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The Gentle and Easy Death
Piers Benn on the ethics of euthanasia.
For a long period earlier in the present century, the study of moral philosophy was widely thought to be irrelevant to the ethical concerns of everyday life. The task of the philosopher was not to defend ‘first-order’ (normative) ethical positions, but to investigate (for example) the nature of moral language and the logic of obligation. Philosophers were not supposed to have any special moral competence.
It is likely that many interested laymen think that moral philosophy is still like this. Those major philosophers who became known to the educated public, such as the late A.J.Ayer, always maintained that moralising and philosophising were to be found in separate compartments, although a philosopher could use his intelligence and analytical ability to reach ethical positions. But such a view is distinctly old fashioned. The study of applied ethics – the application of philosophical techniques to a variety of practical concerns – has been growing for the last twenty years. Journals have sprung into existence to cope with this huge expansion. For some reason, a large amount of the literature is concerned with killing. And the subject of euthanasia – the ‘gentle and easy death’ (to trace the semantic origins of the term) has a fairly prominent place here, which seems to reflect the great public interest – especially in the wake of the recent Nigel Cox affair and the Tony Bland case. Discussion of this must be mindful of the twin dangers facing it: the first being that of presenting banal and hackneyed arguments, the second being that of spurious technicality. For the public debates that ensue from cases such as that of Cox tend to revolve around very familiar themes: on the one hand, the sanctity of life and the ‘slippery slope’ dangers of euthanasia; on the other, the ‘right to die’ when suffering has become unbearable and untreatable. But before examining some of these themes, it is important to keep some distinctions in mind.
Two sets of distinctions have been drawn. There is that between ‘active’ and ‘passive’ euthanasia, and that between ‘voluntary’, ‘involuntary’ and ‘non-voluntary’ euthanasia. Together they yield six types of euthanasia. A popular view is that the most defensible cases are those where the euthanasia is voluntary and passive, that is, when one is ‘allowed to die’ rather than killed, and where this happens according to the express wishes of the patient. The uproar tends to arise when the act is ‘active’, in other words a positive act of killing, or when it goes ahead without the explicit consent of the patient. Involuntary euthanasia occurs in just such cases; it may not be against the wishes of the patient, but it is not known to accord with them. Non-voluntary euthanasia covers cases where consent is in principle impossible, as when an animal is ‘put to sleep’ (to use a popular euphemism). It is a most important question whether any of these distinctions have any moral relevance, in particular, the active/passive distinction. A number of philosophers deny that any moral weight hangs on the latter distinction. I shall examine this question later. But to begin with, it is worth linking this whole issue with a closely related one, namely, that of suicide.
The ethics of suicide
Suicide has traditionally been harshly condemned by popular morality, the Church and the law. It has been legal to take your own life in Britain for only thirty-one years. To many people, this must seem baffling. How can it be wrong to take your own life? And even if it is, why should the law be concerned, if the harm is self-inflicted? Underlying the ‘liberal’ bafflement, I suspect, is an unstated view about what makes it wrong to kill, when it is wrong. To kill another person without his consent is to violate his right to life, just as stealing from him violates his right to property. But you can no more violate your own right to life, than you can steal from yourself (perhaps leaving aside those with multiple-personality disorders!). So if wrongful killing is essentially a violation of rights, then suicide cannot be wrongful in itself. It can be wrong on account of its impact upon others, or on account of its motive (for instance, in cases of ‘revenge suicide’), but moral considerations extend no further.
If such a view is plausible, then it would seem to bring us some way towards the legitimation of some types of euthanasia as well. The main complication would be the involvement of others in bringing about death. Is it fair to expect others to take on this moral burden? And if it were legalised, would this not increase the psychological pressure to co-operate with those who want to die – with possibly damaging results? These are important questions. But it is worth looking more closely at the case of suicide, to begin with. Is it obvious that you have a right to end your own life? Does the question of wrongful killing turn on rights? Or might not human life have an independent, intrinsic value – such that whenever it is taken (barring certain specified circumstances) something of intrinsic value has been ended, and thus a major wrong has been done? Maybe only a religious framework allows us to make sense of this idea, and that without such a framework, the only kind of value we can imagine attaching to life, is value for the person whose life it is. And this would permit us to say that the individual concerned is the best possible authority as to whether his life has value. I confess that I do not know the answers to these problems. But one should baulk at the claim that some answer is simply obvious. Moreover, even if suicide is not wrong in itself, it is always important to ask what it reveals about the character of one who commits suicide. A shallow or cowardly disposition can be exhibited in an act of suicide, just as a noble one can.
