The Ethics of Euthanasia / Assisted Suicide

 

 

 

Active euthanasia:  the deliberate killing of a terminally ill person for the purpose of ending the suffering of that person.

 

          There’s some debate about what counts as “terminally ill”, but we’ll let that slide for now.

 

Active euthanasia is illegal in the United States and in most other countries (exceptions: the Netherlands and Belgium)

 

 

Passive euthanasia:  “letting nature take its course” by withholding further treatment until the patient dies of the illness.

 

Patients have the legal right to refuse medical treatment in the United States and in most other countries.

 

 

Suicide:  S commits suicide iff S intentionally brings about his/her own death.

 

 

          Accidental deaths aren’t intentional, so they aren’t suicide.

 

Death by foreseeable smoking related diseases isn’t suicide either, unless you are actually trying to kill yourself by smoking.

 

         

What about:  A soldier who jumps on a live hand grenade in order to save his buddies in the foxhole?

 

 

He intends to save his buddies, he does not intend to die.  Dying is an unwanted side-effect.  It is not suicide.

 

 

But what about:  A soldier shoots who himself before being captured, in order to avoid being tortured and then killed?

 

 

He intends to bring about his own death in order to avoid torture before being killed.  His action would not be successful if it did not result in his death.  Therefore, it is suicide.

 

 

 

Most cases of euthanasia are also cases of assisted suicide, since they are performed at the request of the sufferer.  But there are differences:  assisted suicide is always done with the consent of the person to be killed, whereas the definition of euthanasia does not require this.  And, obviously, suicides need not involve terminal conditions.

 

 

Is suicide morally permissible?

 

          An important ethical question in its own right

 

          Also important because it bears on the permissibility of assisted-suicide and euthanasia

 

 

 

If suicide is wrong, then so is assisted suicide

 

          If doing X is wrong, then how could it be right to help someone do X?

 

 

 

On the other hand, if suicide is permissible…

 

          If doing X is permissible, then how could it be wrong to help someone do X?

 

                   Actually, it depends on X.  (What if X is taking an exam?)

 

 

 

 

 

 

Argument for the permissibility of suicide

 

 

The Right to Decide One’s Future

 

1)  Mentally competent adults have a right to make decisions about their future insofar as those decisions don’t violate the rights of others.

 

2)  The decision to die is a decision about one’s future and does not violate the rights of others.

 

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3)  Therefore, mentally competent adults have a right to commit suicide.

 

 

 

Is the argument sound?

 

 

·  Objection to premise 1:  If suicide deprives others of happiness, then it is objectionable on utilitarian grounds, even if we wouldn’t normally describe it as a violation of the “rights” of others.

 

·  Objection to premise 2:  Suicide could violate special obligations to others.  If I have a duty (and still have the ability) to provide for my family, and I commit suicide, then I have neglected my duty.  If we think it is wrong for someone to abandon his or her duties and move to Hawaii without telling anyone, then wouldn’t it also be wrong for that person to commit suicide? 

 

·  Another objection to premise 1:  Some of our decisions are wrong because they violate our own rights.  This is the Kantian position on suicide.

 

 

Kant on suicide

 

Is suicide a matter of personal freedom?  Is it a morally permissible goal?  Should we respect this goal in others?  NO, says Kant:

 

"A man reduced to despair by a series of misfortunes feels wearied of life, but is still so far in possession of his reason that he can ask himself whether it would not be contrary to his duty to himself to take his own life. Now he inquires whether the maxim of his action could become a universal law of nature. His maxim is: From self - love I adopt it as a principle to shorten my life when its longer duration is likely to bring more evil than satisfaction. It is asked then simply whether this principle founded on self - love can become a universal law of nature. Now we see at once that a system of nature of which it should be a law to destroy life by means of the very feeling whose special nature it is to impel to the improvement of life would contradict itself, and therefore could not exist as a system of nature; hence that maxim cannot possibly exist as a universal law of nature, and consequently would be wholly inconsistent with the supreme principle of all duty".

 

 

A key premise of Kant’s argument:

 

It is contradictory to suppose that we can improve life by destroying it.

 

 

Kant assumes that self-love entails self-preservation.  This assumption is question-begging.

 

If our future holds nothing but misery, then isn’t it an improvement in one’s life to end it without the misery?

 

 

The last argument proceeded from the first formulation of the Categorical Imperative.  But recall the second formulation of the Categorical Imperative:

 

 

The Formula of the End in Itself [CI2]: 

 

So act as to treat humanity, both in your own person, and in the person of every other, always at the same time as an end, never simply as a means.”

Specifically, one must always respect the freedom of people to pursue their own ends (goals).

 

Anti-Suicide Argument from CI2

1)      CI2

2)      In committing suicide, the suicidal person destroys his humanity/freedom as a means to reduce suffering.

3)      Therefore, the suicidal person treats his own humanity as a mere means to an end.

4)      Therefore, suicide is wrong.

