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Module 5 Introduction

In order to bring all of the previous principles & concepts together, this Module will focus on examining the applied topic of “End-of-life Care.” This is a topic that most people, healthcare professionals included, often find uncomfortable and have a hard time talking about. But this is precisely why it is so important to examine, especially in the context of healthcare ethics; avoiding talking about the challenges that arise at the end-of-life cannot stop patients from dying, it simply leaves us under-prepared when making important decisions about end-of-life care. For example, take a moment to puzzle about the following questions:

• What is the primary goal of healthcare when a patient’s body can no longer be healed? Should assessments about what promotes patient “well-being” change depending on whether the patient’s health is expected to improve or continue to decline? And if healthcare is primarily about promoting a patient’s health, does healthcare still have a role to play when a patient is actively dying? If so, what types of actions or interventions could help to promote a patient’s well-being at the end-of-life?
• Is it ever morally permissible to intentionally hasten a patient’s death? Is there a meaningful moral difference between intentionally allowing a patient to die and taking active steps to hasten or cause a patient’s death? Does it matter if the patient is suffering and makes the request for their death to be hastened? What types of assistance count as allowing a patient’s death vs. hastening or causing the patient’s death: withholding life-extending care, removing life-extending care, providing a patient with the means to end their own life, administering a lethal medication with the intention to relieve the patient’s pain, administering a lethal medication with the intention to end the patient’s life?
• What forms of end-of-life assistance should providers be able to offer? What forms of end-of-life assistance are healthcare providers legally able to provide? And if a certain forms of end-of-life assistance is illegal to provide, does that fact alone make them morally wrong? If not, should the laws be changed to match our assessment of what is morally right? Should patients even be able to request end-of-life assistance, and if so, do all healthcare providers need to provide end-of-life assistance when it is requested of them?

In this final module, we will examine some of the practices and procedures that help providers, patients, and families navigate end-of-life issues, as well as consider the merits and drawbacks of three different forms of end-of-life assistance. While we have thus far focused on the moral limits of treating patients and saving lives, we must also consider the moral limits of assisting patients who are actively dying. Now that you’ve learned to reason using the four bioethical principles (beneficence, non-maleficence, respect for autonomy, and justice), you should think about how they can be applied in analyzing the complex issues that arise at the end-of-life.

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5.1) End-of-Life Conversations & Advance Directives

Death is an uncomfortable, daunting, and even frightening topic for many people. It therefore comes as no surprise that people often find it difficult to engage in end-of-life conversations, even within a healthcare setting. Patients and their families often do not talk openly about end-of-life issues prior to a patient’s significant decline, leaving them unsure about what type of care the patient may have wanted, or might want to avoid. And even when patients and families are ready for such conversations, most of the time they wait for their healthcare provider to start the discussion.^[2] Patients and their families often appreciate when providers start these conversations and are usually willing to engage in them when prompted; however, as a 2006 survey revealed, many healthcare providers themselves feel unprepared for having these end-of-life conversations. Out of over 1,500 medical students and residents surveyed, only 18% had ever received formal training in end-of-life care, suggesting that relatively few providers have a clear idea of how to navigate these challenging conversations with patients and their families.^[3]

If a healthcare provider is unsure of how to start or engage in these conversations, it can result in delayed decisions about the patient’s care, or unclear communication about next-steps. For example, if a provider feels discomfort when talking about death and chooses to use euphemisms when speaking with a patient’s family (such as describing a patient as “slipping away” or “being at rest”) rather than being direct about the fact the patient is dying, the family may not understand what decisions need to be made, how far along the patient is in the dying process, or could even be in denial about the fact that the patient is dying.^[4] Using euphemisms to avoid talking directly about death and dying is often considered a form of medical jargon, as it inhibits clear communication and raises many of the same issues for framing and disclosing information as previously discussed in Module 3.

Challenges surrounding end-of-life conversations are further compounded by the fact that when the overall goal of healthcare is viewed as “promoting patient health and well-being,” then the death of a patient must be viewed as a “failure” to meet this goal by the healthcare provider. Or if a patient is said to be “fighting” or “battling” cancer, does that make the patient a “loser” when the treatments are no longer effective? Phrases such as “beating the disease” or “cheating death” are common in healthcare and meant to inspire hope during difficult times. Yet healthcare providers must be mindful of the fact that this type of language can also have the opposite effect when the treatments stop working and the patient’s health declines. It can become both personally demoralizing for patients who are dying, and also sends the message that healthcare’s only function is to stave-off death. But this fails to recognizing that degeneration and death are natural process that all patients will eventually experience, and that healthcare still has an important role to play in supporting patients through the dying process.^[5]

