Euthanasia

Timothy E. Quill, M.D.
“Death and Dignity:
A Case of Individualized Decision Making”

About the Author: Timothy Quill, M.D., specializes in internal medicine, has had experience as a hospice director, and is an Associate Professor of Medicine and Psychiatry at the University of Rochester Schhol of Medicine and Dentistry. His book, Death and Dignity: Making Choices and Taking Charge (New York: W. W. Norton, 1993) argues in favor of physician-assisted euthanasia.

About the Article: In sharp contrast to the previous selection, this piece depicts a strong and long relationship between a physician and his patient. As the patient, Diane, confronts her terminal cancer, she decides that she does not want extraordinary medical care. Her doctor, Timothy Quill, must then face crucial issues about how willing he is to help to alleviate Diane’s suffering and support her choice to die.

DIANE was feeling tired and had a rash. A common scenario, though there was something subliminally worrisome that prompted me to check her blood count. Her hematocrit was 22, and the white-cell count was 4.3 with some metamyelocytes and unusual white cells. I wanted it to be viral, trying to deny what was staring me in the face. Perhaps in a repeated count it would disappear. I called Diane and told her it might be more serious than I had initially thought–that the test needed to be repeated and that if she felt worse, we might have to move quickly. When she pressed for the possibilities, I reluctantly opened the door to leukemia. Hearing the word seemed to make it exist. “Oh, shit!” she said. “Don’t tell me that.” Oh, shit! I thought, I wish I didn’t have to.

Diane was no ordinary person (although no one I have ever come to know has been really ordinary). She was raised in an alcoholic family and had felt alone for much of her life. She had vaginal cancer as a young woman. Through much of her adult life, she had struggled with depression and her own alcoholism. I had come to know, respect, and admire her over the previous eight years as she confronted these problems and gradually overcame them. She was an incredibly clear, at times brutally honest, thinker and communicator. As she took control of her life, she developed a strong sense of independence and confidence. In the previous 31/2 years, her hard work had paid off. She was completely abstinent from alcohol, she had established much deeper connections with her husband, college-age son, and several friends, and her business and her artistic work were blossoming. She felt she was really living fully for the first time.

Not surprisingly, the repeated blood count was abnormal, and detailed examination of the peripheral-blood smear showed myelocytes. I advised her to come into the hospital, explaining that we needed to do a bone marrow biopsy and make some decisions relatively rapidly. She came to the hospital knowing what we would find. She was terrified, angry, and sad. Although we knew the odds, we both clung to the thread of possibility that it might be something else.

The bone marrow confirmed the worst: acute myelomonocytic leukemia. In the face of this tragedy, we looked for signs of hope. This is an area of medicine in which technological intervention has been successful, with cures 25 percent of the time–long-term cures. As I probed the costs of these cures, I heard about induction chemotherapy (three weeks in the hospital, prolonged neutropenia, probable infectious complications, and hair loss; 75 percent of patients respond, 25 percent do not). For the survivors, this is followed by consolidation chemotherapy (with similar side effects; another 25 percent die, for a net survival of 50 percent). Those still alive, to have a reasonable chance of long-term survival, then need bone marrow transplantation (hospitalization for two months and whole-body irradiation, with complete killing of the bone marrow, infectious complications, and the possibility for graft-versus-host disease–with a survival of approximately 50 percent, or 25 percent of the original group). Though hematologists may argue over the exact percentages, they don’t argue about the outcome of no treatment–certain death in days, weeks, or at most a few months.

Believing that delay was dangerous, our oncologist broke the news to Diane and began making plans to insert a Hickman catheter and begin induction chemotherapy that afternoon. When I saw her shortly thereafter, she was enraged at his presumption that she would want treatment, and devastated by the finality of the diagnosis. All she wanted to do was go home and be with her family. She had no further questions about treatment and in fact had decided that she wanted none. Together we lamented her tragedy and the unfairness of life. Before she left, I felt the need to be sure that she and her husband understood that there was some risk in delay, that the problem was not going to go away, and that we needed to keep considering the options over the next several days. We agreed to meet in two days.

She returned in two days with her husband and son. They had talked extensively about the problem and the options. She remained very clear about her wish not to undergo chemotherapy and to live whatever time she had left outside the hospital. As we explored her thinking further, it became clear that she was convinced she would die during the period of treatment and would suffer unspeakably in the process (from hospitalization, from lack of control over her body, from the side effects of chemotherapy, and from pain and anguish). Although I could offer support and my best effort to minimize her suffering if she chose treatment, there was no way I could say any of this would not occur. In fact, the last four patients with acute leukemia at our hospital had died very painful deaths in the hospital during various stages of treatment (a fact I did not share with her). Her family wished she would choose treatment but sadly accepted her decision. She articulated very clearly that it was she who would be experiencing all the side effects of treatment and that odds of 25 percent were not good enough for her to undergo so toxic a course of therapy, given her expectations of chemotherapy and hospitalization and the absence of a closely matched bone marrow donor. I had her repeat her understanding of the treatment, the odds, and what to expect if there were no treatment. I clarified a few misunderstandings, but she had a remarkable grasp of the options and implications.

I have been a longtime advocate of active, informed patient choice of treatment or nontreatment, and of a patient’s right to die with as much control and dignity as possible. Yet there was something about her giving up a 25 percent chance of long-term survival in favor of almost certain death that disturbed me. I had seen Diane fight and use her considerable inner resources to overcome alcoholism and depression, and I half expected her to change her mind over the next week. Since the window of time in which effective treatment can be initiated is rather narrow, we met several times that week. We obtained a second hematology consultation and talked at length about the meaning and implications of treatment and nontreatment. She talked to a psychologist she had seen in the past. I gradually understood the decision from her perspective and became convinced that it was the right decision for her. We arranged for home hospice care (although at that time Diane felt reasonably well, was active, and looked healthy), left the door open for her to change her mind, and tried to anticipate how to keep her comfortable in the time she had left.

Just as I was adjusting to her decision, she opened up another area that would stretch me profoundly. It was extraordinarily important to Diane to maintain control of herself and her own dignity during the time remaining to her. When this was no longer possible, she clearly wanted to die. As a former director of a hospice program, I know how to use pain medicines to keep patients comfortable and lessen suffering. I explained the philosophy of comfort care, which I strongly believe in. Although Diane understood and appreciated this, she had known of people lingering in what was called relative comfort, and she wanted no part of it. When the time came, she wanted to take her life in the least painful way possible. Knowing of her desire for independence and her decision to stay in control, I thought this request made perfect sense. I acknowledged and explored this wish but also thought that it was out of the realm of currently accepted medical practice and that it was more than I could offer or promise. In our discussion, it became clear that preoccupation with her fear of a lingering death would interfere with Diane’s getting the most out of the time she had left until she found a safe way to ensure her death. I feared the effects of a violent death on her family, the consequences of an ineffective suicide that would leave her lingering in precisely the state she dreaded so much, and the possibility that a family member would be forced to assist her, with all the legal and personal repercussions that would follow. She discussed this at length with her family. They believed that they should respect her choice. With this in mind, I told Diane that information was available from the Hemlock Society that might be helpful to her.

A week later she phoned me with a request for barbiturates for sleep. Since I knew that this was an essential ingredient in a Hemlock Society suicide, I asked her to come to the office to talk things over. She was more than willing to protect me by participating in a superficial conversation about her insomnia, but it was important to me to know how she planned to use the drugs and to be sure that she was not in despair or overwhelmed in a way that might color her judgment. In our discussion, it was apparent that she was having trouble sleeping, but it was also evident that the security of having enough barbiturates available to commit suicide when and if the time came would leave her secure enough to live fully and concentrate on the present. It was clear that she was not despondent and that in fact she was making deep, personal connections with her family and close friends. I made sure that she knew how to use the barbiturates for sleep, and also that she knew the amount needed to commit suicide. We agreed to meet regularly, and she promised to meet with me before taking her life, to ensure that all other avenues had been exhausted. I wrote the prescription with an uneasy feeling about the boundaries I was exploring–spiritual, legal, professional, and personal. Yet I also felt strongly that I was setting her free to get the most out of the time she had left, and to maintain dignity and control on her own terms until her death.

The next several months were very intense and important for Diane. Her son stayed home from college, and they were able to be with one another and say much that had not been said earlier. Her husband did his work at home so that he and Diane could spend more time together. She spent time with her closest friends. I had her come into the hospital for a conference with our residents, at which she illustrated in a most profound and personal way the importance of informed decision making, the right to refuse treatment, and the extraordinarily personal effects of illness and interaction with the medical system. There were emotional and physical hardships as well. She had periods of intense sadness and anger. Several times she became very weak, but she received transfusions as an outpatient and responded with marked improvement of symptoms. She had two serious infections that responded surprisingly well to empirical courses of oral antibiotics. After three tumultuous months, there were two weeks of relative calm and well-being, and fantasies of a miracle began to surface.

Unfortunately, we had no miracle. Bone pain, weakness, fatigue, and fevers began to dominate her life. Although the hospice workers, family members, and I tried our best to minimize the suffering and promote comfort, it was clear that the end was approaching. Diane’s immediate future held what she feared the most–increasing discomfort, dependence, and hard choices between pain and sedation. She called up her closest friends and asked them to come over to say good-bye, telling them that she would be leaving soon. As we had agreed, she let me know as well. When we met, it was clear that she knew what she was doing, that she was sad and frightened to be leaving, but that she would be even more terrified to stay and suffer. In our tearful good-bye, she promised a reunion in the future at her favorite spot on the edge of Lake Geneva, with dragons swimming in the sunset.

Two days later her husband called to say that Diane had died. She had said her final good-byes to her husband and son that morning, and asked them to leave her alone for an hour. After an hour, which must have seemed an eternity, they found her on the couch, lying very still and covered by her favorite shawl. There was no sign of struggle. She seemed to be at peace. They called me for advice about how to proceed. When I Her husband and son were quiet. We talked about what a remarkable person she had been. They seemed to have no doubts about the course she had chosen or about their cooperation, although the unfairness of her illness and the finality of her death were overwhelming to us all.

I called the medical examiner to inform him that a hospice patient had died. When asked about the cause of death, I said, “acute leukemia.” He said that was fine and that we should call a funeral director. Although acute leukemia was the truth, it was not the whole story. Yet any mention of suicide would have given rise to a police investigation and probably brought the arrival of an ambulance crew for resuscitation. Diane would have become a “coroner’s case,” and the decision to perform an autopsy would have been made at the discretion of the medical examiner. The family or I could have been subject to criminal prosecution, and I to professional review, for our roles in support of Diane’s choices. Although I truly believe that the family and I gave her the best care possible, allowing her to define her limits and directions as much as possible, I am not sure the law, society, or the medical profession would agree. So I said “acute leukemia” to protect all of us, to protect Diane from an invasion into her past and her body, and to continue to shield society from the knowledge of the degree of suffering that people often undergo in the process of dying. Suffering can be lessened to some extent, but in no way eliminated or made benign, by the careful intervention of a competent, caring physician, given current social constraints.

Diane taught me about the range of help I can provide if I know people well and if I allow them to say what they really want. She taught me about life, death, and honesty and about taking charge and facing tragedy squarely when it strikes. She taught me that I can take small risks for people that I really know and care about. Although I did not assist in her suicide directly, I helped indirectly to make it possible, successful, and relatively painless. Although I know we have measures to help control pain and lessen suffering, to think that people do not suffer in the process of dying is an illusion. Prolonged dying can occasionally be peaceful, but more often the role of the physician and family is limited to lessening but not eliminating severe suffering.

I wonder how many families and physicians secretly help patients over the edge into death in the face of such severe suffering. I wonder how many severely ill or dying patients secretly take their lives, dying alone in despair. I wonder whether the image of Diane’s final aloneness will persist in the minds of her family, or if they will remember more the intense, meaningful months they had together before she died. I wonder whether Diane struggled in that last hour, and whether the Hemlock Society’s way of death by suicide is the most benign. I wonder why Diane, who gave so much to so many of us, had to be alone for the last hour of her life. I wonder whether I will see Diane again, on the shore of Lake Geneva at sunset, with dragons swimming on the horizon.

Journal/Discussion Questions

- Have you ever known anyone in a situation similar to Diane’s? How did they deal with it? How would you have dealt with it?

1. Do you think that Dr. Quill made the right decision in this case? Why or why not? How would you have responded to Diane’s decision?

2. Do you think physicians should ever be allowed to assist patients in ending their own lives? What guidelines, if any, would you propose for physicians who face this choice?

Euthanasia:
An Introduction to the Moral Issues

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.

How do we draw the line between killing and letting die?

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

	Passive	Active: Not Assisted	Active: Assisted
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
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
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.

Is euthanasia a proper way to express one’s compassion for the suffering of the dying?

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

Do we have a right to die?

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

Would the legalization of euthanasia open the door to further abuses?

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 else that it would encourage certain morally unjustified kinds of euthanasia such as involuntary euthanasia. The latter line of argument seems to be plausible, namely, that the legalization of voluntary euthanasia would result in undue pressure on certain segments of society to ‘choose’ euthanasia when they did not really want to do so.

There is certainly no shortage of undervalued groups in the United States. Some groups are racially constituted: some Native Americans and some African Americans feel that their people have been treated in ways that have genocidal overtones. For them, it is extremely important that they have especially strong guarantees that they will not be the objects of euthanasia disproportionately. Similar issues exist for the poor and the homeless, but they are often less able to advance their own interests in public forums. Finally, and perhaps most pervasively, the elderly in the United States (and elsewhere as well) form a group that is highly undervalued. Several factors contribute to this. First, our society tends to value youth rather than age, aggressive problem-solving intelligence and new ideas rather than the wisdom of long experience. Second, our society tends to value work, and the elderly are often retired and no longer able to be productive. Third, our society tends to be highly mobile, and as a result elderly parents often live in a different location from their children; extended, loving families are hard to find. Fourth, as the percentage of the entire population that is over sixty-five grows, this will put increasing pressure on our social welfare resources; the possibility of increasing resentment toward the aged by younger generations in our society is certainly great.

Moral Pluralism

Any satisfactory proposal for liberalizing the euthanasia laws must contain adequate provisions to prevent it from sliding down the slope to unacceptable practices. It is here that a pluralistic approach has much to recommend itself, for by encouraging both traditions it provides a check on each. Just as pro-choice forces will try to minimize cases in which people are kept alive and suffering against their will, so too pro-life forces will try to insure that euthanasia is used only in cases where everyone wants it. It is precisely the tension between traditions that helps to reduce the likelihood that one will slide down the slope.

Endnotes

¹Miles S. Gomez C. Protocols for Elective Use of Life-sustaining treatment. New York: Springer-Verlag, 1988. Cited in Margaret Battin, “Euthanasia: The Way We Do It, the Way They Do It,” Journal of Pain and Symptom Management, Vol. 6, No. 5, pp. 298-305.

²Immanuel Kant, The Moral Law. Kant’s Groundwork of the Metaphysic of Morals, translated and analyzed by H. J. Paton (London: Hutchinson University Library, 1969), pp. 96-97.

Journal Questions

- Under what conditions, if any, would you want others to withhold medical treatment from you? To withhold fluids and nutrition? to actively terminate your life?

- Write your own living will, including in it all instructions and requests you think are relevant.

John Hardwig
“Is There a Duty to Die?”*

About the Author: John Hardwig is Professor of Philosophy at East Tennessee State University. He has published widely in the area of ethics.

About the Article: Hardwig maintains that modern medicine and American individualistic culture have uncouraged us to think that we have an almost unlimited right to live and to health care. Hardwig argues that there are circumstances in which we have a duty to die, and that this will become a more common scenario as a result of the advances of modern medicine and technology.

