Lecture 16 Euthanasia I

Lecture 16 Euthanasia and Assisted Suicide




Under existing laws people suffering unrelievable pain or distress from an incurable illness who ask their doctors to end their lives are asking their doctors to become murderers.

Peter Singer Practical Ethics (in White, ed. p.116).


Preliminary Discussion:
Hospital death spurs debate on euthanasia Japan Times April 9th 2006

1). What is the difference between ‘passive’ and ‘active’ euthanasia?
Do you think there is a moral difference between the two?
2). The unnamed chief surgeon in the story has disconnected seven respirators from terminally ill patients, killing them. Why did he do this? And what was his motivation?
a). Was his motivation ethical?
b). Even if it was ethical, was it the correct decision?
3). Masahiro Ishimaru criticizes the “50-year old surgeon” on trial for disconnecting respirators. He reasons: “A doctor’s motivation is rooted in an absolute commitment to saving life- that’s why I don’t feel comfortable with disconnecting respirators.” Do you agree?
4). According to Ishimaru, “liking people” means keeping them alive for as long as possible, no matter what. Is this correct, in all cases?
5). Do you agree with the view that Japanese law is too vague on this issue? If so, how could the law be made more exact?
6). What would the benefits be in making the law more explicit?

16.1 Definition of Voluntary Euthanasia
Robert Young defines euthanasia as follows:

When a person carries out an act of euthanasia, he brings about the death of another person because be believes the latter’s present existence is so bad that she would be better off dead, or believes that unless he intervenes and ends her life, it will become so bad that she would be better off dead. The motive of the person who commits an act of euthanasia is to benefit the one whose death is brought about. (Young Euthanasia: 1)

Voluntary euthanasia is defined as a case where the person who is killed volunteers to be killed. Non- voluntary euthanasia is defined as a case where the person killed does not give consent, because they are either not competent (as the case with very young children) or unable to. Involuntary euthanasia is where a competent person’s life is ended against the explicit wishes of the person killed. (One wonders if the latter is even logically possible, insofar as euthanasia means ‘good death.’)
In these lectures we will only be concerned with voluntary euthanasia, and whether it should be legal (or illegal).


16.2 Necessary Conditions for Candidacy for Voluntary Euthanasia
Advocates of voluntary euthanasia contend that if a person meets the following criteria, voluntary euthanasia should be legally permissible.

1). The person is suffering from a terminal illness

2). The person is unlikely to benefit from the discovery of a cure for that illness during what remains of his or her life expectancy

3). He or she is, as a direct result of their illness, either suffering intolerable pain, or will only have a life that is unacceptably burdensome (because the illness has to be treated in ways that lead to her being unacceptably dependant on others, or on life support machinery)

4). He or she has a strong, enduring and voluntary wish to die (or has already expressed such a wish, but has now lost the capacity to do so),

5). He or she is unable to commit suicide by themselves.

(After Young Euthanasia).

Japanese law tolerates active euthanasia, and has done so for some time. The Japanese Medical Association has approved of euthanasia if the following conditions are met (this follows the Yokohama District Court ruling of a 1995 mercy killing case at Tokai University Hospital). The Japanese Academy of Science and Art has also approved of these rules, so long as the euthanasia is passive euthanasia (defined below, 16.3).
Active euthanasia requires the following conditions to be met:

1). The patient’s death is inevitable and imminent
2). The patient is suffering from unbearable physical pain
3). The doctor has done everything possible to remove the pain
4). The wish of the patient has been made clear. [1]

16.3 Active vs. Passive Euthanasia
Active euthanasia involves a deliberate act which results in the patient’s death, such as giving a lethal injection. Passive euthanasia involves a deliberate omission, such as removing hydration (water), nutrition (food) or machines that maintain airflow. Many medical associations and laws make a moral distinction between the two, suggesting that active euthanasia is morally worse than passive euthanasia. We will discuss this debate in the next lecture.

16.4 Historical Background

Philosophical Discussion on Suicide and Euthanasia
The Classical World: The Greeks and Romans were fairly tolerant of voluntary death, and certainly did not believe that all human life is intrinsically sacred and valuable.
Socrates argues that suicide is always wrong as we are essentially relieving ourselves (that is, our souls) from a ‘guard post’ (that is, our bodies) that the Gods have given us as a punishment.
Plato held that suicide is not immoral in the following circumstances:
a). when one’s mind is morally corrupted
b). When the self- killing is by judicial order (as in the case of Socrates, who was ordered to kill himself)
c). When the self- killing is compelled by extreme and unavoidable personal misfortune
d). When self- killing results from the shame of having done some terrible injustice.
The Stoics and Epicureans thought that simply killing yourself because life is no longer valuable was not morally problematic. Seneca, a Roman philosopher, had this to say: “mere living is not a good, but living well.” He also stated that a wise person “lives as long as he ought, not as long as he can.”