Fortunately, healthcare providers who specialize in areas of medicine where patient deaths are more frequent, such as gerontology and oncology, tend to have more training and feel more prepared for engaging in these conversations than providers in other areas.^[6] But issues at the end-of-life are not limited to only these specialties, making it important that all providers have at least some knowledge about how to begin and engage in these conversations. This is important because having open and honest conversations with patients and their families about the prognosis, the goals of care, and potential limitations of care, can be one of the best ways to limit the ethical challenges that arise at the end-of-life.^[7]  Fortunately, approaching end-of-life conversations can be broken down into four main steps:^[8]

1. Initiating a Discussion: It is human nature to avoid or downplay upsetting news, which is what makes end-of-life conversations so challenging for patients and providers alike. But open and honest communication can help to build trust between the clinical team and the patient, and when it becomes clear that a patient is significantly declining or actively dying, this information should be clearly and compassionately communicated in a timely manner. This is important so that the patient, or their surrogate decision-maker, and any family involved in the patient’s care can begin to prepare themselves and think about the decisions that lay ahead. This should be the first conversation of many to ensure that sufficient support is provided throughout the dying process.
2. Clarifying the Prognosis: The provider should be sensitive to the fears and needs of the patient and family when delivering prognostic information related to the patient’s continued decline. This involves recognizing their concerns, being caring yet direct when explaining what to expect and how much time the patient is expected to have left, and avoiding the use of medical jargon or euphemisms when discussing the patient’s death. Providers should also be clear about the limits of therapeutic treatments and the role of supportive measures, such as palliative care and hospice services, to provide comfort for the patient during the dying process.
3. Identifying End-of-Life Goals: Once the patient and family understand that the patient’s death is approaching, the provider should enquire about the patient’s goals of care at the end-of-life. This discussion can include the types of pain management and comfort measures that can be provided, the types of invasive care that may no longer be desired or appropriate, the patient’s wishes regarding having family around, whether the patient would prefer to remain in a facility or to try and go home for their final days, and whether meeting with spiritual council (such as hospital clergy or a trusted spiritual advisor) is desired.
4. Developing a Treatment Plan: Finally, decisions should be made about which end-of-life options to pursue, often related to pain management and maximizing comfort for the dying patient. Sometimes, this simply involves providing supportive services such as palliative care (which involves symptom and pain management) or hospice services (which provides tailored support and grief counseling for dying patients and their families). Other times, this can also include decisions to withdraw ongoing care, including removing life-support measures in order to allow the patient to die naturally. A discussion about the patient’s “code status” should also be had to determine whether the patient’s code status should. “Full code” allows for attempts at cardiopulmonary resuscitation (CPR) when the patient’s heart stops, a “do not resuscitate” (DNR) order prohibits attempts at CPR when the patient’s heart stops but maintains any ongoing treatments, and “DNR: Comfort Care” prohibits attempts at CPR while also stopping any ongoing aggressive treatments. Some end-of-life options, such as hospice care, even require that a patient’s code status be changed to “DNR: Comfort Care” upon enrollment, ensuring that the only measures provided are focused on promoting the patient’s comfort during the dying process.

A major complication for engaging in these discussions is that, as many patients begin to experience a physical decline toward the end-of-life, they often experience a cognitive decline as well. And certain life-sustaining medical interventions, such as the use of ventilators (a form of mechanical breathing), require that patients remain sedated for an extended period of time to avoid intense discomfort. When patients lacks capacity and cannot speak for themselves, we of course turn to a surrogate decision-maker, but what if the surrogate never talked with the patient about the their end-of-life preferences or goals of care prior to the patient losing capacity? And what if the surrogate feels uncomfortable making big decisions for the patient, such as limiting or withdrawing life-sustaining care, without knowing the patient’s wishes on the matter? Surrogates and patient families feel more comfortable making these types of decisions when they know what the patient would likely want, or want to avoid, which is why end-of-life conversations should not be delayed once it is clear the patient is significantly declining or that their treatment options are severely limited. And providers should support patients and families having these discussions with each other to the extent possible.

One way a healthcare provider can help to support patients and families in having these conversations is by offering them the opportunity to complete an “advance directive” document while the patient still retains decision-making capacity. This can open up a conversation about the patient’s end-of-life goals of care, helps to clarify the patient’s healthcare wishes in advance, and clearly documents the patient’s wishes in writing. An “advance directive” is a legal document that allows the patient to designate a healthcare proxy to be the representative decision-maker when the patient loses capacity, and to provide a clear statement about the patient’s healthcare wishes and goals of care. This document must be completed and made official while the patient still has the capacity to express these preferences (for example, see the Ohio Advance Directive form).

