Singapore and Euthanasia

Singapore allows passive euthanasia (if the patient signs the Advance Medical Directive (AMD). The patient's decision in the AMD overrules EVERYTHING else, including his or her family's decisions. If the patient did not sign the AMD and is legally unable (e.g. he's in a comma state and does not have the ability to think rationally or make his own decisions), his family/spouse/relative etc will make the decision for him. Singapore is explicitly against active euthanasia. laws and regulations include the AMD (which reportedly took 8 years to pass due to ethical concerns) and the penal code (which deems active euthanasia as murder or assisted suicide) we do not agree with Singapore's position, since active euthanasia should be allowed as an option in the AMD as well. There may be cases where the patient is suffering and wishes for a quick and painless death, and his quick death may allow his organs to be harvested, thereby saving other lives. Active euthanasia may therefore be respectful of the patient's wishes and may be for the greater good. In some cases, when patients have to wait for their death to come, their whole world is changed, and redefined. some of them with physical deformities may be looked at differently, some of them will not be able to interact with their family members, or carry out their daily routines. this to the patients, will become painful as life can slowly become meaningless. As such, active euthanasia can be a quick way to end their pain, and their family members' pain, who have to watch them suffer and go through this tiring process. If active euthanasia is not allowed in Singapore due to ethical concerns and potential loopholes in such laws, then one should also consider how facilities, or institutions can be made more available for patients undergoing passive euthanasia, to allow them to have their last few days in peace and reserve their last bits of dignity.

Singapore debates where to draw the line for laws on assisted dying
MPs, doctors and churches are among those who have come up to state their opposition to legalising active euthanasia. Mon, Nov 10, 2008 The Straits Times SINGAPORE'S Health Minister Khaw Boon Wan suggested last month that the authorities might have to consider legalising active euthanasia - or assisted dying for presumably the terminally ill who are mentally competent. A euthanasia debate was triggered by a letter published in Lianhe Zaobao on Sept 20 from a 72-year-old woman, who said she and her husband lived in fear of falling ill and becoming dependent on others. For weeks after that, readers of the Chinese daily wrote in, calling for euthanasia to be legalised in Singapore. While several MPs and doctors interviewed by The Sunday Times welcomed the discussion, they all said they were personally against euthanasia, calling instead for palliative care, which involves the management of suffering for terminally ill patients. Yesterday, the National Council of Churches of Singapore, the umbrella body for some 200 Christian churches and organisations, issued a statement denouncing the act of euthanasia. '(Euthanasia) is societal killing; it will have grave implications on the way we think about ourselves and about matters of life, and open the door to serious abuses that would threaten the rights and dignity of persons and society,' stated the council. It maintains that palliative care is the answer for the terminally ill, as patients with inadequate symptom and pain control would request for euthanasia. On Sunday, the Catholic Church's Archbishop Nicholas Chia became the first religious head in Singapore to openly express opposition to euthanasia since Mr Khaw's speech, saying the act was equivalent to committing suicide. The debate comes at a time when the Government is trying to promote Advance Medical Directives, which instruct doctors not to take extraordinary measures to prolong life if a person is terminally ill or unconscious. Euthanasia is legal in Switzerland, the Netherlands, Belgium, Australia and Oregon in the United States.

SINGAPORE NEWS
Experts call for clearer difference between euthanasia and AMD
By Imelda Saad/Julia Ng, Channel NewsAsia | Posted: 10 November 2008 1956 hrs

