euthanasia argumentative essay pdf

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Legal And Ethical Issues of Euthanasia: Argumentative Essay

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Ahmed Rayan

Euthanasia is ethically, religiously, and legally charged topic. Health care professionals should integrate spiritual aspects in their decision making regarding euthanasia while dealing with muslim patients. The purpose of this paper is to examine the Islami view for the concept of euthanasia and its permissiblility in Islam, while discussing different ethical and legal aspects that may affect the perspectives of muslims regarding euthanasia. Active euthanasia is prohibited in Islam. This view is strongly supported by laws and ethical princiles in Islamic communites. However, administering analgesic agents that might shorten the patient's life, with the purpose of relieving the physical pain is accepted, because it is not aimed at killing. On the other hand, negative euthanasia is never accepted. However, withdrawing a futile treatment and allowing death to take its natural course for persons who are already died is acceptable. In this situation, the patient is already dead, and there is no use of keeping life supporting instruments. It is highly recommended for all health care professionals who are providing care for muslim patients to carefully consider the Islamic perspective regarding euthanasia.

Mohammad Yousuf Rathor

Due to globalizing trend of homogenisation of culture, changes in the health care delivery system and market economics infringing on the practice of medicine, there has been a gradual shift in the attitude of the medical community as well as the lay public towards greater acceptance of euthanasia as an option for terminally ill and dying patients. Physicians in developing countries come across situations where such issues are raised with increasing frequency. As the subject has gained worldwide prominence, we want to review this topic from Islamic perspective due to its significance in medical ethics and clinical practice.

Issues in law & medicine

Raphael Cohen-almagor

The essay opens with some background information about the context of euthanasia in Belgium. It proceeds by discussing the Belgian law on euthanasia and concerns about the law, its interpretations and implementation. Finally, the major developments and controversies since the law came into effect are discussed. Suggestions as to how to improve the Belgian law and circumscribe the practice of euthanasia are made, urging Belgian legislators and the medical establishment to reflect and study so as to prevent potential abuse of vulnerable patients.

Israel Law Review

Journal of Geriatric Care and Research (JGCR)

The majority of the British public support medically assisted suicide. However, it remains illegal under British criminal law despite several attempts to legalize it. The uncertainty of medical opinion has impacted on this; studies on the subject have revealed polarized views of doctors affected by religious beliefs, ethnicity and medical specialty as well as concerns about safeguarding the vulnerable. This article discusses how doctors in the UK can utilize evidence collected worldwide to aid in decision-making on this controversial issue, how to improve upon unclear aspects of the world's evidence base and whether there is actually a need to change the law.

Syahira Hozami

Euthanasia is one of the issues that has been the subject of intense debate over time. Euthanasia remians a controversial issue because of its proponents' claim that it is an act of mercy despite its intend on ending human life. Ethical issues arise upon practice of euthanasia, whether a physician is allowed in certain circumstances assisting patients with euthanasia, whether the patients have the right to die, why euthanasia is permissible when alternatives like palliative care and terminal sedation are available, is it worth supporting a patient who has no hope to be cured, and the misleading intentions behind euthanasia practice. From Islamic maqasid al-syar'iyyah perspectives, euthanasia has posed issues regarding the principle of protection of faith (hifz al-deen), lives (hifz al-nafs) and wealth (hifz al-maal). Euthanasia act is regard as homicide in any form of active or passive euthanasia, unless the patients has been clinically diagnosed death, which in this articles include brain deaths as lawful clinical signs of death. This article examines Islam's stance of euthanasia and proposed guidelines on terminating patient's life support system of euthanasia condition based on maqasid al-syar'iyyah perspectives.

“Euthanasia” is derived from the Greek words εὐ- (eu-, “good”) and θάνατος (thanatos, “death”); in other words, it is one’s desire to have a good death. Despite the elegant simplicity of the idea, euthanasia has consistently been one of the most controversial medico-legal issues, over which much ink (and perhaps, blood) has been spilled. It is complicated by the fact that it not only traverses moral and ethical principles, but also faces religious opposition. This paper discusses the various ethico-moral principles and theories and attempts to argue that euthanasia should be legalised in Singapore in order to allow people to die a good death. It is also recognised that the fear of sliding down the slippery slope is a real one, from which far-reaching and horrifying consequences may result. It is thus crucial that the practice of euthanasia be strictly enforced and confined to specific circumstances in order to prevent such an eventuality from materialising.

Euthanasia in Belgium is not limited to terminally ill patients. It may be applied to patients with chronic degenerative diseases. Currently, people in Belgium wish to make it possible to euthanize incompetent patients who suffer from dementia. This article explains the Belgian law and then explores arguments for and against euthanasia of patients with dementia. It probes the dementia paradox by elucidating Dworkin’s distinction between critical and experiential interests, arguing that at the end-of-life this distinction is not clearcut. It argues against euthanasia for patients with dementia, for respecting patients’ humanity and for providing them with more care, compassion, and good doctoring.

