Voluntary Assisted Dying 
Frequently Asked Questions

Ethical Rights
(www.ethicalrights.com)

Contents

Part 1. Introduction

Part 2. Ethical considerations

1. Do we morally have a right to life?
2. Do we morally have a right to die?
3. Do we morally have a right to die as we choose?
4. What is more important: quantity of life of quality of life?
5. What are key features of good ethical arguments for voluntary euthanasia
6. What are the key ethical principles that could apply to voluntary euthanasia?
7. Could it be said that people who advocate voluntary euthanasia are imposing their views on others?
8. Could it be said that people who oppose voluntary euthanasia are imposing their views on others?
9. Who ultimately has responsibility for an individual’s body?
10. Why do some people want to place their own moral views on others?
11. If someone believes in a god that opposes euthanasia, wouldn’t that be a reason to deny voluntary euthanasia to others?
12. Do some religious people support euthanasia?
13. Is it sensible for religious leaders to oppose euthanasia?
14. Couldn’t voluntary euthanasia be considered the same as killing or murder?
15. Is palliative care important?
16. Can palliative care alleviate all suffering?
17. If we have a right to die, does that imply that our lives would be unworthy?
18. Why would someone want to choose voluntary euthanasia?
19. Can voluntary euthanasia have an effect on other people?
20. Is voluntary euthanasia the same as what the Nazis did?
21. Should a person be free to request death if his or her suffering is unbearable?
22. Is voluntary euthanasia preferable to having no food and fluids for terminally ill people?
23. Is death a bad thing?
24. Could pressure be placed on the disabled or elderly to die?
25. What problems could still be addressed?
26. What are some policy positions of some of the euthanasia advocacy groups?
27. What are some views of groups opposed to euthanasia?
28. How could the arguments of those opposed to euthanasia be addressed?
29. General conclusion on ethical issues

Part 3. Regulatory considerations

30. Is it legal in some jurisdictions to terminate one’s life?
31. Is it legal in some circumstances to assist a suicide?
32. Why is it illegal to help with a suicide when suicide is itself a legal act?
33. Is voluntary euthanasia occurring now in some jurisdictions?
34. Why don’t politicians in many jurisdictions regulate where voluntary euthanasia is occurring now?
35. Is there popular support for voluntary euthanasia?
36. Shouldn’t modern societies protect the vulnerable?
37. Should voluntary euthanasia be made illegal because it is impossible in some jurisdictions to ensure that some people will not be coerced to die?
38. What about people who are unable to communicate for themselves?
39. What are some of the common myths surrounding euthanasia and assisted suicide?
40. Is there a slippery slope, i.e. could legalised voluntary euthanasia lead to non-voluntary euthanasia?
41. Could suicides increase with legalised voluntary euthanasia?
42. Won’t people who are deemed a burden be pressured to have euthanasia?
43. Should rational suicide be permitted in individual circumstances?
44. Which regulatory models could be adopted?
45. Should there be regulatory controls within each jurisdiction?
46. Can regulatory controls provide some individual freedom?
47. What conditions are currently being imposed on those seeking voluntary euthanasia?
48. What is the situation in Australia?
49. What is the situation in other parts of the world?
50. What should be the role of medical practitioners in certain euthanasia regulatory systems?
51. Are many doctors opposed to voluntary euthanasia?
52. Are there instances of doctors being forced to assist with voluntary euthanasia?
53. Aren’t doctors obliged to abide by the Hippocratic Oath?
54. Shouldn’t doctors ‘do no harm’?
55. Could the importation of end-of-life drugs be made permissible under certain conditions?
56. General conclusion on regulatory considerations

Part 4. Individual considerations

57. Under what conditions should a person choose voluntary euthanasia?
58. Should I inform my family and friends of my intention to die?
59. Should I tell my doctor that I will want to die, if in the future, I become terminally ill?
60. Should I inform government authorities about when I choose to die?
61. How should I die?
62. Should I involve others to help me to die?
63. Should I help my partner die if he or she is terminally ill and requests my assistance to help him or her die? 
64. Should I have any number of people with me when I die?
65. Should I die in a public place if I choose to?
66. Should I have an advance care plan in place?
67. What if I have developed an advance care plan, but later in life I am demented, content and do not want to die?
68. What if I want to die now and I am not terminally ill yet?
69. Where could I hide illegal end-of-life drugs?
70. Are people who acquire illegal end-of-life drugs culpable?
71. If a terminally ill person chooses to have voluntary euthanasia, at what point should that occur? 
72. When can one determine the tipping point between capacity to have voluntary euthanasia and the onset of ‘missed the window’?
73. General conclusion on individual considerations

Part 5. Some Definitions and Explanations

74. What is voluntary euthanasia?
75. What is not voluntary euthanasia?
76. Is voluntary euthanasia the same as mercy killing?
77. What is physician-assisted suicide?
78. How is terminal illness generally defined?
79. What is the Golden Rule?
80. What is the medical model for voluntary euthanasia?
81. What is the human rights model for voluntary euthanasia?
82. What is rational suicide?

Part 6. Notes

Acknowledgements

Part 1. Introduction

Voluntary euthanasia, or voluntary assisted dying (VAD), is an important issue. It has ethical, regulatory, technical, cultural, religious and individual dimensions.

If humans have a right to their own lives, and how they die, then voluntary euthanasia is an option that many people might choose. It could reduce a person’s pain, suffering and indignity, especially if they are terminally ill. Others consider that people do not have a right to die as they would wish. In polemical, media, political and other discussions on these issues, terms and issues are too rarely discussed in an objective, dispassionate way.

This collection of frequently asked questions (FAQs) and answers about voluntary euthanasia are intended to provide short objective responses that can, if applied with common sense, guide people to a more rational and reasoned position on euthanasia. Definitions of key terms such as voluntary euthanasia, the human rights model and rational suicide are included at the end of this document.

While the answers are designed to be generic and applicable to most jurisdictions (whether cities, cultures, states or countries), jurisdiction-specific answers might vary in some details from those included below.

The FAQs are arranged in three parts according to the ERIC framework, which has been developed by Ethical Rights. ERIC is an acronym describing the Ethical, Regulatory, and Individual Considerations that should be examined sequentially on an issue such as voluntary euthanasia.

We would be pleased to receive any constructive comments on the FAQs below.

Part 2. Ethical Considerations

1.         Do we morally have a right to life?

Generally, yes. A right to life is a right, as with many rights, that we can choose to exercise or not. It is not a duty. There is no obligation to live if we do not wish to do so. If a person attempts to violate another’s right to life by trying to kill them, their own right to life may have to be forfeited. A person who was about to be attacked and killed against their will would be likely to try to defend themselves, and that might result in the death of the attacker. Even a right to life has limitations.

People who commit suicide or choose voluntary euthanasia have chosen to forfeit their right to life.

2.         Do we morally have a right to die?

Given that everyone who is alive will die renders the question somewhat moot. The more appropriate question is whether we have a right to die at a time, place and situation of our choosing.

3.         Do we morally have a right to die as we choose?

Generally, yes. A right to die is a right we can choose to exercise or not. It is not a duty to die. It is an extension of an individual’s right to live their life as they please (consistent with appropriate laws etc.), and to be responsible for their own bodies. People generally do not want others dictating, especially through government regulation, whom they should marry, which house they should buy or how much they should suffer. These are clearly concerns for each individual, and others cannot claim to know what is best for any other person. No reasonable person would agree to taking a deferential position and permitting others to dictate how they should live their life.

A right to die in a particular way could, however, be forfeited if the chosen method for death (for example, terrorist acts or self-immolation at a large sporting event) were to substantially affect others. In such circumstances, civil authorities could and should rightfully act to prevent the means of death.

The right to die has only become an issue in relatively recent times, as modern medicine now provides the means through which people can continue living, even if they are severely or critically ill. People are not only contemplating the right to die, but are now exercising that right at a time of their choosing. Consequently, the right to die is now a fervent area of public debate and is on the regulatory agenda in many jurisdictions.

4.         What is more important: quantity of life of quality of life?

How long a person wants to live, and what quality of life he or she is prepared to accept, is a decision for each individual. Some people will want to maximise their longevity, or quantity of life, by living until medical intervention can no longer keep them alive, regardless of any suffering. That should be their right. If a person chose that option, it would be a large imposition on the health budget in many jurisdictions, but one that many jurisdictions choose to bear.

