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SECTION 8: A critical ethical approach to the problem of euthanasia

‘ It makes a great difference whether a man is lengthening his life or his death. If the body is useless for service, why should one not free the struggling soul?'                                                                                            Seneca (?4 BC-AD 65)

   LEARNING OUTCOMES

   After reading this section of the course, you should be able to:

  • Analyze a health-care dilemma using the discussion of the Principles in the previous sections to assist you.
  • Apply the four stages of analysis to specific principles that might be proposed. These are, isolation of principles, examination of the meaning of the principles, consideration of the implications of the principles and consideration of any change or qualification to the original principle.

KEY POINTS

  •  Glover's two principles governing the direct wrongness of killing:

a. It is wrong to reduce the length of a worthwhile life.
b. Except in the most extreme circumstances, it is wrong to kill someone who wants to go on living, even if there is reason to think this desire not in his own interests
.5

  •  Glover's three conditions for autonomy:

a. existence,
b. development and
c. possession
.

  •  Voluntary euthanasia. The individual has requested to die.
  •  Involuntary euthanasia. The individual has not expressed a wish to die.
  •  Non-voluntary euthanasia. The individual has no views on the continuation of their life either because they have never been in a position to have these views or because they did not express their views when they were capable of expressing them.
  •  Sanctity of Life Principle. Life is of value and should not be destroyed.
  •  If a life is judged not to be worthwhile, ought all ordinary means be taken to preserve that life, but not extraordinary means?
  •  The Principle of Justice. How much money is it fair to allocate to the prolongation of permanently unconscious lives?
  •  If an individual's life is not worthwhile, we take no active measures to kill him or her, but we will take no steps to preserve his or her life. Is this a viable position?
  •  If an individual's life is not worthwhile, we will not kill him or her intentionally, but have as our intention the relief of his or her pain by powerful pain killers, although the foreseen consequences will be his or her death. Is this a viable position?


8.1 THE PERSISTENT VEGETATIVE STATE (PVS) EXAMPLE

An individual, reliably diagnosed to be in PVS, has been in this state for several years. The close relatives of this individual and the attendant health care professionals consider that the best outcome for this individual is death. Should artificial nutrition and hydration be withdrawn from this individual in order that he might die?

The principles that have been discussed and the distinctions that have been drawn are now shown in use by considering the question of whether or not euthanasia is morally justifiable. The structure of the discussion is described in Section 3.3, and the relevance of the Principles of Beneficence, Non-malfeasance, Autonomy and Justice are considered.

Euthanasia interpreted literally means a `good death'. Current understanding of this term indicates that it is used to refer to a deliberate death brought about by one person for the benefit of another person, the person whose life is taken. There are at least two important points to note about this definition. First, euthanasia is distinguished from suicide since someone other than the person whose life is ended does the killing. Second, and more importantly, the death must be seen to be for the benefit of the person whose life is taken. This is crucial since some consequentialist justifications of euthanasia lead to cases where it might be deemed that the best consequences would be achieved if a person is killed, although there is no benefit to the person who dies. Thus we have Singer justifying euthanasia in cases where a `disabled' infant could be replaced by another infant and thus bring about more happiness. He writes:

‘ When the death of a disabled infant will lead to the birth of another infant with better prospects of a happy life, the total amount of happiness will be greater if the disabled infant is killed. ' 1

This slide from genuine cases of euthanasia where the death is for the benefit of the person killed to cases which are justified on the grounds that the best consequences overall will be achieved by the death needs to be rejected. Taken to its extreme, it could lead to a utilitarian improvement policy where relatively minor `defects' could be used as grounds for so-called `euthanasia'. The assumption would be that a greater total benefit is achieved by the replacement of this infant by one not affected in the same way. This sort of argument is only used in cases of non-voluntary euthanasia, which is discussed later in the course.