Palliative Medicine

Erin Andrew , Robert Pool

Ethical Perspectives

Chris Gastmans

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Euthanasia and assisted dying: the illusion of autonomy—an essay by Ole Hartling

Read our coverage of the assisted dying debate.

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Peer review
Ole Hartling , former chairman
Danish Council of Ethics, Denmark
hartling{at}dadlnet.dk

As a medical doctor I have, with some worry, followed the assisted dying debate that regularly hits headlines in many parts of the world. The main arguments for legalisation are respecting self-determination and alleviating suffering. Since those arguments appear self-evident, my book Euthanasia and the Ethics of a Doctor’s Decisions—An Argument Against Assisted Dying 1 aimed to contribute to the international debate on this matter.

I found it worthwhile to look into the arguments for legalisation more closely, with the hope of sowing a little doubt in the minds of those who exhibit absolute certainty in the matter. This essay focuses on one point: the concept of “autonomy.”

(While there are several definitions of voluntary, involuntary, and non-voluntary euthanasia as well as assisted dying, assisted suicide, and physician assisted suicide, for the purposes of brevity in this essay, I use “assisted dying” throughout.)

Currently, in richer countries, arguments for legalising assisted dying frequently refer to the right to self-determination—or autonomy and free will. Our ability to self-determine seems to be unlimited and our right to it inviolable. The public’s response to opinion poll questions on voluntary euthanasia show that people can scarcely imagine not being able to make up their own minds, nor can they imagine not having the choice. Moreover, a healthy person answering a poll may have difficulty imagining being in a predicament where they simply would not wish to be given the choice.

I question whether self-determination is genuinely possible when choosing your own death. In my book, I explain that the choice will always be made in the context of a non-autonomous assessment of your quality of life—that is, an assessment outside your control. 1

All essential decisions that we make are made in relation to other people. Our decisions are affected by other people, and they affect other people. Although healthy people find it difficult to imagine themselves in situations where they do not decide freely, it is also true that all of us are vulnerable and dependent on others.

Yet autonomy in relation to assisted dying is often viewed in the same way as our fundamental right to choose our own course in life. If we are able to control our lives, then surely we can also control our death. Autonomy with respect to your own death, however, is already halved: you can choose to die if you don’t want to live, but you cannot choose to live if you are about to die.

Decisions about your own death are not made in normal day-to-day contexts. The wish to die arises against a backdrop: of desperation, a feeling of hopelessness, possibly a feeling of being superfluous. Otherwise, the wish would not be there. Thus, it is under these circumstances that the right to self-determination is exercised and the decision is made. Such a situation is a fragile basis for autonomy and an even more fragile basis for decision making. The choice regarding your own death is therefore completely different from most other choices usually associated with the concept of autonomy.

Here are just some of the critical matters that would arise if assisted dying were legalised.

A duty to die

The possibility of choosing to die would inhabit everyone’s consciousness—the patient, the doctor, the relatives, and the care staff—even if not formulated as an out-and-out offer. But if a law on assisted dying gives the patient a right to die, that right may turn into a duty to die. How autonomously can the weakest people act when the world around them deems their ill, dependent, and pained quality of life as beyond recovery?

Patients can find themselves directly or indirectly under duress to choose that option if they consider themselves sufficiently pained and their quality of life sufficiently low. Patients must be at liberty to choose assisted dying freely, of course—that is how it is presented—but the point is that the patient cannot get out of having to choose. It has been called the “prison of freedom.”

Internalised external pressure

Pressure on the patient does not have to be direct or articulated. As pointed out by the US professor of biomedical ethics Daniel Sulmasy it may exist as an “internalised external pressure.” 2 Likewise, the French bioethicist Emmanuel Hirsch states that individual autonomy can be an illusion. The theologian Nigel Biggar quotes Hirsch saying that a patient “may truly want to die, but this desire is not the fruit of his freedom alone, it may be—and most often is—the translation of the attitude of those around him, if not of society as a whole which no longer believes in the value of his life and signals this to him in all sorts of ways. Here we have a supreme paradox: someone is cast out of the land of the living and then thinks that he, personally, wants to die.” 3

The end of autonomy

An inherent problem of autonomy in connection with assisted dying is that a person who uses his or her presumed right to self-determination to choose death definitively precludes himself or herself from deciding or choosing anything. Where death is concerned, your right to self- determination can be exerted only by disposing of it for good. By your autonomy, in other words, you opt to no longer have autonomy. And those around must respect the right to self-determination. The respect refers to a person who is respected, but this is precisely the person who disappears.

Danish philosopher Johannes Sløk, who supported legalisation, said, “The actual concept of death has no content, for death is the same as nothing, and one cannot choose between life and nothing. Rather, therefore, one must speak of opting out; one opts out of life, without thereby choosing anything else. Death is not ‘something other’ than life; it is the cessation or annihilation of life.”

