Euthanasia
is a difficult topic for many people. It firstly forces us to
face the unwelcome idea that some people's lives are a burden
to them - and they themselves judge their lives to be not worth
living. It then forces us to address the issue of what we should
do in response to this, as individuals and as a society. This
is difficult for us both because it requires ethical reflection,
and once we undertake such a debate socially it becomes clear
that reasonable people can differ in their views. We are often
not comfortable with challenges to our fundamental values or
our ideas of what is right or wrong, or with how to work through
- for ourselves and as a society - contested moral issues.
Euthanasia presents us with a moral dilemma - not just a problem.
It is not simply a choice between right and wrong; rather all
the options have some elements of wrongness. But that is not
to say we cannot as individuals, and even as a society, resolve
the dilemma. People of courage, amongst others Peter Brown,
Phillip Nitschke, Lesley Martin - have brought this issue of
euthanasia to the fore recently and New Zealanders are engaging
in the ethical debate necessary to resolve the dilemma. The
debate is necessary not just politically but ethically - because
not to engage in it is also a moral act - or perhaps an immoral
act given that it would be to refuse to hear the plea of those
who suffer that we consider a solution to their suffering.
It is always important in any ethical debate to make clear
first how one is understanding the issue and the terms one is
using. (Much moral dispute arises from misunderstanding, as
well as from refusing to hear what the other person is saying.)
I am talking about voluntary euthanasia, which I take to be
a situation in which someone assists another person to end their
life, at their competent and uncoerced request. I won't discuss
refusal (or withdrawal) of treatment. Even where death will
follow (and may be an aim), this is already a recognised right
in NZ (for competent adults). Autonomous persons may also take
their own lives (commit suicide), in medical or non-medical
contexts, but our laws embed a moral view that someone who assists
in this is doing wrong.
'Mercy killing' can obviously extend to cases other than voluntary
euthanasia - to taking the life of those incapable of deciding
for themselves. But the moral implications of such an extension
are more troubling to most than the issues of voluntary euthanasia,
and I'll concentrate this afternoon on the more straightforward
case.
What does an
ethicist want to say about euthanasia?
First: that there are two connected but distinct issues - whether
it is morally right or wrong for someone to assist another to
take their life, and whether the law should treat this as a
crime.
One might hold consistently the view that to assist a suicide
is wrong, but that in at least certain specifiable situations
it is not something that we should prohibit by law. We can recognise
that equally good and sincere people may make different moral
judgements, and allow the act to be one of conscience. (For
many this is what they think about abortion.) We should not
confuse the laws by which we enforce or restrain actions in
order to ensure justice and protect out communal/social life
with morality. (Some argue that anything which is morally wrong
should be legally prohibited - but not all wrongdoing is (or
should be) illegal - consider lying to one's spouse - it may
be morally abhorrent, but it is not a crime.)
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But the issues of whether euthanasia is morally wrong, and
whether it should be illegal are frequently intertwined in the
debate. So let us look at that debate.
Is it morally right or wrong for someone to assist another
competent and uncoerced person to end their own life? At least,
is this wrong in the circumstances normally taken to define
euthanasia - where the person who would end their life is suffering
from a terminal medical condition which they find unbearable.
I just pointed out that equally good and sincere people can
disagree about this. Is that the end of the question? I don't
think it is. I think we owe it to ourselves as persons capable
of right thinking and action to reflect carefully on our own
views about this matter and the reasoning by which we support
them, in the light of open-minded consideration of the views
and reasoning of others. Such ethical reflection is a central
part of ethical action and a moral life. Moreover, the second
issue - whether or not to legally permit euthanasia - requires
that we make a decision as a society, and hence that we explore
our areas of agreement and disagreement.
There are three
major ethical principles or values which underpin views on euthanasia.
1) Respect for life. Sometimes expressed as the sanctity for
life - but to say life is sacred or sacrosanct is one point
on a gradient of levels of respect - and one which is hard to
accept if one does not share certain religious views. One issue
for debate is the degree to which the value of life itself overrides
other values. Respect for life is one of the primary reasons
advanced for the view that euthanasia is morally, and should
be legally, impermissible.
2) Respect for persons - and crucially respect for the informed,
free and deliberate decisions of persons. Sometimes described
as respect for autonomy (self-determination).
Respect for autonomy is the major ground for the right to refuse
treatment, and is a significant reason for accepting euthanasia.
3) The wrongness of suffering is the other major reason in support
of euthanasia. The judgement that human suffering (or indeed
the suffering of any creature capable of feeling) is wrong underpins
principles such as 'do not cause pain'; 'act to reduce or relieve
pain and suffering'.
Most of us would endorse these values - indeed I have expressed
them as best I can in terms which would secure general agreement
- but note that there are different ways of understanding or
expressing them which might remove the apparent agreement (for
example changing 'respect for life' to 'sanctity of life').
But endorsing these values does not yield an answer to the questions
about whether euthanasia is morally acceptable or whether it
should be legal. The moral debate is to do with how such values
apply to euthanasia, and what consequences they yield with respect
to its moral or legal permissibility.
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I also do not think that these values are absolute - by which
I mean that there are likely to be exceptions that people would
endorse, particularly if the values cannot be all sustained
together in some situation. For example, respect for autonomy
is recognised to be overridable when the person's autonomous
choice would have seriously detrimental consequences for others
(and this is one of the arguments against permitting euthanasia).
And some would argue against me that respect for life is absolute
and never overridable.