As You Read, Consider This:

1. Under what circumstances, according to Hardwig, do we have a duty to die?

2. How does Hardwig deal with the case of someone who has a duty to die but does not want to die?

3. What does Hardwig mean by “the individualistic fantasy?”

When Richard Lamm made the statement that old people have a duty to die, it was generally shouted down or ridiculed. The whole idea is just too preposterous to entertain. Or too threatening. In fact, a fairly common argument against legalizing physician-assisted suicide is that if it were legal, some people might somehow get the idea that they have a duty to die. These people could only be the victims of twisted moral reasoning or vicious social pressure. It goes without saying that there is no duty to die.

But for me the question is real and very important. I feel strongly that I may very well some day have a duty to die. I do not believe that I am idiosyncratic, morbid, mentally ill, or morally perverse in thinking this. I think many of us will eventually face precisely this duty. But I am first of all concerned with my own duty. I write partly to clarify my own convictions and to prepare myself. Ending my life might be a very difficult thing for me to do.

This notion of a duty to die raises all sorts of interesting theoretical and metaethical questions. I intend to try to avoid most of them because I hope my argument will be persuasive to those holding a wide variety of ethical views. Also, although the claim that there is a duty to die would ultimately require theoretical underpinning, the discussion needs to begin on the normative level. As is appropriate to my attempt to steer clear of theoretical commitments, I will use "duty," "obligation," and "responsibility" interchangeably, in a pre-theoretical or preanalytic sense.[1]

Circumstances and a Duty to Die

Do many of us really believe that no one ever has a duty to die? I suspect not. I think most of us probably believe that there is such a duty, but it is very uncommon. Consider Captain Oates, a member of Admiral Scott's expedition to the South Pole. Oates became too ill to continue. If the rest of the team stayed with him, they would all perish. After this had become clear, Oates left his tent one night, walked out into a raging blizzard, and was never seen again.[2] That may have been a heroic thing to do, but we might be able to agree that it was also no more than his duty. It would have been wrong for him to urge-or even to allow-the rest to stay and care for him.

This is a very unusual circumstance--a "lifeboat case"--and lifeboat cases make for bad ethics. But I expect that most of us would also agree that there have been cultures in which what we would call a duty to die has been fairly common. These are relatively poor, technologically simple, and especially nomadic cultures. In such societies, everyone knows that if you manage to live long enough, you will eventually become old and debilitated. Then you will need to take steps to end your life. The old people in these societies regularly did precisely that. Their cultures prepared and supported them in doing so.

Those cultures could be dismissed as irrelevant to contemporary bioethics; their circumstances are so different from ours. But if that is our response, it is instructive. It suggests that we assume a duty to die is irrelevant to us because our wealth and technological sophistication have purchased exemption for us . . . except under very unusual circumstances like Captain Oates's.

But have wealth and technology really exempted us? Or are they, on the contrary, about to make a duty to die common again? We like to think of modern medicine as all triumph with no dark side. Our medicine saves many lives and enables most of us to live longer. That is wonderful, indeed. We are all glad to have access to this medicine. But our medicine also delivers most of us over to chronic illnesses and it enables many of us to survive longer than we can take care of ourselves, longer than we know what to do with ourselves, longer than we even are ourselves.

The costs--and these are not merely monetary of prolonging our lives when we are no longer able to care for ourselves--are often staggering. If further medical advances wipe out many of today's "killer diseases" cancers, heart attacks, strokes, ALS, AIDS, and the rest--then one day most of us will survive long enough to become demented or debilitated. These developments could generate a fairly widespread duty to die. A fairly common duty to die might turn out to be only the dark side of our life-prolonging medicine and the uses we choose to make of it.

Let me be clear. I certainly believe that there is a duty to refuse life-prolonging medical treatment and also a duty to complete advance directives refusing life-prolonging treatment. But a duty to die can go well beyond that. There can be a duty to die before one's illnesses would cause death, even if treated only with palliative measures. In fact, there may be a fairly common responsibility to end one's life in the absence of any terminal illness at all. Finally, there can be a duty to die when one would prefer to live. Granted, many of the conditions that can generate a duty to die also seriously undermine the quality of life. Some prefer not to live under such conditions. But even those who want to live can face a duty to die. These will clearly be the most controversial and troubling cases; I will, accordingly, focus my reflections on them.

The Individualistic Fantasy

Because a duty to die seems such a real possibility to me, I wonder why contemporary bioethics has dismissed it without serious consideration. I believe that most bioethics still shares in one of our deeply embedded American dreams: the individualistic fantasy. This fantasy leads us to imagine that lives are separate and unconnected, or that they could be so if we chose. If lives were unconnected, things that happened in my life would not or need not affect others. And if others were not (much) affected by my life, I would have no duty to consider the impact of my decisions on others. I would then be free morally to live my life however I please, choosing whatever life and death I prefer for myself. The way I live would be nobody's business but my own. I certainly would have no duty to die if I preferred to live.

Within a health care context, the individualistic fantasy leads us to assume that the patient is the only one affected by decisions about her medical treatment. If only the patient were affected, the relevant questions when making treatment decisions would be precisely those we ask: What will benefit the patient? Who can best decide that? The pivotal issue would always be simply whether the patient wants to live like this and whether she would consider herself better off dead.[3] "Whose life is it, anyway?" we ask rhetorically.

But this is morally obtuse. We are not a race of hermits. Illness and death do not come only to those who are all alone. Nor is it much better to think in terms of the bald dichotomy between "the interests of the patient" and "the interests of society" (or a third-party payer), as if we were isolated individuals connected only to "society" in the abstract or to the other, faceless members of our health maintenance organization.

Most of us are affiliated with particular others and most deeply, with family and loved ones. Families and loved ones are bound together by ties of care and affection, by legal relations and obligations, by inhabiting shared spaces and living units, by interlocking finances and economic prospects, by common projects and also commitments to support the different life projects of other family members, by shared histories, by ties of loyalty. This life together of family and loved ones is what defines and sustains us; it is what gives meaning to most of our lives. We would not have it any other way. We would not want to be all alone, especially when we are seriously ill, as we age, and when we are dying.

But the fact of deeply interwoven lives debars us from making exclusively self-regarding decisions, as the decisions of one member of a family may dramatically affect the lives of all the rest. The impact of my decisions upon my family and loved ones is the source of many of my strongest obligations and also the most plausible and likeliest basis of a duty to die. "Society," after all, is only very marginally affected by how I live, or by whether I live or die.

A Burden to My Loved Ones

Many older people report that their one remaining goal in life is not to be a burden to their loved ones. Young people feel this, too: when I ask my undergraduate students to think about whether their death could come too late, one of their very first responses always is, "Yes, when I become a burden to my family or loved ones." Tragically, there are situations in which my loved ones would be much better off--all things considered, the loss of a loved one notwithstanding--if I were dead.

The lives of our loved ones can be seriously compromised by caring for us. The burdens of providing care or even just supervision twenty-four hours a day, seven days a week are often overwhelming.[4] When this kind of caregiving goes on for years, it leaves the caregiver exhausted, with no time for herself or life of her own. Ultimately, even her health is often destroyed. But it can also be emotionally devastating simply to live with a spouse who is increasingly distant, uncommunicative, unresponsive, foreign, and unreachable. Other family members' needs often go unmet as the caring capacity of the family is exceeded. Social life and friendships evaporate, as there is no opportunity to go out to see friends and the home is no longer a place suitable for having friends in.

We must also acknowledge that the lives of our loved ones can be devastated just by having to pay for health care for us. One part of the recent SUPPORT study documented the financial aspects of caring for a dying member of a family. Only those who had illnesses severe enough to give them less than a 50 percent chance to live six more months were included in this study. When these patients survived their initial hospitalization and were discharged about one-third required considerable caregiving from their families; in 20 percent of cases a family member had to quit work or make some other major lifestyle change; almost one-third of these families lost all of their savings; and just under 30 percent lost a major source of income.[5]

If talking about money sounds venal or trivial, remember that much more than money is normally at stake here. When someone has to quit work, she may well lose her career. Savings decimated late in life cannot be recouped in the few remaining years of employability, so the loss compromises the quality of the rest of the caregiver's life. For a young person, the chance to go to college may be lost to the attempt to pay debts due to an illness in the family, and this decisively shapes an entire life.

A serious illness in a family is a misfortune. It is usually nobody's fault; no one is responsible for it. But we face choices about how we will respond to this misfortune. That's where the responsibility comes in and fault can arise. Those of us with families and loved ones always have a duty not to make selfish or self-centered decisions about our lives. We have a responsibility to try to protect the lives of loved ones from serious threats or greatly impoverished quality, certainly an obligation not to make choices that will jeopardize or seriously compromise their futures. Often, it would be wrong to do just what we want or just what is best for ourselves; we should choose in light of what is best for all concerned. That is our duty in sickness as well as in health. It is out of these responsibilities that a duty to die can develop.

I am not advocating a crass, quasi-economic conception of burdens and benefits, nor a shallow, hedonistic view of life. Given a suitably rich understanding of benefits, family members sometimes do benefit from suffering through the long illness of a loved one. Caring for the sick or aged can foster growth, even as it makes daily life immeasurably harder and the prospects for the future much bleaker. Chronic illness or a drawn-out death can also pull a family together, making the care for each other stronger and more evident. If my loved ones are truly benefiting from coping with my illness or debility, I have no duty to die based on burdens to them.

But it would be irresponsible to blithely assume that this always happens, that it will happen in my family, or that it will be the fault of my family if they cannot manage to turn my illness into a positive experience. Perhaps the opposite is more common: a hospital chaplain once told me that he could not think of a single case in which a family was strengthened or brought together by what happened at the hospital.

Our families and loved ones also have obligations, of course--they have the responsibility to stand by us and support us through debilitating illness and death. They must be prepared to make significant sacrifices to respond to an illness in the family. I am far from denying that. Most of us are aware of this responsibility and most families meet it rather well. In tact, families deliver more than 80 percent of the long-term care in this country, almost always at great personal cost. Most of us who are a part of a family can expect to be sustained in our time of need by family members and those who love us.

But most discussions of an illness in the family sound as if responsibility were a one-way street. It is not, of course. When we become seriously ill or debilitated, we too may have to make sacrifices. To think that my loved ones must bear whatever burdens my illness, debility, or dying process might impose upon them is to reduce them to means to my well-being. And that would be immoral. Family solidarity, altruism, bearing the burden of a loved ones misfortune, and loyalty are all important virtues of families, as well. But they are all also two-way streets.

Objections to a Duty to Die

To my mind, the most serious objections to the idea of a duty to die lie in the effects on my loved ones of ending my life. But to most others, the important objections have little or nothing to do with family and loved ones. Perhaps the most common objections are: (1) there is a higher duty that always takes precedence over a duty to die; (2) a duty to end one's own life would be incompatible with a recognition of human dignity or the intrinsic value of a person; and (3) seriously ill, debilitated, or dying people are already bearing the harshest burdens and so it would be wrong to ask them to bear the additional burden of ending their own lives.

These are all important objections; all deserve a thorough discussion. Here I will only be able to suggest some moral counterweights--ideas that might provide the basis for an argument that these objections do not always preclude a duty to die.

An example of the first line of argument would be the claim that a duty to God, the giver of life, forbids that anyone take her own life. It could be argued that this duty always supersedes whatever obligations we might have to our families. But what convinces us that we always have such a religious duty in the first place? And what guarantees that it always supersedes our obligations to try to protect our loved ones?

Certainly, the view that death is the ultimate evil cannot be squared with Christian theology. It does not reflect the actions of Jesus or those of his early followers. Nor is it clear that the belief that life is sacred requires that we never take it. There ate other theological possibilities.[6] In any case, most of us--bioethicists, physicians, and patients alike--do not subscribe to the view that we have an obligation to preserve human life as long as possible. But if not, surely we ought to agree that I may legitimately end my life for other-regarding reasons, not just for self-regarding reasons.

Secondly, religious considerations aside, the claim could be made that an obligation to end one's own life would be incompatible with human dignity or would embody a failure to recognize the intrinsic value of a person. But I do not see that in thinking I had a duty to die I would necessarily be failing to respect myself or to appreciate my dignity or worth. Nor would I necessarily be failing to respect you in thinking that you had a similar duty. There is surely also a sense in which we fail to respect ourselves if in the face of illness or death, we stoop to choosing just what is best for ourselves. Indeed, Kant held that the very core of human dignity is the ability to act on a self-imposed moral law, regardless of whether it is in our interest to do so.[7] We shall return to the notion of human dignity.

A third objection appeals to the relative weight of burdens and thus, ultimately, to considerations of fairness or justice. The burdens that an illness creates for the family could not possibly be great enough to justify an obligation to end one's life--the sacrifice of life itself would be a far greater burden than any involved in caring for a chronically ill family member.

But is this true? Consider the following case:

An 87-year-old woman was dying of congestive heart failure. Her APACHE score predicted that she had less than a 50 percent chance to live for another six months. She was lucid, assertive, and terrified of death. She very much wanted to live and kept opting for rehospitalization and the most aggressive life-prolonging treatment possible. That treatment successfully prolonged her life (though with increasing debility) for nearly two years. Her 55-year-old daughter was her only remaining family, her caregiver, and the main source of her financial support. The daughter duly cared for her mother. But before her mother died, her illness had cost the daughter ail of her savings, her home, her job, and her career.

This is by no means an uncommon sort of case. Thousands of similar cases occur each year. Now, ask yourself which is the greater burden:

a) To lose a 50 percent chance of six more months of life at age 87?

b) To lose all your savings, your home, and your career at age 55?

Which burden would you prefer to bear? Do we really believe the former is the greater burden? Would even the dying mother say that (a) is the greater burden? Or has she been encouraged to believe that the burdens of (b) are somehow morally irrelevant to her choices?

I think most of us would quickly agree that (b) is a greater burden. That is the evil we would more hope to avoid in our lives. If we are tempted to say that the mother's disease and impending death are the greater evil, I believe it is because we are taking a "slice of time" perspective rather than a "lifetime perspective."[8] But surely the lifetime perspective is the appropriate perspective when weighing burdens. If (b) is the greater burden, then we must admit that we have been promulgating an ethics that advocates imposing greater burdens on some people in order to provide smaller benefits for others just because they are ill and thus gain our professional attention and advocacy.

A whole range of cases like this one could easily be generated. In some, the answer about which burden is greater will not be clear. But in many it is. Death or ending your own life--is simply not the greatest evil or the greatest burden.

This point does not depend on a utilitarian calculus. Even if death were the greatest burden (thus disposing of any simple utilitarian argument), serious questions would remain about the moral justifiability of choosing to impose crushing burdens on loved ones in order to avoid having to bear this burden oneself. The fact that I suffer greater burdens than others in my family does not license me simply to choose what I want for myself, nor does it necessarily release me from a responsibility to try to protect the quality of their lives.

I can readily imagine that, through cowardice, rationalization, or failure of resolve, I will fail in this obligation to protect my loved ones. If so, I think I would need to be excused or forgiven for what I did. But I cannot imagine it would be morally permissible for me to ruin the rest of my partner's life to sustain mine or to cut off my sons' careers, impoverish them, or compromise the quality of their children's lives simply because I wish to live a little longer. This is what leads me to believe in a duty to die.

Who Has a Duty to Die?

Suppose, then, that there can be a duty to die. Who has a duty to die? And when? To my mind, these are the right questions, the questions we should be asking. Many of us may one day badly need answers to just these questions.

But I cannot supply answers here, for two reasons. In the first place, answers will have to be very particular and contextual. Our concrete duties are often situated, defined in part by the myriad details of our circumstances, histories, and relationships. Though there may be principles that apply to a wide range of cases and some cases that yield pretty straightforward answers, there will also be many situations in which it is very difficult to discern whether one has a duty to die. If nothing else, it will often be very difficult to predict how one's family will bear up under the weight of the burdens that a protracted illness would impose on them. Momentous decisions will often have to be made under conditions of great uncertainty.

