Lecture 7 — End-of-Life Care
Part B: Euthanasia, Assisted Death, and Their Critics
1 Part B — Helping to Die
1.1 Where We Left Off
In Part A every hard case was about whether to let dying happen — to stop or withhold treatment for a patient who could no longer decide. We ended on a puzzle: the law treats withholding and withdrawing treatment as the same, yet many caregivers feel that stopping a machine causes the death in a way that never starting it does not.
Part B takes up a related act: not letting a patient die, but actively helping them die — on their own clear request. This is where medicine, law, and philosophy disagree most deeply.
1.2 A Case to Sit With
In early 2014, Brittany Maynard, 29, was diagnosed with an aggressive brain cancer (glioblastoma) and given about six months to live. Her doctors described the death she could expect: seizures, escalating pain, loss of speech and self.
She and her husband moved from California to Oregon, one of the few states where a terminally ill, mentally competent adult can ask a doctor for a prescription to end their own life. She set a date, spoke publicly about her choice, and on November 1, 2014, took the medication and died at home. (Maynard 2014)
Write or discuss:
- Is what Brittany did different, morally, from a patient who refuses a ventilator and dies?
- Her doctor wrote the prescription; she took it herself. Does who performs the final act matter?
- Should this option be legal everywhere — or are there people it would put at risk?
1.3 After You’ve Discussed
Brittany’s case differs from Nancy Cruzan’s in Part A.
- Cruzan could not speak for herself; others decided whether to let her die.
- Maynard was fully competent and decided for herself; she asked for help to actively end her life.
Part A was about who decides for the silent. Part B is about what a person may ask for — and what others may do — when the patient is the one asking.
1.4 Today
By the end of Part B, you will be able to:
- Sort the key terms — active/passive euthanasia, voluntary/non-voluntary/involuntary, and physician-assisted death — and say why the distinctions matter.
- Reconstruct Rachels’ argument that killing and letting die carry no moral weight in themselves, and Foot’s reply.
- Explain the positive case for assisted death from Brock (autonomy) and Singer (quality of life).
- Explain Velleman’s secular argument against a right to die.
- State the disability-rights critique and how Harriet McBryde Johnson pressed it against Singer.
- Apply the doctrine of double effect to palliative sedation, and describe where assisted death is legal and what the data show.
2 First, Get the Words Right
2.1 Why Vocabulary Comes First
This is a topic where people argue past each other because they are using the same words for different acts. Before any ethics, we need a clean map.
Three distinctions do all the work:
- Active vs. passive — doing something to cause death vs. withholding something.
- Voluntary vs. non-voluntary vs. involuntary — who wanted it.
- Assisted death vs. euthanasia — who performs the final act.
These three distinctions resolve most of the confusion before the ethics even starts.
2.2 Active vs. Passive Euthanasia
Euthanasia means bringing about a death for the sake of the person who dies — a “good death.” It splits in two:
- Active euthanasia — someone administers something that causes death, such as a lethal injection.
- Passive euthanasia — death is allowed to happen by withholding or withdrawing treatment, such as stopping a ventilator.
Almost every legal system treats these very differently: passive euthanasia is widely accepted, while active euthanasia is illegal in most of the world.
2.3 “Withdrawal Is Not Killing” — The Standard View
Most clinicians and courts insist that stopping treatment is not the same as killing.
- When a ventilator is withdrawn and the patient dies, the standard view says the disease kills her; the doctor merely steps out of the way.
- When a doctor injects a lethal drug, the doctor kills her.
On this view, a patient has a strong right to refuse treatment (so passive euthanasia is permissible), but no one has a right to be killed (so active euthanasia is not). Rachels attacks exactly this claim.
2.4 Assisted Death vs. Euthanasia
Physician-assisted death (PAD / MAID)
The doctor prescribes a lethal medication, but the patient takes it themselves. This is what Brittany Maynard did. The final act is the patient’s.
(Active, voluntary) euthanasia
The doctor administers the medication directly — for example, a lethal injection at the patient’s request. The final act is the doctor’s.
