EUTHANASIA

1. EUTHANASIA Edvard Munch, Death in the Sickroom,1895

2. “Doctors Must Not Kill” Edmund D. Pellegrino

3. SUFFERING AND EUTHANASIA • Pellegrino is a physician and writes about euthanasia from that perspective. • His position is that, while doctors have a duty to alleviate suffering, they cannot knowingly and willingly involve themselves in the death of a patient. • And this is the case even if the patient requests it. Thus his view is opposed to voluntary active euthanasia as well as to nonvoluntary and involuntary euthanasia.

4. PELLEGRINO’S POINTS • Although Pellegrino says that “No one can reasonably oppose a ‘good’ death,” he is opposed to euthanasia “even out of compassion” for the following reasons. • 1. Moral arguments for euthanasia are not convincing. • 2. Euthanasia distorts the healing relationship between doctor and patient. • 3. Euthanasia is likely to be abused by society, and so can have terrible social consequences.

5. ARGUMENTS FOR EUTHANASIA I • Those who argue for euthanasia typically say the following basic things: • 1. Euthanasia eliminates suffering, suffering is evil, and so euthanasia is good because it eliminates suffering. • 2. People who are suffering from a terminal illness have the right to choose not to suffer. And if euthanasia is the only means of ending suffering, then those suffering have the right to end their suffering by ending their lives. This is the principle of autonomy. • 3. Terminally ill patients cannot end their own lives, but depend on doctors who know best how to do it. Here a doctor acts as an agent on behalf of the patient.

6. ARGUMENTS FOR EUTHANASIA II • 4. Because part of a doctor’s moral duty is to end suffering, she has a moral duty to assist a patient in obtaining a good death when that is the patient’s desire. • 5. There is no moral difference between a doctor’s killing a patient and letting her die. [Rachels.] • 6. Abuses of euthanasia can be controlled by legislation. • 7. “No physician who is morally opposed need participate.”

7. EUTHANASIA AND RELIGION I • Two arguments against euthanasia from the Judeo-Christian tradition are: • 1. Humans are given the gift of life and have no right to interfere with this gift. [Plato.] • 2. Even human suffering can have meaning, that is, it can be meaningful in a positive way. • Although Pellegrino thinks that these arguments are “not lightly dismissed,” he says that he will not try to make his argument against euthanasia by appeal to these things. And this is because “Even without recourse to religious beliefs, active euthanasia is morally untenable.”

8. EUTHANASIA AND RELIGION II • Pellegrino does say, however, that these are beliefs which are deeply rooted in our culture, and because they are so deeply rooted, he thinks that the burden of proof is on the person who argues against these beliefs in arguing for euthanasia. • The idea here then is that someone who wants to argue against tradition and common opinion must give good reasons for doing so, and he thinks that the arguments offered in favor of euthanasia are not proof that it is morally acceptable.

9. KILLING AND LETTING DIE I • Pellegrino will first look at the idea made by some advocates of euthanasia that there is no moral difference between killing a patient and letting him die “by deliberate withdrawal or withholding of life support or lifesaving treatment.” • The moral parity of killing and letting die can be understood to have two aspects whether it concerns a moral good or a moral evil. • That you are as guilty of a wrongdoing if you let someone die whose death you could have prevented as you are in killing her is to see killing and letting die as equally morally evil. • On the other hand, if letting someone die - passive euthanasia - is a moral good because it ends suffering, then why is not killing someone to end suffering - active euthanasia - also not a moral good? Aren’t these equally morally good?

10. KILLING AND LETTING DIE II • For Pellegrino, the difference is that in active euthanasia the doctor is the direct cause of the patient’s death, whereas in letting the patient die or passive euthanasia the illness is the cause of death. • Therefore he does not see them as morally equivalent because in the first case the doctor does something and in the second instance he does nothing.

11. KILLING AND LETTING DIE III • James Rachels’ response is that it is not true that in passive euthanasia the doctor does nothing. • After all, he lets the patient die, and letting someone die can be subject to moral evaluation - good or bad - as we have seen. • Rachels says that if passive euthanasia is seen as medically acceptable, then that is because it is seen that death is an equal or lesser evil than suffering. • And if passive euthanasia is acceptable to eliminate the equal or greater evil of suffering, then, for Rachels, so is active euthanasia.

