The Philosophical Debate About Euthanasia
The word
‘euthanasia’ derives from Greek and originally meant ‘good death.’ Today we use
it to indicate a mercy killing, when life is cut short for the sake of avoiding
a painful death. Euthanasia is the purposeful killing of a person in order to
avoid chronic physical pain, and a person by be euthanized either by themselves
or by another person. This gives us a strong link to suicide; if suicide is
immoral and wrong in all cases, then it seems that euthanasia is almost
certainly wrong also.
The definition
given above mentions only physical pain, and does not mention psychological
pain such as extreme stress and depression. In many cases physical pain will be
accompanied by psychological trauma, and it is this factor which might decide
whether someone can cope with their pain or not. In some cases (e.g. total
paralysis) there is no actual physical pain but a person may consider their
life not to be worth living. Many people argue that euthanasia should not be
permitted for psychological distress because a person’s psychology can be
treated, hopefully making them happier in the end. Euthanasia is generally
called for when a person is suffering from an incurable physical illness which
will kill them but make the process horrifically painful. For the main part
this article will focus on euthanasia for the sake of avoiding physical pain.
Types of Euthanasia: Voluntary and
Involuntary
There are many
kinds of euthanasia, and this makes it a difficult issue to make general rules
of thumb about euthanasia. Every example of euthanasia will be voluntary or involuntary.
Voluntary euthanasia is when a person specifically asks for their life to be
ended. Involuntary euthanasia is when a
person has not given their permission, but instead the decision is taken by
another person. Involuntary euthanasia is generally treated as murder, after
all, we are talking about ending a person’s life without asking them, or
perhaps against their expressed wishes. However, there are special cases when
it is not regarded as murder, and is actually legally allowed, such as when a
person is actually incapable of making a choice due to being in a coma or
Persistent Vegetative State (PVS). In many cases further treatment (i.e.
keeping them alive) is viewed as futile, and doctors or family make the
decision to turn life preserving machines off. This has sometimes been termed
as ‘non-voluntary’ euthanasia.
Types of Euthanasia: Active and Passive
In addition to being
voluntary or involuntary, every example of euthanasia will be either active or
passive. Active euthanasia is when action is taken to actually end a person’s
life, such as shooting them, giving them a lethal injection, smothering them
with a pillow, and so on. Meanwhile, passive euthanasia is considered more to
be ‘letting die’ rather than killing, as it involves allowing a person to die
due to taking away treatments which could save their life, e.g. switching off a
life support machine, not giving them food and water, not giving them life
extending drugs, not resuscitating them, and so on. Whilst active euthanasia is
an act of commission (doing something), passive euthanasia is an act of
omission (leaving something out). Many view it as ‘letting nature take its
course’ and therefore they do not see it as immoral. Meanwhile others are keen
to point out that this method is often more painful than actively killing
someone and therefore that active euthanasia is actually more humane.
Assisted Suicide
Assisted suicide
is when another person helps you to kill yourself because you are not capable
of doing so yourself; this may include providing a person with the means to
kill themselves, such as giving them a poison which they will then drink, but
it may also take other methods. Dr. Jack
Kevorkian created a device called a thanatron, a machine designed to allow
a person to kill themselves; the machine contained canisters of drugs which
were connected to the person to be euthanised by intravenous lines by
Kevorkian. The person would then press a button to start the machine by
themselves. Kevorkian claims to have helped over 130 people to die in the USA.
He was sent to prison when he was discovered to have killed one himself by
lethal injection.
One point that
is often missed in the debate on assisted suicide is that according to Swiss
law the person must be fully conscious and sane in order to be assisted in
death. Suppose that a woman is diagnosed with Alzheimer’s disease and knows
that she will eventually lose her memories and her sense of herself. This may
horrify her to the extent that she would rather die than continue to live in
such a way. However, since she must be sane at the time she chooses to die this
means that she cannot wait until the disease takes hold and then die afterwards,
she must instead die early whilst she is still mentally healthy. This means
that she will miss out on many final opportunities for good and valuable life experiences
before the disease takes hold. Some argue that people should be allowed to
produce ‘living wills’ stating that if they do fall victim to such problems
they should be killed or allowed to die.
