Brock, D. (1992). Voluntary Active Euthanasia. In Munson, R. (Eds.), Intervention and Reflection Basic Issues in Medical Ethics (p. 180-187) 5th Ed, 1996. Wadsworth: Belmont. (Reprinted from Hastings Center Report,pp. 11-12, 14-17, 19-21., March/April 1992).

Brock explores voluntary active euthanasia primarily from the perspective of self determination. Through self determination individuals evaluate their own lives and its quality through their own values and belief systems. In order to maintain human dignity, the public has to respect these evaluations and allow individuals to act in accordance to their values. Hence euthanasia should become legalized. The major assumption in this argument is that the individuals are fully competent and capable of decision making.

This is an important argument, because patients are beginning to evolve into clients and take a more active role in their health care. Self determination must be maintained at every possible level to achieve maximum client participation.

Modern medical technology has made it possible to extend the lives of many far beyond when they would have died in the past. Death, in modern times, often ensues a long and painful demise where one loses control both physically and emotionally. Some individuals embrace the time that modern technology affords them; while others find the loss of control overwhelming and frightening. They want their loved ones to remember them as they were not as they have become. Due to self determination, the time at which one no longer wants to exist becomes variable and it becomes imperative that individuals control the manner, circumstances, and timing of their death and dying.

The Hippocratic Oath, to which physicians swear allegiance, postulates that physicians must be responsible for their patients well-being; patients are to be done for. However, in modern medicine, this is unrealistic because people have begun to realize that their physician is not God-like but rather a person who has multiple clients to care for. This brings in the concept of impartiality, which states that care is not equal for everyone, we care more and should care more for the people who are closer to us. Also, beneficence on behalf of the physician can conflict the client's principle of autonomy.

There is, however, the issue of competence. There are conditions, such as clinical depression or severe dementia, where an individual's ability to make such an irreversible decision is clouded. In the instance of incompetence a surrogate can make the decision to forgo treatment, however, the surrogate cannot make the decision for voluntary active euthanasia because the act then becomes involuntary.

This is an important factor, as there becomes a point where promoting independence can become dangerous for a client. The concept of "do no harm" or nonmaleficence becomes important because as a health care worker, one is ultimately responsible for the safety of those under their care. What may be applicable in one situation, is no longer pertinent to another situation.

Many Americans believe that if people want euthanasia they should have a right to obtain euthanasia. Most of the individuals who support this claim will never have to actually make that decision in their lifetime. Nonetheless, legalizing euthanasia then becomes a security, or insurance, for them should they ever need it.

This argument could be seen as irrelevant as it is an appeal to numbers, Brock is trying to demonstrate that everyone can benefit through legalizing voluntary active euthanasia. This argument is trying to appeal to the Utilitarian, as it promotes the greatest amount of happiness for the greatest numbers. Many people probably will not need active euthanasia, but if they should it is an option.

Euthanasia provides an escape from the seemingly endless pain, both physical and psychological, that many patients suffer from with little to no relief. There becomes a "catch-22" where if one attempts to control their pain the patient can no longer interact with others or their environment, but if their pain is not controlled they suffer needlessly. Many times those in severe pain are not receiving any treatment for their illness and their lives become a waiting game, where the dying patient loses many of the controls that they have previously lived with.

Many times clients can not have their pain controlled without using a level of narcotics which threatens to paralyse their respiratory muscles. All alternative measures; therapeutic touch, meditation, guided imagery, should be exhausted before one reaches this point. However, a majority of dying clients do not receive alternative therapies which are scientifically proven to work, due to biases in the medical community. According to research, the biases are changing and more alternative therapies are being credited and used. I realize that clients often suffer from overpowering pain, however, the extent to which many of them suffer could be controlled through a more holistic approach to medicine. Which then weakens a main argument to euthanasia.

Nonetheless, if active euthanasia were to become legalized, it could become a final control that a dying patient could have. People who die from a massive heart attack in their sleep are often viewed as lucky because they did not have to undergo a long and painful death, where one loses control of their physical and emotional being. Death and dying in its prolonged state has the ability to take away the patients' dignity. Euthanasia, for some people, may be seen as a more humane way to die.

Physicians have a professional and moral commitment to care for patients and protect life. If physicians were to preform active euthanasia it could cause patients to lose trust in their physicians because it could be viewed as contradictory to what a physician's role is. However, permitting voluntary active euthanasia does not mean that a physician has the right to terminate life at whim. Voluntary active euthanasia, inherently, requires that the patient be:

1. Fully informed of his/her medical condition, prognosis, and all available treatments (traditional and alternative).

2. Committed to euthanasia, there could possibly be a wait period to ensure that this is not a passing desire.

3. Beyond any quality of life, all reasonable alternatives should be explored to improve quality of life and to relieve any pain or suffering.

4. Competent, perhaps a psychiatric evaluation is needed to ensure that this is not the result of treatable clinical depression or any other psychological process.

