The Ethics of Euthanasia (Part One)
The book Contemporary Debates in Applied Ethics recently found its way into my hands. It's a decent collection of essays on topics ranging from abortion, to capital punishment, to world hunger. As might be expected from a debate book, it adopts a “pro” and “anti” format. In other words, there are eleven pairs of essays with each pair consisting of an essay defending a proposition and another one opposing the same proposition. Unfortunately, the interplay between the essays isn’t perfect and, as per usual, the authors occasionally talk past one another. Still, the standard of discussion is high and it makes for rewarding reading.
Anyway, I thought I might share some of the book here on the blog since the argumentative back-and-forth of the essays fits well with the kind of analysis I usually undertake. First up will be the pair of essays on euthanasia. The pro essay is written by Michael Tooley; the anti essay is written by Daniel Callahan. I’ll go over Tooley’s essay first (it might take a few posts), then I’ll turn to Callahan’s essay.
In this post, we’ll go through some conceptual distinctions and we’ll look at Tooley’s basic pro-euthanasia argument. I should clarify at the outset that Tooley isn’t necessarily “pro” euthanasia. He just thinks it isn’t morally wrong. In this respect, his argument might be thought to resemble the pro-choice position on abortion.
1. The Euthanasia Landscape
Tooley adopts the following definition of euthanasia:
“Euthanasia” = Any action where a person is intentionally killed or allowed to die because it is believed that the individual would be better off dead than alive — or else, as when one is in an irreversible coma, at least no one is worse off.
So understood, “euthanasia” captures a rather broad range of activities. Certainly much broader than the range of activities that Tooley’s opponent Callahan thinks fall within the rubric of “euthanasia”. Callahan defines euthanasia as the direct killing of a patient by a doctor. Such a definition is, as Tooley notes, narrower than his in at least three ways. First, it excludes killing by means of omission ( e.g. withdrawing life support). Second, it excludes methods of killing that are indirect (Tooley cites the example of a morphine dose which leads to respiratory failure but which is directly intended to reduce pain). And third, it limits itself to patients. Tooley thinks these limits are morally irrelevant. More on this in a later post.
For now, we need to be a little bit more discriminating in our conceptualisation of euthanasia. In particular, we need to pay attention to two dimensions along which particular instances of euthanasia can vary.
The first of those dimensions captures the distinction between voluntary, non-voluntary and involuntary forms of euthanasia. An instance of euthanasia is voluntary if the person who is euthanised either consents to or requests their death. An instance of euthanasia is non-voluntary if the person who is euthanised does not have the capacity to communicate their desires (e.g. as in a coma). And finally, an instance of euthanasia is involuntary if the person is euthanised against their will.
The second dimension captures the distinction between passive and active forms of euthanasia. There are different ways of understanding this distinction. According to one, the distinction is between killing someone by omission ( i.e. by doing nothing) or by performing some act. Alternatively, the distinction is between the primary causes of death. If the primary cause of death is human action, then we have a case of active euthanasia. And if the primary cause of death is disease or injury, then we have a case of passive euthanasia.
With those dimensions in place, we can construct the following grid.
The grid captures all the possible forms of euthanasia. We can assign moral statuses to each of these forms. I note that most people think that passive voluntary euthanasia is morally permissible, i.e. they think its okay for someone to refuse to undergo life-saving treatment (in certain cases). I also note that many people think that passive non-voluntary euthanasia is morally permissible, i.e. a family can withdraw life-support from a relative who is in a persistent vegetative state. What we’re interested in here is whether active voluntary euthanasia is morally permissible.
2. Making The Case for Active Voluntary Euthanasia
If you have any familiarity with Tooley’s writings you’ll know that he has a penchant for long formal arguments (check out his SEP entry on the problem of evil for a good example of this). It should come as no surprise then to learn that his basic argument for active voluntary euthanasia is quite long. One of the nice features of this approach is that it tends to make for a logically strong argument. Tooley tends to build his case in a series a fairly uncontroversial stages, and these stages tend not to rely on implicit premises — as is often the case in arguments of this sort. That’s not to say there’s no controversy to be had — of course there is — but at least he tries to build a comprehensive case.