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SINGAPORE : Doctors, caregivers and religious groups in Singapore have said there is a distinct difference between euthanasia and the Advanced Medical Directive (AMD) which the Health Ministry wants to simplify. While the AMD extends a person's autonomy on how he would like to die, euthanasia is seen as an act of killing. As Singapore's population ages, the country is in the midst of a debate on how one can die with dignity. At the centre of it is the Advanced Medical Directive. The Health Ministry is studying how to make it easier for people to sign up for the AMD - a document, where you can explicitly state how you want your final days to be, if you are terminally ill. The issue now is a confusion between what is AMD and what is euthanasia. Singapore's Health Ministry has stressed there has been no proposal to legalise euthanasia. Experts said it is all in the definition. They said signing the AMD to say you would rather have the plug pulled - than be kept alive by machines if you are terminally ill - is not euthanasia. Dr Chin Jing Jih, Executive Director, Centre for Medical Ethics and Professionalism, Singapore Medical Association, explained: "A lot of times, people think that when doctors switch off these life support systems, it is as if it is that act of stopping that kills the patient. Photos

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"But in actual fact, it is not. It is the underlying disease that has killed the patient. We are mer intervention that is no longer effective on the patient. Emotionally, it looks as if that act has en patient's life but it is actually the underlying illness.

"We know that if we do not remove the life support, the patient will perish too in a matter of da euthanasia because if we remove these cumbersome machines and the patient is still alive, we and we palliate the patient.

"But if it is euthanasia, I remove the machine and the patient is still alive, then I would say... w have to do to make sure the patient dies. So the intent is very clear. When doctors remove the death is foreseeable, but it is not intended, so we make that ethical decision and intent is centr

euthanasia."

Experts believe the AMD is not a slippery slope towards euthanasia. Doctors said a key issue is optimal palliative care to ease the pain of patients.

Dr Cynthia Goh, head, Palliative Medicine Department, National Cancer Centre Singapore, said: includes care that takes care of physical symptoms and physical pain, but we also do a lot of ps support, which is to support the person emotionally and to sustain hope.

"Much of it is about treating that person as a person... showing that person that he is worth so he will also be worth something provided that he is alive.

"And showing respect and showing that we are there for them and we won't abandon them - I common things that people are afraid of, and they say, 'I would rather be dead before I am ab before the pain becomes unbearable or before my suffering becomes unbearable'.

"But if we can encourage them and say we would do our best to ensure that it does not becom and we will stand by you, very often people will feel encouraged and they generate a little hope themselves to say that things can get a little bit better."

Another point medical professionals agree on is that if euthanasia is allowed, then doctors shou ones administering death because it affects the integrity of the profession. Instead, euthanasia by trained personnel.

Major religious groups in Singapore are also strongly against euthanasia, saying it is tantamoun

Condemning the act as "diminishing the value of human life" has been the National Council of C Singapore, NCCS, not NCSS (National Council of Social Service) which Primetime Morning had attributed a statement to about euthanasia.

While both the Singapore Buddhist Federation and the Islamic Religious Council of Singapore sa euthanasia as tantamount to the act of killing, it remains a grey area for Hindus.

However, it is a grey area for Hindus. Channel NewsAsia understands that the terminally ill can till death or refuse medical treatment, but subject to certain conditions. These include getting t the family and so long as the dying process is unaided.

Meanwhile, all four religious groups support AMD. The Buddhist Federation said that in AMD, "t dying in a natural way as no device is used just to prolong his/her life". - CNA/ms/sf

Angelique Flowers Melbourne writer, Angelique Flowers, was a brave young woman who found herself in a dreadful circumstance.
The Age newspaper in Melbourne ran a very moving front page exclusive after she died. The Age journalist had exclusive access to Angelique in the days immediately prior to her death. The story as reported by journalist Sherrill Nixon of The Age is below:
JUST a month shy of her 31st birthday and half a lifetime since she was diagnosed with the debilitating Crohn's disease at 15, Angelique Flowers was told she had colon cancer. It was so advanced and so aggressive, she was given only months to live. That was in May. She would have dearly loved to have spent her last days with those closest to her, but another desire was overwhelming. Frightened of a slow, painful death from a total bowel obstruction, this softly spoken Melbourne writer wanted her life to end peacefully and on her own terms. It wasn't to be. She regretfully turned away from her loved ones and spent her final weeks searching for information about euthanasia and a dose of the lethal drug Nembutal. Her final hours were robbed of the dignity she had wanted as she died vomiting the content of her bowels.

