Euthanasia
The practice of euthanasia is aimed at supporting dying persons. It encompasses all treatments that (i) aim to reduce suffering at the end of life by shortening a person’s life, or at least by accepting such a shortening as a possible consequence of a corresponding treatment, and that (ii) are intended to enable a person to die in a manner that is as autonomous as possible. Euthanasia is thereby geared towards those who are terminally or incurably ill (physically and/or mentally), and who are experiencing unbearable suffering or a lack of purpose in life and therefore have an urgent desire for euthanasia. It likewise includes permanently unconscious patients or patients in the terminal stage of their illness whose consciousness is already impaired and who are no longer able to express their wishes regarding the ‘medico-technically’ possible use of life-prolonging treatments or their withdrawal. In addition, it addresses seriously ill newborns who are not yet capable of expressing preferences, whose life expectancy is very limited or whose future life would be marked by severe suffering.
Yet not all forms of “letting someone die” fall under the heading of “euthanasia”. Any therapeutic, palliative (i.e. pain reducing) or life-prolonging intervention requires the patient’s consent. If the patient refuses such an intervention and its omission leads to the patient’s premature death, this situation mis widely regarded as the manifestation of a patient’s “right to a natural death”.
An ethical assessment of the question of the permissibility of assistance in dying requires a more fine-grained distinction as to what form of euthanasia is actually involved. In public debates in particular, two forms of medical treatment are repeatedly confused with one another: physician-assisted suicide on the one hand and euthanasia on the other. However, there are many reasons for not viewing assisted suicide as a subcategory of euthanasia. For conflating the two forms would suggest that the issue is an “all or nothing” scenario: either one advocates the legalization of both forms or their joint prohibition. Rather than simply presupposing such a far-reaching assessment by accepting this “all-or-nothing” scenario, the reasons for and against such an equation must first be weighed up.
Against this background, the following four basic forms of euthanasia can be distinguished:
- Pure euthanasia, which includes appropriate palliative care (i.e. pain-relieving care) to the dying person, focusing on nutrition and nursing care as well as interpersonal and emotional support.
- Passive euthanasia, in which life-prolonging or life-sustaining treatments are not initiated or continued.
- Indirect active euthanasia, in which the use of pain-relieving treatment (especially medication) involves the acceptance of a reduction in the patient's life expectancy.
- Direct active euthanasia, whereby a person is deliberately killed at their own request.
This list can also be understood as a gradual ranking of their moral controversy. As will be explained below, pure and passive euthanasia are the least controversial measures, whereas direct active euthanasia is considered the most controversial form.
In contrast to these four basic forms of euthanasia, physician-assisted suicide can be characterised by the fact that a medical professional specifically helps a dying person with a sufficiently clear desire to die in ending their life by providing the means for self-administration. While in assisted suicide the act of causing death is undertaken by the person wishing to die, in active euthanasia it lies in the hands of another person. The descriptive difference that cases of assisted suicide involve a form of self-killing, whereas cases of active euthanasia involve a form of killing by another, is often emphasised in order to highlight a significant normative difference between the two types of actions.
An ethical assessment of the permissibility of assistance in dying does not only depend on differences in how the life-shortening forms of treatment outlined above are described. The weighting and balancing of fundamental moral goods is also of central importance – namely, goods that are indispensable for a flourishing and good life and are therefore morally relevant (or at least potentially so). In this context, there are three fundamental moral goods in particular that are central for such an ethical assessment: the good of autonomy or self-determination, the good of human life, and the good of the absence of pain or of suffering more generally. If, for example, one believes that human life as such must, under all circumstances, be given greater weight than the good of self-determination – here, for example, the desire to choose one's own death freely – then it follows that ending one's own life is morally unjustifiable. It therefore depends largely on how the respective goods are weighted.
On this basis, Héctor Wittwer contrasts four positions that can be taken with regard to the ethical legitimacy of both the above-mentioned forms of euthanasia (1.-4.) and physician-assisted suicide, and which will be central to the following discussion:
- The restrictive extreme position: All life-shortening forms of euthanasia (forms 2.-4.) – including the withdrawal of treatment for patients in severe pain who have no prospect of recovery – as well as assisted suicide are morally impermissible.
