Basic concepts of Euthanasia

JIMMA UNIVERSITY, INSTITUTE OF HEALTH, DEPARTMENT OF POPULATION
AND FAMILY HEALTH
THE ETHICS OF DEATH AND DYING: EUTHANASIA
BY
TEKLEMARIAM ERGAT YARINBAB (MPH, PhD Fellow)
ZERITU DEWANA (MPH, PhD Fellow)
INSTRUCTOR
GURMESSA TURA (PhD)
A TERM PAPER SUBMITTED TO DEPARTMENT OF POPULATION AND FAMILY
HEALTH, INSTITUTE OF HEALTH, JIMMA UNIVERSITY IN PARTIAL
FULFILLMENT OF THE COURSE ON HEALTH CARE AND HEALTH RESEARCH
ETHICS
APRIL 2019
JIMMA, ETHIOPIA

Table of Contents
DEFINITION OF DEATH...................................................................................................... 3
ETHICS OF DEATH AND DYING....................................................................................... 3
EUTHANASIA ....................................................................................................................... 4
THE ETHICS OF EUTHANASIA ......................................................................................... 4
Why euthanasia should be allowed ......................................................................................... 5
Why euthanasia should be forbidden....................................................................................... 5
FORMS OF EUTHANASIA................................................................................................... 5
Active and passive euthanasia................................................................................................. 5
Voluntary euthanasia............................................................................................................... 6
Non-voluntary euthanasia........................................................................................................ 6
Indirect euthanasia................................................................................................................... 7
THE DOCTRINE OF DOUBLE EFFECT ............................................................................. 7
Factors involved in the doctrine of double effect.................................................................... 8
Problems with the doctrine of double effect ........................................................................... 8
Assisted Suicide....................................................................................................................... 9
LEGALITY OF EUTHANASIA ............................................................................................ 9
EUTHANASIA IN AFRICA ................................................................................................ 11
EUTHANASIA IN ETHIOPIA............................................................................................. 11
REFERENCES...................................................................................................................... 12

1. DEFINITION OF DEATH
Death is the permanent cessation of all biological functions that sustain a living organism.
Phenomena which commonly bring about death include aging, predation, malnutrition, disease,
suicide, homicide, starvation, dehydration, and accidents or major trauma resulting in terminal
injury. Death – particularly the death of humans – has commonly been considered a sad or
unpleasant occasion, due to the affection for the being that has died and the termination of social
and familial bonds with the deceased. Other concerns include fear of death, anxiety, sorrow,
grief, emotional pain, depression, sympathy, compassion, or solitude (1).
2. ETHICS OF DEATH AND DYING
There are three sets of ethical issues regarding death and dying: defining ‘life’, quality of life
and body treatment after death (2). These three sets of ethical issues regarding death and dying
need to be considered when determining how best to meet one's end with dignity or support
someone in doing so.
Accordingly, the first issue to be considered regarding the subject of death is the defining of
criteria which constitute life. Before the invention of the mechanical ventilator in the 1950s,
death could typically be determined by the cessation of breathing and the beating of the heart
(although there were still exceptions to the rule). Today, however, scientific advances enable
medical practitioners to prolong the regulation of such bodily functions by artificial means even
when there is no hope of a meaningful recovery. So, the question remains: How are we to define
death? Some theorists advocate for defining death in terms of the higher brain formulation of
death which is defined as the "irreversible loss of that which is considered to be essentially
significant to the nature of man"
The second set of ethical issues regarding death and dying is quality of life that the individual
experiences. The fear of death and the fear of dying are two different things. The first has to do
with one's philosophy and theology; the second has to do with pain and suffering. As opposed to
the people who believe that life (however it is defined) should be preserved at all costs, other
people believe that a terminal diagnosis with a concomitant life of pain and suffering is not life at
all and should be voluntarily terminated. In this set of ethical issues lie questions of death with
dignity, removal of breathing machines, feeding tubes, and other medical devices that only
prolong life but do not cure assisted suicide, and euthanasia.

