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Dr Campbell presents proponents of euthanasia with a dilemma.¹ Only voluntary euthanasia is permissible; involuntary euthanasia is always impermissible. The question of allowing euthanasia arises most frequently when patients are terminally ill and experiencing great pain. But in these cases, he argues, if patients request euthanasia, their decision “is not freely chosen but is compelled by the pain”.² It is easy to exaggerate the problem here; patients may have periods when they are pain-free and affirm repeatedly their desire that death be hastened. Putting this aside, however, what should we conclude if euthanasia performed on patients who are suffering greatly is not voluntary?

Dr Campbell concludes: “If the request to end one's life is not made freely, then it is doubtful that such requests ought to be followed”.² An advance directive will not help, we are told, because the individual may have changed his or her mind. Dr Flew sensibly replies that the best we can do in these cases is to have detailed advance directives, an example of which he provides.³ Society could even add a safeguard to this: require individuals to “renew” these documents periodically—say, every two years.

This practical reply, however, leaves unexposed two questionable aspects of Dr Campbell's argument. The first is that his position presents us with a false dilemma. Dr Campbell says that in cases where patients are suffering “euthanasia turns out to be involuntary” and therefore impermissible. And involuntary euthanasia is characterised as taking the life of another human being “against his or her will”. Most will agree that involuntary euthanasia, so characterised, should not be allowed. But it does not follow from the fact that euthanasia is not voluntary that it is involuntary. There is another category, nonvoluntary euthanasia; it involves taking the life of another human being without his or her consent or request. Involuntary euthanasia is a special case of nonvoluntary; but nonvoluntary also includes cases in which patients are unable or unwilling either to protest or to give free and informed consent. This is pertinent because while most people will readily agree that involuntary euthanasia is wrong, there is less consensus about those cases of nonvoluntary euthanasia that are not against the patient's wishes. And these are precisely the cases with which Dr Campbell is concerned.

The second problematic aspect of Dr Campbell's argument concerns the specific recommendation that he believes follows from the fact that a request for euthanasia is not known to be voluntary. He maintains that in such cases the request should not be followed. Apparently it is permissible to act on the request only if it is known to be voluntary. But this is a very demanding standard, and one that is not at all reasonable in most areas of medicine. If a patient in great pain presents in the emergency room of a hospital and consents to recommended surgery, we do not hesitate to perform the procedure because the pain renders the consent not voluntary. It is question-begging to retort that this case is different from euthanasia because the surgery is obviously rational and in the patient's best interests. For as Dr Campbell rightly concedes, if a patient's pain is irremediable and can be ended only by hastening death, then it may well be rational for that patient to choose to end his or her life.

In many contexts of medicine, doubts can be raised about whether a patient's consent is informed or fully voluntary. The best that fallible humans can do is to look for additional evidence of what the patient wants. That we do this demonstrates our commitment to the precepts dubbed “the advance directive principle” and “the substituted judgment standard”.⁴ We even appeal to these precepts when patients clearly lack decision making capacity. Evidence does not always produce certainty, but we do not demand certainty even when the results will be life-altering or irreversible. Were we to demand certainty, in many cases we would not be authorised to act. In the cases discussed by Dr Campbell, refusal to act in the absence of certainty makes it more likely that we will fail to honour these patients' wishes; in addition, we will deny them relief from their agony.