Chapter 7: Euthanasia and
Assisted Suicide
The “good death”
• Euthanasia means ‘the good death’ and “to euthanize”
means to bring about a person’s death to relieve the
person of a serious distress. Since, for most us, death is
not something we welcome, the phrase “the good
death” can seem almost self-contradictory.
• Yet, most of us know of people tormented by pain or
disability, who find their lives so miserable that dying
appears welcome. This is especially true where the
persons involved are at the end of life.
The “good death”
• How should we, as individuals, as professionals (nurses,
doctors, hospital administrators), or policy-makers
respond to these kinds of cases?
• The question becomes personal because any of us, at
any time, might be in the situation where death is our
best alternative.
• Should we embrace euthanasia?
• The answer is contentious for several reasons.
Reasons for disagreement
• First, there is disagreement over whether it is ethical for a
person to seek his own death to end some kind of misery.
This is suicide and many people condemn it.
• Second, even where it is accepted that a person may seek
his own death, disagreements exist over the ethically
appropriate means and circumstances to achieve it.
• Third, there are cases where a person is incompetent to
make a life or death decision for himself; others must make
it for him, which creates still a third source of controversy:
when, if ever, should an incompetent person be
euthanized?
Reasons for disagreement
• Underlying these disputes are differing
perspectives on two issues:
• The moral meaning and relevance of the
distinction between killing and letting die.
• The weight that should be given to personal
autonomy in cases where a patient requests
euthanasia.
Killing and letting die
• To kill someone (including oneself) is to take a definite
action to end his or her life (e.g., administering a lethal
injection).
• To allow someone to die, by contrast, is to take no steps to
prolong that person’s life when those steps seem called
for—failing to give a needed injection of antibiotics, for
example.
• This distinction is the basis for differentiating two forms of
euthanasia, active and passive. Active euthanasia is killing a
patient who requests to die. Passive euthanasia is allowing
a patient to die who requests to die.
Killing and letting die
• This distinction is used in most contemporary
codes of medical ethics (e.g., the American
Medical Association’s Code of Ethics) and is also
recognized in the Anglo-American tradition of
law.
• Except in special circumstances, it is illegal to
deliberately cause the death of another person. It
is not, however, illegal (except in special
circumstances) to allow a person to die.
Autonomy
• A second major issue fueling disputes over euthanasia
is the extent to which personal autonomy should be
allowed to enter into decisions to end a person’s life.
• Autonomy is the ability to act on decisions we have
made and it is something most people highly value
because it exercise is critical in allowing us to live the
kind of life we find worthwhile.
• The idea of autonomy is also strongly associated with
the idea that a person’s life is his own. That connection
is perhaps most strongly felt in cases where people are
suffering severe pain or disability, as in the Dax Cowart
case (discussed in chapter 1).
Autonomy
• In such cases it is natural to think: the lives of
these people belong to them. Surely they
should be the ones who should decide
whether those lives should continue.
• Yet, there are those who disagree for a variety
of reasons including:
Autonomy
• “Your life” is really not yours but God’s so you have no business
taking it.
• You do not necessarily know what’s in your best interests.
Circumstances could improve. There could be deep value in your
suffering that would be lost if you simply did what you wanted.
• You have obligations to others and can be valuable to others. These
facts can provide powerful reasons for staying alive.
• Society, as an institution, has a deep interest in insisting on a basic
attitude of respect for life. Allowing life and death decisions to rest
on individual autonomy undermines that interest.
Death isn’t what it used to be
• But adding to the complexity of the ethical issues
surrounding euthanasia have been advances in medical
technology over the past forty. For example, up until
recently, the answer to the question of when you were
dead was simple: you are dead when your heart stops
beating. Not any more.
• The question “When is someone dead?” hardly
seemed worth asking until the rise of intensive care
medicine in the 1950s and the increasing success of
organ transplantation in the 1970s. People began to
ask:
Death isn’t what it used to be
• “If a physician switches off the ventilator that is keeping a patient’s
body supplied with oxygen, is this homicide?”
• “If a surgeon removes the heart from a breathing patient, has she
killed him?”
• These questions became more than academic exercises for a few
surgeons who were arrested and charged with homicide, and
finding answers became more urgent for personal and practical
reasons.
•
If surgeons couldn’t remove organs from a body with a beating a
heart without fearing a trial and a prison sentence, they would no
longer perform transplants.
