Overlooked Costs of Legalizing Assisted Suicide and Euthanasia

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Introduction

Human beings are naturally inhibited with regard to intentionally ending their lives and those of innocent others; human beings naturally love their lives and those of others, and human beings naturally regard human lives as having inalienable worth that is not diminished by or lost by an individual’s circumstances or condition. What do all these natural human proclivities have in common? These natural proclivities are acknowledged, sanctioned, and protected as the basis and justification of homicide law. By so doing, homicide law has the effect of defending the natural right to liberty: I will refer to liberty and freedom as self-governance. Being what it is, homicide law grants everyone the right to privacy, that is, immunity from intrusions and restraints on their self-governance. As it now stands, anyone who obeys the laws, particularly homicide law, is free to be self-governing. I now move to consider what would happen to homicide law and what it provides for our inalienable rights to life and liberty when physician-assisted suicide (PAS) and euthanasia are legalized.

The Inhibitions Against Killing Innocent Human Beings

Human beings are naturally inhibited against killing any innocent human beings. If that were not so, it is difficult to see how any laws against intentionally killing innocent human beings could be enforced. Indeed, one can scarcely imagine that such laws would be enacted or that communities could survive or even be formed. In any event, the inhibition against killing innocent human beings is a requisite of the existence and sustenance of individual and communal life.[1]

Preserving and acknowledging the need for—and possibility of—the persistence of the inhibition against killing any innocent human being depends upon viewing the worth of human beings as inalienable, that is, in no way changed by circumstances and conditions of individuals. Furthermore, this persistent worth is legally enforced and is a key basis for homicide law.[2]

Proposals to enact a law that permits the practice of PAS do not accept the whole idea that the worth of human life is inalienable and that our laws should be based on such a concept. Rather, this concept—that life’s worth is inalienable—is directly or indirectly attacked, and the worth of life is asserted to be contingent on the circumstances and conditions individuals find themselves in. In effect, then, individuals should be free to find that they no longer wish to live and that being assisted to end their lives should be part of a right to autonomy (self-governance) and a practice that physicians should be legally permitted to render as a service upon request.[3]

Since there are countries and states that have legalized PAS, we can document what happens to our natural inhibitions about killing and having individuals killed by physicians. The natural inhibition that restrains any willingness to kill innocent human beings or allow individuals to do so, is definitely weakened, even severely eroded. Let us now consider some current examples.

In the Netherlands, once physicians who were assisting individuals to end their lives by lethal means were not being prosecuted, physicians also engaged in euthanasia. And the practice of euthanasia has been extended to ending the lives of patients who have not requested having their lives ended. Furthermore, these patients need not even be terminally ill.[4] Clearly, the inhibitions of the physicians (against killing innocent human beings) who indulge in such practices are very weak indeed: physicians act on the basis of what circumstances and conditions they believe make the lives of individuals no longer worth living. For them, then, the worth of any individual life has no enduring, inherent, and unqualified worth. Later below, we shall examine how this dramatically changes the physician-patient relation and the very role of physicians.

The country of Belgium is undergoing the same kinds of behaviors that can only occur if the natural inhibitions against killing innocent human beings are all too feebly present in physicians who assist patients to commit suicide and euthanize them with and without their consent. Furthermore, the law in Belgium now permits ending the lives of children as well. Toni C. Saad in his review of euthanasia in Belgium comes to the following conclusion: “Is it possible to regulate euthanasia and prevent its abuse, risks, and harms? The case of Belgium appears to indicate that the answer is no.”[5]

Legalization of PAS in Oregon presents us with a very dramatic sketch of what a physician can claim to be a justified reason for assisting in a patient’s suicide. Dr. Kade (a pseudonym) professes to be surprised by the desire of one of his patients to have him terminate her life. Though terminally ill, her life did not seem to him to be “terminal” because, as he observes, it is rather:

in most respects quite remarkable. She was engaged to be married; she still pursued many meaningful activities; and she had a devoted and invested family. She did not seem to manifest any of the characteristics that I considered constituted intolerable suffering…She had no pain, maintained an adequate appetite, and was no longer bothered by night sweats.[6]

So what was there that constituted suffering in her case? She could not live her life as fully and independently as she wished and saw as defining her. As a result, her love of life began to wane and slip away from her. That was a suffering of soul and mind as of body. Dr. Kade could not at first consider what she was suffering as severe.[7]