Flowers' quest dominated her dying days, and her frustration at Australia's current legal situation led her to film a passionate appeal to Prime Minister Kevin Rudd. [Angelique's YouTube.com message can be seen below]
"I don't believe in stoicism. I freely admit to not being a brave soul who grins and bears the pain and soldiers on," she says in the video, filmed during one of her last day trips from her hospice bed. "I deeply admire people who rise above the adversity and their suffering. But I haven't grown from my illness or become a better person from its torments. All I want after 16 years of painful Crohn's disease and now cancer is to die a pain-free peaceful death. "Because euthanasia was banned in Australia I am denied this right

"We finally have in Kevin Rudd a prime minister who is a person as well as a politician. A man who had the conscience to say sorry to our indigenous people, the integrity to ratify the Kyoto Protocol. "I beg the Labor Government to continue beating with the heart it has shown and to ensure euthanasia is made legal once again. "The law wouldn't let a dog suffer the agony I'm going through before an inevitable death. It would be put down. Yet under the law, my life is worth less than a dog's." In the film, Flowers says the stress of having to hide her activity from her family, friends and medical staff made her even more ill, and her composure cracks as she relates how she contemplated violent ways to end her life such as jumping off a building. "I have been robbed of both my living and my dying," she says, her large eyes peering out from her pale face. "At a time when I want to spend what good days and precious moments I have left having meaningful time with the people I love, I've had to cut myself off, writing questions and notes, making inquiries, doing research. "If euthanasia was legal, I could have ended my days as I chose, finding peace before leaving this world, not panic and more pain." The video is one of two she filmed in her final weeks; in the second she explains to those she loved how her excruciatingly painful Crohn's disease had meant she couldn't spend more time with them. For half of her life, the illness had at its worst, left her bedridden in agony, and at best, anxious and socially withdrawn. As her friends studied and celebrated and spent summers at the beach, Flowers stayed at home, too often sapped of the health, energy or confidence to join them. She was a private person, and kept her disease a secret from many of her extended family and friends for a decade. She is scathing of the medical profession her trust eroded by conflicting advice, poor bedside manners, and unbearable pain. Flowers gave the films to Philip Nitschke and his group Exit International, which she encountered in her search. It was through them that she learnt Federal Parliament overturned the Northern Territory's world-first euthanasia law in 1996. She also learnt about Nembutal, a lethal drug often used in euthanasia, but the idea of an arduous trip to Mexico to obtain it was quickly discarded. So, on Dr Nitschke's advice, she used that very generation X tool, YouTube, to broadcast her appeal for Nembutal.

Flowers did obtain a dose , but she never used it. No one knows why perhaps the fear of implicating family members, or the need to also take anti-nausea drugs to keep the Nembutal down. She suffered the bowel obstruction she had feared and died on August 19. Her older brother Damian, 34, was with her, and believes she was still in pain despite massive doses of morphine and other painkillers. In her last hour, he held a bowl under his sister's chin as she vomited faecal matter. "The peaceful ending wasn't there," he told The Age. "From the death she could have had, taking the Nembutal, saying her goodbyes to friends and family, having everyone there for her and being where she wanted to be, compared to what she did actually go through, it just doesn't bear imagining. "How can that be right? How can society believe terminal patients should be put through awful agonising deaths? Angelique wasn't afraid of dying; it was more the way she was going to die that she feared." While Flowers may not have believed she was brave enough, her family credit her inner strength with helping them through the ordeal. Damian and older sister Michelle hope her public appeal brings about legal change. The Victorian upper house this week voted down a private member's bill giving terminally ill people the right to die with the help of a doctor. But hopes are higher for a private member's bill introduced by Greens leader Bob Brown in Federal Parliament. That bill, on which debate and a vote is expected to be held in the life of this Parliament, seeks to restore the right of the Northern Territory or the Australian Capital Territory to legislate for voluntary euthanasia. Dr Nitschke, who met Flowers twice and intends to send her video to Senator Brown and Mr Rudd, described her as an eloquent advocate who was able to distance herself from her own plight. "I found her an amazing and intriguing person it's certainly a very powerful voice," he said. In her videos, Flowers talks of happier times and her achievements the fact she rated in the state's top 7% of students in year 12, and her pride at completing a degree in professional writing despite her illness. She recalls "one of the most wonderful experiences of her life", a four-month trip to the United Kingdom and Europe in 2006, where she travelled to literary sites including Oscar Wilde's grave. Before she was diagnosed with cancer, she wrote three books of inspiring and humorous quotes a tough task when, at times, she could hardly hold a pen that her family now hopes to have published.

