Should active euthanasia be permitted?
• If you believe in the sanctity of human life and think
that causing death is always wrong (for example, you
believe that life is God’s gift, never to be revoked) all
the previous considerations will not make you
support active euthanasia. They were all based on the
assumption that sometimes it was good to end a life
(to stop suffering, pain, etc.).
• If you don’t accept that assumption, you will say that
it is wrong to kill someone even if he expresses a
wish to die, simply because you will think that this
wish is never reasonable.
• Can those who believe in the sanctity of human life
support passive euthanasia?
Sanctity of life and passive euthanasia
• If killing is always wrong, it seems that passive euthanasia
must also be condemned.
• There is a way out of this predicament: it is the doctrine of
double effect (DDE).
• The idea here is that it is morally permissible to do
something that leads to death, but only if the death is a
side-effect and not the intended effect of that action.
• Example: giving someone strong pain killers can lead to
his earlier death. There are two effects here: (1) alleviating
pain, and (2) causing earlier death. According to DDE, it is
OK to do (2) if the intended effect is (1), and (2) is just an
anticipated effect. However it is wrong to do (2) if (2) itself
is intended, and if pain killers are used to bring about (2).
The doctrine of double effect
• There are two different possible actions here:
a) you intend (1), with the awareness that (2) will also
b) You intend (2), which you bring about by doing (1).
• Obviously, the result of your action is the same in both
cases. Both (1) and (2) happen, and in both cases you are
perfectly aware that they will both happen. The only
difference is that your intention is directed at (1) in (a),
whereas it is directed at (2) in (b).
• Is this small difference a sufficient basis to argue that these
two actions have a totally different moral status, namely
that (a) is morally OK but (b) is morally wrong?
DDE applied to passive euthanasia
• Assume that it is anticipated that withholding treatment
(WT) will lead to death (D). But DDE can be used to argue
here that choosing WT is not as bad as active euthanasia
because the intended effect is WT (although one knows that
D will happen as well).
• Patients have a right not to be treated against their will
even in some cases when this leads to death. When the
doctors respect that right, this does not mean that they
intend to kill them!
• Take the case of Jehovah’s witnesses who oppose blood
transfusion. They sometimes die because their autonomy is
respected, and doctors are not blamed for death (for not
forcing the blood transfusion that would have saved their
Double effect is different from means-end relation
• DDE permits a bad outcome if it is a side-effect (unintended).
• Action A produces an intended good effect G, which produces
an unintended bad effect B.
A G B
• Is it then also permissible to do something bad (that we
don’t intend) in order to bring about some good effect (that
we do intend)?
A B G
• Actually, no. If B is a means (instrument) to get G, it cannot
be unintended. For instance, if my goal is to feed my family
by robbing a bank, I can’t say I didn’t intend to rob a bank!
Lives not worth living?
• The idea that some lives are so bad that they are not worth
living goes against the doctrine of the sanctity of human life.
• An issue immediately arising from this idea is that some
lives are then more or less worth living than others.
• The Nazis used a very similar term: lebenunwertes Leben.
• Those defending euthanasia today protest against
comparing their views to the policies in Hitler’s Germany.
• They stress that they are against involuntary euthanasia.
• But many of them are consequentialists (including Singer),
and consequentialists are unable to absolutely exclude
• “If we are preference utilitarians, we must allow that a
desire to go on living can be outweighed by other desires”
(Singer, Practical Ethics, p.99)
What to do with handicapped and sick?
• If it is all right for parents to kill seriously handicapped
children, won’t this also affect how we see adult
• And how about old people with Alzheimer’s disease, who
no longer have a concept of themselves as subjects of
experiences? Is it OK to kill them if a talk about their own
interests becomes dubious and if they become just a burden
for their relatives?
• Moreover, using the consequentialist logic would it not be
possible to introduce a duty to die, not just a right to die?
• The argument for euthanasia in some sense works better for
older people than for children because in these cases death
does not deprive them of the value of “future like ours”.
Opposition to euthanasia
• If you believe that death is sometimes a better option
for a person who wants to die, can you still be against
• In fact, yes. You can agree with the advocates of
euthanasia about everything concerning the person
who wants to die but you can still think that
euthanasia should not be permitted because of the
likely consequences of the permission of euthanasia.
• In other words, you may not have any intrinsically
moral criticism of euthanasia, but only a purely
consequentialist argument against it.
Analogy with abortion
• It very often happens that one’s moral attitude about
a given phenomenon naturally implies a defense of a
particular policy about that issue.
• For example, if you think that abortion is immoral
you would naturally advocate a legal prohibition of
abortion. But suppose that you realize that, the world
being what it is, this would not stop abortions but
would just lead to abortions being done illegally,
under uncontrolled conditions, causing more deaths
and health problems. This could make you oppose
the legal prohibition of abortion, although you think
that abortion is wrong and should not be practiced.
