Philosophy Question

1 Aren Boynagiryan 04/21/2024 2 In Defense of the Moral Permissibility of Euthanasia Is it ever morally permissible to kill a person (with their permission) to end suffering? When a person actively ends another person’s life or assists them in ending it, this action should be justified morally, ethically, and legally. However, the debate on the moral permissibility of euthanasia still remains relevant and unresolved in many communities today. As with other controversial issues, decisions on whether or not euthanasia should be morally permissible depend on the fine details of defining the philosophical issue. Before moving to legalize euthanasia, there must be a high degree of agreement on the moral permissibility in a specific community. Regardless, the American society today and most of Western communities remain divided on the moral permissibility of the practice, warranting further discussions and philosophical debates. In this paper, I defend the moral permissibility of euthanasia by developing a utilitarianism argument and supplementing with an argument in favor of patients’ autonomy for those who choose to end their lives to relieve irreversible suffering. Defining Euthanasia The definition of euthanasia starts with the basic facts that a person, A, dies as a result of deliberate and voluntary action in the context of informed consent and autonomy. Beauchamp and Davidson (1979) are among the first philosophers to define euthanasia in the contemporary context. Their definition includes five main conditions. The first two conditions are that euthanasia occurs when a person A dies through intentional actions by another individual B and that there is sufficient evidence to show that A is suffering from an irreversible terminal condition. Next, actions should be intended to relieve suffering based on evidence that death will cause less suffering and the causal means is as painless as possible. Lastly, person A should be a 3 non-fetal organism (Beauchamp & Davidson, 1979). This definition presents the key conditions to define euthanasia but does not differentiate active and passive euthanasia from physicianassisted suicide. I base my definition on Beauchamp and Davidson (1979) and define active and passive euthanasia as well as differences from physician-assisted suicide. Wreen (1988) improved on Beauchamp and Davidson (1979) by including the option of ‘letting die’. Active euthanasia is defined as an action taken by an individual, say person B, to bring death to person A. Common examples include a lethal injection administered by a physician to end the patient’s life. The physician actively causes the death of the patient because they deliver the final blow that leads to the death. Passive euthanasia is a less aggressive approach where the person is let die, for instance, through withholding life support or feeding tube. Therefore, it is imperative to consider the differentiation between the two approaches. This paper focuses specifically on active euthanasia and its moral permissibility. Further definitions of euthanasia must at least differentiate it from other similar approaches to dying, most relevant being physician-assisted suicide (PAS). Dworkin, Frey, and Bok (1998) define the different approaches including suicide, euthanasia, and PAS. The main difference between euthanasia and PAS is that in the former, the physician will take action to bring about the death of the patient. In the latter, the physician provides means of causing death such as a prescription but does not actively administer the lethal dose. The legal details of PAS exempt physicians from liability in disputed cases. Current policies in the United States and many other nations mostly favor physician-assisted suicide over euthanasia as the legal standard by lifting the responsibility of delivering the killer blow from the medical practitioner (Mroz et 4 al. 2021). This paper’s focus will be on voluntary active euthanasia, where the physician administers the lethal dose at the request of the terminally ill patient, rather than PAS which is a passive means of ending the patient’s life. Arguments for Euthanasia The key arguments for euthanasia are based on autonomy and utilitarianism and ironically, these three bases have also been used to oppose the practice. Autonomy is the right to make decisions regarding one’s life outcomes. As has been argued by various philosophers, humans have inalienable dignity which must be considered in matters of quality of life and decisions on whether one should die. Autonomy extends to include people’s right to seek a life with dignity and choose how to ‘die with dignity.’ Utilitarianism is a theory of morality that promotes taking actions that foster happiness and pleasure as opposed to harm or unhappiness. The key arguments for and against euthanasia can be summarized into these three main foundations. One of the proponents is Sissela Bok, the co-author of the text Euthanasia and PhysicianAssisted Suicide and she promotes an autonomy defense for euthanasia. In chapter 7 of the text, Bok reviews the ethical implications of legalizing euthanasia and the implications of failure to do so. She considers the complexity of the issue including the decision-making process, the risk of a slippery slope, and regulations of the same. Bok admits that it may be challenging to regulate euthanasia and terminally ill patients may be coerced or even forced to request euthanasia if it is legalized (Bok, 1998). However, she argues that close regulation can be achieved and with appropriate safeguards in place and everyone’s interests considered, euthanasia should be permissible (Bok, 1998). Her argument is based on the idea that patients have an inherent right to 5 decide what happens to their body. This right should be honored in cases where patients are under so much suffering as to plead for their own death. Bok’s argument promotes autonomy as an inalienable right for patients. The autonomy debate by Bok focuses largely on the patient’s right to weigh the odds of suffering and pain versus death in their end-of-life decisions. The patient should be allowed the voluntary decision to determine how they will die if they are dying any way. The moral permissibility of euthanasia, according to Bok, boils down to the patient’s ability to choose, as they have all other medical decisions. She summarizes her argument: “considering the individuals whose suffering leads them to plead for death, much more [has] to be done to respect their right to reduce treatment and even, as a last resort, their right to speed their own death” (Bok, 1998, p. 116). Euthanasia, she concludes, is a matter of personal choice and the patient’s suffering so as to plead death should be reason enough to grant it, whichever way the patient chooses. The main issues to consider here are the regulations to ensure the patient’s decision is uninfluenced and they exercise their right to weigh the pros and cons of alternatives. In addition to Bok, other philosophers have also promoted the idea of autonomy as outweighing other medical and ethical principles. In contemporary medical practice, a patient has the right to refuse certain treatments and cannot be compelled to do so. In the context of vaccinations, blood transfusions, and even antibiotics, patients have the right to decline medical care unless doing so causes harm to others (as in the case of vaccines needed for herd immunity and argued by Drew (2019) and others). In matters of euthanasia, no other individual is harmed by the patient’s decision to terminate their life. Braun (2003) argues that the debate on moral and legal permissibility must be understood as an autonomy-based rather than a medical-based 6 argument. Specifically, she argues that the decision to request assistance in dying is not a medical decision and hence should not be evaluated under the medical professional principles of aspects such as beneficence (Braun, 2003). Decisions on the best treatment to provide, how to provide care, and the most appropriate medical decision to make can be made by the physician and medics. However, the decision on whether or not to terminate one’s life based on an untreatable and irreversible health condition is not a medical decision. Instead, it is a debate about one’s control over their life and how to exercise that control. Braun strictly restricts her argument to PAS rather than euthanasia, arguing that people who can request assistance in dying can also administer the lethal dose in some way (Braun, 2003). This premise is questionable because patients may be incapacitated and having developed their living will when in capacity, still choose euthanasia. Nevertheless, her argument seems to support the idea of euthanasia based on the main concept that it is an autonomy-based argument rather than a medical decision to be made. The patient’s decision to live or die under conditions where death is perceived as relieving irreversible suffering is an autonomy and patients’ rights debate rather than a medical decisions debate. Moreover, by restricting patients’ ability to request euthanasia, we would be upholding harmful paternalism on the lives and decision-making of people who experience irresolvable suffering from a medical condition. The feminist point of view supports the autonomy argument for euthanasia. Feminism, in general, can be understood as a movement against paternalistic tendencies and domination in society. Feminists, therefore, tend to oppose all systems that maintain paternalism, the practice of restricting freedoms and responsibilities of people considered subordinate. Gail Tulloch, the author of Euthanasia, choice and death, and a 7 renowned feminist advocate reviews the feminist perspective for euthanasia. She argues that feminist bioethicists are extremely cautious in decisions and situations that could place the medical practitioner in a paternalistic position in making decisions regarding the life