The word euthanasia has its origin millennia ago in Ancient Greece, where it means literally "the good death". However, in today's society, there are deeper and more layers of meaning to euthanasia than before. There are three basic types of euthanasia: voluntary, non-voluntary and involuntary. Voluntary euthanasia concerns itself with the express wish of a mentally competent person to die through the assistance of others. Voluntary euthanasia can further be divided into two categories: passive voluntary which is the specifically requested withholding of unwanted medical treatment, and active voluntary which is the deliberate action of killing the patient at that patient's informed request. Should dying human beings be made to suffer horribly during their last days in this world before looking forward to a painful and undignified death when they wish it to be otherwise? The answer is no. As such, voluntary euthanasia should be legalized for terminally ill patients.
For many people, euthanasia is a preferable option to dependence and unbearable suffering. The results of a 1994 Morgan Poll in Australia showed that 78% of Australians agreed to voluntary euthanasia for patients with fatal diseases or were injured beyond recovery. A study was conducted on patients' assessment of states worse than death by Robert Pearlman, a physician specializing in geriatric care at the Seattle Veterans Health Center. In-depth interviews were held with 56 adults suffering from cancer, AIDS, or who had spent time in a coma from heart attacks. The results, published in the Journal of Clinical Ethics, showed that 96% felt it was worse to be kept alive under hopeless circumstances with impending death than it would be to die. 82% felt that total loss of independence would be worse than death, and 73% were so averse to a life of unremitting pain and suffering that they would rather be dead. For patients suffering from terminal illness, the pain they undergo as the disease progresses can sometimes only be relieved by rendering them unconscious. They would have to spend the last days, weeks or even months of their life heavily sedated and unaware of their surroundings. This places stress on their loved ones as well, who have to stand by and watch as their mind and body degenerate before their eyes. The measure of life lies not only in quantity but in its quality as well. The Law Reform Commission of Canada believes that considerations of quality of life are legitimate factors in decision-making and are valid criteria in justifying certain acts.
Sue Rodriguez was a 42-year-old mother who suffered from amyotrophic lateral sclerosis, otherwise known as Lou Gehrig's Disease. Soon she would lose the ability to speak, swallow, walk and move her body without assistance. As the disease progressed, she would be unable to breathe without a respirator, to eat without a gastrotomy and would eventually be confined to bed. She wished to obtain the assistance of a physician in ending her life by her own hand when she would be in a condition in which she was unable to enjoy life. In 1993, Rodriguez appealed to the Supreme Court of Canada, but was denied the right to doctor-assisted suicide. The Supreme Court found against her favor five by four, and one of the dissenting judges in the case held that "state prohibitions that would force a dreadful, painful death on a rational but incapacitated terminally ill patient is an affront to human dignity". Rodriguez died in February 1994 assisted by an anonymous doctor.
Although the case of Sue Rodriguez gained national attention in Canada, she was by no means the only terminally ill patient seeking release from the agony they are in. In Australia, artist Neil Savage and his wife who were both terminally ill decided to die together in a suicide pact rather than be institutionalized for their illnesses. The couple consumed a lethal cocktail of drugs and alcohol, resulting in the death of Fay Savage, 62, but not of her husband as the morphine caused him to vomit. Neil Savage pleaded guilty to the charge that he aided in his wife's suicide and was sentenced to 200 hours' community service by the presiding judge. They had witnessed the terrible and lingering death of their parents and they did not want to go through a similar experience themselves or put their loved ones through it. It is indeed a sad reflection on the world today that dying people have to go through exhausting legal proceedings and painful, often unsuccessful suicide attempts in order to relieve themselves of their suffering.
Secondly, the negative consequences of not legalizing euthanasia are very real and cannot be ignored. Some terminally ill patients who are denied euthanasia attempt to terminate their suffering by ending their lives themselves and have botched their suicides in the process, bringing further suffering on themselves and those around them. By denying them their right to euthanasia, the government satisfies its own moral standards but ignores the outcome of its action. Some patients cannot bear the excruciating agony that accompanies terminal illness and when they cannot obtain physician-assisted suicide, try to kill themselves even though they may not be in a condition to do so. They may also beg for the help of loved ones not trained in medicine in their suicide. As a result, the suicide may often be messy, painful and sometimes unsuccessful. It is unfair on the family and friends of the patients to have to go through such a nightmare when all they want is to free their loved ones of pain and torment.
