Introduction
As we turn to consider the details of the issue of euthanasia, it is helpful to begin by realizing the pervasiveness of the issue. Increasingly, people die in a medical context–often a hospital–that is unfamiliar to them and populated primarily by strangers. Currently, 85% of Americans die in some kind of health-care facility (this includes not only hospitals, but nursing homes, hospices, etc.); of this group, 70% (which is equivalent to almost 60% of the population as a whole) choose to withhold some kind of life-sustaining treatment.1 It is highly likely that each of us will eventually face that same decision about ourselves; it is even more likely that we will indirectly involved in that decision as family members and loved ones face death.
Dying in a hospital is particularly difficult, for there is nothing within medicine itself–which is tenaciously committed to winning every possible battle with death, even though there is no hope of ever winning the war–that helps physicians to let go, to allow an individual to die peacefully. There are certainly many physicians who show great wisdom in dealing with this issue (the selection from Dr. Quill reprinted below is a good example of this), but their wisdom flows primarily from their character as persons rather than from their medical knowledge. Medical knowledge alone does not tell us when to let go, and medical practice–perhaps quite rightly–is often committed to fighting on and on, no matter what the odds. Yet this means that each of us as patients must face this question squarely.
What Are We Striving For?
Before we begin to consider some of the intricate conceptual issues posed by euthanasia, it is important to ask ourselves what our goal is in this area. In our discussion of abortion, almost everyone would agree that our ultimate goal was to have a society in which there were no unwanted pregnancies; at that point, abortion would disappear as a moral issue. Obviously, in the case of euthanasia, things are much different. Clearly, we are not striving for a society in which there are no unwanted deaths. That would not only be impossible, but also–as least from a population point of view–undesirable. We cannot do away with death or avoid it.
Given this basic fact, our goal in this area is presumably centers around how we die, not whether we die. The word “euthanasia” comes from the Greek, “eu,” which means “good” or “well,” and the Greek word for death, “thanatos.” In its broadest sense, euthanasia is about dying well. How do we do this?
The first, and most obvious, point is that dying well is intimately linked to living well. It is highly unlikely that we will die well if we have not been able to live well. Those who die surrounded by loved ones and at peace with themselves are those who have lived lives filled with love and who have come to peace with their lives; their lives are, in a certain fundamental sense, complete and not marred by unresolved fundamental regrets. It is very different, I think, for those who have not found love or peace in their lives; their deaths are often characterized by loneliness and a sense of incompleteness, a grasping for what could have been. Much of what needs to be said about euthanasia is not about death, but about life. A good life is the best preparation for a good death. Unfortunately, even a good life is no guarantee of a good death; chance can always intervene to make one’s death untimely, unbearably painful, or uncharacteristically lonely.
There is a second, and much narrower, sense of euthanasia: a (relatively) painless death free from the pain and the intrusion of medical attempts to sustain life. Most of the philosophical discussion has centered around this second sense of euthanasia, but some of the difficulties that arise in this second and narrower sense of euthanasia can be reduced if it is placed within the context of this wider sense of euthanasia. All too often, we try through medical means to help an individual to die well, when in actuality all that is within reach medically is to help the person to die painlessly and quickly. A quick and painless death is not the same thing as a good death, but sometimes it is the best we can do.
Some Initial Distinctions
Recent discussions of euthanasia has been dominated by several important distinctions–and by disagreement over exactly how the distinctions are to be drawn and what significance they should have. The three most important of these are the distinction between active and passive euthanasia, voluntary and involuntary euthanasia, and assisted and unassisted euthanasia. Let’s consider each of these in turn.
Active vs. Passive Euthanasia
The distinction between active and passive euthanasia seems, on the surface, easy enough. Active euthanasia occurs in those instances in which someone takes active means, such as a lethal injection, to bring about someone’s death; passive euthanasia occurs in those instances in which someone simply refuses to intervene in order to prevent someone’s death. In a hospital setting, a DNR (do not resuscitate) order is one of the most common means of passive euthanasia.
