The Logic of Relieving Suffering and Voluntary Euthanasia

Recently a seventeen year old Dutch girl, who had been repeatedly raped as a child and who suffered from post-traumatic stress disorder, anorexia and depression, starved herself to death. This was widely reported as an example of euthanasia, see BioEdge . Simply starving oneself to death isn’t euthanasia. It was unclear in this case whether her doctors helped to control her suffering. In this posting I want to explore whether doctors who relieve the suffering of a patient who starves himself to death should be regarded as assisting in suicide. In order to make my argument I will first explore what can be considered as the legitimate use of medical skills. Let us start with the premise that the decreasing of someone’s suffering is a legitimate use of medical skills. However accepting this premise is too simplistic. Surgery might actually increase someone’s suffering in the short term and surgery is clearly a legitimate use of medical skills. Let us revise the premise so that decreasing someone’s overall suffering is always a legitimate use of medical skills when this is possible.

Let us now agree that decreasing someone’s suffering is usually a legitimate use of medical skills but is it always so? I now want to examine two arguments suggesting it isn’t. Firstly it might be argued that some people deserve to suffer and that it would be wrong to alleviate their suffering due to dessert. Consider a convicted rapist who became infected with HIV when committing his crime. Let us assume that he is now serving his sentence in relative isolation due to the hideous nature of this crime and as a result is unable to infect others. Would treating him for his HIV would be an illegitimate use of medical skills? What reason could be advanced for illegitimacy of treatment in this case? It might possibly be argued that in this case the rapist deserves to be HIV positive and that as a result treating him for this state should be an illegitimate use of medical skills. This extreme example might concur with many people’s intuitions but seems to run counter to the caring ethos of medicine. I would argue linking the legitimacy of the use of medical skills to dessert is problematic in all circumstances. Accepting that it is illegitimate to treat some people whilst it is legitimate to treat others because of dessert appears to imply that it is legitimate to use medical skills to achieve dessert. The domain in which the employment of legitimate medical skills is extended from simply treating suffering to treating suffering and ensuring just dessert. We might link suffering and dessert together but nonetheless they remain independent conditions. Someone can suffer without deserving to do so and someone may deserve to suffer without actually doing so. If we accept that the legitimate use of medical skills is linked to dessert in addition to suffering then provided a death sentence could be considered as just it would be a legitimate use of medical skills to carry out this sentence. An interesting account of the death penalty and the proper ends of medicine is to be found can Silver (1).

Secondly it might be argued that medical professionals have no duty to alleviate suffering when this is caused by self-harm and the sufferer is fully aware his behaviour is the cause of his suffering. In practice accepting this argument might mean that there is less of a duty to treat conditions when these conditions are caused by alcoholism, obesity and anorexia. Clearly alcoholics, the obese and anorexics suffer even if this suffering is caused by their own behaviour. What reason could be advanced as to why treating them would be regarded as an illegitimate use of medicals skills? One reason might be that because their suffering is self-imposed they can simply stop the suffering by changing their behaviour and there is no need to employ medical skills. I’m doubtful whether the eating habits of anorexics or the obese can simply change their behaviour and alcoholism is an addiction.  However let us assume that someone’s suffering is self-imposed and that can change his behaviour and he will cease to suffer. In this context is the use of medical skills to alleviate his is an illegitimate use? It might be suggested he deserves to suffer because his suffering is self-imposed. However if we accept this suggestion it would re-introduce all the problems of dessert outlined above. Both of the above arguments as to why medical professionals don’t always have a duty to alleviate suffering when this is possible appear to be unsound. It follows that we should accept the premise that the decreasing someone’s overall suffering is always a legitimate use of medical skills when this is possible. It is of course possible that there are other legitimate uses of medical skills, see Cosmetic Surgery, Enhancement and the Aims of Medicine . 