In the euthanasia essay, Tooley presents his argument initially as one whole unit and then works through the justification of the various stages. I’m going to reverse that order of presentation here: I’m going to go through the various stages first and then I’m going to present the whole argument, with an argument map, at the end. Here we go.
3. Stage One: Suicide can sometimes be in a person’s interest
The first stage of argument proposes that a person’s committing suicide is — under certain circumstances — in that person’s interest. It looks like this:
- (1) If a person is suffering considerable pain due to an incurable illness, then in some cases that person’s death is in his or her own interest.
- (2) If a person’s death is in his or her own interest, then committing suicide is also in that person’s own interest.
- (3) Therefore, if a person is suffering considerable pain due to an incurable illness, then committing suicide is in that person’s own interest.
This argument is logically valid (“If A then B” + “If B then C” → “If A then C”). It is also relatively innocuous: It says nothing, yet, about whether suicide is morally permissible. It only says that it can be in a person’s interest. Still, some people might object to its premises and we must see what can be said in their favour.
As regards premise (1), Tooley makes two supporting observations. First, he notes that many people who suffer from painful and incurable diseases come to welcome their own deaths. Since people are generally assumed to be good judges of what is in their interest, this implies that their deaths are (likely) in their own interests. Second, he notes that the family members of those who suffer from such diseases also welcome their deaths. We will add these two supporting observations into the completed argument map as (1.1) and (1.2) respectively.
As regards premise (2), Tooley notes that some religious believers are likely to reject this premise. For instance, Catholics who believe that suicide is a sin, and that anyone who commits it is destined for Hell, are likely to reject it. We’ll give this objection the number (2.1) There are a couple of ways to respond to this. One would involve a major detour into the philosophy of religion and might end up arguing that a good God is unlikely to send people to Hell for eternity. An alternative response — the one Tooley endorses in the interests of time — is to point out that Catholics think that many things (homosexual acts, premarital sex, contraception and masturbation) are sins. So anyone persuaded by Catholic doctrine on suicide must adopt a similar attitude towards these acts. The suggestion is that most people are unlikely to do this and so this objection to premise (2) fails. These points will be added to the argument map as (2.2) and (2.3).
4. Stage Two: Suicide is not (always) morally wrong
We now move on to the next stage of the argument. This stage focuses on the transition from “in a person’s interest” to “not morally wrong”. As follows (note: (3) serves as the first premise of this argument, but I’m not going to write it out again):
- (4) A person’s committing suicide in such circumstances may very well also satisfy the following two conditions: (a) it neither violates anyone else’s rights, nor wrongs anyone; and (b) it does not make the world a worse off place.
- (5) An action that satisfies conditions (a) and (b), and that (c) is not contrary to one’s own interest, cannot be morally wrong.
- (6) Therefore, a person’s committing suicide when that act does not violate conditions (a), (b) and (c) is not morally wrong.
There are a couple of things going on here. On the one hand, premise (5) is setting down certain conditions for moral rightness. On the other hand, premises (4) and (3) are saying that those conditions are met in certain cases of suicide. Let’s look at the conditions first and then consider whether they actually are met in certain cases of suicide.
Conditions (a) and (c) appeal to the idea that to be morally wrong an act must wrong some sentient being by violating their rights or undermining their interests (on certain conceptions of rights these are one and the same thing). By themselves these conditions would seem uncontroversial. The major objection to them is that they do not exhaust the conditions of moral wrongness. Derek Parfit, for instance, has a famous thought experiment in which you are asked to choose between two actions. The first of which will lead to future generations enjoying an extremely high quality of life, and the second of which will lead to future generations having lives that are not worth living.
The typical reaction to this thought experiment is that to perform the second action would be to do something morally wrong. But this reaction is difficult to explain if (a) and (c) exhaust the conditions of moral wrongness. After all, the future generations who are harmed by the second action are not yet alive and so cannot be wronged by your actions in the present. This suggests that there is more to wrongness than just harming the rights and interests of sentient beings (other thought experiments can be used to reach similar conclusions). And this possibility is exactly what condition (b) is designed to cover.
So the conditions of moral wrongness seem to be sound, now we must ask whether they will be met in certain cases of suicide. We have already seen in stage one how condition (c) can be met when the person is enduring considerable pain due to an incurable illness. So we focus here on (a) and (b).