"I just want you guys to know that I have no regrets I would have liked to have done more things in my life but the things I was able to do I am proud of," she says.

Active and passive euthanasia Active euthanasia

Active euthanasia occurs when the medical professionals, or another person, deliberately do something that causes the patient to die.
Passive euthanasia

Passive euthanasia occurs when the patient dies because the medical professionals either don't do something necessary to keep the patient alive, or when they stop doing something that is keeping the patient alive. switch off life-support machines disconnect a feeding tube don't carry out a life-extending operation don't give life-extending drugs

The moral difference between killing and letting die

Many people make a moral distinction between active and passive euthanasia. They think that it is acceptable to withhold treatment and allow a patient to die, but that it is never acceptable to kill a patient by a deliberate act. Some medical people like this idea. They think it allows them to provide a patient with the death they want without having to deal with the difficult moral problems they would face if they deliberately killed that person. Thou shalt not kill but needst not strive, officiously, to keep alive. Arthur Hugh Clough (1819-1861)
There is no real difference

But some people think this distinction is nonsense, since stopping treatment is a deliberate act, and so is deciding not to carry out a particular treatment. Switching off a respirator requires someone to carry out the action of throwing the switch. If the patient dies as a result of the doctor switching off the respirator then although it's certainly true that the patient dies from lung cancer (or whatever), it's also true that the immediate cause of their death is the switching off of the breathing machine. in active euthanasia the doctor takes an action with the intention that it will cause the patient's death in passive euthanasia the doctor lets the patient die
when a doctor lets someone die, they carry out an action with the intention that it will cause the patient's death

so there is no real difference between passive and active euthanasia, since both have the same result: the death of the patient on humanitarian grounds

thus the act of removing life-support is just as much an act of killing as giving a lethal injection

Is active euthanasia morally better?

Some (mostly philosophers) go even further and say that active euthanasia is morally better because it can be quicker and cleaner, and it may be less painful for the patient.
Top Acts and omissions

This is one of the classic ideas in ethics. It says that there is a moral difference between carrying out an action, and merely omitting to carry out an action. Simon Blackburn explains it like this in the Oxford Dictionary of Philosophy: The doctrine that it makes an ethical difference whether an agent actively intervenes to bring about a result, or omits to act in circumstances in which it is foreseen that as a result of the omission the same result occurs. Thus suppose I wish you dead, if I act to bring about your death I am a murderer, but if I happily discover you in danger of death, and fail to act to save you, I am not acting, and therefore, according to the doctrine, not a murderer. Simon Blackburn, Oxford Dictionary of Philosophy But the acts and omissions doctrine doesn't always work...
The killings in the bath

The philosopher James Rachels has an argument that shows that the distinction between acts and omissions is not as helpful as it looks. Consider these two cases: Smith will inherit a fortune if his 6 year old cousin dies. One evening Smith sneaks into the bathroom where the child is having his bath and drowns the boy. Smith then arranges the evidence so that it looks like an accident. Jones will inherit a fortune if his 6 year old cousin dies. One evening Jones sneaks into the bathroom where the child is having his bath. As he enters the bathroom he sees the boy fall over, hit his head on the side of the bath, and slide face-down under the water. Jones is delighted; he doesn't rescue the child but stands by the bath, and watches as the child drowns.

