Margaret Pabst Battin has established a reputation as one of the top philosophers working in bioethics today. This work is a sequel to Battin's 1994 volume The Least Worst Death. The last ten years have seen fast-moving developments in end-of-life issues, from the legalization of physician-assisted suicide in Oregon and the Netherlands to furor over proposed restrictions of scheduled drugs used for causing death, and the development of "NuTech" methods of assistance in dying. Battin's new collection covers a remarkably wide (...) range of end-of-life topics, including suicide prevention, AIDS, suicide bombing, serpent-handling and other religious practices that pose a risk of death, genetic prognostication, suicide in old age, global justice and the "duty to die," and suicide, physician-assisted suicide, and euthanasia, in both American and international contexts. As with the earlier volume, these new essays are theoretically adroit but draw richly from historical sources, fictional techniques, and ample factual material. (shrink)

Machine generated contents note: Table of Cases xi -- Table of legislation xv -- Introduction: Medicine Men, Outlaws and Voluntary Euthanasia 1 -- 1. To Kill or not to Kill; is that the Euthanasia Question? 9 -- Introduction-Why Euthanasia? 9 -- Dead or alive? 16 -- Euthanasia as Homicide 25 -- Euthanasia as Death with Dignity 29 -- 2. Euthanasia and Clinically assisted Death: from Caring to Killing? 35 -- Introduction 35 -- The Indefinite Continuation of Palliative Treatment 38 -- (...) Withholding or Withdrawing Treatment 44 -- The Principle of Double Effect 54 -- Physician Assisted Suicide 60 -- Mercy Killing 64 -- Conclusions 66 -- 3. Consent to Treatment but Not to Death 69 -- Introduction-Why Consent? 69 -- Without Consent 70 -- Killing and Consent 73 -- Valid Consent, Freely Given? 74 -- Old Enough to Consent 80 -- Deciding for Others 82 -- Conclusions-A Consent Too Far? 93 -- 4. Autonomy, Self-determination and Self-destruction 95 -- Introduction-Autonomous Choices 95 -- Choosing to Die-Suicide and Autonomy 100 -- Suicidal Intentions 107 -- Autonomous Clinical Discretion 110 -- Deciding to Live or Die-Whose Decision? 112 -- 5. Living Wills and the Will to Die 115 -- Introduction 115 -- I Know My Will 118 -- This is My Will 121 -- I Will Decide 128 -- Will My Will be Done? 134 -- Where There's a Will 137 -- Conclusions 143 -- 6. Is Euthanasia a Dignified Death? 145 -- Introduction-Why Dignity? 145 -- Needing Dignity 146 -- Finding Dignity 149 -- Achieving Dignity in Dying 151 -- Dignifying Death 157 -- 7. Conclusions: Dignified Life, Dignified Death and Dignified Law 165 -- Select Bibliography 175 -- Index 183. (shrink)

The use of terminal sedation to control theintense discomfort of dying patients appearsboth to be an established practice inpalliative care and to run counter to the moraland legal norm that forbids health careprofessionals from intentionally killingpatients. This raises the worry that therequirements of established palliative care areincompatible with moral and legal opposition toeuthanasia. This paper explains how thedoctrine of double effect can be relied on todistinguish terminal sedation from euthanasia. The doctrine of double effect is rooted inCatholic moral casuistry, but (...) its applicationin law and morality need not depend on theparticular framework in which it was developed. The paper further explains how the moral weightof the distinction between intended harms andmerely foreseen harms in the doctrine of doubleeffect can be justified by appeal to alimitation on the human capacity to pursue good. (shrink)

Motivated by Lord Joffe’s Assisted Dying for the Terminally Ill Bill, but with one eye on any possible future legislation, I consider the justifications that might be offered for limiting assistance in dying to those who are suffering unbearably from terminal illness. I argue that the terminal illness criterion and the unbearable suffering criterion are not morally defensible separately: that a person need be neither terminally ill (or ill at all), nor suffering unbearably (or suffering at all) to have a (...) right to assisted dying. Indeed: I shall suggest that the unbearable suffering criterion undermines the Bill (or any proposal like it) wholesale. On the other hand, the criteria taken together are defensible, and this defence would be built on a concern for the protection of the vulnerable. However, I also claim that this implies that the law might justifiably—and maybe even properly—aim to prevent a person from gaining access to that to which they have a serious moral right. This seems paradoxical, and, towards the end of the paper, I seek to tease apart the paradox. (shrink)