Tooley argues that in the same circumstances condition (a) can be met. How so? Well, although it is true that those contemplating suicide in such cases will have obligations to others, they are unlikely to be able to meet those obligations due to the pain they are suffering (4.1). Furthermore, obligations usually allow for some level of cost-benefit analysis to determine whether they need to be fulfilled — if the personal cost of fulfilling the obligation is exceptionally high, as it might be in cases of incurable illness, then the obligations may be relaxed (4.2).
There is an obvious objection to this. Some might argue — contra the above — that ending one’s own life violates God’s right of ownership over us (4.3). Tooley detects three flaws with this response. First, it assumes that God exists when this is unlikely to be the case (4.4). Second, and more importantly, even if there is a God such a right of ownership is highly implausible since it conflicts with moral autonomy, which is generally thought to be a great good (4.5). Third, even if there is some right of ownership over non-autonomous beings — as there might be in the case of pets and their owners — this does not give the owner the right to compel the being to suffer needlessly (4.6). Tooley’s approach here is a bit too kitchen-sinky for my taste. I tend to think that in ethical debates of this sort one should either grant the most complex premises (like the existence of God) for the sake of argument, or else one should engage with them more fully. I don’t like the “this is unlikely” approach taken in (4.4).
Anyway, turning to condition (b), Tooley again thinks it highly likely that this condition will be met in the case of incurable illness with considerable pain. He does so on the grounds that death in these cases (i) ends the suffering to the individual, (ii) is likely to ease the emotional suffering of the friends and families of the individual, and (iii) is unlikely to generate any outweighing suffering due to loss of a loved one (4.7).
In sum, stage two of the argument seems well-supported.
5. Stage Three: Assisting Suicide is not morally wrong
Stage three of the argument makes the all-important leap from cases in which the individual takes their own life (suicide) to cases in which another person assists the individual in the taking of their own life. It says (again, (6) is an unwritten premise here):
- (7) It would be morally wrong for a person (call them “A”) to assist another in committing suicide (call them “B”) if and only if: (i) it was morally wrong for B to commit suicide; or (ii) committing suicide was contrary to A’s own interests; or (iii) A’s assisting B to commit suicide violated an obligation that A owed to a third party C.
- (8) Circumstances may well be such that A’s assisting B to commit suicide was neither (i) morally wrong for B; or (ii) contrary to A’s interests; or (iii) in violation of A’s obligations to any third party C.
- (9) Therefore, it may not be morally wrong to assist another in committing suicide.
This stage of the argument follows a similar pattern to the previous one. It sets some conditions for morally wrongful assistance and then it says those conditions are met in certain cases of assisted suicide.
Let’s look to the conditions of morally wrongful assistance first. Here, I must admit, I’ve hit upon a snag. Although conditions (i) and (iii) seem relatively straightforward, condition (ii) seems less so. The problem has to do with the ambiguity of Tooley’s original formulation of premise (7). Whereas I try to make it clear who is being referred to by introducing the characters A and B, Tooley does not and refers simply to “the person”. Unfortunately, this makes it unclear whose interests are being referred to in condition (ii). I’ve interpreted it above as referring A’s interests ( i.e. the interests of the assister) and I think this makes sense: it would seem imprudent (and likely a condition of wrongness) for A to assist another in undermining his interests. That said, it could be that Tooley is referring to B’s interests and drawing a distinction between objective and subject interests. In other words, the idea is that while B might subjectively think that a particular action (in this case suicide) is in their interests, they might be wrong about this when their interests are assessed from the third-person perspective. So if you, as an outside observer, think that the action is not in B’s interests, you should not assist them in performing it. Again, this seems plausible, but it also expresses a thought more complex than Tooley’s original formulation allowed for.
However the ambiguity gets sorted out, it seems like premise (8) will hold. We have already seen how suicide is not necessarily morally wrong for the person committing it, hence condition (i) can be avoided. Furthermore, there would seem to be circumstances in which either interpretation of (ii) fails to hold. Tooley acknowledges that some people may be members of organisations (religious or professional) which impose an obligation on them not to assist in the suicide of another (8.1). For those people, condition (iii) will be met. But Tooley responds by noting that this obligation will not, in general, be present and so, once again, there are circumstances in which (iii) will not be met (8.2).
