agrees with these optimists that the Dutch are not on a slippery slope, but for
a different reason.
"Dutch doctors who practice
euthanasia are not on a slope. From the
very beginning they have been at the bottom." This is because in his
research he has found "involuntary
euthanasia…is rampant." He found that "a staggering 62% of all newborns'
and infants' deaths resulted from
'medical decisions,'" and that in 1995 alone there were 900 lethal
injections given to patients who
had not requested euthanasia.
On this page:
|Dutch protests in 2001 as
parliament debated legislation and euthanasia
Correspondence to: J Keown
Rose F Kennedy Professor of Christian Ethics, Kennedy Institute of Ethics,
Georgetown University, 37th and O Streets NW, Washington DC 20057, USA;
Original version received 4 November 2004
Accepted for publication 22 February 2005
In April 2004 the Parliamentary Assembly of the Council of Europe
debated a report from its Social, Health and Family Affairs Committee
(the Marty Report), which questioned the Council of Europe’s
opposition to legalising euthanasia. This article exposes the
Report’s flaws, not least its superficiality and selectivity.
Keywords: Council of Europe; euthanasia; Marty
In the ongoing international debate about the legalisation of
euthanasia a significant point of reference has been the recommendation
against legalisation passed in 1999 by the Parliamentary Assembly
of the Council of Europe. (The Council of Europe, a larger body
than the European Union, was established in 1949 in order inter alia
to defend human rights.) In Recommendation 1418 the Assembly urged
member states "to respect and protect the dignity of terminally ill
or dying persons in all respects". To this end it recommended a trio
- recognising and protecting a terminally ill or dying person’s
right to comprehensive palliative care ...;
- protecting the terminally ill or dying person’s right
to self-determination ...;
- upholding the prohibition against intentionally taking the
life of terminally ill or dying persons.
In relation to this third means it added:
- recognising that the right to life, especially with regard to
a terminally ill or dying person, is guaranteed by the member
states, in accordance with Article 2 of the European Convention
on Human Rights which states that "no one shall be deprived of
his life intentionally".1
More recently, moves have been afoot to reconsider the Council’s
position. In September 2003 a report on euthanasia emerged from the
Council’s Social, Health and Family Affairs Committee (by a narrow
The Report comprised a draft resolution (of nine paragraphs) and an
Explanatory Memorandum (of 63 paragraphs). The Memorandum was written
by the Committee’s rapporteur, Mr Dick Marty.
THE REPORT’S REASONING
The Report stated that some doctors practised active, voluntary
euthanasia on or assisted in suicide terminally ill patients who
experienced "constant, unbearable pain and suffering without hope of
any improvement". It added that this practice was usually "confined
to the shadows of discretion or secrecy", that decisions may be taken
in an arbitrary manner and depended on the presence of a
"sympathetic" doctor or nurse. Moreover, pressures from the family
could be more pernicious "if exercised in the dark and beyond any
procedures or control" and it was "this reality that carries the
greatest risk of abuse". Furthermore, penal and professional
sanctions were very rare. Hence, there was a "striking divergence"
between the law and practice, and this gap "must be reconciled if
respect for the rule of law is to be maintained".
The closure of this gap was one reason, it claimed, why legislation
had been passed in 2002 in the Netherlands and in Belgium to
permit voluntary euthanasia subject to "rigorously regulated and
controlled conditions". Such legislation was designed
to bring such practices out of the grey area of uncertainty
and potential abuse by establishing strict and transparent procedures,
mechanisms and criteria which doctors and nursing staff have
to observe in their decision-making.
In addition, it was difficult to distinguish ethically between
active voluntary euthanasia and the withholding or withdrawal of
life-sustaining treatment when it was known that the patient would
die sooner, which the Report described as "passive euthanasia".
The Report asserted:
Nobody has the right to impose on the terminally-ill and the
dying the obligation to live out their life in unbearable suffering
and anguish where they themselves have persistently expressed
the wish to end it.
Moreover, it added, we now respected a person’s choice to take
their own life and avoided making value judgements about them, a
development that could in no way be interpreted as a devaluation of
Furthermore, palliative care could not take away unbearable pain
and suffering in all cases and, in any event, the issue went beyond
the alleviation of pain:
the degree of patients’ own suffering, including mental
anguish and loss of dignity that they feel, is something that
only they can assess. Individuals suffering in the same situation
may take different end-of-life decisions, but each human being’s
choice is deserving of respect.
In light of the above considerations the draft resolution recommended
that member states:
- collect and analyse empirical evidence about end-of-life decisions
- promote public discussion of such evidence ...;
- promote comparative analysis taking into account in
particular the results of the legislation in the
Netherlands and Belgium, "notably their effects on
practice in the matter of euthanasia" and, in the
light of the evidence and public discussion:
- consider whether legislation should be envisaged, where it
has not already been introduced, to exempt from
prosecution doctors who agree to help terminally-ill
patients undergoing constant, unbearable pain and
suffering without hope of any improvement in their
condition, to end their lives at their persistent, voluntary
and well-considered request, subject to prescribed rigorous
and transparent conditions and procedures.
The Report is gravely flawed, not least because it overstates the
arguments for legalisation and downplays or ignores arguments against
Arguments advanced by
The rule of law
The Report claims that the rule of law supports legalisation.
However, just as the opening paragraph of Recommendation 1418 notes
that it is the vocation of the Council of Europe "to protect the
dignity of all human beings and the rights which stem therefrom", so
too the rule of law affords protection to all citizens, recognising
their fundamental equality in dignity. Just as no-one is above the
law, so no-one is beneath the law. A law permitting voluntary
euthanasia would, for the first time, allow certain private citizens
to kill other private citizens on the basis of the arbitrary
judgement, historically denied in western law and medical ethics,
that they would be better off dead. In short, the rule of law, to
which the arbitrary exercise of power is repugnant, not least the
power of life and death, tells against not for legalisation.
"Closing the gap"
The argument that there is a "striking divergence" between the law
and medical practice and that the gap must be closed if respect for
the rule of law is to be maintained is unconvincing. First, the
assertion that there is a "striking" discrepancy between law and
practice is controversial. Obtaining reliable data on the incidence
of the offences of murder and assisted suicide by medical
practitioners is, not surprisingly, difficult. The surveys cited by
the Report allegedly demonstrating a "striking" discrepancy in
countries where euthanasia and assisted suicide remain illegal must
be read with caution. For example, the Report pointed out that,
according to a survey of UK doctors,3
almost 60% replied that they had been asked to hasten death, of whom
32% had complied. These are not insubstantial figures. However,
the figures require some qualification. The 60% includes 14% who were
asked to let the patient die "through deliberate inaction", which the
survey defined as "passive euthanasia", and the 32% who said they had
taken active steps to end a patient’s life represented only 9% of all
the doctors who had been sent a questionnaire. Nor did the survey ask
how often euthanasia had been performed. Moreover, unlike the three
comprehensive surveys into end of life decision making in the
Netherlands carried out since 1991 by Professor van der Maas et
the UK survey, as its definition of "passive euthanasia" indicates,
did not consistently define "euthanasia" in terms of the intentional
hastening of death, which may have led to some confusion; nor
did the UK survey involve interviews with doctors, which van der Maas
found important in clarifying the thinking of his respondents in
distinguishing euthanasia from other end of life decisions.7
Another UK survey, commissioned by the BBC and involving a sample
of health professionals over twice the size of the survey cited by
the Report, disclosed that only 4% had assisted in suicide, either by
providing drugs or advice.8
Similarly, a US survey found that only 6% of physicians there had
performed euthanasia or assisted suicide, the author of the survey
concluding that it was a "rare" event.9
Professor van der Maas has written that the proportion of deaths in
the USA from euthanasia and physician assisted suicide is likely to
Secondly, even if there were a serious discrepancy between the law
and the practice of euthanasia, it would not follow that the gap
would be narrowed by relaxing the law. Many criminal laws are
regularly broken. Some prohibitions, such as the law against
possessing hard drugs, are frequently breached without detection, but
it does not follow that the law should therefore be relaxed to
accommodate those who snort coke.