 

If I am already dying and end my life in order to avoid pointless suffering, am I not respecting my own humanity? Kant would point out that death would eliminate one’s autonomy, such as it was.  For Kant, happiness has no intrinsic value, but freedom or autonomy does.

 

 

 

James Rachels,  “Active and Passive Euthanasia”

 

Rachels argues that there is no tenable ethical distinction between killing and letting die.  Therefore, there is no tenable ethical distinction between active euthanasia (which is illegal) and passive euthanasia (which is legal).

 

From the point of view of the

patient, the outcome is the same no matter

whether she is killed or allowed to die: ei-

ther way, she ends up dead. When in par-

ticular cases there is a practical difference

between the two, the difference most often

is that killing involves less suffering. In

this respect Andrea's case is typical.

 

The inconsistency [of the anti-euthanasia position]

emerges when we consider why the physicians were willing to

allow death, when they could have fought

it off for a while longer. Presumably it was

because they felt that prolonging Andrea's

life was pointless-that she would be bet-

ter off not going through the longer proc-

ess of dying that would take place if they

stretched things out to the bitter end. But,

having made that judgment, why should

the no-code designation be preferred over

the injection?

 

…physicians normally

do not let their patients die when

they are sick. In this case the physicians

allow Andrea to die because the usual rea-

sons for keeping people alive do not apply.

But neither do the usual reasons against killing apply.

 

The consent of her parents, who

obviously love her and want what is best

for her, is enough. If this is doubted, it

might help to ask why we are willing to

issue a no-code order without first securing

her consent. If one is permissible, why not

the other?

 

 

Is killing intrinsically worse than letting die?  A thought experiment involving two cases suggests that it isn’t:

 

“In the first, Smith stands to gain a large inheritance if anything should happen to his six-year-old cousin.  One evening while the child is taking his bath, Smith sneaks into the bathroom and drowns the child, and then arranges things so that it will look like an accident. 

In the second, Jones also stands to gain if anything should happen to his six-year-old cousin.  Like Smith, Jones sneaks in planning to drown the child in his bath.  However, just as he enters the bathroom Jones sees the child slip and hit his head, and fall face down in the water.  Jones is delighted; he stands by, ready to push the child’s head back under if it is necessary, but it is not necessary.  With only a little thrashing about, the child drowns all by himself, “accidentally,” as Jones watches and does nothing. 

Now Smith killed the child, whereas Jones “merely” let the child die.  That is the only difference between them.  Did either man behave better, from a moral point of view?

 

NO, says Rachels.

 

Rachel’s implicit Principle of moral equivalency:  If actions A and B have the same motive, the same intended consequences, and the same actual consequences, then actions A and B are morally equivalent.

 

Motives:

          Jones – personal gain

          Smith – personal gain

 

Intended consequences:

          Jones – death of six-year-old cousin

          Smith – death of six-year-old cousin

 

Actual consequences:

Jones – death of six-year-old cousin

          Smith – death of six-year-old cousin

 

Rachels considers an objection:

“The important difference between active and passive euthanasia is that, in passive euthanasia, the doctor does not do anything to bring about the patient’s death.  The doctor does nothing, and the patient dies of whatever ills already afflict him.  In active euthanasia, however, the doctor does something to bring about the patient’s death: he kills him.  The doctor who gives the patient with cancer a lethal injection has himself caused his patient’s death; whereas if he merely ceases treatment, the cancer is the cause of the death.”

 

If the doctor really does nothing, then this suggests that passive euthanasia is not an action, and Rachel’s principle would not apply.  But Rachel’s argues otherwise:

 

“Letting someone die” is certainly different, in some respects, from other types of action–mainly in that it is a kind of action that one may perform by way of not performing certain other actions.  For example, one may let a patient die by way of not giving medication, just as one may insult someone by way of not shaking his hand.  But for any purpose of moral assessment, it is a type of action nonetheless. 

The decision to let a patient die is subject to moral appraisal in the same way that a decision to kill him would be subject to moral appraisal…If a doctor deliberately let a patient die who was suffering from a routinely curable illness, the doctor would certainly be to blame for what he had done, just as he would be to blame if he had needlessly killed the patient.”

According to Rachels, while there is no fundamental difference between the two, there are circumstances in which passive euthanasia is worse, because it leads to more suffering:

“…a patient who is dying of incurable cancer of the throat is in terrible pain, which can no longer be satisfactorily alleviated.  He is certain to die within a few days, even if present treatment is continued, but he does not want to go on living for those days since the pain is unbearable…

Suppose the doctor agrees to withhold treatment, as the conventional doctrine says he may.  The justification for his doing so is that the patient is in terrible agony, and since he is going to die anyway, it would be wrong to prolong his suffering needlessly.  But now notice this.  If one simply withholds the treatment, it may take the patient longer to die, and so he may suffer more than he would if more direct action were taken and a lethal injection given.  This fact provides strong reason for thinking that, once the initial decision not to prolong his agony has been made, active euthanasia is actually preferable to passive euthanasia, rather than the reverse.”

 

Rachel’s Argument for Active Euthanasia

1)      The justification for passive euthanasia is that it eliminates pointless suffering.