Such thoughts are meant only to sow some doubts, not to yield dogmatic conclusions. They suggest that there may be some acts of suicide which are morally questionable, for the reasons given. I would, however, incline to side with the liberal on the question of whether all acts of suicide are wrong in themselves. It is hard to find a cogent argument leading to this strong conclusion. The claim, for instance, that suicide frustrates God’s plan as to when one should die, was masterfully dealt with by David Hume: “What is the meaning then of that principle, that a man who, tired of life, and hunted by pain and misery, bravely overcomes all the natural terrors of death and makes his escape from this cruel scene; that such a man, I say, has incurred the indignation of his Creator by encroaching on the office of divine providence, and disturbing the order of the universe? Shall we assert that the Almighty has reserved to himself in any peculiar manner the disposal of the lives of men, and has not submitted that event, in common with others, to the general laws by which the universe is governed?” (David Hume, ‘Of Suicide’). Likewise, even if human life has intrinsic value, this cannot show that suicide is always immoral. When you have already made much of your talents, and lived well, you can hardly be said to be rejecting your life as a whole, if you decide, near its natural end, that continued existence is incurably painful and degrading, and hence decide to end it.
This clearly leads us to the typical cases where euthanasia is proposed. At a meeting last summer of the Voluntary Euthanasia Society of Scotland, it was impossible not to notice that the vast majority of the delegates were elderly, no doubt afraid of slow and degrading decline. They had surely not rejected life; what they feared was prolonged dying, with pain, total dependence upon others and loss of mental capacities. Is it rational to say that under no circumstances should lives like that be terminated?
Active and passive euthanasia
At this point a familiar distinction will be invoked. It is acceptable, it is said, to discontinue life-preserving treatment under certain circumstances; one need not ‘strive officiously to keep alive’. But one must never kill – at least, not as a means to the relief of suffering. I shall contend that this distinction does not bear the weight put on it. But as a result of a plethora of confusions, it can easily seem to have moral importance.
One reason why the active/passive distinction seems important derives from the plausibility of the act/omission distinction, in general. Our acts seem more intimately related to our wills, to our projects and desires, than our omissions. This is important for the assignment of praise and blame. Thus, to use a well known example: it surely seems far worse to send poisoned food parcels to starving nations, than it does merely to fail to send any food at all. The result in both cases is that people die who might have lived if we had acted differently. But the psychological result of thinking of acts and omissions as being morally on a par is that our sphere of responsibility becomes so enormous as to be effectively dissipated. This is then accompanied by a great difficulty in assigning moral responsibility to specific individuals. If I, through my omissions, am held responsible for all the deaths and diseases I fail to prevent, then numerous others who failed to help are also responsible. But this is not usually so for acts.
In the specific case under discussion, there is another reason why passive euthanasia is thought preferable to active. This is that passive euthanasia is supposed to be only a matter of withdrawing costly treatment, when death is imminent anyway. It becomes a matter of not striving to keep alive; not squeezing every last second of life from a dying patient. Active euthanasia, however, is often thought to be a matter of killing a patient when he is not actually dying.
For a consequentialist, the act/omission distinction is suspect in all cases, and if we retain the habit of adhering to it, this must be justified by deep consequentialist reasons. But I think we can reject the active/passive euthanasia distinction without embracing consequentialism. All we need admit is that our omissions are at least sometimes of great moral import, not that there is no important general distinction to be made between acts and omissions. There are times when we are obliged to prevent evils – and providing medical treatment is a plausible instance. In some cultures this may not be widely believed, especially where there are scarce resources. But where there are such resources, the requirement to treat a patient in a serious medical condition seems almost as important as that of feeding one’s children. One does not have to deny the general validity of the act/omission distinction, to accept that in cases where a special relationship exists – for example, between patient and doctor, certain omissions can be morally grave misdemeanours.