This line is legally decisive. US states that permit assisted death allow only the prescribing model; Canada and several European countries allow the doctor to administer as well. “MAID” (Medical Assistance in Dying) is the Canadian term and covers both.
2.5 The Map of Terms
| Term | Who acts last | Patient’s wish | Typical legal status |
|---|---|---|---|
| Refusing treatment | Patient (refuses) | Voluntary | Legal everywhere |
| Passive euthanasia | Doctor (withholds) | Usually voluntary/non-vol. | Widely accepted |
| Physician-assisted death | Patient (takes drug) | Voluntary only | Legal in some places |
| Active voluntary euthanasia | Doctor (administers) | Voluntary | Legal in fewer places |
| Non-voluntary euthanasia | Doctor | Patient can’t say | Highly contested |
| Involuntary euthanasia | Doctor | Against patient’s wish | Always wrong / murder |
3 Does the Distinction Hold? Rachels vs. Foot
3.1 Rachels vs. the AMA (1975)
The American Medical Association’s 1975 policy captured the standard view exactly: a doctor may stop “extraordinary means” of prolonging life (passive), but “mercy killing” (active) is forbidden — because killing is in itself worse than letting die. (Rachels 1975)
James Rachels argued that this position is confused, and often cruel in practice.
- Once we have decided a patient should die — a newborn whose treatment may permissibly be withheld — passive euthanasia can mean a slow death over days, by dehydration or infection.
- A quick lethal injection would cause less suffering. The act we permit can be worse for the patient than the act we forbid.
3.2 Smith and Jones
Rachels’ thought experiment
- Smith will inherit a fortune if his young cousin dies. He sneaks into the bathroom and drowns the boy in the bath, making it look like an accident.
- Jones stands to inherit the same fortune. He sneaks in planning to drown the boy — but the child slips, hits his head, and slides face-down into the water. Jones watches, ready to push him under if needed, and lets him drown.
Smith killed; Jones merely let die. Is Jones any less monstrous? Almost no one thinks so. (Rachels 1975)
3.3 The Bare Difference — and Its Limits
The case is built so everything is the same except killing vs. letting die — same motive, same outcome, same intention. Rachels calls what is left the bare difference.
If killing were worse in itself, Jones would be at least a little less guilty than Smith. He is not. So the bare difference carries no moral weight on its own — and “but that would be killing” cannot, by itself, settle the euthanasia debate.
Be precise about the conclusion
Rachels does not show that active euthanasia is right. Consent, motive, consequences, and risk of abuse may still make killing usually worse — he denies only that the bare act-type does the work. Whether anything else can rescue the distinction is Foot’s question.
3.4 Foot’s Reply: Duties, Not Acts
Philippa Foot agrees the bare physical difference is thin — but argues the distinction survives once we ground it in duties and rights. (Foot 1977)
- A negative duty not to harm (not to kill) is generally more stringent than a positive duty to aid (to save).
- Her example: an army may permissibly retreat and “let” a wounded soldier die — but may not shoot him. Killing can violate rights where letting die does not.
- On this view Jones is as bad as Smith not because letting die equals killing, but because Jones had a duty to save the boy — and a doctor honoring a refusal violates no duty by stopping, yet would violate one by injecting.
“Killing vs. letting die” was a stand-in for “strong negative duty vs. weaker positive one” — tracking something real after all.
3.5 Scoreboard: Rachels vs. Foot
| Rachels (1975) | Foot (1977) | |
|---|---|---|
| Bare act-type matters? | No | No |
| So the distinction is empty? | Largely, yes | No — re-ground it |
| What does the real work? | Consequences, motive, consent | Negative vs. positive duties |
| Implication for euthanasia | Removes a key objection | Leaves a principled brake |
If the line between active and passive is not bedrock, the next question is whether the values underneath it actually support assisted death.
4 If the Line Blurs, Should We Permit It?
4.1 Brock: The Parity Argument
Dan Brock turns the discussion around: instead of asking whether killing is special, ask what values justify letting patients refuse treatment in the first place (Brock 1992). He finds two — and they are the same two that support voluntary active euthanasia.
