Ethics of euthanasia – introduction

source: BBC

Introduction

Euthanasia is the deliberate killing of a person for the benefit of that person, either with permission (voluntary) or without (non-voluntary).

Euthanasia raises  moral questions.
• is it ever right for another person to end the life of a terminally ill patient who is in severe pain or enduring other suffering?
• if euthanasia is sometimes right, under what circumstances is it right?
• is there any moral difference between killing someone and letting them die?

There are also a number of arguments based on practical issues – how the lethal dose is administered, for example.
It’s not euthanasia to give a drug in order to reduce pain, even though the drug causes the patient to die sooner. This is because the doctor’s intention was to relieve the pain, not to kill the patient. This argument is sometimes known as the Doctrine of Double Effect.

Mercy killing

Very often people call euthanasia ‘mercy killing’, perhaps thinking of it for someone who is terminally ill and suffering prolonged, unbearable pain. The word euthanasia comes from the Greek and means easy death.

Most people think unbearable pain is the main reason people seek euthanasia, but some surveys in the USA and the Netherlands showed that less than a third of requests for euthanasia were because of severe pain.

Terminally ill people can have their quality of life severely damaged by physical conditions such as incontinence, nausea and vomiting, breathlessness, paralysis, or difficulty in swallowing.
Psychological factors that cause people to think of euthanasia include depression, fear of loss of control or of dignity, feeling a burden, or dislike of being dependent.

Changing attitudes

The Times (24 January 2007) reported that, according to the 2007 British Social Attitudes survey, 80% of the public said they wanted the law changed to give terminally ill patients the right to die with a doctor’s help. In the same survey, 45% supported giving patients with non-terminal illnesses the option of euthanasia. “A majority” was opposed to relatives being involved in a patient’s death.

 Forms of euthanasia

1. Active and passive euthanasia

In active euthanasia a person directly and deliberately causes the patient’s death. In passive euthanasia they don’t directly take the patient’s life, they just allow them to die. This is a morally unsatisfactory distinction, since even though a person doesn’t ‘actively kill’ the patient, they are aware that the result of their inaction will be the death of the patient.

Active euthanasia is when death is brought about by an act – for example when a person is killed by being given an overdose of pain-killers.
Passive euthanasia is when death is brought about by an omission – i.e. when someone lets the person die. This can be by withdrawing or withholding treatment:
• Withdrawing treatment: for example, switching off a machine that is keeping a person alive so that they die of their disease.
• Withholding treatment: for example, not carrying out surgery that will extend life for a short time.
Traditionally, passive euthanasia is thought of as less morally bad than active euthanasia.

2. Voluntary and involuntary euthanasia

Voluntary euthanasia occurs at the request of the person who dies.
Non-voluntary euthanasia occurs when the person is unconscious or otherwise unable (for example, a very young baby or a person of extremely low intelligence) to make a meaningful choice between living and dying, and an appropriate person takes the decision on their behalf.
Non-voluntary euthanasia also includes cases where the person is a child who is mentally and emotionally able to take the decision, but is not regarded in law as old enough to take such a decision, so someone else must take it on their behalf in the eyes of the law.
Involuntary euthanasia occurs when the person who dies chooses life and is killed anyway, as in the Nazi euthanasia programmes.

3. Direct and indirect euthanasia

This means providing treatment (usually to reduce pain) that has the side effect of speeding the patient’s death.
Since the primary intention is not to kill, this is seen by some people (but not all) as morally acceptable.
Assisted suicide refers to cases where the person who is going to die needs help to kill themselves and asks for it. It may be something as simple as getting drugs for the person and putting those drugs within their reach.

4. Active and passive euthanasia

Active euthanasia occurs when the medical professionals, or another person, deliberately do something that causes the patient to die.

Passive euthanasia occurs when the patient dies because the medical professionals either don’t do something necessary to keep the patient alive, or when they stop doing something that is keeping the patient alive.
• switch off life-support machines
• disconnect a feeding tube
• don’t carry out a life-extending operation
• don’t give life-extending drugs

Ethical issues surrounding euthanasia

Issue 1: A question of rights

Does an individual who has no hope of recovery have the right to decide how and when to end their life? There are two aspects of this: the question of rights to choose and the issue of autonomy or freedom from non-interference from the state. In 2003 Diane Pretty argued in a series of court cases that the right to life also included the right to choose your own death.