Unfortunately, many patients are unaware that they can complete an advance directive, or might feel overwhelmed by the paperwork, resulting in only a third of adults in the United States having completed one.^[9] This is why it is helpful for the healthcare provider to raise the topic and to provide assistance with when possible, though this paperwork can technically be completed or updated by any adult with decision-making capacity, is ideally completed prior to any medical emergency taking place, and does not require the guidance or signature of a healthcare provider. Once the Advance Directive paperwork has been completed by the patient, it should be notarized or signed by two appropriate witnesses in order to make the document legally binding. Lastly, copies should be provided to the listed DPOA/healthcare proxies, any relevant family members, and the patient’s primary care physician or current medical team so that it can be included in the patient’s medical chart. But while advance directives are important and helpful documents, they should not be viewed as a replacement for engaging in conversations about healthcare goals and wishes at the end-of-life. These conversations are necessary for providing context and illuminating patient broader goals & values, which can help the healthcare team and healthcare proxy to more accurately interpret and apply the patient’s stated wishes in order to meet their goals of care.

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5.2) Passive Euthanasia

There are three broad categories of end-of-life assistance: passive euthanasia, active euthanasia, and physician-assisted death. The term “euthanasia” often has a negative connotation, for reasons that will be explained shortly, but the term itself simply refers to assistance in achieving a good death. It comes from the Greek “eu” meaning “well,” and “thanatos” meaning “death,” which taken together translate to a “well death” or “good death.” In a healthcare context, “euthanasia” therefore describes actions that intentionally bring about the death of a patient for that patient’s own sake, in order to promote a good death for the patient. This raises important questions about whether the death of a patient can ever promote their well-being, and whether our application of beneficence and non-maleficence should focus more on health or non-health considerations for patients at the end-of-life.

The practice of “passive euthanasia” specifically refers to actions that intentionally withhold or withdraw life-sustaining care from a patient, knowing that the patient will likely die as a result. Why might a healthcare provider ever agree to do this? As suggested by the name, performing passive euthanasia is considered and carried out when allowing the patient’s death would likely provide more benefit (or less harm) to the patient than continuing with aggressive medical interventions. For example, for every patient there eventually comes a point when the types of aggressive interventions that previously helped to prolong a patient’s life are no longer able to improve their condition. When this time comes, we may view these interventions as no longer “life-saving” and instead as “extending the dying process.” If these interventions are causing discomfort or risking harm to the patient while failing to offer much benefit (meaning they no longer provide a net-benefit), then stopping these interventions may be viewed as being in the patient’s best interest. And this can include withdrawing even life-sustaining interventions such as mechanical ventilation or artificial hydration/nutrition when the patient fails to show improvement. Perhaps surprisingly, passive euthanasia is actually the most common form of end-of-life assistance both in the United States and globally.

Legal Status of Passive Euthanasia:

So why is passive euthanasia the most common form of end-of-life assistance? A major reason is because it is legal in all developed nations across the globe, including being legally permitted throughout the entire United States. The legal groundwork for passive euthanasia in the US goes back to the 1976 court case of Karen Quinlan, a 21 year old woman who fell into a permanently vegetative state following an overdose.^[10] Karen Quinlan’s parents petitioned the New Jersey Supreme Court to have their daughter removed from a ventilator after the attending physician and hospital refused their request. Her parents were awarded the right to refuse the ventilator on their daughter’s behalf, establishing a right to refuse care and laying the groundwork for the right-to-die movement.

Then in 1990, the case of Nancy Cruzan, a 25 year old woman who fell into a permanently vegetative state following a car accident, raised similar questions around the withdrawal of artificial hydration/nutrition.^[11] Nancy Cruzan’s parents petitioned the Supreme Court to have their daughter’s feeding tube removed after the hospital refused because doing so would result in her death. Once again, the parents were awarded the right to refuse care on behalf of their daughters, but only because Nancy had previously stated her wish not to be kept alive artificially through life-sustaining care. Taken together, these court cases established the rights of patients or their proxies to withhold or withdraw care, even when that care is life-sustaining and doing so would knowingly result in the death of the patient. And because the case of Nancy Cruzan turned on her previously expressed wishes, this case also helped to raise public awareness and interest in the importance of healthcare advance directives.