- Self-determination — competent people have the right to shape their own lives, including their dying.
- Well-being — we let people judge for themselves when continued life is a benefit or a burden.
- If these are weighty enough to let a patient refuse a ventilator and die, why not weighty enough to let her request a lethal drug and die? In both, a competent person judges life worse than death, and a doctor helps carry out that judgment.
You cannot consistently celebrate the right to refuse and flatly forbid voluntary euthanasia, Brock argues — the worries belong to consequences and safeguards, not the act itself.
4.2 Singer: Rejecting Sanctity of Life
Peter Singer pushes further, attacking the premise he thinks blocks clear thinking: the sanctity-of-life doctrine — the idea that human life is always equally precious simply because it is human. (Singer 1994)
- Singer replaces it with a quality-of-life ethic: what matters morally is the character of a life for the one living it.
- For a preference utilitarian like Singer, killing a self-aware being is wrong mainly because it thwarts that being’s preferences — so when a person prefers death, voluntary euthanasia can respect rather than violate them.
4.3 Singer’s Edge: Neonatal Euthanasia
Singer defends some limited cases of neonatal euthanasia — deliberately ending the life of some newborns, a practice critics call infanticide. Two claims combine.
First: on the preference view, no newborn is yet a self-aware being with preferences about its own future, so the wrong that protects an adult does not yet attach to any infant. Second: there are some cases in which neonatal euthanasia produces better outcomes, even considering the eventual life this newborn would have had. (Singer 2011)
The argument’s weight rests on the quality-of-life prognosis, not on impairment as such. Even so, the newborns it identifies are largely disabled ones, which is why the position is most sharply contested among disability-rights advocates.
4.4 Singer’s Two Kinds of Case
The cases are not all alike, and the difference marks where the disagreement actually is.
- Tay-Sachs and similar conditions. A short life of severe suffering. Singer’s claim that living on may be no benefit to that child draws comparatively wide sympathy.
- Down syndrome. Singer grants such a child can have a good life; his argument shifts to the parents’ preferences and the healthier child they could raise instead. This is the far more contested case.
And Singer presses a consistency point: many people accept late-term abortion after a prenatal Down syndrome diagnosis, and he sees no morally significant line between a fetus shortly before birth and a newborn shortly after (Singer 2011). The premise he draws out is one much of society already accepts in another form.
4.5 Thought Question
A patient with ALS is on a ventilator and fully competent. She asks her physician to turn it off, knowing she will die within minutes. The physician does, giving sedation for comfort. The patient dies. Everyone agrees this was lawful and ethical.
The next patient, with the same disease but not yet ventilator-dependent, asks the physician for a lethal medication to take at home.
- Is the physician’s role really different in the two cases?
- If the first is permitted, on what grounds would you forbid the second?
- Does it change your answer that, in the first case, the patient could not have lived long without the machine?
4.6 Make It Contemporary
This is not hypothetical. After Brittany Maynard’s death, California passed the End of Life Option Act (2015), joining Oregon (1997), Washington, Colorado, and others. By 2026, assisted death was legal in fourteen US jurisdictions — Delaware authorized it in 2024, and Illinois’s law takes effect in September 2026, at which point roughly a third of Americans will live where the option exists (Compassion and Choices 2026). The map is still moving.
Every US law allows only the prescribing model, requires a terminal diagnosis (usually six months), and demands the patient be competent and act voluntarily.
Discuss: Are those three safeguards — terminal, competent, voluntary — the right lines? Which would you tighten or loosen?
4.7 After You’ve Discussed
A distinction the safeguards quietly assume:
- In assisted death, the patient performs the final act. This builds in a last check — the person must still, at the end, choose to act.
- In euthanasia, someone else performs it. This is available to patients too disabled to act for themselves, but it removes that final self-check.
US law has chosen the first model precisely because the patient’s last act is itself a safeguard. Canada and the Netherlands accept the second — and inherit a harder problem of verifying consent at the very end.
