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Why Euthanasia Should Be Legal: Analysis of Arguments and Counterarguments

• Categories: Assisted Suicide Euthanasia Right to Die

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Introduction, why euthanasia should be legal, works cited, counterarguments.

• Corder, Mike. “Dutch Euthanasia Center Sees 22% Rise in Requests in 2019.” WAVY.com, 7 Feb. 2020, www.wavy.com/news/health/dutch-euthanasia-center-sees-22-rise-in-requests-in-2019/. Accessed 10 March 2020.
• Davis, Jacky. “Kevin Davis Deserved Choice.” Dignity in Dying, www.dignityindying.org.uk/story/kevin-davis/. Accessed 13 March 2020.
• De La Torre, Esther B. The Right to Assisted Suicide , www.lonestar.edu/rightto-assist-suicide.htm. Accessed 19 March 2020.
• “Euthanasia Laws - Information on the Law about Euthanasia.” Information on the Law about Euthanasia - Suicide, Life, Act, and Mercy - JRank Articles, law.jrank.org/pages/11858/Euthanasia.html. Accessed 10 March 2020.

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Should assisted dying be legalised?

• Thomas D G Frost 1 ,
• Devan Sinha 2 &
• Barnabas J Gilbert 3  

Philosophy, Ethics, and Humanities in Medicine volume  9 , Article number:  3 ( 2014 ) Cite this article

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When an individual facing intractable pain is given an estimate of a few months to live, does hastening death become a viable and legitimate alternative for willing patients? Has the time come for physicians to do away with the traditional notion of healthcare as maintaining or improving physical and mental health, and instead accept their own limitations by facilitating death when requested? The Universities of Oxford and Cambridge held the 2013 Varsity Medical Debate on the motion “This House Would Legalise Assisted Dying”. This article summarises the key arguments developed over the course of the debate. We will explore how assisted dying can affect both the patient and doctor; the nature of consent and limits of autonomy; the effects on society; the viability of a proposed model; and, perhaps most importantly, the potential need for the practice within our current medico-legal framework.

Introduction

Over the past two centuries, the United Kingdom has experienced rapid population growth associated with a substantial decline in mortality from acute infectious diseases and poor nutrition [ 1 ]. As the average life expectancy has increased, so too have the rates of debilitating chronic illness – particularly coronary artery disease and cancers [ 2 ]. These diseases require years of treatment instead of the mere days to weeks that medicine once operated within [ 2 ]. Although healthcare systems have sought to adapt to such changes, aiming to prevent and treat such disease wherever possible, debate has arisen regarding those patients in the latter stages of chronic, incurable, terminal conditions [ 3 , 4 ]. Moreover, there is increasing recognition that the patient must be at the centre of health care decision-making, such that outcomes must be tailored to their individual needs and views. By extension, assisted dying might seem a logical step to help achieve these goals within the realm of end-of-life decision making [ 5 ]. Several jurisdictions, notably Oregon (1997) and the Netherlands (2001) have already legalised assisted dying in some form. These factors have contributed to ongoing legislative discussions within Parliaments for almost a decade, with current opinion polling suggesting a majority of medical practitioners and the public in favour of physician-assisted suicide [ 6 ].

Viability of assisted dying in practice

In the UK, a model for assisted dying has been developed from the legal structure found within the Assisted Dying Bill introduced by Lord Falconer in the House of Lords in 2013 [ 7 ]. Assisted dying could only be considered under circumstances in which a patient of legal age is diagnosed with a progressive disease that is irreversible by treatment and is “reasonably expected to die within six months” [ 7 ]. Registered medical practitioners would make such decisions for patients with terminal illnesses. Addressing the technicalities of ‘assisted dying’ requires distinction between ‘physician-assisted suicide’ (offering patients medical actions or cessation of actions by which they can end their own life) and ‘euthanasia’ (whereby the medical practitioner actively induces death). In light of the strong hostility of the medical profession towards active euthanasia, this proposed model, as with previous attempts to legalise assisted dying, permitted only the former [ 8 – 10 ].

However, there is concern that such distinction may be unrealistic in practice because medical practitioners could find themselves with a patient who had failed to successfully end their own life and was subsequently left in a state of greater suffering. Were such a patient no longer able to give consent, a heavy burden would then be placed on the physician regarding how to proceed. Moreover, the practice of physician-assisted suicide might be deemed discriminatory, for example by giving only patients with good mobility control over their own method of death.

The Assisted Dying Bill 2013 included the provision that any terminal prognosis must be confirmed and attested by a second registered practitioner. The strictness of such criteria has parallels to a similar double-physician requirement when procuring a legal abortion under the 1967 Abortion Act. The stated aims of the provision in both cases are as follows: first, to check the accuracy of the prognosis upon which the decision was being made; second, to ensure that the situation meets the required criteria; and third, to check that such a decision was taken by the patient after full consideration of all available options [ 11 , 12 ]. By having a second independent doctor, the legislation ensures that all three checks are met without prejudice or mistake.

Problematic for any protocol for assisted dying is the fact that estimates of life expectancy in terminal prognoses are erroneous in 80.3% of cases [ 13 ]. Furthermore, the accuracy of such prognoses deteriorates with increased length of clinical predicted survival. Forecasts of survival times are based largely on past clinical experience, and the inherent variability between patients makes this more of an art than a science. This brings to concern both the accuracy of any prognosis meeting the six-month threshold and the validity of requests for assisted dying based partly or wholly on predicted survival times. Whilst the majority of errors in life expectancy forecasts are a matter of over-optimism and hence would not affect either of those two concerns, many cases remain unaccounted for. Overly pessimistic forecasts occur in 17.3% of prognoses; hence we must decide whether the one in six patients making a decision based on an inaccurate prognosis is too high a cost to justify the use of this system. Patients requesting an assisted death often cite future expectations of dependency, loss of dignity, or pain [ 14 ]. If the hypothetical point at which the progression of their illness means they would consider life to be not worth living is not, as informed, mere weeks away but in fact many more months, then this information would have resulted in a different decision outcome and potentiated unnecessary loss of life.

Whilst the presence of a second doctor would be expected to mitigate such forecasting errors, the anchoring bias of the initial prediction may be enough to similarly reduce the accuracy of the second estimate. It is prudent to question the true independence of a second medical practitioner, and whether this second consultation could become more of a formality, as has now become the case with abortion [ 15 ].

Another challenge for an assisted dying system would be to recognise whether patients requesting death were legally competent to make that decision. Consider that any request for suicide from a patient with clinical depression is generally categorised as a manifestation of that mental disorder, thereby lacking capacity. It is arguably impossible to separate out the natural reactions to terminal illness and clinical depression. Indeed, there is evidence that major depressive disorders afflict between 25% and 77% of patients with terminal illness [ 16 , 17 ]. Any protocol for assisted dying must first determine what qualifies as a ‘fit mental state’ for a terminal patient.

The need for assisted dying

It could be argued that a doctor’s fundamental duty is to alleviate forms of suffering in the best interests of the patient. The avoidance of physical pain, as an obvious manifestation of suffering, might explain why assisted dying would be both necessary and within the duties of a doctor to provide. The evolving principle in common law known as the ‘Doctrine of Double Effect’ offers a solution to this problem [ 18 ]. This legal judgement stated that “[a doctor] is entitled to do all that is proper and necessary to relieve pain even if the measures he takes may incidentally shorten life”. This entails that a protocol already exists for patients searching for an escape from chronic pain. Furthermore, numerous retrospective studies have revealed very little correlation between opioid dose and mean survival times: one study of over 700 opioid-treated patients found that the variation in survival time from high-dose opioid treatment is less than 10% [ 19 – 21 ]. It can therefore be said that pain alone, if appropriately managed, should never be cause for considering assisted dying as an alternative.

By contrast, the ‘Doctrine of Double Effect’ might be seen as a subjective interpretation that has been applied unequally due to a lack of specialist training or knowledge [ 22 ]. Despite this, the principle can be easily understood and poor awareness can be remedied by improvements in medical education and standardisation of protocols. Moreover, should we choose to accept arguments for assisted dying that are based upon inadequate administration of pain medication, we set a precedent for conceding shortcomings in palliative care and other end-of-life treatments. Offering hastened death could become an alternative to actively seeking to improve such failings.

Whilst much has been made of the ‘pain argument’ here, the call for assisted dying is rarely this simple. Many patients also suffer a loss of dignity, often due to their lack of mobility – the inability to relieve oneself without help is a potent example. Beyond this are additional fears of further debilitation and the emotional costs of dealing with chronic illness, both for the patient and for their relatives and friends. A study of terminal patients in Oregon showed that these were the most significant reasons behind requests for assisted suicide, the next commonest reason being the perception of themselves as a ‘burden’ [ 14 ]. Clearly, we could seek to provide balanced, compassionate medical care for these patients, and still fail to address these points.

Developments in healthcare and technology may reduce this emotional burden, but remain an imperfect solution.

Rights of patients and limitations of their autonomy

J.S. Mill’s pithy dictum describes autonomy as follows: “over himself, over his own body and mind, the individual is sovereign” [ 23 ]. Not only has the sanctity of bodily autonomy profoundly influenced the development of liberal democracies, it has also provoked a holistic shift in making our healthcare systems more patient-centred – “care that meets and responds to patients’ wants, needs and preferences and where patients are autonomous and able to decide for themselves” [ 5 ]. The ethical principle of controlling the fate of one’s own body is inherently relevant to the debate on assisted dying. It is difficult to reconcile that citizens may have the right to do almost anything to and with their own bodies– from participating in extreme sports to having elective plastic surgery – yet a terminal patient cannot choose to avoid experiencing additional months of discomfort or loss of dignity in their final months of life.

Expectation of individual liberty has been codified in law. The right to bodily autonomy has been interpreted to be included under Article 8 - the right to privacy - of the European Convention on Human Rights (ECHR) and subsequently the Human Rights Act (HRA) [ 24 , 25 ]. Moreover, the ECHR underpins the right of individuals to ‘inherent dignity’ [ 26 ]. Hence, if an individual feels that dignity is unattainable due to the progression of a terminal illness, then taking recourse though assisted dying ought to be a legitimate option.

Conversely, there are two notable oversights in this interpretation of a right to assisted dying as an extension of the principles of bodily autonomy:

First, it would be wrong to view individual liberty as absolute. The HRA allows for exceptions to Article 8 on grounds of ‘health or morals’ [ 25 ]. The principle of autonomy is not inviolable. Governments have limited such privileges for the protection of individuals and society, for example by criminalizing the use of recreational drugs or the selling of one’s own organs. The preservation of life by denying assisted dying could fall within this category.

Second, the right of autonomy is not necessarily intrinsic to human beings but, as Kant argued, is dependent on our ‘rational nature’ [ 27 ]. This concept sees autonomy as an exercise of ‘evaluative choice’ [ 27 ], requiring rationality on the part of individuals to appreciate the nature of options and their consequences. To achieve true autonomy, there must be sufficient information to make those rational decisions; this is the basis of informed consent and why it is a fundamental duty of a doctor to offer a patient an informed series of treatment options [ 28 ]. The logistical issue is that doctors are unable to advise patients regarding the point at which their situation becomes less preferable to being dead. No doctor (or individual) has any knowledge or experience of what ‘death’ may be like. Hence, in this case, the idea of exercising true autonomy through informed consent might be considered meaningless.

Legalising assisted dying by attempting to establish an absolute right to bodily autonomy may undermine other individual and group rights. Vulnerable patients may feel pressured into assisted dying because of social, emotional, or financial strains placed on family and/or friends. This is exemplified by the trend showing that the proportion of patients stating ‘relief of burden’ on others as the reason for requesting assisted dying has risen from 17% to 25% in Oregon since legalisation [ 29 ]. One could even consider the risk of assisted dying becoming an expected choice rather than a free one. Thus, assisted dying may erode the elemental right to life of terminal patients as the value of their life becomes tied to relative costs to society and to those around them.

Moreover, by creating one class of individuals for whom life is expendable, that particular view may be extended by society to all groups possessing such attributes (e.g. the permanently disabled). There would be a definite risk to the rights of these vulnerable groups in the form of society being less willing to provide for their health and social care.

It is often raised that the limited legalisation of assisted dying would inevitably become extended in scope, but this is not necessarily a flaw. Even if the right to determine the manner of death were later extended to a wider group of people, posterity may reflect positively on such a change, just as extending the franchise to women ultimately led to legislation demanding equal pay.

Effect on health professionals and their role

‘To act in the best interest of the patient’ is often cited as a central duty of the doctor [ 28 ]. This concept of ‘best interest’ guiding the doctor’s action has seen the development of two important ethical principles: beneficence and non-maleficence. Beneficence mandates that the actions of the doctor must be aimed to bring about benefit (clinical improvement) for the patient, usually measured in terms of reduced morbidity or mortality; non-maleficence requires that the doctor not carry out treatment that is likely to cause overall harm the patient [ 30 ]. These traditional ethical imperatives on a doctor both conflict with intentionally hastening the death of a patient, and a resolution of this tension would require redefining what constitutes ‘acting in the best interest’.

A further dimension is the potential reluctance of health professionals to engage in a practice that contravenes their own ethical beliefs, particularly as this would affect doctors who never entered training in the knowledge that assisting patients to die would be an expected duty. This is certainly no argument against the introduction of assisted dying; indeed, a recent survey of a cohort of NHS doctors found that 46% would seriously consider requests from patients to undertake steps to hasten death [ 31 ]. It merely expresses the point that any early model would have to account for the fact that an initial 54% of the doctors in the NHS would be required to advise qualifying patients of assisted dying as a legitimate option, despite disagreeing with it in principle.

Furthermore, doctors who agree ethically with this practice may find themselves facing conflicts of interest. It is expensive to treat chronically ill patients, particularly in the final months of life [ 32 ]. Moreover, it would be difficult for commissioners to ignore the fact that the sustained treatment of one individual could deprive many others from access to surgery or access to novel drugs. Such an argument does not suggest that doctors or any other hospital staff would treat this practice without appropriate respect or care; rather it acknowledges the need for appropriate rationing of care and questions the intentions of service providers. The perception of an ulterior motive could negatively impact patient trust. One survey showed that a reasonable minority of patients (27%) – and particularly particularly the elderly – believe that legalising assisted dying would lessen their trust in their personal physician [ 33 ]. The costs of weakened trust in the doctor-patient relationship could far outweigh the benefits of assisted dying, particularly given the importance of trust when treating a chronic patient for an extended period of time.

There is no doubt that assisted dying would empower some patients to maximise control over the timing and manner of their own death. Such expression of autonomy would surely solidify moves towards a patient-centred approach to healthcare. However, the capacity for such consensual requests remains in doubt. Clinically, the patient’s state of mind and the reliability of diagnostic predictions are of issue; philosophically, the idea of informed consent for death is contradictory. The implications for patients, physicians and society have been weighed extensively within this article. The central tenet throughout has been the balancing of an individual’s right to escape a circumstance that they find intolerable, alongside the consequential changes to their other rights, and the rights and responsibilities of third parties. Ultimately, the challenge is for us as a society to decide where this balance lies.

About the debate

The Varsity Medical Debate was started in 2008 with the aim of allowing students, professors and members of the polis, to engage in discussion about ethics and policy within healthcare. Utilising the age-old rivalry between the two Universities, the debate encourages medical students from both Oxford and Cambridge to consider and articulate the arguments behind topics that will feature heavily in their future careers.

The debate was judged on the logic, coherence, and evidence in arguments, as well as flair in presentation. Although the debaters may not have necessarily agreed with their allocated side, the debate format required them to acknowledge a particular school of thought and present the key arguments behind it. Oxford, who opposed the motion, was awarded the victory in the debate; however, this does not mean that the judges believe that position ought to become public policy.

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Acknowledgements

For Cambridge University: Hilmi Bayri (Trinity), Alistair Bolger (Jesus), Casey Swerner (St Johns).

For Oxford University: Devan Sinha (Brasenose), Thomas Frost (Lincoln), Collis Tahzib (Lincoln).

Martin Farrell (Cambridge).

Baroness Finlay: Professor of Palliative Care Medicine and former President of the Royal Society of Medicine.

Dr. Roger Armour: Vascular Surgeon and Inventor of the Lens Free Ophthalmoscope.

Mr. Robert Preston: Director of Living and Dying Well.

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Euthanasia: Right to Live or Right to Die Essay

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Euthanasia or mercy killing as it is informally referred is the act of ending a person life if it is deemed to be the only way to help a person get out of their suffering. Mostly euthanasia is practiced on patients who are suffering from terminal illness are experiencing severe pain. Therefore, assisted death seems to be the only way to help the patient come out of their suffering. There are two types of euthanasia.

Active euthanasia or voluntary mercy killing that entails assisting the terminally ill patient to end his/her intractable pain through death. The consent of the patient has to be sought. The other method is involuntary mercy killing which is practiced without the patients consent as the patient may not be in position to do so such as when in a coma.

Whether voluntary or involuntary, mercy killing is a topic that has generated heated debate not only among professionals, but also the general public and laws makers. The physicians should do everything possible to save the lives of their patients, but in extreme situations euthanasia should be considered as an appropriate alternative to save such patients from excruciating pains.

Both schools of thought focus on the rights of the patient. They claim that a patient has a right to demand or refuse any form of medication that will help in overcoming their suffering. If a doctor continues to give or deny treatment to a patient against the patients will, that can be considered as violating he patient’s rights.

Those who oppose legalizing euthanasia are informed by what has happened in Holland. Active euthanasia is legal in this country. Legalizing active euthanasia can easily pave way to also legalizing involuntary euthanasia (Life Circle Books para 9). They claim that if law makers do legalize active mercy killing, it soon “becomes a responsibility and obligation of the medical practitioners” (Life Circle Books para 13).

This is such a dangerous path as it is potentially riddled with loopholes for abuse. Its consequences are beyond comprehension. Most people could abuse it for their own personal gain. Consider a person who is intends to inherit massive estate from a terminally ill guardian. This person can nudge the guardian toward assisted death. If this is the case, how many more deaths would occur in world?

This would also mean that people who are of unsound mind and those struggling with severe depression can ask to be put out of their misery by assisted death. This would also take the death rates to high levels. Most importantly, many terminally ill patients who are not willing to die would develop an immense distrust toward doctors, who would have the right to end therefore lives if it seems impossible for them to recover.

It would also put onto jeopardy live of millions of the elderly citizens who are a burden both economically and otherwise to their families. In this case therefore euthanasia becomes not only illegal, but unethical. Its consequences are too disastrous to imagine. Every alternative to mercy killing such administering pain killers should be explored until a person either improves or dies naturally (Life Circle Books para 25).

However, there are those who feel that euthanasia needs to be re-thought and debated afresh so that law makers can find ways of stipulating statutes that protects both the patients and the doctors who practice it. They argue that each person has a right to determine the direction of their lives. Lives of individuals are their own responsibilities (Kingsbury para 2).

About 80% of adult Americans would support this move as they feel that if a person is terminally ill and the condition cannot be reversed by any medical intervention, slow and painful death is the consequence. No one wants a slow and painful death. People should therefore be assisted to end their lives quickly thus avoid prolonging the process of death (Kingsbury para 3).

While opponents of this arguer that its consequences are beyond repair and that it is subject to abuse, research proves otherwise. Their decision is only informed by the fear of the unknown. In Oregon where it is legal, the law has proved very successful and only very few instances of abuse have been reported.

Oregon euthanasia laws requires that a person must be 18 years and over, of sound mind and ascertained by at least three medical doctors that death is the only end of suffering. The doctor only prescribes the drugs but cannot administer it. It’s the patient who tales the drug voluntary without any help from the doctor.

The proponents argue that those people who are under intractable and intense suffering should be assisted to die in dignity, without pain.

In conclusion, the patient’s right to life must be protected. There are fundamental issues that need to be considered when deciding if to legalize euthanasia or not. Such issues include the consideration of the patient’s wish. However, euthanasia should not be taken as the easy way out.

All possible means to sustain a person’s life should be explored. Lastly, there is a question that still lingers in mind of many. How is the consents and the wish of a patient who is in deep coma ascertained?

