09 Killing and Letting Die (part one) 1

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					                                                                                                                   PHI125 – Matters of Life and Death
09. Killing and Letting Die (part one)                                                                                       Autumn Semester 2005

                             VARIETIES OF EUTHANASIA                                                     VARIETIES OF EUTHANASIA

                                                                                   And we saw last week that these two distinctions are ORTHOGONAL
         We have looked at two distinctions between kinds of euthanasia:
                                                                                       – which means that they cut across one another
         One was the distinction between:                                              – which means that they can combine to distinguish four
                VOLUNTARY: death is in accordance with the expressed                   different kinds of euthanasia:
                wishes of the patient;                                                     ACTIVE VOLUNTARY                 PASSIVE VOLUNTARY
                NON-VOLUNTARY: not in accordance with expressed wishes                     ACTIVE INVOLUNTARY               PASSIVE INVOLUNTARY
                of the patient (either because the patient has not expressed
                any wishes or because the patient has expressed a wish to
                                                                                   People might make judge each kind of euthanasia differently …
                continue living).
                                                                                               … or argue that there are different constraints on each
         The other was between:                                                                kind, different criteria that a case must fulfil in order to be
                                                                                               morally acceptable.
                ACTIVE: the doctor performs some action that brings about
                the death, such as administering a lethal injection.
                                                                                   But some people question the distinction between ACTIVE and
                PASSIVE: the doctor does nothing, thereby refraining from          PASSIVE euthanasia, arguing either that the distinction makes no
                any action that would keep the patient alive.                      sense or that it makes no moral difference.

                       THE AMERICAN MEDICAL ASSOCIATION                                              AN ARGUMENT FROM SUFFERING

                                                                                   In his paper, ‘Active and Passive Euthanasia’, James Rachels argues
         These two statements were made by the American Medical                    that it cannot be upheld. Here is his first argument:
         Association in 1973:

                                                                                   “If one simply withholds treatment, it may take the patient longer to
                “The intentional termination of the life of one human being by
                another - mercy killing - is contrary to that for which the        die, and so he may suffer more than he would if more direct action
                medical profession stands and is contrary to the policy of the
                                                                                   were taken and a lethal injection given. This fact provides strong
                American Medical Association.”
                                                                                   reason for thinking that, once the initial decision not to prolong the
                “The cessation of the employment of extraordinary means to         agony has been made, active euthanasia is actually preferable to
                prolong the life of the body when there is irrefutable evidence
                                                                                   passive euthanasia, rather than the reverse. To say otherwise is to
                that biological death is imminent is the decision of the
                patient and/or his immediate family.”                              endorse the option that leads to more suffering rather than less, and
                                                                                   is contrary to the humanitarian impulse that prompts the decision
         Can this distinction be upheld in the way that they require?
                                                                                   not to prolong his life in the first place.”
                                                                                                                       – in Singer, ed. Applied Ethics, p. 29

                          AN ARGUMENT FROM SUFFERING                                                AN ARGUMENT FROM IRRELEVANCE

         The structure of this argument is:                                        Rachels adds the following argument.
            1. Passive euthanasia is justified only if it will end the suffering
            of the patient;                                                            In a case where a child has some debilitating condition, such as
                                                                                       severe Downs Syndrome, for example, and also has some life-
            2. But this suffering would be better ended by active euthanasia;          threatening but easily treatable condition such as a blocked
            Therefore,                                                                 intestinal tract …

            3. In any case in which passive euthanasia is justified, active            … The American Medical Association’s criteria allow that if
            euthanasia is also justified – in fact, even more justified!               doctors and family agree that the child’s life is not worth living,
                                                                                       they may allow the child to starve to death …
         This argument seems vulnerable to two kinds of objection:
            A. Might passive euthanasia be justified by other ends, such as            … but would not have been allowed to act on their decision were
            the avoidance of future suffering?                                         it not for the fact that the child had a blocked intestinal tract in
                                                                                       addition to the debilitating illness.
            B. Might the justification of passive euthanasia rest on the fact
            that nobody acts to kill the patient?                                      This means that the medical response to the debilitating
                                                                                       condition is dependent on an irrelevant fact about the child.                                                                                                                                       1
                                                                                                                  PHI125 – Matters of Life and Death
09. Killing and Letting Die (part one)                                                                                      Autumn Semester 2005

