Part III

APPLIED ETHICS

Euthanasia

His enemies put it bluntly. Singer says it’s OK to kill disabled babies. Singer says seriously damaged human beings are on a par with apes. Singer says it would have been OK to kill his own mother. These charges are spat out of the sides of their mouths. One theologian I spoke to said contemptuously, ‘Peter Singer takes the most basic human instincts and tries to reason them out of existence. What does he expect us to do, hug him?’1

1. Euthanasia Introduction

There is an old adage that only two things in life are certain — death and taxes. While the morality of the latter would be an interesting topic itself (and you may look to issues discussed in Chapter 8 for some inspiration), it is the morality of an issue connected to the former that draws the focus of this chapter. Specifically, we consider the ethical issues surrounding euthanasia (sometimes labelled as “mercy killing”).

2. Key Terms

The etymology of euthanasia helps to reveal the meaning of the term. Like most upstanding and respectable philosophical terms, euthanasia has its roots in Ancient Greek language; it is based on a combination of the terms eu meaning “well” and thanatos meaning “death”. Euthanasia is thus the act of seeking to provide a good death for a person who otherwise might be faced with a much more unpleasant death — hence the term “mercy killing”.

There are different ways to categorise the various types of euthanasia and it is critical to be confident and familiar with these categorisations.

Voluntary Euthanasia

Voluntary euthanasia occurs when a person makes their own choice to have their life terminated in order to avoid future suffering.

Non-Voluntary Euthanasia

Non-voluntary euthanasia occurs when a decision regarding premature and merciful death is made by another person, because the individual to be euthanised is unable to make a decision for themselves. This form of euthanasia is most commonly associated with young infants or patients in a coma who cannot, due to the nature of their age or condition, make any decision for themselves.

The above offers a differentiation of types of euthanasia in terms of the person making the decision. In addition, we can differentiate between types of euthanasia based on the method involved in ending a life.

Active Euthanasia

If a person is actively euthanised it means that their death was caused by external intervention rather than natural causes, most likely through a lethal injection or the voluntary swallowing of a deadly cocktail of drugs.

Passive Euthanasia

Passive euthanasia occurs when a person is allowed to die due to the deliberate withdrawal of treatment that might keep them alive. Thus, a person who is passively euthanised is allowed to die via natural causes even though methods to keep them alive might be available. A person who has a life-support machine switched off, for example, dies via natural causes but only as a result of a decision to allow natural causes to take effect.

Although euthanasia that is both voluntary and passive is not particularly common, euthanasia could come in any combination of methods and decision-makers as laid out. Legality of the forms of euthanasia varies from nation to nation; Belgium allows for voluntary and active euthanasia, the UK does not.

In the next two sections, we outline two different forms of medical afflictions that will ground discussion of arguments in favour and against the varying forms of euthanasia. As an applied ethical issue, it is important to make ethical claims in the light of practical and real-world factors.

3. Case One: Persistent Vegetative State

A person is in a Persistent Vegetative State (hereafter PVS) when they are biologically able to support their own continued existence, but they have no meaningful psychological interaction with the world around them. A patient in a PVS, according to the National Health Service in the United Kingdom, can neither follow an object with their eyes nor respond to the sounds of voices and will show no discernible sign of emotion. The vegetative state is defined as persistent when the condition is in place for up to a year and doctors view no prospect of recovery as plausible. The PVS label may seem crude or upsetting, but the message about the difference between the physical and the psychological state of the patient is stark.

In the US, Terri Schiavo fell into a PVS when she suffered oxygen deprivation to her brain as a result of a heart attack. Although she survived the heart-attack, her husband ultimately came to the view that her continued existence was not desirable and that she would be better off being allowed to die.

In the United Kingdom, the parents of Tony Bland — a victim of the Hillsborough football disaster in 1989 — made a similar decision regarding the life of their son after he fell into a PVS. Tony Bland’s parents campaigned for their son to be allowed to “die with dignity” rather than continue existing in his emaciated state. One can only attempt to imagine the emotional turmoil for the relatives in such cases and it is worth mentioning that Terri Schiavo’s parents ultimately fought a legal battle against their son-in-law in attempt to ensure that Terri was not allowed to die.

