Euthanasia &Assisted suicide

Active and passive euthanasiaMoral permissibility and legalisation

of assisted suicide and voluntary euthanasia

Definition and distinctionsEuthanasia (Gr. euthanatos, meaning ‘easy death’) refers to any action where a person is intentionally killed or allowed to die because it is believed that the individual would be better off dead than alive.• Voluntary euthanasia: this happens when the

person who undergoes it has requested it• Non-voluntary euthanasia: this happens

when persons other than the patient request it (e.g. if the patient has permanently lost consciousness).• Involuntary euthanasia: this happens when

the person in question wants to go on living.

Definition and distinctions• Active euthanasia is when an action is

performed that directly causes someone to die (for example, disconnecting a patient from a life-support system). • Passive euthanasia is allowing someone to

die by not performing some life-sustaining action (for example, not giving a patient life-extending drugs).

In the UK, voluntary and non-voluntary passive euthanasia is legal, but voluntary and non-voluntary active euthanasia is against the law.

Active and passive euthanasia

Two questions about active and passive euthanasia

1. What is the distinction between active and passive euthanasia? This distinction is also commonly referred to as the difference between killing and letting die.

2. Is the distinction also a moral one?

Possible factors

• Time factor

• Responsible outside party

• Special responsibility

We have significant reasons for doubting the relevance of these factors.

This distinction matters when we have a conflict, and when either of the

alternatives available to us are ones that will result in someone’s death.

Killing

Doing harm to someone

Letting die

Allowing harm to happen

Understanding the debate: killing and letting die

Passive euthanasia is legal, active euthanasia is against the law.• Those who defend euthanasia: there is

not a difference. The arguments that work for passive euthanasia can be extended to active euthanasia.• Those who oppose euthanasia: there is a

difference. And so the arguments that work for passive euthanasia cannot be extended to active euthanasia.

The difference thesisA. If Anne holds Brian’s head under water until he

drowns, then we can say that Anne kills Brian; we don’t say that she merely lets him die.

B. Anne is on the shore watching Brian, who’s out at sea, drowning. Anne can swim well and she could save him, but she stays on the shore and watches him drown. We don’t say in this case that Anne kills Brian, we say that she lets him die.

Our moral intuitions tell us that Anne’s behaviour in the first case is morally worse than in the second, even though both of them result in Brian’s death.

Interference and non-interference

“often agents step into the causal flow in such a manner as to alter the outcome of processes which were already under way.

This is in contrast to cases where the agent simply lets the on-going process continue. In the former case, but not the latter, the agent

can be said to interfere: he makes a difference in a way that he does not when he merely refrains from altering the causal flow.”

(Shelly Kagan, The Limits of Morality: 94)

Act and omissionPhilippa Foot (Virtues and Vices) distinguishes two kinds of ‘allowing’:i. First is “forbearing to prevent”: this is when you

don’t stop a sequence of events, even though you’re in a position to do so (e.g. Ann could rescue Brian, but she allows him to drown).

ii. Secondly, “enabling”: the removal of some obstacle which is, as it were, holding back a train of events (e.g. when a doctor turns off the life-support machine and allows the patient to die).

According to Foot, forbearing to prevent (an omission) and enabling (an act) are both cases of letting die.

Michael Tooley

• The reason our moral intuitions favour the argument that there is a difference between killing and letting die is because most cases are not adequately set up. • Besides motives, there are other morally relevant

differences that affect our judgement. If we appeal to moral intuitions, we have to make sure that the pairs of cases are similar.• In pairs of similar cases, the only difference being

that in one case we have an act of killing and in the other we have a case of letting die, we would agree that in both cases the agent is as culpable as the other.

The doctrine of double effect

I. You want to bring about GII. But there is no way of bringing about G without

bringing about BIII. The goodness of G outweighs the badness of BIV. You would prefer that B not occur

A. Action involves intentionally bringing about G, knowing that G will necessarily cause B to occur

B. Action involves intentionally doing something that will give rise to two causal processes, one of which will lead to G, he other to B

C. Action involves intentionally bringing about B, knowing that B will cause G to occur

Voluntary euthanasia or

assisted suicide

Michael Tooley: in support of euthanasia

1. Say someone is suffering from an incurable illness, and as a result of this illness they are suffering extreme pain. Then in some cases, that person’s death is in his or her own interest.

2. If a person’s death is in that person’s own interest, then committing suicide is also in that person’s own interest.

3. Therefore, as a result of these two points, if someone’s suffering extreme pain due to an incurable illness, then in some cases committing suicide is in that person’s own interest.

Michael Tooley: in support of euthanasia

4. A person’s committing suicide in such circumstances may very well satisfy the following two conditions:1. It neither violates anyone else’s rights,

nor wrongs anyone2. It does not make the world a worse place

5. If an action satisfies these two conditions, and it is not contrary to one’s own interest, it cannot be morally wrong.

6. Our conclusion, therefore, is that if someone’s committing suicide satisfies all of these conditions, it cannot be morally wrong.

Michael Tooley: in support of euthanasia

7. It is morally wrong to assist only if:1. It was morally wrong for that person to commit

suicide (in other words, the person committing suicide doesn’t meet all of the above conditions). For example, committing suicide was contrary to that person’s own interests.