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How do
we draw the line between killing and letting die? |
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Conceptual Clarity. This distinction has been attacked in at least two ways. First, some have attacked the conceptual clarity of the distinction, arguing that the line between active and passive is much more blurred than one might initially think. One reason this distinction becomes conceptually slippery, especially in regard to the notion of passive euthanasia, is that it is embedded in a background set of assumptions about what constitutes normal care and what the normal duties of care givers are. In typical hospital settings, there is a distinction between ordinary and extraordinary care. At one end of the spectrum, giving someone food and water is clearly ordinary care; at the other end of the spectrum, giving someone an emergency heart and lung transplant to save that person’s life is clearly extraordinary care. Refusing to give food and water seems to be different than refusing to perform a transplant. Both are passive, but one involves falling below the expectations of normal care while the other does not. Typically, DNR’s would fall somewhere in the middle ground on this scale. The source of this bit of conceptual slipperiness comes from that we need to distinguish between two levels on passive euthanasia: (a) refusing to provide extraordinary case, and (b) refusing to provide any life-sustaining care at all. Just as in daily life we would distinguish between the person who refuses to jump into a turbulent sea to save a drowning child and the person who refuses to reach into a bathtub to save a baby drowning there, so too in medical contexts we must distinguish between refusing to take extraordinary means to prevent death and refusing to provide normal care (such as nutrition and hydration) to sustain life.
There is at least a second reason why this distinction is conceptually slippery, especially in regard to the notion of active euthanasia. As we have already seen in our discussion of abortion, philosophers distinguish between the intended consequences of an action and the unintended (but foreseeable) consequences of an action. This distinction is crucial to the principle of the double effect, which under certain specifiable conditions morally permits an individual to perform an action that would otherwise not be allowed. Many Catholic ethicians, for example, would argue that a physician might be morally permitted to perform a surgical procedure such as a hysterectomy to remove a cancerous uterus even if this results in the death of a fetus, as long as the intention was not to kill the fetus, the cause was serious, and there was no other means to that end. Similarly, physicians might give certain terminal patients pain-killers in large dosages, realizing that such dosages might cause death but having no other way of alleviating the patient’s extreme pain.
Moral Significance. In addition to attacking the conceptual clarity of the active/passive distinction, some ethicists have attacked the moral significance of this distinction. The standard view is that active euthanasia is morally much more questionable than passive euthanasia, since it involves actively choosing to bring about the death of a human being. Critics of the moral significance of this distinction have argued that active euthanasia is often more compassionate than passive euthanasia and morally preferable to it. The typical type of case they adduce is one in which (a) there is no doubt that the patient will die soon, (b) the option of passive euthanasia causes significantly more pain for the patient (and often the family as well) than active euthanasia and does nothing to enhance the remaining life of the patient, and (c) passive measures will not bring about the death of the patient. Certain types of cancers are not only extremely painful, but also very resistant to pain-killing medications in dosages that still permit patients to be aware of themselves and those around them. It is not uncommon for situations to occur in which patients will undoubtedly die (within several days, if not hours) and in which their remaining time will be filled either with extreme pain or unconsciousness resulting from pain medication. Removal of life-support may not bring about the death of such patients if their heart and respiratory systems have not been seriously compromised. In such situations, passive euthanasia seems to be crueler than active euthanasia and therefore morally less preferable.
Voluntary, Nonvoluntary, and Involuntary Euthanasia
The second crucial distinction in discussion of euthanasia is among voluntary, nonvoluntary and involuntary euthanasia. Voluntary euthanasia occurs when the individual chooses to die; nonvoluntary euthanasia occurs when the individual’s death is brought about (either actively or passively) without the individual’s choosing to die; involuntary euthanasia occurs when the individual’s death is brought about against the individual’s wishes. Several points need to be made about this distinction.
The Distinction between Nonvoluntary and Involuntary. Involuntary euthanasia covers those cases in which an individual does not want to be euthanized; nonvoluntary euthanasia refers to those in which the individual cannot make an expressed choice at all. The former class of cases is clearly troubling: the individual wishes to live and someone else intentionally terminates that individual’s life. Most would say that this is simply murder. The latter class of cases is more common and morally more ambiguous. How do we treat those individuals, usually terminally ill and unable to choose (due to coma or some other medical condition), who may be in great pain and who have never clearly expressed their wishes about euthanasia in the past? Similarly, infants are unable to express their wishes about this (or any other) matter. If euthanasia is employed in such cases, it is involuntary, but not in the same sense as it is involuntary when the patient has expressed a clear wish not to be euthanized. Thus we get the follow type of division.
The morally most troubling of these cases will be those of involuntary euthanasia where the patient is unable to choose.
