I. Introduction 

The term Euthanasia is subject to a basic conceptual distinction. On the one hand, euthanasia may denote "assistance throughout the dying process", that is, support and accompaniment during the time leading up to death. In this sense, euthanasia entails the support of the dying person by giving care, pain-relieving treatment, and personal comfort. As such, its urgent necessity in the dying process is undisputed. Yet on the other hand, euthanasia can also denote "assistance in achieving death", then entailing the killing or "letting die" of a dying, seriously ill or suffering person in accordance with their own expressed or assumed wishes or interests. 
The issue of "assistance in achieving death" is discussed in the context of varying situations. 
The debate frequently distinguishes four types of euthanasia in the sense of "assistance in achieving death":

  1. "Letting die"/"Passive euthanasia": renunciation of life-prolonging measures (while continuing to give "basic care" and pain-relief treatment,
  2. "Indirect euthanasia"/"Indirect active euthanasia": pain-relief treatment while tolerating a (non-intended) risk of shortening the patient's life span,
  3. "Assisted suicide"/"Support for voluntary death" / "physician-assisted": assisted suicide e.g. by procuring and supplying the lethal drug,
  4. "Active euthanasia"/"Direct active euthanasia"/"Termination of life on request": Intentional and active acceleration or bringing about of death. Contrary to indirect euthanasia, death is not only tolerated but intended. Contrary to assisted suicide, the ultimate decisive impulse is not given by the patient but by a third party.

The range of meaning of the term euthanasia is a wide one. It includes dying persons, seriously or incurably (physically or mentally) ill persons who are suffering unbearably or who see no purpose in continuing to live and thus express an urgent desire to be "released" through euthanasia. It also includes patients who are in a long-term coma or whose consciousness is already impaired in the terminal phase of a disease and who can no longer personally express any opinion regarding the implementation or termination of medically and technically viable, but therapeutically doubtful life-prolonging measures. It ranges to seriously damaged newborn babies incapable of expression, whose life expectancy is very short or who are expected to suffer greatly in life. 

However, not all forms of "letting die" are being summarized under the keywords "medically assisted suicide" or "euthanasia". Any therapeutic, palliative (meaning analgetic) or life-prolonging intervention requires the consent of the patient. If the patient refuses a certain measure and its omission leads to the patient's premature death, this situation is widely regarded as the manifestation of a patient's "right to a natural death". 

From a medical-ethical perspective, there is a general responsibility of the physician to preserve life, but not under all circumstances. Furthermore, life-prolonging measures cannot be responsible if they are ineffective, if their efficiency is questionable or if they involve disproportionately large suffering for the patient. The differentiation between the usage of ordinary and exceptional treatment methods is being discussed here, both from the medical perspective as well as from the moral perspective.

II. Ethical aspects

In the discussion about the licitness of the various types of euthanasia, many different ethical aspects play a role. The main topics of discussion are as follows:

Licitness of suicide

A prerequisite for assuming the licitness of killing a person in accordance with their own wishes is that a person is permitted to end their own life intentionally in the first place. Whether or not this is the case – and if so under what circumstances – is the subject of debate. Basically, there are two approaches, both of which set different limits to an individual's right to self-determination concerning life and death:  

Proponents of the first approach assume that human life is "inviolable" or "sacred". Human life is hence not only not at other people's disposal but also not at one's own disposal. This approach is rooted not least in Jewish-Christian traditions and is supported above all by the churches. The given reason is that life is God-given and that therefore God alone has the jurisdiction over life and death. If life is already coming to an end, there is no absolute obligation to prolong it by any means possible; however, its active shortening through suicide is objectively prohibited as a violation of God's sovereignty. Yet the subjective capacity for bearing responsibility may be diminished in such cases. Based on this approach, passive or indirect euthanasia in the case of a person whose dying process has already begun may be permissible under certain circumstances. However, under no circumstances shall it be permissible to assist suicide or carry out active euthanasia.

From a legal-ethical perspective, it is principally being argued that in a liberal legal order a prohibition such as that of euthanasia can only be demanded if reasons can be given that are ideologically neutral and are thus, in general, comprehensible for everyone.  

In their substantive argumentation, which also opposes the argument of a general elusiveness of human life, supporters of the second approach refer to the capacity of humans to determine their own actions. The grounds of human dignity lie in this ability of self-determination. The obligation to protect this dignity is tied to this ability. Against this background, they argue, there is also an obligation to protect human life from life-threatening acts by third parties, as life is the prerequisite for human self-determination. However, a self-determined ending of one's own life, whether active or passive, cannot be unconditionally prohibited in the name of human dignity. This also applies to all types of voluntary euthanasia. However, the decision must have been taken carefully while in a clear state of mind and with an acute awareness of all circumstances; moreover, the way in which one's own life is ended may not imply any danger for third parties. Neither, therefore, is euthanasia overall nor are its various types and the desire for euthanasia to be prohibited per se. Rather, its permissibility should be assessed with regard to the extent to which the criteria mentioned are or can be fulfilled.

