For millennia, euthanasia (a word I use to include assisted suicide) has
been considered morally and legally unjustifiable. People who oppose euthanasia
still believe it’s inherently wrong – it can’t be morally justified and even
compassionate motives don’t make it ethically acceptable.

But what are the attitudes of pro-euthanasia advocates regarding whether
its use needs to be justified, were it to be legalized? And, if justifications
are required, what are they?

People who would accept euthanasia, but only in some circumstances,
usually limit its access to people who are terminally ill, in serious
unrelievable pain and suffering, and require that euthanasia be used as a last
resort. These limitations show these people believe each case of euthanasia
needs moral justification to be ethically acceptable.

But although the need for euthanasia to relieve pain and suffering is
the justification given, and the one the public accepts in supporting its
legalization, research shows that dying people request euthanasia far more
frequently because of fear of social isolation and of being a burden on others,
than pain. So, should avoiding loneliness or being a burden count as a
sufficient justification?

Recently, some pro-euthanasia advocates have gone further, arguing that
respect for people’s rights to autonomy and self-determination means competent adults
have a right to die at a time of their choosing, and the state has no right to
prevent them from doing so. In other words, if euthanasia were legalized, the
state has no right to require a justification for its use by competent, freely
consenting adults.

For example, they believe an elderly couple, where the husband is
seriously ill and the wife healthy, should be allowed to carry out their
suicide pact. As Ruth von Fuchs, head of the Right to Die Society of Canada,
stated, “life is not an obligation.” But although Ms von Fuchs thought the wife
should have an unfettered right to assisted suicide, she argued that it would
allow her to avoid the suffering, grief and loneliness associated with losing
her husband – that is, she articulated a justification.

We can see this same trend toward not requiring a justification – or, at
least, nothing more than that’s what a competent person over a certain age
wants to do – in the Netherlands. Last month, a group of older Dutch academics
and politicians launched a petition in support of assisted suicide for the
over-70s who “consider their lives complete” and want to die. They quickly
attracted more than 100,000 signatures, far more than needed to get the issue
debated in parliament under citizens’ initiative legislation.

And what about avoiding health-care costs as a justification? Although
this question has largely been dodged – one could say “religiously” – by
pro-euthanasia advocates, euthanasia could be used as a cost-saving measure,
and is likely to be if legalized.

Half of the lifetime health-care costs of the average person are
incurred in the last six months of the person’s life. Euthanasia would be a way
to implement a “reasonably well or dead” approach – sometimes referred to as
“squaring the curve” of health decline at the end of life, so the person drops
precipitously from being reasonably well to dead – which would avoid those

The medical authority of the US state of Oregon – where
physician-assisted suicide is legal – seems to have adopted this approach.
Shortly before he died this month, Montreal journalist Hugh Anderson wrote in
The Gazette that Oregon “has acknowledged that when it turns down an
application to cover the cost of an expensive new drug, it sends out
simultaneously a reminder that the state’s assisted suicide program is available
at an affordable cost.” As Mr Anderson noted, “What a great way to put a crimp
in medical costs. Have the patients kill themselves when the cost of keeping us
alive gets too high.”

The Netherlands’ 30-year experience with euthanasia shows clearly the
rapid expansion, in practice, of what is seen as an acceptable justification
for euthanasia.

Initially, euthanasia was limited to terminally ill, competent adults,
with unrelievable pain and suffering, who repeatedly asked for euthanasia and
gave their informed consent to it. Now, none of those requirements necessarily
applies, in some cases not even in theory and, in others, not in practice.

For instance, parents of severely disabled babies can request euthanasia
for them, 12 to 16-year-olds can obtain euthanasia with parental consent and
those over 16 can give their own consent. More than 500 deaths a year, where
the adult was incompetent or consent not obtained, result from euthanasia. And
late middle-aged men (a group at increased risk for suicide) may be using it as
a substitute for suicide.

Indeed, one of the people responsible for shepherding through the
legislation legalizing euthanasia in the Netherlands recently admitted publicly
that doing so had been a serious mistake, because, she said, once legalized,
euthanasia cannot be controlled. In other words, justifications for it expand
greatly, even to the extent that simply a personal preference “to be dead” will

Legalizing euthanasia causes death and dying to lose the moral context
within which they must be viewed. Maintaining that moral context is crucial in
light of an ageing population and scarce and increasingly expensive health-care
resources, which will present us with increasingly difficult ethical decisions.

Margaret Somerville is founding director of the Centre for Medicine,
Ethics and Law at McGill University.

Margaret Somerville AM, DSG, FRSC, FRSN, DCL is Professor of Bioethics at the University of Notre Dame Australia School of Medicine (Sydney campus). She is also Samuel Gale Professor of Law Emerita, Professor...