12. EUTHANASIA AND AUTONOMY I • Pellegrino next looks at the argument for euthanasia based on the patient’s right of autonomy. • The right of autonomy is the right to self-determination - to make free choices for yourself. • This could include a terminally ill patient’s right to choose to die to end her pain and suffering. The idea is whose life is it anyway?

13. EUTHANASIA AND AUTONOMY II • Pellegrino’s problem with the right to autonomy is that, in exercising her right to die, a person is using her freedom to give up her freedom. • Thus, in the name of autonomy the patient decides to end the life which makes autonomy possible. • When you give up your life you give up everything, including your freedom and “control over a whole set of options, all of which cannot be foreseen and many of which would be of importance if life - the basis of freedom - had not been forgone.”

14. EUTHANASIA AND AUTONOMY III • However, a proponent of euthanasia might argue that a dying patient’s using freedom to eliminate freedom is not a contradiction but is simply a use to which freedom is practically put, given his illness and suffering. • And it might be further argued that, if the medical condition of the patient is such as to restrict or eliminate all future meaningful options, then the most meaningful thing for freedom to do is to eliminate the life which supports the suffering.

15. EUTHANASIA AND AUTONOMY IV • Pellegrino also says in regard to autonomy that, if the patient chooses death because of unbearable suffering, then the choice of death is “really not free.” • But again, a euthanasia advocate might argue that, even if this is the case, and the patient is powerless to act otherwise, euthanasia can yet be seen as the only option to eliminate the evil of suffering. • And here autonomy could yet be relevant in the patient’s having made the free choice to opt for euthanasia if such a medical condition as he now experiences were ever to arise. The patient would have simply exercised his freedom earlier in his life by planning for such an event through a will.

16. THE BURDEN OF TERMINAL ILLNESS • Pellegrino says that terminally ill patients often see themselves as social, economic, and emotional burdens to others. • And in their debilitated condition they may be susceptible to subtle suggestion - such a doctor’s agreeing that they are a burden. They could then decide to choose euthanasia. • For Pellegrino, “euthanasia is too often an act of desperation” - an act that could be avoided if pain is properly managed. • But what about the cases where pain cannot be properly managed? And what about the medical conditions which are so terrible that modern medicine can do nothing for them?

17. KINDNESS AND COMPASSION I • Advocates of euthanasia will cite kindness and compassion as reasons for ending through death the terrible suffering of a terminally ill patient. • Pellegrino recognizes that compassion is part of medicine, since every doctor desires to make his patients well, and he recognizes that even those who see meaning in suffering would prefer that someone not suffer. • Do not compassion and mercy then override all other considerations?

18. KINDNESS AND COMPASSION II • The answer to this, for Pellegrino, is that compassion can concern removing the dying patient’s pain without resorting to euthanasia. • By removing a patient’s pain, he can experience a “good death” - the one which nature intended. • Pellegrino: “The aim of medicine should be to facilitate a death that is as pain-free as possible but that is also a human experience.”

19. DYING, EXPERIENCE, AND UNDERSTANDING • Euthanasia of humans is morally unacceptable for Pellegrino because they have the capacity to understand the experience of dying, and possibly benefit from it, whereas such understanding is not possible for other ‘lower’ life forms such as “our pets.” • The experience of dying is important for Pellegrino since “humans can grow morally even with negative experiences.” • Notice that dying can be treated as an experience for a person who is conscious while his life is ending, whereas death, at least from the perspective of life on earth, is the end of all experience. • [See the first two full paragraphs on page 176 and compare with the questions for Pellegrino on the handout.]

20. THE MOTIVATION FOR EUTHANASIA • Pellegrino says that “The motivation for euthanasia arises principally from two worries: fear of intolerable pain, suffering, and anguish, and fear of becoming a victim of overzealous physicians and dehumanizing medical technologies.” • Although Pellegrino recognizes that both of these are “legitimate worries,” he thinks that each can be handled “without resort to euthanasia” through “improved measures for relief of pain and anxiety” which physicians have a moral obligation to use, and through “hospice programs and palliative care.”

21. MAKING DYING POSITIVE • With the help of such programs, dying, according to Pellegrino, can be “a communal experience, in which the dying person contributes something positive to those around her as well as to her own growth as a person.” • And Pellegrino thinks that “the physician’s obligation to act beneficently and to show respect for the patient’s dignity is better served by these measures than by killing the patient.”

