11.2 Arguing About Euthanasia

The way I would like to assess these various types of euthanasia is by considering some of the major arguments for and against the different varieties of euthanasia. There are no doubt many other ways to argue about euthanasia than the arguments we will look at, but these are simply some of the better known and more worked-out arguments on the topic.

Against medical killing

Our first argument is an argument against making any form of euthanasia, whether it is physician assisted suicide or active euthanasia, legal. It goes like so:

The role of physicians is to aid in the preservation of life.
Legalizing physician assisted suicide or active euthanasia would require at least some doctors to violate that role.

Thus no form of euthanasia should be legalized.

At first glance, this may seem compelling. The Hippocratic oath, after all, mentions, “First do no harm,” as the primary constraint on the job of the physician. The primary role of medicine is, to add to the plausibility of this argument, to cure illness and relieve pain, and not to be involved in the termination of human life. However, on closer consideration, this approach to the topic of euthanasia soon reveals itself to be too general and inflexible to be of much use. First there are the technical issues involved in preserving life. For example, is a patient in an irreversible coma with severe and permanent brain damage really even alive? In a sense yes – such a person has a heartbeat and can be kept alive indefinitely through the use of a feeding tube, and in a sense no – no amount of treatment will be able to restore function to a brain permanently damaged by, say lack of oxygen. To say the least, cases like this make the role of the physician in preserving life quite difficult to understand and put into practice. In addition, this argument seems to lead to a blanket restriction on physicians playing any part whatsoever in the death of patients. But does this mean not giving palliative care, care intended to alleviate suffering, to terminally ill patients dying, say, of cancer? Medicine is not, in other words, always a struggle to maintain life, but is also often concerned with alleviating suffering. It is this additional role of the physician that is behind the second argument to consider – the argument from mercy.

Appealing to mercy

The clearest argument in favor of legalizing at least physician assisted suicide and perhaps also active euthanasia appeals to the idea that we should ease the suffering of the terminally ill. This is the other major role of medicine – helping to relieve the suffering that disease or injury often entail.

Some incurable illnesses cause immense suffering that medicine cannot relieve.
In such cases, preventing someone from dying sooner rather than later is wrong since it causes pointless suffering.
Allowing someone to kill themselves under a physician’s guidance, or when necessary, allowing physicians to administer lethal drugs upon the patients request, is the only merciful option.

Thus physician assisted suicide, or even active euthanasia, should be legalized.

This argument clearly stands in contrast to the first argument, since it emphasizes the other aim of medical treatment, the alleviation of suffering. It insists, moreover, that it should be up to patients to determine whether or not their lives are “worth it.” So why not, it may be countered, allow patients to refuse treatment if they deem that their lives are no longer worth living? Well, in some cases, the suffering involved in a slow death is so bad, that it seems cruel not to allow patients to choose assistance in speeding the process up. (This point is central to Rachels’ argument as we will see in a moment.) The argument from mercy rests on the assumption that someone can and should be allowed to give up on their own lives. That’s obvious, isn’t it? Well, not according to Kant.

Kant’s argument

Part of the difficulty involved in discussing and resolving questions about euthanasia undoubtedly comes from the close relation between euthanasia (voluntary euthanasia at least) and suicide. Suicide has long been a taboo in Western culture, as it is in many other cultures. Suicide is held to be shameful, cowardly, an insult to others towards whom the suicide has responsibilities and/or to God (or the gods). It is a sign of a basic inability to cope with reality. Opponents of euthanasia often emphasize the connection of voluntary euthanasia with suicide. On this view, the person who opts out of struggling to survive a painful illness, or signs a do not resuscitate order is giving up hope and taking the easy way out. Thus as long as suicide is a taboo, voluntary euthanasia, if it is a form of suicide, would clearly also be off limits, not a topic to talk about in polite company, and certainly nothing to seriously consider as a rational response to illness.

On the other hand there have always been defenders of suicide, not as something to encourage, but as a possibly rational solution to certain types of problems. The 18th century Scottish philosopher David Hume, one of the precursors of utilitarianism, wrote a famous essay in defense of suicide. In it he argued that killing oneself in certain circumstances could be rational or even obligatory if the only alternative was to bring harm upon others or suffer needlessly from a painful terminal illness. Kant, in contrast argues that suicide can never be rational, and so, according to his standard method of argument, it cannot be moral.

An act can be rational only if performing that act does not undermine the possibility of attaining the goal towards which it is directed.
Suicide is a self-undermining act, since the point of suicide is relief from suffering, but the result of suicide is death – a condition in which there is neither suffering nor relief.

So suicide is irrational and hence immoral.

According to this argument, suicide can never be defended as a moral act, and thus it should be ruled out of consideration in all cases. The problem here, of course, as utilitarian critics of Kant will be sure to note, is that it seems hopelessly unrealistic to judge the real-life complications of the end of a human life according to an absolute moral standard that insists that we all have a duty to struggle on in pain, no matter how awful it is. Nevertheless, Kant’s claim that suicide is irrational in its intentions should give us pause, and keep up from the easy adoption of the attitude that ending one’s own life is ever a purely rational choice.

Active and passive, is there a moral difference?

