Euthanasia: The Dying Decision

In the timeless debate surrounding the complexities of life and death, euthanasia has emerged as a focal point of ethical and legal discourse. The term, originating from the Greek words “eu” (good) and “thanatos” (death), signifies a "good death" — a concept as ancient as the civilizations that first contemplated the dignity of human existence. The Roman historian Suetonius, in his seminal work De Vita Caesarum, recorded the peaceful death of Emperor Augustus in the arms of his wife, Livia, describing it as the emperor’s wish for a swift and painless end — a true “euthanasia” by his own words. From this account, the term began its journey, weaving through European thought and later permeating global discussions. Euthanasia, or mercy killing, addresses the poignant reality of terminal illness and incurable conditions. It is defined by the Oxford Dictionary as the "painless killing of a person suffering from an incurable illness or in an irreversible coma." Similarly, the Cambridge Dictionary describes it as the act of ending the life of someone who is gravely ill or elderly to alleviate their suffering. The legal status of euthanasia varies widely across nations. Many European countries, acknowledging the right to die with dignity as an extension of human rights, have enacted laws to preserve the dignity of those at the end of life. For example, Belgium, the Netherlands, and Luxembourg have legalized euthanasia under strict conditions, placing Europe at the forefront of this global debate. In contrast, India navigates the issue through the lens of its judiciary. The Indian Constitution upholds the right to life as one of its most fundamental human rights. This right encompasses not only living with dignity but also dying with dignity. However, the country lacks specific legislation governing euthanasia, relying instead on landmark Supreme Court judgments. The evolution of this jurisprudence began with the P. Rathiram case in 1994 and culminated in the Common Cause case of 2018, where the court recognized passive euthanasia and advance directives under stringent safeguards. As the discourse on euthanasia continues to unfold, it reflects society's evolving relationship with the concepts of suffering, autonomy, and compassion. For Europe, with its rich legal traditions and philosophical heritage, the debate remains as much about upholding human dignity as it is about navigating the intricate balance between life, law, and morality. Euthanasia simply refers to the practice of intentionally ending a life in order to relieve pain. This practice has been on since ancient times. Biblical records even show traces of the practice of euthanasia.

Debates about the moral dilemmas of euthanasia date back to ancient times. Many of the historical arguments used for and against the practice remain vu I id today. Indeed, any...

Several surveys of the German population concerning the attitude towards euthanasia in patients with terminal illness yielded contradictory results, ranging from high acquisition to high refusal rates. After a critical discussion of the methodological concepts of these investigations, we present the results of a representative study of 1957 German persons (age range: 14 - 96 years) which was performed by the institute USUMA in February 2001. Four different types of euthanasia were included in the study: active, passive, and indirect euthanasia as well as physician's assisted suicide. The affirmative response categories were "declared will and unbearable pain", "declared will", "referred will", and "in the responsibility of the physician". Additionally, we asked to state the personal preference in the case of an own incurable illness. The resulting frequency distributions stress the autonomy of the patients (declared will) and the legal forms of professional euthanasia (passive and indirect euthanasia), independent from the degree of pain. The rank order of the hypothetic personal preferences was: passive euthanasia (26.1 %), active euthanasia (21.1 %), indirect euthanasia (13.1 %) and assisted suicide (6.2 %). For each category the hypothetic personal will to utilize euthanasia personally is markedly lower than the consent to legalize euthanasia in the society. This points to a diminished readiness of the population to seek for euthanasia. Persons aged 60 years and above deny all types of euthanasia significantly more often than younger persons. Persons with subjectively bad health status prefer the category "in the responsibility of the physician" more often than healthy subjects. The representative study proves that there is no polarized public opinion concerning euthanasia, rather there is a picture of high complexity.