Nevertheless, if euthanasia were legal it could be seen as a cheaper alternative to palliative care. As a result patients might feel pressured into choosing active euthanasia against their personal wishes for the greater good. Also, physicians and other health care professionals could find themselves in another ethical debate if health care funds were to become rationed. However, passive euthanasia is in effect in our hospitals and the care of a dying patient remains consistent wether they request further treatment or not.

Having the option of euthanasia may prove to be a burdensome decision for many critically ill patients. According to David Velleman giving people options can sometimes make them worse off, even if once they have the choice they make the best decision. To most people their life is a given, something that they must cope with. To be given the option of euthanasia could mean that people would have to justify why they are alive.

This is a weak argument as it is a faulty appeal to authority. I disagree with Velleman as I subscribe to the client empowerment model, whereby one increases clients' control through giving them options and a voice (Rissel, 1994). I feel that a part of client empowerment is allowing people to be fully informed of their options; if euthanasia is an option for an individual then that client has every right to make a fully informed, competent decision.

Clients, however, may begin to chose euthanasia to avoid becoming a burden on others. They may feel pressured through media, society, and their families to choose euthanasia to decrease the amount of resources that they use, especially as health care costs continue to rise and resources are becoming scarce. I felt that Brock belittles the argument of clients requesting active euthanasia because they feel that they are a burden. This is an issue that deserves more attention as guilt can play a major role in an individual's outlook on life.

Another possible negative consequence of euthanasia is through the killing of dying patients we may weaken the legal prohibition of homicide. However, if one argues that stopping life support is killing then have not we already weakened this prohibition. The courts have seen the patient or surrogate's right to refuse treatment as a right to privacy, liberty, self determination, or bodily integrity; not as an exception to homicide.

Suicide or attempted suicide, in most states, is no longer a criminal offence. This demonstrates that there is consent among the states to self determination, however, the majority of the states postulate that assisting in suicide is illegal and punishable even when there is written consent from the individual. A problem with the written consent is that it could be coerced; if active euthanasia were to become legal, process would have to be in place to assure that the patient's consent is fully voluntary.

The preceding argument for active euthanasia has good grounds, as it supplies enough evidence to undermine connection between euthanasia and homicide. If one argues that euthanasia is not homicide; it weakens the argument that euthanasia is murder. This sheds new insight into the debate that euthanasia is morally wrong because murder or homicide are, typically, morally wrong acts. Through the separation of the murder and euthanasia, one has isolated euthanasia from a morally wrong act.

Another argument offered is the slippery slope theory, or the question becomes where does one draw the line. If we allow active euthanasia in cases were it is morally right to do so; how long before active euthanasia is used in cases were it is morally wrong. The slippery slope theory states that once we start down the slope we are unable to get off; permitting euthanasia then becomes the first step to Nazism. The argument against the slippery slope is that we have already allowed patients to refuse treatment without falling into the pitfall of the slippery slope. I feel that this theory may have merit, however, if the legal system correctly implements processes there is no need for this to happen. "Any legalization of the practice should be accompanied by a well-considered set of procedural safeguards together with an ongoing evaluation of its use"(p. 186). Perhaps a trial in a few of the states would be beneficial as it would give us data on the positive and negative consequences of the practice.

In the defense against the slippery slope theory Brock has presents a rational premise that the legal system can safeguard euthanasia. He suggests a trial in a few of the states, which could provide more information to the actual positive and negative consequences.

If active euthanasia were to become legal, physicians appear to be the ones who should preform the act. Traditionally, physicians are the ones who are most informed about their patients' condition, prognosis, and possible treatment and are an excellent position to ensure that their patients are well informed and that consent is fully voluntary. Suicide has always had a negative stigma associated with it and physicians could remove that stigma as they are seen in our society as powerful and knowledgeable. "The physician's involvement provides a kind of social approval, or more accurately helps counter what would otherwise be unwarranted social disapproval" (p. 187).

The argument that physicians should be the ones to preform the act involves a truths about our society in the Western World. For example; physicians have traditionally been well-educated, upper class males and hence they are seen to have power. I believe that this power does have the ability to remove stigmas associated with euthanasia because physicians, in the traditional medical model, have a power-over relationship with their patients. However, Brock does not explore euthanasia from a physicians viewpoint, and the argument becomes based on the false truth that all physicians would preform the act.

Brock outlines many of the key arguments facing voluntary active euthanasia, both for and against. He provides insight into theories against euthanasia and then attempts to undermine their principles. Brock provides us with a rational acceptable argument; many of his points are supported by reliable sources, he does not make many false statements, nor does he contradict himself. Although, he does have a tendency to appeal to numbers, tradition, and he made a few assumptions without providing a reference. Nevertheless, he provides the reader with positive and negative consequences of euthanasia, supporting those which strengthen his argument and weakening the positions that could be seen as contradictory. Overall, I felt that Brock's argument was acceptable, rational and had good grounds.

Rissel, (1994). "Empowerment: The holy grail of health promotion". Health Promotion International. 9(1). p. 39-47.