Introduction:

In order to answer the question, one should draw the distinction between withdrawal

life-sustaining treatment, euthanasia and assisted-suicide by stating the key features and

characteristic of each mentioned acts. In addition, each act has the legal and ethical issues

which will addressed below.

Euthanasia can be divided into two main category which are active and passive.

Passive euthanasia is regarding withdrawal of life-sustaining treatment which will be

discussed later. Hence, firstly active euthanasia refers to a physician intentionally act by

administrating lethal drug to the patient to prevent the pain and suffering which results in

their death1. It comes with the definition of murder and punishable by mandatory life

sentence2. The elements required for murder is actus rea where the act cause the death and

mens rea where he has necessary intention3. The intention is showed in R v Woolin4 where it

distinguishes direct intent and oblique intent if the results is virtual certain. The indirect and

oblique intent was defined in R v Nedrick5.

Euthanasia can be further distinct as voluntary euthanasia which means at patient

request, non-voluntary euthanasia where it’s without patient’s request and involuntary means

patient is not in a condition to provide consent. 6.Active Euthanasia is laid as intentional

taking of life even though it carried out in compassionate motive but in criminal motives are

disregarded 7as per R v Mathews & Alleyne8.

1
Kalaivani Annadurai, Raja Danasekaran, and Geetha Mani ‘Euthanasia: Right to Die with Dignity’ (2014) 3(4):
4177-478 Journal of family medicine and primary care
2
Glenys William ‘Intention and Causation in Medical Non-Killing: The Impact of Criminal Law Concept on
Euthanasia and Assisted Suicide’ (2007) Routledge Cavendish
3
Glenys William ‘Intention and Causation in Medical Non-Killing: The Impact of Criminal Law Concept on
Euthanasia and Assisted Suicide’ (2007) Routledge Cavendish
4
[1999] AC 82
5
[1986] 1 WLR 1025
6
Claudia Carr, Unlocking Medical Law and Ethics 2nd pg355
7
Glenys William ‘Intention and Causation in Medical Non-Killing: The Impact of Criminal Law Concept on
Euthanasia and Assisted Suicide’ (2007) Routledge Cavendish
8
[2003] EWCA Crim 192
 According to R v Cox9, the doctor was convicted for administrating the lethal drugs

onto to the patient and she died shortly. The drug he administered was no where near to relive

the pain but effects the life of the patient, so the intention was clearly not to relieve pain

rather it links to bring death to the patient. However, doctrine double effect is a defence under

active euthanasia for the doctor to avoid conviction. The doctrine is only acceptable if the

nature act is morally good, bad effects is not the means of achieving the good effects, the

good effect directly intended while the bad effects is simply foreseen and tolerated and

proportionally the reason for performing the good action must outweigh the unintended bad

outcome10.

This principle of doctrine was followed in a key case which is R v Adams11 the

doctor was acquitted for administrating lethal drug to the patient, and this was explained by

Devlin J stated shortening life by weeks or months still consider as murder even it shortened

by years, but a doctor is entitled to do all that in order to relieve pain and suffering even the

measures leads to incidental shorten life 12. This was further followed in the cases of R v

Moor13 and R v Carr14.

On the other hand, withdrawal life-sustaining treatment although a part of euthanasia

where it is called passive euthanasia, but it is totally different from active euthanasia. The

reason is here the omission of the doctor is caused the death 15. In Airedale NHS Trust v

Bland16, the doctor was not charged murder even though it was not in the best interest to

withdraw the patient life-support but at the same time it was also not the best interest to keep

him alive. In Re R (Adult: Medical Treatment)17, it was held withdrawing the resuscitation
9
[1992] CLY 886
10
Claudia Carr, Unlocking Medical Law and Ethics 2nd pg355.
11
[1957] Crim. LR 365
12
Available at https://nursekey.com/the-end-of-life/ accessed on 9th May.
13
[1999] Crim L.R. 2000
14
[1986] Sunday Times 30 November
15
Jonathan Herring Medical Law and Ethics 8th edn pg541.
16
[1993] 1 ALL ER 821
17
[1981] 1 WLR 1421
and medication would be the best interest of the patient and in R v Arthur18 decided

omissions are not seen criminal.

Thus, the distinction between the active and passive euthanasia lies between the act

and omission. According, the case mentioned above Bland case, it distinguishes the element

of positive act to kill and omission to prevent the death where Lord Goff stated that it will not

be unlawful for the omission done by the doctor and because it is merely putting the patient at

his pre-existing condition and it won’t be breach of duty because it is the best interest of the

patient for withdrawing the life-sustaining treatment19. This was followed in Re A

(Conjoined twin)20.

