This informal paper proposes a simple model of criteria that could be used to decide whether involuntary euthanasia should be considered ethically and legally justified for individuals who are no longer able to function as normal, healthy human beings. The focus is on the humanity and quality of life of the individual.
This paper is focused on involuntary euthanasia, but the criteria likely apply to voluntary euthanasia as well.
The twelve criteria being proposed are:
- Doctors don’t have treatment readily available to enable the patient to substantially recover from their current situation.
- Patient, guardian, or a living will prevents such treatment.
- No longer profess or exhibit a joy to live.
- No longer communicative.
- No longer cooperative in care.
- No longer capable of refraining from harming self.
- No longer capable of refraining from harming others.
- No longer capable of protecting others from harm.
- No longer capable or interested in personal hygiene.
- No longer capable of personal mobility.
- Or, suffering from a terminal and severely debilitating illness.
- Special criteria for extended coma.
To be clear, extreme pain (physical or mental), sorrow, sadness, and depression alone would not be considered reasonable criteria for euthanasia. Only if other criteria are present in a very significant manner and those other criteria are untreatable or resistant to treatment despite best efforts over an extended period of time would euthanasia be justified. Euthanasia is not intended as a substitute for suicide.
The overall focus of those criteria is on humanity and quality of life — is it likely that the patient is likely to recover and resume life as a normal, healthy human being.
The first ten are the main criteria of concern in this paper. Terminal illness and coma are special cases. They are covered here as well, but not intended to be the main focus.
To be clear, there is no intent to prioritize any of those criteria, although individual doctors and guardians may indeed have their own priorities.
A few guiding questions will be suggested for each criteria, not that those specific questions must be answered to judge a particular criterion, but just to give a flavor or what questions could be asked.
To be clear, it is not being proposed that a mere superficial meeting of the criteria will demand or force euthanasia, but simply that meeting the criteria could be used as a legal and ethical justification for doctors and legal guardians to then proceed to euthanasia at their own discretion. Not all doctors or guardians would necessarily be willing to participate in euthanasia.
The goal here is to take some of the burden off of doctors and guardians while facilitating their legal and ethical responsibilities.
The point of this proposal is to take a lot of the anxiety and suffering out of such a decision, to make it as objective, clinical, and impersonal as possible, while still making it an ethical and humane decision, respecting the individual’s humanity and quality of life as far as possible.
Voluntary vs. involuntary
This paper focuses on the really difficult and thorny problem of involuntary euthanasia — medically ending a person’s life without their consent.
Voluntary euthanasia conceivably could have different criteria for when it would be considered acceptable. It will be covered a bit, but may require a separate paper for a full treatment.
Readers can feel free to read between the lines and make their own judgment as to the advisability of using the proposed justification of involuntary euthanasia criteria for voluntary euthanasia as well.
General model for evaluating criteria
There is no one-size-fits-all, technical, mathematical, or legalistic model for evaluating the final judgment about deciding to pursue euthanasia. The point is to provide a general model that has sufficient flexibility to accommodate the near-infinite variety of subtle nuances that will be encountered in each individual’s situation.
Evaluating the criteria
Evaluation of each of the criteria will be discussed by itself in subsequent sections. The point here is how to objectively or subjectively combine those individual evaluations.
Individual guardians or doctors will have their own sense of which criteria should be given higher priority, greater weight, or greater relevance to the individual under consideration. A living will can be used for an individual to give their own priority and weighting in advance, or even to disallow any or all criteria for involuntary euthanasia.
This proposal does not intend to give any individual criteria or subset of the criteria any special or highest weight in the evaluation. But particular doctors and guardians may indeed give special weight to specific criteria. For example, some may give joy to live and communicative as special weight.
The intent is to make it a judgment call, based on facts, but on perspective as well.
The intent is to make it as holistic a judgment as possible.
That said, a few common approaches to evaluation could be:
- If all of the criteria are strongly met, that’s a no-brainer justification for justifying euthanasia.