2)      But active euthanasia eliminates more suffering more than passive euthanasia (because it’s quicker).

3)      Therefore, if passive euthanasia is justified, then active euthanasia is more justified.

 

Life and Death Choices on Irrelevant Grounds?

 

Some babies with Down’s syndrome are also born with intestinal blockages that are unrelated to the syndrome.  The blockages can be surgically corrected.  In some cases, parents opt not to do this, leaving the baby to die of dehydration.  They can do this because it is “letting die” (withholding treatment) not killing.

 

“But notice that this situation is absurd, no matter what view one takes of the lives and potentials of such babies.  If the life of such an infant is worth preserving, what does it matter if it needs a simple operation? Or, if one thinks it better that such a baby should not live on, what difference does it make that it happens to have an unobstructed intestinal tract? In either case, the matter of life and death is being decided on irrelevant grounds.  It is the Down’s syndrome, and not the intestines, that is the issue.  The matter should be decided, if at all, on that basis, and not be allowed to depend on the essentially irrelevant question of whether the intestinal tract is blocked.

What makes this situation possible, of course, is the idea that when there is an intestinal blockage, one can “let the baby die,” but when there is no such defect there is nothing that can be done, for one must not “kill” it.  The fact that this idea leads to such results as deciding life or death on irrelevant grounds is another good reason why the doctrine should be rejected.”

 

 

Philippa Foot:

 

Sometimes it is morally permissible to

allow someone to die when it would not be

permissible to give him a lethal injection.

a man's right to noninterference

usually extends farther than his right to be

cared for. His rights may block our inter-

ference in his life; but if we may not inter-

vene to bring a certain result, it does not

follow that we may not allow it to come

about. We could not, for example, deprive

a man of his property, even for his own

good, in many cases in which we would

have no obligation to prevent it from blow-

ing away. This conclusion is confirmed by

the fact that permission may make all the

difference in such a case.

 

What should we think about

active euthanasia in relation to children

and mentally incompetent adults?

 

Should we say, for instance, that ma-

chinery might be set up by which guard-

ians (though hardly parents alone) could

be held to speak for the patient and to grant

on his behalf the permission that a "com-

petent" adult could give us himself? One

might believe that although no competent

adult could justifiably be the subject of

active euthanasia unless he himself had

consented to it, others could consent for

children and for mentally incompetent

adults, or at least for those adults who had

never been able to give valid consent. I

believe that there would be no decisive ob-

jection on grounds of moral principle if it

were not for the problem of the possibility

of abuse. But in practice there seems to be

grave danger that children and noncompe-

tent adults would be "spoken for" by peo-

ple who were really speaking for relatives,

for the medical staff, or for "society,"

rather than for those whose rights they

were supposed to guard.

 

The reality of the danger is, I think, viv-

idly illustrated by the presentation of An-

drea's case. First, very little is said about

the one absolutely crucial factor in the sit-

uation, namely her state of consciousness

and suffering. Second, the possibility is

mentioned of giving the injection "to spare

the patient and family from suffering" as if

the suffering of others was as relevant as

that of the patient. And third, much is

made of the pain caused to the parents by

the alteration to the point of grotesqueness

in their daughter's appearance.

 

Richard Doerflinger, “Assisted Suicide:  Pro-Choice or Anti-Life?”

 

Doerflinger argues against suicide along Kantian lines.  He extends this to a ban on assisted suicide:

 

[S]uicide is not the ultimate exercise of freedom but its ultimate self-contradiction:  A free act that by destroying life, destroys all the individual’s earthly freedom.  If life is more basic than freedom, society best serves freedom by discouraging rather than assisting self-destruction.  Sometimes one must limit particular choices to safeguard freedom itself, as when American society chose over a century ago to prevent people from selling themselves into slavery even of their own volition.”

 

         

·  Is there a strong analogy between suicide and selling oneself into slavery?

 

·  What about a case where the suicidal person has no prospects for significant freedom?  How much freedom can you have if you are immobilized and/or in intense pain?

 

·  Is freedom the only thing that matters?  Even granting that freedom is important, isn’t happiness and suffering also morally relevant?

 

 

Various Considerations that weigh against legalizing active euthanasia

 

·  The psychological vulnerability of elderly and dying patients

 

          They will feel pressured into choosing death just by being given the choice.

 

·  The crisis in health care costs

 

          The high costs of keeping patients alive supply motivation for choosing death over life.

 

·  Legal doctrines on “substituted judgment”

 

          Potential for conflict of interest between patient and decision-maker.

 

· Prejudice against citizens with disabilities

 

Prejudice can motivate the choice to end life.  Healthy people may be too quick to decide that a disabled life is not worth living, or may find disabilities unpleasant to be around.

 

·  Expanded definitions of terminal illness

 

          Traditional definition:  An incurable and worsening condition that will result in death.

 

Some groups (e.g. The Hemlock Society) want to liberalize this, so as to include incurable conditions that are very serious, but not worsening.