Respect for autonomy is typically considered a key reason for allowing physician assisted suicide and euthanasia. However, several recent papers have claimed this to be grounded in a misconception of the normative relevance of autonomy. It has been argued that autonomy is properly conceived of as a value, and that this makes assisted suicide as well as euthanasia wrong, since they destroy the autonomy of the patient. This paper evaluates this line of reasoning by investigating the conception of valuable autonomy. (...) Starting off from the current debate in end-of-life care, two different interpretations of how autonomy is valuable is discussed. According to one interpretation, autonomy is a personal prudential value, which may provide a reason why euthanasia and assisted suicide might be against a patient’s best interests. According to a second interpretation, inspired by Kantian ethics, being autonomous is unconditionally valuable, which may imply a duty to preserve autonomy. We argue that both lines of reasoning have limitations when it comes to situations relevant for end-of life care. It is concluded that neither way of reasoning can be used to show that assisted suicide or euthanasia always is impermissible. (shrink)

ABSTRACT The Dutch case of Brongersma presents novel challenges to the definition and evaluation of voluntary euthanasia since it involved a doctor assisting the suicide of an individual who was (merely?) ‘tired of life’. Legal officials had called on the courts to ‘set a principled boundary’, excluding such cases from the scope of permissible voluntary euthanasia, but they arguably failed. This failure is explicable, however, since the case seems justifiable by reference to the two major principles in favour of that (...) practice, respect for autonomy and beneficence. Ultimately, it will be argued that those proponents of voluntary euthanasia who are wary of its use in such circumstances may need to draw upon ‘practical’ objections, in order to erect an otherwise arbitrary perimeter. Furthermore, it will be suggested that the issues raised by the case are not peculiarly Dutch in nature and that, therefore, there are lessons here for other jurisdictions too. (shrink)

ABSTRACT The Dutch case of Brongersma presents novel challenges to the definition and evaluation of voluntary euthanasia since it involved a doctor assisting the suicide of an individual who was (merely?) ‘tired of life’. Legal officials had called on the courts to ‘set a principled boundary’, excluding such cases from the scope of permissible voluntary euthanasia, but they arguably failed. This failure is explicable, however, since the case seems justifiable by reference to the two major principles in favour of that (...) practice, respect for autonomy and beneficence. Ultimately, it will be argued that those proponents of voluntary euthanasia who are wary of its use in such circumstances may need to draw upon ‘practical’ objections, in order to erect an otherwise arbitrary perimeter. Furthermore, it will be suggested that the issues raised by the case are not peculiarly Dutch in nature and that, therefore, there are lessons here for other jurisdictions too. (shrink)

Book reviewed in this article: Principles of Biomedical Ethics. By Tom L. Beauchamp and James F. Childress.

Background One of the objectives of medicine is to relieve patients' suffering. As a consequence, it is important to understand patients' perspectives of suffering and their ability to cope. However, there is poor insight into what determines their suffering and their ability to bear it. Purpose To explore the constituent elements of suffering of patients who explicitly request euthanasia or physician-assisted suicide (EAS) and to better understand unbearable suffering from the patients' perspective. Patients and methods A qualitative study using in-depth (...) face-to-face interviews was conducted with 31 patients who had requested EAS. The grounded theory approach was used to analyse the data. Results Medical, psycho-emotional, socio-environmental and existential themes contributed to suffering. Especially fatigue, pain, decline, negative feelings, loss of self, fear of future suffering, dependency, loss of autonomy, being worn out, being a burden, loneliness, loss of all that makes life worth living, hopelessness, pointlessness and being tired of living were constituent elements of unbearable suffering. Only patients with a psychiatric (co)diagnosis suffered unbearably all the time. Conclusions Unbearable suffering is the outcome of an intensive process that originates in the symptoms of illness and/or ageing. According to patients, hopelessness is an essential element of unbearable suffering. Medical and social elements may cause suffering, but especially when accompanied by psycho-emotional and existential problems suffering will become ‘unbearable’. Personality characteristics and biographical aspects greatly influence the burden of suffering. Unbearable suffering can only be understood in the continuum of the patients' perspectives of the past, the present and expectations of the future. (shrink)

IN her work on the distinction between freedom and voluntariness, Serena Olsaretti suggests the following definition of voluntary action: an action is voluntary if it is not non-voluntary, and non-voluntary if it is performed because there are no acceptable alternatives, where ‘acceptable’ means conforming to some objective standard (which Olsaretti suggests might be well-being). Olsaretti suggests that ascriptions of responsibility are underwritten by judgments of voluntariness, rather than freedom. Also, Olsaretti notes that a concern for voluntary choice might be grounded (...) in respect for autonomy. So, two important questions in political philosophy – when an agent is responsible for her actions and what we must do if we want agents to live autonomous lives – hang upon whether Olsaretti's account of voluntariness is correct once it has been developed in detail. This article is a contribution to that development. I show that well-informedness about our options is crucial to whether we act voluntarily or not, and I argue that we should restrict the scope of what we consider relevantly unacceptable to include only things which involve serious prudential harm. Inevitably there are some questions left unanswered, but what follows indicates what I take to be the strongest form of Olsaretti's theory, and one which can play the role described for it above. (shrink)