Other people might choose voluntary euthanasia when their suffering becomes too great, and their quality of life becomes too poor. That also should be their right. For them a death with less suffering would be preferable to a death with suffering. Keeping people alive against their will would also be an unwarranted and costly imposition on the health budget. This is an incidental consequence of their decision, but it is a reason that governments should consider. One ought to consider why some governments are spending scarce taxpayer funds keeping people alive who do not wish to be kept alive.

5.         What are key features of good ethical arguments for voluntary euthanasia

Strong ethical arguments must be objective, and not just a subjective expression of a person’s religious or personal views. Good ethical arguments take the position of an independent third party, and address the question, ‘what ought we do in this situation?’.

Subjective moral arguments against voluntary euthanasia based on gods of religion have no ethical merit. This is because there are no means of determining what is right if an issue comes down to an immature and subjective exchange of ‘my god knows more than your god and my scriptures and views are right, including on voluntary euthanasia’. A person’s religion derives from their culture and the extent of their early childhood indoctrination or acculturation, and can be difficult to change, despite scientific or moral advances. A better rationale is required in a public policy debate on voluntary euthanasia.

An objective approach requires reason to make a case for (or against) voluntary euthanasia, such as an appeal to the principle of the betterment of humankind. If a person wants to avoid suffering when terminally ill, and they choose a more peaceful option, shouldn’t they be allowed this take this option? Seems eminently sensible if they are responsible for their own body.

Good ethical arguments should be universalisable. This means that they should have widespread applicability. An argument that voluntary euthanasia is wrong because it violates the sanctity of life only applies to people of a certain religion who believe in that argument. Others reject it and there is no way of resolving the impasse. Others might argue that voluntary euthanasia violates human dignity, and although proponents argue that it is precisely to maintain dignity that voluntary euthanasia is considered as an option, neither of these is completely objective in nature. They are subjective, because the extent of human dignity is mostly subjective (though it can be objective) and hence invalid.

An appropriate objective approach would for example, refer to the individual autonomy of a person, a feature that can be universalisable. A person is ultimately responsible for his or her own body. A person has a right to life, and can live or choose not to live their life as they please. No one would like to have dictated to them how they should live or die. Hence, a person who chooses voluntary euthanasia should be able to do so, without others dictating that they cannot.

6.         What are the key ethical principles that could apply to voluntary euthanasia?

Possibly the most universally adopted position of most moral frameworks is the Golden Rule: that ‘we should do to others what we would have them do to us’. People would not like others to dictate to them with whom to have sex, what work to pursue, or where they must live, or whether they should choose euthanasia. Therefore, reciprocally, we must not dictate to others how they should live their individual lives, including whether they can have access to euthanasia.

We can certainly try to make a case to educate others about our views, as that is part of reasonable debate in liberal societies. However, dictating something to others by legislative decree that people would not want forced upon themselves would be a violation of the Golden Rule. All people are equal, and if the Golden Rule is to have universal validity, one person’s belief system must not be dictated to others.

Put another way, the Golden Rule proposes that we act toward others as we would have them act towards us. It suggests that if we do not want others to impose their religious or other values on us, then we should not impose our values on others

Another ethical principle that could apply to voluntary euthanasia is the utilitarian principle of the ‘betterment of humankind (and sentient animal-kind)’. According to this principle, if some action betters or improves humankind, then it is a worthy action. Medicine, improvements in education, communications and many technological and social developments are worthy developments.

Actions or lack of action that could cause pain and suffering are not ethically worthy. If voluntary euthanasia reduces the indignity and misery of those at the end-of-life, it similarly can be considered ethically meritorious.

Religious and other people who disapprove of terminally ill people choosing death by euthanasia do not have a valid argument. Shouldn’t they be pleased that other people are choosing to suffer less? Given the Golden Rule outlined above, they would not like the moral principles of others to be imposed on them, so it is difficult to understand why they feel the need to impose their views on others.  

The following summarises some of the key ethical principles that might apply to voluntary euthanasia.

• The principle of individual autonomy: that an individual of sound mind is ultimately responsible for their own behaviour and their own body. Most fundamentally, a person of sound mind has the right to choose what is best for his or her own body. There ought to be respect for the fundamental nature of individual rights. John Stuart Mill said ‘Over himself, over his own body and mind, the individual is sovereign’. This fundamental statement of individual liberty is just as relevant now. Who else but each person has ultimate responsibility for his or her own body?
• The Golden Rule, that we should do to others what we would have them do to us. That is we should not force our views on others if we do not want that done to us. A person’s decision about his or her body should not be determined by others.
• We should act to achieve the betterment of humankind (and sentient animal-kind), subject to sustainable existence. If voluntary euthanasia is supported by many, used to mitigate suffering, and improves humankind by decreasing unhappiness, then it should be an available option.
• That safety should be paramount, if voluntary euthanasia is chosen, it must be done reliably, safely (so that people don’t survive a voluntary euthanasia action in a more precarious medical situation).
• That any end-of-life decision ought to be well informed by ethicists, regulators, medical advice, friends and family as appropriate, and individuals.
• There should be respect for equality. If some people can access means for a peaceful death, ought not that option be available also to others.

7.         Could it be said that people who advocate voluntary euthanasia are imposing their views on others?

No. People who advocate for voluntary euthanasia are not demanding that other people must accept euthanasia. They only request that each one of us be given free choice on all individual matters, including voluntary euthanasia, so that each person can decide for herself or himself. Other matters such as sexual preference and abortion would also quality as individual rights issues.

8.         Could it be said that people who oppose voluntary euthanasia are imposing their views on others?

Generally, yes. People who oppose voluntary euthanasia on ethical grounds require that others should not have the option of choosing voluntary euthanasia, and by doing so deny them choice.

These people might be opposing legalised voluntary euthanasia because they might think a legalised regime does not provide sufficient safeguards against murder, committed under the guise of voluntary euthanasia. This is not an ethical issue, but a regulatory issue, and will be discussed under Part 3. Regulatory Considerations.

9.         Who ultimately has responsibility for an individual’s body?

‘My life is my life’ is an apt truism. Ultimately, every person has responsibility for his or her own body. Each person is the only one who will ever experience the delights of being alive in that his or her body, enjoying experiences and relationships with others. Each person will experience the satisfaction of a warm sunset, a memorable relationship, and an amusing conversation in their own unique way. They are also the only person who knows how much suffering they can bear. And when that suffering becomes unbearable, they might ultimately want to die. An assumption that others might know more about how much another person can suffer is wrong. Indeed, it could be considered arrogant.

10.      Why do some people want to place their own moral or religious views on others?

If the Golden Rule applies, nobody should try to force their personal views about how to live on others. Many peoples’ morals derive from their religious background. Many religions, however, have a history of forcing their values, whether through force of war (crusades to world wars to terrorist attacks), force of power (inquisitions to social opposition to gay relationships and marriage, euthanasia, abortions and women) and force of indoctrination (through fear of disobedience to a religious creed, especially when aimed at young children).

Yet many world religions generally recognise the merit of the Golden Rule. Many religious people now acknowledge the rights of individuals to choose what is best for themselves. They want religious freedom, and respect that if the Golden Rule is to apply, then other people must also have religious freedom. That is, religious freedom extends only so far, that it cannot impact on another individual’s right to be responsible for his or her own body.

Consistent with the principle of religious freedom, each person should be able to choose to believe, not believe or cease believing in whatever religion they want. Although this is not the case in some religions, it is important that each person’s religious views do not prevent others from choosing their own religious views and moral framework.

11.      If someone believes in a god that opposes euthanasia, wouldn’t that be a reason to deny voluntary euthanasia to others?

No. Many people follow religions that in general terms support the Golden Rule as a fundamental ethical principle. It follows that if a person objects to another religion’s moral values being imposed on him or her, then there is no objective basis for his or her views (on euthanasia or other issues) to be imposed on others.

Subjective moral arguments against voluntary euthanasia based on gods of religion have no ethical merit. This is because there are no means of determining what is right if an issue comes down to an immature and subjective exchange of ‘my god knows more than your god and my views are right, including on same-sex marriage’. A better rationale is required in a public policy debate.

12.      Do some religious people support euthanasia?

Polls have generally indicated that the majority of religious people do support voluntary euthanasia, though this depends on the religion and the country. Some poll figures suggest over 60 per cent of Catholics and Protestants support voluntary euthanasia. It is mainly the clergy (religious leaders of many religions) and strongly religious people who strongly oppose voluntary euthanasia.