Works Cited

Kingsbury, Kathleen. “A New Fight to Legalize Euthanasia.” Time Magazine. Posted, 16, May 2008. Retrieved from http://content.time.com/time/health/article/0,8599,1807401,00.html

Life Circle Books. If Mercy Killing Becomes Legal . New York: Lewistown. n.d. Retrieved from http://www.euthanasia.com/mercy.html

• Why Active Euthanasia is Morally Wrong
• Arguments in Favor of Euthanasia
• Euthanasia and Other Life-Destroying Procedures
• End of life: the medical ethical dilemma
• “On Moral Medicine: Theological Perspective in Medical Ethics” by Stephen Lammers and Allen Verhey
• The Problem of Assistance in Self-Deliverance
• Commercialization of Organ Transplants
• Pros and Cons of the Commercialization of Organ Transplants
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• Chicago (N-B)

IvyPanda. (2019, May 27). Euthanasia: Right to Live or Right to Die. https://ivypanda.com/essays/legalizing-euthanasia-essay/

"Euthanasia: Right to Live or Right to Die." IvyPanda , 27 May 2019, ivypanda.com/essays/legalizing-euthanasia-essay/.

IvyPanda . (2019) 'Euthanasia: Right to Live or Right to Die'. 27 May.

IvyPanda . 2019. "Euthanasia: Right to Live or Right to Die." May 27, 2019. https://ivypanda.com/essays/legalizing-euthanasia-essay/.

1. IvyPanda . "Euthanasia: Right to Live or Right to Die." May 27, 2019. https://ivypanda.com/essays/legalizing-euthanasia-essay/.

Bibliography

IvyPanda . "Euthanasia: Right to Live or Right to Die." May 27, 2019. https://ivypanda.com/essays/legalizing-euthanasia-essay/.

Legalizing Euthanasia

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Medical Perspectives on Death and Dying

Several states have begun to consider legislation that would legalize active voluntary euthanasia.

Several states have begun to consider legislation that would legalize active voluntary euthanasia. To address some of the ethical issues raised by such legislation, the Center for Applied Ethics sponsored a symposium entitled Legalizing Euthanasia: Ethical Perspectives on Medicine and Dying . Principal speakers were Derek Humphry, founder and president of the Hemlock Society, and author of the current best-seller, Final Exit , a suicide manual for the terminally ill; and Richard Gula, S.S., Ph.D., a professor of moral theology at St. Patrick's Seminary in Menlo Park, California. The symposium was funded in part by the California Council for the Humanities, a state program of the National Endowment for the Humanities. The following excerpts highlight the remarks of Mr. Humphry and Father Gula.

Derek Humphry Let me explain how I became involved with the subject of euthanasia. In 1974 my first wife, Jean, was dying of bone cancer. Thrombosis had set in, her bones were cracking and she was losing control of her bowels. One day, after a very close brush with death, she sat up in her hospital bed and said to me, "Will you help me die?" That is when I first encountered the issue of euthanasia; from across my late wife's hospital bed.

After she made her request, I asked myself, "What if I were sitting in that hospital bed? What if I had had two years of pain and agony? What if I faced an imminent death? What if I was losing control of my bowels and my bones were cracking and so-forth?" I realized then that I would be asking her to help me to die. That, ladies and gentlemen, is my simple reason for what I did. It was an act of love.

Jean had been a good wife to me for 22 years. She stood by me in good times and bad. And when she was experiencing a bad time, I felt it was my duty to support her in her decision. I am not a Christian. I am an atheist. So, for me there was no question of consulting any god. It was a matter of situational ethics.

In 1980, five years after Jean's death, I helped to establish the Hemlock Society. This organization seeks to change certain laws regarding suicide. We want the government to decriminalize the actions taken by physicians in the assisted suicides of terminally ill patients.

We believe that a mentally competent adult who is dying should be able to submit a written request to their doctor that would state, "I've had all I can take. The pain and suffering are too much. I wish to die. Help me."

The physician, according to the Hemlock movement's prepared law, would have to obtain the opinion of a second doctor. They would both have to agree that the person is dying. The first doctor could then end the life of the patient with an oral or intravenous drug overdose, without the threat of prosecution or lawsuit. Our laws also state that the doctor could elect not to assist the patient with such an action.

There are those who agree with what the Hemlock movement is saying at the present time, but are fearful that such an ideology would result in a system of euthanasia similar to that used by Nazi forces. It is true that the Nazis introduced a program which they called euthanasia. They murdered about 100,000 people who were physically or mentally handicapped. No senior citizens or terminally ill people were allowed to voluntarily end their own lives.

But how can you say to a person who is dying of throat cancer today that they cannot have voluntary euthanasia because of what the Germans did in 1940 and 1942? I think that the person would respond, "It's not relevant. It's me. It's my body. It's my liberty. It's my life. And it's my death. Let me have control."

I would claim that this is the ultimate civil liberty. If we cannot go to our deaths in the manner of our own choosing, what liberty do we have?

Richard Gula Most of the focus on euthanasia so far has been dominated by what I'm going to call the paradigm of individual case analysis. My position is that euthanasia is not primarily an individual issue; it's a societal one. So discussion about euthanasia should not be governed primarily by individual case ethics, but by societal ethics.

The sanctity of life principle is probably the common ground principle. There are two extreme positions that can give sanctity of life as a principle a bad name. One extreme is what I call vitalism, and that is the extreme that tries to absolutize physical life making an idol out of biological existence. This principle says no cost is too great to keep this biological life going. The other extreme interpretation leads to what I'm calling a utilitarian perspective, which values life for its usefulness. This is the interpretation that says only the strongest and the fittest ought to survive. The danger here is the abuse of undertreatment.

I want to think about the sanctity of life from the middle position. This is the interpretation of the principle that recognizes we have limited dominion over life. It's the interpretation that says we are stewards of life, that we ought to care for life and promote it and enhance it in order to allow our lives to flourish and to achieve our potential. This is the interpretation that wants to respect life in all its forms and in all its stages. Interpreting sanctity of life in this way entails two obligations: a positive one--to nurture and support life„and a negative obligation not to harm life. Therefore, to appeal to sanctity of life in a discussion of euthanasia is to create a presumption in favor of life.

The second principle is the principle against the prohibition of killing. I want to look at three ways of interpreting this principle. The first says there is no moral difference between killing and allowing to die -- that once you decide that life no longer needs to be sustained, because the use of treatment would be futile, then it makes no difference whether you actively intervene or simply withhold or withdraw treatment.

The second interpretation is that there is a qualified moral difference. That qualified moral difference is that the distinction holds but gives way at a certain point. Some will say when the person has gone beyond the reach of human care, when there is no longer the capacity to receive love, or to receive comfort, then the distinction dissolves. Others will say when the person is in intractable pain and there's nothing more that can be done to relieve the pain, then the distinction between killing and allowing to die dissolves. Others would say when the patient is overtaken by the dying process -- that is to say, once you have decided that nothing more needs to be done, that life has reached its limits, then it makes no difference whether you withhold treatment or intervene, because in that condition, you are not usurping the dominion that is not yours. Then there's the third position that says the distinction holds all the way through.

The next principle is the principle of autonomy, which is probably going to be at the core of this discussion of whether euthanasia ought to be legalized. In our culture, we interpret autonomy as the right to self determination. The prevailing interpretation of autonomy in our culture is that autonomy is there to maximize self-interest. That means that we are able to pursue our own goals and life plans without external constraints. When we interpret autonomy this way, we answer the question "whose life is it anyway?" in favor of the one whose life is in question. This is solid ground for supporting euthanasia.

Can the principle of autonomy be used to challenge euthanasia? Some argue that the very interpretation of autonomy that says that you have the freedom to have another person intervene to take your life is a contradiction of what autonomy means -- that actually what you're doing is giving away your freedom. The other way of looking at it is to say that euthanasia is not primarily a private affair. It's a public or societal action that involves others, and therefore it is something that ought to be treated as a form of public action.

The third principle is the principle of the common good. To show that euthanasia ought to be sanctioned as a public practice, we need to be able to show that we can justify it in more than the individual case. This is the principle that says that when we establish a policy, we are sanctioning actions as a common practice. When we apply that principle to euthanasia, we need to ask, "how does the goal of my own private killing contribute towards making society the context in which human life can flourish?"

Now let's turn to the perspective of virtue. Virtue asks whether or not a policy on euthanasia creates the right kind of relationship between the physician and the patient, and would a policy on euthanasia create the right kind of community in which health care is delivered. The perspective of virtue asks that the physician deliver compassionate care within the limits of the physician's role. The trust that we extend to the medical profession to heal and protect life is something that we would want to sustain and the perspective of virtue asks whether that kind of trusting relationship would be enhanced or hindered if euthanasia became part of the options that are available to the physician. The perspective of virtue looks on ourselves as a community of interdependents in which we are partners to one another. It sustains the community of trust and care by promising not to abandon anyone, and it tries to be realistic about accepting the limits about what it means to be human. We recognize that life will not be free of suffering, that life will be burdensome, and there will be tragedy. The perspective of virtue tries to be realistic about accepting that. It encourages us to construct structures of support which will enable us to raise those who suffer into the network of the supportive, caring community.

Ultimately we cannot convert individual cases into public policy without having something remaining. The common good resists the temptation. How do the burdens to one individual compare to the burdens and the benefit on society as a whole? I think all of this ultimately is going to turn not on the basis of principles we argue with, but on the kind of people we are. Are we a virtuous people that creates a community of caring or are we going to compromise that in the way we allow euthanasia to become a practice in our healing society?

Videotapes of the symposium are available for $16.50 by writing to the Center for Applied Ethics, Santa Clara University, Santa Clara, CA 95053.

This article was originally published in Issues in Ethics - V. 5, N. 2 Fall 1991

Euthanasia – For Legalizing

There are many arguments for and against legalizing euthanasia. It has ethical benefits as well as downsides. Should euthanasia be legalized? Essay samples like this one will help you understand the issue.

Introduction

There is no respect for autonomy, justice is denied, sympathy for the suffering of others, individual liberty vs. state interest, the voice of the u.s. public.

The legality issue of Euthanasia has been a subject of heated debate since long. On the global scene, the Netherlands was the first country to legalize Euthanasia in April 2002, followed a month later by Belgium.

Switzerland legalized the practice in December 2005 (Reuters U.K). In the U.K where public support for legalization of Euthanasia rose from 69% in 1976 to 82% in 2004, it is widely expected that Parliament will soon legalize the practice (News-medical.net).

In the U.S, many states have been debating the legality issue of Euthanasia but only Oregon has legalized it since 1997 (Reuters U.K). It is my contention that Euthanasia should be legalized all over the country.

The word ‘Euthanasia’ comes from the Greek word ‘Euthanatos’ meaning ‘good health.’ Euthanasia is defined as the deliberate ending of a person’s life by anther person at the specific request of the former. Euthanasia is not the same as other practices such as Physician-Assisted Suicide, Terminal Sedation or Withholding/Withdrawing Life-Sustaining Treatments.

Physician-Assisted Suicide takes place when a physician, responding to specific request from patients, gives information {for example, a prescription for a fatal dose of sleeping pills}, and/or the means {such as a supply of carbon monoxide gas} of committing suicide to patients so that they can easily hasten their death (Religious tolerance.org).

Terminal Sedation occurs in cases where the physician administers sufficient sedatives to cause a terminally ill, competent patient to become unconscious, then permitting the patient to die of starvation, dehydration and the disease which has been contracted (Braddock et al.).

Withholding/Withdrawing Life-Sustaining Treatments takes place where a competent patient refuses to continue taking on-going life-sustaining treatment (Braddock et al.) such as the use of ventilators, dialysis, intravenous fluids and feeding tubes.

There are 3 kinds of Euthanasia. Active Euthanasia takes place when a person is put to death as a direct consequence of a request from him or her.

A famous example is the 1998 case involving Jack Kevorkian who caused the death {by lethal injection} of a patient suffering from ALS {Lou Gehrig’s Disease} who begged for a swift and painless death. Passive Euthanasia occurs when the death of a person is speeded up by changing some type of life-support being administered to him or her, thereby paving the way for nature to take its own course.

Examples of Passive Euthanasia include unplugging a respirator, ceasing administration of medications or not performing CPR {cardio-pulmonary resuscitation} on a person whose heart has ceased functioning. Involuntary Euthanasia involves putting to death persons who have not specifically asked for assistance in dying.

This usually occurs in case of those who have slipped into a Persistent Vegetative State and will in all likelihood never regain consciousness (Religioustolerance.org).

Taking decisions about the time and method of one’s death is considered very personal and confidential. Persons who are terminally ill patients with deadly diseases like ALS, AIDS, Alzheimer’s or Multiple Sclerosis know they will soon die and simply want to exercise control over the process. They cannot tolerate the loss of personal dignity as they are no longer self-sufficient, but have to constantly depend on others for care (Religioustolerance.org).

Secondly, such terminally ill persons do not wish to reduce their financial assets by having to constantly pay massive hospital bills as their death draws nearer; they would prefer to die quickly so that their inheritors of their assets will benefit to a greater degree by way of savings of such heavy hospital expenses.

Heavily underlying these reasons is the inescapable fact that they are living in excessive, chronic pain fully knowing that there is no cure for their ailment and that death is inevitable (Religioustolerance.org).

The Constitution of the country dictates that all persons have the freedom of choice. The freedom of choice in this case refers to the right of all persons – whether in good health, slightly ill or terminally ill – to choose if they want to go on living or if they are restrained so heavily by circumstances such as terminal illness to take the decision that they do not want to continue living and that they would be better off dead.

By not legalizing Euthanasia, terminally ill patients are denied the right to court speedier death by taking matters into their own hands. For some of them, death does not come as speedily as they wish, with the result that they have only one option left – death (Braddock et al.). By denying them the right to escape a life of pain that will anyway end in nothing by death, the State is denying terminally ill persons their Constitutional right

Some illnesses, besides causing intense physical suffering, also cause unbearable psychological burdens to patients (Braddock et al.). A classic example is AIDS. Sufferers of this disease endure horrific suffering as the disease progresses. Their bodily resistance steadily deteriorates, weakness sets in and they literally wither away to death.

Their physical anguish is accompanied by extreme mental suffering as they know that even with the best treatment, their burden of physical and metal suffering will at the most be slight, and that too temporarily, relieved but the onset of death is inevitable.

If these patients may request Euthanasia hasten death, do their loved ones not have the moral duty to end their physical and metal suffering? The key word in this scenario is ‘inevitability.’

The persons who have been entrusted by the patient to administer Euthanasia knows that death is inevitable, therefore, if such death is allowed to come in earlier than scheduled, it is a matter of showing sympathy for the suffering of the patient. In this context, Euthanasia is seen as a compassionate reaction to intense suffering.

There is no doubt that the State has a strong interest in preserving the life of its citizens. It is understandable and widely expected as a sign of a well-run State because such interest stems from the responsibility entrusted to the State.

Therefore when the State takes precautionary measures to safeguard its citizens such as apprehending thieves and muggers, or interning drug dealers and human smugglers, or punishing rapists and wife batterers, or sentencing serial killers to life imprisonment or capital punishment, these actions are viewed as signs of a government correctly doing the job that it was elected to do.

However, when it turns into a matter of private {as opposed to the above various forms of public safeguards}, the intensity of such State interest does not match the interest of terminally ill individuals who opt for death to end life. This lopsided {against the State} level of interest, if strengthened by prohibition by the State, is seen as an infringement on the personal liberty of the individual (Braddock et al.).

Perhaps the greatest U.S President of all time, Abraham Lincoln, described democracy as a rule “by the people, of the people and for the people.” It therefore follows that in this great democracy called the United States of America, it is the voice of the people that is paramount.

It also therefore follows that the voice of the people in case of legalizing Euthanasia should be treated with the greatest of importance. The voice of the people states that Euthanasia should be legalized.

While almost all the U.S states may have been intimated by the 1997 U.S Supreme Court landmark ruling against Euthanasia, the U.S public certainly has not been similarly affected. A 2005 Harris Poll involving 1,010 adults in the U.S discovered that as many as 64% of them disagreed with the 1997 Supreme Court ruling.

It was therefore not surprising that the same poll also found that 70% of them were in favor of legalizing Euthanasia. The greatest support was reserved for Involuntary Euthanasia with an overwhelming 72% of respondents declaring that they would go to the extent of expressly authorizing the administration of Euthanasia against themselves in their last wills and testaments (Taylor).

In addition to the above cited arguments, hard facts show that the most potent argument against legalizing Euthanasia {that it will increase the number of deaths of terminally ill persons} has been soundly refuted. Data from areas that have legalized Euthanasia do not show any marked changes as a result of this action. A good example is the U.S state of Oregon.

Ever since the passing of the Death with Dignity Act, the number of Euthanasia cases has hardly registered any noticeable change as compared to data of previous years. But what did change however, in Oregon as well as all those nations that have legalized Euthanasia, is the great relief that was made available to terminally ill patients – much needed relief that was cruelly denied to them before such legalization.

Their relief has been well articulated by Professor Torbjorn Tannsjo: “They [terminally ill patients] would know that, if, when their turn comes, and things turn out to be terrible, they have a way out” (News-medical.net).

Braddock C.H. & Tonelli M.R. “Physician-Assisted Suicide.” University of Washington. 2008.

“ British Medical Journal Publishes Euthanasia Opinions .” News-medical.net. 2005.

“ Euthanasia & Physician-Assisted Suicide .” Religioustolerance.org. 2002.

“ FACTBOX – Legal Status of Euthanasia around the World .” Reuters U.K. 2007.

Taylor, H. “Poll: U.S Adults Favor Euthanasia & Physician Assisted Suicide.” Death with Dignity National Center. 2005.

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Arguments in Favor of Right-to-Die Legislation

There are many arguments about whether people should have the right to die when they choose, intentionally and by design, to end their own perceived pain and suffering .

Differences of Opinion

Most of the arguments for and against the right to die are ideological, based on many important aspects of civility: the law, religion or spiritual beliefs, ethics, and social mores. Opinions vary based on personal experiences, belief systems, age, culture, and other aspects of humankind that influence how we think about important aspects of life.

Where the Right to Die Is Legal

In the United States, with the exception of a small number of states which have passed right-to-die legislation, a doctor who injects a patient who wants to die with a lethal drug and kills him would technically have committed murder.   Proponents of right-to-die legislation desire a legal remedy for doctors who assist their suffering patients in ending their lives. Outside of the United States, euthanasia is the law of the land in Canada, the Netherlands, Colombia, Belgium, Luxembourg, and Switzerland.

Understanding Right-to-Die Laws

Right-to-Die legislation, also known as physician-assisted death or aid in dying, gives mentally competent adult patients with a terminal illness and a prognosis of six months or less to have the ability to request and receive a prescription medication to bring about their death. Most statutes under consideration at the state level are modeled after Oregon’s Death with Dignity Act, which requires two physicians to confirm the patient’s residence, diagnosis, prognosis, mental competence, and voluntariness of the request to die.   In addition, two waiting periods are required.

The Pros for Right-to-Die Laws

Here are some arguments in favor of giving patients the right to die and protecting healthcare providers who carry out those wishes. Compare these arguments in favor of death with dignity and the right to die against  the cons .

• A patient's death brings him or her the end of pain and suffering.
• Patients have an opportunity to die with dignity, without fear that they will lose their physical or mental capacities.
• The overall healthcare financial burden on the family is reduced.
• Patients can arrange for final goodbyes with loved ones.
• If planned for in advance, organs can be harvested and donated .
• With physician assistance , patients have a better chance of experiencing a painless and less traumatic death (death with dignity).
• Patients can end pain and suffering when there is no hope for relief.
• Some say assisted death with dignity is against the Hippocratic Oath; however, the statement “first do no harm” can also apply to helping a patient find the ultimate relief from pain through death.
• Medical advances have enabled life beyond what nature might have allowed, but that is not always in the best interest of the suffering patient with no hope of recovery.
• A living will, considered a guiding document for a patient's healthcare wishes, can provide clear evidence of a patient's decisions regarding end-of-life care.

Pereira J. Legalizing euthanasia or assisted suicide: the illusion of safeguards and controls . Curr Oncol . 2011;18(2):e38-45. doi:10.3747/co.v18i2.883

Battin MP, Van der heide A, Ganzini L, Van der wal G, Onwuteaka-philipsen BD. Legal physician-assisted dying in Oregon and the Netherlands: evidence concerning the impact on patients in "vulnerable" groups . J Med Ethics . 2007;33(10):591-7. doi:10.1136/jme.2007.022335

By Trisha Torrey  Trisha Torrey is a patient empowerment and advocacy consultant. She has written several books about patient advocacy and how to best navigate the healthcare system. 

