EUTHANASIA Powerpoints prepared by Dr. Peter Vardy, Vice-principal, Heythrop College, University of London If a person had a favourite dog or cat which was in great pain they might want to put it out of its misery and, indeed, it might be considered wrong if the person failed to do this. If, when someone are old, are in great pain, cannot feed yourself, have a colostomy bag, cannot sleep without drugs, cannot walk and have made their peace with their friends and children, their may feel that a peaceful death is a reasonable choice to make…. One danger, however, is that old people may be made to feel that they are a nuisance and quietly pressurised to choose to die…. In order to understand the different perspectives on this issue, it is essential to understand the ethical assumptions underlying different positions. Often people are not aware of the assumptions underlying the arguments and sometimes rhetoric is substituted for careful analysis. Dr. Jack Kavorkian Kavorkian helped a number of people to die in the U.S. using the ‘Mercitron’ machine. There are various types but the idea behind them is that the person wishing to die not only takes the decision but actually performs the action that brings about death – hence Kavorkian helped to put people in a position where they could take their own life. It was not, he therefore argued, murder and was bringing release to people from a life of great pain and suffering. However he was nicknamed ‘Dr. Death’ and was sentenced to a prison term… The devices he used are shown on the following slides. Dr. Jack Kavorkian with the Mercitron DIFFERENT ETHICAL THEORIES IN CONSIDERING EUTHANASIA, OR ANY OTHER ETHICAL ISSUE, IT IS FIRST ESSENTIAL TO DECIDE ON THE THEORETICAL ETHICAL FRAMEWORK TO BE ADOPTED. THE POSSIBILITIES INCLUDE: The Bible or Holy Book such as the Qu’ran; Natural Law; Proportionalism; Situation Ethics or Utilitarianism The Bible It is not possible to absolutise the sixth commandment (‘Thou shalt not kill’). This is put forward in Exodus Ch. 20:13 but the very next chapter (Ex. 21: 12 - 16) gives four reasons for killing a human being: 1) if you strike your parents, 2) if you kidnap someone, 3) if you murder someone or 4) if you curse your parents. The Bible has no universal prohibition against killing - it endorses war and provides for capital punishment. It does not even condemn the four cases which it records of suicide: Saul (1 Sam. 31:4); Anthithopel (2 Sam. 17: 23); Samuel (Judges 16:30); Judas (Matt. 27:5) APPEAL TO REVELATION IN SACRED TEXTS Revelation is claimed by various religious: Jews will appeal to the Torah and Talmud Christians to the Christian scriptures Muslims to the Qu’ran BUT differences immediately arise as to how these texts are to be interpreted. None of them deal unequivocally with modern ethical dilemmas – whether in the field of genetics, abortion, homosexuality, just war, crime and punishment or other issues. Much will depend on how the text is interpreted and there will be considerable disagreements. THE STATUS OF SACRED TEXTS There are considerable differences within all religions as to the status of their sacred texts, as to the role of reason, individual conscience and the teaching authority of any central body. Within Christianity: The Catholic Church attaches great importance to the teaching authority of the Magisterium in Rome, In the Protestant tradition more emphasis is placed on the Bible and Anglicans value the early Church Councils; Tradition; the Bible and personal experience. More recently the Lambeth conference and decisions of local synods have become influential. Because so many issues are raised by appeal to sacred texts, most arguments about euthanasia are based on philosophic grounds as reason is held to provide a common meeting point for those from different traditions. If someone simply says “My sacred texts asserts X and I am not willing to discuss this further” then it becomes difficult to engage in debate with those who do not accept the status of these texts or who interpret them differently. FOUR ETHICAL THEORIES (Very briefly!) Natural Law Situation Ethics Proportionalism Utilitarianism NATURAL LAW The Natural Law approach to ethics has its origins in the philosophy of Aristotle. St. Thomas Aquinas writing between 1265 and 1274 c.e. used Aristotle’s philosophy to provide an intellectual grounding for Christian moral claims and also for NATURAL THEOLOGY. Natural Theology claims that reason can arrive at the existence of God. NATURAL LAW claims that human reason can be used to arrive at what is morally right or wrong. Nothing in revelation contradicts reason – so reason and revelation go hand in hand. ARISTOTLE AND AQUINAS Aquinas followed Aristotle in claiming that all human beings (and all animals and plants of the same genus or species) share a COMMON NATURE. To be morally evil is to freely choose to FALL SHORT OF THE HUMAN NATURE WHICH ALL HUMAN BEINGS SHARE. If, therefore, one can work out what it is to be human, one can then arrive at which acts are morally evil. Acts which go against what it is to be human are ‘intrinsically evil’. They are evil in and of themselves. Situation Ethics Situation Ethics was put forward in its most developed form by the Anglican Joseph Fletcher in 1965. It is a CONTEXTUAL and SITUATIONAL approach – it therefore rejects the DEONTOLOGICAL approach of Natural Law. It has been condemned by the present Pope and the Catholic Magisterium as a position that no Catholic may hold. Some consider that it may not, therefore, be taught in Catholic institutions. Situation Ethics…. Fletcher claims that Jesus came to reject the Law – i.e. the Jewish Torah. It was too inflexible and attempted to transform the spirit that lay behind the law into fixed rules. Fletcher said