Dr. Kade saw himself as involved in a vexing dilemma. On the one hand, he believed that all his patients had the right to make informed decisions providing they were capable of that and the decisions were legal.[8] Yet he opposed the legalization of PAS because it opened the door for a seeking of death for the wrong reasons.[9] He describes himself as caught between his belief in patient “autonomy” and his belief in “protecting the public.”[10]

Some months after aiding his patient to end her life, Dr. Kade expresses his confidence that he “made the right decision for her.”[11] And he considers the decision his patient made the right one. He defends the decision he and his patient made. First of all, the patient had the right to choose to end her life because she saw it as futile and as a decision the Oregon statute allowed her to make. At the same time, Dr. Kade, who resisted at first to honor her request but changed his mind, redefined her suffering as “intolerable.”[12] He pointedly notes that the patient’s love of life was slipping away.[13]

By tying what constitutes intolerable suffering to individuals’ loss of love for their lives, Dr. Kade is not thinking of the worth of life as inalienable, as something that cannot and should not be changed. Love of life is, after all, one of the reasons courts have upheld the constitutionality of homicide law that rejects legalizing PAS.[14] Dr. Kade does not indicate any concern about the natural love of life supported and embedded in homicide law. Nor does he provide any reason to reject people’s claim to have lost their love of life and to be suffering intolerably as a result.

Suicide prevention hinges on efforts to sustain and strengthen the love of life in anyone, such as those who are depressed. Nor does he recognize the role of physicians changing from unconditional advocacy of life to physicians who allow for advocating ending one’s life.[15] Consider that, in the Netherlands, some physicians actually advocate for euthanasia and terminate the lives of their patients, even when they are not terminally ill. One such instance involved a patient being sustained by medication prescribed by her doctor and living what can be described as a meaningful, quite independent life. She’s told by her doctor that she should have her life ended. She complies. The doctor then no longer supplies her with any more medication, and her life ends in three days.[16]

Are there sound reasons for regarding love of life as a natural phenomenon characteristic of human beings as such? There surely are. Our love of our own lives and those of others—that is, wishing the self and others to exist—is the cognitive basis for preventing suicides, suicidal thoughts, and thoughts about perpetrating violence against ourselves and/or others. This perception is based upon the natural love of life expressed in people’s behavior and our many efforts to protect and perpetrate it in all of us.

Love of life occurs abundantly in the human desires and actions to have children and nurture them so that they have every chance to live and thrive. Consider our communal efforts on behalf of the love of life. These are numerous. Communities have police forces, military forces, firefighters, medical care, both in hospitals and by medical personnel, and enforced restrictions governing life-threatening substances, whether in food, air, water, or medications. All of these efforts are generated by an acceptance of the worth of every human being’s life as such, whatever their circumstances or conditions. That is the conviction that is being knowingly or unknowingly neglected or rejected by proposals to legalize PAS and euthanasia.

The love of life is a natural impulse that is requisite of individual and communal life. No child would come into being and survive—nor would any community—if we did not naturally have a love of life for ourselves and others and strong inhibitions against the killing and harming of ourselves and others. Denying that such requisites exist and persist is simply a denial of our real world. This is a denial of why the human species has so far survived. One would think that would be obvious, but the proponents of legalizing PAS and euthanasia appear to be oblivious to the truth concerning what has ensured and will continue to ensure the survival of the human species.

Killing innocent human beings is so threatening that it is regarded and tried as a crime against humanity in an array of circumstances. The practice of involuntary euthanasia by some German doctors in World War II is one of those circumstances. Consider the practices that we have documented as occurring in the Netherlands and Belgium. Freedom from legal prosecution for doctors simply cannot be and is not limited to assisting to end or ending the lives of terminally ill patients. Physicians move from voluntary PAS all the way to involuntary euthanasia, and they do so with impunity, free of being prosecuted. Despite this, proposals to legalize PAS expect to limit PAS to when patients are terminally ill and request it. Where is the evidence that this will be enforceable?

One of the most appealing arguments for legally allowing physicians to end life under these very limited circumstances is that physicians already do just that when they no longer intervene to prolong life—or at least support life—and when they then provide interventions for comfort only.

