In 1990, in the United States (US), Janet Adkins, a 54-year-old newly diagnosed with early Alzheimer’s disease, died after pushing a red button on a suicide machine — or ‘mercitron’, as it has been called — designed by a retired pathologist, Dr Jack Kevorkian, whom she had approached for assistance to die (Gibbs 1993, 1990a). Adkins, who is reported to have ‘feared an excruciating future’, soon came to be viewed as a ‘symbol of all those patients who confront a horrible disease and vow to maintain some dignity in death’ (Gibbs 1990a: 70). Dr Kevorkian, meanwhile, found himself in the forefront of the pro-euthanasia debate and, as Time Magazine put it:

Despite being dubbed ‘Dr Death’, Dr Kevorkian continued his crusade for the legalisation of euthanasia/assisted suicide, or, as he called it, ‘medicide’ in the US (Gibbs 1993: 52; see also Brovins & Oehmke 1993; Kevorkian 1991). As part of this crusade, in December 1998 Dr Kevorkian was successful in getting authorities in the state of Michigan (US) to charge him with first-degree murder after he admitted, for the first time, having directly administered a fatal injection to one of his patients (Riley 1998a, 1998b, 1998c; see also Magnusson 2002: 28–32). In all other cases (130 in total), Dr Kevorkian admitted only to presiding over the suicides of his patient; that is, ‘instructed the patients and supervised them while they activated an injection from his so-called “suicide machine” ’ (Riley 1998c: ii; see also Riley 1999a, 1999b).

Dr Kevorkian’s case went to trial in March 1999, representing the fifth time he had been tried over the deaths of his patients. On 26 March 1999, the jury returned a verdict of second-degree murder and he was sentenced to serve 10–25 years in the Michigan State Prison (Magnusson 2002: 28–32). In passing her sentence, the judge presiding over the case stressed that the trial was not about ‘the political or moral correctness of euthanasia’, but about lawlessness and murder (AFD, DPA 1999). Referring to a national television broadcast several months earlier in which Dr Kevorkian dared legal authorities to arrest him for his actions, the judge responded:

In the Netherlands, during the same period, a very different scenario was at play. In contrast to the US, euthanasia and assisted suicide was, at the time of Janet Adkins’ medically assisted death, legally tolerated (although still a criminal offence). By the time Dr Jack Kevorkian had facilitated his first ‘assisted suicide’ in 1990, Dutch doctors had already participated in thousands of medically assisted deaths. In 1986, for example, the Royal Dutch Medical Association reported that there were between 5000 and 6000 cases of voluntary euthanasia each year in the Netherlands (British Medical Association 1986). In 1990, the overall incidence of euthanasia was estimated by formal sources to be between 4000 and 6000 deaths annually (de Wachter 1992: 24). In 2001 it was reported that approximately 2500 cases of euthanasia were notified to authorities in the previous year, with another 1000 cases going unreported ‘because of “grey” areas in the law’ (Mann 2001: 17). Some contend that the overall incidence of euthanasia is, in reality, unknown and, if informal sources are to be relied upon, could range from 2000 to 20000 cases a year (de Wachter 1992; Keown 1992; ten Have & Welie 1992).

Today, the Netherlands is one of only two countries (the other being Belgium) in which euthanasia is legal (euthanasia was legalised in the Netherlands in 2001, followed by Belgium in 2002) (de Beer et al 2004; Daverschot & van der Wal 2001; Dupuis 2003). This means that under certain clearly defined conditions that have undergone ‘subtle elaborations over the past three decades’, euthanasia and assisted suicide are no longer viewed by the courts as a punishable offence (Magnusson 2002: 64–5). In 1993, legislation was passed clarifying and affirming the strict conditions under which euthanasia and assisted suicide were permitted. The passage of this new law was reported at the time as giving the Netherlands the world’s most lenient policy on ‘mercy killing’ (Hirschler 1993: 7). Seven years later, the leniency of the Dutch ‘mercy killing’ laws was expanded even further when statutory support was given for the first time to the defence of ‘necessity’ (passed by the lower house of the Dutch parliament in November 2000, and the upper house in April 2001) (Magnusson 2002: 65). The defence of ‘necessity’ permits a doctor to avoid legal liability for assisted deaths on the grounds of professional duty; that is, ‘to reduce suffering and respect the autonomy of the patient’ and provided that he or she (the euthanasing doctor) can demonstrate that ‘due care’ was exercised in determining that the patient’s request ‘was voluntary and well-considered, that the patient’s suffering was unbearable, and that there is no prospect of improvement’ and no ‘reasonable’ alternative (Magnusson 2002: 65). Significantly, under the ‘due care’ requirements:

The above legislative reforms have not only given the Netherlands the world’s most lenient policy on euthanasia and assisted suicide, but as some have noted has also given the world a ‘laboratory’ for ‘testing’ and ‘observing’ these practices — and one which has attracted many onlookers from both ends of the moral spectrum in regard to the moral permissibility of euthanasia. Certainly, the Netherlands is currently the only country in the world which is able to offer retrospective studies of substance concerning the practice of euthanasia and any emerging patterns or trends associated with it (see, e.g. Bindels et al 1996; Dupuis 2003; Onwuteaka-Philipsen et al 2003; van der Maas et al 1996; van der Wal et al 1996).

In 1996, Australia became the subject of international attention when it became the first country in the world to fully legalise active voluntary euthanasia. This followed the passage, in May 1995, of the Northern Territory’s controversial Rights of the Terminally Ill Act 1995, which came into effect on 1 July 1996. Almost 1 year later, however, the Act was overturned by the Australian Federal government — although not before five people had sought assistance to die under the Act. Of these people, four were successful in achieving legally assisted deaths; the only person not successful in achieving his wish was eligible for assistance to die under the Act but was ‘unable to find a specialist who was prepared to be one of the three doctors required under the Act’ to certify eligibility for an assisted death (Senate Legal and Constitutional Legislation Committee 1997: 11). To date, despite the success of the Australian Federal government in overturning the Northern Territory’s euthanasia legislation, proponents of euthanasia speculate that it will only be a matter of time before euthanasia and assisted suicide will be legal in not just one, but possibly all jurisdictions in Australia.

In 2002, in what has been described as an unprecedented and ‘landmark legal case’, a British High Court judge ruled that a competent 43-year-old woman with quadriplegia and unable to breathe unaided, had the ‘right to die’ and to have the ‘machine keeping her alive’ switched off ( Herald-Sun 2002: 7). This ruling stands just less than a decade after a House of Lords Select Committee report released in 1994 opposed legalising euthanasia in England (Magnusson 2002: 66). A year later in Australia, in what has also been described as a ‘landmark decision’, a similar ruling was made. In what has become known as the ‘tube woman case’, a Victorian Supreme Court judge ruled that a 68-year-old woman (known only as BMW) suffering from a rare and fatal brain disease, who had been kept alive for 3 years by artificial tube feeding, be allowed to die (Davies 2003: 5). The judge is reported to have said that her ruling would now make it possible for the woman’s advocate ‘to decide, on behalf of BMW, whether it is now time to allow her to die with dignity’ (Davies 2003: 5). It was noted, however, that once the tube feeds were stopped, it could take between 1 and 4 weeks for the woman to die. Margaret Tighe, President of Right to Life Australia, is reported to have criticised the court decision, arguing that it was ‘not an act of love to kill somebody by dehydration and starvation’ (Davies 2003: 5).

In 2005, after Hurricane Katrina had devastated the US city of New Orleans, a new and largely unanticipated dimension was added to the euthanasia debate, notably, climate change. In the aftermath of Hurricane Katrina, allegations were made that ‘mercy killings’ had occurred at the city’s Memorial Medical Centre, leading to autopsies being requested on 45 bodies taken from the hospital after the storm (Johnston 2005; Lugosi 2007). As the inquiries progressed, it was gradually revealed that four nonambulatory patients, aged between 61 and 90 years of age, had been ‘euthanised’ in an attempt to prevent their needless suffering in the face of having ‘no realistic chances of surviving in a stranded, incapacitated hospital’ (Curiel 2006: 2067). The four patients, who were allegedly given a combined lethal intramuscular dose of the drugs morphine and midazolam, were among 24 patients who died in the Life Care Unit situated on the 7th floor of the Memorial Medical Centre.

