Active vs. passive euthanasia: why keep the distinction?
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Ethics↗
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The distinction between active and passive euthanasia.
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Euthanasia↗
[Euthanasia and the doctrine of double effect].
Direct active euthanasia is prohibited in most countries while passive and indirect is not. However, many arguments against the legalization of voluntary active euthanasia are flawed. Ethical differences between active and passive or indirect euthanasia are difficult to maintain especially when the passivity of the actor causes death. The crucial point is not activity or passivity but respect for the autonomy of individual human beings. In particular there appears to be little ethical difference between active and indirect euthanasia. Indirect euthanasia has often been justified by the principle of double effect, which traces back to Thomas Aquinas. But resorting to this rule contains a logical fallacy. The principle of double effect does not allow foreseen and unwanted adverse effects of an action to occur when they are avoidable. In terminal sedation, an example for indirect euthanasia, hypoxemia and dehydration can easily be prevented by respirator therapy and fluid administration. Therefore the rule of double effect is not applicable. Indirect and direct active euthanasia cannot be ethically distinguished by resorting to the principle of double effect.
Double Effect Principle↗
Nurses' attitudes to active voluntary euthanasia: a survey in the ACT.
National public opinion polls show a large majority of Australians are in favour of active voluntary euthanasia (AVE). However, most members of the public have had only limited direct experience with dying people. For this reason, surveys of the opinions of medical practitioners and nurses on this issue are of great interest. The present study involved a postal survey in late 1996 of 2,000 randomly selected registered nurses from the Australian Capital Territory (ACT). The ACT has had extensive public debate about this issue. The questionnaire included some questions asked in earlier Australian surveys of the general public and health practitioners. Responses were received from 1218 nurses (61%). A majority of nurses who responded supported AVE as 'sometimes right', be it homicide by request (72%) or physician-assisted suicide (71%). A slightly smaller majority believed the law should be changed to allow homicide by request (69%) and physician-assisted suicide (67%). If AVE were legal, 66% of the nurses indicated they were willing to be involved in the procedure. Only 30% were willing to assist patients to give themselves the lethal dose, while 14% were willing to administer the lethal dose to the patient. Comparing these results with previous surveys, it appears that nurses are less in favour of AVE than the public, but more in favour than medical practitioners.
Attitude of Health Personnel↗
UK geriatricians' attitudes to active voluntary euthanasia and physician-assisted death.
AIM: To describe the views of British geriatricians on active voluntary euthanasia and physician-assisted death. METHOD: Postal questionnaire to 742 consultant members of the British Geriatrics Society. RESULTS: 81% considered active voluntary euthanasia never to be justified ethically, although 23% supported legalization in some situations and 13% would be willing to administer active voluntary euthanasia in some situations. With regard to physician-assisted death, 68% opposed it on ethical grounds and 24% supported its legalization in some instances, with 12% stating they would be willing to provide such assistance in some situations. Free text comments frequently cited good palliative care as an important response to such issues in clinical practice.
Adult↗
Should euthanasia be legal? An international survey of neonatal intensive care units staff.
OBJECTIVE: To present the views of a representative sample of neonatal doctors and nurses in 10 European countries on the moral acceptability of active euthanasia and its legal regulation. DESIGN: A total of 142 neonatal intensive care units were recruited by census (in the Netherlands, Sweden, Hungary, and the Baltic countries) or random sampling (in France, Germany, Italy, Spain, and the United Kingdom); 1391 doctors and 3410 nurses completed an anonymous questionnaire (response rates 89% and 86% respectively). MAIN OUTCOME MEASURE: The staff opinion that the law in their country should be changed to allow active euthanasia "more than now". RESULTS: Active euthanasia appeared to be both acceptable and practiced in the Netherlands, France, and to a lesser extent Lithuania, and less acceptable in Sweden, Hungary, Italy, and Spain. More then half (53%) of the doctors in the Netherlands, but only a quarter (24%) in France felt that the law should be changed to allow active euthanasia "more than now". For 40% of French doctors, end of life issues should not be regulated by law. Being male, regular involvement in research, less than six years professional experience, and having ever participated in a decision of active euthanasia were positively associated with an opinion favouring relaxation of legal constraints. Having had children, religiousness, and believing in the absolute value of human life showed a negative association. Nurses were slightly more likely to consider active euthanasia acceptable in selected circumstances, and to feel that the law should be changed to allow it more than now. CONCLUSIONS: Opinions of health professionals vary widely between countries, and, even where neonatal euthanasia is already practiced, do not uniformly support its legalisation.