Autonomy is a consistent principle running through the care and management of patients and is enshrined in law. However, a patient’s autonomy means that he or she has the right to decline any treatment. It does not entail a right to have any treatment the patient might wish for. Patients do not have the right to demand treatment that signifies another’s duty to fulfil that right. If that were so, autonomy would be the same as “autocracy”—rule of the self over others. Even though patients have the right to reject any intervention, they do not have the right to demand any intervention. Rejecting any claim that the person might make is not a violation of a patient’s self- determination—for example, there may be sound medical reasons for not complying with a demand. The doctor also has autonomy, allowing him or her to say no. Refusing to kill a person or assist in killing cannot be a violation of that person’s autonomy.

The killing ban

Assisted dying requires the doctor’s moral and physical help. It is a binding agreement between two people: the one who is to be killed and the one who is to kill or assist in killing. But our society does not condone killing as a relationship between two legally competent, consenting people. Exemptions from the killing ban involve war or self-defence and are not justified on the grounds that the killing is done for the “benefit” of someone else.

Valuation of a life

If the action is to be decriminalised, as some people wish, it means the doctor will have to enter into deliberations and arguments for and against a request for assisted dying each time. That is, whether he or she is willing to grant it. The alternative would be to refer the patient to another doctor who might be willing to help—that doctor would still have to assess whether the patient’s life was worth preserving.

Thus, autonomy is not the only factor or even always the key factor when deciding whether assisted dying can be granted. It is not only the patient’s own evaluation that is crucial. The value of the patient’s life must also be assessed as sufficiently low. This demonstrates the limitation of the patient’s self-determination.

Relieving suffering

If a competent and legally capable person must have the option of voluntarily choosing assisted dying in the event of unbearable suffering, why does suffering have to be a requirement? The answer is straightforward: our concepts of assisted dying imply that compassion must form a crucial aspect of the decision—mercy killing and compassionate killing are synonyms. But this leads instantly to the question of why we should not also perform assisted dying on people who are not in a position to ask for it themselves but are also suffering.

Some people find the reasoning unproblematic. It stands to reason that relieving suffering is a duty after all. But in this context it is not unproblematic, because it effectively shifts the focus from the autonomy claimed. According to prevailing ideas about autonomy, patients initially evaluate their quality of life themselves, but ultimately it is those around them who end up gauging that quality and the value of their life. That is to say, the justification for assisted dying is borne on the premise that certain lives are not worth living rather than the presence of a request. The whole point is that in the process, respect for the right to self-determination becomes relative.

Autonomy is largely an illusion in the case of assisted dying. 1 A patient overwhelmed by suffering may be more in need of compassion, care, and love than of a kind offer to help end his or her life. It is not a question of whether people have a right to say that they are unworthy. It is a question of whether they have a right to be believed when saying it.

Ole Hartling is a physician of over 30 years standing, doctor of medical sciences at the University of Copenhagen, professor of health promotion at the University of Roskilde, and an author and co-author of several books and scientific articles published mainly in Scandinavia. Between 2000 and 2007 he was a member of the Danish Council of Ethics and its chair for five years. During this time, the council extensively debated the ethics of euthanasia and assisted dying.

Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

Gastmans C ,
MacKellar C

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Ann Med Surg (Lond)
v.75; 2022 Mar

Euthanasia and assisted suicide: An in-depth review of relevant historical aspects

Yelson alejandro picón-jaimes.

a Medical and Surgical Research Center, Future Surgeons Chapter, Colombian Surgery Association, Bogotá, Colombia

Ivan David Lozada-Martinez

b Grupo Prometheus y Biomedicina Aplicada a las Ciencias Clínicas, School of Medicine, Universidad de Cartagena, Cartagena, Colombia

Javier Esteban Orozco-Chinome

c Department of Medicine, RedSalud, Santiago de Chile, Chile

Lina María Montaña-Gómez

d Department of Medicine, Keralty Salud, Bogotá, Colombia

María Paz Bolaño-Romero

Luis rafael moscote-salazar.

e Colombian Clinical Research Group in Neurocritical Care, Latin American Council of Neurocritical Care, Bogotá, Colombia

Tariq Janjua

f Department of Intensive Care, Regions Hospital, Minnesota, USA

Sabrina Rahman

g Independent University, Dhaka, Bangladesh

End-of-life care is an increasingly relevant topic due to advances in biomedical research and the establishment of new disciplines in evidence-based medicine and bioethics. Euthanasia and assisted suicide are two terms widely discussed in medicine, which cause displeasure on many occasions and cause relief on others. The evolution of these terms and the events associated with their study have allowed the evaluation of cases that have established useful definitions for the legal regulation of palliative care and public policies in the different health systems. However, there are still many aspects to be elucidated and defined. Based on the above, this review aimed to compile relevant historical aspects on the evolution of euthanasia and assisted suicide, which will allow understanding the use and research of these terms.

• The history of euthanasia and assisted suicide has been traumatic.
• The church and research have been decisive in the definition of euthanasia.
• The legal framework on the use of euthanasia and assisted suicide has been strengthened.