- The liberal extreme position: All forms of euthanasia – including the active killing of patients (in the sense of form 4.) – are legitimate under certain conditions.
- The moderate restrictive position: Assisted suicide as well as passive euthanasia are morally permissible. In any case, however, this position argues that direct active euthanasia must remain prohibited, since this form constitutes an act of killing another person.
- The moderate liberal position: Both assisted suicide and direct active euthanasia are morally permissible. However, killing at an individual's request is justified only if the patient is fully conscious, of sound mind, and able to express their will unambiguously. By contrast, killing based solely on a patient's presumed will is morally wrong and should therefore remain prohibited.
Against this background, the central ethical arguments for and against the various forms of euthanasia will be presented below in order of their moral controversy. Since the status of pure euthanasia is morally uncontroversial, we will begin with a discussion of the moral status of passive euthanasia.
The question of admissibility of passive euthanasia
Passive euthanasia, as opposed to active euthanasia, refers to the decision not to initiate or continue life-sustaining treatments for the purpose of a less painful death. The difference between passive and active euthanasia is asserted by those who see a morally relevant difference between the decision not to take life-sustaining medical treatments and active forms of euthanasia: The death of a patient is not actively brought about by a third party – as in active euthanasia – but is allowed to happen by refraining from counteracting a dying process caused by other factors. Thus, anyone who acknowledges the difference between passive and active euthanasia asserts that there is a moral difference between killing and letting die.
There is broad moral agreement that refraining from life-sustaining measures in cases in which an adjective patient has after careful deliberation formed a voluntary decision to that effect is not only ethically permissible but even ethically imperative. For example, if it is a person's explicit and documented wish not to be kept artificially alive in the event of a persistent vegetative state, most approaches in the euthanasia debate hold that this voluntary refusal ought to be recognised and that the person should not be treated contrary to their originally expressed wish. However, an exception to this view may be found in certain variants of the restrictive extreme position, arguing for the sanctity of human life. Those who insist on the sanctity of human life maintain that the life of a particular person is absolutely valuable and therefore possesses value independently of whether that person considers their own life to be valuable or not. The assumption that human life is sacred or absolutely valuable implies that it is intrinsically bad to end a life prematurely once it has begun. If human life is sacred, then there is a strong moral reason to preserve that life.
If one follows such a rigorous variant within the camp of restrictive extreme positions, then, with regard to passive euthanasia, it must be argued that a well-founded wish to die on the part of a suffering person must be disregarded because of the sanctity of their life. Since allowing someone to die in the form of passive euthanasia results in the shortening of a life, this form of action would likewise have to be morally rejected. Premature death would be wrong in itself, even if it were not wrong from the point of view of the person who desires it. According to this view, both actively killing a patient and allowing a patient to die would be morally unjustifiable. It should be emphasised, however, that not all variants of a restrictive extreme position necessarily endorse to such a rigorous stance. Some variants in this camp argue that the sanctity of life may be restricted in certain situations – as, for instance, in cases of self-defence. In such situations, it would then at least be permissible to take another person's life for reasons of self-preservation. Another strategy is to argue, at a lower threshold, that the sanctity of human life prohibits the active killing (both self-killing and killing by others) of a person categorically (i.e., under any circumstances), while allowing a person to die, as in cases of passive euthanasia, remains morally justifiable. As mentioned above, however, all positions other than the restrictive extreme position regard passive euthanasia not merely as morally permissible, but as morally required in relevant cases. The reasons for this assessment will be outlined in the subsequent discussion.
The question of the permissibility of indirect active euthanasia
Indirect active euthanasia encompasses cases of treatment in which a more self-determined and less painful death is enabled through medical treatment such as the use of pain-relieving medication, whose side effects (may) shorten the patient's life expectancy. Unlike passive euthanasia, in which death is brought about by letting events take their course, this form of euthanasia is ‘active’ in that the process of dying is caused by a third party. However, it is to be characterised as ‘indirect’, since the death of a patient is not directly intended but occurs only indirectly, namely as a consequence of an action directed at another goal (such as pain relief).