Those in favour of euthanasia argue that a civilised society should allow people to die in dignity and without pain, and should allow others to help them do so if they cannot manage it on their own.

They say that our bodies are our own, and we should be allowed to do what we want with them. So it’s wrong to make anyone live longer than they want. In fact making people go on living when they don’t want to violates their personal freedom and human rights. It’s immoral, they say, to force people to continue living in suffering and pain.
They add that as suicide is not a crime, euthanasia should not be a crime.

The right to die
Human beings have the right to die when and how they want to:
“In…cases where there are no dependants who might exert pressure one way or the other, the right of the individual to choose should be paramount. So long as the patient is lucid, and his or her intent is clear beyond doubt, there need be no further questions”.The Independent, March 2002

Behind this lies the idea that human beings should be as free as possible – and that unnecessary restraints on human rights are a bad thing. For philopsophers such as Kant and Mill the idea of autonomy is vital to moral decision making. Human beings are independent biological entities, with the right to take and carry out decisions about themselves, providing the greater good of society doesn’t prohibit this. Allied to this is a firm belief that death is the end.

 Issue 2: Intention, and suffering – The moral difference between killing and letting die

Many people make a moral distinction between active and passive euthanasia. The issue involves intention.
It is arguably acceptable to withhold treatment and allow a patient to die, because the intention here is not actively to kill. but that it is never acceptable to kill a patient by a deliberate act.
Some medical people think it allows them to provide a patient with the death they want without having to deal with the difficult moral problems they would face if they deliberately killed that person.
“Thou shalt not kill but needst not strive, officiously, to keep alive.”Arthur Hugh Clough (1819-1861)

There is no real difference
But some people think this distinction is nonsense, since stopping treatment is a deliberate act, and so is deciding not to carry out a particular treatment.

Switching off a respirator requires someone to carry out the action of throwing the switch. If the patient dies as a result of the doctor switching off the respirator then although it’s certainly true that the patient dies from lung cancer (or whatever), it’s also true that the immediate cause of their death is the switching off of the breathing machine.

• in active euthanasia the doctor takes an action with the intention that it will cause the patient’s death
• in passive euthanasia the doctor lets the patient die
o when a doctor lets someone die, they carry out an action with the intention that it will cause the patient’s death
• so there is no real difference between passive and active euthanasia, since both have the same result: the death of the patient on humanitarian grounds
• thus the act of removing life-support is just as much an act of killing as giving a lethal injection

The Doctrine of Acts and Omissions
This is one of the classic ideas in ethics. It says that there is a moral difference between carrying out an action, and merely omitting to carry out an action.
Simon Blackburn explains it like this in the Oxford Dictionary of Philosophy:
“The doctrine that it makes an ethical difference whether an agent actively intervenes to bring about a result, or omits to act in circumstances in which it is foreseen that as a result of the omission the same result occurs.
Thus suppose I wish you dead, if I act to bring about your death I am a murderer, but if I happily discover you in danger of death, and fail to act to save you, I am not acting, and therefore, according to the doctrine, not a murderer”.
Simon Blackburn, Oxford Dictionary of Philosophy

But the acts and omissions doctrine doesn’t always work.

The killings in the bath
The philosopher James Rachels has an argument that shows that the distinction between acts and omissions is not as helpful as it looks. Consider these two cases:
• Smith will inherit a fortune if his 6 year old cousin dies.
• One evening Smith sneaks into the bathroom where the child is having his bath and drowns the boy.
• Smith then arranges the evidence so that it looks like an accident.
• Jones will inherit a fortune if his 6 year old cousin dies.
• One evening Jones sneaks into the bathroom where the child is having his bath.
• As he enters the bathroom he sees the boy fall over, hit his head on the side of the bath, and slide face-down under the water.
• Jones is delighted; he doesn’t rescue the child but stands by the bath, and watches as the child drowns.
According to the doctrine of acts and omissions Smith is morally guiltier than Jones, since he actively killed the child, while Jones just allowed the boy to die. In law Smith is guilty of murder and Jones isn’t guilty of anything.

However, most people would regard any distinction between their moral guilt as splitting hairs.
Suppose Jones defends himself by saying:
I didn’t do anything except just stand there and watch the child drown. I didn’t kill him; I only let him die.
Would we be impressed?