The pros and cons of legalising euthanasia

Help to end suffering for terminal patients could put disabled, elderly and unwell people at risk, opponents warn

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Pro: an end to suffering

Con: losing legal protection, pro: ending 'mercy killings', con: 'slippery slope', pro: shifting opinion, con: religious concerns.

 Demonstrations calling for the decriminalisation of assisted dying are to take place in central London today to coincide with a debate among MPs in Westminster.

The Commons debate – which will not be followed by a vote – was triggered after a petition backed by campaigner Esther Rantzen gained more than 200,000 signatures.

Rantzen, who has stage four lung cancer, revealed last year that she had joined the assisted dying clinic Dignitas, in Switzerland, but that under current UK law her family could be at risk of prosecution if they helped her travel there to end her life.

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"The Great British Bake Off" judge Prue Leith, actor Susan Hampshire and rights campaigner Peter Tatchell are all expected to attend the protests calling for a change in the law. A previous bill in favour of assisted dying was defeated in the Commons by 330 votes to 118 in 2015.

Also known as euthanasia , assisted dying is a controversial issue for legislatures worldwide, with widely cited arguments both for and against a practice that is legal in some countries while totally taboo in others.

It is currently banned in England, Wales, and Northern Ireland – although not a specific criminal offence in Scotland – and carries a maximum prison sentence of 14 years.

Allowing patients to end their suffering is not only morally justified but also essential to upholding the right to personal and bodily autonomy, advocates argue.

A major parliamentary inquiry set up last year to explore whether assisted dying should be legalised in the UK received tens of thousands of submissions from people facing "uncontrollable" pain and "unbearable suffering", which palliative care alone cannot fix,  The Guardian reported.

Paul Lamb, a paralysed former builder from Leeds who died in June 2021, had  lost his legal case to challenge UK laws on assisted dying seven months earlier.

"I cannot understand, in a civilised society like ours, why I should be forced to suffer when millions of people around the world already have the choice I asked for," he said in November 2020.

It is currently a criminal offence under the 1961 Suicide Act to help someone take their own life, punishable by up to 14 years in prison.

Some people believe that legalising euthanasia would put too much power in the hands of doctors, who could abuse their position, or relatives.

Rita Marker, executive director of the International Task Force on Euthanasia and Assisted Suicide in the US, has argued: "Euthanasia and assisted suicide are not about the right to die. They are about the right to kill."

The UK's anti-euthanasia  Care Not Killing alliance said that the law is also in place to protect the vulnerable "from being pressured into ending their lives".

Making her case against any law change, Ilora Finlay, a crossbench peer and palliative care physician, told the parliamentary inquiry that legalising euthanasia in Britain could result in between 5,800 and 58,000 assisted deaths a year, based on extrapolated data from countries where it is already legal. "Such demand would divert an already stretched workforce of NHS clinicians," she said. 

According to  Dignity in Dying , 44% of people would break the law and help a loved one to die, risking 14 years in prison.

In 2022 the Crown Prosecution Service (CPS) said it was considering revising its stance on so-called mercy killings so that defendants are less likely to face criminal charges.

"We are not decriminalising any offence," Max Hill, director of public prosecutions and head of the CPS, told the  i news site, but in offences "born solely out of compassion", justice can sometimes "be achieved by not prosecuting".

Campaigners claim that UK police are also increasingly turning a blind eye to people travelling to other countries to assist loved ones to end their life.

Opponents argue that normalising euthanasia would be a move towards legalised murder.

This "slippery slope is real", said James Mildred of Care (Christian Action Research and Education), which campaigns against assisted suicide. In a 2018 article in  The Economist , Mildred cited "a steady increase year on year in the number of people being killed or helped to commit suicide by their doctors" in countries that have legalised assisted suicide, as the rules are loosened over time.

"Critics say this is happening in Canada," said  New Scientist , "with the criteria for assisted dying having expanded once already and a further change planned for next year." Canada, which introduced Medical Assistance in Dying, or MAID, in 2016, has seen the number of people choosing to end their life rise steadily ever since, with  MAID deaths comprising 4.1% of all deaths in 2022. 

There has been a significant shift in recent years among both the public and professional medical opinion regarding assisted dying for people with a terminal illness.

Polling for  The Guardian last August found 65% of people in the UK believe it should become legal for a doctor to assist an adult of sound mind with less than six months to live to voluntarily end their own life, subject to High Court confirmation.

Dignity in Dying claims this number is even higher, and also that 54% of GPs are supportive or neutral to a law change on assisted dying. 

Many religious people, especially Catholics, believe that life is the ultimate gift and that taking that away is usurping power that belongs to God only. 

In 2020, the Vatican reiterated the Roman Catholic Church's opposition to assisted suicide and euthanasia, describing them as "intrinsically evil" acts "in every situation or circumstance",  The New York Times reported. 

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The Legalisation of Euthanasia

• Policy and Ethics
• Ethical Issues
• Essays and articles

Brian Pollard MB BS, FANZCA, Grad Cert Bioeth. Sydney, Australia

The legalisation of euthanasia is a constantly recurring topic for debate, in which the chief themes include the status of good medical and nursing care for the dying, its morality, legal detail and human rights, especially respect for personal autonomy and perhaps privacy, and the role of public opinion. Since there are deep divisions in society on all those issues, it is not surprising that the debate seems to rotate endlessly about them, without any reasonable prospect of consensus. Those for and those against the proposal are both unwilling to yield on what they see as immutable positions of principle.

If progress is to be made, a way needs to be found whereby personal views about the medico-social role of euthanasia can be excluded, while the subject is discussed on neutral grounds, capable of objective examination.

It is apparent now that such a neutral way has been discovered, though perhaps by chance, it has already been used several times and the results of that use have been published. I refer to the reports of the large government-supported committees of inquiry held in recent years, on four different continents, devoted to the consideration of the consequences of legalising euthanasia.

In sharp contrast to the usual lack of resolution on debate on this topic, every one of these committees independently reached the same conclusion, namely that legalisation would be unwise and dangerous public policy, because unpreventable abuses could not be eliminated. More astonishingly, when it is difficult to find at random even a small number of people who can agree on almost any aspect of euthanasia, three of these four committees reached this conclusion unanimously, though they all included individuals who held opposing personal views about euthanasia.

The committees and their reports were:

- Select Committee on Medical Ethics, House of Lords, January 1994.(1)

- New York State Task Force on Life and the Law, titled Euthanasia and Assisted Suicide in the Medical Context, May, 1994. (2)

- Senate of Canada, June, 1995, titled Of Life and Death.(3)

- Community Development Committee, parliament of Tasmania, titled The Need or Legislation on Voluntary Euthanasia, 1998.(4)

Of the fourteen members of the House of Lords Committee, it can safely be assumed that some of the Peers were for, and some against, the legalisation of euthanasia when they commenced their deliberations and began to hear evidence. When it visited Holland, the Committee learned there of an alarming number of patient deaths without patient consent, and were openly told by Dutch advocates of euthanasia that effective safeguards against abuse had proved impossible to devise (5).

The Committee of the New York State Task Force had 25 members, including some who thought that euthanasia and assisted suicide were sometimes ethical and compatible with good medical practice. This Committee issued a unanimous report rejecting legalisation, a most valuable compendium of important information.

In early 1997, the Tasmanian parliament established a committee to examine the need for legislation on voluntary euthanasia in that State. When she released the final report of this Committee in 1998, the Chairperson revealed that of its five MP members, four, including herself, had originally been in favour of euthanasia. This Committee unanimously found that 'it would be impossible to frame a law that included all the vital safeguards to protect the vulnerable, weak and disabled' (6).

These reports, taken together, constitute an unexpected and valuable body of expert findings, all pointing in the same direction. Thus, any future proposal for the legalisation of voluntary euthanasia (VE) could reasonably be regarded as incomplete and inadequate unless it displayed familiarity with the arguments contained in those reports, and included effective solutions to the many difficulties they uncovered.

Regarding laws on killing, the House of Lords Report said 'The product of an adequate, legal framework should be public confidence that the law protects life...there can be no more important area in which the law's protection should be complete and transparent than where individual's lives are at stake'.

For a law to be unsafe, it does not have to be shown that it will be abused, merely that it is clearly open to abuse. The more open it is, the greater the likelihood that it will be abused.

A good deal of the reasoning in the reports may be summarised in this extract from the report of the New York State Task Force: 'For purposes of public debate, one can describe cases in which all the recommended safeguards would be satisfied. But positing an 'ideal' or 'good' case is not sufficient for public policy, if it bears little relation to prevalent social and medical practices. No matter how carefully any guidelines are framed, (assisted suicide and) euthanasia will be practised through the prism of social inequality and bias that characterises the services in all segments of our society, including health care. The practices will pose the greatest threats to those who are poor, elderly, members of a minority group or without access to good medical care'.

This paper cannot do justice to the whole of the content of the cited reports which need to be read in full, because they cover an extensive range of subjects. It will include:

- discussion of the essential incompatibility of any euthanasia law with the objectives of sound criminal law

- some discussion of the human rights thought relevant to euthanasia

- the role of public opinion in law making, and

- some of the medical factors that would make any such law unsafe.

Incompatibility of legalised euthanasia with existing criminal law.

Since euthanasia is the intentional taking of innocent human life, it is a form of homicide, and even if it were legalised, it would be legalised homicide. The basic aims of criminal law are to provide equal justice for every citizen and to protect the weak. Additionally, the consent of the victim is by legal tradition no defence to a crime.

Equal. The criminal law of every nation holds that all innocent human life is inviolable, innocent persons being those who pose no threat, or have done no harm, to others. The value placed equally by law on each life is such that its intentional destruction is the greatest of crimes, deserving of the greatest penalty. Euthanasia law would provide the first exception to the prevailing universal protection of innocent life, by creating a category of persons whose lives may be taken intentionally, under certain conditions. It would thus constitute a precedent for repeating the process later to further enlarge the scope of the new principle, where no such precedent had previously existed. The concept of equality before the law would have been abandoned.

Justice. For a law to be just, it should be grounded in sound ethical principle capable of receiving general acceptance; its definitions and provisions should be set out in clear terms so they can be interpreted in the same way by all who read them. This would constitute a particular problem with euthanasia, since many of the phenomena associated with death are difficult to define with such precision; its provisions, particularly those intended to act as safeguards, must be capable of being realised and of being monitored, and it must contain no obvious avenues for abuse. If any of its important elements relied for their observance on opinion rather than fact, that would introduce arbitrariness and would be incompatible with justice.

A patient who requested euthanasia would have concluded that his/her life was no longer worth living, and a doctor who agreed to the request would have reached the same conclusion, by an independent but arbitrary judgment. In the same circumstances, different patients and different doctors would have come to different conclusions, depending on their personal values. Thus, under a euthanasia law that simply accepted these personal choices as grounds for lawful killing, the result would represent a kind of lottery of life, whereby a subjective request was met with a subjective response, and neither would be, or could be, objectively validated. The idea that legally taking life may be made dependent on the untestable choice or opinion of persons is at odds with any mature notion of justice.

Protection of the weak. The lives of individuals or groups who are unable to participate fully in the life of the community are especially protected by the current law, because it allows of no exceptions. These groups include the poor, the aged and the very sick, and those who make heavy demands on the community's time or resources, such as physically or intellectually handicapped, or permanently unconscious, people. Once it had been decided in law that the equal right to life may be waived on account of a low quality of that life, it would seem, to some at least, that individuals in the above categories would be the most logical for the extension of that principle, should other circumstances seem to justify it.

Mutual consent. Voluntary euthanasia involves one person asking and another agreeing to the taking of life. Though, in criminal law, consent is no defence to a breach of any of its provisions, with lawful euthanasia both parties would have acted in defiance of that principle.

It is instructive that the statute laws on killing in the Netherlands are much the same as elsewhere, and that the Dutch have to date preferred to try to justify their expanding euthanasia practices by case law or precedent, not by statute. They have wanted to have euthanasia regarded as an arguable exception to the legal principle that they see as vital to maintain, namely that innocent life should be regarded as inviolable. Most of those who promote lawful euthanasia elsewhere fail to see that the retention of this principle is needed to sustain the credibility and strength of the rest of the criminal law, for a person must at least be alive in order to be subject to its provisions.

Human rights and the law.

As outlined above, any proposal to legalise VE would constitute, not only an attempt to change the present laws, but to overturn them. If the proposal appealed to any human rights for its justification, they would have to be acknowledged natural rights, those derived from considerations of the nature of mankind. That right would also need to be properly defined and understood in the same way by all who discuss it.

Natural rights were originally conceived as the entitlements of citizens that would protect them against injustices. Respect for autonomy can be argued to be a genuine natural right, and as such, it would oblige its acceptance by others. Autonomy is the right of every person to decide freely the course of his/her own life, within the limits set by the competing genuine rights of others, and it will oblige compliance when it respects those rights. That is, autonomy involves both the privilege of choice and the duty to restrain one's choice, when that is required. Difficulties arise in relation to VE when (a) autonomy is not defined or not correctly defined, since clarity is essential when discussing such a contentious and emotional subject, and (b) when it is commonly discussed as though it were no more than a welfare right. Autonomy is now commonly presented as, and often thought to be, merely an individual's expression of preference, which is never claimed to be binding on others.

Welfare rights have a well deserved reputation for being divisive and confronting, because they tend to favour one individual above others. Natural rights, which place equal emphasis on furthering the well-being of both the individual and of society, promote harmony and friendship. The facts that rights are so often incorrectly understood and unequally applied led one observer to comment 'when rights come in, love goes out the door'.

Though any proposal to take innocent life has unarguably high moral content, any suggestion that this merits close examination is apt to be met with accusations of 'religious bigotry' or the like, as though secular morality did not hold similar claims to fundamental importance. However that may be, a common practice now is simply to ignore any discussion of it. When absolute morality is rejected, traditional ways of deciding morality become diluted, without any consistent ethic found to replace them. Questions of right and wrong can then be transformed into questions about individual rights, so that 'What is right?' becomes 'What are the rights?', an entirely different topic.

Autonomy is misunderstood or misrepresented when it is assumed to apply to whatever an individual may happen to want sincerely, or when it is assumed that the significance of the consensual killing of VE is a private matter, with no harmful consequences for others. Both assumptions are wrong. Further, it is widely but incorrectly assumed that choice itself is the essence of autonomy, not what is chosen. Individuals have no entitlement at all to be given what they happen to want--that would be nearer to self-indulgence than self-determination.

Depicting euthanasia as no more than a private matter is dangerously naive, ignoring the fact that euthanasia law would set new and lower standards of respect for human life, because in the eyes of many, making a matter legal signifies it has the approval of authority. VE would then become one of the options that may be put to all vulnerable sick patients, and it would be proper to promote and encourage it. In light of the gross imbalance in power between doctors and their patients, some patients would than be powerfully and unfairly influenced. This would place an unnecessary burden on dying patients when they may already be seriously taxed and confused by so many aspects of their illness.

If the right to request death were a genuine right, it would oblige compliance, though VE supporters are careful always to point out that that is not their aim. A human right cannot be claimed at the same time to be genuine and yet only permitted to be exercised arbitrarily. To be consistent, if the right were genuine, VE should then be available to all who ask, sick or not, at any time, for any or no given reason. The young who now commit suicide in alarming numbers should no longer distress us, but be congratulated for showing how to take control of one's dying, as a matter of right.

Further, to depict VE as no more than an individual patient's wish is to ignore the presence of the person asked, the doctor. This second person is an independent moral agent who must make his/her independent and separate autonomous response, be required to justify it when asked, and take due responsibility for it.

The sum of these deficiencies in the common understanding of autonomy to justify VE means that the argument is distorted. No matter how often or how vehemently it is asserted that an individual's wish binds others to comply, just because that is what he/she sincerely wants, the mere expression of a wish is not autonomy. The wish, and all that may flow from it, must be closely examined within the context of its social and medical setting, and in this paper, some of those factors are discussed.

A different form of distortion, in the opposite direction, is the virtual exclusion from the debate of the right of every innocent person to his/her life, the genuine natural right on which the criminal law is founded. Not only must this right be included, logically it should be first.

The 1948 United Nations‚ Universal Declaration of Human Rights is the most widely acclaimed and accepted statement of human rights. It was compiled at a time when member states of the UN, horrified by their discovery of the then recent extent of the abuse of natural rights, were resolved to ensure that this should never happen again. It describes the right of each person to his/her life as equal, inherent, inviolable, inalienable and deserving of the protection of law. This means that the right is not to be made dependent on its quality at a particular time, there are no exceptions and the right may neither taken away nor given away.

There is an urgent necessity for full consideration of this natural right to be reintroduced whenever the legalisation of euthanasia is being discussed, if the proper role of law in the governance of society is to retained.

The doctrine of personhood is a relatively recently added plank in the platform for VE, and is now receiving broad assent. While it may not directly be connected with human rights, the concept is a denial of the right of every person to his/her life, and is therefore an attack on the ethical basis of law. 'Personhood' claims that the value and dignity of a person, which are the reasons that entitle every individual to be treated with equal justice, are said to depend on the prior development of certain currently usable psychological abilities. This raises questions as to which abilities there must be and how developed they must be. Since there are no standards by which every observer could reach the same conclusions, such questions can be answered only by choosing the criteria that will lead to the conclusion one wants. Thus, this will always be an arbitrary exercise, reliant on the values of the observer, and cannot be just.

If it were asked 'What benefits does this new idea confer on society in order to justify the displacement of the traditional understandings of who may be regarded as a person?', the answer can only be 'None, that do not permit and rely on the taking of the lives of certain individuals who are already unwanted by society, for other reasons, without their knowledge'. Those individuals will be some of the disabled, the senile, the seriously ill and the unconscious, whose lives are at present protected by law, and whose specific human rights are proclaimed in various declarations. When the malignant intention of personhood is realised, with its inherent disregard for both law and rights, its advocates‚ real lack of concern for all human life is exposed, to which is added duplicity when they also purport to appeal to other human rights.

The role of public opinion in law making.

One reason given for wanting the laws on killing changed is that a majority of the community have declared, via opinion polls, that that is what they want.

Opinion polls were developed to test views about political issues, but VE is clearly a moral issue, secular or otherwise. When an issue is as complex in almost every respect as VE is, no valid conclusions can be drawn from polls when the respondents' real understanding of them is both unknown and unknowable. To use such results as an argument to change part of the criminal law would be foolish and dangerous. This would be self evident if it were proposed to change other parts of the law, using the same mechanism.

Morgan opinion polls have been asking the following question in Australia since 1962: 'If a hopelessly ill patient, in great pain, with absolutely no chance of recovering, asks for a lethal dose, so as not to wake again, should the doctor be allowed to give the lethal dose?' The proportion of respondents answering 'yes' has increased from about 50% at first to nearly 80% now. As one commentator noted, it would be hard for an uninformed person to say 'no' without feeling negligent, dogmatic or insensitive.

But when the current ability of good palliative care to relieve the severe pain of terminal illness is known, though it is also known that such care is still not sufficiently available for many, the same question could be more accurately phrased 'If a doctor is so negligent as to leave a terminally ill patient in severe pain, severe enough to drive him/her to ask to be killed, should the doctor be able to compound that negligence by killing the patient, instead of seeking expert help?' The question is really about appropriate standards of medical care, not euthanasia.

It cannot be doubted that most of the community's information and opinions on VE have been obtained from the media which, almost without exception, give an emotionally charged and partial, if not distorted, account. When opinion polls claim to show that most people are in favour of VE, the media, which have created this opinion by their advocacy and lack of balance, then cite these figures as evidence of the need to change the law to allow it! Such behaviour is self-serving and lacking in both truth and justice.

If such issues could really be settled satisfactorily by opinion polls or referenda, parliaments could largely be dispensed with, in favour of endless polling.

Some of the medical reasons why any VE law would be unsafe.

Draft VE laws easily become intellectual constructs within an idealised context, with a false appearance of safety, unless the medical environment in which they will operate is well understood. One of the most tragic medical facts, tragic because it is so remediable, is that, while palliative care is now able to mitigate most of the distresses of dying persons, large numbers of these patients still receive substandard treatment because doctors are uninformed about its practices and/or do not refer their patients to those who are more expert, when they have reached the limit of their own abilities.