13.      Is it sensible for religious leaders to oppose euthanasia?

Generally no, if clergy are proselytising or becoming involved in a public debate, then religious leaders do not have a solid foundation to oppose euthanasia. They do not have the moral high ground. The role of the clergy is to uphold what in many religions are ancient and absolute moral practices. In so doing, they establish a following for their religion, but it is not an objective foundation on which to oppose voluntary euthanasia.

Many major world religions do not permit women or gay people to be leaders in their organisations. These religions are therefore discriminatory, sexist and homophobic, and in more liberal societies these attitudes are considered immoral. Some religious leaders worship a deity or god that has, according to various scriptures, killed many people, for example, in a great flood or a Passover.

It is morally perverse, on the one hand, to oppose a person’s choice of voluntary euthanasia to alleviate their end-of-life suffering, but, on the other, worship gods that kill people against their will and discriminate against others.

It would seem that the clergy advocate for their religion despite what is right (that killing people against their will is morally wrong). It would be hoped that they would instead advocate for what is morally right (opposing discrimination and respecting a person’s right to make decisions about his or her own bodies, including voluntary euthanasia), regardless of what their religion says.

If however people choose to invoke imaginary beings (gods) as a basis for public policy on an issue such as voluntary euthanasia, the basis for those arguments must be analysed. As there is no valid scientific evidence for any gods, or any deeds contrary to the laws of physics, there is no objective basis for religions. The anti-euthanasia views of mainstream religions are subjective. They should be rejected.

14.      Shouldn’t voluntary euthanasia be considered the same as killing or murder?

No. Murder, or killing people against their will, is illegal in many jurisdictions. Murder rightfully is morally wrong because it does not involve consent.

Voluntary euthanasia is a voluntary action and consent is explicit in its definition.

The difference between voluntary euthanasia and murder can be applied to an analogous situation between consensual adult sex and rape. Consensual adult sex is to rape as voluntary euthanasia is to murder. The difference is that in these instances it is the inherent voluntary nature of an action that determines whether it is morally right.

15.      Is palliative care important?

Yes. Palliative care at the end-of-life is very important, especially for those who want it. It might be sufficient to alleviate suffering for many people. However, it is recognised that even the best palliative care cannot alleviate pain and suffering for all people. Consequently, palliative care (and life) should not be mandatory those who do not choose it.

16.      Can palliative care alleviate all suffering?

Palliative care cannot eliminate all pain, suffering and indignity for all illnesses. That is, some people will have certain conditions, lack of dignity, pain and suffering regardless of the best possible palliative care. Many individuals will need to choose between palliative care with the possibility that indignity and suffering cannot be fully relieved and voluntary euthanasia. That should be a personal decision.

No one should make that decision for a person of sound mind, because no one would want others to make that decision for him or her.

From an economic perspective, finite health budgets for palliative care can and should be more appropriately targeted at those who want to stay alive regardless of their quality of life. Spending funds on those who wish to die because their quality of life is unacceptably poor would be diluting the funding pool.

It would be wrong to interpret this economic argument as a basis for pressuring people to die in order to save a government’s bottom line. Such coercion would be inconsistent with the ‘voluntary’ aspect of euthanasia. It should, however, be interpreted as a statement that opposing the voluntary euthanasia will be a drain on government budgets. Conversely, voluntary euthanasia would maximise national benefits because it would reduce suffering and hospital and hospice costs, and possibly even free up additional funds for palliative care for those who want it.

17.      If we have a right to die, does that imply that our lives would be unworthy?

No. A right to live or to die is unrelated to how worthy or otherwise we consider our lives to be.

Some people have what they consider the most worthy and fulfilling lives, and they may still choose to die if they are suffering. Analogously, some could say that a right to life should not apply to those murderous despots throughout history who might not have led worthy lives.

A right to live or die can mean that each individual is ultimately responsible for his or her destiny. Whether your life is worthy or not, and whether you have been living a good life, is a personal matter that only each individual can determine.

18.      Why would someone want to choose voluntary euthanasia?

A person may choose voluntary euthanasia for many reasons. These include when a person has

• a terminal illness, with a prognosis of pain, suffering and lack of dignity before death, including
  • cancer
  • other serious illnesses, whether or not palliative care is alleviating all symptoms
  • non-terminal conditions, with a rational reason to die, such as:
  • jumping out of a burning building (possibly suicide, but a rational alternative to being burnt alive)
  • being injured and trapped on a battlefield (to avoid capture or torture)
  • being of sound mind and feeling that one wants to die (in conjunction, for example, with the death of your terminally ill partner)
  • being a criminal with a life sentence and with no prospect of release
  • suffering from dementia, but with an advance care directive indicating the wish to die when dementia becomes advanced.

Ultimately, each person might have his or her own reason. Their unique reason should be sufficient (noting that the individual should be of sound mind).

19.      Can voluntary euthanasia have an effect on other people?

Everybody dies. A person’s death can affect many other people. An argument against a person choosing voluntary euthanasia because that person’s death affects other people is not an argument against voluntary euthanasia; it is an argument against death.

Voluntary euthanasia will generally reduce suffering, so people might prefer it to a death that might involve greater suffering. Ought not we be content that some individuals want to reduce their suffering, rather than have them suffer against their will?

If suffering is considered undesirable, and if voluntary euthanasia reduces suffering, then it could be considered a good option.

If a death occurs because of voluntary euthanasia, then grieving relatives and friends can be somewhat heartened knowing that their loved one did not endure needless suffering or pain.

If others think that a person’s voluntary euthanasia could adversely affect them, then their preference would be, one would think, that that person’s suffering should continue. A desire that suffering should continue could be for inhumane reasons, or that the cessation of suffering that could be made possible by voluntary euthanasia is somehow immoral, or possibly for religious reasons.

The first argument is unacceptable. The religious argument is subjective, and without merit. The possibility here is that there are other moral frameworks used by the people who support voluntary euthanasia.

20.      Is voluntary euthanasia the same as what the Nazis did?

No. Nazis killed and experimented on people without their consent, which is morally wrong. This is murder, as discussed above. No one would like this to happen to them. It should be noted that various scriptures claim that many deities have killed people without their consent—this too is morally wrong.

Voluntary euthanasia is consensual and is a choice for each individually. It is the consensual nature of voluntary euthanasia that makes it morally right.

21.      Should a person be free to request death if his or her suffering is unbearable?

Yes. Why should one be forced to live on if their future only holds suffering? Many people might choose to continue living, but some might not. Only each person knows how much suffering he or she is willing to bear. It could be considered arrogant for one to dictate to others that they must live, regardless of how much suffering others must bear.

John Stuart Mill stated in his essay On Liberty that ‘Over himself, over his own body and mind, the individual is sovereign’. Mill also asserts that the principle should only be applied to certain groups (limited this to sane, intelligent adults in modern societies). On this basis, sane non-feebleminded adults should have individual autonomy, and have the liberty to choose death and have that request honoured.

22.      Is voluntary euthanasia better to having no food and fluids for terminally ill people?

Voluntary euthanasia, including refusal of treatment, should be options for each well-informed person. If terminally ill, each individual should have the right to choose (a) voluntary euthanasia, or (b) forgoing food and fluids, dying over perhaps one week in a palliative care ward. Some people might want to have palliative care, some might want to suffer until the end, and others might want voluntary euthanasia. What is best is an individual decision for each person.

Such a choice should be available to, and be the decision of, each person.

23.      Is death a bad thing?

Death might be a bad thing, and it might not be.

If people do not want to die yet, they are living happy and fulfilling lives, envisaging a future that holds promise, they might consider their life valuable, and something they would not wish to forfeit. This is the situation for most healthy people.

However, if some of the above are not the case, then death can be a good thing. It would not deprive people of an otherwise fulfilling and useful existence, but instead relieve them of unnecessary pain and suffering. Whether it is good or bad is a judgement that should ultimately be made by each individual.

All people will die. Consequently, many people might want to have at least some control over the manner in which they die, and their sane, well-informed views ought to be respected.

24.      Could pressure be placed on the disabled or elderly to die?

Perhaps, but rarely. The contrary is the usual situation. When a person dies, their loved ones and carers are usually distraught and grief-stricken. Common experience is that relatives want to prolong the life of their loved one, and it is often difficult to have them recognise that additional medical intervention could be futile.

Only in extreme cases could pressure be exerted by uncaring, possibly estranged, relatives, possibly seeking an earlier inheritance. These rare cases should be handled by an appropriate regulatory system, and discussed in the next part on Regulatory Considerations.

There is no evidence that pressure is being placed on the disabled or elderly to die in jurisdictions where voluntary euthanasia is currently legal.