The third set of ethical issues is concerned with how the body is to be treated after death.
Some people believe that a dead body is an empty shell requiring neither reverence nor respect.
Others, however, believe that the body - dead or alive - is God's creation and deserves respect
even after death. There are, of course, a range of opinions in between. One's stance on this issue
can affect whether or not one wants to be buried or cremated, whether an autopsy should be
performed, whether or not organs should be donated for transplant, or if the body may be
donated to science. Culture, tradition, and religion all play prominently in this debate.
3. EUTHANASIA
Euthanasia is the act or practice of killing or permitting the death of hopelessly sick or injured
individuals in a relatively painless way for reasons of mercy, i.e. euthanasia is the termination of
a very sick person's life in order to relieve them of their suffering. The term ‘euthanasia’ is
derived from the Greek word “euthanatos” which means easy death. It is also defined as 'Any
action or omission intended to end the life of a patient on the grounds that his or her life is not
worth living.'
4. THE ETHICS OF EUTHANASIA
Euthanasia raises a number of agonising moral dilemmas:
a. Is it ever right to end the life of a terminally ill patient who is undergoing severe pain and
suffering?
b. Under what circumstances can euthanasia be justifiable, if at all?
c. Is there a moral difference between killing someone and letting them die? At the heart of
these arguments are the different ideas that people have about the meaning and value of
human existence (3).
Euthanasia violates basic ethical principles such as autonomy and beneficence.
Autonomy
Euthanasia violates the principle of autonomy, or self-determination, and therefore contradicts
the claim of euthanasia proponents who say we all have the “right to die.” Allowing euthanasia
does not mean that the patient is allowed to die at his or her own choosing; it means that the
physician is allowed to cause the death of the patient.
Beneficence
Euthanasia is not an act of beneficence, even if it may have benefits. Regardless of the extent of
palliative care measures, some suffering will continue to be unbearable for individuals who have

less capacity to cope with the experience than others, especially those in socially vulnerable
positions.
Why euthanasia should be allowed
Those in favor of euthanasia argue that a civilized society should allow people to die in dignity
and without pain, and should allow others to help them do so if they cannot manage it on their
own. They say that our bodies are our own, and we should be allowed to do what we want with
them. So it's wrong to make anyone live longer than they want. In fact making people go on
living when they don't want to violates their personal freedom and human rights. It's immoral;
they say to force people to continue living in suffering and pain. They add that as suicide is not a
crime, euthanasia should not be a crime.
Why euthanasia should be forbidden
Religious opponents of euthanasia believe that life is given by God, and only God should decide
when to end it. Other opponents fear that if euthanasia was made legal, the laws regulating it
would be abused, and people would be killed who didn't really want to die.
5. FORMS OF EUTHANASIA
Euthanasia comes in several different forms, each of which brings a different set of rights and
wrongs. The common forms of euthanasia (4) are: Active and Passive Euthanasia, Voluntary and
Involuntary Euthanasia, Indirect Euthanasia and Assisted Suicide.
5.1 Active and passive euthanasia
Active euthanasia is when death is brought about by an act - for example when a person is
killed by being given an overdose of pain-killers. It occurs when the medical professionals, or
another person, deliberately do something that causes the patient to die. In active euthanasia the
doctor takes an action with the intention that it will cause the patient's death. Some (mostly
philosophers) go even further and say that active euthanasia is morally better because it can be
quicker and cleaner, and it may be less painful for the patient.
Passive euthanasia is when death is brought about by an omission - i.e. when someone lets the
person die. This can be done by withdrawing or withholding treatment:
i. Withdrawing treatment: for example, switching off a machine or disconnecting a
feeding tube that is keeping a person alive, so that they die of their disease.
ii. Withholding treatment: for example, not carrying out surgery or not giving drugs that
will extend life for a short time.

