Euthanasia: its varieties and its justification

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See also: Euthanasia and the law

Terry Pratchett’s harrowing and extraordinary documentary, Choosing To Die, has reignited Britain’s long-simmering debate about euthanasia and assisted suicide. It presents two seriously ill patients who have chosen death, and forces us to watch as one of them exercises this choice in Switzerland’s controversial Dignitas clinic. This is not an easy or pleasant sight, even for an advocate of assisted dying like myself. But it does a great service in making us re-examine the issue, and it is this that I shall do below.

I come to the issue from a philosophical perspective. I will not look at the specifics of the cases in Choosing To Die, as they have been pored over throughout the media. It is more useful to understand the general categories into which all such cases fall (active and passive, voluntary, non-voluntary and involuntary), and the two broad arguments for euthanasia that philosophers have advanced: arguments from autonomy and those from beneficence, or the alleviation of suffering.

Can death be a good thing?

I will begin by considering the argument from beneficence. I will do so at length, since it is at the core of the case for euthanasia, which after all comes from the Greek for ‘good death’.

Now, on first hearing this phrase you may feel some resistance. How can death ever be a good thing? Life is all we have; if we lose it, we’ve lost everything. This will be the first question I consider, and I hope to show that an honest look at the cases in question can show that death can be a very good thing indeed.

For something to be a good thing, it must be a good thing for someone in particular. The ethicist Philippa Foot notes two possibilities: death may be beneficial for (i) everyone, on average, or (ii) the person concerned. She feels that only cases which satisfy (ii) can properly be termed ‘euthanasia’. This implies that the common withdrawal or life-sustaining treatments from newborns with severe mutations and permanently comatose adults does not always deserve the name of (passive) euthanasia. These patients’ lives are sometimes either neutral or good but limited, life, and their death is brought about for the benefit of parents or other relatives and society at large.[1]

Can such deaths be good things in virtue of satisfying (i) rather than (ii)? We understandably prefer not to consider the possibility, adopting the position of the three monkeys: “see no evil, hear no evil, speak no evil”. Yet in doing so we ignore the grave suffering of carers who are sometimes driven to suicide, as movingly documented in a 1975 New Statesman.[2] I will not dwell on the question, but hope you will not ignore it, especially in cases where a patient’s consciousness is primitive or non-existent and their life thus has no positive value for them.

Another question most of us would prefer not to think about is that of cost. Some cases of disability can consume carers’ whole lives, even if they don’t end them. They can consume vast amounts of money too; as technology advances, hospitals are expected to spend ever-larger proportions of their budgets on advanced life-prolonging treatment. After all, we all agree that life is priceless, don’t we?

Actually, if we’re honest, we don’t.

When old people aren’t lying in hospital beds, we’re quite happy for our finance ministers to keep their pensions low enough that some of them will inevitably die in their own beds for lack of heating. And we’re willing to spare even less effort to save those even further removed from our visual fields and thus our consciences. Small sums of money could save those suffering from tropical diseases in poor countries. We face an unpleasant but unavoidable choice as to where to spend finite resources, and this limits the amount we are willing to expend prolonging a life. To illustrate the point with an exaggerated case, a government would not spend its entire budget providing life support to extend one man's death by a month. There is no sharp distinction between this omission and those involved in the paradigmatic cases of passive euthanasia considered below, such as not providing chemotherapy.

Foot is, however, correct that the term 'euthanasia' only applies when the consideration is the good of the patient. Deciding whether to fund certain costly treatments raises quite separate issues. The person I want to consider here is the one lying in the hospital bed, at the heart of the case.

This is where things get complicated. Our attitudes to the value of life, and the badness of death, are confused. Some have gone so far as to deem them incoherent. Several ancient philosophers suggested that death is not even an evil, or something to be feared. We can agree with their second point while rejecting their first. Death is not an unpleasant state, but to suppose that’s why we dislike it does not do us justice. We don’t pity Socrates more than Plato because he’s suffered more death.

This does raise the question of why we do dislike death. The natural answer is that, though most evils are evils because they induce unpleasant states, missing out on pleasant states is also bad. This applies even if we are not in the unpleasant state of being aware of our loss. On this view, if life offers few pleasures, or at least few reasonably rich ones, its termination is not necessarily such a bad thing for the person involved. And it would seem dishonest to let pleasures count in life’s favour without letting agony, depression and despair count against it. This suggests that death can sometimes be a good thing.