The Harmfulness of Killing

The most compelling argument—on the face of it—is that of regarding the refusal of medical efforts to prolong life while terminally ill as morally and legally equivalent to having it ended by physicians supplying such patients with lethal means to end their lives. Among the similarities between refusing life-supportive therapies and ending a life by means of PAS, Beauchamp and Childress contend that there is one that puts the burden of proof on those who think it is morally justifiable to let people die but taking active steps to help them die is not. This they believe they have accomplished by specifying when death harms the one who dies, however that takes place. If an individual, they assert, desires death rather than life’s more typical goods and projects, then causing that person’s death at his or her autonomous request does not at all harm the person who is terminally ill. In other words, the wrong in killing is that individuals killed are thereby deprived of interests they may otherwise pursue and lose the very capacity to plan a future in pursuit of their interests. But individuals who desire death are presumed by Beauchamp and Childress to have no further interests they wish to pursue and so cannot be harmed by taking their lives or having them taken. Beauchamp and Childress have in effect argued that, for individuals desiring death, life has lost all its worth, at least all worth that may be considered morally significant. Add to this individuals who do not desire to pursue life in order to escape from suffering; then denying them their plan is the harm that should be avoided.[17]

Beauchamp and Childress throw out their challenge to those who justify some instances of comfort-only care but no instances of PAS and euthanasia: they must give a different account of the harmfulness of killing than the one offered by Beauchamp and Childress. That is not the difficult task Beauchamp and Childress assume they are setting, since one that now exists is definitely one that is the basis for homicide law and its support for state laws that ban PAS and euthanasia. Now, I turn to what is wrong about killing and requiring oneself to be killed.

What’s wrong with killing and having oneself killed is clearly stated in homicide law. To begin with, current homicide law grants everyone the right to freedom (selfgovernance) by leaving people to make their own moral decisions, subject to obeying the laws of the land against being killed and harmed in a variety of ways, including invasions of privacy by such means as unwarranted searches and seizures. When Beauchamp and Childress declare that individuals who are terminally ill should be permitted to ask to be killed or assisted to commit suicide, they are sanctioning those individuals and others to violate homicide law. What presently is required of individuals—namely obeying homicide law as it now exists—is what allows people to be free (self-governing): Disobeying homicide law results in a loss of one’s freedom.

Consider the presuppositions that are not at all examined and acknowledged for their implications by those who propose legalizing PAS and euthanasia. Such a proposal creates a situation in which individuals have no moral responsibility to live in accord with the moral requisites of individuals and communities; natural inclinations to obey these moral demands is what makes it possible to form and sustain communities and enact laws that protect the individual members of these communities. Beauchamp and Childress do not portray individuals as having such moral responsibilities. In any event, they could argue that the terminally ill no longer need be expected to be bound by such moral responsibilities, as long as they pose no threat to the lives of others by any actions they remain capable of carrying out.

The arguments of Beauchamp and Childress noted above suggest some further unexamined assumptions behind their view that one can be harmlessly killed when one has no more interests and opportunities that one wishes and should be required to retain. Beauchamp and Childress have posited an outlook that sees the worth of life to us as human beings as a matter of having interests and projects—interests and projects no one is morally bound to entertain. For them, this affirmation is the most definitive, compelling reason to legalize PAS and remove the restraint of our current homicide law against doing so. Beauchamp and Childress are presupposing that the worth of being alive is not something that endures and should not be required by law to endure; individuals should be free to repudiate life’s worth.[18] Homicide law as it now exists regards lives of human beings as always worthy and people as naturally inclined to regard life as worthwhile. To be devoid of such inclinations is not characteristic of human beings; indeed, these inclinations are at the very basis of our laws against killing and being harmed.[19] What are these natural inclinations?

Courts that uphold state laws banning PAS, and so euthanasia as well, cite our natural love of life. This love is normally continuous, and it is upheld, protected, and encouraged by law. People who find their love of life eroding or waning are expected to regain it. That is why we have treatments for depression and other efforts to prevent suicidal ideation and attempts to commit suicide. Homicide law is justified on the basis that the worth of a human life should never be questioned. The worth of a human being should not be subject to being changed by law. The right to life in homicide law is treated as inalienable. To endorse enacting laws that repudiate or ignore this reality is to defy the unqualified endorsement of the natural inalienable right to life found in the Declaration of Independence, issued by key founders of what became the United States. That affirmation of an inalienable right to life is at the same time an affirmation of an essential moral requisite that makes it possible to form and perpetuate a community.