In the case of indirect active euthanasia, too, the good of autonomy and the good of freedom from pain conflict with the good of human life. Anyone who, in contrast to the restrictive extreme position, rejects the basic assumption of the sanctity of life can argue for the ethical permissibility of this form of euthanasia. It could be argued that enabling a less painful and more self-determined death overrides the alternative scenario in which the dying person lives only a short time longer in severe pain. This line of argument can be justified either by denying that the premature termination of life is inherently bad. If, for example, one holds that the value of life is a matter of degree and can be determined in relation to a person's future possibilities – such as whether they will still be able to realize their wishes – then it is in principle possible that the value of human life (understood as its continuation) to be limited by other goods, such as in making an autonomous decision.
Another line of argument can be drawn from Kantian approaches, i.e. those in the tradition of Immanuel Kant, which can be classified as moderately restrictive (as defined in III). Similar to the extreme restrictive view, Kantian approaches also assert that a person's life is intrinsically valuable. According to a Kantian account, it is a person's dignity that provides us with strong moral reasons to respect that person. Unlike more rigorous positions, however, this view within the restrictive camp maintains that respect for human life does not necessarily require keeping it in existence at all costs. Rather, respect for a person's dignity is expressed precisely in treating them appropriately – which includes respecting their autonomous decisions. If one follows such a Kantian account, the (intrinsic) good of human life and the good of autonomy are not necessarily incompatible. Even for Kantian views that regard the killing of a person as categorically wrong, given that there is a relevant distinction between killing and letting die, at least indirect active euthanasia could be morally justified. If it is the autonomous decision of a dying person to consent to the administration of medication with life-shortening effects in favour of a more self-determined and less painful death, then respect for that person's dignity is precisely reflected in acknowledging their autonomous choice. In such cases, it is up to the dying person to decide autonomously the circumstances and timing of their own death.
Another attempt to morally justify indirect active euthanasia can be understood against the backdrop of the so-called doctrine of double effect. This doctrine is based on the assumption that there are kinds of actions that are intrinsically bad, regardless of their consequences and the context in which they can be performed. The doctrine of double effect is intended to allow a particular action that belongs to the kind of intrinsically bad actions nevertheless to be regarded as ethically permissible when, alongside its bad effect, the action also has an ethically good or at least permissible effect, and the actor intends the good or permissible effect only. Thus, even if it were true that indirect active euthanasia belongs to the kind of intrinsically bad actions (as Kantian approaches claim), as it causes the death of a dying person, this form of euthanasia could still be morally legitimate because it enables that person to have a less painful life than would otherwise have been possible. If the medical professional's sole intention is to alleviate the suffering of the dying person by taking appropriate treatments, and does not wilfully aim to shorten that person's life but merely accepts this as a side effect of the treatment, then, according to this line of argument, indirect active euthanasia is a morally justifiable practice.
On the ethical permissibility of direct active euthanasia and physician-assisted suicide
Precisely because direct active euthanasia and physician-assisted suicide are often discussed in the same breath, this section will examine both practices in contrast to each other from an ethical perspective.
As already outlined in the introduction, the key difference between the two practices lies in the fact that, in cases of assisted suicide, the death of a patient is caused through an act of self-killing, whereas in cases of direct active euthanasia it is caused through the killing of a third person. Active euthanasia therefore requires a medical professional who intentionally ends the life of a dying person on the basis of that person’s autonomously formed wish to die. In assisted suicide, by contrast, a medical professional enables suicide by deliberately providing a lethal drug to a dying person who has expressed a wish to die. Now, many people will have the intuition that there is a moral difference whether one person is killing another or whether a person is killing themselves. This intuition is expressed in the widely accepted prohibition on killing, according to which it is morally impermissible to kill another human being. Direct active euthanasia does indeed constitute an act of killing, albeit one that is not carried out against the will of the dying person. At the same time, this form of euthanasia appears to require particular justification because, as an act of killing carried out on the basis of an explicit request, it seems at first glance to violate the categorical prohibition on killing – given that both passive euthanasia and indirect active euthanasia do not directly aim at bringing about the earlier death of a terminal ill person, but merely accept it as a consequence. In contrast, assisted suicide seems to remain unaffected by this prohibition.