Second and perhaps even more importantly, I believe that those of us with family and loved ones should not define our duties unilaterally, especially not a decision about a duty to die. It would be isolating and distancing for me to decide without consulting them what is too much of a burden for my loved ones to bear. That way of deciding about my moral duties is not only atomistic, it also treats my family and loved ones paternalistically. They must be allowed to speak for themselves about the burdens my life imposes on them and how they feel about bearing those burdens.

Some may object that it would be wrong to put a loved one in a position of having to say, in effect, "You should end your life because caring for you is too hard on me and the rest of the family." Not only will it be almost impossible to say something like that to someone you love, it will carry with it a heavy load of guilt. On this view, you should decide by yourself whether you have a duty to die and approach your loved ones only after you have made up your mind to say good-bye to them. Your family could then try to change your mind, but the tremendous weight of moral decision would be lifted from their shoulders.

Perhaps so. But I believe in family decisions. Important decisions for those whose lives are interwoven should be made together, in a family discussion. Granted, a conversation about whether I have a duty to die would be a tremendously difficult conversation. The temptations to be dishonest could be enormous. Nevertheless, if I am contemplating a duty to die, my family and I should, if possible, have just such an agonizing discussion. It will act as a check on the information, perceptions, and reasoning of all of us. But even more importantly, it affirms our connectedness at a critical juncture in our lives and our life together. Honest talk about difficult matters almost always strengthens relationships.

However, many families seem unable to talk about death at all, much less a duty to die. Certainly most families could not have this discussion all at once, in one sitting. It might well take a number of discussions to be able to approach this topic. But even if talking about death is impossible, there are always behavioral clues--about your caregiver's tiredness, physical condition, health, prevailing mood, anxiety, financial concerns, outlook, overall well-being, and so on. And families unable to talk about death can often talk about how the caregiver is feeling, about finances, about tensions within the family resulting from the illness, about concerns for the future. Deciding whether you have a duty to die based on these behavioral clues and conversation about them honors your relationships better than deciding on your own about how burdensome you and your care must be.

I cannot say when someone has a duty to die. Still, I can suggest a few features of one's illness, history, and circumstances that make it more likely that one has a duty to die. I present them here without much elaboration or explanation.

1) A duty to die is more likely when continuing to live will impose significant burdens--emotional burdens, extensive caregiving, destruction of life plans, and, yes, financial hardship--on your family and loved ones. This is the fundamental insight underlying a duty to die.

2) A duty to die becomes greater as you grow older. As we age, we will be giving up less by giving up our lives, if only because we will sacrifice fewer remaining years of life and a smaller portion of our life plans. After all, its not as if we would be immortal and live forever if we could just manage to avoid a duty to die. To have reached the age of, say, seventy-five or eighty years without being ready to die is itself a moral failing, the sign of a life out of touch with life's basic realities. [9]

3) A duty to die is more likely when you have already lived a full and rich life. You have already had a full share of the good things life offers.

4) There is greater duty to die if your loved ones' lives have already been difficult or impoverished, if they have had only a small share of the good things that life has to offer (especially if through no fault of their own).

5) A duty to die is more likely when your loved ones have already made great contributions--perhaps even sacrifices--to make your life a good one. Especially if you have not made similar sacrifices for their well-being or for the well-being of other members of your family.

6) To the extent that you can make a good adjustment to your illness or handicapping condition, there is less likely to be a duty to die. A good adjustment means that smaller sacrifices will be required of loved ones and there is more compensating interaction for them. Still, we must also recognize that some diseases--Alzheimer or Huntington chorea--will eventually take their toll on your loved ones no matter how courageously, resolutely, even cheerfully you manage to face that illness.

7) There is less likely to be a duty to die if you can still make significant contributions to the lives of others, especially your family. The burdens to family members are not only or even primarily financial, neither are the contributions to them. However, the old and those who have terminal illnesses must also bear in mind that the loss their family members will feel when they die cannot be avoided, only postponed.

8) A duty to die is more likely when the part of you that is loved will soon be gone or seriously compromised. Or when you soon will no longer be capable of giving love. Part of the horror of cementing disease is that it destroys the capacity to nurture and sustain relationships, taking away a person's agency and the emotions that bind her to others.

9) There is a greater duty to die to the extent that you have lived a relatively lavish lifestyle instead of saving for illness or old age. Like most upper middle-class Americans, I could easily have saved more. It is a greater wrong to come to your family for assistance if your need is the result of having chosen leisure or a spendthrift lifestyle. I may eventually have to face the moral consequences of decisions I am now making.

These, then, are some of the considerations that give shape and definition to the duty to die. If we can agree that these considerations are all relevant, we can see that the correct course of action will often be difficult to discern. A decision about when I should end my life will sometimes prove to be every bit as difficult as the decision about whether I want treatment for myself.

Can the Incompetent Have a Duty to Die?

Severe mental deterioration springs readily to mind as one of the situations in which I believe I could have a duty to die. But can incompetent people have duties at all? We can have moral duties we do not recognize or acknowledge, including duties that we never recognized. But can we have duties we are unable to recognize? Duties when we are unable to understand the concept of morality at all? If so, do others have a moral obligation to help us carry out this duty? These are extremely difficult theoretical questions. The reach of moral agency is severely strained by mental incompetence.

I am tempted to simply bypass the entire question by saying that I am talking only about competent persons. But the idea of a duty to die clearly raises the specter of one person claiming that another--who cannot speak for herself--has such a duty. So I need to say that I can make no sense of the claim that someone has a duty to die if the person has never been able to understand moral obligation at all. To my mind, only those who were formerly capable of making moral decisions could have such a duty.

But the case of formerly competent persons is almost as troubling. Perhaps we should simply stipulate that no incompetent person can have a duty to die, not even if she affirmed belief in such a duty in an advance directive. If we take the view that formerly competent people may have such a duty, we should surely exercise extreme caution when claiming a formerly competent person would have acknowledged a duty to die or that any formerly competent person has an unacknowledged duty to die. Moral dangers loom regardless of which way we decide to resolve such issues.

But for me personally, very urgent practical matters turn on their resolution. If a formerly competent person can no longer have a duty to die (or if other people are not likely to help her carry out this duty), I believe that my obligation may be to die while I am still competent, before I become unable to make and carry out that decision for myself Surely it would be irresponsible to evade my moral duties by temporizing until I escape into incompetence. And so I must die sooner than I otherwise would have to. On the other hand, if I could count on others to end my life after I become incompetent, I might be able to fulfill my responsibilities while also living out all my competent or semi-competent days. Given our society's reluctance to permit physicians, let alone family members, to perform aid-in-dying, I believe I may well have a duty to end my life when I can see mental incapacity on the horizon.

There is also the very real problem of sudden incompetence--due to a serious stroke or automobile accident. for example. For me. that is the real nightmare. If I suddenly become incompetent, I will fall into the hands of a medical-legal system that will conscientiously disregard my moral beliefs and do what is best for me, regardless of the consequences for my loved ones. And that is nor at all what I would have wanted!

Social Policies and a Duty to Die

The claim that there is a duty to die will seem to some a misplaced response to social negligence. If our society were providing for the debilitated, the chronically ill, and the elderly as it should be, there would be only very rare cases of a duty to die. On this view, I am asking the sick and debilitated to step in and accept responsibility because society is derelict in its responsibility to provide for the incapacitated.

This much is surely true: there are a number of social policies we could pursue that would dramatically reduce the incidence of such a duty. Most obviously, we could decide to pay for facilities that provided excellent long-term care (not just health care!) for all chronically ill, debilitated, mentally ill, or demented people in this country. We probably could still afford to do this. If we did, sick, debilitated, and dying people might still be morally required to make sacrifices for their families. I might, for example, have a duty to forgo personal care by a family member who knows me and really does care for me. But these sacrifices would only rarely include the sacrifice of life itself. The duty to die would then be virtually eliminated.

I cannot claim to know whether in some abstract sense a society like ours should provide care for all who are chronically ill or debilitated. But the fact is that we Americans seem to be unwilling to pay for this kind of long-term care, except for ourselves and our own. In fact, we are moving in precisely the opposite direction--we are trying to shift the burdens of caring for the seriously and chronically ill onto families in order to save costs for our health care system. As we shift the burdens of care onto families, we also dramatically increase the number of Americans who will have a duty to die.

I must not, then, live my life and make my plans on the assumption that social institutions will protect my family from my infirmity and debility. To do so would be irresponsible. More likely, it will be up to me to protect my loved ones.

A Duty to Die and the Meaning of Life

A duty to die seems very harsh, and often it would be. It is one of the tragedies of our lives that someone who wants very much to live can nevertheless have a duty to die. It is both tragic and ironic that it is precisely the very real good of family and loved ones that gives rise to this duty. Indeed, the genuine love, closeness, and supportiveness of family members is a major source of this duty: we could not be such a burden if they did not care for us. Finally, there is deep irony in the fact that the very successes of our life-prolonging medicine help to create a widespread duty to die. We do not live in such a happy world that we can avoid such tragedies and ironies. We ought not to close our eyes to this reality or pretend that it just doesn't exist. We ought not to minimize the tragedy in any way.

And yet, a duty to die will not always be as harsh as we might assume. If I love my family, I will want to protect them and their lives. I will want not to make choices that compromise their futures. Indeed, I can easily imagine that I might want to avoid compromising their lives more than I would want anything else. I must also admit that I am not necessarily giving up so much in giving up my life: the conditions that give rise to a duty to die would usually already have compromised the quality of the life I am required to end. In any case, I personally must confess that at age fifty-six, I have already lived a very good life, albeit not yet nearly as long a life as I would like to have.

We fear death too much. Our fear of death has lead to a massive assault on it. We still crave after virtually any life-prolonging technology that we might conceivably be able to produce. We still too often feel morally impelled to prolong life--virtually any form of life--as long as possible. As if the best death is the one that can be put off longest.

We do not even ask about meaning in death, so busy are we with trying to postpone it. But we will not conquer death by one day developing a technology so magnificent that no one will have to die. Nor can we conquer death by postponing it ever longer. We can conquer death only by finding meaning in it.

Although the existence of a duty to die does not hinge on this, recognizing such a duty would go some way toward recovering meaning in death. Paradoxically, it would restore dignity to those who are seriously ill or dying. It would also reaffirm the connections required to give life (and death) meaning. I close now with a few words about both of these points.

First, recognizing a duty to die affirms my agency and also my moral agency. I can still do things that make an important difference in the lives of my loved ones. Moreover, the fact that I still have responsibilities keeps me within the community of moral agents. My illness or debility has not reduced me to a mere moral patient (to use the language of the philosophers). Though it may not be the whole story, surely Kant was onto something important when he claimed that human dignity rests on the capacity for moral agency within a community of those who respect the demands of morality.

By contrast, surely there is something deeply insulting in a medicine and an ethic that would ask only what I want (or would have wanted) when I become ill. To treat me as if I had no moral responsibilities when I am ill or debilitated implies that my condition has rendered me morally incompetent. Only small children⁷, the demented or insane, and those totally lacking in the capacity to act are free from moral duties. There is dignity, then, and a kind of meaning in moral agency, even as it forces extremely difficult decisions upon us.

Second, recovering meaning in death requires an affirmation of connections. If I end my life to spare the futures of my loved ones, I testify in my death that I am connected to them. It is because I love and care for precisely these people (and I know they care for me) that I wish not to be such a burden to them. By contrast, a life in which I am free to choose whatever I want for myself is a life unconnected to others. A bioethics that would treat me as if I had no serious moral responsibilities does what it can to marginalize, weaken, or even destroy my connections with others.

But life without connection is meaningless. The individualistic fantasy, though occasionally liberating, is deeply destructive. When life is good and vitality seems unending, life itself and life lived for yourself may seem quite sufficient. But if not life, certainly death without connection is meaningless. If you are only for yourself, all you have to care about as your life draws to a close is yourself and your life. Everything you care about will then perish in your death. And that--the end of everything you care about--is precisely the total collapse of meaning. We can, then, find meaning in death only through a sense of connection with something that will survive our death.

This need not be connections with ocher people. Some people are deeply died to land (for example, the family farm), to nature, or to a transcendent reality. But for most of us, the connections that sustain us are to other people. In the full bloom of life, we are connected to others in many ways--through work, profession, neighborhood, country, shared faith and worship, common leisure pursuits, friendship. Even the guru meditating in isolation on his mountain top is connected to a long tradition of people united by the same religious quest.

But as we age or when we become chronically ill, connections with other people usually become much more restricted. Often, only ties with family and close friends remain and remain important to us. Moreover, for many of us, other connections just don't go deep enough. As Paul Tsongas has reminded us, "When it comes time to die, no one says, 'I wish I had spent more time at the office.'"

If I am correct, death is so difficult for us partly because our sense of community is so weak. Death seems to wipe out everything when we can't fit it into the lives of those who live on. A death motivated by the desire to spare the futures of my loved ones might well be a better death for me than the one I would get as a result of opting to continue my life as long as there is any pleasure in it for me. Pleasure is nice, but it is meaning that matters.

I don't know about others, but these reflections have l helped me. I am now more at peace about facing a duty to die. Ending my life if my duty required might still be difficult. But for me, a far greater horror would be dying all alone or stealing the futures of my loved ones in order to buy a little more time for myself. I hope that if the time comes when I have a duty to die, I will recognize it, encourage my loved ones to recognize it too, and carry it out bravely.

ACKNOWLEDGMENTS

I wish to thank Mary English, Hilde Nelson, Jim Bennett, Tom Townsend, the members of the Philosophy Department at East Tennessee State University, and anonymous reviewers of the Report for many helpful comments on earlier versions of this paper. In this paper, I draw on material in John Hardwig, "Dying at the Right Time; Reflections on (Un)Assisted Suicide" in Practical Ethics, ed. H. LaFollette (London: Blackwell, 1996), with permission.

REFERENCES

[1.] Given the importance of relationships in my thinking, "responsibility"--rooted as it is in "respond"--would perhaps be the most appropriate word. Nevertheless, I often use "duty" despite its legalistic overtones, because Lamm's famous statement has given the expression "duty to die" a certain familiarity. But I intend no implication that there is a law that grounds this duty, nor that someone has a right corresponding to it.

[2.] For a discussion of the Oates case, see Tom L. Beauchamp, "What Is Suicide?" in Ethical Issues in Death and Dying, ed. Tom L. Beauchamp and Seymour Perlin (Englewood Cliffs, NJ: Prentice-Hall, 1978).

[3.] Most bioethicists advocate a "patient-centered ethics"--an ethics which claims only the patients interests should be considered in making medical treatment decisions. Most health care professionals have been trained to accept this ethic and to see themselves as patient advocates. For arguments that a patient-centered ethics should be replaced by a family-centered ethics see John Hardwig, "What About the Family?" Hastings Center Report 20, no. 2 (1990): 5-10; Hilde L. Nelson and James L. Nelson, The Patient in the Family (New York: Routledge, 1995).

[4.] A good account of the burdens of caregiving can be found in Elaine Brody, Women in the Middle: Their Parent-Care Years (New York: Springer Publishing Co., 1990). Perhaps the best article-length account of these burdens is Daniel Callahan, "Families as Caregivers; the Limits of Morality" in Aging and Ethics: Philosophical Problems in Gerontology, ed. Nancy Jecker (Totowa NJ: Humana Press, 1991).

[5.] Kenneth E. Covinsky et al., "The Impact of Serious Illness on Patients' Families," JAMA 272 (1994): 1839-44.

[6.] Larry Churchill, for example, believes that Christian ethics takes us far beyond my present position: "Christian doctrines of stewardship prohibit the extension of one's own life at a great cost to the neighbor . . . And such a gesture should not appear to us a sacrifice, but as the ordinary virtue entailed by a just, social conscience." Larry Churchill, Rationing Health Care in America (South Bend, Ind.: Notre Dame University Press, 1988), p. 112.