Nevertheless, on an ethical basis it has been argued that there is no distinction

between active and passive euthanasia21. The principle of vitalism shows that human life has

the absolute moral value so killing one person cannot be justified even its active or passive

euthanasia22. Doctors must always ensure to take all the reasonable steps to save the patient

life. This also can be seen in principle of sanctity but what distinguished from vitalism is that

principle of sanctity accepts both passive and active euthanasia if the doctor has no intention

to kill rather has the intention to shorten life to avoid suffering and the treatment is not the

best hope for the patient23. So, the principle of sanctity supports doctrine of double effect and

best interest of patient but in reality, only passive euthanasia is legal and active euthanasia is

not. However, religious believers would argue in an ethical basis that both euthanasia would

18
[1996] 3 FCR 473
19
Claudia Carr, Unlocking Medical Law and Ethics 2nd pg391
20
[2001] 2 WLR 480
21
Mohammed Ratoubi Alanazi, Mansour Moklif Alanzi ‘Is there a moral difference between killing and letting
die in Helathcare?’ 3(1) International Journal of Research in Medical Sciences.
22
Jonathan Herring Medical Law and Ethics 8th edn pg584

23
Jonathan Herring Medical Law and Ethics 8th edn pg584
be illegal where only the god has the right to take a life 24 and some may argue active

euthanasia is more humane than passive25.

The issue is that it’s the right of the patient who has the right live their rights as they

wish and die with dignity, hence legalizing one and not the other one is showing restriction

on the patient autonomy and focusing on paternalistic which is passive euthanasia 26. On one

hand, the slippery slope argument shows that ethically allowing passive euthanasia and not

allowing active euthanasia are not morally acceptable when the result is similar27.

On the flip side, assisted suicide is a statutory offence under s2(1) Suicide Act 196128.

It distinguishes in two parts which are physicians-assisted suicide is where it is practiced by

the doctor to prescribe a medication for the patient with a primary intention to end the life 29

and non-physicians assisted suicide is done by the family or friends to help the patient to end

his or her life which called as mercy killing as per R v Inglis30.

According, the legal basis on assisted suicide as mentioned above which is illegal in

United Kingdom under the s2(1) Suicide Act 196131. However, in certain countries it is legal

such as Switzerland under their law. Hence, in Re Z32, it was held the police has no authority

to the person to go to Dignitas in order to travel and continue with assisted suicide.

Nonetheless, it is important to note that Human Rights plays a big role on assisted

suicide where the patients try to seek in order to access the assisted suicide. In Pretty v UK33,

24
Mohammed Ratoubi Alanazi, Mansour Moklif Alanzi ‘Is there a moral difference between killing and letting
die in Helathcare?’ 3(1) International Journal of Research in Medical Sciences
25
BBC, ‘Ethical Problems of Euthanasia’ (2014)
http://www.bbc.co.uk/ethics/euthanasia/overview/problems.shtml accessed on 11th May.
26
Jonathan Herring Medical Law and Ethics 8th edn pg584
27
Jonathan Herring Medical Law and Ethics 8th edn pg598
28
which amended by s59 Coroners and Justice Act 2009
29
William C.Shiled, ‘Medical Definition of Physician-assisted suicide’ (2017) available at Definition of Physician-
assisted suicide (medicinenet.com) accessed on 11th May
30
[2010] EWCA Crim 2637
31
amended by s59 Coroners and Justice Act 2009
32
(An adult: Capacity) [2004] EWHC 2817
33
[2002] 1 AC 800
she applied for the approval of the husband to help her to committing assisted suicide, but it

has been denied by the court. She claimed that the s2(1) Suicide Act 1961 is in conflict of

European Convention Human Rights (ECHR) such as Article 2 right to life, Article 3

prohibition of torture and Article 8 right to family life. However, it was argued that the

Article 2 ECHR right to life does not meant for right to die but it means everyone life shall

be protected by law34.

According to R(Purdy) v DPP35, she suffered from primary progressive multiple

sclerosis and she relied on Article 8 ECHR by stating that the DPP guidelines 36 was not

accessible nor transparent and the court held that Article 8 was not engaged or legalized

assisted suicide37. The DPP guidelines is not a legislation but a policy to future purposes in

order to allow the patient’s family to bring to Dignitas and proceed with the assisted suicide 38.

The case of R v DPP and another39, was similar which based on Article 8(1) by referring to

Koch v Germany40 where the spouse claims under the Article 8 where the rights was

violated when the courts does not permit their loved one to die, but here the court dismissed

appeal of Nicklinson and other by stating that the blanket ban was not outside the margin of

appreciation given to Member States41.