Death as a ‘side effect’
Death as a side
effect is technically legal in the UK. In many cases terminally ill patients
are given strong pain killing drugs because of the severity of the pain they
are experiencing. Continued usage of these drugs at high levels can shorten
life, for example, use of morphine can cause asphyxiation or pneumonia. Despite
the known risks many doctors continue to give their patients the drugs, with
the patient’s knowledge, and this eventually kills them. However, this is not
considered to be euthanasia as there is no actual intention to kill the person,
the main intention is to take away their pain, not to kill them. Their death is
considered to be a lamentable side effect, or ‘double effect’ of the care they
require. This is not too dissimilar to the way in which a person may die when
having a risky life saving operation like a heart transplant.
UK euthanasia laws
As stated above,
assisted suicide is illegal in the UK, whereas causing death as a side effect
of treatment such as pain relief is considered acceptable. According to the law
all acts of active euthanasia are illegal, whether they are active or passive. Essentially
it is regarded as murder. When making judgements on these matters judges have
made the following statements:
If the
acts done are intended to kill and do kill it does not matter if a life is cut
short by weeks or months, it is just as much murder as if it were cut short by
years. Justice Devlin, 1957
However
gravely ill a man may be he is entitled in our law to every hour that God has
granted him. That hour may be the most precious and important of his life. Justice
Mars-Jones, 1986
The only forms
of euthanasia which are ‘allowed’ are passive, but there is a great deal of
restriction depending on whether it is voluntary, involuntary, or
non-voluntary. A patient has the right to refuse treatment, and in this way
passive voluntary euthanasia is legal because a patient can opt to refuse
life-saving operations, life extending drugs, and even food or water. This can
be done with a ‘living will’ which states, for example, that if the person’s
heart stops then they are not allowed to be resuscitated, although the legal
standing of living wills is an area of debate. However, if the patient is
deemed to be mentally unstable then they can be sectioned under the mental
health act, meaning that a doctor may ignore their wishes not to be treated and
treat them anyway. In many cases the wish to die is itself seen as a sign of
mental instability, and the law states that it cannot be in a person’s best
interests to be dead.
Passive non-voluntary
euthanasia is allowed because the law recognises that in some cases treating a
patient is futile, which means that it is of no benefit to them. In these cases
it is not a crime to withhold treatment. The classic example of this is
switching off the life support system of a person in a coma or PVS, or
withdrawing food and water drips and allowing them to starve to death. This is
viewed as letting nature take its course rather than killing the patient.
However, it is a crime to refuse treatment to a person who has a good chance of
benefiting from it or who has requested it, as health workers have a duty of
care to treat their patients:
For a
doctor deliberately to interrupt life-prolonging treatment in the face of a
patient’s expressed wish to be kept alive, with the intention of thereby
terminating the patient’s life, would leave the doctor with no answer to a
charge of murder. Lord
Phillips, 2005
This means that
in many cases passive non-voluntary euthanasia would be ruled out as there
might be a good chance of a person waking from a coma after some time. It also
means that involuntary euthanasia is illegal in all cases as the patient’s
wishes need to be taken in to consideration and it cannot be right to withhold
food or treatment from a conscious person, this would again be considered
murder.
The Ethical Debate: Voluntary Euthanasia
It is best to
look at one kind of euthanasia at a time as different factors may be involved
in the consideration of each. For the sake of this debate we will assume that
there is no moral difference between active and passive euthanasia as this will
make our considerations easier.
Let’s start with
a moral dilemma: suppose that you were a soldier fighting in a war, and that
you were captured by the evil enemy forces. Your enemies are sadistic and
delight in harming captured prisoners. They offer you a choice: either you will
be killed now relatively painlessly, or you can be tortured every day for two
months and then killed painfully. Now it may well be that you are the kind of
person who would rather be alive, no matter how bad that life is, than die. And
you may be the kind of person who would opt for the torture in the hope of
being rescued at some point. However, most people would more than likely choose
to die sooner and avoid the pain. In a very real sense this is very much like
the option faced by a person requesting euthanasia, such as a person who has a
terminal cancer and can expect to spend the last few months of their lives in
constant pain and being cared for by hospital staff. This gives a strong
argument for allowing voluntary euthanasia out of sympathy and compassion for
those who suffer, however, it is an emotive response rather than one based on
reasoning or principles of any kind.
