Category Archives: Euthanasia

Dan Brock: “Voluntary Active Euthanasia”

Dan Brock says his essay, “Voluntary Active Euthanasia,” discusses voluntary active euthanasia in cases “where the motive of those who perform it is to respect the wishes of the patient and to provide the patient with a “good death…”

The Central Ethical Argument for Voluntary Active Euthanasia –

The values supporting voluntary active euthanasia “are individual self- determination or autonomy and individual well- being.” Self-determination refers to persons being free to make decisions about their own lives. [Rather than governments, religious organizations, political groups, strangers, etc.] And this autonomy ought to extend to the end of life when persons worry about suffering and the loss of dignity. Individual well-being refers to situations in which individuals decide that “life is no longer considered a benefit by the patient, but has now become a burden.” In other words, their well-being is best served by dying. This does not imply that physicians must perform this act against their will.

Potential Good Consequences of Permitting Euthanasia – 1) respect individual autonomy (of about 50,000 persons a year in the US in this situation; 2) give reassurance to those who may want euthanasia in the future; and 3) it will relieve vast amounts of suffering.

Potential Bad Consequences of Permitting Euthanasia – Brock list 3 arguments: 1) performing is incompatible with the “moral center” of being a physician and thus patients would fear their physicians. B replies that patients should not fear that their physicians will kill them, since E would be voluntary and the moral center of medicine should be self-determination and individual well-being not preserving life when persons have deemed they no longer want that. 2) E would weaken respect for life. (Do we respect life in our country?) Brock responds that he is skeptical because a) passive euthanasia had no such consequences; and b) euthanasia would only relevant in a small minority of deaths. 3) Legalizing voluntary euthanasia would lead down a slippery slope to involuntary euthanasia. Brock responds that this is the “last refuge of conservative defenders of the status quo.” When all your arguments against something have been defeated you simply say that this something will lead to something else.

My Commentary – While it is possible that doing x will lead to bad consequence y, that is not enough of a reason not to do x. When in vitro fertilization was introduced in the 1970s, Leon Kass, later the head of President George W. Bush’s bioethics commission, wrote feverishly for years that this would undermine the value we place on human life. In the meantime, millions of persons have been born this way and nothing like that has happened. We don’t want to know if some terrible consequence is possible, rather we want to know if this consequence is plausible. And no one had done this. Brock suggests a number of safeguards to minimize the chance of abuse. However the idea that one must be terminally ill—like the law demands in Oregon and Washington in the US—does not, according to Brock, respect self-determination. As Brock suggests, OR and WA can serve as test cases for such laws. So let’s see if society collapses because of euthanasia laws. Of course to think this will happen is ridiculous. In fact the Netherlands has had the most liberal euthanasia laws on the books for years and it is one of the best, most civilized countries in the world.

James Rachels, “Active and Passive Euthanasia”

The late philosopher James Rachels published one of the most salient pieces on the euthanasia (E) debate in 1975 the New England Journal of Medicine titled “Active and Passive Euthanasia.” Here is a brief outline of his argument.

The distinction between active euthanasia (AE) and passive (PE) is thought crucial. This is mistaken. Why?

  • AE is preferable to PE because it reduces suffering.

Rachels understands saving all defective newborns, or destroying certain ones (if they have down’s syndrome (DS) or congenital defects for example), but he doesn’t understand allowing them to die slowly and painfully.

  • Given the distinction, life & death decisions are made on irrelevant grounds. For example, intestinal blockage (IB) allows us to let a DS baby die, but wo/ the IB we would have to kill it. But the blockage is irrelevant. The issue is whether the DS baby should live. The distinction between AE and PE make this situation absurd—it leads to us thinking IB was important.
  • Killing is not worse than letting die. Consider 1) Smith drowns his cousin for money; and 2) Jones lets his cousin drown for money. It doesn’t seem there is any moral difference between the 2 cases. Similarly, whether you kill or let die for a good motive—say to relieve suffering—the act is right or wrong independent of how you brought death about. In both cases the intent or motive is primarily to terminate life (and relieve suffering or costs).

We tend to think killing is worse than letting die because usually bad guys kill and physicians let die. But this doesn’t mean that there is something intrinsic to killing which is worse than letting die.

Counter argument – In PE the physician does nothing and the disease kills the patient. In AE the physician does something to kill the patient.

Rachel’s Response – 1) Physicians do do something when the allow people to die—they let them die. That is a type of action. 2) It is bad to cause someone’s death because death is ordinarily thought bad for them. But if death has been deemed preferable, then bringing about death is no longer bad. 3) MDs may have to go along with the law, but the distinction between active and passive euthanasia cannot be defended philosophically.