The importance of intention
The Smith/Jones case partly depends on us paying no attention to the intentions of Smith and Jones. But in most cases of right and wrong we do think that intention matters, and if we were asked, we would probably say that Smith was a worse person than Jones, because he intended to kill.

Consider this case (and yes, it’s a fantasy, doctors don’t behave like this):
• Brown is rushed into hospital after being stabbed.
• He arrives in casualty. Although he is bleeding heavily, he could be saved.
• The only doctor on duty wants to go home, and knows that saving Brown will take him an hour.
• He decides to let Brown bleed to death.
• Brown dies a few minutes later.
• Brown’s mother arrives, and on learning what has happened screams at the doctor, “You killed my son!”
• The doctor replies, “No I didn’t. I just let him die.”

No-one would think that the doctor’s reply excused him in any way. In this case letting someone die is morally very bad indeed. And if the lazy doctor defended himself to Brown’s mother by saying, “I didn’t kill him. The dagger in his heart killed him,” we wouldn’t think this an adequate moral argument either.

But there are cases where letting someone die might not be morally bad. Suppose that the reason the doctor didn’t save Brown was that he was already in the middle of saving Green, and if he left Green to save Brown, Green would die. In that case, we might think that the doctor had a good defence against accusations of unethical behaviour.

Further reading
James Rachels, ‘Active and Passive Euthanasia’. The New England Journal of Medicine, Vol. 292, pp 78-80, 1975

Issue 3: We all deserve a good death

What is a good death?
In a Gallup poll in America, more than 70% of individuals surveyed feared dying in pain or alone without the chance to say good-bye.

Twelve principles
The authors of The future of health and care of older people: the best is yet to come [London: Age Concern, 1999] set down 12 principles of a good death:

• to know when death is coming, and to understand what can be expected
• to be able to retain control of what happens
• to be afforded dignity and privacy
• to have control over pain relief and other symptom control
• to have choice and control over where death occurs (at home or elsewhere)
• to have access to information and expertise of whatever kind is necessary
• to have access to any spiritual or emotional support required
• to have access to hospice care in any location, not only in hospital
• to have control over who is present and who shares the end
• to be able to issue advance directives which ensure wishes are respected
• to have time to say goodbye, and control over other aspects of timing
• to be able to leave when it is time to go, and not to have life prolonged pointlessly

Nine key issues
An article in the Journal of the American Medical Association (Vol. 284 No. 19, November 15, 2000) found that there is no one definition of a good death; quality end-of-life care is a dynamic process that is negotiated and renegotiated among patients, families, and health care professionals.
The article ranked the key issues for patients like this (most important at the top):
• freedom from pain
• at peace with God
• presence of family
• mentally aware
• treatment choices followed
• finances in order
• feel life was meaningful
• resolve conflicts
• die at home
The article showed that patients highly valued attention to spirituality; in particular, the importance of coming to peace with God and praying. However the survey found that for some patients it was more important to resolve faith issues with themselves rather than to take part in social or interpersonal expressions of spirituality.

Futile, extraordinary or burdensome medical treatment
Futile, extraordinary or burdensome medical treatment
Euthanasia is not the same thing as refusing burdensome medical treatment.
Refusing such treatment can be seen as allowing the dying to die in an appropriate way, which is not the same thing as causing the death of the living.

But what is burdensome medical treatment? There is no standard answer; each case should be looked at separately, balancing the amount of pain and suffering involved against the amount of good to be done.
The issue is not the value of the life of the person concerned, but the value of the treatment to that person.

Issue 4: Slippery Slope

Argument: If voluntary euthanasia were to become legal, it would not be long before involuntary euthanasia would start to happen.
Vulnerable people – the elderly, lonely, sick or distressed – would feel pressure, whether real or imagined, to request early death.
Those who oppose this argument say that properly drafted legislation can draw a firm barrier across the slippery slope.

The slippery slope argument
If we change the law and accept voluntary euthanasia, we will not be able to keep it under control
Euthanasia would never be legalised without proper regulation and control mechanisms in place
Doctors may soon start killing people without bothering with their permission
There is a huge difference between killing people who ask for death under appropriate circumstances, and killing people without their permission. Very few people are so lacking in moral understanding that they would ignore this distinction
Very few people are so lacking in intellect that they can’t make the distinction above.