As we mentioned in Section 1, our concern is whether cases of euthanasia can be morally justified. We are considering what ought to be the case and this might or might not be coincident with what is at present allowed by particular laws. Conversely, the moral rightness or wrongness of some action does not imply that this should be reflected in laws.

8.2 GLOVER'S GENERAL THEORY

To illustrate a critical ethical approach to this problem, we shall consider Glover's discussion of this issue in Causing Death and Saving Lives. There are two reasons for taking this discussion as our focus point. The first is that he is adopting a non­cognitivist approach (see Section 3.2) and the second is that his treatment combines deontological and consequentialist principles. His adoption of non-cognitivism is illustrated when he writes:

`"There is always the possibility, and sometimes the reality, of ultimate  disagreement. ' 3

Moral judgments are expressions of our ultimate attitudes and hence, although there is room for rational discussion of ethical issues, there is still the possibility that there will not be agreement over ethical issues.

8.2.1 Isolation of Glover's principles

The first step in our critical ethical analysis is to isolate the principles that Glover is adopting (see Section 3.3.1). Isolation of the principles, examination of their meaning, analysis of their implications and the possible qualification of the original principles marks the four stages in the critical ethical approach that was discussed in Section 3.

Glover adopts two principles, one deontological and one consequentialist, which are concerned with the direct objections to killing. Direct objections are those that relate solely to the person killed. There are also side-effects of killing, where these are taken to be the effects on individuals other than the person killed. Glover does not provide any principles to deal with these, although he does note that by calling them side-effects we should not assume that they are less important than direct objections to killing. He writes:

‘The direct objections to killing, although very strong, are not being presented here as ones that cannot be overridden . . . It has not been argued that side-effects must always have less weight than the direct objections to killing. ' 4

The two principles governing the direct wrongness of killing are given by Glover as:

A.  It is wrong to reduce the length of a worth-while life.

B. Except in the most extreme circumstances, it is wrong to kill someone who wants to go on living, even if there is reason to think this desire not in his own interests. ' 5

What do Glover's principles mean?

Principle B is referred to by Glover as the Autonomy Principle and he views it as having intrinsic worth. It is the deontological element in his account since the desire to carry on living is being valued even if there is reason to think that the consequences of this desire are not the best possible. Unlike Mill, Glover is not justifying his Autonomy Principle on consequentialist grounds (see Section 4.2.1). It is not a complete principle of autonomy since it is only concerned with the case of someone expressing the wish to go on living. A complete autonomy principle would cover all the desires of the individual.

Glover makes it explicit that not all human beings can be said to possess autonomy. For questions of autonomy to arise it is necessary for three conditions to be met. He describes these conditions as --

    1. the existence condition,
    2. the developmental condition and
    3. the possession condition.

·       The first condition is that the individual must already exist so that we cannot be said to be overriding the autonomy of potential individuals.

·       Second, the individual must be sufficiently developed to be capable of the relevant desires. For example, someone like Singer would argue that young infants are not capable of having the desire to continue living since, although they are sentient, they are not yet `persons' and hence self-conscious and rational.

·        Finally, the possession condition states that the individual must actually have the relevant desire in question.

Principle A, on the other hand, is a consequentialist principle since the wrongness of killing is being explained in terms of it leading to the shortening of a worthwhile life. Glover considers that worthwhile lives are intrinsically valuable although he is not suggesting that everyone will share the same views about what makes life worthwhile. This will clearly vary from individual to individual.

Whenever more than one principle is proposed, unless they are ordered in terms of priority, there will always be the possibility of them conflicting in particular cases. There is no conflict between the principles as stated in the general theory but they could come into conflict in their application. Therefore, there is an indeterminacy in Glover's account at this point, since he does not provide an ordering for his two principles. He does, of course, insert the clause, `except in the most extreme circumstances' in Principle B, but he is not claiming that Principle B always has priority over Principle A.