25.      What problems could still be addressed?

Globally, the debate on voluntary euthanasia is still immature in many jurisdictions. Aside from voluntary euthanasia for terminally ill people, there are many other issues, and some are listed below, that have yet to be considered in fulsome detail for an ethical public policy position to be developed. People in some of the situations listed below could be appropriate candidates for voluntary euthanasia. In other situations, the death of the person would be morally wrong.  

Rational debate needs to occur from an ethical perspective if the situations below ought to be permitted, and if found ethically acceptable, whether regulation should be required.

1. Anencephalic infants (those with no cerebral hemispheres and no neocortex) (voluntary request comes from parents); such infants generally die soon after birth
2. Rational suicide of an 80 year old person (voluntary request by person)
3. Voluntary euthanasia for a terminally ill 14 year old, or a 5 year old child (with voluntary request from child, including from parents)
4. Prisoners with life sentences (voluntary request from prisoner)
5. Life prisoners in totalitarian regimes (no request from prisoner)
6. Death penalty for criminals (as occurs in the US, China, Indonesia or India (no request by criminal))
7. Mentally disabled persons (no request by person)
8. Persons without cognition (no request by person)
9. Fatally injured soldier who is about to be overrun by the enemy on the battlefield (voluntary request from soldier). Also, the same situation without a voluntary request
10. A 25-year old person suffering from a debilitating disease that will only worsen, but is not life threatening for at least 10 years (voluntary request by person)
11. An elderly person, suffering from dementia, who is otherwise healthy, but has an advance care directive indicating their desire for voluntary euthanasia when they can no longer identify family members, or anybody, and need help with all bodily functions (advance care directive by person).

26.      What are some policy positions of some of the euthanasia advocacy groups?

Euthanasia advocacy groups tend to have the same view that individuals should have responsibility over their own lives. Occasionally they will differ on the best means of achieving these ends, such as whether medical professionals need to be involved or not. There is certainly an understanding that the medical model will be implemented in jurisdictions before a more ethically liberal human rights model could be considered.

Exit International

(www.exitinternational.net)

Exit believes ‘that it is a fundamental human right for every adult of sound mind, to be able to plan for the end of their life in a way that is reliable, peaceful and at a time of their choosing.’

World Federation of Right to Die Societies

(www.worldrtd.net)

‘World Federation of Right to Die Societies (an international non-governmental organization) is aware of the increasing concern to many individuals over their right to die with dignity. Believing in the rights and freedom of all persons, we affirm this right to die with dignity, meaning in peace and without suffering.

All competent adults­—regardless of their nationalities, professions, religious beliefs, and ethical and political views—who are suffering unbearably from incurable illnesses should have the possibility of various choices at the end of their life. Death is unavoidable. We strongly believe that the manner and time of dying should be left to the decision of the individual, assuming such demands do not result in harm to society other than the sadness associated with death.

The voluntarily expressed will of individuals, once they are fully informed of their diagnosis, prognosis and available means of relief, should be respected by all concerned as an expression of intrinsic human rights.’

Ethical Rights

(www.ethicalrights.com)

Every individual of sound mind has the right to choose and implement a peaceful death at a time of his or her choosing. This means that he or she can

• accept or reject any doctor’s involvement in an end-of-life action 
• accept or reject palliative care
• request and be granted assistance with suicide if chosen.

My Death My Decision

(www.mydeath-mydecision.org.uk)

My Death My Decision ‘believe that medically assisted dying should be available to all mentally competent adults with incurable health problems that reduce their quality of life permanently below the level they are willing to accept, provided this is their own persistent request.’

Go Gentle

(www.gogentleaustralia.org.au)

Go Gentle argues ‘for the right of all Australians to have a choice about what happens to them at the end of their lives and not to be forced, when they are at their most vulnerable, into cruel and avoidable suffering.’

27.      What are some views of groups opposed to euthanasia?

Groups and persons opposed to voluntary euthanasia often make religious claims. These range from its being against the will of a god to allow euthanasia, contrary to the ‘sanctity of life’, and/or difficult to prevent people from being coerced into dying.

The latter issue is a regulatory one to be addressed later.

The reader is referred to the websites of religious groups to access the views raised in their scriptures.

28.      How could the arguments of those opposed to euthanasia be addressed?

The clergy in many jurisdictions promote religious arguments against euthanasia. If there is freedom of religion, it should not be ethically permissible for one group’s religious views to be imposed, by legislative fiat or otherwise, on other people.

A maxim that could be useful here is that religions preach ancient scriptures, and adherents are required to abide by these. These are absolute, and their interpretations have not evolved over the centuries as societies have evolved. Many religions do hold to the Golden Rule, discussed above. Consequently, it would be immoral for people to impose their religious values on euthanasia on others if they do not want others’ religious values imposed upon them.

The massive influence of early childhood indoctrination in religions cannot be understated. Aside from

• developing new curricula for students to reduce childhood indoctrination (including on ethical principles, critical thinking, etc. instead of using fear to indoctrinate children into a given religion)
• highlighting the moral inadequacies of religions (discrimination, worship of imaginary beings who murder)
• cutting funding to any organisations that discriminate against others
• continuing the debate on important social, technical, ethical and related issues

it will clearly take some time for society to develop a more ethically sound approach to issues such as voluntary euthanasia.

29.      General conclusion on ethical issues

Arguments against euthanasia are not supported by evidence, or are subjective. If the following conditions hold:

• a person is of sound mind
• all people have equal rights
• the individual views of people should not be forced on others
• people are ultimately responsible for their own bodies

and noting that

• all people will die
• it is preferable not to suffer than to suffer

then it follows that the ethically right option is that each person of sound mind should be able to choose voluntary euthanasia.

Part 3. Regulatory Considerations

After ethical arguments have been considered, and if the ethical arguments for voluntary euthanasia are compelling, then regulatory issues ought to be considered.

30.      Is it legal in some jurisdictions to terminate one’s life?

Suicide, the taking of one’s own life, is legal in many jurisdictions.

In many respects, it would seem absurd that the act of committing suicide was ever a crime. If the suicide act were successful, it would involve condemning a deceased person. However, if the suicidal act were unsuccessful the case might need to be investigated, depending on the intent behind it.

31.      Is it legal in some circumstances to assist a suicide?

Assisting somebody with suicide, the taking of another’s life, is illegal in most jurisdictions. Canada, some states in the United States, Belgium, the Netherlands, Luxembourg and Switzerland are notable exceptions in which assisted suicide is legal.

Peculiarly, in some jurisdictions, the act of suicide is a rare instance of an act, which is legal if done by the person himself or herself, but if the person secures assistance with this act, then it can become illegal.

32.      Why is it illegal to help with a suicide when suicide is itself a legal act?

Regulatory systems have evolved with the objective of protecting people from unwanted death. Nobody wants to die, or be killed. It is contrary to their wishes.

Assisting a suicide often has been deemed illegal because of two main reasons.

First, until recent times (before advanced medical interventions), it was assumed that there was no valid reason for sane people to want to die. Second, it was unclear how assisted suicide could be distinguished from murder (considering that the person who died could not testify orally). Voluntary euthanasia regulatory regimes generally establish frameworks that provide surety that any decision to die has been made voluntarily, and without coercion.

In more recent times, modern medicine has kept many people alive longer than would have been possible. Sometimes this causes unnecessary suffering. Now many people are choosing to die if their suffering becomes too great­. The large membership of Exit International, Dying with Dignity and similar organisations, and the overwhelming popular support for voluntary euthanasia in many jurisdictions, is testament to this trend.

If an individual was assisted to die, due to for example, excessive pain and suffering, and if he or she rationally wanted to die and requested help to do so, assisting suicide could be a morally right option. To address such cases, consideration should then be given to regulating voluntary euthanasia.

33.      Is voluntary euthanasia occurring now in some jurisdictions?

Yes. Voluntary euthanasia is legal and occurring in many jurisdictions. Voluntary euthanasia, or ‘peaceful’ suicide in lieu of legalised voluntary euthanasia, is also occurring in jurisdictions where euthanasia is illegal, such as Australia.

Thousands of Australians have manufactured or acquired drugs or other equipment so that they may have a peaceful death at a time of their choosing. Many of these people are members of Dr Philip Nitschke’s euthanasia organisation, Exit International.

It would be reasonable to say that these people are taking matters into their own hands to avoid any scenario that could result in their being in an end-of-life circumstance involving pain, suffering or lack of dignity.

