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Baroness Mary Warnock
Baroness Mary Warnock is one of Britain’s leading moral philosophers and has also chaired several official commissions of enquiry, including the Committee on Human Fertility and Embryology in the 1980s. She’s currently writing a book in response to Lord Joffe’s Bill, ‘Assisted Dying for the Terminally Ill’. Rick Lewis interviewed her at the House of Lords.
I hear you’re currently writing a book on euthanasia, to coincide with an upcoming House of Lords select committee report on the subject. What are your own personal findings on euthanasia so far, and how do they compare with the committee findings?
Well, the committee was divided. Its report was very good and very thorough. What I liked about it was that they had such a lot of evidence from all over the place. They went to the Netherlands and to Oregon, where euthanasia is permitted in a very limited way, or actually assisted suicide in the case of Oregon. My own conclusions are that it is high time that people spoke honestly about assisted dying. What horrifies me most is that people, mostly old people, who are not competent anymore, are just allowed to wither away. Nobody has any policy about this at all; it just happens. Care for the old and the dying is absolutely terrible in this country. The best of it is almost confined to people with cancer. So my greatest priority is the improvement of palliative care. But this seems to be not incompatible with changing the law to allow a few people who are competent and who know their own minds, who don’t want to go on living, to be helped to die. Because it can be very difficult to commit suicide, even if one is not paralysed. So I would like the law changed.
I understand that a while back you created a bit of a stir in the newspapers when you said that you yourself, if you felt you were in danger of becoming a burden to your family, and were fearfully ill and so on, would under those circumstances prefer to go for assisted suicide.
Oh yes, absolutely, I’ve no doubt about that. I mean, the only thing that I fear about dying is that it might be a very slow process, and I’d much rather have some way of committing suicide, but I can’t quite think what. I have a lot of friends who are retired doctors, and one used to be able to rely on them to provide one with pills, but now they’re not allowed to sign prescriptions after they’ve retired, so that sort of help doesn’t exist anymore. So it really is quite a puzzle to know how one would do it, because I would be very incompetent at taking a lot of pills and so on. Therefore I think a bit of help would come in useful. I simply couldn’t bear to get into the position where my children began to feel, “Oh God, I think we better go and see her.” I couldn’t bear it. And I see no point in living if one were ga-ga. I just wouldn’t want to. One way or another I’d much rather die.
But don’t you worry that if assisted suicide is made legal there might be elderly people who requested it because they feared they were a burden on their families, even though that wasn’t the case or their families didn’t mind?
This is one of those ‘slippery slope’ arguments. One can’t rule it out that they might feel they ought to. But then, I don’t know if that’s such a terribly bad outcome, because their family if they’re very nice will say “you’re not a burden” even if they are really. I don’t see why people should particularly want to stay alive if they’re not ‘enjoying themselves’. But if they are enjoying themselves, put up with it. I think that’s the criterion I’d use.
Sometimes, even in families where everyone is loved, communication isn’t perfect – there are situations where no-one really knows what the other person thinks...
No, no. If everyone does the decent thing then your family saying you’re not a burden doesn’t matter: you know you are. You even know you’re a great expense, either to the family or to the National Health Service. I don’t think people any longer ought to suppose they should go on living the whole of their possible natural lives, because we all live so much longer these days. One’s always reading statistics about the proportion of people who will be over eighty in x years time, and the number of people who will have to support them, and I think that’s a dire situation.
I read some comments you wrote about a previous House of Lords committee back in 1993. You said you were worried about some of the arguments which led that committee to not change the law on euthanasia. In particular you were worried about the distinction made by some on the committee between ‘killing’ and ‘letting die’; you thought that wasn’t a very good distinction to make.