[7.] Kant, as is well known, was opposed to suicide. But he was arguing against taking your life out of self-interested motives. It is not clear that Kant would or we should consider taking your life out of a sense of duty to be wrong. See Hilde L. Nelson, "Death with Kantian Dignity," Journal of Clinical Ethics 7 (1996): 215-21.

[8.] Obviously, I owe this distinction to Norman Daniels. Norman Daniels, Am I My Parents' Keeper? An Essay on Justice Between the Young and the Old (New York: Oxford University Press, 1988). Just as obviously, Daniels is not committed to my use of it here.

[9.] Daniel Callahan, The Troubled Dream of Life (New York: Simon & Schuster, 1993).

Journal/Discussion Questions

! Can you ever imagine a circumstance in which you personally would feel that you had a duty to die? What would you do?

1. What is the fundamental insight that underlies Hardwig’s claim that we may have a duty to die in certain circumstances?

2. What specific circumstances would increase the likelihood that a person would have a duty to die, according to Hardwig? Do you agree with his analysis?

3. How does Hardwig answer the question of whether the incompetent have a duty to die? Do you agree with him? Explain.

4. How does Hardwig see the relationship between the duty to die and questions about the meaning of life?

James Rachels
“Active and Passive Euthanasia”

About the Author: James Rachels is one of the most prominent of contemporary moral philosophers, especially in the area of applied ethics. His books include Created from Animals : the Moral Implications of Darwinism, The Elements of Moral Philosophy, and The End of Life: the Morality of Euthanasia.

About the Article: This article, originally published in a medical journal and directed toward physicians, was the first major challenge to the moral significance of the distinction between active and passive euthanasia.

As You Read, Consider This:

1. Why, according to Rachels, is active euthanasia morally preferable to passive euthanasia in some cases?

2. What, accordig to Rachels, is the difference between killing and letting die?

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, and it is endorsed in a statement adopted by the House of Delegates of the American Medical Association on December 4, 1973:

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

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

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

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

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

Part of my point is that the process of being “allowed to die” can be relatively slow and painful, whereas being given a lethal injection is relatively quick and painless. Let me give a different sort of example. In the United States about one in 600 babies is born with Down’s syndrome. Most of these babies are otherwise healthy–that is, with only the usual pediatric care, they will proceed to an otherwise normal infancy. Some, however, are born with congenital defects such as intestinal obstructions that require operations if they are to live. Sometimes, the parents and the doctor will decide not to operate, and let the infant die. Anthony Shaw describes what happens then:

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

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

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

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

But notice that this situation is absurd, no matter what view one takes of the lives and potentials of such babies. If the life of such an infant is worth preserving, what does it matter if it needs a simple operation? Or, if one thinks it better that such a baby should not live on, what difference does it make that it happens to have an unobstructed intestinal tract? In either case, the matter of life and death is being decided on irrelevant grounds. It is the Down’s syndrome, and not the intestines, that is the issue. The matter should be decided, if at all, on that basis, and not be allowed to depend on the essentially irrelevant question of whether the intestinal tract is blocked.

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

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

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

In the second, Jones also stands to gain if anything should happen to his six-year-old cousin. Like Smith, Jones sneaks in planning to drown the child in his bath. However, just as he enters the bathroom Jones sees the child slip and hit his head, and fall face down in the water. Jones is delighted; he stands by, ready to push the child’s head back under if it is necessary, but it is not necessary. With only a little thrashing about, the child drowns all by himself, “accidentally,” as Jones watches and does nothing.

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

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

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

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

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

“The important difference between active and passive euthanasia is that, in passive euthanasia, the doctor does not do anything to bring about the patient’s death. The doctor does nothing, and the patient dies of whatever ills already afflict him. In active euthanasia, however, the doctor does something to bring about the patient’s death: he kills him. The doctor who gives the patient with cancer a lethal injection has himself caused his patient’s death; whereas if he merely ceases treatment, the cancer is the cause of the death.”

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

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

Finally, doctors may think that all of this is only of academic interest–the sort of thing that philosophers may worry about but that has no practical bearing on their own work. After all, doctors must be concerned about the legal consequences of what they do, and active euthanasia is clearly forbidden by the law. But even so, doctors should also be concerned with the fact that the law is forcing upon them a moral doctrine that may well be indefensible, and has a considerable effect on their practices. Of course, most doctors are not now in the position of being coerced in this matter, for they do not regard themselves as merely going along with what the law requires. Rather, in statements such as the AMA policy statement that I have quoted, they are endorsing this doctrine as a central point of medical ethics. In that statement, active euthanasia is condemned not merely as illegal but as “contrary to that for which the medical profession stands,” whereas passive euthanasia is approved. However, the preceding considerations suggest that there is really no moral difference between the two, considered in themselves (there may be important moral differences in some cases in their consequences, but, as I pointed out, these differences may make active euthanasia, and not passive euthanasia, the morally preferable option). So, whereas doctors may have to discriminate between active and passive euthanasia to satisfy the law, they should not do any more than that. In particular, they should not give the distinction any added authority and weight by writing it into official statements of medical ethics.

Endnote

¹ A. Shaw, “Doctor, Do We Have a Choice?” The New York Times Magazine (January 30, 1972): 54.

Journal/Discussion Questions

- Rachels maintains that active euthanasia is sometimes justified on the basis of a desire to alleviate suffering, and that it is more humane than passive euthanasia. What limits are there on compassionate action? Can compassion ever be a legitimate reason for ending someone’s life?

1. Rachels offers two principal arguments against the distinction between active and passive euthanasia. What are these arguments?

2. What objections does Rachels consider to his position? Are you convinced by his replies to those objections? Can you think of any objections that Rachels does not consider? What are they?

3. Rachels claims that “killing is not in itself any worse than letting die.” What support does he offer for this claim? Do you agree? Why or why not?

Richard Doerflinger
“Assisted Suicide: Pro-Choice or Anti-Life?”

About the Author: Richard Doerflinger is associate director of the Office for Pro-Life Activities of the National Conference of Catholic Bishops, Washington, DC.

About the Article: In this article, Doerflinger argues that respect for life is incompatible with assisting in active euthanasia. He argues, furthermore, that liberalization of the euthanasia laws is dangerous, because it could combine with other factors at work in society to threaten the value of individual lives.

As You Read, Consider This:

1. On what basis does Doerflinger claim that arguments in favor of assisted suicide presuppose a viewpoint on the value of life?

2. What, according to Doerflinger, are the two kinds of slippery slope arguments? Why is this dinstinction crucial for understanding the euthanasia issue?

The intrinsic wrongness of directly killing the innocent, even with the victim’s consent, is all but axiomatic in the Jewish and Christian worldviews that have shaped the laws and mores of Western civilization and the self-concept of its medical practitioners. This norm grew out of the conviction that human life is sacred because it is created in the image and likeness of God, and called to fulfillment in love of God and neighbor.

With the pervasive secularization of Western culture, norms against euthanasia and suicide have to a great extent been cut loose from their religious roots to fend for themselves. Because these norms seem abstract and unconvincing to many, debate tends to dwell not on the wrongness of the act as such but on what may follow from its acceptance. Such arguments are often described as claims about a “slippery slope,” and debate shifts to the validity of slippery slope arguments in general.

Since it is sometimes argued that acceptance of assisted suicide is an outgrowth of respect for personal autonomy, and not lack of respect for the inherent worth of human life, I will outline how autonomy-based arguments in favor of assisting suicide do entail a statement about the value of life. I will also distinguish two kinds of slippery slope argument often confused with each other, and argue that those who favor social and legal acceptance of assisted suicide have not adequately responded to the slippery slope claims of their opponents.

Assisted Suicide versus Respect for Life

Some advocates of socially sanctioned assisted suicide admit (and a few boast) that their proposal is incompatible with the conviction that human life is of intrinsic worth. Attorney Robert Risley has said that he and his allies in the Hemlock Society are “so bold” as to seek to “overturn the sanctity of life principle” in American society. A life of suffering, “racked with pain,” is “not the kind of life we cherish.”^l

Others eschew Risley’s approach, perhaps recognizing that it creates a slippery slope toward practices almost universally condemned. If society is to help terminally ill patients to commit suicide because it agrees that death is objectively preferable to a life of hardship, it will be difficult to draw the line at the seriously ill or even at circumstances where the victim requests death.

Some advocates of assisted suicide therefore take a different course, arguing that it is precisely respect for the dignity of the human person that demands respect for individual freedom as the noblest feature of that person. On this rationale a decision as to when and how to die deserves the respect and even the assistance of others because it is the ultimate exercise of self-determination–“ultimate” both in the sense that it is the last decision one will ever make and in the sense that through it one takes control of one’s entire self. What makes such decisions worthy of respect is not the fact that death is chosen over life but that it is the individual’s own free decision about his or her future.

Thus Derek Humphry, director of the Hemlock Society, describes his organization as “pro-choice” on this issue. Such groups favor establishment of a constitutional “right to die” modeled on the right to abortion delineated by the U.S. Supreme Court in 1973. This would be a right to choose whether or not to end one’s own life, free of outside government interference. In theory, recognition of such a right would betray no bias toward choosing death.

Life versus Freedom

This autonomy-based approach is more appealing than the straightforward claim that some lives are not worth living, especially to Americans accustomed to valuing individual liberty above virtually all else. But the argument departs from American traditions on liberty in one fundamental respect.

When the Declaration of Independence proclaimed the inalienable human rights to be “life, liberty, and the pursuit of happiness,” this ordering reflected a long-standing judgment about their relative priorities. Life, a human being’s very earthly existence, is the most fundamental right because it is the necessary condition for all other worldly goods including freedom; freedom in turn makes it possible to pursue (without guaranteeing that one will attain) happiness. Safeguards against the deliberate destruction of life are thus seen as necessary to protect freedom and all other human goods. This line of thought is not explicitly religious but is endorsed by some modem religious groups:

The first right of the human person is his life. He has other goods and some are more precious, but this one is fundamental–the condition of all the others. Hence it must be protected above all others.²

On this view suicide is not the ultimate exercise of freedom but its ultimate self-contradiction: A free act that by destroying life, destroys all the individual’s future earthly freedom. If life is more basic than freedom, society best serves freedom by discouraging rather than assisting self-destruction. Sometimes one must limit particular choices to safeguard freedom itself, as when American society chose over a century ago to prevent people from selling themselves into slavery even of their own volition.

It may be argued in objection that the person who ends his life has not truly suffered loss of freedom, because unlike the slave he need not continue to exist under the constraints of a loss of freedom. But the slave does have some freedom, including the freedom to seek various means of liberation or at least the freedom to choose what attitude to take regarding his plight. To claim that a slave is worse off than a corpse is to value a situation of limited freedom less than one of no freedom whatsoever, which seems inconsistent with the premise of the “pro choice” position. Such a claim also seems tantamount to saying that some lives (such as those with less than absolute freedom) are objectively not worth living, a position that “pro-choice” advocates claim not to hold.

It may further be argued in objection that assistance in suicide is only being offered to those who can no longer meaningfully exercise other freedoms due to increased suffering and reduced capabilities and lifespan. To be sure, the suffering of terminally ill patients who can no longer pursue the simplest everyday tasks should call for sympathy and support from everyone in contact with them. But even these hardships do not constitute total loss of freedom of choice. If they did, one could hardly claim that the patient is in a position to make the ultimate free choice about suicide. A dying person capable of making a choice of that kind is also capable of making less monumental free choices about coping with his or her condition. This person generally faces a bewildering array of choices regarding the assessment of his or her past life and the resolution of relationships with family and friends. He or she must finally choose at this time what stance to take regarding the eternal questions about Cod, personal responsibility, and the prospects of a destiny after death.

In short, those who seek to maximize free choice may with consistency reject the idea of assisted suicide, instead facilitating all choices except that one which cuts short all choices.

In fact proponents of assisted suicide do not consistently place freedom of choice as their highest priority. They often defend the moderate nature of their project by stating, with Derek Humphry, that “we do not encourage suicide for any reason except to relieve unremitting suffering.” It seems their highest priority is the “pursuit of happiness” (or avoidance of suffering) and not “liberty” as such. Liberty or freedom of choice loses its value if one’s choices cannot relieve suffering and lead to happiness; life is of instrumental value insofar as it makes possible choices that can bring happiness.

In this value system, choice as such does not warrant unqualified respect. In difficult circumstances, as when care of a suffering and dying patient is a great burden on family and society, the individual who chooses life despite suffering will not easily be seen as rational, thus will not easily receive understanding and assistance for this choice.

In short, an unqualified “pro-choice” defense of assisted suicide lacks coherence because corpses have no choices. A particular choice, that of death, is given priority over all the other choices it makes impossible, so the value of choice as such is not central to the argument.

A restriction of this rationale to cases of terminal illness also lacks logical force. For if ending a brief life of suffering can be good, it would seem that ending a long life of suffering may be better. Surely the approach of the California “Humane and Dignified Death Act”–where consensual killing of a patient expected to die in six months is presumably good medical practice, but killing the same patient a month or two earlier is still punishable as homicide–is completely arbitrary.

Slippery Slopes, Loose Cannons

Many arguments against sanctioning assisted suicide concern a different kind of “slippery slope”: Contingent factors in the contemporary situation may make it virtually inevitable in practice, if not compelling at the level of abstract theory, that removal of the taboo against assisted suicide will lead to destructive expansions of the right to kill the innocent. Such factors may not be part of euthanasia advocates’ own agenda; but if they exist and are beyond the control of these advocates, they must be taken into account in judging the moral and social wisdom of opening what may be a Pandora’s box of social evils

To distinguish this sociological argument from our dissection of the conceptual logic of the rationale for assisted suicide, we might call it a “loose cannon” argument. The basic claim is that socially accepted killing of innocent persons will interact with other social factors to threaten lives that advocates of assisted suicide would agree should be protected. These factors at present include the following:

The Psychological Vulnerability of Elderly and Dying Patients

Theorists may present voluntary and involuntary euthanasia as polar opposites; in practice there are many steps on the road from dispassionate, autonomous choice to subtle coercion. Elderly and disabled patients are often invited by our achievement-oriented society to see themselves as useless burdens on younger, more vital generations. In this climate, simply offering the option of “self-deliverance” shifts a burden of proof, so that helpless patients must ask themselves why they are not availing themselves of it. Society’s offer of death communicates the message to certain patients that they may continue to live if they wish but the rest of us have no strong interest in their survival. Indeed, once the choice of a quick and painless death is officially accepted as rational, resistance to this choice may be seen as eccentric or even selfish.⁵

The Crisis in Health Care Costs

The growing incentives for physicians, hospitals, families, and insurance companies to control the cost of health care will bring additional pressures to bear on patients. Curt Garbesi, the Hemlock Society’s legal consultant, argues that autonomy-based groups like Hemlock must “control the public debate” so assisted suicide will not be seized upon by public officials as a cost-cutting device. But simply basing one’s own defense of assisted suicide on individual autonomy does not solve the problem. For in the economic sphere also, offering the option of suicide would subtly shift burdens of proof.

Adequate health care is now seen by at least some policymakers as a human right, as something a society owes to all its members. Acceptance of assisted suicide as an option for those requiring expensive care would not only offer health care providers an incentive to make that option seem attractive-it would also demote all other options to the status of strictly private choices by the individual. As such they may lose their moral and legal claim to public support-in much the same way that the U.S. Supreme Court, having protected abortion under a constitutional “right of privacy,” has quite logically denied any government obligation to provide public funds for this strictly private choice. As life-extending care of the terminally ill is increasingly seen as strictly elective, society may become less willing to appropriate funds for such care, and economic pressures to choose death will grow accordingly.