there is no ethical system that can be said to be Christian. Jesus’ two commands to love (God and neighbour) are the foundation and heart of all Christian morality. There are no moral absolutes except love – everything depends on what is the loving thing to do in the particular situation. PROPORTIONALISM This is based on the Natural Law approach and stems from the Catholic tradition. Many Catholic moral theologians maintain that it is more faithful to this tradition than a strict Natural Law approach. It holds that there ARE firm moral rules – BUT THERE CAN BE EXCEPTIONS if there is a proportionate reason which would justify this. It maintains that an action maybe objectively WRONG but morally RIGHT and that another action may be objectively RIGHT but morally WRONG Proportionalism contd. A distinction has to be made between acts which are good and acts which are right and this distinction, proportionalists maintain, is often not made. A person may have a good intention but may be able to achieve that intention only through an act which is considered to be, in itself, evil. The proportionalists hold that it is possible for an action, in itself, to be wrong, whilst based on the actual situation in which the action is done the action may be morally right. UTILITARIANISM This aims for the ‘greatest happiness’ or the ‘greatest good’ for the greatest number of people. It was put forward by Jeremy Bentham but modified by John Stuart Mill. Bentham considered pleasure was a single thing no matter what its source, but Mill considered that there were higher and lower pleasures – for instance listening to music and writing poetry were ‘higher’ pleasures than ‘piggy’ pleasures such as food, drink and sex because these are shared with animals. Once one differentiates between higher and lower pleasures, however, a criteria is being introduced that goes beyond mere happiness. Central to the debate about euthanasia are: 1) Does God exist and do human beings have a duty to God in considering how to behave? 2) Is the maintenance of life an absolute value which no other ‘good’ can outweigh? 3) Does one hold that an act is morally right or wrong because of the very nature of the act or, by contrast, does one hold that it is the consequences of the act which make it right or wrong? 4) Is euthanasia the start of a ‘slippery slope’ that may justify the killing of handicapped people and others? Key distinctions in the debate about Euthanasia DIRECT AIM OR A BY PRODUCT? It is important to separate: Acts whose direct aim and intention is the bringing about of death (euthanasia falls under this heading) and Acts such as providing pain relief whose main purpose is not to bring death but may cause death as a side-effect. There is generally considered to be no moral problem with the second of these positions. The principle of double effect This is a long established principle in ethics that an action may have more than one effect. If the side effect is regrettable but inevitable, then it is still permitted. For instance, the removal of the cancerous womb in a woman is a good action and is permitted even if, as a by-product, the life of a foetus may be destroyed. In the case of euthanasia, the giving of drugs to relieve pain is permitted even if, as a by-product, the death of the person is hastened. The early death is then a byproduct of a good action. ACTS OF OMISSION AND COMMISSION Acts of Omission involve not doing something (for instance not giving a blood transfusion) whilst Acts of Commission involve a positive action (administering an injection or giving tablets). Leaving someone to die (subject to certain caveats) would fall under the first heading and would not be classified as euthanasia. The British Medical Association recognises a distinction between withholding treatment that may be burdensome and deliberately bringing a person’s life to an end. Its 1988 statement on Euthanasia maintained that the deliberate bringing to an end of life should remain a crime. ORDINARY AND EXTRAORDINARY MEANS A distinction needs to be drawn between ‘ordinary’ and ‘extraordinary’ means - this was particularly important in the days of warfare before anaesthetics when a decision could be made to forego amputation even if this meant the death of the individual. ‘Extraordinary’ means effectively means ‘disproportionate’ means - in other words means of attempting to save life which are out of proportion, in terms of the pain and degradation suffered, to the possibility of prolonging life. A major problem is what is decided to be ‘extraordinary’ means and in relation to what is this to be measured (e.g. length of subsequent life; quality of life; pain during the procedure, etc.) ORDINARY MEANS Ordinary means has been taken to include air, water and food. If this is accepted, then it can never be permissible to deprive someone of these even if they are in a permanent coma and even if these have to be administered in ways that are highly invasive. THE CATHOLIC DECLARATION ON EUTHANASIA CATHOLIC DECLARATION ON EUTHANASIA 1980 The document represents the official moral position on euthanasia of the Roman Catholic Magisterium (the teaching authority in Rome) Even though this is not an 'infallible' teaching, it is still normative for the Catholic community. As 'normative' this moral position calls for the presumption of truth on the part of the faithful who ought to attend carefully to this teaching. Since 1990, all Catholic priests prior to ordination (except for members of a few religious orders) have to sign an oath giving ‘religious assent of will and intellect to all teachings of the Magisterium’). This means that the Magisterium’s teaching is effectively binding on priests and, Cardinal Ratzinger, the Head of the Holy Office, has said that this teaching must be accepted by the laity as well. Key Principles in the Catholic declaration 1) The Value of Human Life This recognises that most people regard life 'as something sacred'. There are three norms 1)The Universal prohibition against attempts on the life of an innocent person. 