I think the medical profession as a whole have had too much input into the whole discussion, because it isn’t really a medical problem, but a social problem. But the medical profession in particular is hooked on an extraordinarily primitive notion of causation. We all are, in a way, because so many of our concepts of cause come from physical contact. I push you off the sofa; I push you down the stairs; I kick the ball. All of those things involve physical contact, and I think that idea of causality runs very deep. After all, David Hume had a terrible problem trying to persuade people that ‘cause’ is really a function of the imagination, so that we sort-of fill in all the gaps. The most lovely, plain and obvious ‘non-gappy’ causations are things like pushing and pulling and kicking. So words like ‘kill’ have a causal element in them and it’s very direct, and doctors frequently say things like “I wouldn’t like to administer a lethal injection,” because that’s terribly close to the bone, so to speak – you actually know you’re killing a patient. So they would prefer to withdraw nutrition and hydration, and allow the patient to die, slowly, often taking up to a week, because then the doctor can withdraw from the actual ‘pushing and pulling’ aspect of causation – although if they give the order that nutrition is to be withdrawn, they are just as much causally responsible for the patient’s death as if they stabbed them. I think that that concept of cause is frightfully difficult to eradicate, but it lies at the heart of the distinction between killing and letting die. So I’m not very favourable to that distinction, but I think it will take a long time to eliminate, if ever, because the word ‘kill’ still has a derogatory connotation. In many languages like, say, Portuguese, there’s only one word for ‘kill’ and ‘murder’. So it has the bad element in it right from the start.
Do you think that ‘killing’ might be against the Hippocratic Oath whereas ‘letting die’ might not be?
Well, apparently ‘letting die’ isn’t, because it’s a well-known thing that doctors do. The other theme that I very much got irritated about with the former committee, and again in the reading I’ve been doing, is the argument from double effect. Doctors use it frequently, with various degrees of dishonesty, I think. Put basically, it is the idea that if you do something which is good and you intend to do it, and it has bad consequences, then even though you can foresee the bad consequences, you can say that you’re responsible for the good consequences but not for the bad. That seems to me completely dishonest. It’s become an absolute cliché in the medical profession. In fact, Lord Walton of Detchant, who chaired the previous committee, in his evidence to this committee invented the term ‘to do a double effect’. He tried to make it into a verb. He would say, if you’ve given the patient a massive dose of pain relief that’s bound to shorten his life, you can say, “I’m doing a double effect. I’m not responsible for the unwanted consequence that he died.” That seems to me terrible, in all kinds of ways.
I would very much like to demedicalise the whole question, and have some more lay people and philosophers looking at it, because the doctors have too much influence, at least in this House. There are a lot of them here – a lot of retired eminent medical people – and they do get listened to very much. The other people who get listened to unduly of course are the bishops. I think euthanasia can’t really be a religious debate. I know a lot of people have religious objections to it, and of course they’re entitled to them; but I don’t see any reason why the religious view should be imposed on the people who aren’t religious. So I don’t think Joel Joffe’s Bill will get through because of the combined effect of the bishops and the doctors, whatever other people may think.
I’d like to ask you about that, and in particular, about the question of rights. I read some very interesting points in your book Making Babies, and I think I read in something you wrote in relation to this Bill, that you weren’t in favour of a right to assisted suicide, but you were in favour of assisted suicide being allowed on the grounds of compassion.
Let me put it this way. In the committee that has just reported, that report said that the conflict was between the duty of doctors and society to look after people on the one hand, and autonomy on the other hand. I think that’s over-simplified. It partly depends on our interpretation of ‘autonomy’. But I don’t think that everybody necessarily has a right to decide for themselves what to do, even their own treatment if they’re ill. I mean, I know one has a right to refuse treatment, and that is true of everybody, and is recognised in law, and even doctors recognise it, because of a famous judgement by Lord Donaldson. He held that it doesn’t matter if your decision to refuse medical treatment is foolish or not in your best interests: it’s your decision, and you have a right to make it. So doctors have to recognise that. I believe that people who are competent and suffering and who say they do want to die should be able to do so, but I don’t think I base that belief on their autonomy, or not in any very general sense. I think that the decision should be theirs because they are the people who are suffering. I think therefore that one should take a sort of Good Samaritan view from the outside: you’re not the person in the ditch, but you feel for him when you get him out of the ditch. So I don’t think I want to make a general rights issue out of this. I’m not particularly keen on a morality of rights anyway: given the many conflicting rights, one doesn’t quite know what one can claim as a right.