We are of course reluctant to say this too readily. Isn’t something better than nothing? Isn’t being alive and aware good in itself? To the first question we can say: “it depends on the something”. The second is a little trickier. It draws our attention to the many banal goods in life we often ignore or underrate, which probably account for our feeling that life is good in itself. But if we imagine a mere stream of consciousness devoid of any reflection, such as a lower animal may have, it is hard to see any value in it. And if even that disappears, leaving us alive but not aware, it is hard to see how that state is in any way preferable to death.

This should put us off the position known as vitalism, which considers that life is always a great, perhaps untrumpable, good, worth preserving and prolonging wherever possible. The feelings of relatives are important, but coma victims provide an example where death is no loss, at least from the victim’s perspective.

It should also put us off the related doctrine of the sanctity of life. Historically, the justification for this doctrine was that only God had the right to destroy those He had created in His image, but this will be rejected by those who do not share this theology, either because they are atheists or because it seems to treat humans more as chattel than as objects of compassion. Robbed of this justification, claims that life has inviolable sanctity make little sense. When we consider the rich and good states which make life worthwhile, it is obvious that not everyone has them. Those who defend the sanctity of life class all human life together, and if they cannot do so by invoking “souls” common even to those wrecked by disease are forced to speak of common “capacities”. But aside from the difficulties with valuing lives based on their future capacities rather than their present state, the permanently disabled, comatose or senile lack even the relevant capacities.

The varieties of euthanasia

Now that we have considered how death can be a good thing for the person involved, and others too, the presumptive case for euthanasia should be clear. We believe in beneficence – helping people achieve good things. If suicide can be a good, how can we deny it to those too weak to manage it by themselves, or too far gone to decide? Unlike the argument for autonomy, which I shall consider shortly, this case applies to all types of euthanasia. So I shall examine these different types, and see whether additional considerations make some unacceptable.

The first distinction to explore is that between active and passive euthanasia. On the face of it, this is relatively easy to define: active euthanasia involves killing, passive euthanasia involves allowing people to die. But, as I argue elsewhere, it is hard to render this distinction meaningful, let alone morally relevant. Even leaving aside those considerations, it runs into trouble. Letting someone die is often far less humane than giving them a quick death, and if our end is the same, it is hard to justify using the crueller means.

If we want to justify this, some morally relevant difference will have to be found. The ethicist James Rachels suggests this is impossible, and offers a thought experiment to show this. Suppose Smith wants to kill his young cousin, and so sneaks into his bathroom and drowns him. Would his actions have been any better had he found the child was already drowning and stood by to let him do so? In this case, where everything else is held constant, including Smith’s intention and murderous character, the moral difference between act and omission appears to collapse.

Philippa Foot suggests that Smith’s actions would be wrong for different reasons in the two scenarios – drowning ignores the claims of justice, letting drown ignores the calls of charity. But this is implausible, and our reaction to Rachels’ thought experiment is to deem Smith equally evil in either case, not only in degree but also in kind.

To be sure, Foot can offer other thought experiments which suggest we should give considerations of justice ultimate importance . Retreating armies often accord charitable bullets to soldiers they must leave behind to die (an example where active euthanasia is felt to be an obligation, it should be noted). But justice seems to dictate that if one of them demands to be left alive, his comrades should respect his wish. Justice is here bound up with the notion of a ‘right to life’. But this is a right to non-interference, not a 'claim-right'; the other soldiers would be within their rights to practice passive euthanasia, omitting to give life-prolonging treatment

Whether doctors are within their rights to practice passive euthanasia, Foot is not sure. She suggests that the right to life takes the form of a claim-right on doctors, in our society. They have an obligation to take any reasonable steps we ask them to to prolong our lives. But some demands are unreasonable: we would obviously not expect a hospital to spend a billion pounds on saving the life of one patient. Foot defends this on the grounds that our right to life may clash with other people’s rights. This is one of those instances where the notion of rights gets messy, and we may prefer to adopt a straightforward consequentialism.

