The Case For Voluntary Physician Assisted Suicide

By Kevin Williams 

The following introduction is from Derek Humphry who is the author of the ground-breaking book on assisted suicide entitled Final Exit and the founding father of the Hemlock Society - now known as The Euthanasia Research & Guidance Organization (ERGO) - the world's premier right-to-die organization. ERGO is a nonprofit educational corporation based in the State of Oregon, U.S., and was founded in 1993 to improve the quality of background research and information for hastened dying for persons who are terminally or hopelessly ill and wish to end their suffering. ERGO holds that voluntary euthanasia, assisted suicide, physician-assisted suicide, physician-assisted dying and self-deliverance, are all appropriate life endings depending on the individual medical and ethical circumstances. In the following paragraphs, Humphry presents a very simple and powerful case in favor of the right-to-die position.  

Table of Contents
1. Introduction to Voluntary Euthanasia by Derek Humphry
2. End-of-Life Political Terminology
3. End-of-Life Death Terminology
4. End-of-Life Medical Terminology
5. End-of-Life Diagnostic Terminology
6. End-of-Life Ethical Terminology
7. End-of-Life Legal Terminology
8. The Case for Voluntary Physician Assisted Suicide in General
9. The Case in Favor of Assisted Suicide and Active Voluntary Euthanasia
 
a. People Should Be Free to Control Their Life and Death
b. People Should Be Allowed to End Their Suffering
c. Some People are Physically Unable to End Their Lives When the Option is Open to Others
d. Voluntary Euthanasia is Legal
e. Suicide is Legal
10. The Case Against Assisted Suicide and Active Voluntary Euthanasia
 
a. Life is Sacred and Killing is Wrong
b. It Violates Our Duties to God, Ourselves and Others
c. An Incorrect Diagnosis is Possible or a New Treatment Might Be Discovered
d. Voluntary and Informed Consent Can Never Be Absolutely Sure
e. Terminal Patients May Feel Obligated to End Their Lives to Prevent Being a Burden to Others
f. Voluntary Euthanasia Will Eventually Lead to Non-Voluntary Euthanasia Tomorrow
g. It Could Be Used as a Cover for Committing Homicide
h. It Will Create a Decision-Making Bureaucracy That Will Just Prolong Their Agony
i. Physicians Don't Want to Be Nor Should Be Involved in This Kind of Activity
j. Hospice and Pain Control Has Advanced in Recent Years and is a Better Option
k. It Will Discourage the Search for New Cures and Treatments for Terminal Patients
l. It Will Encourage Patients to Give Up and Significantly Decrease Their Chances for Recovery
11. Conclusion
12. Links to Voluntary Physician Assisted Suicide Sites and Articles
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1. Introduction by Derek Humphry

Final Exit book cover. While it is true that we have no control over our births, at least we ought to have control over our deaths. How can we claim to be free people if someone else's morals and standards govern the way we die? Physician-assisted suicide for an adult who is in a rational state of mind, whose terminal suffering happens to be unbearable despite the best medical efforts, is an idea whose time has come. I'll explain why. We die differently today from our forebears. In this century, medicine has made tremendous strides towards keeping us healthy and living longer, for which we are all grateful. But modern medicine has not entirely solved the problem of terminal pain, and it certainly never will be able to answer the very personal question of an individual person's quality of life. Some people can stand more pain than others. Some patients in their dying days suffer distressing symptoms, like loss of bowel control, hemorrhaging, bedsores, permanent hiccups and so forth. So psychic pain is added to the rest of the problems. Take note that I have liberally used the word some. Most people die quickly, peacefully, and painlessly. Of that there is no doubt. Physician-assisted suicide is needed for very few dying patients - probably two percent or less of total deaths. But, two points:

a. You or I could be in that two percent;
b.

If we're not included, then we should have the decency to speak up for those who unluckily are.

As I said, we die differently nowadays. There is the scourge of AIDS, which in some cases is a terrible death. More of us die of degenerative diseases like A L S (motor neuron disease), Parkinson's, Multiple Sclerosis, Alzeheimer's Disease, and Osteoporosis. These wasting diseases take years to run their course - sometimes 10 to 15. Our grandparents knew very little of such diseases because they died earlier. Two out of every five of us is going to die from a degenerative disease. Knowledge gives choice. At my present age of 69, I can remember when as a young man we took the word of doctors and nurses as gospel. They knew better. We had almost no medical informational sources. But you've probably noticed that things are different nowadays. Television and radio programs graphically describe health matters; books and magazines on medical and psychological affairs are big sellers; and non-medical persons can attend conferences and workshops about their special subject. With the empowerment of better knowledge, we nowadays make more decisions for ourselves. Of course, working intelligently with our medical advisors to come to the best decision for our case remains important. But we live in a more autonomous age; gone are the days when the doctor played God.