22. MAJORITY OPINION • Pellegrino points out, correctly, that that the majority of people believe something does not make it morally correct or incorrect. Thus comment consent does not guarantee the truth of whatever it is about which the majority agree, and philosophical argument with relevant evidence must be established to determine the truth of something, not popular opinion. • If the majority is in favor of euthanasia that does not in itself show that euthanasia is morally correct, and if most people are against, that majority opinion also does not show that euthanasia is immoral.

23. DISTORTING THE HEALING RELATIONSHIP I • According to Pellegrino, euthanasia distorts the healing relationship between doctor and patient. • A doctor’s aim is to heal her patient if possible, and if that is not possible, then the physician has an obligation to treat the patient’s pain to the best of her ability. • [Notice that he says this in spite of his respect for the moral value of suffering. Is this a problem for his view?] • Pellegrino notes that medicine is grounded in trust, and he thinks that euthanasia could destroy that trust.

24. DISTORTING THE HEALING RELATIONSHIP II • Euthanasia could destroy the patient’s trust of his doctor since, if euthanasia were legal, then some doctors might opt for killing their patients rather than healing them. • The doctor who thinks his patient is better off dead might try to convince his patient to end his life rather than waiting to die naturally. • This is the slippery slope idea that if we legalize euthanasia then abuses of the system would inevitably occur, human nature being what it is.

25. A SLIPPERY SLOPE I • As Mary Warnock puts it: “The ‘slippery slope’ is the name of an argument based on a certain view of human nature, not on logic, and commonly used in nonphilosophical discussions of moral issues.” • Warnock: “The reasoning is that, though a practice may be unobjectionable in one type of case, if it is once permitted, its use will inevitably be extended to other more morally dubious cases.” • Warnock: “The inevitability here supposed is not logical inevitability, but is thought to result from people’s always wanting more than they have.” • Warnock: “In fact, legislation or other forms of regulation can usually control an undesirable slide down the slippery slope.”

26. A SLIPPERY SLOPE II • According to the slippery slope argument then, although a certain kind of practice may be acceptable in one kind of case, once it is permitted, it will be extended to cases where it ought not to be used. • The idea is that we slide down the slope from a good thing to a bad thing. • In this instance, if euthanasia were okay for one kind of terminally suffering patient, it would be used in cases where it should not - where it is not really the wish of the patient to be put to death.

27. A SLIPPERY SLOPE III • A slippery slope argument such as this depends on seeing human beings as basically morally irresponsible, unable to make reasonable judgements, susceptible to external influence, or all of these. • The common rebuttal to such slippery slope arguments is that potential bad cases can be prevented through proper legislation. • Advocates of euthanasia, such as James Rachels, recognize the possibility of system abuses, but are willing to rely on legislation and the good judgement of the medical community to correct them.

28. A SLIPPERY SLOPE IV • The idea then is that the remedy for abuses is either to enforce legislation so that they don’t occur, and if the violations become too excessive you simply repeal the law which legalized euthanasia. • But Pellegrino might respond that this is not a risk worth taking. In fact he says that “laws will not prevent abuses,” and thinks that abuse “is inevitable.” • On the other hand, James Rachels is a philosopher who thinks that the benefits of euthanasia will outweigh any abuses that may occur.

29. A SLIPPERY SLOPE V • Whatever the case about likely abuses of euthanasia though, Pellegrino’s view is that the doctor has an obligation to alleviate or eliminate suffering so that the patient could experience a good death, and she must reject euthanasia since that eliminates the prospect of a good death and distorts the healing relationship between doctor and patient.

30. “VOLUNTARY ACTIVE EUTHANASIA” Dan W. Brock

31. V.A.E. AND P.A.S. I • Brock thinks that both euthanasia and physician assisted suicide are morally permissible. • Remember that voluntary active euthanasia (v.a.e.) is when the doctor intentionally kills a terminally ill patient with the patient’s consent. • In physician assisted suicide (p.a.s.) the patient kills herself with the assistance of the doctor, the doctor does not act directly to kill the patient.