According to the doctrine of acts and omissions Smith is morally guiltier than Jones, since he actively killed the child, while Jones just allowed the boy to die. In law Smith is guilty of murder and Jones isn't guilty of anything. However, most people would regard any distinction between their moral guilt as splitting hairs. Suppose Jones defends himself by saying: I didn't do anything except just stand there and watch the child drown. I didn't kill him; I only let him die. Would we be impressed?
An objection to this analogy

You might argue that we can't compare the case of a doctor who is trying to do their best for their patient with Smith and Jones who are obvious villains. Of course you can't. But if you don't find the difference between killing and letting die persuasive in the Smith/Jones case, you shouldn't find it effective in the case of the well-meaning doctor and euthanasia.
The importance of intention

The Smith/Jones case partly depends on us paying no attention to the intentions of Smith and Jones. But in most cases of right and wrong we do think that intention matters, and if we were asked, we would probably say that Smith was a worse person than Jones, because he intended to kill. Consider this case (and yes, it's a fantasy, doctors don't behave like this): Brown is rushed into hospital after being stabbed. He arrives in casualty. Although he is bleeding heavily, he could be saved. The only doctor on duty wants to go home, and knows that saving Brown will take him an hour. He decides to let Brown bleed to death. Brown dies a few minutes later. Brown's mother arrives, and on learning what has happened screams at the doctor, "You killed my son!" The doctor replies, "No I didn't. I just let him die."

No-one would think that the doctor's reply excused him in any way. In this case letting someone die is morally very bad indeed.

And if the lazy doctor defended himself to Brown's mother by saying, "I didn't kill him. The dagger in his heart killed him," we wouldn't think this an adequate moral argument either. You can probably invent many similar examples. But there are cases where letting someone die might not be morally bad. Suppose that the reason the doctor didn't save Brown was that he was already in the middle of saving Green, and if he left Green to save Brown, Green would die. In that case, we might think that the doctor had a good defence against accusations of unethical behaviour.
Further reading

James Rachels, 'Active and Passive Euthanasia'. The New England Journal of Medicine, Vol. 292, pp 78-80, 1975
Top Preferring active to passive euthanasia

This section is written from the presumption that there are occasions when euthanasia is morally OK. If you believe that euthanasia is always wrong, then this section is not worth reading. Active euthanasia is morally better because it can be quicker and cleaner, and it may be less painful for the patient. Doctors faced with the problem of an incurable patient who wants to die have often felt it was morally better to withdraw treatment from a patient and let the patient die than to kill the patient (perhaps with a lethal injection). But some philosophers think that active euthanasia is in fact the morally better course of action. Here's a case to consider: A is dying of incurable cancer. A will die in about 7 days. A is in great pain, despite high doses of painkilling drugs. A asks his doctor to end it all. If the doctor agrees, she has two choices about what to do:

The doctor stops giving A the drugs that are keeping him alive, but continues pain killers - A dies 3 days later, after having been in pain despite the doctor's best efforts.

The doctor gives A a lethal injection - A becomes unconscious within seconds and dies within an hour.

Let's suppose that the reason A wants to die is because he wants to stop suffering pain, and that that's the reason the doctor is willing to allow euthanasia in each case. Active euthanasia reduces the total amount of pain A suffers, and so active euthanasia should be preferred in this case. To accept this argument we have to agree that the best action is one the which causes the greatest happiness (or perhaps the least unhappiness) for the patient (and perhaps for the patient's relatives and carers too). Not everyone would agree that this is the right way to argue. We can look at this situation is another way: Causing death is a great evil if death is a great evil. A lesser evil should always be preferred to a greater evil. If passive euthanasia would be right in this case then the continued existence of the patient in a state of great pain must be a greater evil than their death. So allowing the patient to continue to live in this state is a greater evil than causing their death. Causing their death swiftly is a lesser evil than allowing them to live in pain. Active euthanasia is a lesser evil than passive euthanasia.