Some terminal pain is managed well, but the medical literature is full of examples where it is not. Sometimes it is medical ignorance through sloppy training, occasionally carelessness due to overwork, and in a few cases indifference by second-rate doctors. There are rare instances where a request for physician-assisted suicide is justified in being made because of intractable pain, and that's why an appropriate law is necessary. Sometime in the next century, laws will be altered to permit voluntary euthanasia and physician-assisted suicide -- at least in western countries. In my view, supporters of this concept should constantly work in whatever way they can for such important reforms. - by Derek Humphry

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2. End-of-Life Political Terminology

Before delving into the issues it is important to first understand the terminology involved. The following is a glossary of terms to help you better understand end-of-life issues.

 
Right to Die The belief that end-of-life decisions should be an individual choice and that everyone has a fundamental right over their own life and death
Right to Life The belief that death should only come about by the will of a god or gods, or the belief that life is the prevailing value, regardless of medical conditions or desires to end it for whatever reason.
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3. End-of-Life Death Terminology
 
Murder Unlawfully ending the life of a person who wished to be alive
Kill Lawfully or unlawfully ending the life of a person
Mercy Killing Ending the life of a person without their explicit request in the belief that it is the only compassionate thing to do (this term is loosely used to describe all acts of euthanasia)
Suicide Deliberately ending one's own life
Assisted Suicide Providing someone else with the means, such as drugs or other agents, for them to take their own life (assisted suicide differs from euthanasia in that it is only assistance)
Physician-Assisted Suicide A doctor providing the lethal drugs with which a dying person may end their life
Euthanasia Literally means "good death." Helping yourself or someone else have a good death (euthanasia differs from assisted suicide in that it is actively participating - rather than assisting - a person end their life)
Passive Euthanasia Deliberately disconnecting life support equipment, or stopping any life-sustaining medical procedures, to permit the natural death of the patient ("passive" refers to an act that indirectly causes death)
Active Euthanasia Deliberately taking action that directly end the life of a dying patient to avoid further suffering ("active" refers to an act that directly causes death)
Active Voluntary Euthanasia A lethal injection by a doctor into a dying patient when the patient has consented to it
Active Non-Voluntary Euthanasia A lethal injection by a doctor into a dying patient when the patient's consent is unknown (usually a patient who is no longer able to communicate)
Active Involuntary Euthanasia A lethal injection by a doctor into a dying patient when the patient has refused (this is so-called "Nazi euthanasia")
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4. End-of-Life Medical Terminology
 
Hospice A program of care for a person in the last six months of life, providing pain management, symptom control, and family support (palliative care is the medical term for hospice)
Heroic Measures Medical procedures which are pointless because the patient is certain to die shortly
Double Effect Giving large amounts of opiate drugs to a patient to relieve pain while at the same time recognizing that these will hasten death
Slow Code The deliberate slow response to a medical alert of heart or breathing stoppage which is designed to make resuscitation impossible (also known as "blue code")
Negotiated Death A formal agreement between family, physicians, hospital management, etc., that life support systems to an incompetent person are better disconnected in the best interest of the patient (all parties agree not to bring lawsuits)
Snow A slang word which means administering heavy doses of opiate drugs to completely sedate a person who is dying painfully (person dies whilst unconscious)
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5. End-of-Life Diagnostic Terminology
 
Terminally ill A person dying from an illness which has no known cure
Irreversibly ill Same as terminally ill but more likely to be a lengthier dying process
Hopelessly ill A person with a disease that has no known cure but is not immediately life-threatening
Vegetable A crude but popular way of describing a person who is in a long-term coma (the correct term is persistent vegetative state)
Persistent Vegetative State A severely brain-damaged person in a permanent coma from which they will not recover (the person is almost always on life-support systems)
Coma Prolonged unconsciousness from which a patient may or may not recover
Brain dead Complete cessation of cognitive function - life support systems could keep the body operating but pointless - the point of death is defined by what is known as "the Harvard criteria"
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6. End-of-Life Ethical Terminology
 
Ethics A system of moral standards or values
Bioethics A study of the moral problems which face modern medicine
Rule Ethics Obeying the moral standards dictated by a religion
Situation Ethics Moral standards as dictated by the prevailing circumstances
Medical Ethicist A person with philosophical and/or legal training who offers opinions on the moral dilemmas which face physicians and psychiatrists
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7. End-of-Life Legal Terminology
 
DNR (Do Not Resuscitate) an order on the patient's medical chart advising health professionals that extraordinary measures should not be used to attempt to save this person's life
Advance Directives The legally accurate name for the next two documents dealing with passive euthanasia
Living Will The popular name for an advance directive by which a person requests in writing a physician not to connect, or to disconnect, life-supporting equipment if this procedure is merely delaying an inevitable death
Durable Power of Attorney for Health Care An advance directive by which a person nominates another person to make health care decisions if and when she/he becomes incompetent, thus allowing by proxy decision a treating physician to obtain informed consent to a medical procedure or withdrawal of treatment
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8. The Case for Voluntary Physician Assisted Suicide in General

The following are excerpts from a 1994 executive summary on assisted voluntary euthanasia and other end-of-life decisions of The British Columbia Civil Liberties Association.