As to the second reason for thinking passive euthanasia more acceptable than active, it is simply not true that passive euthanasia merely amounts to a refusal to adopt extraordinary means to give short extensions to life. It is more often a deliberate causing of death by withholding treatment, where continued treatment would significantly prolong life. To see this, it is useful to distinguish three kinds of malady: 1) those which are fatal, even with treatment (such as AIDS), 2) those which are fatal without treatment, but which can successfully be treated, and 3) those which are not fatal at all in normal circumstances. Now it is true that in the first sort of case, doctors may decide that continued treatment will not defeat the disease, even if it briefly postpones its victory. Hence they discontinue treatment and ‘allow nature to take its course’. But this is different from withholding treatment in the second kind of case. Here, life can be significantly prolonged with treatment. But doctors, patients or their families may decide that the quality of life it would sustain would be unacceptably low, or that too much suffering would be involved. So it is decided to withdraw life-sustaining treatment. It is cases like these which I take as the paradigm of passive euthanasia. And it is not clear that it is morally different from active euthanasia, in similar cases.
Acts, omissions and intention
To back up this intuition, it is worth stressing the central importance of our intentions in both the active and the passive cases. It is tempting to think that the outcomes of our omissions are less likely to be intended than are the outcomes of our acts, and that therefore, death resulting from withdrawal of treatment is not really intended. However, whilst it may, in general, be true that our intentions are more often fulfilled in the outcomes of our acts than in the consequences of our omissions, this is by no means necessarily so. We do sometimes intend our omissions, and their attendant consequences. It seems to me, for example, that a suicidally-inclined diabetic, who needs insulin to stay alive, could choose as his method of suicide a deliberate failure to take the insulin. It is crucial, in fact, not to confuse the act/omission distinction with the so-called ‘doctrine of double effect’, which allows that it may be permissible knowingly to bring about certain bad consequences, provided that they are sideeffects rather than means. Of course, in certain medical cases, death can be a foreseen but unintended side-effect of treatment (or lack of it). But in passive euthanasia just as much as active, death is directly intended.
Objections to euthanasia
Those who accept this conclusion can therefore hold a permissive view, either of both kinds of euthanasia, or of neither. Which way is it best to go?
My earlier homily on suicide was intended to deny the obviousness of any proposed answer to this sort of question. However, in so far as suicide can be acceptable, it would appear that certain cases of euthanasia should also be accepted. But there are complications worth looking into.
Firstly, if what is being discussed is not only the moral but the legal aspect of this problem, then euthanasia could be open to abuses that suicide is not open to. The spectre of mercenary relatives, anxious to be rid of a burdensome patient or to lay hands on his money, is frequently raised. There is also the possibility that once euthanasia is considered a moral or legal possibility – once it is thinkable – patients will start worrying that they are a burden upon others, and feel under pressure to accede to euthanasia.
Secondly, as was mentioned above, there may be problems in involving others in one’s own decision to end one’s life. Is it acceptable to saddle others with this moral burden? Some people are happy to help their relatives die peacefully, but a ban or a taboo on euthanasia may afford, to those who would agonise, protection from the damage they would otherwise do to their sense of integrity. For even if, with the best motives, they decide that euthanasia is right, they must face the fact that (at least in ‘active’ cases) they are killing a human being – something generally considered absolutely wrong. The point is not to do with social disapproval, but with the violence they would do to their own basic moral instincts. A parallel could help here. It may be right, for example, to torture a child if this is, beyond all reasonable doubt, the only way (and a certain way) to save ten children from being tortured. But we should be highly suspicious of someone who decides, unflinchingly and in advance, that this is what he would do. What should revolt him is not just the suffering of the child, but the fact that he is inflicting it; that he wills it directly. Now, of course, this case and the case of euthanasia seem very different. But perhaps a decent person ought to feel a deep resistance to willing the death of a loved one, and ought to feel dreadful if he does so. And (so the argument goes) he has a right to be protected from such choices.
Thirdly, it is often pointed out that even in the cases of voluntary euthanasia, we can never be sure that a patient would still wish to die when the time comes to kill him. He might indeed have written a ‘living will’ (a document making clear that he does not wish to be kept alive in certain circumstances), but how do we know he hasn’t changed his mind? Cases of involuntary euthanasia raise this problem even more acutely. Who are we to declare that a particular patient’s life is not worth living? Is there not, in fact, a danger of offering a ‘persuasive definition’ of death, such that death is equated with the cessation of ‘worthwhile life ’? The result here is that our consciences are eased when we kill somebody, because we have persuaded ourselves that we have not really killed him at all.