5 The Brakes: Velleman and the Critics
5.1 Velleman: Against the Right to Die
J. David Velleman offers the most interesting secular objection — one that grants almost everything to the other side. (Velleman 1992)
- He concedes that death can genuinely benefit some patients, and that they may be entitled to it.
- He still argues against establishing a right or institution of assisted death.
The claim is not that euthanasia is intrinsically wrong, or that no one should ever have it. His worry is what offering the option to everyone does to everyone — including those who never wanted it.
5.2 Velleman: The Cost of Having a Choice
Why an option can harm you
Right now, a gravely ill person who keeps living needs no justification — there was simply no choice. But once death becomes an accepted option, the situation changes for everyone, including those who never wanted it.
Now a patient must, in effect, justify continuing to live — to family, to caregivers, even to herself. The frail and dependent may feel they ought to “stop being a burden.” Merely making the choice available can strip away the protection of having no choice at all. (Velleman 1992)
5.3 The Disability-Rights Critique
For disability-rights groups such as Not Dead Yet, Velleman’s abstract worry is daily reality. Their objection is not religious; it is about who is actually at risk.
- “Better dead than disabled.” Assisted-death laws rest on the judgment that some lives are not worth living — and the lives singled out are usually disabled ones.
- People often request death not because of pain but because of dependence, lost dignity, and being a burden — conditions that better support could change.
- The same society that offers suicide prevention to the able-bodied may offer suicide assistance to the disabled. That asymmetry is the heart of the critique.
5.4 McBryde Johnson Meets Singer
Harriet McBryde Johnson was a lawyer and disability-rights activist who had a progressive neuromuscular condition and used a wheelchair. In 2002 she debated Peter Singer at Princeton and wrote about it in “Unspeakable Conversations.” (Johnson 2003)
Her core reply to Singer: his confidence that disability makes a life worse is an outsider’s assumption. Survey research finds that disabled people often rate their own quality of life far higher than the non-disabled predict they would — the so-called disability paradox. The premise of the quality-of-life argument, she said, is at least far shakier than Singer assumes.
Why she found it hard to answer
Johnson granted that Singer was personable and his logic internally consistent. That was her difficulty: she could not locate an obvious flaw to point to. Her objection was therefore aimed at his premises — the quality-of-life judgments the argument starts from — rather than at any slip in his reasoning.
5.5 Coercion, Duty, and Access
The critics converge on three concrete risks that safeguards must answer.
- Coercion — subtle pressure from family, cost, or exhausted caregivers, not held at gunpoint but nudged.
- The “duty to die” — once dying is an option, the dependent may feel obligated to take it (Velleman’s worry, lived).
- Access disparities — those with the least social support may find death the most available form of “care,” while the well-resourced get treatment.
These are empirical questions, which is why both sides now argue about data — taken up after one more conceptual tool.
6 Double Effect and Palliative Sedation
6.1 The Doctrine of Double Effect
The doctrine of double effect tries to explain how an act with a foreseen bad effect can still be permissible — if the bad effect is not intended. (McIntyre 2023)
A classic four-part test: the act is permissible only if
- the act itself is good or neutral (giving pain medication);
- the bad effect is not the means to the good (relief doesn’t work by killing);
- the bad effect is foreseen but not intended; and
- there is a proportionate reason (the suffering is grave enough).
6.2 Morphine, Sedation, and Intention
The standard example: a dying patient in severe pain is given escalating morphine. The dose needed for comfort may also depress breathing — permissible under double effect, because the doctor intends relief and merely foresees the risk. The same act would be wrong if death were the intention and pain relief the cover.
Palliative sedation extends the logic: sedating a dying patient — sometimes to unconsciousness — to relieve symptoms nothing else can touch.
- Legal and widely accepted, justified by double effect: the aim is relief, not death.
- In its deepest form — continuous sedation to unconsciousness, often with artificial nutrition withheld — the patient never wakes and dies within days.
6.3 Is Palliative Sedation “Slow Euthanasia”?
The defense
The intention is to relieve refractory suffering, not to kill. Studies suggest properly titrated sedation does not clearly shorten life. By double effect, it stays on the right side of the line.
