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EUTHANASIA, PHYSICIAN-ASSISTED SUICIDE, LIVING WILLS, MERCY KILLING
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Euthanasia: good medical practice, or murder?
Good deeds do not require long statements; but when evil is done the whole art of oratory is employed as a screen for it.
(Thucydides)
The practice of euthanasia contradicts one of the oldest and most venerated of moral injunctions: ‘Thou shalt not kill’. The practice of euthanasia, under some circumstances, is morally required by the two most widely regarded principles that guide medical practice: respect for patient autonomy and promoting patient’s best interests. In the
Outline of the requirements in order for active euthanasia to be legal in the
1. The patient must face a future of unbearable, interminable suffering.
2. The request to die must be voluntary and well-considered.
3. The doctor and patient must be convinced there is no other solution.
In
Playing the Nazi card
There is a common, but invalid, argument against euthanasia that I call ‘playing the Nazi card’. This is when the opponent of euthanasia says to the supporter of euthanasia: ‘Your views are just like those of the Nazis’. There is no need for the opponent of euthanasia to spell out the rhetorical conclusion: ‘and therefore your views are totally immoral’.
Let me put the argument in a classic form used in philosophy and known as a syllogism:
Premise 1: Many views held by Nazis are totally immoral.
Premise 2: Your view (support for euthanasia under some circumstances) is one view held by Nazis.
Conclusion: Your view is totally immoral.
This is not a valid argument. It would be valid only if all the views held by Nazis were immoral.
I will therefore replace premise 1 by premise 1* as follows:
Premise 1*: All views held by Nazis are totally immoral. In this case the argument is logically valid, but in order to assess whether the argument is true we need to assess the truth of premise 1*.
There are two possible interpretations of premise 1*. One interpretation is a version of the classic false argument known as argumentum ad hominem (or bad company fallacy): that a particular view is true or false, not because of the reasons in favour or against the view, but by virtue of the fact that a particular person (or group of people) holds that view. But bad people may hold some good views, and good people may hold some bad views. It is quite possible that a senior Nazi was vegetarian on moral grounds. This fact would be irrelevant to the question of whether there are, or are not, moral grounds in favour of vegetarianism. What is important are the reasons for and against the particular view, not the person who holds it. Hitler’s well-known vegetarianism, by the way, was on health, not on moral, grounds.
The other, more promising, interpretation of premise 1* is that those views that are categorized as ‘Nazi views’ are all immoral. Some particular Nazis may hold some views about some topics that are not immoral, but those would not be ‘Nazi views’. The Nazi views being referred to are a set of related views, all immoral, that is driven by racism and involve killing people against their will and against their interests. Thus, when it is said that euthanasia is a Nazi view, what is meant is that it is one of these core immoral views that characterize the immoral Nazi worldview. The problem with this argument, however, is that most supporters of euthanasia – as it is practised in the
What is needed is some conceptual clarity.
Clarifying concepts in the euthanasia debate
Let us begin with some definitions. The purpose of these is twofold: to make distinctions between different kinds of euthanasia; and to provide us with a precise vocabulary. Such precision is often important in evaluating arguments and reasons. If a word is used in one sense at one point in the argument, and in another sense at another point in the argument, then the argument may look valid when in fact it is not.
If you study these definitions it will be immediately clear that playing the Nazi card rides roughshod over some important distinctions. The first point is that the term euthanasia, at least as I am suggesting that it should be used, implies that the death is for the person’s benefit. What the Nazis did was to kill people without any consideration of benefit to the person killed. The second point is that euthanasia can be voluntary, involuntary, or non-voluntary.
The third point is that it can be active or passive. Let us start with the first point.
Euthanasia and suicide: some terms
Euthanasia comes from the Greek eu thanatos meaning good or easy death.
Euthanasia:
X intentionally kills Y, or permits Y’s death, for Y’s benefit.
Active euthanasia:
X performs an action which itself results in Y’s death.
Passive euthanasia:
X allows Y to die. X withholds or withdraws life-prolonging treatment.
Voluntary euthanasia:
Euthanasia when Y competently requests death himself, i.e. a competent adult wanting to die.
Non-voluntary euthanasia:
Euthanasia when Y is not competent to express a preference, e.g. Y is a severely disabled newborn.
Involuntary euthanasia:
Death is against Y’s competent wishes, although X permits or imposes death for Y’s benefit.
Suicide:
Y intentionally kills himself.
Assisted suicide:
X intentionally helps Y to kill himself.
Physician assisted suicide:
X (a physician) intentionally helps Y to kill himself.