6. Stage Four: From Assisted Suicide to Voluntary Active Euthanasia
The last stage of the argument is the easiest. It simply suggests that if assisted suicide is morally permissible, then so too is voluntary active euthanasia. The only difference between the two is that, in the former, the individual plays an active role in bringing about their own demise, whereas, in the latter, a third party does all the work. Tooley contends that this difference cannot be morally significant. So we get:
- (10) Wherever assisting a person in committing suicide is permissible, voluntary active euthanasia is also justified, provided the latter does not violate any obligation that one has to anyone else.
- (11) Therefore, voluntary active euthanasia can, in certain circumstances, be morally permissible.
The completed argument map is below.
Okay, that’s all for this post. In the next part, we’ll consider the distinction between passive and active voluntary euthanasia, and we’ll also look at the legalisation of euthanasia.
Against the will of God
Religious people don't argue that we can't kill ourselves, or get others to do it. They know that we can do it because God has given us free will. Their argument is that it would be wrong for us to do so.
They believe that every human being is the creation of God, and that this imposes certain limits on us. Our lives are not only our lives for us to do with as we see fit.
To kill oneself, or to get someone else to do it for us, is to deny God, and to deny God's rights over our lives and his right to choose the length of our lives and the way our lives end.
The value of suffering
Religious people sometimes argue against euthanasia because they see positive value in suffering.
The religious attitude to suffering
Most religions would say something like this:
The nature of suffering
Christianity teaches that suffering can have a place in God's plan, in that it allows the sufferer to share in Christ's agony and his redeeming sacrifice. They believe that Christ will be present to share in the suffering of the believer.
Pope John Paul II wrote that "It is suffering, more than anything else, which clears the way for the grace which transforms human souls."
However while the churches acknowledge that some Christians will want to accept some suffering for this reason, most Christians are not so heroic.
So there is nothing wrong in trying to relieve someone's suffering. In fact, Christians believe that it is a good to do so, as long as one does not intentionally cause death.
Dying is good for us
Some people think that dying is just one of the tests that God sets for human beings, and that the way we react to it shows the sort of person we are, and how deep our faith and trust in God is.
Others, while acknowledging that a loving God doesn't set his creations such a horrible test, say that the process of dying is the ultimate opportunity for human beings to develop their souls.
When people are dying they may be able, more than at any time in their life, to concentrate on the important things in life, and to set aside the present-day 'consumer culture', and their own ego and desire to control the world. Curtailing the process of dying would deny them this opportunity.
Several Eastern religions believe that we live many lives and the quality of each life is set by the way we lived our previous lives.
Those who believe this think that suffering is part of the moral force of the universe, and that by cutting it short a person interferes with their progress towards ultimate liberation.
A non-religious view
Some non-religious people also believe that suffering has value. They think it provides an opportunity to grow in wisdom, character, and compassion.
Suffering is something which draws upon all the resources of a human being and enables them to reach the highest and noblest points of what they really are.
Suffering allows a person to be a good example to others by showing how to behave when things are bad.
M Scott Peck, author of The Road Less Travelled, has written that in a few weeks at the end of life, with pain properly controlled a person might learn
The nature of suffering
It isn't easy to define suffering - most of us can decide when we are suffering but what is suffering for one person may not be suffering for another.
It's also impossible to measure suffering in any useful way, and it's particularly hard to come up with any objective idea of what constitutes unbearable suffering, since each individual will react to the same physical and mental conditions in a different way.
The slippery slope
Many people worry that if voluntary euthanasia were to become legal, it would not be long before involuntary euthanasia would start to happen.
This is called the slippery slope argument. In general form it says that if we allow something relatively harmless today, we may start a trend that results in something currently unthinkable becoming accepted.
Those who oppose this argument say that properly drafted legislation can draw a firm barrier across the slippery slope.
Various forms of the slippery slope argument
If we change the law and accept voluntary euthanasia, we will not be able to keep it under control.
- Proponents of euthanasia say: Euthanasia would never be legalised without proper regulation and control mechanisms in place
Doctors may soon start killing people without bothering with their permission.