When considering the morality of euthanasia for patients in a PVS, it is clear that we should be considering only non-voluntary euthanasia, due to the fact that such patients are clearly unable to make any kind of voluntary decision regarding their future interests. For the sake of simplicity, we will assume there are no relevant letter of intent from such patients, written in case they should lose their faculties, describing their desires should they fall into such a condition. However, you may find it rewarding to consider the moral implications of such a letter. Would the letter provide a voluntary decision that morally ought to be respected even when the patient is in a PVS?

4. Case Two: Incurable and Terminal Illness

Imagine a patient who has been diagnosed with an incurable disease that will ultimately bring about their death. As the condition progresses over time, the patient knows that their ability to live a normal life will decrease and that their physical suffering will increase. You can imagine for yourselves the range of diseases and conditions that may have such unfortunate effects upon a person.

Unlike the patient in a PVS, the patient in this example retains the ability to ask for euthanasia themselves and so these cases can highlight moral issues surrounding voluntary euthanasia. Again, for simplicity in our discussion, we do not consider where the line can be drawn regarding patients in fit or unfit psychological states when it comes to an ability to make a voluntary decision to be euthanised, although this is also an issue that would reward further moral thought.

5. Pro-Euthanasia: Argument One

In this section, we consider the first of the arguments in favour of the moral acceptability of euthanasia. This argument is a general argument and would apply to both non-voluntary and voluntary forms of euthanasia. However, the argument, if sound, would also seem to suggest that active euthanasia is more morally acceptable than passive euthanasia for reasons discussed at the end of this section.

This initial argument can be labelled as the argument from quality of life. According to this relatively simple idea, sometimes life is actually less preferable than death. On such occasions, when quality of life is so dreadful that a person would be “better off” dead, then euthanasia would be morally justifiable. Evidently, much turns on what counts as a worthwhile life. Recalling the section on well-being from Chapter 1, there are various philosophical positions that might seek to provide a criterion to measure the quality of a person’s life. A hedonist, for example, would suggest that the quality of a life depends on how much happiness/pleasure a person experiences; a supporter of a desire-satisfaction theory would suggest the quality of a life depends on how many of a person’s desires are satisfied; an objective-list theorist would suggest that the quality of a life depends on how many objectively valuable goods a person possesses — goods including, but not limited to, knowledge and love, for example.

Whichever one of these views a person supports, or even if they understand other factors as being determinants of the quality of a life, there can little doubt that a person in a PVS has, at best, a non-existent quality of life in virtue of their extreme psychological limitations. Suggesting that some form of consciousness is necessary to having any kind of quality of life, Jonathan Glover (1941–) says:

I have no way of refuting someone who holds that being alive, even though unconscious, is intrinsically valuable [valuable irrespective of the form of being alive]. But it is a view that will seem unattractive to those of us who, in our own case, see a life of permanent coma as in no way preferable to death. From the subjective point of view, there is nothing to choose between the two.2

Deprived of happiness and other capabilities, the life of a patient in a PVS seems to be at best utterly neutral and at worst negative in respect of quality of life, perhaps depending on any experience of physical pain. Patients in a PVS are not merely bed-ridden like some who might have suffered severe strokes or other such afflictions; they are biological entities lacking the distinguishing psychological qualities of typical human beings. This may go some way to explain why some (but by no means all) partners and parents of people in PVS’s are willing to favour an end to the patient’s life.

The case of Diane Pretty is informative when considering the quality of life of a person with a terminal illness who is nearing the end of their life. Diane Pretty suffered from motor-neurone disease and although she remained mentally proficient, the worsening of her condition over time led her to request to be allowed to die quickly and without undue suffering. Although the point in time cannot be sharply labelled, it seems extremely plausible that many of those with worsening terminal illnesses will reach a point in time where their quality of life is non-existent or negative in virtue of their physical suffering and their inability to enjoy life, satisfy desires or acquire objectively valuable goods. I recall, as a young teenager, listening to Diane Pretty express her desire to be allowed to die and wondering how anyone could reach a point where they would not want to see one more sunrise or live one more day — these questions, I suggest, reflected more of my inability to empathise with her daily existence than they did with undue depression on her part.