This is an extensive critical review of Euthanasia in International and Comparative Perspective. My Review is divided into five parts. First, I outline the book's strengths. I proceed by speaking of the need for clear and cohesive terminology. I then discuss end-of-life decision-making in some of the countries: Belgium, The Netherlands, and the State of Oregon in the United States, all allow PAS. Belgium and The Netherlands also allow euthanasia. I also discuss Israel's Dying Patient Law,13 enacted by the Knesset (...) on December 5, 2005. Finally, I make some suggestions for improvement, including a detailed proposal for PAS which I conceive to be the best policy when balancing one against the other the autonomy of the patient, on the one hand, and the safeguards against abuse when life might be considered too lightly, on the other. Indeed, the main difference between euthanasia and PAS is that in euthanasia, it is the physician who makes the final act of taking patient's life, whereas in PAS it is the patient who takes his or her life. In euthanasia, the physician has control over the process. In PAS, the physician controls the procedure up until the last act. The patient has control over the very act of suicide. (shrink)

In contemplating any life and death moral dilemma, one is often struck by the possible importance of two distinctions; the distinction between killing and “letting die”, and the distinction between an intentional killing and an action aimed at some other outcome that causes death as a foreseen but unintended “side-effect”. Many feel intuitively that these distinctions are morally significant, but attempts to explain why this might be so have been unconvincing. In this paper, I explore the problem from an explicitly (...) consequentialist point of view. I first review and endorse the arguments that the distinctions cannot be drawn with perfect clarity, and that they do not have the kind of fundamental significance required to defend an absolute prohibition on killing. I go on to argue that the distinctions are nonetheless important. A complete consequentialist account of morality must include a consideration of our need and ability to construct and follow rules; our instincts about these rules; and the consequences (to the agent and to others) that might follow if the agent breaks a good general rule, particularly if this involves acting contrary to moral instinct. With this perspective, I suggest that the distinctions between killing and letting die and between intending and foreseeing do have moral relevance, especially for those involved in the care of the sick and dying. (shrink)

There has been much debate regarding the 'double-effect' of sedatives and analgesics administered at the end-of-life, and the possibility that health professionals using these drugs are performing 'slow euthanasia.' On the one hand analgesics and sedatives can do much to relieve suffering in the terminally ill. On the other hand, they can hasten death. According to a standard view, the administration of analgesics and sedatives amounts to euthanasia when the drugs are given with an intention to hasten death. In this (...) paper we report a small qualitative study based on interviews with 8 Australian general physicians regarding their understanding of intention in the context of questions about voluntary euthanasia, assisted suicide and particularly the use of analgesic and sedative infusions (including the possibility of voluntary or non-voluntary 'slow euthanasia'). We found a striking ambiguity and uncertainty regarding intentions amongst doctors interviewed. Some were explicit in describing a 'grey' area between palliation and euthanasia, or a continuum between the two. Not one of the respondents was consistent in distinguishing between a foreseen death and an intended death. A major theme was that 'slow euthanasia' may be more psychologically acceptable to doctors than active voluntary euthanasia by bolus injection, partly because the former would usually only result in a small loss of 'time' for patients already very close to death, but also because of the desirable ambiguities surrounding causation and intention when an infusion of analgesics and sedatives is used. The empirical and philosophical implications of these findings are discussed. (shrink)

The 1998 elections were held just about two weeks ago.1 All across the country, Americans went to the polls to vote for Senators, Representatives to the House, Governors, and local officials. In many states they were also given the opportunity to vote on a wide variety of ballot questions, and among these ballot questions several concerned physician assisted suicide.

