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‘’ Euthanasia and Physician- Assisted Suicide

For fifteen years, Terri Schiavo existed between life and death in that shadow land called a persistent vegetative state, a place where she was wakeful but without awareness or any purposeful behavior. Severe brain damage had left her there, with vir- tually no chance of recovery. And all the while, a storm of caustic debate swirled around her, reach- ing its greatest strength in the last few days before her death on March 31, 2005. In 1990 her heart had stopped briefly because of a chemical imbalance, leaving her in that twilight state, kept alive by a feeding tube. She had left no living will, no written record of her wishes should she become indefinitely incapacitated. Her husband, Michael Schiavo, insisted that Terri had told him once that she would prefer death to being kept alive with machines. Her parents rejected his claim and demanded that Terri be kept alive, holding out hope that with proper care she might recover.

The battle between Michael Schiavo and Terri’s parents raged on in the courts for years. Again and again, state and federal courts sided with the hus- band, while the U.S. Supreme Court repeatedly refused to hear the case. In the final days before Terri died, President George W. Bush, the U.S. Con- gress, the governor of Florida (where she lived), and Florida legislators weighed in on the controversy, supporting Terri’s parents.

Finally, a judge allowed the feeding tube to be removed, and Terri Schiavo, age forty- one, died thirteen days later. The parents called the removal “judicial homicide.” A Vatican official called it “an attack against God.”1

So it goes with all public debates on the moral permissibility of euthanasia. Passions rise, claims and counterclaims collide, and stakes are high. In the balance are issues of life and death, science and religion, murder and mercy. The tragic end of Terri Schiavo is only the most dramatic (and dramatized) case in a series of tragic ends that turned into widely publicized moral battlegrounds (see the box “The Death of Karen Ann Quinlan”). The moral ques- tions it incited are typical of such cases: Was remov- ing Terri Schiavo’s feeding tube really a case of murder? Or was it a morally permissible act allow- ing her to die with dignity and escape her bleak condition? What if instead of stopping the tube feeding, her doctors had never started it because they deemed her situation hopeless? Would that have been murder— or a permissible act of mercy? Or suppose that soon after Schiavo collapsed, her doctors had decided to give her a lethal injection? Would such an act have been morally wrong? What if Schiavo had left a living will that clearly specified that she did not want to be kept alive by any means if she fell into a persistent vegetative state? Would withdrawing the feeding tube or giving her a lethal injection then have been morally acceptable?

Of course, in every instance of euthanasia there are plenty of nonmoral questions too— primarily legal, judicial, medical, scientific, and political. (In the Schiavo case, for example, the moral ques- tions arose side by side with what most informed observers saw as the real issue: Who, if anyone, had the legal right to decide for Schiavo what was to become of her?) But these nonmoral concerns

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preserved in the Greek roots of euthanasia, which literally means “easy death.” Euthanasia makes sense to many people because they believe that a quick and painless death would be preferable to a slow and painful dying (such as the kind that some terminal cancer patients endure) or a long, vegeta- tive sleep without a chance for a meaningful life.

As you might expect, the moral permissibility of euthanasia depends heavily on the consent of the patient (the person whose death is being con- sidered). Moral philosophers therefore distinguish between euthanasia that is voluntary, nonvolun- tary, and involuntary. In voluntary euthanasia, the patient requests or agrees to the act. She may make the request in person or leave instructions to be followed in case she becomes incapacitated. Such instructions are usually in the form of an advance directive (for example, a living will), a legal docu- ment allowing physicians to withhold or withdraw treatments if a patient becomes terminally ill and unable to express her wishes. For any voluntary euthanasia request to be valid, the patient at the time of the request must be competent— that is, capable of making an informed, rational choice. In nonvoluntary euthanasia, others besides the patient (family or physicians, for example) choose euthanasia for her because she is not competent (due to illness or injury) and has left no instruc- tions regarding her end- of- life preferences. Eutha- nasia performed on infants and small children is, of course, nonvoluntary. In involuntary euthana- sia, the act is carried out against the wishes of the patient and is therefore illegal and widely regarded as immoral.

People also draw a distinction between active and passive euthanasia. Active euthanasia is taking a direct action to kill someone, to carry out a “mercy killing.” A doctor who gives a patient a lethal injection is performing active euthanasia, and so is a man who suffocates his dying brother to spare him from an unbearably painful pass- ing. Passive euthanasia is allowing someone to die by not doing something— by withholding

are intertwined with the moral concerns. Our task here is to apply moral reasoning to try to unravel the knot.

ISSUE FILE: BACKGROUND

Euthanasia is directly or indirectly bringing about the death of another person for that person’s sake.2 It is thought to provide a benefit or a good for the person by ending a life deemed no longer worth living— a situation that typically arises when some- one has an incurable or terminal disease that causes great suffering or when someone experiences an irreversible loss of consciousness (as in the Schiavo case). This notion of dying as a kind of blessing is

’The Death of Karen Ann Quinlan Like nothing else before it, the case of Karen Ann Quinlan focused the world’s attention on the medical truths, the legal complexities, and the moral problems of euthanasia. She was just twenty- one years old when she sustained acute brain damage after imbibing alcohol along with a tranquilizer. She was left in a persistent vege- tative state, kept alive by a feeding tube and a respirator, a machine that maintained her breath- ing mechanically. After several months, members of her family came to accept that her recovery was hopeless and sought permission from the courts to unplug the respirator to allow her to die. Finally in 1976 the New Jersey Supreme Court granted their request. But to everyone’s surprise, she continued to breathe without the respirator until 1985, ten years after she slipped into the vegetative state. She died on June 11.*

*See “Famous Cases: Karen Ann Quinlan,” CBC News Online, March 22, 2005, http://www.cbc.ca/news2 /back ground/schiavo/vegetative_state.html (January 20, 2015); Barran H. Lerner, “Planning for the Long Goodbye,” New York Times, June 18, 2004.

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the agent who ultimately causes the death in active voluntary euthanasia is the physician, whereas the ultimate causal agent in physician- assisted suicide is the patient. In the former, the physician is primarily responsible for the killing; in the latter, the patient is. In most cases, the physician provides help by pre- scribing a lethal dose of drugs, which the patient then administers to himself.

In the United States, physician- assisted suicide is legal in six states— Oregon, Washington, Montana, Colorado, Vermont, and California— and in the District of Columbia. U.S. Supreme Court rul- ings allow each state to decide for itself whether to legalize assisted suicide. The official position of the American Medical Association (AMA), the main professional group for American physicians, is that “ physician- assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks.”3

A factor that can complicate all the foregoing issues is the concept of death itself. One prob- lem is that thanks to modern medical technol- ogy, determining when a person is dead is not so straightforward as it once seemed. Death has become more difficult to define. Years ago the pre- vailing notion was that a person is dead when his breathing and blood flow stop (no respiration and no heartbeat). But nowadays machines can keep an individual’s heart and lungs functioning long after the brain permanently and completely shuts down. Thus we can have an individual whose organs are mechanically operated while he is in a coma or persistent vegetative state— for years. By the traditional definition of death, such an individual would still be alive, but many people would insist that he is no longer there: he is dead. So the conventional notion of death seems to be inadequate.

Why does correctly defining death matter at all? Say an individual is in the kind of state just described. If we judge him to be dead and thus no longer a person, then perhaps it would be morally

or withdrawing measures necessary for sustaining life. A doctor, then, would be performing passive euthanasia if she removed a patient’s respirator, did not administer antibiotics to halt a life- threatening infection, or withdrew hydration and nutrition (fluids and nutrients).

Many believe that this active- passive distinc- tion is essential to understanding the moral permis- sibility of euthanasia. It allows them to maintain that whereas active euthanasia is always wrong, in some cases passive euthanasia may be permissible. This view is widespread among physicians and fits with the popular notion that killing people is mor- ally worse than letting them die. Others, however, argue that there is no moral difference between killing and letting die: in both active and passive euthanasia the patient’s death is caused, and they are therefore morally equivalent.

Taking into account the categories of voluntary, nonvoluntary, active, and passive (and disregarding involuntary), we can identify four kinds of euthana- sia: (1) active voluntary (mercy killing at the patient’s request), (2) active nonvoluntary (mercy killing with- out the patient’s consent or request), (3) passive voluntary (letting the patient die at her request), and (4) passive nonvoluntary (letting the patient die without his consent or request). Generally, the law forbids active euthanasia (either voluntary or nonvoluntary), and the medical profession is offi- cially opposed to it (though the views of individual physicians vary). Passive voluntary euthanasia is legal; by law, competent patients have the right to refuse any kind of medical treatment. Passive non- voluntary euthanasia may be legal provided that someone (a family member, for example) can be des- ignated to make decisions on behalf of the patient.

Related to, but distinct from, active voluntary euthanasia is physician- assisted suicide— the killing of a person by the person’s own hand with the help of a physician. Like active voluntary eutha- nasia, physician- assisted suicide is requested by the patient, and the intended outcome is the patient’s death for the relief of pain and suffering. But

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permissible to disconnect him from the machines, or administer a fatal drug overdose, or remove his feeding tube, or even harvest his organs for trans- plant into another person. Or would it? If we deem him alive and still a person, perhaps we are not jus- tified in doing any of the above. Maybe taking any one of these actions is to commit murder. Depend- ing on the concept of death accepted by the legal system, killing him or allowing him to die could have serious legal consequences.

To overcome the drawbacks of the traditional definition of death, alternative definitions have

been suggested. According to the whole- brain defi- nition of death, an individual is dead when all brain functions (including those performed in the brain stem) permanently stop. It has become the primary standard in both medicine and the law for determining death. Critics of the whole- brain standard, though, have pointed out that it is based on a faulty assumption: that the brain is the control center for all physiological functions. Yet some functions (such as respiration) are par- tially independent of brain activity. In addition, by the whole- brain standard, individuals in an

’ In the past five decades, U.S. courts have several times weighed in on the controversial issues of euthanasia and physician- assisted suicide. The fol- lowing are some of the more far- reaching rulings:

• 1976 The New Jersey Supreme Court ruled that a life- sustaining respirator could be legally dis- connected from Karen Ann Quinlan, a young woman who had lapsed into a persistent vegeta- tive state. After it was removed, she remained comatose and lived for another ten years, finally dying in June 1985.

• 1990 The U.S. Supreme Court (in Cruzan v. Direc- tor, Missouri Department of Health) ruled that a feeding tube could be removed from Nancy Cruzan, a woman in a persistent vegetative state due to an automobile accident, if “clear and convincing evidence” shows that she would have approved of the withdrawal. The ruling recog- nized the legitimacy of living wills, surrogates to act for incapacitated individuals, and a qualified “right to die.”

• 1997 The U.S. Supreme Court (in Washington v. Glucksberg) ruled that a Washington State prohibition of physician- assisted suicide did not violate the due process clause of the Fourteenth Amendment.

• 1997 The U.S. Supreme Court (in Vacco v. Quill) ruled that a New York State prohibition of physi- cian- assisted suicide did not violate the equal pro- tection clause of the Fourteenth Amendment. The Court acknowledged a crucial distinction between withdrawing life- sustaining treatment and assisted suicide. People may refuse life- sustaining treat- ment, but assisted suicide is prohibited.

• 2006 In a 6–3 decision in Gonzales v. Oregon, the U.S. Supreme Court ruled that the U.S. attorney general is not authorized to ban controlled sub- stances used in physician- assisted suicide. The decision had the effect of upholding Oregon’s Death with Dignity Act.

• 2009 In a 4–3 decision in Baxter v. State of Mon- tana, the Montana Supreme Court ruled that physician- assisted suicide is not “against public policy.” The decision applied only to Montana. The court also ruled that doctors who help terminally ill patients commit suicide cannot be prosecuted under Montana state law.

• 2015 In a 2–1 ruling, the New Mexico Court of Appeals struck down a lower court ruling legal- izing physician- assisted suicide, concluding that “aid in dying is not a fundamental liberty inter- est under the New Mexico Constitution.”

Landmark Court Rulings

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disappeared is no longer a person and is therefore rightly considered dead. By the higher- brain stan- dard, individuals in a persistent vegetative state (who continue to breathe and have a heartbeat) but whose higher brain functions have ceased are thought to be dead— also a result that some people find counterintuitive.

MORAL THEORIES

Utilitarianism, Kant’s ethics, and natural law the- ory lead to divergent conclusions on the issue of euthanasia. An act- utilitarian would certainly try to take into account how much overall happiness various possible actions could bring about, every- one considered. But she could make this calcula- tion in different ways. The basic approach would be to consider the patient’s suffering (as well as that of others involved, such as family members) and the likely success of any treatments and try to determine how much overall happiness would be generated by different actions, including bring- ing about the patient’s death. If the patient’s situ- ation were hopeless and his suffering great, an act- utilitarian could decide that the greatest net happiness would result from killing the patient or letting him die. The patient’s consent to eutha- nasia might or might not be a primary concern, depending on how his consent would affect overall happiness. On the other hand, the act- utilitarian might say that euthanasia is contrary to the goal of maximizing happiness because killing a person rules out any possibility of his experiencing hap- piness in the future. Happiness does not occur in a vacuum; it exists only when persons experience it. So eliminating a person eliminates potential happiness.

Some people— even those who are not thor- oughgoing utilitarians— argue against euthanasia on what amounts to rule- utilitarian grounds or something close to it. They contend that regard- less of the moral permissibility of euthanasia in

irreversible persistent vegetative state (who have some detectable brain activity) are thought to be alive— a result that some regard as counterintui- tive or puzzling.

The higher- brain definition of death says that an individual is dead when higher brain functions— those that give rise to consciousness— permanently stop. Some have maintained that because consciousness is necessary for personhood, an individual whose higher brain functions have

’ QUICK REVIEW euthanasia— Directly or indirectly bringing about

the death of another person for that person’s sake.

voluntary euthanasia— Euthanasia performed on a person with his or her permission.

advance directive— A legal document allowing physicians to withhold or withdraw treatments if a patient becomes terminally ill and unable to express his or her wishes.

nonvoluntary euthanasia— Euthanasia performed on a person who is not competent to decide the issue and has left no instructions regarding end- of- life preferences. In such cases, family or physi- cians usually make the decision.

involuntary euthanasia— Euthanasia performed on a person against his or her wishes.

active euthanasia— Euthanasia performed by tak- ing a direct action to cause someone’s death; “mercy killing.”

passive euthanasia— Euthanasia performed by withholding or withdrawing measures neces- sary for sustaining life.

physician- assisted suicide— The killing of a per- son by that person’s own hand with the help of a physician.

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who have slipped from waking life into a coma or a vegetative state? Are they still persons with full moral rights? If they are persons, then performing euthanasia on them would be immoral. If they are not persons, then euthanasia might be morally acceptable. In fact, a Kantian might argue that performing euthanasia on individuals in comas or vegetative states may be morally permissible pre- cisely because persons have intrinsic worth and dignity. The bioethicist Ronald Munson explains this view well:

It may be more in keeping with our freedom and dig- nity for us to instruct others either to put us to death or to take no steps to keep us alive should we ever be in such a state. Voluntary euthanasia may be compatible with (if not required by) Kant’s ethics.

By a similar line of reasoning, it may be that nonvoluntary euthanasia might be seen as a duty that we have to others. We might argue that by put- ting to death a comatose and hopeless person we are recognizing the dignity that person possessed in his or her previous state.5

According to the dominant reading of natural law theory, euthanasia is wrong in almost every instance. It is wrong because we have a moral duty to preserve life. So intentionally performing any kind of euthanasia, active or passive, is impermis- sible. The doctrine of double effect, however, allows one exception to this rule. Recall that this doctrine makes a distinction between (1) performing a good action that happens to have a bad effect and (2) per- forming a bad action to achieve a good effect. The former may be permissible, but the latter is not. In the case of euthanasia, the doctrine implies that giving a pain- racked patient a large dose of mor- phine to end her life (a practice known as terminal sedation) is never morally acceptable. But giving her a large dose of morphine with the intention of easing her pain— an act that has the side effect of expediting her death— is permissible. The hasten- ing of the patient’s death is permissible because even though it was foreseen, it was not intended.

specific cases, a general rule (that is, a social policy or law) permitting some types of euthanasia would cause more harm than good. They offer slippery slope arguments such as the following: Passing a law (making a rule) permitting active voluntary euthanasia would inevitably lead to abuses such as more frequent use of nonvoluntary euthanasia and unnecessary killing; therefore, no such law should be passed. Similarly, some argue that a general rule allowing physician- assisted suicide would destroy the “moral center” of the medical profession; if physicians are allowed to kill patients, they will violate their pledge to protect life and to heal, caus- ing patients to distrust them. Of course, it is also possible to argue for euthanasia on rule- utilitarian grounds. (Whether such arguments are sound is another matter.) A rule- utilitarian could devise a rule that he thinks would result in a maximization of happiness for everyone if the rule were consis- tently followed.

Like the utilitarian, the Kantian theorist could also take several different positions on euthana- sia, consistent with Kantian principles. She could argue that euthanasia is never permissible because it would entail treating persons as mere disposable things. Kant underscores this view in his discus- sion of suicide. He maintains that “suicide is in no circumstances permissible” because it robs individuals of their personhood, which is the very foundation of all moral values. Furthermore, it treats persons as if they had no more value than a beast. As Kant puts it, “But the rule of moral- ity does not admit of [suicide] under any condi- tion because it degrades human nature below the level of animal nature and so destroys it.”4 This stern prohibition against suicide may or may not apply equally well to euthanasia— depending on whether those considered for euthanasia are to be regarded as persons. Certainly those who are competent (coherent and rational) are persons and therefore should not be killed or allowed to die. But what would Kant say about individuals

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is morally permissible and that it should not be legalized— or vice versa. We might plausibly argue that in some cases, performing active voluntary euthanasia is the right thing to do but that legal- izing it would have terrible consequences. Legal- ization could, say, lead doctors to practice active nonvoluntary euthanasia or encourage them to care less about preserving life or cause patients to fear or mistrust doctors. To mix up these two kinds of issues— moral and legal— is to invite confusion.

We begin by examining arguments for active voluntary euthanasia. The strongest of these are built on two fundamental moral principles: per- sons have (1) a right of self- determination and (2) an obligation to help someone in serious dis- tress or peril (if they are in a position to help with- out great risk to themselves). Principle 1 refers to the patient’s right of self- determination, and Principle 2 to other persons who might be able to benefit her. Principle 1 assumes that persons have autonomy— the capacity, as Kant would have it, to use reason to guide their own actions and make their own decisions. It asserts that persons have the

In the doctrine of double effect, intention makes all the difference.

MORAL ARGUMENTS

Most plausible euthanasia arguments are about active euthanasia (mercy killing, as opposed to let- ting the patient die). As suggested earlier, passive euthanasia (both voluntary and nonvoluntary) is legal, provided certain conditions are met, and both forms of it are widely believed to be morally acceptable. So let us confine our evaluation here to moral arguments for and against active voluntary euthanasia (mercy killing at the patient’s request). The question these arguments address, then, is straightforward: Is active voluntary euthanasia mor- ally permissible?