Another factor that supports an ethically relevant distinction between the two practices is the degree of risk of error involved in carrying out a lethal action. In the case of assisted suicide, it is plausible to assume that the person remained convinced of their wish to die until the end of their life, as otherwise the suicide could not have been carried out. After all, suicide can only be performed if the dying person is conscious, has formed a determined wish to die and, on the basis of this wish, voluntarily carries out the act of suicide. Direct active euthanasia, on the other hand, may also be performed in cases in which a patient has lost consciousness, and it may therefore no longer be possible to determine whether such a wish to die is present or not. For this reason, a further distinction is commonly made between voluntary and non-voluntary active euthanasia. Active euthanasia is voluntary if a patient is of sound mind and conscious and expresses a corresponding wish to die. It is non-voluntary, by contrast, if a patient is no longer capable of articulating their previously expressed wish for the termination of their life. At least in the latter cases, the risk that patients could be killed against their will cannot be ruled out.
The ethical status of physician-assisted suicide
Let us first look at the ethical status of physician-assisted suicide. Physician-assisted suicide is not a criminal offence in Germany. However, subsequent to the decision of 26 February 2020 by the Federal Constitutional Court which declared the previous statutory regulation in Section 217 of the German Criminal Code (StGB) to be unconstitutional, there has been an ongoing debate in Germany about a new legal framework for the regulation of assisted suicide, due to the lack of a legally binding provision since that ruling. From an ethical point of view, however, assisted suicide is considered morally legitimate by all of the positions outlined above except for the restrictive extreme position, provided that access to it is limited to strict conditions. Thus, even from a moderate restrictive standpoint, such as a Kantian position, it can again be argued that the recognition of the value of human life is expressed precisely in respecting the autonomous decision of a dying person. This can be understood with reference to one version of Kant's categorical imperative, according to which we must treat another person “always at the same time as an end, never merely as a means”, that is, as something that must be morally respected for its own sake (and thus not merely as a means to a (higher) end). In Kant's formulation, the formulation “at the same time” plays a decisive role. According to this, a medical professional may assist a dying person in committing suicide provided that the dying person is, simultaneously, regarded as an end in themselves. It could thus be argued that a dying person is recognised as an end in itself by a medical professional insofar as the latter acknowledges the dying person's autonomous decision and supports them in their wish to die – and thereby does not treat them merely as a means to an end. Since only the medical professional has the knowledge and access to lethal drugs necessary to enable a safe and as painless as possible death, their assistance is essential in order for the dignity of the dying person to be respected until the end of their life. By providing a person in such a situation with a lethal drug, one does not appear to be treating them merely as a means but rather recognising their intrinsic value as a person. Consider, for instance, cases in which a dying person no longer has the physical strength to end their own life by other means. It follows that their wish to die can be realised only through assisted suicide. Anyone who rejects this line of argument would have to explain why continuing such a life, under extreme pain and against one's own will, should count as an expression of respect for human dignity.
On the other hand, however, it could be argued – also from a Kantian point of view – that forms of suicide are morally prohibited because one has a duty to oneself not to end one’s own life. Since a dying person would violate a duty to themselves by an act of self-killing, such an act cannot be morally permissible. It may be true that, from a Kantian point of view, the medical professional does not violate any moral duty towards the dying person; the dying person, however, would violate a duty to themselves by committing suicide. Ending one's own life would therefore constitute an unjustifiable violation of one's own dignity, as the person in question would no longer see herself as an end in itself by committing such an act. Against this, it can be objected that, insofar as a dying person uses themselves as a means to their own end, they do not reduce themselves to a mere means. According to Kant, moral wrongdoing only occurs when a person uses themselves or someone else exclusively as a means to an end. However, it can be argued that this criterion is not necessarily fulfilled in the case of an autonomous act of suicide.