- Proponents say: There is a huge difference between killing people who ask for death under appropriate circumstances, and killing people without their permission
- Very few people are so lacking in moral understanding that they would ignore this distinction
- Very few people are so lacking in intellect that they can't make the distinction above
- Any doctor who would ignore this distinction probably wouldn't worry about the law anyway
Health care costs will lead to doctors killing patients to save money or free up beds:
- Proponents say: The main reason some doctors support voluntary euthanasia is because they believe that they should respect their patients' right to be treated as autonomous human beings
- That is, when doctors are in favour of euthanasia it's because they want to respect the wishes of their patients
- So doctors are unlikely to kill people without their permission because that contradicts the whole motivation for allowing voluntary euthanasia
- But cost-conscious doctors are more likely to honour their patients' requests for death
- A 1998 study found that doctors who are cost-conscious and 'practice resource-conserving medicine' are significantly more likely to write a lethal prescription for terminally-ill patients [Arch. Intern. Med., 5/11/98, p. 974]
- This suggests that medical costs do influence doctors' opinions in this area of medical ethics
The Nazis engaged in massive programmes of involuntary euthanasia, so we shouldn't place our trust in the good moral sense of doctors.
- Proponents say: The Nazis are not a useful moral example, because their actions are almost universally regarded as both criminal and morally wrong
- The Nazis embarked on invountary euthanasia as a deliberate political act - they didn't slip into it from voluntary euthanasia (although at first they did pretend it was for the benefit of the patient)
- What the Nazis did wasn't euthanasia by even the widest definition, it was the use of murder to get rid of people they disapproved of
- The universal horror at Nazi euthanasia demonstrates that almost everyone can make the distinction between voluntary and involuntary euthanasia
- The example of the Nazis has made people more sensitive to the dangers of involuntary euthanasia
Allowing voluntary euthanasia makes it easier to commit murder, since the perpetrators can disguise it as active voluntary euthanasia.
- Proponents say: The law is able to deal with the possibility of self-defence or suicide being used as disguises for murder. It will thus be able to deal with this case equally well
- To dress murder up as euthanasia will involve medical co-operation. The need for a conspiracy will make it an unattractive option
Patient's best interests
A serious problem for supporters of euthanasia are the number of cases in which a patient may ask for euthanasia, or feel obliged to ask for it, when it isn't in their best interest. Some examples are listed below:
- the diagnosis is wrong and the patient is not terminally ill
- the prognosis (the doctor's prediction as to how the disease will progress) is wrong and the patient is not going to die soon
- the patient is getting bad medical care and their suffering could be relieved by other means
- the doctor is unaware of all the non-fatal options that could be offered to the patient
- the patient's request for euthanasia is actually a 'cry for help', implying that life is not worth living now but could be worth living if various symptoms or fears were managed
- the patient is depressed and so believes things are much worse than they are
- the patient is confused and unable to make sensible judgements
- the patient has an unrealistic fear of the pain and suffering that lies ahead
- the patient is feeling vulnerable
- the patient feels that they are a worthless burden on others
- the patient feels that their sickness is causing unbearable anguish to their family
- the patient is under pressure from other people to feel that they are a burden
- the patient is under pressure because of a shortage of resources to care for them
- the patient requests euthanasia because of a passing phase of their disease, but is likely to feel much better in a while
Supporters of euthanasia say these are good reasons to make sure the euthanasia process will not be rushed, and agree that a well-designed system for euthanasia will have to take all these points into account. They say that most of these problems can be identified by assessing the patient properly, and, if necessary, the system should discriminate against the opinions of people who are particularly vulnerable.
Chochinov and colleagues found that fleeting or occasional thoughts of a desire for death were common in a study of people who were terminally ill, but few patients expressed a genuine desire for death. (Chochinov HM, Tataryn D, Clinch JJ, Dudgeon D. Will to live in the terminally ill. Lancet 1999; 354: 816-819)
They also found that the will to live fluctuates substantially in dying patients, particularly in relation to depression, anxiety, shortness of breath, and their sense of wellbeing.
Other people have rights too
Euthanasia is usually viewed from the viewpoint of the person who wants to die, but it affects other people too, and their rights should be considered.