The following points are to be found in the cited reports:

1. Necessity for adequate disclosure of medical detail.

Since it would clearly be wrong to allow VE for dying patients with unrelieved symptoms that could be treated by good palliative care, but who had not received such care, information about the quality of their medical care should be an essential requirement before approval could be given for the taking of their lives. No draft euthanasia law in Australia (or elsewhere, as far as the author can discover) has required these facts to be available for scrutiny - it is usual to find only a requirement for medical certificates. These concern opinions, not facts. Thus, the doctor's actions would be unsupervised at the time and could not be reviewed later. Only open, expert scrutiny of a patient's medical care, before euthanasia was carried out, could satisfy the community's need to be assured of a doctor's good judgment and probity.

The community at present properly demands the highest standards of supervision, even when the state has the power to take life. Open hearings, legal representation, avenues of appeal and mechanisms for review are supplied before permitting any legal taking of life, even when deciding the fate of convicted criminals, such as serial killers. In contrast, draft euthanasia bills fail to offer more than token protection for the seriously sick. When examined, their only really effective safeguards are found to be those that protect doctors from civil or criminal action, after euthanasia.

2. Pain and suffering cannot safely be made the basis for taking life because they cannot be measured or compared.

Although palliative care doctors insist that it is not necessary to take life in order to relieve pain, a common reason given by other doctors for wanting VE is to relieve pain. It must be presumed that some doctors take life that could have been relieved by experts, but who are not consulted. Even many advocates of VE now concede that unrelieved pain is probably no longer sufficient justification for taking life. Among the reasons given for euthanasia in the Netherlands, the relief of pain is not prominent.

If pain were a genuine reason to take life, it could not rationally be restricted to the pain of terminal illness, since many other causes of pain are equally distressing.

The mental anguish or suffering associated with life-threatening illness requires different strategies for its management, but it too usually responds to good emotional support. Suffering is evident in a wide range of human conditions, since it is an existential problem, not a medical problem. It has many causes, only some of which are of medical origin, even in those with terminal illness. Most of the causes of suffering are social, requiring understanding of the underlying social, relational and cultural factors.

If suffering were a genuine reason to take life, it could not be restricted to those with terminal illness, since many others causes of suffering are equally distressing. To do so would not only be discriminatory, it would be tragic and a gross abuse to empower doctors to take life for what would commonly be chiefly social reasons.

Neither pain nor suffering can be objectively measured or compared between persons, and so, neither could be subject to the objective standards on which sustainable, just public policy would need to be based. What one person can bear, another finds intolerable. Everything would have come down to the opinion of the patient, based on his/her personal characteristics.

If VE were legalised while the prevailing standards of palliative care were as patchy and unpredictable as they are at present, it would be inevitable that some lives would be taken on account of the medical ignorance of the doctor, even though effective treatment was available. The conclusion is inescapable that such a situation is the probable cause of at least some of the known instances of illegal euthanasia at present, and this would not change, even though the law was changed, in the absence of a widespread correction of the present medical deficiencies in palliative care training and practice.

3. A right to involve another person in one's intentional killing does not exist.

Autonomy has already been discussed, including the point that personal autonomy cannot be extended to others. A right to ask another person to take one's life is not found in any code of ethics or the law or in any statement of human rights. Despite this, such a right is often confidently asserted, even claimed to be 'sovereign' or 'supreme', entirely without warrant. The fact that it is not more often challenged is a reflection of how little is commonly known about rights. Failing its validation by argument, this putative right must continue to be seen for what it is - no more than a wish.

Nor is there a 'right to die', if by that one means a 'right to have one's life taken on request'. There is however a genuine right to die, by which dying persons are entitled to expect that they will be afforded every comfort in their dying, and when it is in their interest to die, not to have their dying unnecessarily impeded.

VE is sometimes said to be permissible as an expression of a claim to privacy, as though it were a matter only of importance between patient and doctor. If a doctor agreed to perform euthanasia, it could only be because he/she had concluded that that life had lost sufficient value - nobody would destroy a life they valued. But if a doctor became comfortable with the idea that it was acceptable for him/her to assign low value to certain patients‚ lives, backed by law, that could be fateful for others of his patients who were in a similar state, but who had not asked to die. He/she would be entitled to interpret any discussion of euthanasia in positive terms, ignoring the evidence that many such discussions are initiated by patients in their desperate need to have their lives affirmed, not rejected. It is well known that to-day's medical systems increasingly depersonalise patients.

3. It would never be certain that a request to be killed was voluntary.

There are no criteria for detecting undue influence on another person, and doctors are no better able to do so than other people. When considering euthanasia in 1982, the Canadian Law Reform Commission observed that coercion would be 'an ever present possibility' (7). The report of the House of Lords declared 'It would be next to impossible to ensure that all acts of euthanasia were truly voluntary, and that any liberalisation of laws would not be abused'. Coercion, particularly if it were subtle, would be very difficult to detect with certainty, and would be impossible if concealment was really wanted.

But would it be likely? After a long inquiry into mental health, a former Australian Human Rights Commissioner said he had discovered that the sick were already 'the most systematically abused, and the most likely to be coerced' (8).

To be seriously ill has been described as being in the 'quintessential state of vulnerability'. Doctors can act coercively even without intending it. Regarding the sexual abuse of patients by doctors, a newspaper editorial claimed 'Even apparent consent is coerced by the power of the professional person in whom the client has placed his or her trust'. The imbalance in power between patient and doctor is far greater than is usually supposed. Just as a doctor's response can forestall suicide, a doctor's ready acceptance of a patient's request to be killed can encourage that outcome, and make the patient feel abandoned.

In such an environment, a patient's request for euthanasia could never be guaranteed to be voluntary.

5. It would never be certain that a request was informed.

Although a draft VE law may require a doctor to inform the patient of the different treatment options, their effects and their likely chances of success, this information will be given in private. Unless an independent, informed observer was present on every occasion, it could never be known whether the information was adequate, correct, unbiased and/or non-coercive. If anyone wished later to check, the only other witness would not be available. Many doctors do not know enough about palliative care-how could they give adequate information about it?

Doctors are often subject to significant stress in dealing with terminally ill patients and their families, arising from frustration at being unable to cure, from uncertainty when faced with difficult problems for which they have not been prepared by their training, and subject to competing and perhaps unfair pressures from distracted patient and family. To suppose that all doctors will behave rationally in these emotionally charged situations is itself irrational, and it would be dangerous to presume it.

6. Even in terminally ill patients, a persistent wish to die is abnormal, while the diagnosis of the underlying psychological disturbance is hard to make and is often missed in those already under medical care.

The true nature of a sustained wish to die, even in the dying, is widely misunderstood, too often being accepted as a natural response to the threat of death. Many persons with terminal illness have suicidal ideation at some time, but never attempt or commit suicide. The great power of fear was revealed in a study that found that more people over 50 committed suicide in the mistaken belief that they had cancer than among those who actually had cancer and committed suicide.

Factors that are consistently found to be strongly associated with a sustained wish to die include: unrelieved severe distress due to pain or other symptoms, previous psychiatric disorder or history of suicide attempt, and the presence of depression or despair. Depression is widely under-diagnosed and under-treated in the elderly, being mistaken for a natural response to aging or dementia. Treatment for depression can remove suicidal ideation in up to 90% of these patients.

The significance of these facts is only half grasped when it is supposed that having a psychiatrist see the patient will provide an effective safeguard. In a recent poll of psychiatrists, only 6% thought they could properly assess mental status in a single consultation. More importantly, only those psychiatrists with training with terminally ill patients will be able to make these diagnoses with confidence in these circumstances.

One experienced Professor of Psychiatry maintains that if these patients were always seen by a psychiatrist with the appropriate training, 'euthanasia would virtually never take place' (9). The scope for abuse in this area would be extraordinary.

Nor are doctors immune to the high emotional content of their patients' situation. A committee of psychiatrists, established in the Netherlands to assist and counsel doctors faced with requests for euthanasia, reported that 'without such consultation, the professionals would often have assisted suicide, even though viable treatment alternatives were available, because of an emotional involvement with the patients'. This caused an American psychiatrist, an expert on suicide, to comment: 'One suspects that those doctors who are most emotionally involved in euthanasia, and most interested in performing it, may be those who whose own needs in the matter should disqualify them' (10).

This important point was emphasised by the comment of a forensic psychiatrist: 'I have, on more occasions than I care to recall, failed professionally to recognise depression because I have been caught up in, and dazzled by, the tragedy of my patient's life. I have accepted their wish for death as a rational and proper desire only to see these desires melt away with their depression when...less involved colleagues treated the process in which the patients were trapped' (11).

7. Progression from voluntary to non-voluntary euthanasia would be simply logical.

Non-voluntary euthanasia (NVE) is discussed more fully in a separate paper, but the core of the message in this title may be simply stated. While VE is regarded by many as a compassionate act, it is assumed that taking life without a patient's expressed wish or consent could only be motivated by some degree of malice. How then could the known incidence of NVE in the Netherlands, United States and Australia be explained, since doctors are not malicious people?

It is because such life taking is seen by its practitioners as an exercise in beneficence. Once taking life on request is regarded as a benefit for that person, it can be thought unfair and discriminatory to withhold that benefit from others who are in a similar plight, just because they cannot ask. That view is logical, if taking life truly supplies a benefit.

No arguments have prevailed to prevent the spread of one practice to the other, and no guarantee could be given that such extension would not occur wherever and whenever VE was introduced. Lawmakers can never guarantee that the law they make will not be modified, perhaps in ways which they could not foresee and would oppose, by subsequent lawmakers. In fact, by making the first exception to the principle of universal protection for innocent human life, they would have created the first precedent for change.

It is sometimes heard that it would be better to have a law to regulate euthanasia practice, even though that law may not be perfect, than to persist with the present position, where euthanasia is practised in secret, without control. That raises several points.

First, there is currently a law to regulate euthanasia-it is the criminal code, which forbids euthanasia as a form of murder, though that law is not commonly invoked. This is because hard evidence is not easy to obtain and the community properly sees a distinction between mercy and malice, even though motive is not taken into account by the law. Thus, euthanasia is presently practised by lawbreakers, who put their own view of their duty above the law, while other practitioners find their duty in the same circumstances fulfilled by different means, such as good palliative care. The former respond to the patient's demands, while the latter look to the demands of the patient's illness.

Second, there is already a proven incidence of secret NVE at the hands of doctors who also carry out VE, because, as stated, they believe it to be compassionate also. Because they include NVE in their concept of duty to certain patients, there could be no guarantee that a law that allowed only VE would not also be disregarded by them. In fact, it would be foolish not to expect it.

Third, given the common finding by inquiries that the lives of other vulnerable sick people could not be protected by any VE law, the House of Lords Committee thought that more lives could be put at risk by such a law than is the case at present. Because abuse would be undetectable, often if not usually, it could then appear to observers that matters had improved, when they had actually deteriorated. To expose the most vulnerable patients to this risk should be seen as unacceptable.

Conclusion.

A number of important factors, hitherto ignored or misunderstood in the debate about the legalisation of VE, have now been revealed in several large studies. They concluded that no such law could be guaranteed to be free of the possibility, if not the likelihood, of abuse, chiefly centred on the lives of other sick persons who did not want their lives taken. An especially dangerous aspect is that such abuse may be easily made undetectable. Thus, impartial observers may believe that a particular law was safe, while many or even every one of its subjects were in fact victims of abuse.

The medical loopholes listed above would alone have justified the common finding of the inquiries, that legalisation would be dangerous. Rather than seek recourse to medical life-taking, all doctors with responsibility for the care of terminally ill patients should accept their duty to deliver this care at the known best standards, as they are legally obliged to do in other branches of medical practice. That means they will familiarise themselves with the principles and practices of palliative care, at the standard required of their peer group, and when for any reason they cannot do that, they will refer their patients to others who can. If they have remaining doubts about the evidence regarding the abuse of euthanasia law, they should acquaint themselves with the contents of the reports listed in this paper, before supporting further attempts to legalise VE.

References.

1. Select Committee on Medical Ethics. House of Lords. January, 1994.

2. When Death Is Sought - Assisted Suicide and Euthanasia in the Medical Context. The New York State Task Force on Life and the Law. May, 1994.

3. Of Life and Death. Report of the Special Senate Committee on Euthanasia and Assisted Suicide. Senate of Canada. June 1995.

4. Report on the Need for Legislation on Voluntary Euthanasia. Community Development Committee, Parliament of Tasmania. June 1998.

5. Gormally L. Why the Select Committee on Medical Ethics of the House of Lords Unanimously Rejected the Legalization of Euthanasia. Proceedings of a Seminar held at St Vincent's Hospital, Sydney. 10 November 1995.

6. Jackson J. Hobart Mercury. 5 June 1998.

7. Working Paper 21, Euthanasia, Assisting Suicide and Cessation of Treatment. Law Reform Commission of Canada. 1982.

8. Burdekin B. Sydney Morning Herald. 21 October 1993.

9. Varghese F. The Australian. 6 June 1995.

10. Hendin H. Seduced by Death: Doctors, Patients and the Dutch Cure. Issues Law Med. 1994. 10; 123-168.

11. Zalcberg JR, Buchanan JD. Clinical Issues in Euthanasia. Med J Aust. 1997. 166: 150-152.

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Doctor-Assisted Death Is Legal in 10 States. Could New York Be No. 11?

Activists have renewed attention on legislation related to the emotional issue of so-called medical aid in dying that has long languished in Albany.

By Erin Nolan and Grace Ashford

Reporting from the State Capitol in Albany, N.Y.

The sounds of protest came forcefully from the Assembly chamber gallery, the chants echoing the words emblazoned on handmade banners that were held aloft: “Stop the suffering, pass the bill!”

But as New York State troopers began to remove some of the protesters — some holding canes, others slowed by the effects of cancer treatment — it was clear that this demonstration held personal and immediate resonance to those participating.

The protest was the latest in an increasingly desperate series of demonstrations aimed at persuading state legislators to pass a bill that would legalize so-called medical aid in dying , allowing terminally ill people access to life-ending medication for the first time in the state.

New York is one of 19 states where lawmakers are considering bills that would legalize medical aid in dying, a practice that is legal in 10 states and Washington, D.C.

The bill in New York would allow mentally competent, terminally ill adults with no more than six months to live to request prescriptions from their doctors for life-ending medication. The patients would have be able to ingest the medication on their own, and only the person seeking to die could request the prescription.

“I’m not someone who enjoys conflict or who has much experience in civil disobedience,” said Jules Netherland, a protester who was detained in the Capitol. “But I really believed this was the only way to get people’s attention.”

Roughly a decade has passed since the first medical aid in dying bill was introduced in Albany, and it has yet to reach the floor for a vote. But the proposal has gained momentum this year, because of endorsements from groups like the Medical Society of the State of New York, a trade group of roughly 20,000 doctors, and the efforts of activists like Ms. Netherland, who was diagnosed with Stage 4 breast cancer last year.

Opponents worry that some patients might choose to end their lives based on an inaccurate prognosis or after being pressured to do so. And while the current bill is restricted to terminally ill people, they worry that lawmakers could expand eligibility for medical aid in dying after any initial legislation is passed.

“Even if there is just one case of abuse or coercion, or even if there is just one mistake, that is a dead person,” said Colleen Barry, a nurse and board member of Euthanasia Prevention Coalition USA.

With roughly a week left in the 2024 legislative session, the bill faces an uphill climb in the Legislature, which Democrats control, especially without the official support of Gov. Kathy Hochul or the leaders of the Assembly and Senate.

Still, Assemblywoman Amy Paulin, the chairwoman of the body’s Health Committee, said that it had gradually garnered support since she first sponsored it in 2016.

“It’s an emotional vote,” not unlike those on abortion or marriage equality, said Ms. Paulin, who represents parts of Westchester County and is motivated by the memory of her sister, who could not get such aid when she was dying of ovarian cancer. “A lot of my colleagues have come to me with stories that drove them to change their minds. It’s about life, and it’s about choice. More members are feeling that and living that and understanding that.”

But it is precisely the emotional gravity of the issue that has some in leadership hesitating, according to numerous lawmakers.

“I just think that, as a culture, in terms of the country, there has not been a lot of conversation about dying,” the State Senate majority leader, Andrea Stewart-Cousins, said of the proposal earlier this year, adding that she was not opposed to having that conversation.

Opponents, including the Center for Disability Rights and the New York State Catholic Conference , warn that even this narrow application of aid in dying will invariably lead to broader use. They point to places, mostly outside the United States, where the practice is available not only to patients struggling with terminal physical illnesses, but also to those with mental illnesses as well.

The vast majority of people who have availed themselves of such laws in the United States were facing terminal physical illnesses — most commonly cancer. But rare exceptions, like a 36-year-old Colorado woman who was prescribed life-ending medication after a diagnosis of “terminal anorexia nervosa,” have sparked controversy and raised questions about suffering, autonomy and the role and responsibilities of physicians.

The American Medical Association is formally opposed to physician-assisted suicide, which it describes as “ ​​fundamentally incompatible with the physician’s role as healer. ” For many years, the Medical Society of the State of New York agreed.

But recent conversations around the legislation — which not only restricts the practice to terminally ill people but also allows individual providers to opt out based on their own convictions — caused the group to reverse course and endorse the measure .

Supporters of the practice say that legalizing medical aid in dying would help untold numbers of people avoid suffering and die peacefully. They point to polls like one commissioned earlier this year by YouGov that found 72 percent of New Yorkers supported “death with dignity.”

Between 1994, when Oregon became the first state to legalize the practice, and 2020, 8,451 people received prescriptions under medical aid in dying laws. Of those, 5,329 took the life-ending medication, according to a 2022 study published in the Journal of the American Geriatrics Society .

Barbara Thomas, 87, fought tears as she tried to imagine a reality where that would have been an option for her husband, Bob Thomas, who died 15 months after he was diagnosed with glioblastoma multiforme — a type of terminal brain cancer — in the fall of 2010.

“I think it would have been much more loving. We could have all gathered,” she said, pausing to blink back tears. “He would have, I’m sure, preferred to be able to have everyone around so he could speak to them all, give them his wishes for their lives and hear them say what they liked about him.”

Instead, Mr. Thomas, a proud outdoorsman who enjoyed fly fishing, hunting, camping and hiking, spent most of his final months in his bed at home in West Milton, N.Y., tired and frail, Ms. Thomas said.

“Sometimes we would just lay in the bed and cry about what an impossible situation we were in,” she recalled.

Twice, Mr. Thomas asked his wife to bring him his gun and help him kill himself, Ms. Thomas said. She never did it, but it pained her to see how miserable he was and to know there was nothing she could do to alleviate his suffering.

“He was the person I had lived with longer than any other person — longer than my parents, longer than any of my children,” Ms. Thomas said, adding that they had been married for 55 years. “We were still in love.”

To her, allowing people like her husband to choose when and how they die is “the compassionate, loving thing to do.”

Erin Nolan is a reporter covering New York City and the metropolitan region. She is a member of the 2023-24 Times Fellowship class. Email her at [email protected] . More about Erin Nolan

Grace Ashford covers New York government and politics for The Times. More about Grace Ashford

Politics in the New York Region

Plastic Waste: As plastic continues to fill landfills and oceans, New York lawmakers are considering a proposal to limit single-use plastic products. Here’s what to know about the legislation .

Expensive Hotel Rooms: The average hotel room rate in New York City is $301 a night, a record, and a major reason is that one of every five hotels is now a shelter , contributing to a shortage of tourist lodging.

A Quiet Suspension: A little-known New York State fund that paid the medical expenses of children who suffered neurological injuries as a result of medical malpractice during childbirth has been suspended .

Limiting Donations to Israel: Representative Alexandria Ocasio-Cortez, who rarely wades into state politics, publicly backed a bill  that could strip New York nonprofits of their tax-exempt status if their funds are used to support Israel’s military or settlements.

Transgender Student-Athlete Rules: A parent group in New York City asked for a review of rules that let students play on sports teams that align with their gender identity. Democratic officials responded angrily .

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Why euthanasia should not be legalised

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Why active euthanasia and physician assisted suicide should be legalised

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Rapid Response:

In response to the editorial regarding the legalisation of active euthanasia and physician-assisted suicide,1 I present the following arguments against the legalisation of active euthanasia.

Active euthanasia is unnecessary because alternative treatments exist

It is widely believed that there are only two options for patients with terminal illness: either they die suffering or receive euthanasia. Recent research in palliative medicine has shown that virtually all unpleasant symptoms experienced in terminal illness can be relieved or alleviated by existing techniques.

Requests for active euthanasia are rarely free and active.