To draw the distinction between active euthanasia and assisted suicide was explained

in an article where it was held that active euthanasia is an act done by the doctor which

explained above, so the last act is done by the doctor but contrast for assisted suicide the last

34
Claudia Carr, Unlocking Medical Law and Ethics 2nd pg360.
35
[2009] UKHL 45
36
Crown Prosecution Service, ‘Policy for prosecutors in respect of cases of encouraging or assisting suicide’
(2014) https://www.cps.gov.uk/sites/default/files/documents/legal_guidance/assisted-suicide-policy.pdf
accessed on 11th May
37
Claudia Carr, Unlocking Medical Law and Ethics 2nd pg363
38
Claudia Carr, Unlocking Medical Law and Ethics 2nd pg363
39
R(on the application of Nicklinson) and Lamb v MOJ and DPP and others; R(on the application of AM) v DPP
and another [2013] EWCA Civ 961
40
497/09 [2012] ECHR 1621
41
Claudia Carr, Unlocking Medical Law and Ethics 2nd pg368
act is done by the patient in order to end his or her life 42. A fine example can be seen in

Kamisar’s tablet scenario where it involves a competent woman with a wish to die 43. She

swallows a lethal medication and dies, which the doctor has (a) placed under pillow or by her

bed, (b) placed in her hand and (c) put in her mouth 44. According to the scenario it has been

argued that both (a) and (b) could amount to assisted suicide since the last act done by the

patient and (c) would be euthanasia45 but it still can be argued that it is still her choice to

swallow it or not46. Contrarily, it was argued by Gostin that (b) and (c) would still amount to

active participation which is sufficient to cause death47 thus it can be euthanasia in his view48.

Another important part to distinguish is whether withdrawing life-sustaining treatment

which mentioned as passive euthanasia would amount to commit suicide? To answer the

question the court have interpreted that doctor would be not seen as assisting the suicide as

per Re B (Adult of Medical Treatment)49 and the reason was because if it is seen as

assisting than most of the passive euthanasia would be an offence. This distinction further

explained in Rodriguez v Attorney-General of British Columbia50 it was held that if a

patient refused the treatment, the doctor is not required to make a choice which result to death

42
Norman L. Cantor ‘ON KAMISAR, KILING, KILLING, AND THE FUTURE OF PHYSICIAN_ASSITED DEATH’ (2004)
102(8) Michigan Law Review.
43
William.G Intention and Causation in Medical Non-Killing: The Impact of Criminal Law Concept on
Euthanasia and Assisted Suicide’ Routledge Cavendish (2007) pg154
44
William.G Intention and Causation in Medical Non-Killing: The Impact of Criminal Law Concept on
Euthanasia and Assisted Suicide’ Routledge Cavendish (2007) pg156
45
William.G Intention and Causation in Medical Non-Killing: The Impact of Criminal Law Concept on
Euthanasia and Assisted Suicide’ Routledge Cavendish (2007) pg156
46
Norman L.Cantor ‘On Kamisar, Killing, and the Future of Physicians-Assisted Death’ (2004) 102(8) Michigan
Law Review
47
Lawrence O. Gostin ‘Drawing a line between Killing and Letting Die: The Law and Reform on Medically
Assisted Dying’ (1993) 21(1) Journal Law Medical Ethics.
48
William.G Intention and Causation in Medical Non-Killing: The Impact of Criminal Law Concept on
Euthanasia and Assisted Suicide’ Routledge Cavendish (2007) pg156
49
[2002] 2 All ER 449
50
Rodriguez v British Columbia (AG) [1993] 3 SCR 519
as he would be if he chooses to assist suicide or perform active euthanasia 51. Whereas passive

euthanasia shows that the doctor removing the life-sustaining treatment because it his best

interest of the patient and no choice was given to him.

Essentially, can be drawn that assisted suicide has never been legalized even certain

cases involves with ECHR. So, from the ethical issue it raises the issue of ‘Dying with

Dignity’. The issue shows the patient losing the dignity, self-determination and autonomous

in order to end his or her life52. In a journal it has been argued that healthy physician does not

ensure the patient dies with dignity but rather dies with unbearable pain53. This eventually

connect the patient autonomy where it never been fulfilled since the patients request always

been denied same as active euthanasia54.

Important to note that if assisted suicide and active euthanasia is legalized it would

affect the doctor patient relationship where a Latin phrase says that Primum Non Nocere

which means ‘above all do no harm’ 55. So, this means, patient always think doctor has the

care for us but if it is legalized puts a dent to the patient doctor relationship as doctor are

supposed to prioritize patient’s life. As for a slippery slope argument it will open flood gate

of request coming from the patients who would use assisted suicide as a first resort because

the pain is unbearable56.

In summary, withdrawal of life-sustaining treatment, euthanasia and assisted suicide

has a fine distinction which mention as above. From the distinction tone can tell that

withdrawals of life-sustaining treatment as passive euthanasia are a legal and where the other

51
William.G Intention and Causation in Medical Non-Killing: The Impact of Criminal Law Concept on
Euthanasia and Assisted Suicide’ Routledge Cavendish (2007) pg162
52
Claudia Carr, Unlocking Medical Law and Ethics 2nd pg383
53
Allmark, ‘Death with Dignity’ (2008) 28 Journal of Medical Ethics 255-7.
54
Jonathan Herring Medical Law and Ethics 8th edn pg598
55
Claudia Carr, Unlocking Medical Law and Ethics 2nd pg385
56
Claudia Carr, Unlocking Medical Law and Ethics 2nd pg386
two is not legal. The important part to notice is that as for the ethical base each links to the

same dot since the result is same and shows no morality of legalizing one and not the other

two.