Tuesday, January 15, 2019

An Argument for “Passive” and “Active” Mercy Killing, or Euthanasia

Nathan Nobis, Associate Professor of Philosophy, Morehouse College, Atlanta, GA

Written for this open-access ethics textbook.
Draft 2/7/19; Current: 3577 words; can easily be cut down to the sought 2500.

6. Conclusions 10 

The format of this cut and paste of text below is horrible; please click on the link for better formatting!

1. Introduction

Sadly, there are people in very bad medical conditions who want to die. They are in pain, they are suffering, and they find their quality of life to no longer be at an acceptable level anymore. Given all that, they want their lives to end: they want to be out of their misery.

Some of these people are kept alive by machines or other medical treatments. If these machines were turned off or the medical interventions stopped, these people would die.

Those are some facts. Here is an ethical question: can it be morally permissible, or not wrong, to turn off these machines or stop treatment and so let someone die, in circumstances like these?

Many people, perhaps most people (at least in many Western cultures, including the United States) think it can be. They believe that, morally, we do not have to do everything we can to keep someone alive, no matter their quality of life or what they want. Indeed, sometimes keeping someone alive, when they could be allowed to die, would be wrong: we really should just let them die.

Here I develop an argument for this view, that what’s usually called “passive euthanasia” can be morally permissible.

More interestingly though, I explain how the reasons in favor of passive euthanasia suggest and support thinking that in some circumstances “active euthanasia” is justified: it can be OK to actively kill some patients, for example, by giving them an overdose of drugs that will painlessly end their lives. So, I argue that if you think it can sometimes be OK and appropriate to let some patients die, then you should also think it can sometimes be OK and appropriate to actively kill some patients.

2. Definitions

Let’s begin with some definitions to better understand the issues.

First, our topic is euthanasia, which is sometimes called “mercy killing.” The word euthanasia relates to the idea of a “good death.” People typically seek euthanasia to avoid a very bad death full of agony, pain, and suffering and all that results from that: for example, people wracked with horrific pain might not be able to meaningfully experience their final days or weeks with loved ones, due to the constant agony: it’s hard to talk, and listen, and share when you are in terrible pain.

The most common type of euthanasia involves someone euthanizing someone else. Another type involves someone performing euthanasia on themselves, or euthanizing themselves: this is a type of suicide. If they need assistance from someone else to do that, because their medical condition prevents them from doing it themselves (say, they are bedridden and lack the means to get the necessary drugs or supplies), that would be assisted suicide. If the assistant is a physician, this would be physician-assisted suicide.

Some argue that physicians shouldn’t be involved in any suicides, arguing that a doctor’s jobs is to preserve life and health, not to help people die. This view, however, overlooks the traditional physicians’ oath to “do no harm” and the argument that, in some difficult circumstances, continuing to stay alive is very harmful and so, therefore, to “do no harm,” one would help someone die: indeed, keeping someone alive would be more harmful and, thus, wrong. This concern about doctors’ roles can easily be avoided, however, since people who aren’t doctors are able to competently and compassionately provide assistance with these matters.

Whoever is doing it, euthanasia is usually classified as three broad types: voluntary, involuntary, and non-voluntary:

  • Voluntary euthanasia involves a person who wants their life to end and communicates this desire: the person wants to die and says so.  

  • Non-voluntary euthanasia involves an individual who neither wants nor does not want to live or die. Typical cases of non-voluntary involve patients who have been unconscious for a long time, in a coma or permanent vegetative state, and we have good reason to believe that consciousness will never return. Do such individuals want to live? Do they want to die? Since they don’t literally want anything at least now and haven’t wanted anything for a long time, due to being unconscious, both answers seem to be ‘no’: they don’t “volunteer” or ask for euthanasia and they don’t ask to be kept alive. Sometimes we know what such patients would have wanted for themselves in situations like these, but usually we don’t: most people don’t say in advance what they’d want for themselves in difficult situations like these.

  • Involuntary “euthanasia” involves someone who wants to stay alive and expresses this desire to stay alive. It is very important to be clear that if this person is killed this is not euthanasia, or “a good death”: in all or nearly all cases, this is murder or wrongful killing. Almost no ethicists argue for involuntary “euthanasia,” since most believe killing people against their will is profoundly wrong. Except perhaps in very unlikely circumstances (e.g., we are in a situation where we have very scarce medical resources, so we must “triage” patients and focus our resources on those most likely to live and live longest, or there’s a case where we somehow have excellent reasons to believe that even though someone says they want to live, they really don’t), we should respect someone’s stated desire to stay alive and act accordingly.