Irrespective of the varying limits of self-determination, the respect for self-determination is a core aspect in the entire euthanasia debate. In order to protect one's right of self-determination one can make a living will.

Licitness of active euthanasia

Independently of the question of whether suicide is permissible, one must also consider whether killing by third parties, an aspect of active euthanasia, is permissible. There is debate as to whether the categorical prohibition of killing allows for any exceptions in this respect, what reasons there could be for these exceptions and whether the exceptions may create a "slippery slope" towards increasing their number.

From a moral perspective, too, the question concerning the difference between active euthanasia and other forms of euthanasia arises. It depends on the possibility or impossibility of such a differentiation whether active euthanasia can be unconditionally prohibited if the other forms of euthanasia are, at least conditionally, being permitted.  

Opponents of the unconditional prohibition of active euthanasia argue that a moral distinction between killing someone and letting someone die is impossible to draw if either takes place for the same unselfish reasons. This is the case because in either case the result is the death of the patient. Further, it is argued that a "gradual", passive "letting die", to the extent that it involves unbearable, untreatable pain, may in certain cases be less humane than "quick" active euthanasia (e.g. by the administration of an intended overdose of pain-relieving medication).

Advocates of the unconditional prohibition of active euthanasia above all point out that the "permission to kill" – more precisely, the permission to kill innocent people in situations not involving self-defence – is linked to a "weakening of the prohibition to kill". This could provoke misinterpretations and misuse, thereby destroying any trustful relationships between humans. This is the case even if the permit is only conditional. Besides, they assume that such a "weakening of the prohibition to kill" could lead to an increase in the readiness to kill. This, again, could entail a more widespread application of active euthanasia, possibly extending it to more groups of people than originally intended. Even if the permission to kill originally only refers to dying persons who, at the time in question, are capable of judgement and expression and who request their killing of their own free will, it could eventually still extend. Seriously ill but not yet dying patients as well as elderly or disabled people without an exhibition of their will could be affected by a further development of this permission. Thinkable is even an extension to (involuntary) euthanasia against the wishes of those concerned, out of "pity" or for "economic reasons". Advocates of the unconditional prohibition consider it impossible to eliminate these risks of “slippery slope”, neither by means of fully comprehensive regulations governing exceptions nor by exempting active euthanasia conditionally from being a punishable offence while maintaining its unconditional illegality. This latter approach is pursued by proponents of partially allowing active euthanasia.

Furthermore, there is an argument concerning the question whether more people would choose active euthanasia, if it were made legal. It is expected, that there would be a higher death rate due to the medically assisted, pain free bringing about of death. It is feared, that, given these circumstances, people would prematurely choose to die, not regarding alternatives, like for example palliative care. Evidence that would confirm such expectations cannot be clearly provided at present. For a study, that was published in “Lancet”, scientists of the Universities Rotterdam and Amsterdam analyzed 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.

Medical professionals in the role of a "killer"

The patient-physician relationship and the request for euthanasia

When physicians are involved in the euthanasia process, the implied weakening of the categorical prohibition of killing has significant impacts on the patient-physician relationship. Traditionally, the physician's role vis-à-vis the patient is that of a "healer" and "helper". However, by practising active euthanasia the physician becomes an "active agent" in the achievement of death. This, it is argued, is in fundamental conflict with the basic principles of the profession and is accordingly viewed with scepticism or even rejected by the medical community. In this context, critical positions can also be found closely interwoven with the debate for expanding or promoting suicide prevention as a priority over euthanasia regulations. 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 physicians’ assistance of suicide is not a medical task. Instead, the German Medical Association and the German Medical Assembly agitate for a stronger palliative care. In August 2010, the German Medical Association, the German Association for Palliative Medicine (Deutsche Gesellschaft für Palliativmedizin), and the German Hospice and Palliative Association (Deutscher Hospiz- und Palliativverband) issued a "Charta for the care of seriously ill and dying humans" (Charta zur Betreuung schwerstkranker Menschen) as a recommendation for palliative care. 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. In addition, the 30th Ordinance on the Amendment of Narcotics Regulations also increased the maximum prescription quantities of three narcotics (levomethadone, methadone and morphine).

The question of legal legitimacy of medically assisted suicide

The question whether physicians are allowed to provide assisted suicide continues to arouse debate. This becomes apparent in the debate about the new regulation of euthanasia in Germany. The medically assisted suicide falls within the domain of assisted suicide and is not subjected to prosecution in Germany. Nevertheless, subsequent to the decision of February 26, 2020 of the Federal Constitutional Court declaring the previous regulation in Act 217 as unlawful, a new discussion about the regulation of euthanasia in Germany sparked off.