As we proceed, we must keep an important dis- tinction in mind: moral permissibility is not the same thing as legal permissibility. Whether eutha- nasia is morally acceptable is a separate issue from whether it should be legalized. It is possible that we could be justified in believing both that euthanasia

’ Dr. Jack Kevorkian was known as a champion of the right- to- die movement, having helped many incur- ably ill people commit suicide. He was also known as “Dr. Death,” the physician who helped desper- ate people kill themselves. After many unsuccessful tries, prosecutors finally won a conviction against him for murder: in 1999, he was sentenced to ten to twenty- five years in prison. The New York Times reported that the sentence was handed down “despite emotional courtroom pleas on his behalf from the widow and brother of the terminally ill man he was convicted of killing.”*

Do you agree with the verdict in this case? Why or why not? If you do not agree, would your opinion change if you knew that many of Dr. Kevorkian’s sui- cide patients were not mentally competent at the time of their deaths (because of depression), as some people allege? If so, why? If you were terminally ill and in horrendous pain with no hope of relief, might you think it morally permissible to use the services of someone like Dr. Kevorkian? If not, why not?

*Dirk Johnson, “Kevorkian Sentenced to 10 to 25 Years in Prison,” New York Times, April 14, 1999.

CRITICAL THOUGHT: Dr. Kevorkian and Physician- Assisted Suicide

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patient is in agony and asks to be put out of her misery (active voluntary euthanasia), rejecting her plea for mercy would be both cruel and wicked. They also insist that merely withholding treatment from her to hasten her death (passive euthanasia) would only prolong her suffering.

Here is one way to incorporate both Principles 1 and 2 into a single argument for active voluntary euthanasia:

1. Competent persons have a right of self- determination (as long as exercising this right does not violate others’ rights).

2. The right of self- determination includes the right of competent persons to decide the man- ner of their dying and to choose active (volun- tary) euthanasia.

3. We have an obligation to help others in serious distress or peril (if we are in a position to help without great risk to ourselves).

4. This duty of beneficence includes the duty, under appropriate conditions, to ease the pain and suffering of competent dying persons by performing active (voluntary) euthanasia.

5. Therefore, active voluntary euthanasia for com- petent dying persons is permissible.

The central idea behind this argument is that if competent dying persons have a right to choose active euthanasia, and if the duty of beneficence includes performing active voluntary euthanasia, then active voluntary euthanasia is morally permis- sible. But does the conclusion follow from the prem- ises, and are the premises true? The answer to the first part of this question is yes. The answer to the second part is more complicated. Look at Premises 1 and 3; they articulate the two basic moral principles we began with. These principles qualify as consid- ered moral judgments and are accepted by virtually all parties to the euthanasia debate. We have good reason, then, to say that Premises 1 and 3 are true.

Premises 2 and 4, however, are controversial. Critics of Premise 2 would say that we do indeed

right to exercise this power to direct their lives as they see fit (with the proviso that their actions not violate the rights of others). Many who appeal to this principle argue that if it applies to how persons live, then it surely applies to how they die, because their dying is part of their life. This is how the bio- ethicist Dan W. Brock explains the importance of this end- of- life self- determination:

Most people are very concerned about the nature of the last stage of their lives. This reflects not just a fear of experiencing substantial suffering when dying, but also a desire to retain dignity and control dur- ing this last period of life. Death is today increasingly preceded by a long period of significant physical and mental decline, due in part to the technological inter- ventions of modern medicine. Many people adjust to these disabilities and find meaning and value in new activities and ways. Others find the impairments and burdens in the last stage of their lives at some point sufficiently great to make life no longer worth living. For many patients near death, maintaining the qual- ity of one’s life, avoiding great suffering, maintaining one’s dignity, and insuring that others remember us as we wish them to become of paramount importance and outweigh merely extending one’s life. But there is no single, objectively correct answer for everyone as to when, if at all, one’s life becomes all things con- sidered a burden and unwanted. If self- determination is a fundamental value, then the great variability among people on this question makes it especially important that individuals control the manner, cir- cumstances, and timing of their dying and death.6

Principle 2 is a duty of beneficence (a duty to benefit others). Applied to euthanasia, it says that if we are in a position to ease the agony of another, and we can do so without excessive cost to ourselves, we should try to render aid. This tenet applies to persons generally, but it carries extra weight for people with a special relationship with the suffering person, such as family members, close friends, and doctors. Physicians have an explicit obligation to try to relieve the misery of their patients— especially dying patients who often must endure horrific pain and suffering. Many advocates of euthanasia contend that if a competent dying

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escape her agony. Modern medicine is better than ever at alleviating pain— even very intense pain. Spinal blocks, drug combinations, new ways to deliver powerful analgesics (drugs that ease pain)— these options and others can offer dying patients unprecedented levels of pain relief. So euthanasia is uncalled for. If this claim is correct, then opponents can argue that contrary to Premise 4, active eutha- nasia will actually harm patients by cutting their lives short unnecessarily and thus depriving them of the benefits that may accrue in their remain- ing days— benefits such as profoundly meaningful moments spent with their families, the chance to come to terms with their dying, and even the pos- sibility of a newfound cure for their disease.7 Pro- ponents of active euthanasia, however, charge that this upbeat view of pain management is not accu- rate. They point to several unpleasant facts: though it is possible to manage even severe pain well, too often pain is not well managed (for a variety of reasons, including the reluctance of health care workers to administer large doses of pain- relieving drugs); the side effects of the best pain medications (especially when used over the long term) often add to the suffering of the patient; and many dying patients endure not physical pain, but psychologi- cal suffering that is unbearable and untreatable by any medication.

Proponents can put forth another kind of argu- ment for active voluntary euthanasia, this one based on the moral significance of killing (active euthanasia) and letting die (passive euthanasia). As we saw earlier, active euthanasia is taking a direct action to kill someone, while passive euthanasia is allowing someone to die by withholding or with- drawing measures necessary for sustaining life. Pas- sive euthanasia is legal (competent patients have the right to refuse treatment) and widely believed to be morally permissible. Active euthanasia is gen- erally illegal, and debate continues over its moral permissibility. Opponents of active euthanasia generally think that there is a profound moral dif- ference between killing and letting die: killing is

have a right of self- determination but that this right does not include the right to opt for active vol- untary euthanasia. The reason is that active eutha- nasia is killing, and killing is always wrong. We may have all sorts of rights, but killing is still killing.

This reply, though, is based on a superficial understanding of prohibitions against killing. Some kinds of killing are considered by most people to be morally permissible— for example, killing in self- defense and killing in war. These are regarded as justified killings; unjustified killings are known as murder. So even though all killing may be regret- table, not all killing is immoral. Active euthanasia may in fact be a form of acceptable killing.

The opponent of active euthanasia can make a stronger reply along the same lines. He can say that the problem with active euthanasia is not that it is a type of killing, but that it is a type of unwarranted killing. A dying patient in the grip of unimagina- ble pain, for example, does not have to be killed to

’Public Opinion and Euthanasia Many opinion polls have shown that most people favor some form of euthanasia or physician assis- tance in dying. A 2016 Gallup poll of 1,025 adults aged eighteen and over echoed these findings:

• 69 percent of Americans approve of doctor- assisted suicide.

• 51 percent of Americans say they would con- sider ending their own lives by some painless means if they had an incurable disease and they were in severe pain.

• 53 percent of Americans say they believe doctor- assisted suicide is morally acceptable.*

*“Euthanasia Still Acceptable to Solid Majority in U.S.,” Gallup Poll, May 4–6, 2016, http://www . gallup.com/poll/193082/euthanasia-acceptable-solid -majority.aspx.

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morally, then we would judge one man’s action (either Smith’s or Jones’s) to be more blamewor- thy than that of the other. But our judgment is the same for both, so there must be no moral difference.

Some reject this argument and insist that there is in fact a moral difference between killing and letting die but that the distinction is often obscured in thought experiments like the Smith- Jones story. One critic claims, for example, that in this scenario the two men are equally repre- hensible and the two actions appear to be morally equivalent simply because both men were prepared to kill. Remove this common factor, and the moral difference between killing and letting die will be apparent.9

Some of the strongest arguments against active voluntary euthanasia take a slippery slope approach. The gist of most of them is that lifting a moral or legal prohibition against this kind of mercy killing will dilute respect for life and encourage a slow slide from active voluntary euthanasia to active nonvol- untary euthanasia and then perhaps to involuntary euthanasia. This argument is therefore consequen- tialist: active voluntary euthanasia is wrong because it leads to bad consequences. (The argument is also sometimes lodged against legalizing this form of euthanasia.) Here is how one bioethicist describes the descent down the slope:

A person apparently hopelessly ill may be allowed to take his own life. Then he may be permit- ted to deputize others to do it for him should he no longer be able to act. The judgment of others then becomes the ruling factor. Already at this point euthanasia is not personal and voluntary, for others are acting “on behalf of” the patient as they see fit. This may well incline them to act on behalf of other patients who have not autho- rized them to exercise their judgment. It is only a short step, then, from voluntary euthanasia ( self- inflicted or authorized), to directed euthanasia administered to a patient who has given no autho- rization, to involuntary euthanasia conducted as part of a social policy.10

far worse than letting die; in fact, killing is morally wrong while letting die is permissible. But propo- nents of active voluntary euthanasia assert that the two are morally equivalent. Using this alleged moral equivalence, proponents can construct an argument like this:

1. Passive euthanasia is morally permissible.

2. If passive euthanasia is morally equivalent to active euthanasia, active euthanasia is also morally permissible.

3. Passive euthanasia is morally equivalent to active euthanasia.

4. Therefore, active (voluntary) euthanasia is mor- ally permissible.

The conclusion follows from the premises, and Premises 1 and 2 are uncontroversial. The crux of the matter is Premise 3. What reasons are there for thinking that it is true? Here is an argument for Premise 3 in the form of a classic thought experi- ment. Suppose Smith will inherit a fortune if his six- year- old cousin dies. So he decides to take mat- ters into his own hands. He slips into the bathroom while his little cousin is taking a bath and drowns him. He makes the whole thing look like an acci- dent and leaves undetected. Now consider Jones, who also will inherit a fortune if his six- year- old cousin dies. He too decides to kill the child, and he too slips into the bathroom while the boy is bath- ing. But before Jones has a chance to commit the deed, the boy slips in the tub, gets knocked uncon- scious, and will surely drown unless Jones rescues him. Jones is happy to do nothing and lets the boy drown on his own— a simple “accident.” Now which man behaves better morally? If there is a sig- nificant moral difference between killing and let- ting die, we would want to say that Jones’s actions are less blameworthy than Smith’s. But this distinc- tion doesn’t seem correct. The motives and aims of both men are the same.8

The line taken here is that if the difference between killing and letting die really is important

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possible slippery slope worry could have been raised to securing competent patients’ rights to decide about life support, but recent history shows such a worry would have been unfounded.11

CHAPTER REVIEW

SUMMARY

Euthanasia is directly or indirectly bringing about the death of another person for that person’s sake. Its moral status depends in large measure on the consent of the patient. In voluntary euthanasia, the patient agrees to the act. In nonvoluntary euthanasia, others besides the patient decide on euthanasia because he or she is incompetent and has left no statement about end- of- life preferences. In involuntary euthanasia, the act is performed against the patient’s wishes. Active euthana- sia is taking direct action to kill someone (administer- ing a lethal injection, for example); passive euthanasia is allowing the patient to die by withholding or with- drawing life- sustaining measures.

The traditional notion of death as the cessation of breathing and heartbeat has been revised in light of new developments in medical technology. Accord- ing to the whole- brain view of death, the individual is dead when all brain functions permanently stop. The higher- brain view of death says that an individual is dead when higher brain functions permanently stop.

An act- utilitarian might see euthanasia as morally permissible because it results in the greatest happi- ness for all concerned. She could also consistently say that euthanasia is contrary to the goal of maximizing happiness because killing an individual rules out any possibility of that person’s future happiness. A rule- utilitarian might say that a general rule permitting some kinds of euthanasia would do more harm than good— or that such a rule would maximize happiness in the long run. A Kantian theorist could consistently reject euthanasia because it entails treating persons as disposable things. Or he could consistently maintain

We can formulate a version of the argument thus:

1. If the general acceptance or approval of active voluntary euthanasia leads to widespread abuses (unjustified killing), then the practice is mor- ally wrong.

2. The general acceptance or approval of active voluntary euthanasia will lead to widespread abuses (unjustified killing).

3. Therefore, active voluntary euthanasia is morally wrong.

This is a valid argument, an instance of modus ponens, so we need to focus only on the truth or falsity of the premises. Probably most people who have thought carefully about this kind of argu- ment accept Premise 1 or a variation of it. Premise 2 is the sticking point. Because of a lack of solid evidence on the subject, the social consequences of a general acceptance of active euthanasia are difficult to ascertain. For example, to prove their case, some opponents of euthanasia cite reports on the Dutch experience with physician- assisted suicide. Proponents point to the same reports to undermine that case. The difficulty is that the research is not robust enough to lend unequivo- cal support to one side or the other. It therefore does not show that Premise 2 is true. Many of the arguments for Premise 2 are arguments by analogy or inferences based on observations concerning human behavior. Generally, these arguments, too, are weak and conjectural.

Those who are skeptical of Premise 2 often sim- ply point out that no good reasons have been pro- vided to support it. At best, they say, arguments for Premise 2 show only that dreadful consequences from widespread use of active euthanasia are pos- sible. As one skeptic puts it,

Now it cannot be denied that it is possible that per- mitting euthanasia could have these fateful con- sequences, but that cannot be enough to warrant prohibiting it if it is otherwise justified. A similar

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8. What is the American Medical Association’s official view of physician- assisted suicide? (p. 287)

9. What is an advance directive? (p. 286) 10. What is the higher- brain definition of death?

(p. 289)

Discussion Questions

1. Do you think voluntary active euthanasia is morally permissible in some cases? Why or why not?

2. Critique the Terri Schiavo case. Who was right in their view of what should be done for Terri? Was the participation of politicians in the case helpful? Distracting? Wrong?

3. Was removing Terri Schiavo’s feeding tube a case of murder? If not, what was it?

4. What actions (or lack of actions) should have been performed in her case?

5. Would you consider her a person in her brain- damaged state? Why or why not?

6. Do you consider Dr. Kevorkian’s practice of physician- assisted suicide morally acceptable? Why or why not?

7. Is there a moral difference between killing and letting die? Give reasons for your answer.

8. How might an act- utilitarian argue for physician- assisted suicide? Critique this argument.

9. How might a Kantian argue against physician- assisted suicide?

10. Is the use of terminal sedation ever morally permissible? If so, in what situations?

FURTHER READING Tom L. Beauchamp, ed., Intending Death: The Ethics of

Assisted Suicide and Euthanasia (Englewood Cliffs, NJ: Prentice Hall, 1995).

R. B. Brandt, “The Morality and Rationality of Suicide,” in A Handbook for the Study of Suicide, ed. Seymour Perlin (New York: Oxford University Press, 1975).

Lonnie R. Bristow, President of the American Medical Association, statement on physician- assisted suicide to the U.S. House of Representatives Committee on the

that individuals in comas or persistent vegetative states are no longer persons, and therefore euthanasia is morally acceptable.

Arguments in favor of active voluntary euthanasia are often based on a right of self- determination and a duty to help others in distress. Some arguments for euthanasia, however, depend on the alleged equiva- lence between active and passive euthanasia. Some of the strongest arguments against euthanasia are of the slippery slope type: active voluntary euthanasia is wrong because it leads to bad consequences, such as an increased risk of unjustified killings.

KEY TERMS euthanasia (p. 286) voluntary euthanasia (p. 286) advance directive (p. 286) nonvoluntary euthanasia (p. 286) involuntary euthanasia (p. 286) active euthanasia (p. 286) passive euthanasia (p. 286) physician- assisted suicide (p. 287)

EXERCISES Review Questions

1. What is euthanasia? What is physician- assisted suicide? (p. 286)

2. What is the difference between voluntary euthanasia and nonvoluntary euthanasia? (p. 286)

3. What is the difference between active and passive euthanasia? (p. 286)

4. Who was Terri Schiavo and what are the main medical and legal facts of her case? (p. 285)

5. Who was Dr. Kevorkian and what role did he play in the debate over physician- assisted suicide? (p. 291)

6. What percentage of American adults think physician- assisted suicide is morally permissible? (p. 293)

7. In what states is physician- assisted suicide legal? (p. 287)

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Medical Ethics, ed. Ronald Munson, 7th ed. (Belmont, CA: Wadsworth, 2004).

Jeffrey Olen and Vincent Barry, “Euthanasia,” in Apply- ing Ethics: A Text with Readings, 6th ed. (Belmont, CA: Wadsworth, 1999).

The President’s Commission for the Study of Ethical Prob- lems in Medicine and Biomedical and Behavioral Research (Washington, DC: Government Printing Office, 1983).

Bonnie Steinbock and Alastair Norcross, eds., Killing and Letting Die, 2nd ed. (New York: Fordham University Press, 1994).

Thomas D. Sullivan, “Active and Passive Euthanasia: An Impertinent Distinction?” Human Life Review 3, no. 3 (1977): 40–46.

Robert Young, “Voluntary Euthanasia,” in Stanford Ency- clopedia of Philosophy, Summer 2005 ed., ed. Edward N. Zalta, http://plato.stanford.edu/archives/sum2005/ entries/ euthanasia- voluntary/ (March 1, 2015).

Judiciary, Subcommittee on the Constitution, 104th Cong., 2nd sess., Congressional Record 142 (April 29, 1996).

Dan W. Brock, “Medical Decisions at the End of Life,” in A Companion to Bioethics, ed. Helga Kuhse and Peter Singer (1998; reprint, Malden, MA: Blackwell, 2001).

Daniel Callahan, “When Self- Determination Runs Amok,” Hastings Center Report 22, no. 2 (March/April 1992): 52–55.

Philippa Foot, “Euthanasia,” Philosophy & Public Affairs 6, no. 2 (1977): 85–112.

Walter Glannon, “Medical Decisions at the End of Life,” in Biomedical Ethics (New York: Oxford University Press, 2005).

John Lachs, “When Abstract Moralizing Runs Amok,” Journal of Clinical Ethics 5, no. 1 (1994): 10–13.

Ronald Munson, “Euthanasia and Physician- Assisted Suicide,” in Intervention and Reflection: Basic Issues in

E T H I C A L d I L E M M A S

1. Assisted Suicide or Murder?

One of the more bizarre cases of assisted suicide in recent times came to its con- clusion on September 29, 2014, when New Yorker Kenneth Minor was convicted of manslaughter after stabbing a Long Island motivational speaker. Minor claimed that the man wished to die and had paid him to help him do so.

Minor received a sentence of twelve years when he accepted the prosecutors’ plea deal and pled guilty to first- degree manslaughter.

However, Minor’s lawyer claims, “We will be back again . . . Our hope is the appellate division will once again reverse this case.”

Minor’s lawyer, Daniel J. Gotlin, hopes to overturn the conviction by bringing the case to an appeals court. Gotlin argues that the verdict should be thrown out based on procedural grounds. Minor’s indictment includes murder charges and assisted suicide charges, which Gotlin claims are mutually exclusive.

Minor has been incarcerated for more than five years, and, according to Gotlin, accepted the plea deal because “he wants finality; he wants this to be over.” If Minor is unsuccessful in his appeal, he will have to serve five more years before he is eligible to be released.

Moments before Minor entered his plea, Justice Laura A. Ward of the New York Supreme Court in Manhattan denied Gotlin’s request to dismiss the case, stating that a man can be charged for both murder and assisted suicide. However, she did not refute that Minor had a right to appeal her ruling, and said, “Perhaps we will get a definite ruling from the appellate division.”

