PHILOSOPHICAL AND ETHICAL ISSUES Consequences count: against absolutism at the end of life Paul C. Snelling BSc MA RGN Senior Lecturer in Adult Nursing, Gloucester Centre, Hartpury Campus, University of the West of England, Gloucester, UK Submitted for publication 20 January 2003 Accepted for publication 11 October 2003 Correspondence: Paul Snelling, Gloucester Centre, Hartpury Campus, University of the West of England, Gloucester GL19 3BE, UK. E-mail: Paul2.Snelling@uwe.ac.uk SNELLING P.C. (2004) SNELLING P.C. (2004) Journal of Advanced Nursing 46(4), 350–357 Consequences count: against absolutism at the end of life Background. There has been a considerable amount of debate in the nursing lit- erature about euthanasia, and especially the distinctions between acts and omis- sions, and killing and letting die. These distinctions are required by opponents of euthanasia to justify allowing some cases of passive euthanasia while forbidding all cases of active euthanasia. Aim. This paper adds to the debate by arguing that the position that absolutely forbids euthanasia is theoretically inconsistent. Methods. The paper first considers the place of moral theory in analysing moral problems, within the framework of the principles of biomedical ethics. It is argued that despite a moral pluralism that operates in many areas, the legal status of euthanasia is based upon an absolute deontological position against deliberate killing, which cannot be overridden by appeals to favourable consequences. In order that certain forms of passive euthanasia can be allowed, this position allows dis- tinctions within three pairs of concepts – acts and omissions, killing and letting die, and ordinary and extraordinary means. A further method of justifying certain actions near the end of life is the doctrine of double effect. These paired concepts and the doctrine of double effect are analysed with special reference to their con- sequences. Conclusion. The application of the doctrine of double effect and the three distinc- tions relies on consideration of their consequences, allowing in practice what in theory is denied. This is important because it weakens the absolute case against euthanasia, which disallows any direct consequentialist appeal. If consequences count in the application of the doctrine and the distinctions, then they should also count directly prior to their application. This strengthens the argument for active euthanasia in certain cases. Keywords: euthanasia, consequences, killing, letting die, doctrine of double effect, nursing Background End of life issues, and in particular the debate surrounding the moral and legal justification of active euthanasia, are topics for debate throughout the world. In Europe, differ- ences in attitudes to euthanasia and other issues in palliative care (Ten Have & Clark 2002) have been highlighted by the recent high profile journeys made by terminally ill Britons to Switzerland, where they have been assisted in committing suicide (Hurst & Mauron 2003). Recent studies have shown some support for active euthanasia by nurses in Hungary (Fekete et al. 2002), and Japan and Australia (Tanida et al. 2002). Even if there has not been a rush to follow The Netherlands’ lead in allowing euthanasia (Emanuel 2001), a recent review of the first 25 years’ experience in that country (Dupuis 2003, p. S64) concludes that ‘it is to be expected that every society with a very advanced high-tech medicine will at a certain moment be confronted with the problem of 350 Ó 2004 Blackwell Publishing Ltd