This is a bit of a loop round really, but at the moment I’m reviewing a terrible American book about whether or not people should be allowed to sell body parts for transplants; and it’s an on-going, very interesting debate, I think. Anyway, its author is arguing very much in favour of a controlled market for body parts, and it’s interesting because it’s quite difficult to sort out why one is inclined to think that’s not how it ought to be. The ethics of it tends to be a sort of gut reaction really, but I think my real reason for being against it is that there is a real danger of exploitation. After all, it would be the poor, in poor countries, who would be inclined to sell a kidney or tissue. But anyway, the author of the book uses the word ‘autonomy’ absolutely [wrongly]... He says “I’m not using the word ‘autonomy’ in a Kantian sense; I’m using it more-or-less in the sense that anyone can be allowed to do whatever they’d like” which seems to me to be absolutely rubbish. Anyway, he thinks it’s a matter of autonomy that someone can sell their body parts if they choose. And he goes further and says that it’s actually a duty that everybody else has to permit this. Again, this seems to me to be rubbish. ‘If somebody has a right, someone else has a duty’ – he’s quite correct about that; but he’s taking it for granted that everybody has a right to sell his own kidneys if he wants. But I just don’t think there is such a right.
Then what are, or should be, the limits on people’s autonomy? Why shouldn’t people be allowed to do whatever they like with their body parts?
I think the law is the limit; and as the law is at present – well, I know the whole point of Joffe’s Bill is to change the law – but as the law is at present, it’s no good saying that somebody who is terminally ill has a right to decide to die, because they don’t, as things stand. But if Joffe’s bill got through then they would, just as they have a right, as the law currently stands, to refuse treatment.
I’m very much a Benthamite positivist about rights: you either have to have a law which specifically confers the right, or you have to claim there’s an absolutely agreed moral principle that confers it. I mean, I wouldn’t hesitate to say that people have a right not to be tortured, but that seems to not be universally agreed, alas. But it’s a moral principle which... well, I have to except the Americans, don’t I? – but I was going to say, we in the West tend to accept it. If we don’t accept it we certainly ought to.
I was struck by that contrast in the first chapter on rights in your book Making Babies where you say you’re a legal positivist like Jeremy Bentham. But then you also talk about certain basic human needs which generate rights of their own accord, and I wonder whether in this case you regarded a desire to avoid intense suffering as generating a right to suicide?
I think from the point of view of the person who’s suffering, I can imagine this person saying “I need to be relieved of the suffering, I can’t go on with this any more, it’s pointless and I need some way out,” and so it [the desire] would ease its way into a need. But then the palliative care people would say that what he needs is a relief from suffering – he doesn’t need to die, if they could find a way of satisfying this need. But most people who are involved in that aspect of medicine recognise that there is some suffering that no drugs can relieve. There is such a thing as terminal sedation, where you make a person permanently unconscious so therefore they don’t suffer. But it does seem to me to make an empty distinction to say that if the person is terminally sedated – that is to say, he’s never going to recover consciousness – it’s okay to render him unconscious for the rest of his life, but that it’s not okay to kill him.
Terminal sedation does seem effectively to be about the same as death.
Well, it wouldn’t make any difference to me if I were in that position, I wouldn’t care if he offered me terminal sedation or death. It comes to the same thing. Yes, it seems a pretty absurd distinction for them to rest on, simply so that they don’t have to say “the doctor killed him”, which is going back to where we started.
Lord Joffe’s Bill would apply to a small number of cases where people in full possession of their faculties, terminally ill, in unbearable pain and with death looming up, would be allowed assisted suicide. Do I gather that if you were writing legislation yourself now, you would allow euthanasia in a wider range of cases?
