Defining the Terms of the Debate: Euthanasia and Euphemism (Professor David Albert Jones)

The debate concerning whether to legalise voluntary euthanasia or physician-assisted suicide is complicated by a variety of different terms, often developed euphemisms, for the realities under discussion. This leads to confusion, and requires clarification.

Euthanasia is the ending of a patient’s life by their physician, but important distinctions remain between whether this voluntary, involuntary, or non-voluntary, and whether it is active or passive. Whilst ethically a wider definition which includes all these facets is helpful, in the political debate only voluntary and active euthanasia is advocated, making a more narrow definition more helpful.

The difference between euthanasia and assisted suicide is between who does the killing the patient themselves (in the latter) or a medical professional (in the former).

These conceptual and practical distinctions are important, but it would be helpful to have an umbrella term when discussing the various form of physician involvement in the death of patients, which could be served by EAS (Euthanasia and / or Assisted Suicide).

By contrast, the phrase ‘assisted dying’, the preferred nomenclature of those proposing either euthanasia or assisted suicide (depending on the jurisdiction) begs the question due to the assumption of ‘dignified deaths’ in the way it is commonly used, and also collapses any important distinctions that should be made in the practice. It introduces ambiguity and sanitised euphemism where precision is important.

The phrases ‘euthanasia’ and ‘assisted suicide’ are the clearest, most well-established, and most widely used terms for the intentional termination of life by or with the assistance of a healthcare professional.

The debate over whether to legalise voluntary euthanasia and/or physician assisted suicide is made more difficult by a confusing variety of terms. In addition to ‘euthanasia’ and ‘assisted suicide’, people use acronyms such as VE, NVE, PAS and EAS and proponents also use alternative terms such as ‘right to die’, ‘death with dignity’, ‘end of life choice’, ‘medical aid in dying’, and, increasingly, ‘assisted dying’. This paper aims to clarify what is meant by these terms and how they differ.

The word ‘euthanasia’ was used in the ancient world to mean ‘a good death’. However, it was only in the late nineteenth century, in Britain and America, that the word came to be used for the medical killing of patients who had no hope of recovery. [1] The word was chosen as a euphemism, to avoid phrases such as ‘mercy killing’. John Keown cites a common and widely accepted definition:

Euthanasia is the active, intentional termination of a patient’s life by a doctor who thinks that death is a benefit to that patient. [2]

Using this definition, some distinctions need to be made: voluntary euthanasia (VE) is where life is terminated at the person’s request. Non-voluntary euthanasia (NVE) is where the person whose life is terminated was not able to make a request. Involuntary euthanasia (IVE) is where the person was able to make a request but did not do so. Most proponents support the legalisation only of VE. [3]

The definition given above refers to the termination of life by active means, such as lethal injection, and does not include deliberate omissions, such as intentionally starving someone to death. In contrast, a definition that includes both acts and omission is given by Pope John Paul II:

Euthanasia is an action or omission which of itself and by intention causes death, with the purpose of eliminating all suffering. [4]

This may be termed a ‘wider definition’ [5] in contrast to the earlier ‘narrow definition’ that includes only active euthanasia. If a wider definition is used then it is necessary to make further distinctions, for example between voluntary active euthanasia (VAE) and voluntary passive euthanasia (VPE). Note that both in the narrow and in the wider definition, intention plays a key role. Withdrawal of treatment is only ‘passive euthanasia’ if it is done with the intention of ending life. If treatment is withdrawn for other reasons, for example because it is of limited benefit and is excessively burdensome, then this withdrawal of treatment is not passive euthanasia, even if it leads to death.

The wider definition is more consistent from an ethical perspective, since action or deliberate omission are but different means for the same intended end. However, the narrow definition is what advocates had in mind when they coined the term. For the sake of common understanding, therefore, it is helpful to tie usage to context.

When debating changes in the law that would introduce active euthanasia, it is better to use the narrow definition of euthanasia. The wider definition can then be introduced, if it is useful to do so, in discussion of withholding and withdrawing treatment and care.

In Nazi Germany, the term Euthanasie, along with Gnadentod (mercy death), was used for the systematic non-voluntary or involuntary killing of children and adults with mental and physical disabilities. The victims of these programmes were said to have ‘life unworthy of life’ (lebensunwertes Leben). [6] After the war, knowledge of these abuses led to a reaction against euthanasia in Britain and America.