1. Introduction

Euthanasia and assisted suicide are two topics discussed throughout history, mainly because they fall within the scope of life as a human right, which has been universally defended for many years [ 1 ]. However, the mean of the word euthanasia as good death generates conflicts at social, moral, and ethical levels. Mainly because death is a loss, it is difficult to understand it as something positive and; additionally, several historical events such as the Nazi experiments related the term euthanasia more to murder than to a kind and compassionate act [ 1 ]. More current texts mention that euthanasia is the process in which, through the use or abstention of clinical measures, the death of a patient in an incurable or terminal condition can be hastened to avoid excessive suffering [ 2 ].

The difference between euthanasia and assisted suicide is that in the latter, the patient takes the final action; however, both practices can be combined in the term assisted death [ 2 ]. At present, several countries authorize assisted death, including Holland, Luxembourg, and Canada [ 3 ]. Belgium and Colombia have regulations that decriminalize only euthanasia; other places where assisted suicide is legal are Switzerland and five states of the United America states, specifically Oregon, Vermont, Washington, California, and Montana [ 2 , 3 ]. Spain recently joined the list of countries that have legislated on euthanasia through the organic law March 2021 of March 24 that regulates euthanasia in that state in both public and private institutions [ 4 ]. The fact that more and more countries were joining the legislation on euthanasia and assisted suicide has brought to light the opinion of thinkers, politicians, philosophers, and physicians. Several nations have initiated discussions on the matter in their governmental systems. Latin America is trying to advance powerfully in this medical-philosophical field. Currently, in Chile, the “Muerte digna y cuidados paliativos” law, which seeks to regulate the issue of euthanasia and assisted suicide in the country, is being debated in Congress [ 5 ].

It is essential to know the point of view of physicians on euthanasia and assisted suicide, especially taking into account that these professionals who provide care and accompany patients during this moment, which, if approved, would involve the medical community in both public and private health systems. Although it seems easy to think that physicians have a position in favor of the act of euthanasia because they are in direct and continuous contact with end-of-life situations, such as palliative care, terminally ill, and critically ill patients. It is important to remember that the Hippocratic medical oaths taken at the time of graduation of professionals are mostly categorical in mentioning the rejection of euthanasia and assisted suicide [ 6 ]. Furthermore, it is also important to note that many of the oldest universities in the Western world originated through the Catholic Church; and just this creed condemns the practice of euthanasia and continues to condemn it to this day. This situation generates that many medical students in these schools have behaviors based on humanist principles under the protection of faith and religion and therefore reject the possibility of euthanasia [ 7 , 8 ].

The relevance of the topic and the extensive discussion that it has had in recent months due to the COVID-19 pandemic added to the particular interest of bioethics in this topic and the need to know the point of view of doctors and other health professionals on euthanasia and assisted suicide.

2. Origin and meaning of the term euthanasia

The word euthanasia derives from the Greek word “eu” which means good, and the word “thanatos” which means death; therefore, the etymological meaning of this word is “good death”. Over time the evolution of the meaning has varied; even as we will see below was considered a form of eradication of people categorized under the designation of leading a less dignified life. Assisted suicide is a condition in which the patient is the one who carries out the action that ends his life through the ingestion of a lethal drug but has been dispensed in the context of health care and therefore called assisted. This care is provided by a physician trained in the area. However, it requires the prior coordination of a multidisciplinary team and even the assessment by an ethics committee to determine that the patient is exercising full autonomy, free from coercion by the situation he/she is living and free from the fatalistic desires of a psychiatric illness [ 9 ]. In a more literary sense, the word euthanasia meaning of “giving death to a person who freely requests it in order to free himself from suffering that is irreversible and that the person himself considers intolerable” [ 9 ].

Some authors go deeper into the definition and consider that for the meaning of euthanasia, are necessary to consider elements that are essential in the word itself; such as the fact that it is an act that seeks to provoke death and that carried out to eliminate the suffering in the person who is dying. Other elements with a secondary character in the definition are the patient's consent (which must be granted respecting autonomy and freedom in the positive and negative sense; that means the fact must be not be coerced in any way). Another element is the terminal nature of the disease, with an irreversible outcome that generates precariousness and a loss of dignity. The third secondary element is the absence of pain of the death through the use of drugs such as high-potency analgesics, including opioids, high-potency muscle relaxants, and even anesthetic drugs. Finally, the last element is the health context in which the action is performed (essential in some legislations to be considered euthanasia) [ 10 ]. According to the World Health Organization, the union of these two components is the current definition of euthanasia, which describes as “the action performed by a person to cause the painless death of another subject, or not preventing death in case of terminal illness or irreversible coma. Furthermore, with the explicit condition that the patient must be suffering physical, emotional, or spiritual and that affliction is uncontrollable with conventional measures such as medical treatments, analgesics, among others; then the objective of euthanasia is to alleviate this suffering” [ 11 ]. Unfortunately, the term euthanasia has been misused over the years, and other practices have been named with this word. An example of this situation occurred during the Nazi tyranny when the word euthanasia concerned the murder of people with disabilities, mental disorders, low social status, or gay people. At that time, euthanasia was even a simultaneous practice to the Jewish genocide [ 11 ].