These definitions cover most actual cases of euthanasia, but they aren’t perfect. First, it could happen that someone said they would very much want their body to be kept alive in permanent coma, but nobody knows that’s what they wanted: if they are euthanized, is that involuntary or non-voluntary? It could also happen that someone wants to die, but has no way of communicating that (suppose they have an extreme form of “locked in syndrome,” with eye paralysis too, so they cannot even blink out messages). If they are euthanized, is that voluntary or non-voluntary? This is unclear, given the characterizations above, as are related possibilities of wanted to die, but nobody knows that and wants to live, but nobody can tell.

Nevertheless, these three types of euthanasia can further be classified as “passive” and “active,” which are typically characterized these ways:

  • Passive” euthanasia involves “allowing” someone to die; it involves “letting” someone die; the person who lets the person die is not the cause of the death, the medical condition is.

  • Active” euthanasia involves “doing something”; it involves killing; it involves being the cause of the death.

We will soon see that these common ways of distinguishing active and passive euthanasia aren’t entirely clear. This will be relevant to the argument that if passive euthanasia can be morally permissible, then so can active euthanasia.

A chart, with examples, might be helpful for thinking about the different types of euthanasia. This chart could also include who is doing the act of euthanasia, that is, who is letting someone die or doing the killing (who is also the recipient of the euthanasia, in cases of suicide), but we won’t include that dimension:

Type of Euthanasia
Voluntary Passive Euthanasia:

Example: taking someone off life support, who asks to be taken off.
Non-voluntary Passive Euthanasia:

Example: taking someone in a long-term coma off life support when we don’t know what they would have wanted.
Involuntary Passive “Euthanasia”:

Example: turning off life support machines, when the person wants to live and states this.

Note: this is universally agreed to be wrong or almost always wrong.
Voluntary Active Euthanasia:

Example: giving someone an overdose of painkillers, who asks to be given that dose.
Non-voluntary Active Euthanasia:

Example: giving someone in a long-term coma a lethal injection, when we don’t know what they would have wanted.
Involuntary Active “Euthanasia”:

Example: giving someone who wants to live and states this an overdose of pain medications to kill them.

This is universally agreed to be wrong or almost always wrong.

Here we will only discuss arguments about voluntary euthanasia, but readers can thoughtfully extend that discussion to the unique circumstances of non-voluntary euthanasia. Since  involuntary euthanasia, passive or active, is generally wrong, it won’t be discussed further.

3. An Argument for Passive Euthanasia

Can it be morally permissible to let someone die, or perform voluntary passive euthanasia? The options are ‘yes’ and ‘no.’

‘No’ suggests that we must always do everything we can to keep someone alive, even if they are miserable, want to die, and say so. To many, that’s just cruel. If a dog or cat were in a similar condition, we would do the merciful and humane thing and put them out of their misery: this is perhaps the one way that animals are often treated better than humans.

The judgment that ‘yes, it can be OK to let someone die’ can be supported by both consequentialist (or utilitarian) and Kant-inspired moral reasoning. (What Kant himself argued about these issues, however, might be different from what’s argued here: Kant sometimes applied his own moral principles to practical issues in unconvincing ways).

For the consequentialist, the person being out of their misery is a better consequence for them, and in general, than their staying alive: killing them decreases the net unhappiness, pain, and badness in the world. For the Kantian, killing them respects their autonomy (or personal self-governance): we should respect people’s decisions about profound issues in their own lives.  Given their reasonable desires, killing them treats them as “end in themselves,” but forcing them to live in their unwanted condition treats them as a “mere means” toward our own ends, not their own.

‘Yes’ can also be supported by spelling out conditions in which it can be OK to let someone die. We begin with an ‘if’ and develop a moral principle:

If . .

a.                   someone is dying, and

b.                  is in horrible pain and suffering, and

c.                   that pain and suffering cannot be relieved, and

d.                  that person wants to die and clearly says so, and

e.                   informed, thoughtful and caring people agree that the person would be better off no longer living . . ,

then it can be permissible to let that person die.