and life outcomes of the patient (Tulloch, 2005). The ideals of feminist oppose the idea of a government or person with relatively more power than the individual imposing decisions that have a significant effect on the life and liberties of the subordinate. Disallowing euthanasia is one such situation whereby the government takes away one’s power to make decisions that relieve them suffering. Although Tulloch (2005) does not necessarily support euthanasia, she advocates for conditions in which the patient’s autonomy is protected and gatekeeping prevented. A feminist perspective, therefore, supports the moral permissibility of euthanasia based on the principle of patients’ autonomy. The right to die with dignity is another major defense for euthanasia. Dignity can loosely be defined as the quality of deserving some respect regardless of one’s social status in the community. Preserving one’s dignity includes preserving their ability to make decisions regarding how to live a fulfilled life, seeking eudemonia in all life phases. Eudemonia is a Greek word emanating from Aristotelian ethics with no single English-word translation. However, it is roughly translated to mean a condition of human flourishing which includes but is not limited to happiness (Carson, 2006). David M. Shaw of the Institute of Biomedical Ethics at the University of Basel defends euthanasia on the basis of eudemonia. He argues that eudemonia, as proposed by both Aristotle and Plato, would support euthanasia or assisted dying. Shaw understands eudemonia as the individual’s ability to live a fulfilled life without letting aspects of nature interrupt that. His argument, therefore, logically follows that it is “inconsistent to allow people to 8 live their lives as they choose in a liberal society but to inflict harm on them by refusing to allow them options at the end of life” (Shaw, 2009, p. 533). If one is to exercise their autonomy in seeking dignity throughout life, they should then be allowed to do so at the end of life, consistently with principles of eudemonia; the fulfilled life. Eudemonia promotes approaches that help the individual to avoid suffering and live a flourishing life. If one is to adhere to stoicism and the concept of eudemonia, therefore, they have to consider the quality of life and be allowed to make choices that will reduce or prevent suffering. The second argument for euthanasia is utilitarianism and proponents mostly uphold the total utilitarian view. Utilitarianism proposes that an action is morally permissible if it promotes the most ‘good’ compared to alternatives (Tännsjö, 2005). Using this argument, one would have to define the ‘good’ or utility of different aspects of euthanasia. The benefits and utility of the euthanasia decision are thus put to test. A utilitarian defense of euthanasia argues that the ‘utility’ of allowing euthanasia could produce the most happiness to not only the patient but also other stakeholders. Tännsjö (2005) argues that euthanasia has a higher utility than living a painful and poor quality of life as long as it brings more happiness and contentment to the patient than their pain and suffering at the end of life. They mention that other than the patient, this process will benefit others through reduced burden of care and even freeing up medical resources for others who need it. A criticism raised against this point could be that the individual’s utilitarianism does not outweigh the pain and grief of losing a loved one. Nevertheless, one could argue that the society generally gains when the wishes of a person who independently weighs the quality of life in end-of-life decisions and chooses euthanasia are granted. Arguments against Euthanasia 9 Numerous philosophers and bioethicists have argued against euthanasia and the argument of the inherent value of human life stands out. The idea of human life being inherently valuable, despite the quality of life, is not new. Philosophical and religious scholars from different eras have often argued that life has inherent value. The inherent value is an intrinsic quality that human life should not be destroyed, regardless of the circumstances since it is sacred. John Finnis, an Australian philosopher, is one of the contemporary defenders of the value of human life, in his vehement opposition against euthanasia. His argument against euthanasia are based on concepts of naturalism, specifically focusing on the idea of basic human goods. These are aspects of human nature that have intrinsic value and hence must be valued for their own sake. Finnis (1995) argues specifically against active euthanasia because it requires intentionally killing a person. Here, the issue of intent and side-effect is raised. From his argument, one can understand his reasoning that if euthanasia is a result of a side-effect of an action, say pain management with a potentially fatal dose, it could then be excused. However, intentionally injecting a patient with a lethal dose meant to kill