                              KILLING AND LETTING DIE                                                    KILLING AND LETTING DIE

         Rachels goes on to argue that …                                           CASE ONE:
                                                                                   Smith stands to gain a large inheritance if anything should happen to
            The American Medical Association’s position is based on the            his six-year-old cousin. One evening while the child is taking his
            false idea that:                                                       bath, Smith sneaks into the bathroom and drowns the child, and
                                                                                   arranges things so that it will look like an accident.
                                                                                   CASE TWO:
                                                                                   Jones also stands to gain if anything should happen to his six-year-
         Rachels argues that this false by presenting the example of SMITH         old cousin. Like Smith, Jones sneaks in planning to drown the child
         (who kills his nephew) and JONES (who lets his nephew die) …              in his bath. However, just as he enters the bathroom Jones sees the
                                                                                   child slip and hit his head, and fall face down in the water. Jones is
                … he wants us to agree that there is no moral difference           delighted; he stands by, ready to push the child’s head back if
                between Smith and Jones in these stories.                          necessary, but it is not necessary. With only a little thrashing about,
                                                                                   the child drowns all by himself, ‘accidentally’, as Jones watches and
                                                                                   does nothing.

                              KILLING AND LETTING DIE                                                    KILLING AND LETTING DIE

         Is there really no moral distinction between Smith and Jones?             You are a doctor in a hospital and you have five patients in need of
                                                                                   transplant organs: one a heart, one a lung, one a kidney, one a
            UTILITARIANISM: both situations have the same outcome, with            pancreas, one a spleen. If we don’t find any organs soon they will all
                                                                                   die. But with the transplants they will live happy and healthy lives.
            the same amount of suffering caused, so Jones behaved as
                                                                                   (And for some reason you just cannot use the organs from one of
            badly as Smith.                                                        them to save the other four.)

            VALUE OF LIFE PRINCIPLE: You should act in ways that                   Then Jim walks into your hospital with a broken finger and perfectly
            preserve life (with perhaps some exceptions), and since neither        healthy organs that can be used to save the other five people.
            Smith nor Jones did this, their actions are equally wrong.
                                                                                   If it is as bad to let someone die as it is to kill, then it is much worse
                                                                                   to let five patients die than it is to kill Jim …
         But are either of these views right?
                                                                                   Does this example show that there is a clear moral distinction
         Are there cases where killing seems clearly worse than letting die?       between killing and letting die?

                              KILLING AND LETTING DIE                                                    KILLING AND LETTING DIE

         If you think, that it might be okay to kill Jim, then remember that the   Ways in which one might want to uphold the distinction between
         number of patients is irrelevant so long as it is more than one.          killing and letting die …
         So perhaps you should support the following idea as a new
                                                                                               … and also show that in these cases we should not kill
         government initiative:
                                                                                               Jim or vote in favour of the survival lottery …

         THE SURVIVAL LOTTERY                                                                                                                    … include:
            Every citizen is given a number. Whenever doctors have two or
                                                                                   1. The claim that people have a right to non-interference, which is
            more dying patients who could be saved by transplants, and no
                                                                                   violated when someone is killed but not when they just die.
            suitable organs have come to hand through ‘natural’ deaths, they
            can ask a central computer to supply a suitable donor. The
                                                                                   2. Limitations on what we can be expected of people mean that
            computer will then pick a number at random and that citizen will
                                                                                   although it would be better for Jim to be killed than for the other five
            be killed so that the lives of two or more others may be saved.
                                                                                   patients to die, we cannot expect Jim to agree to this sacxrifice, and
            The citizen will be formally honoured for this sacrifice.
                                                                                   so cannot kill him.                                                                                                                                      2
                                                                                                                  PHI125 – Matters of Life and Death
10. Killing and Letting Die (part two)                                                                                      Autumn Semester 2005