32. V.A.E. AND P.A.S. II • In physician assisted suicide, the patient is the one who directly ends her own life. • An example of physician assisted suicide is when a patient ends her life with a drug that the doctor prescribes. • In voluntary active euthanasia, the doctor directly kills the patient at the request of the patient. • In voluntary active euthanasia the doctor or a medical assistant acting on the doctor’s orders administers the drug to the patient.

33. V.A.E. AND P.A.S. III • In both euthanasia and assisted suicide “the choice [of death] rests fully with the patient. In each case “the patient acts last in the sense of retaining the right to change his or her mind.” • And in each case the doctor is directly involved, and “plays an active and necessary causal role.” • In fact, for Brock, “the only difference that need exist between the two [v.a.e. and p.a.s.] is the person who actually administers the dose - the physician or the patient.” • Brock wants to know then how there could be “a substantial moral difference between the two [v.a.e. and p.a.s.] based only on this small difference in the part played by the physician in the causal process resulting in death?”

34. V.A.E. AND P.A.S. IV • Thus Brock wonders why some people think that there is a major moral difference here between euthanasia and assisted suicide since the doctor is necessarily and actively involved in both cases. • Some might respond that the moral difference is clear since in euthanasia the doctor kills the patient, while in p.a.s the patient kills the patient, with, of course, the doctor’s assistance. • But Brock says that “this is misleading at best.” • It’s misleading because in p.a.s the doctor and patient together kill the patient. And they do it together since the patient cannot kill himself without the doctor’s help.

35. V.A.E. AND P.A.S. V • Brock points out that, if a doctor gave a patient a lethal dose of medication with full knowledge that the patient will use it to kill someone else, we would hold the doctor responsible for a wrongful death. • So if the doctor gives his patient a lethal drug with the full knowledge that he will use it to kill himself then he is also responsible for the death of the patient. • And Brock says that if it is really the case that there is no significant difference between euthanasia and p.a.s, then why should people be in favor of one and not the other? • Accordingly, a law which permitted p.a.s. on moral grounds ought also to permit euthanasia on moral grounds.

36. THE CENTRAL ARGUMENT FOR EUTHANASIA • Brock will focus on voluntary active euthanasia only, which I will call ‘euthanasia’ for short. • The argument for euthanasia comes typically from two fundamental moral points regarding persons: • 1. The right to self-determination [the right of autonomy]. • 2. The right to well-being. • A person’s right to self-determination is his or her right to make free choices about his or her life to the extent that such choices do not interfere with someone else’s right to self-determination. • And a person’s right to well-being includes the right not to suffer, physically, psychologically, or both.

37. SELF-DETERMINATION I • Self-determination in regard to euthanasia means that a terminally ill patient whose suffering only death will end has the right to decide about her own life. • Thus a person suffering from a terminal illness should be free to make up her own mind about her future in relation to that illness. • We take self-determination to be a good thing, and we take suffering to be a bad thing.

38. SELF-DETERMINATION II • Brock says that “By self-determination as it bears on euthanasia, I mean people’s interest in making important decisions about their lives for themselves according to their values or conceptions of a good life, and in being left free to act on those decisions.” • For Brock, self-determination is both valuable and “a central aspect of human dignity.” • Basing euthanasia on the right of self-determination means that people must have the ability to decide for themselves.

39. SELF-DETERMINATION III • Basing euthanasia on the right of self-determination also “presupposes some minimum of decision-making capacities or competence . . . and cannot justifiably be administered, for example, in cases of serious dementia or treatable clinical depression.” • Those in favor of euthanasia would say the right to self-determination extends to a person’s right to decide about her own death. • For them, we ought to have the right to discontinue our lives when faced with terminal suffering.

40. SELF-DETERMINATION IV • People have a natural fear of suffering and a fear of losing dignity due to illness, and euthanasia would give them an option then to avoid both. • However, Brock says that everyone has to decide for himself, and that people and life are complicated enough that “there is no single objectively correct answer for everyone” about how much suffering you can take, and about when loss of dignity will occur. • Accordingly, where euthanasia may be proper for some it may not be for others, and this is why the emphasis is on euthanasia being voluntary. • Because people are so different, and the right of self-determination is so important, it is especially important that terminally ill people are able to “control the manner, circumstances, and timing of their dying and death.”