him is indefensible to Finnis. The morality of Finnis and other naturalists is based on the concept of inalienable intrinsic human goods, the inherent dignity and value that human life has. Human life is distinguished from other lifeforms and hence it is one of the essential human goods. In line with this belief and doctrine, acting to harm or end a natural human good is unreasonable and immoral Finnis (1995) claims that “one who intends to destroy, damage, or impede some instantiation of a basic human good necessarily acts contrary not merely to a reason but to reason, i.e. immorally” (p. 29). An analysis of this statement shows that Finnis banks on the sanctity of human life as the essential issue to consider in debates regarding euthanasia. The argument follows that if life is an 10 inalienable human good and any action to harm or impede human good is immoral, then euthanasia, which involves intentionally taking action to kill someone, hence impede human life, is immoral. Moreover, the immorality of euthanasia has further been extended based on John Stuart Mill’s principles of individual liberty. Neil Brown, an Australian philosopher, argues that euthanasia, any act of killing a person is morally impermissible because it causes harm to the fabric of society. Brown argues that in society, individuals are free to act as they wish, with the limitation being the ‘harm’ principle which is the cause of harm to others. While proponents may perceive euthanasia as exercise of that freedom and not causing harm to others, Brown (1996) argues that it indeed causes harm through destroying the basis of the individual in community, this is a harm to society. Mill’s freedom argument can be generally defined as: one cannot use their freedom to derive themselves of the very freedom (i.e. one selling themselves into slavery). Mills logic is used by Brown (1996) who argues that, given the freedom to choose, the individual should, therefore, not make deliberate decisions to end this freedom, requesting euthanasia. Brown’s argument makes a major assumption based on the sanctity of life. The assumption made here is that it is generally agreeable that human life is sacred and it is the basis on which the principle of liberty is based. Other than the sanctity of human life, the slippery slope argument has also been developed and supported by various philosophers. A slippery slope is a metaphor for unintended adverse consequences that may occur due to the initial action of allowing a small and controlled action. The general slippery slope argument is usually something like this: euthanasia, in itself, and when closely regulated and controlled to ensure rights and autonomy are observed, may be 11 morally permissible. However, if it is deemed so, there is a risk of increasing misuse and abuse of this practice and encroaching on the ‘ideal’ situation that is originally intended. For that matter, even allowing the strictest of these practices opens the door to increasing risk of abuse and misuse of the right to actually cause harm. Therefore, by the virtue of this slippery slope, allowing euthanasia would be morally and legally impermissible. Specific arguments of the slippery slope can be examined in isolation. van der Haak (2021) uses a utilitarian approach to argue against euthanasia, specifically citing the slippery slope associated with its permissibility. The author argues that even moderate death anxiety has been associated with the likelihood of people to pursue ‘immortality projects,’ mulling with decisions that can help them to deal with death (van der Haak, 2021). The immortality projects, the author argues, are a slippery slope towards planning for and executing one’s will regarding ‘dignified’ death. The argument developed here is that when euthanasia is permitted, people develop more curiosity regarding it being an option for end-of-life decisions. Consequently, the decisions they make even in cases of moderate death anxiety may be in favor of euthanasia, causing more harm than good if their health condition could be managed otherwise. This is a logical slippery slope argument because it provides evidence of the premises that moderate death anxiety leads to immortality projects and exploring euthanasia is indeed an immortality project. Therefore, the conclusion that euthanasia permissibility may lead to more people choosing the option is logical and valid. In summary, those who oppose euthanasia seem to follow a specific route of argument. First, they may quote some ‘truths’ of life that they believe are inalienable such as the sanctity of human life and the impermissibility to take human life regardless of the conditions and situation. 