The Netherlands had no prominent history of euthanasia advocacy before the war and was not inhibited from considering euthanasia in the 1960s. Euthanasia in the Netherlands was established in medical practice in the 1970s, then through case law in the 1980s, and was eventually codified in statute law in 2001. [7]  The practice spread from the Netherlands to neighbouring Belgium, which legalised euthanasia in 2002, and then to Luxembourg, which legalised euthanasia in 2009.

Within a legal context, at least, in the Netherlands, Belgium, [8] and Luxembourg the phrase ‘non-voluntary euthanasia’ would be considered a contradiction in terms, as they define euthanasia (euthanasie) as terminating life at the patient’s request. [9] Nevertheless, the practice of NVE, as commonly understood, exists in these countries. It is just that such actions are not called ‘euthanasia’. They are called ‘life-terminating acts without explicit request’ (LAWER).

There are thus slight variations in how the word ‘euthanasia’ is used. There is a narrow and a wider definition and there is the way the word is used in the English-speaking countries and the way it is used in the Netherlands, Belgium and Luxembourg. However, there is great overlap between these uses and the clear central case remains the narrow definition with which this paper started.

The word ‘suicide’ also arose as a euphemism. The Latin-sounding word was coined in England in the seventeenth century to avoid using harsh terms such as ‘self-murder’, ‘self-homicide’ or ‘felo-de-se’ (felon of himself). It marked a greater appreciation of the disturbed states of mind that lead people to end their lives. The word was used prominently by the sociologist Émile Durkheim in his study of different types of suicide and their prevalence in different groups. The term ‘suicide’ has come to be associated with looking for factors that increase risk of suicide and factors that can be protective.

There is a broad consensus in contemporary society that ‘every suicide is a tragedy’. [10] For this reason, in England and Wales, it is illegal for anyone to ‘encourage or assist’ suicide. [11] Furthermore, people with a duty of care, such as healthcare workers, also have an added professional and/or legal obligation to prevent suicide.

Despite this consensus in favour of suicide prevention, in the late twentieth century two jurisdictions established organised forms of assisted suicide with the same aim as euthanasia. ‘Physician-assisted suicide’ was legalised in Oregon in 1997 by the Death with Dignity Act. Similarly, in 1998, the Swiss organisation Dignitas was formed ‘to assist people to obtain a pain-free suicide’ (assisting suicide in Switzerland not being illegal unless done ‘for selfish motives’ [12]). Three years later, the Netherlands passed the Termination of Life on Request and Assisted Suicide (Review Procedures) Act. This act provided a model for the law in Luxembourg,  which defines assisted suicide thus:

Assisted suicide should be understood as the fact that a doctor intentionally assists another person to commit suicide or provides another person with the means to that end, on the express and voluntary request of that person. [13]

Note that assisted suicide, according to this definition, is not only a matter of providing the means that someone uses for suicide. The lethal drug must be provided ‘intentionally’ to assist suicide, that is for the purpose of assisting suicide.  In contrast, a doctor might prescribe pain relief, despite the fear that the patient might use the drugs for suicide, without thereby intentionally assisting suicide.

The difference between assisted suicide and euthanasia is who does the killing. With voluntary euthanasia the healthcare professional ends the life of the patient at the patient’s request, e.g. by lethal injection. With assisted suicide, patients have to administer the means themselves, such as by swallowing pills; they kill themselves with lethal drugs obtained from the healthcare professional for that purpose.

Some people have argued that the same word should not be used for ‘unassisted’ suicide (i.e. what we more conventionally call suicide) and assisted suicide because there is a big difference between these two groups in the reasons people have for seeking death, in their health status and in the way that they die. Hence it is claimed, ‘the suicidal patient has no terminal illness but wants to die; the Death with Dignity patient has a terminal illness and wants to live’. [14] However, there is certainly overlap between these two groups. Many who attempt suicide without assistance also have chronic or terminal illnesses. Many who seek assisted suicide are depressed and no longer want to live. The most common concerns reported in Oregon as reasons for seeking assisted suicide may also make people vulnerable to unassisted suicide: fear of losing autonomy, being less able to engage in activities that make life enjoyable, perception of loss of dignity, fear of being a burden on family, friends or caregivers. [15]

Addressing such concerns, including the unwarranted feeling of being a burden to others, is an important element in suicide prevention in older and disabled people. [16]

Euthanasia and assisted suicide share a common intention, which is to end suffering by ending the life of the person who is suffering. They are alternative forms of intentional termination of life by or with the assistance of a doctor. It is useful to have an umbrella term when discussing different forms of euthanasia and / or assisted suicide and  the acronym EAS can perform this function.