 

Modern medicine has been enormously successful in saving and extending lives. No one can reasonably regret this, but it exacerbates a problem which has always been with us, namely, how to treat those patients who are alive, but not living lives they think worthwhile, and have no prospects for anything better. Under current law, patients who want to die can either commit suicide, or, if they are competent, refuse all treatment necessary for life. But patients do not always have the ability and opportunity to do the former, and the latter does not always bring about a gentle and easy death for either them or their loved ones. The question thus arises as to whether we should make legal provision for assisted suicide - providing the means of suicide - and active voluntary euthanasia - killing patients on request.

 

There is a strong case for allowing persons who are facing intractable pain or indignities in the final stages of their lives to determine for themselves when life is no longer worth living, and, where necessary, receive assistance in ending their lives. This case is constructed from the principles of liberty, autonomy and equality; from the value of preventing unnecessary suffering and preserving the dignity of the individual; and from the inconsistency between legally allowing suicide and passive voluntary euthanasia while denying legal space to assisted suicide and active voluntary euthanasia. If we are to continue legally to bar these practices, there must be a compelling reason for doing so. None of the reasons that have been put forward for continuing the current absolute ban on assisted suicide and active voluntary euthanasia is compelling. We consider separately each of these arguments, which include: the sanctity of life and the moral wrongness of killing; the possibility of an incorrect diagnosis or a miracle cure; the alleged inability to know that voluntary informed consent has been obtained; the "slippery slope" argument; and the ability of modern medicine to control pain.

Since none of the arguments against prohibiting assisted suicide and active voluntary euthanasia is compelling, the strong case for the legalization of these practices must prevail. We note that, although the objections are not compelling, they do raise concerns which must be addressed in making legal provision for aid in dying. The logic of the debate is this: There is a case for legalizing assisted suicide and active voluntary euthanasia. There is a long list of objections to doing so. If all the objections can be answered, the pro-legalization case will be left in sole possession of the field, and governments should act accordingly. On the other hand, if any of the objections is good, that case will be cancelled, and governments should keep the legal door to the practices in question shut. We will argue that none of the objections is good. Our rejection of the objections to legalizing these practices does not mean that the objections cease to function at all. This web page will spell out more explicitly our belief that some of the objections function as limits on access to these practices, and form the rationale for procedural requirements designed to ensure that access to these practices is not abused.

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9. The Case in Favor of Assisted Suicide and Active Voluntary Euthanasia  
a. People Should Be Free to Control Their Life and Death

The first and simplest argument appeals to the value of liberty. Freedom is a good. Restraint is an evil. This forms the basis of the common view that individuals can do as they want unless there are weighty reasons which dictate otherwise. Restrictions on liberty are certainly sometimes justifiable, but the onus of justification always lies on their defenders. Thus, given that prohibiting assisted suicide and active voluntary euthanasia are restrictions on liberty - patients are prevented from getting what they want, and physicians from providing it - there is a good case for legalizing those practices, and it is up to their opponents to show why they should be forbidden.

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b. People Should Be Allowed to End Their Suffering

This case can be strengthened by appealing to two other equally uncontroversial values: the prevention of suffering and the dignity of the individual. Patients sometimes are in medical conditions for which there is no relief, and awaiting them is a future filled with suffering, or the indignity of the disintegration of their bodily and mental functions, or both. They often want to avoid these evils, and shield loved ones from their sight. It is also sometimes the case that the only way to do this is to die, and the only way to do that is to receive some assistance in the form of help in committing suicide or active voluntary euthanasia. If we now grant that people have a right to preserve their dignity and minimize their suffering and that of others, we again get a strong presumption in favor of making some kind of legal allowance for assisted suicide and active voluntary euthanasia.

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c. Some People are Physically Unable to End Their Lives When the Option is Open to Others

The principle of equality supports another argument. The prohibition against assisted suicide creates an inequality since it prevents persons physically unable to end their lives unassisted from choosing suicide, when that option is open to others. Although the blanket prohibition on assisted suicide appears to treat all persons equally, its actual effect is to deprive persons who are unable to commit suicide without assistance of the ability to commit suicide in any way that is lawful.

