Slides (PDF) · Student tasks · Български
Set aside about 15 minutes to read and think. The text follows the presentation “Care at the end of life”. Afterwards you should be able to say what makes a patient terminally ill, what palliative care is for, how euthanasia differs from physician-assisted suicide and from decisions that are not euthanasia at all, what Bulgarian law says, and which arguments carry weight on each side.
The terminally ill patient
The Bulgarian Medical Institutions Act defines terminally ill patients as persons with progressive and incurable diseases in which treatment does not change the unfavourable prognosis for length of life (Additional Provisions, § 1, item 4). It sets no limit in days or months, and rightly so: prognosis is a probability, not a clock. Three words are often confused. An incurable disease cannot be removed but may be controlled for years. A terminal stage means the disease limits life and recovery is no longer a realistic goal. Dying means that irreversible failure of vital functions has begun.
Two errors frame the ethics of this stage. One is abandonment: “there is nothing more we can do” ends the relationship just when the patient needs it most. The other is therapeutic obstinacy: continuing or starting burdensome interventions that only prolong dying. Between them lie the familiar problems: how much to tell and when, a family asking to hide the diagnosis, a capable patient refusing dialysis or ventilation, decisions about resuscitation, a patient who can no longer decide, and fair access to care. Terminal status must never be assigned because of age, disability or dependence alone. A shortage of beds is not clinical futility.
A terminal prognosis does not reduce any patient right. Under the Health Act the patient may refuse offered care, or its continuation, at any time; the refusal is recorded with signatures (Art. 90). Care against the patient’s will is possible only in cases set by law (Art. 91). The patient may decline information about the disease and prognosis and may authorise another person in writing to be informed instead (Art. 92(2) and (4)). The right not to know belongs to the patient, not to the family. When a patient refuses needed treatment without understanding the danger, the physician must explain the unfavourable prognosis, unless the patient explicitly does not want to hear it (Code of Professional Ethics, Art. 29).
Withholding and withdrawing treatment can rest on the same ethical ground. If a time-limited trial of ventilation fails its agreed goal, the fact that it has started does not make it obligatory forever. Treatment is proportionate when its expected benefit reasonably matches its risks and burdens for this patient’s goals. A do-not-resuscitate decision covers only resuscitation at arrest. Pain relief, oxygen, fluids, nursing care and presence continue. Artificial nutrition and hydration are medical interventions with their own indications, not a choice between “feeding” and “letting someone starve”.
Palliative care and hospice
The World Health Organization defines palliative care as an approach that improves the quality of life of patients and their families facing life-threatening illness, through the prevention and relief of suffering by early identification, impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual (Sepúlveda et al., 2002). The word comes from the Latin pallium, a cloak. Palliative care is not reserved for cancer or for the last days. It starts according to need and can run alongside treatment aimed at the disease. In a randomised trial in metastatic lung cancer, early palliative care improved quality of life and mood, and median survival was 11.6 rather than 8.9 months (Temel et al., 2010).
Its goals: relief of pain and other symptoms; regarding dying as a normal process that is neither hastened nor postponed; psychological, social and spiritual support; helping the patient live as actively as possible; and support for the family during the illness and in bereavement. The Health Act puts the goal in similar terms: maintaining quality of life by reducing or removing manifestations of the disease and its unfavourable psychological and social effects (Art. 95(2)).
Cicely Saunders, who opened St Christopher’s Hospice in London in 1967, called this total pain: physical, psychological, social and spiritual suffering reinforce one another, so a higher analgesic dose does not cure fear or loneliness (Clark, 1999). Palliative care, end-of-life care and hospice care overlap but are not the same. A palliative consultation is not a death sentence.
In Bulgaria the patient with an incurable disease and unfavourable prognosis has a right to palliative care (Health Act, Art. 95). It includes medical monitoring, care to remove pain and psycho-emotional effects, and moral support for the patient and family, provided by the GP, outpatient and hospital care, and hospices (Art. 96(1)–(2)). Under the Medical Institutions Act a hospice is a medical institution in which specialists provide palliative care to terminally ill patients; it may also offer social services (Arts. 10 and 28). There is a gap, though. Art. 96(3) requires an ordinance of the Minister of Health on the requirements for palliative care. Ilieva and Musurlieva found that it had still not been issued nineteen years later and concluded that there is no clear mechanism for providing and controlling the scope of palliative care (2023). In March 2026 the caretaker health minister committed to developing a palliative care standard.
Opioids are indispensable for severe pain. Under the rule of double effect an act with a good and a foreseen bad effect is permissible if the act itself is good or neutral, only the good effect is intended, the bad effect is not the means to the good, and there is a proportionate reason (Sulmasy and Pellegrino, 1999). The textbook warns against the myth that properly titrated opioids routinely hasten death; the real choice is never “pain or a lethal dose”. Palliative (terminal) sedation is a proportionate, monitored lowering of consciousness for a refractory symptom, one that cannot be relieved within an acceptable time or burden. The lowest effective level is used; continuous deep sedation is reserved for the last hours or days (Cherny and Radbruch, 2009). Its aim is relief; death is neither the goal nor the means.
Euthanasia and assisted suicide: concepts and types
Euthanasia is the deliberate ending of a patient’s life by a physician at the voluntary, explicit request of a patient with decision-making capacity; the physician performs the last act. In physician-assisted suicide the physician prescribes or provides the means and the patient performs the last act. In the broader term assisted suicide the helper need not be a physician. The decisive question is who performs the last act, with what intention, and what causes death.
