The Concept and Ethics of Passive Euthanasia
Rick Garlikov

Background

When someone is suffering and dying from a terminal illness, injury, or congenital abnormality, many people believe euthanasia should be an option because they think the value of life depends on its quality, and that once the quality of life becomes too low, a person should be allowed to terminate their life or be assisted in doing so.  Many other people – those who believe in the sanctity of life – believe that life is sacred and of infinite value, no matter how poor its quality, and that all life (or all innocent life, at least) should be preserved for as long as possible (with one possible exception – taking a risk or making a sacrifice to save a greater number of other innocent or deserving lives or lives of more value insofar as there can be lives of more value in some way if each life is of infinite value, perhaps the life of someone who does considerably more good for others, or the lives of one’s children or someone else for whom one has certain moral obligations that might include sacrifice).  This essay only pertains to the view that the value of life depends in some way on its quality – on some significant balance of the amount of good in one’s life relative to the amount of suffering in it.  The essay is not relevant to the belief or those who hold it, that life is so sacred and has sanctity, or infinite value, no matter how bad it might be.

Moreover, there are two different aspects to the concept of quality of life: 1) actual (likely) quality and 2) potential quality.  The difference is more apparent or pronounced when circumstances prevent the potential possibility of life having as high quality as it theoretically could.  While on the one hand life under the right circumstances and with the right people as friends or loved ones could have supreme value, one’s actual circumstances might not let it have much quality or value.  In some cases of a patient seeking euthanasia, the better course of action is not to end their life to stop the misery, but to improve their life to lessen the misery sufficiently by diminishing it, by distracting one from it, or by helping them find something new (or realize they already have) something to make the misery worth enduring in order to achieve or experience.  In other words to help their actual quality of life live up to its potential high value.

It is my contention, as explained in “The Right to Physician-Assisted Suicide” that euthanasia of any sort is only right if there is nothing likely possible for the patient to experience or reasonably be helped to experience that would make it, to them, worth enduring the suffering or hardship s/he would experience during the remainder of his or her life.  It is not simply about the mere balance of joy and other good there is in one’s life compared with the sorrows and suffering or other ills of life, but about whether there is sufficient likely good in one’s life to make it worth enduring the ills, harms, sorrows, and suffering one is likely to experience.  In terms of significance, rather than simply intensity or duration, a little good or even the likely prospect of it can more than make up for even intense and prolonged agony.  The concept and element of “significance” of joys and sorrows or benefits and burdens is important because most people’s lives are worth living even though on balance, if we count all the moments of either boredom or just moving about or preparing for more important moments, life typically tends to have greater durations and intensity of unsatisfying, unpleasurable, if not sorrowful moments than satisfying, pleasurable, or joyful ones.

To some extent people who believe in the sanctity of life, also believe life’s good moments should make the bad ones worth enduring, but believe that all life, no matter how much suffering it involves, has sufficient quality because of its infinite value or sacredness to make all suffering worth enduring and euthanasia therefore unnecessary and unjustified.  In other words they might accept that life below a certain quality would not be worth living, but yet believe it is impossible for life to reach that low a quality.  (It seems to me, though I could be wrong, that belief in the sanctity of life would require the belief that one should conceive every child one can if even the poorest or lowest quality of life was better than no life, and it also seems to me that belief in the sanctity of life would require doing everything one could to prolong one’s life, such as whatever sorts of exercise or workout, healthy diet,  and other activities, no matter how much one dislikes them or finds them undesirable.  Although, as I will  point out later, I do not believe that it is euthanasia or suicide, or even wrong, to shorten one’s life by not choosing to always adhere to the lifestyle that will provide the longest life, I am not sure one who believes in the sanctity of life can agree with that.)

I also believe, as pointed out in “Determining, Declining, and Terminating Medical Treatments“ that everyone should reasonably try to help others have (and feel or see they have) sufficient joy in life to want to continue to live – we should all, as much as is reasonable (meaning not requiring unfair or unreasonable self-sacrifice) help others have, and reasonably believe/know they have, something to live for that is possible and/or likely for them to experience.