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The man who Minor admits to killing, Jeffrey Locker, was found tied up in his car in East Harlem in July 2009. Multiple stab wounds were found on his chest.

Minor claims that Locker, a middle- aged father who had fallen deeply into debt, had hired him to assist in his suicide plan. Minor says he held a knife to a steering wheel while Locker flung himself against it multiple times. Minor’s prosecutors found his story incredible and brought a murder charge against him instead of a charge of assisting suicide.

In 2011, Minor was tried and convicted of second- degree murder by a jury. The judge gave him twenty years to life in prison, but the verdict was invalidated two years later by an appellate panel. They concluded that the trial judge had given the jury an incorrect definition of assisted suicide.

Minor was given another trial in January. This time, a charge of assisting suicide was added to his indictment at the request of Cyrus R. Vance Jr., Manhattan district attorney. A jury could now convict him of a lesser charge.

During Minor’s first trial, the defense and the prosecution agreed that Minor had participated in Locker’s suicide at the request of the deceased, who wished to make his death look like a murder so that his family could claim life insurance.

However, prosecutors argued that it was a case of murder for hire, not assisted suicide, as Minor was still the cause of Locker’s death. According to a medical expert, Minor did not simply hold a knife to a steering wheel, but stabbed Locker as he lay in his car. He then used Locker’s credit card to withdraw money from an ATM.*

Suppose Minor killed Locker at Locker’s request. Would the killing then be morally permissible? Is there a moral difference between physician- assisted suicide and Locker’s murder when both actions are taken at the victim’s request? What is the differ- ence, if any, between murder and assisted suicide?

Suppose Locker’s motive for asking Minor for aid in dying, and for making the death look like murder, was that Locker’s life insurance money would pay for the only medical treatment that could save his daughter’s life. How would these facts change your moral judgment about the killing?

*Based on James C. McKinley Jr., “Harlem Man Pleads Guilty to Assisting 2009 Death,” New York Times, September 29, 2014, http://www.nytimes.com/2014/09/30/nyregion/- harlem- man-pleads-guilty-to-assisting-2009-death. html?_r=0 (March 23, 2015).

2. Euthanasia for Newborns

Imagine the unimaginable: Your newborn baby is born with a severe, deadly birth defect or contracts a fatal illness. The baby will die and is in tremendous pain. In this case, is it justified, perhaps even humane, to euthanize the child?

In Holland, some doctors and parents say the answer is yes. Back in 2005, the Netherlands adopted the Groningen Protocol, which is designed to help doctors end the suffering of very sick newborns through euthanasia. The rule requires that five criteria must be met before taking the decision to end the child’s life: beyond-

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a- doubt diagnosis; presence of unbearable suffering; a second expert medical opinion to verify the child’s condition; consent of both parents; and compliance with medical standards.

Some critics feared that this would create a “slippery slope” of infanticide, but new research published in the Journal of Medical Ethics contends that that has not been the case. The authors reviewed all reported cases of infant euthanasia between 2001 and 2010 (doctors sometimes covertly practiced infanticide before the protocol was passed) and found that in 95 percent of cases the mode of euthanasia was withholding or withdrawing treatment. In 60 percent of those cases, this was because the infant would soon die from an incurable disease. For the remaining 40 percent, quality of life prompted the decision.

However, since 2007, doctors reported euthanizing just two babies. The authors of the new paper suspect that an increase in abortions when fatal problems are detected in the womb may explain this. Alternatively, doctors may be confused about what constitutes euthanasia– such as withholding treatment, food or water— and may be underreporting it. Either way, the authors write, there has not been a detectable snowballing of euthanized babies in Holland as a result of the new protocol.†

Provide reasons for your answers to the follow- ing questions. Under the circumstances described (severe pain, terminal illness), would child eutha- nasia ever be morally permissible? Would child euthanasia be permissible if the newborn was not

terminal, but in an unalterable vegetative state? Would it be permissible if the newborn suffered from a severe birth defect such as Down syndrome, which causes severe disabilities but does not rule out a worthwhile life?

† Rachel Nuwer, “Is It Ever OK to Euthanize a Baby?” Smithsonianmag.com, May 3, 2013. Copyright 2013 Smith- sonian Institution. Reprinted with permission from Smithsonian Enterprises. All rights reserved. Reproduction in any medium is strictly prohibited without permission from Smithsonian Institution.

3. The Suicide of Admiral Nimitz

The name of Chester W. Nimitz is legendary in the annals of naval warfare. In June 1942, Admiral Nimitz commanded the U.S. forces assigned to block a Japanese invasion of Midway.

In the Battle of Midway, Nimitz’s fighter- bombers caught the Japanese fleet off guard, as its carrier aircraft were being refueled on deck. His pilots swooped in and sent to the bottom four of the Japanese carriers— Hiryu, Soryu, Akagi and Kaga— that had led the attack on Pearl Harbor. Midway broke the back of Japanese naval power and was among the most decisive battles in all of history.

Nimitz’s son and namesake, Chester W. Nimitz Jr., would rise to the same rank of admiral and become a hero of the Pacific war— a submarine commander who would sink a Japanese destroyer bearing down on his boat by firing torpedoes directly into its bow.

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But Chester W. Nimitz Jr. achieved another kind of fame on Jan. 2. In a suicide pact with his 89- year- old wife, the 86- year- old hero ended his life with an overdose of sleeping pills.

Having lost 30 pounds from a stomach disorder, suffering from congestive heart failure and in constant back pain, the admiral had been determined to dictate the hour of his death. His wife, who suffered from osteoporosis so severe her bones were breaking, had gone blind. She had no desire to live without her husband.

So, as the devoted couple had spent their lives together, they decided to end their lives together. The admiral’s final order read: “Our decision was made over a considerable period of time and was not carried out in acute desperation. Nor is it the expression of a mental illness. We have consciously, rationally, deliberately and of our own free will taken measures to end our lives today because of the physical limitations on our quality of life placed upon us by age, failing vision, osteoporosis, back and painful orthopedic problems.”

According to The New York Times obituary, “The Nimitzes did not believe in any afterlife or God, and embraced no religion. But one of Mr. Nimitz’s three surviving sisters, Mary Aquinas, 70, is a Catholic nun. . . . Sister Mary said that she could not condone her brother’s decision to end his life, but that she felt sympathetic. ‘If you cannot see any value to suffering for yourself or others,’ she said, ‘Then maybe it does make sense to end your life.’”‡

Provide reasons for your answers: Was Admiral Nimitz justified in his decision to commit suicide? Is suicide morally wrong in all circumstances? Is

suicide a matter of personal choice, morally per- missible if a person freely opts to end her life for whatever reason?

‡Patrick J. Buchanan, “The Sad Suicide of Admiral Nimitz,” World Net Daily, January 18, 2002. Reprinted by per- mission of Patrick J. Buchanan and Creators Syndicate, Inc.

The distinction between active and passive eutha- nasia is thought to be crucial for medical ethics. The idea is that it is permissible, at least in some cases, to withhold treatment and allow a patient to die, but it

is never permissible to take any direct action designed to kill the patient. This doctrine seems to be accepted by most doctors, and it is endorsed in a statement adopted by the House of Delegates of the American Medical Association on December 4, 1973:

The intentional termination of the life of one human being by another— mercy killing— is contrary to that for which the medical profession stands and is contrary to the policy of the American Medical Association.

R E A d I n G S

Active and Passive Euthanasia James R achels

James Rachels, excerpts from “Active and Passive Euthana- sia,” from The New England Journal of Medicine, Vol. 292, No. 2, pp. 78–80. Copyright © 1975 Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society.

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The cessation of the employment of extraordinary means to prolong the life of the body when there is irre- futable evidence that biological death is imminent is the decision of the patient and/or his immediate fam- ily. The advice and judgment of the physician should be freely available to the patient and/or his immediate family.

However, a strong case can be made against this doc- trine. In what follows I will set out some of the relevant arguments, and urge doctors to reconsider their views on this matter.

To begin with a familiar type of situation, a patient who is dying of incurable cancer of the throat is in ter- rible pain, which can no longer be satisfactorily alle- viated. He is certain to die within a few days, even if present treatment is continued, but he does not want to go on living for those days since the pain is unbear- able. So he asks the doctor for an end to it, and his fam- ily joins in the request.

Suppose the doctor agrees to withhold treatment, as the conventional doctrine says he may. The justifi- cation for his doing so is that the patient is in terrible agony, and since he is going to die anyway, it would be wrong to prolong his suffering needlessly. But now notice this. If one simply withholds treatment, it may take the patient longer to die, and so he may suffer more than he would if more direct action were taken and a lethal injection given. This fact provides strong reason for thinking that, once the initial decision not to prolong his agony has been made, active euthana- sia is actually preferable to passive euthanasia, rather than the reverse. To say otherwise is to endorse the option that leads to more suffering rather than less, and is contrary to the humanitarian impulse that prompts the decision not to prolong his life in the first place.

Part of my point is that the process of being “allowed to die” can be relatively slow and painful, whereas being given a lethal injection is relatively quick and painless. Let me give a different sort of example. In the United States about one in 600 babies is born with [Down] syndrome. Most of these babies are otherwise healthy— that is, with only the usual pediatric care, they will proceed to an otherwise nor- mal infancy. Some, however, are born with congeni- tal defects such as intestinal obstructions that require

operations if they are to live. Sometimes, the parents and the doctor will decide not to operate, and let the infant die. Anthony Shaw describes what happens then:

. . . When surgery is denied [the doctor] must try to keep the infant from suffering while natural forces sap the baby’s life away. As a surgeon whose natural incli- nation is to use the scalpel to fight off death, standing by and watching a salvageable baby die is the most emotionally exhausting experience I know. It is easy at a conference, in a theoretical discussion, to decide that such infants should be allowed to die. It is altogether different to stand by in the nursery and watch as dehy- dration and infection wither a tiny being over hours and days. This is a terrible ordeal for me and the hospi- tal staff— much more so than for the parents who never set foot in the nursery.1

I can understand why some people are opposed to all euthanasia, and insist that such infants must be allowed to live. I think I can also understand why other people favor destroying these babies quickly and painlessly. But why should anyone favor letting “dehy- dration and infection wither a tiny being over hours and days”? The doctrine that says that a baby may be allowed to dehydrate and wither, but may not be given an injection that would end its life without suffering, seems so patently cruel as to require no further refu- tation. The strong language is not intended to offend, but only to put the point in the clearest possible way.

My second argument is that the conventional doctrine leads to decisions concerning life and death made on irrelevant grounds.

Consider again the case of the infants with [Down] syndrome who need operations for congenital defects unrelated to the syndrome to live. Sometimes, there is no operation, and the baby dies, but when there is no such defect, the baby lives on. Now, an operation such as that to remove an intestinal obstruction is not prohibitively difficult. The reason why such opera- tions are not performed in these cases is, clearly, that the child has [Down] syndrome and the parents and doctor judge that because of that fact it is better for the child to die.

But notice that this situation is absurd, no matter what view one takes of the lives and potentials of such

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push the child’s head back under if it is necessary, but it is not necessary. With only a little thrashing about, the child drowns all by himself, “accidentally,” as Jones watches and does nothing.

Now Smith killed the child, whereas Jones “merely” let the child die. That is the only difference between them. Did either man behave better, from a moral point of view? If the difference between kill- ing and letting die were in itself a morally important matter, one should say that Jones’s behavior was less reprehensible than Smith’s. But does one really want to say that? I think not. In the first place, both men acted from the same motive, personal gain, and both had exactly the same end in view when they acted. It may be inferred from Smith’s conduct that he is a bad man, although that judgment may be withdrawn or modified if certain further facts are learned about him— for example, that he is mentally deranged. But would not the very same thing be inferred about Jones from his conduct? And would not the same further considerations also be relevant to any modification of this judgment? Moreover, suppose Jones pleaded, in his own defense, “After all, I didn’t do anything except just stand there and watch the child drown. I didn’t kill him: I only let him die.” Again, if letting die were in itself less bad than killing, this defense should have at least some weight. But it does not. Such a “defense” can only be regarded as a grotesque perversion of moral reasoning. Morally speaking, it is no defense at all.

Now, it may be pointed out, quite properly, that the cases of euthanasia with which doctors are con- cerned are not like this at all. They do not involve personal gain or the destruction of normal healthy children. Doctors are concerned only with cases in which the patient’s life is of no further use to him, or in which the patient’s life has become or will soon become a terrible burden. However, the point is the same in these cases: the bare difference between killing and letting die does not, in itself, make a moral differ- ence. If a doctor lets a patient die, for humane reasons, he is in the same moral position as if he had given the patient a lethal injection for humane reasons. If his decision was wrong— if, for example, the patient’s illness was in fact curable— the decision would be

babies. If the life of such an infant is worth preserv- ing, what does it matter if it needs a simple operation? Or, if one thinks it better that such a baby should not live on, what difference does it make that it happens to have an unobstructed intestinal tract? In either case, the matter of life and death is being decided on irrelevant grounds. It is the [Down] syndrome, and not the intestines, that is the issue. The matter should be decided, if at all, on that basis, and not be allowed to depend on the essentially irrelevant question of whether the intestinal tract is blocked.

What makes this situation possible, of course, is the idea that when there is an intestinal blockage, one can “let the baby die,” but when there is no such defect there is nothing that can be done, for one must not “kill” it. The fact that this idea leads to such results as deciding life or death on irrelevant grounds is another good reason why the doctrine should be rejected.

One reason why so many people think that there is an important moral difference between active and passive euthanasia is that they think killing someone is morally worse than letting someone die. But is it? Is killing, in itself, worse than letting die? To investi- gate this issue, two cases may be considered that are exactly alike except that one involves killing whereas the other involves letting someone die. Then, it can be asked whether this difference makes any difference to the moral assessments. It is important that the cases be exactly alike, except for this one difference, since otherwise one cannot be confident that it is this dif- ference and not some other that accounts for any variation in the assessments of the two cases. So, let us consider this pair of cases:

In the first, Smith stands to gain a large inheri- tance if anything should happen to his six- year- old cousin. One evening while the child is taking his bath, Smith sneaks into the bathroom and drowns the child, and then arranges things so that it will look like an accident.

In the second, Jones also stands to gain if anything should happen to his six- year- old cousin. Like Smith, Jones sneaks in planning to drown the child in his bath. However, just as he enters the bathroom Jones sees the child slip and hit his head, and fall face down in the water. Jones is delighted; he stands by, ready to

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however, the doctor does something to bring about the patient’s death: he kills him. The doctor who gives the patient with cancer a lethal injection has himself caused his patient’s death: whereas if he merely ceases treatment, the cancer is the cause of the death.”

A number of points need to be made here. The first is that it is not exactly correct to say that in pas- sive euthanasia the doctor does nothing, for he does do one thing that is very important: he lets the patient die. “Letting someone die” is certainly different, in some respects, from other types of action— mainly in that it is a kind of action that one may perform by way of not performing certain other actions. For example, one may let a patient die by way of not giving medi- cation, just as one may insult someone by way of not shaking his hand. But for any purpose of moral assess- ment, it is a type of action nonetheless. The decision to let a patient die is subject to moral appraisal in the same way that a decision to kill him would be subject to moral appraisal: it may be assessed as wise or unwise, compassionate or sadistic, right or wrong. If a doctor deliberately let a patient die who was suffering from a routinely curable illness, the doctor would certainly be to blame for what he had done, just as he would be to blame if he had needlessly killed the patient. Charges against him would then be appropriate. If so, it would be no defense at all for him to insist that he didn’t “do anything.” He would have done something very seri- ous indeed, for he let his patient die.

Fixing the cause of death may be very impor- tant from a legal point of view, for it may determine whether criminal charges are brought against the doc- tor. But I do not think that this notion can be used to show a moral difference between active and passive euthanasia. The reason why it is considered bad to be the cause of someone’s death is that death is regarded as a great evil— and so it is. However, if it has been decided that euthanasia— even passive euthanasia— is desirable in a given case, it has also been decided that in this instance death is no greater an evil than the patient’s continued existence. And if this is true, the usual reason for not wanting to be the cause of some- one’s death simply does not apply.

Finally, doctors may think that all of this is only of academic interest— the sort of thing that philosophers

equally regrettable no matter which method was used to carry it out. And if the doctor’s decision was the right one, the method used is not in itself important.

The AMA policy statement isolates the crucial issue very well: the crucial issue is “the intentional ter- mination of the life of one human being by another.” But after identifying this issue, and forbidding “mercy killing,” the statement goes on to deny that the ces- sation of treatment is the intentional termination of a life. This is where the mistake comes in, for what is the cessation of treatment, in these circumstances, if it is not “the intentional termination of the life of one human being by another”? Of course it is exactly that, and if it were not, there would be no point to it.

Many people will find this judgment hard to accept. One reason, I think, is that it is very easy to conflate the question of whether killing is, in itself, worse than letting die, with the very different ques- tion of whether most actual cases of killing are more reprehensible than most actual cases of letting die. Most actual cases of killing are clearly terrible (think, for example, of all the murders reported in the news- papers), and one hears of such cases every day. On the other hand, one hardly ever hears of a case of letting die, except for the actions of doctors who are moti- vated by humanitarian reasons. So one learns to think of killing in a much worse light than of letting die. But this does not mean that there is something about killing that makes it in itself worse than letting die, for it is not the bare difference between killing and letting die that makes the difference in these cases. Rather, the other factors— the murderer’s motive of personal gain, for example, contrasted with the doc- tor’s humanitarian motivation— account for different reactions to the different cases.

I have argued that killing is not in itself any worse than letting die: if my contention is right, it follows that active euthanasia is not any worse than passive euthanasia. What arguments can be given on the other side? The most common, I believe, is the following:

“The important difference between active and pas- sive euthanasia is that, in passive euthanasia, the doc- tor does not do anything to bring about the patient’s death. The doctor does nothing, and the patient dies of whatever ills already afflict him. In active euthanasia,

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However, the preceding considerations suggest that there is really no moral difference between the two, considered in themselves (there may be important moral differences in some cases in their consequences, but, as I pointed out, these differences may make active euthanasia, and not passive euthanasia, the morally preferable option). So, whereas doctors may have to discriminate between active and passive euthanasia to satisfy the law, they should not do any more than that. In particular, they should not give the distinction any added authority and weight by writing it into official statements of medical ethics.

NOTE

1. Anthony Shaw, “Doctor, Do We Have a Choice?” New York Times Magazine, 30 January 1972, 54.

may worry about but that has no practical bearing on their own work. After all, doctors must be concerned about the legal consequences of what they do, and active euthanasia is clearly forbidden by the law. But even so, doctors should also be concerned with the fact that the law is forcing upon them a moral doctrine that may well be indefensible, and has a considerable effect on their practices. Of course, most doctors are not now in the position of being coerced in this matter, for they do not regard themselves as merely going along with what the law requires. Rather, in statements such as the AMA policy statement that I have quoted, they are endorsing this doctrine as a central point of medical ethics. In that statement, active euthanasia is condemned not merely as illegal but as “contrary to that for which the medical profes- sion stands,” whereas passive euthanasia is approved.