Voluntary Euthanasia – The Teleological
Approach
Teleological
moral theories consider the consequences when choosing whether to allow
euthanasia or not, the most famous version of the theory being Utilitarianism
which seeks to minimise pain and maximise happiness. Suppose that a man is
mauled by a tiger in the jungle and that he is so badly injured that he cannot
survive more than an hour, with help being at least six hours away; he asks you
to shoot him and end his pain. You have two options, to kill or not to kill; whichever
option you take part of the final result is the same, the death of the
suffering person, except that in performing euthanasia the person will suffer
much less pain, which surely makes it the better option. This short term
example of euthanasia shows us the basic jist of the teleological position:
that in many cases where a person is suffering euthanasia will be allowed
because it minimises pain before their eventual death.
Of course, this
is an over simplification of the Utilitarian position as all of the
consequences need to be taken into consideration before a judgement can be
made. Utilitarians will also consider the wider implications, such as the
effect that killing a person will have on the one who performs the euthanasia,
the effects it will have on the person’s friends and family, and the effects it
will have on the judge or authority who allowed the euthanasia to occur, and so
on. The one who performs the euthanasia may feel guilty for ending a life, but
then again, some people may feel guilty for not ending a life and leaving the
person to suffer instead. Family and friends might feel abandoned because their
loved one has chosen to die, but on the other hand they may feel relieved that
their loved one is no longer suffering, and relieved that their lives can go
back to normality, since caring for a loved one who is ill can take your entire
life up and be extremely upsetting and stressful. Looking at wider implications
again, keeping people alive may be very expensive, so allowing them to end
their lives could mean that the money can be spent elsewhere to help other
patients, a clear utilitarian benefit.
Euthanasia
certainly prevents a person from feeling anymore pain, but it may also mean
that they lose opportunities for final moments of happiness. There is a strong
argument that the best approach to ensure happiness is to give palliative care
in hospices where people can die naturally and in relative comfort, share
precious moments with friends and relatives, and help everyone to achieve
closure. Sisley Saunders, a Christian who founded a hospice had this to say:
“I’m against euthanasia for a positive reason. I have seen people achieve so
much in the ending of their lives – times that their families would have
missed… They perhaps would have gone in bitterness, whereas they finally go in
peace and fulfilment.” If we take a
teleological standpoint we must take all of the factors in to account, and it
may be that these wider factors indicate that euthanasia is not appropriate in
a particular case.
Voluntary Euthanasia: The Deontological
Approach
Deontology is
not concerned with the consequences of an action, nor necessarily the action
itself, but instead the principles that underpin the action. There are
deontological principles that support euthanasia as well as oppose it.
The very fact
that we distinguish between voluntary and involuntary euthanasia is telling of
our moral assumption of a principle of self-determination.
There are supporters of euthanasia who believe that individuals should have a
right to die because it is their own life and that we others ought to respect
their autonomy and choices of what to do with their life. This, then, is a
deontological argument for allowing voluntary euthanasia. Interestingly, a
large number of the people who go to the Dignitas euthanasia clinic in
Switzerland opt not to end their lives; it seems that the knowledge that they
could kill themselves if they wanted to makes their suffering easier to cope
with because it gives them a sense of control and removes feelings of
helplessness; they are choosing to stay alive rather than being forced to do so.
A problem is that if people have a right to die, and a right to choose, then
this seems to indicate that anyone who wants to die, for any reason, should be
allowed to kill themselves, and possibly helped to do so. Can we really
legalised assisted suicide for depressed people, or those in similar
situations? Euthanasia is meant to only be reserved for those whose suffering
is greatest, rather than for everyone, and it seems strange to say that only
those who are suffering have a right to die, since rights are meant to be
universally applicable.
When it comes to
the euthanasia debate two of the most important principles are Sanctity of Life and Quality of Life. The sanctity of life
principle states that human life is special and of extremely high value, and
therefore that life is not to be taken: people are not to be disposed of, but
preserved. Many people would argue that if a dog was in severe pain we would be
kind and put it down, and they argue that the same should be allowed with human
beings, but many others respond that human life is sacred and that it should
not be so easily cast aside. The Sanctity of Life principle is a major
deontological principle standing against euthanasia, and it is most often
linked to religious perspectives which see life as belonging to God, and as
special because we are made in God’s image (Genesis 1:26). However, there are
also secular reasons to be of similar mind, for example, Immanuel Kant placed infinite value on all rational beings meaning
you cannot abuse or mistreat them in any way, and the UN declaration of human
rights describes human beings as endowed with reason, conscience, and dignity.
