diverse states of mind from that of the
determined suicide, pathologically depressed, to that
of one who is surprised to find that the thought of a
fatal accident is viewed with relief. On the one hand,
a man may see his life as a burden but go about his
business in a more or less ordinary way; on the other
hand, the wish for death may take the form of a rejec-
tion of everything that is in life, as it does in severe
depression. It seems reasonable to say that life is not

320 Á  PART 4: ETHICAL ISSUES

goods are already absent for a different reason. So, for
instance, the connection between life and good may
be broken because consciousness has sunk to a very
low level, as in extreme senility or severe brain dam-
age. In itself this kind of life seems to be neither good
nor evil, but if suffering sets in one would hope for a
speedy end.

The idea we need seems to be that of life which is
ordinary human life in the following respect— that it
contains a minimum of basic human goods. What is
ordinary in human life— even in very hard lives— is
that a man is not driven to work far beyond his capac-
ity; that he has the support of a family or community;
that he can more or less satisfy his hunger; that he
has hopes for the future; that he can lie down to rest
at night. Such things were denied to the men in the
Vyatlag camps described by Panin; not even rest at
night was allowed them when they were tormented
by bed- bugs, by noise and stench, and by routines
such as body- searches and bath- parades— arranged
for the night time so that work norms would not be
reduced. Disease too can so take over a man’s life that
the normal human goods disappear. When a patient
is so overwhelmed by pain or nausea that he cannot
eat with pleasure, if he can eat at all, and is out of the
reach of even the most loving voice, he no longer has
ordinary human life in the sense in which the words
are used here. And we may now pick up a thread from
an earlier part of the discussion by remarking that
crippling depression can destroy the enjoyment of
ordinary goods as effectively as external circumstances
can remove them.

This, admittedly inadequate, discussion of the
sense in which life is normally a good, and of the
reasons why it may not be so in some particular case,
completes the account of what euthanasia is here
taken to be. An act of euthanasia, whether literally act
or rather omission, is attributed to an agent who opts
for the death of another because in his case life seems
to be an evil rather than a good. The question now to
be asked is whether acts of euthanasia are ever justi-
fiable. But there are two topics here rather than one.
For it is one thing to say that some acts of euthanasia
considered only in themselves and their results are
morally unobjectionable, and another to say that it

very severely mentally handicapped is not to do them
a service or confer a benefit. But of course it need not
be the reverse: only if there is suffering would one wish
for the sake of the patient that he should die.

It seems, therefore, that merely being alive even
without suffering is not a good, and that we must
make a distinction similar to that which we made
when animals were our topic. But how is the line to be
drawn in the case of men? What is to count as ordinary
human life in the relevant sense? If it were only the
very senile or very ill who were to be said not to have
this life it might seem right to describe it in terms of
operation. But it will be hard to find the sense in which
the men described by Panin were not operating, given
that they dragged themselves out to the forest to work.
What is it about the life that the prisoners were living
that makes us put it on the other side of the dividing
line from that of some severely ill or suffering patients,
and from most of the physically or mentally handi-
capped? It is not that they were in captivity, for life in
captivity can certainly be a good. Nor is it merely the
unusual nature of their life. In some ways the prison-
ers were living more as other men do than the patient
in an iron lung.

The suggested solution to the problem is, then,
that there is a certain conceptual connection between
life and good in the case of human beings as in that of
animals and even plants. Here, as there, however, it is
not the mere state of being alive that can determine,
or itself count as, a good, but rather life coming up to
some standard of normality. It was argued that it is as
part of ordinary life that the elements of good that a
man may have are relevant to the question of whether
saving his life counts as benefiting him. Ordinary
human lives, even very hard lives, contain a minimum
of basic goods, but when these are absent the idea of
life is no longer linked to that of good. And since it is
in this way that the elements of good contained in a
man’s life are relevant to the question of whether he is
benefited if his life is preserved, there is no reason why
it should be the balance of good and evil that counts.

It should be added that evils are relevant in one
way when, as in the examples discussed above, they
destroy the possibility of ordinary goods, but in a dif-
ferent way when they invade a life from which the

CHAPTER 10: EUTHAnASIA And PHySICIAn- ASSISTEd SUICIdE Á  321

of others. An act of charity is in question only where
something is not demanded by justice, but a lack
of charity and of justice can be shown where a man
is denied something which he both needs and has a
right to; both charity and justice demand that wid-
ows and orphans are not defrauded, and the man who
cheats them is neither charitable nor just.

It is easy to see that the two grounds of objec-
tion to inducing death are distinct. A murder is an
act of injustice. A culpable failure to come to the aid
of someone whose life is threatened is normally con-
trary, not to justice, but to charity. But where one
man is under contract, explicit or implicit, to come to
the aid of another injustice too will be shown. Thus
injustice may be involved either in an act or an omis-
sion, and the same is true of a lack of charity; charity
may demand that someone be aided, but also that an
unkind word not be spoken.

The distinction between charity and justice will
turn out to be of the first importance when voluntary
and nonvoluntary euthanasia are distinguished later
on. This is because of the connection between justice
and rights, and something should now be said about
this. I believe it is true to say that wherever a man acts
unjustly he has infringed a right, since justice has to
do with whatever a man is owed, and whatever he is
owed is his as a matter of right. Something should
therefore be said about the different kinds of rights.
The distinction commonly made is between having
a right in the sense of having a liberty, and having a
“ claim- right” or “right of recipience.” The best way to
understand such a distinction seems to be as follows.
To say that a man has a right in the sense of liberty is
to say that no one can demand that he do not do the
thing which he has a right to do. The fact that he has a
right to do it consists in the fact that a certain kind of
objection does not lie against his doing it. Thus a man
has a right in this sense to walk down a public street or
park his car in a public parking space. It does not fol-
low that no one else may prevent him from doing so.
If for some reason I want a certain man not to park in
a certain place I may lawfully park there myself or get
my friends to do so, thus preventing him from doing
what he has a right (in the sense of a liberty) to do. It is
different, however, with a claim- right. This is the kind

would be all right to legalize them. Perhaps the prac-
tice of euthanasia would allow too many abuses, and
perhaps there would be too many mistakes. Moreover
the practice might have very important and highly
undesirable side effects, because it is unlikely that we
could change our principles about the treatment of
the old and the ill without changing fundamental
emotional attitudes and social relations. The topics
must, therefore, be treated separately. In the next part
of the discussion, nothing will be said about the social
consequences and possible abuses of the practice of
euthanasia, but only about acts of euthanasia consid-
ered in themselves.

What we want to know is whether acts of eutha-
nasia, defined as we have defined them, are ever mor-
ally permissible. To be more accurate, we want to know
whether it is ever sufficient justification of the choice
of death for another that death can be counted a ben-
efit rather than harm, and that this is why the choice
is made.