Those who are terminally ill need not and should not shed all interests and projects. All human beings have a moral responsibility to act in accord with the moral requisites that forbid killing and harming innocent lives and asking anyone to kill them or any innocent individual. Retaining those interests and projects is something terminally ill persons can and should do. By various means they can specify their dedication to continuing to affirm the worth of their lives by remaining in compliance with the moral requisites that make their lives and communities realizable. They can specify that their lives not be ended by lethal means and that, under certain circumstances, they wish to be attended by comfort-only medical services. What they are thereby achieving is retaining their worth and freedom to retain it to the very end of their lives.

They are also doing nothing to subvert the interests and projects they view as the most important responsibility of physicians—that is, to remain as advocates of life in every way that their skills and knowledge allow them to carry out these professional responsibilities. These are indispensable interests and projects that are not morally justifiable to curtail; they are interests and projects now supported and enforced by homicide law, affirming that the worth of human beings is not and should never by abrogated by a practice or law. Contrary to the claims made by Beauchamp and Childress, individuals who disown all interests and projects are harmed when they are killed.

The proposals being made by Beauchamp and Childress and the like-minded have us wondering when suicides are to be prevented. When we come upon a person poised to jump off a high bridge, are we to ask them whether they have the proper reasons for ending their lives? Or are we to leave them free to do what they intend to do and free to hold the reasons they have for doing so?

One wonders also what basis for homicide law Beauchamp and Childress and the other advocates for legalizing PAS and euthanasia have to offer. What laws and what view of life’s worth can ward off what is happening in countries like Belgium and Holland, once you accept as their basis the view that life’s worth is justifiably ended when PAS and euthanasia are allowed by the law of the land? Our present homicide law certainly does not justify any laws or practices that claim it should be permissible by law, for those who choose, to dispense with the worth of life. It is a very serious threat to the very survival of individuals and communities to reject the notion that humans by nature love life and are naturally guided by the very moral requisites for the existence and continuation of individuals and their communities. Beauchamp and Childress do not explicitly attend to or address these unfortunate consequences of legalizing PAS and euthanasia.

Among the untoward and life-threatening results wrought by the legalization of PAS are the changes in the role of physicians and physician-patient relations. First and foremost, physicians who prove willing to engage in PAS are no longer predictably or completely advocating and working on behalf of sustaining the lives of all their patients. Herbert Hendin, a U.S. psychiatrist, has called attention to the effect upon physician decision-making in the Netherlands by the practice of ending human lives.[20] On the basis of the considerable data on the practice, Hendin concluded that “euthanasia, fought for on the basis of the principle of autonomy and self-determination of patients, has actually increased the paternalistic power of the medical profession.”[21] Advocacy for the lives of their patients is at a low ebb indeed when you have physicians ending the lives of patients by means of involuntary euthanasia, and, for some of them, on the grounds that their patient has a low quality of life.[22] And so whether physicians advocate for the lives of their patients is literally a matter of life or death. Robert Twycross is clearly asserting advocacy for life and for improving the quality of life for patients in the care of hospice in an article entitled “Where There is Hope, There is Life: A View from the Hospice.”[23]

I will present two of the cases cited by Twycross, beginning with the situation of Sydney Cohen. He was told by his physician that he had cancer and would die a painful death in less than three months. Sydney Cohen described himself as “bedbound by pain and weakness, having been unable to drink water for six weeks… desperate, isolated and frightened, wishing for euthanasia.”[24] If this is all one knows about Sydney’s condition, there are those who would argue that it is humane to grant him a painless death instead of three months of agony if the prognosis is presumed to be correct. Had the law then allowed it, that would have been highly likely to happen at his request.

However, this is not the whole story. Eight months after being diagnosed with cancer and told he had three months to live, Sydney wrote, that under the care of the MacMillan Service (hospice home care), he is still alive and enjoying life because his pain is gone, eating normally, regaining his weight and strength, and thus feeling he is living a full life, worth living. He and his wife have changed their minds about euthanasia: they now oppose it on religious, moral, intellectual, and spiritual grounds.[25]

Sydney’s experiences illustrate what a profound difference it makes to be cared for by physicians and nurses who are advocates for life. In his case, it means care that works to increase the quality of life of their patients rather than end the life of patients who profess and/or are deemed to have a low quality of life.