- If all but one of the criteria are met, it becomes a question of whether that lone holdout criteria is truly an awe-inspiring reason to live. If so, euthanasia is not particularly recommended, but this is probably an evaluation that is very unlikely to occur — when things go bad, they tend to go really bad.
- If a supermajority of the criteria are met, with a few that aren’t met, it becomes a judgment call whether those few remaining reasons to live really are awe-inspiring.
- If half or fewer of the criteria are not met, it doesn’t completely rule out euthanasia, but it does put a special burden on doctors and guardians to think more carefully.
The point is not that any of those approaches is mandatory, but that doctors and guardians have the criteria available to facilitate such decisions using whichever approach they choose.
It may well be that some of the criteria are met at times but not all of the time. Medical conditions can come and go episodically, although the main focus of this proposal is for difficult medical situations which have essentially no hope for cure.
I would simply suggest that:
- If a criterion is met most of the time even if not 100% of the time, treat it as being met.
- If a criterion is met only some of the time, treat it as not being met, unless the times when it is met are particularly overwhelming.
Obligation to protect human life
The proposed criteria or the concept of euthanasia are not intended to automatically negate the solemn ethical, professional, and moral obligation of doctors and guardians to protect human life to the best of their ability.
The point here is that once the overwhelming weight of the criteria begin to point towards an inability to thrive as a normal, healthy human being — a clear lack of humanity, the obligation to protect life diminishes rapidly.
Quality of life
Quality of life is the general proposition being proposed.
Once quality of life has diminished dramatically, the whole point of living becomes quite problematic, more of a technical detail rather than a matter of humanity.
The proposed criteria are really simply evaluating the degree to which the individual retains their basic humanity.
If they have physically, mentally, or emotionally devolved to the stage where they no longer have any significantly visible level of humanity, then our obligation to preserve their life seems dubious at best.
Dignity and self-respect
Dignity and self-respect are critical to quality of life and basic humanity. They are both reflected in the criteria.
Once an individual feels they no longer have a strong sense of dignity and self-respect, they are in real trouble.
And if the individual has no ability to even feel at all or is unable or unwilling to even communicate at all, they are also in real trouble.
People are social creatures, so a continued interest in social activities is part of the criteria, covered by the joy to live and communicative criteria.
Granted, some people are not incredibly social to begin with, so a disinterest in social interaction is not necessarily a strong criteria for justifying euthanasia, but a dramatic decline in existing interest in social interaction would be notable and could be a part of justifying euthanasia.
Autism spectrum disorder would not count as a marked decline in interest in social interaction.
A key motivation for the criteria is to prevent the distressing and harmful individual and social effects as an individual proceeds through a long, slow, tortured terminal decline.
Simply packing a person up and shipping them off to a nursing home or similar facility, or having them remain bedridden or indoors for the indefinite future, seems particularly inhumane.
If they are relatively healthy and reasonably happy, with only significant mobility issues, a nursing home or similar confinement might be a reasonable choice, but if a substantial fraction of the proposed criteria are met, it is unlikely to be very humane to warehouse them like that.
I mean, either they are still human beings or, they are not. This twilight region in the middle is rather inhumane.
To be clear, there is no precise mathematical formula for evaluating the criteria.
The criteria are simply information to highlight the scope of the problem for doctors and guardians.
Three strikes and you’re out?
To be clear there is no specific subset or count of criteria that would automatically trigger a full justification for euthanasia.
The intent is to still leave it to the professional and ethical judgment of doctors and guardians whether the criteria are sufficient to outweigh their legal and ethical obligations to protect life.
If anything, the proposed criteria are very ripe for application of special cases, extenuating circumstances, etc.
No one-size-fits-all model is being proposed.
An individual may choose to take their own life for a variety of reasons, but that would be considered outside the scope of supported euthanasia.
As previously noted, voluntary euthanasia is beyond the scope of this particular paper anyway.
The distinction between morality and ethics is vague, arbitrary, and a matter of debate.
For some it may be a religious or spiritual matter.
For others it may be more a matter of personal values. Or family or community values.
This paper focuses on ethics, acknowledging that for some people it is their morality that determines their ethics.