Thirdly, if the law against voluntary euthanasia is occasionally
broken, so too is the law against non-voluntary euthanasia (both in
jurisdictions where, like the UK and the USA, voluntary euthanasia is
illegal and in jurisdictions, notably the Netherlands, where it is
legal). If the Report believes the gap between the law and the
practice of voluntary euthanasia militates in favour of legalisation,
then why not the gap between the law and practice of non-voluntary
Fourthly, the Report seems to assume that if voluntary euthanasia
is practised it should therefore be condoned. Revealingly, the Draft
Resolution does not propose that, in the light of whatever evidence
may emerge from studies into the incidence of euthanasia, there
should be a review of various options, including improving the
provision of quality palliative care and/or tighter enforcement of
the criminal law. It proposes solely that member states consider
legalising euthanasia. That this is the Report’s not-too-skilfully-hidden
agenda is also clear from its underlying argument in principle
for reform, for, if there is a right to voluntary euthanasia, why
should it not be recognised by law whatever the evidence might
disclose about levels of current practice? Moreover, what if, as much
voluntary euthanasia is carried out on patients whose autonomy is
compromised by clinical depression or whose suffering could have been
alleviated by palliative care? In other words, why does the Report
seem to assume that the problem with the alleged gap between the
criminal law and medical practice lies with the former rather than
the latter, that the law is bad and the practice good? Was Dr
Kevorkian a model of good medical practice? Of the 69 people he
assisted in suicide only a quarter were terminally ill.13
Why assume that the law should accommodate Kevorkians rather than
Finally, relaxing the law to allow euthanasia to be performed in
certain circumstances would not mean that euthanasia would be
performed only in those circumstances. Legislative proposals for
regulating euthanasia typically set out procedural requirements aimed
at monitoring the practice of euthanasia; they do not seek to
prohibit the practice of euthanasia that fails to satisfy those
requirements. In other words, the potential for "abuse", for breaking
the law against murder and assisted suicide, remains. Indeed, it may
well be that legalising euthanasia in certain circumstances would
result in euthanasia in other circumstances being regarded by the
criminal justice system as less, not more, serious: a lower, not a
higher priority. It is noteworthy that in the Netherlands very few
doctors have been prosecuted for breaching the requirements for
lawful euthanasia, and that those doctors who have been convicted of
murder have typically been dealt with by the courts with remarkable
The Dutch example
The Report implicitly endorses the Dutch and Belgian legislation. It
describes the procedures prescribed by the legislation as "strict and
transparent" and claims that the Dutch surveys have shown that "close
monitoring" is possible. There is a problem with all this: the Dutch
surveys show precisely the opposite.
For example, the so-called "strict and transparent procedures" in
the Dutch legislation (which essentially enshrine guidelines that
have been in operation since 1984 when the Dutch Supreme Court first
declared voluntary euthanasia lawful) include a requirement for
doctors to report all cases to the authorities. The three Dutch
surveys carried out by Professor van der Maas et al have
demonstrated that a clear majority of cases have been covered up by
In other words, in the bulk of cases there has not even been an
opportunity for control. Even in relation to the minority of cases
that have been reported, the reports are filed by the doctors
themselves, who are hardly likely to disclose that they have breached
the guidelines. The surveys indicate, moreover, that failure to
report is by no means the only important requirement that has been
widely ignored, with virtual impunity, by Dutch doctors. Thousands of
Dutch patients have been killed without request.
The conspicuous failure of the Dutch regulatory mechanisms over
the last 20 years has been repeatedly demonstrated by commentators of
whose work the Report seems oblivious.12,16,17
(The focus of this paper is on the Dutch rather than the Belgian
experience, partly because Dutch law has approved euthanasia for much
longer—and there is accordingly more evidence about Dutch
practice—and partly because the Belgian law largely emulates the
Dutch law.) Also notably absent from the Report is any reference to
the serious concerns that have been expressed, not least about the
non-voluntary euthanasia of disabled newborns, by the UN Human
In short, there is indeed a "striking divergence", but it is
between the law and the practice of euthanasia in the Netherlands.
Another gap, hardly less striking, is that between the reality of
Dutch practice and its (mis)representation by the Report.
Changing attitudes toward
The Report also presents a contentious interpretation of changing
attitudes to suicide. In England, for example, the decriminalisation
of suicide by the Suicide Act 1961 reflected, as the Government of
the time made abundantly clear,19
not a condonation of suicide but a realisation that criminal
punishment was an inappropriate way of dealing with suicidal persons.
As Lord Bingham confirmed in the Pretty case,20
in which the House of Lords rejected an alleged right to assisted
suicide, the Suicide Act 1961 conferred no right on anyone to commit
The Report claims that public opinion polls show a majority in favour
of legalisation. Such polls must be read cautiously, but even
assuming the claim to be true it could hardly be allowed to dictate
law and public policy any more than a finding that a majority of
people favour capital punishment.
Equating euthanasia with
The Report’s equation of "euthanasia" with the withdrawal of
life-sustaining treatment when the shortening of life is foreseen,
which it describes as "passive euthanasia", is misleading. It defines
"euthanasia" as "any medical act intended to end a patient’s life at
his or her persistent, carefully considered and voluntary request in
order to relieve unbearable suffering". How, then, can the withdrawal
of treatment when the doctor merely foresees that it will shorten
life count, on the Report’s definition, as "euthanasia"? For one
thing, there is no "act" and even if there is foresight of death it
does not follow that there is also an intention to end life. Simply
to conflate these two forms of conduct, which there are good ethical
reasons to regard as distinct, is undeniably controversial and
invites confusion. Moreover, by defining "euthanasia" as "active,
voluntary euthanasia", the Report adopts the controversially narrow
Dutch definition. One danger of this definition is that it can be
used (as it has been by the Dutch) to deflect discussion of
non-voluntary and involuntary euthanasia on the grounds that they are
not "euthanasia" and therefore lie outside the boundaries of the
Misrepresenting the case
The Report states that opponents of legalisation reject the claim
each individual, out of respect for his or her dignity and
value, has a right to take decisions concerning his or her own
life and death in accordance with his or her own values and
beliefs, as long as no harm is done to others, and not to have
It would have been less misleading to state that opponents of
euthanasia, while supporting the right of patients to make a range of
decisions concerning their medical treatment, reject one decision as
being incompatible with the patient’s dignity and value: the decision
to be intentionally killed, or to be helped to commit suicide.
Moreover, to prohibit that choice does not deny the patient’s dignity
but affirms it, just as disallowing other choices that a person may
want to make, such as to be executed rather than imprisoned, equally
respects his or her inalienable dignity. The fact that, through
depression or pain or loneliness, some patients may lose sight of
their worth is no argument for endorsing their misguided judgement
that their life is no longer worth living. Were the law to allow
patients to be intentionally killed by their doctors, it would be
accepting that there are two categories of patients: those whose
lives are worth living, and those who are better off dead. What
signal, moreover, would that send out to people who are sick,
elderly, disabled, or dying?
