Philosophy 220

1. Philosophy 220 Euthanasia: Gay-Williams, Rachels and Steinbock

2. Euthanasia and Physician- Assisted Suicide • As the long public debate about the case of Terri Schaivo revealed, Euthanasia and Physician-Assisted Suicide are controversial moral issues. • If progress is going to be made in resolving these issues, there are some basic questions that need to be addressed. • Are euthanasia or suicide (including physician-assisted suicide ever morally permissible? • If either is morally permissible, what accounts for this permissibility. If either is not, why not?

3. Euthanasia: Some Definitions • Euthanasia: “…the act or practice of killing or allowing someone to die on grounds of mercy” (295). • When we take into account the difference between acting to bring about someone’s death and merely allowing it, we must observe a distinction between active euthanasia and passive euthanasia. • Typically, passive euthanasia is further subdivided into instance of withholding treatment and withdrawing treatment. • Though not a specific feature of the definition, it is also important to distinguish between those instances when an agent knowingly and voluntarily consents to either active or passive euthanasia (voluntary euthanasia), those instances when not consent has or cannot be given (nonvoluntary euthanasia), and those instances when consent has been denied (involuntary euthanasia)

4. Reviewing the Theories • Kant insists that the categorical imperative (particularly the humanity formulation) rules out suicide, and it is generally assumed that he would render the same verdict with regard to euthanasia. The claim, however, that respect for the moral humanity of the affected individuals requires a negative verdict in all cases is controversial, and Kant’s writings don’t do much to clear up the controversy. • Consequentialist reasoning requires us to consider the consequences for the affected parties. When we include consideration of broader social goods, the specter of a slippery slope problem becomes evident: if we allow euthanasia or physician assisted suicide in some cases, don’t we risk the expansion of permissible cases to the point where clear violations of people’s rights would occur? • A natural law theoretical approach like that of Aquinas is generally going to rule against either practice on the grounds that intentionally ending a human life is always wrong. However, as we’ve seen, the doctrine of double effect provides the basis for a more nuanced analysis, including the distinction between “ordinary” and “extraordinary” means of life-support.

5. Gay-Williams, “The Wrongfulness of Euthanasia” • Gay-Williams (Ronald Munson) begins by noting that public support of at least some forms of euthanasia is on the rise. • Though some have suggested this is due to the increasing devaluing of human life, G-W suggests a more noble (though still ultimately misplaced) motive: feelings of sympathy and benevolence. • These feelings are misplaced, insists G-W, because euthanasia is morally wrong, a conclusion that G-W justifies with three different arguments.

6. Setting the Terms • As we typically do, G-W begins by establishing the terms of his discussion. • He defines euthanasia as the “intentional taking of a life of a presumably hopeless person” either your own or someone else’s (300c1). • 2 implications: you can’t accidentally euthanize someone and the goal of the euthanizing is to end the ‘hopeless’ suffering of the individual. • G-W goes on to insist that there is no such thing as passive euthanasia because the cases usually classified as such involve the intentional cessation of treatment, and: “in such cases, the person is not killed…nor is the death of the person intended”(ibid.). • That is, the intention is to end suffering, rather than cause death.

7. The Argument from Nature • The argument is straightforward. P1. We are naturally inclined to our own survival. P2. This is not just a conscious intention, “the organization of the human body and our patterns of behavioral responses make the continuation of life a natural goal” (301c1). Conclusion: Euthanasia sets us against “our own nature.” • Moreover, since “our dignity comes from seeking our ends,” euthanasia “does violence to our dignity” (ibid.). • This shows that euthanasia “requires that we regard ourselves as less than fully human,” as creatures that are not conscious of “our nature and our ends” (ibid.).

8. The Argument from Self-Interest • This is another very simple argument. P1 Diagnosis and prognosis is an inexact activity, and can always be wrong. P2 Until death, it is always possible that disease remission or the invention of a life-saving treatment or technology could reverse the situation of the individual. P3 “Knowing that we can take our life at any time (or ask another to take it) might well incline us to give up too easily” (301c2) Conclusion: Accepting the permissibility of euthanasia could lead to many unnecessary deaths.

9. The Argument from Practical Effects • Finally, the consequentialist argument to the conclusion that euthanasia is morally wrong. P1. Legalizing euthanasia could have bad effects on medical care, because physicians would be less inclined to go “all out” to save people, because killing them would be an option P2 Legalizing voluntary euthanasia is the first step on a slippery slope to nonvoluntary(unplugging people in comas) and finally involuntary euthanasia (killing people against their will) (i.e., slipping fatal doses to those doctors deem hopeless. Conclusion: To avoid these negative consequences, euthanasia should be forbidden.

10. Final Analysis (no pun intended) • Ultimately, it’s on the first argument that G-W rests his case, though he thinks the other two arguments do provide compelling support for his conclusion.

11. Rachels, “Active and Passive Euthanasia” • Rachels’s focus in this article is the distinction between active and passive euthanasia. • As we saw, this is a distinction that Gay-Williams denies, insisting that the concept of Euthanasia implies activity. • Though Rachels does admit the distinction, noting that it is central to the medical ethical discussion of the issue (as enshrined in the AMA policy), he too denies its moral significance, arguing that while the distinction is legitimate, there is no moral difference between active and passive euthanasia. • Thus, whatever moral judgment we have of one, we must have of the other.