The intent of this paper is to sidestep issues of morality per se, focusing on ethics, leaving it to individuals to decide for themselves whether the practical and humane criteria suggested herein for involuntary euthanasia satisfy their own ethical conceptions, which may or may not be informed by some overarching moral framework.
I imagine that if my criteria were to be adopted, it would make sense to have a corresponding living will that allows individuals to indicate which criteria for involuntary euthanasia if any they are willing to authorize to be used in their own medical situation, should the need arise.
Personally, I would advise that all of the criteria be used by default unless explicitly stated, but prioritizing and weighting them or even disallowing some of them can certainly be matters of personal choice.
Suggested questions for the suggested criteria
This preliminary, informal proposal does not propose highly technical criteria.
What follows are some suggested questions to guide evaluation of each criterion.
Doctors don’t have treatment readily available to enable the patient to substantially recover from their current situation
- Is the patient likely to substantially recover without dramatic medical intervention?
- Is the cost of intervention so prohibitively high that it would bankrupt the patient or their family?
- Do doctors have a clear plan for a course of action, or are they just taking shots in the dark, prolonging pain or anxiety on the part of the patient and their family?
Patient, guardian, or a living will prevents such treatment
- Does the patient or guardian reject proposed medical care?
- Does the patient have a living will which rejects the proposed medical care?
No longer profess or exhibit a joy to live
- Is the patient in such constant pain that they experience absolutely no joy at being alive?
- Is the individual reasonably content with the here and now?
- Do they smile and laugh with some frequency?
- Are they reasonably optimistic about the future?
- Do they retire for the evening looking forward to the coming day?
- Do they rise in the morning full of energy and enthusiastic for the new day?
- Do they enjoy and look forward to socializing with friends?
- Do they enjoy interacting with others in social situations?
No longer communicative
- Is the patient conscious? If not, see the coma criterion.
- Is the patient so vegetative or drugged that they are virtually unable to communicate in any significant manner?
- Can you carry on a pleasant, adult conversation with them?
- Is their memory intact enough for the conversations to be coherent?
- Do friends and family feel like they’re talking with a child or complete stranger?
- Are they angry in most conversations?
- Do they refuse to engage in casual conversation?
- Do they express a desire to engage in casual conversation?
- Are they able to comprehend and comply with simple requests?
- Do they enjoy and look forward to interacting with friends?
- Do they enjoy and look forward to interacting with others in social situations?
No longer cooperative in care
- Do they voluntarily take any required medication?
- Do they voluntarily eat as required?
- Do they voluntarily get required exercise?
- Do they voluntarily communicate problems?
- Do they resist care in an irrational, childlike, or angry manner?
No longer capable of refraining from harming self
- Can you leave them in a room by themselves without any worry about their safety?
- Can you leave they at home for hours or longer without any worry?
- Can you expect them to stay inside when left alone?
- Do they have a tendency to wander off and get lost?
- Do they have the good sense to refrain from walking out into the street?
- Do you feel comfortable leaving them alone in the kitchen or the yard?
- Do you feel comfortable with them using a kitchen or dinner knife?
- Do you feel comfortable that they are fully capable of sensing danger, such as fire, flood, or intruders, and acting accordingly?
- Can you depend on them to call 911 if needed?
No longer capable of refraining from harming others
- Do you feel safe leaving small children in their care?
- Do you feel safe leaving them with a spouse or other elderly relatives?
- Do you feel safe with them if there are guns or knives, even if only kitchen or dinner knives, in the house?
- Do you feel safe with them driving a car or truck?
No longer capable of protecting others from harm
- Do you feel safe leaving small children in their care?
- Do you feel safe leaving other elderly adults in their care?
- Can you depend on them to call 911 if needed?
No longer capable or interested in personal hygiene
- Can they bathe, dress, and groom themselves?
- Are they still interested and willing to do so?
- Are people in their daily lives (family, friends, people in the community) comfortable being around them?
No longer capable of personal mobility
- Can they walk or move around without assistance?
- Can they experience the freedom and human dignity of traveling where they want when they want?