The environmental conditions at the time were extreme. According to one CNN report, the medical centre had been a storm refuge for up to 2000 people, where patients, staff and their families ‘rode out the storm inside’ (Griffin & Johnston 2005). However, as CNN goes on to report,

It is alleged that nurses started to discuss ‘who would be evacuated and, for the first time, who would not’, for example, patients who were ‘DNR’ (do not resuscitate) (Griffin & Johnston 2005). It was further reported that ‘at about the same time, some members of the hospital staff were discussing euthanising patients’ (Griffin & Johnston 2005). Although, none of the four patients in question were expected to die immediately from natural causes, were in pain, or had consented to the drugs they were given, they did have one thing in common: they were all the subject of a consented ‘Do Not Resuscitate’ (DNR) directive. As one commentator has noted, however, no one had warned the patients that ‘in case of a natural disaster, hospital administrators would interpret DNR to mean “Do Not Rescue” ’ (Lugosi 2007: 74).

In July 2006, a New Orleans physician (Dr Anna Pou) and two nurses (Lori Budo and Cheri Landry) were arrested and charged with second-degree murder in relation to the patients’ deaths, sparking public debate on whether the killings were ‘murder or mercy’ (Curiel 2006; Griffin & Johnston 2005; Johnston 2007; Lugosi 2007; Nossiter & Dewan 2006; Safer 2006, 2007; Skipp & Campo-Flores 2006). Commenting on the case, Curiel raised a number of important questions, including: What might lead a health care professional to consider euthanasia in such a situation? and Were the Memorial staff prepared to make life-and-death decision during a disaster, and, if not, what could have prepared them? — pointing out that tsunamis, earthquakes, fires and other calamities ‘are present and evolving threats that can rattle unprepared respondents to the core and expose complex ethical, legal and medical conundrums’ (Curiel 2006: 2067 & 2068).

While acknowledging the extreme conditions under which health care providers were operating at the time, Curiel nonetheless found it ‘unimaginable’ that effective team decision-making would have — and could have — led to a decision to euthanise patients (Curiel 2006). Referring to his own experience in the aftermath of Katrina, Curiel writes:

He concludes that if the allegations against the physician and two nurses in the Katrina case are ‘borne out’, then:

Other commentators have been more circumspect. Lugosi (2007), for example, warns that the killings have served unacceptably to model ‘a new way to manage patients when natural disaster strikes — the non-consensual deceptive killing of patients that are too difficult to move because of logistics or lack of resources’ (p 76). Controversially, he has also suggested that racism and poverty may have influenced the decisions made that day, pointing out that another feature that all four patients had in common was that they were black and poor (p 78).

In June and July of 2007, the two nurses and then the physician were respectively all cleared of criminal charges after a New Orleans grand jury decided not to indict them ( American Medical News 2007; Jervis 2007). However, as CBS reports, ‘the case continues to resonate and raise questions about ethics, and compassion in what has been described as battlefield conditions’ (Safer 2007).

Euthanasia and assisted suicide continues to receive widespread attention both locally and globally, and remains the subject of much controversy. Central to the controversy is the fundamental question of whether a doctor should intentionally and actively assist a patient to die, and, if so, under what circumstances and by what means. These same questions can (and should), of course, also be asked of nurses — particularly given the fundamental role nurses play in caring for and promoting the dignity of patients who are incurably ill, suffering intolerably, dying (Asch 1996; Berghs et al 2005; Bilsen et al 2004; Crock 1998; Daverschot & van der Wal 2001; de Beer et al 2004; Gastmans et al 2006; van der Arend 1998), or, as has just been considered above, left hopelessly stranded by catastrophic emergency events linked to climate change.

In this chapter, attention is given to examining the nature and moral implications of the euthanasia/assisted suicide question for nurses. Attention is also given to clarifying what euthanasia is, how it differs from assisted suicide and ‘mercy killing’, and the kinds of moral arguments that can be raised both for and against the legitimation of euthanatic practices. It is hoped that by examining these and related issues, members of the nursing profession will move a step closer towards answering the following kinds of questions:

Next to abortion, euthanasia is probably one of the most controversial bioethical issues to have captured the world’s attention. And, like the abortion issue, it is unlikely to be resolved to the satisfaction of all concerned.

Euthanasia and the so-called ‘right to die’ are not new issues for nurses. In Australia, one of the first articles addressing the subject was published as early as 1912 in the Australasian Nurses Journal. Reprinted from the British MedicalJournal, the article contains concerns and viewpoints which remain current — including the agonising question of whether euthanasia should be legalised. Citing an 1873 essay on the subject, the article contends that ‘a modified harikari should be made lawful in England’ (and, one presumes, her colonies, including Australia), and, quoting the essay’s author, that: ‘On the whole it cannot be doubted that the benefits resulting from a change in the law would be simply enormous’ (Lionel Tollemache, cited in the Australasian Nurses Journal 1912: 304).