In contrast, liberal positions often determine the value of a particular life in terms of the circumstances and condition in which that life finds itself. On this view, the value of a life is therefore gradual in nature – it can be higher or lower. If, from the perspective of the person suffering, an extremely painful life is no longer worth living, the value of such a life may be so low that it is morally justifiable to end it under certain circumstances. According to a liberal position, a life that is no longer worth living can be understood as a life that is almost exclusively determined by suffering that can neither be alleviated in the future nor outweighed by other life-improving goods. In such cases, where the life of a dying person is no longer worth living and they also express a well-considered desire to die, liberal positions argue that assisted suicide is not only morally permissible, but even morally required.
Another liberal argument in favour of assisted suicide is seen in the outcome of the terrible scenario of a self-initiated but failed suicide attempt. If assisted suicide were to be prohibited by law, such scenarios in which a person suffering greatly attempts to take their own life would become more likely. For such a person, it is argued, there is only one possible scenario that is worse than continuing to live: namely, the moment after a failed suicide attempt. Consequently, medical assistance in suicide should be permitted for preventive reasons, in order to keep the frequency of such scenarios as low as possible. Instead of forcing a dying person, through a prohibition, into such a desperate situation in which they see no other way out but to carry out suicide on their own – at the risk that the attempt may fail – assisted suicide should instead be regarded as the appropriate course of action.
The ethical status of direct active euthanasia
Active euthanasia focuses on the question of the permissibility of killing by a third party (killing by others). It is therefore the most controversial form of euthanasia. In particular, the central issue of the debate concerns on whether the widely accepted prohibition on killing allows for exceptions in this context, what reasons there might be for such exceptions, and whether such exceptions may create a slippery slope leading to a further expansion of these exceptions. First, the arguments of the liberal extreme position, which challenge the unconditional inadmissibility of active euthanasia, will be presented. It will then outline possible objections in the form of various slippery-slope arguments directed against direct active euthanasia – and, accordingly, in favour of the unconditional validity of the prohibition of killing others.
In general, proponents of active euthanasia argue that no moral distinction can be made between (active) killing and (passive) letting die, provided that both actions are carried out for the same reasons. A central objection to this distinction is that the death of the person concerned is the result of both types of actions. And if medical professionals were to perform both actions for the same moral reasons – for example, in order to recognise the dying person's wish to die and to end their incurable suffering – both actions must have the same moral status.
Furthermore, it is argued that (passively) letting someone to die “slowly”, especially when this is associated with incurable, unbearable pain, can in some circumstances be more “inhumane” than a “quick” form of active euthanasia (e.g. through a deliberate overdose of analgesic medication). By contrast, ethicists who consider active euthanasia to be categorically impermissible argue that a – albeit conditional – “permission to kill”, or more precisely, a permission to kill innocent persons beyond situations of self-defence, entails an intolerable relativisation of the prohibition of killing.
However, if one adheres to the strict validity of the prohibition of killing, the liberal side puts forward the following criticism: incurable persons who wish to die but are no longer able to end their lives by their own means would have to be denied the right to premature death by the restrictive side. Those who declare the killing of dying people inadmissible even in situations where patients are so disabled that they cannot take their own lives are thus responsible for the continuation of an agonising life that, from the point of view of the dying person, is no longer worth living. Consequently, it is argued that a position that permits assisted suicide but forbids direct active euthanasia is discriminatory towards all those dying persons who no longer have the ability to end their lives by their own.