A person with terminal illness is vulnerable, lacking the skills and knowledge to alleviate their symptoms. It is very difficult for him to be entirely objective about his own situation. Their capacity for decision-making may equally be affected by confusion, dementia or symptoms, which could be relieved with appropriate treatment. Patients who on admission say "let me die" usually after effective treatment are grateful that their request was not acceded to.

Active euthanasia gives too much power to doctors

Ironically, active euthanasia legislation makes doctors less accountable and gives them more power. Patients generally decide in favour of euthanasia on the basis of information given to them by doctors. If a doctor confidently suggests a certain course of action, it can be difficult for a patient to resist. However, diagnoses may be mistaken and prognoses may be widely misjudged. Active euthanasia gives the medical practitioner power, which in turn can be abused.

Active euthanasia leads inevitably to involuntary euthanasia

When active euthanasia has been previously accepted and legalised, it has led inevitably to inactive euthanasia.

Holland is moving rapidly down the slippery slope with the public conscience changing quickly to accept such action as acceptable. The Royal Dutch Medical Association has recommended that the termination of the lives of patients suffering from dementia is acceptable under certain conditions. Case reports include a woman killed at her own request for reasons of "mental suffering".[2]

Such a progression requires only four accelerating factors: favourable public opinion, willing doctors, economic pressure and a law allowing it. In most Western countries the first three ingredients are present already. When legislation comes into effect and political and economic interests are brought to bear, the generated momentum inevitably follows.

Dr Liz Croton SHO A&E City Hospital NHS Trust, Dudley Rd,Birmingham B18 7QH [email protected]

1. Doyle L, Doyle L. Why active euthanasia and physician assisted suicide should be legalised. BMJ 2001:323;1079-80.

Competing interests: No competing interests

• Open access
• Published: 21 May 2024

Ethical perspectives regarding Euthanasia, including in the context of adult psychiatry: a qualitative interview study among healthcare workers in Belgium

• Monica Verhofstadt 1 ,
• Loïc Moureau 2 ,
• Koen Pardon 1 &
• Axel Liégeois 2 , 3  

BMC Medical Ethics volume  25 , Article number:  60 ( 2024 ) Cite this article

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Introduction

Previous research has explored euthanasia’s ethical dimensions, primarily focusing on general practice and, to a lesser extent, psychiatry, mainly from the viewpoints of physicians and nurses. However, a gap exists in understanding the comprehensive value-based perspectives of other professionals involved in both somatic and psychiatric euthanasia. This paper aims to analyze the interplay among legal, medical, and ethical factors to clarify how foundational values shape the ethical discourse surrounding euthanasia in both somatic and psychiatric contexts. It seeks to explore these dynamics among all healthcare professionals and volunteers in Belgium.

Semi-structured interviews were conducted with 30 Dutch-speaking healthcare workers who had encountered patients requesting euthanasia for psychiatric conditions, in Belgium, from August 2019 to August 2020. Qualitative thematic analysis was applied to the interview transcripts.

Participants identified three pivotal values and virtues: religious values, professional values, and fundamental medical values encompassing autonomy, beneficence, and non-maleficence, linked to compassion, quality care, and justice. These values interwove across four tiers: the patient, the patient’s inner circle, the medical realm, and society at large. Irrespective of their euthanasia stance, participants generally displayed a blend of ethical values across these tiers. Their euthanasia perspective was primarily shaped by value interpretation, significance allocation to key components, and tier weighting. Explicit mention of varying ethical values, potentially indicating distinct stances in favor of or against euthanasia, was infrequent.

The study underscores ethical discourse’s central role in navigating euthanasia’s intricate landscape. Fostering inclusive dialogue, bridging diverse values, supports informed decision-making, nurturing justice, and empathy. Tailored end-of-life healthcare in psychiatry is essential, acknowledging all involved actors’ needs. The study calls for interdisciplinary research to comprehensively grasp euthanasia’s multifaceted dimensions, and guiding policy evolution. While contextualized in Belgium, the implications extend to the broader euthanasia discourse, suggesting avenues for further inquiry and cross-cultural exploration.

Peer Review reports

Medical assistance in dying is allowed in 27 jurisdictions in the world and if so, it is mainly restricted to the terminally ill (see BOX 1 in OSF) [ 1 ]. Medical assistance in dying entails that a patient’s death request can be granted via euthanasia , defined as the intentional termination of life by a physician at the patient’s explicit request, which is currently decriminalised in Australia, Belgium, Canada, Colombia, Luxembourg, the Netherlands, Spain, and New Zealand. In addition, it can be granted by means of assisted suicide , also defined as the intentional termination of life by a physician at the patient’s explicit request, but in these cases, the lethal drugs are provided by a physician and self-administered by the patient at a time of the latter’s own choosing (e.g., Australia, Austria, Switzerland, United States). In some countries, not only a physician, but also a nurse practitioner can be involved in the procedure (e.g., Canada, New Zealand).

Euthanasia has been legal in Belgium since 2002, positioning the country as a pioneer in this field with two decades of euthanasia practice [ 2 ]. According to Belgian legislation, individuals can be deemed eligible for euthanasia when they are, among other criteria, in a medically futile state characterized by constant and unbearable physical or psychological suffering resulting from a serious and incurable disorder caused by accident or illness [ 2 ]. Belgium is one of the few countries that does not exclude people from assisted dying who suffer predominantly from irremediable psychiatric conditions (see BOX 2 in OSF for all legal criteria in Belgium). As regards prevalence, euthanasia accounted for up to 3.1% of all registered deaths in 2023 in Belgium [ 3 ]. Whereas most registered euthanasia deaths concerned the terminally ill (approximately 84%), predominantly suffering from cancer, only 48 or 1.4% of euthanasia deaths concerned non-terminally ill adults predominantly suffering from psychiatric conditions. Since euthanasia was legalised, in total 457 such euthanasia cases have been reported, less than 1.5% of all registered euthanasia cases in Belgium [ 3 , 4 , 5 , 6 , 7 , 8 , 9 ].

However, this is only the tip of the iceberg, as there is reason to believe that the total number of requests for euthanasia in Belgium (regardless of outcome), is at least 10 times higher. For instance, recent annual reports from Vonkel, an end-of-life consultation centre in Belgium, revealed around 100 unique patients per year applying for euthanasia for psychiatric reasons. Less than 10% of those euthanasia requests were reported to be carried out [ 10 , 11 , 12 ]. Moreover, a recent survey among psychiatrists working in Flanders, Belgium, revealed that 8 out of 10 respondents had been confronted at least once throughout their career with patients requesting euthanasia for psychiatric reasons [ 13 ]. The survey also showed that, although three-quarters are supportive of not excluding the option of euthanasia for this specific patient group [ 14 ], the majority is hesitant to be actively engaged in a euthanasia procedure [ 13 , 14 ]. The literature ascribed the reluctance to the complexity of euthanasia assessment in this patient group, inherently high in professional and emotional demands [ 15 , 16 , 17 , 18 , 19 ]. The complexity was for a large part described in terms of the practical considerations surrounding euthanasia requests and assessment, e.g., whether and when these patients can meet the legal criteria.

There is thus reason to believe that healthcare workers’ overarching ethical considerations influence their attitudes on euthanasia in general and in the context of psychiatry specifically, and their practice. As empirical in-depth studies are lacking, this area is largely understudied. To date, only two recent qualitative studies among Dutch physicians emphasised the value-based reasons for euthanasia decision-making, but did not [ 20 ] or only summarily [ 21 ] scratch the specific context of psychiatry. Another recent qualitative study among Dutch physicians, including psychiatrists, emphasized the value-based reasons for supportive attitudes towards euthanasia, e.g. the value of self-determination, compassion, fairness, and suicide prevention, versus the value-based reasons for not supporting euthanasia, e.g. the mission of medicine of hope and healing [ 22 ]. Furthermore, a recent systematic review described the main ethical challenges surrounding the euthanasia practice in the context of psychiatry [ 23 ]. However, this ethical debate was mainly concentrated on the permissibility and implementation of euthanasia from a practical-clinical point of view, e.g. whether euthanasia in the context of psychiatry should be permitted, and why the legal requirements can (not) be adequately embedded in the field of psychiatric medicine. How practically and juridically relevant these considerations may be, they remain the outcome of ethical values being weighed up, which means that no single consideration can be considered ethically irrelevant, neutral, or value-free. Moreover, the review was based on articles that have been selected in a timeframe in which sound empirical data regarding euthanasia in the context of psychiatry were largely lacking.

Also, the overarching value-based views of other professionals involved in psychiatric euthanasia practice have not yet been studied. This is striking, as a recent Belgian survey study revealed that that half of the psychiatric nurses (53%) are frequently and directly confronted with such euthanasia requests [ 24 ], but in-depth insights into their value-based views are lacking. Furthermore, there are many more formal caregivers, other than psychiatric nurses, involved in euthanasia assessment procedures. End-of-life centres employ e.g., paramedical personnel such as psychologists, psychiatric nurses for intake and registration purposes, and well-trained volunteer personnel such as buddies, entrusted with the task to help these patients to cope with the euthanasia procedure. In addition, rehabilitation-oriented support groups (REAKIRO) were established to help these patients (and their relatives) in walking the tightrope of life and death [ 25 ]. All of these caregivers may also have an unacknowledged but influential role in these euthanasia assessment procedures, and therefore, an interesting perspective to reflect on euthanasia legislation and practice. Gaining insight into healthcare workers’ ethical considerations related to euthanasia in psychiatry will lay bare the ethical foundations underlying current practice and is important to inform and spark further debate around this extremely thorny issue, and to promote sound ethical analysis.

Hence, the purpose of this research is to explore healthcare workers’ ethical considerations regarding euthanasia in general and euthanasia concerning adults suffering predominantly from psychiatric conditions in particular.

Theoretical research framework

Our research was guided by the framework of ‘critical social constructionism’ [ 26 ], providing a nuanced perspective that diverges from the acknowledgment of an objective reality. This approach intricately examines the interplay of personal, social, and societal dimensions within the phenomena under study. It necessitates an acknowledgment of the layered complexities influencing our understanding of phenomena such as euthanasia, a notion supported by both our prior research [ 27 ] and additional studies [ 23 , 28 ].

Our interpretation of the data was informed by social constructionism, which recognizes the role of internalized societal norms in shaping individuals’ perceptions of reality over time. Furthermore, we embraced a contextualist epistemology [ 29 ], acknowledging the contextual influence on knowledge formation among both researchers and participants. This methodological approach aimed to capture diverse lived experiences (e.g., diversity in clinical and euthanasia trajectories) and perspectives, including varied attitudes toward euthanasia based on specific relationships (e.g., professional healthcare worker or volunteer). Consequently, we maintained a reflexive stance regarding the potential impact of our individual experiences and identities on our analyses and interpretations, as elaborated in the Ethical Considerations section.

Study design

The qualitative research design consisted of semi-structured face-to-face interviews with healthcare workers in Flanders and Brussels, Belgium.

Participants

All participants were Dutch-speaking and had at least one concrete experience with euthanasia requests and procedures concerning adults with psychiatric conditions in the period 2016–2020, either as professional or volunteer healthcare workers. We adopted a broad recruitment approach, with a particular focus on all healthcare providers directly involved in medical practice rather than in managerial or policy-making roles. No further exclusion criteria were employed.

Recruitment and interview procedure

Purposive sampling was used to ensure diversity and heterogeneity in terms of: participants’ affiliation with institutions holding different stances on ‘euthanasia and psychiatry’; being to a different extent confronted with these euthanasia procedures as regards the amount of experiences (sporadically versus regularly); the nature of the experiences (e.g. confronted with or engaged in euthanasia procedures that were still under review or that had been rejected, granted, performed or withdrawn); and their specific role as professional or volunteer healthcare worker.

Participants were recruited via assistance of our contact persons at: (1) the end-of-life consultation centre Vonkel; (2) the Brothers of Charity; (3) the rehabilitation-oriented centre REAKIRO in Louvain; and (4) the Review Belgian Euthanasia Law for psychological suffering (REBEL) group, a group of Belgian physicians (e.g. psychiatrists), therapists (e.g. psychologists) as well as academics who express their concern on euthanasia in the context of psychiatry via the media. Participants were also recruited via a notice on the sites, newsflashes and/or in the online newsletters of LEIF (Life End Information Forum), Recht op Waardig Sterven (the Flemish Right to Die with Dignity Society) and Vlaamse Vereniging voor Psychiatrie (Flemish Psychiatric Association).

Potential participants contacted MV or a study assistant by phone or mail. The patients were then given an information letter and informed consent form that consisted of 2 main parts. All interviews were conducted by MV or a study assistant, who both have experience in conducting interviews on end-of-life topics. Interviews were held at the participant’s location of choice, except for five interviews which were held online via video call by Whereby 14 due to the Covid-19 crisis lockdown regulations. Interviews lasted between 55 min and 2 h, and were audio recorded (the online video interviews were recorded by Whereby’s software and immediately transferred in an mp.3 format).

Measurements

The interview guide (see OSF) contained the following consecutive questions of importance to the present report: (1) What is your personal stance regarding euthanasia as a legalised medical end-of-life option? and (2) What is your personal stance regarding euthanasia in the context of psychiatry?

Data management and analysis

We used a model of sampling-based saturation, namely inductive thematic saturation, that relates to the emergence of new themes (defined as 7 consecutive interviews without new themes) [ 30 ]. We continued to recruit and conduct interviews so that the sample would be heterogenous in terms of socio-demographics, clinical profile, and clinical setting. In particular, our focus was on recruiting individuals with the following profiles: psychologists, male psychiatric nurses and moral consultants/spiritual caregivers employed in residential psychiatric settings ( n  = 5).

All interviews were then transcribed verbatim and de-identified by the interviewers.

We made use of hybrid inductive and deductive coding and theme development by means of a 2-staged process. Stage 1 consisted of an inductive data-driven thematic coding procedure.

We made use of these four phases; (1) identification and coding of all transcripts; (2) the placing of the codes in subthemes, i.e., arguments in favour versus critical concerns; (3) the placing of these subthemes in overarching main themes, i.e., different stakeholders (patient/medicine/society); (4) the comparison and discussion of the findings (with all co-authors). In addition to the inductive approach, we also used a deductive, theory-driven template approach during stage 2. We made use of these four phases; 1) the development of an ethical interpretation framework (see OSF). The framework consists of four key concepts, each involving a multitude of ethical concepts: (a) ethical theories and methodologies, (b) ethical values, (c) basic ethical virtues, and (d) dialogue/decision making ethics; 2) the identification of codes that fit the ethical framework and the theory-driven renaming of these codes; 3) the placing of some of the subthemes in an additional main theme; and 4) the comparison and discussion of the findings (with all co-authors).

Ethical considerations

The research team comprised two experienced clinical psychologists, one specializing in euthanasia within the cancer patient population and the other skilled in conducting interviews on this sensitive topic within the adult psychiatric context. Additionally, two ethicists with expertise in assisted dying, including euthanasia, were part of the team. Some authors also have backgrounds in psychiatric practice, including outpatient and residential settings, while others bring expertise through personal experiences. Furthermore, all contributing authors have personal and/or professional connections with individuals navigating death ideation, offering diverse perspectives on euthanasia. Additionally, some authors hold religious beliefs, while others maintain a more agnostic stance. These perspectives vary depending on the predominant viewpoints adopted—whether that of the patient, a close relation, a clinician, an ethicist, or policy stances. To mitigate potential undue influence on data interpretation, three team assemblies were convened. These sessions served to share firsthand encounters from interviews and their outcomes, fostering reflection and deliberation among team members. This proactive measure was implemented to prevent both personal and professional biases from affecting the interpretation of the data.

The main characteristics of the 30 participants are listed in Table  1 . The sample consisted of 16 physicians, 7 other care professionals (ranging from psychiatric nurses to mobile support teams), and 7 volunteers, all of whom were engaged in one or more euthanasia procedures predominantly based on psychiatric conditions.

The participating physicians held various roles regarding the handling of euthanasia requests:

1 physician refused to discuss the request with the patient on principle grounds.

7 physicians managed the clarification of euthanasia requests from their own patients or referred them to colleagues for further clarification.

10 physicians provided one of the two legally required formal advices or an additional advice on the euthanasia request.

5 physicians performed the act of euthanasia.

3 physicians held a more normative, dissuasive stance against euthanasia in the context of psychiatry but were willing to explore and discuss the euthanasia request with the patient.

The sample further included 14 non-physicians, among them members holding one or more roles:

2 members were part of mobile teams providing psychiatric care and support in the patient’s home setting.

3 were psychiatric nurses working either in a general hospital or in a psychiatric residential setting.

2 were Experts by Experience, individuals with a history of mental distress trained to provide support for individuals new to the euthanasia procedure and/or rehabilitation approaches.

3 were buddies, individuals entrusted with assisting and supporting the patient throughout the euthanasia procedure.

3 were moral consultants/spiritual caregiver, tasked with offering various forms of existential guidance and support to patients considering euthanasia, including religious, moral, and/or other perspectives.

5 were consultants at end-of-life information and/or consultation centers responsible for patient intake.

Participants’ ethical considerations regarding euthanasia, in the broadest context of medicine

As can be seen from the coding structure in Table  2 , we ordered coding categories on the level of 1) the individual patient, 2) the patient’s social inner circle, 3) the (para)medical field, and 4) the society. Note that words used verbatim by the interviewees (often interview fragments instead of quotes, as to better illuminate the complexities and nuances of interviewees’ first-hand lived experiences) from the transcribed interviews are incorporated that provide both additional insightful details and reveal the at times interwoven nature of the analysed codes.”

The level of the individual patient

On the level of the individual patient, the following five ethical considerations were distinguished: (1) autonomy, (2) dignity, (3) quality of life, (4) compassion, and (5) the meaning and transformative value of suffering.

First, Autonomy was a recurrent theme in all the interviews. Some participants expressly valued individual autonomy , and more specifically its following two underpinning characteristics: (1) self-determination in terms of the fundamental right for each individual to direct the course of one’s own life, which also includes ‘taking control over the timing and circumstances of one’s end-of-life’, and (2) freedom of choice , as they strongly believed that individuals are free to choose what meaning and purpose they assign to their lives. According to them, as each individual should be enabled ‘to live according to one’s own value system’, so should the ending of one’s life also be congruent with one’s own value system. Hence, in their opinion, euthanasia should remain ‘one of the many options to die’.

Other participants called this individualistic approach of autonomy ‘unrealistic’ or even ‘delusional’, as it shies away from: (1) the relational account of autonomy, in which a true autonomous decision was seen as the outcome of a decision-making process which is shaped by individual, social and contextual components, and (2) the internalised downside of autonomy, as the feeling underpinning many euthanasia requests, namely ‘not wanting to be a burden to others’ may lead to ‘self-sacrifice’ and ‘the duty to die’ under the false pretence of autonomy. In addition, some pointed to the power of susceptibility and subliminality, as human beings are subliminal creatures whose behaviour is continuously influenced on both a subconscious and even conscious level. Consequently, internalised pressure cannot be excluded when a patient requests euthanasia. One psychiatrist even stated that ‘ there exists no such thing as a free will, as human beings are always manipulated in many areas of human life and functioning’ .

“I believe that that there should still be places in society where you could die without considering euthanasia. While many people today are facing dementia, and you almost must…. Interviewer: Yes. “Yes, like how should I deal with it? Should I exit life before it becomes inevitable dementia or something similar? Because I think that in a neo-liberal society, many people internalize the idea that at some point, it becomes a moral duty to step aside. They feel obliged to eliminate themselves. Self-elimination. In a neo-liberal model, as long as you can keep up and contribute, everything is fine. But if you can’t keep up, well, if you cannot fully exercise autonomy, then… Essentially, you should hold your honour and step aside.” (spiritual caregiver)

Second, participants mentioned euthanasia as an option to die with dignity . For those in favour of the Law, euthanasia is considered (1) a ‘dignified way of dying’ when everything that leads up to death, including individual, medical, and social needs and expectations, is consistent with one’s own sense of integrity, belief-system and lifestyle, and (2) a ‘good death’, when referring to the literal meaning of the concept ‘euthanasia’, namely ‘a soft and gentle passing’. Other participants raised concerns on the reference to euthanasia and dignified dying in the same breath, as if “ other ways of dying are not or less dignified ”.