16.5 Early Modern Period:
Euthanasia has been prohibited in Western medicine roughly since the 15th Century, with the introduction of the Hippocratic Oath (an early Greek ethical code for medical practitioners).
In the 16th Century, Thomas More, in his text Utopia, envisaged a community where those with lives that were merely burdensome due to ‘torturing and lingering pain’ could request euthanasia.

16.6 Later Modern Period: Nietzsche

Many die too late, and some die too early. yet strange sounds the precept: “Die at the right time!”
Die at the right time! So teach I, Zarathustra.
…My death, praise I unto you, the voluntary death, which cometh unto me because I want it.
Nietzsche Thus Spake Zarathustra

Discussion: Nietzsche cared for neither deontology nor Utilitarianism, so what is the basis for his apparent advocacy of voluntary death? Is it a good idea, or not?

16.7 The Current Legal Status of Euthanasia
One Australian state (Northern Territories, 1997) Switzerland, the Netherlands and Belgium have essentially legalized euthanasia. Japan tolerates euthanasia, as mentioned above (the situation in Japan will be discussed more thoroughly in the next lecture). U.S law still considers all euthanasia to be equivalent to murder. (Recall the case of Dr. Anna Pou, charged with murdering patients at Memorial Hospital in New Orleans following Hurricane Katrina). For further details of the history of euthanasia, and the current status of euthanasia laws around the world, see the Stanford article Voluntary Euthanasia by Robert Young.

16.8 Cultural Background: The Buddhist Approach
There is little explicit discussion of the ethics of either suicide or euthanasia, or indeed any bioethical issue, in the Buddhist texts. Most of the secondary literature on this topic is reconstructive or speculative (that is, scholars have to guess or ‘reconstruct’ what the practical implications of Buddhist concepts might be).
Does Buddhism condemn suicide? On the one hand, the Vinaya considers assisting a suicide as a breach of monastic discipline (that is, against the rules that monks must abide by), resulting in expulsion. Yet even in the Pali canon (amongst the oldest Buddhist writings) the suicide of monks, so long as it was done out of the correct motivation, was acceptable. In Japanese Buddhism, even the non-voluntary euthanasia of infants was traditionally accepted.
The Dalai Lama himself has given the following statement:

In the event a person is definitely going to die and he is either in great pain or has virtually become a vegetable, and prolonging his existence is only going to cause difficulties and suffering for others, the termination of his life may be permitted according to Mahayana Buddhist ethics.[2]



16.9 Cultural Background: Buddhism and Shinto in Japan

In Japan, Buddhist and Shinto groups are far more tolerant of euthanasia than are Christian groups. Both Buddhist and Shinto groups advocate “being natural” when medical treatment becomes futile for the terminally ill. (One assumes that this means accepting ‘passive euthanasia’). Some Buddhist groups take prolongation of life using artificial means to be a “disgraceful act against life”; others claim that the patient should cede all control to the doctors, whilst some Shinto groups are accepting of full active euthanasia. In one survey, at least one Zen Buddhist group held that it was up to the patient what the best decision was. In short, the literature on the subject suggests that there is no consensus in Japanese religion as to whether euthanasia should be
permissible. [3]
Question: What are the merits of the principle of ‘being natural?’


16.10 Cultural Background: The Jewish Approach

There are two suicides in the Torah/ Old Testament, and neither is condemned within the text for being a suicide. Suicide is not mentioned in the Ten Commandments as being a specific sin. The first explicit discussion of suicide in Jewish writings appeared in the Semachot, and is a clear condemnation. [4]
However, some Jewish religious experts think that if something hinders the departure of one's soul--for example, if the sound of a woodchopper can be heard close by the house, or if there is salt on the dying person's tongue--it is permitted to remove this noise or the salt. There is also a story in the Talmud (the Jewish law book) that has been interpreted as defending euthanasia. As a rabbi lay dying, his disciples gathered in prayer to prolong his life. Their prayers were unable to restore him to health, sufficing only to keep him alive in great pain and suffering. Seeing this, his maidservant climbed to the upper chamber of the house and tossed a glass vase to the ground. The crashing sound interrupted the praying, and Rabbi died. The Talmud’s authors do not condemn her action, implying approval of it.