Adult↗
Active voluntary euthanasia or physician-assisted suicide?
OBJECTIVE: To find out why Dutch general practitioners (GPs) and nursing home physicians (NHPs), and patients (according to their physician) opt for active voluntary euthanasia rather than for physician-assisted suicide, or vice-versa. DEFINITIONS: The following definitions were used in the study: Euthanasia is the intentional termination of life, by someone other than the patient, at the patient's request; physician-assisted suicide is intentionally helping a patient to terminate his or her life at his or her request. DESIGN: Two descriptive, retrospective studies. SETTING: The Netherlands. METHOD: Data were collected by means of anonymous questionnaires sent to a random sample of 521 GPs from the province of North Holland, 521 GPs from the rest of the Netherlands, and all 713 NHPs who were members of the Dutch Association of Nursing Home Physicians. Data were collected over the period 1986-1989 (inclusive) for GPs and the period 1986-June 1990 (inclusive) for NHPs. RESULTS: Forty-eight percent of the Gps, 78% of the NHPs, and about half of the patients who opted for euthanasia did so because of the physical condition of the patient. The reason GPs, NHPs, and patients gave most often for opting for physician-assisted suicide was that they wanted 'as far as possible to let the patient bear the responsibility.' CONCLUSION: In 38% of all cases for GPs and 57% of all cases for NHPs, only active voluntary euthanasia could be performed because of the patient's condition. In the other cases, where there was a choice, most GPs performed euthanasia, while most NHPs assisted in suicide. Active voluntary euthanasia was chosen primarily for medico-technical reasons, whereas physician-assisted suicide was selected primarily for moral reasons.
Adult↗
Life shortening and physician assistance in dying: euthanasia from the viewpoint of German legal medicine.
BACKGROUND: Around the world heated debates have broken out on the topic of active euthanasia. Specialists in the field of 'forensic medicine' have taken full part in these discussions. OBJECTIVE: The present survey from the point of view of forensic medicine begins with a look at current terminology and at the laws pertaining to euthanasia in Germany. These laws are then contrasted with actual practice, including a description of the increasing acceptance of active euthanasia by the German population and its legalization in Holland. The main argument against active euthanasia is that its formal acceptance in law would cause the dam of restraint to burst, culminating in widespread misuse, as already seen in recent serial killings by nurses in hospitals and homes for the elderly around the world. CONCLUSIONS: Contrasted to this are the arguments for taking active steps at the end of life, including emotional considerations such as the revulsion against mechanized medicine and the fear of pain and rational arguments such as the necessity to end a 'life unworthy of life', to save medical costs, and obtaining prior consent in 'living wills'. Such considerations have put in jeopardy the moral integrity of the medical profession - and thus the layperson's trust in physicians - around the world. In Germany especially the history of mass killing during the Nazi era constitutes a fundamental argument against active euthanasia. As a consequence, in Germany active euthanasia will not receive legal sanction, although recommendations on rendering dying more bearable are permitted.
Ethics, Medical↗
Conditions required for a law on active voluntary euthanasia: a survey of nurses' opinions in the Australian Capital Territory.
OBJECTIVES: To ascertain which conditions nurses believe should be in a law allowing active voluntary euthanasia (AVE). DESIGN: Survey questionnaire posted to registered nurses (RNs). SETTING: Australian Capital Territory (ACT) at the end of 1996, when active voluntary euthanasia was legal in the Northern Territory. SURVEY SAMPLE: A random sample of 2,000 RNs, representing 54 per cent of the RN population in the ACT. MAIN MEASURES: Two methods were used to look at nurses' opinions. The first involved four vignettes which varied in terms of critical characteristics of each patient who was requesting help to die. The respondents were asked if the law should be changed to allow any of these requests. There was also a checklist of conditions, most of which have commonly been included in Australian proposed laws on AVE. The respondents chose those which they believed should apply in a law on AVE. RESULTS: The response rate was 61%. Support for a change in the law to allow AVE was 38% for a young man with AIDS, 39% for an elderly man with early stage Alzheimer's disease, 44% for a young woman who had become quadriplegic and 71% for a middle-aged woman with metastases from breast cancer. The conditions most strongly supported in any future AVE law were: "second doctor's opinion", "cooling off period", "unbearable protracted suffering", "patient fully informed about illness and treatment" and "terminally ill". There was only minority support for "not suffering from treatable depression", "administer the fatal dose themselves" and "over a certain age". CONCLUSION: Given the lack of support for some conditions included in proposed AVE laws, there needs to be further debate about the conditions required in any future AVE bills.