The next distinction to consider is that between voluntary, non-voluntary and involuntary euthanasia. Voluntary euthanasia follows a request by the patient, involuntary euthanasia goes against their requests, and non-voluntary euthanasia occurs when patients cannot communicate their wishes, often because they are comatose. Naturally, few people advocate involuntary euthanasia, except where the cost of keeping someone alive is prohibitive (passive euthanasia may then be permissible where active euthanasia is not, but that has nothing to do with its being passive rather than active). Voluntary euthanasia is what is normally advocated, and it certainly makes sense to legalise that before anything else. People can certainly waive their right to life, unless as discussed earlier we think it a divine offer they can’t refuse.

Advocates of voluntary euthanasia rarely intend to allow those going through an irrational and short-lived suicidal desire to die. They thus propose that doctors evaluate the reasonableness of requests for euthanasia. This implies that although respect for people’s autonomy is often presented as the primary justification for euthanasia (with rhetoric such as “their life, their right”), it should take a back seat to the question of whether it genuinely benefits the patient. This conclusion can also be supported by the claim that autonomy’s value derives from the way it improves people’s lives by giving them a sense of control and letting them use their (normally unrivalled) knowledge of what will benefit them. This is a claim that most consequentialists, at least, are committed to.

There are two other problems with allowing unbridled respect for autonomy. One is quite general: as McCall Smith observes, it can shade into moral relativism. The other is particular to euthanasia: it is quite difficult to decide when a request is truly autonomous. Many patients are depressed, find it hard to think straight, or feel pressure from their carers and relatives. Bishop Butler’s thoughts on egoism suggest that there is not even a clear line here: proud patients may genuinely wish not to be a burden, for their own sake. Rejecting this reason may be denying them their autonomy.

Some advocates of the argument from autonomy see it as the only way to license voluntary but not involuntary euthanasia. But the argument from beneficence also gives us good reason to do so. I gave an irrational suicidal desire as a case in which absolute respect for autonomy is inappropriate. Another classic example is the taking of highly addictive drugs. What both cases have in common is that they remove the chance to change your mind later. Dropping absolute respect for autonomy would not license involuntary euthanasia. The advocate of beneficence can think she might be thanked for her intervention later, and that if not the potential suicide or drug-taker will always have another chance. The opposite would be true if she performed involuntary euthanasia, say on a wounded soldier who begs not to be put out of his misery. Only in the most exceptional circumstances could involuntary euthanasia be permissible: if your children were being taken off to a torturous death they could not comprehend, perhaps.

The argument from autonomy is thus weaker than commonly thought. On some moralities, including many but not all consequentialist ones, it can even be completely subsumed by the argument from beneficence. This is because autonomy has enormous instrumental value, both because people value it greatly and because individual patients are normally the best judges of whether their suffering is worth enduring. This value should however be weighed against others that compete with it, and not taken as absolute, even though in practice a wise and sustainable law would afford people wide discretion over their own lives.

The slippery slope

I have now examined the different varieties of euthanasia, and the two major arguments in its favour. I have defended the argument from beneficence, claiming that euthanasia can sometimes be a good thing. However, this is not quite sufficient to show that it should be legalised, for legalisation could have sufficiently bad side effects to outweigh the benefits individual acts of euthanasia can bring.

This is just what ‘slippery slope’ arguments famously claim. There are actually two types of slippery slope argument: the logical and the empirical. The empirical claim about what will actually result from a policy of euthanasia is by far the better known, and we shall deal with it first.

Every action obviously has innumerable side effects, and it is impossible to predict them all. At best we can try to identify the major possibilities, and see if there is reason to expect the good consequences of legalising euthanasia to outweigh the bad. Actual experience is invaluable here, and opponents often cite the Dutch legalisation, which has had some adverse consequences. Palliative care has seen underinvestment, while euthanasia is treated casually and often sought by people who, rather than suffering unbearably, are simply in despair about their terminal disease, or even tired of old age. Some feel euthanasia is inappropriate in some cases, while others think they can contain suffering as genuine as that of a cancer patient, with equally little chance of happiness. Even if we accept this latter view, pressure from carers is worth worrying about in such circumstances, though there is, predictably, little evidence of this.

The direr predictions of anti-euthanasia activists have, however, failed to materialise even in the Netherlands. Nazi death camps have yet to appear among the windmills. What such fears ignore is the fact that compassionate doctors and nurses would be following the principle ‘kill when requested to and/or it’s merciful’, not ‘kill whenever’, and the universalisation of this would not be a bad thing. Hospital patients who understood this would not fear sudden execution.