2) The Universal duty to live one's life in accord with God's plan that human life be fruitful and find its full perfection in eternal life. 3) The Prohibition of suicide on the grounds that suicide rejects God's sovereignty and plan. II. Euthanasia The document recognises that the word has different means for different people. It defines euthanasia as "an act or an omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated." It is not permissible for one person to do this to another or to ask for it for oneself even when this request comes from the experience of prolonged and barely tolerable pain. The document holds that the pleas of gravely ill people who ask for death should be seen as an anguished plea for help and love, not only in terms of medical care, but also for human and supernatural support and comfort. THIS LAST POINT CAN BE DEBATED III. The Meaning of Suffering for Christians and the Use of Painkillers Whilst seeing that some things e.g. prolonged illness, advanced old age, bring about psychological conditions that facilitate the acceptance of death, nevertheless, death is something which naturally causes people anguish. Suffering may so exceed its biological and psychological usefulness that it can cause the desire to remove it in any way and at whatever price. It accepts that only a very few who can limit the dosage of pain killers to associate in a conscious way with the sufferings of Christ. Most people will want to use pain killers and may do so even though the drugs will reduce consciousness and shorten life. Death is then a by-product to pain relief (principle of double effect) IV. Due proportion in the use of remedies The document says that it is "Important to protect, at the moment of death, both the dignity of the human person and the Christian concept of life against a technological attitude that threatens to become an abuse." The document interprets the phrase 'the right to die' as "rather the right to die peacefully with human and Christian dignity." Decisions about how the ill will live whilst dying should be taken by the sick person. The documents cites with approval an alternative distinction between 'proportionate' and ‘disproportionate' means. Disproportionate means to preserve life occur when the gains of continuing life outweigh the costs to the patient. Proportionalism in Euthanasia Proportionalism is the Declaration's basic approach to applying the traditional principle of ordinary/extraordinary means when solving dilemmas affecting the duration of life. It advocates weighing of relative values (such as risk, cost, burden to patient and benefit) and recognises that some means are disproportionate to the result sought. When death is imminent, an individual may in good conscience "refuse forms of treatment that would only secure a precarious and burdensome prolongation of life, so long as the normal care due the sick person in similar cases is not interrupted.“ GERMAIN GRISEZ & JOSEPH M BOYLE jr. Life and Death with Liberty and Justice Notre Dame Press (1979) p336-439 These authors challenge what they see as two basic assumptions of a pro-euthanasia position. 1) The assumption that there is a distinction between bodily life and personal life. In other words they reject the view that one can cease to be a person and yet still be bodily alive. 2) They also reject the consequentialist position that consequences determine the rightness or wrongness of human actions. Their basic premise is that there are certain basic human goods constitutive of human well-being. The fundamental human goods which are inherently worthwhile and give meaning to one's life and serve as motives for human action include : play and recreation; knowledge of truth and appreciation of beauty, life and health, friendship and self-integration (NOTE the inclusion of ‘life’ in this list).. Grisez and Boyle - 2 These goods cannot be measured against one another in order to establish any form of hierarchy. These basic human goods provide motives for moral action and are the source of the moral obligation to promote human wellbeing. Once this is accepted, then it can never be right to act against one of these basic goods. If this is accepted, then euthanasia would be absolutely prohibited because it intends to realise some good (such as freedom or dignity) by directly turning against one or more basic goods (life or health).Euthanasia wrongly assumes that the choice for death over life can be morally right because it serves the higher goods of freedom, integrity or dignity. JOSEPH FLETCHER Fletcher is an advocate of SITUATION ETHICS and he is a consequentialist (a position specifically rejected by the Vatican’s ‘Veritatis Splendour’) in other words Fletcher believes that the rightness or wrongness of actions are to be judged not according to something intrinsic to the action but in terms of the consequences of the action. This is directly opposed, therefore, to the position taken by Grisez and Boyle. Fletcher rejects any absolutes and believes that the situation has to be taken into account and a decision has to be made as to the most loving thing to do in the circumstances. Fletcher maintains that there is more to being human than just being alive and that the key feature of humanity is rationality - this rationality may, in certain circumstances, be used to make a free choice to die. PROPORTIONALISM IN EUTHANASIA DANIEL C MAGUIRE Maguire is a Catholic moral philosopher and he puts forward which is effectively