Legal Doctrines on “Substituted Judgment”

American courts recognizing a fundamental right to refuse life-sustaining treatment have concluded that it is unjust to deny this right to the mentally incompetent. In such cases the right is exercised on the patient’s behalf by others, who seek either to interpret what the patient’s own wishes might have been or to serve his or her best interests. Once assisted suicide is established as a fundamental right, courts will almost certainly find that it is unjust not to extend this right to those unable to express their wishes. Hemlock’s political arm, Americans Against Human Suffering, has underscored continuity between “passive” and “active” euthanasia by offering the Humane and Dignified Death Act as an amendment to California’s “living will” law, and by including a provision for appointment of a proxy to choose the time and manner of the patient’s death. By such extensions our legal system would accommodate nonvoluntary, if not involuntary, active euthanasia.

Expanded Definitions of Terminal Illness

The Hemlock Society wishes to offer assisted suicide only to those suffering from terminal illnesses. But some Hemlock officials have in mind a rather broad definition of “terminal illness.” Derek Humphry says “two and a half million people alone are dying of Alzheimer’s disease.”⁴ At Hemlock’s 1986 convention, Dutch physician Pieter Admiraal boasted that he had recently broadened the meaning of terminal illness in his country by giving a lethal injection to a young quadriplegic woman–a Dutch court found that he acted within judicial guidelines allowing euthanasia for the terminally ill, because paralyzed patients have difficulty swallowing and could die from aspirating their food at any time.

The medical and legal meaning of terminal illness has already been expanded in the United States by professional societies, legislatures, and courts in the context of so-called passive euthanasia. A Uniform Rights of the Terminally Ill Act proposed by the National Conference of Commissioners on Uniform State Laws in 1986 defines a terminal illness as one that would cause the patient’s death in a relatively short time if life-preserving treatment is not provided–prompting critics to ask if all diabetics, for example, are “terminal” by definition. Some courts already see comatose and vegetative states as “terminal” because they involve an inability to swallow that will lead to death unless artificial feeding is instituted. In the Hilda Peter case, the New Jersey Supreme Court declared that the traditional state interest in “preserving life” referred only to “cognitive and sapient life” and not to mere “biological” existence, implying that unconscious patients are terminal, or perhaps as good as dead, so far as state interests are concerned Is there any reason to think that American law would suddenly resurrect the older, narrower meaning of “terminal illness” in the context of active euthanasia?

Prejudice against Citizens with Disabilities

If definitions of terminal illness expand to encompass states of severe physical or mental disability, another social reality will increase the pressure on patients to choose death: long-standing prejudice, sometimes bordering on revulsion, against people with disabilities. While it is seldom baldly claimed that disabled people have “lives not worth living,” able-bodied people often say they could not live in a severely disabled state or would prefer death. In granting Elizabeth Bouvia a right to refuse a feeding tube that preserved her life, the California Appeals Court bluntly stated that her physical handicaps led her to “consider her existence meaningless” and that “she cannot be faulted for so concluding.” According to disability rights expert Paul Longmore, in a society with such attitudes toward the disabled, “talk of their ‘rational’ or ‘voluntary’ suicide is simply Orwellian newspeak”⁵

Character of the Medical Profession

Advocates of assisted suicide realize that most physicians will resist giving lethal injections because they are trained, in Garbesi’s words, to be “enemies of death.” The California Medical Association firmly opposed the Humane and Dignified Death Act, seeing it as an attack on the ethical foundation of the medical profession.

Yet California appeals judge Lynn Compton was surely correct in his concurring opinion in the Bouvia case, when he said that a sufficient number of willing physicians can be found once legal sanctions against assisted suicide are dropped. Judge Compton said this had clearly been the case with abortion, despite the fact that the Hippocratic Oath condemns abortion as strongly as it condemns euthanasia. Opinion polls of physicians bear out the judgment that a significant number would perform lethal injections if they were legal.

Some might think this division or ambivalence about assisted suicide in the medical profession will restrain broad expansions of the practice. But if anything, Judge Compton’s analogy to our experience with abortion suggests the opposite. Most physicians still have qualms about abortion, and those who perform abortions on a full-time basis are not readily accepted by their colleagues as paragons of the healing art. Consequently, they tend to form their own professional societies, bolstering each other’s positive self-image and developing euphemisms to blunt the moral edge of their work.

Once physicians abandon the traditional medical self-image, which rejects direct killing of patients in all circumstances, their new substitute self-image may require ever more aggressive efforts to make this killing more widely practiced and favorably received. To allow killing by physicians in certain circumstances may create a new lobby of physicians in favor of expanding medical killing.

The Human Will to Power

The most deeply buried yet most powerful driving force toward widespread medical killing is a fact of human nature: Human beings are tempted to enjoy exercising power over others; ending another person’s life is the ultimate exercise of that power. Once the taboo against killing has been set aside, it becomes progressively easier to channel one’s aggressive instincts into the destruction of life in other contexts. Or as James Burtchaell has said: “There is a sort of virginity about murder; once one has violated it, it is awkward to refuse other invitations by saying, ‘But that would be murder!’”⁶

Some will say assisted suicide for the terminally ill is morally distinguishable from murder and does not logically require termination of life in other circumstances. But my point is that the skill and the instinct to kill are more easily turned to other lethal tasks once they have an opportunity to exercise themselves. Thus Robert Jay Lifton has perceived differences between the German “mercy killings” of the 1930s and the later campaign to annihilate the Jews of Europe, yet still says that “at the heart of the Nazi enterprise...is the destruction of the boundary between healing and killing”⁷ No other boundary separating these two situations was as fundamental as this one, and thus none was effective once it was crossed. As a matter of historical fact, personnel who had conducted the “mercy killing’ program were quickly and readily recruited to operate the killing chambers of the death camps.⁸ While the contemporary United States fortunately lacks the anti-Semitic and totalitarian attitudes that made the Holocaust possible, it has its own trends and pressures that may combine with acceptance of medical killing to produce a distinctively American catastrophe in the name of individual freedom.

These “loose cannon” arguments are not conclusive. All such arguments by their nature rest upon a reading and extrapolation of certain contingent factors in society. But their combined force provides a serious case against taking the irreversible step of sanctioning assisted suicide for any class of persons, so long as those who advocate this step fail to demonstrate why these predictions are wrong. If the strict philosophical case on behalf of “rational suicide” lacks coherence, the pragmatic claim that its acceptance would be a social benefit lacks grounding in history or common sense.

Endnotes

¹ Presentation at the Hemlock Society’s Third National Voluntary Euthanasia Conference, “A Humane and Dignified Death,” September 2-27, 1986, Washington, DC. All quotations from Hemlock Society officials are from the proceedings of this conference unless otherwise noted.

²Vatican Congregation for the Doctrine of the Faith, Declaration on Procured Abortion (1974), para. 11.

³I am indebted for this line of argument to Dr. Eric Chevlen.

⁴Denis Herbstein, “Campaigning for the Right to Die,” International Herald Tribune, 11 September 1986.

⁵Paul K Longmore, “Elizabeth Bouvia, Assisted Suicide, and Social Prejudice,” Issues in Law Medicine 3:2 (1987), 168.

⁶James T. Burtchaell, Rachel Weeping and Other Essays on Abortion (Kansas City: Andrews & McMeel, 1982), 188.

⁷Robert Jay Lifton, The Nazi Doctors: Medical Killing and the Psychology of Genocide (New York: Basic Books, 1986), 14.

⁸Yitzhak Rad, Belzec, Sobibor, Treblinka (Bloomington, IN: Indiana University Press, 1987), 11, 16-17.

Journal/Discussion Questions

- Doerflinger’s analysis takes place within the larger context of a Christian worldview. Do you share this worldview? Do you agree with Doerflinger’s conclusions about euthanasia?

1. According to Doerflinger, the prohibition against killing the innocent is grounded in the Judeo-Christian conviction that life is sacred. Do you think that the religious belief that human life is sacred necessarily leads to the conclusion that voluntary euthanasia is always morally wrong? Do other religious traditions permit euthanasia? Discuss.

2. Both Doerflinger and Vaux (“The Theologic Ethics of Euthanasia”) claim to present Christian positions. How are their positions different? Are they both Christian? Discuss.

3. Doerflinger argues that proponents of euthanasia claim that liberty is their highest value, but this claim is misleading. Why, according to Doerflinger, is it misleading?

4. In the “loose cannon” argument, Doerflinger maintains that legalizing euthanasia will interact with seven other factors in our society in ways that are ultimately harmful. What are these other factors? How plausible do you think each of these sever arguments is? Which of the seven factors do you think is the greatest threat?

5. Doerflinger sees euthanasia as related to “the human will to power.” What does he mean by this? Are you convinced by his analysis? Discuss.

Gregory S. Kavka
“Banning Euthanasia”

About the Author: Gregory Kavka is the author of Hobbesian Moral and Political Theory (Princeton, 1986) and Moral Paradoxes of Nuclear Deterrence (Cambridge, 1987) as well as numerous articles in moral and political philosophy. He died of cancer in 1994 at the age of 46.

About the Article: In the following article, Kavka maintains that it is wrong to prevent people from rescuing others in great suffering, and that banning voluntary euthanasia does precisely this, for it prevents some people (usually physicians) from rescuing someone else (usually a patient) from great suffering.

As You Read, Consider This:

1. What is the basic moral principle that Kavka’s argument rests on?

2. On what basis does Kavka prevent his argument from justifying (assisted) suicide in general?

Recently, the Dutch Parliament has made active voluntary euthanasia ^“quasi-legal^” in the Netherlands by voting to formally protect from prosecution physicians who carry it out under strict and clearly defined guidelines.¹ Yet, with the failure of Proposition 161 in the November 1992 election in California, active voluntary euthanasia remains illegal in all fifty states of the United States. Indeed, the legislature of the state of Michigan has recently passed a law specifically designed to prevent retired Pathologist Jack Kevorkian (or any of his followers) from euthanizing patients by assisting them in committing suicide.²

In this paper, I will present a simple, but novel, moral argument for legalizing active voluntary euthanasia. In brief, I argue that banning active voluntary euthanasia, by forbidding it either in law or in professional codes of medical practice, is very morally wrong because it prevents some people from rescuing others from great suffering. Spelled out more fully, my argument rests on some general, but highly plausible, factual claims combined with a simple and attractive moral principle. Below, I set out the argument by presenting its factual and moral elements in turn, explaining its conclusion, and defending it from some important objections.

The Argument

Factual Premises

The factual premisses of my argument concern, respectively, those who may wish to be euthanized and those (especially some physicians) who might be willing to euthanize them. First, it is evident that there are some people who are in such great suffering due to irreversible and adverse medical circumstances that they wish to have their lives ended very soon, even though they are aware that–in their own case–this can be done only by active euthanasia (e.g., a fatal injection). This is merely to say that there are some patients who would want active euthanasia if it were available to them.³ Second, banning active voluntary euthanasia–by law or codes of medical ethics–deters some people (in particular, some physicians) from actively euthanizing some people who want to have their lives ended in this manner.⁴ In other words, if medical codes and laws were liberalized to allow active voluntary euthanasia, there would be more physicians who would make this option available to more patients. Putting these two simple assertions together yields the main conclusion of the factual component of my argument: Banning active voluntary euthanasia prevents some people (physicians) from rescuing some others (patients) from great suffering in a manner in which these others wish to be rescued.

The Moral Principle

The Case of the Evil Colonel. Turning to the moral component of my argument, let us begin our inquiry by imagining a non-medical situation in which a person^’s only release from great suffering is death. An evil Colonel is the unrestrained ruler of his military district in some backward country, and he is greatly angered at some unfortunate Private (e.g., for not showing the Colonel sufficient respect). He begins to slowly and agonizingly torture the Private to death over a period of weeks, making no bones of his aim of inflicting maximum suffering ending in death. After only a few hours of torture, the Private (even during intervals between the torture sessions) begs repeatedly to be killed immediately by any means rather than have the torture go on. The only one–besides the heartless Colonel–in a position to save him from weeks of torture (without sharing his fate) is the Water Boy who periodically brings water for the Private to drink. In the kitchen, he slips a fatal dose of poison in the cup of water he is about to take to the prisoner. (The poison will kill the prisoner in a short time, but is not likely to be discovered–the Colonel is not the type to ask for an autopsy when a prisoner drops dead during torture.) The Cook in the kitchen sees what the Water Boy is doing and stops him by threatening to tell the Colonel if the Water Boy delivers the poison to the Private.

It is clear that in this situation the Cook has acted wrongly, very wrongly. He has eliminated the Private^’s only real hope of rescue from weeks of agonizing torture. His conduct is not, of course, as wrongful as that of the Colonel, but that is hardly to say anything in its favor. It is also worth noting that what the Cook does is much worse than merely allowing torture to go forward without intervening. Suppose, for example, that the Water Boy had declined to poison the water even though he was certain he could do so without risk of detection. Whether, in that case, he acts wrongly in failing to rescue to the Private is, perhaps, a difficult question to answer. But the Cook does not merely fail to rescue, he prevents a rescue-in-progress from taking place. That this is much worse is evident when we consider the parallel case of aiding the world^’s starving poor. Philosophers have extensively debated the issue of whether citizens in wealthy nations are failing to live up to their obligations if they do not provide aid to the world^’s starving poor.⁵ But it is not debatable that it would be very wrong to prevent others who are willing to provide such aid from doing so. No one, for example, would regard a law preventing U.S. citizens or charities from providing aid to the world^’s starving poor as anything but iniquitous. Clearly, however bad it is to fail to rescue someone in dire need, it is worse to actively intervene to prevent someone else from rescuing them.

These considerations flowing from our hypothetical torture case suggest the following moral principle: It is very wrong to prevent someone from rescuing someone else from great suffering (in a manner in which the latter person wishes to be rescued). It is this principle which explains what the Cook has done wrong. He has prevented one person, the Water Boy, from rescuing another, the Private, from great suffering, the Colonel^’s torture, in a manner in which the Private–in his constant pleading for an early death–wishes to be rescued.

Combining this simple moral principle with the earlier factual claim that banning active voluntary euthanasia prevents some people from rescuing others from great suffering in a manner in which the latter wish to be rescued immediately yields the conclusion that banning active voluntary euthanasia is very wrong.⁶ And it is wrong for one of the same reasons that torture is wrong: it involves acting in such a way as to insure that people experience great suffering that they would not experience, save for the actor^’s intervention.⁷ (The Private’s continued great suffering, past the point at which the Water Boy would have poisoned him absent the Cook^’s threat, is the result of the interventions of both the Colonel and the Cook.) Of course, if banning active voluntary euthanasia is very wrong, as this argument indicates, legislators and physicians^’ organizations should act forthwith to remove their blanket bans on it.

Note, however, that the argument allows for the legitimacy of strict restrictions on the practice of active euthanasia, to insure both the voluntariness of the patient^’s choice and the presence of great suffering brought on by a medical condition. The Dutch rules, for example, ^“state that the request for euthanasia must come from a patient who is doing so voluntarily, who is mentally competent, has a hopeless disease without prospect for improvement, and is undergoing unbearable physical or mental suffering.^”8Such restrictions conflict with neither the spirit nor the letter of my argument. It is only in those cases in which considerations concerning the patient^’s well being (i.e., ending of great suffering from a hopeless medical condition) and her autonomous choices concur in recommending early death as the best course of action, that my argument implies we may not prevent physicians from pursuing this course. It is an argument for legalizing active voluntary euthanasia, not for allowing suicide (or assisted suicide) in general.

Notice, however, that my argument does not require that the patient be in terminal condition. Why not? Because if it is wrong to prevent a terminal patient being relieved of a short period of great suffering, it is at least as wrong to prevent non-terminal patients being relieved of longer periods of great suffering. Intuitively, we tend to recoil from this conclusion. If, for example, you survey a large class of undergraduates, you typically find a large majority in favor of euthanasia for the terminally ill who are suffering, and a large majority against euthanasia for patients suffering from horrible chronic conditions that are not terminal.⁹ You can bring out the tension between these two beliefs by simply asking them ^“Which is worse, suffering for a short time or suffering for a long time?^”10The Same point can be made by considering a variation of our earlier torture case in which the Colonel plans to extend the Private^’s torture over months and years. The Cook^’s interference with the Water Boy^’s rescue-by-poisoning plan would be even more reprehensible in this case than in the case described earlier. For it would doom the Private to a much longer period of extreme misery.