Attitude of Health Personnel↗
The medicalization of dying.
Physician assisted suicide or active euthanasia is analyzed as a medicalization of the needs of persons who are suffering interminably. As with other medicalized responses to personal needs, the availability of active euthanasia will likely divert attention and resources from difficult social and personal aspects of the needs of dying and suffering persons, continuing the pattern of privatization of the costs of caregiving for persons who are candidates for active euthanasia, limiting the ability of caregivers to assist suffering persons to make their continued suffering tolerable, and casting doubt on the voluntariness of the choice of active euthanasia.
Euthanasia↗
[Assisted dying and the principle of double effect].
Direct active euthanasia is prohibited in most countries while passive and indirect is not. However, many arguments against the legalization of voluntary active euthanasia are flawed, because a critical ethical difference between passive and active euthanasia is difficult to establish especially when the passivity of the actor causes death. The crucial point is not activity or passivity but respect for the autonomy of individual human beings. In particular there appears to be little ethical difference between active and indirect euthanasia. Indirect euthanasia has often been justified by the doctrine of double effect (Thomas Aquinas), which I argue contains a logical fallacy. This rule does not allow foreseen and unwanted adverse effects of an action to occur when they are avoidable. In terminal sedation, an example for indirect euthanasia, hypoxemia and dehydration can easily be prevented by respirator therapy and fluid administration. Therefore the rule of double effect is not applicable. Indirect and direct active euthanasia cannot be ethically distinguished by resorting to the doctrine of double effect.
Austria↗
Consequences count: against absolutism at the end of life.
BACKGROUND: There has been a considerable amount of debate in the nursing literature about euthanasia, and especially the distinctions between acts and omissions, and killing and letting die. These distinctions are required by opponents of euthanasia to justify allowing some cases of passive euthanasia while forbidding all cases of active euthanasia. AIM: This paper adds to the debate by arguing that the position that absolutely forbids euthanasia is theoretically inconsistent. METHODS: The paper first considers the place of moral theory in analysing moral problems, within the framework of the principles of biomedical ethics. It is argued that despite a moral pluralism that operates in many areas, the legal status of euthanasia is based upon an absolute deontological position against deliberate killing, which cannot be overridden by appeals to favourable consequences. In order that certain forms of passive euthanasia can be allowed, this position allows distinctions within three pairs of concepts--acts and omissions, killing and letting die, and ordinary and extraordinary means. A further method of justifying certain actions near the end of life is the doctrine of double effect. These paired concepts and the doctrine of double effect are analysed with special reference to their consequences. CONCLUSION: The application of the doctrine of double effect and the three distinctions relies on consideration of their consequences, allowing in practice what in theory is denied. This is important because it weakens the absolute case against euthanasia, which disallows any direct consequentialist appeal. If consequences count in the application of the doctrine and the distinctions, then they should also count directly prior to their application. This strengthens the argument for active euthanasia in certain cases.
Ethical Analysis↗
[Voluntary euthanasia in the Netherlands].
On 10 April last, the Dutch Senat accepted a new bill concerning voluntary active euthanasia and physician assisted suicide. This bill legally embodies a ground for exemption from punishment for physicians who conducted voluntary active euthanasia or physician assisted suicide and who complied with certain requirements. Hence, the old policy of tolerance has been transformed into a legal system of acceptance of certain forms of voluntary active euthanasia and physician assisted suicide. This contribution describes these legal changes as the final stage of a process of integration of voluntary active euthanasia and physician assisted suicide in Dutch society. In this way, it endeavours to contribute to a constructive debate.
Adolescent↗
Velcro on the slippery slope: the role of psychiatry in active voluntary euthanasia.
OBJECTIVE: The aim of the paper is to determine the role that psychiatrists should play in legislation that establishes a right to active voluntary euthanasia (AVE). METHOD: One version of the "slippery slope" argument, usually invoked against the legalisation of AVE, is recast as an argument for the introduction of strong safeguards in any future AVE legislation. The literature surrounding the prevalence of psychiatric illnesses in the terminally ill, physicians' ability to identify such illnesses and the aetiology of suicide in the terminally ill is examined. RESULTS: The strength of the slippery slope argument, combined with the poor ability of general physicians to diagnose psychiatric illness in the terminally ill, demands that any legislation allowing AVE should require a mandatory psychiatric review of the patient requesting euthanasia. CONCLUSIONS: Any legislation adopted that establishes a right to active voluntary euthanasia should include a mandatory psychiatric review of the person requesting euthanasia and a cooling off period before the request is acceded to. In addition, the discovery of a serious mental illness ought to disqualify the affected person from the right to AVE until that illness resolves.