- Is debilitation severe enough, with enough pain and distress and with no relief in site?
- Are a number of the other criteria satisfied?
- Is there still a joy to live?
- Is the patient still communicative, and interested in carrying on casual conversations?
Terminal illness is a special case in the criteria.
Terminal illness alone would not be a sufficient criterion to justify euthanasia, but once the other criteria begin to kick in, the fact that the illness is terminal is moot.
Even without very severe debilitation, eventually some number of the other criteria will likely kick in, so that at some stage of a terminal illness euthanasia may become advisable. The point of this proposal is to take a lot of the anxiety and suffering out of such a decision, to make it as objective, clinical, and impersonal as possible, while still making it an ethical and humane decision, respecting the individual’s humanity and quality of life as far as possible.
If there is no relief, there really is no point in prolonging an inhumane level of pain and distress.
Is euthanasia appropriate for someone in a coma? It depends.
Each coma has its own duration. No clear rules.
A typical coma may last 2–4 weeks, but a persistent vegetative state could last for years.
Sometimes people never wake up from a coma and die.
In rare cases people have woken up from a coma after years or even decades.
Since there is no medical science to accurately predict the end of a coma, there is no answer as to whether someone will ever recover.
My suggested criteria:
- Wait two months in all cases, unless doctors firmly believe no recovery is possible due to health conditions other than the coma.
- Wait at least another 2–3 months to be sure. But if health deteriorates significantly as time passes, no need to wait.
- Guardians or doctors may opt to wait longer, at their discretion.
- After a few months, doctors can render a judgment to keep waiting if they have some medical reason to indicate that a full recovery is likely and that the patient would be likely to live a full, healthy, and normal life, assuming the coma does in fact end.
- After a few months, unless doctors believe there is a very strong prospect of full recovery, guardians and doctors may then feel fully justified in concluding that euthanasia would be ethically and legally justified.
Yes, euthanasia might in very rare cases kill somebody who would have eventually recovered, but the rarity should fully justify euthanasia. And, guardians are of course able to withhold permission for euthanasia if they sincerely believe there is still hope.
Extreme Pain, sorrow, sadness, and depression
Extreme pain (physical or mental), sorrow, sadness, and depression alone would not be considered reasonable criteria for euthanasia. Only if other criteria are present in a very significant manner and those other criteria are untreatable or resistant to treatment despite best efforts over an extended period of time would euthanasia be justified. Euthanasia is not intended as a substitute for suicide.
Extreme depression might indeed be the initial trigger for considering euthanasia, but it would have to be so untreatable and be having such a negative impact on the individual, their family, and their community, as exemplified by the various other criteria.
In short, extreme depression and extreme pain themselves wouldn’t be the criteria for considering euthanasia. The consequences of depression and pain, if severe enough, prolonged enough, and untreatable enough might though.
Who pulls the plug?
To repeat, this paper focuses only on the criteria for justifying euthanasia, and completely sidesteps a range of issues related to making the final decision and exactly who carries it out.
Just a few of the issues:
- How is the final decision made?
- Who makes the final decision?
- How is euthanasia actually carried out? Presumably some drug, as in assisted suicide, but… that needs to be explored, but not here.
- Can doctors participate in euthanasia? Currently, no, but…
- Should there be a new class of health professional for euthanasia, to avoid the ethics issues for doctors as healers?
- Is some sort of Death Panel needed?
- Is euthanasia a state, federal, or local legal issue?
- What sort of consumer education is needed?
- Can it be tested on a trial basis, in selected states or selected locales before considering for widespread use?
My only intention here is to put this proposal out in public for consideration. I don’t intend to personally pursue it any further at this time.
Whether doctors and lawyers adopt it is entirely outside of my hands. I do hope that doctors struggling with difficult cases will find some relief and encouragement in my proposal.
I do hope that advocates for patient and family rights may find it useful.
Ultimately action requires:
- A solid, rational proposal.
- Patients and their families want it.
- Doctors approve of it, to the extent that their involvement is required.
- Hospitals and other medical facilities are willing to perform it.
- Lawmakers make it legal.