Assisted vs. Unassisted Euthanasia
The final important distinction in the discussion of euthanasia centers about the fact that many instances of euthanasia occur when an individual is no longer physically able to carry out the act. Assistance becomes necessary, either to perform the action at all or at least to die in a relatively painless and non-violent way. Several important points need to be noted about this distinction.
The following chart helps us to see the ways in which these basic distinctions relate to one another, the types of acts they designate, and their current legal status in the United States.
Euthanasia:
Some Fundamental Distinctions
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Passive |
Active: Not Assisted |
Active: Assisted |
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Voluntary |
Currently legal; often contained in living wills |
Equivalent to suicide for the patient |
Equivalent to suicide for the patient; Possibly equivalent to murder for the assistant |
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Nonnvoluntary:
Patient Not Able to Choose |
Sometimes legal, but only with court permission |
Not possible |
Equivalent to either suicide or being murdered for the patient; Legally equivalent to murder for the assistant |
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Involuntary:
Against Patient’s Wishes |
Not Legal |
Not possible |
Equivalent to being murdered for the patient; Equivalent to murder for assistant |
Equipped with these distinctions, let’s now turn to a consideration of the fundamental moral issues raised by euthanasia, looking first at the justifications that have been offered for and against euthanasia and then considering the three most typical types of cases: defective newborns, adults with profoundly diminished lives, and those in the final and painful phase of a terminal illness.
Euthanasia as the Compassionate Response to Suffering
One of the principal moral motives that moves us toward euthanasia is compassion: we see needless suffering, whether in ourselves or others, we want to alleviate or end it, and euthanasia is the only means of doing so. The paradigmatic situation here is that of a patient who is near death, who is in great pain that is not responsive to medication, and who has made an informed choice to die. At that juncture, those who care about the patient simply want the patient’s suffering to end–there seems to be no point in further suffering, for there is no hope of recovery–and euthanasia becomes the way of ending it.
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Is
euthanasia a proper way to express one’s compassion for the suffering of the
dying? |
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It is important to understand the intention contained in this kind of response. The direct intention is not to kill the patient; neither is it is utilitarian intention concerning the reduction of the overall amount of suffering; nor is it an egoistic intention that simply seeks to be rid of an annoying relative. Rather, the direct intention is simply to stop the patient’s pointless suffering. In passive euthanasia, the means is the withholding or withdrawal of life-sustaining treatment; in active euthanasia, the means for ending that suffering is some action–such as a lethal injection–that brings about the death of the patient. There are certainly situations in which passive euthanasia would not quickly end the suffering; patients may continue to live, sometimes for days, in great agony once life-support has been removed. In such cases, active euthanasia offers the only avenue for ending the pain. It is precisely this type of response that has come to be known as “mercy killing.” If any situation justifies active euthanasia, this would seem to be it.
Some cases of compassionate euthanasia can be viewed as an instance of the principle of double effect, but only when the intention was still to relieve pain. If a physician was administering increasingly large doses of pain medication which eventually and foreseeable resulted in the patient’s death, this could be covered under the principle of the double effect as long as the intention throughout was to relieve the patient’s pain. It’s not clear, however, whether this is really euthanasia; it seems better described as a last-ditch, high risk attempt to alleviate the patient’s suffering.
There is a sense in which the motivation and justification of compassionate euthanasia may appear to be utilitarian, or at least consequentialist, in character: the concern is with eliminating pointless suffering. It asks what good comes from the suffering and what bad comes from the termination of the suffering. But there are two ways in which the motivation for this response is not utilitarian in the standard sense. First, it is concerned principally, perhaps even exclusively, with the welfare of the patient, not with the overall welfare. Second, it is not a calculated response in the way in which classical utilitarianism is; rather, it is a response from the heart, a compassionate response that seeks to eliminate the pointless suffering of someone we care about. It arises, not out of calculation, but out of care.
The adjective “pointless” is crucial here for two reasons. First, it indicates that euthanasia is not a proper response to all suffering, only to that suffering which serves no purpose. Generally, suffering that results in the patient’s getting better (or at least improving to some minimally acceptable level) is not seen as pointless. Second, it helps explain part of the disagreement in our own society about the morality of euthanasia. Our views on euthanasia will depend in part on our background assumptions about the nature and purpose of suffering. Once again, we see that there are at least two distinct traditions here. On the one hand, many in our society hold that suffering always has a purpose–usually a purpose that God can discern, even if we mere mortals cannot. It may build character, purify an individual, provide an example to others, provide retribution, or serve some part in a larger plan beyond our grasp. On this view, even the suffering in the final stage of a terminal illness serves some purpose, although we may not be able to say what it is. On the other hand, many others in our society believe that suffering is simply an unqualified evil that should be eradicated whenever possible. Suffering, on this view, is always pointless in itself, even if it is sometimes unavoidable for the sake of some other goal such as recovering from an illness. These two views on suffering will be discussed in more detail in the next section.