In addition, doctors are afraid to openly discuss end-of-life decisions with patients due to illegalities. This prevents an open and honest relationship between doctor and patient in which the doctor can discover the patient's wishes regarding his/her own life and death. According to Associate Professor Helga Kuhse, director of Monash University's Centre for Human Bioethics, "Doctors are reticent with the patients because once you raise the issue... it looks as a case of the intentional termination of life". Often, doctors are left to make their own decisions which concern the survival of the patients. It is ironic that while euthanasia is deemed illegal, there are many cases of doctors who do not obtain patient consent when they withdraw or withhold treatment, or administer potentially life-shortening palliative care. It is much better to have the decision of voluntary euthanasia made after open discussion with some sort of "institutional safeguards" than leaving it to the judgment and conscience of individual doctors. Medical practitioners need to know where they stand on this issue, instead of making decisions themselves while being in fear of being prosecuted or torn between socially accepted norms and compassion.
Currently there are cases of misuse of euthanasia, for example in cases where the patient is pressured by family members to give consent to the ending of their lives. The legalization of voluntary euthanasia provides an opportunity for safeguards against just such a situation, and other instances of coercion and fraud. The legalizing of voluntary euthanasia would provide a set of guidelines and regulations for the parties involved to follow, such as psychological counseling and psychiatric evaluation (which will ensure that the patient's choice is one given freely without coercion), signed legal agreements and a cooling-off period, as outlined in the Rights of the Terminally Ill Act of Australia's Northern Territory, and the regulation that only doctors can perform euthanasia. An example of misuse of euthanasia is the case of Dr Jack Kevorkian, who has caused fear and repugnance by his unethical methods of offering euthanasia to all and sundry who request it. Some of his patients are not terminally ill and could have committed suicide without assistance if they wanted to, as in the case of Marjorie Wantz and Sherry Miller. Dr Kevorkian has also offered his patient's organs for transplant without following proper medical regulations and procedures, thus inciting further widespread fear of euthanasia.
Thirdly, every terminally ill patient has the basic fundamental right to voluntary euthanasia. The law must recognize the principle of personal autonomy and self-determination which is the right of every human being to make decisions regarding his own body and have these decisions respected. Patients suffering from a fatal disease who wish to end their life but are incapable of doing so themselves have the right to a physician-assisted suicide. However, doctors are in no way obligated to perform euthanasia if they do not want to. No medical staff who is opposed to euthanasia shall be required to administer it. Thus, legalizing euthanasia not only ensures that the right of the patient is respected, but the right of the physician as well. It has been found in a survey by the University of New South Wales that a majority of doctors (59% out of 2000) agreed with the principle of euthanasia but they fail to implement it because they fear the legal consequences. For those who oppose euthanasia for religious or personal reasons, euthanasia is not forced upon them and likewise, they should not impose their own moral standards on those who agree to euthanasia. Those who object to euthanasia on moral grounds can face death in accordance with their personal beliefs and will still have this freedom when voluntary euthanasia is decriminalized. Nobody forces them to change their moral outlook and they should not expect everyone else to live according to their own set of tenets.
Furthermore, in a society where people are letting technology take over their lives and allowing other parties to make decisions for them, they need to know that they at least have some manner of control over their own dying. Even if most people do not want euthanasia, it reassures them that they would have the freedom to make their own choice if and when such a situation arises. The existence of a public policy gives them peace of mind and assures them that they live in a society that is not only free and democratic, but also compassionate, in which personal autonomy is respected. As the disease progresses in terminally ill patients and they slowly lose their freedom of movement and hold over their own bodily functions, they need to know that they still have control over their life. If even that is taken away from them, then they are subjected to an undignified and bitter death. Just as everyone has the right to live with dignity, they also have the right to die with dignity.
A terminally ill man, Bob Dent, 66, became the first person to commit suicide under new voluntary euthanasia legislation in Australia's Northern Territory in 1996 before it was overturned a year later. Diagnosed with prostate cancer in 1991, Dent obtained the three signatures required from his own doctor, a cancer specialist and a psychiatrist, observed the nine-day cooling off period, and was then free to choose the time and place of his own dying. He committed suicide with help from his doctor by intravenous feeding of drugs into his cancer-ridden body. He was asleep within a few seconds, and a few minutes later he was dead. His doctor, Peter Nitschke, said that Dent saw his death as an end to suffering. Dent's case is an example of personal autonomy being respected by law and of a dying man who made a voluntary and informed decision to end his own existence. He was lucid and in full control of his faculties and his own life when he died. Despite strong public support for voluntary euthanasia (70% of Australians were in favor according to a Morgan Poll) the law was overturned by the Federal Parliament in 1997. By its action, the government did not seem to take into account its citizens' rights and wishes, and instead impose its own moral code upon them, expecting the people to follow its definition of right and wrong and what is "good" for them.
Everyone may be searching for a "good death", but terminally ill patients merely wish to have a painless, merciful death at the time of their own choosing. Surely that is not asking much. It is easy for society, the government, and people to deny them this one act of mercy by spouting "moral", "ethical" and religious tenets by the dozen. They have not traveled in their shoes, and they do not know what dying is. In the end, all that these patients want is to die, peacefully, with dignity, and no pain.
Copyright 1999 Amis Lee
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.