Third, the value of quality of life underpinned the arguments made in favour of the Law on Euthanasia, as (1) life itself should not be prolonged unnecessarily, (2) meaningless suffering should be prevented, and (3) a good life should pertain to all stages in life, from the very beginning until the very end, which is feasible if quality of dying circumstances can be guaranteed. As one buddy stated: “ Living a full and good life implies dying a good death ”. Other participants made use of this value underpinning their argument against euthanasia, based on (1) the “protect-worthiness” of life itself and (2) the suffering that must be considered an inherent feature of the human condition.

Fourth, and seamlessly fitting with the former value, divergent courses also emerged regarding the aspect of how to deal with suffering . Some participants were in favour of euthanasia out of compassion in terms of (1) bringing a kind of relief to the patient when providing her the prospect of an end to the suffering and (2) ending the suffering once it has become ‘useless and meaningless’ and ‘disclosing the limits of the carrying capacity of the self’. Some participants referred to the insufficient degree of quality of life in some patients and valued euthanasia as sort of ‘ compensation for a life gone wrong’.

Others considered the option of euthanasia as compromising patients’ ability to accept, bear and cope with suffering experiences by offering the opportunity ‘to quickly resign from it’.

Some participants referred to the dynamic features and hence, the potential enriching value of suffering. They believed that one can and must revolt against the perception of pointless suffering, as suffering may offer unique opportunities to achieve personal growth through the realisation of self-actualising tendencies amidst the suffering and though all kinds of hardship and adversity in life. Therefore, the real challenge is to support the sufferer to (re)gain the ability to transform the suffering by means of redefining, accepting, and making sense of it. One psychiatrist referred to the Myth of Sisyphus and stated:

A rock that must be pushed up the mountain, which is terrible, and then Sisyphus lets the rock fall back down, and he must start all over again. And what is the purpose of that suffering? Pushing the rock up? It’s absurd, really, but still. I find it so vital, human, uh, yes. That is something that inspires me enormously and often makes me, well, yes, vitality and suffering, suffering is inherent to being, of course, and one can suffer, of course, that is very serious suffering, terrible suffering. I know that. But well, accept suffering, right? I’m not glorifying suffering, no, I don’t belong to that category. Some Catholics do that; the suffering of Christ, we must… No, not at all. Suffering is inherent to life. Interviewer: It’s just more bearable for some than for others. Interviewee: Then it’s our task to make it more bearable. Yes. (…) Look, that sets a dynamic in motion. By dynamic, I also mean movement. A euthanasia request is often rigid. I am for movement. That’s what Eastern philosophy teaches us too, that everything moves, and we must keep that movement and that the question may change or that people may also discover things. Or indeed, a suffering that is even more exposed, but on which one can then work. There is still much to do, yes, before the ultimate and final act of euthanasia, by a doctor for all sakes, should be considered. (psychiatrist)

The level of the patient’s inner circle

On the level of the social inner circle, the following three ethical considerations were distinguished: (1) involvement, (2) connectedness, and (3) attentiveness.

Some participants stressed that euthanasia can only be a soft and thus ‘good’ way of dying, if the patient’s social inner circle can be involved in the euthanasia procedure and if sufficient support to them can be provided. All participants in favour of the legal framework on euthanasia echoed the importance of the social circle being involved in an early stage of the euthanasia procedure, as the prospect of the end of life may challenge a patient’s ability of staying and feeling connected . If the euthanasia request is to be carried out, it offers a unique opportunity for both the patient and her social inner circle of consciously being present and sharing goodbyes. Other participants considered this reasoning as potentially deceiving, as concern was raised regarding the trap of false assumptions, in terms of words being left unspoken and the bottling up of one’s own needs for the sake of the other.

As the third doctor, I was asked to provide advice about someone, and the [adult child] was present, a charming [adult child]. The [adult child] was also very friendly but didn’t say much. The man explained why he himself wanted euthanasia and so on. To be honest, at first, I thought, “Well, this won’t take long,” because there were many arguments and reports I had received, but as the conversation went on, I started to feel something different. It turned into a very long conversation, during which the [adult child] also had their say. In short, the father believed that he couldn’t burden his children. He was a kind man who knew what he wanted, and his children were inclined to follow his idea, to follow his vision. However, the children thought, “Yes, we are actually going to agree with our father, and we’ll allow it,” but deep down, they still wanted to take good care of him. The father didn’t want them to take care of him, and there were many other things, but after that long conversation with the [adult child] and the father, and everything else, like, “We’ll still celebrate Christmas together,” there was a complete turnaround. The other physicians involved accepted this very well, and they said, “Okay, for us, it wasn’t clear. (physician)

In addition, concern was raised regarding the inner circle’s respect of individual patient autonomy and freedom of choice outweighing their r esponsibility and accountabilit y to take care for one another and to act according to all these subjects’ best interest.

Consequently, divergent discourses on the virtue of attentiveness emerged. Whereas for some, the euthanasia procedure may offer a unique opportunity for both the patient and her relatives to be better prepared for death and for the bereaved to better cope with grief, others pointed to the inner circle’s continued grappling with unresolved feelings and perceived helplessness after such a fast-track to death.

Yes, and sometimes I also see people, family members after such euthanasia, yeah, I’ve experienced it several times. They say things like, “Yes, I supported it, but I didn’t know it would affect me like this,” you know? They try to convince themselves, saying, “It was good, it was good, and I stand behind it.” Yeah, you are hardly allowed to do otherwise, but you feel that inner struggle in them, you know? Like, “Was it really okay?” But you can’t question it because you think, “Poor them,” but you still feel it, like, “How sad, how sad. (psychiatrist)

The level of medicine

The following five ethical considerations were distinguished: (1) professional duties, (2) responsibility to alleviate suffering, (3) subsidiarity, (4) professional integrity, and (5) monologic versus dialogic approaches.

First and as regards professional duties, it was (only) reported by some physicians that the physician’s duty is “ to provide good care, which includes good end-of-life care ”. Hence, physicians are the ones who should have euthanasia “as a tool in their end-of-life toolbox”. Others held a different stance and referred to Hippocrates’ Oath when stating that the physician’s duty is to save life at all costs.

Second, all the participants agreed that clinicians have the responsibility to alleviate the patient’s suffering . Whereas some welcomed the option of euthanasia due to the experienced limits of palliative care, that in some cases is deemed an insufficient response to intractable suffering, others stated that euthanasia is not needed as physicians have proper palliative care in their toolbox to alleviate all kinds and degrees of suffering.

Third and as regards the subsidiarity principle , opinions differed on the use of a palliative filter, i.e., whether a consultation with specialist palliative care units should precede euthanasia.

Fourth and as regards professional integrity , some participants relativized the physicians’ executive autonomy. As one psychiatrist stated “because in the end, we do not decide whether someone might die or not. We only decide whether we want to be of help and assist in it.” All the ones in favour of the current legal framework echoed that as physicians are the ones that have better access to the lethal drugs and the technical expertise to end the patient’s life in more efficacious ways than non-physicians, they should remain entrusted with euthanasia assessment procedures. Others (only physicians) criticized the Belgian legislator for placing too much power in the physicians’ hands so that the latter “ can play for God instead of using their pharmacological and technical know-how to save lives ”.

Fifth, and as regards the decision-making process, most participants valued the ethical principle of shared decision-making between the patient and her physicians, and some even preferred a triadic dialogue in which the patient, her relevant health carers and her social inner circle is involved in euthanasia assessment procedures. For most of them, this type of extended or relational autonomy is considered as best clinical euthanasia practice, especially when death is not foreseeable. According to some non-physicians, a strict dyadic patient-physician approach is to be preferred when death is reasonably foreseeable in a patient with sufficient mental competence. In this event, no intermediary should be tolerated as the medical secret is considered ‘sacred’. One participant elaborated further on this strict dyadic approach and said:

“ But actually, in my opinion, the request for euthanasia is something between two people. So…. Interviewer: The singular dialogue? “So, a relationship between the patient and the doctor, yes. That’s what I think. And I do understand that the legislation exists, primarily to protect the doctor against misuse or accusations, because euthanasia used to happen before too, but in secret. But for me as a doctor, it would be enough if a patient whom I’ve known for years, followed for years, maybe 20 years, 30 years, 40 years, and who is terminally ill, asks me in private, ‘I want it.’ For me, it doesn’t need to be more than that for me to say, ‘yes.’ So, there’s no need for a whole set of legislation, except of course to protect myself, maybe from the heirs who might have a different idea about it, yes, but I find it beautiful. And they say, you know, our legislation is such that you can write your euthanasia request on the back of a beer coaster and that’s enough, you know? But how it used to be, euthanasia happened just as well, that’s what I heard from my older colleagues. But it was done in private. Actually, that is the most beautiful sign of trust between a doctor and a patient. ” (Physician and consultant)

Others, all physicians without a favourable stance on euthanasia, considered medical paternalism morally justified in the end-of-life context, as (1) physicians have more intimate knowledge of the patient and are thus best placed to act in the patient’s best interests, (2) only the independent evaluation from well-trained and experienced physicians may rule out external or internalized pressure from the patient’s social inner circle, and (3) some patients may show impaired decision-making capacity when confronted with the end of life.

The level of society

As regards the origins and impact of euthanasia legislation on the level of society, the following four ethical themes emerged: (1) protection, (2) dignified dying, (3) solidarity, and (4) distributive justice.

First and as regards protection , some participants valued the existence of a legal framework for an ‘underground’ practice before 2002. According to them, this framework was highly needed to protect the patient against malicious practices and the physician against being charged for murder when ensuring herself that all the legal requirements are met.

So, I believe that it should be well-regulated in a state. In a country, it should be well-regulated. You can either be in favour of it, have reservations, or question it, but when it happens and many people want it or think it’s okay, then it should be regulated. And those, like me, who may be against it, have doubts about it, or wonder, “Is this really necessary?” I would say, or “Does it align with our purpose?” the existential comments that you can make about it, we must accept it because it would be terrible if it, well, it would be even worse if it happened in the underground, like before those laws were established, that’s, yeah. So, I think the laws should exist. Whether I would have made those laws is a different question, or whether I would vote for the parties in parliament that, you know, that support it, that’s another question, but apparently, here in North-western Europe, the need for those practices exists, and it should be regulated properly. And yes, it shouldn’t be left to amateurs or something like that, that’s not the intention. Yes, well, it serves to protect, both in terms of health and to ensure that it doesn’t become a business, of course. I’d prefer it to be integrated into the healthcare system rather than turning it into a profit-driven and exploitative affair for some others. So, that’s…. (psychiatric nurse)

Critical concerns were raised on the lack of protection of the most vulnerable people, i.e., the mentally ill and the elderly. Some of them referred to the amended Law in 2014, that also allowed minors to die by means of euthanasia – be it under more strict circumstances, inter alia, when based on unbearable physical suffering resulting from a medically terminal condition – and feared that the Law will be amended again, so it would no longer exclude the people suffering from dementia or for groups without serious incurable illness, e.g., the elderly with a perceived ‘completed life’.

Second, a major societal shift in thoughts regarding what constitutes dignified dying was reported. For some, the Law on Euthanasia reflects a nascent movement of death revivalism, in terms of people reclaiming control over their dying process. In this respect, euthanasia is deemed a counterreaction to the former dominant paternalistic attitude in Western society to systematically marginalise conversations on death and dying, e.g., due to the mechanisms of denial, avoidance, and postponement, and with the line between life and death increasingly held in physician’s hands, which has left many people ill-equipped to deal with dying and death. The current broad public support for euthanasia is seen as the individual patient taking back the decision-making process of dying and death in her own hands. They further considered euthanasia as a logical consequence of living an artificially prolonged life due to e.g., advances in medicine, that have not necessarily enhanced the quality of life.

“ One thing I also consider is that a part of our lives is artificially prolonged, you know. We don’t live longer because we are healthier, but because we have good pills or better surgical procedures, so we can afford to buy our health. So that part of life is still valuable to me, it’s not less valuable, but it’s artificially extended. So, I think we should keep that in mind, that we can prolong something artificially and maybe even go beyond a point where it no longer works. Interviewer: Beyond the expiration date? That’s what I was looking for (laughs). So, in that sense, I believe we should keep in mind that we can artificially extend something and then maybe, even if it’s just that artificial part, stop or be allowed to stop when the person no longer wants to, I think that makes perfect sense. ” (psychiatrist)

Others provided arguments against the increased death revivalism, referring to euthanasia as a ‘fast-track to death’ resulting in ‘the trivialisation of death’ in the face of formerly known and experienced Art of Dying. For instance, the current societal tendency to avoid suffering and the fear of dying may lead to patients (too quickly) resigning from a slow track to death, in which there is time to e.g., hold a wake.

But I won’t just grab a syringe, fill it up, and administer a lethal injection, you know? I follow the symptoms. And if they become uncomfortable, then I’ll increase the dosage so they can rest peacefully and not have to suffer. That’s what I call a dignified death. And if the family can be present, sometimes it takes a while for them to arrive, and they’ll say, “Come on, even a dog is not allowed to suffer that long.” Meanwhile, the person is just lying peacefully. But that too. Everything should, even that, should progress, and there isn’t much time left for vigil and, yes, I don’t want to romanticize it, but sometimes you see so much happening between families. There’re all kinds of things happening in those rooms, with the family, reconciliations being made. Memories being shared. “Oh, I didn’t know that about our father.“, an aunt walking in and telling a story. Well, so much still happens. I don’t want to romanticize it, but to say that all that time is useless, that’s not true either. And at the farewell, there’s always, the time, you think there’s time for it, but people are still taken aback when an infusion is given, that it can happen within a minute, even if they’re behind it and have been informed beforehand. Just a minute… and it’s done. The banality of death, it’s almost like that. (psychiatrist)

These and other participants also criticised ‘the romanticised image of euthanasia’, that masks the economics of the death system, taking financial advantage of ‘patients not wanting to be a burden to society’.

Third and consequently, divergent discourses on the value of solidarity emerged. For some, decades of civic engagement pointed to the need of death revivalism and patient empowerment, that resulted in the current legal framework. Others strongly criticised the lack of solidarity underpinning the legal framework on the following three counts: 1) the emphasis on patient autonomy is deemed a ’societal negligence in disguise’, as citizens are no longer urged to take care of others, 2) equating autonomy and dignity in euthanasia debates leads to the trap of viewing the ill or the elderly as having ‘undignified’ lives, and 3) wealth over health has become the credo of the current neoliberal society, as the Law on Euthanasia discourages further investments in health care but settles on the ‘commodification’ of health care.

“ I believe that we should take care of each other and especially care for the most vulnerable in our society. We shouldn’t just leave them to fend for themselves. I don’t think the motto should be all about autonomy, autonomy, and then the flip side, saying, “figure it out on your own.” That’s not acceptable. We have a responsibility to take care of each other. We are meant to care for one another. In biblical terms, we are each other’s keeper, right? “Am I my brother’s keeper?” Yes, I am my brother’s keeper. I must take care of each other, take care of others. So, I think in the long term, speaking maybe 100 years from now, people might say, “Sorry, that was a real mistake in the way they approached things.” I don’t know, but that’s looking at it from a meta-level, as historians call it, “longue durée,” and combining it with a neoliberal model, right? Neoliberalism and euthanasia thinking, it would be interesting to do a doctoral thesis on how they fit together perfectly. How they fit together perfectly… They are no longer patients, they are no longer clients, and I also don’t like the word ‘clients.’ They have become ‘users’. Sorry, but that’s our Dutch translation of the English word ‘consumers’ right? It’s like buying Dash detergent or a car; you buy care, just like the Personal Budget for people with disabilities. You buy your care, sorry, this goes against the very essence of what care fundamentally is. Care is a relationship between people; it’s not something you buy. It’s not something you say, “It’s a contract, and I want that.” It doesn’t work like that. [raising voice] The burden is on society. [end of raising voice] And when the money runs out, you have nothing left. If you can’t buy it, then it doesn’t come. “Here’s your little package,” that’s how it’s translated, and it’s always a hidden cost-cutting operation, let’s be very honest about it, a nice story, but it’s always a hidden cost-saving measure. I see right through that story, but well, big stories are always told, and they are always about saving money. [raising voice] It doesn’t bring anything, right? [end of raising voice] People’s self-reliance, they must stay at home, etc. How many people would benefit from going to a care centre, not at the end of their lives, but just because they feel totally lonely at home, but they can’t get in because nobody wants them there, as they don’t bring any profit. ” (spiritual caregiver)

Fourth, critical concerns were expressed concerning the lack of (distributive) justice due to the many existing misperceptions and misconceptions regarding medical end-of-life options that need to be uncovered. For instance, many people would be unaware of euthanasia and palliative sedation can both be dignified ways of dying, with euthanasia functioning as a fast-track and palliative sedation functioning as slow track to death. Also, the evolution of death literacy was contested: there was a sense that patients did not become more death literate, as many of them have insufficient knowledge of the content of the many end-of-life documents in circulation.

Yeah, I mean, you see, and I hear many people saying, “My papers are in order.” I won’t say every day, but I hear it almost every day, “My papers are in order.” That’s also something. It’s an illusion of control, right? Because what papers are they talking about? “My papers are in order.” When you ask them about it, they themselves don’t really know what that means, some kind of ‘living will’, ‘an advance care plan’, but yeah, with all… A living will or advance care plan is not that simple either, and then they think, “Oh, if I get dementia and I don’t recognize anyone anymore, they will give me an injection.” Ah yes, but then we are in a different domain, and that’s a whole other… But yeah, people are not well-informed, I find. They have totally wrong ideas and sometimes fear the wrong things, don’t know what is possible and what is not, and they also let themselves believe all kinds of things. Well, there are many misconceptions out there. (psychiatrist)

Participants’ ethical considerations regarding the additional procedural criteria for people with a non-terminal illness

As can be seen from the coding structure in Table  3 , participants made use of the principle justice to motivate their stance on additional (procedural) criteria that people with a non-terminal illness must meet before euthanasia can be carried out, in comparison with people with terminal illness. Those in favour of the additional procedural criteria referred to the differences between the terminally ill and the non-terminally ill regarding the aspect of content (i.e., the difference between general life expectancy and healthy life expectancy) and the aspect of time (i.e., the probability verging on certainty concerning the terminally ill versus the rough estimation concerning the non-terminally ill). Some of them also referred to the legal proceedings and stated that the Law was meant only for people with terminal illnesses to die by means of euthanasia. Others were of the opinion that it concerns only an arbitrary difference due to 1) the vagueness of the concept ‘naturally foreseeable’, i.e., suffering from a terminal illness, and the subjectivity of the calculated course and prognosis of e.g., degenerative somatic illnesses and dementia. A few participants said that this is beside the question, as one’s individual carrying capacity trumps the course and prognosis of an illness.

Participants’ ethical considerations regarding adults with psychiatric conditions

As can be seen from the coding structure in Table  4 , when asked about participants’ stances on euthanasia in the context of psychiatry, we distinguished value-based themes at the level of (1) the patient, (2) the field of psychiatry, and (3) society in general.

The level of the patient

Justice was the main value-based principle that emerged at the level of the patient. Participants in favour of not legally amending additional procedural criteria in the context of psychiatry stated that every patient with a non-terminal illness should receive equal end-of-life care options. The main counterargument given concerned the differences in patient profile, as some questioned whether the mentally ill can meet the legal criteria or stated that extreme caution is needed and thus additional criteria are in place due to the factor of e.g., ambiguity, impulsivity, and manipulation in the mentally ill.

“I find, the way the procedure is conducted for psychiatric suffering, I find it only natural that they handle it more cautiously because it’s indeed less… It’s not so easy to determine everything, is there really no other option left? And then I understand somewhere that time must be taken to investigate all of that. Because some of these people can be very impulsive, and that impulsivity needs to be addressed somewhere, of course. You also have people who can use their setbacks in the sense of, ‘I’ve been through all that, so I deserve euthanasia.’ And those are the people you need to single out because that’s just… I think those are also people who, with the necessary guidance, can still get out of it. Do you understand? It’s a form of self-pity, in a way. I think there might be resilience there, but they haven’t tapped into it themselves yet; it’s a kind of deflection or something. People with a history of, who say ‘I’ve experienced this and that, so I don’t need it anymore, just give me euthanasia, I deserve that. I’ve been through all that.’ While maybe, if they see, that’s still worth something to me, who knows, maybe that can still happen. They’re people who give up a little too quickly.” (Moral consultant)

Regarding the field of medicine, the following four value-based considerations emerged: (1) justice, (2) responsiveness to suffering, (3) protection, and (4) proportionality.