While euthanasia may not be a new issue for nurses, it has nevertheless become a more complex, intense and significant one. Evidence of this can be found in the increased attention being given to the experiences of nurses in regard to euthanasia in both the professional and lay press over the past 20 years or so. In 1987, for example, the English nursing periodical Nursing Times carried a provocative report on the fate of four Dutch nurses who had been arrested in Amsterdam after it was alleged they had practised euthanasia on three hopelessly ill patients. The report concluded that, if the nurses were found guilty of killing the patients, they could face prison sentences of up to 20 years ( Nursing Times 1987: 8).

Almost a decade later, in another (although unrelated) case in 1995 in the Netherlands, a 38-year-old Dutch registered nurse was given a 2-month suspended prison sentence for performing active voluntary euthanasia on a patient suffering end-stage AIDS (Staal 1995: 7; van de Pasch 1995; van der Arend 1995; see also Daverschot & van der Wal 2001). What was particularly significant about this case was that the sentence was passed despite the fact that:

As I have discussed elsewhere (Johnstone 1996c: 21–2), this case helped to demonstrate the tenuous position of nurses in relation to euthanatic practices — even in countries where euthanasia and assisted suicide are ‘legally tolerated’. In this case, the court’s decision seemed to hinge on the view that euthanasia and assisted suicide were medical procedures of a nature that could not (and should not) be delegated to nurses. More specifically, the court clarified that the deed of ‘ultimate care’ (the procedure that is the act of euthanasia itself) could only be performed by a doctor and could not be delegated to anyone else (Daverschot & van der Wal 2001; Staal 1995: 7).

Nurses in the United Kingdom (UK) have also experienced significant problems in relation to the euthanasia issue. For example, in 1991, a UK registered nurse experienced threats of violence and obscene phone calls, was vilified by some sections of the media, and was made a scapegoat in the eyes of the public after reporting to the appropriate authorities that a terminally ill patient had died possibly as a result of being administered 10 mmol of potassium chloride by a consultant physician, Dr Nigel Cox (Hart & Snell 1992: 19). The incident was discovered after nurses noted the blatant documentation of the drug administration in the patient’s case history which ‘had been left in the nurses’ station for all to see’ (Hart & Snell 1992: 19). The registered nurse’s attempts to contact Dr Cox about the matter were unsuccessful. Not wishing to implicate other staff in the matter and recognising her professional duties as prescribed in the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (1992) Code of Professional Conduct, the registered nurse decided that she ‘had no choice but to report the incident’. Accordingly she notified the director of nursing services and the unit general manager. One month later, Dr Cox was convicted of attempted murder at Winchester Crown Court, after the justice hearing the case rejected the argument that ‘Cox’s intention in injecting lethal quantities of a drug which lacked analgesic properties was to relieve pain, rather than to kill’ (Magnusson 2002: 26). He subsequently received a 1-year suspended prison sentence (Hart & Snell 1992: 19). He was not deregistered by the General Medical Council (UK), however, and continued to practise medicine. The registered nurse meanwhile carried a disproportionate burden of suffering for her actions.

Besides sometimes finding themselves unwitting witnesses to the illegal euthanatic practices of others, there is anecdotal evidence, some published research and a number of court cases suggesting that a small percentage of nurses (e.g. in the US, Hungary, Australia, England and the Netherlands) have also taken active steps to bring about the death of a patient themselves (Rozsos 2003; Magnusson 2002; Crock 1998; Kitchener 1998; Asch 1996; Walsh & Pirrie 1996; Staal 1995; Stevens & Hassan 1994; Kuhse & Singer 1992, 1993; Turton 1992). One commentator has even alleged controversially that British nurses are ‘often’ involved in performing euthanasia on patients:

Euthanasia and assisted suicide is, however, a controversial issue for nurses in the UK (Johnstone 1996c). Significantly, the prestigious Royal College of Nursing (RCN), a leading professional nursing organisation in the UK, has historically and unequivocally rejected the role of nurses in participating in euthanasia. This position has been made explicit in an issues paper on living wills. In this paper, the RCN takes the following position (RCN 1994):

It further asserts:

In 2003, the RCN’s opposition to euthanasia was reaffirmed by its General Secretary, Dr Beverly Malone, who reportedly stated in an RCN media release:

In 2004, after a survey of its members found that 70% did not support a ‘softening’ of its stance against the legalisation of euthanasia, the RCN again reiterated its opposition to the legalisation of euthanasia and assisted suicide (McDougall 2004; Hawkes 2005). In response to a House of Lords select committee on an assisted dying Bill, the then RCN Vice-President, Maura Buchanan (now president of the RCN), was reported to have said: ‘Our patients do not want nurses and doctors to be skilled in delivering lethal injections’ (quoted by BBC News 2005).