Moral Considerations Regarding Passive Euthanasia:

The previous discussion helps to explain the support for passive euthanasia from a legal perspective, but we can still question whether this practice is morally appropriate. As discussed in Module 2, the right to refuse care is grounded in a negative liberty, which is then expressed by the bioethical principle of respect for autonomy. When applied to in an end-of-life healthcare context, this principle supports passive euthanasia insofar as patients have the right to consent or refuse care, including the right to refuse life-sustaining. Forcing life-sustaining care on a patient against their wishes would be an instance of medical paternalism and violate the patient’s right to give or refuse their informed consent. The moral rights of patients to self-determine, either directly or through the use of a healthcare proxy, is precisely what the courts upheld in the cases of Quinlan and Cruzan. And the courts acknowledged that the right to self-determine includes the right to refuse even life-sustaining care knowing the patient will likely die as a result. In cases where the life-sustaining care is withheld or removed due to the clear wishes of the patient, either expressed directly by the patient, through their healthcare proxy (surrogate decision-maker or Healthcare Power of Attorney), or in their advance directive, then the action is described as “voluntary passive euthanasia.” This clarifies that the reason to withhold or remove the care is to respect the decision of the patient.

However, as discussed in the previous section, in many instances the patient has not completed an advance directive, nor have they discussed their end-of-life wishes with anyone prior to losing capacity. Yet there still comes a time when a decision needs to be made about whether to continue or stop life-sustaining care. When the patient’s goals of care or preferences regarding end-of-life care are unknown, the healthcare team and healthcare proxy must make a determination about what would be in the patient’s best interest. When it is determined that stopping care and allowing the patient to die would be in the patient’s best interest, for the reasons discussed previously, then that action is described as “non-voluntary passive euthanasia.” This clarifies that from a clinical standpoint, it is justifiable to stop the care for the benefit of the patient, but that the patient’s own wishes on the matter are unknown.

In some cases, the healthcare proxy or patient’s family may want aggressive life-sustaining care to continue, but the healthcare provider may determine that continuing with care would be medically futile and inappropriate (rarely does the patient have decision-making capacity in these situations). When the determination of futility is agreed upon by at least two independent physicians, a unilateral decision can be made to stop the provision of medically futile care against the wishes of the proxy or family.^[12] In such instances, the action can be described as “involuntary passive euthanasia.” This clarifies that the withholding or withdrawal of care is done against the wishes of the patient, which are often expressed through a healthcare proxy or advance directive. This might not sound like a “good death” if the patient’s wishes are being overridden, but in such cases, the stopping of care is still arguably “for the benefit of the patient” given that futile care always risks harm to the patient without offering any benefit. Or said another way, futile care by definition fails to produce a net-benefit, and this can negatively impact the well-being of the patient by increasing or prolonging suffering without offering any hope of improvement. When care is determined to be medically futile, the healthcare provider should first speak with the proxy and family about the importance of de-escalating the care, with the hope that they will come to understand and accept the decision. However, if they still refuse to consent to the withdrawal of futile care, the healthcare team should communicate that the care will be withdrawn regardless, and provide the proxy and family with clear notice about the date and time the withdrawal of care will take place (often 24 or 48 hours after the decision is made) in order to give them time to gather and say their goodbyes to the patient.

So when a provider withholds or withdraws life-sustaining care, knowing the patient will die as a result, how can we best describe that action? Passive euthanasia is described as allowing the patient to die, rather than causing the patient’s death. Although some people might argue that unlike withholding care, withdrawing care involves taking an action that directly contributes to the patient’s death, the American Medical Association (AMA) makes no moral distinction between withholding or withdrawing life-sustaining treatments.^[13] This is because a patient who dies via passive euthanasia is already significantly declining due to an underlying medical condition, meaning the provider’s actions (whether withholding or withdrawing care) are viewed as simply allowing the underlying health condition to progress. The patient’s death is therefore attributed to the uninhibited progression of the medical condition, rather than as being caused by the actions of the provider. This is why passive euthanasia is often described as allowing the patient to die by “pulling back on aggressive interventions” and “allowing nature to take its course.”