Thus, passive euthanasia occurs when the patient dies because the medical professionals either
don't do something necessary to keep the patient alive, or when they stop doing something that is
keeping the patient alive. Traditionally, passive euthanasia is thought of as less bad than active
euthanasia. But some people think active euthanasia is morally better as stated above.
Many people make a moral distinction between active and passive euthanasia. They think that it
is acceptable to withhold treatment and allow a patient to die, but that it is never acceptable to
kill a patient by a deliberate act. Some medical people like this idea. They think it allows them to
provide a patient with the death they want without having to deal with the difficult moral
problems they would face if they deliberately killed that person.
But some people think this distinction is nonsense, since stopping treatment is a deliberate act,
and so is deciding not to carry out a particular treatment. Switching off a respirator requires
someone to carry out the action of throwing the switch. If the patient dies as a result of the doctor
switching off the respirator then although it's certainly true that the patient dies from lung cancer
(or whatever), it's also true that the immediate cause of their death is the switching off of the
breathing machine.
5.2 Voluntary and Involuntary Euthanasia
5.2.1 Voluntary euthanasia
Voluntary euthanasia occurs at the request of the person who dies. This includes cases of asking
for help with dying, refusing burdensome medical treatment, asking for medical treatment to be
stopped or life support machines to be switched off, refusing to eat, and/or simply deciding to
die.
5.2.2 Non-voluntary euthanasia
Non-voluntary euthanasia occurs when the person is unconscious or otherwise unable to make a
meaningful choice between living and dying, and an appropriate person takes the decision on
their behalf. It occurs when the person who dies chooses life and is killed anyway. This is
usually called murder, but it is possible to imagine cases where the killing would count as being
for the benefit of the person who dies. The person cannot make a decision or cannot make their
wishes known.
This includes cases where the person is in a coma, the person is too young (eg a very young
baby), the person is senile, the person is mentally retarded to a very severe extent and the person
is severely brain damaged, the person is mentally disturbed in such a way that they should be

protected from themselves. In involuntary euthanasia the person wants to live but is killed
anyway. This is usually murder but not always. Consider the following examples:
a. A soldier has their stomach blown open by a shell burst. They are in great pain and
screaming in agony. They beg the army doctor to save their life. The doctor knows that
they will die in ten minutes whatever happens. As he has no painkilling drug with him he
decides to spare the soldier further pain and shoots them dead.
b. A person is seen at a 10th floor window of a burning building. Their clothes are on fire
and fire brigade has not yet arrived. The person is screaming for help. A passer by nearby
realizes that within seconds the person will suffer an agonising death from burns. He has
a rifle with him and shoots the screaming person dead.
c. A man and a woman are fleeing from a horde of alien monsters notorious for torturing
human beings that they capture. They fall into a pit dug to catch them. As the monsters
lower their tentacles into the pit to drag the man out he begs the woman to do something
to save him. She shoots him, and then kills herself.
5.3 Indirect euthanasia
This means providing treatment (usually to reduce pain) that has the side effect of speeding the
patient's death. Since the primary intention is not to kill, this is seen by some people (but not all)
as morally acceptable. A justification along these lines is formally called the doctrine of double
effect.
5.3.1 THE DOCTRINE OF DOUBLE EFFECT
The doctrine of double effect - says that if doing something morally good has a morally bad side-
effect it's ethically OK to do it providing the bad side-effect wasn't intended. This is true even if
you foresaw that the bad effect would probably happen. The principle is used to justify the case
where a doctor gives drugs to a patient to relieve distressing symptoms even though he knows
doing this may shorten the patient's life.
This is because the doctor is not aiming directly at killing the patient - the bad result of the
patient's death is a side-effect of the good result of reducing the patient's pain. Many doctors use
this doctrine to justify the use of high doses of drugs such as morphine for the purpose of
relieving suffering in terminally-ill patients even though they know the drugs are likely to cause
the patient to die sooner.