The Wrongfulness of Euthanasia J. Gay- Williams

conclusion is wrong. I want to show that euthanasia is wrong. It is inherently wrong, but it is also wrong judged from the standpoints of self- interest and of practical effects.

Before presenting my arguments to support this claim, it would be well to define “euthanasia.” An essential aspect of euthanasia is that it involves tak- ing a human life, either one’s own or that of another. Also, the person whose life is taken must be someone who is believed to be suffering from some disease or injury from which recovery cannot reasonably be expected. Finally, the action must be deliberate and intentional. Thus, euthanasia is intentionally taking the life of a presumably hopeless person. Whether the life is one’s own or that of another, the taking of it is still euthanasia.

It is important to be clear about the deliberate and intentional aspect of the killing. If a hopeless person is given an injection of the wrong drug by mistake and this causes his death, this is wrongful killing but not euthanasia. The killing cannot be the result of

My impression is that euthanasia— the idea, if not the practice— is slowly gaining acceptance within our society. Cynics might attribute this to an increasing tendency to devalue human life, but I do not believe this is the major factor. The acceptance is much more likely to be the result of unthinking sympathy and benevolence. Well- publicized, tragic stories like that of Karen Quinlan elicit from us deep feelings of compas- sion. We think to ourselves, “She and her family would be better off if she were dead.” It is an easy step from this very human response to the view that if someone (and others) would be better off dead, then it might be all right to kill that person. Although I respect the compassion that leads to this conclusion, I believe the

J. Gay- Williams, “The Wrongfulness of Euthanasia.” Copy- right © 1979 by Ronald Munson. Published from Ronald Munson, Intervention and Reflection: Basic Issues in Medical Ethics, 4th Edition. Wadsworth Publishing Company: Belmont, California. Reprinted with permission.

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bacteria, antibodies are produced to fight against the alien organisms, and their remains are swept out of the body by special cells designed for clean- up work.

Euthanasia does violence to this natural goal of survival. It is literally acting against nature because all the processes of nature are bent towards the end of bodily survival. Euthanasia defeats these subtle mech- anisms in a way that, in a particular case, disease and injury might not.

It is possible, but not necessary, to make an appeal to revealed religion in this connection. Man as trustee of his body acts against God, its rightful possessor, when he takes his own life. He also violates the com- mandment to hold life sacred and never to take it without just and compelling cause. But since this appeal will persuade only those who are prepared to accept that religion has access to revealed truths, I shall not employ this line of argument.

It is enough, I believe, to recognize that the organiza- tion of the human body and our patterns of behavioral responses make the continuation of life a natural goal. By reason alone, then, we can recognize that euthanasia sets us against our own nature. Furthermore, in doing so, euthanasia does violence to our dignity. Our dignity comes from seeking our ends. When one of our goals is survival, and actions are taken that eliminate that goal, then our natural dignity suffers. Unlike animals, we are conscious through reason of our nature and our ends. Euthanasia involves acting as if this dual nature— inclination towards survival and awareness of this as an end— did not exist. Thus, euthanasia denies our basic human character and requires that we regard ourselves or others as something less than fully human.

2. THE ARGUMENT FROM SELF- INTEREST

The above arguments are, I believe, sufficient to show that euthanasia is inherently wrong. But there are rea- sons for considering it wrong when judged by stan- dards other than reason. Because death is final and irreversible, euthanasia contains within it the possi- bility that we will work against our own interest if we practice it or allow it to be practiced on us.

Contemporary medicine has high standards of excellence and a proven record of accomplishment,

accident. Furthermore, if the person is given an injec- tion of a drug that is believed to be necessary to treat his disease or better his condition and the person dies as a result, then this is neither wrongful killing nor euthanasia. The intention was to make the patient well, not kill him. Similarly, when a patient’s condi- tion is such that it is not reasonable to hope that any medical procedures or treatments will save his life, a failure to implement the procedures or treatments is not euthanasia. If the person dies, this will be as a result of his injuries or disease and not because of his failure to receive treatment.

The failure to continue treatment after it has been realized that the patient has little chance of benefit- ing from it has been characterized by some as “passive euthanasia.” This phrase is misleading and mistaken. In such cases, the person involved is not killed (the first essential aspect of euthanasia), nor is the death of the person intended by the withholding of additional treatment (the third essential aspect of euthanasia). The aim may be to spare the person additional and unjustifiable pain, to save him from the indignities of hopeless manipulations, and to avoid increasing the financial and emotional burden on his family. When I buy a pencil it is so that I can use it to write, not to contribute to an increase in the gross national prod- uct. This may be the unintended consequence of my action, but it is not the aim of my action. So it is with failing to continue the treatment of a dying person. I intend his death no more than I intend to reduce the GNP by not using medical supplies. His is an unin- tended dying, and so- called “passive euthanasia” is not euthanasia at all.

1. THE ARGUMENT FROM NATURE

Every human being has a natural inclination to con- tinue living. Our reflexes and responses fit us to fight attackers, flee wild animals, and dodge out of the way of trucks. In our daily lives we exercise the caution and care necessary to protect ourselves. Our bodies are sim- ilarly structured for survival right down to the molecu- lar level. When we are cut, our capillaries seal shut, our blood clots, and fibrogen is produced to start the pro- cess of healing the wound. When we are invaded by

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enough to save the patient. They might decide that the patient would simply be “better off dead” and take the steps necessary to make that come about. This attitude could then carry over to their dealings with patients less seriously ill. The result would be an over- all decline in the quality of medical care.

Finally, euthanasia as a policy is a slippery slope. A person apparently hopelessly ill may be allowed to take his own life. Then he may be permitted to depu- tize others to do it for him should he no longer be able to act. The judgment of others then becomes the rul- ing factor. Already at this point euthanasia is not per- sonal and voluntary, for others are acting “on behalf of” the patient as they see fit. This may well incline them to act on behalf of other patients who have not authorized them to exercise their judgment. It is only a short step, then, from voluntary euthanasia ( self- inflicted or authorized), to directed euthanasia admin- istered to a patient who has given no authorization, to involuntary euthanasia conducted as part of a social policy. Recently many psychiatrists and sociologists have argued that we define as “mental illness” those forms of behavior that we disapprove of. This gives us license then to lock up those who display the behav- ior. The category of the “hopelessly ill” provides the possibility of even worse abuse. Embedded in a social policy, it would give society or its representatives the authority to eliminate all those who might be con- sidered too “ill” to function normally any longer. The dangers of euthanasia are too great to all to run the risk of approving it in any form. The first slippery step may well lead to a serious and harmful fall.

I hope that I have succeeded in showing why the benevolence that inclines us to give approval of eutha- nasia is misplaced. Euthanasia is inherently wrong because it violates the nature and dignity of human beings. But even those who are not convinced by this must be persuaded that the potential personal and social dangers inherent in euthanasia are sufficient to forbid our approving it either as a personal practice or as a public policy.

Suffering is surely a terrible thing, and we have a clear duty to comfort those in need and to ease their suffering when we can. But suffering is also a natural part of life with values for the individual and for others

but it does not possess perfect and complete knowl- edge. A mistaken diagnosis is possible, and so is a mis- taken prognosis. Consequently, we may believe that we are dying of a disease when, as a matter of fact, we may not be. We may think that we have no hope of recovery when, as a matter of fact, our chances are quite good. In such circumstances, if euthanasia were permitted, we would die needlessly. Death is final and the chance of error too great to approve the practice of euthanasia.

Also, there is always the possibility that an experi- mental procedure or a hitherto untried technique will pull us through. We should at least keep this option open, but euthanasia closes it off. Furthermore, spon- taneous remission does occur in many cases. For no apparent reason, a patient simply recovers when those all around him, including his physicians, expected him to die. Euthanasia would just guarantee their expectations and leave no room for the “miraculous” recoveries that frequently occur.

Finally, 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. The will to live is strong in all of us, but it can be weakened by pain and suffering and feelings of hopelessness. If during a bad time we allow ourselves to be killed, we never have a chance to recon- sider. Recovery from a serious illness requires that we fight for it, and anything that weakens our determi- nation by suggesting that there is an easy way out is ultimately against our own interest. Also, we may be inclined towards euthanasia because of our concern for others. If we see our sickness and suffering as an emotional and financial burden on our family, we may feel that to leave our life is to make their lives easier. The very presence of the possibility of euthanasia may keep us from surviving when we might.

3. THE ARGUMENT FROM PRACTICAL EFFECTS

Doctors and nurses are, for the most part, totally com- mitted to saving lives. A life lost is, for them, almost a personal failure, an insult to their skills and knowl- edge. Euthanasia as a practice might well alter this. It could have a corrupting influence so that in any case that is severe doctors and nurses might not try hard

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NOTE

1. Arthur Dyck, “Beneficent Euthanasia and Benemortasia,” in Beneficent Euthanasia, ed. Marvin Kohl (Buffalo, NY: Pro- metheus Books, 1975), 117–29.

that we should not overlook. We may legitimately seek for others and for ourselves an easeful death, as Arthur Dyck has pointed out.1 Euthanasia, however, is not just an easeful death. It is a wrongful death. Eutha- nasia is not just dying. It is killing.

From Voluntary Active Euthanasia Dan W. Brock

administered, for example, in cases of serious dementia or treatable clinical depression.

Does the value of individual self- determination extend to the time and manner of one’s death? Most people are very concerned about the nature of the last stage of their lives. This reflects not just a fear of expe- riencing substantial suffering when dying, but also a desire to retain dignity and control during this last period of life. Death is today increasingly preceded by a long period of significant physical and mental decline, due in part to the technological interven- tions of modern medicine. Many people adjust to these disabilities and find meaning and value in new activities and ways. Others find the impairments and burdens in the last stage of their lives at some point sufficiently great to make life no longer worth living. For many patients near death, maintaining the qual- ity of one’s life, avoiding great suffering, maintaining one’s dignity, and insuring that others remember us as we wish them to become of paramount impor- tance and outweigh merely extending one’s life. But there is no single, objectively correct answer for everyone as to when, if at all, one’s life becomes all things considered a burden and unwanted. If self- determination is a fundamental value, then the great variability among people on this question makes it especially important that individuals control the manner, circumstances, and timing of their dying and death.

The other main value that supports euthanasia is individual well- being. It might seem that individual well- being conflicts with a person’s self- determination when the person requests euthanasia. Life itself is

* * *

THE CENTRAL ETHICAL ARGUMENT FOR VOLUNTARY ACTIVE EUTHANASIA

The central ethical argument for euthanasia is familiar. It is that the very same two fundamental ethical values supporting the consensus on patient’s rights to decide about life- sustaining treatment also support the ethical permissibility of euthanasia. These values are individual self- determination or autonomy and individual well- being. By self- determination as it bears on euthanasia, I mean people’s interest in making important decisions about their lives for themselves according to their own values or conceptions of a good life, and in being left free to act on those decisions. Self- determination is valu- able because it permits people to form and live in accor- dance with their own conception of a good life, at least within the bounds of justice and consistent with others doing so as well. In exercising self- determination people take responsibility for their lives and for the kinds of persons they become. A central aspect of human dig- nity lies in people’s capacity to direct their lives in this way. The value of exercising self- determination presup- poses some minimum of decision making capacities or competence, which thus limits the scope of euthanasia supported by self- determination; it cannot justifiably be

Dan W. Brock, excerpts from “Voluntary Active Euthanasia” from Hastings Center Report 22(2): 10–22. Copyright © 1992 The Hastings Center. Reproduced with permission of John Wiley & Sons, Inc.

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against it that on their view outweigh or override this support. The first kind of argument is that in any indi- vidual case where considerations of the patient’s self- determination and well- being do support euthanasia, it is nevertheless always ethically wrong or impermis- sible. The second kind of argument grants that in some individual cases euthanasia may not be ethi- cally wrong, but maintains nonetheless that public and legal policy should never permit it. The first kind of argument focuses on features of any individual case of euthanasia, while the second kind focuses on social or legal policy. In the next section I consider the first kind of argument.

* * *

WOULD THE BAD CONSEQUENCES OF EUTHANASIA OUTWEIGH THE GOOD?

The argument against euthanasia at the policy level is stronger than at the level of individual cases, though even here I believe the case is ultimately unpersua- sive, or at best indecisive. The policy level is the place where the main issues lie, however, and where moral considerations that might override arguments in favor of euthanasia will be found, if they are found anywhere. It is important to note two kinds of dis- agreement about the consequences for public policy of permitting euthanasia. First, there is empirical or factual disagreement about what the consequences would be. This disagreement is greatly exacerbated by the lack of firm data on the issue. Second, since on any reasonable assessment there would be both good and bad consequences, there are moral dis- agreements about the relative importance of dif- ferent effects. In addition to these two sources of disagreement, there is also no single, well- specified policy proposal for legalizing euthanasia on which policy assessments can focus. But without such specification, and especially without explicit proce- dures for protecting against well- intentioned mis- use and ill- intentioned abuse, the consequences for policy are largely speculative. Despite these difficul- ties, a preliminary account of the main likely good and bad consequences is possible. This should help clarify where better data or more moral analysis and

commonly taken to be a central good for persons, often valued for its own sake, as well as necessary for pursuit of all other goods within a life. But when a competent patient decides to forgo all further life- sustaining treatment then the patient, either explic- itly or implicitly, commonly decides that the best life possible for him or her with treatment is of sufficiently poor quality that it is worse than no further life at all. Life is no longer considered a benefit by the patient, but has now become a burden. The same judgment underlies a request for euthanasia: continued life is seen by the patient as no longer a benefit, but now a burden. Especially in the often severely compromised and debilitated states of many critically ill or dying patients, there is no objective standard, but only the competent patient’s judgment of whether continued life is no longer a benefit.

Of course, sometimes there are conditions, such as clinical depression, that call into question whether the patient has made a competent choice, either to forgo life- sustaining treatment or to seek euthanasia, and then the patient’s choice need not be evidence that continued life is no longer a benefit for him or her. Just as with decisions about treatment, a deter- mination of incompetence can warrant not honoring the patient’s choice: in the case of treatment, we then transfer decisional authority to a surrogate, though in the case of voluntary active euthanasia a determi- nation that the patient is incompetent means that choice is not possible.

The value or right of self- determination does not entitle patients to compel physicians to act contrary to their own moral or professional values. Physi- cians are moral and professional agents whose own self- determination or integrity should be respected as well. If performing euthanasia became legally permissible, but conflicted with a particular physi- cian’s reasonable understanding of his or her moral or professional responsibilities, the care of a patient who requested euthanasia should be transferred to another.

Most opponents do not deny that there are some cases in which the values of patient self- determination and well- being support euthanasia. Instead, they commonly offer two kinds of arguments

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who have it, not just those whose houses actually burn down, by reassuring them that in the unlikely event of their house burning down, they will receive the money needed to rebuild it. Likewise, the legalization of euthanasia can be thought of as a kind of insurance policy against being forced to endure a protracted dying process that one has come to find burdensome and unwanted, especially when there is no life- sustaining treatment to forgo. The strong concern about losing control of their care expressed by many people who face serious illness likely to end in death suggests that they give substantial importance to the legalization of euthanasia as a means of maintaining this control.

A third good consequence of the legalization of euthanasia concerns patients whose dying is filled with severe and unrelievable pain or suffering. When there is a life- sustaining treatment that, if forgone, will lead relatively quickly to death, then doing so can bring an end to these patients’ suffering with- out recourse to euthanasia. For patients receiving no such treatment, however, euthanasia may be the only release from their otherwise prolonged suffering and agony. This argument from mercy has always been the strongest argument for euthanasia in those cases to which it applies.

The importance of relieving pain and suffering is less controversial than is the frequency with which patients are forced to undergo untreatable agony that only euthanasia could relieve. If we focus first on suffering caused by physical pain, it is crucial to dis- tinguish pain that could be adequately relieved with modern methods of pain control, though it in fact is not, from pain that is relievable only by death. For a variety of reasons, including some physicians’ fear of hastening the patient’s death, as well as the lack of a publicly accessible means for assessing the amount of the patient’s pain, many patients suffer pain that could be, but is not, relieved.

Specialists in pain control, as for example the pain of terminally ill cancer patients, argue that there are very few patients whose pain could not be adequately controlled, though sometimes at the cost of so sedating them that they are effectively unable to interact with other people or their environment. Thus, the argument from mercy in cases of physical

argument are needed, as well as where policy safe- guards must be developed.

Potential Good Consequences of Permitting Euthanasia

What are the likely good consequences? First, if eutha- nasia were permitted it would be possible to respect the self- determination of competent patients who want it, but now cannot get it because of its illegality. We simply do not know how many such patients and people there are. In the Netherlands, with a popula- tion of about 14.5 million (in 1987), estimates in a recent study were that about 1,900 cases of voluntary active euthanasia or physician- assisted suicide occur annually. No straightforward extrapolation to the United States is possible for many reasons, among them, that we do not know how many people here who want euthanasia now get it, despite its illegality. Even with better data on the number of persons who want euthanasia but cannot get it, significant moral disagreement would remain about how much weight should be given to any instance of failure to respect a person’s self- determination in this way.

One important factor substantially affecting the number of persons who would seek euthanasia is the extent to which an alternative is available. The wide- spread acceptance in the law, social policy, and medi- cal practice of the right of a competent patient to forgo life- sustaining treatment suggests that the number of competent persons in the United States who would want euthanasia if it were permitted is probably rela- tively small.

A second good consequence of making euthana- sia legally permissible benefits a much larger group. Polls have shown that a majority of the American pub- lic believes that people should have a right to obtain euthanasia if they want.1 No doubt the vast majority of those who support this right to euthanasia will never in fact come to want euthanasia for themselves. Nev- ertheless, making it legally permissible would reassure many people that if they ever do want euthanasia they would be able to obtain it. This reassurance would sup- plement the broader control over the process of dying given by the right to decide about life- sustaining treat- ment. Having fire insurance on one’s house benefits all

310 Á  PART 4: ETHICAL ISSUES

Potential Bad Consequences of Permitting Euthanasia

Some of the arguments against permitting euthanasia are aimed specifically against physicians, while others are aimed against anyone being permitted to perform it. I shall first consider one argument of the former sort. Permitting physicians to perform euthanasia, it is said, would be incompatible with their fundamental moral and professional commitment as healers to care for patients and to protect life. Moreover, if euthanasia by physicians became common, patients would come to fear that a medication was intended not to treat or care, but instead to kill, and would thus lose trust in their physicians. This position was forcefully stated in a paper by Willard Gaylin and his colleagues:

The very soul of medicine is on trial. . . . This issue touches medicine at its moral center; if this moral center col- lapses, if physicians become killers or are even licensed to kill, the profession— and, therewith, each physician— will never again be worthy of trust and respect as healer and comforter and protector of life in all its frailty.

These authors go on to make clear that, while they oppose permitting anyone to perform euthanasia, their special concern is with physicians doing so:

We call on fellow physicians to say that they will not deliberately kill. We must also say to each of our fellow physicians that we will not tolerate killing of patients and that we shall take disciplinary action against doctors who kill. And we must say to the broader community that if it insists on tolerating or legalizing active eutha- nasia, it will have to find nonphysicians to do its killing.2

If permitting physicians to kill would undermine the very “moral center” of medicine, then almost cer- tainly physicians should not be permitted to perform euthanasia. But how persuasive is this claim? Patients should not fear, as a consequence of permitting vol- untary active euthanasia, that their physicians will substitute a lethal injection for what patients want and believe is part of their care. If active euthanasia is restricted to cases in which it is truly voluntary, then no patient should fear getting it unless she or he has voluntarily requested it. (The fear that we might in time also come to accept nonvoluntary, or even invol- untary, active euthanasia is a slippery slope worry

pain can probably be met in a large majority of cases by providing adequate measures of pain relief. This should be a high priority, whatever our legal policy on euthanasia— the relief of pain and suffering has long been, quite properly, one of the central goals of medi- cine. Those cases in which pain could be effectively relieved, but in fact is not, should only count signifi- cantly in favor of legalizing euthanasia if all reason- able efforts to change pain management techniques have been tried and have failed.