Furthermore, abuses in the Netherlands actually suggest that keeping euthanasia illegal has its own slippery slope. Passive euthanasia does not fall under legal regulation in Holland, but is tolerated there as elsewhere. This is where most of the abuses happen, and it is often non-voluntary, as is to be expected of a practice outside explicit legal guidelines. Preventing passive euthanasia is infeasible, and would be an exercise in hypocrisy unless unlimited funds were made available for terminal cases.

Another empirical slippery slope argument, which draws on the claims of the logical slippery slope arguments we shall shortly consider, suggests that euthanasia would erode society’s moral principles. However, as I have just pointed out, legalising euthanasia would involve following a more restricted principle than ‘always kill’, and I have heard no reason why this principle would not be stable. Furthermore there is something unsavoury about suggesting that people’s autonomy should be deeply compromised, condemning them to appalling suffering, simply to preserve the moral fibre of society.

The other type of slippery slope argument is the logical one, which suggests that legalising only voluntary euthanasia would be incoherent. It seems unfair to deny the merciful death they would likely want to those who cannot request it (a practice not followed for life-shortening pain relief). Killing these patients is known as 'non-voluntary' euthanasia, and it is quite distinct from involuntary euthanasia, which actively goes against patients' desires. Another logical link between arguments for voluntary euthanasia and those for non-voluntary euthanasia is that doctors have the ultimate decision in voluntary euthanasia, unless it is made available on demand. If they can judge it to be appropriate in voluntary cases, can they not also do so in non-voluntary ones?

Autonomy, meanwhile, seems to dictate allowing euthanasia not only in circumstances where life is an evil, but also in those where someone simply does not want it. Human freedom must obviously be allowed considerable scope if doctors are not to be seen as dictators who do not trust a patient’s judgment, as this may allow some such deaths. But if we do not give autonomy absolute value, we will refuse to kill when it is clearly a bad thing, not least for loved ones, so there is no slippery slope here.

These logical arguments are powerful, and, as indicated in my discussion of the varieties of euthanasia, my response is to bite the bullet and accept active and non-voluntary euthanasia. Those who do not wish to do so, including many public advocates of assisted dying, have difficult questions to answer, and their opponents are right to press them on these.

The doctrine of double effect: is euthanasia avoidable?

Advocates of euthanasia have logical slippery slope arguments of their own to offer. One such argument has already been offered: we already tolerate passive euthanasia. Sometimes people find the pull of euthanasia too strong, but are reluctant to use that word to describe what they are doing. This final section considers whether the well-known 'doctrine of double effect' can square this circle.

On this doctrine intentional shortening of life is forbidden, but shortening that is merely foreseen is sometimes permitted. This is often confused with the distinction between killing and letting die but it is different, as the consequences of an omission may be intended.

Now, it could be argued that any foreseen consequence is intended. Psychologically disavowing it makes no moral difference. But the distinction can be seen to be genuine by considering cases in which foresight is far from certain. For example, a failed hit man would feel that his ends had been frustrated, whereas a doctor who foresaw that necessary surgery might cause death would be thankful if it didn't. There is a distinction between ends, their unsought by-products and their unavoidable means.

This observation does not however help those doctors who invoke the doctrine of double effect when they flood suffering patients with morphine that will hasten their deaths, motivated by having foreseen this hastening but claiming to intend only pain relief. These doctors are not thankful when their patients survive, revealing their claim not to intend a compassionate death for the psychological pretence that it is.

So I suggest we abandon the doctrine of double effect. It lacks any real justification. It has highly off-putting consequences, suggesting that we can never abort a foetus as an intended means to saving its mother, even where both will die. And above, all, it dishonestly ‘disowns’ consequences that doctors perfectly well foresee, and often embrace.

This was the last obstacle to my case for euthanasia. I have argued that the popular argument from autonomy is weaker than that from beneficence. This frees us from accepting any request for death, but it forces us to consider euthanasia in all its varieties, not just the voluntary and generally passive form embraced in polite society. This is not a drawback; it is a duty. Just as the current unjustified restriction to passive euthanasia condemns those in appalling pain to slow rather than quick deaths, so our refusal to consider all forms of euthanasia means ignoring a great deal of suffering.