Australia↗
Killing, letting die and moral perception.
There are a number of arguments that purport to show, in general terms, that there is no difference between killing and letting die. These are used to justify active euthanasia on the basis of the reasons given for allowing patients to die. I argue that the general and abstract arguments fail to take account of the complex and particular situations which are found in the care of those with terminal illness. When in such situations, there are perceptions and intuitions available that do not easily find propositional form but lead most of those whose practice is in the care of the dying to resist active euthanasia. I make a plea for their intuitions to be heeded above the sterile voice of abstract premises and arguments by examining the completeness of the outline form of the pro-euthanasia argument. In doing so, I make use of Nussbaum's discussion of moral perception and general claims to be found in the literature of moral particularism.
Altruism↗
Do German general practitioners support euthanasia? Results of a nation-wide questionnaire survey.
OBJECTIVE: To learn more about the attitudes of German general practitioners (GPs) concerning euthanasia and the frequency of its performance in Germany. METHODS: 500 GPs from all parts of Germany were randomly selected from telephone listings, and were sent a postal questionnaire with anonymous return envelopes. Participants were asked to make decisions based on hypothetical scenarios involving terminally ill patients and were questioned about their attitudes towards active euthanasia or physician assisted suicide (PAS). RESULTS: The questionnaire was returned by 48% of all 481 eligible GPs (mean age 51 years, 68% male). Although the option of performing euthanasia was rarely chosen in hypothetical scenarios, its performance was considered acceptable by 34% (active euthanasia) and 80% (PAS). Seventy-seven percent of respondents believed that a comparison between euthanasia today and the atrocities committed during the 3rd Reich was not appropriate. Sixty-two percent of respondents had received requests for active euthanasia and 73% for PAS. Thirteen percent and 38% of respondents seem to have performed euthanasia themselves in the past. CONCLUSIONS: The majority of German GPs reject active euthanasia and physician-assisted suicide (PAS). Nonetheless, requests for and performance of euthanasia do not seem to be a rare occurrence. Only a small proportion of respondents are willing to perform euthanasia at a patient's request under the current legislation which make these acts illegal in Germany. German history seems to play only a minor role in shaping respondents' attitudes towards active euthanasia or PAS.
Adult↗
The varying ethical attitudes towards resuscitation in Europe.
OBJECTIVE: This study was conducted to assess the varying attitudes in Europe towards ethical aspects of resuscitation in Europe. METHOD: The ethics of resuscitation is a key discussion topic in the European Resuscitation Council Advanced Life Support (ALS) course. A questionnaire was sent to all leading ALS course directors in 20 European countries. All completed the questionnaire. The results were compiled in March 2004. Views were sought on the following ethical aspects:When not to attempt resuscitation Active euthanasia When to abandon resuscitation efforts The diagnosis of death by non physicians Permission for relatives to be with the patient during resuscitation if they wish Teaching on the recently dead Breaking bad news Results: The results reveal a considerable variation in the interpretation of ethical dilemmas within European countries. It is interesting to note that the results do not necessarily conform to traditional beliefs in the characteristic differences between Northern and Southern Europe. The Mediterranean countries do not all have the same attitudes, any more than the Nordic or Central European countries share the same views. CONCLUSIONS: There remains a widespread divergence of views on ethical aspects of resuscitation with the countries of Europe that are largely unpredictable according to commonly perceived national characteristics. The trend over the past 6 years is towards a more permissive attitude. For many ethical questions there can be no clear and correct didactic answers.
Attitude of Health Personnel↗
Medical killing--an Evangelical perspective.
Evangelicals are unconditionally opposed to active euthanasia. Indirect euthanasia is seen as simply belonging to the risks inherent in any medical intervention. Passive euthanasia is accepted if used in order to save the dignity of the dying and is seen as merely ceasing to interfere with an irreversible dying process. The basis of evangelical ethics is the Bible supplemented by science and experience as a kind of natural law. Even though natural law comes under Biblical revelation, its acceptance is the reason for the similarity of the Evangelical and the Roman-Catholic position of Evangelicals. Evangelicals stress the necessity of a better counseling and investment for the deadly ill patient.
Bible↗