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d. Voluntary Euthanasia is Legal

Finally, we turn to a pair of arguments which proceed by alleging there is an inconsistency between what the law permits and prohibits, and since it is right to permit what it does, the prohibition should be removed. The first of these begins with the fact that passive voluntary euthanasia is allowed by the law: a competent and fully informed person may, for whatever reason, appropriately refuse any treatment necessary for life. Thus, if active voluntary euthanasia is to be legally proscribed, there must be some relevant difference between killing and letting die. It is, however, not clear there is: if both the intention - to bring about a death - and the certainty of outcome - death coming about - are the same in each, it is hard to see how there could be any morally relevant difference between killing patients and letting them die. It does not follow that we can appropriately aid persons in securing death whenever they can refuse treatment, for they may refuse treatment for bad reasons, and while there may be nothing immoral or properly preventable about them harming themselves, there is something wrong in our assisting them in doing so. However, it does follow that if they have a good reason for refusing treatment - if, say, their future is brief and only holds pain and indignity - there is a presumption that there is nothing wrong with our assisting them, and the law should not stand in our way either to help them kill themselves or to kill them on their authority.

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e. Suicide is Legal

The next argument runs along exactly similar lines, and begins with the fact that suicide is not a criminal offence. This does not mean we should not prevent suicide when we can. In most cases we certainly should, for suicides typically have very bad reasons for wanting to die, and need our help. But suicide cannot be properly prevented in all cases. If persons have a good reason for death - if, for instance, they are elderly and terminal and suffering - it would be unspeakably meddlesome to interfere. But if so, we get the presumption that in just those circumstances in which we should not prevent persons from bringing about their own death, we can appropriately help them do so by either assisting their suicide or delivering active voluntary euthanasia. If persons have a good reason to die, and do not have the means to commit suicide, they should be legally allowed to request and receive those means from those willing to provide them, and if they are too weak to swallow a pill or inject themselves, to authorize others to deliver the fatal dose. Thus under certain conditions the right to suicide entails the right to assisted suicide and active voluntary euthanasia.

 

This completes the case for the legalization of assisted suicide and active voluntary euthanasia. Insofar as we value liberty, the prevention of suffering, and dignity, and admit that sometimes people have a good reason for wanting to die and need help to do so - all surely uncontroversial claims - there is no avoiding the conclusion that the burden of proof lies on those who wish to oppose legalizing the practices in question. But this is also a burden which opponents have taken up, and they have provided a formidable list of obstacles to those practices. It is to these that we must now turn.

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10. The Case Against Assisted Suicide and Active Voluntary Euthanasia   
a. Life is Sacred and Killing is Wrong

One objection to assisted suicide and active voluntary euthanasia is that they involve killing, and all killing is morally wrong. This principle may be based on religious views (e.g., the sixth commandment) or maintained on purely secular grounds. But whatever its basis, we cannot appeal to this unqualified principle to condemn the practices in question unless we are prepared to condemn, for example, the killing of steers for food, fish for sport, trees for paper, weeds to beautify a garden, mosquitoes for comfort, and so forth. 

Few are prepared to accept such consequences. But if we are not, our task is find some version of the sanctity of life principle which will allow instances of killing we want to allow, while at the same time excluding assisted suicide and active voluntary euthanasia. However, this is not easy to do. One might try to avoid the above repugnant consequences by restricting the principle to human beings. The question immediately arises as to whether this is an arbitrary restriction, but we will not pursue that here. It is sufficient to notice that the restricted principle still excludes too much, prohibiting as it does killing in self-defense and to protect the defenseless. Nor would it help to stipulate that it is the killing of innocent human beings which is morally prohibited. For not only is it strained to morally proscribe assisted suicide and active voluntary euthanasia because they involve "taking an innocent life", the principle itself is problematical. We do not want to disallow killing insane (and therefore presumably innocent) attackers, and it is highly controversial to condemn bombing enemy civilian populations in wartime when not doing so would result in the heavier bombing of our own. One could continue doing moral carpentry, and tack further qualifications onto the sanctity of life principle to secure just the conclusions one wants. For example, one could specify further that killing innocent but insane aggressors and innocent civilians in wartime are not absolutely prohibited, but that assisted suicide and active voluntary euthanasia nonetheless are. But then the principle starts to appear to arbitrarily exclude those practices, and we must ask what reason there is for excluding them at all.

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b. It Violates Our Duties to God, Ourselves and Others

There are three possible reasons: assisted suicide and active voluntary euthanasia violate some duty to God, or to ourselves, or to others. We will take each in turn.