I now want to consider the relationship between the relief of suffering and voluntary euthanasia. In particular I want to focus on the relief of suffering of those people who voluntary stop eating and drinking (VSED). Most people who adopt VSED do so because they have a terminal illness but this isn’t true in all cases as the Dutch girl shows. Let us assume that the relief of someone’s suffering caused by VSED is assisting in voluntary euthanasia. I have argued above that decreasing someone’s overall suffering is always a legitimate use of medical skills. It follows relief of someone’s suffering caused by VSED is a legitimate use of medical skills. It further follows that assisting in voluntary euthanasia is a legitimate use of medical skills. Some might be unhappy to accept these conclusions but being unhappy about these conclusions has nothing to do with the logic of the argument or the validity of the conclusions. 

Lastly let us assume that the relief of someone’s suffering caused by VSED isn’t assisting in voluntary euthanasia. If this is the case then there would seem to be no reason to be unhappy about the deployment of medical skills to alleviate someone’s suffering caused by VSED. However I find hard to see how alleviating someone’s suffering, when this suffering is caused by a desire to die, shouldn't be regarded as a case of physician assisted suicide without using the principle of double effect.

1. Silver D, (2003) Lethal Injection, Autonomy and the proper ends of Medicine, Bioethics 17(2), pp. 205-211.

A right to anaesthesia, a right to physician euthanasia?

In an editorial in Anaesthesia Julian Savulescu and Janet Radcliffe‐Richards suggest that many people who are against the deliberate killing of terminally ill patients who wish to die should have no objection to what is known as terminal sedation, bringing about unconsciousness for terminally ill patients until their natural death, see Anaesthesia . I agree with Savulescu and Radcliffe‐Richards that most people would accept that sedation for terminally ill patients is not wrong when death is imminent. In France in 2016 a law came into effect granting terminally ill patients the right to anaesthesia until death. Sinmyee et al go further and argue that a right to anaesthesia should be available to all patients who choose to end their life by starvation or dehydration, see Sinmyee . Would most people accept that sedation for terminally ill patients is not wrong when death is inevitable but not imminent? Perhaps a patient has a prognosis that he has only six months to live. Secondly would most people accept that sedation for terminally ill patients is not wrong when used to relieve suffering which they cause themselves by a refusal to eat or to drink? I’m not sure what most people would find acceptable in either of these scenarios. In this posting I will firstly briefly summarise the argument why it isn’t morally wrong to sedate terminally ill patients even if their current suffering is due caused by a refusal to eat or drink. I will then consider what implications accepting this argument has for accepting physician assisted suicide and voluntary euthanasia.

Let us accept that any competent person has right to refuse to take food and water. It might be objected that in some cases the person in question is unlikely to be competent due to eating disorders such as anorexia. However clearly this objection doesn’t carry much weight when considering terminally ill patients. Let us also accept that relieving pain is a legitimate end of medicine even when this lessens a patient’s life span. Let us still further accept that relieving pain remains a legitimate end of medicine even when this pain is due to self-harm. We treat drug users for their addiction. Lastly let us accept that if pain cannot be controlled by any other means that it can be controlled by deep sedation. It appears to follow that deeply sedating a patient suffering from a terminal illness, even if his immediate suffering is caused by his refusal to eat or drink, is a legitimate end of medicine. It follows that in these circumstances deep sedation would not be morally wrong.

Let us now consider how permanent deep sedation differs from death. For a dead person conscious life is over. Conscious life is also over anyone who will be deeply sedated until he dies. Of course for someone who is deeply sedated some important unconscious physiological processes such as breathing will continue. The same is not true of the dead. But do these unconscious physiological processes matter if someone will never resume consciousness or take part in life again? If they do matter who do they matter to? These unconscious physiological processes certainly don’t matter to the sedated person. If they doesn’t matter to the person involved why should they matter morally to others? It would appear to follow that there is no significant moral difference between being dead and being deeply sedated until death. If this is so is there any moral difference between a doctor deeply sedating someone until he dies and helping him die a good death if he requests help to do so? If dying and being deeply sedated until death are equivalent for moral concerns then we should be prepared to conclude that if we are prepared to accept deep sedation until death that we should be prepared to accept physician assisted suicide PAS.