The Marty Report goes on to imply that opponents of euthanasia are
imposing on terminally ill people "the obligation to live out their
life in unbearable suffering and anguish ...". On the contrary, many
of the leading opponents of euthanasia, such as Dame Cicely Saunders,
foundress of the hospice movement, have devoted their lives to the
alleviation of suffering and anguish. Again, opponents of euthanasia
recognise the right of patients to refuse treatments because they are
futile or too burdensome, even if it is foreseen that death will come
sooner. Those opposed to euthanasia do not believe that life
should be preserved at all costs; that is a cheap caricature.
The Report glosses over several important counterarguments. To take
but one, it mentions but nowhere rebuts the counterargument that
legalising voluntary euthanasia leads as a matter of practice and of
logic to non-voluntary euthanasia. The counterargument runs that the
slide will occur as a matter of practice because "safeguards" to
prevent it cannot be made effective, and as a matter of logic because
the case for voluntary euthanasia for terminally ill people contains
the seeds of its own extension to those who are not terminally ill or
to those who cannot request it.
The failure of "safeguards" as a matter of practice is amply
demonstrated by the Dutch experience, but that experience also
illustrates the force of the logical "slippery slope", a product of
the unresolved tension in the argument for voluntary euthanasia
between patient autonomy and patient welfare.
Respect for patient autonomy
The Report states that opponents of euthanasia dismiss
the individual’s right to take decisions concerning his
or her own life and death in accordance with his or her own
beliefs and values, as long as no harm is done to others.
It concludes that consideration should be given to exempt from
prosecution doctors who agree to help
terminally-ill patients undergoing constant, unbearable pain
and suffering without hope of any improvement in their condition,
to end their lives at their persistent, voluntary and well-considered
However, if there is a right to make decisions concerning life and
death in accordance with one’s own values and beliefs why should
euthanasia not be available to any autonomous person who believes,
for whatever reason (terminal, chronic or mental illness, "tiredness
of life", bereavement, divorce, unemployment, lost election ...) that
their life is no longer "worth living"? By imposing conditions such
as "terminal illness" on candidates for euthanasia, why is the Report
not denying each individual’s "right to take decisions concerning his
or her own life and death in accordance with his or her own values
Interestingly, the former Dutch Health Minister, Mrs Borst, a
leading defender of the Dutch euthanasia regime, has stated that she
thinks elderly people should be able to obtain suicide pills to take
if they simply felt "tired of living". Mr Marty could not claim to be
unaware of her viewpoint—it was pointed out by the author in his
response to Mrs Borst’s speech at a hearing on euthanasia held by his
Committee in Paris in 2002 (a hearing which, like the Report, was
unbalanced: invited speakers in favour of legalisation markedly
outnumbered those against).
Respect for patient welfare:
the life "not worth living"
No responsible doctor would kill a patient merely because the patient
requested it, however autonomously, any more than a responsible
doctor would amputate a healthy leg just because the patient
requested it. Indeed, in the Netherlands doctors refuse many
autonomous requests for euthanasia. The doctor grants the request
only if the doctor personally judges that the patient is right in
thinking that death would be a benefit. If the doctor, however,
thinks he or she can make this judgement—that the patient would be
better off dead—in relation to a patient who asks for euthanasia, why
cannot the doctor make that decision in relation to a patient in the
same situation who is unable to request it? In other words, if death
would benefit the patient why should it be denied the patient merely
because of incompetence?
In 1996, two Dutch Courts of Appeal, adapting the reasoning
previously used by the courts to justify voluntary euthanasia, held
it lawful for doctors to give lethal injections to disabled babies,21
which illustrates the force of this counterargument. It was,
moreover, recently reported that Dutch doctors are drafting protocols
for euthanising children aged under 12 years (which is the minimum
age specified in the present legislation) and that Members of
Parliament from the ruling party in Belgium have introduced a Bill
that would extend euthanasia to minors.22
As this trend confirms, once the rhetorical mask of autonomy is
stripped away, the true face of euthanasia is revealed: the judgement
that certain patients are better off dead. The Marty Report is an
exercise in failed cosmetic surgery.
Mr Marty’s Explanatory Memorandum concludes:
As a lawyer and a legislator, I note that all over the
world, doctors are ending the lives of patients, often in secrecy
and with a sense of guilt. The law seems to want to ignore this
fact of life, whereas it ought to have the courage to address
it. Decriminalising euthanasia, rather than keeping the ban,
might enable us to better supervise it and also prevent it.
He seems unaware that around the world the case for legalising
voluntary euthanasia has already been considered by "lawyers and
legislators" and that they have, with few exceptions, rejected that
case. It is puzzling why the Report fails even to mention important
and relevant publications such as that of the New York State Task
11 whose members, both pro- and anti-euthanasia,
unanimously rejected legalisation on the ground that it would be
The core argument informing the Marty Report—that because
euthanasia takes place illegally the Council of Europe should, in the
light of empirical evidence, consider legalising it so as to "bring
it out into the open" where it can be better "controlled"—has been
refuted by the evidence from the Netherlands. This is hardly
surprising: if some doctors are prepared, when euthanasia is illegal,
to ignore the law of murder which prohibits it, why should we expect
them, when euthanasia is legal, to observe the guidelines that permit
The Marty Report appeared in September 2003. It was strongly
criticised by the Council of Europe’s Committee on Legal Affairs and
Human Rights later that month.23
This Committee concluded (at paragraph 25): "The Dutch situation
demonstrates that legalizing euthanasia and assisted suicide, far
from introducing greater controls, simply introduces more euthanasia
and more assisted suicide". The Report was debated in April 2004 by
the Parliamentary Assembly of the Council of Europe.24
The Assembly decided not to vote on the text but to refer it back to
the Committee so it could prepare a new text bringing together the
widely diverging viewpoints expressed in the debate. It is to
be hoped that any new text avoids the pitfalls of superficiality and
selectivity into which its predecessor so clumsily fell.
Competing interests: none declared
- Parliamentary Assembly of the Council of Europe.
Protection of the human rights and dignity of the terminally ill and the
dying. (Recommendation 1418) 1999.
(accessed 21 Mar 2005).
- Social, Health and Family Affairs Committee, Council of
Europe, rapporteur D Marty. Euthanasia. (Doc. 9898) 10 September 2003.
(accessed 21 Mar 2005).
- Ward BJ, Tate PA. Attitudes among NHS doctors to
requests for euthanasia. BMJ 1994;308:1332–4.[Abstract/Free Full Text]
- van der Maas PJ, van Delden JMM, Pijnenborg L.
Medische beslissingen rond het levenseinde. Het onderzoek voor de Commissie
onderzoek medische praktijk inzake euthanasia. [Euthanasia and other
medical decisions concerning the end of life.] The Hague: SDU Uitgeverij
- van der Wal G, van der Maas PJ. Euthanasie en andere
medische beslissingen rond het levenseinde. De praktijk en de
meldingsprocedure. [Euthanasia, physician-assisted suicide and other
medical practices involving the end of life.] The Hague: SDU Uitgevers,
- van der Wal G, van der Heide A, Onwuteaka-Philipsen BD,
et al. Medische besluitvorming aan het einde van het leven: De
praktijk en de toetsingprocedure euthanasiae. [Medical decision making
at the end of life: the practice and the verification procedure (in cases
of) euthanasia.] Utrecht: De Tijdstroom, 2003.