The euthanasia/assisted suicide question has also proved to be a significant professional issue for Australian nurses. For example, in January 1995, recognising the seriousness of the euthanasia issue for members of the nursing profession, the Royal College of Nursing, Australia (RCNA) took the unprecedented step of releasing for comment a discussion paper entitled ‘Euthanasia: an issue for nurses’ (Hamilton 1995). As I have discussed elsewhere (Johnstone 1996b), the RCNA received over 70 responses to this discussion paper from concerned and interested nursing organisations, groups and individuals from around Australia. The responses received represented nurses working in a variety of clinical areas and fields of nursing (including education) and reflected a great diversity of knowledge, opinion, values and beliefs about euthanasia and assisted suicide. In some cases, the responses also demonstrated an overwhelming need for information and guidance on how best to respond to the uncertainty, controversy, complexity and perplexity that has become so characteristic of the right to die movement generally. Perhaps most confronting of all, however, was the emerging difficult question of whether the nursing profession should formally and publicly support the legalisation of active voluntary euthanasia. Related to this was the equally confronting question of whether representative nursing organisations should adopt a formal position statement either supporting or rejecting the role of nurses in active voluntary euthanasia and assisted suicide. Not surprisingly, while the responses demonstrated the need to raise and address these troubling questions, they fell far short of offering a definitive answer to them. Recognising the complexity and perplexity of the issue, the RCNA subsequently commissioned, as part of its professional development series, a monograph entitled: The politics of euthanasia: a nursing response (Johnstone 1996a). The purpose of this monograph was not to provide nurses with definitive answers to the difficult questions posed by the euthanasia debate. Rather, it was to advance a discussion that would enable nurses ‘to formulate their own thinking and viewpoints on the subject and to be able to contribute to broader professional discussion on the whole issue of the right to die’ (Johnstone 1996b: 22). In July 1996, the RCNA also issued its first position statement on voluntary euthanasia and assisted suicide — subsequently revised and reaffirmed respectively in 1999 and 2006 (Royal College of Nursing, Australia 1996, 1999, 2006). This position statement primarily focuses on clarifying the illegal status of euthanasia/assisted suicide in Australia, acknowledging that there exists a diversity of moral viewpoints on the euthanasia issue, reminding nurses of their professional responsibility to be reliably informed about the ethical, legal, cultural and clinical implications of euthanasia and assisted suicide, and recognising and supporting the appropriateness of nurses taking a ‘conscientious’ position on the matter.

The RCNA’s initiatives (just outlined above) were to prove extremely timely, coinciding as they did with the enactment of the Northern Territory of Australia’s controversial Rights of the Terminally Ill Act 1995 which came into effect on 1 July 1996. As already stated in the opening paragraphs of this chapter, the passage of this legislation earned Australia the controversial distinction of being the first country in the world to legalise active voluntary euthanasia. Of significance to nurses (and to this discussion) is that the legislation anticipated and provided for nurse participation in active voluntary euthanasia and assisted suicide (either by way of preparing, or being delegated the task of actually administering, a substance to terminate life [see section 16(1); see also Trollope 1995: 21]). What, arguably, was troubling about the legislation’s provisions in regard to nurse participation was that they had been enacted even before the broader nursing profession itself had:

Significantly, in May 1996, less than 2 months before the Rights of the Terminally Ill Act 1995 (NT) came into effect, the Nurses’ Board of the Northern Territory took the unprecedented step of formulating and ratifying a formal position statement on euthanasia (see Nurses’ Board of the Northern Territory Position Statement on the Nurse’s Role in Euthanasia, included in full as Appendix 5 in Johnstone 1996a). This position statement was keyed to the Rights of the Terminally Ill Act 1995 (NT) and sought to clarify the role and function of nurses in relation to the Act’s provisions. Specifically, the position statement supported:

The position statement also outlined the obligations of nurses in regard to the ethical and legal aspects of euthanasia, employment policies, professional competence and education (Johnstone 1996c: 36–7).