I. It violates our duty to God:  There exist both strongly held and intellectually coherent religious reasons for a demand on the part of some people that the current legal prohibitions on assisted suicide and active voluntary euthanasia be retained or even strengthened. However, in American society we do not use the criminal law to enforce the religious views held by some people on others who do not share these views. This is not a denigration of those religious views, but an assertion of the principle that a state which respects the right of its citizens to choose their own religious values cannot use the criminal law to enforce such views.
II. It violates our duty to ourselves:  The claim that we have duties to ourselves is conceptually incoherent. Because to say that I have a duty to myself is to say that I have a right against myself. And since I can always waive my rights, but can never release myself from a duty, it is contradictory to speak of duties to oneself: I have something from which I both can and cannot release myself.
III. It violates our duty to others:  It is hard to see what duties to others could be exacted from realistic candidates for assisted death. Such patients are not typically going to be in a position to render very many services to others, and even if they were, it is plausible to suggest that their medical distress cancels any duty to provide them.

Much more could be said about all these grounds for claiming that assisted suicide and active voluntary euthanasia are immoral. But we need not dilate on them. For even if assisted suicide and active voluntary euthanasia were shown to be immoral in any of the above senses, it would not follow without considerable further argument that they should be illegal. We might view them as many currently do homosexuality and adultery: immoral, perhaps, but nonetheless not the law's business.

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c. An Incorrect Diagnosis is Possible or a New Treatment Might Be Discovered

There is always the possibility of an incorrect diagnosis or the discovery of a treatment that will permit either survival or recovery.

 

Rebuttal:  While these things cannot be ruled out as absolutely impossible, they can often be ruled out as impossible for all practical purposes. It is frequently beyond all reasonable doubt that the diagnosis is mistaken or some cure will not be discovered in time to help, and it is not clear why this should not be sufficient. The law has never taken a "pigs might fly" attitude towards the risks attendant on any activity. We only need to establish "guilt beyond reasonable doubt" to send a person to prison or even to his execution, and it is not possible to require more without making the enforcement of the law impossible. Why a more stringent standard should be demanded in the cases of assisted suicide and active voluntary euthanasia needs to be explained. Moreover, when the likelihood of being restored to what one would regard as a worthwhile life is small, and that of enormous pain and degradation relievable only by death great, no one can plausibly say that the decision to die is an unreasonable one. But if so, respect for the autonomy of the individual requires that we not prohibit him from authorizing others to help put it into effect.

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d. Voluntary and Informed Consent Can Never Be Absolutely Sure

We can never be absolutely sure that we have voluntary and informed consent. If the request is made prior to patients' coming to be in a desperately bad way - say in the form of a living will - it cannot be considered binding because it is insufficiently informed. On the other hand, if the request is made when patients are in a bad way, then the pain and drugs prevent them from making a fully rational decision. In either case, it is not possible to secure a death-request which would justify the deed.

 

Rebuttal:  The demand for absolute certainty with which this objection begins is too strong. But even if we purge the complaint of that feature, it is still not good. It is indeed true that prior request ought not always be considered binding. Certainly it should not be if individuals subsequently renounce their decisions. Again, if individuals alternately reaffirm and renounce their decisions we may be in a quandary about what to do. But it cannot reasonably be claimed that a prior request can never be binding because it is always insufficiently informed. If individuals reaffirm their decisions under pain, after the first shock of it has passed, we have very good grounds for claiming to know their fixed and settled desires. Again, if individuals fall into a state which does not permit them to either reaffirm or renounce their decisions, and are not expected to recover from that state, then we have the same reason to act on their prior death-requests as we would subsequently have to distribute their estates in accordance with their wills. In both cases, such decisions are momentous, irrevocable, and ones that might not have been made if the persons could have foreseen their futures. But to deny the bindingness of such requests is to say that persons should not be permitted to make such decisions, and that is surely unacceptable. 

Where the individuals make the death-requests in pain and under the influence of narcotics, it must be admitted that they are not in the best condition to make a fully rational decision. But it must also be granted that they are in an excellent position to say whether or not they wants to continue living in such a state. It may also be that such an existence is the best they can expect, and there will come a time when it is quite unreasonable to tell patients that they will adjust to their condition, and a time when it is unreasonable to hold out any hope for any improvement. It is hard to see why the appropriate facts of this sort, conjoined with the patients' judgment that their present state is intolerable, should not yield a request for death that is sufficient to justify action.

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e. Terminal Patients May Feel Obligated to End Their Lives to Prevent Being a Burden to Others

The chronically and terminally ill are often vulnerable and feel themselves to be (and often are) a burden to others. Many of the ill, however, are not tired of life and do not want to die. But if assisted suicide and active voluntary euthanasia were readily available, they might feel obligated to opt for death, and relatives or others in whose care they are, who often would just as soon be rid of the burden, may consciously or unconsciously exert pressures, in a way difficult to detect and avoid, to request assistance in committing suicide or active voluntary euthanasia.