It is a very widely held belief that there is absolutely nothing wrong with voluntary passive euthanasia. Writing a living will and demanding that it be respected does not involve taking any moral risks, and is something that is perfectly legal in all fifty states in the USA, and throughout much of the world. Each of us has the right to refuse medical treatment and thus there is absolutely nothing wrong with asking doctors to stand back and allow us to die in certain circumstances. On the other hand, many people, perhaps even the majority, are opposed to active euthanasia, and assisted suicide. Requiring that doctors passively let us die, at our own request, is one thing, asking them to actually help us to do so is something else entirely. Or is it? James Rachels, in a well known article claims that this moral distinction between letting someone die (acceptable in some cases) and actively killing someone (unacceptable in most cases) does not stand up to scrutiny. In fact he argues that there is no moral difference between actively killing someone and passively letting them die. His argument is based on consideration of a fictional and somewhat implausible case, that of Smith and Jones, both of whom have rich uncles whose money they will inherit. Both Smith and Jones, morally corrupt as they are, decide that they do not want to wait for their uncles to die of natural causes, that is, they decide to kill their uncles.

Example 11.1 Jones goes to visit his uncle, who is upstairs at home taking a bath and does not hear Jones come in. Jones, after having picked up a brick outside, creeps in and the up the stairs. He quietly opens the bathroom door and knocks his uncle on the head with the brick. Jones’ uncle is knocked unconscious and sinks into the tub where he drowns. Smith, likewise, pays a visit to his uncle, grabs a brick from outside and creeps up to the bathroom where his uncle, as luck may have it, is also taking a bath. Just as Smith is about to kill him, however, his uncle bumps his head on the soap dish, gets knocked unconscious and thus drowns while Smith silently watches.

Considering the details of this case, it seems that both Jones and Smith are evil people. Further, their acts seem equally bad – both stand to gain from their respective uncles’ death, both decide to kill their uncles, both approach them to carry out this intention. But only Jones’ brick actually make contact with his uncle’s head, while Smith’s brick hovers a short distance above his uncle’s head. But that seems like a completely inconsequential detail. So what if all Smith did was watch his uncle die, he is just as bad as Jones. Now the point of this case is just to show that in and of themselves, removing all other factors, killing and letting die are morally equivalent. In this case they are equivalently bad. As Rachels argues, in the case of euthanasia, if we accept that passive voluntary euthanasia can be a good thing, then active euthanasia in the same circumstances would be just as good.

If there is no essential moral difference between killing and letting die then there is no way to defend the position that passive euthanasia is acceptable while active euthanasia is not. The Jones and Smith case shows that there is no essential moral difference between killing and letting die. Thus we should either allow both active and passive euthanasia or forbid both. This seems like a pretty compelling argument. Is there really any way to distinguish active killing and passive letting die? If not then their moral status, whatever it might happen to be, would have to be the same.

Peter Singer’s argument

Some people have absolutely no hope for survival for medical reasons – for example, babies born with anencephaly.
There are two choices in such cases, either they can be allowed to die naturally, or they can be painlessly killed.
Medical resources are limited.

Rather than waste medical resources on allowing anencephalic babies to die slowly, they should be killed to free up the medical resources where they will do some good.

In this argument, developed by Peter Singer, the claim is that in some very rare cases active non-voluntary euthanasia can be acceptable. These cases would be very clearly defined cases where there is absolutely no hope for someone, and yet allowing them to die (which will inevitably happen), as opposed to speeding up the process, prevents other people from getting the medical attention that they need. In such cases people should be killed in order to enable others to benefit from medical resources, such as hospital beds, IV drips, etc., that others might benefit from. Clearly this kind of argument is going to ruffle some feathers. But isn’t it true that if we are devoting any resources to someone who has absolutely no chance of survival (and who is also not capable of being even conscious, as is true of anencephalic babies), that is a waste of those resources?

Slippery slopes?

Naturally, arguments like Singer’s raise the question of whether even thinking seriously about killing any babies, no matter how hopeless their cases may be, is already going too far. Isn’t this just disrespectful of human life, to contemplate throwing it away, however damaged it may be? And doesn’t this kind of disrespect of human life often lead to disrespect for people with less severe afflictions? That is, are we not sliding down a slippery slope, if we accept Singer’s argument? This brings up a standard objection to all varieties of euthanasia that are not currently acceptable, that is to anything stronger than passive voluntary euthanasia.

Legalizing assisted suicide or active euthanasia will lead inevitably to the following consequences:

• Elderly people will give up hope sooner than they would if they did not have the opportunity to kill themselves or request euthanasia.
• Those who pay for expensive treatments will put pressure on patients to choose death.
• Doctors will lose a degree of respect for human life and will give up sooner.
  

All of these consequences are unacceptable.

Thus neither physician assisted suicide nor active euthanasia should be legalized.

In general, slippery slope arguments are not to be trusted – “slippery slope” is the name of a fallacy because the fact that one thing happens does not logically require that something worse will happen, if there is no law of nature that forces it to happen. There clearly is no law of nature that would force us to carry out involuntary euthanasia just because we happen to have legalized physician assisted suicide. As philosophers put it, there is no nomic or law-like necessity here. But, nevertheless, we may wonder whether doing something that seems innocent may not end up having long term detrimental consequences. The slippery slope argument at least demands that we take this possibility seriously.