It might be objected that deep sedation involves no suffering whilst helping a patient to die might do so. However even if we accept this objection the above question might be reframed. Is there any moral difference between a doctor deeply sedating someone until he dies and deeply sedating someone prior to carry out his previously expressed wishes for voluntary euthanasia? If there isn’t any difference then we should be prepared to conclude that if we are prepared to accept deep sedation until death that we should be prepared to accept voluntary euthanasia, which might require prior sedation, when requested by a terminally ill patient.

I now want to examine two major objections to the above conclusion. Firstly it might be objected that the above argument depends on the concept of a person and that when considering deep sedation and voluntary euthanasia we should consider human beings instead. My objector might argue that that matters is not whether a person continues to exist bur whether a human being continues to exist. What does it mean for a human being to continue existing? Is someone who will never regain consciousness but for whom unconscious physiological processes such as breathing continue still a human being? My objector might conclude the answer is obvious and is affirmative. However if we consider the concept of brain death commonly used in transplant medicine the answer is not obvious. Someone is brain dead if he has a permanent absence of cerebral and brainstem functions, however mechanical ventilators and other advanced critical care services can maintain unconscious physiological processes such as breathing for some time. Whether someone who is brain dead remains a human being is far from obvious for we can use his organs for transplant subject to consent. Why does brain death matter? It matters not simply because of a loss of cerebral and brainstem functions but because the implications of these losses. These losses lead to a permanent loss of consciousness. If the above is accepted then substituting human for persons doesn’t affect my original argument.

I now want to consider a second objection to my argument that if we are prepared to accept deep sedation of the terminally ill patients until death that we should also be prepared to voluntary euthanasia for such patients. It might be objected that I have slipped too easily from considering PAS to considering voluntary euthanasia and that the two aren’t equivalent. PAS is self-administered whilst voluntary euthanasia is carried out by a physician. I made this move because it has been suggested that PAS might involve suffering by the terminally ill patient. As a philosopher I am unable to say much about whether PAS might involve suffering. However I can say something about the possible scenarios. Firstly if PAS doesn’t necessarily involve suffering then my original conclusion stands. Next let us assume that PAS involves some limited suffering. In this scenario it might be questioned whether a terminally ill patient needs to be fully anaesthetised for PAS to take place? Perhaps a patient’s pain might be alleviated without affecting his cognitive abilities allowing him to carry out PAS. Once again my original conclusion stands. Lastly let us assume that PAS involves suffering that cannot be fully alleviated without full anaesthesia. In this scenario PAS isn’t possible with full pain relief. In this scenario the question changes and becomes, if we are prepared to accept deep sedation until death then why shouldn’t we be prepared to accept voluntary euthanasia?

