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«1. Introduction Voluntary active euthanasia refers to a clearly competent patient making a voluntary and persistent request for aid in dying (Brock ...»

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Voluntary Active Euthanasia: The Debate

Louis-Jacques van Bogaert

Fellow of the Centre for Applied Ethics

University of Stellenbosch

South Africa

1. Introduction

Voluntary active euthanasia refers to a clearly competent patient making a voluntary and

persistent request for aid in dying (Brock 1999; Ogubanjo & Knapp van Bogaert 2008). In

this case, the individual or a person acting on that individual’s behalf (physician or lay

person, depending on the law of the country) takes active steps to hasten death (LaFollette, 1997). That active step can be either the provision of the means (i.e. a lethal drug) for self- administration (orally or parenterally), or the administration by a tier. The provision of the means to die is called assisted suicide, assistance in dying, or physician assisted suicide. The patient acts last. With voluntary active euthanasia the assistant acts last. Doctor Jack Kevorkian’s (dubbed “doctor death”) “Mercitron” is an example of assisted suicide. The contraption is hooked to the candidate who initiates the delivery of the lethal drug. With voluntary active euthanasia the lethal drug needs to be administered by an assistant because the candidate is physically unable to proceed unaided. In both circumstances, the individual expresses a competent and voluntary wish to die, and the conditions that would make it right to allow or assist a suicide are satisfied. In both cases the aim is to spare that person pain, indignity, emotional and financial burdens. Yet, suicide is seen as morally reprehensible but is not prohibited by any law. Voluntary active euthanasia, on the other hand, is illegal in most countries and the object of conflicting and polarised moral debates.

Physician assisted suicide involves an affirmative act, writing a prescription or providing the lethal drug. Voluntary active euthanasia requires the acts of providing and administering the lethal drug. In physician-assisted suicide, the individual who wishes to die poses the final act; in voluntary active euthanasia, because that individual is unable to pose the last act, a proxy acts on his or her behalf. The difference is about the person who acts last. The intention and motivation are the same. Therefore, one might wonder whether the distinction is not a kind of hypocritical hair splitting. It reminds us of the omission/commission debates and of the doctrine of double effect.

The doctrine of double effect states that for an action with two consequences, one good and one bad, to be morally permissible the bad consequence may be foreseeable but not intended, and the bad cannot be used to achieve the good. The Dutch debate about indirect euthanasia is a case in point. “Terminal sedation” is legally permissible; it consists of administering large oral doses of barbiturates to induce coma followed by neuromuscular blocking agent to cause death on request of patients hoping their death to be hastened www.intechopen.com 66 Euthanasia – The “Good Death” Controversy in Humans and Animals (Veldink et al., 2002). Death is foreseen (and in fact wished by the candidate) but not intended. Furthermore, the candidate takes the first step actively; the second step inevitably requires the active intervention of an assistant. So, here we have two actors with the same motives. Both foresee the result. To claim that it is not intended is sheer casuistry.

Many red tapes need to be overcome by those wishing to die. The main reason is to avoid the legendary “What if?” In spite of good evidence against it, the most commonly advanced reason is avoiding the slippery slope. For instance, in Switzerland, where assisted suicide and voluntary active euthanasia have been tolerated (though not legal it is not prosecuted if the assistant has no hidden agenda, i.e. personal interest in the death of the assisted person) since 1918, it accounts for 0.45 percent of deaths, only a little more than the 0.3 percent in the Netherlands (Veldink et al. 2002; Van der Heide et al., 2007). The candidate has to activate the “death machine” or has to swallow the lethal drug; in other cases the candidate first ingests the drug but the final blow is administered by a tier. The death is foreseen but not intended. Who is the actor? What is active (commission) and what is passive (omission)?

Removing a feeding tube is an act of commission; since the intention is death it is killing.

Not pouring sustenance in the tube is omission, letting die. The intention is the same; the type of action is different. Does it really matter? As pointed out by Sullivan (1999), the debate places the doctor at the centre instead of the applicant, it leaves out the good of the person who wishes to die, which is the purpose of end of life decisions.

2. Facing death Etymologically, euthanasia means a good or happy death. Many might wonder if death could ever be a happy event. To be good, death should be desired and ought to be peaceful and painless. The concept of euthanasia would not apply to a person who slips away peacefully and painlessly without any intervention after a fulfilled life. Euthanasia requires an intervention by the person wishing to die or by a person acting on her behalf to hasten a wanted death.

The word euthanasia has three meanings: 1) a quiet, peaceful, and painless death; 2) the means of procuring it; and 3) the action inducing it. What is missing is that the three definitions leave out the good of the person whose death is in question and that the death is desired by that person and for its own sake. Euthanasia cannot be morally justified unless it benefits the person who dies (Foot, 1996), and if no one else is harmed by it (Hook, 1995).





Some might consider that death is welcome after a happy and fulfilled life. Others who had an unhappy life or who are burdened with sorrow and suffering view death as deliverance.

It seems, though, that for many who are clinging to life death is the last thing on their wish list. In other words, death is inevitable and is either wished or feared.

LaFollette (1997) has argued that we have not decided to enter life, but that we should be granted the right to choose to exit life. Such view, of course, is highly debatable and debated. Those who believe in the principle of sanctity of life argue that life is God given;

therefore, God only can take it back. This argument does not hold for non-believers though.

The principle that life is sacred, says Dworkin (1995), “that’s the easy part”; the crucial question is which decisions best respect it.