Not only has the term been misused; also exists an enormous variability of terms to refer to euthanasia. For example, the laws created to regulate euthanasia have different names around the world; in the Netherlands (Holland), the law that regulates this practice is known as the law of termination of life; in Belgium, it is called euthanasia law, in France, it is called euthanasia law too. In Oregon (USA), it is called the death with dignity act; in California, it is the end of life option act. In Canada is called the medical assistance in dying act. Victoria (Australia) is the voluntary assisted dying bill, but all these denominations refer to the already well-known term euthanasia [ 11 ].

3. Evolution of euthanasia and assisted suicide: digging into historical events

To understand the evolution and relevance of these concepts should analyze the history of euthanasia and assisted suicide; from the emergence of the term, going through its first manifestations in antiquity; mentioning the conceptions of great thinkers such as Plato and Hippocrates; going through the role of the Catholic Church; mainly in the Middle Age, where following the thought of St. Thomas Aquinas, self-induced death or death contemplated by own will, was condemned. Later, with the renaissance age and the resurgence of science, technology, and the arts, the term euthanasia made a transition to a form similar to what we know today from thinkers such as Thomas More and Francis Bacon. Finally, the first signs of eugenics were known in London, Sweden, Germany, and the United States in the twentieth century. There was a relationship with the term euthanasia that was later used interchangeably, especially in the Nazi regime, to denote a form of systemic murder that sought to eradicate those who were not worthy of living a life.

Since the sixties, with emblematic cases, the path towards the decriminalization of euthanasia began in some countries, especially concerning the cessation of extreme support measures in cases of irreversible illness or a terminal condition. The practice has progressed to the appearance of laws on euthanasia in several countries.

4. Euthanasia and assisted suicide in ancient times

In book III of Plato's “The Republic”, the author stated that those who live their lives amidst illnesses and medicines or who were not physically healthy should be left to die; implying that it was thought that people in these conditions suffered so much that their quality of life diminished, which seemed understandable to these thinkers. However, other authors such as Hippocrates and his famous Hippocratic oath sought the protection of the patient's life through medicine, especially in vulnerable health conditions prone to fatal outcomes. This Hippocratic oath is the same oath that permeates our times and constitutes an argument among those who mark their position against euthanasia and assisted suicide [ 12 , 13 ].

Other texts that collect thoughts of Socrates and his disciple Plato point out that it was possible and well understood to think of ceasing to live in the face of a severe illness; to consider death to avoid a long and torturous agony. This fact is compatible with the conception of current euthanasia since this is the end of this health care procedure [ 13 ].

In The Republic, the text by Plato, the physician Heroditus is also condemned for inventing a way to prolong death and over manage the symptoms of serious illnesses, which is currently known as distanasia or excessive treatment prolongs life. This kind of excessive treatment prolongs the sick person's suffering, even leading him to maintain biological signs present but in a state of alienation and absolute dependence on medical equipment such as ventilators and artificial feeding [ 13 ]. However, the strongest indication that Euthanasic suicide was encouraged in Greece lies in other thinkers such as the Pythagoreans, Aristotelians, and Epicureans who strongly condemned this practice, which suggests that it was carried out repeatedly as a method and was therefore condemned by these thinkers [ 12 , 13 ]. According to stoicism, the pain that exceeded the limits of what was humanly bearable was one of the causes for which the wise man separates himself from life. Referring to one of the nuances that euthanasia touches today, that is, at a point of elevated suffering, the dignity and essence of the person are lost, persisting only the biological part but in the absence of the person's well-being as a being. In this sense, Lucius Seneca said that a person should not love life too much or hate it; but that person should have a middle ground and end their life when they ceased to perceive life as a good, worthy, and longed-for event [ 1 , 12 ].

During the Roman Empire and in the territories under its rule, it was believed that the terminally ill who commit suicide had sufficient reasons to do so; so since suicide caused by impatience and lack of resolution to pain or illness was accepted, when there was no access to medicines. In addition, there was little development in medicine during that time, and many of the sick died without treatment [ 12 ]. This situation changed later with the emergence of the Catholic church; in this age, who attempted against own life, was deprived of burial in the ground. Saint Augustine said that the suicide was an abominable and detestable act; from 693 AD, anyone who attempted against his physical integrity was excommunicated. Rejecting to the individuals and their lineage, depriving them of the possibility of attending the funeral and even expelled from cities and stripped of the properties they owned [ 12 , 13 ].