First, and as regards the principle of justice , participants in favour of equal procedural criteria for all non-terminally ill pointed to the indissociable unity of soma and psyche. A few physicians went one step further and reported that some psychiatric conditions can be considered terminal, e.g., suicidality, or predominantly of somatic nature, e.g., anorexia. The main counterarguments in this respect were (1) the firm belief in the inexistence of irremediableness in psychiatry (only mentioned by some physicians) or (2) that more caution is needed due to the higher level of subjectivity in terms of diagnostics, prognosis, and outcome.

Second, arguments against the distinction between the somatically versus the mentally ill were based on the attitude of responsiveness to the extreme extent and duration of mental suffering that can also render the mentally ill in a medically futile situation and the field of psychiatry empty-handed.

And many of the psychiatric patients I see suffer more than the average ALS patient who has to endure it for three years. In my experience, we’re less advanced in psychiatry compared to most other medical fields. You can easily say “we don’t know” in other areas of medicine and people will understand, but when it comes to psychiatric conditions, it’s different. Doctors might admit “it’s not working” or “there’s no trust,” and they might refer patients elsewhere or even refuse further appointments. I’ve even told a judge during a forced admission, “There’s simply no treatment available.” Yes, sometimes it’s just over and society must accept that there’s no solution. I’m not saying euthanasia is the solution for everyone, but I think it can be an option for some people. (Psychiatrist)

Other participants were not blind to the deep suffering, but strongly believed in the ground principle and core strength of psychiatry, namely the beneficial effect of hope. In addition, they pointed to the differences in the nature and course of somatic versus psychiatric illnesses when stating that considerably more time is needed in psychiatry, with inclusion of the therapeutic effect of hope to become effective.

“And I also believe that collectively, within psychiatry, we can and must provide additional support to endure profound despair. So, even in the face of seemingly endless hopelessness, we must maintain hope, look towards the future with trust, and continuously offer encouragement to those who feel hopeless. Our unwavering optimism and support convey the message that together, we can overcome. Because individuals who suffer from severe mental illness are treatable, I consider myself to be a genuinely optimistic psychiatrist. I have witnessed individuals who have harbored feelings of hopelessness and despair for extended periods, sometimes even decades, undergo profound transformations and experience significant improvement, and in some cases, complete recovery.” (Psychiatrist)

Third, participants in favour of the current legal framework reported that allowing euthanasia for the mentally ill was needed in the light of protection , as it might protect the patient against brutal suicides and also against therapeutic tenacity that more often occurs in psychiatry. Other participants in favour of, as well as participants against the current framework held a different stance on the following two counts: (1) allowing euthanasia conflicts with the aim of psychiatry to prevent suicide at all costs, and (2) the mentally ill are insufficiently protected by the Law as there are insufficient built-in safeguards against therapeutic negligence.

But usually with a psychiatric condition, death isn’t imminent. That’s the tricky part, you know? How many suicides do we have here? But anyway, I have an issue with that, using euthanasia as a kind of antidote against, well, against suicide, that’s a completely different matter. But death and psychiatry, why do we have all those government programs against suicide then? Isn’t that dying as a result of a psychiatric condition? (Psychiatrist, supportive of maintaining euthanasia option in psychiatric settings)

Fourth and as regards proportionality , a few participants with a normative stance against euthanasia in the context of psychiatry argued that psychiatric patients may not be allowed to die by means of euthanasia for as long as the field of psychiatry is under-resourced. They pointed to e.g., the lack of sufficient crisis shelters with a 24/7 availability and the lack of palliative approaches in the field of psychiatry. Instead of allowing euthanasia, they argue ‘to jolt the Belgian government’s conscience on mental health policies’. As a revolution to defeat the built-up inequalities in the field of medicine and knowing that palliative and rehabilitation initiatives in psychiatry require time.

“I oppose euthanasia in psychiatry. Compared to somatic medicine, psychiatry lags behind by 50 years. While physical pain can be managed with medication, there’s insufficient research on treatments for psychological suffering. Promising options like psilocybin and ketamine show potential in easing existential mental struggles. Magnetic stimulation can also alleviate depression, yet access remains limited. Unfortunately, these treatments are underused and under-researched. Many patients aren’t informed about these alternatives to euthanasia. It’s frustrating to see reluctance in exploring these options, especially when they offer hope to long-suffering patients. Utilizing these methods in psychiatric settings carries no risk of addiction. However, current restrictions impede access to these treatments, depriving patients of viable alternatives.” (Shortened excerpt from an interview with a psychiatrist)

When taking a societal perspective, no new arguments emerged from the respondents strongly in favour of the current euthanasia legislation, other than the main value of justice described in the subsection above. According to some, the current Law on Euthanasia busts some myths on the malleability of life and medical omnipotence, and even on psychiatric illnesses as a ‘Western phenomenon’, with e.g., depression and suicidality as a consequence of material wealth instead of a neurologic issue in the brain (only reported by some non-physicians).

There are quite a few people who consider the whole issue of the unbearable nature of psychological suffering a luxury problem, you know? They say something like, “Yeah, where are the suicide rates, to put it in equivalent terms, the lowest in the world? In Africa, because they obviously don’t have the luxury to concern themselves with that. They are already happy if they have a potato on their plate every day.” This is a viewpoint held by many, right? They call it a luxury problem, a modern, typical Western luxury problem. And perhaps there is some truth to it, right? But there are other causes of mortality there, which are much higher, such as child mortality, for example. (non-physician)

Counterarguments were also given and pointed to the value of (distributive) Justice. First, euthanasia was considered as ‘a logical but perverse consequence of systemic societal inequities’ on the one hand and the ‘further evolution towards the commodification or commercialisation of health care in individualised Western societies’ on the other. This would then lead to another vicious circle, with a rapidly growing ‘perception of vulnerable patient groups as irremediable’ and hence less likely to receive potentially beneficial treatment or other interventions. Some took a more radical stance against euthanasia in psychiatry, as they were convinced that euthanasia is nothing but ‘a perverse means to cover societal failures’. In addition, some participants with permissive stances on euthanasia in the context of psychiatry pointed to gender disparities in euthanasia requestors. This was based on the evidence that in the context of psychiatry, many more females request and die by means of euthanasia than males, and proportionally more female patient suffering from psychiatric disorders request and die by means of euthanasia compared to their fellow peers suffering from life-limiting or predominantly somatic conditions.

Finally, some respondents said that they could understand and, in some cases, even support euthanasia in some individual cases, but felt uncomfortable with its impact on the societal level. They pointed to the vicious circle of stigma and self-stigma that may impede the mentally ill to fully participate in societal encounters. In the long run, this type of societal disability may lead to vulnerable patients no longer wanting to perceive themselves a burden to society or to remain ‘socially dead’.

While considering their ethical perspectives towards euthanasia, participants weigh up various values related to and intertwining with the following levels: (1) the patient, (2) the patient’s inner circle, (3) the field of medicine, and (4) society in general. Overall, the participants shared an amalgam of ethical values on each of these four levels, regardless of their stance on euthanasia. It was mainly the interpretation of some values, the emphasis they placed on the key components underpinning each value and the importance they attach to each of the four levels, that determined their stance towards euthanasia. It was uncommon for different ethical values to be explicitly mentioned, which could distinguish distinct stances for or against euthanasia.

As regards euthanasia in the context of psychiatry, the focus has primarily been on arguments for and against euthanasia [ 23 ]. However, our study takes a more comprehensive approach, exploring the issue from a wider range of perspectives. This approach allowed us to uncover more complex insights that may have been overlooked if we had only considered it as a black-and-white issue.

Both the systematic review of Nicolini et al. [ 23 ] and our study emphasized fundamental ethical domains such as autonomy, professional duties, and the broader implications of euthanasia on mental healthcare. While our findings aligned with those of the systematic review, our inquiry delved deeper into psychiatry-specific considerations, including the influence of sudden impulses and feelings of hopelessness. This underscores the importance of healthcare professionals carefully assessing the timing and contextual aspects of such decisions within psychiatric contexts, ensuring individuals receive timely and tailored support and interventions.

Furthermore, our study extended beyond the boundaries of medical discourse, addressing broader societal ramifications. Participants engaged in discussions about ‘social death,’ a phenomenon that describes the marginalization of individuals despite their physical existence. This discussion highlighted entrenched structural inequities and societal attitudes perpetuating social alienation, particularly affecting marginalized demographics, including individuals grappling with mental health issues. Advocating for societal inclusivity and supportive measures, our study strongly emphasized the need to foster a sense of unity and respect for everyone’s worth, regardless of their circumstances.

Interpretation of the main findings

We make explicit and discuss the values corresponding to the four classical principles of biomedical ethics, in particular beneficence, non-maleficence, respect for autonomy and justice [ 31 ]. We place these values in the context of different ethical approaches, such as religious, professional, emancipatory, social, societal, and virtue-oriented approaches (see the ethical interpretation framework in OSF).

In the discussion section, therefore, the following main values and virtues are addressed: (1) the values of beneficence and non-maleficence in a religious perspective, (2) those same values in the professional context, (3) the value of autonomy in the contemporary emancipation paradigm, (4) the virtue of compassion stemming from virtue ethics theory, (5) the value of quality care in a social approach, and (6) the value of justice in societal policy contexts.

Beneficence and non-maleficence: religious perspective

In the realm of euthanasia debates, the interplay of religious beliefs and the values of ‘beneficence’ (the act of doing good) and ‘non-maleficence’ (do no harm) has emerged as a pivotal point of contention, often giving rise to divergent perspectives on this complex ethical issue [ 32 , 33 ]. Some religious traditions staunchly oppose medical end-of-life decisions, including euthanasia and abortion, viewing them as morally wrong and as disruptive to the natural order of life and death. The principle of ‘sanctity of life’ forms the bedrock of their belief system, underscoring the significance they attach to preserving life at all costs, as an embodiment of beneficence [ 34 , 35 ]. Conversely, those who argue for the ethical consideration of euthanasia emphasize the concept of beneficence in alleviating suffering and granting autonomy to individuals in their final moments. However, intriguingly, our examination of the topic has revealed a nuanced relationship between religious beliefs and attitudes toward euthanasia. While some individuals in our sample expressed strong religious convictions ( n  = 5) and even considered themselves as practicing Catholics, they did not necessarily adopt a firm normative stance against euthanasia, signifying a complex balancing of beneficence and possible maleficence within their belief system. Conversely, certain participants who held steadfastly against euthanasia ( n  = 3) did not identify with any religious belief system, yet their position was firmly grounded in their perception of potential maleficence associated with medical intervention in life and death decisions. This observation aligns with recent studies highlighting the intricate and multifaceted nature of religiosity, where individuals within various religious frameworks may hold diverse beliefs and values surrounding beneficence and non-maleficence [ 36 , 37 ]. Moreover, it underscores the powerful influence of societal culture on shaping personal perspectives on euthanasia, and how these views are entwined with the values of beneficence and non-maleficence [ 36 , 37 ].

Beneficence and non-maleficence: professional values

Second, a profound division arises between proponents and opponents, particularly in the field of medicine, where interpretations of the Oath of Hippocrates play a central role. At its core, the Oath emphasizes the deontological values of beneficence and non-maleficence, as physicians are bound by a prohibition against administering a deadly drug to ‘anyone,’ even at their explicit request, highlighting the reverence for the sanctity of life inherent in medical practice. This interpretation has led some to perceive active euthanasia as contrary to these sacred principles of preserving life. The notion of beneficence, understood as promoting the well-being of patients, appears to be in tension with the act of intentionally ending a life. Critics argue that euthanasia undermines the fundamental duty of physicians to protect and preserve life. Additionally, the principle of ‘non-maleficence,’ which entails not harming the patient or their life, is seen by some as being in accordance with the ‘sanctity of life’. However, the Oath also recognizes the significance of alleviating relentless suffering, opening the door to a nuanced debate on how these timeless principles align with the modern concept of euthanasia. As the discourse unfolds, perspectives emerge, with some viewing euthanasia as a compassionate form of care, that respects the autonomy and dignity of patients facing terminal illness or unbearable suffering. Advocates argue that euthanasia can be an act of beneficence, providing relief from pain and allowing individuals to die with dignity and control over their own fate. On the other hand, opponents of euthanasia steadfastly uphold the sanctity of life principle, viewing it as an ethical imperative that must not be compromised. They argue that intentionally ending a life, even in the context of relieving suffering, undermines the fundamental values of medical ethics and the intrinsic worth of every human life. For these individuals, euthanasia represents a profound ethical dilemma that conflicts with the near sanctity of medical ethics and the value of preserving life [ 38 , 39 , 40 ].

Autonomy: contemporary emancipation paradigm

The principle of autonomy emerges as one of the most prominent and contentious values in our contemporary emancipation paradigm. Autonomy, grounded in the belief in individual self-governance, is often cited as a foundational ethical principle in euthanasia legislation, emphasizing the significance of an individual’s capacity to make choices aligned with their own personal values and desires [ 31 ]. However, the discussion on autonomy extends beyond pure individualism, with considerations for relational autonomy, recognizing that individuals are not isolated entities but are shaped by their relationships, communities, and broader societal structures [ 41 ]. Within the context of euthanasia, the complexities of autonomy become evident as participants in the debate strived to find a delicate balance. On one hand, they stress the importance of respecting a patient’s individual autonomy in end-of-life decisions, ensuring that their choices are honoured and upheld. Simultaneously, they acknowledge the necessity of accounting for the patient’s social context and broader community when considering euthanasia as a compassionate option. Nevertheless, concerns are raised by some about the potential risks posed by euthanasia legislation, particularly for the most vulnerable individuals, such as the elderly and the mentally ill. These concerns centre on the negative consequences that may arise when individual autonomy is exercised without consideration for others or for societal well-being, and the concept of “social death,” which refers to the marginalization and exclusion of individuals from social relationships and networks due to illness or disability [ 42 , 43 ].

Amidst these complexities, the ethical value of autonomy stands as a paramount consideration. However, its application necessitates thoughtful consideration and balance with other values, including justice, equality, and societal responsibility. Recent reflections on “relational autonomy” have prompted critical evaluations of the idea of pure autonomy, emphasizing the need to delve deeper into the micro, meso, and macro levels that underpin autonomy and address potential conflicts between individual and relational autonomy [ 44 ]. Further, it highlights the imperative to take the broader societal context into account when grappling with the ethical challenges associated with euthanasia [ 45 ].

Compassion: virtue ethics

Our study confirms that while the value of autonomy holds importance, it is not the sole determinant in the ethical considerations surrounding euthanasia [ 46 ]. In this complex discourse, numerous other ethical values and virtues come to the fore, including the significance of compassion towards suffering individuals and the imperative of alleviating their distress. Notably, compassion is not merely a singular principle, but rather a profound ground attitude or virtue that motivates individuals to empathize with the pain of others and take actions to provide relief.

As revealed in our research, participants who opposed euthanasia did not invoke religious frameworks; instead, they explored diverse philosophical approaches to comprehend suffering and compassion. Among these, non-Western philosophies emphasized embracing suffering as an intrinsic aspect of life, acknowledging the impermanence of all things, including suffering. Additionally, the existentialist perspective of Albert Camus underscored suffering’s innate connection to human existence, leading to deeper self-understanding and comprehension of the world.

These philosophical viewpoints find relevance in the realm of ethics as well. Virtue ethics, in particular, highlights the significance of cultivating virtues such as courage and resilience, while narrative ethics emphasizes storytelling as a means to gain profound insight and reflection on experiences of suffering [ 47 , 48 ]. Such narratives foster empathy and create a shared sense of experience and community.

Our results show that, for some, suffering may hold positive value in various ways. The nature and intensity of suffering, alongside an individual’s values and virtues, beliefs, and coping capacity, significantly influence the ethics of euthanasia decision-making. An intricate approach that recognizes the multifaceted impacts of suffering becomes essential, acknowledging that various factors could potentially influence the experience of suffering as well as the interpretation of the consequences of the suffering experience. It’s possible that this approach doesn’t solely depend on the quantity of suffering or even its nature. Instead, it could be related to the delicate balance between one’s ability to endure suffering, the burden it places on them, and the (ir)remediableness of this burden, which can vary greatly among individuals as well as it might change over time. Such an approach aims to alleviate relentless suffering and, in certain cases, relieve unnecessary and enduring distress without consistently imposing interpretations upon it. Thus, acknowledging that, experiences of suffering are inherent to life and might act as drivers for personal development, fostering resilience, empathy, and a deeper apprehension of life’s essence, while it also might represent something irremediable, underscores the significance of a broader meaning of the concept of compassion as guiding principle in euthanasia discussions. These discussions further extend to the recognition of the dynamic trajectory inherent to the burden of suffering, as well as its potential for temporal evolution within the individual experiences of the afflicted. Such recognition not only fosters a more intricate understanding of the complex interplay between suffering and resilience but also highlights the acknowledgment that there may be moments when suffering becomes unendurable, surpassing the individual’s capacity to cope. This dimension introduces a layer of intricacy to the ethical considerations inherent in these discussions, thus necessitating a nuanced approach that contemplates the potentialities as well as the constraints of human endurance and the associated ethical ramifications.

Quality care: social approach

Examining euthanasia debates from a sociological perspective sheds light on the influence of societal inequalities in healthcare access and quality on the practice of euthanasia, and how it can shape personal, relational, and societal values, leading to the normalization or culturalization of euthanasia [ 49 ]. A noteworthy finding in this context is the contrasting perspectives on the evolving process of dying, transitioning from being perceived as in God’s hands to a more medical realm, where proponents of euthanasia view medicine as a catalyst for granting individuals greater control over the timing, manner, and circumstances of their own deaths. They envision the opportunity to be surrounded by loved ones and maintain consciousness while embracing the option of euthanasia, which they believe improves the quality of life at the end.

Proponents also emphasize additional benefits, such as enhanced transparency and regulation, ensuring ethical conduct through regulatory measures. They express concerns about a cultural environment where certain physicians adopt paternalistic attitudes and resist accepting death, prioritizing the extension of life as a moral imperative. In contrast, critical voices argue that death and dying have become increasingly medicalized, leading to their institutionalization. Some critics further contend that this medicalization has devalued the dying process and commodified life itself, leading patients, and families to increasingly rely on medical interventions at life’s end.

Moreover, as shared by some of the interviewees, the growing acceptance of medical assistance in dying may raise concerns. It’s conceivable that this evolving attitude could contribute to a perception of death undergoing a shift in seriousness, resulting in decisions about one’s life conclusion being made with less comprehensive thought and insufficient reflection. Consequently, this scenario could potentially lead individuals who are more susceptible to experiencing feelings of life’s insignificance, weariness, or sense of being ‘through with life’, to lean towards considering euthanasia. However, this inclination might also be driven by a lack of sufficient access to the necessary, long-term quality mental health care that would otherwise facilitate the pursuit of a life imbued with adequate significance, comfort, and dignity, achievable through appropriate (mental) healthcare.

Earlier research indicates that Belgium’s psychiatric care system has been grappling with underfunding and fragmentation, leading to individuals falling through the gaps in the mental health safety net [ 50 ]. One critical aspect is, e.g., the inadequate investment in long-term, intensive care, which is precisely the kind of support that individuals grappling with such existential questions may require.

Hence, in the context of euthanasia debates, the value of quality care emerges, encompassing the principle of beneficence, which emphasizes the obligation to provide good care and enhance the overall well-being of individuals. Ethical considerations go beyond the individual’s right to autonomy, extending to societal factors that influence healthcare practices and attitudes towards euthanasia. Addressing the impact of healthcare disparities and the medicalization of dying becomes imperative to ensure ethical and compassionate decision-making that upholds the true value of quality care and respect for human dignity.

Justice: societal policy contexts

In the context of euthanasia in somatic versus psychiatric medicine, ethical considerations regarding euthanasia often revolve around the fundamental value of justice [ 23 , 51 , 52 ]. Some respondents in our study emphasized the need for parity between somatic and psychiatric illnesses, recognizing that there should be no distinction between patients suffering from either. They argued that upholding the principle of justice demands equal treatment and recognition of the suffering experienced by individuals with psychiatric illnesses.

However, for others, achieving justice requires acknowledging and addressing the unique challenges faced by patients predominantly suffering from psychiatric illnesses. A comprehensive and integrated healthcare approach is proposed, where mental health is regarded as an integral part of overall health. This approach involves allocating the same level of attention and resources to psychiatric medicine as given to somatic illnesses, aiming to combat stigma and discrimination towards individuals with psychiatric conditions. Equitable treatment during life and at the end of life becomes the focus.