Any doctor who would ignore this distinction probably wouldn’t worry about the law anyway
Though p’raps I may incur your blame the things are few I would not do in Friendship’s name
And I may say, I think, the same; not even love should rank above True Friendship’s name
Very few people are so lacking in moral understanding that they would ignore this distinction
But no one yet in the world so wide has yielded up a promised bride.

Health care costs will lead to doctors killing patients to save money or free up beds:
• The main reason some doctors support voluntary euthanasia is because they believe that they should respect their patients’ right to be treated as autonomous human beings
• That is, when doctors are in favour of euthanasia it’s because they want to respect the wishes of their patients
• So doctors are unlikely to kill people without their permission because that contradicts the whole motivation for allowing voluntary euthanasia
• But cost-conscious doctors are more likely to honour their patients’ requests for death
• A 1998 study found that doctors who are cost-conscious and ‘practice resource-conserving medicine’ are significantly more likely to write a lethal prescription for terminally-ill patients [Arch. Intern. Med., 5/11/98, p. 974]
• This suggests that medical costs do influence doctors’ opinions in this area of medical ethics
The Nazis engaged in massive programmes of involuntary euthanasia, so we shouldn’t place our trust in the good moral sense of doctors:
• The Nazis are not a useful moral example, because their actions are almost universally regarded as both criminal and morally wrong
• The Nazis embarked on invountary euthanasia as a deliberate political act – they didn’t slip into it from voluntary euthanasia (although at first they did pretend it was for the benefit of the patient)
• What the Nazis did wasn’t euthanasia by even the widest definition, it was the use of murder to get rid of people they disapproved of
• The universal horror at Nazi euthanasia demonstrates that almost everyone can make the distinction between voluntary and involuntary euthanasia
• The example of the Nazis has made people more sensitive to the dangers of involuntary euthanasia
Allowing voluntary euthanasia makes it easier to commit murder, since the perpetrators can disguise it as active voluntary euthanasia:
• The law is able to deal with the possibility of self-defence or suicide being used as disguises for murder. It will thus be able to deal with this case equally well
• To use active voluntary euthanasia as a criminal action will involve medical co-operation. The need for a conspiracy will make it an unattractive option
“Many are needlessly condemned to suffering by the chief anti-euthanasia argument: that murder might lurk under the cloak of kindness”. A C Grayling, Guardian 2001

The Oregon approach and the slippery slope
The US state of Oregon legalised physician assisted suicide in 1998. During the first three years only around 2 people a month used this to end their lives. This was partly because of the severe conditions that had to be satisfied before a request for euthanasia could be granted – conditions which arguably prevent the slippery slope.

• patient must be resident in Oregon
• patient must be aged over 18
• patient must make 2 oral and 1 written request for euthanasia
• there must be at least 15 days between the first and the last request
• patient must be terminally ill with a life expectancy of less than 6 months
• this prognosis must be confirmed by a second consultant physician
• both doctors must confirm that the patient is capable of making this decision
• both doctors must confirm that the patient does not have medical condition that impairs their judgement
• patient must self-administer the lethal medication

About 30% of patients who started the process died before it was completed. 19 patients in the period who were given access to lethal medication decided not to use it. One survey showed that 45% of patients who were given good palliative care changed their mind about euthanasia.

Another reason for the low take-up was the difficulty of finding a doctor who go along with the request: The Oregon Health Division reported that only a fifth of physicians of control patients dying of similar terminal illnesses would have prescribed a lethal medication if asked.

Kantian Ethics and euthanasia

James Rachels has offered some other arguments that work differently.
Do as you would be done by (Kant’s first formulation of the Categorical Imperative)
The rule that we should treat other people as we would like them to treat us also seems to support euthanasia, if we would want to be put out of our misery if we were in A’s position. But it isn’t necessarily so:

• A person might well not want to be killed even in this situation, if their beliefs or opinions were not against active euthanasia.
• There are many examples of people who have accepted appalling pain for their beliefs.
Only rules that apply to everyone can be accepted
One well-known ethical principle says that we should only be guided by moral principles that we would accept should be followed by everyone.
If we accept that active euthanasia is wrong, then we accept as a universal rule that people should be permitted to suffer severe pain before death if that is the consequence of their disease.