Consider another case in which not only the prognosis is wrong but so is the diagnosis. Mr. CJ at age forty-eight was diagnosed with cancer, told he would die in two months, and would go blind during that time. Yet, thirteen months later, he had suffered no blindness and was in an improved condition that allowed him to go back to work, and that is what he did.[26]

Again, those who sanction and practice PAS and/or euthanasia would consider CJ an appropriate candidate for putting an end to his life before going blind. But during this thirteen-month period in 1989-1990 this was not a legal option: Hospice care was available then and still is now.

What we learn from these two cases is how highly important homicide law’s unconditional support of human life is; it allows for and supports the traditional advocacy for human life as a necessary, morally justifiable guide for all medical practitioners, puts a floor under hospice care, and also promotes the efforts to improve the quality of life of all patients in the care of medical practitioners.

There are some additional undesirable consequences that may ensue from legalizing PAS and euthanasia. Such a law may stipulate that all physicians engage in such practices when they receive a request from a terminally ill patient who requests what they are legally allowed to receive. Making such demands of physicians mirrors similar demands for people in business who do not wish to compromise their convictions by being forced to comply with requests from would-be customers that they regard as doing just that. This same problem could possibly arise with respect to the obligation to provide informed consent for patients. Physicians could well be compelled to inform patients who are terminally ill that PAS and euthanasia are options for them to receive upon request. These situations would in many instances weaken or destroy trust in physicians. At the very least, patients opposed to PAS and euthanasia would need to seek physicians who also oppose PAS and euthanasia and will not engage in them, thereby remaining as life-advocating physicians.

No one is able to ascertain all the consequences that will follow from legalizing PAS for the U.S. health care system that now obtains. All we know is that it does change and complicate the lives of physicians from whom the practice of medicine is already more complicated than many would ideally desire. Am I wrong in thinking that people generally would want a physician who errs on the side of life?

The Metaphysical/Theological Nature of Life and Death Decisions

In addressing the question whether PAS and euthanasia can justifiably be practiced and legalized, the term “sacred” is one of the ways in which the worth of the lives of human beings has been characterized. Does this mean that those who refer to life’s worth as sacred are expressing a religious conviction? That has not been the case in every instance.

In 1980, The American Bar Association drew up the Model Penal Code. That code asserted that “the interests in the sanctity of life are represented in the criminal homicide laws” and are “threatened” by anyone “who expresses a willingness to participate in taking the life of another even though the act might be accomplished with the consent, or at the request of the suicide victim.”[27] That an individual’s life is sacred is to describe its worth as continuous and in no respect contingent on life’s circumstances.[28] That in homicide law the worth of human life is not diminished by a person’s medical condition and the wishes of the one whose life is at stake is the view enforced in homicide law by defending life’s sacredness and inviolability.

The characterization of human life as sacred is to be found in the Supreme Court of Canada’s decision in 1993.[29] That court ruled that the law should completely prohibit PAS, since the argument for doing so, as Judge Sopinka wrote, “focuses on the generally held and deeply rooted belief in our society that human life is sacred, sacred and inviolable.”[30] To ban PAS expresses a state interest in not permitting human life to be “depreciated” by “allowing life to be taken;” it is also an interest articulated in the Criminal Code that prohibits “murder and other violent acts against others notwithstanding the consent of the victim.”[31]

Sopinka was well aware that the belief in the sacredness of human life is espoused in the Jewish and Christian traditions. He wished to avoid any entanglement with the issues surrounding the relations between the church and the state. This he did by denying that he at all appealed to authority but rather relied on logic and facts to legitimize his decision to ban PAS.[32] That decision equates “sacred” with “inviolable.” Metaphysically, Sopinka is assuming that human beings naturally affirm the inviolability (sacredness) of their life and thus the continuity of their worth. That same assumption is found in the Christian tradition arrived at from a theological and rational perspective.

In an anthology of Christian responses to suicide, Robert Orr’s article clearly articulates a theologically derived affirmation of the sacredness and inviolability of the worth of human life.[33] Orr considers the reality of the sacredness and inviolability of the worth of human life to be one of the strongest arguments against PAS. That is because, theologically, human beings are portrayed as created by God in God’s image and they, therefore, have the knowledge of right and wrong and are inclined to do what is morally right. This means that:

We are not totally autonomous but accountable to a sovereign God who has said “Thou shalt not kill” and has also shown the compassion of the Good Samaritan. We must treat each other with the reverence and respect befitting vessels containing God’s image.[34]

In a nutshell, physicians’ use of lethal means to assist suicides at their patients’ requests to put an end to their lives is strictly an unjustifiable violation of life’s sanctity and so of the continuous worthiness of human life under all circumstances; legalizing PAS would undercut homicide law’s current support for the sacredness and inviolability of human life.