Anyone interested in the morality of suicide reads David Hume's essay on the subject even today. There are numerous reasons for this, but the central one is that it sets up the starting point for contemporary debate about the morality of suicide, namely, the debate about whether some condition of life could present one with a morally acceptable reason for autonomously deciding to end one's life. We shall only be able to have this debate if we think that at least (...) some acts of suicide can be moral, and we shall only be able to think this if we give up the blanket condemnation of suicide that theology has put in place. I look at this strategy of argument in the context of the wider eighteenth-century attempt to develop a non-theologically based ethic. The result in Hume's case is a very modern tract on suicide, with voluntariness and autonomy to the fore and with reflection on the condition of one's life and one's desire to carry on living a life in that condition the motivating circumstance. (shrink)

Since 1998, physician-assisted suicide has been legal in the American state of Oregon. In this paper, I defend Oregon’s physician-assisted suicide (PAS) law against two of the most common objections raised against it. First, I try to show that it is not intrinsically wrong for someone with a terminal disease to kill herself. Second, I try to show that it is not intrinsically wrong for physicians to assist someone with a terminal disease who has reasonable grounds for wanting to kill (...) herself. (shrink)

abstract Many have held that there is some kind of incompatibility between a commitment to good end-of-life care and the legalization of physician-assisted suicide. This opposition to physician-assisted suicide encompasses a cluster of different claims. In this essay I try to clarify some of the most important of these claims and show that they do not stand up well to conceptual and empirical scrutiny.

Dutch euthanasia and physician-assisted suicide stand on the eve of important legal changes. In the summer of 1999, a new government bill concerning euthanasia and physician-assisted suicide was sent to Parliament for discussion. This bill legally embodies a ground for exemption from punishment for physicians who conduct euthanasia or physician-assisted suicide and comply with certain requirements. On November 28, 2000, the Dutch parliament approved an adapted version of this bill. Since the approval by the Dutch Senate can be regarded as (...) a formality, it is expected that the bill will come into force in the course of this year (2001). In this paper we discuss these new developments. (shrink)

This article reviews the Dutch societal debate on euthanasia/assisted suicide in dementia cases, specifically Alzheimer's disease. It discusses the ethical and practical dilemmas created by euthanasia requests in advance directives and the related inconsistencies in the Dutch legal regulations regarding euthanasia/assisted suicide. After an initial focus on euthanasia in advanced dementia, the actual debate concentrates on making euthanasia/assisted suicide possible in the very early stages of dementia. A review of the few known cases of assisted suicide of people with so-called (...) early dementia raises the question why requests for euthanasia/assisted suicide from patients in the early stage of (late onset) Alzheimer's disease are virtually non-existent. In response to this question two explanations are offered. It is concluded that, in addition to a moral discussion on the limits of anticipatory choices, there is an urgent need to develop research into the patient's perspective with regard to medical treatment and care-giving in dementia, including end-of-life care. (shrink)

In the first part of this article, I raisequestions about Dworkin''s theory of theintrinsic value of life and about the adequacyof his proposal to understand abortion in termsof different ways of valuing life. In thesecond part of the article, I consider hisargument in ``The Philosophers'' Brief on AssistedSuicide'''', which claims that the distinctionbetween killing and letting die is morallyirrelevant, the distinction between intendingand foreseeing death can be morally relevantbut is not always so. I argue that thekilling/letting die distinction can be (...) relevantin the context of assisted suicide, but alsoshow when it is not. Then I consider why theintention/foresight distinction can be morallyirrelevant and conclude by presenting analternative argument for physician-assistedsuicide. (shrink)

In this article, I shall present three arguments for thc pcrmissibility 0f physician-assisted suicide (PAS), and then examine several objections 0f 21 "K21nti2m" and non-Kantian nature against them. These are really 0bjcctions against certain types of suicide. I shall focus 0n active PAS (eg., when 21 patient takes 21 lethal drug given by E1 physician, in which case both thc physician and patient are active). I shall assume the patient is 21 competent, responsible, rational agent, who gives his being in (...) physical discomfort (pain, nausea, ctc.) as thc reason for intending his death. I am assuming, therefore, thc pain while 21 sourcc of suffering docs not undermine his rational agency in 21 way that threatens responsibility for choice.] Current legal proposals for permitting PAS focus 0n procedures.. (shrink)