But this still won't satisfy some people. James Rachels has offered some other arguments that work differently.
Do as you would be done by

The rule that we should treat other people as we would like them to treat us also seems to support euthanasia, if we would want to be put out of our misery if we were in A's position. But this isn't necessarily so: A person might well not want to be killed even in this situation, if their beliefs or opinions were not against active euthanasia. There are many examples of people who have accepted appalling pain for their beliefs.
Only rules that apply to everyone can be accepted

One well-known ethical principle says that we should only be guided by moral principles that we would accept should be followed by everyone.

If we accept that active euthanasia is wrong, then we accept as a universal rule that people should be permitted to suffer severe pain before death if that is the consequence of their disease.

Types of euthanasia
Pregnant Pause Home Euthanasia Search this site

The Basic Definitions

Euthanasia is generally classified as either "active" or "passive", and as either "voluntary" or "involuntary". Similar to euthanasia is "assisted suicide".

Active vs Passive
"Passive euthanasia" is usually defined as withdrawing medical treatment with the deliberate intention of causing the patient's death. For example, if a patient requires kidney dialysis to survive, and the doctors disconnect the dialysis machine, the patient will presumably die fairly soon. Perhaps the classic example of passive euthanasia is a "do not resuscitate order". Normally if a patient has a heart attack or similar sudden interruption in life functions, medical staff will attempt to revive them. If they make no such effort but simply stand and watch as the patient dies, this is passive euthanasia.

"Active euthanasia" is taking specific steps to cause the patient's death, such as injecting the patient with poison. In practice, this is usually an overdose of pain-killers or sleeping pills. In other words, the difference between "active" and "passive" is that in active euthanasia, something is done to end the patient's life; in passive euthanasia, something is not done that would have preserved the patient's life. An important idea behind this distinction is that in "passive euthanasia" the doctors are not actively killing anyone, they are simply not saving him. While we would usually applaud someone who saves another person's life, we do not normally condemn someone for failing to do so. If you rush into a burning building and carry someone out to safety, you will probably be called a hero. But if you see a burning building and people screaming for help, and you stand on the sidelines -- whether out of fear for your own safety, the belief that an inexperienced and ill-equipped person like yourself would only get in the way of the professional firefighters, or whatever -if you do nothing, few would judge you for your inaction. You would surely not be prosecuted for homicide. (At least, not unless you started the fire in the first place.) Thus, proponents of euthanasia say that while we can debate whether active euthanasia should be legal, there can be no debate about passive euthanasia: You cannot prosecute someone for failing to save a life. Even if you think it would be good for people to do X, you cannot make it illegal for people to not do X, or everyone in the country who did not do X today would have to be arrested. In practice, though, the distinction can get hazy. It's like the old joke about the child who says to his teacher, "Do you think it's right to punish someone for something that

he didn't do?" "Why, of course not," the teacher replies. "Good," the child says, "because I didn't do my homework." In fact we have many laws that penalize people for what they didn't do. You cannot simply decide not to pay your income taxes, or not bother to send your children to school, or not to obey a policeman's order to put down your gun. The most common method of euthanasia in the United States today is withholding food and fluids. In other words, the patient is starved to death. This is routinely classified as "passive euthanasia". But in other circumstances, if you locked someone in a room and kept all food away from him so that he starved to death, you could surely be prosecuted not just for kidnapping -- locking the person in the room -- but also for homicide. I sincerely doubt that a court would pay much attention to a defense based on the argument that you did not kill this person, you simply failed to save his life when he was starving.

Voluntary vs Involuntary
"Voluntary euthanasia" is when the patient requests that action be taken to end his life, or that life-saving treatment be stopped, with full knowledge that this will lead to his death.