12. AMA and Euthanasia • Written in 1975, Rachels’s article focusses on the policy on euthanasia adopted by the AMA in December of 1973. • “The intentional killing of the life of one human being by another—mercy killing—is contrary to that which the medical profession stands and is contrary to the policy of the [AMA],” but “the cessation of the employment of extraordinary means to prolong the life of the body when there is irrefutable evidence that biological death is imminent is the decision of the patient and/or his immediate family.” • Though the language is different, the current version of the policy (issued in June of 1994) takes essentially the same position regarding the responsibilities of physicians, though it is more circumspect about the withdrawal of life support. http://www.ama-assn.org//ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion221.page

13. Active vs. Passive • As James reads it, the 1973 AMA policy embodies the distinction between active and passive euthanasia, but this distinction is ultimately morally incoherent. • Consider the example of the patient with incurable throat cancer (303c2). The AMA policy would seem to allow an attending physician to agree with a patient or family request to withdraw or withhold life preserving treatment. • But this course of action may in fact needlessly prolong the suffering of the affected individual. • Consider also the case of the downs baby with intestinal blockage. According to Rachels, either the conservative (no euthanasia) or the liberal (any euthanasia is ok) position is more understandable than “favor[ing] letting ‘dehydration and infection wither a tiny being over hours and days’” (304c1).

14. Active, rather than Passive • Rachels’s conclusion from this analysis is that the AMA’s preference for passive euthanasia is productive of needless cruelty. It would be better for doctors to actively seek the death of patients than merely withdraw or withhold care. • He then makes a further point, “the conventional doctrine (i.e., the distinction between active and passive euthanasia) leads to decisions concerning life and death made on irrelevant grounds” (304c1). • For example, in the Downs case, the reason the parents are allowing the babies to die is because they have Downs – there is no way the intestinal blockage would be a reason to let non-Downs babies die.

15. Refusing the Distinction • Rachels’s basis for rejecting the distinction between active and passive is that there is no moral difference between the two, so you should have the same policy for both. • He offers the following thought experiment as the basis for an argument from analogy in support of the conclusion. • Consider two related cases: • Smith drowns his cousin to get the inheritance (304c2-305c1). • Jones allows his cousin to drown, also to get the inheritance (305c1). • If, as it seems reasonable to conclude, Smith and Jones are equally bad, the fact that Smith actively killed his cousin, while Jones passively allowed his cousin to, makes no moral difference. • To the extent that a doctor is in a relevantly similar position (and here the relevant similarity is doing something or merely standing by), the choice between active and passive euthanasia would similarly make no moral difference.

16. A Possible Disanalogy • Of course, the situations might not be relevantly similar: in active euthanasia, the doctor does something (kills her patient). In passive euthanasia, it is the patient’s condition that kills him. • Rachels’s response: • It is wrong to say that in passive euthanasia the doctor does nothing. In fact, she does do something: she lets the patient die. An omission in this case is a decision. • The cause of death may be important from a legal point of view, but not from a moral. • Thus, Rachels concludes that there is no reason for the AMA to forbid active but permit passive euthanasia. • Though he doesn’t argue for this, the discussion of the desirability to limit needless suffering (the grounds of the permissibility of passive euthanasia) would seem to support the conclusion that active euthanasia is morally permissible.

17. Steinbock, “The Intentional Termination of Life” • Steinbock’s article is a response to Rachels’s criticism of the AMA policy. • According to Steinbock, Rachelsis mistaken in the belief that the AMA doctrine rests on a distinction between “intentionally killing” and “letting die”. • As such, arguments showing that the distinction has no moral force do not reveal that adherents to the AMA doctrine are morally confused. • The AMA doctrine does not imply support of the active/passive euthanasia distinction: it rejects both.

18. Rachels’s Mistake • Rachels’s mistake is in identifying the cessation of life-prolonging treatment with passive euthanasia (“intentionally letting die”). • If it were correct to equate the two, then the AMA statement would be self-contradictory, for it would begin by condemning, and end by allowing, the intentional termination of life. • But if the cessation of life-prolonging treatment is not always or necessarily passive euthanasia, this problem needn’t arise.

19. Withdrawal does not equal Euthanasia • Making a distinction like we saw in the Gay-Williams article, Steinbock insists that there are at least two situations in which the termination of life-prolonging treatment cannot be identified with euthanasia (understood here as the intentional termination of the life of one human being by another). • Where the patient has refused treatment. • Where continued treatment has little chance of improving the patient’s condition and brings greater discomfort than relief.

20. A Right to Refusal • Steinbock’s distinction relies heavily on the claim that patient consent relieves the doctor of responsibility: if the patient or the patient’s authorized agents chose to withdraw treatment, the doctor is removed from the picture (and thus the AMA policy is no longer at issue). • It’s generally agreed that the patient has a right to refuse treatment – even where the treatment is necessary to prolong life.

21. But not a right to assistance in dying • If one has the right to refuse life-prolonging treatment, why doesn’t she also have the right to end her life, and obtain help in doing so? • On Steinbock’s analysis, the right to refuse treatment is a right to bodily self-determination: in particular, a right to be protected from unwanted interference from others (i.e., a negative right). • This negative right does not include a positive “right to die.” • If it did, Steinbock insists, we would have to agree that people have a right to be killed. • Why shouldn’t we agree with this?

22. A Better Distinction • The distinction that Steinbock thinks the AMA is really making is between ordinary means to preserve life and extraordinary. • Consider a case where treatment is unlikely to benefit for the patient, but will cause more discomfort than the disease itself. • Such treatment is often called “extraordinary,” but it is important to note that what is ordinary in one instance may be extraordinary in another. • “Ordinary” treatment is what a doctor would normally be expected to provide. • Failure for a doctor to administer ordinary treatment would constitute neglect of the doctor’s moral (and legal) obligations. • While a doctor is under no moral obligation to ignore appropriately grounded requests to withhold extraordinary treatment, this is not euthanasia.