5.3.2 Factors involved in the doctrine of double effect
a. The good result must be achieved independently of the bad one: For the doctrine to
apply, the bad result must not be the means of achieving the good one. So if the only way
the drug relieves the patient's pain is by killing him, the doctrine of double effect doesn't
apply.
b. The action must be proportional to the cause: If I give a patient a dose of drugs so
large that it is certain to kill them and that is also far greater than the dose needed to
control their pain, I can't use the Doctrine of Double Effect to say that what I did was
right.
c. The action must be appropriate (a): I also have to give the patient the right medicine. If
I give the patient a fatal dose of pain-killing drugs, it's no use saying that my intention
was to relieve their symptoms of vomiting if the drug doesn't have any effect on
vomiting.
d. The action must be appropriate (b): I also have to give the patient the right medicine
for their symptoms. If I give the patient a fatal dose of pain-killing drugs, it's no use
saying that my intention was to relieve their symptoms of pain if the patient wasn't
suffering from pain but from breathlessness.
e. The patient must be in a terminal condition: If I give the patient a fatal dose of pain-
killing drugs and they would have recovered from their disease or injury if I hadn't given
them the drugs, it's no use saying that my intention was to relieve their pain. And that
applies even if there was no other way of controlling their pain.
5.3.4 Problems with the doctrine of double effect
Some philosophers think this argument is too clever for its own good.
a. We are responsible for all the anticipated consequences of our actions: If we can
foresee the two effects of our action we have to take the moral responsibility for both
effects - we can't get out of trouble by deciding to intend only the effect that suits us.
b. Intention is irrelevant: Some people take the view that it's sloppy morality to decide the
rightness or wrongness of an act by looking at the intention of the doctor. They think that
some acts are objectively right or wrong, and that the intention of the person who does
them is irrelevant. But most legal systems regard the intention of a person as a vital

element in deciding whether they have committed a crime, and how serious a crime, in
cases of causing death.
c. Death is not always bad - so double effect is irrelevant: Other philosophers say that the
Doctrine of Double Effect assumes that we think that death is always bad. They say that
if continued life holds nothing for the patient but the negative things of pain and
suffering, then death is a good thing, and we don't need to use the doctrine of double
effect.
d. Double effect can produce an unexpected moral result: If you do think that a quicker
death is better than a slower one then the Doctrine of Double Effect shows that a doctor
who intended to kill the patient is morally superior to a doctor who merely intended to
relieve pain.
5.4 Assisted Suicide
Assisted suicide usually refers to cases where the person who is going to die needs help to kill
them and asks for it. It may be something as simple as getting drugs for the person and putting
those drugs within their reach.
6. LEGALITY OF EUTHANASIA
Efforts to change government policies on euthanasia of humans in the 20th and 21st centuries
have met limited success in Western countries. Human euthanasia policies have also been
developed by a variety of NGOs, most notably medical associations and advocacy organizations.
As of March 2018, Active human euthanasia is legal in the Netherlands, Belgium, Colombia,
Luxembourg, and Canada; Assisted suicide is legal in Switzerland, Germany, the Netherlands,
and in the US states of Washington, Oregon, Colorado, Hawaii, Vermont, Montana, Washington
D.C., and California. A law legalizing euthanasia in the Australian state of Victoria will come
into effect in mid-2019 (5).
Table 1: Practice of Euthanasia law by country, April 2019
S.No Country Promulgation Remark
1 Argentina 24 May 2012 Law 26,742
2 Australia Mid-2019* Voluntary assisted dying – will
come in to effect in mid-2019
3 Belgium 28 May 2002
4 Canada 6 February 2015 Voluntary active euthanasia
5 Chile 2012 Passive euthanasia is legalized.
Active euthanasia is being
discussed by the congress