One must respect the wishes of those, believers or not, who wish to stay alive no matter what. On the other hand, to what extent should one respect the wish to die? One answer would be allowing them to commit suicide. Every one has the right to commit suicide; no www.intechopen.com 67 Voluntary Active Euthanasia: The Debate single law prohibits suicide. However, one may not have the courage or the means to take that step. Considering suicide one may be discouraged by the impact it has on one’s loved ones. However, this argument is double-edged. The person who plans committing suicide may well make this decision because his entourage failed him. In that case, should he refrain from the act to avoid guilt feelings and remorse among the survivors?

Is there a right to die? Is there a duty to die? If there is a right to die, is there a correlative duty of a tier party to assist in dying?

In an attempt to answer these though questions the topic of euthanasia is riddled with inconsistencies and twists. Thou shalt not kill, of course, but it needs qualification: thou shalt not kill the innocent (Battin, 1995). It is legally and ethically impermissible to take some one’s life against her will. Mass murder in war, camps, or campuses is fittingly condemned.

Even if this was labelled euthanasia by the Nazi regime, it was murder of innocent and nonconsenting persons. This is not negotiable. Then we have the debate whether killing and letting die are one and the same thing or not. Should active voluntary euthanasia be accessible only for intractable physical pain? What is the difference, if any, between early terminal sedation and terminal sedation? What is the difference, if any, between ordinary and extraordinary means to keep some one alive? And last but not least, what are the duties of health care providers towards terminally ill patients? As pointed out by Sullivan (1999), the euthanasia debate tends to place the doctor in the centre of the debate instead of the candidate. It too often leaves out the good of the person who wishes to die (Angell, 1998).

All these queries illustrate our concerns with death, our own and the other’s. Death is inevitably part of life; we cannot avoid taking a moral position, because we can now choose to interrupt and delay nature’s progress (Gorsuch, 2006). Euthanasia claims Moreno (1995), “appears as the ultimate postmodern demand for personal dignity”.

3. Euthanasia’s historical background Rachels (1993) has given a historical overview of euthanasia from which some of the following is borrowed. In Ancient Greece, there was nothing similar to the current view on the sanctity of life. Infanticide of deformed newborns and infants was seen as benefiting them by avoiding a miserable life. Currently, such practices would be regarded as offensive and a deep lack of respect for differently able persons. This is not to say that every one believes that non-existence might be preferable to existence with different abilities. Peter Singer (1994), notoriously, has argued in favour of the permissibility of infanticide in such circumstances. Needless to say that Singer’s view did provoke public outrage.

Hippocratic physicians represented only a small minority of all self-proclaimed healers.

Markel (2004) claims that it is doubtful that Hippocrates would recognise most pledges ascribed to him because many revisions of the oath were written under Christian influence during the Middle Ages. In those early times, it was not uncommon for physicians to recommend suicide to a patient with incurable disease.

Even if great thinkers as Plato, Aristotle, and Pythagoras considered that suicide was mostly an act of cowardice, they admitted to exceptions. It should also be noted that the Pythagorean School of medicine did not follow Hippocrates’ teachings with regards to physicians’ duty to refrain from assistance in dying. Pythagoras of Samos (582-507 BCE) shifted philosophy from Asia Minor to Southwest Italy, where he founded a school, a religious and mathematical community where his intellectual and moral authority was absolute (autos ephê, ipse dixit, the master has spoken). Against the Homeric world-view, he www.intechopen.com 68 Euthanasia – The “Good Death” Controversy in Humans and Animals introduced features of the mystery religions. Pythagoras’ community was influenced by Orphic mysticism. Pythagoras believed in the immortality of the soul (“the body is a tomb”, just like later Plato’s “body the dungeon of the soul”). Therefore, one should strive to give priority to the soul and respect all living beings because they are all ensouled. Purity of the soul was important (because of his belief in metempsychosis) and can be only achieved through philosophy – the quest for knowledge, understanding, and competence.

During the following twenty centuries, Western Europe was so much under the influence of Christianity that there was a silent condemnation of suicide and no discussion on euthanasia (Curzer, 1999). During the Enlightenment, Immanuel Kant clearly rejected the permissibility of suicide. His argument was rooted in the belief that persons have an incomparable worth.

Suicide degrades humanity. Even during the Enlightenment, it would have been risky to express personal liberal view on any topic, in this case to contest the sanctity of life that would upset the Church’s fundamentalism.

It was not until the twentieth century that the legal and ethical aspects of euthanasia came to the public fore. In 1918, a comment by the Swiss federal government on Article 115 of the

first penal code stated (quoted in Hurst & Mauron, 2003):

In modern penal law, suicide is not a crime … Aiding and abetting suicide can themselves be inspired by altruistic motives.

This is why the project incriminates them only if the author has been moved by selfish reasons (Hurst & Mauron 2003). The act is called “murder upon request of the victim”, not euthanasia. De facto, a 1997 attempt to decriminalise euthanasia failed. The article does not require the involvement of a physician nor that the patient is terminally ill. Switzerland permits anyone to assist in another’s death regardless whether the candidate is terminally ill or not (Ziegler & Bosshard, 2007). The Swiss Academy of Medical Sciences states that assistance in dying is “not part of a physician’s activity”. Nevertheless, like any other citizen, a physician is allowed to altruistically assist in dying.

The argument from palliative care (including pain palliation) is often used against assistance in dying because of excruciating pain. The promoters of the argument claim that no pain is beyond palliation. A survey in Switzerland showed that 73% of palliative care physicians opposed the legislation of euthanasia; however, 19% would practice euthanasia if it became legal (Hurst & Mauron, 2003).



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