Thus, if we focus on the quality of life for patients in a PVS, or for those nearing the final stages of a terminal illness, we may well grant that there is a time when quality of life either becomes negative or ceases to be relevant. If we suggest that a life with no discernible quality of life is not worthwhile, then euthanasia may appear morally justifiable.

If you find the argument from quality of life convincing, then you may judge that active euthanasia is far more morally defensible than passive euthanasia; after all the judgment that euthanasia is morally acceptable may seem to be the load-bearing judgment, with the choice of method more of a practical than a moral issue. Indeed, in this context, passive euthanasia might seem to be the worst of all worlds.

According to Peter Singer, “Having chosen death [as a morally acceptable course of action] we should ensure that it comes in the best possible way”.3 The best possible way, if we remain interested in quality of life, might seem to be a lethal injection designed to send a patient painlessly to sleep before shutting down their organs, or a selection of drinkable liquids that have the same effect. The best possible way might not seem to involve turning off a life support machine or withdrawing proactive treatment in order to allow nature to take its course, when the course of nature may be directed by starvation, dehydration or secondary infections. Although these passively viewed death-causing effects may be managed with pain killers, Singer’s relatively simple thought is that if death is deemed morally desirable, then why not simply provide death actively rather than passively?

In addition, if we recall the ideas of Situation Ethicist Joseph Fletcher (as outlined in Chapter 5) then we may wonder whether or not (assuming death is morally desirable) passively allowing death to occur is actually less loving than actively bringing death about. As a relativistic normative ethical theory, Situation Ethics provides no absolute guidance regarding the moral acceptability of euthanasia in any of its forms; situation-specific, practical and pragmatic judgments will need to form the basis of moral judgments in individual cases. However, it is important to consider how loving active euthanasia might actually be in the circumstance where the death of the patient is actually our ambition.

6. Pro-Euthanasia: Argument Two

The second argument we can offer in support of euthanasia — both in voluntary and non-voluntary forms — can be labelled the argument from resource use. Whereas the former argument attempted to defend the moral acceptability of euthanasia by utilising the perspective of the patient and their associated quality of life, this argument may seem a little more detached and you may or may not view this as a strength or weakness.

According to Peter Singer, the non-voluntary euthanising of a severely disabled and suffering young infant child (who cannot express any wishes regarding their future) may be justifiable on the following grounds:

When the death of a disabled infant will lead to the birth of another infant with better prospects of a happy life, the total amount of happiness will be greater if the disabled infant is killed.4

Singer’s suggestion may sound callous, and if you view killing an innocent life as an absolute moral wrong then you may view his claim as immediately morally out of bounds (this kind of objection to euthanasia is considered in a later section). For now, however, let us take Singer’s claim at face value. Being a preference utilitarian (further detail on this theory is available in Chapter 1), Singer makes his judgment regarding how to act in such a case based on the quality of life of the individuals involved. So, on his view, the disabled infant may have a lower quality of life than a healthy child who might be born in their stead because the latter, and not the former, can secure greater preference satisfaction. Thus, we morally ought to bring about the situation in which the healthy child is born.

If we assume that those who are in a PVS, or those suffering near the end of a terminal condition, have a low quality of life then we might think that spending our limited medical resources on maintaining their existence, rather than spending those resources elsewhere, is not morally desirable. This kind of argument will appeal to a teleologist rather than a deontologist, for it ascribes moral values to actions based on consequences rather than duties. In this setting, the consequences of spending resources on PVS patients may be less positive than spending those same resources on effectively treating other diseases or funding medical research to benefit future generations.

Some financial figures may put this possible argument into context. According to the Madison County Record, Christina McCray (a patient in a PVS) had medical bills that average out to $250,000 per year.5 If we consider the years of life that a patient in a PVS may have, along with the number of PVS patients that exist, then the cost of keeping such individuals alive becomes clearer. If medicine is sometimes about making difficult decisions, then it may become clear why non-voluntary euthanasia of such patients might be considered desirable (at least with the support of the family). In addition, if a patient with a poor quality of life, who is facing future suffering with associated expensive care, voluntarily requests euthanasia then it may be that their death will allow resources to be better directed to other patients who might have their suffering reduced more significantly.