Byline: Bir. Chavan, Suravi. Patra The honorable Supreme Court of India passed a landmark judgment of legalizing passive euthanasia on 7 [sup]th March 2011. The 110-page long document which gave this verdict was delivered in response to a criminal writ petition filed on behalf of Aruna Ramchandra Shanbaug in 2009. The petitioner requested for withdrawal of feeding to bring an end to her suffering. She has been lying in a persistent vegetative state since last 36 years following attempt of sexual assault and strangulation by a ward boy when she was on duty at the K. E. M. Hospital. The staffs of the hospital have been providing her with supportive medical care since then. Justice Markandey Katju and Justice Gyan Sudha Mishra in their judgment commended the dedicated efforts of K. E. M. hospital in providing selfless continuous care to Aruna and dismissed the petition. The judgment accepted the significance of the doctrine of "parens patriae" while deciding the case where the affected person has lost the decision-making capacity. This doctrine recognizes the responsibility of the state in taking care of its citizens when they are in need of a father figure to take decision on their behalf. The bench felt that withdrawal of life-supporting measures cannot be left to the sole discretion of the treating physician, relative, care giver, or friend of a person. The judgment has laid provision for care givers of cognitively incapacitated persons to request for non-voluntary and passive euthanasia to the High Court. Till the legislation from the Parliament is in place, the judgment has cited the powers of article 226 of the constitution for such a provision. On receipt of any application for passive euthanasia, the High Court would appoint a board of doctors comprising a physician, a psychiatrist, and a neurologist to examine the patient based on which the court would take the decision about life-supporting treatment. Passive euthanasia is legalized in India in this process. [sup][1] Persistent vegetative state has resulted in Aruna being partially conscious and awake but unaware of her surroundings. Her higher mental functions as well as motor and sensory functions are compromised. The inability to experience self and the environment and the loss of capacity of voluntary control over self questions the very definition of being alive. Being alive is a continuous state of experience from the past to the future and the relationship with family, society, work, and culture rather than being a machine capable of carrying out biological functions. [sup][2] Mere presence of biological functioning cannot define life. The current clinical state of Aruna has sparked off the debate on euthanasia; is life unworthy of living worthy of ending? Is moral dimension of continuing life more important than quality of life? What would Aruna wish had she been capable of expressing her desire? Persistent vegetative state resulting from asphyxiating injury to brain has a poorer prognosis than a traumatic insult. [sup][3] With only 7% chance of improvement in the state of consciousness, the efficacy of current medical interventions remains questionable. Though these interventions can prolong life, their impact on quality of life is not encouraging. Many a times, these interventions are felt as merely prolonging the process of dying. Adding to this is the amount and extent of emotional and financial burden imposed on the care givers. Withdrawal of life-supporting treatment in such states is a difficult decision to take both by the treating physician as well as by the care givers. [sup][4] End of life decisions are complex with ethical, religious, moral, and legal implications. Autonomy and self-determinism have become the guiding principles of life. People have started talking about right to die. They have started deciding their time and mode of death. The whole idea is to have a comfortable painless death at a convenient time. …

In her article 'Active and Passive Euthanasia' (Philosophy 53, No. 204, April I978) Natalie Abrams argues that active euthanasia is preferable to passive euthanasia on the basis of a moral difference between acting and refraining in 'positive' cases where the outcome is desirable for the victim. She contends that in positive cases we intuitively feel an individual who merely allows a good thing to occur is not as praiseworthy as one who actually does something to bring it about, assuming identical motives and outcomes. Thus if Dick rescues his wife from a flaming building, we find him praiseworthy. But if Ernest's wife staggers out of a flaming building by herself before Ernest is able to find a way to go into the building to take her out, we do not believe him praiseworthy. Abrams then claims that euthanasia should be classified as a positive case, since it is performed only where the outcome is believed to be the more desirable outcome for the patient. Therefore a doctor who acts to bring about the death of a patient is more praiseworthy than one who merely allows the death to occur. There are a number of questionable points in Abrams's argument. For example, we may disagree that euthanasia should be classified as a positive case. Are there not cases in which death is mistakenly judged to be desirable for the patient? Also, one could argue that Ernest is just as praiseworthy as Dick, not for his inaction in allowing another to live but for his actions in attempting a rescue. After all, Ernest did not merely allow another to live. He took certain steps with the intention of bringing about the positive outcome. However, I will grant Abrams these points. Still, I believe her argument fails, because it is not true that given identical motives allowing a positive outcome to occur is never as praiseworthy as acting to bring about that outcome. Consider the following pairs of cases:

Distinguishing Between Active and Passive Euthanasia

BackgroundDoctors are increasingly faced with end-of-life decisions. Little is known about how medical students approach euthanasia. The objective of this study was to evaluate, among medical students and residents, the view on euthanasia and its variants; correlate such a view with empathy and religiosity/spiritualism; and with the stages of medical training in Brazil.MethodsThis is an exploratory cross-sectional study using an online questionnaire to be filled out on a voluntary basis among medical students and residents, consisting of: socio-demographic data, an empathy questionnaire and questions with elaborate clinical cases that typify situations of the variants of euthanasia.ResultsFrom 1550 invitations, 273 volunteer participants responded (17.6%). The percentages of strong agreement/agreement on the concepts were: passive euthanasia (72.9%); active euthanasia (22.3%), orthothanasia (90.1%), dysthanasia (18.7%), assisted suicide (33%) and sedation (82.8%). Passive euthanasia, active euthanasia, dysthanasia and assisted suicide showed greater refusal with increasing length of medical training. Religious belief and degree of empathy did not significantly influence the opinion about the concepts. Strong agreement/agreement were: passive euthanasia (72.9%); active euthanasia (22.3%), orthothanasia (90.1%), dysthanasia (18.7%), assisted suicide (33%) and sedation (82.8%).ConclusionsPassive euthanasia, active euthanasia, dysthanasia and assisted suicide showed greater refusal with increasing length of medical training. The external validation of our findings relies on the distinct legal, cultural, and religious frameworks found across various countries.