There is a further indeterminacy in Glover's general theory since there is nothing included in it about when direct objections to killing should override side-effects and when the opposite should be the case. He also does not, as we have already noted, provide any general principles to guide us in the consideration of side-effects.

8.1.3 What are the implications of Glover's principles?

Having considered these general points from Glover's theory, we now examine some implications of these principles when they are applied to the problem of euthanasia.

THE PROBLEM OF EUTHANASIA

How far will this general theory about killing take us in considering the problem of euthanasia? When discussing euthanasia it is usual to divide cases of euthanasia into three types. First we have voluntary euthanasia. This occurs when the individual has requested to die. An illustration of this would be the `euthanasia example' in Section 1. There are problems with determining which cases fall into this category since there are two difficulties with this definition.  First, is it limited to requests that are made at the time that the situation arises?  Alternatively, can requests made earlier for what should happen to an individual in certain situations be considered as making this a case of voluntary euthanasia?  This point is particularly pressing with the advent of `living wills' in the US.

Second, what is to count as a `request to die'? Does this request have to be made more than once? To whom should the request be made? The verification of whether or not the request is indeed an accurate reflection of what this individual wants is difficult to determine. The request might be based on faulty information about the quality of life that the individual can expect to enjoy if he or she does not end his or her life. Also, the request might just be a passing one felt, for example, when the individual was particularly depressed. It has also been argued that were euthanasia to become legal, individuals might feel pressurized into making requests to die from fear that they are becoming a burden on their families and not because they genuinely want to end their lives.

Setting these problems aside, if we assume that we do have a genuine case of voluntary euthanasia then how far will Glover's principles take us in the consideration of these sorts of cases? Glover argues that when we have a case of voluntary euthanasia, then both his principles apply. Strictly speaking, he is not entitled to claim that his autonomy principle applies since, as formulated, that only applies to requests to continue living. However, allowing this extension to requests to die to be included in the autonomy principle we then have cases where both principles are applicable. Therefore, we are confronted with the indeterminacy that is present in Glover's general theory concerning the ranking of the two principles. If we also assume that side-effects are always present in these sorts of cases, then we have the further indeterminacy of no principles governing side-effects. Also, there is no general way of ranking side-effects and direct objections to killing.

Although there is this indeterminacy in Glover's general theory, it would surely be naive to expect a moral theory to operate like a mathematical formula, where all one had to do is to enter in the features of the situation and then read off the moral conclusion. The assistance that Glover's theory provides is that it gives us a way of thinking about the problem. It gives us a way of distinguishing the different issues that are relevant. Also, we can see the problem in the wider context of being another case of killing alongside abortion, suicide and other life-and-death issues. He proposes the same principles for all life-and-death issues, which will assist in a consistent view being held about all these different dilemmas.

The theory is surely correct in the importance that it assigns to the Principle of Autonomy. First, it is given intrinsic worth and not justified on consequentialist grounds. Second, it claims that the Principle of Autonomy should only be overridden in ‘the most extreme circumstances'. If we can be confident that the request for euthanasia is a genuine one, then the wish to die ought surely to be respected.

The second type of euthanasia is easier to deal with than voluntary euthanasia. This is involuntary euthanasia and is defined as euthanasia where the individual in question has not expressed the wish to die. For this to be classed as a case of euthanasia and not murder it must be understood that although the individual has not expressed a wish to die, it is thought to be in that individual's best interests that he or she should die. Appeal is therefore being made to a Principle of Beneficence coupled with a paternalistic evaluation of what is of benefit to the individual (see Section 5.5). These are cases where we have individuals who are capable of making or not making requests to die and have either explicitly asked not to die or they have just not requested death. Clearly, if any justification for involuntary euthanasia is possible, it will be based on consequentialist grounds. It is assumed that the consequences of continuing living will not be a worthwhile life. Both Glover's principles apply, but the autonomy principle is overridden since it is assumed that someone else, other than the individual concerned, can better evaluate what makes that individual's life worth living. It is extremely unlikely that this paternalistic class of cases of euthanasia could ever be justified and the only conceivable case that Glover constructs is not likely to provide a sufficient justification given the uncertainty governing future events.