The ethical problems surrounding voluntary assisted suicide remain formidable, and are unlikely to be resolved in pluralist societies. An examination of historical attitudes to suicide suggests that modernity has inherited a formidable complex of religious and moral attitudes to suicide, whether assisted or not. Advocates usually invoke the ending of intolerable suffering as one justification for euthanasia of this kind. This does not provide an adequate justification by itself, because there are (at least theoretically) methods which would relieve suffering without (...) causing the physical death of the suffering person. Carried to extremes, these methods would finish the life worth living, but leave a being which was technically alive. Such acts, however, would provide no moral escape, since they would create beings without meaning. Arguments seeking to justify ending the lives of others need some grounding in concepts of the meaning of a life. The euthanasia discourse therefore needs to take at least some account of the meaning we construct for our lives and the lives of others. (shrink)

The Elimination of Morality poses a fundamental challenge to the dominant conception of medical ethics. In this controversial and timely study, Anne Maclean addresses the question of what kind of contribution philosophers can make to the discussion of medico-moral issues and the work of health care professionals. She establishes the futility of bioethics by challenging the conception of reason in ethics which is integral to the utilitarian tradition. She argues that a philosophical training confers no special authority to make pronouncements (...) about moral issues, and proposes that pure utilitarianism eliminates the essential ingredients of moral thinking. Maclean also exposes the inadequacy of a utilitarian account of moral reasoning and moral life, dismissing the claim that reason demands the rejection of special obligations. She argues that the utilitarian drive to reduce rational moral judgment to a single form is ultimately destructive of moral judgment as such. This vital discussion of the nature of medical ethics and moral philosophy will be important reading for anyone interested in the fields of health care ethics and philosophy. (shrink)

Medical decisions concerning noncompetent patients that are most morally problematical are those that involve life and death choices. In making these choices for others, I urge that decision-makers carefully attend to the degree and history of a person's noncompetence, and distinguish four relevant categories of competence: partial, potential, lost and never possessed. Attending to these will help enable us to sort out when and how autonomous choice is possible and desirable and when and how to rely upon a judgment of (...) a patient's best interests instead. This conflict is explored with particular reference to the Quinlan, Fox and Saikewicz cases. I argue that respect for autonomy, wherever possible, has presumptive priority, and that it is more often possible than frequently supposed. On the other hand, the notion of autonomous choice itself is perverted when forced upon inappropriate cases, such as those presented by the never competent. Here it is not merely legitimate, but inescapable to use a best interest criterion that ignores autonomy in making treatment decisions. Specific cases in which these normally distinct guidelines for decision-making concur, conflict and need resolution are discussed. In the end it is often more important to determine who will choose than by what substantive criteria he or she will be guided. In considering this issue, I try to show that the substantive criteria have implications for who the proper decision-makers are in many problematical cases. (shrink)

Margaret Otlowski investigates the complex and controversial issue of active voluntary euthanasia. She critically examines the criminal law prohibition of medically administered active voluntary euthanasia in common law jurisdictions, and carefully looks at the situation as handled in practice. The evidence of patient demands for active euthanasia and the willingness of some doctors to respond to patients' requests is explored, and an argument for reform of the law is made with reference to the position in the Netherlands (where active voluntary (...) euthanasia is now openly practiced). (shrink)

Objectives: The aims of this study were to: (1) investigate patients’ views on euthanasia and physician-assisted suicide (PAS), and (2) examine the impact of question wording and patients’ own definitions on their responses. Design: Cross-sectional survey of consecutive patients with cancer. Setting: Newcastle (Australia) Mater Hospital Outpatients Clinic. Participants: Patients over 18 years of age, attending the clinic for follow-up consultation or treatment by a medical oncologist, radiation oncologist or haematologist. Main Outcome Measures: Face-to-face patient interviews were conducted examining attitudes (...) to euthanasia and PAS. Results: 236 patients with cancer (24% participation rate; 87% consent rate) were interviewed. Though the majority of participants supported the idea of euthanasia, patient views varied significantly according to question wording and their own understanding of the definition of euthanasia. Conclusions: Researchers need to be circumspect about framing and interpreting questions about support of ‘euthanasia’, as the term can mean different things to different people, and response may depend upon the specifics of the question asked. (shrink)

The article examines from an historical perspective some of the key ideas used in contemporary bioethics debates both for and against the practices of assisted suicide and euthanasia. Key thinkers examined--spanning the Ancient, Medieval and Modern periods--include Plato, Aristotle, Augustine, Aquinas, Hume, Kant, and Mill. The article concludes with a synthesizing summary of key ideas that oppose or defend assisted suicide and euthanasia.