It will be impossible to get a clear view of the area
to which this topic belongs without first marking the
distinct grounds on which objection may lie when
one man ops for the death of another. There are two
different virtues whose requirements are, in general,
contrary to such actions. An unjustified act of killing,
or allowing to die, is contrary to justice or to charity, or
to both virtues, and the moral failings are distinct. Jus-
tice has to do with what men owe each other in the way
of noninterference and positive service. When used in
this wide sense, which has its history in the doctrine of
the cardinal virtues, justice is not especially connected
with, for instance, law courts but with the whole area
of rights, and duties corresponding to rights. Thus
murder is one form of injustice, dishonesty another,
and wrongful failure to keep contracts a third; chi-
canery in a law court or defrauding someone of his
inheritance are simply other cases of injustice. Justice
as such is not directly linked to the good of another,
and may require that something be rendered to him
even where it will do him harm, as Hume pointed out
when he remarked that a debt must be paid even to a
profligate debauchee who “would rather receive harm
than benefit from large possessions.”7 Charity, on the
other hand, is the virtue which attaches us to the good

322 Á  PART 4: ETHICAL ISSUES

should be said to have “a claim,” distinguishing this
from a “valid claim,” which gives a claim- right.

The manifesto writers on the other side who seem to
identify needs, or at least basic needs, with what they
call “human rights,” are more properly described,
I think, as urging upon the world community the
moral principle that all basic human needs ought to
be recognized as claims (in the customary prima facie
sense) worthy of sympathy and serious consideration
right now, even though, in many cases, they cannot yet
plausibly be treated as valid claims, that is, as grounds
of any other people’s duties. This way of talking avoids
the anomaly of ascribing to all human beings now,
even those in pre- industrial societies, such “economic
and social rights” as “periodic holidays with pay.”8

This seems reasonable, though we notice that
there are some actual rights to service which are not
based on anything like a contract, as for instance the
right that children have to support from their parents
and parents to support from their children in old age,
though both sets of rights are to some extent depen-
dent on existing social arrangements.

Let us now ask how the right to life affects the
morality of acts of euthanasia. Are such acts some-
times or always ruled out by the right to life? This is
certainly a possibility; for although an act of euthana-
sia is, by our definition, a matter of opting for death for
the good of the one who is to die, there is, as we noted
earlier, no direct connection between that to which a
man has a right and that which is for his good. It is
true that men have the right only to the kind of thing
that is, in general, a good: we do not think that people
have the right to garbage or polluted air. Neverthe-
less, a man may have the right to something which
he himself would be better off without; where rights
exist it is a man’s will that counts not his or anyone
else’s estimate of benefit or harm. So the duties com-
plementary to the right to life— the general duty of
noninterference and the duty of service incurred by
certain persons— are not affected by the quality of
a man’s life or by his prospects. Even if it is true that
he would be, as we say, “better off dead,” so long as he
wants to live this does not justify us in killing him and
may not justify us in deliberately allowing him to die.
All of us have the duty of noninterference, and some

of right which I have in addition to a liberty when, for
example, I have a private parking space; now others
have duties in the way of noninterference, as in this
case, or of service, as in the case where my claim- right
is to goods or services promised to me. Sometimes one
of these rights gives other people the duty of securing
to me that to which I have a right, but at other times
their duty is merely to refrain from interference. If a
fall of snow blocks my private parking space there is
normally no obligation for anyone else to clear it away.
Claim- rights generate duties; sometimes these duties
are duties of noninterference; sometimes they are
duties of service. If your right gives me the duty not to
interfere with you I have “no right” to do it; similarly,
if your right gives me the duty to provide something
for you I have “no right” to refuse to do it. What I lack
is the right which is a liberty; I am not “at liberty” to
interfere with you or to refuse the service.

Where in this picture does the right to life belong?
No doubt people have the right to live in the sense of
a liberty, but what is important is the cluster of claim-
rights brought together under the title of the right to
life. The chief of these is, of course, the right to be free
from interferences that threaten life. If other people
aim their guns at us or try to pour poison into our
drink we can, to put it mildly, demand that they desist.
And then there are the services we can claim from doc-
tors, health officers, bodyguards, and firemen; the
rights that depend on contract or public arrangement.
Perhaps there is no particular point in saying that the
duties these people owe us belong to the right to life;
we might as well say that all the services owed to any-
one by tailors, dressmakers, and couturiers belong to a
right called the right to be elegant. But contracts such
as those understood in the patient- doctor relationship
come in an important way when we are discussing the
rights and wrongs of euthanasia, and are therefore
mentioned here.

Do people have the right to what they need in
order to survive, apart from the right conferred by spe-
cial contracts into which other people have entered for
the supplying of these necessities? Do people in the
underdeveloped countries in which starvation is rife
have the right to the food they so evidently lack? Joel
Feinberg, discussing this question, suggests that they

CHAPTER 10: EUTHAnASIA And PHySICIAn- ASSISTEd SUICIdE Á  323

speak of the disconnecting of the apparatus as killing
the man, or of the hospital as allowing him to die. By
and large, it is the act of killing that is ruled out under
the heading of noninterference, but not in every case.

Doctors commonly recognize this distinction,
and the grounds on which some philosophers have
denied it seem untenable. James Rachels, for instance,
believes that if the difference between active and pas-
sive is relevant anywhere, it should be relevant every-
where, and he has pointed to an example in which it
seems to make no difference which is done. If some-
one saw a child drowning in a bath it would seem just
as bad to let it drown as to push its head under water.
If “it makes no difference” means that one act would
be as iniquitous as the other this is true. It is not that
killing is worse than allowing to die, but that the two
are contrary to distinct virtues, which gives the pos-
sibility that in some circumstances one is impermis-
sible and the other permissible. In the circumstances
invented by Rachels, both are wicked: it is contrary
to justice to push the child’s head under the water—
something one has no right to do. To leave it to drown
is not contrary to justice, but it is a particularly glar-
ing example of lack of charity. Here it makes no prac-
tical difference because the requirements of justice
and charity coincide; but in the case of the retreating
army they did not: charity would have required that
the wounded soldier be killed had not justice required
that he be left alive.9 In such a case it makes all the dif-
ference whether a man opts for the death of another in
a positive action, or whether he allows him to die. An
analogy with the right to property will make the point
clear. If a man owns something he has the right to it
even when its possession does him harm, and we have
no right to take it from him. But if one day it should
blow away, maybe nothing requires us to get it back
for him; we could not deprive him of it, but we may
allow it to go. This is not to deny that it will often be an
unfriendly act or one based on an arrogant judgment
when we refuse to do what he wants. Nevertheless,
we would be within our rights, and it might be that
no moral objection of any kind would lie against our
refusal.