In order to answer the above question I want to consider two further scenarios. In both scenarios I will assume the patient is fully competent. In the first I will assume that the patient is capable of initiating the start of his anaesthesia before his physician takes over and delivers a fatal dose. In this scenario why is the patient initiating his own anaesthesia? I would suggest he isn’t only initiating a form of pain relief. He is only initiating pain relief in order to die. In this scenario the patient’s actions resemble those of a patient undergoing PAS.  However the two are not identical. In PAS the physician only supplies the means and need not be present at the time of death whilst in the above scenario the physician must not only be present but also deliver the lethal dose. Let us accept that the physician’s presence or lack of it is not relevant morally. However we must ask ourselves whether the fact that the physician supplies the means of dying differs in a morally significant way from the physician applying the lethal dose. It might be suggested that this a case in which we could use the principle of double effect to explain the difference. I would be reluctant to accept this suggestion. When supplying the means to die the physician involved in PAS has the intention of allowing the patient to kill himself, it isn’t a foreseen consequence of something else. The physician’s intention is the same whether he is involved in PAS or voluntary euthanasia as described in the above scenario. It seems provided the patient involved is able to initiate his own anaesthesia that there is no morally significant difference between voluntary euthanasia in these circumstances and PAS. Let us now consider a second scenario in which the patient is unable to initiate his own anaesthesia. I would suggest that there are no morally significant differences between a physician carrying out voluntary euthanasia on a terminally ill patient in this scenario and a physician suppling him with the means to carry out PAS provided the degree of voluntariness is the same in both cases. However is the degree of voluntariness the same in both cases? In the case of PAS the patient’s intentions seem to be clear because he initiates the dying process. If a patient can initiate his own anaesthesia I have argued he is initiating his death and once again his intentions seem clear cut. However if a patient is unable to initiate his own anaesthesia his intentions aren’t quite so clear cut. Perhaps this situation can be remedied by a rigorous consent process and a clear last directive. None the less differences remain between this scenario and the one in which the patient initiates his own anaesthesia and for this reason I would be reluctant to conclude that the scenario in which the patient is unable to initiate his own anaesthesia is equivalent to PAS. The above suggests some consequences for the process of deep sedation. Let us accept that the deep sedation of terminally ill patients who are unable to initiate their own sedation and voluntary are equivalent. It follows if we aren’t prepared to accept voluntary euthanasia we shouldn’t be prepared to accept deep sedation if the patient is unable to initiate his own anaesthesia.

In this posting I have argued that the deep sedation of terminally ill patients should be morally acceptable. I further argued such sedation was a legitimate use of medical skills. I have also assumed that most people would find such sedation acceptable and less contentious than either PAS or voluntary euthanasia. If most people find PA and voluntary euthanasia unacceptable and deep sedation is a legitimate use of medical skills then such sedation should be an option for the terminally ill. I then examined the moral implications of accepting deep sedation. The main implications of this acceptance are summarised below.

1. If we are prepared to accept deep sedation for terminally ill patients until death then we should be prepared to accept PAS when this process does not involve suffering.
2. If we are prepared to accept deep sedation until death and PAS involves some suffering then we should accept PAS provided that this suffering can be controlled without anaesthesia.
3. If we are prepared to accept deep sedation until death and a patient is able to initiate his own anaesthesia then in these circumstances we should be prepared to accept voluntary euthanasia.
4. If we are not prepared to accept voluntary euthanasia then we should not be prepared to accept deep sedation until death when a patient is unable to initiate his own anaesthesia.

A Duty to permit Assisted Suicide?

In previous postings I have argued that we should accept that terminally ill people have a right to die and that we should respect that right by accepting assisted suicide. My arguments were based on respecting autonomy and of course respecting autonomy involves duties. However in this posting I want to focus more directly on duties. I will argue that we have a duty not to cause terminally ill people who are suffering to continue to existing against their will. We have a duty not to force innocent people endure pain in order to protect the vulnerable, surely the vulnerable can be protected in better ways.My argument will be based on the premise that we have a duty not to bring into existence any being which would find its life not worth living.


Let us accept the above premise without argument. I now want to suggest that the duty not to bring into existence any being we think would not find its life worth living is analogous to a proposed duty not to cause any being to continue to exist against its will if its life is not living. Accepting this analogy would have implications for using animals in medical research but in the following discussion I will limit my argument to assisted suicide. It might be objected that my suggested analogy fails for two reasons. First, it might we objected that by refusing to grant the right to assisted suicide to these people we do not cause them to lead lives which are not worth living. Secondly it might be objected even if some people do experience lives which are not worth living this would be better rectified by changing the conditions of these lives rather than by making assisted suicide available to such people. I will deal with each of these objections in turn.