Comment – This is one of the most air-tight and flawlessly reasoned pieces I have read in the medical ethics literature. And my sense is that this argument is increasingly winning the day.

J. Gay Williams, “The Wrongfulness of Euthanasia”

In his article, The Wrongfulness of Euthanasia, J. Gay Williams rejects the view that “that if someone (and others) would be better off dead, then it must be all right to kill that person.” For Gay-Williams euthanasia (E) is intentional or deliberate killing, not accidental killing or letting one die. Given his subsequent rejection of the notion of passive E, it is clear he is using the narrow definition of E. E is intentional killing only, in other words, it is active E. Passive E is not E because one does not intend the person’s death—it is a foreseeable, but unintended consequence. (I foresee my driving will wear out my tires, but I don’t intend to wear them out by driving.)

The argument from nature – We have a natural desire to survive and E violates this desire. (Do we have this desire if we are suffering terribly? Isn’t it natural to want to relieve our suffering? And even if we do, have a natural desire to survive, does the fact that we have natural desires make them things we should follow? It may be natural for me to be violent, envious, lustful, scheming, etc. Does that mean these are good? It may be natural to die of bacterial infections, but that doesn’t mean its good, does it?) His argument in this section may be reconstructed as follows:

  1. Acts of euthanasia are contrary to our human nature.
    2. If (1), then acts of euthanasia are a denial of human dignity.
    3. If acts of euthanasia are a denial of human dignity, then euthanasia is morally wrong.
    4. Therefore, euthanasia is morally wrong.

The argument from self-interest – may be summarized as follows:

1. Acts of euthanasia contain the possibility that we will work against our own interests.
2. If (1), then acts of euthanasia are morally wrong.
3. Therefore, acts of euthanasia are morally wrong.

Support for (1): (a) Possibility of misdiagnosis/misprognosis; (b) possibility of new medical procedures; (c) thinking euthanasia permissible may encourage one to give up too easily; (d) choose E because of our concern for others.

The argument from practical effects – may be summarized as follows:

1. Cases of euthanasia could have a corrupting influence on doctors and nurses.
2. If (1), then acts of euthanasia are morally wrong.
3. Therefore, acts of euthanasia are morally wrong.

Support for 1: a) doctors and nurses might not try hard enough to save someone; and b) this may lead to involuntary E. (A “slippery slope” argument.)

Reflections – I find this argument ridiculously weak. Over the next two days I will outline some counter-arguments.

Outline of The Euthanasia Debate

Technology prolongs and sustains life artificially. Parallel to the question of when becomes a person in the abortion debate, a central question in the euthanasia debate is when does one cease to be a person?  If one is deemed no longer to be a person, then the question of their rights is less important.

What is death? Until recently the cessation of breathing and heartbeat defined death. Now machines maintain respiration and heartbeat even when there is no brain functioning. So increasingly brain death is the preferred definition.

Also relevant to discussion of death are: 1) philosophical concerns about what is a person; 2) physiological concerns about what criteria define death; and 3) methods used to determine physiological states. Moreover the various definitions have a huge impact on moral decisions (if one is already dead, the moral situation is different than if one is not.)

Another important distinction is between ordinary treatment that offer a hope of benefit without undue cost vs. extraordinary treatment that offer no hope of benefit at great cost. The most obvious difficulty here is that the definitions keep changing, as what was once extraordinary—say heart surgery—becomes ordinary.

Also to be differentiated is killing vs allowing to die. The former refers to an act of commission (causing harm) that brings about death; the latter to an act of omission (permitting harm) that brings on death. Defenders of the importance of the distinction argue that if we kill, we are the cause of death; whereas if we allow someone to die, the disease is the cause of death. Opponents argue the distinction is not relevant.

A narrow definition of euthanasia (E) includes only killing as E; allowing to die is not E. Proponents typically view E as wrong; but allowing to die as not wrong.

A broad definition of E includes both killing (active E) and allowing to die (passive E). Proponents typically argue that both killing and letting die can be moral.

Another distinction is between voluntary E—where the patient consents to treatment or non-treatment—and non-voluntary E—where someone other than the patient gives consent.  In addition sometimes the category of involuntary E is introduced, cases where one doesn’t consent but had not made their wishes known beforehand.

Another important category is assisted suicide, typically by a physician (PAS). This is similar to voluntary active E except that in PAS the physician does not kill the patient but enables it.

In addition the right to refuse treatment has been recognized in America since 1990. In addition the use of living wills, durable power of attorney, advanced directives, and similar documents are now allowed.

Other problematic cases include the issue of defective newborns (DN). Here positions range from: 1) allowing to die in most circumstances; 2) allowing to die only when DN won’t have meaningful lives; 3) never allow to die. (At the other extreme would be killing in most circumstances.)

In the next few posts we will outline some views on the issue.