12 These claims are based on a higher principle considered in the morality of humans such as the duty to preserve human life or religious basis. Secondly, the utilitarian argument is based on the potential harm perceived with euthanasia, as in the harm caused to individuals and the society at large. The measurement of what amounts to ‘harm’ in the context of euthanasia is still debatable. Another approach common in arguments against euthanasia is the slippery slope approach. This approach is legally valid and relevant. However, it may be viewed as morally irrelevant. Morality and legality are distinct in that although laws often emanate from a society’s moral compass, legality also involves matters of regulations and enforceability of certain laws. The focus of this argument is to determine whether euthanasia should be morally permissible, not the legal aspect of the controversial issue. An act can be morally impermissible and still legal or the vice versa. The slippery slope argument largely focuses on the government’s ability to regulate euthanasia and not whether euthanasia is moral or immoral. Therefore, considering morality is more philosophically relevant than considering legality. As will be argued in the next section, euthanasia is morally permissible and these arguments against it can be refuted through analysis of flaws in the arguments’ validity and logic. My Defense of Euthanasia In this defense, I argue that euthanasia is morally permissible based on utilitarian and autonomy arguments. My first justification of euthanasia is based on utilitarianism and I will adopt the classical case of utilitarianism. At its basis, utilitarianism posits that an actor ought to always promote overall wellbeing. Utilitarinism is a form of consequentialism, meaning that the morality of action is judged based on the outcomes it is anticipated to produce if the action is taken. In classical utilitarianism, hedonism and total view are promoted. In hedonism, the 13 concepts of happiness and suffering or positive and negative conscious experiences are proposed (Rosen, 2005). Based on hedonism, it is possible to see that euthanasia promotes positive conscious experience. Starting with the individual who requests euthanasia, the request is made to relieve suffering. By relieving suffering, there is a reduction of the negative conscious experience through death. A major objection to utilitarianism usually promoted is the grief that death causes on close family members. However, while weighing the ‘happiness’ versus ‘suffering’, it can be generally agreeable that euthanasia promotes the former. When a person has a terminal illness and they suffer pain that cannot be relieved, even those around him, family members and friends, suffer psychological torture of seeing their loved one in such a state. The end of life causes grief and in the case of euthanasia, this grief is expected, unlike, say a person is hit by a vehicle and dies. Therefore, because grief may not be taken away from the equation whether the person dies of euthanasia or later from the terminal disease, it should not be considered as either causing ‘happiness’ or ‘suffering.’ Instead, it is a constant. Additionally, the total view of utilitarianism could support euthanasia based on the allocation of resources in a society. When euthanasia is permitted, people who truly believe, based on adequate information, that they are better off dead than alive will relieve medical resources for those whose conditions can be improved. Admittedly, this foundation could be abused and used to even justify murder. However, regulation and definition of circumstances where such decisions on euthanasia can be taken are important. The patient must be in a state of suffering where no more comfort of improvement of their condition can be realistically achieved and the conditions must be limited to specific medical issues. This concept is not new and has increasingly been used in making decisions regarding resource allocation in cases of scarcity. For 14 instance, hospital ethics committees usually meet to discuss the allocation of human organs such as heart and liver transplant. One of the essential principles considered in these meetings is the quality of life and likelihood that the individual will make a full recovery (Oedingen et al., 2019). In the same manner, life-saving equipment is often scarce in many institutions. Patients who are terminally ill and willing to give up these resources (medications, facilities, and equipment) will contribute positively to other patients. By allowing euthanasia, we are allowing patients to voluntarily give up scarce resources to others who have a better chance at living a dignified life, hence contributing to the society’s positive conscious experiences. Secondly, individuals’ autonomy must be upheld in all matters including euthanasia, provided no direct harm is caused to others through the process. Western medicine is founded on the idea of autonomy and physicians are especially keen on its practice. As I have stated before, a patient is permitted to decline treatment even if this causes self-harm and physicians are obligated to respect this right. Why then, should patients be required to take life-preserving treatment at the end of life? In Aristotelian ethics, living a ‘good life’ means exercising control over all aspects of one’s life to maximize their flourishing (Shaw, 2009). The question that arises is whether controlling how a person dies amounts to eudemonia. It would be argued that all pursuits to promote happiness and minimize suffering are indeed part of pursuing eudemonia. The exception, as in Mill’s philosophy, is when one causes others harm. Euthanasia asserts a person’s control over their own will, the idea that I should be able to pursue happiness or at least minimize suffering even at the last stage of my life. Therefore, it would be pretentious and philosophically unsound to affirm the principles of autonomy and eudemonia while rejecting euthanasia. 