- van der Maas PJ, van Delden JMM, Pijnenborg L.
Medische beslissingen rond het levenseinde. Het onderzoek voor de Commissie
onderzoek medische praktijk inzake euthanasia. [Euthanasia and other
medical decisions concerning the end of life.] The Hague: SDU Uitgeverij
Plantijnstraat, 1991:162 Cited in: Keown J. Euthanasia, ethics and public
policy. Cambridge: Cambridge University Press, 2002:94.
- McLean SAM, Britton A. Sometimes a small victory.
Glasgow: Institute of Law and Ethics in Medicine, University of Glasgow,
1996:31–2 (appendix III, table 17).
- Meier DE, Emmons CA, Wallenstein S, et al. A
national survey of physician-assisted suicide and euthanasia in the United
States. N Engl J Med 1998;338:1193–201.[Abstract/Free Full Text]
- van der Maas P, Emanuel LL. Factual findings. In:
Emanuel LL, ed. Regulating how we die. Cambridge, MA: Harvard
University Press, 1998:151.
- New York State Task Force on Life and the Law. When
death is sought: assisted suicide and euthanasia in the medical context.
New York, NY: New York State Task Force on Life and the Law, 1994.
- Keown J. Euthanasia: ethics and public policy.
Cambridge: Cambridge University Press, 2002.
- Roscoe L, Malphurs J, Dragovic L, et al. Dr
Jack Kevorkian and cases of euthanasia in Oakland County, Michigan,
1990–1998 [Letter]. N Engl J Med 2000;343:1735–6.[Free Full Text]
- Keown J. Euthanasia, ethics and public policy.
Cambridge: Cambridge University Press, 2002:113,132.
- Fenigsen R. Dutch euthanasia: the new government
ordered survey. Issues Law Med 2004;20:73,77.[Medline]
- Gomez CF. Regulating death: euthanasia and the case
of the Netherlands. New York, NY: Free Press, 1991.
- Hendin H. Seduced by death: doctors, patients and
assisted suicide. revised edition. New York, NY: Norton, 1998.
- United Nations, International Covenant on Civil and
Political Rights. Concluding observations of the Human Rights Committee:
Netherlands. Paras 5–6. (CCPR/CO/72/NET.) 27 August 2001.
(accessed 21 Mar 2005).
- Keown J. Euthanasia, ethics and public policy.
Cambridge: Cambridge University Press, 2002:64–66.
- Regina (Pretty) v . Director of Public Prosecutions
(Secretary of State for the Home Department Intervening)  3 WLR
- Jochemsen H. Dutch court decisions on nonvoluntary
euthanasia critically reviewed. Issues Law Med 1998;13:447–58.[Medline]
- Reuters. Dutch doctors drafting protocols for child
euthanasia. Bioedge, 10 September, no. 134.
(accessed 21 Mar 2005).
- Opinion of the Legal Affairs and Human Rights Committee of
the Council of Europe. Rapporteur K McNamara, United Kingdom, Socialist
Group. Euthanasia. (doc. 9923) 23 September 2004.
(accessed 21 Mar 2005).
- Council of Europe. News item. 2000–.
(accessed 21 Mar 2005).
Journal of Medical Ethics 2006;32:29-33;
© 2006 by BMJ Publishing Group Ltd & Institute of Medical Ethics
Vol. 13 No. 6 (June 2003)
Reviewed by Susan M. Behuniak,
Department of Political Science, Le Moyne College. Email:
The issue of euthanasia has all the
components that make for a political-legal morass. Emerging at the intersection
of medicine, ethics, law, and politics, it is inspired by profound human
suffering, shaped by clashing cultural values and practices regarding death and
dying, and colored by the historical specter of human rights abuses. EUTHANASIA,
ETHICS AND PUBLIC POLICY, by John Keown of the Faculty of Law at the University
of Cambridge, skillfully navigates readers through this mire, while arguing a
point of view that resists polemics.
The thesis that drives the book is
both compelling and uncommon. Keown forcefully argues that neither voluntary
euthanasia nor, more specifically, physician-assisted suicide should be
legalized. What sets this book apart from other anti-euthanasia volumes,
however, is that Keown does not argue against these practices on a principled
basis, but for the pragmatic reason that they cannot be effectively controlled.
That neither practice can be contained nor regulated to prevent abuses leads him
to conclude that their legalization will inevitably lead down the “slippery
slope” to involuntary active euthanasia—i.e., murder.
In garnering sources to support his
position, Keown offers a comparative dimension by drawing on the euthanasia
policies of Australia, Canada, England, Netherlands, and the United States—five
countries that are currently grappling with the question of under what
circumstances, if any, different euthanasia practices should be allowed.
Given the confusion over terminology
within any given country and most certainly between them, Keown wisely uses Part
I of the book to establish the vocabulary of euthanasia. After a brief survey of
three definitions, he defines “euthanasia” as “doctors making decisions which
have the effect of shortening a patient’s life and that these decisions are
based on the belief that the patient would be better off dead” (p. 10). He then
surveys the academic disagreements over the finer distinctions drawn between
various euthanasia practices. For example, although the issue of patient consent
is divided into “voluntary,” (i.e., with the patient’s consent), “nonvoluntary,”
(i.e., lacking patient’s consent, usually because the patient lacks capacity but
also when the patient is not asked), and “involuntary,” (i.e., contrary to the
patient’s wishes), the distinctions are not accepted as relevant by all. There
is also disagreement over whether “acts” (e.g., an injection) are to be treated
differently than “omissions” (e.g., a decision not to administer antibiotics),
as well as whether the withdrawal of life support would constitute an act or an
omission. Finally, there is the controversial principle of the “double effect”
that distinguishes that which is “intended” from that which is merely
Keown’s position is that voluntary
active euthanasia (VAE) should be broadly defined to include both acts and
omissions, and to include physician-assisted suicide (PAS), a practice in which
terminally ill patients self-administer a fatal dose of a drug prescribed by a
physician. On the other hand, he supports the distinction drawn between intended
and foreseen consequences maintaining that a physician who prescribes a drug to
reduce a patient’s pain, even though it may hasten death, is not participating
in euthanasia; whereas a physician who purposely does so to kill the patient is
In Part II, another background
section necessary to set up his argument, Keown distinguishes between the
ethical perspectives of Vitalism (the position that life must be preserved at
all costs), Inviolability (the position that life is sacred, but that treatment
may be stopped when it does not benefit the patient) and Quality of Life (the
position that it is the value of the life itself, and not the specific value of
the treatment, that determines when death may be sought). This section also
contains one chapter that examines how the right to personal autonomy is not an
absolute right, and another that demonstrates how logically difficult it is to
support PAS or VAE without sliding public policy toward NVAE. For example, if
physicians are allowed to prescribe deadly drugs to terminally ill patients,
then why not permit them to give direct injections to those who cannot swallow
the pills, and then why not expand this to those who are suffering but not
terminally ill, and then to patients who have a poor quality of life but are
unable to consent to termination?
This is Keown at his strongest. Even
among proponents of PAS and VAE, of which I am one, he will raise doubts as to
whether he may in fact be right about the dangers of legalization. In drawing
out the scenario of the descent to legalized murder, his analysis is most
disturbing in that it does not rely on the existence of evil intentions within a
regime like that of Nazi Germany, but on well-meaning policymakers in
democracies sensitive to human rights whose goal it is to end human suffering.