When passive euthanasia is performed, the patient’s death can happen within a few minutes, can take several hours, an in some cases can take up to a few weeks or even month depending on the level of support the patient required and how quickly (or slowly) their condition is progressing. This can make it challenging for a patient’s family to know when to say their final good-byes, and it can be a frightening time for patients who remain cognitively alert as they slowly die. When described in this way, passive euthanasia can easily sound callous, as though the healthcare providers are “give up” on the patient or leaving them to die without any further support. However, this is often far from the truth. Passive euthanasia is the recognition that death is inevitable and that every patient eventually reaches a point where their body can no longer be healed. When that time comes, aggressive healthcare interventions (often referred to as “life-support” measures) start to cause more harm to the patient than benefit and can only function to extend the dying-process, rather than being able to “save the patient’s life.” This is the point at which discussions about passive euthanasia typically being, and when it is decided, the patient’s code status is changed to “comfort care” which shifts the focus to symptom management and pain-relief rather than life-sustaining treatments. Comfort care measures often include providing pain management through palliative services and offering end-of-life focused support through hospice services. Occasionally, some therapeutic interventions are still provided, such as antibiotics or minor surgery, but only when they are necessary to improve the comfort of the patient (these measures are not used as an attempt to stop the patient from dying).

It is now clear that passive euthanasia does not involve simply stopping all care provided to the patient, but instead shifts the focus of healthcare away from life-sustaining interventions and toward measured aimed at providing comfort care. This is because healthcare still has a role to play in supporting patients even when their bodies can no longer be healed. Though the types of care provided to patients at the end-of-life must change with our changing assessments about what promotes patient well-being; after all, patients who have reached the end-of-life have different needs and goals of care as compared to patients who have a chance at healing and recovery. And while hospice and palliative services provide sufficient support for many dying patients, there are still some patients for whom this end-of-life assistance may not be enough, leading us to next consider yet another end-of-life option.

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5.3) Physician-Assisted Death

End-of-life measures such as passive euthanasia are most relevant when a patient has been receiving aggressive treatments or life-support and it is determined they will no longer benefit from that level of care. In these cases, it can be helpful to change the type of care being provided to comfort measures and hospice services, in order to provide specialized support while the patient dies. However, not all patients experience this type of rapid or significant decline prior to their deaths. In some cases, patients who outwardly appear healthy are diagnosed with an incurable illness, such as an inoperable tumor or a type of cancer that doesn’t respond to treatments. When the prognosis for a patient is less than six months left to live, they are referred to as “terminally ill.” For patients like these, aggressive treatments can be withheld, and hospice services can be provided, but this can still leave these patients to face their inevitable deaths for months on end as their bodies slowly begin to weaken and shut down.

In cases such as these, some patients want more control over the dying process than passive euthanasia affords, instead preferring “physician-assisted death” (also commonly referred to as “physician-assisted suicide”) as an end-of-life option. “Physician-assisted death” is an end-of-life option in which a willingly participating physician provides a “lethal medication” to a qualifying patient, which the patient can then ingests on their own when they determine that it is the right time to die. Unlike passive euthanasia in which the provider intentionally allows the patient to die from natural causes, physician-assisted death provides the patient with the means to intentionally hasten their own dying process. So, although the provider “assists” the patient in their death by providing the prescription, because the patient is one in full control of their own dying, physician-assisted death is not typically considered an act of euthanasia by the provider.

Legal Status of Physician-Assisted Death:

Unlike passive euthanasia, physician-assisted death is only legal in certain places in the United States. The first legislation allowing for physician-assisted death in the US was Oregon’s “Death with Dignity Act” in 1997. According to the Oregon Health Authority, “On October 27, 1997, Oregon enacted the Death with Dignity Act which allows terminally ill individuals to end their lives through the voluntary self-administration of lethal medications, expressly prescribed by a physician for that purpose.”^[14] This remained the only such law for over a decade, until Washington state passed its own “Death with Dignity Act” in 2008. In the years following, more states introduced similar legislation, bringing the total up to ten states who have legalized physician-assisted death as of 2025, as well as Washington DC.^[15] And it is expected that many more states will soon vote on death with dignity legislation in the years to come. In addition to being legalized in some of the US, physician-assisted death has also been fully legalized in at least ten other countries across the globe as of 2025, including Canada which passed the “Medical Assistance in Dying (MAiD)” Act in 2016.

Although the names of the legislation differ slightly, they all share strong similarities with regard to the rules and regulations surrounding this form of end-of-life assistance. To avoid abuses of the law, the practice of physician-assisted death is highly regulated included strict criteria that the patient must meet in order to qualify for physician-assistance in dying: 1) The patient must be a legal adult, at least 18 years of age; 2) The patient must have the capacity to make their own healthcare decisions at the time of the request; 3) The patient must be diagnosed with a terminal illness that will result in their death within six months.

In addition to the qualifying criteria for patients, laws governing physician-assisted death also include many other safeguards to ensure that patient participation is fully informed and voluntary. For example, most legislation requires that a qualifying patient must verbally request for assistance in dying on two separate occasions at least two weeks apart, that an additional written request also be witnessed and submitted, that an additional physician to confirm the terminal diagnosis, that a capacity assessment and/or psychological examination of the patient be performed, and that the patient be informed of alternative end-of-life support measures such as comfort care and hospice services. Importantly, no physician or other healthcare provider is ever required to participate in physician-assisted death; their participation and willingness to assist the patient in dying is always voluntary.