Theologically, the injunction against killing is described as a commandment of God. However, that killing is a wrong-making characteristic of our actions and is affirmed in our common morality and in homicide law. Indeed, as explained earlier, legally enforcing adherence to this moral requisite is also a requisite of individual and communal life. Were humans not naturally possessed of this inhibition against killing, the human species could not exist. To initiate these practices and laws that undercut this inhibition threatens the existence of the human species.

There are, then, rational and empirically sound reasons to uphold homicide law and the understanding of the image of God put forward by Christian scholars like Robert Orr. On that view of the image of God, human beings are endowed with the necessary natural abilities to make moral decisions and to do so on rational and empirical grounds.

John Kilner has provided us with a remarkably thorough and extensively documented study of the Christian notions of the image of God, in historical and contemporary scholarship.[35] There are differing conceptions of the image of God; most notably, the idea that being in the image of God is something one can lose by losing rational, moral, functional, or relational capabilities. Kilner, like Orr, is among those who affirm that being in the image of God is never lost; our worth as human individuals is inviolable and continuous. For Kilner, that is because being in God’s image is not a matter of traits or capacities people have and can lose. Accordingly, we should never portray any human being as unworthy of life. He cannot agree with those Christian scholars who have decided that PAS should be legalized since doing so supports the view that an individual’s life can become unworthy of life—that is to say, not worth continuing.[36] We know, historically and even now, the tragic consequences of acting on such an idea.[37]

I am fully aware that there is much more to be said about arguments on behalf of and against legalizing PAS and euthanasia. I have provided more detailed accounts of these matters in Rethinking Rights And Responsibilities and in Life’s Worth.[38] However, what I had not sufficiently discerned and highlighted in either of those publications is that the indispensable basis for rejecting PAS and euthanasia is found in the rationale of our homicide law. What homicide law does is affirm and protect for us the very moral requisites of life that make it possible for individuals and communities to come to be and be sustained. Change homicide law in the way and on the basis of the legal change being sought by proponents of PAS and euthanasia, and you destroy the current protection of behavior vital to the survival of individual and communal lives and existence respectively.

Surely, therefore, we do not dare legalize PAS and euthanasia. The price of legalizing PAS and euthanasia is too high. It is nothing less than the weakening or destruction of the natural forces that have so far fueled the survival of the human species. That is the price for enacting laws that sanction PAS and euthanasia. That is a price too high to pay. We must not and should not pay it.

References

[1]Arthur J. Dyck, Rethinking Rights And Responsibilities: The Moral Bonds of Community (Washington, D.C.: Georgetown University Press), 93–113.

[2] Ibid. See in particular, Washington v Glucksberg 177 S.Ct 225 (1997); Vacco v Quill, S. Ct, 2293 (1997); Washington v Glucksberg, 2265; Rodriguiz v British Columbia (107 D.L.R. 4th 342, 1993), 389. See also Arthur J. Dyck, When Killing Is Wrong: Physician-Assisted Suicide and the Courts (Cleveland, Ohio: Pilgrim Press, 2001).

[3] Timithy Quill, Death and Dignity: Making Choices and Taking Charge (New York: W.W. Norton & Co., 1993).; Walter J. Kade, “Death with Dignity: A Case Study,” Annals of Internal Medicine 132, no. 6 (March 21, 2000), 504–6; Ronald Dworkin et alia, “Amicus Curiae Brief” to U.S. Supreme Court reprinted in Issues in Law and Medicine 15, no. 2 (Fall 1997), 197.

[4] Herbert Hendin, “Seduced by Death: Doctors, Patients and the Dutch Cure,” Issues in Law and Medicine 10, no. 2 (Fall 1994), 123–68. Richard Fenigsen, “Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia,” Issues in Law and Medicine 26, no. 3 (Spring 2010), 267. Fenigsen cites the official report of the Dutch Government’s Committee on Euthanasia that provides the following statistics: In 1990, 4,941 patients who did not request or consent to euthanasia were actively terminated by doctors. Of these patients, 27 percent or 1,334 were fully competent.