Closely related to this is furthermore the question, whether persons, that request assistance for suicide, should also obtain entitlement for state or medical assistance in getting access to the relevant medication. Since the decision of the Federal Constitutional Court of February 26, 2020, the provision of drugs for the purpose of suicide by doctors and assisted suicide associations is considered lawful and not pursued by law. This legal situation was preceded by controversies whereas on the one side the legislation on narcotics prohibited the purchase of lethal drugs fundamentally. On the other side, some exceptions have been allowed in extreme cases by pointing to the right of self-determination and in the absence of palliative alternatives for incurably critically ill people. The right of self-determination has been discussed critically, e.g. by the former constitutional federal judge Udo di Fabio, who stated, that “the free individual decision, which places the individual at the centre of the legal system, has an exceptional weight as it includes the right to suicide. Personal self-determination does, however, not lead to an absolute validity resulting in a governmental duty of participation in a highly personal decision.” This statement is being reflected in the current legal situation insofar as the Federal Administrative Court emphasises that the general right to freedom does not imply a legal claim towards third parties to effectively offer such support. They thereby emphasise that doctors cannot be bound to offer support for assisted suicide and, therefore, help can only be offered voluntarily.

In the course of the debate on the regulation of assisted suicide, two draft laws for a new regulation of assisted suicide were presented to the Bundestag on July 6, 2023, but each failed to gain a majority. At the same time, a proposal to expand state suicide prevention was passed by a large majority. It foresees the development of a draft law by 2024 as well as a concept for a stronger expansion of suicide prevention services and a nationwide prevention service.

The danger of a latent destruction of solidarity

"Slippery slope" arguments are not only brought forward against allowing active euthanasia – they also play a role in the debate surrounding other types of euthanasia. The main concern is that too liberal a treatment of the euthanasia issue could lead to a destruction of society's solidarity with ill, suffering and dying people, and maybe even to pressure being put on ill and weak persons to seize the opportunity of euthanasia in order to "take their burden" off society.

Such considerations do not necessarily oblige society to reject all forms of euthanasia unconditionally. However, they do call for prerequisites to be put into place in order to prevent the according developments.

Issues relating to the "authenticity" of the desire for euthanasia and the lack of alternatives to euthanasia

If a person who wishes to die expresses their desire for euthanasia, it must be considered whether their desire is "authentic", i.e. whether he*she genuinely wants to die, and whether this wish could be fulfilled in some other way.
Here, too, various points of view have been put forward: 

It is often pointed out that dying persons experience typical stages of dying which can be accompanied by major mood swings. If a dying person requests euthanasia in such a situation, – according to the respective opinion – that may not be the expression of a genuine wish to die but rather a "natural" and transient accompanying phenomenon of the dying process.

It is also frequently maintained that the desire for euthanasia is rooted in great pain, feelings of abandonment and loneliness, but also in shame about one's helplessness and the resulting depression. These causes can be met by pain-relief treatment and/or personal comfort measures – an approach also pursued by the hospice movement in their support of dying patients.  

Opponents of these theories state that although personal comfort and pain-relief treatment and, in the case of mentally ill patients, psychotherapy, can often lead to a reversal of the wish to die, there are also patients whose severe physical and/or psychological suffering cannot be relieved by such measures. That, they argue, is the reason why – if only in exceptional cases – there may in fact be no alternative to euthanasia.

The problem of determining the assumed wishes of patients unable to make decisions

Any kind of euthanasia can only be permissible if it is in line with the wishes of the person in question. The permissibility of euthanasia in cases involving patients who are no longer (or in the case of newborns, not yet) capable of judgement or expression is therefore only permissible if it is possible to previously determine the patient's assumed wishes. Basic issues here include first and foremost the "medical criteria", i. e. diagnosis and prognosis.  

Moreover, various tools for determining the assumed wishes of a patient have been discussed as further steps. One possibility is a "living will" (or "patient's directives") drawn up by the patient themself in which the patient has expressed relevant wishes while still fully competent. Another option is consultation with a caretaker or legal guardian appointed beforehand by the patient or, if such was not appointed, one or more persons close to the patient.  

Whether or not these tools are adequate is a matter of some controversy. Sceptics point out that the period of time between drawing up a living will and its application can often be very long, that a healthy person cannot always adequately envisage their own dying process and that such a living will cannot account for every possible scenario and set forth instructions accordingly. In addition, the question is raised whether a patient's representative – a lawyer or a close relative – assesses or can assess the patient's wishes accurately, or whether such a representation may be open to possible abuse. For these reasons, none of these tools can be used in good faith; determining the patient's precise wishes is sometimes not even possible at all.

Suggested citation

German Reference Centre for Ethics in the Life Sciences (2024): In Focus: Euthanasia. URL [date of access]

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