Dying patients often undergo substantial psycho- logical suffering that is not fully or even principally the result of physical pain. The knowledge about how to relieve this suffering is much more limited than in the case of relieving pain, and efforts to do so are prob- ably more often unsuccessful. If the argument from mercy is extended to patients experiencing great and unrelievable psychological suffering, the numbers of patients to which it applies are much greater.

One last good consequence of legalizing eutha- nasia is that once death has been accepted, it is often more humane to end life quickly and peacefully, when that is what the patient wants. Such a death will often be seen as better than a more prolonged one. People who suffer a sudden and unexpected death, for example by dying quickly or in their sleep from a heart attack or stroke, are often considered lucky to have died in this way. We care about how we die in part because we care about how others remember us, and we hope they will remember us as we were in “good times” with them and not as we might be when disease has robbed us of our dignity as human beings. As with much in the treatment and care of the dying, people’s concerns differ in this respect, but for at least some people, euthanasia will be a more humane death than what they have often experienced with other loved ones and might otherwise expect for themselves.

Some opponents of euthanasia challenge how much importance should be given to any of these good consequences of permitting it, or even whether some would be good consequences at all. But more frequently, opponents cite a number of bad conse- quences that permitting euthanasia would or could produce, and it is to their assessment that I now turn.

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surrogates’ rights to forgo life- sustaining treatment, yet there is no persuasive evidence that recognizing the right to refuse treatment has caused a serious erosion in the quality of care of dying patients. The second reason for skepticism about this worry is that only a very small proportion of deaths would occur from euthanasia if it were permitted. In the Netherlands, where eutha- nasia under specified circumstances is permitted by the courts, though not authorized by statute, the best estimate of the proportion of overall deaths that result from it is about 2 percent.3 Thus, the vast majority of critically ill and dying patients will not request it, and so will still have to be cared for by physicians, families, and others. Permitting euthanasia should not dimin- ish people’s commitment and concern to maintain and improve the care of these patients.

A third possible bad consequence of permitting euthanasia (or even a public discourse in which strong support for euthanasia is evident) is to threaten the progress made in securing the rights of patients or their surrogates to decide about and to refuse life- sustaining treatment. This progress has been made against the backdrop of a clear and firm legal prohibition of eutha- nasia, which has provided a relatively bright line limit- ing the dominion of others over patients’ lives. It has therefore been an important reassurance to concerns about how the authority to take steps ending life might be misused, abused, or wrongly extended.

Many supporters of the right of patients or their surrogates to refuse treatment strongly oppose eutha- nasia, and if forced to choose might well withdraw their support of the right to refuse treatment rather than accept euthanasia. Public policy in the last fif- teen years has generally let life- sustaining treatment decisions be made in health care settings between physicians and patients or their surrogates, and with- out the involvement of the courts. However, if eutha- nasia is made legally permissible greater involvement of the courts is likely, which could in turn extend to a greater court involvement in life- sustaining treat- ment decisions. Most agree, however, that increased involvement of the courts in these decisions would be undesirable, as it would make sound decisionmak- ing more cumbersome and difficult without sufficient compensating benefits.

I address below.) Patients’ trust of their physicians could be increased, not eroded, by knowledge that physicians will provide aid in dying when patients seek it.

. . . In spelling out above what I called the posi- tive argument for voluntary active euthanasia, I sug- gested that two principal values— respective patients’ self- determination and promoting their well- being— underlie the consensus that competent patients, or the surrogates of incompetent patients, are entitled to refuse any life- sustaining treatment and to choose from among available alternative treatments. It is the commitment to these two values in guiding physi- cians’ actions as healers, comforters, and protectors of their patients’ lives that should be at the “moral cen- ter” of medicine, and these two values support physi- cians’ administering euthanasia when their patients make competent requests for it.

What should not be at that moral center is a com- mitment to preserving patients’ lives as such, without regard to whether those patients want their lives pre- served or judge their preservation a benefit to them. . . .

A second bad consequence that some foresee is that permitting euthanasia would weaken soci- ety’s commitment to provide optimal care for dying patients. We live at a time in which the control of health care costs has become, and is likely to continue to be, the dominant focus of health care policy. If euthanasia is seen as a cheaper alternative to adequate care and treatment, then we might become less scru- pulous about providing sometimes costly support and other services to dying patients. Particularly if our society comes to embrace deeper and more explicit rationing of health care, frail, elderly, and dying patients will need to be strong and effective advocates for their own health care and other needs, although they are hardly in a position to do this. We should do nothing to weaken their ability to obtain adequate care and services.

This second worry is difficult to assess because there is little firm evidence about the likelihood of the feared erosion in the care of dying patients. There are at least two reasons, however, for skepticism about this argument. The first is that the same worry could have been directed at recognizing patients’ or

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This argument correctly identifies the reason why offering some patients the option of euthanasia would not benefit them. [David] Velleman takes it not as a reason for opposing all euthanasia, but for restricting it to circumstances where there are “unmistakable and overpowering reasons for persons to want the option of euthanasia,”4 and for denying the option in all other cases. But there are at least three reasons why such restriction may not be warranted. First, polls and other evidence support that most Americans believe euthanasia should be permitted (though the recent defeat of the referendum to permit it in the state of Washington raises some doubt about this support). Thus, many more people seem to want the choice than would be made worse off by getting it. Second, if giving people the option of ending their life really makes them worse off, then we should not only pro- hibit euthanasia, but also take back from people the right they now have to decide about life- sustaining treatment. The feared harmful effect should already have occurred from securing people’s right to refuse life- sustaining treatment, yet there is no evidence of any such widespread harm or any broad public desire to rescind that right. Third, since there is a wide range of conditions in which reasonable people can and do disagree about whether they would want continued life, it is not possible to restrict the permissibility of euthanasia as narrowly as Velleman suggests without thereby denying it to most persons who would want it; to permit it only in cases in which virtually everyone would want it would be to deny it to most who would want it.

A fifth potential bad consequence of making euthanasia legally permissible is that it might weaken the general legal prohibition of homicide. This pro- hibition is so fundamental to civilized society, it is argued, that we should do nothing that erodes it. If most cases of stopping life support are killing, as I have already argued, then the court cases permitting such killing have already in effect weakened this prohibi- tion. However, neither the courts nor most people have seen these cases as killing and so as challenging the prohibition of homicide. The courts have usually grounded patients’ or their surrogates’ rights to refuse life- sustaining treatment in rights to privacy, liberty,

As with the second potential bad consequence of permitting euthanasia, this third consideration too is speculative and difficult to assess. The feared erosion of patients’ or surrogates’ rights to decide about life- sustaining treatment, together with greater court involvement in those decisions, are both pos- sible. However, I believe there is reason to discount this generally worry. The legal rights of competent patients and, to a lesser degree, surrogates of incom- petent patients to decide about treatment are very firmly embedded in a long line of informed consent and life- sustaining treatment cases, and are not likely to be eroded by a debate over, or even acceptance of, euthanasia. It will not be accepted without safe- guards that reassure the public about abuse, and if that debate shows the need for similar safeguards for some life- sustaining treatment decisions they should be adopted there as well. In neither case are the only possible safeguards greater court involvement, as the recent growth of institutional ethics committees shows.

The fourth potential bad consequence of permit- ting euthanasia . . . turns on the subtle point that making a new option or choice available to people can sometimes make them worse off, even if once they have the choice they go on to choose what is best for them. Ordinarily, people’s continued existence is viewed by them as given, a fixed condition with which they must cope. Making euthanasia available to peo- ple as an option denies them the alternative of stay- ing alive by default. If people are offered the option of euthanasia, their continued existence is now a choice for which they can be held responsible and which they can be asked by others to justify. We care, and are right to care, about being able to justify ourselves to others. To the extent that our society is unsympathetic to justifying a severely dependent or impaired exis- tence, a heavy psychological burden of proof may be placed on patients who think their terminal illness or chronic infirmity is not a sufficient reason for dying. Even if they otherwise view their life as worth living, the opinion of others around them that it is not can threaten their reason for living and make euthanasia a rational choice. Thus the existence of the option becomes a subtle pressure to request it.

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cases of euthanasia we should not permit even mor- ally justified performance of it.

Slippery slope arguments of this form are prob- lematic and difficult to evaluate. From one per- spective, they are the last refuge of conservative defenders of the status quo. When all the opponent’s objections to the wrongness of euthanasia itself have been met, the opponent then shifts ground and acknowledges both that it is not in itself wrong and that a legal policy which resulted only in its being performed would not be bad. Nevertheless, the opponent maintains, it should still not be permitted because doing so would result in its being performed in other cases in which it is not voluntary and would be wrong. In this argument’s most extreme form, permitting euthanasia is the first and fateful step down the slippery slope to Nazism. Once on the slope we will be unable to get off.

Now it cannot be denied that it is possible that permitting euthanasia could have these fateful con- sequences, but that cannot be enough to warrant pro- hibiting it if it is otherwise justified. A similar possible slippery slope worry could have been raised to secur- ing competent patients’ rights to decide about life support, but recent history shows such a worry would have been unfounded. It must be relevant how likely it is that we will end with horrendous consequences and an unjustified practice of euthanasia. How like, and widespread would the abuses and unwarranted extensions of permitting it be? By abuses, I mean the performance of euthanasia that fails to satisfy the conditions required for voluntary active euthanasia, for example, if the patient has been subtly pressured to accept it. By unwarranted extensions of policy, I mean later changes in legal policy to permit not just voluntary euthanasia, but also euthanasia in cases in which, for example, it need not be fully voluntary. Opponents of voluntary euthanasia on slippery slope grounds have not provided the data or evidence nec- essary to turn their speculative concerns into well- grounded likelihoods.

It is at least clear, however, that both the charac- ter and likelihood of abuses of a legal policy permit- ting euthanasia depend in significant part on the procedures put in place to protect against them. I will

self- determination, or bodily integrity, not in excep- tions to homicide laws.

Legal permission for physicians or others to per- form euthanasia could not be grounded in patients’ rights to decide about medical treatment. Permit- ting euthanasia would require qualifying, at least in effect, the legal prohibition against homicide, a pro- hibition that in general does not allow the consent of the victim to justify or excuse the act. Neverthe- less, the very same fundamental basis of the right to decide about life- sustaining treatment— respecting a person’s self- determination— does support eutha- nasia as well. Individual self- determination has long been a well- entrenched and fundamental value in the law, and so extending it to euthanasia would not require appeal to novel legal values or princi- ples. That suicide or attempted suicide is no longer a criminal offense in virtually all states indicates an acceptance of individual self- determination in the taking of one’s own life analogous to that required for voluntary active euthanasia. The legal prohibi- tion (in most states) of assisting in suicide and the refusal in the law to accept the consent of the vic- tim as a possible justification of homicide are both arguably a result of difficulties in the legal process of establishing the consent of the victim after the fact. If procedures can be designed that clearly estab- lish the voluntariness of the person’s request for euthanasia it would under those procedures repre- sent a carefully circumscribed qualification on the legal prohibition of homicide. Nevertheless, some remaining worries about this weakening can be captured in the final potential bad consequence, to which I will now turn.

This final potential bad consequence is the cen- tral concern of many opponents of euthanasia and, I believe, is the most serious objection to a legal pol- icy permitting it. According to this “slippery slope” worry, although active euthanasia may be morally permissible in cases in which it is unequivocally voluntary and the patient finds his or her condi- tion unbearable, a legal policy permitting euthana- sia would inevitably lead to active euthanasia being performed in many other cases in which it would be morally wrong. To prevent those other wrongful

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THE ROLE OF PHYSICIANS

If euthanasia is made legally permissible, should physi- cians take part in it? Should only physicians be permit- ted to perform it, as is the case in the Netherlands? In discussing whether euthanasia is incompatible with medicine’s commitment to curing, caring for, and comforting patients, I argued that it is not at odds with a proper understanding of the aims of medicine, and so need not undermine patients’ trust in their physicians. If that argument is correct, then physicians probably should not be prohibited, either by law or by profes- sional norms, from taking part in a legally permissible practice of euthanasia (nor, of course, should they be compelled to do so if their personal or professional scruples forbid it). Most physicians in the Netherlands appear not to understand euthanasia to be incompat- ible with their professional commitments.

Sometimes patients who would be able to end their lives on their own nevertheless seek the assis- tance of physicians. Physician involvement in such cases may have important benefits to patients and oth- ers beyond simply assuring the use of effective means. Historically, in the United States suicide has carried a strong negative stigma that many today believe unwarranted. Seeking a physician’s assistance, or what can almost seem a physician’s blessing, may be a way of trying to remove that stigma and show others that the decision for suicide was made with due seriousness and was justified under the circumstances. The physi- cian’s involvement provides a kind of social approval, or more accurately helps counter what would other- wise be unwarranted social disapproval.

There are also at least two reasons for restricting the practice of euthanasia to physicians only. First, physicians would inevitably be involved in some of the important procedural safeguards necessary to a defensible practice, such as seeing to it that the patient is well- informed about his or her condition, prognosis, and possible treatments, and ensuring that all reason- able means have been taken to improve the quality of the patient’s life. Second, and probably more impor- tant, one necessary protection against abuse of the practice is to limit the persons given authority to per- form it, so that they can be held accountable for their

not try to detail fully what such procedures might be, but will just give some examples of what they might include:

1. The patient should be provided with all relevant information about his or her medical condition, current prognosis, available alternative treat- ments, and the prognosis of each.

2. Procedures should ensure that the patient’s request for euthanasia is stable or enduring (a brief wait- ing period could be required) and fully voluntary (an advocate for the patient might be appointed to ensure this).

3. All reasonable alternatives must have been explored for improving the patient’s quality of life and reliev- ing any pain or suffering.

4. A psychiatric evaluation should ensure that the patient’s request is not the result of a treatable psychological impairment such as depression.

These examples of procedural safeguards are all designed to ensure that the patient’s choice is fully informed, voluntary, and competent, and so a true exercise of self- determination. Other proposals for euthanasia would restrict its permissibility further— for example, to the terminally ill— a restriction that cannot be supported by self- determination. Such additional restrictions might, however, be justified by concern for limiting potential harms from abuse. At the same time, it is important not to impose procedural or substantive safeguards so restrictive as to make euthanasia impermissible or prac- tically infeasible in a wide range of justified cases.

These examples of procedural safeguards make clear that it is possible to substantially reduce, though not to eliminate, the potential for abuse of a policy permitting voluntary active euthanasia. Any legaliza- tion of the practice should be accompanied by a well- considered set of procedural safeguards together with an ongoing evaluation of its use. Introducing euthanasia into only a few states could be a form of carefully limited and controlled social experiment that would give us evi- dence about the benefits and harms of the practice. Even then firm and uncontroversial data may remain elusive, as the continuing controversy over what has taken place in the Netherlands in recent years indicates.5

* * *

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2. Willard Gaylin, Leon R. Kass, Edmund D. Pellegrino, and Mark Siegler, “Doctors Must Not Kill,” Journal of the American Medical Association 259 (1988): 2139–40.

3. Paul J. Van der Maas et al., “Euthanasia and Other Medi- cal Decisions Concerning the End of Life,” Lancet 338 (1991): 669–74.

4. David Velleman commented on an earlier version of the paper delivered at the American Philosophical Association Central Division meetings.

5. Richard Fenigsen, “A Case against Dutch Euthanasia,” Special Supplement, Hastings Center Report 19, no. 1 (1989): 22–30.

exercise of that authority. Physicians, whose training and professional norms give some assurance that they would perform euthanasia responsibly, are an appro- priate group of persons to whom the practice may be restricted.

* * *

NOTES

1. P. Painton and E. Taylor, “Love or Let Die,” Time, 19 March 1990, 62–71; Boston Globe/Harvard University Poll, Boston Globe, 3 November 1991.

Euthanasia Philippa Foot

Under this program, planned before the War but brought into full operation by a decree of 1 Septem- ber 1939, some 275,000 people were gassed in centers which were to be a model for those in which Jews were later exterminated. Anyone in a state institution could be sent to the gas chambers if it was considered that he could not be “rehabilitated” for useful work. As Dr. Leo Alexander reports, relying on the testimony of a neu- ropathologist who received 500 brains from one of the killing centers,

In Germany the exterminations included the mentally defective, psychotics (particularly schizophrenics), epi- leptics and patients suffering from infirmities of old age and from various organic neurological disorders such as infantile paralysis, Parkinsonism, multiple sclerosis and brain tumors. . . . In truth, all those unable to work and considered nonrehabilitable were killed.1

These people were killed because they were “useless” and “a burden on society”; only the manner of their deaths could be thought of as relatively easy and quiet.

Let us insist, then, that when we talk about eutha- nasia we are talking about a death understood as a good or happy event for the one who dies. This stipulation follows etymology, but is itself not exactly in line with

The widely used Shorter Oxford English Dictionary gives three meanings for the word “euthanasia”: the first, “a quiet and easy death”; the second, “the means of pro- curing this”; and the third, “the action of inducing a quiet and easy death.” It is a curious fact that no one of the three gives an adequate definition of the word as it is usually understood. For “euthanasia” means much more than a quiet and easy death, or the means of pro- curing it, or the action of inducing it. The definition species only the manner of the death, and if this were all that was implied a murderer, careful to drug his vic- tim, could claim that his act was an act of euthanasia. We find this ridiculous because we take it for granted that in euthanasia it is death itself, not just the man- ner of death, that must be kind to the one who dies.

To see how important it is that “euthanasia” should not be used as the dictionary definition allows it to be used, merely to signify that a death was quiet and easy, one has only to remember that Hitler’s “euthanasia” program traded on this ambiguity.

Philippa Foot, “Euthanasia” from Philosophy and Public Affairs 6(2): 85–112. Copyright © 1977 Blackwell Publishing Ltd. Reproduced with permission of Blackwell Publishing Ltd.

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But is it enough that he acts with this thought, or must things actually be as he thinks them to be? If one man kills another, or allows him to die, thinking that he is in the last stages of a terrible disease, though in fact he could have been cured, is this an act of euthanasia or not? Nothing much seems to hang on our decision about this. The same condition has got to enter into the definition whether as an element in reality or only as an element in the agent’s belief. And however we define an act of euthanasia culpability or justifiability will be the same: if a man acts through ignorance his ignorance may be culpable or it may not.2

These are relatively easy problems to solve, but one that is dauntingly difficult has been passed over in this discussion of the definition, and must now be faced. It is easy to say, as if this raised no problems, that an act of euthanasia is by definition one aim- ing at the good of the one whose death is in question, and that it is for his sake that his death is desired. But how is this to be explained? Presumably we are think- ing of some evil already with him or to come on him if he continues to live, and death is thought of as a release from this evil. But this cannot be enough. Most people’s lives contain evils such as grief or pain, but we do not therefore think that death would be a blessing to them. On the contrary life is generally sup- posed to be a good even for someone who is unusu- ally unhappy or frustrated. How is it that one can ever wish for death for the sake of the one who is to die? This difficult question is central to the discussion of euthanasia, and we shall literally not know what we are talking about if we ask whether acts of euthanasia defined as we have defined them are ever morally per- missible without first understanding better the reason for saying that life is a good, and the possibility that it is not always so.