Objections and Replies

First Objection. Having set out my main argument, and having clarified the sorts of restrictions on active voluntary euthanasia it supports, I proceed to defend the argument by answering six objections to it. The first objection says that it is permissible–even obligatory–to stop someone from being rescued from great suffering if they will die as the result of the ^“rescue.^” Thus, for example, if someone is suffering greatly from a painful but life-saving medical procedure, and an onlooker attempts to interrupt the proceedings to stop the patient^’s pain, it would be correct for you to subdue the onlooker so that the procedure may continue.

This objection establishes that some rescues to prevent great suffering may be permissibly prevented on the grounds that the rescue would result in the sufferer^’s death. But it fails to establish that such prevention is permissible whenever the rescue would kill the sufferer. For consider our earlier example of the Private being tortured by the Colonel. The Water Boy^’s rescue-by-poisoning would kill the Private, yet we judge the Cook^’s interference with this rescue to be wrong in full knowledge of this fact, because the rescue is in the Private^’s interest and has his consent. And clearly the physician who provides a fatal injection to a patient suffering horribly from an irreversible medical condition is acting in a situation parallel to that of the Water Boy, rather than that of the onlooker who attempts to disrupt a painful life-saving procedure.

This reply may not satisfy the objector. For he may believe in absolute deontological prohibitions against certain kinds of actions, including deliberately (or intentionally) killing the innocent. Even if there are such absolute prohibitions, it does not follow immediately that they should be enshrined in, or enforced by, law. For example, while deceitful betrayal of a close friend, or blasphemy against the true deity, are kinds of acts that may always be wrong, it might be unwise and harmful to legally punish such acts. Still, the prohibition on deliberately killing the innocent might be regarded as so central to social life that it must be enshrined in law.

But is there any such absolute prohibition? Supposing so has wildly counterintuitive implications concerning a class of cases I call Extra Death cases. In such cases, deliberately killing an innocent person is the only way to prevent that person and other innocent persons from being killed. In such cases, if we refrain from killing, innocent people will die that we could have saved, and no innocent people will be saved. A common case of this sort arises fairly frequently if–at least for the sake of argument–we regard the human fetus as a person. When an abortion can save the mother^’s life, but both mother and fetus will die if one is not performed, we have an Extra Death case. The fetus perishes whatever is done, but aborting saves the mother. Yet the absolute prohibition view says–quite implausibly–that we must not abort, that we must sacrifice the mother^’s life, even though the fetus cannot benefit.¹¹

Would it help to modify the absolute prohibition view to allow killing the innocent when other lives are saved and the victim consents? It does make the view more plausible, but only at the cost of undermining the objection to my argument. Suppose, for example, that the modified doctrine allows physicians to kill a terminal patient, with her consent, to allow her still healthy kidneys to be transplanted to save the lives of two of her children who each need one of her kidneys to live. If this is so, it would seem arbitrary to deny the permissibility of the same action to save her children the sufferings involved in a lifetime of kidney-dialysis. But if she may be killed, with her consent, to prevent the great suffering of others, it would be outrageous to suppose that she could not be killed, with her consent, to prevent her own great suffering. Thus, the objection based on an absolute prohibition on deliberately killing the innocent leads to a painful dilemma for its supporters: either they accept the highly implausible implications of their view in Extra Death cases, or they allow for reasonable modifications in their absolutism and end up unable to condemn voluntary euthanasia. We may leave them impaled on the horns of this dilemma and move on.

Second Objection. A second objection notes that my argument implicitly (and wrongly) assumes that early death may benefit a person in great suffering. Despite rejection of this assumption by some writers on euthanasia,¹² I feel safe in relying on it. Can we deny that the dead victims of torture would have been better off if they had died earlier in the horrible process? Can we deny that some of those who endure the ^“natural tortures^” imposed by painful and debilitating illnesses without hope of recovery would benefit from an early death? If we do deny this, if we hold that early death harms all patients, then we must oppose passive as well as active euthanasia, a position that few would be willing to accept.

Third Objection. Another implicit assumption of my argument–that death is the only alternative to great suffering–leads to a third objection. In my torture cases, I have stipulated that the Private may be rescued from torture only by death. Otherwise, if–for example–the cavalry is on the way to capture the Colonel, the Water Boy is wrong to poison the Private and the Cook is right to stop him. But, continues the objection, in the real world, the cavalry is on the way for suffering patients, in the form of better medical treatment for pain. Thus, active euthanasia is no longer justified, because it is no longer needed.¹³

To the extent that improved pain management techniques make life bearable and worth continuing for the afflicted, the urgency of legalizing active voluntary euthanasia is reduced. But no one is supposing that now, or in the near future, all the afflicted will be successfully treated by these techniques. Pain-killers do not address all of the sufferings of the afflicted: the disabilities, the mental anguish, the loss of the enjoyments of normal life, the loss of independence, and so on.¹⁴ And even if all significant physical pain could be eliminated short of death in principle (an unrealistic prospect in any case), real suffering patients actually being relieved of their physical pains by an overburdened and imperfect medical system is too much to expect. For those whose sufferings remain untreatable, or untreated, death may remain the only way in fact in their own case to relieve their suffering. If and when pain management techniques overcome the need for voluntary euthanasia, patients will stop requesting it. In the meantime, it is wrong to deprive those who do request it of their only practical succor from great suffering by preventing willing physicians from euthanizing them under appropriate safeguards.

Fourth Objection. Perhaps the most likely objection to my argument that it is wrong to ban active voluntary euthanasia is the claim that regardless of the beneficial effects such acts of euthanasia may have for particular patients, legalizing euthanasia would have bad effects on society as a whole. Various possible negative effects are often cited in this context, including negative effects on the morale of medical personnel, and reduction of incentives to manage pain. But the most common, and significant objection of this form is a slippery slope argument: if we legalize active voluntary euthanasia, this will eventually lead to the legalization of other, more objectionable, forms of euthanasia, to the great detriment of society.

Now to succeed, slippery slope arguments must establish two things: first, that following policy A is likely to lead to later policy or effect B, and that B is socially harmful or morally odious. In other words, we should not adopt A, because we will then slide down the slippery slope and end up at an undesirable place. But there are two different possible long-range effects of legalizing active voluntary euthanasia–the legalization of active non-voluntary euthanasia (e.g., of the permanently comatose and others who cannot express their will) and the legalization of active involuntary euthanasia (e.g., of those who do not want to die but are pressured into saying that they do, or are killed against their wishes to economize on medical costs). Legalization of active non-voluntary euthanasia might well follow from the legalization of active voluntary euthanasia, but it is unclear that this is undesirable if there are appropriate restrictions and safeguards. Active involuntary euthanasia, on the other hand, is clearly undesirable–tantamount to murder, we might say without much exaggeration. But it seems highly unlikely, in a civilized society, that its legalization would result from legalizing active voluntary euthanasia. So legalizing active voluntary euthanasia has one purported ^“slippery slope^” effect that is bad (i.e., legalized active involuntary euthanasia), and one that is likely (i.e., legalized non-voluntary euthanasia), but none that is both bad and likely. Hence, the slippery slope argument against active voluntary euthanasia apparently fails.¹⁵

The objection to legalization of active voluntary euthanasia based on bad social consequences–whether or not it is formulated as a slippery slope argument–fails for a more general reason. Preventing patients who wish to be euthanized from being rescued from their great sufferings, in order to benefit society, would unfairly sacrifice their vital individual interests to the end of collective benefit. Most philosophers find strict utilitarian moral theory unacceptable for precisely this reason–it allows, indeed requires, the well-being of individuals to be sacrificed to promote group good.¹⁶ This is especially outrageous when the individual losses are large, concrete, certain, and fall on some of society^’s least fortunate members (e.g., those in the most hopeless and painful medical conditions), while the group gains are indirect, diffuse, and speculative. And this is precisely the situation as regards the banning of active voluntary euthanasia.

Fifth Objection. But perhaps the worry of opponents of legalizing euthanasia is not about social harm, but the harm to individuals who might be euthanized against their wills. And even if a slide down the slippery slope to legalized involuntary euthanasia is unlikely, it is more plausible to claim that once any form of euthanasia is legalized, safeguards will inevitably be abused so that many patients end up being killed against their wills. Indeed, critics of legalized euthanasia have contended that the Dutch experience validates this claim, with statistics indicating that about 140 patients a year in the Netherlands are actively euthanized without being consulted, even though they were competent to be consulted and to give or withhold consent.¹⁷ The implication is that some of these people would not have consented, and hence were killed against their wills.

Others have interpreted the Dutch data differently. They point out that these ^“unconsulted competent^” patients were all in a hopeless terminal condition, a significant fraction of them had previously expressed a desire for early life-termination, that families were consulted in nearly all cases, and that life expectancy was less than a day for more than half these patients, and less than a week for eighty-seven per cent of them.¹⁸ Thus, one knowledgeable observer writes, ^“There is no evidence of any patient being put to death against his or her implied wish.^”19 It has also been observed that there are characteristics of the American legal system that would make involuntary euthanasia less likely here than in Holland if voluntary euthanasia were legalized,²⁰ and that there are a number of institutional safeguards that can be instituted to prevent involuntary euthanasia from occurring in a significant number of cases.²¹ In light of this, it seems that to oppose legalizing euthanasia in the United States one must either (1) take a quite pessimistic view of our legal and medical systems^’ capacities to enact, heed and enforce such safeguards, or (2) must consider it more important to save a few imminently terminal patients from unwanted earlier deaths than to save very many times that number of patients from great, unwanted, and unnecessary suffering. In my view, we should not be so cynical about our institutions, or so convinced of the great value of life irrespective of its quality for the person whose life it is, as to endorse either of these attitudes.

Sixth Objection. A final objection to my argument is that–contrary to my conclusion–laws prohibiting active voluntary euthanasia are morally permissible because as individuals have no right to be euthanized, society has no obligation to allow euthanasia. The astute deontological ethicist F. M. Kamm presents a version of this argument in the following passage:

Yet even if it is permissible to perform voluntary active euthanasia, we are not obligated to do so, and so even the person who requests it does not have a right to active euthanasia. And even though many people are willing to kill someone for his own good, many others are not. . . . Although many people who wish to be actively euthanized may not get their wish if we do not permit active euthanasia, they also will not have their rights violated, nor will we fail in our duties to them if there is a law prohibiting active euthanasia.²²

Now I would agree that individuals have no unconditional right to be actively euthanized–that is, a right to be actively euthanized even if no one volunteers to perform this service for them. And this is so for the very reason that Kamm suggests: some people object to performing active euthanasia, and no one who so objects should be obligated to do so. But it does not follow that individuals lack the conditional right to be actively euthanized, the right to be actively euthanized (under appropriate circumstances) provided there are volunteers who are willing to supply this service. This can readily be seen by considering the right to marry. This is clearly not a right to be married regardless of whether anyone wants to marry you, but a conditional right to marry if a volunteer can be found. The fact that some people (indeed most) would not wish to marry you in no way implies that you lack this conditional right. But this conditional right to marry would be violated, or negated, by a law banning marriage, as the conditional right to be actively euthanized by a willing volunteer is violated by laws banning active euthanasia. Thus, Kamm^’s argument that we may permissibly ban active euthanasia turns out to be a non sequitur, apparently brought on by failure to note in this context the important moral difference between failing to rescue someone from suffering and preventing a willing third-party from carrying out such a rescue. Even lacking an unconditional right to be rescued, we may possess a right that third parties not interfere with (or prevent) our rescue by a willing party.

Of course, even the conditional right to be actively euthanized has been challenged. Leon Kass writes,

Even if we…merely allow those to practice it [active voluntary euthanasia] who are freely willing, our society would be drastically altered. For unless the state accepts the job of euthanizer, which God forbid that it should, it would thus surrender its monopoly on the legal use of lethal force, a monopoly it holds and needs if it is to protect innocent life, its first responsibility.²³

How are we to understand this argument? If the state^’s ^“first responsibility^” of protecting innocent life is understood to include protecting a suffering patient from active euthanasia at his own request, Kass^’ argument begs the question by assuming what is to be proved: that the state should prevent voluntary active euthanasia. But if protecting innocent life does not include this sort of protection, an argument is needed why the state^’s surrendering authority over this particular use of lethal force (e.g., to physicians) would undermine its effective exercise of its right to use force to protect innocent life in other contexts. Are we to suppose that legalizing active voluntary euthanasia will undermine the efforts of the police and courts to deter and punish crime, or of the armed forces to defend the state in just wars? If so, Kass owes us an argument to that effect.

In closing, I should note that the success of my argument does not strictly depend on asserting possession of an individual right to be actively euthanized, even the conditional right to be actively euthanized at your request if conditions are appropriate and there is a willing volunteer. Rather, my argument establishes that it is morally wrong for the state (and medical groups) to prevent physicians from rescuing patients from great suffering at the patients^’ request by blanket bans on active euthanasia. My argument does not assert that this is wrong because of some right the patient has, but rather because it is wrong to make a person undergo great, unwanted, and unnecessary suffering if we can prevent that suffering by merely standing aside and letting a willing volunteer rescue that person from it.

Acknowledgements

An earlier version of this paper was presented to the Moral and Political Philosophy Society of Orange County (MAPPS) and to the Liberty Society of Irvine. I am grateful to members of those groups, and to Jefferson McMahan, for helpful comments. Ronald B. Miller and Kurt Norlin provided useful references.

Endnotes

^1“Dutch Parliament Approves Law Permitting Euthanasia,^” New York Times, International Edition, February 10, 1993, Section A, page 5.

^2“Dr. Kevorkian^’s Death Wish,^” Newsweek, March 8, 1993, pp. 46-48. In this paper, I treat assisted suicide of those facing a life not worth living because of their medical condition as a special case of voluntary euthanasia.

³It would be hard for opponents of legalizing active voluntary euthanasia to reject this premise. If it were false, legalization would not have a significant practical effect for want of any volunteers.

⁴Again, opponents of active voluntary euthanasia would have to acknowledge the truth of this premise or admit that laws banning active voluntary euthanasia have only a symbolic function.

⁵Aiken, William, and LaFollette, Hugh, eds. World Hunger and Moral Obligation (Englewood Cliffs: Prentice Hall, 1977).

⁶Since a legal ban prevents rescue from great suffering in many cases, it is presumably much worse than preventing rescue from suffering in a single instance, other things being equal.

⁷There is another possible difference between preventing rescue from human torture and preventing rescue from the ^“natural torture^” endured by some patients. Torture, unlike a patient^’s suffering, may be thought of as a bad with two components--the natural evil of the patient^’s horrible experience, and the moral evil of its deliberate infliction by the torturer. It might therefore be thought that, other things being equal, it is more important to prevent torture inflicted by people than torture inflicted by nature. If so, it would perhaps be worse to prevent the prevention of torture in a particular instance (e.g., stop the Water Boy from poisoning the Private) than to prevent the prevention of natural suffering in a particular instance (e.g., by restraining a Dr. Kevorkian from assisting a patient in committing suicide). Whether this argument works, however, depends on whether you think the moral evil created by the Colonel is diminished if the Private drops dead of poison before the Colonel is finished with him. I am inclined to doubt that it is.

Jefferson McMahan has suggested to me the following additional argument (which he attributes to Thomas Scanlon) that it is not more important to stop harms caused by evil people than by natural events. If it were, then we should choose to rescue nineteen people from suffering (or death) caused by evil people rather than save twenty others from equal suffering (or death) caused by natural disaster. But, faced with such a choice, and all other things being equal, it seems clear we should save the greater number.

^8“Dutch Parliament Approves Law Permitting Euthanasia,^” op. cit.