EAS (euthanasia and/or assisted suicide) is an umbrella term for different forms of intentional termination of life by or with the assistance of a doctor.

In most jurisdictions that have legalised EAS this is restricted to cases involving a doctor and hence the organised practice of assisted suicide in Oregon and elsewhere is sometimes referred to as ‘physician-assisted suicide’ (PAS). However, in Switzerland there are no restrictions on who can assist suicide and in Canada a nurse practitioner can both prescribe the lethal drug for assisted suicide and administer the lethal drug for euthanasia. It is therefore useful to broaden the definitions of euthanasia, assisted suicide and EAS so that these include death brought about by or with the assistance of a healthcare professional.

That said, it is good to restrict the definition to healthcare professionals, notwithstanding the law in Switzerland, because it is characteristic of EAS that it occurs in a healthcare context. This context distinguishes EAS from other forms of mercy killing (such as in war) and from other forms of assistance in suicide. Furthermore, the appearance of healthcare helps explain why the practice has, at least in some times and places, been able to secure social acceptance.

As already mentioned, euthanasia involves another person performing the act of killing on the patient, while assisted suicide is where the patient ultimately administers the lethal dose themselves. This distinction between euthanasia and assisted suicide makes a practical difference in that, by and large, people are less inclined to kill themselves than they are to ask someone else to kill them. Where jurisdictions allow both, an overwhelming majority opt to be killed by the healthcare professional. For example, in 2019, of 5,631 ‘medically assisted deaths’ in Canada, only 7 were self-administered [17] and of 2,655 euthanasia or assisted suicide deaths officially reported in Belgium, in only 8 cases was the lethal dose taken orally. [18] Unsurprisingly, countries with euthanasia have far higher rates of EAS than countries that have assisted-suicide-but-not-euthanasia. [19] Countries that have legalised voluntary euthanasia also have high rates of ‘life-terminating acts without explicit request’ (whereas it is more difficult for assisted suicide to become non-voluntary since it is self-administered). Different actions carry different risks. Permitting assisted suicide risks encouraging unassisted suicides. [20] Permitting voluntary euthanasia risks encouraging non-voluntary euthanasia. [21]

In 2006, in what it called a ‘major rebranding exercise’, British campaign organisation the Voluntary Euthanasia Society changed its name to Dignity in Dying. After more than 70 years campaigning expressly for ‘euthanasia’, the organisation stopped using the term. The following year, the annual report into deaths due to the Death with Dignity Act in Oregon dropped the term ‘physician-assisted suicide’ (PAS), despite having used the term prominently in the first eight reports. Instead of the two well-understood terms ‘euthanasia’ and ‘assisted suicide’ campaigners began to use a bewildering variety of other terms including ‘right to die’, ‘death with dignity’, ‘end of life choice’, ‘medical aid in dying’, and, perhaps most commonly, ‘assisted dying’.

All these new terms are question-begging. They imply that EAS is a legal or human ‘right’, that it always or typically provides ‘dignity’, that it is an authentic or beneficial ‘choice’, that it is properly ‘medical’, and that terminating someone’s life is ‘assisting’ them through the dying process. These implications are not generally accepted other than by those who are already in favour of the legalisation of EAS.

These terms are euphemisms in that they deliberately avoid making explicit what distinguishes EAS from other deaths. For example, someone who believes that EAS can provide a ‘death with dignity’ would not deny that some non-EAS deaths also have ‘dignity’. However, if the phrase ‘death with dignity’ is applicable to other deaths then it does not specify what new feature is being proposed by legalising EAS. What is being proposed, specifically, is the intentional ending of human life.