It is worth noting, for those uncomfortable with this kind of resource allocation planning when it comes to treating ill, suffering and frail patients that decisions in the National Health Service are already being made in the light of teleological and quality-of-life based reasoning. The NHS utilises QALYs when making financial planning and treatment costing decisions. QALY is shorthand for Quality Adjusted Life Year, a measurement designed to consider the benefits of different treatment costs in respect of their pay-offs to the patients involved. If a potential treatment will lead to a patient being free from pain and able to perform daily activities (this is a somewhat rough definition, but enough for our purposes) then the year in which this outcome is expected can be given a value of 1. Each following year can then be given a value between 0 and 1 according to the expected lasting impacts of the treatment. Thus, allocating spending to different forms of treatment for different patients can be objectively calculated against a common standard in order to inform those spending decisions in terms of where the better consequences might be secured.

The argument from resource use is, therefore, an extension of the use of a QALY to inform medical decision-making. If the positive consequences of spending money on treating patients who might be cured or helped to have a higher quality of life are greater than spending money to keep people alive who either wish to die and have a diminishing quality of life or who are in a PVS, then spending on the former is morally defensible rather than spending on the latter. Again, you might consider how loving it is to spend money keeping a patient in a PVS alive versus investing in research for cures and treatments that could improve the quality of life for other patients in a world where resources are finite.

7. Pro-Euthanasia: Argument Three

The final argument we will offer in favour of euthanasia is an argument often viewed as the most powerful in this applied ethical area, the argument from personal autonomy. This argument proceeds from the fairly plausible assumption that people should have the right to make their own decisions and should be able to decide the paths of their own lives. If the right to choose our own path applies in life, then why would this not apply in respect of our choice of how and when to die?

Perhaps the most famous philosophical proponent of a right to personal autonomy and decision-making was John Stuart Mill. As discussed in Chapter 1, Mill elucidated the harm principle, which suggested that the only legitimate government interference in a person’s life is to stop that person from harming others; all other interference is not to be justified. If you subscribe to this principle, then you seemingly must believe that a person voluntarily requesting euthanasia should not be denied the right to die, unless their dying would cause harm to another person. If we discount emotional harm (because many normal things that we do seem to cause emotional harm to other people — getting a job over another candidate, for example) then it is not easy to envisage a circumstance in which a terminally ill patient, requesting a merciful death before their suffering becomes too extreme, would have a death that causes physical harm to another person. Therefore, if we believe in the power and moral right of the individual to act in the way that they deem correct, unless physically harming another, then we must seemingly allow that voluntary euthanasia is morally justifiable. Singer sums up the position:

…the principle of respect for autonomy tells us to allow rational agents to live their own lives according to their own autonomous decisions, free from coercion or interference; but if rational agents should autonomously choose to die, then respect for autonomy will lead us to assist them to do as they choose.6

We have spoken above of voluntary euthanasia specifically, for the patient in a PVS obviously cannot choose how to die. If we return to the earlier mentioned possibility of a letter of intent, written prior to the condition taking hold, then in certain instances non-voluntary euthanasia may also be justified on this basis — though of course, such cases seem to a species of voluntary euthanasia.

However, if we would trust loved ones to make other important medical decisions for us if we were incapacitated, then perhaps the same should apply in this context and non-voluntary euthanasia might be justifiable in virtue of properly respecting the choices made by one relative on behalf of another. It is for you to consider if a theory of personal autonomy can be extended to familial autonomy in such a way.

8. Anti-Euthanasia: Argument One

Thus far we have only outlined pro-euthanasia arguments. In fact, we have really only provided pro-active euthanasia arguments in virtue of Singer’s suggestions regarding the undesirability of passive euthanasia. It is now time to give anti-euthanasia, and anti-active euthanasia, arguments their fair hearing.

The first objection to euthanasia may be termed the objection from Sanctity of Life. The Sanctity of Life ethic is usually founded on religious, and specifically Christian, thinking. Essentially, a belief that life is sacred suggests an absolute value to life, of a type that means it is worthwhile in all circumstances; in Glover’s earlier words it is the view that life has an intrinsic value that supersedes any qualitative aspect. For Sanctity of Life theorists and supporters as described in this section, problems with the quality of a life never undermine the ultimate value and worth of a life.