Definition of death
• Discussions during the 1970s and 1980s about determining
criteria for death led to the development of four basic ideas
about what it means to be dead:
• 1. Cardiopulmonary. A person is dead when her heart stops
beating and she is no longer breathing. (traditional
definition of death)
• 2. Whole Brain. Death is “the irreversible cessation of all
brain functions.” A person is dead when his brain displays
no organized electrical activity and even the brain stem,
which controls basic functions such as breathing and blood
pressure, is electrically silent.
Definition of death
• 3. Higher Brain. Death is the permanent loss of
consciousness. An individual in an irreversible coma is
dead, even though her brain stem continues to
regulate her heartbeat and blood pressure.
• 4. Personhood. Death occurs when someone ceases to
be a person. Relevant to deciding whether this has
happened is information about the absence of mental
activities such as reasoning, remembering,
experiencing an emotion, anticipating the future, and
interacting with others.
Definition of death
• Legally, in the US, death is defined by the 1985 federal Universal
Determination of Death Act which is based on criteria (1) and (2). A
person is dead when either (1) or (2) is true. This definition is
embodied in the laws of all fifty states.
• These changed definitions of death have become a critical part of
the euthanasia debate in cases where a person has been kept
“alive” on life-support technology.
• When, if ever is justifiable to take such individuals off life support,
especially when they are not competent to give consent?
• The high profile court cases of Nancy Cruzan, Karen Quinlan, and
Terri Schiavo, summarized in this chapter, highlight the moral
relevance of the new definitions of death.
Section 1: The Killing–Letting-Die
Distinction
• In many contexts, killing and letting die is a simple and
straightforward distinction. If I push a person’s head
under water until he drowns, I have killed him. If a
novice swimmer is floundering next to my boat and I
can save him by tossing a nearby life preserver and
don’t, I have allowed him to die.
• But, matters are not always so simple, particularly in
the context of euthanasia. A distinction is sometimes
drawn between active and passive euthanasia which
rests on the killing- letting die distinction.
Section 1: The Killing–Letting-Die
Distinction
• In a classic example: if a doctor injects a patient
with a fatal dose of morphine to relieve the
suffering of the patient who wishes to die, the
doctor has actively euthanized or killed the
patient.
• In contrast, where a doctor removes some form
of life support, at the patient’s request, and the
patient dies, the doctor has passively euthanized
the patient. The doctor has allowed the patient to
die; he has not killed the patient.
Section 1: The Killing–Letting-Die
Distinction
• But as Rachels’ paper (“Active and Passive
Euthanasia”) suggests, the distinction between
doing and allowing depends on background
conditions.
• He offers the example of insulting a person by not
shaking their hand. You come to a party with
three others: I shake their hands but I don’t shake
yours. If criticized, I might say “I didn’t do
anything!” but the reasonable reply is yes I did: I
insulted him by not shaking his hand”.
Section 1: The Killing–Letting-Die
Distinction
• The hand-shaking example illustrates another feature of
the debate over the killing-letting die distinction.
• In some instances at least, even if we agree that an action,
A, is an instance of killing and another action, B, is an
instance of letting die, it may be that from a moral point of
view, there is no difference between A and B. A and B are
equally right or equally wrong.
• The question of the moral equivalence of killing and letting
die is taken up in this section by James Rachels (“Active and
Passive Euthanasia”) and Winston Nesbitt (“Is Killing No
Worse Than Letting Die?”)
Reading: Active and Passive Euthanasia
James Rachels
• James Rachels challenges both the use and the moral
significance of the distinction between active and passive
euthanasia.
• Rachels argues that since both forms of euthanasia result in
the death of a person, active euthanasia ought to be
preferred to passive. Active euthanasia is more humane
because it allows suffering to be brought to a speedy end.
• Furthermore, Rachels claims, the distinction itself can be
shown to be morally irrelevant. Is there, he asks, any
genuine moral difference between drowning a child and
merely watching a child drown and doing nothing to save
it?
Reading: Active and Passive Euthanasia
James Rachels
• Finally, Rachels attempts to show that the bare
fact that there is a difference between killing and
letting die doesn’t make active euthanasia wrong.
• Killing of any kind is right and wrong depending
on the intentions and circumstances in which it
takes place; if the intentions and circumstances
are of a certain kind, then active euthanasia can
be morally right.
Reading: Active and Passive Euthanasia
James Rachels
• For these reasons, Rachels suggests that the approval
given to the active–passive euthanasia distinction in
the Code of Ethics of the American Medical Association
is unwise.