There are two kinds of cases that I’ve written about in this forthcoming book, where I haven’t drawn any conclusion, because I simply don’t know enough, but where I think people need to clarify the concepts. One is the case of very small babies. I mean babies can be born so light now that they would have certainly died in times gone by. But if you have a baby that weighs barely a pound, the question is whether it is really sensible to try to resuscitate that baby and keep it going, because a huge proportion of those babies are brain-damaged, or in some other way very badly damaged, and most of them don’t live more than a couple of years. This seems to be a separate problem, but one which needs to be resolved, otherwise medical technology will really determine whether the baby lives or dies, and then the consequence is just to send the baby out of hospital eventually, and the parents have to get on with it. I was told a ghastly story, years ago now, on this issue, by an American paediatrician called Silverman, who had worked in a hospital in Harlem, New York. There was a woman who had several children already and she gave birth to a very, very premature baby. She didn’t want the baby, as she knew that she wouldn’t be able to look after it; she had four children and lived in a tenement. The nurses and doctors became over-excited about keeping this baby alive. It was the lightest baby they had ever had, I’ve forgotten how many grammes it weighed, but anyway they kept it alive and they all became terribly keen, and they handed it back to the woman. The home visitor went round after a fortnight and the baby was dead; it had been eaten by rats. The woman knew she wouldn’t be able to cope and it was just so terrible. And that’s just the sort of thing one needs to remember in medicine. I talked about this for ages to a very nice Scottish doctor whom I know well and who specialises in very premature neonates, and he said he went to any lengths to get agreement with the parents, that was his main consideration, so that there isn’t a conflict like this [mother’s] conflict. But anyway, that’s one area where I think different considerations from the normal ones have to come in.
Secondly, and I think even trickier, is possible assisted suicide for the mentally ill. I don’t know if you’ve ever come across a periodical called Philosophy, Psychiatry & Psychology. It’s very good, and it has issues devoted to particular topics, and in about 1998 there was one devoted to this very question: whether you had a duty to prevent your patient committing suicide if he was suicidal, or whether you even had a duty to help him commit suicide, if he was between episodes of manic depression. If the only way you can stop someone committing suicide when they are depressed is to take them into hospital, and their condition in general gets worse in hospital but you can prevent them committing suicide, then it seems a very tricky moral question whether you ought to do that or not. But again, I think there’s so much confusion over what counts as mental illness and what counts as disease, and terminally ill, and all those things that before such concepts are clarified in this field there can be no moral solution.
I wonder if I can briefly return to the distinction between killing and letting die. You explained why you don’t believe in that distinction. Do you only not believe in it when everybody involved is present in the same place? What about letting people die if they’re a long way away and you don’t know them – people starving in Africa for example – is that the same as killing them?
‘Letting die’ is a curious expression, isn’t it, because it suggests that somehow you’re in control if you ‘let’ something happen. It’s almost as if you permitted it to happen; and the people who are dying of starvation at the moment in Africa – yes, you let them die in the sense that you don’t rush out with food and water to save any one of them. But it’s not got anything to do with you in particular whether they die or live. So it’s not in your ‘gift’ that they should live, and I think ‘letting die’ in the sense in which that distinction is drawn does suggest that it is [should be] in your gift to save the person.
So if I don’t make a huge effort to save someone, that doesn’t mean I’ve killed them.
No, quite so. But then, I don’t think that you have any particular duty to save those people – that’s another way of looking at it. I think it was Mary Midgley in her book Beast and Man who said it was impossible to suppose you have a duty to everybody. Duties must be contained. ‘Ought’ implies ‘can’, in fact, and you can’t be thought to have an absolutely universal duty to everybody in the world. This is one of the things incidentally that I object to in talk about rights. For example if we say of some country that it has a terrible human rights record, then on whom does the duty lie to save those people from repression, or from being arbitrarily thrown out of their houses or whatnot? It isn’t within our gift to stop people being killed in Zimbabwe or being driven out of their homes. So although their human rights are violated – I mean, I’ve got used to having to say that – I don’t know whose duty it is to uphold those rights, except to enunciate a moral principle about the bad government. It’s they who are violating their duties, not us.
