DRZE/In Focus Euthanasia Last update: October 2009 Contact: Christina Rose I. Introduction and basic conceptual distinctions On the one hand, the term Euthanasia (see module Euthanasia) may denote "assistance throughout the dying process", that is, support and accompaniment during the time leading up to death. In this sense, euthanasia entails the support of the dying person by giving care, pain-relieving treatment and personal comfort. As such, its urgent necessity in the dying process is undisputed. Yet on the other hand "euthanasia" can also denote "assistance in achieving death", then entailing the killing or "letting die" of a dying, seriously ill or suffering person in accordance with their own express or assumed wishes or interests. The issue of "assistance in achieving death" is discussed in the context of varying situations. The debate frequently distinguishes four types of euthanasia in the sense of "assistance in achieving death": 1 "Letting die"/"Passive euthanasia": renunciation of life-prolonging measures (while continuing to give "basic care" and pain-relief treatment 2 "Indirect euthanasia"/"Indirect active euthanasia": pain-relief treatment while tolerating a (non-intended) risk of shortening the patient's life span 3 "Assisted suicide"/"Support for voluntary death": assisted suicide e.g. by procuring and supplying the lethal drug 4 "Active euthanasia"/"Direct active euthanasia"/"Termination of life on request": Intentional and active acceleration or bringing about of death. Contrary to indirect euthanasia, death is not only tolerated but intended. Contrary to assisted suicide, the ultimate decisive impulse is not given by the patient but by a third party. The range of meaning of the term euthanasia is a wide one. It includes dying persons, seriously or incurably (physically or mentally) ill persons who are suffering inbearably or who see no purpose in continuing to live and thus express an urgent desire to be "released" through euthanasia. It also includes patients who are in a long-term coma or whose consciousness is already impaired in the terminal phase of a disease who can lo longer personally express any opinion regarding the implementation or termination of medically and technically viable, but therapeutically doubtful life-prolonging measures. It ranges to seriously damaged newborn babies incapable of expression, whose life expectancy is very short or who are expected to suffer greatly in life. However, not all forms of "letting die" are being summarized under the keywords "medically assisted suicide" or "euthanasia". Any therapeutic, palliative (meaning analgetic) or life-prolonging intervention requires the consent of the patient. If the patient refuses a certain measure and its omission leads to the patient's premature death, this situation is widely regarded as the manifestation of a patient's "right to a natural death". From a medical-ethical perspective, there is a general responsibility of the physician to preserve life, but not under all circumstances. Furthermore, life-prolonging measures cannot be responsible if they are ineffective, if their efficiency is questionable or if they involve disproportionately large suffering for the patient. The differentiation between the usage of " ordinary " and " exceptional " treatment methods (see module http://www.drze.de/in-focus/euthanasia (1) DRZE/In Focus Ordinary and extraordinary treatment) are being discussed here, both from the medical perspective as well as from the moral perspective. http://www.drze.de/in-focus/euthanasia (2) DRZE/In Focus II. Central discussion topics In the discussion about the licitness of the various types of euthanasia, many different aspects play a role. The main topics of discussion are as follows: Licitness of suicide A prerequisite for assuming the licitness of killing a person in accordance with his own wishes is that a person is permitted to end his own life intentionally in the first place. Whether or not this is the case - and if so under what circumstances - is the subject of debate. Basically, there are two approaches, both of which set different limits to an individual's right to self-determination concerning life and death: Proponents of the first approach (see module Unconditional illicitness of suicide) assume that human life is "inviolable" or "sacred". Human life is hence not only not at other people's disposal but also not at one's own disposal. This approach is rooted not least in Jewish-Christian traditions and is supported above all by the churches (see module Churches). The given reason is that life is God-given and that therefore God alone has the jurisdiction over life and death. If life is already coming to an end, there is no absolute obligation to prolong it by any means possible; however, its active shortening through suicide is objectively prohibited as a violation of God's sovereignty. Yet the subjective capacity for bearing responsibility may be diminished in such cases. Based on this approach, passive or indirect euthanasia in the case of a person whose dying process has already begun may be permissible under certain circumstances. However, under no circumstances shall it be permissible to assist suicide or carry out active euthanasia. From a legal-ethical perspective, it is principally being argued that in a liberal legal order a prohibition such as that of euthanasia can only be demanded if reasons (see module The burden of proof) can be given that are ideologically neutral and are thus, in general, comprehensible for everyone. In their argumentation as regards the content , which also opposes the argument of a general elusiveness of human life, supporters of the second approach (see module Conditional permissibility of euthanasia) refer to the capacity of humans to determine their own actions. The grounds of human dignity lie in this ability of self-determination. The obligation to protect this dignity is tied to this ability. Against this background, they argue, there is also an obligation to protect human life from life-threatening acts by third parties, as life is the prerequisite for human self-determination. However, a self-determined ending of one's own life, whether active or passive, cannot be unconditionally prohibited in the name of human dignity. This also applies to all types of voluntary euthanasia. However, the decision must have been carefully taken while in a clear state of mind and with an acute awareness of all circumstances; moreover, the way in which one's own life is ended may not imply any danger for third parties. Neither, therefore, is euthanasia overall nor are its various types and the desire for euthanasia to be prohibited per se. Rather, its permissibility should be assessed with regard to the extent to which the criteria mentioned are or can be fulfilled. Irrespective of the varying limits of self-determination, the respect for self-determination is a core aspect in the entire euthanasia debate. In order to protect one's right of self-determination one can make a living will (see module Living wills). Licitness of active euthanasia http://www.drze.de/in-focus/euthanasia (3) DRZE/In Focus Independently of the question of whether suicide is permissible, one must also considered whether killing by third parties, an aspect of active euthanasia, is permissible. There is debate as to whether the categorical prohibition of killing allows for any exceptions in this respect, what reasons there could be for these exceptions and whether the exceptions may create a "slippery slope" towards increasing their number. From a moral perspective, too, the question concerning the difference between active euthanasia and other forms of euthanasia arises. It depends on the possibility or impossibility of such a differentiation whether active euthanasia can be unconditionally prohibited if the other forms of euthanasia are, at least conditionally, being permitted. Opponents of the unconditional prohibition of active euthanasia argue that a moral distinction between killing someone and letting someone die is impossible to draw if either takes place for the same unselfish reasons. This is the case because in either case the result is the death of the patient. Further, it is argued that a "gradual", passive "letting die", to the extent that it involves unbearable, untreatable pain, may in certain cases be less humane than "quick" active euthanasia (e.g. by the administration of an intended overdose of pain-relieving medication). Advocates of the unconditional prohibition of active euthanasia above all point out that the "permission to kill" - more precisely, the permission to kill innocent people in situations not involving self-defence - is linked to a "weakening of the prohibition to kill". This could provoke misinterpretations and misuse, thereby destroying any trustful relationships between humans. This is the case even if the permit is only conditional. Besides, they assume that such a "weakening of the prohibition to kill" could lead to an increase in the readiness to kill. This, again, could entail a more widespread application of active euthanasia, possibly extending it to more groups of people than originally intended. Even if the permission to kill originally only refers to dying persons who, at the time in question, are capable of judgement and expression and who request their killing of their own free will, it could eventually still extend. Seriously ill but not yet dying patients as well as elderly or disabled people without an exhibition of their will could be affected