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(3) Ethics in medicine

Medical Ethics

Ethics - World Health Organization - WHO




Is mercy killing wrong in principle?

 At this stage we need to get clear what ‘killing’ means. Those who believe that mercy killing, but not the common medical practice of passive euthanasia, is wrong in principle do so on the grounds that mercy killing involves actively causing death rather than failing to prevent it.

But this is not sufficient. Consider the following medical situation. Morphine is sometimes given to patients close to death from an untreatable illness, in order to ensure that the patient suffers as little pain as possible. In addition to preventing pain, morphine also reduces the depth and frequency of breathing (through its action on the part of the brain that controls respiration). In some situations, although not all, morphine can have the foreseeable effect of shortening the patient’s life, as well as reducing pain. A doctor who gave morphine to a terminally ill patient in order to reduce the suffering of the patient and foreseeing (although not intending) the earlier death of the patient, would not have broken the law. Indeed, giving morphine in these circumstances is often good clinical practice. And yet injecting morphine into a patient is just as active a thing to do as is injecting potassium chloride. The key difference is that, in the case of potassium chloride, the intention is for the patient to die – and this is the means to reducing the patient’s suffering. In the case of morphine the intention is to relieve the pain; an earlier death is foreseen but not intended. That is, at any rate, how the law in England and many other countries sees it.

On this analysis, killing, as in mercy killing, involves two aspects: that what is done is a positive act (rather than simply an omission to act); and that death is intended (and not simply foreseen). Both these aspects are necessary to the definition of killing but neither by it is sufficient.

In short, the argument to the effect that mercy killing is wrong in principle puts great moral importance on (1) the distinction between acts and omissions; and (2) the distinction between intending and foreseeing the death. Both the question of whether there is a moral, or even a conceptual, difference between acts and omissions on the one hand, or between intention and foresight on the other, have been much debated, and no single definitive position is generally agreed. I do not want to discuss the general question of these moral distinctions - only where they are relevant to the euthanasia debate. It is noteworthy that all these thought experiments involve killing, or failing to save, that is not for a person’s benefit. Some of the examples, furthermore, involve killing one person to save another. In the setting of euthanasia, of course, this is not the situation. I know of no convincing thought experiment that shows a moral distinction between acts and omissions, or intention and foresight, which includes the following three key features of euthanasia:

(1) That the person whose act we are evaluating has a clear duty of care to the person who dies;

(2) That there is no issue of harming one person to benefit another;

(3) Where death is in the best interests of the person who dies.

It is the harm of death that makes killing wrong Opponents of euthanasia may ultimately rest their case on one basic principle: killing is morally wrong. They may accept that there are difficult cases when killing one person may save another – or many others. They may accept that in such circumstances killing may be the right thing to do. But in the case of euthanasia, no other person’s life will be saved. The wrong of euthanasia is based on the wrong of killing, and is not balanced by saving any other life.

It is right that we have a strong intuition that killing is wrong. For most people dying now would be a great harm compared with continuing to live. The reason why killing is normally a great wrong is that dying is normally a great harm. The wrong of killing, however, is a result of the harm of dying, not vice versa. If, therefore, it is in the best interests of a patient to die now rather than suffer a prolonged and painful dying, then killing is no longer a wrong. In other words when death is a benefit, and not a harm, then killing is not a wrong. Those who argue that mercy killing is wrong in principle forget the conceptual link between the wrong of killing and harm of dying.

I reject the view that voluntary active euthanasia is wrong in principle on the grounds that this argument puts the cart before the horse: it is the harm of dying that makes killing a wrong and not the other way round. When suffering is the result of following a moral principle then we need to look very carefully at our moral principle and ask whether we are applying it too inflexibly. I believe this is what we are doing when we claim that voluntary active euthanasia is morally wrong. It is perverse to seek a sense of moral purity when this is gained at the expense of the suffering of others.

Hypothetical cases (thought experiments) to examine the moral importance of the distinction between acts and omissions; and between intending and foreseeing an outcome

  1. The cases of Smith and Jones

Smith sneaks into the bathroom of his 6-year-old cousin and drowns him, arranging things so that it will look like an accident. The reason Smith does this is that the death of his cousin will result in his coming into a large inheritance. Jones stands to gain a similar large inheritance from the death of his 6-year-old cousin. Like Smith, Jones sneaks into the bathroom with the intention of drowning his cousin. The cousin, however, accidentally slips and knocks his head and drowns in the bath. Jones could easily have saved his cousin, but far from trying to save him, he stands ready to push the child’s head back under. However, this does not prove necessary.

Is there a moral difference between Smith’s and Jones’s behaviour?

This pair of cases is used to support the view that there is no moral distinction between an act (killing) and an omission (failing to save) when the outcome and intention are the same.

  1. The cases of Robinson and Davies

Robinson does not give £100 to a charity that is helping to combat starvation in a poor country. As a result, one person dies of starvation who would have lived had Robinson sent the money. Davies does send £100 but also sends a poisoned food parcel for use by a charity that distributes food donations. The overall and intended result is that one person is killed from the poisoned food parcel and another person’s life is saved by the £100 donation.

Is there a moral difference between what Robinson and Davies do? If there is, is this because Davies acts to kill, whereas Robinson only omits to act? This pair of cases is used to counter the conclusion from the cases of Smith and Jones and to show that, even when the overall outcome is the same, an act (sending the poison parcel) together with the intention to kill is morally very much worse than the omission (failing to send charitable aid).

 3. Sacrificing one to save five

The runaway train: A runaway train is approaching points on the railway line. If the points are not switched then the train will kill five people who are strapped to the line. If the points are switched the train will go along a different line and kill just one (different) person. There is no way of stopping the train; but you can switch the points so that one person, rather than five people, dies.

Should you switch the points?

Organ donation: One healthy person could be killed in order to use his organs to save the lives of five people with various types of organ failure.

Should you kill the healthy person and use his organs?

A common intuition is that it would be right to switch the points in the first case (so that fewer people die) but wrong to kill the healthy person in order to use his organs to save more lives. In both cases, however, by not acting five people die and by acting only one person dies.

What justifies the common intuitions?

This pair of examples is used in support of the view that the nature of the act can make enormous moral difference even when the outcome is the same.



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