15 Possible Objections to my Argument and Responses A possible objection to my argument is the slippery slope objection. The argument against euthanasia based on the slippery slope idea has been promoted in many ethics discussions but a clear rebuttal is evident in historical studies. Opponents of euthanasia may often agree to the principle of autonomy. This is usually quickly followed by the argument that voluntary euthanasia, if permitted, may slip into cases of abuse and involuntary euthanasia. For instance, in the case of total utilitarianism whereby resources benefit other patients who can get better, one could argue that this is open to abuse and could be used to permit murder. Agreeably, I must contend that it is impossible to guarantee that cases of abuse and involuntary euthanasia as well as coercion will not be experienced in the context of legalizing euthanasia. However, Downie and Schuklenk (2021) conducted a study of the ethical implications of a slippery slope argument in Canada and found only isolated cases of abuse, generally concluding that such cases cannot preclude the legal permissibility of euthanasia based on the slippery slope argument. Other studies conducted in the Netherlands (a nation with some of the most permissive euthanasia laws) show that no such slippery slope in adhering to regulations has been realized (Rietjens et al., 2009; Van der Heide et al., 2017). By quoting these studies, I do not claim that euthanasia laws may not cause cases of abuse. I simply argue that even with such cases, there is no such thing as a slippery slope into an undesired territory of permissive killing and abuse of regulations. This argument largely depends on the premise that governments that permit euthanasia can effectively regulate the practice and practice oversight. A possible objection to my autonomy argument is that we cannot affirmatively determine whether the decision to euthanize comes from a competent and genuinely voluntary individual. 16 This objection is mostly pertinent in cases where the patient is in a vegetative state and a proxy may be needed to make that decision for them. Simmons et al. (2022) argue that another person cannot truly know what is best for the patient or the patient’s wishes. Similarly, due to their vulnerability and the undeniable influence by medical professionals and friends and families, it may be argued that true autonomy is rarely achieved in decisions of euthanasia (van der Haak, 2021). In response to the first claim of understanding a patient’s true wishes, advanced directives are important and may be used for patients in early stages or when the individual is still healthy. In the same manner a person’s will is executed after his death, advanced directives are executed when he is incapacitated and these decisions can be made early when the patient is not in a position of vulnerability. Therefore, since one can make decisions regarding euthanasia when they are in a health and non-vulnerable state, it can be argued that euthanasia promotes autonomy regarding decisions on one’s death with dignity if they are in an irreversible condition foreseeably leading to their death. In response to the second objection, it is agreeable that a patient will be influenced by their own vulnerability and the input of medical professionals and family members. However, euthanasia regulations can be created and enforced in such a way that these influences are minimized. For instance, regulations should describe the information needed from medical professionals, the time duration required for the patient to make a decision, and circumstances in which such decisions may be challenged (Braun, 2023). In practice, no ethical decision is made in full autonomy; even current debates and politics will influence the patient. That said, undue influence from others and one’s state of vulnerability should not be used as an excuse to bar the 17 individual from finding a way out of the misery and suffering they experience at the end of life. Undue influence can only be minimized in all important life decisions. Conclusion Euthanasia should be morally permissible because it promotes autonomy in decisions of dying in dignity and ending suffering and the practice has a utilitarian value to