It is not necessary to be religious to hold the view that all lives are worth preserving, irrespective of quality. A non-religious person may prefer to speak of an absolute right to life that cannot be taken away through non-voluntary euthanasia, and cannot be revoked by personal decree in the context of voluntary euthanasia. However, more often, the view is supported by Biblical reference. In the Bible, we are told that God said: “Let us make mankind in our image, in our likeness”.7

In addition, our bodies are described as sacred and as containing God’s Holy Spirit: “Don’t you know that you yourselves are God’s temple and that God’s Spirit dwells in your midst? If anyone destroys God’s temple, God will destroy that person; for God’s temple is sacred, and you together are that temple”.8 These quotes not only reveal the sanctity of our bodies and the cause of that sanctity — our creation in the image of God and the presence of God’s spirit within us — they also reveal the punishment for those who might take life; might this relate to doctors who administer euthanasia?

Whilst the arguments from quality of life and use of resources were avowedly teleological in nature, considering the painful and potentially costly consequences of continued life, the argument from Sanctity of Life is deontological in nature since it relates to a duty to avoid killing. Linking the Sanctity of Life view to both abortion and euthanasia, Mother Teresa gave a statement of the appeal of this ethical stance:

For me, life is the most beautiful gift of God to mankind, therefore people and nations who destroy life by abortion and euthanasia are the poorest. I do not say legal or illegal, but I think that no human hand should be raised to kill life, since life is God’s life us in us.9

All human life, whether in the womb or in a PVS, is of sacred and God-given worth such that killing (including euthanising, as a form of killing) is morally impermissible.

The notion of a sacred life lays behind Catholic teaching on the issue of euthanasia. A 1980 Catholic Declaration of Faith is clear and absolute in nature:

…no one is permitted to ask for this act of killing, either for himself or herself or for another person entrusted to his or her care, nor can he or she consent to it, either explicitly or implicitly, nor can any authority legitimately recommend or permit such an action. For it is a question of the violation of the divine law, an offence against the dignity of the human person, a crime against life, and an attack on humanity.10

The language is somewhat complex but the key points are given in our previous discussions in this chapter — life is sacred and so euthanasia, whether voluntarily requested or non-voluntarily encouraged for someone else, is morally impermissible. No legislator, guided by moral ideals, can ever morally recommend this type of killing, whether motivated by a mistaken sense of mercy or not.

9. Anti-Euthanasia: Argument Two

A related objection to euthanasia, premised on a commitment to Christianity, is the objection from valuable suffering (keep in mind that not all Christians, by any stretch, would defend an objection of this type). Let us return to the 1980 Catholic Declaration of Faith. The document states that:

According to Christian teaching, however, suffering, especially suffering during the last moments of life, has a special place in God’s saving plan; it is in fact a sharing in Christ’s passion and a union with the redeeming sacrifice which He offered in obedience to the Father’s will.11

Thus, even if someone requests euthanasia in order to avoid pain, that request should not be granted because it deprives a person of an element of God’s plan for them; the experience of suffering at the end of life brings that person closer to sharing in the experience of Christ. This does not mean that Christians oppose palliative care (a type of care that does not attempt to extend life, so much as make an individual as comfortable as possible as they face the end of their life). However, it does explain why a life should be seen through to its natural end and why it might therefore be viewed as morally wrong to shorten it.

10. Anti-Euthanasia: Argument Three

The third anti-euthanasia argument to consider can be labelled the slippery slope objection (sometimes called the Wedge argument). This objection does not require any view regarding the Sanctity of Life or a deontological duty not to kill; indeed, the slippery slope objection is both teleological in nature and does not even require a denial that euthanasia might be desirable in certain instances when viewed in the abstract or in isolation.

The slippery slope objection is that if euthanasia were to become legal in some situations, then it would lead to euthanasia becoming legal and acceptable in situations where it is actually morally undesirable. To see the strength of such an objection, consider earlier pro-euthanasia arguments couched in terms of resource allocation and personal autonomy.