From this deontological perspective life is to be preserved regardless of its
quality or lack thereof. Additionally, there are numerous commandments in holy
texts such as the Bible forbidding killing, such as the sixth commandment “thou
shalt not kill.”
Many supporters
of euthanasia would argue that life is indeed precious and special, but that
there comes a point when it is undignified to continue living, so euthanasia
should be allowed to preserve dignity.
Think of your life as you live it now; perhaps you are proud of yourself
because of your sporting achievements, or how popular you are with your
friends, or how well you do at your job or in school. There are things about
you which make your life valuable to you and worth protecting and preserving.
However, extreme suffering can rob a person of all the things which, in their
view, give their life its dignity and sanctity. As an example, the author Terry
Pratchett has been diagnosed with Alzheimer’s disease. Over time he will lose
his personality, and his memories, and everything that made him the man he is;
he will no longer be able to write, and he probably will barely be able to even
remember having been an author at all. Pratchett is now a leading campaigner
for the legalisation of euthanasia in the UK. Many supporters of euthanasia argue
that those who are afflicted by extreme pain and debilitating conditions should
be allowed to die while they still have their dignity.
Opposing the
principle of Sanctity of Life there is the principle of Quality of Life; roughly
speaking this concerns the degree to which a life is fulfilling, pain free, and
enjoyable. The idea of quality of life supports euthanasia because it indicates
that life is only worthwhile if it is purposeful and enjoyable, so that it is
better not to live at all rather than live a poor quality life. As David Hume put it: “That suicide may
often be consistent with interest and with our duty to ourselves, no one can
question, who allows that age, sickness, or misfortune, may render life a burden,
and make it worse even than annihilation. I believe that no man ever threw away
life, while it was worth keeping.” However, many may disagree with Hume’s last
point and state that many people have thrown away worthwhile lives; how
precisely quality of life can be measured, and who should be doing the
measuring, is highly debatable.
Another point of
principle to be taken in to account is the Hippocratic Oath. The Hippocratic Oath which doctors swear
before being allowed to practice medicine specifically says that the doctor
should keep their patients from harm and also states “I will not give a drug
that is deadly to anyone if asked, nor will I suggest the way to such a
counsel.” Surely it is the job of doctors to preserve lives, and it is
dangerous or at least a bad practice to introduce the killing of people in to
their job? Could this not lead to abuses such as those performed by Harold
Shipman who killed at least fifteen of his patients, if not many more? Might
not a doctor pressure someone into euthanasia so that he could reap their organs
for donation, or to save the hospital trust the cost of expensive treatments?
On the other hand, it might be noted that doctors already perform abortions,
which many view as a form of murder.
The famous
deontological thinker Immanuel Kant
specifically argued against suicide, and so by extension we can also say that
getting someone else to end your life for you would also be wrong in his
opinion. First of all, for Kant the lives of rational beings are of infinite
value, which means throwing them away is never an option; remember that for
Kant people should be seen as “ends in themselves” who should therefore not
simply be used or simply disposed of like mere objects. Kant can be seen as
trying to defend the traditional Christian position on suicide and euthanasia,
but rather than relying on the religious commandment of “Thou shalt not kill” he
is instead trying to give the Sanctity of Life a secular grounding in
Reason.
It can be argued
that neither killing nor suicide are universalisable, since this would lead to
the destruction of the human race. However, Kant asks us to universalise the
principle on which we are acting rather than the action itself, which may mean
that something like killing in self defence is allowable, but not killing for
monetary gain. This makes it difficult to see whether euthanasia could be
allowable in the right circumstances, for which reason Kant’s theory has been
accused of being quite hollow and unhelpful in most issues. Arguably it is
perfectly possible to universalise a maxim such as “I will end my life
painlessly to avoid a painful death.”