In this, he is convincing that advocacy for the Inviolability of life position
would safeguard patients from most abuses by shifting the focus to an evaluation
of the benefit of the treatment for a specific patient, and not an evaluation of
the worth of an individual life.
With definitions and ethical
perspectives reviewed, Keown turns in Part III to the main question at hand: Can
VAE and PAS be effectively controlled? To answer, he explores data collected
from the Netherlands, a nation whose Supreme Court in 1984 declared VAE lawful
under certain conditions. After comparing statistical data on deaths with the
guidelines established by the Royal Dutch Medical Association, he concludes that
not only are the guidelines “elastic” rather than strict and therefore open to
abuse, but that the slide to NVAE has already taken place. To support this
latter claim, he draws on 1990 data that indicate that, while only 2300 patients
are reported to have died by VAE and 400 by PAS, doctors
intended to accelerate the deaths
of another 6350 cases, some without the “explicit request” of the patient (pp.
In Part IV, Keown moves on to the
Northern Territory (NT) of Australia and the state of Oregon in the U.S. to
explore whether legalization efforts through the legislative process have
succeeded in ways that the Netherlands policy, based on case law, has not. In
1995 the NT passed the Rights of the Terminally Ill Act (ROTTI) permitting both
PAS and VAE. Keown criticizes ROTTI for its lack of specificity, its laxity, and
its weak safeguards, flaws that led to its repeal by the Federal Parliament nine
months later. Oregon’s Death With Dignity Act (DWDA), legalizing PAS under
certain circumstances, was implemented in November 1997 after it passed twice as
a voter’s referendum and surmounted court challenges. Keown again criticizes
what he sees as a lack of specificity in the Act as well as the data of the
first three annual reports (1998-2000) indicating that among the most frequent
reasons that patients sought PAS were loss of autonomy, fear of becoming a
burden, decreasing ability to participate in activities, and loss of control of
bodily functions. Keown concludes: “The Oregon Act can claim to be the most
permissive regime for PAS yet devised. Unlike the Netherlands and the NT there
is no requirement that the patient be suffering, let alone be suffering severely
or unbearably” (p. 179). For Keown then, “suffering” in this instance seems to
mean physical pain and not psycho-social distress.
Keown’s critiques of existing laws
are so penetrating and detailed (at times even nitpicking, e.g., that the DWDA’s
definition of “terminal”—expecting death to occur within six months—is not
precise enough) that it makes me wonder why he would not suggest how
imprecisions could be refined, loopholes plugged, and his fears about the
slippery slope quelled. Indeed, if the objection to PAS and VAE is just a
pragmatic one, and not one of logic or of ethics, why not agree to laws that
draw a clear line between voluntary and nonvoluntary euthanasia for no other
reason than that a line must be drawn somewhere?
But where Keown falters most is in
his description and analysis of the U.S. experiences with PAS and the right to
die. He criticizes the DWDA in its original version and not as amended in 1999;
he ignores how the Supreme Court upheld a right to what he would call passive
euthanasia in CRUZAN v. DIRECTOR, MISSOURI DEPARTMENT OF HEALTH (1990); and he
overstates the Court’s rejection of PAS bans in WASHINGTON v. GLUCKSBERG
(1997) and VACCO v. QUILL (1997),
failing to note that the rulings allowed the states to ban not only PAS, but
indeed, the choice to legalize PAS just as Oregon has done.
Keown adds more fuel to his argument
against legalization in Part V by enlisting expert opinion from ethics
committees, courts, and medical associations of the five countries under review
to heighten an argument that there is worldwide consensus that legalization is a
Pandora’s box that should not be opened.
What he leaves unexplored, however,
is the apparent conflict between such experts and citizens of these nations.
That there is such uniformity among expert opinion against legalization and such
a groundswell among patients, families, and interest groups for legalization
surely indicates a disconnect between public policy and medical practice. Keown
does acknowledge patient suffering. But to argue that the solution to the
euthanasia quagmire is to forbid it while encouraging doctors to treat suffering
more effectively hardly seems like an answer given the current failures of these
most sophisticated and expensive of medical systems. Indeed, it may be the
medicalization of death and dying that has spawned this very issue.
My concern about the potential impact
of his anti-euthanasia position is only heightened by the final section of the
book in which he explains his opposition to even passive euthanasia (PE)—defined
as withholding or withdrawing life sustaining treatment with the intent to kill
the patient. It is here that his previously drawn distinction between intending
death and foreseeing death is most critical. If two doctors each decide to stop
nutrition and hydration of their patients, one can be charged with practicing PE
if the intent was to kill the patient; while the other would be safeguarded from
punishment if death was merely foreseen and the intent was to stop a treatment
no longer of benefit to the patient. Again, Keown declares that the essential
difference is that of evaluating the treatment, not the life of the patient.
This raises two questions: How would
a prosecutor or a Court get into the head of the physician to know what truly
motivates the treatment decision, and would physicians be confident enough to
trust the system so that they would aggressively offer palliative care? Keown’s
response to the first is that MENS REA is evaluated in criminal court all the
time. While true, presumably physicians would be loath to be treated as criminal
suspects who must answer for their state of mind when practicing medicine.
Secondly, physicians in the U.S. are so fearful about being prosecuted that they
too often under-medicate, thus leaving patients in pain—contributing again to
the very reasons why patients and families cry out for legalization of PAS or
VAE, and illustrating the flip-side of Keown’s pragmatic argument.
This book is written with a clarity
that is rare in this complicated, cross-disciplinary field, and so should be
well received by Keown’s intended audience of a general reader. It would also be
an effective text in health policy, medical law, or comparative law courses.
Keown’s contribution is in educating the public, policy makers, and academics
about what is at stake as five different nations struggle over the question of
how we die.
CRUZAN v. DIRECTOR, MISSOURI
DEPARTMENT OF HEALTH, 497 U.S. 261 (1990).
VACCO v. QUILL, 512 U.S. 793 (1997).
WASHINGTON v. GLUCKSBERG, 512 U.S.
Copyright 2003 by the author, Susan M. Behuniak.
Perhaps the most surprising thing about the Dutch Parliament's action on
April 2001 to legalize euthanasia and physician assisted suicide is the
reaction to it. After all, these practices have been going on under an
umbrella of official tolerance for decades. Nevertheless the act of
giving it full legal recognition has raised new concerns both in the
Netherlands and around the world. Yet an estimated 10,000 protesters
surrounded the Parliament building, singing hymns and reading scripture,
in vigorous protest against the steps being taken inside the building.
Euthanasia has been practiced the Netherlands under an agreement worked
out between the government and the medical association, but it has not
been officially "legal." Even in this legally murky environment,
euthanasia has been practiced freely in that country, although the exact
number of cases is not known because of underreporting. Dutch physician
Richard Fenigsen has written that Dutch general practitioners are
estimated to perform from 5000 to 20,000 cases per year, which he notes
that in American terms would be from 80,000 to 300,000 cases per year.