If a man should save my life he would be my benefactor. In normal circumstances this is plainly true; but does one always benefit another in saving his life? It seems certain that he does not. Suppose, for instance, that a man were being tortured to death and was given a drug that lengthened his sufferings; this would not be a benefit but the reverse. Or suppose that in a ghetto in Nazi Germany a doctor saved the life of someone threatened by disease, but that the man once

current usage, which would be captured by the condi- tion that the death should not be an evil rather than that it should be a good. That this is how people talk is shown by the fact that the case of Karen Ann Quinlan and others in a state of permanent coma is often dis- cussed under the heading of “euthanasia.” Perhaps it is not too late to object to the use of the word “eutha- nasia” in this sense. Apart from the break with the Greek origins of the word there are other unfortunate aspects of this extension of the term. For if we say that the death must be supposed to be a good to the subject we can also specify that it shall be for his sake that an act of euthanasia is performed. If we say merely that death shall not be an evil to him, we cannot stipulate that benefiting him shall be the motive where eutha- nasia is in question. Given the importance of the ques- tion, For whose sake are we acting? it is good to have a definition of euthanasia which brings under this heading only cases of opting for death for the sake of the one who dies. Perhaps what is most important is to say either that euthanasia is to be for the good of the subject or at least that death is to be no evil to him, thus refusing to talk Hitler’s language. However, in this paper it is the first condition that will be under- stood, with the additional proviso that by an act of euthanasia we mean one of inducing or otherwise opt- ing for death for the sake of the one who is to die.

A few lesser points need to be cleared up. In the first place it must be said that the word “act” is not to be taken to exclude omission: we shall speak of an act of euthanasia when someone is deliberately allowed to die, for his own good, and not only when posi- tive measures are taken to see that he does. The very general idea we want is that of a choice of action or inaction directed at another man’s death and causally effective in the sense that, in conjunction with actual circumstances, it is a sufficient condition of death. Of complications such as overdetermination, it will not be necessary to speak.

A second, and definitely minor, point about the definition of an act of euthanasia concerns the question of fact versus belief. It has already been implied that one who performs an act of euthanasia thinks that death will be merciful for the subject since we have said that it is on account of this thought that the act is done.

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people have more evil than good in their lives; we do not, however, conclude that we would do these people no service by rescuing them from death.

To get around this last difficulty Thomas Nagel has suggested that experience itself is a good which must be brought in to balance accounts.

. . . life is worth living even when the bad elements of experience are plentiful, and the good ones too meager to outweigh the bad ones on their own. The additional positive weight is supplied by experience itself, rather than by any of its contents.4

This seems implausible because if experience itself is a good it must be so even when what we experi- ence is wholly bad, as in being tortured to death. How should one decide how much to count for this experi- encing; and why count anything at all?

Others have tried to solve the problem by arguing that it is a man’s desire for life that makes us call life a good: if he wants to live then anyone who prolongs his life does him a benefit. Yet someone may cling to life where we would say confidently that it would be better for him if he died, and he may admit it too. Speaking of those same conditions in which, as he said, a bullet would have been merciful, Panin writes,

I should like to pass on my observations concerning the absence of suicides under the extremely severe condi- tions of our concentration camps. The more that life became desperate, the more a prisoner seemed deter- mined to hold onto it.5

One might try to explain this by saying that hope was the ground of this wish to survive for further days and months in the camp. But there is nothing unintel- ligible in the idea that a man might cling to life though he knew those facts about his future which would make any charitable man wish that he might die.

The problem remains, and it is hard to know where to look for a solution. Is there a conceptual connection between life and good? Because life is not always a good we are apt to reject this idea, and to think that it must be a contingent fact that life is usually a good, as it is a contingent matter that legacies are usually a benefit, if they are. Yet it seems not to be a contingent matter that to save someone’s life is ordinarily to benefit him. The problem is to find where the conceptual connection lies.

cured was transported to an extermination camp; the doctor might wish for the sake of the patient that he had died of the disease. Nor would a longer stretch of life always be a benefit to the person who was given it. Comparing Hitler’s camps with those of Stalin, Dmitri Panin observes that in the latter the method of extermination was made worse by agonies that could stretch out over months.

Death from a bullet would have been bliss compared with what many millions had to endure while dying of hunger. The kind of death to which they were condemned has nothing to equal it in treachery and sadism.3

These examples show that to save or prolong a man’s life is not always to do him a service: it may be better for him if he dies earlier rather than later. It must therefore be agreed that while life is normally a benefit to the one who has it, this is not always so.

The judgment is often fairly easy to make— that life is or is not a good to someone— but the basis for it is very hard to find. When life is said to be a benefit or a good, on what grounds is the assertion made?

The difficulty is underestimated if it is supposed that the problem arises from the fact that one who is dead has nothing, so that the good someone gets from being alive cannot be compared with the amount he would otherwise have had. For why should this par- ticular comparison be necessary? Surely it would be enough if one could say whether or not someone whose life was prolonged had more good than evil in the extra stretch of time. Such estimates are not always possible, but frequently they are; we say, for example, “He was very happy in those last years,” or, “He had little but unhappiness then.” If the balance of good and evil determined whether life was a good to some- one we would expect to find a correlation in the judg- ments. In fact, of course, we find nothing of the kind. First, a man who has no doubt that existence is a good to him may have no idea about the balance of happi- ness and unhappiness in his life, or of any other posi- tive and negative factors that may be suggested. So the supposed criteria are not always operating where the judgment is made. And secondly the application of the criteria gives an answer that is often wrong. Many

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as that an animal is better or worse off for something that happened, or that it was a good or bad thing for it that it did happen. And new things count as benefit. In the first place, there is comfort, which often is, but need not be, related to health. When loosening a col- lar which is too tight for a dog we can say, “That will be better for it.” So we see that the words “better for it” have two different meanings which we mark when necessary by a difference of emphasis, saying “better for it” when health is involved. And secondly an ani- mal can be benefited by having its life saved. “Could you do anything for it?” can be answered by, “Yes, I managed to save its life.” Sometimes we may under- stand this, just as we would for a plant, to mean that we had checked some disease. But we can also do something for an animal by scaring away its preda- tor. If we do this, it is a good thing for the animal that we did, unless of course it immediately meets a more unpleasant end by some other means. Similarly, on the bad side, an animal may be worse off for our inter- vention, and this not because it pines or suffers but simply because it gets killed.

The problem that vexes us when we think about euthanasia comes on the scene at this point. For if we can do something for an animal— can benefit it— by relieving its suffering but also by saving its life, where does the greater benefit come when only death will end pain? It seemed that life was a good in its own right; yet pain seemed to be an evil with equal status and could therefore make life not a good after all. Is it only life without pain that is a good when animals are concerned? This does not seem a crazy suggestion when we are thinking of animals, since unlike human beings they do not have suffering as part of their nor- mal life. But it is perhaps the idea of ordinary life that matters here. We would not say that we had done anything for an animal if we had merely kept it alive, either in an unconscious state or in a condition where, though conscious, it was unable to operate in an ordi- nary way; and the fact is that animals in severe and continuous pain simply do not operate normally. So we do not, on the whole, have the option of doing the animal good by saving its life though the life would be a life of pain. No doubt there are borderline cases, but that is no problem. We are not trying to make new

It may be good tactics to forget for a time that it is euthanasia we are discussing and to see how life and good are connected in the case of living beings other than men. Even plants have things done to them that are harmful or beneficial, and what does them good must be related in some way to their living and dying. Let us therefore consider plants and animals, and then come back to human beings. At least we shall get away from the temptation to think that the connection between life and benefit must everywhere be a mat- ter of happiness and unhappiness or of pleasure and pain; the idea being absurd in the case of animals and impossible even to formulate for plants.

In case anyone thinks that the concept of the ben- eficial applies only in a secondary or analogical way to plants, he should be reminded that we speak quite straightforwardly in saying, for instance, that a certain amount of sunlight is beneficial to most plants. What is in question here is the habitat in which plants of particular species flourish, but we can also talk, in a slightly different way, of what does them good, where there is some suggestion of improvement or remedy. What has the beneficial to do with sustaining life? It is tempting to answer, “everything,” thinking that a healthy condition just is the one apt to secure survival. In fact, however, what is beneficial to a plant may have to do with reproduction rather than the survival of the individual member of the species. Nevertheless there is a plain connection between the beneficial and the life- sustaining even for the individual plant; if something makes it better able to survive in conditions normal for that species it is ipso facto good for it. We need go no further, and could go no further, in explaining why a certain environment or treatment is good for a plant than to show how it helps this plant to survive.6

This connection between the life- sustaining and the beneficial is reasonably unproblematic, and there is nothing fanciful or zoomorphic in speaking of ben- efiting or doing good to plants. A connection with its survival can make something beneficial to a plant. But this is not, of course, to say that we count life as a good to a plant. We may save its life by giving it what is ben- eficial; we do not benefit it by saving its life.

A more ramified concept of benefit is used in speaking of animal life. New things can be said, such

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a good to one permanently in the latter state, and we must return to this topic later on.

When are we to say that life is a good or a benefit to a man? The dilemma that faces us is this. If we say that life as such is a good we find ourselves refuted by the examples given at the beginning of this discussion. We therefore incline to think that it is as bringing good things that life is a good, where it is a good. But if life is a good only because it is the condition of good things why is it not equally an evil when it brings bad things? And how can it be a good even when it brings more evil than good?

It should be noted that the problem has here been formulated in terms of the balance of good and evil, not that of happiness and unhappiness, and that it is not to be solved by the denial (which may be rea- sonable enough) that unhappiness is the only evil or happiness the only good. In this paper no view has been expressed about the nature of goods other than life itself. The point is that on any view of the goods and evils that life can contain, it seems that a life with more evil than good could still itself be a good.

It may be useful to review the judgments with which our theory must square. Do we think that life can be a good to one who suffers a lot of pain? Clearly we do. What about severely handicapped people; can life be a good to them? Clearly it can be, for even if someone is almost completely paralyzed, perhaps liv- ing in an iron lung, perhaps able to move things only by means of a tube held between his lips, we do not rule him out of order if he says that some benefactor saved his life. Nor is it different with mental handicap. There are many fairly severely handicapped people— such as those with [Down] Syndrome (Mongolism)— for whom a simple affectionate life is possible. What about senility? Does this break the normal connection between life and good? Here we must surely distin- guish between forms of senility. Some forms leave a life which we count someone as better off having than not having, so that a doctor who prolonged it would ben- efit the person concerned. With some kinds of senility this is however no longer true. There are some in geri- atric wards who are barely conscious, though they can move a little and swallow food put into their mouths. To prolong such a state, whether in the old or in the

judgments possible, but rather to find the principle of the ones we do make.

When we reach human life the problems seem even more troublesome. For now we must take quite new things into account, such as the subject’s own view of his life. It is arguable that this places extra constraints on the solution: might it not be counted as a necessary condition of life’s being a good to a man that he should see it as such? Is there not some difficulty about the idea that a benefit might be done to him by the saving or prolonging of his life even though he himself wished for death? Of course he might have a quite mistaken view of his own pros- pects, but let us ignore this and think only of cases where it is life as he knows it that is in question. Can we think that the prolonging of his life would be a benefit to him even though he would rather have it end than continue? It seems that this cannot be ruled out. That there is no simple incompatibility between life as a good and the wish for death is shown by the possibility that a man should wish himself dead, not for his own sake, but for the sake of someone else. And if we try to amend the thesis to say that life can- not be a good to one who wishes for his own sake that he should die, we find the crucial concept slipping through our fingers. As Bishop Butler pointed out long ago not all ends are either benevolent or self- interested. Does a man wish for death for his own sake in the relevant sense if, for instance, he wishes to revenge himself on another by his death? Or what if he is proud and refuses to stomach dependence or incapacity even though there are many good things left in life for him? The truth seems to be that the wish for death is sometimes compatible with life’s being a good and sometimes not, which is possible because the description “wishing for death” is one covering diverse states of mind from that of the determined suicide, pathologically depressed, to that of one who is surprised to find that the thought of a fatal accident is viewed with relief. On the one hand, a man may see his life as a burden but go about his business in a more or less ordinary way; on the other hand, the wish for death may take the form of a rejec- tion of everything that is in life, as it does in severe depression. It seems reasonable to say that life is not

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goods are already absent for a different reason. So, for instance, the connection between life and good may be broken because consciousness has sunk to a very low level, as in extreme senility or severe brain dam- age. In itself this kind of life seems to be neither good nor evil, but if suffering sets in one would hope for a speedy end.

The idea we need seems to be that of life which is ordinary human life in the following respect— that it contains a minimum of basic human goods. What is ordinary in human life— even in very hard lives— is that a man is not driven to work far beyond his capac- ity; that he has the support of a family or community; that he can more or less satisfy his hunger; that he has hopes for the future; that he can lie down to rest at night. Such things were denied to the men in the Vyatlag camps described by Panin; not even rest at night was allowed them when they were tormented by bed- bugs, by noise and stench, and by routines such as body- searches and bath- parades— arranged for the night time so that work norms would not be reduced. Disease too can so take over a man’s life that the normal human goods disappear. When a patient is so overwhelmed by pain or nausea that he cannot eat with pleasure, if he can eat at all, and is out of the reach of even the most loving voice, he no longer has ordinary human life in the sense in which the words are used here. And we may now pick up a thread from an earlier part of the discussion by remarking that crippling depression can destroy the enjoyment of ordinary goods as effectively as external circumstances can remove them.

This, admittedly inadequate, discussion of the sense in which life is normally a good, and of the reasons why it may not be so in some particular case, completes the account of what euthanasia is here taken to be. An act of euthanasia, whether literally act or rather omission, is attributed to an agent who opts for the death of another because in his case life seems to be an evil rather than a good. The question now to be asked is whether acts of euthanasia are ever justi- fiable. But there are two topics here rather than one. For it is one thing to say that some acts of euthanasia considered only in themselves and their results are morally unobjectionable, and another to say that it

very severely mentally handicapped is not to do them a service or confer a benefit. But of course it need not be the reverse: only if there is suffering would one wish for the sake of the patient that he should die.

It seems, therefore, that merely being alive even without suffering is not a good, and that we must make a distinction similar to that which we made when animals were our topic. But how is the line to be drawn in the case of men? What is to count as ordinary human life in the relevant sense? If it were only the very senile or very ill who were to be said not to have this life it might seem right to describe it in terms of operation. But it will be hard to find the sense in which the men described by Panin were not operating, given that they dragged themselves out to the forest to work. What is it about the life that the prisoners were living that makes us put it on the other side of the dividing line from that of some severely ill or suffering patients, and from most of the physically or mentally handi- capped? It is not that they were in captivity, for life in captivity can certainly be a good. Nor is it merely the unusual nature of their life. In some ways the prison- ers were living more as other men do than the patient in an iron lung.

The suggested solution to the problem is, then, that there is a certain conceptual connection between life and good in the case of human beings as in that of animals and even plants. Here, as there, however, it is not the mere state of being alive that can determine, or itself count as, a good, but rather life coming up to some standard of normality. It was argued that it is as part of ordinary life that the elements of good that a man may have are relevant to the question of whether saving his life counts as benefiting him. Ordinary human lives, even very hard lives, contain a minimum of basic goods, but when these are absent the idea of life is no longer linked to that of good. And since it is in this way that the elements of good contained in a man’s life are relevant to the question of whether he is benefited if his life is preserved, there is no reason why it should be the balance of good and evil that counts.

It should be added that evils are relevant in one way when, as in the examples discussed above, they destroy the possibility of ordinary goods, but in a dif- ferent way when they invade a life from which the

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of others. An act of charity is in question only where something is not demanded by justice, but a lack of charity and of justice can be shown where a man is denied something which he both needs and has a right to; both charity and justice demand that wid- ows and orphans are not defrauded, and the man who cheats them is neither charitable nor just.

It is easy to see that the two grounds of objec- tion to inducing death are distinct. A murder is an act of injustice. A culpable failure to come to the aid of someone whose life is threatened is normally con- trary, not to justice, but to charity. But where one man is under contract, explicit or implicit, to come to the aid of another injustice too will be shown. Thus injustice may be involved either in an act or an omis- sion, and the same is true of a lack of charity; charity may demand that someone be aided, but also that an unkind word not be spoken.

The distinction between charity and justice will turn out to be of the first importance when voluntary and nonvoluntary euthanasia are distinguished later on. This is because of the connection between justice and rights, and something should now be said about this. I believe it is true to say that wherever a man acts unjustly he has infringed a right, since justice has to do with whatever a man is owed, and whatever he is owed is his as a matter of right. Something should therefore be said about the different kinds of rights. The distinction commonly made is between having a right in the sense of having a liberty, and having a “ claim- right” or “right of recipience.” The best way to understand such a distinction seems to be as follows. To say that a man has a right in the sense of liberty is to say that no one can demand that he do not do the thing which he has a right to do. The fact that he has a right to do it consists in the fact that a certain kind of objection does not lie against his doing it. Thus a man has a right in this sense to walk down a public street or park his car in a public parking space. It does not fol- low that no one else may prevent him from doing so. If for some reason I want a certain man not to park in a certain place I may lawfully park there myself or get my friends to do so, thus preventing him from doing what he has a right (in the sense of a liberty) to do. It is different, however, with a claim- right. This is the kind

would be all right to legalize them. Perhaps the prac- tice of euthanasia would allow too many abuses, and perhaps there would be too many mistakes. Moreover the practice might have very important and highly undesirable side effects, because it is unlikely that we could change our principles about the treatment of the old and the ill without changing fundamental emotional attitudes and social relations. The topics must, therefore, be treated separately. In the next part of the discussion, nothing will be said about the social consequences and possible abuses of the practice of euthanasia, but only about acts of euthanasia consid- ered in themselves.

What we want to know is whether acts of eutha- nasia, defined as we have defined them, are ever mor- ally permissible. To be more accurate, we want to know whether it is ever sufficient justification of the choice of death for another that death can be counted a ben- efit rather than harm, and that this is why the choice is made.

It will be impossible to get a clear view of the area to which this topic belongs without first marking the distinct grounds on which objection may lie when one man ops for the death of another. There are two different virtues whose requirements are, in general, contrary to such actions. An unjustified act of killing, or allowing to die, is contrary to justice or to charity, or to both virtues, and the moral failings are distinct. Jus- tice has to do with what men owe each other in the way of noninterference and positive service. When used in this wide sense, which has its history in the doctrine of the cardinal virtues, justice is not especially connected with, for instance, law courts but with the whole area of rights, and duties corresponding to rights. Thus murder is one form of injustice, dishonesty another, and wrongful failure to keep contracts a third; chi- canery in a law court or defrauding someone of his inheritance are simply other cases of injustice. Justice as such is not directly linked to the good of another, and may require that something be rendered to him even where it will do him harm, as Hume pointed out when he remarked that a debt must be paid even to a profligate debauchee who “would rather receive harm than benefit from large possessions.”7 Charity, on the other hand, is the virtue which attaches us to the good

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should be said to have “a claim,” distinguishing this from a “valid claim,” which gives a claim- right.