However, Kant
does provide his own argument against suicide: the reason why we are averse to
pain is because pain is a risk to continued survival, therefore, we avoid pain
to save our lives. Therefore, suicide to avoid pain or suffering is killing
yourself for the sake of saving your life, which is absurd, it is destroying
yourself for the sake of self-preservation. This he believes is irrational and
contradictory. For Kant this means that suicide and euthanasia must be immoral
since they cannot be universalised without contradiction. However, arguably
Kant is presuming too much here by assuming that we avoid pain purely for the
sake of survival, so his argument actually turns out not to be based on Reason
at all, but actually traditional Christian notions of Natural Law (the idea
that there is a God given purpose to our nature).
Involuntary Euthanasia
Involuntary
euthanasia can be when someone is killed without being asked if they want to
live or not, alternatively, it could go directly against their wishes, ending
their life when they have specifically said that they want to live. In the UK
involuntary euthanasia is automatically considered to be murder, and it is easy
to understand why as it denies autonomy, self-ownership, and the right to life
enshrined within the UN declaration of human rights.
The first and
most obvious argument against involuntary euthanasia is that the right to
choose is extremely important. Some use the principles of autonomy and personal
choice to argue that voluntary euthanasia should be legalised, but even if you
reject legalisation it still seems to be true that ending the life of someone
who has not asked for it, or who has even declared a wish to live, is utterly
wrong. This is a deontological perspective, however, whether a person actually wants
to die or not might not be the biggest factor in a teleological ethicist’s
calculations. From a teleological point of view principles don’t matter, what
matters is the consequences, so whether the person actually wants to die or not
may not be wholly relevant. Imagine an old man suffering from a terminal
cancer; let’s imagine that despite the pain of his life he is determined to
persevere until the end; let’s further imagine that this is causing his family
a great deal of upset and pain, and also that his treatment is very expensive
and due to limited hospital funds it is preventing other patients from having
life saving operations. An Act Utilitarian would have to say that regardless of
whether he wants to live or not, the consequences will be better if he is
killed, if he is killed then this will alleviate the burden on his friends and
family and allow us to save other lives instead, so in the big scheme of things
his own wishes are outweighed by the needs of others. Involuntary euthanasia
has often been practiced in times of war, when it was decided by army chiefs or
doctors that it would be better to kill wounded men than allow them to be taken
alive by their enemies.
However, from a
Rule Utilitarian perspective it makes sense to forbid involuntary euthanasia. JS Mill believed that it was the goal
of morality to create happiness, but that this was best done by having strict
rules which protected people, in other words, rights. It is clear to see that
people will be happier if they feel protected from having their lives terminated
without being asked. Mill believed that people would be most happy if they were
free to pursue their own ends and not interfered with, so he declared that
there was a ‘private sphere’ into which outsiders (e.g. the government) could
not pry. Essentially people can do what they want so long as they do not harm
others, which is indeed how most of our law works. For Mill bodies like the
government could not interfere with people’s lives, even if they were suffering
from alcoholism, or gambling addiction. Involuntary euthanasia would severely
violate Mill’s idea of the private sphere, as it means controlling people’s
lives at a fundamental level.
There are,
however, times when involuntary euthanasia may seem reasonable. After an
earthquake in America three men were trapped on the roof of a burning building
and there was no chance of them being saved; though they were calling out to be
saved they were instead shot to save them from the pain of burning to death. Does this seem reasonable in this exceptional
circumstance?
One of the great
worries about involuntary euthanasia is that a slippery slope might be created
allowing more and more involuntary killings to be performed, and there is often
the worry that we could end up with a regime of eugenics like that practiced in
Nazi Germany whereby the state made decisions about whose lives were worth
living and whose were not. Nazi doctors murdered somewhere in the region of
700,000 German citizens whom they deemed to be unworthy of life, such as
disabled children and the mentally ill.
Non-Voluntary Euthanasia
This generally
applies to the ending of the life of someone in a coma, who therefore cannot possibly
make any decisions about continuing their life or dying. It is most usually
done passively, e.g. through withdrawing food and water from the coma victim,
or removing their life support. However, there are three further issues to think
about which muddy the waters.
Firstly, it is
thought that coma victims may be able to experience pain, particularly if they
are left to starve to death through withdrawal of food and water. Because of
this it can be argued that it would be more humane to give such people a lethal
injection (active euthanasia) which kills instantly, thus causing less pain.