If euthanasia can be justified on teleological grounds when resources would be better deployed elsewhere, then what is to stop us justifying not merely voluntary and non-voluntary euthanasia, but involuntary euthanasia also? If euthanasia is justified on the basis of money and time being better spent on some patients rather than others, then why would permission be required from the patient or the patient’s family?

If morality is determined by consequences, and consequences justify euthanasia, then we seem to be slipping down a dangerous slope to euthanising people without their consent. After all, if you are a teleologist (perhaps, an act utilitarian) you have already given up ideas concerning absolute rules against certain actions. It therefore may be objected that either life is sacred, or it is not, and if it is not then we may end up in a situation we find utterly morally indefensible even if we start from apparently moral motivations.

In addition, if personal autonomy is respected to the degree that someone can choose when to end their life, then what is to stop a seriously depressed person who is otherwise physically healthy from opting for voluntary euthanasia? Most people might view such enabling of suicide for patients with mental health needs as being very different from euthanasia for PVS patients or the terminally ill, but if personal autonomy justifies euthanasia then how can we justifiably draw a strong enough line so as to allow some people to choose death, but not others? Again, it may be objected that either personal autonomy matters or it does not. If we enable a person to have their life ended, then it is obvious they can never come to a different view on the value of their life at a later stage, as they might have had they still been alive. On this issue, it may be worthwhile revisiting the discussion from Chapter 1 regarding a person’s preferences and whether they are only morally relevant if they stand up to some sort of psychological testing and counselling; the relevant idea is due to Richard Brandt.

In addition, opponents of euthanasia often suggest that if one group of people are euthanised, others may begin to feel pressure to take up that same option. If non-voluntary euthanasia is granted, and a legal, moral and cultural line in the sand is thereby crossed, may not elderly patients feel pressured to not be a burden to their families? May not the financially well-off elderly feel pressure to allow their children to inherit any accumulated wealth rather than see that wealth spent on their own care? Granting non-voluntary euthanasia in even a small number of cases may, over time, send us down a slippery slope to the non-morally defensible euthanising of many other types of patients who, as things stand, are quite content to remain alive since they have no reason to consider other options.

Of course, an easy response to any slippery slope objection is simply to deny that a change in one fact must lead to a suggested negative change elsewhere. Why think of negative consequences from a change in the law, when these consequences might not happen? Indeed, some slippery slope arguments are logical fallacies if they are premised on the idea that a possible negative outcome must, of necessity, follow from some change in policy. However, we should not “straw-man” the objection in this way (i.e. phrase it in such a weak way that it is easy to argue against). The slippery slope objection suggests that the negative outcomes might be probable, rather than be certain. Thus, a response should deal with the issue of probable negative consequences, rather than cheapening a plausibly reasonable objection through wilful misrepresentation of its structure. Researching the situation in Belgium, where the law regarding euthanasia is perhaps the most liberal in the world, should provide a good grounding to either support or oppose this line of thought, as would considering the application of Rule Utilitarianism.12

11. Anti-Euthanasia: Argument Four

A fourth anti-euthanasia objection is the objection from modern treatment. This objection brings together two distinct, but relevantly similar, lines of thought. Firstly, it might be suggested that to euthanise those who are terminally ill, or those in a PVS, is to kill people earlier than would otherwise happen and thereby to artificially eliminate their chances of living to experience a cure to their condition. At the very least, if not a cure, euthanised people are not around to benefit from any step-forward in treatment that might alleviate their suffering.

In addition, given the modern advances in palliative care it might also be argued that end of life care is now so advanced that euthanasia is not necessary in order to avoid suffering and so cannot be justified even on quality of life grounds. It might be thought plausible that a person with a severe and worsening disease who is not euthanised could have their condition and pain carefully managed by skilled healthcare professionals so as to greatly diminish any suffering.

In response to these types of objections, Singer grants that were euthanasia legalised then some deaths may occur for people who could have been treated had they been kept alive. However, he urges that:

Against a very small number of unnecessary deaths that might occur if euthanasia is legalised we must place the very large amount of pain and distress that will be suffered if euthanasia is not legalised, by patients who really are terminally ill.13

On balance, Singer suggests, euthanasia would cause more pain to cease than pleasure missed by those who die early. Whether or not palliative care is able to reduce suffering to the extent suggested by the objection is something you may wish to consider and further research, as it would seem to be an empirical claim requiring contemporary evidence to further the discussion.