                                  SMITH AND JONES                                                            SMITH AND JONES

         In the last lecture, we looked at the arguments James Rachels              We then applied two moral principles to the case of Smith and Jones:
         presents against the distinction between ACTIVE and PASSIVE
         euthanasia …                                                                  UTILITARIANISM: both situations have the same outcome, with
                                     … or between KILLING and LETTING DIE.             the same amount of suffering caused, so Jones behaved as
                                                                                       badly as Smith.
         The central argument he presents is the case of …
            SMITH, who drowns his cousin in order to inherit a fortune,                VALUE OF LIFE PRINCIPLE: You should act in ways that
                                                                                       preserve life (with perhaps some exceptions), and since neither
            and JONES who intends to drown his cousin in order to inherit a
            fortune, but doesn’t need to as he just stands by while his cousin         Smith nor Jones did this, their actions are equally wrong.
            drowns anyway.
                                                                                    But then we saw that there were examples that seemed to make us
         Rachels wants us to agree that Smith and Jones behaved equally             want to distinguish between killing and letting die …
         badly, and that therefore there is no moral difference between killing
         someone and letting them die.

                           IN FAVOUR OF THE DISTINCTION                                            LETTING NATURE TAKE ITS COURSE

         One example was the remote hospital in which a doctor faces the            Some people respond to these kinds of case by saying that …
         choice of killing a healthy patient with a broken finger in order to
                                                                                       … while it is not wrong to interfere in the course of events, it is
         harvest his organs, or allowing five patients to die in need of organ
                                                                                       not wrong either to refrain from interfering …
         transplants …
                                                                                           … so it is not wrong to allow the patients in need of
                … most people want to say that it is WORSE to kill one
                                                                                           transplants to die, because that is what would happen
                healthy patient in this way than to let the other five die!
                                                                                           anyway if there were no doctors or transplant technology …
                                                                                               … but it is wrong to kill someone who isn’t about to die
         The other was the survival lottery: should we have a lottery such that
         when two or more patients need organs of the same blood-type etc.
         and no organs are available, one member of the population is picked
                                                                                    The problem with this is that it means that …
         at random and killed so that the organs can be transplated?
                                                                                                       JONES DID NOTHING WRONG!
                … most people think that this kind of lottery would be wrong:
                that it would be WORSE to kill one random person than allow         … and most people simply do not accept this. They think Jones DID
                two patients to die for the want of organs to transplant.           do something wrong, because he SHOULD have saved his cousin
                                                                                    from drowning.

                                JUSTICE AND CHARITY                                                        JUSTICE AND CHARITY

         In her article ‘Euthanasia’ , Philippa Foot argues that the right             ‘Murder is an act of injustice. A culpable failure to come to the
         response to this problem rests on the distinction between JUSTICE             aid of someone whose life is threatened is normally contrary, not
         and CHARITY …                                                                 to justice, but to charity. But where one man is under contract,
                                                                                       explicit or implicit, to come to the aid of another injustice too will
                “Justice has to do with what men owe each other in the way             be shown.’ (p. 45).
                of non-interference and positive service. When used in this
                wide sense . . . justice is not especially connected with, for
                                                                                    On this view, SMITH committed an injustice because he murdered
                instance, law courts but with the whole area of rights, and         his cousin …
                duties corresponding to rights.”
                                                    – Foot, ‘Euthanasia’, p. 44.           … and JONES committed an injustice because he was
                                                                                           obliged to help the child, either because the child was his
                                                                                           cousin, or because the child was a child and there would
         Charity, on the other hand, has to do with ‘the good of others’ (p. 45).          have been no risk in helping.