This compassionate response may not be limited just to cases of extreme pain in terminally ill patients; it may extend, at least in respect to passive euthanasia, to cases of extreme physical debility or to cases of Alzheimer’s where the individual’s personal identity has long ago been lost. The principal criterion here would seem to be the individual’s wish no longer to be alive under such conditions–whether that wish is currently expressed or had been expressed clearly at an earlier point in life. Again, the focus here is on what the person wants and what is in the person’s best interest.
The Sanctity of Life and the Right to Die
There are very few villains in the debate over euthanasia, but there are disagreements about the interpretation and relative place of certain fundamental values and rights. One of the most prominent areas of conflict centers around the relationship between the sanctity of life and the right to die.
The Sanctity of Life
Human life, many of us believe, is sacred. In its original form, this belief is a religious one; the sanctity of life is an indication that life is a gift from God and therefore cannot be ended by human hand without violating God’s law or rejecting God’s love. Moreover, in its original form–one sees this most clearly in Buddhism, but also in other religious traditions–this belief encompasses all life, not just human life. In this form, it is not only a tradition that encompasses pacifism and opposes capital punishment, abortion, and euthanasia, but also one that respects the lives of animals and the living environment as a whole. Life is a sacred gift from God, and it is not the proper role of human beings to take it away from anyone. Respect for life, in the words of one Catholic bishop, is a “seamless garment” which covers the entire fabric of living creation. No distinction is drawn about the quality of life. All life is to be respected, loved, and cared for. It is this tradition which leads to the compassion of the Buddha and of Mother Theresa.
Followers of this tradition do not support either active or passive euthanasia in the senses discussed here. However, they certainly are committed to the broader sense of “dying well” discussed above, and spiritual discipline is often part of that commitment. So, too, is ministering to the sick and dying. Their alternative to active or passive euthanasia in the Western sense is not neglect, but compassion and love and ministering to the sick, the infirm, and the dying.
The Right to Die
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Do we
have a right to die? |
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Those who argue that human beings have a right to die usually differ from those who stress the sanctity of life on two principal points. First, and more importantly, they do not see life as a gift from God which cannot be disposed of at will; instead, they often see life ontologically as an accident and almost always morally as the possession of an individual. The dominant metaphor here is of life as property rather than gift. In this tradition, each person is seen as owning his or her own life, and owners are allowed to do whatever they want with their property. Second, respect for life in this tradition entails allowing the proper owner–that is, the individual–to decide for himself or herself whether to continue living. Notice that this tradition does not deny respect for life; rather, it has a different view of the source of life and of who holds proper dominion over life.
Those in this tradition respond quite differently to illnesses that profoundly reduce the quality of an individual’s life or produce great and needless pain. Their focus is on reducing suffering, maintaining a minimal threshold of quality for the individual’s life, and encouraging individuals to make their own decisions about the termination of their own life. The focus is thus on the quality of life and individual autonomy. The types of cases that those in this tradition point to are usually cases in which individuals want to die in order to end their suffering but are kept alive against their own wishes because a family member, the court, or in some cases the administrators of health care facilities–ever fearful of suits and federal investigations–are unwilling to let them die.
Yet there is also an irony in this tradition, for its emphasis on technology and control helps to create the very problem which it then seeks to solve through euthanasia. Just as it prolongs life through technology, it then must figure out how to end life technologically. Active euthanasia for the chronically ill and slowly dying rarely arises as an issue in non-technological societies because, prior to the introduction of modern, high-tech medicine, people either died or got better.
The Conflict of Traditions
It is important to understand the nature of this disagreement–and it is especially important to avoid certain easy ways of misunderstanding it. This is not a conflict between those who respect life and those who do not, nor is it a conflict between those who are indifferent to suffering and those who seek to eliminate it. Rather, it is a conflict between two types traditions, both of which respect life and both of which encourage compassion and the reduction of suffering. The differences between them center around how they understand life and what they accept as legitimate ways of reducing suffering.