2. Secondly, assisting that person in committing suicide violated an obligation one had to someone else.

8. Now, if committing suicide, nor assisting with it, don’t violate any obligations you might have towards someone else, and if you satisfy the above conditions, then we can say that it is not morally wrong to commit suicide or to assist.

Michael Tooley: in support of euthanasia

9. Whenever assisting a person in committing suicide is justified (i.e. it meets all the conditions we’ve talked about and doesn’t violate any obligation you might have to someone else), then voluntary active euthanasia is also justified.

‘In Defense of Voluntary Active Euthanasia and Assisted Suicide’

The Philosophers’ Brief• The strongest argument in favour of active

voluntary euthanasia is derived from the principle of autonomy. • This is fundamental to the ‘philosophers’ brief’,

which was written by six major liberal political philosophers: Ronald Dworkin, Thomas Nagel, Robert Nozick, John Rawls, Thomas Scanlon and Judith Jarvis Thomson. • Core argument: if it’s permissible to omit or

terminate medical treatment with the intention that the patient dies, then it is permissible to assist in killing with the intention that the patient dies (there is no intrinsic moral difference between killing and letting die).

The Philosophers’ Brief• The existence of a right to refuse treatment also

implies a right to assistance in suicide from a willing doctor (cf. Cruzan case).• Several justices rejected this link by appealing to a so-

called common-sense distinction between the moral significance of acts and omissions.• Philosophers’ Brief: the distinction between acts and

omissions doesn’t have much moral weight.• “the ‘common-sense’ distinction, which is not between

acts and omissions, but between acts or omissions that are designed to cause death and those that are not.” • The key moral argument is intending death versus not

intending death, or intending death versus foreseeing death.

The Philosophers’ Brief

Philosophers’ Brief: intending versus foreseeing death matters.• This doesn’t mean nothing else matters. • They argue against the act-omission

distinction. This implies a criticism of the killing-letting die distinction (which is not an important distinction for them).• But someone can act without killing.

Against the moral permissibility of assisted suicide: David Velleman

• Argues against voluntary euthanasia: there isn’t a fundamental right to choose between life and death and a person’s rights don’t expand when they become terminally ill or psychologically distressed. • Velleman is a Kantian and argues that

morality requires that we respect the dignity of persons. A person’s dignity can’t be traded against their well-being or happiness.

Against the moral permissibility of assisted suicide

• Emphasis on autonomy and choice implies life is a possession (not a gift). Cf. Michael Sandel (reproductive engineering).• Locke and Kant were the founders of liberal political

philosophy (cf. the Philosophers’ Brief), but both opposed the right to commit suicide.• Michael Sandel: people who “prefer to view their

lives as episodes in a larger drama rather than as autonomous creations would remain free to do so.” If the Supreme Court declared, “in the name of autonomy, a right to assisted suicide”, this would “encourage the tendency to view life less as a gift and more as a possession” (Sandel, Public Philosophy: 116).

First argument against legalisation: possible harm

• Some people will choose to be killed in circumstances where being killed is against their interest.

• Objection: couldn’t this same logic be applied to passive euthanasia?

Second argument against legalisation: slippery slope• The slippery slope argument is one where

if you allow this situation to happen (with all the best intentions), it will lead to these, very bad, consequences.

• Two kinds of slippery slope arguments:1. Logical2. Empirical or psychological (this one

has more credibility)

Explaining the slippery slope arguments

“The logical [or conceptual] form of the argument goes like this. Once a certain practice is accepted, from a logical point of view we are committed to accepting certain other practices as well, since there are no good reasons for not going on to accept the additional practices once we have taken the all important first step. But, the argument continues, the additional practices are plainly unacceptable, therefore, the first step had better not be taken…The [empirical or psychological] form of the argument is very different. It claims that once certain practices are accepted, people shall in fact go on to accept other, more questionable practices. This is simply a claim about what people will do and not a claim about what they are logically committed to.”

James Rachels, The End of Life: Euthanasia and Morality, pp.172-173.

Case study: the Netherlands

During the 1970s and 1980s, the Dutch courts permitted euthanasia under certain conditions:• A free choice• A considered and persistent request• Unacceptable suffering• Consultation with another physician• Accurate reporting on the cause of death

In 1990, the Dutch government established a Commission on Euthanasia. The results showed that out of 3,300 euthanasia deaths, nearly one-third were voluntary, and less than 50% were reported as euthanasia. And 10% of the non-voluntary cases were instances of euthanasia with competent patients whose consent was not sought.

Slippery slope arguments

Critics who rely on the slippery slope argument often omit two important elements:1. The argument is only effective against legalisation

if it is legalisation which causes the slippery slope2. It is only effective if it is used comparatively (to

show that the slope is more slippery in the Netherlands than it is in jurisdictions which have not legalised assisted suicide or voluntary euthanasia).

The challenge is to show the causal relation, and not just to infer it.

Slippery slope arguments can be logically flawed, but does that mean we should reject them?

Take-home questions

1. What is the distinction between killing and letting die? Is it a morally significant one?

2. Is active voluntary euthanasia morally permissible? Why?

3. Should active voluntary euthanasia be legal?

4. How would you adjudicate in the van den Bleeken case (assuming he persisted for death by lethal injection)?

5. Do you agree with the premises in Michael Tooley’s defence of assisted suicide?