                                                                                    So Smith and Jones acted equally badly.                                                                                                                                      1
                                                                                                                PHI125 – Matters of Life and Death
10. Killing and Letting Die (part two)                                                                                    Autumn Semester 2005

                               JUSTICE AND CHARITY                                                        JUSTICE AND CHARITY

         Hospital doctors would be committing acts of injustice if they killed    As Foot puts it:
         healthy patients in order to harvest their organs …
                                                                                         “Where everyone may have a duty to leave someone alone, it
                                             … as indeed would governments!              may be that no one has a duty to maintain his life.” (p. 48)

         But would a doctor be committing a greater injustice by letting two
                                                                                  How does this relate to euthanasia?
         or more people die instead?
                                                                                         ACTIVE euthanasia seems as though it might always be an
         The doctor DOES have a duty to keep patients alive … so letting                 act of injustice, since it is always an act of killing;
         them die purely out of carelessness IS an act of injustice …
                … but it seems that this duty is not entirely unrestricted …the   But so long as the doctor’s duty to keep a patient alive is restricted
                doctor does not have a duty to keep a patient alive at            by the best interests of that patient (as well as by the best interests
                whatever cost to other people!                                    of other people) …
                                                                                         PASSIVE euthanasia might sometimes be an act of injustice
         So in letting two or five patients die, the doctor might be failing to
                                                                                         and sometimes not, depending on the circumstances.
         perform an act of charity, but since this could only be performed by
         performing an act of injustice, this failure is the right thing to do.

                         THE DOCTRINE OF DOUBLE EFFECT                                               THE DOCTRINE OF DOUBLE EFFECT

         A second way to uphold the distinction between killing and letting       In his paper ‘Suicide’, Tom Beauchamp puts it this way:
         die is to invoke ‘the doctrine of double effect’ …
                                                                                     “Whenever from an action there occur two effects, one good and
             … this is a theory central to roman catholic moral thought …
                                                                                     the other evil, it is morally permissible to perform the action and
                                 … and it is based on distinguishing between:        to permit the evil only if:

                                                                                     1. The intention is to bring about the good effect and not to bring
            * the INTENDED outcome of an action;
                                                                                     about the evil effect (which is merely foreseen).
            * UNITENDED outcomes, whether foreseen or not foreseen.
                                                                                     2. The action intended must be good or at least not evil.
         In order to count as an unintended outcome, an effect of your action
                                                                                     3. The good effect must bring at least as much good into the
         must not be the means to the intended outcome.
                                                                                     world as the evil effect brings evil into the world.

         The idea then is that an action with a bad outcome is morally               4. The evil result must not be the cause or means to the good
         acceptable only if the bad outcome is an unintended outcome.                effect.”
                                                                                                                         – p. 89, see also footnote 39.

                         THE DOCTRINE OF DOUBLE EFFECT                                               THE DOCTRINE OF DOUBLE EFFECT
         People who use this distinction to uphold a moral difference
                                                                                  What Smith did was bad not just because his cousin died, but
         between active and passive euthanasia argue that:
                                                                                  because Smith’s intention was that his cousin should die ...
         ACTIVE euthanasia involves …                                                    … and what Jones did (i.e. stand and watch instead of saving
                * EITHER the intention that the patient should die;                      the child) is bad because he did this with the intention that
                                                                                         the child would die.
                * OR the intention that the patient should not suffer any
                more, as a result of dying.                                       So Smith and Jones are equally bad on this account.
         Whichever of these is the intention, the doctrine of double effect       But what about the doctor who harvests organs from a healthy
         says that the action is still killing and therefore wrong.               patient? Could we say that the doctrine of double effect makes this
                                                                                  okay, on the grounds that the death was only a foreseen side-effect
         PASSIVE euthanasia involves …                                            of the intended action of harvesting the organs?
                * ceasing to treat the patient in order that the patient should
                suffer no more                                                    Does this raise a problem with specifying the difference between an
                * with the foreseen consequence that the patient will die as a    intended outcome and a foreseen outcome?

         But does this make sense?                                                                                                                                  2

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