Many of those who sympathise with the considerations above, and oppose euthanasia, are motivated at root by a religiously-based conviction about the sanctity of life. Such considerations as those above function as supporting reasons, but probably do not lie at the root of their opposition. Although I do not subscribe to such beliefs, I am sensitive to the difficulties which arise from the abandonment of such deontological constraints. For there is, it seems, a disturbing air of arbitrariness about many of the standard non-religious grounds for adopting positions on matters such as euthanasia, abortion, just warfare, and so on. Sometimes we are told that it is not life as such, but the ‘quality of life’ that matters, and then various criteria are suggested for judging life’s quality: autonomy, ‘personhood’, rationality, and similar notions. But there is a certain arbitrariness about all of this. In the abortion debate, for instance, some supporters of the ‘right to choose’ think that self-awareness is what confers a right to life upon a creature. Others think that being human is what matters (and proceed to argue that a foetus is not a human being in the early stages). Opponents mention the potential to be human, or rational, or whatever it is. Is one answer really more convincing than another? I am not sure.
All of these points are a lengthy caveat. Answers are not obvious, and moral instincts die hard. However, sometimes we must just take the plunge. In spite of the objections outlined, it seems that euthanasia is probably justified in principle. How then should the objections be dealt with?
Replies to the objections
The first objection suggests that euthanasia is open to various abuses. It is primarily an objection to the legalisation of euthanasia, rather than to its intrinsic moral character. But it is important to note its tacit assumption: that it is so much worse to commit euthanasia when it is not warranted, than to fail to commit euthanasia when it is warranted, that even small chances of doing the former must be avoided at practically all costs. And the costs are indeed great; they include the prolonged agony of Lilian Boyes (to whom Dr. Cox gave the fatal potassium chloride), and the unrelievable suffering of countless others. But suppose the chances of the abuse of euthanasia are not small? Should we then prefer to err on the side of life than on the side of the relief of suffering? Even if this is so, the various voluntary euthanasia societies have taken considerable pains to try to make the chance of abuse as small as possible, in their quasi-legal guidelines. (This is detailed in Ludovic Kennedy’s ‘Counterblast’ pamphlet on the subject).
What of the objection that individuals should be protected from involvement in such decisions of life and death? I would not deny that a deep aversion to killing others, even when they ask for it, is part of the constitution of a decent person. On the other hand, this doesn’t show that it is never right to do so. A deep aversion to the suffering of others is also found in decent persons. There may be times when this should overcome the aversion to killing. Certainly, let us be suspicious of those who simply experience no conflict. (And perhaps we should also doubt the compassion of those who are not at all moved by a suffering patient’s desire to die). But, more important, let us not deny to autonomous beings the right to make agonising decisions. The moral paternalism that would have it otherwise is not (in my view) a desirable thing.
The third objection is to a certain extent a variation on the first. It is, of course, possible that a ‘living will’ gets out of date and no longer represents the wishes of the patient. And again, voluntary euthanasia societies are well aware of the objection and have their own suggestions for dealing with it. But even when this happens, is it so clearly a more catastrophic mistake than not respecting a wish to die, when the patient has not changed his mind? As to the persuasive redefinitions of death, it is true that some philosophical skullduggery has gone on here. I, for one, do not hold the view that death should be thought of as the ‘cessation of worthwhile life’. Death is a deeply enigmatic concept, well worth investigating in its own right. But for evidence of death, even if not a definition of death, it is better to look for the integrated functional cessation of the organism, rather than to ‘brain death’ or the absence of some supposedly valuable characteristic such as sentience or rationality.
This does not settle our moral difficulties. It merely neutralises a certain argument for euthanasia (usually, in these cases, involuntary). It makes us reject the claim that, for example, a person in a ‘persistent vegetative state’ is really dead; a corpse in a weird state of simulated life. On the other hand there is a serious question of why we should think of such lives as having intrinsic and absolute value. Perhaps a cautious moral conservatism is defensible, in cases in which those in this unfortunate state have left no clear instructions as to what should be done with them in such an eventuality. But in cases where a person has specified that, should he end up like this, he should not be kept alive, euthanasia – active or passive – seems to be justified.
If some are still dissatisfied, then I join their ranks. Some philosophical writing has been too self-confident, making use of complex notions (such as ‘personhood’) which are presented as both simple and morally decisive. But decisions still have to be made. Let us trust those who make them and feel awful about it, more than those who make them, and get a good night’s sleep.
© Piers Benn 1993
Piers Benn lectures in moral philosophy at the University of St. Andrews.