How do we respond to such a conflict? Certainly one common response is to look for a winner, marshaling arguments in support of one tradition and against the other. My own inclination, however, is quite different. I think that we are better off as a society precisely because both of these traditions are present and vital. Each keeps the other in check, as it were. The sanctity of life tradition continually reminds us of our own frailty, of the fact that we are not masters of the universe; it check our inclination toward hubris. The right to die tradition, on the other hand, stresses the importance of reducing suffering in the world and increasing individual autonomy. I think our moral world would be impoverished if we had only one of these traditions. Let’s see how this works out in practice.
The Value of Life and the Cost of Caring
In the Groundwork of a Metaphysics of Morals, Immanuel Kant drew a crucial moral distinction between rational beings and mere things.2 Everything, Kant maintains, has either a price or a dignity. Mere things always have a price, that is, an equivalent value of some kind (usually a monetary one); they can be exchanged one for the other. Rational beings, however, have dignity, for the value of a human being is such that it is beyond all calculations of price; they cannot be exchanged, one for the other. In drawing this distinction, Kant articulated a moral insight which remains powerful today: the belief that human life is priceless and that we therefore ought not to put a price tag on it. Human life is to be preserved at all costs, for the value of human life is beyond that of any costs. Indeed, this may well be one of the motivations in critical care situations when the full arsenal of medicine’s skill and technology is brought to bear on a frail, old, dying person in order to prolong his or her life for a few days, weeks, or even months. We cannot put a price tag on human life, the Kantian inside us says. There is something morally odious about thinking that a human life can be traded for something else.
Many of us find that Kant’s insight strikes a resonant chord in our moral lives, but that there is another, potentially dissonant note in all of this. Costs do matter, as utilitarians such as Richard Brandt make clear, although there is much disagreement about the kinds of costs and how much they matter. We can see this on both the personal level and on the level of social policy. On the personal level, individuals and families struggle with this issue. Imagine a family, such as the one given in the case study at the beginning of this chapter, with a member who requires costly and continual medical care that goes well beyond insurance; family resources–emotional as well as financial–may be drained in the attempt to continue care. Here costs are not simply monetary, but also emotional and spiritual. Financial costs are not limited simply to restrictions on the family vacation, but may extend into areas such as education that directly affect the welfare of the children in the family. Similarly, emotional and spiritual costs to the family may be quite high, although these costs may be more evenly distributed over the range of options.
On the social policy level, we recognize that an amazingly large percentage of our health care dollars are spent on persons during the final weeks of their lives, and ethicists such as Daniel Callahan have maintained that we ought not to spend our money and resources in this way. Although firmly opposing active euthanasia, Callahan maintains that we should respect the natural life span and we should not use intrusive means–such as respirators and feeding tubes–to keep the elderly alive. Here we have some degree of passive involuntary euthanasia, at least for those who lack the private financial resources to pay for continued extraordinary care. This raises the specter of involuntary passive euthanasia for all but the rich. Of course, this is only an inequity if we believe that a longer life under such conditions is better than a shorter one.
Slippery Slopes
Even among those who are not opposed to euthanasia in principle, there are serious reservations about the possibility that legalizing euthanasia could lead to abuses. Once the door is opened even a little, the danger is that more will be permitted–either through further legalization or because of objectionable but common abuses which, while not permitted by the new proposal, could not be effectively curbed–than we would originally wanted. History makes us cautious. Euthanasia of the physically and mentally handicapped was part of Hitler’s plan, and by some estimates as many as 200,000 handicapped people were killed as part of the Nazi eugenics program. Not surprisingly, many are watching the Netherlands very carefully now, for active euthanasia has been tolerated there for a number of years and legalized in 1994.
Undervalued Groups
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Would
the legalization of euthanasia open the door to further abuses? |
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The slippery slope argument has an added dimension when placed within a social context of discrimination. In a society in which the lives of certain classes of people are typically undervalued, legalized euthanasia could become a further instrument of discrimination. The classes discriminated against may vary from society to society, and the classes may be based on race, ethnicity, gender, social orientation, religious beliefs, social class, age, or some other characteristic. However the classes are determined, the point remains the same: legalized euthanasia would be more likely to encourage the early deaths of member of those classes that are discriminated against in society. For this argument to work, it must either presuppose that euthanasia is bad in itself or