If you feel a duty to help people, is there actually then a duty upon you to help them?
No, I don’t think it’s a duty. I think that’s a rather old-fashioned use of the word ‘duty’. That’s the way it was used in Victorian times, when people were brought up to know that they had duties. But it’s more like an intense wish to do it – a vocation if you like – than actually having a duty. I mean, I think – a rather old-fashioned context again – if I had a starving beggar at my door, I would feel I had a duty to do something for him, and if he was also sick I’d have a duty to get hold of medical care, because it’s my door. This is where you started. It’s within a contained environment [of duties]. But I’m not quite sure that I feel I speak truly about this starving beggar... I remember in Oxford, a drunk beggar, one of the winos who lived in Radcliffe Square, fell over into our garden – we had a low wall – and the only duty I felt was to call the police, and I’m afraid I did. So maybe I’m exaggerating.
What underlying principles guide your approach to public ethical problems?
One distinction I think is very important in moral philosophy, is the distinction between private and public morality. There’s a very good essay by Stuart Hampshire in a volume called Public and Private Morality. I’ve come more and more to see the difference between policy decisions and private moral decisions – even if the policy decisions have to reflect morality in some way, as obviously with the policy decision about euthanasia, or stem-cell research. Those are policy decisions, and they’re based on morality, but you have to think in terms of the consequences. So you have to take a much more consequentialist approach if you’re a legislator.
Do you think utilitarianism is a promising philosophy in public morality?
Well, as I’ve said, in the sphere of public policy consequentialist morality has to be the guide, but I wouldn’t want to go along with the Benthamite definition of the greatest happiness for the greatest number. I prefer the admittedly very vague concept of what is for the common good, or for the good of society. I think all the people who use slippery slope arguments against, for example, stem cell research, are saying it will be a disaster for society if we go in for reproductive cloning. I think there are two things we can say about that. First, I can’t quite see why it will necessarily be disastrous for society. But secondly, we can stop the slope, as we have in fact, by saying that therapeutic cloning is all right but banning reproductive cloning, and that’s the way the law is at the moment. The whole point of the law is to block the slope.
What slippery slopes should we look out for in the debate about euthanasia? Can we stop ourselves from slipping down them?
Very often legislation is the way to block a slope. The trouble with a slippery slope argument is that it’s bound to be hypothetical. People are always saying, well, if you pass this law, where will it end? – and you know, you can never produce evidence to show where it will end. But people do say these things. For example in the euthanasia case, they say that once you start on this road, you’ll inevitably find standards will slip. They point to the 1961 abortion law and argue that all the restrictions that were imposed have gradually been loosened, until we now have abortion on demand. Well, I don’t know: I don’t think it’s as easy as all that to get an abortion, but it may be. But I think there’s a very practical argument why you have to have regulation not prohibition in the case of abortion, and that is all the back-street illegal abortions which used to happen when it was prohibited. That’s a case where the good of society, the common good, covers the consequential benefits of having the law the way it is. So yes, some form of ‘at least consequentialism’, I’dlike to call it, inevitably has to be in the mind of legislators.
There’s a very good Labour peer called Lord Parker, who’s a pig farmer by profession. Anyway, to my delight, when we were debating the euthanasia report he said exactly what I believe to be true, that you must separate religion from morality or legislation, and that he was opposed to the proposed change in the law because as a legislator it was his duty to think about the good of society, or the common good. I forget his precise words, but that was a distinction I thought was very sound. I think he’s a fairly religious man himself, but he didn’t base his opposition on anything but what he thought the consequences would be, some sort of slippery slope.
Many thanks for the interview!