Chapter 3.

Assisted Death

Background Reading:
Rachels, Active and Passive Euthanasia and Weisbard and Siegler, On Killing Patients with Kindness: An Appeal for Caution

The Standard Policy on Killing (Spoiler: We Don't Do It)

There is a long history of allowing patients to die, while at the same time disallowing them to be killed. For example, pope Pius XII emphasized in 1958 that we may "allow a patient who is virtually already dead to pass away in peace."

The NHS policy agrees, stating that, If the court agrees with the decision, nutritional support will be withdrawn and the person will die peacefully within a few days or weeks." (NHS Website.)

However, letting die isn't always peaceful. This fact is on display in a lovely report called, The Art of Dying, which tells the story of a doctor who stood by her elderly patient's wishes to succumb to a stroke. In particular she writes, "It was clear to me that Jane and I were holding people up. Everyone had places to go, things to do. No one had time to sit around waiting, especially waiting for someone to die."

This is perhaps one of the nicer scenarios. In other circumstances, allowing death by starvation and dehydration can be brutal. A conscious person will typically experience 1-3 days of extreme discomfort as the body reacts to lack of food and water, until the body begins drawing on fat cells to nourish itself for another 7-10 days. Such patients typically lose consciousness at the end, and then the body finally expires.

A refusal to allow death by starvation and deyhdration was one of the motivating factors for Jack Kevorkian, an American doctor and activist. He served 8 years in prison from 1999-2007 on a manslaughter conviction after helping many terminally ill people commit suicide. Below is a brief interview with Dr. Kevorkian in 2011, soon before he died of complications due to liver cancer.

Active and Passive Euthanasia

Although it is vague definition in many borderline cases, it is sometimes obvious when your means of achieving something is active vs passive. For example, to fail an exam, Smith might (although it's not advisable) consciously mark the wrong answers, thereby actively failing the exam. Or, Smith could go to the park and play frisbee with her friends during the exam period, thereby passively failing it. The first intuitively involves active manipulative influence, and the second does not.

Of course, the distinction is not always clear. For example, suppose someone removes all of the air in an ant farm causing them to die. Since this is not so easy to do, there is clearly something active about your action, more so than just refusing to feed your ants. But in another sense your action was passive, in that you didn't add anything new to the ant farm, but only refused to supply a life-sustaining feature.

But suppose that we consider cases where it is clear. Let us define euthanasia as the act of intentionally bringing about deathfor the purpose of ending pain or suffering. Then euthanasia can be given an "active" form or a "passive" form, depending on whether we actively kill or simply allow a patient to die. For example, administering a lethal injection is active euthanasia. Letting a patient die from an infection by refusing to treat it is passive euthanasia.

This week, we will be concerned with two main questions about euthanasia in two forms.

First, are active and passive euthanasia morally equivalent? The standard policy is that they are not; passive euthanasia is allowed while active euthanasia is not. Against this standard view, James Rachels (our first reading for the week) argues that they are equivalent.

Second, is either ever morally right or wrong? With Wiesbard and Siegler (our second reading) we will think about one special case of this quesiton, the case of removing a feeding tube.

Reasons to Kill

Rachels gives three arguments as to why killing and letting die are actually equivalent. Let's think about each of these arguments in turn.

First is the Why suffer more? argument. Suppose we've already decided to shorten someone's life bcecause of pain. Then why on earth would we allow the pain to continue for any longer? Why wouldn't we end it immediately?

An important example of this is the case of Down's syndrome babies, which until 1984 were allowed to be let left untreated until death in the United States when they have an intestinal blockage.

A doctor who had to deal with this order reports: "It is easy at a conference, or in a theoretical discussion, to decide that such infants [with an intestinal blockage]" should be allowed to die. It is altogether different to stand by in the nursery and watch as deyhdration and infection whither a tiny being over hours and days."