Let us accept that that we have a duty not to bring into existence any being we think would find its life not worth living. We have a duty not to cause the existence of such lives. My objector might accept this premise. We shouldn’t enslave or torture people for instance. But he might argue that we don’t cause terminally ill patients or prisoners serving life sentences to lead lives not worth living and as a result my analogy fails. The cause of their misfortune is due to disease or past crimes. He might then proceed further by suggesting even if we are a partial cause of the type of lives some people live that a partial cause doesn’t give rise to a duty. Let accept that my objector does accept that he has duty not cause a child to come into existence who wouldn’t have a life worth living. Let us assume this child wouldn’t have a life worth living due to some genetic defect. It follows anyone who permits such a child come into existence is only a partial cause of the child not having a life worth living. It would appear my objector must accept either that our partial causation of some event can incur duties or that there is nothing wrong with causing a child to exist when he will not have a life worth living due to genetic defects. In the light of the above example my initial premise might be amended as follows. We have a duty not to be the partial cause of the existence of any being which wouldn’t have a life worth living. If someone accepts my amended premise, then it might be argued by analogy that we also have a duty not to be the partial cause of someone continuing to live a life he doesn’t find worth living.


At this point my objector might raise a second objection to my analogy. He might point out that in my amended premise we only have a binary option of causing or not causing existence. He might proceed to further point out that for both those suffering from terminal illnesses and prisoners serving life sentences other options are available. For terminally ill patients we could improve palliative care and for prisoners serving life sentences we might improve penal conditions. I accept my objectors point and accept that provided other options are available which would allow both of these categories of people to live lives they would find worth living my analogy fails. I also accept that improvements in palliative care and prison conditions are desirable and should be carried out. However, I do not accept that such improvements always means we are not the cause of making someone live a live he finds not worth living. Simply removing pain from a terminally patient’s life doesn’t mean he has a life worth living. We can remove all pain from someone by putting him in an induced coma for the rest of his life. Would such a patient really be alive? I would argue if someone is unconscious and will never regain consciousness he is in a state equivalent to being dead, he is certainly not living any sort of live at all. Whether it is possible to remove almost all the pain from all conscious terminally ill patients so that pain by itself doesn’t mean they don’t have lives worth living is an empirical question. Personally I doubt whether this will be possible in all cases but I will not pursue the point here. However, even if we could reduce pain to acceptable levels for all terminally ill patients it does not follow that they have lives which they believe are worth living. A life worth living is not just a question of having a relatively pain free conscious existence. Is simply existing really living? A very limited lifespan together with vastly impaired capabilities might well mean some such people find their lives lacking all meaning, find their lives not worth living. I would suggest anyone who suggests otherwise might be accused of epistemic arrogance. It follows even if palliative care was much improved there would still be some terminally ill patients living lives which they would find to be not worth living. It might also be argued much improved prison conditions don’t automatically mean prisoners serving life sentences always find their lives worth living. Some such prisoners might suffer from remorse which makes their lives not worth living. Indeed, better penal conditions might increase such prisoners’ propensity to suffer remorse. Other such prisoners might find the impossibility of freedom makes their lives meaningless, not worth living. It again follows that improved penal conditions would not mean all prisoners serving life sentences would have lives they considered to be worth living.

In the light of the above it appears, if we accept the premise that we have a duty not to bring into existence any being which would find its life not worth living that we also have a duty not to cause people to continue to exist if they have lives not worth living. It follows we should permit assisted suicide to those suffering from terminal illness. Accepting the above might also mean some patients with a terminal diagnosis who find their lives worth living might better enjoy their lives if they had the reassurance that if these lives became unbearable they could be helped to end them removing their worries about how these lives might end.