It is important to emphasize that a man’s rights
may stand between us and the action we would dearly

of us may have the duty to sustain his life. Suppose,
for example, that a retreating army has to leave behind
wounded or exhausted soldiers in the wastes of an arid
or snowbound land where the only prospect is death
by starvation or at the hands of an enemy notoriously
cruel. It has often been the practice to accord a mer-
ciful bullet to men in such desperate straits. But sup-
pose that one of them demands that he should be left
alive? It seems clear that his comrades have no right
to kill him, though it is a quite different question as to
whether they should give him a life- prolonging drug.
The right to life can sometimes give a duty of positive
service, but does not do so here. What it does give is
the right to be left alone.

Interestingly enough we have arrived by way of
a consideration of the right to life at the distinction
normally labeled “active” versus “passive” euthana-
sia, and often thought to be irrelevant to the moral
issue. Once it is seen that the right to life is a distinct
ground of objection to certain acts of euthanasia, and
that this right creates a duty of noninterference more
widespread than the duties of care there can be no
doubt about the relevance of the distinction between
passive and active euthanasia. Where everyone may
have the duty to leave someone alone, it may be that
no one has the duty to maintain his life, or that only
some people do.

Where then do the boundaries of the “active”
and “passive” lie? In some ways the words are
themselves misleading, because they suggest the dif-
ference between act and omission which is not quite
what we want. Certainly the act of shooting someone
is the kind of thing we were talking about under the
heading of “interference,” and omitting to give him a
drug a case of refusing care. But the act of turning off
a respirator should surely be thought of as no different
from the decision not to start it; if doctors had decided
that a patient should be allowed to die, either course
of action might follow, and both should be counted
as passive rather than active euthanasia if euthanasia
were in question. The point seems to be that interfer-
ence in a course of treatment is not the same as other
interference in a man’s life, and particularly if the
same body of people are responsible for the treatment
and for its discontinuance. In such a case we could

324 Á  PART 4: ETHICAL ISSUES

classes of persons such as bodyguards, firemen, or doc-
tors? Unlike the general public they are not within
their rights if they merely refrain from interfering and
do not try to sustain life. The subject’s claim- rights are
two- fold as far as they are concerned and passive as
well as active euthanasia may be ruled out here if it is
against his will. This is not to say that he has the right
to any and every service needed to save or prolong
his life; the rights of other people set limits to what
may be demanded, both because they have the right
not to be interfered with and because they may have
a competing right to services. Furthermore one must
enquire just what the contract or implicit agreement
amounts to in each case. Firemen and bodyguards
presumably have a duty which is simply to preserve
life, within the limits of justice to others and of rea-
sonableness to themselves. With doctors it may how-
ever be different, since their duty relates not only to
preserving life but also to the relief of suffering. It is
not clear what a doctor’s duties are to his patient if life
can be prolonged only at the cost of suffering or suffer-
ing relieved only by measures that shorten life. George
Fletcher has argued that what the doctor is under con-
tract to do depends on what is generally done, because
this is what a patient will reasonably expect.10 This
seems right. If procedures are part of normal medical
practice then it seems that the patient can demand
them however much it may be against his interest to
do so. Once again it is not a matter of what is “most
humane.”

That the patient’s right to life may set limits to
permissible acts of euthanasia seems undeniable. If he
does not want to die no one has the right to practice
active euthanasia on him, and passive euthanasia may
also be ruled out where he has a right to the services of
doctors or others.

Perhaps few will deny what has so far been said
about the impermissibility of acts of euthanasia sim-
ply because we have so far spoken about the case of
one who positively wants to live, and about his rights,
whereas those who advocate euthanasia are usually
thinking either about those who wish to die or about
those whose wishes cannot be ascertained either
because they cannot properly be said to have wishes
or because, for one reason or another, we are unable

like to take for his sake. They may, of course, also pre-
vent action which we would like to take for the sake
of others, as when it might be tempting to kill one
man to save several. But it is interesting that the lim-
its of allowable interference, however uncertain, seem
stricter in the first case than the second. Perhaps there
are no cases in which it would be all right to kill a
man against his will for his own sake unless they could
equally well be described as cases of allowing him to
die, as in the example of turning off the respirator.
However, there are circumstances, even if these are
very rare, in which one man’s life would justifiably be
sacrificed to save others, and “killing” would be the
only description of what was being done. For instance,
a vehicle which had gone out of control might be
steered from a path on which it would kill more than
one man to a path on which it would kill one. But it
would not be permissible to steer a vehicle towards
someone in order to kill him, against his will, for his
own good. An analogy with property rights illustrates
the point. One may not destroy a man’s property
against his will on the grounds that he would be bet-
ter off without it; there are however circumstances in
which it could be destroyed for the sake of others. If his
house is liable to fall and kill him that is his affair; it
might, however, without injustice be destroyed to stop
the spread of a fire.

We see then that the distinction between active
and passive, important as it is elsewhere, has a special
importance in the area of euthanasia. It should also
be clear why James Rachels’ other argument, that it
is often “more humane” to kill than to allow to die,
does not show that the distinction between active and
passive euthanasia is morally irrelevant. It might be
“more humane” in this sense to deprive a man of the
property that brings evils on him, or to refuse to pay
what is owed to Hume’s profligate debauchee; but if
we say this we must admit that an act which is “more
humane” than its alternative may be morally objec-
tionable because it infringes rights.

So far we have said very little about the right to
service as opposed to the right to noninterference,
though it was agreed that both might be brought
under the heading of “the right to life.” What about
the duty to preserve life that may belong to special

CHAPTER 10: EUTHAnASIA And PHySICIAn- ASSISTEd SUICIdE Á  325

In the last paragraph we have begun to broach the
topic of voluntary euthanasia, and this we must now
discuss. What is to be said about the case in which there
is no doubt about someone’s wish to die: either he has
told us beforehand that he would wish it in circum-
stances such as he is now in, and has shown no sign of
a change of mind, or else he tells us now, being in pos-
session of his faculties and of a steady mind. We should
surely say that the objections previously urged against
acts of euthanasia, which it must be remembered were
all on the ground of rights, had disappeared. It does
not seem that one would infringe someone’s right to
life in killing him with his permission and in fact at
his request. Why should someone not be able to waive
his right to life, or rather, as would be more likely to
happen, to cancel some of the duties of noninterfer-
ence that this right entails? (He is more likely to say
that he should be killed by this man at this time in
this manner, than to say that anyone may kill him
at any time and in any way.) Similarly someone may
give permission for the destruction of his property,
and request it. The important thing is that he gives a
critical permission, and it seems that this is enough to
cancel the duty normally associated with the right. If
someone gives you permission to destroy his property
it can no longer be said that you have no right to do
so, and I do not see why it should not be the case with
taking a man’s life. An objection might be made on the
ground that only God has the right to take life, but in
this paper religious as opposed to moral arguments are
being left aside. Religion apart, there seems to be no
case to be made out for an infringement of rights if a
man who wishes to die is allowed to die or even killed.
But of course it does not follow that there is no moral
objection to it. Even with property, which is after all a
relatively small matter, one might be wrong to destroy
what one had the right to destroy. For, apart from its
value to other people, it might be valuable to the man
who wanted it destroyed, and charity might require us
to hold our hand where justice did not.