Now, in medical ethics, the distinction is made between what is called passive euthanasia (removing, or never starting treatment that would likely keep a dying person alive longer, thus letting their illness or injury kill them sooner than it would if they were treated or continued to be  treated) and active euthanasia (administering something that will actively kill them immediately or much sooner than their condition itself, whether treated or not, would have).  Both forms of euthanasia make or let the person die sooner than they would die if they were treated or continued treatment that is effectively working or likely would work to prolong their life.  The conventional claim is that passive euthanasia chosen by a patient is potentially morally acceptable but active euthanasia is not, because in passive euthanasia it is the disease or injury that causes the death, not the physician’s nor the patient’s act that directly causes the patient’s life to end relatively quickly or abruptly.

However, both active and passive euthanasia are still suicide to the extent they are deaths resulting immediately or relatively soon from the voluntary intentional choice to die sooner than the person has to, because 1) there is little, if any, moral difference between killing someone and letting someone die whom you could easily have kept alive (in this case, oneself); one is just as responsible for the death of a child one allows to run into a busy street instead of easily stopping it as one is for pushing a child into the street; and not taking pills or other treatments one could easily take that would keep one alive makes one just as responsible for one’s own death as would be intentionally taking poison or shooting oneself, 2) when veterinarians say the time has come to euthanize your pet, they don’t then say “so take it back home and let it starve to death over the coming month”, and 3) that is because euthanasia is chosen to prevent unnecessary further suffering, not chosen to increase the suffering or its intensity even if somewhat shortening its duration.  Normally, if euthanasia is right at all, then when one has reached the point where it is time to prevent future suffering, active euthanasia would actually be preferable to passive euthanasia because it ends the suffering relatively quickly, rather than simply shortening it while also making it worse or adding to it in the way that passive euthanasia is likely to (apart from the withdrawal of a treatment that is necessary at each moment to sustain life, such as turning off a ventilator or other machine necessary for sustaining life, where death would then occur relatively immediately).

But there are activities and  inactivities which tend to shorten life in ways we do not necessarily call suicide or euthanasia, and which we not only do not consider to be wrong, but we even extol, honor, praise, and revere as heroic.  Not every intentional failure to prolong one’s life is suicide nor passive euthanasia, and not every act that intentionally risks or intentionally even ends one’s life is necessarily suicide or euthanasia, although if the risk is high enough for an activity that others consider of insufficient value, they might say something like “That would be suicide” even though not literally either suicide or euthanasia. They mean something like tantamount or almost tantamount to ending one’s own life voluntarily, or voluntarily having someone else end it.  For example, a military mission of inordinate risk might be considered a suicide mission, even if right and even if there is good reason ; and kamikaze pilots in WWII definitely were intentionally ending their own lives, but for what they considered a higher purpose.  Or an insurance company might void a policy for dangerous activities in the same way it might void a policy for suicide.  But normally we do not call it suicide to take what are considered normal risks or to eschew annual doctor visits, hours of daily physical exercise, or healthier diets, even if we believe avoiding the risks or doing the healthier activity would prolong one’s life.  And we do not consider avoiding healthier activities, particularly ones which are onerous or arduous, or which take time and energy away from things more important to us, to be passive euthanasia.  

Calling the avoidance or cessation of an activity passive euthanasia seems to require the activity ended or avoided in the first place be some sort of treatment, particularly a recognized one or one with at least some reasonable potential success prolonging life during a terminal illness or terminal condition caused by injury.  In places where passive euthanasia is legally permitted, it generally requires official diagnosis of some sort of relatively short time left of life even with treatment.  There might be exceptions for terribly intense, excruciating, unbearable prolonged physical pain or suffering, which cannot be ended or mitigated without rendering the person permanently unconscious, but which would not in itself be fatal. I do not know whether there are such legal exceptions or not.  And the usual medical treatment offered is to end the suffering, but not the life, by providing sufficient morphine or similar drug to render the person permanently unconscious.  Apart from the fact that high doses of morphine do tend to also shorten life somewhat by adversely affecting vital systems like the renal system, I consider permanent loss of consciousness to be not significantly different enough from death to make it worth having just so one can technically still be ‘alive’.  In some ways, it is probably even worse than death, and generally much more expensive (in cases where cost of care is a relevant concern). I am willing to entertain arguments to the contrary, but do not know of any.

