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istence is dreaded rather than desired however, the desire to die
may take the place of the normal desire to live, reversing the
reasons against killing based on the desire to live. Thus the case
for voluntary euthanasia is arguably much stronger than the
case for non-voluntary euthanasia.
Some opponents of the legalisation of voluntary euthanasia
might concede that all this follows, if we have a genuinely free
and rational decision to die: but, they add, we can never be
sure that a request to be killed is the result of a free and rational
decision. Will not the sick and elderly be pressured by their
relatives to end their lives quickly? Will it not be possible to
commit outright murder by pretending that a person has requested
euthanasia? And even if there is no pressure of falsification,
can anyone who is ill, suffering pain, and very probably
in a drugged and confused state of mind, make a rational decision
about whether to live or die?
These questions raise technical difficulties for the legalisation
of voluntary euthanasia, rather than objections to the underlying
ethical principles; but they are serious difficulties nonetheless.
The guidelines developed by the courts in the Netherlands
have sought to meet them by proposing that euthanasia
is acceptable only if
• It is carried out by a physician.
• The patient has explicitly requested euthanasia in a manner
that leaves no doubt of the patient's desire to die.
• The patient's decision is well-informed, free, and durable.
• The patient has an irreversible condition causing protracted
physical or mental suffering that the patients finds unbearable.
• There is no reasonable alternative (reasonable from the patient's
point of view) to alleviate the patient's suffering.
• The doctor has consulted another independent professional
who agrees with his or her judgment.
Euthanasia in these circumstances is strongly supported by the
Royal Dutch Medical Association, and by the general public in
the Netherlands. The guidelines make murder in the guise of
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Taking Life: Humans
euthanasia rather far-fetched, and there is no evidence of an
increase in the murder rate in the Netherlands.
It is often said, in debates about euthanasia, that doctors can
be mistaken. In rare instances patients diagnosed by two competent
doctors as suffering from an incurable condition have
survived and enjoyed years of good health. Possibly the legalisation
of voluntary euthanasia would, over the years, mean
the deaths of a few people who would otherwise have recovered
from their immediate illness and lived for some extra years. This
is not, however, the knockdown argument against euthanasia
that some imagine it to be. Against a very small number of
unnecessary deaths that might occur if euthanasia is legalised
we must place the very large amount of pain and distress that
will be suffered if euthanasia is not legalised, by patients who
really are terminally ill. Longer life is not such a supreme good
that it outweighs all other considerations. (If it were, there
would be many more effective ways of saving life - such as a
ban on smoking, or a reduction of speed limits to 40 kilometres
per hour - than prohibiting voluntary euthanasia.) The possibility
that two doctors may make a mistake means that the
person who opts for euthanasia is deciding on the balance of
probabilities and giving up a very slight chance of survival in
order to avoid suffering that will almost certainly end in death.
This may be a perfectly rational choice. Probability is the guide
of life, and of death, too. Against this, some will reply that
improved care for the terminally ill has eliminated pain and
made voluntary euthanasia unnecessary. Elisabeth Kubler-Ross,
whose On Death and Dying is perhaps the best-known book on
care for the dying, has claimed that none of her patients request
euthanasia. Given personal attention and the right medication,
she says, people come to accept their deaths and die peacefully
without pain.
Kubler-Ross may be right. It may be possible, now, to eliminate
pain. In almost all cases, it may even be possible to do it
in a way that leaves patients in possession of their rational
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Practical Ethics
faculties and free from vomiting, nausea, or other distressing
side-effects. Unfortunately only a minority of dying patients now
receive this kind of care. Nor is physical pain the only problem.
There can also be other distressing conditions, like bones so
fragile they fracture at sudden movements, uncontrollable nausea
and vomiting, slow starvation due to a cancerous growth,
inability to control one's bowels or bladder, difficulty in breathing,
and so on.
Dr Timothy Quill, a doctor from Rochester, New York, has
described how he prescribed barbiturate sleeping pills for 'Diane',
a patient with a severe form of leukaemia, knowing that
she wanted the tablets in order to be able to end her life. Dr
Quill had known Diane for many years, and admired her courage
in dealing with previous serious illnesses. In an article in
the New England Journal of Medicine, Dr Quill wrote:
It was extraordinarily important to Diane to maintain control of
herself and her own dignity during the time remaining to her.
When this was no longer possible, she clearly wanted to die. As
a former director of a hospice program, I know how to use pain
medicines to keep patients comfortable and lessen suffering. I
explained the philosophy of comfort care, which I strongly believe
in. Although Diane understood and appreciated this, she
had known of people lingering in what was called relative comfort,
and she wanted no part of it. When the time came, she
wanted to take her life in the least painful way possible. Knowing
of her desire for independence and her decision to stay in control,