Possible negative effects of legalizing euthanasia
• It would be very hard to regulate it.
• There would be less respect for human life.
• People would start requesting euthanasia on a massive
• Slippery slope (If voluntary euthanasia is allowed, this
could make it easier to accept non-voluntary or even
involuntary euthanasia later. Is it a road to reviving the
Nazi practice of killing sick and retarded?)
• Older and sick people would be pressured to request
euthanasia (which is not possible if euthanasia is not an
• The medical profession would lose the trust of the
Can having a choice be harmful?
• It may seem that having more choices cannot be bad.
• If you expect A (no other options exist) but are then offered
a choice between A and B, how can this harm you?
• To see that it is not that simple, consider a situation where
you are invited to dinner. Now you have a choice between
going to dinner (D) and not going to dinner (-D). But before
receiving the invitation, your only option was -D.
• It is actually possible that you were better off before, and
that the new option just made the situation worse for you.
• Previously, you could have (a) stayed home without
offending anyone, and now you have a choice, say, between
(b) attending the dinner you don’t want to attend or (c)
refusing to attend and offending someone.
• You prefer (a) to both (b) and (c), but (a) is no longer
available as an option.
Can having a choice of euthanasia be harmful?
• Consider a similar situation about euthanasia.
• If euthanasia is illegal then A will die a natural death.
• But if euthanasia is legalized, A has two options: die a
natural death or ask for euthanasia.
• Suppose that A’s relatives want him to choose euthanasia
but he doesn’t want it.
• Previously he had no choice, there was only one option: (a)
die a natural death (without disappointing anyone)
• Now his choices are (b) choose euthanasia, which he
actually doesn’t want, and (c) die a natural death, and
disappoint his relatives.
• A prefers (a) to both (b) and (c), but (a) is no longer available
to him as an option.
• In the end he may choose (b) because he prefers (b) to (c).
A right or… pressure?
• Is this the kind of choice...that we want to offer a gravely
ill person? Will we not sweep up, in the process, some
who are not really tired of life, but think others are tired
of them; some who do not really want to die, but who feel
they should not live on, because to do so when there
looms the legal alternative of euthanasia is to do a selfish
or a cowardly act? Will not some feel an obligation to
have themselves "eliminated“?
(Yale Kamisar, 1970, 'Euthanasia legislation: Some non-
religious objections', in A.B. Downing (ed.), Euthanasia and
the Right to Die, Humanities Press, New York, pp. 85-133.)
Euthanasia in practice: the case of Holland
• In Holland, both active voluntary euthanasia (VAE)
and physician assisted suicide (PAS) are legalized.
The difference between the two is that in PAS, the
last link in the causal chain that leads to the patient’s
death is the patient’s action (e.g. taking the pill
provided by the doctor). In VAE, in contrast, the last
link is the doctor’s action (e.g. giving a lethal
• Holland is widely discussed in relation to
consequentialist considerations about legalization of
euthanasia because it is the only country where
euthanasia has been practiced legally for a number of
The Dutch guidelines for euthanasia
1. The request for euthanasia [i.e., VAE] must come only
from the patient and must be entirely free and voluntary.
2. The patient's request must be well considered, durable
3. The patient must be experiencing intolerable (not
necessarily physical) suffering, with no prospect of
4. Euthanasia must be a last resort. Other alternatives to
alleviate the patient's situation must have been considered
and found wanting.
5. Euthanasia must be performed by a physician.
6. The physician must consult with an independent
physician colleague who has experience in this field.
The points raised by the critics
• According to some calculations, taking all deaths in
Holland in 1990, 1 out of 15 deaths was caused by
euthanasia (more than 9,000 out of 130,000).
• Some patients received euthanasia on the grounds of their
“pointless and empty existence” (no illness was involved).
It seems that the phrase “intolerable (not necessarily
physical) suffering” was interpreted very broadly.
• Apparently, serious breaches of all the guidelines were
• There was not much support for non-voluntary euthanasia
at the beginning, but this changed in a short time, and non-
voluntary euthanasia increased in frequency.
• After a visit to Holland in 1993, a UK fact-finding
committee recommended against adopting the practice.
• The two ways of discussing euthanasia:
a) Discussing paradigmatic cases, and trying to see
what is the best moral choice for those involved
b) Discussing the consequences of a possible
legalization of euthanasia
• The debate about (a) turns on questions about the
sanctity of human life, the doctrine of double effect,
rights of patients, etc.
• The debate about (b) focuses on empirical issues.
(What is the correct picture of the Dutch experience?
Are their negative experiences avoidable?)
• Even if the conclusion is in favor of euthanasia in (a),
it can be reversed by considerations raised in (b).