Let us review the conclusion of this part of the
argument, which has been about euthanasia and the
right to life. It has been argued that from this side come
stringent restrictions on the acts of euthanasia that
could be morally permissible. Active nonvoluntary

to form a reliable estimate of what they are. The ques-
tion that must now be asked is whether the latter type
of case, where euthanasia though not involuntary
would again be nonvoluntary, is different from the
one discussed so far. Would we have the right to kill
someone for his own good so long as we had no idea
that he positively wished to live? And what about
the life- prolonging duties of doctors in the same cir-
cumstances? This is a very difficult problem. On the
one hand, it seems ridiculous to suppose that a man’s
right to life is something which generates duties only
where he has signaled that he wants to live; as a bor-
rower does indeed have a duty to return something
lent on indefinite loan only if the lender indicates
that he wants it back. On the other hand, it might be
argued that there is something illogical about the idea
that a right has been infringed if someone incapable
of saying whether he wants it or not is deprived of
something that is doing him harm rather than good.
Yet on the analogy of property we would say that a
right has been infringed. Only if someone had ear-
lier told us that in such circumstances he would not
want to keep the thing could we think that his right
had been waived. Perhaps if we could make confident
judgments about what anyone in such circumstances
would wish, or what he would have wished before-
hand had he considered the matter, we could agree
to consider the right to life as “dormant,” needing to
be asserted if the normal duties were to remain. But as
things are we cannot make any such assumption; we
simply do not know what most people would want, or
would have wanted, us to do unless they tell us. This is
certainly the case so far as active measures to end life
are concerned. Possibly it is different, or will become
different, in the matter of being kept alive, so general
is the feeling against using sophisticated procedures
on moribund patients, and so much is this dreaded
by people who are old or terminally ill. Once again
the distinction between active and passive euthana-
sia has come on the scene, but this time because most
people’s attitudes to the two are so different. It is just
possible that we might presume, in the absence of spe-
cific evidence, that someone would not wish, beyond
a certain point, to be kept alive; it is certainly not pos-
sible to assume that he would wish to be killed.

326 Á  PART 4: ETHICAL ISSUES

wounded soldier a drug that would keep him alive to
meet a terrible end. And it is even more obvious that
charity does not always dictate that life should be
prolonged where a man’s own wishes, hypothetical or
actual, are not known.

So much for the relation of charity to nonvolun-
tary passive euthanasia, which was not, like nonvol-
untary active euthanasia, ruled out by the right to life.
Let us now ask what charity has to say about voluntary
euthanasia both active and passive. It was suggested
in the discussion of justice that if of sound mind and
steady desire a man might give others the right to allow
him to die or even to kill him, where otherwise this
would be ruled out. But it was pointed out that this
would not settle the question of whether the act was
morally permissible, and it is this that we must now
consider. Could not charity speak against what justice
allowed? Indeed it might do so. For while the fact that
a man wants to die suggests that his life is wretched,
and while his rejection of life may itself tend to take
the good out of the things he might have enjoyed,
nevertheless his wish to die might here be opposed
for his own sake just as it might be if suicide were in
question. Perhaps there is hope that his mental condi-
tion will improve. Perhaps he is mistaken in thinking
his disease incurable. Perhaps he wants to die for the
sake of someone else on whom he feels he is a burden,
and we are not ready to accept this sacrifice whether
for ourselves or others. In such cases, and there will
surely be many of them, it could not be for his own
sake that we kill him or allow him to die, and there-
fore euthanasia as defined in this paper would not be
in question. But this is not to deny that there could be
acts of voluntary euthanasia both passive and active
against which neither justice nor charity would speak.

We have now considered the morality of euthana-
sia both voluntary and nonvoluntary, and active and
passive. The conclusion has been that nonvoluntary
active euthanasia (roughly, killing a man against his will
or without his consent) is never justified; that is to say,
that a man’s being killed for his own good never justifies
the act unless he himself has consented to it. A man’s
rights are infringed by such an action, and it is there-
fore contrary to justice. However, all the other combi-
nations, nonvoluntary passive euthanasia, voluntary

euthanasia is ruled out by that part of the right to life
which creates the duty of noninterference though
passive nonvoluntary euthanasia is not ruled out,
except where the right to life- preserving action has
been created by some special condition such as a
contract between a man and his doctor, and it is not
always certain just what such a contract involves. Vol-
untary euthanasia is another matter: as the preceding
paragraph suggested, no right is infringed if a man is
allowed to die or even killed at his own request.

Turning now to the other objection that nor-
mally holds against inducing the death of another,
that it is against charity, or benevolence, we must tell
a very different story. Charity is the virtue that gives
attachment to the good of others, and because life is
normally a good, charity normally demands that it
should be saved or prolonged. But as we so defined
an act of euthanasia that it seeks a man’s death for his
own sake— for his good— charity will normally speak
in favor of it. This is not, of course, to say that charity
can require an act of euthanasia which justice forbids,
but if an act of euthanasia is not contrary to justice—
that is, it does not infringe rights— charity will rather
be in its favor than against.

Once more the distinction between nonvoluntary
and voluntary euthanasia must be considered. Could
it ever be compatible with charity to seek a man’s
death although he wanted to live, or at least had not
let us know that he wanted to die? It has been argued
that in such circumstances active euthanasia would
infringe his right to life, but passive euthanasia would
not do so, unless he had some special right to life-
preserving service from the one who allowed him to
die. What would charity dictate? Obviously when a
man wants to live there is a presumption that he will
be benefited if his life is prolonged, and if it is so the
question of euthanasia does not arise. But it is, on
the other hand, possible that he wants to live where
it would be better for him to die: perhaps he does not
realize the desperate situation he is in, or perhaps he is
afraid of dying. So, in spite of a very proper resistance
to refusing to go along with a man’s own wishes in the
matter of life and death, someone might justifiably
refuse to prolong the life even of someone who asked
him to prolong it, as in the case of refusing to give the