16.11 Cultural Background: The Christian Approach

St. Augustine, in the text The City of God (5th Century) condemned suicide. His argument was based on an original reading of the Biblical commandment “thou shalt not kill.” The rest of his arguments were taken from Plato’s Phaedra.
-Many Christians believe in the sanctity of human life; that is, humans are created in the image of God, and that human life itself is the miraculous gift of a divine Creator. Therefore, they argue, they must not kill themselves.
-The standard modern Christian view is that one’s life is the property of God and that to destroy it is to go against God’s wishes. (We’ll discuss David Hume’s counterargument in the next lecture).

The Donatists: Ironically, some early Christians believed that dying as soon as possible was the right thing to do, and would frequently kill themselves or had themselves be killed for the sake of spiritual perfection. (They considered this ‘martyrdom’). The logic is simple enough: This World is corrupt, and the longer one lives, the more opportunity one has to sin. Further, Tertullian, an early Christian, thought that Jesus’s death was a suicide (so, to live the life of Jesus required having someone else kill you, in effect). The Donatist Church, which flourished in the 4th and 5th Centuries in Roman Africa, was such a group. Some have suggested that St. Augustine’s explicit ban on suicide in Christianity was as a result of the Donatist Heresy.
-For the record, many early Christians were famous for doing risky, self- destructive things in the name of their faith, so the condemnation on killing yourself seems a little peculiar, given the reasoning offered (ie. self destruction is against God’s wishes, or that human life is a divine gift, etc). Origen of Alexandria, a major Christian thinker, allegedly castrated himself; medieval penitents were famous for scouring themselves with whips.

General Problems with relying on Religious Traditions for Ethical Guidance:
All of the religious texts cited here- the Buddhist canon, the Torah, Talmud and New Testament- were written thousands of years ago, by people who had no idea of the ethical problems presented by new medical technologies. Even if we assume that the basic ethical principles of these traditions are still tenable, we still need to work out what those principles are, and how to best implement them. Shinto and Japanese Buddhism are extraordinarily vague on bioethical issues; the ethical principles of Judaism and Christianity (like the deontological approach that they inspired) can run into conflict. The more general problem: philosophy begins when we can no longer rely purely on received tradition to make important, sound decisions.

16.12 The Problem of New Technologies; Ordinary vs. Extraordinary Measures

a). The Problem of Progress in Medical Science
Euthanasia has become a much more pressing problem in recent decades because of massive advances in technology used to prolong life. Whereas, until the mid- 20th Century, the chronically ill would simply die, it is now possible to keep chronically ill people alive for years. Consequently, technology can now stretch out physical and intellectual suffering in the very ill to an unprecedented degree.


b). Ordinary vs. Extraordinary Treatment.
It is often argued that there is a relevant distinction between ‘ordinary’ and ‘extraordinary’ medical treatment. While it is always necessary to use ‘ordinary’ medicine to take care of people, it is morally permissible to remove ‘extraordinary’ treatments. Writes one Christian commentator:

The Church makes a distinction between “ordinary” and “extraordinary” medical treatment. We are required to administer all ordinary treatment because of the dignity of human life and the natural respect owed the person. When death is imminent, we may administer extraordinary treatment according to the wishes of the patient. Extraordinary treatments are those that offer little hope of benefit and are burdensome, such as procedures that are experimental or overly aggressive.


Discussion: Is this a morally relevant distinction? Or is it arbitrary?


16.13 The Utilitarian Argument for Euthanasia: The Argument from Mercy

No human being with a spark of pity would let a living thing suffer so, to no good end.

Stewart Alsop, (in Rachels TRTTD: 176).


According to Utilitarianism, one should maximize pleasure (or whatever absolute good), and minimize pain. Further, Utilitarianism requires that we make the choice with the optimum consequences. When a patient wants to die, due to incurable and unbearable pain, we should assist them. As Rachels puts it, “[t] erminally ill patients sometimes suffer pain so horrible that it is beyond the comprehension of those who have not actually experienced it.” (Rachels “The Morality of Euthanasia,” TRTTD: 175-179, p.175). It is worth reading pp.175-177 of the Rachels essay here just to get a sense of how horrible life may be for the terminally ill.
Rachels gives the following formulation of the Argument from Mercy:

1). Any action or social policy is morally right if it serves to increase the amount of happiness in the world or to decrease the amount of misery. Conversely, an action or social policy is morally wrong if it serves to decrease happiness or to increase misery.