Secondly, who
should make the decision to end the person’s treatment or end their life? There are often times when a hospital trust
will say that there is no point and purpose in keeping the patient alive,
whilst the family wish the treatment to continue. Who should make the choice
here? Should the views of the family be given priority, or should they be
viewed as being biased or irrational in their wishes? It might be said that a
family which refuses to allow the life support to be switched off are failing
to accept that their loved one is already gone, and that the choice should be
left to the impartial medical experts. On the other hand, it might be said that
hospital staff are simply thinking about saving money, and so are also biased.
Thirdly, there
is the possibility that a person could wake up from their coma. Some people
have been in comas for years and suddenly woken up, and it might be argued that
we should always keep coma victims alive in case they recover. On the other
hand, keeping them alive in a coma is expensive and puts the family under a lot
of stress for years, so teleological thinkers argue that it may be kinder to
switch their life support machines off and make a clean break for the family
and friends. Note that those in PVS are brain dead, their bodies are simply
kept going by machinery and there is no hope of recovery.
Passive Euthanasia Vs Active Euthanasia
In the UK active
euthanasia is automatically considered to be murder, but passive euthanasia is
not, there are some circumstances when it is allowed or ‘tolerated’ for
example, in switching life support machines off. It is illegal to refuse
treatment to someone who has asked for it and can still possibly benefit from
it, but if treatment is of no avail, or if a person refuses treatment (and is
of sound mind) then passive euthanasia can be allowed. As previously explained,
passive euthanasia is considered to be a case of letting nature take its course,
whereas active euthanasia is actively killing someone, and so is viewed as
murder.
However,
according to philosophers such as James
Rachels we should consider active and passive euthanasia as morally the
same, and perhaps even consider active euthanasia to be better. In Rachels’
view acts of commission and omission are morally equal. Suppose someone who is
paralysed wishes to die believing that their life now has no meaning or
enjoyment; how could it be acceptable to allow the person to die slowly over
several weeks due to starvation and dehydration (which is extremely painful)
when it is not acceptable to simply kill them painlessly in mere moments?
Rachels uses the
following thought experiment: suppose that Smith wants his 6 year old nephew to
die so that he can inherit his parent’s money. Consider the difference between
the following two events: (i) Smith plots to drown his nephew in the bath and
does so; (ii) Smith plots to drown his nephew, and arrives at the door just in
time to see his nephew slip in the bath and start to drown by himself; Smith
then takes the passive course of omitting to act and stands idly by with a
smile on his face watching him drown. Can we really say that Smiths actions in
(i) are worse than in (ii)? Surely if the initial intentions are the same, and
if the outcome is the same, then the method is practically irrelevant? Smith’s
actions in (ii) are no better than those in (i). Thus according to Rachels
active euthanasia is no worse than passive as both have the same intentions and
the same results: an intended death. However, if active euthanasia is less
painful (as is often the case) then Rachels would argue that it is the more
moral course to choose.
There is a large
problem though, because treating acts of omission as equal with acts of
commission has huge implications for ethics. There are people starving in
various parts of the world, and we in rich nations have done little or nothing
to help them; at the least we could have done much more than we have done. We
have neither provided them all with food nor the resources to grow their own,
despite having the ability to do so. We have omitted to help them and left them
to their own devices to die. If actions of omission and commission are morally
equal then we are no better than genocidal mass murderers. Can this be correct?
Summary and conclusion
There are a huge
amount of issues to consider when it comes to deciding on your moral view of
euthanasia, and this is partly because there are so many different forms that
euthanasia can take. Perhaps we should say that all euthanasia is wrong and
that it should be illegal in all cases, an absolutist approach? Perhaps we should
say that sometimes euthanasia is acceptable whilst other times it is not, a
relativist approach? The main issues to consider are the following:
(i) Whether people have a right to die in order to avoid
pain, or whether all life is sacred and to be preserved;
(ii) Whether it is possible to legalise voluntary euthanasia
and yet at the same time ensure that it is not abused and that no one is forced
to die when they do not want to, or when they still have a life worth living;
(iii) In what way euthanasia should be performed, actively or
passively;
(iv) Who should decide whether it is allowed or not, doctors
or the family; and
(v) Whether people should be allowed to make living wills
which state that they ought to be euthanised should certain illnesses befall
them.
Finding a
solution to these problems is no easy task.
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