CHAPTER 10: EUTHAnASIA And PHySICIAn- ASSISTEd SUICIdE Á  327

in our sense or only as the Nazis understood it is
another matter. We must ask the crucial question,
“Is it for the sake of the child himself that the doc-
tors and parents choose his death?” In some cases the
answer may really be yes, and what is more important
it may really be true that the kind of life which is a
good is not possible or likely for this child, and that
there is little but suffering and frustration in store
for him.12 But this must presuppose that the medi-
cal prognosis is wretchedly bad, as it maybe for some
spina bifida children. With children who are born
with [Down] Syndrome it is, however, quite different.
Most of these are able to live on for quite a time in
a reasonably contented way, remaining like children
all their lives but capable of affectionate relationships
and able to play games and perform simple tasks.
The fact is, of course, that the doctors who recom-
mend against life- saving procedures for handicapped
infants are usually thinking not of them but rather of
their parents and of other children in the family or of
the “burden on society” if the children survive. So it
is not for their sake but to avoid trouble to others that
they are allowed to die. When brought out into the
open this seems unacceptable: at least we do not eas-
ily accept the principle that adults who need special
care should be counted too burdensome to be kept
alive. It must in any case be insisted that if children
with [Down] Syndrome are deliberately allowed to
die this is not a matter of euthanasia except in Hitler’s
sense. And for our children, since we scruple to gas
them, not even the manner of their death is “quiet
and easy”; when not treated for an intestinal obstruc-
tion a baby simply starves to death. Perhaps some will
take this as an argument for allowing active eutha-
nasia, in which case they will be in the company of
an S.S. man stationed in the Warthgenau who sent
Eichmann a memorandum telling him that “Jews in
the coming winter could no longer be fed” and sub-
mitting for his consideration a proposal as to whether
“it would not be the most humane solution to kill
those Jews who were incapable of work through some
quicker means.”13 If we say we are unable to look after
children with handicaps we are no more telling the
truth than was the S.S. man who said that the Jews
could not be fed.

active euthanasia, and voluntary passive euthanasia
are sometimes compatible with both justice and char-
ity. But the strong condition carried in the definition of
euthanasia adopted in this paper must not be forgotten;
an act of euthanasia as here understood is one whose
purpose is to benefit the one who dies.

In the light of this discussion let us look at our
present practices. Are they good or are they bad? And
what changes might be made, thinking now not only
of the morality of particular acts of euthanasia but
also of the indirect effects of instituting different prac-
tices, of the abuses to which they might be subject and
of the changes that might come about if euthanasia
became a recognized part of the social scene.

The first thing to notice is that it is wrong to ask
whether we should introduce the practice of eutha-
nasia as if it were not something we already had. In
fact we do have it. For instance it is common, where
the medical prognosis is very bad, for doctors to rec-
ommend against measures to prolong life, and par-
ticularly where a process of degeneration producing
one medical emergency after another has already set
in. If these doctors are not certainly within their legal
rights this is something that is apt to come as a sur-
prise to them as to the general public. It is also obvious
that euthanasia is often practiced where old people
are concerned. If someone very old and soon to die
is attacked by a disease that makes his life wretched,
doctors do not always come in with life- prolonging
drugs. Perhaps poor patients are more fortunate in this
respect than rich patients, being more often left to die
in peace; but it is in any case a well recognized piece of
medical practice, which is a form of euthanasia.

No doubt the case of infants with mental or phys-
ical defects will be suggested as another example of
the practice of euthanasia as we already have it, since
such infants are sometimes deliberately allowed to
die. That they are deliberately allowed to die is cer-
tain; children with severe spina bifida malformations
are not always operated on even where it is thought
that without the operation they will die; and even in
the case of children with [Down] Syndrome who have
intestinal obstructions the relatively simple opera-
tion that would make it possible to feed them is some-
times not performed.11 Whether this is euthanasia

328 Á  PART 4: ETHICAL ISSUES

people want, and want very badly, to be rid of their
elderly relatives and even of their ailing husbands or
wives. Would any safeguards ever be able to stop them
describing as euthanasia what was really for their own
benefit? And would it be possible to prevent the occur-
rence of acts which were genuinely acts of euthana-
sia but morally impermissible because infringing the
rights of a patient who wished to live?

Perhaps the furthest we should go is to encourage
patients to make their own contracts with a doctor by
making it known whether they wish him to prolong
their life in case of painful terminal illness or of inca-
pacity. A document such as the Living Will seems emi-
nently sensible, and should surely be allowed to give
a doctor following the previously expressed wishes
of the patient immunity from legal proceedings by
relatives.14 Legalizing active euthanasia is, however,
another matter. Apart from the special repugnance
doctors feel towards the idea of a lethal injection, it
may be of the very greatest importance to keep a psy-
chological barrier up against killing. Moreover it is
active euthanasia which is the most liable to abuse.
Hitler would not have been able to kill 275,000 peo-
ple in his “euthanasia” program if he had had to wait
for them to need life- saving treatment. But there are
other objections to active euthanasia, even voluntary
active euthanasia. In the first place it would be hard
to devise procedures that would protect people from
being persuaded into giving their consent. And sec-
ondly the possibility of active voluntary euthanasia
might change the social scene in ways that would be
very bad. As things are, people do, by and large, expect
to be looked after if they are old or ill. This is one of
the good things that we have, but we might lose it,
and be much worse off without it. It might come to
be expected that someone likely to need a lot of look-
ing after should call for the doctor and demand his
own death. Something comparable could be good in
an extremely poverty- stricken community where the
children genuinely suffered from lack of food; but in
rich societies such as ours it would surely be a spiri-
tual disaster. Such possibilities should make us very
wary of supporting large measures of euthanasia, even
where moral principle applied to the individual act
does not rule it out.

Nevertheless if it is ever right to allow deformed
children to die because life will be a misery to them,
or not to take measures to prolong for a little the life
of a newborn baby whose life cannot extend beyond
a few months of intense medical intervention, there
is a genuine problem about active as opposed to pas-
sive euthanasia. There are well- known cases in which
the medical staff has looked on wretchedly while an
infant died slowly from starvation and dehydration
because they did not feel able to give a lethal injection.
According to the principles discussed in the earlier
part of this paper they would indeed have had no right
to give it, since an infant cannot ask that it should be
done. The only possible solution— supposing that vol-
untary active euthanasia were to be legalized— would
be to appoint guardians to act on the infant’s behalf.
In a different climate of opinion this might not be
dangerous, but at present, when people so readily
assume that the life of a handicapped baby is of no
value, one would be loath to support it.

Finally, on the subject of handicapped children,
another word should be said about those with severe
mental defects. For them too it might sometimes be
right to say that one would wish for death for their
sake. But not even severe mental handicap automati-
cally brings a child within the scope even of a possible
act of euthanasia. If the level of consciousness is low
enough it could not be said that life is a good to them,
any more than in the case of those suffering from
extreme senility. Nevertheless if they do not suffer it
will not be an act of euthanasia by which someone
opts for their death. Perhaps charity does not demand
that strenuous measures are taken to keep people in
this state alive, but euthanasia does not come into the
matter, any more than it does when someone is, like
Karen Ann Quinlan, in a state of permanent coma.
Much could be said about this last case. It might even
be suggested that in the case of unconsciousness this
“life” is not the life to which “the right to life” refers.
But that is not our topic here.

What we must consider, even if only briefly, is the
possibility that euthanasia, genuine euthanasia, and
not contrary to the requirements of justice or char-
ity, should be legalized over a wider area. Here we are
up against the really serious problem of abuse. Many

CHAPTER 10: EUTHAnASIA And PHySICIAn- ASSISTEd SUICIdE Á  329

act of injustice which would have been for someone’s
good.