Second, there is an irrationality argument. It says that in typical cases of letting die, the reason that one is allowed to die has nothing to do with the actual cause of one's death. So, since bringing about a particular means of death without having a reason to bring about that means of dying, we are acting irrationally.

For example, in the case of the Down syndrome babies, Down syndrome was the reason they were allowed to die. On the other hand, an intestinal blockage was the cause of their ultimate death. This means that there are cases in which babies were deemed to have a reason to die, but did not die (because they did not have an intestinal blockage), and other cases in which such babies did die. Rachels argues that this misalignments of our reasons for allowing death and the actual cause is irrational.

The third argument is the let a baby drown argument. Two cases are set up.

We begin by considering Jones, who wants to earn an inheritence, but a baby has priority over him. So, he holds the baby underwater in the bathtub until it dies so that he can win the inheritence.

Next we consider Smith, who also wants to earn an inheritence, but a baby has priority over him. So, he observes the baby to slip and drown and allows this to happen so that he can win inheritence.

Is there a difference between these two cases? Legally, there may well be. But is there a moral difference? Rachels observes that both the intentions and the consequences are the same in the cases of Jones and Smith. The intentions were to steal the inheritence (presumably bad), and the consequences were the death of the baby (also bad). So, whether we are the type of ethicist that cares about intentions or consequences, these two cases are equivalent.

Thus, Rachels concludes, the two cases are morally equivalent. He calls this claim the equivalence thesis.

Objections to the equivalence thesis

Doctors often give three reasons above all why passively allowing someone to die is preferable to killing them.

First: one might say that being the cause of someone's death is morally different than allowing nature to take its course. For example, you are normally held legally liable for causing a traffic accident, in a way that you are not when the accident is caused by a falling tree.

Rachels respond firstly that it's not easy to say when something is a cause. Just look at the case of the ants: it is mirrored in the case of the respirator.

But more importantly, if death is determined to be a good thing, then there's no obvious reason why causing it should be wrong. In this way, euthanasia is different than traffic accidents, which are not generally considered to be a good thing.

Secondly, one might say that it's more important to avoid harm than it is to do good.

Rachels responds that it only looks that way just because no harm seems easier than doing good. But when it's just as easy to do good, as in the case of the drowning baby, then it's not at all clear that it's better to avoid harm.

Thirdly, one might say observe that the guilt is more extreme when a doctor actively kills someone as compared to letting that person die. Letting someone die somehow feels less personal; many report finding it easier for this reason.

However, Rachaels responds, one's feelings of guilt are irrelevant when what we are trying to determine whether or not something is right or wrong. Of course they are related, in that you tend to feel guilty when you do something wrong. But just feeling more or less guilty is not enough to imply that your action is more or less wrong. Another thought is that such feelings of guilt can often be avoided or diffused, as when half the members of a firing squad are armed with blanks without their knowledge.

Objections to Rachels' Argument

In addition to the three somewhat superficial objections to the equivalence thesis discussed above, Rachels considers four more substantial objections to his argument.

1. As a matter of fact, many doctors have personal moral commitments against killing. A 2009 study found that only 33% of doctors in the UK support euthanasia, whereas 82% of the general public supports it.

The problem, Rachels points out, is that the personal moral commitments of of doctors (like their feelings of guilt) are irrelevant when one is trying to determine what is right and formulate policy judgements about it. Why favor the personal moral commitments of doctors over anyone else?

2. Many doctors consider themselves subject to a professional prohibition against killing. that one (Rachels: That's silly. A mechanic doesn't have a professional commitment not to destroy a car, does he? These things are independent of moral questions.)

3. Judith Thomson, an important moral philosopher, has responded to Rachels' discussion by arguing that it leads to absurd conclusions. Recall the nature of the baby example. Rachels said that if there's no difference in either he outcomes or the intentions of a person's actions, then they must be morally equivalent. Thomson rejects this claim, and therefore the argument for the equivalence thesis, because she thinks it gives bad advice in other scenarios.