The language of ‘medical aid-in-dying’ or ‘assisted dying’ is particularly misleading.  These phrases seem to imply that those who die other than by EAS do not receive medical assistance when they are dying. That is simply false. What is more, the description ‘assisted dying’, taken at face value, should be applicable to the provision of palliative care to the dying patient. However, what is being proposed in legislation to permit ‘assisted dying’ is not the palliation of symptoms in those who are dying. That  is already permitted. What is being proposed, specifically, is the intentional ending of human life.

The term ‘assisted dying’ is also problematic because it is ambiguous between euthanasia, assisted suicide and EAS. Sometimes ‘assisted dying’ is used, like EAS, as an umbrella term, but at other times it is used for specific legislative proposals. The same term is thus used in diverse and incompatible ways. For example, in a series of bills introduced into the House of Lords between 2003 and 2014 ‘assisted dying’ was defined first to include assisted suicide and euthanasia equally; then to include assisted suicide but euthanasia only in the case of those for whom assisted suicide was impossible; and finally to include assisted suicide but not to include euthanasia. Again, it is sometimes stated that the term ‘assisted dying’ only applies to ending the life of those who are terminally ill, but the term is also commonly applied to euthanasia in the Netherlands and to assisted suicide in Switzerland, neither of which is restricted to people who are terminally ill.

It should be noted that not everyone who is in favour of euthanasia or assisted suicide is in favour of the indirect and euphemistic language of ‘assisted dying’. For example, the late Mary Warnock, writing in 2015, stated that she preferred to use ‘the terms “euthanasia” and “assisted suicide” – not sanitising these words with euphemisms like “assisted dying”’. [22]

The fundamental problem with the term ‘assisted dying’ is that it invites confusion because it is ambiguous. There is no commonly agreed definition and the term is used in contradictory ways for quite different proposals. It is best avoided and, if others use it, they should be asked whether they intend the term to cover euthanasia, or assisted suicide, or both, or either.

It remains that the terms (voluntary) ‘euthanasia’ and (physician) ‘assisted suicide’ are the clearest, most well-established, and most widely used terms for the intentional  termination of life by or with the assistance of a healthcare professional. The question to be addressed in subsequent briefing papers is whether euthanasia and assisted suicide, as defined in this paper, should be permitted in law and in medical practice in the United Kingdom and Ireland.

Euthanasia (narrow definition)

The active, intentional termination of a patient’s life by a healthcare professional who thinks that death is a benefit to that patient.

Euthanasia (wider definition)

The intentional termination of a patient’s life, whether by act or omission, by a healthcare professional who thinks that death is a benefit to that patient.

Voluntary euthanasia (VE) 

The active, intentional termination of a patient’s life, at the patient’s request, by a healthcare professional who thinks that death is a benefit to that patient.

Non-voluntary euthanasia (NVE)

The active, intentional termination of the life of a patient who is not able to make a euthanasia request, by a healthcare professional who thinks that death is a benefit to that patient.

Assisted suicide

A healthcare professional intentionally assisting another person to commit suicide or intentionally providing another person with the means to that end.

Physician-assisted suicide (PAS)

A doctor intentionally assisting another person to commit suicide or intentionally providing another person with the means to that end.

Euthanasia and/or assisted suicide (EAS)

An umbrella term for different forms of intentional termination of life by or with the assistance of a healthcare professional.

Assisted dying

A misleading and ambiguous term easily confused with care of the dying. It is used sometimes to mean euthanasia and assisted suicide, sometimes to mean assisted suicide but not euthanasia, sometimes to denote a specific form of euthanasia and / or assisted suicide, for example assisted suicide for the terminally ill, and sometimes as an umbrella term to cover diverse forms of euthanasia and / or assisted suicide. It is best avoided.

[1] One of the earliest examples of this use of the term was that of Samuel Williams in 1870: https://en.wikisource.org/wiki/Popular_Science_Monthly/Volume_3/May_1873/Euthanasia See also I. Dowbiggin, A Concise History of Euthanasia Lanham, MD: Rowman & Littlefield, 2005.