10. George Fletcher, “Legal Aspects of the Decision not
to Prolong Life,” Journal of the American Medical
Association 203, no. 1 (1 Jan. 1968): 119–122. Reprinted in
Gorovitz.

11. I have been told this by a pediatrician in a well- known
medical center in the United States. It is confirmed
by Anthony M. Shaw and Iris A. Shaw, “Dilemma of
Informed Consent in Children,” The New England Journal of
Medicine 289, no. 17 (25 Oct. 1973): 885–890. Reprinted in
Gorovitz.

12. It must be remembered, however, that many of the
social miseries of spina bifida children could be avoided.
Professor R.B. Zachary is surely right to insist on this. See,
for example, “Ethical and Social Aspects of Spina Bifida,” The
Lancet, 3 Aug. 1968, pp. 274–276. Reprinted in Gorovitz.

13. Quoted by Hannah Arendt, Eichmann in Jerusalem (Lon-
don, 1963), p. 90.

14. Details of this document are to be found in J.A. Behnke
and Sissela Bok, eds., The Dilemmas of Euthanasia (New York,
1975), and in A.B. Downing, ed., Euthanasia and the Right to
Life: The Case for Voluntary Euthanasia (London, 1969).

NOTES

1. Leo Alexander, “Medical Science under Dictatorship,” New
England Journal of Medicine, 14 July 1949, p. 40.

2. For a discussion of culpable and nonculpable ignorance see
Thomas Aquinas, Summa Theologica, First Part of the Second
Part, Question 6, article 8, and Question 19, articles 5 and 6.

3. Dmitri Panin, The Notebooks of Sologdin (London, 1976),
pp. 66–67.

4. Thomas Nagel, “Death,” in James Rachels, ed., Moral Prob-
lems (New York, 1971), p. 362.

5. Panin, Sologdin, p. 85.

6. Yet some detail needs to be filled in to explain why we
should not say that a scarecrow is beneficial to the plants it
protects. Perhaps what is beneficial must either be a feature
of the plant itself, such as protective prickles, or else must
work on the plant directly, such as a line of trees which give
it shade.

7. David Hume, Treatise, Book III, Part II, Section 1.

8. Feinberg, “Human Rights,” Moral Problems in Medicine,
p. 465.

9. It is not, however, that justice and charity conflict. A
man does not lack charity because he refrains from an

Killing and Allowing to Die
Daniel Callahan

rests on the commonplace observation that lives can
come to an end as the result of: (a) the direct action of
another who becomes the cause of death (as in shoot-
ing a person), and (b) the result of impersonal forces
where no human agent has acted (death by lightning,
or by disease). The purpose of the distinction has been
to separate those deaths caused by human action, and
those caused by nonhuman events. It is, as a distinc-
tion, meant to say something about human beings
and their relationship to the world. It is a way of
articulating the difference between those actions for
which human beings can be held rightly responsible,
or blamed, and those of which they are innocent. At

* * *

If a lessened worry about the consequences of legal
euthanasia has been gaining ground, there has been
an even more powerful threat to the traditional pro-
hibition against it. No valid distinction, many now
argue, can be made between killing and allowing
to die, or between an act of commission and one of
omission. The standard distinction being challenged

Daniel Callahan, “Can We Return Death to Disease?” from
Hastings Center Report 19(1): 4–6. Copyright © 1989 The Hastings
Center. Reproduced with permission of John Wiley & Sons, Inc.

330 Á  PART 4: ETHICAL ISSUES

Of course that is a fantasy. The fact that we can
intervene in nature, and cure or control many dis-
eases, does not erase the difference between the self
and the external world. It is as “out there” as ever,
even if more under our sway. That sway, however
great, is always limited. We can cure disease, but not
always the chronic illness that comes with the cure.
We can forestall death with modern medicine, but
death always wins in the long run because of the
innate limitations of the body, inherently and stub-
bornly beyond final human control. And we can dis-
tinguish between a diseased body and an aging body,
but in the end if we wait long enough they always
become one and the same body. To attempt to deny
the distinction between killing and allowing to die
is, then, mistakenly to impute more power to human
action than it actually has and to accept the conceit
that nature has now fallen wholly within the realm of
human control. Not so.

Moral. At the center of the distinction between
killing and allowing to die is the difference between
physical causality and moral culpability. To bring
the life of another to an end by an injection kills the
other directly; our action is the physical cause of the
death. To allow someone to die from a disease we
cannot cure (and that we did not cause) is to permit
the disease to act as the cause of death. The notion
of physical causality in both cases rests on the differ-
ence between human agency and the action of exter-
nal nature. The ambiguity arises precisely because
we can be morally culpable for killing someone (if
we have no moral right to do so, as we would in self-
defense) and no less culpable for allowing someone
to die (if we have both the possibility and the obli-
gation of keeping that person alive). Thus there are
cases where, morally speaking, it makes no difference
whether we killed or allowed to die; we are equally
responsible. In those instances, the lines of physical
causality and moral culpability happen to cross. Yet
the fact that they can cross in some cases in no way
shows that they are always, or even usually, one and
the same. We can normally find the difference in all
but the most obscure cases. We should not, then, use
the ambiguity of such cases to do away altogether
with the distinction between killing and allowing to

issue is the difference between physical causality, the
realm of impersonal events, and moral culpability, the
realm of human responsibility.

The challenges encompass two points. The first is
that people can become equally dead by our omissions
as well as our commissions. We can refrain from saving
them when it is possible to do so, and they will be just
as dead as if we shot them. It is our decision itself that
is the reason for their death, not necessarily how we
effectuate that decision. That fact establishes the basis
of the second point: if we intend their death, it can be
brought about as well by omitted acts as by those we
commit. The crucial moral point is not how they die,
but our intention about their death. We can, then, be
responsible for the death of another by intending that
they die and accomplish that end by standing aside
and allowing them to die.

Despite these criticisms— resting upon ambigui-
ties that can readily be acknowledged— the distinction
between killing and allowing to die remains, I con-
tend, perfectly valid. It not only has a logical validity
but, no less importantly, a social validity whose place
must be central in moral judgments. As a way of put-
ting the distinction into perspective, I want to suggest
that it is best understood as expressing three differ-
ent, though overlapping, perspectives on nature and
human action. I will call them the metaphysical, the
moral, and the medical perspectives.

Metaphysical. The first and most fundamental
premise of the distinction between killing and allow-
ing to die is that there is a sharp difference between
the self and the external world. Unlike the childish
fantasy that the world is nothing more than a projec-
tion of the self, or the neurotic person’s fear that he
or she is responsible for everything that goes wrong,
the distinction is meant to uphold a simple notion:
there is a world external to the self that has its own,
and independent, causal dynamism. The mistake
behind a conflation of killing and allowing to die is to
assume that the self has become master of everything
within and outside of the self. It is as if the conceit
that modern man might ultimately control nature
has been internalized: that, if the self might be able
to influence nature by its actions, then the self and
nature must be one.