Yet, the Belgian context of psychiatry presents significant challenges. The field is characterized by underfunding and fragmented care, particularly for individuals with longstanding and complex psychiatric problems [ 53 ]. Additionally, the end-of-life care for psychiatric patients is still underdeveloped, and palliative psychiatry is in its early stages, lacking a uniformly agreed-upon definition or clear implementation guidelines [ 54 ]. In response, Belgium is exploring the “Oyster Care” model, designed to provide flexible, personalized care for individuals with severe and persistent mental illness who may be at risk of neglect or overburdened by psychiatric services [ 55 ]. This model aims to create a safe “exoskeleton” or supportive environment for patients, recognizing that recovery, reintegration, and resocialization might not be attainable for everyone with certain psychiatric conditions [ 55 ].

However, the integration of Oyster Care in today’s psychiatric practice is still limited and requires further development. Emphasizing the value of justice calls for continued efforts to enhance and refine psychiatric care, ensuring that individuals with psychiatric illnesses receive equitable treatment throughout their lives, including end-of-life care decisions [ 55 , 56 ].

Implications for future research, policy, and practice

In terms of policy and practice, our findings indicate that the discourse surrounding euthanasia extends beyond legal or medical considerations and encompasses fundamental ethical values that underpin our society. These values may not always be aligned and can create ethical dilemmas that are challenging to address. A value-centred approach to the euthanasia debate necessitates a constructive ethical dialogue among various actors involved, including patients, healthcare practitioners, and the wider community. This conversation should strive to comprehend the diverse values involved and endeavour to achieve a balance between these values. Additionally, ethical dialogue might encourage individuals to reflect on their own assumptions and beliefs, leading to more informed and thoughtful decision-making on ethical and moral issues. Ultimately, ethical dialogue can promote a more just and equitable society that prioritizes empathy, understanding, and mutual respect.

It is also crucial to acknowledge that patients with somatic illnesses and those with psychiatric illnesses may have different needs and expectations regarding the end of life. Hence, end-of life healthcare must be sensitive to the unique needs of each group. This recognition of differences does not justify unequal treatment or discrimination based on the type of illness. Instead, it involves addressing the different needs and expectations of each patient group while ensuring equitable and high-quality care for all.

As regards research, most articles on euthanasia legislation to date placed the emphasis on what other countries and states can learn from the Belgian and Dutch euthanasia practice. In addition, what can be learned is mainly restricted to the evidence and reflections on factual issues from a global practical-clinical perspective. Consequently, one of the main ethical, clinical, and societal issues remains unrequited, namely the impact of legislation and its consequences on an intrapersonal, interpersonal, medical, social, and societal level. Although cultural diversity is recently put high on the research agenda concerning general health care and mental health care, it is largely understudied in the context of end-of-life decisions and largely ignored in the context of psychiatry. Fewer articles have focused on what the latter countries may learn from those not implementing or not considering euthanasia legislation. In an increasingly diverse society, rapidly evolving in terms of fluidity and multi-ethnicity, cross-cultural research can help us learn from one another. To address the many dimensions of euthanasia, there is a need for input from a variety of academic fields, including sociology, anthropology, communication studies, and history. Further interdisciplinary research in all these areas could help inform policy and practice related to euthanasia.

Strengths and limitations

This is the first empirical in-depth interview study that uncovered the underlying ethical considerations of a variety and relatively large sample of health care professionals and volunteers in Belgium, a country with one of the most permissive legislative frameworks regarding euthanasia, as – unlike in some other countries – it does not exclude adults with psychiatric conditions per definition. Belgium is also one of the pioneering countries with such a legislative framework and can boast on two decades of euthanasia legislation and implementation.

We succeeded in providing a unique and representative sample of participants, varying in gender, work setting and expertise, and stances regarding euthanasia. Finally, and unlike former scientific studies that focused on either the somatic or psychiatric context, we now gauged for participants’ ethical perspectives on euthanasia in both fields of medicine.

There are also several limitations to our study. We may have experienced selection bias, as our sample of non-physicians had varying ages, but the sample of physicians was mostly older than 60. In addition, some interviews had to be postponed or cancelled due to COVID-19 restrictions and, potentially, due to legal and emotional concerns surrounding a high-profile euthanasia case being brought to court. Additionally, our sample exhibited heterogeneity regarding worldview (religious or non-religious), but possibly not regarding other culture-sensitive aspects, like migration background. As our qualitative research focused on exploring themes, narratives, and shared experiences rather than on ensuring high participation rates for statistical generalizability, drawing definitive conclusions regarding the prevalence of each opinion (pro/ambivalent/critical/against), the level of experience, or perspective across the entire spectrum of euthanasia practice is beyond the scope of our study.

Finally, although there is a growing number of countries and states around the globe with a legislative framework on euthanasia, all the legal frameworks differ from one another, so the results of our study cannot be generalized to the specific euthanasia context in e.g., Switzerland or Canada.

Our study illuminates the foundational values guiding perceptions of euthanasia, including autonomy, compassion, quality care, and justice, which permeate through four interconnected tiers: the patient, their inner circle, the medical community, and society at large. Despite varied stances on euthanasia, participants demonstrated a convergence of ethical principles across these tiers, shaped by nuanced interpretations and considerations. While explicit discussions of distinct ethical values were infrequent, their profound impact on euthanasia perspectives underscores the importance of ethical discourse in navigating this complex issue. By fostering inclusive dialogue and reconciling diverse values, we can promote informed decision-making, justice, and empathy in end-of-life care, particularly in psychiatric settings. Interdisciplinary research is essential for a comprehensive understanding of euthanasia’s dimensions and to inform policy development. While our study is rooted in Belgium, its implications extend to the broader euthanasia discourse, suggesting avenues for further exploration and cross-cultural understanding.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due reasons of privacy and anonymity, but are available from the corresponding author on reasonable request, following procedures from all 3 Medical Ethics Committees involved. To access the supplementary materials, see the Open Science Framework repository at https://osf.io/26gez/?view_only=af42caddb2554acfb7d1d5aabd4dec7a . Upon publication of this paper, the repository will be made public, and a shorter link will be provided.

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Acknowledgements

The authors wish to thank prof. dr. Kenneth Chambaere and prof. dr. Kurt Audenaert for their preliminary advice regarding the ethics of the research methodology, dr. Steven Vanderstichelen for his help with the interviews (i.e., conducting and transcribing) and all the participants for sharing their professional and in some cases also personal experiences during the interview. We’d also like to thank prof. dr. Kenneth Chambaere for the supervision during the conducting of the interviews and his feedback on the ‘near to final’ draft.

MV is funded by the Research Foundation Flanders via research project (G017818N) and PhD fellowship (1162618 N).

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End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, Brussels, 1090, Belgium

Monica Verhofstadt & Koen Pardon

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Loïc Moureau & Axel Liégeois

Organisation Brothers of Charity, Ghent, Belgium

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The article has been developed with the following authors’ contributions: MV was responsible for the study methodology and managed ethical approval; MV conducted most of the interviews and wrote the main manuscript texts. AL drafted the ethical interpretation framework. MV, LM, KP and AL were responsible for the coding structure and data interpretation and performed a critical review and revision of the final manuscript.

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Correspondence to Monica Verhofstadt .

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This research project was performed in accordance with the Declaration of Helsinki and the European rules of the General Data Protection Regulation. It received ethical approval from the Medical Ethics Committee of the Brussels University Hospital with reference BUN 143201939499, from the Medical Ethics Committee of Ghent University Hospital with reference 2019/0456, and from the Medical Ethics Committee of the Brothers of Charity with reference OG054-2019-20. The interviews were held after obtaining informed consent from all the participants.

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MV has received research grants from the Research Foundation Flanders; no other relationships or activities that could appear to have influenced the submitted work were declared. All other authors declare that they do not have any competing interest.

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Verhofstadt, M., Moureau, L., Pardon, K. et al. Ethical perspectives regarding Euthanasia, including in the context of adult psychiatry: a qualitative interview study among healthcare workers in Belgium. BMC Med Ethics 25 , 60 (2024). https://doi.org/10.1186/s12910-024-01063-7

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A legal right to die: responding to slippery slope and abuse arguments

To be forced to continue living a life that one deems intolerable when there are doctors who are willing either to end one’s life or to assist one in ending one’s own life, is an unspeakable violation of an individual’s freedom to live—and to die—as he or she sees fit. Those who would deny patients a legal right to euthanasia or assisted suicide typically appeal to two arguments: a “slippery slope” argument, and an argument about the dangers of abuse. Both are scare tactics, the rhetorical force of which exceeds their logical strength.

Slippery slope arguments, which are regularly invoked in a variety of practical ethics contexts, make the claim that if some specific kind of action (such as euthanasia) is permitted, then society will be inexorably led (“down the slippery slope”) to permitting other actions that are morally wrong.

It is, of course, easier to assert the existence of a slippery slope than to prove that it exists. Opponents of a legal right to die thus point to the Netherlands, for example, and note how the law permitting euthanasia and doctor-assisted suicide in that country has become steadily more permissive. At first, euthanasia was permitted only for the terminally ill who requested it, but then it was permitted for the chronically ill, for those whose suffering was psychological, and for incompetent patients, including children.

It is indisputable that the Dutch laws regarding euthanasia and doctor-assisted suicide have become more permissive, but those who invoke the slippery slope argument fail to realize that those changes are insufficient to demonstrate the existence of a (noxious) slippery slope. To understand why this is the case, imagine, for example, that you are an opponent of apartheid in South Africa in the 1950s. If you are seeking to bring about legal change, through legal channels, you might realize that you have little hope of convincing the white electorate of abandoning apartheid. Thus, you might decide to begin by chipping away at the edges of the apartheid structure. You might recommend, for example, abolishing separate entrances to the post office for blacks and whites. A defender of apartheid might resist that move by pointing to the possibility of a slippery slope: “If we abolish separate entrances,” that defender might say, “we shall soon find that people of different races are permitted to marry one another, and before we know it, there will be no more apartheid.” It should be readily apparent that, even if the defender of apartheid is correct that the stated trajectory is a likely consequence of abolishing the separate entrances, that consequence would not be a noxious slippery slope.

With that scenario in mind, we can see the hidden assumption in the slippery slope argument against legalizing euthanasia: It is the assumption that the instances of euthanasia that the Netherlands now permits are morally wrong. But the problem is that very many defenders of a legal right to die would deny that those instances of euthanasia are wrong. Some of us think that the suffering that a person endures need not be the product of a terminal disease in order for it to be intolerable. We also recognize that some mental suffering is intractable and as unbearable as physical suffering. And we recognize that it is not only competent patients, but also incompetent ones who can suffer from conditions that make their lives not worth living. Accordingly, we would like to see euthanasia and assisted suicide permitted in such a wider range of cases. If, however, we cannot effect that legal change in one step, we recommend, in the first instance, a more limited liberalization of the law. Once that change has been made, people might realize that the next step and then the next are also acceptable, even if they cannot see it now.

The second argument invoked by opponents of a legal right to die is the argument that such a right will be abused and that no legal safeguards can prevent that abuse. Thus, for example, it has been said that where written voluntary consent to euthanasia is a legal requirement, that consent has not always been obtained. Similarly, it has been said that euthanasia or assisted suicide are often not reported, even in jurisdictions in which reporting is obligatory.

The problem with that argument is that citing many examples of abuse of a legal right is not sufficient to justify withholding that right. If the likelihood of abuse were thought to be grounds for withholding a right, then much more than euthanasia would have to be banned. Driving, for example, would have to be prohibited on the grounds that this right is abused and that none of the safeguards we have against such abuse are completely effective. People drive faster than they should. They drive through red traffic lights and weave through traffic, and they drive cars that are not roadworthy. Some even drive without a license or while under the influence of alcohol. Moreover, the abuse of a legal right to drive often has fatal consequences, and thus, it is not unlike euthanasia in the severity of the outcome of the abuse. (And unlike the case of euthanasia, fatalities from car accidents often involve people who were in excellent health, which makes abuse of driving worse than abuse of euthanasia.) Few opponents of a legal right to die are prepared to accept the implication that driving should be banned. Nor is it a conclusion that should be accepted. There is no reason to withhold from some people a legal right to reasonable activity merely because other people will abuse that right. The appropriate response is regulation, imperfect though that may be.

The opponents of euthanasia and assisted suicide who cite the dangers of abuse in support of their view also fail to notice that abuse is possible even when euthanasia and assisted suicide are legally prohibited. It is naïve to think that covert forms of euthanasia and assisted suicide are not occurring in places where those practices are illegal. At least some of those instances would constitute abuse if a legal right to die existed. It is hard to say how much abuse occurs in such jurisdictions, but that is partly because where euthanasia and assisted suicide are prohibited, doctors will be even less likely to admit to participating in such practices a .

Banning alcohol consumption, prostitution, gambling, and so forth, does not result in the elimination of those practices, in either abusive or non-abusive forms. Similarly, the choice is not between euthanasia and no euthanasia, with abuse occurring only in the former. Instead the choice is between euthanasia with or without regulation. Abuse will occur in any event, and thus, on the assumption that there is nothing wrong with euthanasia in itself, we may as well legalize and regulate it.

The slippery slope and the abuse argument are both compatible with the view that there is nothing intrinsically wrong with the practices at issue. Any person could hold the view that euthanasia and assisted suicide are morally permissible, but then deny that they should be made legal on account of the slippery slope and the danger of abuse. As it happens, however, many if not most of those who advance the slippery slope and dangers of abuse arguments do think that euthanasia is immoral.

Those who think that euthanasia and assisted suicide are immoral often suggest that there are always alternatives to death for those whose lives have become intolerable. Thus, it is suggested that palliation is always a possibility, even if palliation requires sedating the patient to the point of minimal or no consciousness. What that suggestion fails to recognize, however, is that it is not always pain that renders a life not worth living. For some people, the prospect of continuing in a minimally conscious or unconscious state for the rest of their biological life is a fate worse than death. Opponents of a right to die sometimes reply that people with such views can be helped to realize that such a condition is not worse than death. However, this line of argument is dangerous precisely because it could as easily be argued that those who think that death is worse than sedation until natural death could be helped to realize that they are wrong and that they should therefore agree to euthanasia.

It is not at all unreasonable to view as undesirable continued biological life with only minimal (if any) consciousness. Nor is depression in response to such a prospect in any way irrational. To suggest that people who manifest such depression should rather be provided with psychiatric help is to pathologize an entirely reasonable response to an appalling situation.

The quality of life can fall to dismal levels. Not everyone agrees about just how bad life must be before it ceases to be worth living. However, the fact of that disagreement provides no more reason for prohibiting euthanasia than it does for requiring it. To force people to die when they think that their lives are still worth living would be an undue interference with people’s freedom. It is no less a violation of human freedom to force a continuation of life when people believe that their continued life is worse than death.

Opponents of a legal right to die are fond of saying that freedom has its limits. However, just because freedom has its limits does not mean that a right to die falls beyond those limits. When a person deems that life is no longer worth living, then taking action to prevent that person from gaining assistance to die imposes a very serious harm. Although society may restrict a person’s freedom to prevent the infliction of harm on others, it is very difficult to justify restricting a person’s freedom when that restriction will result in an immense personal harm.

a Some of the arguments in the preceding few paragraphs are developed at greater length in Benatar D. Assisted suicide, voluntary euthanasia, and the right to life. In: Jon Yorke, ed. The Right to Life and the Value of Life: Orientations in Law, Politics and Ethics. Aldershot, U.K.: Ashgate; 2010: 291–310.

Plessy V. Ferguson: the Case that Legitimized Segregation

This essay is about the landmark Supreme Court case Plessy v. Ferguson and its significant impact on American society. It explains how the 1896 ruling established the “separate but equal” doctrine, which sanctioned racial segregation and reinforced systemic inequality through Jim Crow laws. The essay discusses the inferior conditions imposed on African Americans and the societal divisions that resulted. It highlights the eventual challenge to Plessy with the Brown v. Board of Education decision in 1954, which began to dismantle legalized segregation. The legacy of Plessy v. Ferguson is shown to persist in modern racial disparities, emphasizing the ongoing struggle for true equality and civil rights.

How it works

The adjudication of Plessy v. Ferguson, a watershed moment in the annals of U.S. judicial history, looms large as a seminal event in the trajectory of civil rights within the nation. This epochal verdict, etched into the legal tapestry in 1896, delineated the contours of the “separate but equal” principle, thereby leaving an indelible imprint on race relations and public policy for generations. Delving into the contextual backdrop, the judicial reasoning, and the enduring ramifications of Plessy v. Ferguson is imperative to fathom the profound magnitude of its impact on the American societal landscape.

The genesis of the case can be traced to Louisiana, where Homer Plessy, an individual of mixed heritage, purposefully challenged the state’s segregation statutes by steadfastly declining to vacate a railway car designated exclusively for Caucasian passengers. Plessy’s subsequent arrest precipitated a legal maelstrom wherein he contended that his constitutional liberties enshrined in the Thirteenth and Fourteenth Amendments had been transgressed. While the Thirteenth Amendment had ostensibly abolished the shackles of slavery, the Fourteenth Amendment ostensibly guaranteed parity under the law. Despite the cogency of these arguments, the Supreme Court, led by Justice Henry Billings Brown, delivered a ruling against Plessy, affirming the constitutionality of segregation as long as parity was ostensibly maintained in the quality of facilities provided.

This judicial pronouncement effectively conferred legitimacy upon racial segregation and furnished a legal pretext for the proliferation of Jim Crow laws across the Southern landscape. Public amenities, encompassing educational institutions, transportation facilities, lavatories, and even potable water sources, were bifurcated along racial lines, engendering a society riven by profound schisms. However, the ostensibly equitable premise of the “separate but equal” doctrine was a mirage; in actuality, the amenities and services afforded to African Americans paled in comparison to those extended to their Caucasian counterparts. This institutionalized asymmetry perpetuated a vicious cycle of disenfranchisement and socio-economic disparity that would persist across successive generations.

The reverberations of Plessy v. Ferguson reverberated far beyond the confines of the legal domain, permeating the very sinews of American societal fabric. By conferring judicial imprimatur upon segregation, the verdict fortified racist ideologies and emboldened advocates of white supremacy. Furthermore, it underscored the limitations inherent within the judicial apparatus in effectuating substantive advances in civil liberties, illustrating how entrenched societal attitudes and local statutes could effectively subvert constitutional imperatives. It was not until the mid-20th century that significant strides were made in dismantling the segregationist edifice erected by Plessy.

A watershed moment in the protracted struggle against institutionalized racism materialized with the 1954 Supreme Court ruling in Brown v. Board of Education. This judicial landmark, which squarely addressed the issue of segregated educational facilities, emphatically pronounced that “separate educational facilities are inherently unequal.” The Brown verdict heralded a seismic shift in American jurisprudence and heralded the denouement of legalized segregation. Moreover, it underscored the pivotal role assumed by the judiciary in safeguarding civil liberties, galvanizing the nascent Civil Rights Movement of the 1950s and 1960s.

Despite the strides made subsequent to Brown, the vestiges of Plessy v. Ferguson continue to reverberate within contemporary societal frameworks. Racial disparities persist across domains encompassing education, housing, and the criminal justice system, serving as poignant reminders of the enduring legacies of segregationist policies. The case serves as a poignant admonition against complacency in the face of injustice and underscores the exigency of unwavering vigilance in the protection of civil liberties.

The historical saga of Plessy v. Ferguson transcends mere legalistic battles and judicial pronouncements; it constitutes a testament to America’s enduring struggle with issues of race and equity. The case encapsulates the codification of entrenched prejudices into statutory frameworks and underscores the formidable hurdles entailed in effectuating the redressal of systemic discrimination. While strides have undoubtedly been made, the odyssey towards genuine parity remains a work in progress.

In summation, Plessy v. Ferguson emerges as a seminal juncture in the annals of American jurisprudence, emblematic of the nation’s intricate dance with issues of race and justice. The legacy of its pronouncements, both immediate and enduring, continues to animate contemporary discourses surrounding civil rights and equality. As we reflect upon this pivotal legal saga, it behooves us to acknowledge the strides made thus far while remaining cognizant of the ongoing imperative to foster a more equitable and just society. Through a nuanced understanding of the profound import of Plessy v. Ferguson, we may chart a course towards the safeguarding of civil liberties and the unrelenting pursuit of racial parity.

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