The worry
If you sedate someone to permanent unconsciousness and stop feeding them, the outcome is certain death. Critics call this “slow euthanasia” — euthanasia that keeps the form of double effect while abandoning its substance.
This is the same fault line as Rachels vs. Foot, in a new place: does the intention behind an act change what the act is?
7 The Law on the Ground
7.1 Where It Is Legal
| Jurisdiction | Since | Model | Who is eligible |
|---|---|---|---|
| Oregon (US) | 1997 | Assisted death (prescribe) | Terminal, ~6 months, competent |
| Other US states | 1997– | Assisted death (prescribe) | Same; 14 jurisdictions by 2026 |
| Netherlands | 2002 | Euthanasia + assisted | “Unbearable suffering,” incl. some psychiatric |
| Belgium | 2002 | Euthanasia + assisted | Incl. minors (since 2014) |
| Switzerland | (long-standing) | Assisted suicide only | Non-residents allowed; no terminal requirement |
| Canada | 2016 | Euthanasia + assisted (MAID) | Expanded beyond terminal in 2021 |
7.2 Oregon After 25+ Years
Oregon’s law is the most studied in the world, because the state publishes annual data. The findings are consistent year after year. (Oregon Health Authority, Public Health Division 2024)
- The top reasons patients give are loss of autonomy, being less able to enjoy activities, and loss of dignity — each cited by most patients.
- Inadequate pain control (or fear of it) is cited by a minority — roughly a quarter.
- About a third of patients who get the prescription never take it; having the option is itself a comfort.
The data complicate both sides: little evidence of the predicted “carnage,” but confirmation that the drivers are existential, not just physical pain.
7.3 Canada: The Fastest Expansion
Canada moved further and faster than anywhere else.
- 2015: In Carter v. Canada, the Supreme Court struck down the ban on assisted death. (Supreme Court of Canada 2015)
- 2016: Parliament legalized MAID for adults whose natural death was “reasonably foreseeable.”
- 2021: A new law removed the terminal requirement, allowing MAID for serious, incurable conditions that are not life-threatening.
By 2024, MAID accounted for 5.1% of all deaths in Canada — about 1 in 20, or 16,499 cases in a single year — among the highest rates in the world, and the speed of expansion is itself now part of the debate. (Roughly 96% of those cases involved patients whose natural death was already reasonably foreseeable.) (Health Canada 2025)
7.4 The Psychiatric MAID Controversy
The hardest frontier is assisted death for psychiatric suffering — where the illness is mental, not terminal.
- The Netherlands, Belgium, and Spain permit assisted death for non-terminal suffering, including conditions that are partly or wholly psychiatric.
- The dispute is sharp because two of the law’s safeguards strain here: Is the suffering truly irremediable? Can a condition that distorts judgment leave the patient fully competent to consent?
7.5 A Case at the Frontier: Noelia Castillo
In 2022, Noelia Castillo, a young Spanish woman with OCD and borderline personality disorder, attempted suicide and was left paraplegic and in constant pain. In 2024 she asked to die under Spain’s euthanasia law.
Her father fought her in court for 601 days, arguing her mental illness made her wish to die a symptom, not a choice. Every court — up to the European Court of Human Rights — found she had capacity. She died in March 2026, age 25.
Why it’s the hard case
Her death was approved for physical pain, but fought over psychiatric capacity. She was not dying — she was disabled. So the case fuses both critiques: Is this autonomy honored, or a vulnerable woman society failed first and offered death second?
7.6 Castillo: Two Readings of the Same Facts
Autonomy honored
Refusing a capable woman’s request only because her suffering is psychiatric applies a double standard we never use for physical illness. Every court agreed she could choose.
Vulnerability abandoned
Safeguards checked whether she qualified, not why she got there: lost home, institutional care, untreated trauma, assaults never investigated. A pianist offered to fund her care. Was death simply more available than a livable life?