12. Allowing versus Doing

James Rachels (1941–2003) sums up the supposed moral importance of the distinction between allowing and doing in the euthanasia debate:

The distinction between active and passive euthanasia 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.14

Thus, according to Rachels, most doctors at the time of his paper — and not much seems to have changed in the UK context since — would think it permissible to allow a patient to die (passive euthanasia, on our definitions) but think it impermissible to kill a patient even if they request it or if it is deemed to be in their interests (active euthanasia).

The plausibility of this distinction is supported by consideration of the Doctrine of Double Effect, as drawn from the normative Natural Law moral theory discussed in Chapter 4. Recall from the chapter on Natural Law ethics that one of the primary precepts for human beings is the preservation of life. No moral prescription, we might think, could speak more strongly and absolutely against euthanasia — especially given the Catholic background of Aquinas’s Natural Law stance and the earlier reference to Catholic views in the context of the Sanctity of Life ethic. A secondary precept, derived from this primary precept, would certainly seem to deny the moral acceptability of artificial shortening of life. However, Natural Law theorists are able to to have a nuanced stance in the euthanasia debate.

A Natural Law theorist, via the Doctrine of Double Effect, can describe an action as moral even if it results in an outcome that might not be considered morally permissible in the abstract. If an act is directed by a desire to do moral good, yet has a foreseeable but unintended consequence of a bad effect, then this action may be moral so long as the bad effect was not aimed at, does not outweigh the good effect and is not directly the cause of the bad itself. If this brief comment is unclear, it is critical to look back to the relevant discussion of the Doctrine of Double Effect in the chapter on Natural Law.

Now, let us apply this doctrine directly to the context of euthanasia. A doctor may be aware that a patient has not long to live and is suffering immensely. The doctor may prescribe a multitude of painkillers to treat the pain, even though this will have the foreseeable but unintended effect of killing the patient as a result of the side-effects of the drugs. Indeed, a doctor may simply refrain from offering painful treatment methods in order to avoid causing suffering, with the unintended but foreseeable consequence that the patient will die as a result of the non-intervention. These actions are not morally wrong, says the Natural Law theorist, because death is not intended directly but rather the morally good end of pain reduction is intended directly. Thus, the doctor who engages in active euthanasia by provision of a lethal cocktail of drugs in order to artificially kill a patient so that their suffering is reduced is morally wrong (for the good of “suffering reduction” is directly achieved by the bad of killing), while the doctor who withdraws treatment in order to relieve suffering, with the unintended but foreseeable outcome of death, acts morally justly (for the good of “suffering reduction” is achieved by not administering painful treatment, death is just a proportionately acceptable side-effect).

Both Rachels and Singer have little time for the distinction between allowing and doing, and the Doctrine of Double Effect, in this debate. Rachels says that:

If a doctor lets a patient die, for humane reasons, he is in the same position as if he had given the patient a lethal injection for humane reasons…if the doctor’s decision was the right (to not intervene on the patient’s death) one, the method used is not itself important.15

Meanwhile, Singer comments that “We cannot avoid responsibility simply by directing our intention to one effect rather than another. If we foresee both effects, we must take responsibility for the foreseen effects of what we do”.16 Singer gives the example of a business seeking to save money in order to hire more workers. This outcome is good and motivates bosses to act to save money on their recycling bill, with the foreseeable but unintended consequence of polluting a local river. If we would not excuse the company for ignoring a foreseeable consequence, says Singer, then we do not really believe we escape responsibility for allowing death in the euthanasia context.

The application of the Doctrine of Double Effect, and Natural Law ethics in general, to the euthanasia debate should be considered carefully and in the light of the earlier chapter outlining the normative theory itself. Despite both Singer’s and Rachel’s attack, Natural Law and the Doctrine of Double Effect retain many proponents. If one views moral outcomes as based on more than consequences alone, then this approach may seem to have more merit than a preference utilitarian like Singer might grant it; this is for you to judge.