Moral rules must be universalisable

One of the principles in ethics is that only those ethical principles that could be accepted as a universal rule (i.e. one that applied to everybody) should be accepted. This is reflected in the golden rule and in Kant’s first formula of the categorical imperative.

So you should only do something if you’re willing for anybody to do exactly the same thing in exactly similar circumstances, regardless of who they are.The justification for this rule is hard to find – many people think it’s just an obvious truth (philosophers call such truths self-evident). You find variations of this idea in many faiths; for example “do unto others as you would have them do unto you”.

To put it more formally:
A rule is universalisable if it can consistently be willed as a law that everyone ought to obey. The only rules which are morally good are those which can be universalised.

The person in favour of euthanasia may argue that giving everybody the right to have a good death through euthanasia is acceptable as a universal principle, and that euthanasia is therefore morally acceptable.

Necessary but not sufficient…
This is true, but only up to a point…
If a person wants to be allowed to commit euthanasia, it would clearly be inconsistent for them to say that they didn’t think it should be allowed for other people.
But the principle of universalisability doesn’t actually provide any positive justification for anything – genuine moral rules must be universalisable, but universalisability is not enough to say that a rule is a satisfactory moral rule. Universalisability is therefore only perhaps a necessary condition, not a sufficient condition for a rule to be a morally good rule.
So universalisibility doesn’t advance the case for euthanasia at all.

Every case is different in some respect, so anyone who is inclined to argue about it can argue about whether the particular differences are sufficent to make this case an exception to the rule.

Oddly enough, the law of universalisability allows there to be exceptions – as long as the exceptions are themselves universalisable. So you could have a universal rule allowing voluntary euthanasia and universalise an exception for people who were less than 18 years old.

The Sulmasy test

Daniel P. Sulmasy has put forward a way for a doctor to check what their intention really is. The doctor should ask himself, “If the patient were not to die after my actions, would I feel that I had failed to accomplish what I had set out to do?”
Is there a duty to die?
Is there a duty to die?
It sounds an odd question – most of us would say ‘no’, except perhaps for military and similar personnel in certain circumstances.After all, when we say someone did their duty when they gave up their life to save others, we often mean that they did an act of heroism, well beyond the call of duty.

But some cultures, and some modern thinkers, think that there is a duty on a person to die in certain circumstances. Japanese kamikaze pilots believed they had a duty to die to preserve national honour. Eskimos believe that after a certain age they have a duty to die to protect the young in harsh times. Might it be that old people in our culture believe they have a duty to die if they live too long, say, over 100?

The ideas of John Hardwig
The philosopher John Hardwig re-opened this debate with an article in 1997. He says that an individual is not the only person who will be affected by decisions over whether they live or die. So, when deciding whether to live or die, a person should not consider only themselves; they should also consider their family and the people who love them.
What produces a duty to die?

Hardwig thinks that we may have a duty to die when the burden of caring for us seriously compromises the lives of those who love us:
• they may be physically exhausted by caring for us
• they may be emotionally exhausted by caring for us
• they may be financially destroyed by the cost of our healthcare
• they may be financially destroyed by having to give up work to care for us
• their home may become a place of grief and sickness
• other family members may be neglected as all attention is focused on us

Hardwig says that there are no general rules – each case will be different, and he openly admits:
“I can readily imagine that, through cowardice, rationalisation, or failure of resolve, I will fail in this obligation to protect my loved ones. If so, I think I would need to be excused or forgiven for what I did”. John Hardwig

Nor does Hardwig think that a person should make their final decision without consulting their family – although he points out the difficulties in doing this.

Arguments against euthanasia

You can argue about the way we’ve divided up the arguments, and many arguments could fall into more categories than we’ve used.