⁹I owe this point to Virginia Warren.

¹⁰Favoring euthanasia only in terminal cases could make sense if accompanied by certain empirical background assumptions, e.g., suffering is much worse in the terminal stages of illness, non-terminal patients may be saved by new miracle cures.

¹¹For an example of an otherwise well-argued deontological view that founders on its failure to recognize and address the Extra Death problem, see Charles Fried, Right and Wrong (Cambridge, Mass.: Harvard University Press, 1978) The various attempts of supporters of the Doctrine of Double Effect to get around this problem face an unsolved dilemma: if they allow sufficient ^“redescription^” in this sort of case so that the fetus^’ death turns out unintended (hence permissible), similar redescriptions will vitiate the bite of the Doctrine so that it cannot proscribe what its supporters want it to proscribe, e.g. civilian bombing in warfare.

¹²Leon R. Kass (^“Is There a Right to Die?^”, Hastings Center Report, 23 [January-February, 1993]: 42) writes: ^“[W]e cannot serve the patient^’s good by deliberately eliminating the patient.^”

¹³An argument of this form is suggested in Alexander Morgan Capron, ^“At Law--Even in Defeat, Proposition 161 Sounds a Warning,^” Hastings Center Report 23 (January-February, 1993): 32-34.

¹⁴While 46% of patients in the Netherlands requesting euthanasia gave ^“pain^” as a reason for their request, an equal percentage mentioned ^“unworthy dying,^” and a greater number (57%) mentioned ^“loss of dignity.^” See Paul J. Van Der Maas et al., ^“Euthanasia and Other Medical Decisions Concerning the End of Life,^” The Lancet 338 (Sept. 14, 1991): 669-74, at 672.

¹⁵For a more detailed reply to the Slippery Slope argument, along somewhat similar lines, see Dan Brock, ^“Voluntary Active Euthanasia,^” Hastings Center Report 22 (1992): 10-22.

¹⁶See, for example, John Rawls, A Theory of Justice (Cambridge, Mass.: Harvard University Press, 1971), pp. 22-27.

¹⁷ Richard Fenigsen, ^“The Report of the Dutch Governmental Committee on Euthanasia,^” Issues in Law and Medicine 7 (1991): 339-44, at 342.

¹⁸Chris Ciesielski-Carlucci, ^“The Termination of Life without Request in the Netherlands,^” VES News (May 1993), London, forthcoming.

¹⁹Margaret P. Battin, ^“Seven (More) Caveats Concerning the Discussion of Euthanasia in the Netherlands,^” American Philosophical Association Newsletter on Philosophy and Medicine 92 (1993): 76-80, at 78.

²⁰Gary Seay, review of Carlos Gomez, Regulating Death: Euthanasia and the Case of the Netherlands, American Philosophical Association Newsletter on Medicine and Philosophy 92 (1993): 89-92, at 91.

²¹Margaret Battin, ^“Voluntary Euthanasia and the Risks of Abuse: Can We Learn Anything from the Netherlands,^” Law, Medicine, and Health Care 20 (1992): 133-43.

22F. M. Kamm, Creation and Abortion: A Study in Moral and Legal Philosophy (New York: Oxford University Press, 1992), p. 35.

23“Is There a Right to Die?^”, p. 42.

Journal/Discussion Questions

- Kavka’s objection to banning euthanasia centers, in part, on the claim that it is wrong to prevent someone from rescuing someone else from great suffering. The focus, in other words, in on rescuing someone from suffering. Presuming you were qualified to do so (e.g., that you were a physician), how would you respond to a request from someone in great and terminal pain to save that person from further suffering through euthanasia? What would the moral issues be for you?

1. According to Kavka, people do not have to be in terminal condition in order to justifiably request euthanasia. Why not? Do you agree?

2. Some opponents of euthanasia maintain that human life is sacred and that we therefore must never intentionally kill any human being. How does Kavka reply to supporters of this position? Do you agree or disagree with his reply? Explain.

3. How does Kavka deal with the “slippery slope” objection to legalizing euthanasia? Are you convinced by his reply?

Daniel Callahan
“Pursuing a Peaceful Death”

About the Author: A co-founder of The Hastings Center, Daniel Callahan has been a major voice in biomedical ethics for the last thirty years. His books include Abortion: Law, Choice, and Morality, Abortion: Understanding Differences, edited with Sidney Callahan , Setting Limits: Medical Goals in an Aging Society and The Troubled Dream of Life: Living with Mortality. He has a particular interest in the relationship of ethics and culture, and of the way in which problems require not only careful rational analysis, but also a feel for culture, for one’s own understanding of the world, and for the way we are individually and socially shaped by the technologies and artifacts of our society.

About the Article: Recognizing that modern medicine has made dying much more difficult than before, Callahan considers some of the ways in which this may deform the process of dying. He then sketches out what a “good death” would involve, and argues that medicine should see one of its tasks as helping people to die well.

As You Read, Consider This:

1. How does Callahan define a “peaceful death?” What things would you add or subtract from his list of characteritics?

2. What does Callahan mean by “medical futility?” What role does this notion play in his argument?

On the face of it, one might be forgiven for thinking that death at the hands of modern technological medicine should be a far more benign, sensitive event than it was in earlier times. Do we not have a much greater biological knowledge, thus enabling more precise prognoses of death? Do we not have more powerful analgesics, thereby enhancing the capacity to control pain?

Do we not possess more sophisticated machines, capable of better managing organs gone awry? Do we not have greater psychological knowledge, suitable to relieve the anxieties and suffering of an anticipated death? Do we not, adding all that up, have at hand exactly what we need to enhance the possibility of a peaceful death?

The answer in each case is yes and no. Yes, we do have much more knowledge than we did prior to modern medicine. But no, that knowledge has not made death a more peaceful event, either in reality or in anticipation. The enhanced biological knowledge and technological skill have served to make our dying all the more problematic: harder to predict, more difficult to manage, the source of more moral dilemmas and nasty choices, and spiritually more productive of anguish, ambivalence, and uncertainty. In part this is because, with the advent of modern medicine, the earlier superstructure of meaning and ritual was dismantled, thus setting death adrift in a world of uncertain value and import. But also in part it is because modern medicine brought with it a stance toward death that is ambivalent about its necessity and inevitability.

In response to that ambivalence, without knowing it, without using quite that language, we have come to feel only now the loss of what the late French historian Philippe Aries called a “tame” death.¹ By that he meant a death that was tolerable and familiar, affirmative of the bonds of community and social solidarity, expected with certainty and accepted without crippling fear. That kind of human ending, common to most people throughout history until recently, Aries contrasted with the “wild” death of technological medicine. The latter death–which began to occur in the nineteenth century–is marked by undue fear and uncertainty, by the presence of medical powers not quite within our mastery, by a course of decline that may leave us isolated and degraded. It is wild because it is alien from and outside of the cycle of life, because modern technologies make its course highly uncertain, and because it seems removed from a full, fitting presence in the life of the community.

The technologies of that death, ever more clever in their ability to sustain failing organs, provide a set of tools that endlessly sustain our ambivalence and allow it to be played out in tortuous detail. Precisely because they have opened up new possibilities in the ancient struggle with our mortality, those technologies have made our understanding of that mortality all the more difficult. To confound us more, they have misled us into thinking we have a greater dominance over our mortality than was earlier the case.

What can be done to gain a better way of thinking about medical technology and our human mortality? How can that technology be made to serve a peaceful death, not to be its enemy? What can be done to bring about a change? I want to try to make plausible a different way of thinking about the use of technology and then suggest some ways of implementing it. The change I propose can be put very simply, however strange and odd it may sound. We should begin backward. Death should be seen as the necessary and inevitable end point of medical care.

Death as the End Point of Medical Care

In considering its appropriate goals, medicine should, so to speak, simultaneously work backward as well as forward. Medicine now characteristically works forward only, looking to promote the good of life, both to lengthen life and improve its quality. Death is reluctantly admitted into the realm of medicine as the limit to achieving those ends, but that limit is itself uncertain at its boundary, not readily located. Thus also is the termination of treatment judged to be a lesser moral evil, because the quality of life cannot be sustained at the level at which, ideally, medicine would like to sustain it.

What if, however we began our thinking with death? What if we asked how medicine should conduct itself to promote both a good life and a peaceful death? What if medicine once and for all accepted death as a limit that cannot be overcome and used that limit as an indispensable focal point in thinking about illness and disease? The reality of death as a part of our biological life would be seen, not as a discordant note in the search for health and well-being, but as a foreseeable endpoint of its enterprise, and its pacification as a proper goal of medicine from the outset. What if the aim of scientific medicine was not an endless struggle against death, with the fight against disease as the token of that struggle, but helping humans best live a mortal, not immortal, life?

These questions are almost naive. But I see no evidence that they are deeply and persistently asked in modern medicine. If they were, then death would have to be taken seriously, allowed an honored role in the ideals of medicine, not treated as only a necessary evil and a temporary scientific failure. The acceptance, management, and understanding of death would become as fully a part of the mainline enterprise of medicine as the pursuit of health. It would not be necessary even to conceive of a hospice movement, a separate system of caring for the dying; that would be taken for granted as central to the enterprise of medicine itself, not a specially constructed sideshow, out of sight of the main tent.

If the ordinary goal of medicine is the preservation or restoration of health, death should be the understood and expected ultimate outcome of that effort, implicitly and inherently there from the start. The only question is when and how, not whether. Medicine’s pursuit of health should be leavened by its need when health fails, as it must, to prepare the way for as peaceful a death as possible. If death is part of the human life cycle, then care for the dying body must be integral to the ends of medicine.

Death is, to sharpen the point, that to which medical care should be oriented from the outset in the case of all serious, potentially life-threatening illnesses, or of a serious decline of mental and physical capacities as a result of age or disease. Of each serious illness–especially with the elderly–a question should be asked and a possibility entertained: could it be that this illness is the one that either will be fatal or, since some disease must be fatal, should soon be allowed to be fatal? If so, then a different strategy toward it should come immediately into play, an effort to work toward a peaceful death rather than fight for a cure.

What am I saying that is different from the present stance of medicine? At present medicine takes as its task only the pursuit of health, or the preservation of a decent quality of life, with death as the accidental result of illnesses and diseases thought to be avoidable and contingent, even though in fact still fatal. Death is what happens when medicine fails, and is thus outside its proper scientific scope. That is why, I surmise, a great medical classic, Cecil Textbook of Medicine, a primary guide for physicians, refers in only twenty-five of its twenty-three hundred pages to death (and only in five to pain)² For a book filled with accounts of lethal diseases and ways to treat them, there is a strikingly scant discussion–three pages only of treatment for those in the terminal phase of disease. It tells what to do to hold off death, but not what is to be done when that is not possible. That omission is a stark example of the way death is kept beyond the borders of medicine, an unwelcome, unwanted, unexpected, and ultimately accidental intruder. What if, by contrast, every section of that book dealing with potentially fatal diseases had a part dealing with the care of those dying from the disease? The care of the dying cancer patient is not identical with the care of a person dying from congestive heart disease or kidney failure. But this could never be guessed from reading standard treatment textbooks.

An incorporation of that approach in textbooks and clinical training would make clear, in the most direct way, that this disease may be, sometimes voluntarily and sometimes not, the cause of death–death, which must come to all and is thus no accident. Then the physician’s task would become that of accepting a particular illness as the likely cause of death, opening the way for a peaceful death by choosing that combination of treatment and palliation of the accepted condition most likely to make it possible. The objective here would be exactly the opposite of technological brinkmanship, which goes as far as possible with aggressive treatment, stopping only when it is useless to go further. In the task of allowing a peaceful death, brinkmanship would be repudiated from the outset. Active treatment to cure disease and stop death from coming would stop well short of its technical possibilities, at that point when a peaceful death could be most assured and best managed. The worry that a patient might die sooner than technologically necessary would be actively balanced by anxiety that a patient might die later than was compatible with a peaceful death.

Deforming Our Dying

A peaceful death can be understood both positively and negatively. I will begin with the latter, specifying some ways in which our dying can be deformed. If we can better discern some of the ways that happens, the ideal of a peaceful death can be given greater substance. Our dying can be deformed in three ways: by deforming the process of dying, by deforming the dying self, and by deforming the community of the living.

Deforming the Process of Dying

The process of dying is deformed when it is subject to the violence of technological attenuation, drawn out and unduly extended by medical interventions, directly or indirectly. Technological brinkmanship is the most common way of creating the deformity–that is, pushing aggressive treatment as far as it can go in the hope that it can be stopped at just the might moment if it turns out to be futile. That brinkmanship and the gamble it represents can both save life and ruin dying; that is the dilemma it poses. The most obvious kind of technological violence comes when a particular course of treatment–some forms of chemotherapy for cancer, or cardiopulmonary resuscitation for a dying person–itself directly imposes the violence.

Less noticed, but bound to become increasingly important, is the violence done when the cure of one disease sets the stage for the advent of another, perhaps even more cruel than the death one has just averted. Consider, for instance, the person cured of cancer at seventy-five who is set up for the enhanced risk, by virtue of age alone, of the onset of a fatal case of Alzheimer’s disease at eighty, or for an excessively long period of severe frailty. We increase the likelihood of spending our declining years helpless, demented, and incontinent if medicine saves our lives long enough to help us avert all of the lethal diseases that stand in the way of that (not so splendid) final outcome.

We may of course gain some extra good years before that happens, and for some it will not happen at all. I only want to underscore the gamble implicit here, a kind of technological Russian roulette with one’s last years of life. We must reckon whether it is a good or bad gamble, and how much we are prepared to accept a deformed dying as a result. Increasing frailty and bodily decline are themselves part of the aging process, the wasting away that ordinarily precedes death in old age. There is no inherent evil in the dependency that withering can bring. My complaint is instead directed against a kind of medicine that drives us toward technological brinkmanship and thus needlessly exacerbates and attenuates the withering in destructive ways, genuinely deforming the process of dying. The process of dying is deformed when, through overconfidence in our power to manage technology and to manage our own ambivalence toward death, we fail to take account of what an overzealous medicine can do.

The process of dying is also deformed when there is an extended period of a loss of consciousness well before we are actually dead. It is deformed when there is an exceedingly and unduly long period of debility and frailty before death. It is deformed when there is a lengthy period of pain and suffering prior to death. Note the words I have used: “extended,” “exceedingly,” “unduly,” and “lengthy.” By these I mean to say that death may well and unavoidably be preceded by some pain and suffering, some loss of consciousness, some debility and frailty, but that we human beings have generated our own miseries when we allow technology to create a situation that produces exceedingly long periods of those evils. I offer no precise definition of “ exceedingly. “ Frailty and debility can be tolerated for longer periods of time than straight pain and suffering, and a few days even of unconsciousness might be tolerable.

It is when those evils go on and on that a problem, a desperate one, arises. Left unattended, the biological process of dying would not ordinarily lead to such deformities, even if it will happen in some minority of cases. That is something we can know from the dying of other biological organisms, especially higher animals, and from the historical record of human death itself before our modern era, where an extended period of dying was the exception rather than the rule. Our contemporary deformities of dying, it is then fair to say, ordinarily arise only as the result of human medical intervention.

Deforming the Dying Self

The most obvious way the dying self can be deformed is by allowing the fear of death, or the fear of what dying may do to our ideal self, itself to corrupt the self. Obsessions with a loss of control, or with a diminishment of the idealized optimal self, or with the prospect of pain, are other ways this can happen. That is to turn our dying into an occasion of unrelenting self-pity and self-castigation: I can never be again what I once was, I do not want to be what I now am, and I do not want to be what I will become as my death draws even closer.

Some delicacy is in order in trying to make this point. It is understandable that we should not want to lose all control or to become less of a self than we once were, or that we should fear pain. Anxiety, even terror, is to be expected as we approach our death, both because of the physical threats of dying and because of the challenge to our sense of self-worth and self-coherence. It is the preoccupation with those evils that introduces the potential deformity, the feeling that we cannot be worthy human beings if they are our fate, and an inability to think of anything but our losses, our failures, our diminution.