a proportionist’s position. It holds that: 1) Life is a BASIC but not an absolute good 2) ONE IS BOUND TO RESPECT LIFE, BUT NOONE IS BOUND TO PROLONG IT IN ALL CIRCUMSTANCES Maguire argues that issues such as euthanasia can only be handled adequately within the broad context of a complete ethical theory. The special task of ethics is to bring sensitivity, reflection and method to the way people decide the sort of persons they ought to be and the sort of actions they ought to perform. The first step is to discover the moral objective. This is done by asking reality-revealing questions such as what, why, how, who, where, when, what if and what else. Only when this is done can evaluations, using rational analysis, feelings, creative imagination, group experience be undertaken. Maguire’s Central Questions: 1) ‘Can it be moral and should it be legal to take direct action to terminate life in certain circumstances?’. Maguire answers ‘Yes’. (2) ‘Must we in all cases await the good pleasure of biochemical and organic factors and allow these to determine the time and manner of death?‘ Answer ‘No’ (3) ‘Can the will of God regarding a person's death be manifested only through the collapse of sick or wounded organs?’ Answer ‘No’ (4) ‘Can the will of God be discovered through human sensitivity and reasoning?’ Answer ‘Yes’. (5) ‘Could there be circumstances when it would be reasonable and therefore moral to terminate life through either positive action or calculated benign neglect?’ Answer ‘Yes’. Deciding on death Maguire rejects the idea of a kind of fatalistic theism which forbids expanding the human dominion over dying because the time of death is organised by God alone - this implies that human beings are God’s property. If we should not intervene in nature then all medicine would be immoral, there is no essential difference between ending life and preserving life. Maguire maintains that we have underestimated our dominion over life and death - we have been given the responsibility to discover the good and choose it, even when the good in question is death. Terminating a life under certain circumstances may be good so long as a greater good than physical life is being served. Maguire therefore challenges the 'absolute' and 'exceptionless' character often given to the principle "Thou shall not kill". Maguire’s defence against attack! Maguire defends his position of death by choice against the objections of the "no direct killing of innocent life" principle on the basis of his understanding of the source, function and limits of moral principles. The principle that there should be "No direct killing of innocent life" is valid most of the time, but in the specific circumstances of the patient's moral situation, the principle may not apply and would have to yield to the principle of achieving a good death. Unless someone holds that continued living in any condition is always preferable, (s)he will have to enter into the weighing of proportional values. He accepts that making the judgement between conflicting values is not easy and it may be mistaken, but he maintains that the whole purpose of ethical reflection is to achieve a finer sensitivity to the values in conflict and make possible options less arbitrary. Therefore euthanasia can sometimes be a legitimate moral choice. CHARLES E CURRAN Curran accepts life as a primordial value: he accepts the sanctity of life as a basic principle and respect for life as a moral imperative BUT he does not see euthanasia as the taking of full control if it only happens once the dying process has begun. Curran emphasises relationships between persons and also responsibility so that direct taking of life may be allowed when the process of dying has begun. He therefore gives a qualified acceptance to euthanasia in limited circumstances. His is a more limited position than Maguire's. The sanctity of life, the dignity of life, or the value of life, comes from "the special relation of the human being to the life-giving act of God and from the destiny of each person." The value of life is more than a person’s achievements, possessions or capacities which contemporary society often counts as essential to the value of human life. Life is not just a gift… Curran warns against too great a stress on life as a gift as this can play down the role and place of human responsibility in exercising self-determination and stewardship in a reasonable way. 1. exercising stewardship does not exclude weighing the value of life against other values, such as cost, physical and mental suffering or freedom, and 2. already implied in the Christian traditions acceptance of the distinction between ordinary and extraordinary means of treatment [see separate paper on ordinary and extraordinary means. UTILITARIANISM EUTHANASIA AND UTILITARIANISM Today utilitarianism is the ethical theory most often applied in practice – if happiness is maximised, then an action is right. On this basis, to help an old person to die when they are in great pain and terminally ill and they want their life to be brought to an end might be argued to be right as happiness is being increased and pain is being minimised. The most common arguments in favour of euthanasia tend, therefore, to be utilitarian ones. However utilitarianism fails to make a distinctions between actions that are absolutely RIGHT or WRONG and if this distinction is accepted then it may be challenged as an ethical theory. Underlying, therefore, different positions on euthanasia are different ethical frameworks and unless these framework assumptions are identified and the pre-suppositions on which they rest are analysed and questioned, the debate is not likely to make significant progress except at a level that may owe more to rhetoric than careful argument.