[5] Toni C. Saad, “Euthanasia in Belgium: Legal, Historical and Political Review,” Issues in Law and Medicine 32, no. 2 (Fall, 2017), 204. This conclusion comes at the end of Saad’s thorough review.

[6] Kade, “Death with Dignity,” 504.

[7] Ibid.

[8] Ibid.

[9] Ibid.

[10] Ibid.

[11] Ibid, 506.

[12] Ibid.

[13] Ibid.

[14] Washington v Glucksberg 117 S. CT 2258 (1997) 2264, 2272–73.

[15] Hendin, “Seduced by Death.” See especially pages 160 and 163.

[16] Richard, Fenigsen, “Physician-Assisted Death in the Netherlands: Impact on Long Term Care,” Issues in Law and Medicine 11, no. 3 (Winter 1995): 283-97. See especially p. 295.

[17] Beauchamp and Childress, Principles of Biomedical Ethics Fifth Edition (New York: Oxford University Press, 2001), 146–149.

[18] The freedom to treat and regard the lives of some individuals as living an unworthy life is based on a dangerous concept, especially when physicians and their government adopt it. The idea of ‘’life unworthy of life” is what was behind the atrocities committed by Nazi doctors and urged  by the German government. See Robert J Lifton, The Nazi Doctors: Medical Killing and the Psychology of Genocide (New York: Basic Books, 1986), 21–144. See also the chapter entitled “The Destruction of Lives Not Worth Living,” in Robert N. Proctor, Racial Hygiene: Medicine Under The Nazis (Cambridge, Mass.: Harvard University Press, 1988), 177–222.

[19] Washington v Glucksberg, 2264 and 2272–73.

[20] Henden, “Seduced by Death,” 123–68.

[21] Ibid, 163.

[22] See, for example, John Keown, “Euthanasia in the Netherlands: Sliding Down the Slippery Slope?” Notre Dame Journal of Law, Ethics and Public Policy 9, no. 2 (1995), citing data on page 428, data showing that in 31 percent of every 1,000 cases of involuntary euthanasia physicians gave “low quality of life” as their justification for such acts. See also Henk Jochemsen, “The Netherlands Experiment,” in John F. Kilner et al., eds., Dignity and Dying: A Christian Appraisal (Grand Rapids, MI: Eerdmans, 1996), 165–79.

[23] Robert G. Twycross, “Where There is Hope, There is Life: A View from the Hospice,” in John Keown, ed., Euthanasia Examined: Ethical, Clinical, and Legal Perspectives (Cambridge: Cambridge University Press, 1995), 142.

[24] Twycross, “Where There is Hope,” 142.

[25] Ibid, 142–43.

[26] Ibid, 158.

[27] Washington v Glucksberg, 225.

[28] Ibid.

[29] Rodriguez v British Columbia, 107 DLR 4th 342 (1993).

[30] Ibid, 389.

[31] Ibid, 396.

[32] Ibid.

[33] Robert Orr, “The Physician-Assisted Suicide: Is It Ever Justified?” in Timothy J. Demy and Gary P. Stewart, eds., Suicide: A Christian Response (Grand Rapids, MI: Eerdmans, 1998), 63–72.

[34] Ibid, 69. See also Francis J. Beckwith, “Absolute Autonomy and Physician-Assisted Suicide: Putting a Bad Idea Out of Its Misery,” in Suicide, 223–53.

[35] John F. Kilner, Dignity and Destiny: Humanity in the Image of God (Grand Rapids, MI: Eerdmans, 2015).

[36] For a Christian scholar’s defense of legalizing PAS, see Daniel C. Maguire, Death by Choice (Garden City, N.Y.: Doubleday, 1984). For a moral argument favoring PAS, see Karen Lebacqz, “Reflection,” in Lammers and Verhey, eds., On Moral Medicine: Theological Perspectives in Medical Ethics (Grand Rapids, MI: Eerdmans, 1998). Maguire is a Roman Catholic; Lebacqz is Protestant.

[37] For numerous examples, see Kilner, Dignity and Destiny, ch. 1.

[38] Arthur J. Dyck, Rethinking Rights and Responsibilities and Life’s Worth.

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