4.1. Euthanasia and assisted suicide in the Middle Age

During the Middle Age, Catholicism governed the sciences, arts, and medicine; the sciences fell asleep. Due to this solid religious tendency and the persistence of Augustinian thought, suicide was not well seen. It was not allowed to administer a lethal substance to a person to end the suffering of a severe or terminal illness [ 9 , 12 ]. People who took their own lives at this time could not be buried “Christianly”; therefore, they did not have access to a funeral, nor to the accompaniment of their family in a religious rite. Physical suffering and pain were then seen as a path to glorification. Suffering was extolled as the form that god purified the sin, similar to the suffering that Jesus endured during his Calvary days. However, a contrary situation was experienced in battles; a sort of short dagger-like weapon was often used to finish off badly wounded enemies and thus reduce their suffering, thus depriving them of the possibility of healing and was called “mercy killing” [ 12 ].

5. Euthanasia in renaissance

With the awakening of science and philosophy, ancient philosophers' thoughts took up again, giving priority to man, the world, and nature, thus promoting medical and scientific development. In their discourse, Thomas More and Francis Bacon refer to euthanasia; however, they give a eugenic sense to the concept of euthanasia, similar to that professed in the book of Plato's Republic. It is precise with these phylosophers that the term euthanasia got its current focus, referring to the acceleration of the death of a seriously ill person who has no possibility of recovery [ 12 ]. In other words, it was during this period that euthanasia acquired its current meaning, and death began to be considered the last act of life. Therefore, it was necessary to help the dying person with all available resources to achieve a dignified death without suffering, closing the cycle of life that ends with death [ 13 , 14 ].

In his work titled “Utopia”, Thomas More affirmed that in the ideal nation should be given the necessary and supportive care to the dying. Furthermore, in case of extraordinary suffering, it can be recommended to end the suffering, but only if the patient agrees, through deprivation of food or with the administration of a lethal drug; this procedure must be known to the affected person and with the due permission of authorities and priests [ 12 , 13 ]. Later, in the 17th century, the theologian Johann Andreae, in his utopia “Christianopolis”, contradicts the arguments of Bacon and Moro, defending the right of the seriously ill and incurably ill to continue living, even if they are disturbed and alienated, advocating for the care based on support and indulgence [ 15 , 16 ]. Similarly, many physicians rejected the concepts of Plato, Moro, and Bacon. Instead, they focused on opposing euthanasia, most notably in the nineteenth century. For example, the physician Christoph Hufeland mentioned that the doctor's job was only to preserve life, whether it was a fate or a misfortune, or whether it was worth living [ 16 ].

5.1. Euthanasia in the 20th century

Before considering the relevant aspects of euthanasia in the 20th century, it is vital to highlight the manuscript by Licata et al. [ 17 ], which narrates two episodes of euthanasia in the 19th century. The first one happened in Sicily (Italy) in 1860, during the battle of Calatafimi, where two soldiers were in constant suffering, one because he had a serious leg fracture with gangrene, and the other with a gunshot wound. The two soldiers begged to be allowed to die, and how they were in a precarious place without medical supplies, they gave them an opium pill, which calmed them until they died [ 17 ]. The second episode reported by Licata et al. [ 17 ] was witnessed by a Swedish doctor named Alex Munthe; who evidenced the pain of many patients in a Parisian hospital. So he decided to start administering morphine to help people who had been seriously injured by wolves and had a poor prognosis; therefore, the purpose of opioid use was analgesia while death was occurring.

It is also important to highlight the manuscript entitled “Euthanasia” by S. Williams published in 1873 in “Popular Science Monthly”, a journal that published texts by Darwin, Edison, Pasteur, and Beecher. This text included the report for the active euthanasia of seriously ill patients without a cure, in which the physicians were advised to administer chloroform to these patients or another anesthetic agent to reduce the level of consciousness of the subject and speed up their death in a painless manner [ 16 ].

Understanding that euthanasia was already reported in the nineteenth century, years after, specifically in 1900, the influence of eugenics, utilitarianism, social Darwinism, and the new currents of thought in England and Germany; it began in various parts around the world, projects that considered the active termination of life, thus giving rise to euthanasia societies in which there were discussions between philosophers, theologians, lawyers, and medical doctors. Those societies discussed diverse cases, such as the tuberculous patient Roland Gerkan, who was considered unfit and therefore a candidate to be released from the world [ 16 ]. The scarcity of resources, famine, and wars were reasons to promote euthanasia as a form of elimination of subjects considered weak or unfit, as argued in texts such as Ernst Haeckel's. However, opponents to the practice, such as Binding and Hoche, defended the principle of free will in 1920 [ 16 ].

5.2. Euthanasia in the time of the Nazis

As mentioned above, the term euthanasia was misused during this period; approximately 275,000 subjects (as reported at the Nuremberg International Military Tribunal 1945–1946), who had some degree of physical or mental disability, were killed during Adolf Hitler's Euthanasia program [ 13 ]. However, the Nazis were not the first to practice a form of eugenics under the name of euthanasia, since the early 1900s in London had already begun the sterilization of the rejected, such as the blind, deaf, mentally retarded, people with epilepsy, criminals, and rapists. This practice spread to different countries like Sweden and the United States [ 13 , 16 ].