CHAPTER 10: EUTHAnASIA And PHySICIAn- ASSISTEd SUICIdE Á  331

be, and be seen to be, a limited power. It may be used
only to cure or comfort, never to kill. They have not
been given, nor should they be given, the power to use
their knowledge and skills to bring life to an end. It
would open the way for powerful misuse and, no less
importantly, represent an intrinsic violation of what it
has meant to be a physician.

Yet if it is possible for physicians to misuse their
knowledge and power to kill people directly, are they
thereby required to use that same knowledge always
to keep people alive, always to resist a disease that
can itself kill the patient? The traditional answer has
been: not necessarily. For the physician’s ultimate
obligation is to the welfare of the patient, and exces-
sive treatment can be as detrimental to that welfare
as inadequate treatment. Put another way, the obliga-
tion to resist the lethal power of disease is limited—
it ceases when the patient is unwilling to have it
resisted, or where the resistance no longer serves the
patient’s welfare. Behind this moral premise is the
recognition that disease (of some kind) ultimately
triumphs and that death is both inevitable sooner or
later and not, in any case, always the greatest human
evil. To demand of the physician that he always strug-
gle against disease, as if it was in his power always to
conquer it, would be to fall into the same metaphysi-
cal trap mentioned above: that of assuming that no
distinction can be drawn between natural and human
agency.

A final word. I suggested earlier that the most
potent motive for active euthanasia and assisted sui-
cide stems from a dread of the power of medicine.
That power then seems to take on a drive of its own
regardless of the welfare or wishes of patients. No
one can easily say no— not physicians, not patients,
not families. My guess is that happens because too
many have already come to believe that it is their
choice, and their choice alone, which brings about
death; and they do not want to exercise that kind of
authority. The solution is not to erase the distinction
between killing and allowing to die, but to under-
score its validity and importance. We can bring
disease as a cause of death back into the care of the
dying.

die. The ambiguity may obscure, but does not erase,
the line between the two.

There is one group of ambiguous cases that is
especially troublesome. Even if we grant the ordi-
nary validity between killing and allowing to die,
what about those cases that combine (a) an illness
that renders a patient unable to carry out an ordi-
nary biological function (to breathe or eat on his
own, for example), and (b) our turning off a respi-
rator or removing an artificial feeding tube? On the
level of physical causality, have we killed the patient
or allowed him to die? In one sense, it is our action
that shortens his life, and yet in another sense his
underlying disease brings his life to an end. I believe
it reasonable to say that, since his life was being
sustained by artificial means (respirator or feeding
tube) made necessary because of the fact that he had
an incapacitating disease, his disease is the ultimate
reality behind his death. But for its reality, there
would be no need for artificial sustenance in the
first place and no moral issue at all. To lose sight of
the paramount reality of the disease is to lose sight
of the difference between our selves and the outer
world.

I quickly add, and underscore, a moral point: the
person who, without good moral reason, turns off a
respirator or pulls a feeding tube, can be morally cul-
pable; that the patient has been allowed to die of his
underlying condition does not morally excuse him.
The moral question is whether we are obliged to con-
tinue treating a life that is being artificially sustained.
To cease treatment may or may not be morally accept-
able; but it should be understood, in either case,
that the physical cause of death was the underlying
disease.

Medical. An important social purpose of the dis-
tinction between killing and allowing to die has been
that of protecting the historical role of the physician
as one who tries to cure or comfort patients rather
than to kill patients. Physicians have been given spe-
cial knowledge about the body, knowledge that can be
used to kill or to cure. They are also given great privi-
leges in making use of that knowledge. It is thus all the
more important that physicians’ social role and power

332 Á  PART 4: ETHICAL ISSUES

Euthanasia for Disabled People?
Liz Carr

Frustrated by the lack of opportunity to have the
voices of people like me— of disabled people— heard
on this issue, I have decided to combine my activism
with my career as a performer.

I’ve never seen a piece of art or theatre which
expresses opposition to legalising assisted suicide from
a disabled person’s perspective— so I decided to try to
rectify that. The result is Assisted Suicide: The Musical—
a show which premieres this weekend at the Royal Fes-
tival Hall, London, and marks the first anniversary of
the defeat of the assisted dying bill in parliament.

There were of course religious people there with
me and many others outside Westminster on Friday
11 September 2015. But MPs who glanced out the
window would have seen more Not Dead Yet (NDY) T-
shirts and banners than religious ones. NDY is made
up of disabled people opposed to a change in the law.
Every major disabled group in the UK, it should be
stressed, is opposed to this legislation.

Suicide is, of course, an individual choice. Dis-
abled people who are determined to take their lives
may even find it easier to do so than abled people,
given the often precarious nature of their existences.
But that does not mean that when a fellow human
being— disabled or abled— expresses the wish to die
because their life is shit, that we should agree with
them. The value of a life is not just in its physicality
but in our relationships with those around us.

The bill, had it passed, would have licensed doc-
tors to assist in the deaths of terminally ill people who
had less than six months to live, were mentally compe-
tent and requested such assistance. But the direction
legislation has taken in other countries shows that the
sympathy we disabled people evoke can be used to jus-
tify support for us to kill ourselves while non- disabled
people are told they have “everything to live for”. How
many times has someone come up to me and said how
much they admired me just for existing because they
could not, in my condition?

There is a fine line between those who are ter-
minally ill and those who are disabled in public

If I said I wanted to die, the press, celebrities and the
public would support my choice, seeing it as rational
and understandable. Hell, they would probably set up
a GoFundMe campaign to help me make it happen.

Yet when a healthy, non- disabled person wants
to kill themself it’s seen as a tragedy, and support and
prevention tools are provided. If nothing else convinces
me that to legalise assisted suicide is not a safe option
for many of us, then this does. Suicide is not seen as
socially desirable— so why is assisted suicide seen as
compassionate when it’s for ill or disabled people?

Marieke Vervoort, the 38- year- old Belgian Para-
lympian gold medallist, is only the most recent dis-
abled person to announce that she is considering
euthanasia, saying her “body is exhausted”. She is not
imminently dying. Yet no one seems to be trying to
persuade her that life is worthwhile. Would Usain Bolt
be met with the same reaction if he announced his
decision to end it all after his last Olympics?

Although proponents of assisted suicide legisla-
tion say it’s only for those with six months or less to
live, they propagandise with cases like that of Daniel
James, the 23- year- old man paralysed (but not dying)
following a rugby accident, who killed himself at the
Swiss clinic Dignitas after he said he did not want
to live a “ second- class” (that is, disabled) life. Jeffrey
Spector, a 54- year- old man also not imminently dying,
also killed himself at Dignitas.