Regulated voluntary euthanasia based on the medical model (see Part 5) is unlikely to meet the needs of all terminally ill people.

34.      Why don’t politicians in many jurisdictions regulate where voluntary euthanasia is occurring now?

It is perplexing that politicians do not regulate voluntary euthanasia in jurisdictions where there is substantial evidence that it is occurring. The ethical arguments for voluntary euthanasia are compelling if one supports the notion that individual rights take precedence over the rights of those people who seek to impose their conservative, usually religious, values, on others.

In Australia for example, where perhaps eight per cent of the population are regular churchgoers, politicians might be reluctant to regulate for fear of losing the religious vote. It would be encouraging if politicians in all jurisdictions had the moral fortitude to enact legislation that would allow individuals access to a peaceful death if they wished it.

35.      Is there popular support for voluntary euthanasia?

Yes. In most jurisdictions euthanasia is supported by 60–80 per cent of the population. The question often asked in surveys is:

‘If a hopelessly ill patient, experiencing unrelievable suffering, with absolutely no chance of recovering, asks for a lethal dose, should a doctor be allowed to give a lethal dose or not?’

Voluntary euthanasia is usually supported by the majority of religious people (depending on the religion and extent to which the religion is followed in a jurisdiction), but is usually opposed by a large majority of the clergy.

36.      Shouldn’t modern societies protect the vulnerable?

Yes. Current voluntary euthanasia regulatory systems require that only terminally ill people are eligible for voluntary euthanasia.

People who are vulnerable and/or not of sound mind, or who might have a depressive illness (for example, a young person who has financial and relationship problems) must be protected in any voluntary euthanasia regulatory regime. They need help and support, and efforts ought to be made to discourage them from suicide. Most people would understand that people in these groups ought to be directed to medical professionals, or organisations that support such people. In Australia such organisations include Beyond Blue and Lifeline.

Many depressed people will have good times ahead in their lives. We ought do all we can to ensure that they have the best counselling to help them through the occasional down times or more permanent depressive illnesses that many people have. Other vulnerable people need protection in a regulatory system to ensure (as far as possible within any regulatory system) that any end-of-life decisions are free of coercion and are made willingly.

We require such protections because we would like to be similarly protected in case we were stricken with a depressive illness. Nobody would like the option of euthanasia to be available to a young person who for example, might have occasional financial or relationship problems. Regulatory systems currently address this through a requirement that a person be terminally ill.

However, if a person is terminally ill or is otherwise living in unbearable circumstances that clearly will not improve, then his or her well-considered and sane request for a death should not be rejected by those who think they know better than him or her.

37.      Should voluntary euthanasia be made illegal because it is impossible in some jurisdictions to ensure that some people will not be coerced to die?

Voluntary euthanasia is ethically sound. Strong regulatory controls, involving checks by doctors, psychologists etc., can be used to ensure that only the people who meet the criteria specified in legislation can access the option of voluntary euthanasia. Around the world, eligibility conditions for those accessing current voluntary euthanasia regulatory systems include that they must be terminally ill.

All regulatory systems involve situations in which people break the law. People speed in vehicles, avoid tax, steal from and murder others. They do so, despite laws that stipulate that all of these acts are illegal. Wrongdoers are prosecuted, and if found guilty, suffer consequences under the law in each jurisdiction.

Similarly, jurisdictional voluntary euthanasia legislation in many jurisdictions sets out requirements for compliance with the legislation, enforcement provisions, and penalty regimes, if legislative requirements are not met. In this respect, voluntary euthanasia legislation could have the same fundamental structure as other crime-based regulatory systems.

38.      What about people who are unable to communicate for themselves?

If individuals cannot communicate a voluntary decision in any way, they would be unable to request or legally be granted the option of voluntary euthanasia. The only situation that would apply here is if they had voluntarily prepared a valid instruction, an advance care directive, indicating a wish for euthanasia under certain conditions. Advance care directives requesting voluntary euthanasia in certain medical instances might not be legal options in many jurisdictions.

39.      What are some of the common myths surrounding euthanasia and assisted suicide?

Possibly the most unsupported contention is that once voluntary euthanasia is permitted, then non-voluntary euthanasia will be allowed. This slippery slope argument is not supported by evidence. Regulation by politicians sets boundaries on what is permitted and what is not. This is what regulatory systems (laws) do.

Boundaries of what is acceptable will change with time, but this is expected, encouraged, and should occur, in modern democracies. It has happened with moves away from slavery, restricted immigration, tariff controls, as well as improvements in social equality and the rights of minorities.

40.      Is there a slippery slope, i.e. could legalised voluntary euthanasia lead to non-voluntary euthanasia?

The slippery slope argument is suggested as one of two arguments: (a) that legalised voluntary euthanasia will inevitably lead to future legalisation of practices such as non-voluntary euthanasia, or (b) that the incidence of non-voluntary euthanasia will increase.

The inference from the slippery slope argument is that there should be no change. This slippery slope argument against voluntary euthanasia is presented without evidence, and consequently is often used by euthanasia opponents when they cannot produce substantive arguments for their case. 

The key feature of a democracy is that people elect politicians, who establish regulatory systems that set the limits for what is permissible. If some action does not comply with the conditions specified in a law, it can be subject to regulatory penalty. The limits of what is permissible may change in the future and ought to be expected in a democracy. If change were ever undesirable, we would never have evolved from the dark ages.

Internationally, there is no evidence for a slippery slope. Experience from jurisdictions in which voluntary euthanasia or physician assisted suicide is legal have sufficient compliance and enforcement mechanisms. It would seem that physicians should not need to guess about the needs of patients if voluntary euthanasia is regulated.

Before the introduction of any voluntary euthanasia regulatory system, doctors might have had to second-guess the needs of terminally ill patients. In Australia many doctors have been surveyed and have admitted to helping patients die without an explicit request. However, after any regulation, doctors will not need to do this, as they will only be able to assist with a request for euthanasia when a patient makes the request. Hence it is likely that the incidence of euthanasia without an explicit request will decrease upon regulation, contrary to slippery slope arguments.

Voluntary euthanasia is currently occurring, but remains unregulated in many jurisdictions. As there are risks in this activity, surely it is preferable to regulate it beforehand with formal regulatory oversight.

41.      Could suicides increase with legalised voluntary euthanasia?

The evidence suggests that the rate of suicide will not increase with legalised voluntary euthanasia. The rate of people choosing voluntary euthanasia will necessarily increase (given that before legalisation it would have been illegal, so even one person choosing euthanasia is an increase).

In jurisdictions such as Australia, elderly people are committing suicide prematurely, to avoid the risk of a more prolonged and painful death otherwise. If voluntary euthanasia were legal, then such premature suicides would be unnecessary.

42.      Won’t people who are deemed a burden be pressured to have euthanasia?

There are a number of responses to this question.

In developed countries, which are the ones contemplating and debating regulated voluntary euthanasia, nobody should be considered a ‘burden’. Civilised societies should care for all citizens. However, certain people, perhaps those who receive, more than they contribute, to the national purse, or for any other reason, could be considered as burdens. On this basis, some children, elderly pensioners, the ill, the disabled and the unemployed could all be considered in this category. But no one in civilised societies is suggesting that any of these people are ‘burdens’ that ought to be eliminated.

Suicide is legal in many jurisdictions now, but there is no evidence indicating that anybody who could be classified as a burden on society, or other people, are committing suicide because it is a legal option.

If people are concerned that they could be persuaded to feel that they ought to request voluntary euthanasia if it were legally available, they should then think what they would do if gay marriage were legally available (and they are currently heterosexual). Would legalised gay marriage mean they could be talked into a gay marriage? Clearly, coercing people to die is difficult. Moreover, if a person were to do so, it would be considered a criminal offence.

Similarly, for voluntary euthanasia, it would not be expected that all people would avail themselves of that law just because it is a legal option. The legal availability of a course of action does not mean that people must take that action.

If voluntary euthanasia were legal, then it can only occur, by definition, in response to a voluntary request. Most current voluntary euthanasia regulatory systems require that a person be terminally ill before their request can be granted. If a non-terminally ill person were to consider himself or herself a burden, whether or not this was accurate, the doctors and psychologists would not grant his or her request. The person would not qualify for voluntary euthanasia.

Finally, and possibly most importantly, the experience in countries where voluntary euthanasia is permitted, regulated, and monitored, has indicated that there has been no systemic cases of abuse of anyone. The opposite seems to be true. The regulatory hurdles that must be overcome to obtain permission to have voluntary euthanasia are such that many people have been rejected in their attempts to comply with legislation.