There is some vagueness or imprecision, perhaps even some inconsistency, involved in distinguishing euthanasia from suicide, and also in distinguishing passive euthanasia from mere avoidance of more healthful activities believed to help people live longer.  In short, pun intended, not all ways of ending one’s life prematurely are considered suicide or even passive euthanasia.  And although active euthanasias, when aided by a physician is sometimes called physician-assisted suicide, it is normally distinguished from what I call “garden variety suicide” – suicide over some emotional despondency such as a bad break-up of a relationship, or losing a job, rather than a terminal illness or injury, by all but the most die-hard (pun also intended) believers in the sanctity of life.  Suicide is often referred to as a permanent solution to a temporary problem, even if the problem seems permanent to the person suffering from it.^[1]

I explain in my essay “Active Vs Passive Euthanasia: Moral Equivalence or Not?  Philippa Foot Vs James Rachels” there is at least one kind of case, assuming that euthanasia of some sort is justified at all, where passive euthanasia may be morally preferable to active euthanasia, but that normally passive euthanasia is not actually morally preferable even if the medical profession mistakenly believes it is, as they seem to currently.  The case I point out is one where the dying person needs time to ‘come to grips with’ their impending death more fully than they are at the time they decide to shorten their life or be assisted in letting it be shortened.  This may be purely an emotional and psychological acceptance or it may necessitate or involve sufficient further health and energy deterioration or increased physical suffering to make death “feel” more desirable and not just be intellectually believed to be even if one is correct.  The additional time and worsening of the condition may help the person emotionally and  psychologically “come to grips” with their dying and accept their death.

There is more to making life and death decisions, however, than whether life is worth living, or has sufficient value to make it worth living, or not, because one might choose to risk or sacrifice a life worth living for something of more important value to one – to save others whose lives are individually or collectively more important, or to fight to preserve certain values for one’s country, one’s community, one’s family, oneself, or even for complete strangers, whether foreigners or others distant in space and geography or for posterity, whether one’s descendants or not, distant in time.  Patrick Henry’s invocation “Give me liberty or give me death” was not a suicide note, even though it was a profession of the quality of life view over the sanctity of life one.  He would prefer to live, but not at all costs, in this case the cost of liberty.  This is not to say that every principle for which one would risk or give their life rightly deserves that risk or sacrifice, just that insofar as we accept a principle does or might deserve or justify it, we do not consider the sacrifice – the choice to die, or risk dying, prematurely – to be suicide.  For example, there were American contemporaries of Patrick Henry who felt that life under British rule was sufficiently good not to throw it away or risk throwing it away.  Later I will discuss other qualities which people find important besides political and economic liberty.

And on the opposite hand, even if one would prefer to die, that doesn’t mean one is suicidal rather than simply ready to die, and accepting of death, if it should happen, but is not therefore necessarily enthusiastic about making it happen or pursuing, or even highly risking, its occurring.  Many things in life are acceptable without being sufficiently desirable or preferable to be sought or pursued.  When Lyndon Johnson withdrew from the 1968 presidential race, it was important for him to say both (as he did) that he did not seek and would not accept the Democratic party’s nomination for the presidency https://youtu.be/h81dfX5ztsk.  Moreover, there are probably plenty of people who would not refuse their party’s nomination for president (or any office) but who do not want to go through the arduous political process of winning or trying to earn it.  That is in part because the traits necessary to win a political office are not necessarily the traits necessary to govern well.  Or consider working real hard to earn more money than one really needs by doing hated work, versus willingly accepting that extra money as a gift or lottery winning.  Seeking and accepting in general are two different things, including life and death.  One can accept death without seeking or preferring it, and one can accept life without actively seeking to preserve or prolong it and without even preferring to continue living. One can be willing to accept one’s fate without being willing to go to any extra effort that simply seems too much bother or trouble to prolong one’s life or to shorten it.  The following seeming digression will explain this further.

Good comedy often embodies (much more subtly and succinctly) philosophical insight and wisdom.  This excerpt from a Ron White performance telling about flying from Flagstaff to Phoenix does that with regard to the meaning and value of life and conditions potentially relevant to ending it, particularly involving the difference between accepting versus preferring or seeking: https://youtu.be/lFW4n3_50jI 

The two significant lines in the video are about 1) hitting something hard so he doesn’t have to limp away from this crash and 2) the fellow sitting next to him having something to live for – although I think he should have stated it as that fellow “thought he had something to live for”, particularly using his hallmark cynical, sneering tone of voice that would have indicated the fellow mistakenly thought that.  These lines imply and depend for their humor on two distinctions involving two different forms or rationales for passive euthanasia: 1) discontinuing treatment or not beginning treatment because the treatment makes one, or will likely or potentially make one, feel even worse, adding to the intensity of one’s problems, and 2) discontinuing treatment or not beginning treatment because the joys, rewards, or benefits in life even healthier, and perhaps even at its healthiest, no longer are sufficient to make it worth enduring the suffering to try to attain them.  In both cases, treatment possibly or likely will put you (or maintain you) below the threshold of joy or satisfaction worth enduring or for a longer amount of time than is worth enduring.