To illustrate, she asks us to imagine two unfortunate friends Alfred and Bert. Bert has a rare condition which causes him immediate death upon being punched in the nose; this condition is known to an attacker who hates Bert, and who proceeds to punch him in the nose and kill him. Alfred, on the other hand, is attacked and has his head chopped off with an axe. The intentions of the attackers are the same in both cases, and the outcomes are the same (namely death). But it seems absurd to say the actions are morally equal, since chopping off someone's head is clearly worse than punching someone in the nose.

Rachels is not convinced, arguing that these actions really are equal given Bert's condition. And for people without the condition, the outcomes don't both lead to death, and so Rachels would agree that chopping off someone's head is worse.

4. Finally, Rachels considers the plausibility of a Compromise View, which counsels that sometimes killing and letting die are morally equivalent, sometimes they are not, and that which is which must be decided on a case by case basis.

However, Rachels argues that this view doesn't hold water either. Here he simply thinks it goes against the nature of moral judgements. According to Rachels, whether or not an action is right or wrong does not depend on the time, place, or any other contextual features of the action. Whether or not an action is right or wrong is once and for all. According to Rachels, there can be no compromises.

Reasons not to stop feeding?

Our discussion so far has been about whether or not killing and letting die are morally equivalent. Now, we'll turn to at least one aspect of the question of whether either is wrong. We will focus in particular on the question of whether or not it is morally permissible to remove a feeding tube.

Weisbard and Siegler make two arguments that there are reasons not to remove feeding tubes. They are simple and straightforward, and you should ask yourself the extent to which you agree with them.

On the face of it, you might think that it doesn't matter how you die if the amount of suffering is the same. If you Jones dies from the removal of a respirator, and Smith dies from the removal of a feeding tube, and both suffer the exact some amount as a consequence before dying, then what could possibly be the difference between these two cases?

According to Weisbard and Siegler, there is a difference: removing a feeding tube leaves the future open. You might die, or you might not. Indeed, it often happens that a person lives for a significant amount of time after a respirator is removed, sometimes against our best predictions. Although surviving may be unlikely, there is a sense in which you've let "nature run its course," insofar as nature is the kind of thing that is unpredictable.

Removing a feeding tube, on the other hand, can have only one outcome. If you don't eat or drink, you will die. In this sense, removing a feeding tube is different than removing a respirator. And for this reason, Weisbard and Siegler consider the removal of a feeding tube to be morally impermissible.

One might ask why this difference matters. Why is something morally permissible just because there is some chance associated with the outcome? For example, suppose instead of removing the feeding tube a doctor asked the patient to play a version of Russian Roulette, in which the patient is invited to attempt to kill herself by firing a gun at her head, but where there is only a 5/6 chance that a bullet is in the chamber. Is this really morally more permissible than inviting the patient to kill herself with a gun that is guaranteed to have a bullet in the chamber? I leave this to you to think about.

Weisbard and Siegler's second point is more pragmatic. They argue that the removal of feeding tubes will inevitably be viewed as a means of cost-control. In such cases, one can imagine that the judgement that an incapacitated patient should die can become a self-fullfilling prophecy. In particular, if removing feeding tubes becomes an issue of cost control, then patients may be put death merely for contingent social facts like their "social productivity," and not on the basis of their biological well-being.

As an example, they warn about cases like Clarence Herbert, who resulted in an infamous court case in the United States. Herbert was in a coma, and thought at the time to be brain dead, although this turned out not to be the case. Herbert's respirator was removed on the judgement of the family and the doctor. But to everyone's surprise, he didn't die. So, they proceeded to remove the feeding tube instead. Only then did he succumb, and only 13 days later when his body had dehydrated and starved.

The two physicians who carried out the removal of the feeding tube were charged with murder in the United States.

What you should know

Practice Questions On to Chapter 4 »