The manifesto writers on the other side who seem to identify needs, or at least basic needs, with what they call “human rights,” are more properly described, I think, as urging upon the world community the moral principle that all basic human needs ought to be recognized as claims (in the customary prima facie sense) worthy of sympathy and serious consideration right now, even though, in many cases, they cannot yet plausibly be treated as valid claims, that is, as grounds of any other people’s duties. This way of talking avoids the anomaly of ascribing to all human beings now, even those in pre- industrial societies, such “economic and social rights” as “periodic holidays with pay.”8

This seems reasonable, though we notice that there are some actual rights to service which are not based on anything like a contract, as for instance the right that children have to support from their parents and parents to support from their children in old age, though both sets of rights are to some extent depen- dent on existing social arrangements.

Let us now ask how the right to life affects the morality of acts of euthanasia. Are such acts some- times or always ruled out by the right to life? This is certainly a possibility; for although an act of euthana- sia is, by our definition, a matter of opting for death for the good of the one who is to die, there is, as we noted earlier, no direct connection between that to which a man has a right and that which is for his good. It is true that men have the right only to the kind of thing that is, in general, a good: we do not think that people have the right to garbage or polluted air. Neverthe- less, a man may have the right to something which he himself would be better off without; where rights exist it is a man’s will that counts not his or anyone else’s estimate of benefit or harm. So the duties com- plementary to the right to life— the general duty of noninterference and the duty of service incurred by certain persons— are not affected by the quality of a man’s life or by his prospects. Even if it is true that he would be, as we say, “better off dead,” so long as he wants to live this does not justify us in killing him and may not justify us in deliberately allowing him to die. All of us have the duty of noninterference, and some

of right which I have in addition to a liberty when, for example, I have a private parking space; now others have duties in the way of noninterference, as in this case, or of service, as in the case where my claim- right is to goods or services promised to me. Sometimes one of these rights gives other people the duty of securing to me that to which I have a right, but at other times their duty is merely to refrain from interference. If a fall of snow blocks my private parking space there is normally no obligation for anyone else to clear it away. Claim- rights generate duties; sometimes these duties are duties of noninterference; sometimes they are duties of service. If your right gives me the duty not to interfere with you I have “no right” to do it; similarly, if your right gives me the duty to provide something for you I have “no right” to refuse to do it. What I lack is the right which is a liberty; I am not “at liberty” to interfere with you or to refuse the service.

Where in this picture does the right to life belong? No doubt people have the right to live in the sense of a liberty, but what is important is the cluster of claim- rights brought together under the title of the right to life. The chief of these is, of course, the right to be free from interferences that threaten life. If other people aim their guns at us or try to pour poison into our drink we can, to put it mildly, demand that they desist. And then there are the services we can claim from doc- tors, health officers, bodyguards, and firemen; the rights that depend on contract or public arrangement. Perhaps there is no particular point in saying that the duties these people owe us belong to the right to life; we might as well say that all the services owed to any- one by tailors, dressmakers, and couturiers belong to a right called the right to be elegant. But contracts such as those understood in the patient- doctor relationship come in an important way when we are discussing the rights and wrongs of euthanasia, and are therefore mentioned here.

Do people have the right to what they need in order to survive, apart from the right conferred by spe- cial contracts into which other people have entered for the supplying of these necessities? Do people in the underdeveloped countries in which starvation is rife have the right to the food they so evidently lack? Joel Feinberg, discussing this question, suggests that they

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speak of the disconnecting of the apparatus as killing the man, or of the hospital as allowing him to die. By and large, it is the act of killing that is ruled out under the heading of noninterference, but not in every case.

Doctors commonly recognize this distinction, and the grounds on which some philosophers have denied it seem untenable. James Rachels, for instance, believes that if the difference between active and pas- sive is relevant anywhere, it should be relevant every- where, and he has pointed to an example in which it seems to make no difference which is done. If some- one saw a child drowning in a bath it would seem just as bad to let it drown as to push its head under water. If “it makes no difference” means that one act would be as iniquitous as the other this is true. It is not that killing is worse than allowing to die, but that the two are contrary to distinct virtues, which gives the pos- sibility that in some circumstances one is impermis- sible and the other permissible. In the circumstances invented by Rachels, both are wicked: it is contrary to justice to push the child’s head under the water— something one has no right to do. To leave it to drown is not contrary to justice, but it is a particularly glar- ing example of lack of charity. Here it makes no prac- tical difference because the requirements of justice and charity coincide; but in the case of the retreating army they did not: charity would have required that the wounded soldier be killed had not justice required that he be left alive.9 In such a case it makes all the dif- ference whether a man opts for the death of another in a positive action, or whether he allows him to die. An analogy with the right to property will make the point clear. If a man owns something he has the right to it even when its possession does him harm, and we have no right to take it from him. But if one day it should blow away, maybe nothing requires us to get it back for him; we could not deprive him of it, but we may allow it to go. This is not to deny that it will often be an unfriendly act or one based on an arrogant judgment when we refuse to do what he wants. Nevertheless, we would be within our rights, and it might be that no moral objection of any kind would lie against our refusal.

It is important to emphasize that a man’s rights may stand between us and the action we would dearly

of us may have the duty to sustain his life. Suppose, for example, that a retreating army has to leave behind wounded or exhausted soldiers in the wastes of an arid or snowbound land where the only prospect is death by starvation or at the hands of an enemy notoriously cruel. It has often been the practice to accord a mer- ciful bullet to men in such desperate straits. But sup- pose that one of them demands that he should be left alive? It seems clear that his comrades have no right to kill him, though it is a quite different question as to whether they should give him a life- prolonging drug. The right to life can sometimes give a duty of positive service, but does not do so here. What it does give is the right to be left alone.

Interestingly enough we have arrived by way of a consideration of the right to life at the distinction normally labeled “active” versus “passive” euthana- sia, and often thought to be irrelevant to the moral issue. Once it is seen that the right to life is a distinct ground of objection to certain acts of euthanasia, and that this right creates a duty of noninterference more widespread than the duties of care there can be no doubt about the relevance of the distinction between passive and active euthanasia. Where everyone may have the duty to leave someone alone, it may be that no one has the duty to maintain his life, or that only some people do.

Where then do the boundaries of the “active” and “passive” lie? In some ways the words are themselves misleading, because they suggest the dif- ference between act and omission which is not quite what we want. Certainly the act of shooting someone is the kind of thing we were talking about under the heading of “interference,” and omitting to give him a drug a case of refusing care. But the act of turning off a respirator should surely be thought of as no different from the decision not to start it; if doctors had decided that a patient should be allowed to die, either course of action might follow, and both should be counted as passive rather than active euthanasia if euthanasia were in question. The point seems to be that interfer- ence in a course of treatment is not the same as other interference in a man’s life, and particularly if the same body of people are responsible for the treatment and for its discontinuance. In such a case we could

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classes of persons such as bodyguards, firemen, or doc- tors? Unlike the general public they are not within their rights if they merely refrain from interfering and do not try to sustain life. The subject’s claim- rights are two- fold as far as they are concerned and passive as well as active euthanasia may be ruled out here if it is against his will. This is not to say that he has the right to any and every service needed to save or prolong his life; the rights of other people set limits to what may be demanded, both because they have the right not to be interfered with and because they may have a competing right to services. Furthermore one must enquire just what the contract or implicit agreement amounts to in each case. Firemen and bodyguards presumably have a duty which is simply to preserve life, within the limits of justice to others and of rea- sonableness to themselves. With doctors it may how- ever be different, since their duty relates not only to preserving life but also to the relief of suffering. It is not clear what a doctor’s duties are to his patient if life can be prolonged only at the cost of suffering or suffer- ing relieved only by measures that shorten life. George Fletcher has argued that what the doctor is under con- tract to do depends on what is generally done, because this is what a patient will reasonably expect.10 This seems right. If procedures are part of normal medical practice then it seems that the patient can demand them however much it may be against his interest to do so. Once again it is not a matter of what is “most humane.”

That the patient’s right to life may set limits to permissible acts of euthanasia seems undeniable. If he does not want to die no one has the right to practice active euthanasia on him, and passive euthanasia may also be ruled out where he has a right to the services of doctors or others.

Perhaps few will deny what has so far been said about the impermissibility of acts of euthanasia sim- ply because we have so far spoken about the case of one who positively wants to live, and about his rights, whereas those who advocate euthanasia are usually thinking either about those who wish to die or about those whose wishes cannot be ascertained either because they cannot properly be said to have wishes or because, for one reason or another, we are unable

like to take for his sake. They may, of course, also pre- vent action which we would like to take for the sake of others, as when it might be tempting to kill one man to save several. But it is interesting that the lim- its of allowable interference, however uncertain, seem stricter in the first case than the second. Perhaps there are no cases in which it would be all right to kill a man against his will for his own sake unless they could equally well be described as cases of allowing him to die, as in the example of turning off the respirator. However, there are circumstances, even if these are very rare, in which one man’s life would justifiably be sacrificed to save others, and “killing” would be the only description of what was being done. For instance, a vehicle which had gone out of control might be steered from a path on which it would kill more than one man to a path on which it would kill one. But it would not be permissible to steer a vehicle towards someone in order to kill him, against his will, for his own good. An analogy with property rights illustrates the point. One may not destroy a man’s property against his will on the grounds that he would be bet- ter off without it; there are however circumstances in which it could be destroyed for the sake of others. If his house is liable to fall and kill him that is his affair; it might, however, without injustice be destroyed to stop the spread of a fire.

We see then that the distinction between active and passive, important as it is elsewhere, has a special importance in the area of euthanasia. It should also be clear why James Rachels’ other argument, that it is often “more humane” to kill than to allow to die, does not show that the distinction between active and passive euthanasia is morally irrelevant. It might be “more humane” in this sense to deprive a man of the property that brings evils on him, or to refuse to pay what is owed to Hume’s profligate debauchee; but if we say this we must admit that an act which is “more humane” than its alternative may be morally objec- tionable because it infringes rights.

So far we have said very little about the right to service as opposed to the right to noninterference, though it was agreed that both might be brought under the heading of “the right to life.” What about the duty to preserve life that may belong to special

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In the last paragraph we have begun to broach the topic of voluntary euthanasia, and this we must now discuss. What is to be said about the case in which there is no doubt about someone’s wish to die: either he has told us beforehand that he would wish it in circum- stances such as he is now in, and has shown no sign of a change of mind, or else he tells us now, being in pos- session of his faculties and of a steady mind. We should surely say that the objections previously urged against acts of euthanasia, which it must be remembered were all on the ground of rights, had disappeared. It does not seem that one would infringe someone’s right to life in killing him with his permission and in fact at his request. Why should someone not be able to waive his right to life, or rather, as would be more likely to happen, to cancel some of the duties of noninterfer- ence that this right entails? (He is more likely to say that he should be killed by this man at this time in this manner, than to say that anyone may kill him at any time and in any way.) Similarly someone may give permission for the destruction of his property, and request it. The important thing is that he gives a critical permission, and it seems that this is enough to cancel the duty normally associated with the right. If someone gives you permission to destroy his property it can no longer be said that you have no right to do so, and I do not see why it should not be the case with taking a man’s life. An objection might be made on the ground that only God has the right to take life, but in this paper religious as opposed to moral arguments are being left aside. Religion apart, there seems to be no case to be made out for an infringement of rights if a man who wishes to die is allowed to die or even killed. But of course it does not follow that there is no moral objection to it. Even with property, which is after all a relatively small matter, one might be wrong to destroy what one had the right to destroy. For, apart from its value to other people, it might be valuable to the man who wanted it destroyed, and charity might require us to hold our hand where justice did not.

Let us review the conclusion of this part of the argument, which has been about euthanasia and the right to life. It has been argued that from this side come stringent restrictions on the acts of euthanasia that could be morally permissible. Active nonvoluntary

to form a reliable estimate of what they are. The ques- tion that must now be asked is whether the latter type of case, where euthanasia though not involuntary would again be nonvoluntary, is different from the one discussed so far. Would we have the right to kill someone for his own good so long as we had no idea that he positively wished to live? And what about the life- prolonging duties of doctors in the same cir- cumstances? This is a very difficult problem. On the one hand, it seems ridiculous to suppose that a man’s right to life is something which generates duties only where he has signaled that he wants to live; as a bor- rower does indeed have a duty to return something lent on indefinite loan only if the lender indicates that he wants it back. On the other hand, it might be argued that there is something illogical about the idea that a right has been infringed if someone incapable of saying whether he wants it or not is deprived of something that is doing him harm rather than good. Yet on the analogy of property we would say that a right has been infringed. Only if someone had ear- lier told us that in such circumstances he would not want to keep the thing could we think that his right had been waived. Perhaps if we could make confident judgments about what anyone in such circumstances would wish, or what he would have wished before- hand had he considered the matter, we could agree to consider the right to life as “dormant,” needing to be asserted if the normal duties were to remain. But as things are we cannot make any such assumption; we simply do not know what most people would want, or would have wanted, us to do unless they tell us. This is certainly the case so far as active measures to end life are concerned. Possibly it is different, or will become different, in the matter of being kept alive, so general is the feeling against using sophisticated procedures on moribund patients, and so much is this dreaded by people who are old or terminally ill. Once again the distinction between active and passive euthana- sia has come on the scene, but this time because most people’s attitudes to the two are so different. It is just possible that we might presume, in the absence of spe- cific evidence, that someone would not wish, beyond a certain point, to be kept alive; it is certainly not pos- sible to assume that he would wish to be killed.

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wounded soldier a drug that would keep him alive to meet a terrible end. And it is even more obvious that charity does not always dictate that life should be prolonged where a man’s own wishes, hypothetical or actual, are not known.

So much for the relation of charity to nonvolun- tary passive euthanasia, which was not, like nonvol- untary active euthanasia, ruled out by the right to life. Let us now ask what charity has to say about voluntary euthanasia both active and passive. It was suggested in the discussion of justice that if of sound mind and steady desire a man might give others the right to allow him to die or even to kill him, where otherwise this would be ruled out. But it was pointed out that this would not settle the question of whether the act was morally permissible, and it is this that we must now consider. Could not charity speak against what justice allowed? Indeed it might do so. For while the fact that a man wants to die suggests that his life is wretched, and while his rejection of life may itself tend to take the good out of the things he might have enjoyed, nevertheless his wish to die might here be opposed for his own sake just as it might be if suicide were in question. Perhaps there is hope that his mental condi- tion will improve. Perhaps he is mistaken in thinking his disease incurable. Perhaps he wants to die for the sake of someone else on whom he feels he is a burden, and we are not ready to accept this sacrifice whether for ourselves or others. In such cases, and there will surely be many of them, it could not be for his own sake that we kill him or allow him to die, and there- fore euthanasia as defined in this paper would not be in question. But this is not to deny that there could be acts of voluntary euthanasia both passive and active against which neither justice nor charity would speak.

We have now considered the morality of euthana- sia both voluntary and nonvoluntary, and active and passive. The conclusion has been that nonvoluntary active euthanasia (roughly, killing a man against his will or without his consent) is never justified; that is to say, that a man’s being killed for his own good never justifies the act unless he himself has consented to it. A man’s rights are infringed by such an action, and it is there- fore contrary to justice. However, all the other combi- nations, nonvoluntary passive euthanasia, voluntary

euthanasia is ruled out by that part of the right to life which creates the duty of noninterference though passive nonvoluntary euthanasia is not ruled out, except where the right to life- preserving action has been created by some special condition such as a contract between a man and his doctor, and it is not always certain just what such a contract involves. Vol- untary euthanasia is another matter: as the preceding paragraph suggested, no right is infringed if a man is allowed to die or even killed at his own request.

Turning now to the other objection that nor- mally holds against inducing the death of another, that it is against charity, or benevolence, we must tell a very different story. Charity is the virtue that gives attachment to the good of others, and because life is normally a good, charity normally demands that it should be saved or prolonged. But as we so defined an act of euthanasia that it seeks a man’s death for his own sake— for his good— charity will normally speak in favor of it. This is not, of course, to say that charity can require an act of euthanasia which justice forbids, but if an act of euthanasia is not contrary to justice— that is, it does not infringe rights— charity will rather be in its favor than against.

Once more the distinction between nonvoluntary and voluntary euthanasia must be considered. Could it ever be compatible with charity to seek a man’s death although he wanted to live, or at least had not let us know that he wanted to die? It has been argued that in such circumstances active euthanasia would infringe his right to life, but passive euthanasia would not do so, unless he had some special right to life- preserving service from the one who allowed him to die. What would charity dictate? Obviously when a man wants to live there is a presumption that he will be benefited if his life is prolonged, and if it is so the question of euthanasia does not arise. But it is, on the other hand, possible that he wants to live where it would be better for him to die: perhaps he does not realize the desperate situation he is in, or perhaps he is afraid of dying. So, in spite of a very proper resistance to refusing to go along with a man’s own wishes in the matter of life and death, someone might justifiably refuse to prolong the life even of someone who asked him to prolong it, as in the case of refusing to give the

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in our sense or only as the Nazis understood it is another matter. We must ask the crucial question, “Is it for the sake of the child himself that the doc- tors and parents choose his death?” In some cases the answer may really be yes, and what is more important it may really be true that the kind of life which is a good is not possible or likely for this child, and that there is little but suffering and frustration in store for him.12 But this must presuppose that the medi- cal prognosis is wretchedly bad, as it maybe for some spina bifida children. With children who are born with [Down] Syndrome it is, however, quite different. Most of these are able to live on for quite a time in a reasonably contented way, remaining like children all their lives but capable of affectionate relationships and able to play games and perform simple tasks. The fact is, of course, that the doctors who recom- mend against life- saving procedures for handicapped infants are usually thinking not of them but rather of their parents and of other children in the family or of the “burden on society” if the children survive. So it is not for their sake but to avoid trouble to others that they are allowed to die. When brought out into the open this seems unacceptable: at least we do not eas- ily accept the principle that adults who need special care should be counted too burdensome to be kept alive. It must in any case be insisted that if children with [Down] Syndrome are deliberately allowed to die this is not a matter of euthanasia except in Hitler’s sense. And for our children, since we scruple to gas them, not even the manner of their death is “quiet and easy”; when not treated for an intestinal obstruc- tion a baby simply starves to death. Perhaps some will take this as an argument for allowing active eutha- nasia, in which case they will be in the company of an S.S. man stationed in the Warthgenau who sent Eichmann a memorandum telling him that “Jews in the coming winter could no longer be fed” and sub- mitting for his consideration a proposal as to whether “it would not be the most humane solution to kill those Jews who were incapable of work through some quicker means.”13 If we say we are unable to look after children with handicaps we are no more telling the truth than was the S.S. man who said that the Jews could not be fed.

active euthanasia, and voluntary passive euthanasia are sometimes compatible with both justice and char- ity. But the strong condition carried in the definition of euthanasia adopted in this paper must not be forgotten; an act of euthanasia as here understood is one whose purpose is to benefit the one who dies.

In the light of this discussion let us look at our present practices. Are they good or are they bad? And what changes might be made, thinking now not only of the morality of particular acts of euthanasia but also of the indirect effects of instituting different prac- tices, of the abuses to which they might be subject and of the changes that might come about if euthanasia became a recognized part of the social scene.