As medical technology advances and severely injured or ill people can be kept alive and functioning long beyond what was previously medically possible, the debate surrounding the ethics of end-of-life care and quality-of-life issues has grown more urgent. In this lucid and vigorous book, Craig Paterson discusses assisted suicide and euthanasia from a fully fledged but non-dogmatic secular natural law perspective. He rehabilitates and revitalises the natural law approach to moral reasoning by developing a pluralistic account of just why we (...) are required by practical rationality to respect and not violate key demands generated by the primary goods of persons, especially human life. Important issues that shape the moral quality of an action are explained and analysed: intention/foresight; action/omission; action/consequences; killing/letting die; innocence/non-innocence; person/non-person. Paterson defends the central normative proposition that ‘it is always a serious moral wrong to intentionally kill an innocent human person, whether self or another, notwithstanding any further appeal to consequences or motive’. (shrink)

The work of Dan Brock and Helga Kuhse is typical of the current stream of thought rejecting the validity of sanctity of life appeals to instill objective inviolable worth in human life regardless of the quality of life of the patient. The context of a person's life is supremely important. In their systems life can have high value, yet the value of life can be outweighed by the force of other disvalues. The notion of quality of life has increasingly come (...) to signify the measurement of the worth of a person's life itself. Having a life equals personal life. Any objectivity to life resides in 'personal', 'biographical', or 'creative' life, not mere biological life. Personal life represents the minimal threshold for any objective worth. In responding to this challenge, John Finnis has argued extensively that life is an intrinsic good – a basic human good. Following from our grasp of human life as a basic incommensurable good, it cannot be practically reasonable both to affirm that (a) 'human life is a basic human good', and (b) that 'human life qua human life can be intentionally acted against to its destruction'. Yet, if the good of human life can be considered self-evident, the self-evidence of the basic human good qua good does not mean that dialectical reasoning cannot be engaged in to indirectly support the practical reasonableness of respecting the good of human life in the deliberative choices that persons make concerning their actions. It is to the use of such dialectical reasoning, supportive of the status of human life as such a basic human good, that the article is primarily concerned to draw out and articulate. (shrink)

All too often in applied ethics debates, there is a danger that a lack of analytical clarity and precision in the use of key terms serves to cloud and confuse the real nature of the debate being undertaken. A particular area of concern in my analysis of the bioethics literature has been the uses to which the key terms "suicide," "assisted suicide," and "euthanasia" are put. The modest aim of this article is to render a contribution to the applied ethics (...) debate on these topics by seeking to delimit the scope and meaning of these terms. The criteria of specificity, non-arbitrariness, consistency (between various terms), and the avoidance of strong pejorative presuppositions, supply the main standards guiding my adoption of usages. (shrink)

A review of the literature was conducted to better understand the (potential) role of mental health professionals in physician-assisted suicide. Numerous studies indicate that depression is one of the most commonly encountered psychiatric illnesses in primary care settings. Yet, depression consistently goes undetected and undiagnosed by nonpsychiatrically trained primary care physicians. Noting the well-studied link between depression and suicide, it is necessary to question giving sole responsibility of assisting patients in making end-of-life treatment decisions to these physicians. Unfortunately, the use (...) of mental health consultation by these physicians is not a common occurrence. Greater involvement of mental health professionals in this emerging and debated area is advocated. Beyond describing mental health professionals' role in the assessment of patient competency or decision making capacity, other areas of potential involvement are described. A discussion of ethical principles relevant to this area follows, along with comments on the training necessary to adequately serve patient needs. (shrink)

This essay first discusses the three major arguments in favor of euthanasia and physician-assisted-suicide in contemporary Western society, viz ., the arguments of mercy, preventing indignity, and individual autonomy. It then articulates both Confucian consonance and dissonance to them. The first two arguments make use of Confucian discussions on suicide whereas the last argument appeals to Confucian social-political thought. It concludes that from the Confucian moral perspectives, none of the three arguments is fully convincing.