1. Religious arguments
• Euthanasia is against the word and will of God
• Euthanasia weakens society’s respect for the sanctity of life
• Suffering may have value
• Voluntary euthanasia is the start of a slippery slope that leads to involuntary euthanasia and the killing of people who are thought undesirable

2. Ethical arguments
• Euthanasia weakens society’s respect for the sanctity of life
• Accepting euthanasia accepts that some lives (those of the disabled or sick) are worth less than others
• Voluntary euthanasia is the start of a slippery slope that leads to involuntary euthanasia and the killing of people who are thought undesirable
• Euthanasia might not be in a person’s best interests
• Euthanasia affects other people’s rights, not just those of the patient

3. Practical arguments
• Proper palliative care makes euthanasia unnecessary
• There’s no way of properly regulating euthanasia
• Allowing euthanasia will lead to less good care for the terminally ill
o Allowing euthanasia undermines the committment of doctors and nurses to saving lives
o Euthanasia may become a cost-effective way to treat the terminally ill
o Allowing euthanasia will discourage the search for new cures and treatments for the terminally ill
o Euthanasia undermines the motivation to provide good care for the dying, and good pain relief
• Euthanasia gives too much power to doctors
• Euthanasia exposes vulnerable people to pressure to end their lives
o Moral pressure on elderly relatives by selfish families
o Moral pressure to free up medical resources
o Patients who are abandoned by their families may feel euthanasia is the only solution

4. Historical arguments
• Voluntary euthanasia is the start of a slippery slope that leads to involuntary euthanasia and the killing of people who are thought undesirable.
Against the will of God
Euthanasia is against the word and will of God
Religious people don’t argue that we can’t kill ourselves, or get others to do it. They know that we can do it because God has given us free will. Their argument is that it would be wrong for us to do so.
They believe that every human being is the creation of God, and that this imposes certain limits on us. Our lives are not only our lives for us to do with as we see fit.
To kill oneself, or to get someone else to do it for us, is to deny God, and to deny God’s rights over our lives and his right to choose the length of our lives and the way our lives end.
The value of suffering
Religious people sometimes argue against euthanasia because they see positive value in suffering.
Down through the centuries and generations it has been seen that in suffering there is concealed a particular power that draws a person interiorly close to Christ, a special grace. Pope John Paul II: Salvifici Doloris, 1984

The religious attitude to suffering
Most religions would say something like this:
We should relieve suffering when we can, and be with those who suffer, helping them to bear their suffering, when we can’t. We should never deal with the problem of suffering by eliminating those who suffer.

Christianity teaches that suffering can have a place in God’s plan, in that it allows the sufferer to share in Christ’s agony and his redeeming sacrifice. They believe that Christ will be present to share in the suffering of the believer.
Pope John Paul II has written that “It is suffering, more than anything else, which clears the way for the grace which transforms human souls.”
However while the churches acknowledge that some Christians will want to accept some suffering for this reason, most Christians are not so heroic.
So there is nothing wrong in trying to relieve someone’s suffering. In fact, Christians believe that it is a good to do so, as long as one does not intentionally cause death.

Dying is good for us
Some people think that dying is just one of the tests that God sets for human beings, and that the way we react to it shows the sort of person we are, and how deep our faith and trust in God is.
Others, while acknowledging that a loving God doesn’t set his creations such a horrible test, say that the process of dying is the ultimate opportunity for human beings to develop their souls.
When people are dying they may be able more than at any time in their life to concentrate on the important things in life, and to set aside the present-day ‘consumer culture’, and their own ego and desire to control the world.

Eastern religions
Several Eastern religions believe that we live many lives and the quality of each life is set by the way we lived our previous lives.
Those who believe this think that suffering is part of the moral force of the universe, and that by cutting it short a person interferes with their progress towards ultimate liberation.

A non-religious view
Some non-religious people also believe that suffering has value. They think it provides an opportunity to grow in wisdom, character, and compassion.
Suffering is something which draws upon all the resources of a human being and enables them to reach the highest and noblest points of what they really are.
Suffering allows a person to be a good example to others by showing how to behave when things are bad.
M Scott Peck, author of The Road Less Travelled, has written that in a few weeks at the end of life, with pain properly controlled a person might learn how to negotiate a middle path between control and total passivity, about how to welcome the responsible care of strangers, about how to be dependent once again … about how to trust and maybe even, out of existential suffering, at least a little bit about how to pray or talk with God.M Scott Peck

The nature of suffering
It isn’t easy to define suffering – most of us can decide when we are suffering but what is suffering for one person may not be suffering for another.
It’s also impossible to measure suffering in any useful way, and it’s particularly hard to come up with any objective idea of what constitutes unbearable suffering, since each individual will react to the same physical and mental conditions in a different way.
a patient was receiving good palliative care before a request for euthanasia is considered.
Although the procedures outlined above are time-consuming and expensive, that does not mean that they are impractical.