41. WELL-BEING • We think that life is good and death is evil, but, more particularly, we think that a healthy life is good and that suffering is an evil. And we think that everyone has a right to well-being - that no one should suffer who does not have to. • Proponents of euthanasia say that, since everyone has a right to well-being, and a right to self-determination, when someone loses her feeling of well-being; when life becomes an unbearable burden; and when a life of suffering is “worse than no further life at all,” then a person has the right to end her suffering through death. • Again, Brock says that “there is no objective standard [about what constitutes an unbearable life], but only the competent patient’s judgement of whether continued life is no longer a benefit.”

42. PHYSICIANS AND EUTHANASIA • Brock says that a person’s right to self-determination cannot be used to compel doctors to practice euthanasia or p.a.s. • If a doctor objects to either on moral grounds, then she cannot be forced to participate in bringing about the death of the patient. • That is, the doctor’s right of self-determination also has to be respected. • Even if euthanasia becomes legal, a doctor who objects to it need not be involved, and his role can be taken by another willing physician.

43. ARGUMENTS AGAINST EUTHANASIA • Two main arguments against euthanasia cited by Brock are: • 1. The deliberate killing of an innocent person is always ethically wrong. • 2. Perhaps euthanasia is morally acceptable in certain cases, but it ought not to be legally permitted since it will be abused, and so the bad consequences will outweigh the good. [Slippery slope.]

44. DELIBERATE KILLING OF AN INNOCENT PERSON I • Opponents of euthanasia say that euthanasia is the deliberate killing of an innocent person, and they object to euthanasia because they think that this deliberate killing is always immoral. • Brock says that they are right that euthanasia is the deliberate killing of an innocent person. • The killing is done deliberately at the patient’s request to end her suffering, and the person is not guilty of any crime or wrongdoing in virtue of being terminally ill and suffering.

45. DELIBERATE KILLING OF AN INNOCENT PERSON II • The question of the morality of euthanasia then concerns whether or not the deliberate killing of an innocent person is always wrong. • If it is then euthanasia is immoral. • If it is not then euthanasia may be permissible, at least in some cases.

46. KILLING AND ALLOWING TO DIE I • While some think that voluntary active euthanasia is wrong, they do not think that deliberately allowing a person to die, or passive euthanasia is wrong. • Thus, allowing someone to die by deliberately withholding life sustaining treatment is thought to be morally acceptable and different from euthanasia, because in allowing to die you are allowing the disease to kill the patient and so the doctor is not killing the patient. • But Brock says that this view is “confused and mistaken.” • [See Brock’s example on pp. 188-189.]

47. KILLING AND ALLOWING TO DIE II • The idea here is that the same physical actions are performedby the greedy son as by the compassionate physician. If the son’s action is killing why is not the doctor’s? • Brock understands that there is a difference of intention here, and that both the intention and other considerations make us think that there is a moral difference here. • For instance, the doctor acts with the patient’s consent, has a good motive - ending suffering - and is performing a social role for which he is legally authorized. • On the other hand, the son acts without the patient’s consent, with a bad motive - greed - and is not performing a social role for which he is legally authorized.

48. KILLING AND ALLOWING TO DIE III • Brock’s point is that these things show that what the doctor did to the patient and what the son did are morally different - one is moral and the other is immoral - but what the example does not show is that “the son killed the patient while the doctor allowed her to die.” • For Brock, even if we suppose that killing is worse than allowing to die, and that withdrawing life support is allowing to die, while euthanasia is killing, it need not follow that euthanasia is morally wrong.

49. WHY IS KILLING WRONG I? • Brock asks: just what is it that makes the deliberate killing of an innocent person wrong? • He thinks that a good answer is that killing deprives a person of the possibility of having a valuable future. [Don Marquis uses this as an argument against abortion.] • Every innocent person has a right to the possibility of a valuable future, and as killing deprives a person of this right, killing is wrong. Another way to put this is “people have a moral right not to be killed.”

50. WHY IS KILLING WRONG II? • People are a kind of being which can have a sense of the future, can plan for the future, and can see life in the future as something which they value and can anticipate taking pleasure in. • But making plans for and valuing the future presupposes the continued existence of the life whose plans and valuing they are. • If that life is ended so is the possibility of realizing those plans, and so ends the possibility of value to be realized in the future.