For the Nazis, euthanasia represented the systematic murder of those whose lives were unworthy of living [ 13 ]. The name given to this doctrine was “Aktion T4”. At first and by law, from 1939, the hospitals were obliged to account for all disabled newborns, which led to the execution of more than 5000 newborns utilizing food deprivation or lethal injection [ 12 , 18 ].

A year before that law, in 1938, one of the first known cases of euthanasia in children arose in Germany. That history called the story of child K, in which it was the father of the minor who asked Hitler in writing for euthanasia for his son because the child had a severe mental disability and critical morphic disorders. Hitler gave his consent to carry out the procedure on child K, and thus the program began to spread throughout the Aleman territory. Since then, physicians and nurses had been in charge of reporting the newborns with alterations, arising the “Kinderfachabteilugen” for the internment of children who would be sentenced to death after a committee's decision [ 12 , 18 , 19 ]. A list of diseases and conditions that were considered undesirable to be transmitted to Hitler's superior Aryan race was determined; thus, any child with idiocy, mongolism, blindness, deafness, hydrocephalus, paralysis, and spinal, head, and hip malformations were eligible for euthanasia [ 19 ].

Subsequently, the program was extended to adults with chronic illness, so those people were selected and transported by T4 personnel to psychiatric sanatoriums strategically located far away. There, the ill patients received the injection of barbiturate overdoses, and carbon monoxide poisoning was tested as a method of elimination, surging the widely known gas chamber of the concentration camp extermination; this situation occurred before 1940 [ 12 , 19 ]. Again, physicians and nurses were the ones who designated to the patients to receive those procedures; in this case, these health professionals supported Nazi exterminations. They took the patients to the sanatoriums, where psychiatrists evaluated them and designated with red color if they should die and with a blue color if they were allowed to live (this form of selection was similar in children) [ 12 , 13 , 19 ]. In this case, the pathologies considered as criteria for death were those generating disability such as schizophrenia, paralysis, syphilis with sequelae, epilepsy, chorea, patients with chronic diseases with many recent treatments, subjects of non-German origin and individuals of mixed blood [ 19 ]. Once in the sanatoriums, they were informed that they would undergo a physical evaluation and take a shower to disinfect themselves; instead, they were killed in gas chambers [ 12 , 13 ]. Despite the church's action in 1941 against Nazis and after achieving suspension of the Aktion T4 project; the Nazi supporters kept the practices secretly, resuming them in 1942, with the difference that the victims were killed by lethal injection, by an overdose of drugs, or left to starve to death, instead of the use of gas chambers. This new modified form of euthanasia, which did not include gas chambers, became known as “savage euthanasia” [ 12 , 13 , 19 ].

5.3. Euthanasia since the 1960s

In September 1945, trials began for crimes perpetrated by Nazi supporters; the victorious Allied forces conducted these trials at the end of the war. During these tribunals, cases of human experimentation were identified and the public exposure of the Nazi euthanasia program. After the Nuremberg trials and the abolition of Nazi experiments, a series of seven documents emerged, among which the Nuremberg code containing the ten basic principles for human research stood out [ 20 , 21 ].

After these judgments, biotechnology was accelerated, with the apparition of new techniques to intervene in the health-disease process. Additionally, the increase in life expectancy and the appearance of diseases that chronically compromise the state of health of people generated a change in the conception of the critically ill patient and the terminal state of life [ 20 , 21 ]. Cases such as Karen Ann Quinlan brought to the forefront the issue of euthanasia and precisely the control of extreme treatment measures. Karen, a young American woman, was left in a vegetative state due to severe neurological damage following alcohol and barbiturate intoxication. After six months in that state and under the guardianship of a Catholic priest, Karen's parents requested the removal of the artificial respirator, arguing that in her state of consciousness prior to the incident, she had stated that she disagreed with artificially maintaining life in comatose patients. The hospital refused to remove the ventilator, arguing the legal issues for the date, and the parents went to court, which in the first instance granted the hospital the right. Nevertheless, the New Jersey Supreme Court granted Karen Ann's right to die in peace and dignity. Despite the withdrawal of the artificial respirator, he continued to live until 1985, when he finally died [ [21] , [22] , [23] ].

Another important case was Paul Brophy, which also occurred in the United States. Paul was a firefighter in Massachusetts and went into a deep coma due to the rupture of a basilar artery aneurysm; initially, his family advocated for support measures but later requested the hospital to disconnect these means to allow death, as Paul had indicated when he was still conscious. The hospital refused to carry out this procedure, so the family went to court, where the removal of the support measures (gastrostomy) was initially denied. Hence, the family went to the state supreme court, achieving the transfer of Paul to another medical center where the gastrostomy was removed, leading to his death within a few days [ 23 ].