Moral Considerations Regarding Physician-Assisted Death:

As the difference in legal status would suggest, physician-assisted death is considered more controversial than passive euthanasia. This is primarily due to the fact that the patient’s death is artificially hastened through medical assistance, rather than allowing the patient to die “naturally.” Those who object to physician-assisted death argue that by assisting the patient in dying, the physician to some degree becomes “morally responsible” for the death of the patient, and that this type of action is inconsistent with a physician’s role as a healer. Other objections focus on more practical aspects, such as the possibility of abuse of the law for vulnerable populations, or a lack of societal trust in healthcare providers, or that it undermines the important role of hospice and palliative services. ^[16] These objections ask us to think carefully about what the proper role of healthcare is and whether it has a role to play in not just helping patients to live, but also helping them to die.

This leads into the final argument in favor of physician-assisted death which focuses heavily on respecting the autonomy of the patient. Proponents of physician-assisted death point out that slowly dying from an incurable condition is an undoubtedly traumatic experience, likely leaving the patient feeling emotionally exhausted and out of control. And while hospice and palliative services can offer pain management and therapeutic support, they cannot meaningfully alter the situation in which these patient find themselves. However, physician-assisted death allows the patient to regain some sense of control over what little life they have remaining, insofar as it allows the patient to determine both the timing and manner of their inevitable death. And quite literally, physician-assisted death puts control into the hands of the patient, because the patient is responsible for taking the lethal medication and thereby causing their own death, if or when they determine the time is right. This makes physician-assisted death somewhat akin to passive euthanasia, given that the provider is not directly causing the patient’s death in either case. And unlike passive euthanasia where the patient’s death could be non-voluntary or even involuntary, physician-assisted death guarantees that the patient’s death is always voluntary (assuming the previously mentioned legal safeguards worked as intended).

Importantly, those who argue in favor of the legalization of physician-assisted death do not claim that this option is right for every terminally ill patient, or for every physician, or even that every patient who requests physician-assisted death needs to go through with it. They merely argue that physician-assisted death should should be a legally available option for terminally ill patients to consider, in order to provide patients with greater autonomous choice about what type of assistance they want to receive at the end-of-life. And the data supports the idea that physician-assisted death is primarily about wanting to regain a sense of control, given that over a third of patients who received prescriptions through Oregon’s “Death with Dignity Act” in 2016 ultimately chose not to take the medication.^[17] Rather, it would seem that these patients appreciated having the option of controlling the time and manner of their death, even if they did not end up choosing to die through those means. This is one of the strongest arguments in favor of physician-assisted death, namely that it quite literally puts the decision in the patient’s hands, giving the patient full control over when and how their death takes place, as well as the ability to decide not to go through with at any moment.

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5.4) Voluntary Active Euthanasia

While passive euthanasia and physician-assisted death can meet the needs of most dying patients, there are still a select few patients for whom even these options are not sufficient, bringing us to a discussion of one last form of end-of-life assistance referred to as “active euthanasia.” In a healthcare context, “active euthanasia” involves taking active steps to intentionally and directly end the life of the patient. As previously mentioned, the term “euthanasia” often has a negative connotation, and this is because people sometimes use this term when referring specifically to instances of “active euthanasia.” And there is understandably a lot of stigma and concern surrounding the practice of active euthanasia, given that it can accurately be described as intentionally killing a patient. Yet a surprising number of people actually have direct experience with the practice of active euthanasia in a slightly different context, yourself included if you’ve ever had a pet “put down” or “put to sleep.”

In the United States, approximately a million domestic animals are actively euthanized each year. Unfortunately, a large portion of these animals are euthanized due to overcrowding in “kill shelters,” and this is in addition to the billions of agricultural animals that are slaughtered each year for food through less humane measures. But let us focus on the domestic animals that have the privilege of becoming members of our families and often live to an old age. Once these animals begin to decline and show signs that they may be suffering, they are usually taken to a veterinarian who compassionately euthanizes the animal by injecting them with a lethal medication, in order to put the beloved pet “out of it’s misery” and to “stop their suffering.” I’ve personally had two beloved dogs actively euthanized, and while each occasion was a sad experience, it didn’t feel “morally wrong” to hasten their deaths. In fact, it felt like “the right thing to do” to ease their pain at the end-of-life, and was a stark contrast to when my cat slowly died in my arms from “natural causes.” In contrast, the death of my cat felt like a much more traumatic experience, even though it was more akin to passive euthanasia than active euthanasia. This is because my cat’s death was clearly painful for him and drawn out over several hours, rather than  being quick and relatively painless as it has been for the dogs that were euthanized. This type of realization can makes us wonder about what the comparative experiences of people with regard to passive and active euthanasia, and to see why some people may be in favor of active euthanasia to ease the suffering of people, much like we do for our pets.