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Objective: To explore the experiences of people with a “terminal illness”, focusing on the patients’ perspective of euthanasia and assisted suicide.Method: A qualitative study using narrative interviews was conducted throughout the UK. The views of the 18 people who discussed euthanasia and assisted suicide were explored. These were drawn from a maximum variation sample, who said that they had a “terminal” illness, malignant or non-malignant.Results: That UK law should be changed to allow assisted suicide or voluntary euthanasia was felt strongly (...) by most people. Those who had seen others die were particularly convinced that this should be a right. Some had multiple reasons, including pain and anticipated pain, fear of indignity, loss of control and cognitive impairment. Those who did not want to be a burden also had other reasons for wanting euthanasia. Suicide was contemplated by a few, who would have preferred a change in the law to allow them to end their lives with medical help and in the company of family or friends. The few who opposed a change in UK law, or who felt ambivalent, focused on involuntary euthanasia, cited religious reasons or worried that new legislation might be open to abuse.Conclusion: Qualitative research conducted on people who know they are nearing death is an important addition to the international debate on euthanasia and assisted suicide. Those who had seen others die were particularly convinced that the law should be changed to allow assisted death. (shrink)

Whether the law should permit voluntary euthanasia or physician-assisted suicide is one of the most vital questions facing all modern societies. Internationally, the main obstacle to legalisation has proved to be the objection that, even if they were morally acceptable in certain 'hard cases', voluntary euthanasia and physician-assisted suicide could not be effectively controlled; society would slide down a 'slippery slope' to the killing of patients who did not make a free and informed request, or for whom palliative care would (...) have offered an alternative. How cogent is this objection? This book provides the general reader with a lucid introduction to this central question in the debate, not least by reviewing the Dutch euthanasia experience. It will interest all in any country whether currently for or against legalisation, who wish to ensure that their opinions are better informed. (shrink)

In 1993, Professor of Jurisprudence, Ronald Dworkin of Oxford University and Professor of Law at New York University, delivered the Georgetown Law Center’s thirteenth Annual Philip A. Hart Memorial Lecture: "Life’s Dominion: An Argument About Abortion and Euthanasia." Dworkin is Professor of Philosophy and Frank Henry Sommer Professor of Law at New York University. He received B.A. degrees from both Harvard College and Oxford University, and an LL.B. from Harvard Law School and clerked for Judge Learned Hand. He was associated (...) with a law firm in New York (Sullivan and Cromwell) and was a professor of law at Yale University Law School from 1962-1969. He has been Professor of Jurisprudence at Oxford and Fellow of University College since 1969. He has a joint appointment at Oxford and at NYU where he is a professor both in the Law School and the Philosophy Department. He is a Fellow of the British Academy and a member of the American Academy of Arts and Sciences. Professor Dworkin is the author of many articles in philosophical and legal journals as well as articles on legal and political topics in the New York Review of Books. He has written Taking Rights Seriously (1977), A Matter of Principle (1985), Law’s Empire (1986), Philosophical Issues in Senile Dementia (1987), A Bill of Rights for Britain (1990), Life’s Dominion (1993), and Freedom’s Law (1996). (shrink)

Suppose that we think it important that people have the chance to enjoy autonomous lives. An obvious corollary of this thought is that people should, if they want it, have control over the time and manner of their deaths, either ending their own lives, or by securing the help of others in doing so. So, generally, and even if we overall think that the practice should not be legalized on other grounds, it looks like common sense to think that considerations (...) of autonomy tell at least somewhat in favour of legalizing at least some acts of suicide and voluntary euthanasia. In this paper, I argue that, in fact, when we scrutinize the reasons for most end of life decisions, it turns out that they are seriously problematic from the point of view of autonomy. Full autonomy requires that we are responsible for the consequences of our decisions, and responsibility is precluded by non-voluntariness, which is to say decisions made because there are no acceptable alternatives. Since most end of life decisions are made for precisely this reason, it looks as though most such decisions are non-voluntary, and therefore undermine our autonomy: a discomforting and paradoxical claim. I argue that we should respond by taking the paradox to illuminate the context required by an autonomy-respecting framework for legalizing assisted suicide and euthanasia. People should have a legal right to a reasonable choice about when and how to die. However, this must go hand in hand with institutions that ensure, as far as possible, that such choices are made against a background which ensures, as far as possible, that people choose death clear-sightedly and not because nothing else is acceptable. (shrink)