- family and friends
- medical and other carers
- other people in a similar situation who may feel pressured by the decision of this patient
- society in general
Proper palliative care
Palliative care is physical, emotional and spiritual care for a dying person when cure is not possible. It includes compassion and support for family and friends.
Competent palliative care may well be enough to prevent a person feeling any need to contemplate euthanasia.
The key to successful palliative care is to treat the patient as a person, not as a set of symptoms, or medical problems.
The World Health Organisation states that palliative care affirms life and regards dying as a normal process; it neither hastens nor postpones death; it provides relief from pain and suffering; it integrates the psychological and spiritual aspects of the patient.
Making things better for patient, family and friends
The patient's family and friends will need care too. Palliative care aims to enhance the quality of life for the family as well as the patient.
Effective palliative care gives the patient and their loved ones a chance to spend quality time together, with as much distress removed as possible. They can (if they want to) use this time to bring any unfinished business in their lives to a proper closure and to say their last goodbyes.
Palliative care should aim to make it easier and more attractive for family and friends to visit the dying person. A survey (USA 2001) showed that terminally ill patients actually spent the vast majority of their time on their own, with few visits from medical personnel or family members.
Spiritual care may be important even for non-religious people. Spiritual care should be interpreted in a very wide sense, since patients and families facing death often want to search for the meaning of their lives in their own way.
Palliative care and euthanasia
Good palliative care is the alternative to euthanasia. If it was available to every patient, it would certainly reduce the desire for death to be brought about sooner.
But providing palliative care can be very hard work, both physically and psychologically. Ending a patient's life by injection is quicker and easier and cheaper. This may tempt people away from palliative care.
Legalising euthanasia may reduce the availability of palliative care
Some fear that the introduction of euthanasia will reduce the availability of palliative care in the community, because health systems will want to choose the most cost effective ways of dealing with dying patients.
Medical decision-makers already face difficult moral dilemmas in choosing between competing demands for their limited funds. So making euthanasia easier could exacerbate the slippery slope, pushing people towards euthanasia who may not otherwise choose it.
When palliative care is not enough
Palliative care will not always be an adequate solution:
- Pain: Some doctors estimate that about 5% of patients don't have their pain properly relieved during the terminal phase of their illness, despite good palliative and hospice care
- Dependency: Some patients may prefer death to dependency, because they hate relying on other people for all their bodily functions, and the consequent loss of privacy and dignity
- Lack of home care: Other patients will not wish to have palliative care if that means that they have to die in a hospital and not at home
- Loss of alertness: Some people would prefer to die while they are fully alert and and able to say goodbye to their family; they fear that palliative care would involve a level of pain-killing drugs that would leave them semi-anaesthetised
- Not in the final stages: Other people are grateful for palliative care to a certain point in their disease, but after that would prefer to die rather than live in a state of helplessness and distress, regardless of what is available in terms of pain-killing and comfort.
Pressure on the vulnerable
This is another of those arguments that says that euthanasia should not be allowed because it will be abused.
The fear is that if euthanasia is allowed, vulnerable people will be put under pressure to end their lives. It would be difficult, and possibly impossible, to stop people using persuasion or coercion to get people to request euthanasia when they don't really want it.
The pressure of feeling a burden
People who are ill and dependent can often feel worthless and an undue burden on those who love and care for them. They may actually be a burden, but those who love them may be happy to bear that burden.
Nonetheless, if euthanasia is available, the sick person may pressure themselves into asking for euthanasia.
Pressure from family and others
Family or others involved with the sick person may regard them as a burden that they don't wish to carry, and may put pressure (which may be very subtle) on the sick person to ask for euthanasia.
Increasing numbers of examples of the abuse or neglect of elderly people by their families makes this an important issue to consider.
The last few months of a patient's life are often the most expensive in terms of medical and other care. Shortening this period through euthanasia could be seen as a way of relieving pressure on scarce medical resources, or family finances.
It's worth noting that cost of the lethal medication required for euthanasia is less than £50, which is much cheaper than continuing treatment for many medical conditions.
Some people argue that refusing patients drugs because they are too expensive is a form of euthanasia, and that while this produces public anger at present, legal euthanasia provides a less obvious solution to drug costs.
If there was 'ageism' in health services, and certain types of care were denied to those over a certain age, euthanasia could be seen as a logical extension of this practice.