 

Rebuttal:  It is unrealistic to suppose that some such tragedies will not occur. But that should not be taken as a decisive objection to the practices in question. We allow policemen to carry guns and young people to choose their marriage partners, and tragedies result from these too. But we accept such tragedies, however regretfully, as a part of the price of policies which are on the whole beneficial, and a similar line is plausible in the case of assisted suicide and active voluntary euthanasia. It is a mistake to think that if we do not liberalize the law no tragedies will occur. The pain and degradation which euthanasia laws address will continue; the sick will continue occasionally to attempt suicide in ways which are neither painless to themselves or others nor always successful; friends and relatives will be faced with the terrible choice of either standing by and watching the suffering and disintegration of a loved one, or acting in a way which is contrary to law and for which they have no expertise. We must also be careful not to exaggerate the susceptibility of persons. Persons who are competent to make a legally binding death-requests will also typically be able to resist the pressures in question; if they cannot do the latter, they will not typically be able to do the former. Nor should we presuppose that the pressures in question cannot be adequately counteracted by informal means such as counseling and discussion. If they can be - and there is no reason to think otherwise - it would certainly be more appropriate to so control them, for we do not thereby deprive everyone of the right to death in order to protect a few who could be protected in some other way.

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f. Voluntary Euthanasia Will Eventually Lead to Non-Voluntary Euthanasia Tomorrow

Legalizing assisted suicide and active voluntary euthanasia today will lead to active non-voluntary euthanasia tomorrow, and that will lead to active involuntary euthanasia the day after: the antisocial, the ethnically unattractive, the politically deviant, the aged, etc., will all become potential victims. Thus if we do not draw the line where it is, we will not be able to prevent substantial harm to others. This is the famous slippery slope argument.

 

Rebuttal:  This argument is singularly implausible if one who makes it means that there is a logical connection between the killings in question such that one who endorses the first cannot without inconsistency refuse to endorse the last. The fact that in one case a person is killed in his own interest because he requests it, whereas in the other a person is killed in the interest of others without (or contrary to) his consent, is surely a morally relevant difference. Since this is so, the question "How can we draw the line?" should not perplex one for long. No one thinks that making killing in self-defense an exception to criminal homicide starts one on a slippery slope which logically must end in the abolition of the crime of murder; no one should think the same about legalizing voluntary euthanasia. 

A more common and plausible way of understanding the objection is to take it as alleging an empirical connection between the killings in question. If, however, the claim is an empirical one, it stands in need of evidence. What is the evidence that a policy of allowing death on request, begun in good faith and motivated by compassion, will lead to unwanted killings? Two items of evidence are commonly alleged. The first is the Nazi experience. However, there is no parity between the cases; all they have in common is the name euthanasia. In these cases, the name stands for quite different policies. The Nazi program of euthanasia was neither voluntary nor based on compassion; it was, rather, motivated by the desire to remove useless eaters and preserve the purity of the Volk, and hence was the result of a vicious and racist ideology already firmly in place, not the unwanted and unexpected upshot of an intrinsically desirable social reform. The second, which is currently attracting the most attention, is the Netherlands experience. In the Netherlands we have a living laboratory in which the euthanasia experiment in being conducted, and it is claimed that active non-voluntary and involuntary euthanasia are openly practiced there, exactly as predicted by the slippery slope argument. But the claim of the open and common practice of involuntary euthanasia has been often repeated but has never been substantiated, and indeed has been repeatedly challenged. To begin with, to say that a slippery slope has taken place is to make a causal claim to the effect that legalizing assisted suicide and active voluntary euthanasia caused an increase in the incidence of active non-voluntary euthanasia. But a high incidence rate does not, in itself, establish causation. 

Nor can one argue for causation on the ground that legalizing assisted suicide and active voluntary euthanasia was followed by an increase in active non-voluntary euthanasia. To establish causation, it is necessary to show that if assisted suicide and active voluntary euthanasia were not legalized, then there would not have been an increase in incidence of active non-voluntary euthanasia. However, there is no evidence to support this, and hence no evidence for a slippery slope having taken place in Holland. Moreover, even if a slippery slope were demonstrated, the wrongness of legalizing assisted suicide and active voluntary euthanasia would not follow without considerable further argument. Two defenses are open to defenders of legalization. First, one can argue that the occurrence of that incidence of active non-voluntary euthanasia is a regrettable but acceptable consequence of an on-balance beneficial policy. This is the argument which accepts the downside alleged, but contends that there is a countervailing upside. Second, one can take the line that the incidence of active non-voluntary euthanasia is acceptable and not regrettable. The cases of active non-voluntary euthanasia which comprise the bulk of those which occurred in Holland involved severely defective newborns or debilitated elders (many of whom had made a prior request for euthanasia, but not in a way which satisfied the stringent consent requirements laid down in Dutch law). Further, some Dutch physicians argue that active non-voluntary euthanasia is more humane and dignified for all concerned than the alternatives of keeping the patient alive or letting nature take its course. 