• He encourages physicians to rely upon the distinction
only to the extent that they are forced to do so by law
but not to give it any significant moral weight.
• In particular, they should not make use of it when
writing new policies or guidelines.
Reading: Is Killing No Worse Than Letting Die?
Winston Nesbitt
• Winston Nesbitt rejects the claim that there is no moral difference
between killing and letting die. He holds that the pair of cases
offered by Rachels (see previous article) to show that there is no
difference, as well as the pair offered by Tooley described in the
article, fail to demonstrate the claim.
• In both pairs, the agent is prepared to kill and fails to do so only
because unexpected circumstances make it unnecessary. This
feature, Nesbitt argues, makes both cases in each pair equally
reprehensible.
• The examples used by Rachels and Tooley are flawed and cannot
support the claim that because letting die is morally acceptable, so,
too, is killing. Both, in their cases, are morally unacceptable.
Sections 2 and 3: The Case for Allowing
Euthanasia and Assisted Suicide
• The readings in these sections address a second general
issue underlying the euthanasia debate: how much weight
should autonomy have in decisions to end life?
• As noted earlier, we value autonomy highly and its value
seems especially relevant in life or death decisions because,
in such cases, it seems reasonable to say that a patient’s life
is his, not somebody else’s.
• As a consequent, what the patient wants to do with his
own life seems like an extremely relevant, if not decisive,
consideration in deciding whether to honor his request to
end his life.
Sections 2 and 3: The Case for Allowing
Euthanasia and Assisted Suicide
• The first two writers in these sections challenge this view.
• J. Gay-Williams in “The Wrongfulness of Euthanasia”
adopts a natural law perspective (natural law theory is
discussed in Part VI “Foundations of Bioethics”, at the end
of the book.)
• According to this view, human beings have a variety of
natural goals or inclinations.
• These goals and inclinations represent standards of
morality against which we can judge human behavior.
Sections 2 and 3: The Case for Allowing
Euthanasia and Assisted Suicide
• Humans are capable of acting against these goals.
When they do, they are acting contrary to the moral
standards that are part of nature. In such instances
they are acting immorally.
• One important natural goal is to continue living. Since
euthanasia involves ending life (one self’s or someone
else’s) it violates this goal and so is morally wrong.
• On this view, personal autonomy has no moral weight
in decisions about euthanasia.
Sections 2 and 3: The Case for Allowing
Euthanasia and Assisted Suicide
• Daniel Callahan in “When Self-Determination Runs Amok”
contends there are considerations relevant to life and death
decisions that severely limit the weight that autonomy
should play in those decisions. Among these are the
following:
• There exists long-standing societal goal of reducing the
killing of one person by another, which endorsement of
euthanasia would clearly violate.
• There also exists a common good, embodied in our public
institutions, such as medicine, which represents more than
simply an aggregate of the interests of individuals.
Sections 2 and 3: The Case for Allowing
Euthanasia and Assisted Suicide
• The autonomy argument for euthanasia wrongly implies that
individuals may “in the name of their own private, idiosyncratic
view of the good life” demand support from this common good.
• In particular, the autonomy argument suggests that the practice of
medicine, whose long-standing purpose has been to preserve life,
can be legitimately commandeered to end it.
• The papers by John Lachs (“When Abstract Moralizing Runs Amok”)
and Peter Singer (“Voluntary Euthanasia: A Utilitarian Perspective”),
in contrast, offer a defense of the relevance of autonomy to
euthanasia decisions.
Reading: The Wrongfulness of Euthanasia
J. Gay-Williams
• J. Gay-Williams defines euthanasia as intentionally taking the life of
a person who is believed to be suffering from some illness or injury
from which recovery cannot reasonably be expected.
• Gay-Williams rejects passive euthanasia as a name for actions that
are usually designated by the phrase but seems to approve of the
actions themselves.
• He argues that euthanasia as intentional killing goes against natural
law because it violates the natural inclination to preserve life.
• Furthermore, both self-interest and possible practical consequences
of euthanasia provide reasons for rejecting it.
Reading: When Self-Determination Runs Amok
Daniel Callahan
• Daniel Callahan argues against any social policy
allowing voluntary euthanasia and assisted suicide. He
maintains that self-determination and mercy (the two
values supporting them) may become separated.
• When this happens, assisted suicide for any reason and
nonvoluntary euthanasia for the incompetent will
become acceptable.
• Callahan rejects Rachels’ claim that the difference
between killing and letting die is morally irrelevant.