The legal consensus that has evolved through adjudication and legislation since the Karen Quinlan case in 1976 is founded on the premise that there is a bright line between passive euthanasia and active euthanasia. Indeed, the term passive euthanasia is often eschewed in favor of less emotionally-laden terminology such as "forgoing life-sustaining treatment" or "terminating life support" so as to further sever any possible connection with active euthanasia. Legal approval has been bestowed upon passive euthanasia under certain circumstances while active euthanasia is routinely condemned. This consensus was put to a test in 1990 when the United States Supreme Court ruled on the Cruzan case. However, the Court's narrow decision did not upset the consensus, and in the most significant appellate decisions handed down by state courts since Cruzan, there has been a reaffirmation--and possibly even an extension--of the consensus. Two other threats to the legal consensus about forgoing life-sustaining treatment have begun to manifest themselves: the increasing pressure for mercy killing and "futility" cases. Both of these challenge the fundamental premises on which the consensus is grounded.

This paper presents a philosophical defense of medical pessimism, often termed active euthanasia or “mercy killing,” by arguing that in specific clinical contexts, the moral distinction between active and passive euthanasia is untenable. The author critiques the Judeo-Christian and vitalist positions that prioritize the preservation of biological life at all costs, contending that such a stance can lead to an inhumane idolization of mere existence. Through an analysis of arguments from philosophers like James Rachels and within a framework informed by Kantian duty, the paper asserts that the intentional relief of unbearable, intractable suffering can constitute a moral imperative. The central thesis is that once a collective decision has been made that death is the preferable outcome to relentless suffering, the primary moral question shifts from “whether” to allow death to “how” to achieve it most compassionately. The paper concludes by proposing “potential for human relationship” as the key ethical criterion for preserving life, arguing that when this potential is irrevocably lost, the biological continuation of life no longer serves its human purpose, and a compassionate, responsible death becomes ethically permissible.

The author examines various claimed differences between active and passive euthanasia and, if there are differences, whether they are morally significant. He refutes arguments based on acting vs. not acting, intention, double effect, cause of death, and natural law theory. Reichenbach proposes that the most helpful distinction is the one between intentional killing (active euthanasia) and appropriate treatment for the dying or terminally ill (passive euthanasia). Significant moral difference, however, rests on the contention that intentional killing is always wrong and that, all else being equal, dying by natural means is intrinsically good, whereas dying by unnatural means is not.

I argue that ‘classical liberalism’ does not sanction any easy permissiveness about suicide and active euthanasia. I will use liberal arguments to argue that the distinction between active and passive euthanasia is real and that assisted suicide is, at the very least, deeply troubling when viewed from an authentic liberal perspective. The usual argument for active euthanasia is a utilitarian, not a liberal argument, as recent calls to eliminate the conscientious objection rights of doctors who refuse participation in such procedures plainly demonstrate. The paper focuses on arguments in the public sphere (such as those articulated by James Rachels).