Patients’ best interests
Can it be in someone’s best interests to die? I believe it can. The courts believe it can. Most doctors, nurses, and relatives believe it can. The question arises quite frequently in health care. A patient with an incurable and fatal disease may reach a stage where she will die within a day or two, but could be kept alive, with active treatment, for a few weeks more. This situation might occur because the patient gets a chest infection, or because there is a chemical imbalance in her blood, in addition to the underlying fatal disease. Antibiotics, or intravenous fluids, might treat this acute problem although they will do nothing to stop the progress of the underlying disease. All those caring for the patient will often agree that it is in the patient’s best interests to die now rather than receive the life-extending treatment. The decision not to treat is even more straightforward if the patient’s quality of life is now very poor, perhaps because of sustained and untreatable difficulty in breathing – a distressing feeling that is often more difficult to ameliorate than severe pain. If, however, we thought that it was in the patient’s best interests to continue to live, rather than to die within days, we ought to give the life-extending treatment. But we do not think this: we believe it is in her best interests to die now rather than receive the life-extending treatment, because her quality of life, due to the underlying fatal illness, is so poor.
Respecting a patient’s wishes
Most countries that put a value on individual liberty allow competent adults to refuse any medical treatment even if such treatment is in the patient’s best interests; even if it is life-saving. A Jehovah’s Witness, for example, may refuse a life-saving blood transfusion. If doctors were to impose treatment against the will of a competent patient then the doctor would be violating the bodily integrity of the person without consent. In legal terms this would amount to committing a ‘battery’.
Passive euthanasia is widely accepted.
The withholding, or withdrawing, of treatment is widely accepted as morally right in many circumstances. And it is protected in English law. There are two grounds on which it is accepted:
(1) That it is in the patient’s best interests; and
(2) That it is in accord with the patient’s wishes.
Either of these two conditions is sufficient reason to support passive euthanasia.
In common with widespread medical practice, I believe that there are circumstances when it is in a person’s best interests to die rather than to live. I also believe that a competent person has the right to refuse life-saving treatment. Withholding or withdrawing treatment from a patient is justified in either set of circumstances, even though this will lead to death.
If I am right (and the law in
murder?
What Dr Cox did
Lillian Boyes was a 70-year-old patient with very severe rheumatoid arthritis. The pain seemed to be beyond the reach of painkillers. She was expected to die within a matter of days or weeks. She asked her doctor, Dr Cox, to kill her. Dr Cox injected a lethal dose of potassium chloride for two reasons:
(1) Out of compassion for his patient, and
(2) Because this is what she wanted him to do.
Dr Cox was charged with, and found guilty of, attempted murder.
(The reason for not charging him with murder was that, given her condition, Lillian Boyes could have died from her disease and not from the injection.)
The judge, in directing the jury, said:
Even the prosecution case acknowledged that he [Dr Cox] . . . was prompted by deep distress at Lillian Boyes’ condition; by a belief that she was totally beyond recall and by an intense compassion for her fearful suffering. Nonetheless . . . if he injected her with potassium chloride for the primary purpose of killing her, or hastening her death, he is guilty of the offence charged [attempted murder] . . . neither the express wishes of the patient nor of her loving and devoted family can affect the position.
This case clearly established that active (voluntary) euthanasia is illegal (and potentially murder) under English common law. It is noteworthy that the patient was competent and wanted to be killed; close and caring relatives and her doctor (as well as the patient) believed it to be in her best interests to die, and the court did not dispute these facts.
The key difference, on which much legal and moral weight is placed, between the case of Dr Cox and the examples of withholding and withdrawing treatment that are a normal and perfectly legal part of medical practice, is that Dr Cox killed Lillian Boyes, and did not simply allow her to die.
Mercy killing
Moral philosophers use ‘thought experiments’. These are imaginary and sometimes quite unrealistic situations that tease out and examine the morally relevant features of a situation. They are used to test the consistency of our moral beliefs. The thought experiment that I want you to consider is a case, like the Cox case, of mercy killing.
Mercy killing: the case of the trapped lorry driver
A driver is trapped in a blazing lorry. There is no way in which he can be saved. He will soon burn to death. A friend of the driver is standing by the lorry. This friend has a gun and is a good shot. The driver asks this friend to shoot him dead. It will be less painful for him to be shot than to burn to death.
I want to set aside any legal considerations and ask the purely moral question: should the friend shoot the driver?
There are two compelling reasons for the friend to kill the driver:
1. It will lead to less suffering.
2. It is what the driver wants.
These are the two reasons we have been considering with regard to justifying passive euthanasia. What reasons might you give for believing that the friend should not shoot the driver? I will consider seven reasons.
1. The friend might not kill the driver but might wound him and cause more suffering than if he had not tried to kill him.
2. There may be a chance that the driver will not burn to death but might survive the fire.
3. It is not fair on the friend in the long run: the friend will always bear the guilt of having killed the driver.
4. That although this seems to be a case where it might be right for the friend to kill the driver it would still be wrong to do so; for unless we keep strictly to the rule that killing is wrong, we will slide down a slippery slope. Soon we will be killing people when we mistakenly believe it is in their best interests. And we may slip further and kill people in our interests.