[2] This definition is provided by John Keown (Euthanasia, ethics and public policy: an argument against legalisation. Cambridge: Cambridge University Press, 2018, p. 10).  It agrees in its key elements with the definition provided by the NHS website: https://www.nhs.uk/conditions/euthanasia-and-assisted-suicide/. Note that the word ‘euthanasia’ is also used for the painless killing of domestic animals and of animals used in scientific experimentation.  Here also euthanasia is killing with the aim of eliminating the bearer of suffering.

[3] However, it is disputed whether VE can be accepted without conceding the acceptability in principle of NVE in some circumstances. See D.A. Jones ‘Is there a logical slippery slope from voluntary to non-voluntary euthanasia?’ Kennedy Institute of Ethics Journal (2011) 21.4: 379-404. This argument will be considered in a future briefing paper.

[4] John Paul II Evangelium Vitae (25 March 1995), section 65.

[5] The term ‘wider definition’ is taken from Keown, Euthanasia, ethics and public policy, p. 12.

[6] There is an extensive literature on the Aktion T4 programme and subsequent phases of the Nazi euthanasia programme which claimed the lives of perhaps 250,000 people:

https://encyclopedia.ushmm.org/content/en/article/euthanasia-program

[7] See R. Cohen-Almagor, Euthanasia in the Netherlands: the policy and practice of mercy killing Dordrecht: Springer-Kluwer, 2004.

[8] See D.A. Jones, C. Gastmans and C. MacKellar Assisted Suicide and Euthanasia: Lessons from Belgium. Cambridge: Cambridge University Press, 2017.

[9] See, for example, The Belgian Act on Euthanasia (28 May 2002): Chapter I, Section 2.

[10] World Health Organisation (WHO). (2014). Preventing suicide: A global imperative. Geneva: World Health Organisation, p. 2:

https://www.who.int/mental_health/suicide-prevention/exe_summary_english.pdf?ua=1

[11] Suicide Act 1961, Section 2 as amended by the Coroners and Justice Act 2009.

[12] Swiss Criminal Code.

[13] Law on euthanasia and assisted suicide (16 March 2009) Chapter I, Article 1. Translation taken from Euthanasia and assisted suicide: Law of 16 March 2009 (Luxembourg, 2010), Appendix 1.

https://sante.public.lu/fr/publications/e/euthanasie-assistance-suicide-questions-reponses-fr-de-pt-en/euthanasie-assistance-suicide-questions-en.pdf This definition also agrees in its key elements with the definition provided by the NHS website: https://www.nhs.uk/conditions/euthanasia-and-assisted-suicide/.  

[14] K.L. Tucker and F.B. ‘Patient choice at the end of life: Getting the language right’ Journal of Legal Medicine (2007) 28.3: 305-32, p. 316.

[15] Public Health Division, Center for Health Statistics, Oregon Death with Dignity Act 2020 Data Summary, p. 12:

https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Documents/year23.pdf

[16] See D.A. Jones ‘Assisted dying and suicide prevention’ Journal of Disability & Religion (2018) 22.3: 298-316.

[17] First Annual Report on Medical Assistance in Dying in Canada, 2019:

https://www.canada.ca/en/health-canada/services/medical-assistance-dying-annual-report-2019.html

[18] ‘Euthanasie – Chiffres de l’année 2019’, Communiqué de presse de la Commission fédérale de Contrôle et d’Évaluation de l’Euthanasie – CFCEE Secrétariat CFCEE:

https://organesdeconcertation.sante.belgique.be/sites/default/files/documents/cfcee_chiffres-2019_communiquepresse.pdf

[19] Borasio, Gian Domenico, Ralf J. Jox, and Claudia Gamondi, “Regulation of assisted suicide limits the number of assisted deaths”. The Lancet 393.10175 (2019): 982-983.

[20] See D.A. Jones and D. Paton, ‘How does legalization of physician assisted suicide affect rates of suicide?’ Southern Medical Journal, (2015) 180: 599–604; this argument will be considered in a future briefing paper.

[21] See D.A. Jones ‘Is there a logical slippery slope from voluntary to non-voluntary euthanasia?’ Kennedy Institute of Ethics Journal (2011) 21.4: 379-404; this argument will be considered in a future briefing paper.

[22] C. Brewer, M. Irwin (eds.) I’ll See Myself Out, Thank You Newbold on Stour: Skyscraper, 2015, p.130.