Since the case of Karen Quinlan first seized public attention fifteen years ago, no issue in biomedical ethics has been more prominent than the debate about forgoing life-sustaining treatment. Controversy continues regarding some aspects of that debate, such as forgoing life-sustaining nutrition and hydration, and relevant law varies some from state to state. Nevertheless, I believe it is possible to identify an emerging consensus that competent patients, or the surrogates of incompetent patients, should be permitted to weigh the benefits and burden of alternative treatments. including the alternative of no treatment. according to the patient's values, and either to refuse any treatment or to select from among available alternative treatments. This consensus is reflected in bioethics scholarship, in reports of prestigious bodies such as the President's Commission for the Study of Ethical Problems in Medicine, The Hastings Center, and the American Medical Association, in a large body of judicial decisions in courts around the country, and finally in the beliefs and practices of health care professionals who care for dying patients.
More recently, significant public and professional attention has shifted from life-sustaining treatment to euthanasia - more specifically, voluntary active euthanasia - and to physician-assisted suicide. Several factors have contributed to the increased interest in euthanasia. In the Netherlands, it has been openly practiced by physicians for several years with the acceptance of the country's highest court. In 1988 there was an unsuccessful attempt to get the question of whether it should be made legally permissible on the ballot in California. In November 1991 voters in the state of Washington defeated a widely publicized referendum proposal to legalize both voluntary active euthanasia and physician-assisted suicide. Finally, some cases of this kind, such as "It's Over, Debbie," described in the Journal of the American Medical Association, the "suicide machine" of Dr. Jack Kevorkian, and the cancer patient "Diane" of Dr. Timothy Quill, have captured wide public and professional attention. Unfortunately, the first two of these cases were sufficiently problematic that even most supporters of euthanasia or assisted suicide did not defend the physician's actions in them. As a result, the subsequent debate they spawned has often shed more heat than light. My aim is to increase the light, and perhaps as well to reduce the heat, on this important subject by formulating and evaluating the central ethical arguments for and against voluntary active euthanasia and physician-assisted suicide. My evaluation of the arguments leads me, with reservations to be noted, to support permitting both practices. My primary aim, however, is not to argue for euthanasia, but to identify confusions in some common arguments, and problematic assumptions and claims that need more defense or data in others. The issues are considerably more complex than either supporters or opponents often make out; my hope is to advance the debate by focusing attention on what I believe the real issues under discussion should be.
In the recent bioethics literature some have endorsed physician-assisted suicide but not euthanasia. Are they sufficiently different that the moral arguments for one often do not apply to the other? A paradigm case of physician-assisted suicide is a patient's ending his or her life with a lethal dose of a medication requested of and provided by a physician for that purpose. A paradigm case of voluntary active euthanasia is a physician's administering the lethal dose, often because the patient is unable to do so. The only difference that need exist between the two is the person who actually administers the lethal dose - the physician or the patient. In each, the physician plays an active and necessary causal role.
In physician-assisted suicide the patient acts last (for example, Janet Adkins herself pushed the button after Dr. …