5. The argument from Nature: whereas withholding or withdrawing treatment, in the setting of a dying patient, is allowing nature to take its course, killing is an interference in Nature, and therefore wrong.
6. The argument from Playing God, which is a religious version of the argument from Nature. Killing is ‘Playing God’ – taking on a role that should be reserved for God alone. Letting die, on the other hand, is not usurping God’s role, and may, when done with care and love, be enabling God’s will to be fulfilled.
7. Killing is in principle a (great) wrong. The difference between passive euthanasia and mercy killing is that the former involves ‘allowing dying’ and the latter involves killing; and killing is wrong – it is a fundamental wrong.
How good are these arguments? Let’s consider them one by one.
Argument 1
It is true that in real life we cannot be certain of the outcome. If you rely on argument 1 then you are not arguing that mercy killing is wrong in principle, but instead that in the real world we can never be sure that it will end in mercy. I am happy to accept that we can never be absolutely sure that the shooting will kill painlessly. There are three possible types of outcome:
(a) If the friend does not shoot (or if the bullet completely misses) then the driver will die having suffered a considerable amount of pain – let us call this amount X.
(b) The friend shoots and achieves the intended result: that the driver dies almost instantaneously and almost painlessly. In this case the driver will suffer an amount Y where Y is much smaller than X – indeed Y is almost zero if we are measuring suffering from the moment when the friend shoots.
(c) The friend shoots but only wounds the driver, causing him overall an amount of suffering Z, where Z is greater than X.
It is because of possibility (c), according to argument 1, that it would be better that the friend does not shoot the driver.
We can now compare the situation where the friend does not shoot the driver with the situation where the friend does shoot. In the former case the total amount of suffering is X. In the latter case the amount of suffering is either Y (close to zero) or Z (greater than X).
Thus, by shooting, the friend may bring about a better state of affairs (less suffering) or a worse state of affairs (more suffering). If what is important is avoiding suffering, then whether it is better to shoot or not depends on the differences between X, Y, and Z and the probabilities of each of these outcomes occurring. If almost instantaneous death is by far the most likely result from shooting, and if the suffering level Z is not a great deal more than X, then it would seem right to shoot the driver because the chances are very much in favour that shooting will lead to significantly less suffering.
We can rarely be completely certain of outcomes. If this uncertainty were a reason not to act we would be completely paralysed in making decisions in life. It would be very unlikely; furthermore, that mercy killing in the medical setting (e.g. what Dr Cox did) would lead to more suffering. I conclude that argument 1 does not provide a convincing argument against voluntary active euthanasia.
Argument 2
Argument 2 is the other side of the coin from argument 1, and suffers the same weakness. The question of whether the chance that the driver might survive outweighs the greater chance that he will suffer greatly, and die, depends on what the probabilities actually are. If it is very unlikely that the driver will survive, then argument 2 is not persuasive.
Supporters of argument 2 might counter this conclusion by arguing that the weight to be given to the remote possibility of rescue from the burning lorry should be infinite. In that case, however low the probability of its occurring, the chance should be taken. There are three responses to this argument: first, what grounds are there for giving infinite weight to the possibility of rescue? Second, if we consider that very remote possibilities of rescue justify not shooting then we could equally well conclude that we should shoot. This is because it is also a remote possibility that the bullet, although intended to kill the driver, might in fact enable him to be rescued (e.g. through blowing open the cab door). Third, if argument 2 provides a convincing reason for rejecting mercy killing, it also provides a convincing reason for rejecting the withholding of medical treatment in all circumstances. This is because giving treatment might provide sufficient extension of life for a ‘miracle’ to occur and for the person to be cured and live healthily for very much longer.
Argument 3
The third argument fails because it begs the very question that is under debate. The friend should only feel guilt if shooting the driver were the wrong thing to do. But the point at issue is what is the right and wrong thing to do. If it is right to shoot the driver, then the friend should not feel guilty if he shot him (thus reducing the driver’s suffering). The possibility of guilt is not a reason, one way or the other, for deciding how the friend should act. Rather we first have to answer the question of what is the right thing to do and only then can we ask whether the friend ought to feel guilty.
Argument 4
Argument 4 is a version of what is known as the ‘slippery slope argument’. This is such an important type of argument in medical ethics that I will consider it in more detail later. I will distinguish two types of slippery slope – the logical, or conceptual, slope; and the empirical, or in-practice, slope. The types of reason needed to counter a slippery slope argument depend, as we shall see, on which type of argument is being advanced.
Arguments 5 and 6
The arguments from Nature and from Playing God have, like the slippery slope argument, a more general application in medical ethics. I will consider them in more detail later.
Argument 7
Of all the arguments considered, it is only argument 7 that views killing as wrong in principle.