The first of these points is embodied in his comment about ‘not wanting to limp away from the crash’ because that would make his life even worse, and 2) the second point is embodied in his having made it clear his life (at least on that day) was already not worth continuing as it was.  He referred to it as “one of those days” where that happens or feels like it does, but in euthanasia cases, such days are what seem to be the only kinds left.  Both points together are that he already has insufficient reason to live and definitely doesn’t want there to be even less reason to want to live or ability to enjoy life if his life is going to be further prolonged and take more effort than he is already putting in and reluctantly willing to continue putting in but effort he is not wanting, or perhaps even willing, to have to increase.        

But that doesn’t mean one wants to make an effort to shorten one’s life either, although one will accept whichever happens or however long one has left.  Just accept whatever comes without making any effort to shorten or to prolong it under the circumstances.  The idea is it will be too much added trouble in some cases to do what will prolong your life or too frightening or just too much trouble to end it sooner or at least not right to throw it away just because it is not sufficiently satisfying.  It is basically “giving up on life” although not to the point of trying to end it sooner through suicide or what would generally be called euthanasia.  Whether we want to call giving up on life to the extent we don’t try to prolong it a form of “passive euthanasia” or not, and whether we want to call taking risks for something of perceived value (whether others also perceive it of value or not) “suicide” may be an arbitrary linguistic choice, but I think, and will explain later, there is an important distinction to keep in mind that may reduce or eliminate the arbitrariness of it, so that risking life for a perceived greater value is not suicide and giving up on life to the extent one does avoids or passes up opportunities and methods to prolong it is not passive euthanasia.  However, the real ethical issue is whether any of these things is right or wrong, not what to call them.

I do want to make clear here that I am talking about cases that cannot readily be improved by a good friend, a new interest, reminder and revival of an old interest, an adapted purpose in life, or sufficient rehabilitation to make life worthwhile again.  Most people who  are healthy and able-bodied, for example, imagine they would prefer to die than to be severely paralyzed, and many people immediately after a paralyzing injury strongly believe death would be preferable.  But after some rehabilitation and adaptation to their condition, paralyzed people tend to evaluate their own quality of life pretty much as high as able-bodied people evaluate their own quality of life.  Paralyzed people, in short, often find things in life to make it worth the (possibly additional) hardships they experience, just as most able-bodied people do, to put the matter in the terms and perspective I am offering here about euthanasia.  And generally, whenever feasible or reasonable we should try to help others find worthwhile moments in life, unless they are terribly bad, undeserving people, or unless it would cost us or cause us to risk too much for the amount it would help them^[2], or unless we have some moral obligation to others that would take precedence.  So I am not talking about justifying voluntarily premature dying in those kinds of cases where we can help people find sufficient joy or purpose in life, but cases where, even with effort, desire, help, and friendship, one cannot find anything that makes him or her look (more) forward to tomorrow, even if s/he is willing, but not wanting, to endure the same level of sorrow, suffering, disappointment, frustration, etc. as s/he has been enduring in the form of resignation to an unhappy life.

Of course, if one gets in a position where the suffering becomes so great and the joys and interests in life become so diminished that they do not make the endurance of the suffering worthwhile, that tends to be a case where one contemplates suicide or euthanasia if one does not hold the sanctity-of-life view.  It is called suicide if the person is not dying from a relatively imminently terminal health condition, and called euthanasia if what is causing the suffering is an  imminently fatal health condition that is also understandably painful and sorrowful.  I suspect that suicide, or what I call ‘garden variety suicide’ is considered wrong because it seems like there is still vast opportunity – in terms of time – left for the person’s life to improve and find something worth enduring any suffering, but that euthanasia, if it is considered acceptable at all, is considered acceptable because there is thought to be no prospect for finding something making the little time one has left worth enduring even more intense or prolonged suffering.  As I have written before, however, that is not necessarily true, and every reasonable attempt should be made to help a dying patient find joys or purpose to make the suffering worth enduring and to actually minimize the suffering by serving as a distraction from it.  But for purposes of this discussion, let’s assume we are talking about someone, whether ill or not, and whether dying or not, whose life has reached a point where the joys and purposes in life barely, if at all, make the suffering and sorrow worth enduring, and they cannot likely or readily change that balance, even with the best of help from us or others.