"Involuntary euthanasia" is when a patient's life is ended without the patient's knowledge and consent. This may mean that the patient is kicking and screaming and begging for life, but in practice today it usually means that the patient is unconscious, unable to communicate, or is too sick and weak to be aware of what is happening or to take any action on his own behalf. While this distinction appears clear - the patient willing agreed to euthanasia or he did not - it too is often made ambiguous in court cases and some public debate. It is not uncommon for courts to declare someone "legally incompetent". This does not mean that the person is stupid, but rather that the court believes that he is unable to make informed decisions and/or to communicate them to others. The judge then appoints a guardian to make decisions for this person. Usually this will be a close relative, like a spouse, parents, or children. But if no such person is available, or if the judge believes that none of the relatives have this person's best interests at heart, then someone else may be appointed: a social worker, a lawyer, etc. Children are routinely considered legally incompetent, and their parents are expected to make decisions for them. No one asks a two-year-old whether or not he wants to go to the dentist: that decision is normally made for him by his parents. A judge may conclude that a person is senile, mentally retarded, suffering from delusions, or has some other psychological problem that makes it impossible for him to make truly informed, rational decisions. If someone is in a coma or is otherwise so sick that she is unable to communicate, then even if she is capable of making informed decisions, there is no way for anyone else to know what her decisions are. When courts declare someone legally incompetent and appoint a guardian, any decisions that the guardian makes are, for legal purposes, considered to be decisions of the incompetent person. A little thought will show that this must be so for the system to work: there would be little point in saying that you are authorized to make

decisions for this comatose person ... except that you do not have the authority to sign anything that would otherwise require his signature. That would exclude almost all important decisions. But it can also lead to legal statements that are very misleading: Suppose Nancy Smith convinces a court that her grandfather, Fred Jones, is senile, and she is appointed his guardian. Then she decides that she wants to have him euthanized. He objects but he is too old and sick to fight her in court herself, so he gets his other granddaughter, Mary Brown, to fight for him. Because Nancy Smith's decisions are legally considered to be Fred Jones's decisions, the case will be referred to as "Brown versus Jones", and court documents will routinely describe this as Fred Jones choosing euthanasia and Mary Brown attempting to overrule this decision. News reports on the court case may or may not make clear who actually made the euthanasia decision. It is not uncommon for medical personnel to treat someone as legally incompetent without any official court decision. For example, if someone is in the operating room under anesthesia, and there is a sudden crisis and a life-altering decision must be made now, it is often not possible to sew the person back up, wait for them to wake up, and then discuss the matter. A spouse or other close relative will be asked to make a decision on this person's behalf. Clearly under such circumstances it would be impractical to take this to court and hold hearings on the patient's competence and the suitability of the spouse as a guardian. But in euthanasia cases, the problem is often not that the patient is incapable of making and communicating a decision, but rather that those around her do not approve of her decision. Even when the legality of such actions is questionable, in real life the authorities are not going to intervene unless someone challenges it. And if the patient is weak, sick, and bed-ridden, she may not be capable of getting to court to protest. Unless there is another relative who disagrees with the decision to euthanize, the patient's wishes can simply be ignored.

Assisted suicide
In "assisted suicide", a doctor provides a patient with the means to end his own life, but the doctor does not administer it. For example, if a doctor gives you an injection of morphine sufficient to cause your death, this is euthanasia. But if the doctor puts the hypodermic needle beside your bed, explains to you what it is, and leaves, and you later inject yourself, this is considered assisted suicide.

The extremes
Clearly there is a big difference between "voluntary passive euthanasia" and "involuntary active euthanasia".

In voluntary passive euthanasia, a person decides for himself that medical treatment that he is receiving is making his life more unpleasant than the disease, and that he would rather end the treatment and go home. Presumably he concludes that a shorter but more comfortable life is preferable. Or perhaps he is simply tired of fighting, and wants to just give up and die. In involuntary active euthanasia, one person decides that another person's life is no longer worth living or no longer of value, and has him killed.

While both of these things result in the person's death, they are so dramatically different that it strains the language to lump them both under the single term "euthanasia". It reminds me of those gangster movies where the criminal says, "We ... ahem ... acquired this item from Mr Jones." What actually happened is that he beat Jones up and stole it. But by saying he "acquired" it, he neatly glosses over the subtle legal and moral distinctions between buying, borrowing, trading, stealing, and other methods of "acquiring" things.