In this or similar ways, liberal positions aim to undermine the distinction between killing and letting die. Another influential argument by the American philosopher Jeff McMahan starts from an analogy between actions that harm someone and actions benefitting someone. Now, based on the assumption that (actively) doing harm is worse than (passively) allowing harm to occur, it follows that actively benefiting someone is, in general, better than merely allowing someone to be benefited passively. So, if the possibility of suffering in the future provides us with a strong moral reason not to actively cause it, then the possibility of future well-being also provides us with a strong reason to actively promote it. Based on this analogy, McMahan then draws a momentous conclusion regarding the moral status of direct active euthanasia. For if it is not merely worse when a medical professional actively kills a patient who wishes to die than when they only allow that patient to attempt suicide on their own, then, under certain circumstances, it is even better for the medical professional to acknowledge their wish to die and actively kill them rather than simply allowing the dying person to take their own life. Consequently, according to McMahan, direct active euthanasia is at least as morally obligated in certain situations as assisted suicide.
Based on this line of argument, it is therefore doubted that it is morally relevant who is responsible for the death of a dying person – i.e., whether it is the dying person themselves or a third party. Instead of categorically tabooing the important question of the moral status of acts of killing from the outset, as this liberal extreme position argues, it should rather appear morally required, in light of the painful situation of a dying patient in question, to justify exceptions to the prohibition of killing in order to adequately respect the autonomy of dying patients.
As mentioned at the outset, however, there is controversy within the liberal camp as to whether only voluntary active euthanasia or, more far-reaching, also non-voluntary active euthanasia should be considered morally permissible. A moderately liberal position argues that the will of the dying person is decisive. Consequently, active killing of a third party at the person’s request is permissible only if this request is expressed explicitly or on the basis of a previously documented advanced directive. An extreme liberal position goes further and argues that active killing by a third party may be morally permissible even in circumstances where there is no current consent – for example, if a terminally ill person is no longer capable of making decisions and/or if, due to severe cognitive impairments, they can no longer be regarded as a person in the full sense. On this view, it is not only the (current) voluntary consent that is relevant for moral decision-making, but also the health status and mental condition of a dying person. Accordingly, killing by others could be morally justified even if (i) the person concerned has not previously objected, (ii) no further conflicting interests can arise in the future, and (iii) the present suffering of the dying person, as well as that of those close to them, outweighs competing considerations.
Potential slippery slope arguments as a consequence of liberalising direct active euthanasia
Arguments concerning potential slippery slopes are frequently raised against the liberalisation of direct active euthanasia, and thus in defence of an unconditional and categorical prohibition on killing others. These arguments are often supported empirically by reference to developments in the Netherlands and Belgium, where various forms of euthanasia are legal. Critics of a liberal position argue that the negative consequences of legalising active euthanasia in these countries support the case for an unconditional prohibition on killing others. In this debate, slippery slope arguments focus on the potential dangers that may arise from relativising the prohibition of killing others. It is argued that, once an exception to this categorical prohibition has been granted, the door has been opened to misinterpretation and abuse. This is said to be the case even if permission to kill an innocent person outside of a situation of self-defence is granted only under strict conditions – for example, if a living will is in place.
Furthermore, critics of active euthanasia argue that relativising the prohibition of killing others leads to a decrease in inhibitions against killing. This, in turn, might result in an expansion of the practice of euthanasia to groups of people other than those originally intended. Even if such permission is initially only available to dying patients who are capable of judgement and expression at the relevant time and who freely request their own death, it could still be extended to other groups of people at some point. The further development of this authorisation could then affect both persons who are not capable of judgement and expression, as well as seriously ill persons who are not yet dying, and older or disabled persons who have not expressed a corresponding wish. Moreover, an extension to the aforementioned non-voluntary euthanasia could also be anticipated, in which the will of the person concerned would no longer serve as the sole criterion for decision-making. This leads to the further serious objection that, if non-voluntary euthanasia were legalised, acts of killing could be justified on the grounds of “compassion” or even for “economic reasons”.