Paired case: Noelia Castillo: Psychiatric Suffering, Decisional Capacity, and the Limits of Euthanasia Law
7.7 Canada Hits the Brakes
Canada’s pause
Canada planned to extend MAID to people whose sole underlying condition is a mental illness. The start date was set for March 2023 — then delayed to 2024 — then delayed again to March 2027.
The reasons cited were exactly the critics’ worries: clinicians were not confident they could reliably tell an irremediable mental illness from a treatable one, or a settled wish from a symptom. Even a system committed to expansion found a line it was not ready to cross.
The pause may become permanent. In June 2026, the Special Joint Committee on Medical Assistance in Dying recommended an indefinite exclusion of people whose sole underlying condition is a mental illness — not another delay, but a recommendation to stop planning for the expansion at all. A recommendation is not yet law, and Parliament may or may not follow it. But it marks the first time Canada’s expansion has been proposed to run in reverse.
Why this matters for the slippery-slope argument: critics predicted that each extension would make the next one easier, with no natural stopping point. Canada extended MAID three times — and then, at psychiatric illness, stopped, delayed three times, and moved toward closing the door. That is evidence against the strong version of the slope claim. Defenders of the argument can reply that the door is not shut, that Spain and the Benelux countries did cross this line, and that a decade of pressure is not a long test. Hold both thoughts.
7.8 After You’ve Discussed: Two Kinds of Slope
“Slippery slope” is often dismissed as a fallacy, but separate two versions:
- A logical slope says permitting A commits you to B. This is usually weak — you can permit voluntary, terminal cases and still forbid the rest, as Oregon does.
- An empirical slope says that in practice, categories drift: eligibility widens, safeguards loosen, numbers climb. Canada’s trajectory is evidence this can happen — not as logic, but as politics and habit.
The honest question is not “is there a slope?” but “which slope, and is this society good at stopping on it?”
7.9 Wrap-Up
We began with one disputed line — killing vs. letting die — and watched Rachels argue it carries no weight in itself while Foot rebuilt it from duties. Brock and Singer pressed the case for assisted death from autonomy and quality of life; Velleman and the disability-rights critics, led here by Harriet McBryde Johnson, pressed back — not from religion, but from concern for the vulnerable and for what a mere option does to them.
Palliative sedation raised the same question in a new form: does intention change what an act is? And the law on the ground — Oregon’s steady data, Canada’s rapid expansion and its sudden pause on psychiatric cases — shows a society still arguing over where the brakes belong. Where the line between mercy and danger falls is not yet settled.
7.10 Review Questions
Recall
Explain the Smith and Jones case and state precisely what Rachels concludes from it — and what he does not conclude.
Apply
A hospice patient with no pain asks for assisted death, citing loss of dignity and fear of being a burden. Using Velleman and the disability critique, what would worry you about granting it?
Debate
Should assisted death ever be available for psychiatric suffering alone, as in Belgium and the Netherlands — or was Canada right to pause?
7.11 Key Terms
- Active euthanasia — administering something that causes death.
- Passive euthanasia — allowing death by withholding or withdrawing treatment.
- Voluntary / non-voluntary / involuntary — with the patient’s request / without their input / against their wish.
- Physician-assisted death (PAD/MAID) — the doctor prescribes; the patient performs the final act.
- Bare difference argument (Rachels) — killing vs. letting die carries no moral weight in itself.
- Negative vs. positive duties (Foot) — the duty not to harm is more stringent than the duty to aid.
- Doctrine of double effect — a foreseen bad effect can be permissible if unintended and proportionate.
- Palliative sedation — sedating a dying patient to relieve refractory suffering.
7.12 Further Reading
- Rachels, James. “Active and Passive Euthanasia.” New England Journal of Medicine (1975). (Rachels 1975)
- Foot, Philippa. “Euthanasia.” Philosophy & Public Affairs (1977). (Foot 1977)
- Johnson, Harriet McBryde. “Unspeakable Conversations.” The New York Times Magazine (2003). (Johnson 2003)
- Young, Robert. “Voluntary Euthanasia.” Stanford Encyclopedia of Philosophy. (Young 2024)