And, again, I am assuming we are accepting that the possibility or impossibility of sufficient quality of life, as correctly perceived by the  person, is a reasonable determining factor for continuing, prolonging, or ending it, not the view that even the most painful, sorrowful, and pointless or purposeless life is worth living and should be prolonged as long as possible.  None of what I am saying here will make sense to or seem reasonable to anyone who truly believes that even the most sorrowful and painful life or the most deteriorating merely vegetative state is worth preserving and prolonging.

I also want to insert one other distinction or point here.  One might be willing to die, not just because one’s life is miserable, painful, and sorrowful, but because one has already experienced everything one has wanted to and had profound joys and pleasures one doesn’t want to tarnish in any way, and there is no point, for whatever reason, in even trying to repeat them or relive them other than in memory.  We often feel less grief over the death of someone who lived a full and meaningful life than we do of others.  There possibly comes a point where not only “enough suffering is enough” but where enough joy is enough and it would only be going downhill to try to prolong it or add to it.  This might also be the idea of “going out on a high note” or saying “I can die happy now.  I have successfully done everything I ever wanted and needed to.”

What this means for the moral consideration of euthanasia is that, if there is a threshold level of what makes suffering worth enduring or justifies enduring it, it is not necessarily wrong to refuse to begin or refuse to continue treatment that will make one’s life even worse, and beyond the threshold worth enduring.  One can refuse self-preservation that causes or increases irredeemable suffering while also holding that life should not be prematurely ended by either passive or active suicide over suffering, no matter how intense or prolonged, that is worth enduring for joys or other benefits one can likely still experience.  

Whether preventing premature death when possible is right or obligatory or not is an issue about whether the likely benefits of continued life can make the likely harms worth enduring or not, or whether they ought to make them worth enduring.  And if the threshold level principle is correct, one can reasonably hold that it is right or obligatory to begin and continue treatment that will maintain life at an acceptable level of suffering, but not therefore right to begin or continue treatment that will increase the duration of one’s life at the cost of also intensifying its suffering without sufficient benefit to make that suffering worth enduring.  And this is true for both suicide and euthanasia, though it will less likely apply to cases of garden variety suicide.  But there is also more to all this, as already partly pointed out and explained further in the following.

The Concept of Euthanasia Does Not Include All Voluntary Premature Death

The choice between choosing suicide or choosing to prolong one’s life is a false dichotomy, although choosing suicide is choosing not to prolong one’s life.  But suicide is not the only form of choosing not to prolong one’s life.  One can choose, as already pointed out for example, to die or to risk being killed for a good cause (such as a justified war, an important moral principle, or to save the lives of others, etc.).

Moreover, I think it is not suicide or euthanasia to choose to do something that will shorten one’s life (or to refrain from doing something that will prolong one’s life) if that choice is made in order to do anything that is reasonably more worthwhile than living longer, not just risking or sacrificing one’s own life to save the lives of others.  

Perhaps the easiest example of that is choosing not to conceive a child in the first place because it is likely to have a sad or miserable life that is not worth having.  That is not killing anyone prematurely, of course, but it is not creating nor prolonging a life that could be created and prolonged.  It is denying the existence of a singular combination of DNA that would be a distinct person.  

Or  suppose, for example, that before you were born, you got to, and had to, choose between a life where you would die in later middle age, having lived a happy and meaningfully productive life on the one hand versus living to be very old, having an unproductive, unhappy life that was full of suffering.  Would it be denying the sanctity of life to choose the shorter but better life?  I don’t think so.  

