Article Text

Download PDFPDF
Rawlsian reasoning about fairness at the end of life
  1. Niels Lynøe1,
  2. Ingemar Engström2 and
  3. Niklas Juth1
  1. 1 Stockholm Centre for Healthcare Ethics (CHE), Karolinska Institutet, Stockholm, Sweden
  2. 2 Clinical Science/Psychiatry, Örebro universitet, Orebro, Örebro, Sweden
  1. Correspondence to Professor Niels Lynøe, Stockholm centre for healthcare ethics (CHE), Karolinska Institutet, Stockholm, Sweden; niels.lynoe{at}


Objectives The aim of this study was to discuss end-of-life care in the context of Rawls’ and Daniels’ philosophy of justice. The study is based on an empirical survey of Swedish physicians who were asked whether they would want the option of physician-assisted suicide (PAS) for themselves (hereafter called own preferences), what are their attitudes towards PAS in general and whether they were prepared to prescribe PAS drugs to eligible patients. The question is to what extent the physicians’ answers are impartial and consistent in a Rawlsian sense.

Methods The underlying indicator was the physicians’ own preferences. Kappa score inter-rater agreement was measured between that response and that same physician’s general attitude towards allowing PAS and preparedness to prescribe PAS drugs. The coherence of provided comments and arguments were analysed using content analysis.

Results Palliative care physicians are the least willing to offer PAS, and surgeons and psychiatrist the most willing. There is a discrepancy between physicians’ general attitudes about allowing PAS, their own wishes to be offered PAS at the end of life and the concrete action of prescribing PAS drugs. Arguments given for not prescribing PAS by those in favour of PAS are seemingly but not truly inconsistent.

Conclusions Those supporting PAS provided impartial and consistent arguments for their stances in a Rawlsian sense, while those against PAS provided partial arguments. Two specialties, psychiatrists and palliative care physicians, were coherent in their reasoning about PAS for themselves and their willingness to prescribe the needed drugs.

  • end of life care
  • ethics
  • hospice care
  • methodological research
  • terminal care

Data availability statement

Data are available upon reasonable request.

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Data availability statement

Data are available upon reasonable request.

View Full Text


  • Contributors NL conducted the analysis of both the kappa values (table 1–3) and the first draft of the qualitative data (table 4). After that, all authors contributed equally. NL is responsible for the overall content as guarantor.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.