To many people, a principle like this seems plausible. And it justifies passive euthanasia in many circumstances.

The details of a principle like this take us to harder questions about euthanasia, harder than those that arise in most circumstances: e.g., what if someone wants to die now but isn’t currently in horrible pain and suffering, or is expecting to die, but many years later after a very slow decline? Should anyone else have “say” over your own life or judge whether some pain and suffering is “horrible enough” for you to reasonably wish to die? If so, who? What if someone isn’t dying and doesn’t even have a bad medical condition but just finds their life not worth living and so wants to die (and so, say, plans to starve themselves to death or do other things that will result in their death)? These harder questions, and others, would need to be addressed for a complete defense of this principle and any arguments based on it or similar principles.

People sometimes have immediate, “knee-jerk” reactions to questions like these, but utilitarian and Kantian insights are often good correctives. First, utilitarians would, and should, urge anyone who doesn’t have a challenging medical condition but wishes to die to seek counseling and assistance to help find happiness and fulfillment: in most cases, this would be better than death for that person and for promoting overall happiness: “it gets better,” as the saying goes. And Kantians don’t think that autonomy has no limits: just because we want something for ourselves doesn’t mean we should get it. Kantians don’t think “it’s your life, so do whatever you want with it,” since we have obligations to respect ourselves (and our future selves), given our value as persons. This respect for ourselves could rule out some cases of euthanasia and suicide.

In sum, a basic case for passive euthanasia can be supported by utilitarian, Kantian and common-sense moral thinking. Let’s consider two objections before moving on to the case for active euthanasia.

3.1. First, some claim that pain can always be controlled, and patients always kept comfortable, so there is never a need to let anyone die (or, of course, actively kill them).

In reply, medical professionals try their best to control pain and make patients comfortable and they often are effective. But the insistence that pain can always be made bearable for everyone is, unfortunately, not true: some patients’ pains cannot be controlled to their own satisfaction.

3.2. Second, some argue that “miracles” are always possible, so there’s always a chance that someone gets better and even survives, and so we shouldn’t let patients die.

These hopes are understandable, but there are conditions that nobody has ever recovered from, and so the chances are very slim. And we don’t usually make important decisions based on very unlikely chances: for example, you could be in an unlikely car accident where a seatbelt harms you, rather than helps you: nevertheless, wearing a seatbelt is the smart choice.

Also, no type of euthanasia, passive or active, would prevent a miracle, especially a genuine miracle involving divine intervention: turning off the machines could be the occasion for a miraculous recovery, and an overdose of painkillers could be miraculously transformed into life-saving medications. People hoping for a miracle shouldn’t forget what miracles really could be.

4. An Argument for Active Euthanasia

The basic argument for active euthanasia, that is, for intentionally killing people who, due to their medical conditions, wish to be killed and say so is fairly simple.

We begin by reflecting on the basic reasons why passive euthanasia can be OK: it gets people out their misery and respects what they want for their own lives. “Letting people die” is a means toward those ends or goals. However, these goals can be pursued more directly and immediately by actively killing patients who wish to die. Letting people die often takes a long time, and that time will often be filled with pain and suffering, which the patient wants to avoid. Killing people, when they want to be killed, achieves the goals that they want, that is, to be out of their misery, more quickly and with less pain. And that is what they want, so they get what they want, quicker.

So, the basic assumptions that less unwanted pain and suffering is typically better than more and people’s desires about profound matters affecting their own lives and deaths usually should be fulfilled sooner than later, and the fact that killing someone is often a more effective means towards those ends, justifies active euthanasia, at least in some circumstances.

5. Objections: Potentially Relevant Differences Between Active and Passive Euthanasia

There are many objections to this type of reasoning, all intended to explain why active euthanasia is wrong but passive euthanasia can be permissible. Let’s consider some of the most common.

5.1. First, some claim that it’s always wrong to intentionally kill someone, so passive euthanasia can be OK but active euthanasia is wrong.

In reply, while we should agree that it’s, at least, nearly always wrong to intentionally kill someone, we should that most people want to live and do not currently have lives full of pain, suffering, and misery. So, the rule against killing is good in general, but we can argue that there are justifiable exceptions to this rule and that euthanasia is one of them.

