A major factor underlying whether active or passive euthanasia is legal is whether the doctor intends to kill the patient or not (Lewis, 2009, p. 126). Rachels hits on the intent piece in one of his constructed examples, "Rather, the other factors - the murderer's motive of personal gain, for example, contrasted with the doctor's humanitarian motivation -account for different reactions to the different cases." The Colombian Constitutional Court actually ruled doctors are negligent if they ignore a terminally ill, competent patient's request for active euthanasia, a position which actually moves closer to Rachels' side of the debate (Michlowski, 2009, p. 192). The Canadian Medical Association's inquiry into Belgian euthanasia included asking about the doctors' "explicit intention of hastening the end of life or of enabling the patient to end his or her own life" (Chambaere et al., 2010, p. 896). This intent underlies the principle of "double effect," if palliative treatment that carries the known likely or expected side effect of hastening death, does not constitute the intent to end the patient's life, and this is a widely recognized and accepted practice (Michlowski, 2009, p. 185). Where the doctor cannot prove the intent was not to hasten death, consequences are usually severe (Lewis, 2009, p. 126), although some argue prosecutors look the other way (Tucker & Steele, 2007, p. 322).
While these three components are nearly universal in states where passive and sometimes active euthanasia are legal, these jurisdictions are the exception rather than the norm, a minority vastly outweighed by the rest of the world where allowing someone to die through negligence remains at the top of the list of heinous crimes (Michlowski, 2009, p. 187). At the same time, individuals usually have the right to refuse even life-saving emergency medical treatment (Columbian Court, quoted in Michlowski, 2009, p. 204). The result is that "even the most advanced and liberal countries in the world have not reached an agreement on the desirability of legalizing active euthanasia" (Michlowski, 2009, p. 216), and disagree on practice within the group where passive and active euthanasia are condoned.
Nor do professional associations provide a clear consensus to anyone outside their membership, because they often contradict each other. Many of them disagree with the AMA position Rachels frames his argument in terms of. The American Geriatrics Society (AGS) asserts "Most would choose to live if they had full confidence that the care system would serve them well," and so justifies continued prohibition of voluntary assisted suicide and monetary compensation...
On the other hand, the American Psychological Association's assertion that the cognition behind the terminally ill patient's decision to die differs from the logic employed by the clinically depressed in deciding to commit suicide is echoed by the American Public Health Association, the American Academy of Hospice and Palliative Medicine, and the American College of Legal Medicine, who justify their recommendation against the negative associations between suicide and what they describe as "the principles of personal autonomy and free will" on grounds of material difference long recognized by the U.S. Supreme Court (Tucker & Steele, 2007, p. 325).
A fourth commonality that runs through the discussion but with much less prominence is a qualification that a patient's decision can be overridden if euthanasia has significant effects on people other than the patient, although those effects are even more rarely, if ever, defined. The Columbian courts qualified their acceptance of personal autonomy as sovereign under the constitution with the competency requirement but also where the exercise of that autonomy carried only " private nonpublic effects" (Michlowski, 2009, p. 192). The petitioner who brought the Columbian complaint claimed in part that non-voluntary euthanasia ("mercy-killing" to the 1973 AMA) left the doctor free to "end the lives of those who are regarded as an obstacle, a nuisance, or whose health raises high costs" (Michlowski, 2009, p. 186), but the court took it upon itself to generalize this even farther. This 'externality' effect rarely appears in such abstract terms, but runs throughout the research and opinion on the ethics of euthanasia in various guises.
The newer AMA policy statement claims euthanasia "would pose serious societal risks," without elaborating specifically what those may be (1996). Numerous patients have included consideration of their family's emotional pain caused by prolonged terminal illness as a factor leading them to choose euthanasia (Chambaere et al., 2010, p. 897); but fewer overtly discuss the callous topic of monetary expense as a factor in that decision. Tucker and Steele mention that voluntary euthanasia consumers may consider the cost to their estate, but only in passing (2007, p. 322). Campbell (2005, p. 45) claims family concern is justified under some Buddhist and Hindu perspectives if the choice to take life is made out of compassion for
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