The classical literature divides euthanasia by four criteria, and you will meet them in older texts and exams:
| Criterion | Types | Assessment today |
|---|---|---|
| By the act | Active (an act causes death); passive (treatment is withheld or withdrawn) | “Passive euthanasia” is misleading: proportionate withdrawal is legitimate care |
| By the will | Voluntary, non-voluntary (no capacity), involuntary (against the will) | Only voluntary can be euthanasia; involuntary is murder |
| By intention | Direct (death intended); indirect (death foreseen, not intended) | Indirect is the rule of double effect, not euthanasia |
| By the actor | Euthanasia or (physician-)assisted suicide | Decided by who performs the last act |
Rachels argued that killing and letting die do not differ morally in themselves (1975). The textbook and the World Medical Association keep the distinction. Four questions separate the decisions: what is done, what is intended, what causes death, and whether care continues. Refusal by a capable patient, withdrawal of futile treatment, titrated pain relief and proportionate palliative sedation are not euthanasia. Relatives cannot request euthanasia on behalf of a patient who lacks capacity, and an advance refusal of a specific treatment is not an advance request to be killed.
“I want to die” is a message that needs an answer. It may mean uncontrolled pain, breathlessness, fear of losing control, depression, delirium, loneliness, poverty or the feeling of being a burden. Ask openly what makes life unbearable now; assess symptoms, mood, capacity and suicide risk; treat what can be treated; explain the legal limits; and promise not to abandon the patient.
The normative framework
In Bulgaria everyone has the right to life, and an attack on it is punished as the gravest crime (Constitution, Art. 28). Euthanasia is not applied on the territory of Bulgaria (Health Act, Art. 97). The physician has no right to end the patient’s life and must do everything possible so that the incurably ill spend the rest of their lives without pain and suffering, with their dignity preserved (Code of Professional Ethics, Arts. 30 and 31). The Criminal Code has no privileged offence of “killing on request”: deliberate killing is murder (Art. 115), and consent is no defence. Assisting or persuading another person to commit suicide is a crime if suicide or an attempt follows (Art. 127). The prohibition does not cancel the right to refuse treatment or the right to palliative care.
The European Court of Human Rights leaves states a wide margin. Pretty v United Kingdom (2002) held that the right to life confers no right to die. Haas v Switzerland (2011) placed the decision how and when to end one’s life within private life (Art. 8). In Lambert and Others v France (Grand Chamber, 2015), withdrawing artificial nutrition from a patient in a vegetative state did not breach Art. 2. Mortier v Belgium (2022) found a violation of Art. 2 because the review of a euthanasia case was not independent, not because of the Belgian law itself. Karsai v Hungary (2024) found no duty to allow assisted dying and stressed palliative care. The Oviedo Convention requires previously expressed wishes to be taken into account (Art. 9), and the Parliamentary Assembly has stated that euthanasia must always be prohibited (Resolution 1859, 2012). The World Medical Association is firmly opposed to euthanasia and physician-assisted suicide (Declaration of Tbilisi, 2019) and calls palliative care part of good medical care (Declaration of Venice, revised 2022).
A short global overview
As of October 2026, euthanasia and assisted suicide are legal in the Netherlands, Belgium, Luxembourg, Canada, Spain, Colombia, New Zealand and every Australian state and the ACT. Uruguay legalised euthanasia in 2025. Switzerland allows assisted suicide without a selfish motive; Oregon (1997) and more than ten other US jurisdictions allow it, New York since August 2026; Austria, Germany and Italy allow it after court rulings. France adopted a law in July 2026 that is under constitutional review; the bill for England and Wales fell in the House of Lords, Scotland rejected its bill, Portugal’s 2023 law never came into force, and Slovenian voters rejected theirs in a 2025 referendum. Where it is legal, 0.3–4.6% of deaths are euthanasia or assisted suicide, more than 70% involve cancer, and pain is mostly not the main motive (Emanuel et al., 2016).
Arguments and philosophical positions
The case for legalisation rests on autonomy over one’s own death, on compassion where suffering cannot be relieved, on dignity understood as living by one’s own values, and on transparency instead of hidden practice. The case against rests on the inherent value of life and the healer’s role, on uncertain prognosis and an irreversible act, on pressure on old, poor and disabled people, on the slippery slope, and on palliative care as the first answer. “Dignity” and “do no harm” are used by both sides, so define them before you argue.
Each philosophical tradition pulls in its own direction. Autonomy (Mill) supports a capable person’s choice, yet a right to refuse is not a right to oblige someone else to kill. The sanctity of life forbids intentional killing but does not demand endless treatment. Kant gives persons dignity rather than a price and held that ending one’s life to escape suffering treats oneself as a mere means. Utilitarianism aims to minimise suffering (Singer supports voluntary euthanasia) but must also weigh trust in medicine and risk to the vulnerable. The slippery slope has a logical form (the reasons extend beyond terminal illness) and an empirical one: one study found no heightened risk for vulnerable groups in Oregon and the Netherlands (Battin et al., 2007), while others worry about psychiatric cases (Lerner and Caplan, 2015). The Hippocratic tradition says: “I will not give a deadly drug to anybody who asks for it.”
The cited provisions were checked against current consolidated texts on 9 October 2026.
Before you open the student tasks, try to answer in three sentences: why stopping dialysis at a capable patient’s request is not euthanasia; what the four conditions of double effect are; and what a Bulgarian physician should say to a patient who asks for help to die.