The law specifies the conditions in which euthanasia will be
· The patient must have an incurable illness (note it does not
specify "terminal illness"-the patient need not actually be dying to
· The patient must be experiencing "unbearable suffering"
· The patient is sound mind and has given consent
· Doctors will administer "medically appropriate" means to terminate
Despite the fears of many who have argued that Dutch society and
medicine are on a "slippery slope," official apologists for the law
claim that there is no reason to fear one. Health Minister Els Borst
argued that Dutch euthanasia has appropriate safeguards against abuse,
claiming that ``There are sufficient measures to eliminate those
concerns,'' She claimed that euthanasia will remain a last resort for
those who otherwise would face suffering.  Similarly, Peter Bootsma,
counselor for health and welfare at the Dutch embassy in Washington,
says that ``Euthanasia is not something which will be forced on people.
But this should be an option as a last resort for people who have a
permanent and long-lasting wish not to live any more.'' 
Surprisingly, Dr. Fenigsen agrees with these optimists that the Dutch
are not on a slippery slope, but for a different reason. "Dutch doctors
who practice euthanasia are not on a slope. From the very beginning they
have been at the bottom." This is because in his research he has found
"involuntary euthanasia…is rampant." He found that "a staggering 62% of
all newborns' and infants' deaths resulted from 'medical decisions,'"
and that in 1995 alone there were 900 lethal injections given to
patients who had not requested euthanasia.  Among that group, an
amazing189 were fully competent and could have been consulted about
their consent but were not. He concludes that "those who contend that it
is possible to accept and practice ‘voluntary’ euthanasia and not allow
involuntary totally disregard the Dutch reality.”
Fenigsen's grim assessment of euthanasia in Holland even before the
law was changed is supported by the research of an American team led by
Herbert Hendin published in the Journal of the American Medical
Association. Hendin and his associates found that
From our point of view there has been an erosion of medical
standards in the care of terminally ill patients in the Netherlands.
The 1990 and the 1995 studies document that 59 percent of Dutch
physicians do not report their cases of assisted suicide and
euthanasia, more than 50 percent feel free to suggest euthanasia to
their patients, and about 25 percent admit to ending patients' lives
without their consent. How is it that the Dutch researchers are so
sanguine about their data?
Like Fenigsen, Hendin and his colleagues conclude that " the Dutch
experience indicates that these practices defy adequate regulation...."
As the pro euthanasia movement grows in most of Western Europe and in
North America, we are well advised to remember the words of one of the
Dutch protesters mentioned earlier in this article: "We believe in the
Lord, and he is the only one who can decide on taking life."
David B. Fletcher, Ph.D.
Chair, Steering Committee of CACE
 "A Case Against Dutch Euthanasia," Hastings Center Report
special supplement, Jan/Feb, 1989.
 Anthony Deutsch, "Dutch Approve Euthanasia Bill." Associated
Press, Tuesday April 10 3:53 PM ET.
 Karen Iley, "Dutch Senate Passes Euthanasia Law Amid Protests,"
Reuters, Tuesday April 10 2:17 PM ET.
 Richard Fenigsen, "Dutch euthanasia revisited, " Issues in Law &
Medicine, Winter 1997 v13 n3 p301-311
 Herbert Hendin et al, JAMA, June 4, 1997.
encouraging the formation of moral character
and the application of biblical ethics to contemporary moral decisions
for Applied Christian Ehtics
BMJ 2005;331:717 (1 October), doi:10.1136/bmj.331.7519.717-c
Clare Dyer, legal correspondent
A retired GP and campaigner for the legalisation of voluntary
euthanasia who agreed to help a terminally ill friend commit
suicide was unfit to practice, the General Medical Council decided
Michael Irwin, 74, was facing a strong possibility that he would
be struck off the medical register as the BMJ went to press
A GMC panel decided on Tuesday that his fitness to practise was
impaired and told him that he had abused his position as a doctor.
The panel criticised Dr Irwin for stockpiling temazepam tablets
and for "an act of deception" and a criminal offence in writing
prescriptions for the drug in his own name, intending to use it to
help his friend die.
Dr Irwin's case was referred to the GMC after he was given a
police caution for possession with intent to supply a class C drug.
He said he kept a supply of temazepam for his own use to relieve jet
lag, but the panel found the numbers of pills "excessive."
A former chairman of the Voluntary
Euthanasia Society, Dr Irwin travelled to the Isle of
Man after agreeing to help a fellow
euthanasia campaigner, Patrick Kneen, who was dying of prostate
But by the time Dr Irwin arrived his friend was too ill to take
the pills. His own doctor put him on a diamorphine drip, and he died
a few days later in a coma.
Dr Irwin, 74, told the panel that he knew of several doctors with
"twinning" arrangements with fellow doctors to help each other commit
suicide if a painful death threatened. He said he was twinned with a
retired doctor in Glasgow, and he accused doctors of "double
standards" if they refused to do the same for a friend or long term
patient who is terminally ill and suffering.
|Dr Michael Irwin
SERVICE LTD OLD BAILEY
In a statement to the GMC he said: "I believe passionately that in
this apparently enlightened 21st century, terminally ill patients
should have the right to obtain medical assistance to die, if this is
their wish: to be able to pick a time for their death, preferably in
their own familiar home environment.
"Although our British society is in principle just, I strongly
believe that the existing law on assisted suicide is unjust and that
sometimes a compassionate physician has a greater duty to a patient
or a close friend than his or her duty to the state."
Dr Irwin, who was medical director of the United Nations in New
York before he retired 15 years ago, represented himself at the two
day GMC hearing, which he welcomed as a focus for renewed debate over
the issue of doctor assisted suicide.
A poll last month by the UK polling organisation YouGov found huge
popular support for the legalisation of doctor assisted suicide, with
86% of respondents agreeing with the statement that people who are
terminally ill "should have the right to decide when they want to die
and to ask for medical assistance to help them."
Doctor assisted suicide is legal in the US state of Oregon and in
the Netherlands and Belgium and has been decriminalised in
BMJ 2005;330:1041 (7 May), doi:10.1136/bmj.330.7499.1041-a
The Netherlands' first reported case of a doctor complying with a
request for assisted suicide from a patient with Alzheimer's disease
was lawful, a report has said.
The case was reported to the Netherlands' assessment committee
system, which consists of five regional committees and checks whether
doctors have followed the requirements of the law. If members of the
relevant committee judge that the legal requirements have been met,
they do not forward the case to the public prosecution service.
Committee members have defended their decision, maintaining that
approval for the case did not show that the country was on a
"slippery slope" towards a general acceptance of
euthanasia for cases of Alzheimer's disease.
The case emerged in the 2004 annual report of the five committees
of doctors, lawyers, and ethicists to whom doctors must report
euthanasia. The committees judged that four out of 1886 cases
euthanasia and assisted suicide in 2004 failed the legal
requirements, and, as the law requires, forwarded these to the
public prosecution service.
But, in contrast, the case of a patient with Alzheimer's disease
was considered to have met requirements as a "well-considered and
voluntary request" to die. The patient was also considered to be
"suffering hopelessly and unbearably," which is another of the
criteria that makes
The committees' report states that, in general, patients with
Alzheimer's disease could not always comply with the requirements but
that "in specific circumstances" they could. The 65 year old patient
had had Alzheimer's disease for three years. Since his diagnosis he
had said that he did not wish to endure the full course of his
illness and had in the previous year repeatedly asked for help to
The doctor judged him to be suffering unbearably. He was conscious
that he could no longer function independently and faced the future
prospect of increasing dementia.
A second opinion from a doctor trained through the national
support and consultation with
euthanasia programme, however, did not recognise such
suffering. This doctor argued that the patient's awareness of his
suffering would decline as the disease progressed and doubted that
the patient was competent to express his wishes.