Deforming the Community of the Living

Just as we can harm the self, our sense of self-worth, in responding to the threat of death, so too can we do harm to others. If the horror of death–or, more likely, of illness, decline, and dying together–yields social policies designed to relieve that suffering at all costs, then the community of the living is put at risk. A society that takes the relief of the ordinary burdens of life (of which death is surely one) as a goal to be pursued with singular dedication must ultimately fail, putting its members in harm’s way even as it does so.

This can happen when the pursuit of health and the avoidance of death become an excessively high priority, gained at the cost of ignoring other social evils. It can happen when the medical community comes to believe it must, as the price of relieving suffering, be prepared to kill or assist in suicide, thus distorting its oldest and most central traditions. It can happen when, as a community ideal, a life that includes any suffering is rejected as intolerable. It can happen when a life thought “not worth living” (the Nazi expression) is one marked by suffering, a less than ideal self, and a failure to make adequate contributions to society.

The possibility of a peaceful death will, then, require as a minimal condition that death not be deformed, either individually or socially. But more will be required to enhance its possibility.

Defining a Peaceful Death

It is not difficult, just listening to the way people talk about the kind of death they would like, to gain a decent sense of what they would count as a peaceful death. I could try to do that, but I would prefer to put it in my own voice, recognizing that there may be individual variations:

¨ I want to find some meaning in my death or, if not a full meaning, a way of reconciling myself to it. Some kind of sense must be made of my mortality.

¨ I hope to be treated with respect and sympathy, and to find in my dying a physical and spiritual dignity.

¨ I would like my death to matter to others, to be seen in some larger sense as an evil, a rupturing of human community, even if they understand that my particular death might be preferable to an excessive and prolonged suffering, and even if they understand death to be part of the biological nature of the human species.

¨ If I do not necessarily want to die in the public way that marked the era of a tame death, with strangers coming in off the streets, I do not want to be abandoned, psychologically ejected from the community, because of my impending death. I want people to be with me, at hand if not in the same room.

¨ I do not want to be an undue burden on others in my dying, though I accept the possibility that I may be some burden. I do not want the end of my life to be the financial or emotional ruination of another life.

¨ I want to live in a society that does not dread death–at least an ordinary death from disease at a relatively advanced age–and that provides support in its rituals and public practices for comforting the dying and, after death, their friends and families.

¨ I want to be conscious very near the time of my death, and with my mental and emotional capacities intact. I would be pleased to die in my sleep, but I do not want a prolonged coma prior to my death.

¨ I hope that my death will be quick, not drawn out.

¨ I recoil at the prospect of a death marked by pain and suffering, though I would hope to bear it well if that is unavoidable.

There is a difference between this desired peaceful death and Philippe Aries’s tame death. Technological advances make it possible to manage better those conditions that could not, in the past, be made amenable to a tame death, especially the degenerative diseases of aging. We can, that is, have both the advantages of the older tame death and, with the help of technology, many improvements in contemporary death.

The most evident characteristic of a peaceful death as I have outlined it is the way it blends personal, medical, and social strands. Whatever meaning we find in our dying and death must come from within ourselves, though we may and probably will of course draw upon religious and other traditions for important help. We could also reasonably look to the larger society for public practices, rituals, and attitudes that can provide a more comforting context for the acceptance of death. A modified return to special symbols of mourning, such as black armbands for men and dark clothes for women, as well as the enhancement of groups organized for grieving spouses, or religious services, would be examples of the possibilities here. As for the relief of pain, there we can look to medical practice, and even expect from that practice some help with suffering, a more subtle condition stemming in part from an interior perception of the significance of dying and from the kind of external support we are given in the face of our anxieties.

Could a peaceful death be assured every patient? No. Medicine cannot now and probably never will be able to avert all pain and suffering or ensure a tranquil course of illness. No society could wholly overcome the fear of death or the rending of community that is death. No one can be confident that fear, anguish, or a sense of pointlessness and futility will not be one’s lot, even if one has lived the kind of life most conducive to reducing that possibility. Since no one can give us, as our own, a meaning to our dying and death, we must find that for ourselves; some of us will never find it.

Since there can be no guarantee that a peaceful death will be ours, some store of courage must be available. If I am correct in my surmise that the obsessively feared loss of control of our dying is itself part of the problem–a fear that we will not be either ourselves or in command of ourselves–then one way to resist the force of this fear is to be willing to accept some loss of control. The price of obsession is undue fear. Relief can be sought in a willingness to live with, and die with, less than perfection here. Yet if we can understand that there is a middle way, then the possibility of a peaceful death can be greatly enhanced. It is at least as likely that we could create the possibility of a peaceful death for a majority of people by changing our medical attitudes and expectations as by the more violent course of euthanasia and assisted suicide, and with far less loss of other values in the process.

Medical Futility

The general orientation and resource allocation priorities of the health care system can make a considerable difference, albeit indirectly for the most part, in the care of the dying. Of more direct and immediate impact will be the aggregate effect of what clinicians at the bedside come to consider futile or marginally useful treatment. As a concept, futility’ has both medical and moral dimensions.³ Its medical feature is that of a probability that a particular treatment for a particular person will not be efficacious, that is, it will not return the patient to good health or sustain the patient in any medically viable way. The moral feature is a judgment that some forms of medical treatment, with either a low or no probability of success, should be morally judged to be useless. Taken together, then, a judgment of medical futility is medical insofar as it relies on judgments of probability of medical outcome, and moral in that it relies upon judgments about whether the pursuit of low-probability outcomes is morally required.

There is already considerable pressure from physicians to be allowed to make judgments of medical futility on their own, without having to ask patients or their families. Their goal is not to avoid a doctor-patient interaction, but to be spared the pressure of unrealistic patient demands. It is one thing, they say, to be asked by patients or their families to stop treatment; that is acceptable. It is still another to be asked to provide treatment of a kind physicians think futile or useless; that they take to be unacceptable, a threat to their professional integrity.

Their instinct is correct and reasonable. Physicians ought not to be required to perform procedures or provide treatment that they believe will do no good. Yet it would be arbitrary to allow physicians unilaterally to make those judgments, given the fights of patients to be informed of their situation. It would be better if the standards here were established collectively, by joint bodies of lay people and physicians.

This might best be done in individual hospitals, where joint medical-lay panels could help establish an institutional policy sensitive to local needs and values. It should not, I believe, be done with individual patients on a case-by-case basis. Judgments of futility could then be made, and treatment denied, but on the basis of consensual norms and publicly visible policies.⁴ The development of such policies would, of course, have a potentially significant impact on the options available to patients. Some general societal standards would come to replace unlimited patient choice.

What would be the pertinence of such a development for the termination of treatment? It would be valuable if in coming years some consensus were achieved about futile treatment. Futility’ needs, however, to be understood in two senses: futile because no benefit whatever can be achieved from treatment, and futile because, given resource limitations, the treatment is economically unjustifiable. Thus we must have a general social agreement on the right of physicians to withhold medical treatment from persons in the persistent vegetative state, and an agreement on the forms of medical treatment that would be considered futile for those faced with imminent death from an acute or chronic illness or from the slow death of dementia.

A standard of futility compatible with the goal of avoiding an unnecessarily painful or extended death would be most valuable. The test of futility could be twofold: first, an inability to arrest more than momentarily (by a few days or weeks) a downward, deteriorating course; and second, the probability, should that kind of effort be made, that a peaceful death would become increasingly unlikely. At that point, curative medical treatment has indeed become futile and ought to be stopped. The standard is thus one that looks to the possibility of sustaining life in some decent fashion, but also and simultaneously to the choices necessary for enhancing the possibility of a peaceful death.

The most difficult but impending problem of futility judgments is whether to embody them in public policy. As matters now stand, it is customary for both federal and private health care plans to provide reimbursement for the care of those in a persistent vegetative state; families and medical staffs that want medical treatment to be continued for these patients can be reimbursed for its cost. Should financial support continue in the future? I believe that, in principle, it should not. Ideally speaking, it makes no sense in light of budget restraints or humane public policy to use medical technology to sustain for an extended period the life of someone who will almost certainly never return to consciousness.

The temptation here is to adopt an either-or approach. If we consider the patient alive, then we think we should provide the patient with all those forms of health care that we would provide any other live person; or if we simply consider the patient as dead, even if not legally so, we think we should stop all care. The problem, however, is that we as a society remain uncertain about the status of patients who manage to combine, in a bewildering way, elements of both life and death. An appropriate compromise, I believe, would be to provide minimal nursing care but not the extended artificial nutrition and hydration that many institutions now routinely provide–probably because of public disagreement about the moral status of someone in that condition.

My guess is that increasingly few people will for long believe that this form of “life” merits being called human. It is a moribund life sustained by technological artifact in the face of a biological condition crying out to come to an end, as in nature it ordinarily would. Yet as long as disagreement persists, it would be unwise to stop treatment precipitately or high-handedly. That could seem to bespeak an indifference to the important convictions of some people, convictions not without some merit. But every effort should slowly be made to change those convictions so that a social consensus could build to form the basis of new policy that would refuse reimbursement for patients in that condition. A softer, perhaps more tolerable alternative would be to assign a low priority to such treatment, to help assure it would not capture resources that could be better spent on more needy patients with a chance of real recovery or amelioration of their condition.

A peaceful death should have both an individual and a public face. For the individual it can bring life to a fitting close, marked by connection to the self through reason and self-consciousness, and by connection to others through dying within the circle of human companionship and caring. But death should also have a peaceful public face. The control and management of death, understood as an unavoidable part of life, should not consume an undue share of resources, as if keeping death at bay represented society’s most important goal. People should have a chance to live a healthy life, avoid premature death, and then die without that technological brinkmanship that knows no boundaries in the war against mortality.

I would define a peaceful death in a public context as a death that, on the one hand, rejected a disproportionate share of resources which, through a kind of economic violence, threatened other societal goods such as education and housing; and, on the other hand, rejected euthanasia and assisted suicide as still other forms of violence, though medical and social rather than economic.

What about family burdens as a form of quasi-domestic violence? It is not improper for people to worry about being a burden on their families or to wish they could spare them undue emotional and financial hardship. We can readily recognize the possibility of taking down with us, in a parallel destruction, those family members whose devotion–economic or emotional or both–is pressed too far. It is hard to see how a death that impoverishes a family, or destroys the later years of an elderly spouse, or wrecks the family life of a dutiful child caring for an elderly parent, can be called entirely peaceful.

At the same time, however, it is right and proper that we bear one another’s illness and dying. We should not only be willing to care for others; no less important, we should allow them to care for us if there is no moral or humane way to avoid that burden. We do not need a medical system and a set of moral values that will impose upon families the drain of extended illness and death, especially when that has been brought about not by natural forces but by an excessive application of life-sustaining technologies. We should be willing to bear what nature and human mortality bring to us. But there is no reason why we should have to bear artificially extended deaths. A patient should reject them for the sake of the family’s welfare after he or she is gone. And when a patient is incompetent and death on the way, family members should not be forced, through guilt or a confusion about killing and allowing to die, to believe that a termination of treatment is wrongful killing. It is not killing at all.

References

¹Philippe Aries, The Hour of Our Death, trans. Helen Weaver (New York: Alfred A. Knopf, 1981), pp. 5-28; see also Philippe Aries, Western Attitudes Toward Death, trans. Patricia M. Ranum (Baltimore: Johns Hopkins University Press, 1974).

²James R. Wyngaarden, Lloyd H. Smith, and J. Claude Bennett, eds., Cecil Textbook of Medicine, 19th ed. (Philadelphia: W. B. Saunders, 1992).

³See Lawrence J. Schneiderman, Nancy S. Jecker, and Albert R. Jonsen, “Medical Futility: Its Meaning and Ethical Implications,” Annals of Internal Medicine 112, no. 12 (1990): 949-54; John D. Lantos et al., “The Illusion of Futility in Medical Practice,” American Journal of Medicine 87 (July 1980): 81-84; Tom Tomlinson and Howard Brody, “Futility and the Ethics of Resuscitation,” JAMA 264, no. 10 (1990): 1276-80; Stuart J. Youngner, “Who Defines Futility?” JAMA 260, no. 14 (1988): 2094-95.

⁴See Daniel Callahan, “Medical Futility, Medical Necessity: The Problem-Without-A-Name,” Hastings Center Report 21, no. 4 (1991): 30-35.

Journal/Discussion Questions

- What kind of death do you want to have? What do you think will be the greatest barriers to dying in the way you want?

1. To what extent, according to Callahan, has modern medicine changed the ways in which we die? In what ways has dying been deformed? Why has this given rise to a moral problem?

2. How would Callahan’s suggestions change the way in which physicians today typically treat dying patients? Discuss.

* The Hastings Center Report, Vol. 27, No. 2 (March 13, 1997). Pp. 34-42.

Chapter 3 Euthanasia

Anonymous “It’s Over, Debbie”

Timothy E. Quill, M.D. “Death and Dignity: A Case of Individualized Decision Making”

Euthanasia: An Introduction to the Moral Issues

Introduction

What Are We Striving For?

Some Initial Distinctions

Active vs. Passive Euthanasia

Voluntary, Nonvoluntary, and Involuntary Euthanasia

Assisted vs. Unassisted Euthanasia

Euthanasia as the Compassionate Response to Suffering

The Sanctity of Life and the Right to Die

The Sanctity of Life

The Right to Die

The Conflict of Traditions

The Value of Life and the Cost of Caring

Slippery Slopes

Undervalued Groups

Moral Pluralism

Endnotes

John Hardwig “Is There a Duty to Die?”*

Circumstances and a Duty to Die

The Individualistic Fantasy

A Burden to My Loved Ones

Objections to a Duty to Die

Who Has a Duty to Die?

Can the Incompetent Have a Duty to Die?

Social Policies and a Duty to Die

A Duty to Die and the Meaning of Life

ACKNOWLEDGMENTS

REFERENCES

James Rachels “Active and Passive Euthanasia”

Endnote

Richard Doerflinger “Assisted Suicide: Pro-Choice or Anti-Life?”

Assisted Suicide versus Respect for Life

Life versus Freedom

Slippery Slopes, Loose Cannons

The Psychological Vulnerability of Elderly and Dying Patients

The Crisis in Health Care Costs

Legal Doctrines on “Substituted Judgment”

Expanded Definitions of Terminal Illness

Prejudice against Citizens with Disabilities

Character of the Medical Profession

The Human Will to Power

Endnotes

Gregory S. Kavka “Banning Euthanasia”

The Argument

Factual Premises

The Moral Principle

Objections and Replies

Acknowledgements

Endnotes

Daniel Callahan “Pursuing a Peaceful Death”

Death as the End Point of Medical Care

Deforming Our Dying

Deforming the Process of Dying

Deforming the Dying Self

Deforming the Community of the Living

Defining a Peaceful Death

Medical Futility

References

Review Questions Where Do You Stand Now?

For Further Reading: A Guide to the Euthanasia Discussion

Web Resources

Journals

Anthologies

Review Articles

Journal Articles

Books

Suicide

Chapter 3
Euthanasia

Anonymous
“It’s Over, Debbie”

Timothy E. Quill, M.D.
“Death and Dignity:
A Case of Individualized Decision Making”

Euthanasia:
An Introduction to the Moral Issues

John Hardwig
“Is There a Duty to Die?”*

James Rachels
“Active and Passive Euthanasia”

Richard Doerflinger
“Assisted Suicide: Pro-Choice or Anti-Life?”

Gregory S. Kavka
“Banning Euthanasia”

Daniel Callahan
“Pursuing a Peaceful Death”

Review Questions
Where Do You Stand Now?

For Further Reading:
A Guide to the Euthanasia Discussion