The Netherlands, which legalised euthanasia to pro-
vide relief for the terminally ill, now regularly provides
euthanasia for disabled people who can demonstrate
“unbearable suffering”. Canada, the most recent nation
to legalise euthanasia and assisted suicide, allows it for
“serious and incurable illness, disease or disability”.

Usually, the two sides of the argument are char-
acterised as “religious” (opposed to legalisation) or
“secular” (in favour). But it’s not that simple.

Liz Carr, “Legalising Assisted Dying Is Dangerous for Disabled
People, Not Compassionate,” The Guardian, September 9, 2016.
Copyright © Guardian News & Media Ltd. 2018. Reprinted with
permission.

CHAPTER 10: EUTHAnASIA And PHySICIAn- ASSISTEd SUICIdE Á  333

also know from the US that some people have been
denied life- extending treatments because they are too
costly while the cheaper assisted suicide option has
been offered as an alternative. Think this won’t hap-
pen here? Medical rationing is the reality of our over-
stretched NHS.

No one wants us, those we love, or even those
we don’t to suffer and die in pain. But shouldn’t
we try to get end- of- life care right before we throw
physician- assisted killing into the mix? Currently
hospices and palliative care are only available to the
few, and hospices continue to rely on donations for
their survival.

Please, don’t wish death upon us because you feel
pity for our condition. It is demoralising when dis-
abled people like Vervoort express— understandably—
exhaustion with the everyday struggle of existence
and discouragement with life and are met with sad,
understanding nods. On Saturday, it is world suicide
prevention day. Can we be included in suicide preven-
tion efforts, too, please?

perception, and the emotional power behind the cam-
paign for assisted suicide is based on misplaced pity.
Rather than telling us we have everything to live for—
and we do— we are helped to the proverbial cliff edge
and offered a push.

People— disabled and not, with many years or
only a few months ahead of them— become suicidal
for many, many reasons. We know from surveys in
Oregon, one of just four states in the US where assisted
suicide is legal, that the reasons people choose this
option have little to do with pain, although this is
always the emphasis of supporters of assisted dying.

In fact, loss of dignity, loss of autonomy, loss
of ability to do daily activities, and fear of being a
burden— reasons which are essentially more about the
realities of living with a disability in our society— are
all more important than pain.

It is worth keeping in mind, too, that, in the con-
text of economic arguments about a health service
overly concerned with “waste” of resources, disabled
people may be seen as a drain, just like the elderly. We

Cover (Doing Ethics: Moral Reasoning and Contemporary Issues)
Front Matter
Title Page�����������������
Copyright����������������
Contents���������������
Preface��������������

Part 1 – Fundamentals����������������������������
Chapter 1 – Ethics and the Examined Life�����������������������������������������������
The Ethical Landscape����������������������������
The Elements of Ethics�����������������������������
Religion and Morality����������������������������

Chapter 2 – Subjectivism, Relativism, and Emotivism����������������������������������������������������������
Subjective Relativism����������������������������
Cultural Relativism��������������������������
Emotivism����������������

Part 2 – Moral Reasoning�������������������������������
Chapter 3 – Evaluating Moral Arguments���������������������������������������������
Claims and Arguments���������������������������
Arguments Good and Bad�����������������������������
Implied Premises�����������������������
Deconstructing Arguments�������������������������������
Moral Statements and Arguments�������������������������������������
Testing Moral Premises�����������������������������
Assessing Nonmoral Premises����������������������������������
Avoiding Bad Arguments�����������������������������
Writing and Speaking About Moral Issues����������������������������������������������

Chapter 4 – The Power of Moral Theories����������������������������������������������
Theories of Right and Wrong����������������������������������
Major Theories���������������������
Evaluating Theories��������������������������
Devising a Coherent Moral Theory

Part 3 – Theories of Morality������������������������������������
Chapter 5 – Consequentialist Theories: Maximize the Good���������������������������������������������������������������
Ethical Egoism���������������������
Utilitarianism���������������������
Learning from Utilitarianism����������������������������������������������������������������������������������������������������
Social Contract Theory�����������������������������

Chapter 6 – Nonconsequentialist Theories: Do Your Duty�������������������������������������������������������������
Kant’s Ethics��������������������
Learning from Kant’s Theory�������������������������������������������������������������������������������������������������
Natural Law Theory�������������������������
Learning from Natural Law

Chapter 7 – Virtue Ethics: Be a Good Person��������������������������������������������������
The Ethics of Virtue���������������������������
Virtue in Action
Evaluating Virtue Ethics�������������������������������
Learning from Virtue Ethics

Chapter 8 – Feminist Ethics and the Ethics of Care���������������������������������������������������������
Feminist Ethics����������������������
The Ethics of Care�������������������������

Part 4 – Ethical Issues������������������������������
Chapter 9 – Abortion���������������������������
Issue File: Background�����������������������������
Moral Theories���������������������
Moral Arguments����������������������

Chapter 10 – Euthanasia and Physician-Assisted Suicide
Issue File: Background�����������������������������
Moral Theories���������������������
Moral Arguments����������������������

Chapter 11 – Delivering Health Care������������������������������������������
Issue File: Background�����������������������������
Moral Theories���������������������
Moral Arguments����������������������

Chapter 12 – Animal Welfare����������������������������������
Issue File: Background�����������������������������
Moral Theories���������������������
Moral Arguments����������������������

Chapter 13 – Environmental Ethics����������������������������������������
Issue File: Background�����������������������������
Moral Theories���������������������
Moral Arguments����������������������

Chapter 14 – Racism, Equality, and Discrimination��������������������������������������������������������
Issue File: Background�����������������������������
Moral Theories���������������������
Moral Arguments����������������������

Chapter 15 – Sexual Morality�����������������������������������
Issue File: Background�����������������������������
Moral Theories���������������������
Moral Arguments����������������������

Chapter 16 – Free Speech on Campus�����������������������������������������
Issue File: Background�����������������������������
Moral Theories���������������������
Moral Arguments����������������������

Chapter 17 – Drugs, Guns, and Personal Liberty�����������������������������������������������������
Issue File: Background�����������������������������
Moral Theories���������������������
Moral Arguments����������������������

Chapter 18 – Capital Punishment��������������������������������������
Issue File: Background�����������������������������
Moral Theories���������������������
Moral Arguments����������������������

Chapter 19 – Political Violence: War, Terrorism, and Torture�������������������������������������������������������������������
Issue File: Background�����������������������������
Moral Theories���������������������
Moral Arguments����������������������

Chapter 20 – The Ethics of Immigration���������������������������������������������
Issue File: Background�����������������������������
Moral Theories���������������������
Moral Arguments����������������������

Chapter 21 – Global Economic Justice�������������������������������������������
Issue File: Background�����������������������������
Moral Theories���������������������
Moral Arguments����������������������

Glossary
Answers to Argument Exercises
Notes
Index




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