As stated earlier, the decriminalisation of euthanasia and assisted suicide in the Northern Territory of Australia was short-lived. Less than 1 year after its enactment, intense political pressure resulted in the Rights of the Terminally Ill Act 1995 (NT) being overturned by the Australian Federal government. Currently, euthanasia and assisted suicide is illegal in Australia, and anyone who wilfully assists a person to die would be viewed by the courts as having committed the criminal offence of homicide (Wallace 1991: 265, ss. 14–65; see also Forrester & Griffiths 2005; Magnusson 2002). As Dix et al warn (1996: 339, s. 1223):

Despite the current legal prohibition against euthanasia and assisted suicide in Australia, Magnusson (2002: 272) asserts that it is a ‘virtual certainty’ that many medical practitioners are ‘heavily involved in assisted death’. Magnusson (2002: 24, 32) points out, however, that ‘doctors are rarely punished for their involvement in assisted death’ — even when making ‘front page news’ with admissions of having performed euthanasia. This is the situation not only in Australia, but also in the UK and the US. For example, in the US, between 1950 and 1991, only 11 doctors were prosecuted for euthanasia (Cox 1993: 234). Thus, while euthanasia as such is illegal, it nevertheless seems to be tolerated where it can be shown that the intention was ‘therapeutic’ (i.e. to alleviate suffering) rather than homicidal (i.e. to kill).

In Australia, proponents of euthanasia/assisted suicide speculate that it will only be a matter of time before euthanasia and assisted suicide will be legal in all jurisdictions in Australia. In light of the looming health and welfare implications of climate change (scientists are warning that ‘changes to the environment are rapidly becoming a threat to many of our life support systems’ [Anderson 2007: 10; Haines & Patz 2004; McMichael et al 2006]), and the perceived need of some to have an ‘exit strategy’ if and when stranded by climate change, impetus for the legalisation of euthanasia is likely to take on a whole new dimension. Given these predictions, there is ample room to speculate that it will only be a matter of time before Australian nurses will once again have to grapple with the complex and perplexing questions raised by the legalisation of euthanasia/assisted suicide, and, in particular, the possible and actual implications of this for nurses at a personal, professional, societal and political level (Johnstone 1996a).

In reaching a position on the euthanasia/assisted suicide issue, it might be tempting to appeal to and/or be persuaded by public opinion on the matter. Consider the following.

Over the past two decades, public opinion polling in Australia, Canada, Europe and the US suggests majority support (around 75%) for the legalisation of euthanasia and physician-assisted suicide (Marcoux et al 2007; Voluntary Euthanasia Society [VES] 2003; Somerville 1996; Kuhse 1991; Australian Dr Weekly 1990: 9; Kuhse & Singer 1988; Humphries 1983; Radic 1982; see also Gallup polling at http://www.gallup.com/). In Australia, for example, opinion polls conducted by Morgan and Newspoll respectively during 1995 and 1996 showed 75–78% public support for physician-assisted suicide. In 2007, a national Newspoll report (prepared for Dying with Dignity Victoria) found that around 80% of the 2423 respondents surveyed by telephone thought that doctors ‘should be allowed to provide a lethal dose to a patient experiencing unrelievable suffering and with no hope of recovery’ (Newspoll Market Research 2007: 6). In 2002, a UK public opinion poll indicated that 81% of those surveyed supported the legalisation of euthanasia for people suffering unbearably from a terminal illness (VES 2003). Similar support has also been indicated by public opinion polls conducted in France (88%), Belgium (72%), Germany (75%), Italy (75%), the Netherlands (85%), Spain (70%) and the US (75%) (VES 2003). Just what is to be made of this public opinion, however, is open to question.

As discussed earlier in Chapter 2 of this book, public opinion is not a reliable guide to moral conduct; all that it tells us is that a certain group of people hold a particular opinion, not that the opinion held is ‘morally right’ all things considered. In short, it tells us nothing about the moral acceptability or the moral authority of the opinion held. We must therefore look elsewhere (i.e. beyond public opinion) to guide our deliberations on whether euthanasia and assisted suicide are morally right or wrong. It is to looking ‘elsewhere’ that the remainder of this chapter will now turn. This exploration will begin firstly by clarifying what euthanasia is, and how, if at all, it differs from other end-of-life practices such as assisted suicide and ‘mercy killing’. This, in turn, will be followed by a critical examination of views popularly raised for and against the legitimation of euthanasia and assisted suicide.