In 1973 a lady doctor who had killed her sick mother was sentenced by the court in Leeuwaarden to a one-week suspended prison sentence. The judge declared that the court never doubted the defendant's integrity. The trial initiated the present open practice of euthanasia in the Netherlands. Many people expressed support for the accused doctor, and in the wake of this campaign two associations were founded: the Dutch Society (Vereniging) for Voluntary Euthanasia, and the Foundation (Stichting) for Voluntary Euthanasia. The public had been prepared for these events, first and foremost by the publication of Dr. Jan Hendrik van den Berg's book Medical Power and Medical Ethics in 1969.(1) In this work Van den Berg, a professor of neurology, declared that the ethics of unconditional respect for human life belonged to the past, to the time when medicine had been powerless. The new era of medical power required a new ethic allowing doctors to terminate human life.(2) Why it should be so was not clear, since Van den Berg failed to validate this assertion. However, his vivid pictures of human suffering (supposedly created by doctors exercising their power), the serene descriptions of euthanasia, and the daring reversal of many habits of thinking immediately captured the public imagination. The book went through ten printings in the first year and twenty-five in all. Since this work has strongly influenced Dutch public opinion on the issue of euthanasia, it is important to know the ideas it promoted. Van den Berg insisted that defective children must not be allowed to live.(3) In his view doctors are not only authorized(4) but have the duty to terminate meaningless lives.(5) In his book Van den Berg did not mention voluntary active euthanasia, but advocated involuntary active euthanasia. In all model case histories he cited, the decisions to actively terminate the patients' lives were taken by the doctors and the patients' families without the patients' knowledge. Van den Berg condemned the families who failed to request euthanasia and showed an attachment to hopelessly ill patients, this being a dishonor and an adherence to the old dismissed ethics.(6) Neither the patient's nor the family's consent was necessary to carry out euthanasia: in case of the family's refusal a committee of doctors and laymen should impose the decision.(7) Thus, Van den Berg went further than the demand to release the destruction of lives unworthy of being lived: he planned the enforcement of such policy and made provisions for the suppression of possible resistance. The book was an enormous publishing success and evoked virtually no protests. On the contrary, many concurring declarations followed, issued by Protestant ministers,(8) Protestant church authorities,(9) Catholic intellectuals,(10) ethical bodies,(11) and even by leaders of the movement in favor of voluntary euthanasia.(12) Apparently, Van den Berg expressed the views held by a large part of the public. This was later confirmed by opinion polls,(13) which showed that 77% of the public supported involuntary euthanasia. The Present Open Practice of Euthanasia During the Leeuwaarden trial it was revealed that some practice of euthanasia had already existed: in support of the defendant, eighteen doctors declared that they, too, had actively terminated the lives of their patients. It is certain, however, that after the Leeuwaarden trial the practice of euthanasia increased. How many people at present die by active euthanasia is not known because so long as Article 293 of the Dutch Penal Code, which makes euthanasia a punishable crime, remains formally valid, many doctors who perform euthanasia do not state it in the death certificates. All published figures are estimates, often based on questionnaires. The most often cited figure is ten thousand cases of active euthanasia a year.(14) However, a recent study done by VARA TV Corporation and interview polling firm has indicated that the number of cases of active euthanasia may be as high as 18,400 a year, and that in another 21,600 cases medical treatment is withdrawn with intention to cause death. …

Health care professionals frequently justify moral decisions by appealing to the acts and omissions distinction and the principle of double effect. These principles are often quoted and criticised in the nursing literature, particularly in relation to active and passive euthanasia. Authors are, however, inclined to acknowledge the fact that they are a philosophical minefield, but fall short of providing a substantial critical analysis. Those who uphold the acts and omissions distinction claim that we are morally less responsible for our omissions than for our acts. The principle of double effect suggests that there is a moral distinction between direct and indirect intention and that we are morally less responsible for that which we intend indirectly. This article offers an examination of these often quoted, but sometimes little understood, principles and it is hoped that it will serve as a basis for debate. Since the intention is to challenge assumptions which can lull us into believing that our moral decisions can be justified by appealing to principles such as these, it is necessary to examine them critically and to go beyond a superficial grasp of the implications of such distinctions. There is a tendency to appeal to the acts and omissions doctrine and the principle of double effect in life and death situations such as euthanasia, infanticide and abortion, but are they valuable tools which should be used in moral decision making, or are they so flawed that they can seriously mislead us when it comes to hard cases? The conclusion reached in this paper is that there is no significant moral difference between an act and an omission, particularly within the context of killing and letting die, and that the principle of double effect encourages hypocrisy rather than honesty.

Every human being should enjoy right to life. Article 21 of the Indian Constitution as well as under article 3 of International Convention Universal Declaration of Human Rights, 1948, guaranteed the right to life. Every aspect of right to life has been always subject to consideration of judiciary and depend upon the facts and situations. Right to die is also claimed under this head. Euthanasia is interpreted as 'mercy killing' or 'good death'. It is advocated that there are different situations in which it should be allowed to the person to let him choose his death in place of compelling him living alive. There are different approaches in this regard which either opposes the grant of mercy killing or denies to grant the death as right to die due to some causes. Everyone has the right to live dignified life according to his wish being living into certain limits and it is expected that a human being should struggle also in adverse circumstances around him. He should not lean in front of the situations. The Indian culture gives us such teachings. Hindu religion believes in the eternity of soul. Death is only the way to change a body. The soul never dies, it is eternal. Muslim religion also believes that life should be finished only upon the wish of Allah, it condemns the unnatural ending of life. But in present society in some situations, it is defended that the person should have the right to choose death. Thus, in this context the paper concentrated on the law of euthanasia in India in a legislative perspective and judicial interpretations on euthanasia.

The basic idea motivating this paper is that something can be done intentionally even when it is not done with the intention of doing it. An implication of this idea is that the distinction between doing what one intends and doing something as a foreseen avoidable consequence of doing what one intends cannot be used to exonerate agents for misdeeds.My immediate purpose here is to illustrate these points and show how they pertain to the morally relevant difference between active and passive euthanasia, and to the exoneration of God for the production of evil. In particular, I shall try to show, first, that the American Medical Association's recent attempt to distinguish between active and passive euthanasia is seriously defective. Second, I shall try to show that a popular version of the so-called Free Will Defense of God for Evil is also seriously defective.