While the medical model is the preferred regulatory model in every jurisdiction so far, there are so many hurdles in the medical model that the human rights model is more appealing to many people (see Part 5). However, regulating for the human rights model for voluntary euthanasia will require considerably more debate across many societies before it is likely to be available.

43.      Should rational suicide be permitted in individual circumstances?

Rational suicide, i.e. a form of voluntary euthanasia or suicide that involves the death of a person for, what to them are, rational reasons, has the same ethical basis as voluntary euthanasia. In some cases that have become known, those who have opted for rational suicide have not been terminally ill. In one case a person was elderly and had had enough of life, and in another, the person chose to die at the same time as her terminally ill partner, who had procured an illegal drug to die. Whether or not society approves of these decisions, people will find a way to meet their needs.

44.      Which regulatory models could be adopted: the medical and human rights models?

Different regulatory models will be suited to different jurisdictions and would build on existing law. The medical model, which requires the involvement of medical practitioners to assist or participate in the voluntary euthanasia process, has been used in jurisdictions where voluntary euthanasia is currently legal.

The human rights model for voluntary euthanasia is more ethically acceptable, given that it gives greater autonomy to each person. It does not require medical professionals to be involved in a person’s end-of-life decision, but it will require innovative regulation to address concerns about it being available to somebody who may not be terminally ill and/or of sound mind.

See Part 5 for definitions of the medical model and human rights model.

45.      Should there be regulatory controls within each jurisdiction?

Voluntary euthanasia has been regulated in many jurisdictions. In some jurisdictions, such as Australia, many European countries and many USA states, voluntary euthanasia is illegal. Although illegal, voluntary euthanasia and assisted suicide are occurring.

Without legislation, well-meaning organisations such as Exit International provide information about end-of-life matters, including options for voluntary euthanasia without medical involvement. Other organisations, including the Dying with Dignity groups, are working to achieve regulatory reform. If they are successful, governments could regulate voluntary euthanasia­—it could be transparent, with appropriate monitoring, compliance and enforcement regimes.

46.      Can regulatory controls provide some individual freedom?

It will be difficult for many politicians who still have not fully considered voluntary euthanasia to take a large step and regulate for the human rights model of voluntary euthanasia. More discussions need to occur on voluntary euthanasia, and this can only occur if politicians want to engage with the issue.

The Netherlands has been considering the option of providing a peaceful pill (for the purposes of voluntary euthanasia) for all people over 70, for their personal use if they choose to use it. This is an encouraging step from a human rights perspective. It will be interesting to watch developments in that country.

47.      What conditions are currently being imposed on those seeking voluntary euthanasia?

Jurisdictions with voluntary euthanasia legislation have proceeded according to the medical model. Key eligibility requirements under this legislation include that the person seeking voluntary euthanasia is required to be an adult, of sound mind, and terminally ill. Such regulatory models usually involve confirmation by one or more physicians to confirm that the person is terminally ill, possible checks by a psychologist that the person is of sound mind, and cooling-off periods to allow the person to change his or her mind, and compliance, enforcement and reporting conditions.

In jurisdictions where voluntary euthanasia is illegal many people are procuring drugs, often illegally, for their own use if required.

48.      What is the situation in Australia?

Regulation is an ideal outcome, but many people want information on end-of-life options now. In some areas, debate has moved ahead in Australia, and issues such as rational suicide, without doctors or psychologists being involved, are being debated and acted upon outside of regulatory frameworks and political discourse.

In the absence of a regulatory environment, euthanasia advocacy groups such as Dr Philip Nitschke’s Exit International are put in the invidious position of determining who should and should not have access to end-of-life information. Generally, Exit workshops are limited to those who are seriously ill or who are over 50 years old.

49.      What is the situation in other parts of the world?

At the time of writing, voluntary euthanasia or similar options (e.g. assisted suicide) are legal in the Netherlands, Belgium, Luxembourg, Switzerland, Germany, Colombia, Japan, Canada, the US jurisdictions of Washington State, Oregon, Colorado, Vermont, Montana, Washington DC and California, as well as the state of Victoria in Australia.

50.      What should be the role of medical practitioners in certain euthanasia regulatory systems?

Doctors can play a number of roles in euthanasia regulatory systems. In the oft-implemented medical model, doctors could be required to attest to the terminal nature of a patient’s illness or refer the person to a specialist, such as a psychologist. The option of administering drugs directly to a patient is also a possible role. This makes it difficult for terminally ill patients to jump all these regulatory hurdles, especially when they are unwell and would prefer spending time with loved ones.

In the human rights model of voluntary euthanasia doctors do not play a role. Patients could acquire drugs for their personal use and use them if and as required. The legalisation of the possession of end-of-life drugs for personal use is one option that regulators could consider.

It should be emphasised that it ought to be required that people be of sound mind in making such decisions. No one would want a loved one to die because of a decision made at a time when, for a short time, he or she was not of sound mind.

51.      Are many doctors opposed to voluntary euthanasia?

In countries where voluntary euthanasia is illegal, many doctors are opposed to it, but many are supportive of it also. Interestingly, medical organisations’ views on voluntary euthanasia tend to reflect the legal situation in each jurisdiction.

52.      Are there instances of doctors being forced to assist with voluntary euthanasia?

In many jurisdictions where voluntary euthanasia is legal, doctors who have a moral objection to voluntary euthanasia are not being forced to assist with voluntary euthanasia. This means that they will not be required to prescribe an end-of-life drug to terminally ill patients, even by request.

Another way of considering this issue is from the perspective of discrimination. Ought society allow the clergy to decline a request to marry a gay couple, a pastry chef not to provide a cake for a gay wedding, a doctor not to treat a gay or black patient, or churches to decline a women’s application to join the clergy, due to the bias or invidious discrimination of those providing a service? The offensive discrimination should be condemned, not condoned.

That noted, the last thing a terminally ill person would want would be to argue unnecessarily about their issues with an unsupportive doctor. If patients’ best wishes are to be considered, it is likely that there would be many doctors who would assist them, without declaring that doctors must assist. It might well be that some doctors will specialise in seeing patients with end-of-life issues, as happens in many fields of medicine.

53.      Aren’t doctors obliged to abide by the Hippocratic Oath?

The Hippocratic Oath is an historical one required for some medical graduates to uphold specific ethical standards. The argument is that in upholding the oath requires that the doctor not act to harm a patient.

First, it is an oath drawn from ancient times, before surgery and modern medical interventions were known, and even its updated versions would not be expected to provide the most appropriate moral guidance.

Second, not all medical graduates take the oath: some take a modified version that would allow the option of abortion and/or voluntary euthanasia, and some may not take an oath at all.

54.      Shouldn’t doctors ‘do no harm’?

Some opposed to voluntary euthanasia argue that ‘doctors should do no harm’. They claim that doctors who might prescribe a drug for a terminally ill patient are doing harm because the drug, if taken, would cause the death of the patient.

This argument ignores the fact that, from the patient’s perspective, his or her hastened death is good. It is a better outcome than remaining alive and suffering, which, according to the patient, would be more harmful. Consistent with people being able to determine what is right for their own bodies, it would be arrogant for some doctors and others who oppose euthanasia to mandate that the patient must instead stay alive and suffer. Any reasonable person would appreciate that each individual is his or her own arbiter of what is harm to his or her body, and what is not.

55.      Could the importation of end-of-life drugs be made permissible under certain conditions?

In the human rights model of voluntary euthanasia, individuals are empowered to make decisions about their own life without the required intervention of medical practitioners. In such a model, the ability of people to acquire drugs, in small amounts for personal usage, is desirable. People could then use these drugs, for example, if they were to ever to become terminally ill. Many people would, however, be buying drugs that they might not ever need to use, and so this could be an inefficient use of their funds and resources.

A better option would be to have a situation whereby drugs could be easily and legally procured if and when a person were to be terminally ill.

56.      General conclusion on regulatory considerations.

Voluntary euthanasia has been found to be ethically sound. The regulatory option being most adopted in developed countries is the medical model. There are sufficient, and some would claim excessive, regulatory hurdles to ensure that only terminally ill people, of sound mind, have access to these regulatory schemes. Substantial compliance, enforcement and reporting regimes give jurisdictions confidence that only those persons who are eligible for voluntary euthanasia are able to access it.

The medical model is not as liberal, or accessible to individuals, as the human rights model. The human rights model will require substantially more debate before its issues can be addressed and then regulated in many jurisdictions.