6 Colombia 1997
7 Denmark UN Doctors take “end-life”decisions
8 Finland UN Passive euthanasia
9 France January 2016 allow doctors to keep terminal
patients sedated until death
10 Germany 17 May 2014 - Passive
euthanasia
November 6, 2015 - legalized
assisted suicide
11 India 7 March 2018 – passive
euthanasia
Active euthanasia is illegal
12 Ireland UN – Passive Active euthanasia is illegal
13 Israel 2006 – passive By Steinberg Commission
14 Japan Tentative legal framework Passive & Active
15 Latvia Euthanasia is not legal in
Latvia
But a doctor may refuse further
treatment of a patient if they
believe it is the best course of
action
16 Lithuania Not legal A draft of a law about the right to
die has been produced in 2016
17 Luxembourg 20 February 2008 Euthanasia - needs approval of two
doctors and a panel of experts
18 Mexico 7 January 2008 Passive euthanasia
19 Netherlands 2001 Sep 2004 – Groningen protocol –
child euthanasia
20 New Zealand December 2017 Assisted suicide for a select group
of people if successful
21 Norway Euthanasia remains illegal A caregiver may receive a reduced
punishment for taking the life of
someone who consents to it
22 Peru Under an attempt
23 Portugal Not yet formally legalized But already practiced by doctors in
the public health system
24 South Korea February 2018 Passive and active euthanasia
25 Switzerland Art 115 of Swiss penal code Considers assisting suicide a crime
if and only if the motive is selfish
26 Sweden Following a landmark Court
ruling in 2010
However administering a lethal
substance is illegal
27 UK Previous court decisions Passive euthanasia is legal
28 US Assisted suicide is legal Active euthanasia is illegal
29 Uruguay 1933 Penal Code Compassionate homicide

7. EUTHANASIA IN AFRICA
The African Region of World Medical Association rejects Euthanasia. The African Region of the
WMA in their meeting on February 3, 2018 in Abuja, Nigeria, also rejected Euthanasia calling
instead for strengthening of Palliative Care for terminal patients across Africa. Besides, without
any surprise the WMA maintains the condemnation of euthanasia and physician assisted suicide
in the Medical Ethics Manual. It claims that medical aid in dying is contrary to the physician's
oath (6). On the other hand, the South African Law Commission published (in 1997) a report that
included a draft law to legalize both euthanasia and physician-assisted suicide. The report was
largely ignored and a law never passed (7).
The recent South African High Court decision to allow euthanasia has polarized many people
regarding their stance on the matter. Euthanasia or mercy killing has been illegal, but recently the
Gauteng North High Court (April 2015) held that euthanasia is lawful. The case refers to the
request by Stransham-Ford in the Gauteng North High Court (of 29 April 2015) to have medical
doctors help him to end his life. The decision of the court does not mean that euthanasia is now
legalized in South Africa (8).
8. EUTHANASIA IN ETHIOPIA
The Medical Ethics for Physicians Practicing in Ethiopia in its article 1 dictates “No doctor can
take life deliberately as an act of mercy even at the request of the patient or the patient’s family.”
Besides, the 2004 criminal code of Ethiopia article 538(1) state that “whoever causes the death of
a human being intentionally or by negligence, no matter what the weapon or means used,
commits homicide.” (9, 10) Accordingly, euthanasia is not legalized in Ethiopia.

REFERENCES
1. Accessed online at BBC archive: https://en.wikipedia.org/wiki/Death
2. Accessed online: https://www.enotes.com/research-starters/ethical-issues-death-dying
3. Accessed online: http://www.bbc.co.uk/ethics/euthanasia/overview/introduction.shtml
4. James Rachels, 'Active and Passive Euthanasia'. The New England Journal of
Medicine, Vol. 292, pp 78-80, 1975
5. Legality of euthanasia, Wikipedia, the free encyclopedia:
file:///C:/Users/i5/Desktop/euthanasia/Legality%20of%20euthanasia%20-
%20Wikipedia.htm
6. https://www.worldrtd.net/news/african-region-world-medical-association-rejects-
euthanasia
7. South African Law Commission, "Euthanasia and the Artificial Preservation of Life,"
justice.gov.za, June 30, 1997
8. http://www.emacpd.org/sites/default/files/resource_center/Medical%20Ethics.pdf
9. Koenane, M.L.J., 2017, ‘Euthanasia in South Africa: Philosophical and theological
considerations’, Verbum et Ecclesia 38(1), a1549. https:// doi.org/10.4102/ve.
v38i1.1549
10. The criminal code of the Federal democratic republic of Ethiopia 2004

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