2). The policy of killing, at their own request, hopelessly ill patients who are suffering great pain would decrease the amount of misery in the world.

3). Therefore, such a policy would be morally right. (Rachels TRTTD: 177).


Defenders of euthanasia, against their Christian opponents, make the following point: How could merciful euthanasia oppose the wishes of a benevolent, all- loving, merciful God? (more on this argument in the next lecture).

Note: This argument presupposes Classical Utilitarianism, that is, the reduction of all value down to pleasure- maximization and pain- minimization. Recall the criticisms we’ve already discussed concerning the limits of such a doctrine. Are these criticisms relevant to the Argument from Mercy?
Someone might say: -“Is happiness the only thing to be considered? What about other things, like knowledge, or achievement? Perhaps an unhappy life could still be good because of achievements or knowledge.” (James E. White Contemporary Moral Problems p.99)
-discussion: how is this problem relevant to this case? We are, after all, talking about Voluntary Euthanasia.

The Question of Fear.
Some argue that doctors will become more likely to kill patients without consent if euthanasia is legalized. This will lead, they argue, to fear and insecurity in hospitals.
Singer replies:

In fact, the argument from fear points in favour of voluntary euthanasia, for if voluntary euthanasia is not permitted we may, with good cause, be fearful that our deaths will be unnecessarily drawn- out and distressing.” (White, ed. p.117).

16.14 Euthanasia and Dignity

Given that the terminally ill may be bedridden, in extreme pain, and incapable of any sort of valuable life, it can be argued that euthanasia may be a more dignified death than merely wasting away. Rachels cites a description of one ‘Jack,’ a terminally ill cancer patient who was reduced to crying like a dog when his painkillers ran out; “always poor Jack’s whimpers and howls would become more loud and frequent until at last the blessed relief [the morphine] came.”


16.15 The Preference Utilitarianism Argument for Euthanasia/
Respect for Autonomy

A Preference Utilitarian may also argue that we should maximize people’s choices, including the choice to die, or to refuse medication. (Recall the standard objection to Preference Maximization: some people may just have incorrect preferences. Is this objection valid here?). This appears to be the view of Singer.


It is […] highly paternalistic to tell dying patients that they are now so well looked after they need not be offered the option of euthanasia. It would be more in keeping with respect with individual freedom and autonomy to legalize euthanasia and let patients decide whether their situation is bearable- let them… have the dignity of choosing their own endings. (in White, ed. p. 119).

Interestingly, the Deontological approach- the respect for autonomy, is very similar to the Preference- Maximization approach. Simply put: we must respect people’s autonomy, in particular their free, rational choice to end their own lives.

Writes Robert Young,

There is no single, objectively correct answer as to when, if at all, life becomes a burden and unwanted. But that simply points up the importance of individuals being able to decide autonomously for themselves whether their own lives retain sufficient quality and dignity to make life worth living. Given that a critically ill person is typically in a severely compromised and debilitated state, it is, other things being equal, the patient’s own judgment of whether continued life is a benefit that must carry the greatest weight… (Young Euthanasia p.3).


16.16 Broader issues: Paternalism vs. Autonomy

One of the more general problems behind this debate is the clash between paternalistic principles, and the principle of respecting autonomy. In simple terms, a paternalistic approach holds that people are simply not capable of deciding for themselves what is best for them, and so they need to be told what to do, or have certain products or choices taken away from them. To respect autonomy, on the other hand, is to accept and facilitate the decisions of the individual. Obviously, a blanket condemnation of voluntary euthanasia will be paternalistic; accepting the choices made by patients (including the decision to die) appears to be unambiguously pro- autonomy.
This issue will reappear when we discuss the drugs debate in Lectures 21 and 22.



WHAT YOU NEED TO KNOW
You need to be able to give a definition of Voluntary Euthanasia
You need to be able to explain the difference between Voluntary Euthanasia and Non- Voluntary Euthanasia
You need to be able to explain the two main arguments in favor of VE: Utilitarianism (both Classical and Preference Utilitarianism) and Deontological (respect for rights).
You need to be able to explain Paternalism and Autonomy

Reading Homework for Lecture 17.
Please try to read the two essays on euthanasia in Rachels The Right Thing to Do, “The Morality of Euthanasia” by James Rachels and “Assisted Suicide: Pro-Choice or Anti-Life?” by Richard Doerflinger.
-Identify and summarize the arguments
-Which arguments are the strongest?
-Which arguments are the weakest? Why are they weak? And how would you respond?