Similarly people often choose (not always correctly or reasonably, or even if reasonable, not accepted as so by others^[3]) to pursue something more pleasurable that may have some risk of shortening their life over time, even if not immediately.  Some people sky dive or climb mountains or do mountain biking.  People smoke or drink knowing it is not likely good for them. Tom and Ray Magliozzi, the Peabody Award-winning hosts of Car Talk on NPR, dispensed car and relationship advice, generally the latter while addressing car maintenance as an excuse to do it.  They expressed the facetious, but pointed, view that exercise only prolonged your life the amount of time you spent doing it.  And they said that therefore by exercising you were only shifting the time in your youth which you could have spent doing something fun and/or useful with it till later in life when you were too old and frail to be able to do anything fun or useful.  It was wasting time by exercising instead of doing something meaningful, merely to time-shift it to an age you couldn’t do anything.  Jackie Kennedy was reported to have wryly said, after finding out she had a fatal illness, that if she had known she was going to die from this illness, she would not have done all those sit-ups.  And others have said that “eating healthy” generally might help you live to a ripe old age never having had a good meal.  Avoiding prolonging (or avoiding trying to prolong) one’s life in order to have, or try to have, a better, even if shorter, life is not a form of suicide.  Or, as  Edna St. Vincent Millay, expressed it:

My candle burns at both ends;

   It will not last the night;

But ah, my foes, and oh, my friends—

   It gives a lovely light!

Insofar as it is important to use your time most wisely, that could be more important than having more time that you use unwisely or that is wasted, or worse, horrible.  In a famous commencement address pointing out what he considered to be the 10 most valuable lessons in life he learned in Navy SEAL training, Admiral William H. McRaven began with “make your bed first thing every morning” and giving the reasons for that.  However, it seems to me that particular principle and the reasons for it only apply to an active life, not a contemplative one, where staying in bed to compose music as Rossini did, or speeches and plans, as Winston Churchill did is more important and productive than making your bed.  Or suppose you wake up with an insight how to treat cancer successfully or how to make an invention work or that might solve any other important problem you are working on.   Surely writing that down or taking time to work it out thoroughly before you forget the insight should take precedence over making your bed if that would make you forget something crucial before you have a chance to write it down or work it out.

Of course, some things people think are more important than living longer are not more important.  In April 1996, 7-year-old Jessica Dubroff died when the  plane she was piloting crashed in Cheyenne, Wyoming during her attempt to become the youngest person to fly across the U.S.; her father and instructor also perished, with investigations citing the instructor's decision to fly in bad weather as a primary cause, leading to the Child Pilot Safety Act. Her mother was reported to have made the comment people often make about such a death, that at least she had died doing something she loved.  Wouldn’t it be better to live doing what you love?  And wouldn’t it be better that if you had to die, you did it before having to do more of something you hate, not something you love.  Isn’t it sad when someone dies just after graduating high school or retiring from a long career one didn’t enjoy that much and was looking forward to enjoying retirement?  Wouldn’t Jessica have had a better life if she lived longer?  

Moreover, it seems to me that there are things worth finishing once you start them but which are not worth starting in the first place because of the principle of spending your time most wisely in the best way.  Suppose you go to a show that is not very enjoyable up to the point of intermission – a show you would never have gone to if you had known how boring it was going to be up to that point at least.  You wouldn’t have gone because you would have found something more worthwhile to do with that time.  But once you are there and have endured the first hour or hour and a half or so, unless you know there is something better to do with the next hour of your time, waiting to see whether the show resolves well and makes the first hour worth having experienced, you should wait to see how the show ends and whether it pays off.  Also, if you leave early, you will have for sure wasted the time you spent there, unless you are, for example, leaving early with someone exciting you would not have met except for going to the show.

With all that as prelude, it seems to me that euthanasia and garden variety suicide are choices to die in order to avoid suffering but that it is not suicide or euthanasia to choose to do something that risks ending or does end your life earlier than necessary in order to (try to) achieve something of significant positive value to you.  There is a significant difference between dying (or risking death) to achieve something worthwhile versus dying to avoid suffering or other things of negative value.   In both cases, however, the early death is wrong to choose if one either values the wrong thing one mistakenly believes is more important than life, or if there is something one would experience to make the longer life more worthwhile and more worth enduring whatever suffering would be or would have been involved.