the patient, family, and community. Many bioethicists and philosophers have argued on either side of euthanasia, with a compromise commonly made on physician aid in dying as the more acceptable option. Arguments for and against euthanasia are not new but have become more common and pertinent in the context of contemporary medical industry where technologies to prolong and preserve life and debates surrounding autonomy and liberal decision-making have become more common. I argue in favor of euthanasia, specifically focusing on its moral permissibility. Autonomy in medical decision-making should not be limited to life-preserving decisions only and should include end-of-life decisions. Otherwise, the universality of the principle of autonomy would be questionable. Also, euthanasia increases ‘benefits’ to society and the individual through relieving pain and allocating scarce resources. It is admissible that euthanasia may be accompanied by cases of abuse and the individual’s autonomy may be unduly influenced. However, these objections do not necessarily lead to a slippery slope or rule out the utility and applicability of autonomy. In all other medical and non-medical life decisions, the individual’s autonomy is also influenced. Euthanasia should be morally permissible because doing so honors the principle of autonomy and promotes utilitarianism and moral relativism. 18 References Beauchamp, T. & Davidson, A. (1979). The Definition of Euthanasia. The Journal of Medicine and Philosophy, 4, 294–312. https://doi.org/10.1093/jmp/4.3.294 Bok, S. (1998). Euthanasia. In Dworkin, G., R. Frey, and S. Bok (editors), Euthanasia and Physician-Assisted Suicide: For and Against. Cambridge University Press, pp. 107-127. Braun, E. (2023). An autonomy-based approach to assisted suicide: A way to avoid the expressivist objection against assisted dying laws. Journal of Medical Ethics, 49: 497– 501. https://doi.org/10.1136/medethics-2022-108375 Brown, N. (1996). The ‘harm’ in euthanasia. The Australian Quarterly, 68(3), 26-35. https:// www.jstor.org/stable/20634736 Carson, S. (2006). Eudaimonia. Encyclopedia of philosophy, 10, 10-12. Downie, J., & Schuklenk, U. (2021). Social determinants of health and slippery slopes in assisted dying debates: Lessons from Canada. Journal of Medical Ethics, 47(10), 662-669. https:// doi.org/10.1136/medethics-2021-107493 Drew, L. (2019). The case for mandatory vaccination. Nature, 575(7784), S58+. https:// link.gale.com/apps/doc/A650901674/HRCA? u=anon~b87fdc30&sid=googleScholar&xid=101a42fa Finnis, J. (1995). A philosophical case against euthanasia. In J. Keown (ed.), Euthanasia Examined: Ethical, Clinical and Legal Perspectives. Cambridge University Press. Mroz, S., Dierickx, S., Deliens, L., Cohen, J. & Chambaere, K. (2021). Assisted dying around the world: A status question. Annals of Palliative Medicine, 10(3), 3540-3553. http:// dx.doi.org/10.21037/apm-20-637 19 Oedingen, C., Bartling, T., Mühlbacher, A. C., Schrem, H., & Krauth, C. (2019). Systematic review of public preferences for the allocation of donor organs for transplantation: principles of distributive justice. The Patient, 12, 475-489. https://doi.org/10.1007/ s40271-019-00363-0 Rietjens, J. A., Van Der Maas, P. J., Onwuteaka-Philipsen, B. D., Van Delden, J. J., & Van Der Heide, A. (2009). Two decades of research on euthanasia from the Netherlands. What have we learnt and what questions remain? Journal of Bioethical Inquiry, 6, 271-283. https://doi.org/10.1007/s11673-009-9172-3 Rosen, F. (2005). Classical utilitarianism from Hume to Mill. Routledge. Shaw, D.M. (2009). Euthanasia and eudaimonia. Journal of Medical Ethics, 35 (9). pp. 530-533. https://eprints.gla.ac.uk/18453/1/18453.pdf Simmons, D. B., Levi, B. H., Green, M. J., La, I. S., Lipnick, D., Smith, T. J., & Van Scoy, L. (2022). What surrogates understand (and don’t understand) about patients’ wishes after engaging advance care planning: A qualitative analysis. American Journal of Hospice and Palliative Medicine®, 39(4), 427-432. https://doi.org/10.1177/10499091211026674 Tännsjö, T. (2005). Moral dimensions. BMJ, 331(7518), 689-691. https://doi.org/10.1136/ bmj.331.7518.689 Tulloch, G. (2005). A feminist utilitarian perspective on euthanasia: from Nancy Crick to Terri Schiavo. Nursing Inquiry, 12(2), 155-160. https://doi.org/10.1111/ j.1440-1800.2005.00266.x 20 van der Haak, D. (2021). Death anxiety, immortality projects and happiness: A utilitarian argument against the legalization of euthanasia. Conatus – Journal of Philosophy, 6(1), 159-174. https://doi.org/10.12681/cjp.24316 Van der Heide, A., Van Delden, J. J., & Onwuteaka-Philipsen, B. D. (2017). End-of-life decisions in the Netherlands over 25 years. New England Journal of Medicine, 377(5), 492-494. https://doi.org/10.1056/NEJMc1705630 Wreen, M. (1988). The definition of euthanasia. Philosophy and Phenomenological Research, 48(4), 637-653. https://www.jstor.org/stable/2108012

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