Further consultations with a psychologist, a nursing home doctor,
and a gerontopsychiatrist, however, all concluded that the patient
was suffering unbearably because he was conscious that the disease
was removing control over his life. They believed too that he
BMJ 2005;330:1388 (11 June), doi:10.1136/bmj.330.7504.1388
"Right to die"
EDITOR—Grayling claims that the "right to life" means
quite a rich life; withholding treatment with death as the result
and giving treatment that causes death are indistinguishable;
and death is the ultimate analgesic.1
Grayling also implies that the double effect is widely abused.
The EC Convention for the Protection of Human Rights and Fundamental
Freedoms protects against intentional deprivation of life.2
Quality of life is not mentioned, and terminating a life at a
person's request is clearly not permitted. "Right to life" is perhaps
a "right not to be killed," in medicine, generally relating to
survival and not assisted death. However, some interpret it as giving
patients a right to cardiopulmonary resuscitation regardless of the
extrapolation to all potential interventions at the life-death
interface could have disastrous consequences for the medical
Patients obviously can wish for their life to be terminated
without needing to explain why, and they arguably have a right to
attempt suicide. However, a right to assisted dying equates to a
right that somebody else will kill or help to kill them on
request—very different from withholding treatment or the double
Withholding treatment relates to interventions unable to produce
the desired benefit.4
In palliative care withholding treatment does not directly cause
death that arises from an irreversible and unsustainable pathological
burden. And death without adequate analgesia is possibly the ultimate
pain for everyone. Judicious use of analgesia is an essential part of
good terminal care, and, in 15 years as a doctor, I have yet to see a
death attributable to deliberate analgesic overdose by a doctor.
Palliative care affirms life until the moment of death, regarding
death from advanced incurable disease as a natural process.5
It aims to relieve pain and other distressing symptoms, enhance
remaining quality of life, and neither hasten nor postpone death.
These human "death rights" should perhaps be protected by legislation.
Ill-conceived legislative changes that take the right to life
or the right to death beyond sensible limits or give certain doctors
the right to kill on request could jeopardise palliative care.
John C Chambers, medical director
Katharine House Hospice, Adderbury, Oxfordshire OX17 3NL
Competing interests: None declared.
- Grayling AG. "Right to die." BMJ 2005;330: 799. (9
- Council of Europe Convention for the Protection of Human
Rights and Fundamental Freedoms as amended by Protocol No 11.
http://www.echr.coe.int/Convention/webConvenENG.pdf (accessed 8 Apr
- Higginson IJ. Doctors should not discuss resuscitation with
terminally ill patients: against. BMJ 2003;327: 615-6.
- British Medical Association. Withholding and withdrawing
life-prolonging treatment: guidance for decision making. London: BMJ
- World Health Organization. Definition of palliative care.
http://www.who.int/cancer/palliative/en/ (accessed 8 Apr 2005).
BMJ 2005;331:684-685 (24 September),
Education and debate
Legalised euthanasia will violate the rights of vulnerable patients
R J D George, senior lecturer1,
I G Finlay, baroness2, David Jeffrey,
chair of ethics committee3
1 Centre for Bioethics and Philosophy of Medicine, University
College London UB1 3HW, 2 House of Lords, London SW1A 0PW, 3
Association for Palliative Medicine of Great Britain and Ireland, Southampton
Doctors in the United Kingdom can accompany their
patients every step of the way, up until the last. The law stops them
helping their patients take the final step, even if that is the
patient's fervent wish. Next month's debate in the House of Lords
could begin the process of changing the law. To help doctors decide
where they stand we publish a range of opinions
The chameleon of euthanasia continues to change, and the current
shade is physician assisted suicide. The politically correct position
for clinicians is "studied neutrality" since doctors will not really
be involved in assisted suicide. Thus the issue has slipped past the
and the recent House of Lords' report on assisted dying suggests that
euthanasia and assisted suicide are different.2
This cannot be. What doctor prescribing for assisted suicide would
refuse to complete it with euthanasia? In the Netherlands just under
one in five physician assisted suicides ends in lethal injection.3
Were physician assisted suicide legalised, doctors would have the new
duty of therapeutic killing,4
even if they planned only to prescribe lethal medication. Both are
killings justified as treatment, hence we use the term therapeutic
killing simply because it describes precisely what is done. Medicine
cannot escape; quite aside from patient safety, legalising physician
assisted suicide will have a profound and ubiquitous effect on
clinical codes, duties, and practice.w1-w15
Change is unjustified
Autonomy and suffering are the usual justifications for change. The
autonomy argument is thin. In all legislatures, the final decision
for physician assisted suicide or therapeutic killing rests with the
doctor. Patients' perception of total control over this type of death
is illusory. Evidence from Oregon shows that patients have to shop
around for compliant doctors, and in the Netherlands about a fifth of
requests are denied because patients are not suffering enough.5-7
Protecting the vulnerable
The cardinal argument against legalised euthanasia, however, is the
insoluble ethical conflict between meeting individuals' demands for
therapeutic death and ensuring that incapable, vulnerable, or
voiceless patients will not have lethal treatment prescribed as their
best interest. Coercion is a real, immeasurable risk. As with
cardiopulmonary resuscitation, clinicians will have to discuss the
potential for assisted suicide with all dying patients. Arguably this
promotes freedom, trust, and openness, yet, as disabled people find
with discussions about resuscitation, it could also infer a duty to
9 Requests for physician assisted suicide because of "being
a burden" have risen in Oregon from 1:5 to 1:3 since its Death with
Dignity Act was implemented.10
Treatments are medical goods. Since justice dictates that rights
to appropriate treatment are universal, if assisted suicide is legal
it becomes an optional treatment, not just for patients who want it
but also for those who need it. A moral obligation exists for death
to be a legitimate interest for all our patients. Therefore, assisted
suicide or therapeutic killing becomes our proper duty towards anyone
claiming or appearing to suffer unbearably, regardless of prognosis
or capacity to consent. The inevitable accommodation of this shift in
the status of assisted suicide and therapeutic killing is seen
clearly in the Netherlands. Therapeutic killing is now extended to
12 people with psychiatric illness,13
14 and those who are mentally incapable.15
Therapeutic killing without consent has become laudable and
17 The Netherlands now plans a committee to decide on such
Even UK protagonists recognise that safeguards are limited and expect
legislation to be incremental.2
Yet therapeutic killing without explicit request, or of those
lacking capacity, is the ultimate violation of autonomy. Although the
principle of autonomy is extended for requesting individuals, this is
at the expense of others' freedoms.
Such collateral damage from the entitlement to therapeutic killing
is inescapable. Dutch legislation has failed to improve reporting
beyond 54% of all cases or to limit therapeutic killing without
19 which consistently accounts for about 1 in 7 of reported
Experience is similar in Belgium.20
Oregon does not police its deaths. The size of this problem is
unknowable, and the argument that this promotes autonomy in the sick
population as a whole is misleading and unsustainable. Extrapolating
the current Dutch figures to the United Kingdom suggests that at
steady state, 13 000 deaths may result each year, with around
2000 occurring without request or consent.2
In short, any safeguards have no ethical basis once any form of
assisted suicide or therapeutic killing is sanctioned. The real
question, therefore, is whether we are happy with the moral cost to
society and loss of life among vulnerable patients as a result of
reclassifying the freedom to die to the right to be killed.