Better Off Dead or Worse Off Alive?

Yesterday’s post promised a few thoughts on death with dignity. Having taught medical ethics for more than a decade, I have spent some time reading, thinking and writing about the subject. In 1994 I published a piece called, “Worse Off Alive: Reply to Garcia” in the American Philosophical Association’s Newsletter On Philosophy and Medicine. The newsletter is still published, but a twenty year old hard copy is hard to find and no soft copy exists, at least as far as I know. Here is the original version based on my hard copy.

“Worse Off Alive: Reply to Garcia” (from the American Philosophical Association’s Newsletter On Philosophy and Medicine, 1994.)

The goal of J.L.A Garcia’s article, “Better Off Dead,”(Volume 92, No. 1, pp. 82-85) “is to cast doubt on the doctrines that someone’s dying can be a good thing for that person, that some lives are not worth living, and that there can be a right to die.” Thus, he argues, we are never “better off dead” and that nearly all human lives are worth living. He also implies—but never specifically argues—that there is no right to die. I argue that, though we are not “better off dead,” we may be “worse off alive” when enduring extraordinary suffering. I also argue that lives deprived of certain goods are not worth living. Let us examine Garcia’s arguments in turn.

According to Garcia, euthanasia proponents deem death an instrumental good because it relieves a patient’s suffering. But instrumental goods, he argues, are good only when they “make our lives go better,” and being free from anxiety or physical pain “is good inasmuch as it yields a less troubled life.” Since causing or allowing someone to die does not make their lives go better, it is not an instrumental good. In short, dying brings about no good for a person—since dead persons don’t exist—and thus, one cannot be “better off dead.”

Garcia is partly correct. It is never better to be dead in the sense that one’s life benefits or improves by dying, and therefore, if death is non-existence as he seems to suppose, no good or bad comes from being dead. The problem with this argument is twofold: 1) it reduces to the self-evident and trivial assertion that non-existent persons cannot experience good; and 2) it misconstrues the issue. Few persons who desire to be relieved from excruciating suffering believe they will gain from their death by experiencing some benefit, except possibly in an afterlife. What they obviously do believe is that, in their present condition, they are “worse off alive,” and this justifies euthanasia for them. In their condition they prefer death to life because life offers so little, not because death offers some gain or benefit. In certain cases Garcia seems to agree: “When we permissibly withhold or terminate treatment in such cases, it is because we judge that the kind of life that aggressive treatment could secure the patient is not so great a good as to require us to secure it at staggering cost to the patient herself or to others.” Presumably, the cases to which he refers are those that employ extraordinary means, though he does not explain why this rationale applies only to these cases. Nonetheless, if life is not the only good, as he admits, and the kinds of life secured by certain treatments are not good enough to be preferred to death, then we are sometimes “worse off alive.”

Next Garcia turns to the claim that some lives are not “worthwhile.” This claim, he argues, results from the disparity between healthy, highly educated, refined, and economically advantaged bioethicists, and the dying. These professionals judge the quality of life of the dying to be quite minimal, overlooking many similarities between themselves and the dying, particularly their shared existential despair. Such considerations [should] caution us against hasty generalizations about the value of human lives. Who is to say that our lives, projects, and goals are valuable? And if we cannot be certain about the value of our own lives, how can we be so sure about the value of the lives of others? This argument is problematic for at least two reasons: 1) it applies only to those advocating non-voluntary active euthanasia; and 2) what follows from it is that we [should] reject proxy judgments of the value of individual lives, not that it is never better to die or that all lives are worth living. What he has shown is that by resisting generalizations and proxy judgments we respect human autonomy, a fundamental value according to Garcia, “even if the choices we make are often disastrous.” So pointing to universal human despair doesn’t show that all lives are worth living.

Garcia concludes by “rejecting the suggestions that it might be better for someone to die and that her life might be improved by her death.” He correctly assumes that our lives do not improve when we die because then, obviously, we no longer [have] experience[s]. And if life is a good so great that no possible agony, suffering, evil, pain, or torment negate its value, then life is always preferable to death.

However, most ordinary individuals disagree. They applaud the advanced directives for health care, sign their living wills, and ask their spouses, friends, sons or daughters to act as their surrogates. They choose to forgo the remainder of lives deprived of those things that make life valuable—the ability to love, think, touch, reflect, and remember—for the uncertainty of death. They prefer not to debase human life or glorify suffering but to exercise human autonomy. For those who believe there is meaning in the most excruciating forms of physical pain and dementia—let them be free to do so. But for those of us who believe that, at least sometimes, we are “worse off alive”—let us be free to choose.

Note – I still agree with the sentiment of this paper from twenty years ago. Ideally, however, we will use our science and technology to overcome death and suffering.