But let us now suppose that all the above is mistaken; let us suppose, that is, that slippery slope has taken place in Holland, and that this is unacceptable. The question still remains whether this provides compelling evidence that a slippery slope would certainly or likely occur if assisted suicide and active voluntary euthanasia were legalized in America. There is a difference between the two cultures which makes that inference problematic. There also may be ways of making legal space for those practices - say with greater safeguards or stiffer penalties - which will prevent unacceptable results. Even if Holland's way of legalizing assisted suicide and active voluntary euthanasia led to active non-voluntary euthanasia there, that provides no evidence for saying that other means of legalizing those practices will lead to that consequence elsewhere. The upshot of the above is that we do not have convincing evidence that legalizing assisted suicide or active voluntary euthanasia will certainly or probably lead to unacceptable consequences. Thus the empirical version of the slippery slope argument fares no better than the logical version. 

There is one final version of the slippery slope argument to be considered. It is sometimes argued that while there is no evidence for a slippery slope taking place, it is something which everyone must admit is possible, and do we want to take that chance? This argument assumes that things are just fine now. The problem with the argument is that the assumption is false. We know that legalizing assisted suicide and active voluntary euthanasia will help. We do not have any evidence that bad consequences will ensue. Put this way, which we submit is the accurate way, the gamble seems eminently reasonable.

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g. It Could Be Used as a Cover for Committing Homicide

The proposed legislation would make it easier to commit malevolent homicide. Many people want, and badly want, to be rid of others, and the deaths of those persons could be brought about under the cover of voluntary euthanasia.

 

Rebuttal:  This objection applies with equal force to allowing killing in self-defense as non-criminal homicide. So, insofar as it is not used to advocate the repeal of that classification, its application to the case of voluntary euthanasia is unsound and discriminatory. With certain safeguards, it would also be difficult to pass off murder as euthanasia. Certainly that would be no easier - and probably a good deal harder - to do than to pass of murder as self-defense or suicide. Since this is so, it is unlikely that legalizing voluntary euthanasia will cause an increase in the incidence of murder or of undetected murder.

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h. It Will Create a Decision-Making Bureaucracy That Will Just Prolong Their Agony

Patients seeking assisted suicide or active voluntary euthanasia clearly do not wish to prolong their agony, but seeks a quick end to their suffering. Yet any proposal for the legalization of these practices must necessarily include some process of ensuring that their decision is voluntary and informed. Any such procedures would have to be carefully followed and the results painstakingly confirmed. All this would demand time, and by wrapping the decision-making process in red tape, create the very delays which those who advocate the practices seek to avoid.

 

Rebuttal:  To ensure that assisted suicide and active voluntary euthanasia are not misapplied, time consuming procedures must be followed. But to conclude from this that these practices should not be legalized is like arguing that no one should get a driver's license or unemployment benefits, because it would be irresponsible to hand them out without verifying the information, and that means that people cannot get them as speedily as they wish. The unavoidable necessity of delaying assisted suicide and active voluntary euthanasia is no reason for denying them altogether. We must also not exaggerate the time and red tape that need be involved in following procedures which are reasonable safeguards against misuse and abuse.

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i. Physicians Don't Want to Be Nor Should Be Involved in This Kind of Activity

The medical profession exists to provide important professional services, and neither wants to be nor should be involved in the kind of bureaucratic activity involved in responsibly administering the delivery of assisted suicide and active voluntary euthanasia.

 

Rebuttal:  This objection begs the question by assuming that assisted suicide and active voluntary euthanasia are not "important professional services." But that is false. It is important to most people to die painlessly and with dignity, and engineering such a death by way of assisting suicide or delivering active voluntary euthanasia is a matter calling for medical expertise. Grant this, and the objection that we should not legalize the practices because of the paperwork involved - which could not be any greater than that involved in determinations of competency - is embarrassingly lame.

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j. Hospice and Pain Control Has Advanced in Recent Years and is a Better Option

The extraordinary development of palliative care and pain control in recent years is a more positive and safer response to the problems than assisted suicide or active voluntary euthanasia.

 

Rebuttal:  The hospice movement and advances in pain control are certainly welcome developments which do something to reduce the need for legalizing assisted suicide and active voluntary euthanasia. But they do not remove it altogether, and we should not view these things as alternatives. There are indeed drugs which, if properly administered, can control pain. Nonetheless, insofar as the patient remains conscious, there are other forms of distress such as the terror of breathlessness, uncontrollable vomiting, paralysis, incontinence, inability to swallow and sheer weakness and helplessness which cannot always be adequately controlled. We must also remember that it is often difficult to arrive at and maintain the correct dosage of drugs under the most conscientious surveillance of patients, and the practical realities of contemporary medical care mean the patients often get less than this. However, even if pain and distress were not a problem, there is frequently a strong fear on the part of patients of the abject dependency and degradation involved in the loss of bodily and mental functions which often accompany the dying process, and no amount of care services can remove these.