However, it must be recognised that in the absence of more liberal regulatory systems, many elderly people worldwide are accessing end-of-life drugs, consistent with the human rights model. Governments ought to realise that, even as they give effect to regulatory systems based on the medical model, many people will continue to procure drugs, just in case they might ever need them. Regulation is not keeping pace with people’s concerns about control over their own lives and their fear of horrific end-of-life circumstances.

Part 4. Individual Considerations

If ethical arguments for euthanasia are compelling, regardless of a jurisdiction’s regulatory restrictions, individuals need to decide what and how they might act on the end-of-life options available to them. If voluntary euthanasia were legal in a jurisdiction, the legal options for individuals would possibly be preferred. Otherwise, individuals will need to act outside the law.

Note that if somebody is not of sound mind, then he or she may not be able to make a well-considered opinion about an end-of-life decision. If people are concerned about their health and end-of-life options, they should see their health professional. Alternatively, support groups such as Beyond Blue and Lifeline (based in Australia) provide useful support information.

57.      Under what conditions should a person choose voluntary euthanasia?

One would hope that no one would ever need to choose voluntary euthanasia and that there was no further pain and suffering, but even the best medical and palliative care cannot ensure that. The conditions under which a person might choose to die require consideration.  People might want to talk to family, friends, medical professionals and others to make sure they have all the information they need to make an informed decision.

If a person is ill, he or she should understand the nature of and prognosis for his or her illness, the risks of action or inaction, and give consideration to the key questions of why, what and how, when, where, who and how much. Being well informed means that individuals are well equipped to make the right decision for themselves.

58.      Should I inform my family and friends of my intention to die?

Whether a person should inform others that he or she is going to die is an individual matter. Many people would doubtlessly wish to be informed that someone they care about was about to die through voluntary euthanasia, to have a chance to say goodbye, rather than be hit with the grief and shock of a relative’s sudden death.

However, if family and friends oppose a person’s proposed course of action, they could well act to prevent it. Early discussions with family and friends, before a person becomes terminally ill, would be desirable.

59.      Should I tell my doctor that I will want to die, if in the future, I become terminally ill?

The decision to tell a doctor about plans for your death has its advantages and disadvantages. If your doctor is supportive of euthanasia, in a jurisdiction where euthanasia is permitted, the advice, comfort and support that he or she could provide could be invaluable.

If a person’s doctor is not supportive of euthanasia, or the person lives in a jurisdiction where voluntary euthanasia and assisted suicide are illegal, then the person informing him or her of any voluntary euthanasia end-of-life plans could result in any end-of-life plans being thwarted.

60.      Should I inform government authorities about when I choose to die?

If voluntary euthanasia is legal, there may be a requirement to inform authorities. If it is not legal, then informing authorities could mean that they might prevent a person’s planned voluntary euthanasia.

61.      How should I die?

The question of how one should die would not have been worthy of serious consideration when people struggled to survive to old age and when medicine was no more that superstitious nonsense. Since medical science can now keep people alive to a point when their quality of life might become unacceptable to them, this question now merits serious consideration.

Of course, it is hoped that all people will eventually die peacefully, without any pain and suffering. If this is not to be, a person might want to consider availing themselves of voluntary euthanasia laws if it is legal in their jurisdiction.

If voluntary euthanasia is illegal, then many people will continue to act on their own to procure, manufacture or otherwise obtain drugs or other means by which they can end their lives peacefully, and with certainty.

The self-administration of life-ending drugs is tantamount to an act of suicide, which, again, is a legal act in many jurisdictions. But not all terminally ill people are sufficiently well to carry out their end-of-life plan, and so how someone dies might need to be considered in conjunction with when they should die.

62.      Should I involve others to help me to die?

Obtaining help to die is illegal in many jurisdictions. In places where voluntary euthanasia or assisted suicide is legal, assistance might only be available from the medical fraternity, consistent with the medical model for voluntary euthanasia.

Where voluntary euthanasia is illegal, a person should not seek assistance unless he or she is prepared to put their loved ones in a position of possible legal penalty. However, clear requests to relatives from terminally ill people to stop their suffering have been known to cause family members, or other persons, to assist in the dying process. On many occasions, the legal penalty has been light. This reflects society’s view that the person who assisted was not acting out of hatred or malice, but out of the love and respect for his or her loved one.

Some people who are considering voluntary euthanasia in the event of a possible terminal illness are planning carefully to ensure that they will have the means to commit suicide without others being involved. Others are arranging with friends and relatives, and developing effective, if not legal, means of ensuring that their end-of-life plan can be carried out.

Where voluntary euthanasia is legal, there may be regulatory requirements that ought to be met. This might involve visits to doctors and psychologists, and these may be time-consuming.

63.      Should I help my partner die if he or she is terminally ill and requests my assistance to help him or her die?

Nobody wants to see a loved one suffer, and we would ordinarily do what we can to make his or her last days as comfortable as possible, whether at home or in a palliative care hospice.

Assisting a person to die may or may not be legal, depending on the jurisdiction. In cases where assisted suicide is illegal, penalties for assisting a death of a terminally ill person have varied from the heavy to extremely light.

64.      Should I have any number of people with me when I die?

If a person wants to die in the company of loved ones, they can arrange for that to occur.

In jurisdictions where voluntary euthanasia or assisted suicide is illegal, it is possible that loved ones could face criminal penalties. This is especially so if there is doubt about whether the death was voluntary or assisted.

65.      Should I die in a public place if I choose to?

We should all be able to choose the manner, time and place of our death. The possible use of a public place raises concerns. When the rights of others are to be infringed, for example, by being forced to view a person’s death or suicide that they might not wish to see, the use of a public place should be strongly discouraged. It could cause stress and anxiety for other people, including children.

There is also the possibility that emergency services could be called to stop a suicide. The average passer-by would not know that a person committing suicide is of sound mind or not. In addition, a member of the public would assume that if someone were about to die, they should try to prevent that, either individually or with the assistance of others.

The presumption, without knowing the situation of the person who is dying, would be to save a life.  

66.      Should I have an advance care plan in place?

Every person should seriously consider an advance care plan. It sets out the conditions under which, for example, one might not want to be revived if terminally ill. In some jurisdictions, it is possible that it could set out the conditions for euthanasia.

67.      What if I have developed an advance care plan, but later in life I am demented, content and do not want to die?

Some see an advanced care plan as a two-edged sword. A person might set out the conditions under which he or she would want euthanasia, including for example when he or she is demented and cannot recognise his or her partner or children. However, it is also possible that, with dementia, a person might nonetheless be content, and would not wish to die.  While an advance care plan is an excellent individual option, the conditions in any such plan will require careful consideration.

68.      What if I want to die now and I am not terminally ill yet?

All people have the right to live or not live, with some conditions discussed above. If a person is not of sound mind, they should be treated for their condition. If a person were affected during their life, with grief, misfortune or illness, our spirits could improve with the ordinary passage of time. A person would not wish that he or she, or his or her loved ones, should die during a momentary departure from our normal ebullient selves.

It is rare that a person would want to die if he or she was not terminally ill, but instances of rational suicide are now being documented.

A regulatory question is to what extent should the state pay for people to assist others to die, especially if they are not terminally ill.  In any event, the utmost support should be given to people considering rational suicide, to ensure that they are of sound mind. While many people may not understand a person’s decision to die when it is for a reason other than a terminally illness, the choice of rational suicide must ultimately rest with each person.

Every person’s life is his or her life; it is not for the state to interfere in the individual lives of others.

69.      Where could I hide illegal end-of-life drugs?

In jurisdictions where voluntary euthanasia is illegal many people have acquired illegal end-of-life drugs, just in case they are needed. Depending on the drugs, most people store them in cool, secure positions. People would understand that these drugs could not be stored where they could be inadvertently accessed or used by others, including children.

It would be inappropriate here to provide advice on how to acquire and store illegal drugs.

70.      Are people who acquire illegal end-of-life drugs culpable?

In many legal systems, those who acquire illegal end-of-life drugs for their own use have committed an illegal act, and if caught, could thus be classified as criminals. This, however, does not seem to perturb many thousands of people, mostly the elderly, who have acquired such drugs for their personal end-of-life use. Many are members of euthanasia advocacy groups such as Exit International.

Is it right for these people to be considered criminals? No, not if the ethical arguments in favour of voluntary euthanasia are stronger than those against.