Prisoners serving Life Sentences and Voluntary Euthanasia

In previous postings I have suggested that prisoners serving life sentences have a right to be assisted to commit suicide, see Prisoners serving Life Sentences. In this posting I will argue that this right should only apply to assisted suicide and should not extend to euthanasia. Before commencing my argument I will make some definitions I will use clear. Euthanasia means someone deliberately ends another’s life to end his suffering. Involuntary euthanasia means this is done when he does not consent. Non voluntary euthanasia means this is done when he is incapable of giving consent. Voluntary euthanasia means this is done with his consent. Assisted suicide means someone deliberately provides the means for another to end his own life. I will assume without any further argument that involuntary and non voluntary euthanasia are inapplicable to prisoners serving life sentences. In what follows I argue voluntary euthanasia should also be inapplicable to such prisoners.

Let us consider a prisoner serving a life sentence for some gruesome murder of an innocent person. Let us further assume this prisoner decides he wants to die. Why if he fully consents shouldn’t someone end his life? One reason might be that, unless the prisoner was suffering, doing so would not be a case of voluntary euthanasia. Moreover, unless the prisoner was suffering, it is not clear what would be the motive of whoever carried out the act. The motive could not be one of punishment for punishment should not depend on the wishes of the prisoner. However let us now assume our hypothetical prisoner is suffering. Why in these circumstances, provided the prisoner fully consents, shouldn’t someone end his life? One reason might be that the prisoner’s suffering could and should be relieved by other means. If his suffering is caused by poor penal conditions then these should be addressed. Voluntary euthanasia should never be used to tackle poor penal conditions; even if it tackles overcrowding! Let us now further assume that the prisoner’s suffering is not caused by poor penal conditions. Perhaps his suffering is caused by mental health problems. If a prisoner suffers from a physical illness such as diabetes then his suffering should be addressed by medical means. Similarly I would argue if a prisoner suffers from mental problems his suffering should be addressed by mental health experts. Voluntary euthanasia should not be used to address mental health problems. Lastly let us consider a scenario in which the prisoner’s suffering is not caused by penal conditions or any mental health problems. Perhaps he simply does not want to spend the rest of his days in prison or more unlikely perhaps he suffers from remorse because of the terrible crimes he committed. Surely if assisted suicide is permissible in such circumstances then so should voluntary euthanasia? I will now argue that voluntary euthanasia should also remain inapplicable even in these circumstances.

In my previous postings I have argued that a prisoner should retain some limited autonomy. Part of that limited autonomy is the right to commit suicide. As the state deprives a prisoner of the means to commit suicide it should provide him with these means in a controlled environment. The prisoner’s right to be assisted to commit suicide depends on his ability to make an autonomous decision. At this point an objector might point out voluntary euthanasia also involves an autonomous decision. She might proceed to argue, if I use a prisoner’s retention of limited autonomy to justify assisted suicide that, the same justification could apply to voluntary euthanasia.

I have two responses to my objector’s argument. Firstly I would suggest we have no need to kill someone provided he can be assisted to commit suicide. My objector might respond by suggesting that there is no real moral difference between killing and assisting someone to die. This is simply a variation of the acts and omissions problem and I will not deal with his suggestion here. My second response carries more weight. I would suggest we can never be completely certain whether someone’s decision is an autonomous one or not. I will then argue we can be more certain that someone has made an autonomous decision to commit suicide than when he gives informed consent to voluntary euthanasia. I will base my argument on the importance of what we care about when making autonomous decisions, see (1). Frankfurt argues autonomous decisions are decisions the agent cares about. I have suggested that autonomous decisions are decisions which are not discordant with what the agent cares about, see autonomous decisions . However I would agree with Frankfurt by suggesting an agent’s actions are better indicators of his autonomous decisions than the choices he makes or what he decides to do. The choices he makes and what he decides to do are only intentions. Sometimes when we come to act we find we cannot carry out our prior intentions because it was not clear to us what we really care about until we came to act. A prisoner giving informed consent to voluntary euthanasia is making a choice and deciding what would be best for him. His intentions are of course an indicator of an autonomous decision. However in the light of the above a prisoner’s actions in committing assisted suicide are a much better indicator of his autonomous decision.

1. Harry Frankfurt, 1988, The Importance of What We Care About. Cambridge University Press, page 84.