Arguably, the most difficult cases of euthanasia are those that fall into the class of non-voluntary euthanasia. The `persistent vegetative state' example with which we started this course is an illustration of this. These are cases where the individual has no views about the continuation of their life, either because they are, for example, babies or because they are not in a position to communicate such views, for example, if they are in a coma. In these cases the only principle that is relevant is the Worthwhile Life Principle, since the Principle of Autonomy will not be applicable. Although the existence condition for autonomy will be met, the individual does not possess or is not capable of communicating the desire to either continue or not continue living. In Singer's sense of the term, the individual is not a `person'.

In one sense, the lack of applicability of the Principle of Autonomy might appear to make these cases easier, since there is no possibility of conflict between the two principles. There is, of course, still the consideration of side-effects to be taken into account and these might conflict with the Worthwhile Life Principle, but one potential source of conflict has been removed. However, despite the removal of this potential area for conflict, these cases are still the most intractable of the three.

There are tremendous difficulties in determining whether or not an individual's life is worth living. In addition to the uncertainty of how accurate their future prospects are taken to be, there is the whole question of how these should be evaluated with reference to this particular individual. Also, who ought to make this evaluation? Should it be a member of the health care team or a close relative of the individual? The health care team are probably in a better position to predict the physical conditions that an individual will be placed in, but it is more likely that a close relative of the individual would be in a better position to evaluate what these conditions would mean to the individual in question. Expertise in health care does riot automatically provide one with expertise to make these evaluations.

Even if we assume that we have a case where we arc as certain as we can be that the individual's life is not worthwhile, it is still an open question whether that individual ought to be killed. For example, there are those that support a Sanctity of Life Principle who would argue that even if it is accepted that this individual's life is not worthwhile, life itself is of value and should not be destroyed. Now, in cases of non-voluntary euthanasia the most that we have are lives that are merely conscious and sometimes we do not even have this. The individual in the `persistent vegetative example' was not even conscious. Since we have assumed in this class of cases that the life involved would not be a worthwhile life, adherents to the Sanctity of Life Principle can only be valuing, at most, mere consciousness. The question then arises, does mere consciousness have intrinsic value or is it only of value because of what it might lead to?

If you argue that mere consciousness as such has intrinsic value then you are arguing that dimensions such as sight, hearing and smell are of intrinsic value. They are of value in themselves and not because of what they might lead to. However, an implication of this sort of view that there are no grounds for giving priority to the life of a human being as opposed to that of many other species since they also possess these features of consciousness. This might not be an implication that some people find acceptable, since they consider that human life is of more value than the life of other species. However, someone like Singer would be quite prepared to accept this implication, since he claims that what is of importance is the possession of conscious­ness and not what species is involved (see Section 3.4).

Those who wish to continue claiming that the consciousness of human beings is of more value than that of other species might do so by arguing that consciousness in human beings has a greater potential for becoming more than mere consciousness. However, if this claim is made, it would contradict the previous claim than conscious­ness has intrinsic value. This is because the superiority of human consciousness is being supported on the grounds that it is instrumental to something else whereas the original claim was that consciousness had intrinsic value. Also, in the example we are considering, we assume that we do not have anything else, that we do not have a worthwhile life. Hence, if one holds that consciousness has intrinsic worth it would seem that one would have to accept that there are no grounds for giving priority to human beings as a species. Indeed, there might be certain cases where priority could be given to members of other species on the grounds that their level of consciousness is superior. A human being who lacked sight and hearing might, on these arguments, be accorded less value than a member of another species with the full complement of consciousness.