It is quite likely that euthanasia, while illegal, will be considered in a similar way to homosexuality and gay marriage. While illegal many years ago (or still illegal), these individual rights issues are increasingly being considered as perfectly legitimate in more progressive societies.

71.      If a terminally ill person chooses to have voluntary euthanasia, at what point should that occur?

If a person wishes voluntary euthanasia in a jurisdiction where voluntary euthanasia is legal, the answer to when one should choose euthanasia can be relatively straightforward. It should be when the most accurate prognosis is that the person’s desired minimum quality of life is unsatisfactory and will never again be attained.

That is one view. Others might conclude that, although their quality of life might be unsatisfactory, they would prefer to postpone their access to euthanasia to see a grandchild marry or graduate.

It would be important to give such matters appreciable consideration. Ultimately, this will be the most personal of all decisions one could make in one’s life.

72.      When can one determine the tipping point between capacity to have voluntary euthanasia and the onset of ‘missed the window’?

The most vexing question for many people now, particularly in jurisdictions where voluntary euthanasia is illegal, is to know when they must take a pill lest they be left to pain and suffering, and unable to have it.

There is no straightforward answer. Many elderly people in terrible circumstances might commit suicide prematurely, or might wait too long, and then spend their last weeks in a hospice, unable to commit suicide, and suffer nonetheless.

73.      General conclusion on individual considerations.

Voluntary euthanasia is ethically sound. The human rights model allows the greatest individual liberty but the medical rights model is the regulatory model being legislated in jurisdictions. Depending on the regulatory options available, individuals are confronted with a range of issues that they will need to consider. They should consider their end of life plans, and how they might implement them, well in advance of when they might ever need to use them. Individuals will have concerns about acting prematurely, but leaving matters too late could mean that individuals will suffer.

Part 5. Some Definitions and Explanations

74.      What is voluntary euthanasia?

The word euthanasia originates from the Greek words meaning ‘good death’.

Voluntary euthanasia is a deliberate act intended to cause the death of an individual, at that individual’s request, for what he or she sees as being in his or her best interests.

Voluntary euthanasia is often referred to simply as ‘euthanasia’. From the above definition of voluntary euthanasia, the voluntary nature of it, being ‘at that individual’s request’ is explicit. The term voluntary has been explicitly included in these FAQs to provide emphasis for that voluntary aspect, though its use should be unnecessary.

According to the World Federation of Right to Die Societies, euthanasia is defined as a ‘deliberate termination of life by someone else, on the explicit request of the person involved. “Voluntary” euthanasia is a term to emphasise the voluntariness of the request for euthanasia. Some add the terms passive/active to make a distinction between palliative sedation (passive) and euthanasia (active)’.

Voluntary euthanasia may involve, for example, the administration of life ending drugs to a person, often by the person himself or herself, or by a physician.

The former could also be considered a form of suicide, the latter could be considered as active voluntary euthanasia. Voluntary euthanasia may also involve a person’s choosing to take drugs that he or she has acquired, either through a legal prescription or illegally.

According to the World Federation of Right to Die Societies, voluntary active euthanasia ‘entails the physician taking an active role in carrying out the patient’s request, and usually involves intravenous delivery of a lethal substance’.

Voluntary euthanasia throughout these FAQs is taken to have as broad a meaning as possible, and depending on the context and FAQ includes physician-assisted suicide.

75.      What is not voluntary euthanasia?

For the purposes of discussion on the issues being debated worldwide, the following are not classified as voluntary euthanasia:

• any act, or omission of activity, causing death that is not at the request of the patient (the patient must be of sound mind and well informed)
• doctors causing patients to die through overdosing them on painkillers or similar drugs
• doctors letting patients die of natural causes, possibly with some palliation (sometimes referred to as passive voluntary euthanasia)
• any act inconsistent with the definition of voluntary euthanasia above.

76.      Is voluntary euthanasia the same as mercy killing?

Voluntary euthanasia might not be a mercy killing, because a mercy killing might not, and oftentimes is not, voluntary. A mercy killing is the killing of someone who is very sick or injured in order to prevent any further suffering.

The word ‘killing’ has connotations of an action that usually is unwanted by the person being killed, so the word ‘killing’ is also inappropriate. While the intent and consequences of voluntary and mercy killing may be the same (e.g. to relieve unrelievable suffering), the main distinguishing feature between voluntary euthanasia and mercy killing is the voluntary aspect of voluntary euthanasia.

77.      What is physician-assisted suicide?

According to the World Federation of Right to Die Societies, ‘physician-assisted suicide entails making lethal means available to the patient to be used at a time of the patient’s own choosing’.

In the context of euthanasia discussions, a physician could prescribe end-of-life drugs, at the request of the patient. Consequently, it could be recognised as a form of voluntary euthanasia that requires minimal action from a physician. In this way, a person can be in control of his or her own death, and nobody other than the individual themselves has a direct involvement in the act that causes death.

78.      How is terminal illness generally defined?

A terminal illness is one that cannot be adequately treated and could reasonably be expected to result in death in a fairly short timeframe. This period could be a few weeks or months, six months or even one year. It can be and usually is defined in voluntary euthanasia legislation.

There are debilitating illnesses and conditions that might not result in the deaths of patients for many years, and although not terminal according to the above definition, these illnesses and conditions are just as concerning for the people suffering from them.

79.      What is the Golden Rule?

The Golden Rule is a fundamental ethical principle ‘that one should do to others as you would have them do to you’.

Many moral systems, including those of major religions, have adopted a form of this ethical principle.

It follows that if you do not want others to dictate how you should live or die, you should not similarly dictate to, and force your views on, others about how they should live and die.

80.      What is the medical model for voluntary euthanasia?

The medical model for voluntary euthanasia involves the medical fraternity being involved in the implementation of individuals’ end of life decision making. This can occur through the administration of drugs, the assessment of a person as terminally ill, or by attesting to the state of mind of the person (in particular, are they of sound mind) requesting euthanasia. The medical model is the predominant voluntary euthanasia regulatory model legislated in jurisdictions.

81.      What is the human rights model for voluntary euthanasia?

The human rights model of voluntary euthanasia provides individuals with the rights and means to make end-of-life decisions about their own lives, without the involvement of medical doctors at the implementation stage. Involvement from doctors, including obtaining drugs, may not be required under the human rights model for voluntary euthanasia.

82.      What is rational suicide?

Rational suicide is suicide that does not require that the person be terminally ill; a person with a severely debilitating condition might choose to die. Any strong rational case that suicide is a better option than living would qualify as rational suicide.

An Australian woman committed a rational suicide when she was tired of life at age 80, claiming that it was nobody’s decision but hers. Another chose to die, although not terminally ill, when her terminally ill husband chose to die.

Rational suicide in cases where terminal illness is not involved would be considered suicide, though that carries connotations of a decision made for irrational reasons.

Suicide that might occur because of depression or other like illnesses would not be classified as rational suicide. This is because the person in those instances may not be considered to be of sound mind.

Part 6. Notes

Many of the frequently asked questions (FAQs) contain information obtained and summarised from other sources. These FAQs are a summary of the major questions that arise in euthanasia debates, structured according to the ERIC (ethical, regulatory, individual considerations) model.

The FAQs are intended to be easily accessible by those interested in euthanasia issues, and are not a comprehensive philosophical, technical and legal treatise of the euthanasia issue. Readers are of course at liberty and are encouraged to conduct more research on overseas models, and the ethical, regulatory and individual considerations that are important to them.

There are different views on euthanasia across jurisdictions. An attempt has been made here to generalise responses across jurisdictions without going into the specific details of each issue. As the FAQs are general in nature, it is possible and regrettable that there could be specific details on an issue, or for a jurisdiction, that might not be correct in this more general context.

Responses to FAQs should not be considered as legal advice. If people are concerned about their health and end-of-life options, they should see their health professional. Alternatively, support groups such as Beyond Blue and Lifeline (based in Australia) provide useful support information.

Ethical Rights advises that individuals should consider end-of-life arguments critically and carefully, assess their objectiveness, and make their own decisions about the issues. They should do so as far as possible free of religious, cultural, political or other bias. They should ask themselves the questions: what would an objective third party consider the ethical merits of voluntary euthanasia to be, how ought it be regulated, and how should people act when they are confronted with having to make end-of-life decisions.

For a better world…

David Swanton

Director, Ethical Rights

Acknowledgements

Ethical Rights would like to thank Jeanne K, Tash and others for their constructive and valuable comments on this document. 

David Swanton is an ethicist, scientist and director of Ethical Rights . He is also ACT Chapter Coordinator for Exit International.