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k. It Will Discourage the Search for New Cures and Treatments for Terminal Patients

The legalization of assisted suicide and active voluntary euthanasia will discourage the search for new cures and treatments for the terminally ill patient.

 

Rebuttal:  There is no difficulty in showing any policy to work ill if we conjoin idiocy with it; and if we suppose that people will accept assisted suicide and active voluntary euthanasia as substitutes for treatments and cures, there is no difficulty in showing a serious problem with their legalization. But if one is to look askance at these practices for this reason, one must do so at a host of other things as well, such as improvements in palliative care, fire and theft insurance, and airbags in automobiles. But this is surely absurd. There is no reason to think these mitigating measures have that effect, and it remains to be shown why we should think that legalizing assisted suicide and active voluntary euthanasia would have it either.

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l. It Will Encourage Patients to Give Up and Significantly Decrease Their Chances for Recovery

Patients who struggle to recover have better recovery rates than those who have given up hope. The availability of assisted suicide and active voluntary euthanasia will encourage patients to give up, and so significantly decrease their chances for recovery.

 

Rebuttal:  On the face of it, this argument applies with equal force against allowing people to divorce, drop out of college, or refuse medical treatment, for removing those options would likewise make people struggle with sometimes good effect. But even if we limit the scope of the argument to assisted suicide and active voluntary euthanasia, it is not a good one. One cannot argue that the struggle would be beneficial in all cases. Nor could one realistically argue that medical prognoses are so fallible that it may be valuable in any given case. The prohibition must therefore be based on the claim that it would be beneficial on the whole. There is, however, no evidence to suppose that this is so. But even if there were, criminalizing the conduct for this reason relies on a questionable theory of interference. Certainly, society may interfere to prevent individuals from harming others. It is more problematical, but also arguable, that it may interfere to prevent unencumbered individuals from harming themselves. This argument, however, depends on the still more controversial view that society can prevent some unencumbered individuals from acting in their interest in order to prevent other unencumbered individuals from acting to their detriment, and this principle seems impossibly strong.

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11. Conclusion

This brings us to an end of our review of the arguments for and against assisted suicide and active voluntary euthanasia. Two things are evident: the arguments against these practices are very weak, and each applies with equal force against some other entrenched practice or practices, most notably passive voluntary euthanasia and killing in self-defense. Given the latter, if we do not allow the arguments to rule out those practices, we should not let them rule out assisted suicide and active voluntary euthanasia. And, given the former, we should not allow the arguments to rule out those practices. Thus we have failed to find any objection sufficient to cancel the case in favor of assisted suicide and active voluntary euthanasia. Unless some such objection is produced, legal provision should be made for those practices.

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12. Links to Voluntary Physician Assisted Suicide Sites and Articles
a. Derek Humphry's Official Blog - www.assisted-dying.org
b. Derek Humphry's TheFinalExit YouTube Channel - www.youtube.com/TheFinalExit
c. Derek Humphry's Book "Final Exit" - www.amazon.com
d. Derek Humphry's DVD "Final Exit" - www.amazon.com
e. Final Exit: Home of ERGO - www.finalexit.org
f. Final Exit Network - www.finalexitnetwork.org
g. Exit International (Assisted Suicide / Voluntary Euthanasia) - www.exitinternational.net
h. Compassion & Choices - www.compassionandchoices.org
i. The Peaceful Pill Handbook - www.peacefulpillhandbook.com
j. The World Federation of Right to Die Societies - www.worldrtd.net
k. Death With Dignity National Center - www.deathwithdignity.org
l. Scholarly Articles on Voluntary Physician Assisted Suicide - www.google.com/scholar
m. Wikipedia Category: Euthanasia - www.wikipedia.org
n. Wikipedia Article: Euthanasia - www.wikipedia.org
o. Wikipedia Article: Voluntary Euthanasia - www.wikipedia.org
p. Wikipedia Article: Right To Die - www.wikipedia.org
q. Wikipedia Category: Suicide - www.wikipedia.org
r. Wikipedia Article: Suicide - www.wikipedia.org
s. Voluntary Euthanasia Article on Stanford's Encyclopedia of Philosophy - plato.stanford.edu
t. The British Columbia Civil Liberties Association - www.bccla.org
u. YouTube Videos on "Voluntary Euthanasia" - www.youtube.com
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"The right to choose to die when in advanced terminal or hopeless illness is the ultimate civil liberty." - Derek Humphry

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