Although this might sound unbelievable, some might try to convince themselves that their intention in any euthanasia is not to kill anyone: killing is an unintended consequence of their real intention, which might be to make the patient comfortable. If this make sense, they might claim that they are not engaged in any intentional killing, so they aren’t breaking that that rule.

5.2. Second, some argue that allowing active euthanasia puts us on a “slippery slope” to murdering patients, and people in general, who are not in challenging medical circumstances or do not want to die. That’s wrong, so we shouldn’t allow euthanasia, which might lead to that.

In reply, we can rightly wonder why that would happen, since arguments for euthanasia are very specific on the conditions where it might be permissible. They are especially clear that if someone wants to live, they should not be euthanized. Finally, there are serious doubts that killing people who don’t have serious medical difficulties could be OK, given better options for them. This concern is usually directed at active euthanasia, and we should recall that that accepting passive euthanasia could take us on a slippery slope to letting people die who want to live, but it doesn’t; and we don’t conclude that since it might, we must never let anyone die when we can keep them alive, irrespective of their quality of life or what they want.

Slippery slope “arguments” often assert “Do this and something else bad might happen, so don’t do this!” The keyword is ‘might. Here we have no good reason to think this bad thing would happen or that it must happen or that nothing can be done to likely prevent it. We can, would and do implement safeguards to prevent or lessen any bad results that are unlikely but might happen from any acceptance of euthanasia, just as we do with many other things that might lead to bad results if misused or abused.

5.3. Third, some argue there is always an important (moral) difference between “allowing” something to happen and “doing” something, and so passive euthanasia is OK but active is not.

We might first wonder if there is a clear distinction here. Consider this example:

In a deep forest, hiking alone, you find someone who has fallen into a deep pit. They ask you to throw them a rope so they can climb out. You don’t and they eventually starve to death. You learn of this on the news but feel fine since, you tell yourself, “I didn’t do anything to cause their death.”

Many would find this unbelievable: you did do something: what you did was stand there and not throw them the rope. Another thing you did was not tell anyone they needed help. “Inaction” is itself an action: doing nothing is doing something.  

Furthermore, what you did (in “doing nothing”) was wrong. (Places with “Good Samaritan” laws make doing nothing a crime, when you could easily assist someone with types of immediate, life or death needs). Maybe it would have been worse if you pushed the person into the pit yourself (or maybe not?), but your letting them die was wrong. Part of what caused their death is what you did: had you acted differently, they would still be alive.

Examples like these suggest that there are not clear and bright moral or conceptual differences between allowing something to happen and doing something. This objection assumes there are.

5.4. There’s an important (moral) difference between killing and letting die, and so passive euthanasia is OK but active is not.

This final objection is similar to the previous. James Rachels famously responds with an example like this:

An evil aunt will inherit lots of money if her five-year-old nephew dies. She plans to drown him in the bathtub and make it look like an accident. She will get away with it. He just started his bath and she’s on her way to the bathroom to drown him. She opens the bathroom door and is delighted to see that he has slipped in the bathtub and is drowning. She watches, ready to push him under if he steadies himself and is able to save his own life. But, as her luck would have it, he doesn’t and so he drowns. She never touches him throughout the ordeal and inherits the cash, never telling a soul what happened.

What an awful story. What an awful aunt. Her motives were awful and what she did was wrong. If she explained that she didn’t “do anything,” that she didn’t do anything wrong, that, at best, she merely “let someone die”  – it’s not like she killed anyone! – she is profoundly mistaken: letting someone die can be just as bad (or nearly as bad) as killing someone. We might even say that a way to kill someone is to let them die.

The objection here depends on a clear moral distinction between killing and letting die. There is no such distinction.

6. Conclusions

There are, of course, more objections to these arguments, and other important arguments and concerns to discuss, and factual information to review, to have genuinely responsible views about these matters: this essay is just a start.

These issues of this essay are important and not just for people currently facing difficulties where euthanasia might be part of the response. These issues are important to all of us since we have no idea what will happen to us, and our loved ones, years down the road, tomorrow, or even later today: an accident or illness might befall us that forces us to ask and answer hard questions about whether our lives are still worth living. While we hope these questions aren’t forced on us, we should ask them now and work on answering them now, together and as individuals. Part of a good death is that it is an end of a good life, and an opportunity to begin a better life is always now.

No comments:

Post a Comment