However, humans are quite different from cats and dogs, so even if active euthanasia is a morally appropriate practice for our pets, this does not mean that it is an appropriate end-of-life option for people. Some people argue that a human life has intrinsic value that an animal life does not, which justifies the killing of animals but makes it always morally wrong to kill humans. Others disagree, arguing that all lives matter equally insofar as all living being can feel pleasure and pain, and that responding appropriately to their suffering is what matters most. But regardless of what you think about the comparative value of human lives and animal lives, we can all agree that causing the death of a person against their will or without their explicit consent is clearly morally wrong (this often referred to as murder or manslaughter). This is because unlike most animals, humans have individual autonomy, meaning they have the power to make decisions about how to live their own lives based on their unique goals, values, beliefs, and preferences. Ending a person’s life without their consent and/or against their wishes is in clear violation of this, even when the killing is argued to be for that sake of that individual’s welfare (sometimes referred to as a “mercy killing”). This is why our discussion of active euthanasia as an end-of-life option will only consider the moral permissibility of “voluntary active euthanasia,” which involves taking active measures to intentionally cause the death of a patient upon their explicit request, such as injecting the patient with a lethal medication. 

Legal Status of Voluntary Active Euthanasia:

Voluntary active euthanasia is a highly controversial practice that remains illegal throughout the entire United States. This means that a healthcare provider in the US can lose their medical license and be criminally prosecuted if they intentionally take active measures to cause the death of a patient, even when the patient clearly requested and consented to the action. However, this is not true of all countries. The first country to legalize voluntary active euthanasia was the Netherlands in 2002 via the “Termination of Life on Request and Assisted Suicide (Review Procedures) Act.”^[18] Since then, a number of other countries have similarly changed their laws to legalize and regulate voluntary active euthanasia as a form of end-of-life assistance. As of 2025, at least ten countries across the globe have legalized voluntary active euthanasia, including Canada with the passing of the “Medical Assistance in Dying (MAiD)” Act in 2016.

Similarly to physician-assisted death, voluntary active euthanasia is highly regulated in these countries through strict legislation and patient criteria that must be met to qualify. This is to help limit abuse of the practice, to maintain societal trust in healthcare, and to ensure providers, patients, and their loved ones feel comfortable when pursuing this form of end-of-life assistance. However, some of these international regulations are interestingly less restrictive than those regulating physician-assisted death in the United States. For example, in Canada rather than requiring that a patient be terminally ill to qualify, the patient must be suffering from a “grievous and irremediable medical condition,” and in the Netherlands the patient must be experiencing “unbearable suffering with no prospect of improvement.”^[19] As a result, patients in these countries who are suffering from long-term debilitating conditions, or conditions that cause a slow deterioration of the body, are able to request end-of-life assistance when they feel the time is right, rather than being required to wait until they reach the final six months of their decline. And in the Netherlands, these practices have also been approved for minors who qualify, requiring parental consent if the minor is under 15 years of age.^[20]

One last thing to clarify are the differences between voluntary active euthanasia, which is illegal in the United States, and capital punishment (also referred to as “the death penalty”) which is legal in certain states across the US including Ohio. While these both involve ending the life of human beings, they are quite dissimilar. The first notable difference is that voluntary active euthanasia is always for the benefit of the individual being killed, which is why it is classified as a form of euthanasia, whereas capital punishment is intended to hurt the individual being killed, which is why it is classified as a form of punishment. Secondly, voluntary active euthanasia is always done with the consent of the individual being killed, which is why it is classified as a voluntary killing, whereas capital punishment is often performed against the wishes of the individual being killed, which classifies it as an involuntary killing. Lastly, voluntary active euthanasia is often performed using lethal medications that ease the pain and suffering of the individual, resulting in a relatively painless death, whereas capital punishment has historically been carried out through many differently painful means including hanging, electrocution, firing squad, and lethal injections that can result in hours of pain before the person’s death.^[21]

While capital punishment could be carried out using less painful means by using the same lethal medications as voluntary active euthanasia, in 2016 virtually all pharmaceutical manufacturers stopped supplying drugs to be used for capital punishment in the United States,^[22] resulting in the use of sub-optimal drug combinations that have left inmates writhing in pain for hours.^[23] The refusal of pharmaceutical companies to be complicit in capital punishment raises interesting questions about why capital punishment (a form of punitive, involuntary killing) is legal in the United States while voluntary active euthanasia (a form of arguably compassionate, voluntary killing) is illegal.