SUMMARY

Euthanasia is an applied moral topic that has profound implications; successful moral arguments may lead to legislative changes that quite literally shorten or extend lifespans. There are a host of subtleties in the debate to which we can only pay lip-service — such as the acceptability of active euthanasia of depressed patients, the importance of pre-injury requests for treatment or for death; the best way of allocating medical resources; the powers of people over both their bodies and the bodies of incapacitated family members. Further issues are discussed in works such as that by J. David Velleman, and we suggest the references below as a guide to useful and enquiring texts.17 However, we hope that you now feel confident to explain and evaluate the key arguments both in favour and against the various methods of euthanasia and the various contexts in which those methods may be employed.

COMMON STUDENT MISTAKES

• Making the slippery slope objection simpler than it is — it focuses on likelihood of future consequences, not certainty of future consequences.
• Dismissively suggesting that not being religious is enough to oppose Sanctity of Life claims out of hand. Life might have absolute value for non-religious reasons and this is an idea one should engage with.
• Dismissing the quality of life argument just because of a religious faith without proper engagement — the idea that a life should be prolonged even in the face of suffering needs suitable defence.
• Misrepresenting the Doctrine of Double Effect in application to euthanasia — keep in mind the more detailed knowledge gained from the chapter on Natural Law ethics.
• Thinking that pro-euthanasia views must be secular and that anti-euthanasia views must be religious. All options remain open.

ISSUES TO CONSIDER

1. What makes a life worth living? Is a life ever without value?
2. Should the Doctrine of Double Effect be ethically relevant? Is there a moral difference between allowing and doing?
3. What is assisted suicide? Is it different from Euthanasia?
4. If euthanasia is morally acceptable, should passive euthanasia ever be viewed as an acceptable method?
5. Can the slippery slope objection be blocked in this context? Answer with reference to the development of euthanasia laws in Belgium.
6. Is Rule Utilitarianism the only teleological theory that survives the slippery slope objection?
7. Is there something morally uncomfortable about the argument from resource allocation? If so, what?
8. If you were designing euthanasia laws, what would they look like?
9. Should a Sanctity of Life ethic have any role in twenty-first century medicine?
10. Is the morality of euthanasia determined by empirical factors such as levels of palliative care available?
11. Should a depressed patient ever be allowed euthanasia? Is personal autonomy something we must always respect? If not, when should it not be respected?
12. Could involuntary euthanasia (euthanasia against a person’s wishes) ever be justified in any circumstance?

KEY TERMINOLOGY

Doctrine of double effect

Palliative care

Persistent Vegetative State

Well-being

Sanctity of Life

Straw-man

References

‘Belgian Convicted Killer with “Incurable” Psychiatric Condition Granted Right to Die’, the Guardian (16 September 2014), freely available at https://www.theguardian.com/world/2014/sep/16/belgium-convict-granted-right-to-die

Bible, New International Version, freely available at https://www.biblegateway.com/

Chaliha, Jaya, and Le Joly, The Joy in Loving: A Guide to Daily Life with Mother Teresa (London: Penguin, 1996).

Glover, Jonathan, Causing Death and Saving Lives (London: Penguin, 1990).

Madison-St. Clair Record, freely available at http://madisonrecord.com/stories/510564252-nursing-expert-testifies-that-plaintiff-s-bills-could-be-8-4-million

Hari, J., ‘Peter Singer: Some People are More Equal than Others’, freely available at http://www.independent.co.uk/news/people/profiles/peter-singer-some-people-are-more-equal-than-others-551696.html

Sacred Congregation for the Doctrine of the Faith, ‘Declaration on Euthanasia’, freely available at http://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_19800505_euthanasia_en.html

Singer, Peter, Practical Ethics (Cambridge: Cambridge University Press, 2011), https://doi.org/10.1017/cbo9780511975950

Rachels, James, ‘Active and Passive Euthanasia’, Biomedical Ethics and the Law, 5 (1979): 511–16, https://doi.org/10.1007/978-1-4615-6561-1_33

Velleman, J. David, Beyond Price: Essays on Birth and Death (Cambridge, Open Book Publishers, 2015), https://doi.org/10.11647/OBP.0061; freely available at https://books.openbookpublishers.com/10.11647/obp.0061.pdf

---