Another argument against active forms of euthanasia is that legalising it could have a significant impact on the patient-physician relationship. Patients usually view physicians as “healers” and “helpers”. However, if physicians were to participate in active euthanasia, they would inevitably become an active role in the achievement of death. It is precisely this role that contradicts the fundamental goals of medical practice and is therefore viewed critically or even negatively by the medical community. Critical views in this context are also closely interwoven with the debate for expanding or promoting suicide prevention as a priority over euthanasia regulations. In April 2024, the Federal Ministry of Health published a National Suicide Prevention Strategy that presents measures and recommendations in the areas of health literacy and empowerment, psychosocial counselling and support as well as networking and coordination of suicide prevention. In the German Medical Association’s Principles regarding the accompaniment of the dying process by physicians of 2004, respectively 2011, it thus explicitly says that the assistance of a physician in suicide is not a medical task. Instead, the German Medical Association and the German Medical Assembly advocate for a stronger palliative care. As a recommendation for palliative care, a “Charta for the care of the seriously ill and dying humans” was adopted in August 2010, supported by the German Medical Association (BÄK), the German Association for Palliative Medicine (DGP) and the German Hospice and Palliative Association (DHPV). With its five guiding principles, it is supposed to indicate a type of palliative care that is oriented on the needs of terminally ill and dying people. A revised edition was published in 2015, which remained identical content-wise, but was amended with an outlook on further feasibility. Legislation is also pursuing the approach of strengthening palliative care: With the "Second Act to Amend Drug Law and Other Regulations", which came fully into force in October 2012, physicians in Germany can, by way of exception, provide a narcotic painkiller to people undergoing treatment if it is not possible to obtain the drug from the pharmacy, or not in time, in order to bridge a foreseeable palliative care crisis situation in the ambulatory sector.
Another question raised by critics is whether more people would choose active euthanasia or assisted suicide if these were legal. There are fears that liberalisation of both active euthanasia and medically assisted suicide would lead to higher mortality rates. The objection based on this is that, under these circumstances, decisions about death would be made prematurely without considering alternatives, like for example palliative care. However, there is currently no clear empirical evidence to confirm such expectations. For a study, that was published in “Lancet”, scientists of the Universities Rotterdam and Amsterdam analysed death rates by reference to the register of deaths of the Netherlands in the years 1990, 1995, 2001, 2005 and 2010. What the scientists found was that, in the midterm, there was no significant increase of cases of active euthanasia after it was legalized in the Netherlands in the year 2002. The percentage of people who died by active euthanasia in the year 2010, which is 3% (475 in 6861 death cases) was higher than the percentage in the year 2005, which is 1,7% (294 in 9965 death cases), but it is comparable to the years 1995 and 2001. In contrast, a study published in the "Ärzteblatt" in 2022, which looked at developments in Belgium, recorded an increase in the practice of active euthanasia since its legalization. In 2003, 235 cases, 0.2% of all deaths, were registered, whereas in 2021 there were 2,699 cases, 2.4% of all deaths. A further instructive observation can be made when comparing Canada with the U.S. state of California, which legalised assisted suicide in the same year (2016) as Canada and has a similar population size of nearly 40 million. While 486 people died in California in 2021 under the state programme, in the same year 10,064 people in Canada made use of the state MAID programme. Various reports attribute this high number in Canada, at least in part, to insufficient welfare support, particularly for people living in precarious socioeconomic conditions. This observation runs counter to the thrust of slippery slope arguments, according to which the legalisation of assisted suicide or active euthanasia must be a primary cause of increased mortality rates. Rather, the socio-critical observations from Canada suggest that it is not only the question of the legality of forms of euthanasia, but (at least) equally economic and welfare-state factors that play a decisive role in explaining why more people in difficult life situations decide in favour of death.
Regardless of the more general question of the significance and impact of slippery slope arguments, liberals can pass the buck here by pointing out that these slippery slopes could also be feared as a consequence of legalising assisted suicide. This would indeed be correct if the liberal side is right in claiming that there is no morally relevant difference between killing and letting die. Whether, for example, a lethal substance is actively administered by medical professionals to a person who is suffering severely and wishes to die, or whether this substance is “merely” made available by medical professionals, would then no longer make a decisive moral difference. In both cases, corresponding slippery slope arguments could then be put forward. Thus, liberals could argue, for example, that the relationship between physicians and patients could be seriously affected just as profoundly in either case.