This is a central issue in the debate. As I have described
it, voluntary euthanasia is a situation in which the values
of respect for autonomous choices and the wrongness of suffering
conflict with at least some understandings of the value of respect
for life.
So does respect
for life mean that it is never morally acceptable to take a
human life?
Capital punishment is endorsed by some, and all but a few would
allow killing where it is necessary to save one's own life (or
the lives of loved ones). We might still hold in such situations
that killing is a moral wrong, but that it is the lesser wrong.
Or we might hold that in such situations, when all things are
considered, killing is not wrong but right. Similarly for euthanasia
- we might hold that killing, or aiding a suicide, is the lesser
wrong, or we might argue that in the situation it is not wrong
at all. But if it is neither a matter of justice nor preservation
of another life, on what grounds could we argue that it is a
morally acceptable taking of life?
The other two principles or values provide those grounds. Some
argue that the situation of euthanasia, where someone is suffering
(and that is the operative word) from a terminal illness, the
wrongness of suffering outweighs the wrongness of taking a life.
This argument needs more elaboration.
First we need to note that it cannot be simply the wrongness
of suffering which licenses taking a life. We are not licensed
to kill someone because they have toothache. We could amend
the argument by saying that it is the wrongness of intolerable
suffering which warrants the taking of life, and (perhaps) only
where this is the only remedy. This of courses raises the factual
question as to whether there are ever situations in which death
is the only remedy to suffering. Many palliative care specialists
would say 'no', and I am not qualified to answer that question.
But I can say that there are situations in which death is the
only remedy acceptable to the person, and that brings us to
the role of respect for autonomy in this debate.
We also need to note that if the acceptability of taking a
life were to be argued solely on the basis of it being a remedy
for suffering, this would license taking the lives of sufferers
who do not request this action. While some would accept this,
it isn't a point I want to defend this afternoon.
So does the
weight of the argument for the moral acceptability of euthanasia
lie on the principle of respect for persons and their autonomous
choices?
I think that this is a crucial element, and note that all countries
where euthanasia is permitted have stringent requirements for
establishing the autonomous quality of the decision. Some would
argue that voluntary euthanasia is a natural extension of the
arguments which support the right die through rejecting treatment
(also called passive euthanasia). But we should note that if
all that matters is the decision of an autonomous (a competent,
informed and uncoerced) person that they wish to die, we would
not be justified in limiting the acceptability of euthanasia
to cases of terminal illness, or even of unbearable suffering.
The decision (and that it was fully autonomous) would be enough,
without reference to the condition which prompted it.
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I noted before that respect for autonomous choice is not an
absolute principle; we are not morally required to respect (in
the sense of 'comply with') autonomous choices which are detrimental
to others. Euthanasia requires an action by another person,
whether a loved one or a medical professional, of a kind which
is not - and should not be - easy to perform. For this reason
we do not require of anyone that they comply with a response
for euthanasia. However the moral argument is not about requiring
compliance, but about permitting it. If the person requested
to assist such an autonomous choice is willing to do so, on
what grounds could their compliance be morally condemned or
legally prohibited.
One ground is the view that taking another person's life is
never permissible - which I discussed earlier. But the more
interesting reasons are the arguments that compliance with such
requests, and particularly giving legal permission to do so,
would have detrimental consequences for others. The consequences
often suggested are: that there would be abuse of any legal
permission to carry out euthanasia, that to permit taking life
will lead to devaluing life, and loss of respect for life; that
it would lead to explicit and subtle coercion of vulnerable
persons to request euthanasia; that it would lead to 'mercy
killing' in contexts where this is not warranted by the person's
autonomous choice in the face of intolerable suffering; that
it would undermine fundamental values essential to the medical
and health-oriented professions.
Whether these would be consequences is a matter of fact about
which there is genuine doubt. (The evidence from countries which
have legalised voluntary euthanasia suggests these fears may
be exaggerated.) Whether the possibility of such consequences
warrants continued prohibition of euthanasia is a matter of
ethical judgement - and depends firstly, on the strength one
accords to the moral reasons in support of voluntary euthanasia
and secondly on whether these consequences might not be addressed
in some other way than rejecting euthanasia. Where individual
freedoms are limited in order to protect other persons, the
harms we are trying to avoid must be both worse than the harm
of limiting freedom and not able to be avoided by any other
less intrusive means. (As the great defender of individual freedom,
John Stuart Mill, argued in his famous essay On Liberty.)
It is these possible consequences which I take to be most critical
to the question of whether euthanasia should be legally permitted.
But when considering such arguments, one needs to address also
the harmful consequences for all concerned of failing to legalise
voluntary euthanasia in clearly specified contexts. Underground
and illegal acts of mercy, love and obligation - from promises
to help loved ones of the kind which brought several New Zealanders
to the attention of the law and the public in 2002 - have scary
consequences also (as well as the harm of denying and frustrating
people's wishes with respect to their own lives).
My final comment is that some people feel that a focus on consequences
is to miss the real moral quality of the issue. This view is
often derived from a sense that morality is a matter of principles,
antithetical to the pragmatic (may I say 'Utilitarian') orientation
of a focus on consequences. I think this view is wrong, and
that consequences, particularly those to do with the well-being
of individuals and the social structures within which individuals
necessarily exist, are central moral concerns. But I note also
that assertions of principles, particularly where these derive
from ethical, religious or cultural frameworks which are not
universal in a society, raise the fundamental political question
of when the actions of some may legitimately be restricted by
the principles of others.
Jan Crosthwaite
Associate Professor of Philosophy
The University of Auckland