Naturally, once promoted to a medical good, therapeutic killing
becomes a legitimate consideration in resource management. In the
first Dutch report in 1990, only one case was cited of a dying
patient who was killed to free the bed,21
whereas in the latest survey, 15% of doctors were concerned about
The nursing literature records similar experience.22
Achieving a good death
Finally, suffering is extremely complex, part of our humanity, and
not exclusive to people who are dying. Paradoxically, as disease
overwhelms the dying person, the challenge is not how to be killed,
but how either to hang on, or to let go, of life. Suffering can be
mitigated but it requires the highly specialised skills and
perseverance of a multidisciplinary team and goes well beyond
controlling symptoms with drugs.23
Although the presence of specialist palliative care is no argument
against therapeutic killing, its absence certainly is, and lack of
even basic, consistent provision across the UK is clear.24
An average general practitioner cares for fewer than five dying
patients a year; educational programmes consistently find general
practitioners and hospital consultants are poor at controlling
symptoms and relieving suffering, and many still believe that opioids
and sedatives hasten death.25
26 It is unsurprising, then, that many clinicians have seen
suffering patients who they have been unable to help. Many doctors
assume that they already kill frequently with analgesia or sedation
when they do nothing of the sort.
On a balance of harms, legalising physician assisted suicide or
therapeutic killing is a far greater risk than compassion for the
small minority pleading to be killed might imply. In detailed
evidence to the Select Committee the implications for individual
doctors in the UK was glossed.2
Every doctor caring for patients will be asked at some stage to
assist suicide or kill therapeutically. Before another bill is laid
before parliament every doctor must think through all the moral and
practical implications for their own practice, for all the others in
their clinical team, and, of course, for other patients in their
care. Promoting autonomy for all is to help people understand that
they can let go and to learn the skills to assist them to do
Any legislation will leave vulnerable groups
open to therapeutic killing without consent
Since this is the ultimate violation of autonomy
assisted suicide cannot be separated from euthanasia
Arguments that legalised euthanasia promotes
autonomy do not stand
Doctors need to consider carefully the full
implications of legalisation
w1-w15 are on bmj.com
Competing interests: RJDG and DJ gave oral evidence
to the Select Committee on the Assisted Dying for the Terminally Ill
Bill on behalf of the Association for Palliative Medicine. IGF was
a member of that committee.
Contributors and sources: The authors are among the
national leaders in specialist palliative care, practising
clinicians, and have researched, taught, and published widely in the
discipline. IGF is also professor of palliative medicine, School of
Medicine, Cardiff University. This article arose from discussions to
distil the issues that emerged from a systematic literature review
by RJDG of euthanasia and assisted suicide. RJDG is the guarantor.
(Accepted 18 July 2005)
- British Medical Association. Assisted dying.
&Highlight=2,Annual,Representatives,Meeting,2005 (accessed 31 Aug 2005).
- House of Lords Select Committee on the Assisted Dying for the
Terminally Ill Bill. Report [HL Paper 86-I]. London: Stationery
- Groenewoud JH, van der Heide A, Onwuteaka-Philipsen BD,
Willems DL, van der Maas PJ, van der Wal G. Clinical problems with the
performance of euthanasia and physician-assisted suicide in the Netherlands.
N Engl J Med 2000;342: 551-6.[Abstract/Free Full Text]
- British Medical Association, General Medical Council. Oral
evidence to the select committee on the assisted dying for the terminally
ill bill [HL] Vol II Evidence. London: Stationery Office, 2005: 125-6.
- Ganzini L, Nelson HD, Lee MA, Kraemer DF, Schmidt TA, Delorit
MA. Oregon physicians' attitudes about and experiences with end-of-life care
since passage of the Oregon death with dignity act. JAMA 2001;285:
2363-9.[Abstract/Free Full Text]
- Ganzini L, Nelson HD, Schmidt TA, Kraemer DF, Delorit MA, Lee
MA. Physicians' experiences with the Oregon death with dignity act. N
Engl J Med 2000;342: 557-63.[Abstract/Free Full Text]
- Haverkate I, Onwuteaka-Philipsen BD, van der Heide A, Kostense
PJ, van der Wal G, van der Maas PJ. Refused and granted requests for
euthanasia and assisted suicide in the Netherlands: interview study with
structured questionnaire. BMJ 2000;321: 865-6.[Free Full Text]
- Campbell J. A right to die? I'm more concerned that everyone
has the right to live. Times 2004 Dec 2.
- Templeton S-K. Better for old to kill themselves than be a
burden, says Warnock. Times 2004 Dec 12.
- Oregon Department of Human Services. Fifth annual report
on Oregon's death with dignity act.
- Leenen JI, Ciesielski-Carlucci C. Force majeure (legal
necessity). Justification for active termination of life in the case of
severely handicapped newborns after forgoing treatment. Camb Q Healthc
Ethics 1993;2: 271-4.[Medline]
- Van Thiel GJ, van Delden JJ, de Haan K, Huibers AK.
Retrospective study of doctors' "end of life decisions" in caring for
mentally handicapped people in institutions in the Netherlands. BMJ
1997;315: 88-91.[Abstract/Free Full Text]
- Jochemsen H. Dutch court decisions on nonvoluntary euthanasia
critically reviewed. Issues Law Med 1998;13: 447-58.[ISI][Medline]
- Sheldon T. Dutch GP cleared after helping to end man's
"hopeless existence". BMJ 2000;321: 1174.[Free Full Text]
- Sheldon T. Euthanasia endorsed in Dutch patient with
dementia. BMJ 1999;319: 75.[Free Full Text]
- Onwuteaka-Philipsen BD, van der Heide A, Koper D,
Keij-Deerenberg I, Rietjens JA, Rurup ML, et al. Euthanasia and other
end-of-life decisions in the Netherlands in 1990, 1995, and 2001. Lancet
- Sheldon T. Dutch GP found guilty of murder faces no penalty.
BMJ 2001;322: 509.[Free Full Text]
- Sterling T. Netherlands hospital euthanizes babies.
http://aplancasteronline.com/4/netherlands_child_euthanasia (accessed 15
- Jochemsen H,
Keown J. Voluntary euthanasia under control? Further
empirical evidence from the Netherlands. J Med Ethics 1999;25: 16-21.[Abstract]
- Deliens L, Mortier F, Bilsen J, Cosyns M, Vander SR,
Vanoverloop J, et al. End-of-life decisions in medical practice in Flanders,
Belgium: a nation-wide survey. Lancet 2000;356: 1806-11.[CrossRef][ISI][Medline]
- Dutch Department of Health. The Remelink report. The
Hague: DoH, 1990.
- Hendin H. The Dutch experience. Issues Law Med
- George RJD, Martin J. Non-physical pain: suffering in action.
In: Hoy A, Finlay I, Miles A, eds. The effective prevention and control
of symptoms in cancer. London: Aesculapius Medical Press, 2004: 107-26.
- House of Commons Health Select Committee. Palliative care
fourth report session 2003-4. HC 454-I. London: Stationery Office, 2004.
- Sykes N, Thorns A. Sedative use in the last week of life and
the implications for end-of-life decision making. Arch Intern Med
2003;163: 341-4.[Abstract/Free Full Text]
- Thorns A, Sykes N. Opioid use in last week of life and
implications for end-of-life decision making. Lancet 2000;356: 398-9.[CrossRef][ISI][Medline]
This page was added March 15, 2007, since that day you are visitor
to this page