Moral Considerations Regarding Voluntary Active Euthanasia:

Given the fact that voluntary active euthanasia involves a provider directly causing the death of the patient, it is clear to see why this practice is more controversial than passive euthanasia or physician-assisted death. Whereas the provider allows the patient to die in both passive euthanasia or physician-assisted death, the provider is directly responsible for causing the patient’s death in voluntary active euthanasia. Even though all three end-of-life options are meant to promote the well-being of the patient in a non-health sense, people generally think that intentionally causing the harm of death is morally worse than intentionally failing to prevent the harm of death. However, we should also consider the fact that in the cases of physician-assisted death and voluntary active euthanasia, the patient’s death is always of their own choosing, whereas in the case of passive euthanasia it could be non-voluntary or involuntary. This fact requires us to consider what role the autonomous choices of the dying individual have, or should have, in determining how they want to die. As it stands, the legality of end-of-life practices in the United States track more closely with regulating the type of actions that can be performed by the provider (allowing death vs. causing death), rather than giving patients the rights to make autonomous choices about the type of end-of-life assistance they would prefer to receive. Some could even argue that if each of these end-of-life options could produce a net-benefit for dying individuals from a non-health perspective, then limiting these choice sets “for the good of the patients” is an example of legalized medical paternalism with regard to end-of-life care.

But this raises the most important question; why would a patient ever prefer voluntary active euthanasia over the other forms of end-of-life assistance? Voluntary active euthanasia is usually raised as an end-of-life option when patients want more control over the dying process than passive euthanasia affords, but who are unable to qualify for participating in physician-assisted death. Most notably, this includes patients suffering from conditions that cause significant physician deterioration over a long period of time, such that by the time they have six months left to live they are unable to physically perform the actions necessary for taking the terminal medication themselves. This most often occurs with patients diagnosed with a neurodegenerative diseases such as amyotrophic lateral sclerosis (ALS), motor neuron disease (MND), Huntington’s disease, or multiple system atrophy (MSA). Patients with these conditions do not require aggressive life-sustaining care for most of the disease progression, meaning there are no treatments to “withhold or withdraw” in the form of passive euthanasia. And due to the nature of these disease, these individuals often develop muscle weakness or paralysis over time, to the point that they can no longer raise their hands to their mouths or swallow medications. This then rules them out of being able to participate in physician-assisted death, given that they cannot physically end their own lives, even if they retain the cognitive capacity to otherwise qualify for such assistance. So in such case where the patient retains capacity and makes a voluntary request for end-of-life assistance, we must consider whether there is a significant moral difference between actions that would allow the patient’s death through their own actions, and actions where the physician causes the patient’s death by  actively assisting (such as administering a painless lethal injection) patients who are incapable of taking action themselves.

Interestingly, as discussed in Module 1, healthcare provides cause (or risk causing) harm to their patients with almost every action they take. However, so long as these harms are outweighed by the likely benefits, we can justify the harm by saying that the action will likely produce a net-benefit overall. Might this argument also apply to end-of-life situations, wherein the health-related harm of death could be justified by the non-health benefits of easing the patient’s suffering? Or is the harm of death a unique type of harm that should never be intentionally caused, regardless of the possible benefits or the patient’s expression of autonomy? These questions continue to divided our society, and even our medical community, yet they are worth considering in order to ensure that healthcare isn’t simply focused on helping patients to live, but also provides the appropriate types of support and assistance in helping patients to die when the time comes.

As we can see, to assess the moral permissibility of passive euthanasia, physician-assisted death, and voluntary active euthanasia, we must sort through a number of different considerations and form judgements about what features matter the most at the end-of-life. This includes thinking about how much choice a patient should have regarding end-of-life assistance options, the degree to which the patient is suffering or actively dying from their condition, whether causing a death is always morally worse than allowing a death, whether the death of a person is a unique type of harm with special moral significance, and the extent to which healthcare providers should be given professional autonomy to take actions that best align with the wants and needs of their patients at the end-of-life. There are no easy answers, challenging us to think deeply and compassionately about these issues as individuals and as a society. This is important to ensure that the laws governing end-of-life assistance align with our moral judgements about these practices.

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Works Cited