In the previous section we assumed that the individual's life was not worthwhile. However, surely one of the most important questions in cases of non-voluntary euthanasia is to determine how we are going to establish whether or not an individual's life is worthwhile. Glover suggests that the best procedure is to put yourself in the other individual's position and consider the question from his or her point of view. But how is this to be done? It is surely not possible to achieve a complete identification with all the preferences of another individual but, if this is not the case, what preferences of one's own does one retain? Also, there is one preference that the individual by definition does not have and that is the preference about whether or not they want their life to continue or not. In other words, the evaluation will still be your own and it is on this basis that you will determine whether or not the individual's life is worthwhile.

Let us now assume that we are confident that the life in question is not worthwhile and that we have rejected the sanctity of life principle. What ought we to do in these sorts of cases? A standard reply might be that given that the life is judged not to be worthwhile then all ordinary means ought to be taken to preserve life but that we need not resort to extraordinary means. However, we have argued (see Section 7.3) that the distinction between ordinary and extraordinary means is not a distinction that can be drawn between particular treatments. It is a distinction that can only be drawn after the value questions about someone's life have been settled. Of how much value is it that this life be continued since we have assumed that it is not worthwhile? We have to compare this with the side-effects of keeping this individual alive. Side-effects include the effects on the carers, relatives and other individuals requiring medical resources which might otherwise be used on this individual. It is in connection with this last point that the Principle of Justice becomes relevant to the discussion. In the context of scarce health care resources, how much money ought to be allocated to the prolongation of merely conscious or permanently unconscious lives? It is answers to these sort of questions that enable us to describe a particular procedure as being ordinary or extraordinary. The treatments themselves are only described as ordinary or extraordinary once the value questions described have been answered.

Another reply might be to say that given that this individual's life is not worthwhile, we will not take any active procedures to kill him but we will take no steps to preserve the individual's life. This reply is based on there being a distinction between acts and omissions. In this sort of case the omission would be the result of a conscious decision and it would be more appropriate to describe it as an act of omission. In the case of omissions of this sort, we argued in Section 7.1.1 that there was no intrinsic moral difference between these and acts. Therefore, given that we have agreed that this individual's life is not worthwhile, omitting treatments to preserve his or her life is the same as actively killing him if the consequences are the same. Of course, in many cases the consequences will not be the same and usually, in terms of lack of pain for the individual, there will be less pain as a result of active procedures than by omitting treatment.

A third reply in this sort of case might he to argue that we are justified in performing an action that has death as a foreseen consequence but not as an intended consequence. For example, we might advocate the use of very powerful pain killers with the intended effect of alleviating pain but whose foreseen consequences is the death of the individual. However, as we argued in Section 7.2,  the distinction between intended and foreseen consequences is dependent on a contingent decision about how one describes the situation. Moral evaluations cannot be made dependent on how one decides to describe a situation.

Presumably, if it is decided that the individual's life is not worthwhile and that death is the best outcome for that individual, then the only other considerations that are necessary to raise before killing the individual are the side-effects of this action. The side-effects include not only the effects on the relatives and health care team but also the effects on society at large if euthanasia were practiced in these sort of cases. The consideration of side-effects might well lead one to adopt the policy of giving the pain killer which will ultimately lead to the death of the individual rather than performing a direct act of killing. However, this decision would not be based on a distinction between intended and foreseen consequences but would be the result of balancing the side-effects and direct objections to killing.

LEARNING EXERCISES


1.      ‘ It is wrong to terminate life because life is sacred.’ Critically assess this view by subjecting the principle of the sanctity of life to the four stages of discussion illustrated in this course. You might find it helpful to refer back to Section 3 where these stages were first discussed.


REFERENCES

1.    Singer, P. (1993) Practical Ethics (2nd edn). Cambridge University Press, Cambridge, p186.

2.    Glover, J. (1977) Causing Death and Saving Lives. Penguin Books, London.

3.    Ibid, p35.

4.    Ibid, p 115.

5.    Ibid, p 113.

6.    Ibid, pp 191-2.