Reading: When Self-Determination Runs Amok
Daniel Callahan
• He holds that the difference is fundamental and that the
decision to terminate a life requires a judgment about
meaning and quality that physicians are not competent to
make.
• In general, Callahan warns us, we must not allow physicians
to move beyond the bounds of promoting health, and
exercise the power of deciding questions about human
happiness and wellbeing.
• Permitting them to make such decisions will lead to
widespread abuse and destroy the integrity of the medical
profession.
Reading: When Abstract Moralizing Runs Amok
John Lachs
• John Lachs claims that Callahan fails to grasp the moral
problems leading people to consider euthanasia.
• They are not interested in it as an escape from the
suffering inherent in “the human condition,” but as an
end to pain and a burdensome life.
• Callahan holds that even if we have the right to kill
ourselves, it intrinsically cannot be transferred to
others. But Lachs argues that the idea of a right that
cannot be transferred makes no sense.
Reading: When Abstract Moralizing Runs Amok
John Lachs
• Callahan also claims that once the principle of taking
life has been “legitimized,” there can be no good moral
reasons for not killing someone for any reason at all.
• Lachs argues that Callahan’s claim rests on the view
that judgments about our suffering and the value of
our lives are subjective (and so not necessarily shared
by others).
• Yet physicians are able to review objectively a patient’s
request to die with respect to the patient’s condition
and situation.
Reading: When Abstract Moralizing Runs Amok
John Lachs
• Contrary to Callahan’s implication, no one has
ever endorsed the principle of autonomy as
absolute. It expresses one value among
others.
• But it recognizes that our lives belong to
ourselves and that society must justify
infringements, and this is what the debate
over euthanasia is about.
Reading: Voluntary Euthanasia: A Utilitarian
Perspective
Peter Singer
• Singer asks what makes it wrong, from a nonreligious view, to kill
any being, including a human. The utilitarian answer, which he
accepts, is that killing ends the possibility that the being can
experience whatever further good life holds.
• For a “hedonistic utilitarian” this means happiness, and for a
“preference utilitarian” it means the satisfaction of preferences.
Thus, when unhappiness or the frustration of preferences
outweighs life’s positive elements, killing is preferable to not killing.
• Singer addresses only voluntary euthanasia (including assisted
suicide) and accepts Mill’s view that individuals are the best judges
of their own interests and should be allowed to decide when the
good things of life are outweighed by the bad, making death
desirable.
Reading: Voluntary Euthanasia: A Utilitarian
Perspective
Peter Singer
• He argues that the right to life should be viewed as an option, not
as inalienable, which would make life a duty.
• It is necessary to determine that candidates for voluntary
euthanasia are competent to make decisions and have access to
palliative care, but in some instances even depressed people may
be acceptable candidates.
• Finally, Singer asks whether allowing voluntary euthanasia would
lead to the deaths of vulnerable individuals pressured into
consenting to involuntary killing, then points to studies in the
Netherlands and Oregon showing that the evidence does not
support this view.
• He concludes that the utilitarian case for allowing patients to
choose euthanasia is strong.
Section 4: Deciding for the Incompetent
• In many cases of where euthanasia might be considered,
the patient is unquestionably alive and capable making an
autonomous decision and the moral question, as explored
in sections 1-3, is whether it is ethically acceptable to end
the patient’s life at his request.
• The court decision in the case of Karen Quinlan, discussed
here, looks at questions that arise when the patient is
incapable of exercising autonomy and so is incompetent to
even make a request to die. In particular, it examines the
legitimacy of having others make the decision to end a
person’s life for that person.
Reading: In the Matter of Karen Quinlan, an Alleged
Incompetent
Supreme Court of New Jersey
• The 1976 decision of the New Jersey Supreme Court in the
case of Karen Quinlan was significant in establishing that a
legally based right of privacy permits a patient to decide to
refuse medical treatment.
• The court also held that this right can be exercised by a
parent or guardian when the patient herself is in no
position to do so.
• Thus, in the opinion of the court removal of life-sustaining
equipment would not be a case of homicide (or any other
kind of wrongful killing), even if the patient should die as a
result.
Reading: In the Matter of Karen Quinlan, an Alleged
Incompetent
Supreme Court of New Jersey
• The ruling in the Quinlan case has had an
enormous impact on decisions about
discontinuing extraordinary medical measures.
• However, the ruling has generally been construed
rather narrowly so as to apply only to mentally
incompetent patients who are brain dead,
comatose, or in an irreversible coma.