I contend that, under the quality of life view, any moral differences between ordinary suicide and euthanasia, depend, not simply on how much time left in life one is cutting off, but on the fact that in ordinary suicide one is preempting far greater opportunity to find something worth enduring the suffering for (timewise at least) than one has left to do that for death rapidly approaching from a terminal illness or injury – if it is necessary to find something new, rather than already having something.  It is not simply the amount of time one has remaining, but what one could reasonably do with that time which is relevant to whether the coming anguish is worth enduring.  Ordinary suicide tends to cut off a greater amount of (new or unknown) potential opportunities for making suffering worth enduring than does voluntary euthanasia when one is dying from a somewhat rapidly progressing terminal illness or injury. 

There are, of course, illnesses and injuries that even if they tend to shorten life, still allow for a somewhat long life, and in those cases when the end of life is not particularly near, choosing to end life is more reasonably considered to be ordinary suicide than considered to be euthanasia, although the hardships involved in contending with a lifelong illness or injury are usually thought to make suicide in those cases somewhat more generally sympathetically understandable at least or perhaps excusable, even if not quite right or justified, to those who hold the quality of life view. I think that sympathy is misused however.  One should be helped to find something worth enduring the sufferings of life, not helped to kill oneself, nor excused for doing so, to avoid the sufferings.

Advocates for the right to euthanasia often focus on the suffering, while advocates for the sanctity of life focus on the benefits of life.  But one side is only looking at the burdens and the other the benefits.  That is like buying something without considering the costs or considering only the costs.  When my students advocate for euthanasia to avoid worse suffering or advocate never to give up, no matter how painful, I ask them whether they would buy a car for $27,000.  If they say, “no”, then I say “I’ll just have to do something else with this brand new Lamborghini Aventador (a half million dollar car).
If they say yes, then I say they can pick up the used Yugo at the junkyard where it is currently.  

The point is that in making any decision, you should consider both the burdens and the benefits to see which is greater and what the significance is of the imbalance.  You should not look at only the burdens or only the benefits.  You need to consider both, including what are called “opportunity costs” – what you might do that would be better with your time, money, energy, effort, or other resources than either of the two options you are considering.  As pointed out, even if life, especially end of life painful, terminal conditions, contains burdens that last longer and have more intensity than the benefits do, the benefits may be significant enough to make the burdens worth enduring.  If so, and if the benefits are likely able to be experienced, voluntary premature dying would be the wrong choice to make.  But if there are no or insufficient benefits likely able to be experienced in the time one has remaining that would be good enough or significant enough to make the suffering worth enduring, then, and only then, it seems to me that euthanasia would be a reasonable choice for someone who  prefers death to suffering.  

The problem, and particularly the practical problem, is knowing whether any experiences are reasonably available to a terminally ill person that would make it worthwhile to them to endure the suffering.  Unfortunately medical “ethics committees” for deciding these things upon patient requests to be allowed to die or helped to die often have the wrong people trying to make the decision, typically physicians, psychologists or psychiatrists, clergy, etc. when what is needed is one or more people who can help ferret out of the patient what might make his/her suffering worth enduring, and what might even serve as sufficient distraction from the suffering to make it not exist, at least while one is pursuing the object of interest.  

I admire Dr. Atul Gawande for recognizing that patients should be helped to have their “best possible days” available, rather than focusing on just keeping them alive as long as possible, even if it means lowering the quality of the time they have remaining.  But I think he does not recognize that physicians and other caregivers need to help dying people find and be able to pursue interests that will make their suffering worth enduring and able to be endured.  Gawande, in his book Being Mortal: Medicine and What Matters in the End, and last I knew, seems to leave it up to the patient to know how s/he could best use her/his remaining time.  I think that is great for patients who have a passion or drive they are aware of, but insufficient for the many who could have a passion of which they are unaware.  Often, it can be simple things that make one’s life better.  

One of my students once said he would have no idea what would make his mother’s end of life better if she were dying.  I asked if she liked to cook and did his family have special dishes she prepared that they loved.  He said “yes”, and I suggested that her children, grandchildren, and their spouses ask her to teach them how to prepare those dishes.  He thought that might work.  The idea of helping a dying loved one find a passion that gets them through the dark days ahead is really no different from trying to help a child or anyone find joys in life they might otherwise never have even thought to pursue or been able to pursue without your helping them know about those things and find them enjoyable.  Or, to put it in Ron White’s terms, as much as is feasible and reasonable, we should all be helping decent people find and have something to live for, however long they have left.