The first thing to notice is that it is wrong to ask whether we should introduce the practice of eutha- nasia as if it were not something we already had. In fact we do have it. For instance it is common, where the medical prognosis is very bad, for doctors to rec- ommend against measures to prolong life, and par- ticularly where a process of degeneration producing one medical emergency after another has already set in. If these doctors are not certainly within their legal rights this is something that is apt to come as a sur- prise to them as to the general public. It is also obvious that euthanasia is often practiced where old people are concerned. If someone very old and soon to die is attacked by a disease that makes his life wretched, doctors do not always come in with life- prolonging drugs. Perhaps poor patients are more fortunate in this respect than rich patients, being more often left to die in peace; but it is in any case a well recognized piece of medical practice, which is a form of euthanasia.

No doubt the case of infants with mental or phys- ical defects will be suggested as another example of the practice of euthanasia as we already have it, since such infants are sometimes deliberately allowed to die. That they are deliberately allowed to die is cer- tain; children with severe spina bifida malformations are not always operated on even where it is thought that without the operation they will die; and even in the case of children with [Down] Syndrome who have intestinal obstructions the relatively simple opera- tion that would make it possible to feed them is some- times not performed.11 Whether this is euthanasia

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people want, and want very badly, to be rid of their elderly relatives and even of their ailing husbands or wives. Would any safeguards ever be able to stop them describing as euthanasia what was really for their own benefit? And would it be possible to prevent the occur- rence of acts which were genuinely acts of euthana- sia but morally impermissible because infringing the rights of a patient who wished to live?

Perhaps the furthest we should go is to encourage patients to make their own contracts with a doctor by making it known whether they wish him to prolong their life in case of painful terminal illness or of inca- pacity. A document such as the Living Will seems emi- nently sensible, and should surely be allowed to give a doctor following the previously expressed wishes of the patient immunity from legal proceedings by relatives.14 Legalizing active euthanasia is, however, another matter. Apart from the special repugnance doctors feel towards the idea of a lethal injection, it may be of the very greatest importance to keep a psy- chological barrier up against killing. Moreover it is active euthanasia which is the most liable to abuse. Hitler would not have been able to kill 275,000 peo- ple in his “euthanasia” program if he had had to wait for them to need life- saving treatment. But there are other objections to active euthanasia, even voluntary active euthanasia. In the first place it would be hard to devise procedures that would protect people from being persuaded into giving their consent. And sec- ondly the possibility of active voluntary euthanasia might change the social scene in ways that would be very bad. As things are, people do, by and large, expect to be looked after if they are old or ill. This is one of the good things that we have, but we might lose it, and be much worse off without it. It might come to be expected that someone likely to need a lot of look- ing after should call for the doctor and demand his own death. Something comparable could be good in an extremely poverty- stricken community where the children genuinely suffered from lack of food; but in rich societies such as ours it would surely be a spiri- tual disaster. Such possibilities should make us very wary of supporting large measures of euthanasia, even where moral principle applied to the individual act does not rule it out.

Nevertheless if it is ever right to allow deformed children to die because life will be a misery to them, or not to take measures to prolong for a little the life of a newborn baby whose life cannot extend beyond a few months of intense medical intervention, there is a genuine problem about active as opposed to pas- sive euthanasia. There are well- known cases in which the medical staff has looked on wretchedly while an infant died slowly from starvation and dehydration because they did not feel able to give a lethal injection. According to the principles discussed in the earlier part of this paper they would indeed have had no right to give it, since an infant cannot ask that it should be done. The only possible solution— supposing that vol- untary active euthanasia were to be legalized— would be to appoint guardians to act on the infant’s behalf. In a different climate of opinion this might not be dangerous, but at present, when people so readily assume that the life of a handicapped baby is of no value, one would be loath to support it.

Finally, on the subject of handicapped children, another word should be said about those with severe mental defects. For them too it might sometimes be right to say that one would wish for death for their sake. But not even severe mental handicap automati- cally brings a child within the scope even of a possible act of euthanasia. If the level of consciousness is low enough it could not be said that life is a good to them, any more than in the case of those suffering from extreme senility. Nevertheless if they do not suffer it will not be an act of euthanasia by which someone opts for their death. Perhaps charity does not demand that strenuous measures are taken to keep people in this state alive, but euthanasia does not come into the matter, any more than it does when someone is, like Karen Ann Quinlan, in a state of permanent coma. Much could be said about this last case. It might even be suggested that in the case of unconsciousness this “life” is not the life to which “the right to life” refers. But that is not our topic here.

What we must consider, even if only briefly, is the possibility that euthanasia, genuine euthanasia, and not contrary to the requirements of justice or char- ity, should be legalized over a wider area. Here we are up against the really serious problem of abuse. Many

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act of injustice which would have been for someone’s good.

10. George Fletcher, “Legal Aspects of the Decision not to Prolong Life,” Journal of the American Medical Association 203, no. 1 (1 Jan. 1968): 119–122. Reprinted in Gorovitz.

11. I have been told this by a pediatrician in a well- known medical center in the United States. It is confirmed by Anthony M. Shaw and Iris A. Shaw, “Dilemma of Informed Consent in Children,” The New England Journal of Medicine 289, no. 17 (25 Oct. 1973): 885–890. Reprinted in Gorovitz.

12. It must be remembered, however, that many of the social miseries of spina bifida children could be avoided. Professor R.B. Zachary is surely right to insist on this. See, for example, “Ethical and Social Aspects of Spina Bifida,” The Lancet, 3 Aug. 1968, pp. 274–276. Reprinted in Gorovitz.

13. Quoted by Hannah Arendt, Eichmann in Jerusalem (Lon- don, 1963), p. 90.

14. Details of this document are to be found in J.A. Behnke and Sissela Bok, eds., The Dilemmas of Euthanasia (New York, 1975), and in A.B. Downing, ed., Euthanasia and the Right to Life: The Case for Voluntary Euthanasia (London, 1969).

NOTES

1. Leo Alexander, “Medical Science under Dictatorship,” New England Journal of Medicine, 14 July 1949, p. 40.

2. For a discussion of culpable and nonculpable ignorance see Thomas Aquinas, Summa Theologica, First Part of the Second Part, Question 6, article 8, and Question 19, articles 5 and 6.

3. Dmitri Panin, The Notebooks of Sologdin (London, 1976), pp. 66–67.

4. Thomas Nagel, “Death,” in James Rachels, ed., Moral Prob- lems (New York, 1971), p. 362.

5. Panin, Sologdin, p. 85.

6. Yet some detail needs to be filled in to explain why we should not say that a scarecrow is beneficial to the plants it protects. Perhaps what is beneficial must either be a feature of the plant itself, such as protective prickles, or else must work on the plant directly, such as a line of trees which give it shade.

7. David Hume, Treatise, Book III, Part II, Section 1.

8. Feinberg, “Human Rights,” Moral Problems in Medicine, p. 465.

9. It is not, however, that justice and charity conflict. A man does not lack charity because he refrains from an

Killing and Allowing to Die Daniel Callahan

rests on the commonplace observation that lives can come to an end as the result of: (a) the direct action of another who becomes the cause of death (as in shoot- ing a person), and (b) the result of impersonal forces where no human agent has acted (death by lightning, or by disease). The purpose of the distinction has been to separate those deaths caused by human action, and those caused by nonhuman events. It is, as a distinc- tion, meant to say something about human beings and their relationship to the world. It is a way of articulating the difference between those actions for which human beings can be held rightly responsible, or blamed, and those of which they are innocent. At

* * *

If a lessened worry about the consequences of legal euthanasia has been gaining ground, there has been an even more powerful threat to the traditional pro- hibition against it. No valid distinction, many now argue, can be made between killing and allowing to die, or between an act of commission and one of omission. The standard distinction being challenged

Daniel Callahan, “Can We Return Death to Disease?” from Hastings Center Report 19(1): 4–6. Copyright © 1989 The Hastings Center. Reproduced with permission of John Wiley & Sons, Inc.

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Of course that is a fantasy. The fact that we can intervene in nature, and cure or control many dis- eases, does not erase the difference between the self and the external world. It is as “out there” as ever, even if more under our sway. That sway, however great, is always limited. We can cure disease, but not always the chronic illness that comes with the cure. We can forestall death with modern medicine, but death always wins in the long run because of the innate limitations of the body, inherently and stub- bornly beyond final human control. And we can dis- tinguish between a diseased body and an aging body, but in the end if we wait long enough they always become one and the same body. To attempt to deny the distinction between killing and allowing to die is, then, mistakenly to impute more power to human action than it actually has and to accept the conceit that nature has now fallen wholly within the realm of human control. Not so.

Moral. At the center of the distinction between killing and allowing to die is the difference between physical causality and moral culpability. To bring the life of another to an end by an injection kills the other directly; our action is the physical cause of the death. To allow someone to die from a disease we cannot cure (and that we did not cause) is to permit the disease to act as the cause of death. The notion of physical causality in both cases rests on the differ- ence between human agency and the action of exter- nal nature. The ambiguity arises precisely because we can be morally culpable for killing someone (if we have no moral right to do so, as we would in self- defense) and no less culpable for allowing someone to die (if we have both the possibility and the obli- gation of keeping that person alive). Thus there are cases where, morally speaking, it makes no difference whether we killed or allowed to die; we are equally responsible. In those instances, the lines of physical causality and moral culpability happen to cross. Yet the fact that they can cross in some cases in no way shows that they are always, or even usually, one and the same. We can normally find the difference in all but the most obscure cases. We should not, then, use the ambiguity of such cases to do away altogether with the distinction between killing and allowing to

issue is the difference between physical causality, the realm of impersonal events, and moral culpability, the realm of human responsibility.

The challenges encompass two points. The first is that people can become equally dead by our omissions as well as our commissions. We can refrain from saving them when it is possible to do so, and they will be just as dead as if we shot them. It is our decision itself that is the reason for their death, not necessarily how we effectuate that decision. That fact establishes the basis of the second point: if we intend their death, it can be brought about as well by omitted acts as by those we commit. The crucial moral point is not how they die, but our intention about their death. We can, then, be responsible for the death of another by intending that they die and accomplish that end by standing aside and allowing them to die.

Despite these criticisms— resting upon ambigui- ties that can readily be acknowledged— the distinction between killing and allowing to die remains, I con- tend, perfectly valid. It not only has a logical validity but, no less importantly, a social validity whose place must be central in moral judgments. As a way of put- ting the distinction into perspective, I want to suggest that it is best understood as expressing three differ- ent, though overlapping, perspectives on nature and human action. I will call them the metaphysical, the moral, and the medical perspectives.

Metaphysical. The first and most fundamental premise of the distinction between killing and allow- ing to die is that there is a sharp difference between the self and the external world. Unlike the childish fantasy that the world is nothing more than a projec- tion of the self, or the neurotic person’s fear that he or she is responsible for everything that goes wrong, the distinction is meant to uphold a simple notion: there is a world external to the self that has its own, and independent, causal dynamism. The mistake behind a conflation of killing and allowing to die is to assume that the self has become master of everything within and outside of the self. It is as if the conceit that modern man might ultimately control nature has been internalized: that, if the self might be able to influence nature by its actions, then the self and nature must be one.

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be, and be seen to be, a limited power. It may be used only to cure or comfort, never to kill. They have not been given, nor should they be given, the power to use their knowledge and skills to bring life to an end. It would open the way for powerful misuse and, no less importantly, represent an intrinsic violation of what it has meant to be a physician.

Yet if it is possible for physicians to misuse their knowledge and power to kill people directly, are they thereby required to use that same knowledge always to keep people alive, always to resist a disease that can itself kill the patient? The traditional answer has been: not necessarily. For the physician’s ultimate obligation is to the welfare of the patient, and exces- sive treatment can be as detrimental to that welfare as inadequate treatment. Put another way, the obliga- tion to resist the lethal power of disease is limited— it ceases when the patient is unwilling to have it resisted, or where the resistance no longer serves the patient’s welfare. Behind this moral premise is the recognition that disease (of some kind) ultimately triumphs and that death is both inevitable sooner or later and not, in any case, always the greatest human evil. To demand of the physician that he always strug- gle against disease, as if it was in his power always to conquer it, would be to fall into the same metaphysi- cal trap mentioned above: that of assuming that no distinction can be drawn between natural and human agency.

A final word. I suggested earlier that the most potent motive for active euthanasia and assisted sui- cide stems from a dread of the power of medicine. That power then seems to take on a drive of its own regardless of the welfare or wishes of patients. No one can easily say no— not physicians, not patients, not families. My guess is that happens because too many have already come to believe that it is their choice, and their choice alone, which brings about death; and they do not want to exercise that kind of authority. The solution is not to erase the distinction between killing and allowing to die, but to under- score its validity and importance. We can bring disease as a cause of death back into the care of the dying.

die. The ambiguity may obscure, but does not erase, the line between the two.

There is one group of ambiguous cases that is especially troublesome. Even if we grant the ordi- nary validity between killing and allowing to die, what about those cases that combine (a) an illness that renders a patient unable to carry out an ordi- nary biological function (to breathe or eat on his own, for example), and (b) our turning off a respi- rator or removing an artificial feeding tube? On the level of physical causality, have we killed the patient or allowed him to die? In one sense, it is our action that shortens his life, and yet in another sense his underlying disease brings his life to an end. I believe it reasonable to say that, since his life was being sustained by artificial means (respirator or feeding tube) made necessary because of the fact that he had an incapacitating disease, his disease is the ultimate reality behind his death. But for its reality, there would be no need for artificial sustenance in the first place and no moral issue at all. To lose sight of the paramount reality of the disease is to lose sight of the difference between our selves and the outer world.

I quickly add, and underscore, a moral point: the person who, without good moral reason, turns off a respirator or pulls a feeding tube, can be morally cul- pable; that the patient has been allowed to die of his underlying condition does not morally excuse him. The moral question is whether we are obliged to con- tinue treating a life that is being artificially sustained. To cease treatment may or may not be morally accept- able; but it should be understood, in either case, that the physical cause of death was the underlying disease.

Medical. An important social purpose of the dis- tinction between killing and allowing to die has been that of protecting the historical role of the physician as one who tries to cure or comfort patients rather than to kill patients. Physicians have been given spe- cial knowledge about the body, knowledge that can be used to kill or to cure. They are also given great privi- leges in making use of that knowledge. It is thus all the more important that physicians’ social role and power

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Euthanasia for Disabled People? Liz Carr

Frustrated by the lack of opportunity to have the voices of people like me— of disabled people— heard on this issue, I have decided to combine my activism with my career as a performer.

I’ve never seen a piece of art or theatre which expresses opposition to legalising assisted suicide from a disabled person’s perspective— so I decided to try to rectify that. The result is Assisted Suicide: The Musical— a show which premieres this weekend at the Royal Fes- tival Hall, London, and marks the first anniversary of the defeat of the assisted dying bill in parliament.

There were of course religious people there with me and many others outside Westminster on Friday 11 September 2015. But MPs who glanced out the window would have seen more Not Dead Yet (NDY) T- shirts and banners than religious ones. NDY is made up of disabled people opposed to a change in the law. Every major disabled group in the UK, it should be stressed, is opposed to this legislation.

Suicide is, of course, an individual choice. Dis- abled people who are determined to take their lives may even find it easier to do so than abled people, given the often precarious nature of their existences. But that does not mean that when a fellow human being— disabled or abled— expresses the wish to die because their life is shit, that we should agree with them. The value of a life is not just in its physicality but in our relationships with those around us.

The bill, had it passed, would have licensed doc- tors to assist in the deaths of terminally ill people who had less than six months to live, were mentally compe- tent and requested such assistance. But the direction legislation has taken in other countries shows that the sympathy we disabled people evoke can be used to jus- tify support for us to kill ourselves while non- disabled people are told they have “everything to live for”. How many times has someone come up to me and said how much they admired me just for existing because they could not, in my condition?

There is a fine line between those who are ter- minally ill and those who are disabled in public

If I said I wanted to die, the press, celebrities and the public would support my choice, seeing it as rational and understandable. Hell, they would probably set up a GoFundMe campaign to help me make it happen.

Yet when a healthy, non- disabled person wants to kill themself it’s seen as a tragedy, and support and prevention tools are provided. If nothing else convinces me that to legalise assisted suicide is not a safe option for many of us, then this does. Suicide is not seen as socially desirable— so why is assisted suicide seen as compassionate when it’s for ill or disabled people?

Marieke Vervoort, the 38- year- old Belgian Para- lympian gold medallist, is only the most recent dis- abled person to announce that she is considering euthanasia, saying her “body is exhausted”. She is not imminently dying. Yet no one seems to be trying to persuade her that life is worthwhile. Would Usain Bolt be met with the same reaction if he announced his decision to end it all after his last Olympics?

Although proponents of assisted suicide legisla- tion say it’s only for those with six months or less to live, they propagandise with cases like that of Daniel James, the 23- year- old man paralysed (but not dying) following a rugby accident, who killed himself at the Swiss clinic Dignitas after he said he did not want to live a “ second- class” (that is, disabled) life. Jeffrey Spector, a 54- year- old man also not imminently dying, also killed himself at Dignitas.

The Netherlands, which legalised euthanasia to pro- vide relief for the terminally ill, now regularly provides euthanasia for disabled people who can demonstrate “unbearable suffering”. Canada, the most recent nation to legalise euthanasia and assisted suicide, allows it for “serious and incurable illness, disease or disability”.

Usually, the two sides of the argument are char- acterised as “religious” (opposed to legalisation) or “secular” (in favour). But it’s not that simple.

Liz Carr, “Legalising Assisted Dying Is Dangerous for Disabled People, Not Compassionate,” The Guardian, September 9, 2016. Copyright © Guardian News & Media Ltd. 2018. Reprinted with permission.

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also know from the US that some people have been denied life- extending treatments because they are too costly while the cheaper assisted suicide option has been offered as an alternative. Think this won’t hap- pen here? Medical rationing is the reality of our over- stretched NHS.

No one wants us, those we love, or even those we don’t to suffer and die in pain. But shouldn’t we try to get end- of- life care right before we throw physician- assisted killing into the mix? Currently hospices and palliative care are only available to the few, and hospices continue to rely on donations for their survival.

Please, don’t wish death upon us because you feel pity for our condition. It is demoralising when dis- abled people like Vervoort express— understandably— exhaustion with the everyday struggle of existence and discouragement with life and are met with sad, understanding nods. On Saturday, it is world suicide prevention day. Can we be included in suicide preven- tion efforts, too, please?

perception, and the emotional power behind the cam- paign for assisted suicide is based on misplaced pity. Rather than telling us we have everything to live for— and we do— we are helped to the proverbial cliff edge and offered a push.

People— disabled and not, with many years or only a few months ahead of them— become suicidal for many, many reasons. We know from surveys in Oregon, one of just four states in the US where assisted suicide is legal, that the reasons people choose this option have little to do with pain, although this is always the emphasis of supporters of assisted dying.

In fact, loss of dignity, loss of autonomy, loss of ability to do daily activities, and fear of being a burden— reasons which are essentially more about the realities of living with a disability in our society— are all more important than pain.

It is worth keeping in mind, too, that, in the con- text of economic arguments about a health service overly concerned with “waste” of resources, disabled people may be seen as a drain, just like the elderly. We