The case of Arthur Koestler, an influential English writer and activist diagnosed with Parkinson's disease and later with leukemia, who served as vice-president of the voluntary euthanasia society (Exit) and wrote a manual book with practical advice for euthanasia called “Guide to Self-Liberation”. He stood out because he applied one of his advice and ingested an overdose of barbiturates, causing his self-death. According to his writings, Koestler was not afraid of death but of the painful process of dying [ 23 ]. In this sense, it was a relevant case because it involved someone who held an important position in an association that advocated euthanasia, in addition to being the author of several works, which made him a recognized public figure [ 23 ].

Baby Doe was a case that also occurred in the United States; it was a small child with Down syndrome who had a tracheoesophageal fistula and esophageal atresia; in this case, surgery was necessary. On the advice of the obstetrician, the parents did not allow surgery, so the hospital managers took the case before a judge who ruled that parents could decide to perform or not the surgery. The case was appealed before a county judge who upheld the parents' power to make the decision, in the course of which the case became public and many families offered to take care of the child; however, before the case reached the supreme court, the child died at six days of age [ 23 ].

In the case of Ingrid Frank, a German woman who was in a quadriplegic state by a traffic accident, who initially sought rehabilitation but later insisted on being allowed to die; it was provided with a drink containing a cyanide solution that she drank. At the same time, she was filmed, which shows a kind of assisted suicide. For that reason, this is another case that deals with this issue and is important to know as background in the development of euthanasia and assisted suicide [ 22 , 23 ].

6. Current and future perspectives

The definition of brain death, the rational use of the concept of euthanasia and assisted suicide, and scientific literacy are the objectives of global bioethics to regulate euthanasia and assisted suicide, which can be accessible in all health systems [ [24] , [25] , [26] , [27] , [28] , [29] , [30] ]. End-of-life care will continue to be a subject of debate due to the struggle between biomedical principles, the different existing legal frameworks, and the general population's beliefs. Medical education and preparation in the perception of death, especially of a dignified death, seems to be the pillar of the understanding of the need to develop medical-legal tools that guarantee the integrity of humans until the end of their existence [ 31 , 32 ]. This is the reason why the new generations of physicians must be trained in bioethics to face these ethical conflicts during the development of their professional careers.

In addition, although the conception of bioethics belongs to the Western world, it is crucial to take into account the point of view of other cultures and creeds, for example, a study carried out in Turkey, where nursing students were questioned, found that many of them understood the reasons for performing euthanasia; however, they know that Islam prohibits it, as well as its legislation, and therefore they would not participate in this type of procedure [ 33 ]. Furthermore, Christianism and Islam prohibit euthanasia, but Judaism also prohibits it; in general, the so-called Abrahamic religions are contrary to any form of assisted death, whether it is active euthanasia, passive, or assisted suicide [ 34 ].

7. Conclusiones

The history and evolution of euthanasia and assisted suicide have been traumatic throughout human history. The church, politics, and biomedical research have been decisive in defining these concepts. Over the years, the legal framework and bioethical concepts on euthanasia have been strengthened. However, there is still much work to educate the general population and health professionals about end-of-life care and dignified death.

It is also important to remember that life is a concept that goes beyond biology. Currently, bioethics seeks to prioritize the concept of dignity, which must be linked to the very definition of life. Although the phrase is often heard that it is not necessary to move to be alive, what is important is that person feels worthy even if they have limited movement. The person's treatment must be individualized in bioethics since each individual is a unique unit. Therefore, medical paternalism must be abandoned. Instead, the subject must be more involved to understand their context and perception of life and dignity.

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All authors equally contributed to the analysis and writing of the manuscript.

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Sabrina Rahman. Independent University, Dhaka, Bangladesh. [email protected] .

Declaration of interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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Published: 15 January 2014

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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All authors planned and elucidated the layout. TDGF and DS drafted the manuscript which was critically edited and added to by BJG. All authors have read and approved the final draft.

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Frost, T.D.G., Sinha, D. & Gilbert, B.J. Should assisted dying be legalised?. Philos Ethics Humanit Med 9 , 3 (2014). https://doi.org/10.1186/1747-5341-9-3

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Received : 12 November 2013

Accepted : 11 January 2014

Published : 15 January 2014

DOI : https://doi.org/10.1186/1747-5341-9-3

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Assisted dying
Legalisation
Physician-assisted suicide

Philosophy, Ethics, and Humanities in Medicine

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The legal and ethical debates concerning both types of euthanasia are discussed, focusing on both the supporter of euth euthanasia and the opponent of euthocide. Euthanasia is one of the issues that has been the subject of intense debate over time. It has been a pertinent issue in human rights discourse as it also affects ethical and legal issues pertaining to patients and health care providers.
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The essay opens with some background information about the context of euthanasia in Belgium. It proceeds by discussing the Belgian law on euthanasia and concerns about the law, its interpretations and implementation. Finally, the major developments and controversies since the law came into effect are discussed.
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History of Euthanasia. Euthanasia statistics in countries where it is legal. Impact of legal Euthanasia on people's life. Negative consequences of illegal Euthanasia. Transition to Conclusion. Conclusion. Summary. Unexpected twist or a final argument. Food for thought.
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