Saturday, June 25, 2011

The Ethics of Euthanasia (Part One)

The book Contemporary Debates in Applied Ethics recently found its way into my hands. It's a decent collection of essays on topics ranging from abortion, to capital punishment, to world hunger. As might be expected from a debate book, it adopts a “pro” and “anti” format. In other words, there are eleven pairs of essays with each pair consisting of an essay defending a proposition and another one opposing the same proposition. Unfortunately, the interplay between the essays isn’t perfect and, as per usual, the authors occasionally talk past one another. Still, the standard of discussion is high and it makes for rewarding reading.

Anyway, I thought I might share some of the book here on the blog since the argumentative back-and-forth of the essays fits well with the kind of analysis I usually undertake. First up will be the pair of essays on euthanasia. The pro essay is written by Michael Tooley; the anti essay is written by Daniel Callahan. I’ll go over Tooley’s essay first (it might take a few posts), then I’ll turn to Callahan’s essay.

In this post, we’ll go through some conceptual distinctions and we’ll look at Tooley’s basic pro-euthanasia argument. I should clarify at the outset that Tooley isn’t necessarily “pro” euthanasia. He just thinks it isn’t morally wrong. In this respect, his argument might be thought to resemble the pro-choice position on abortion.

1. The Euthanasia Landscape
Tooley adopts the following definition of euthanasia:

Euthanasia” = Any action where a person is intentionally killed or allowed to die because it is believed that the individual would be better off dead than alive — or else, as when one is in an irreversible coma, at least no one is worse off.

So understood, “euthanasia” captures a rather broad range of activities. Certainly much broader than the range of activities that Tooley’s opponent Callahan thinks fall within the rubric of “euthanasia”. Callahan defines euthanasia as the direct killing of a patient by a doctor. Such a definition is, as Tooley notes, narrower than his in at least three ways. First, it excludes killing by means of omission ( e.g. withdrawing life support). Second, it excludes methods of killing that are indirect (Tooley cites the example of a morphine dose which leads to respiratory failure but which is directly intended to reduce pain). And third, it limits itself to patients. Tooley thinks these limits are morally irrelevant. More on this in a later post.

For now, we need to be a little bit more discriminating in our conceptualisation of euthanasia. In particular, we need to pay attention to two dimensions along which particular instances of euthanasia can vary.

The first of those dimensions captures the distinction between voluntary, non-voluntary and involuntary forms of euthanasia. An instance of euthanasia is voluntary if the person who is euthanised either consents to or requests their death. An instance of euthanasia is non-voluntary if the person who is euthanised does not have the capacity to communicate their desires (e.g. as in a coma). And finally, an instance of euthanasia is involuntary if the person is euthanised against their will.

The second dimension captures the distinction between passive and active forms of euthanasia. There are different ways of understanding this distinction. According to one, the distinction is between killing someone by omission ( i.e. by doing nothing) or by performing some act. Alternatively, the distinction is between the primary causes of death. If the primary cause of death is human action, then we have a case of active euthanasia. And if the primary cause of death is disease or injury, then we have a case of passive euthanasia.

With those dimensions in place, we can construct the following grid.

The grid captures all the possible forms of euthanasia. We can assign moral statuses to each of these forms. I note that most people think that passive voluntary euthanasia is morally permissible, i.e. they think its okay for someone to refuse to undergo life-saving treatment (in certain cases). I also note that many people think that passive non-voluntary euthanasia is morally permissible, i.e. a family can withdraw life-support from a relative who is in a persistent vegetative state. What we’re interested in here is whether active voluntary euthanasia is morally permissible.

2. Making The Case for Active Voluntary Euthanasia
If you have any familiarity with Tooley’s writings you’ll know that he has a penchant for long formal arguments (check out his SEP entry on the problem of evil for a good example of this). It should come as no surprise then to learn that his basic argument for active voluntary euthanasia is quite long. One of the nice features of this approach is that it tends to make for a logically strong argument. Tooley tends to build his case in a series a fairly uncontroversial stages, and these stages tend not to rely on implicit premises — as is often the case in arguments of this sort. That’s not to say there’s no controversy to be had — of course there is — but at least he tries to build a comprehensive case.

In the euthanasia essay, Tooley presents his argument initially as one whole unit and then works through the justification of the various stages. I’m going to reverse that order of presentation here: I’m going to go through the various stages first and then I’m going to present the whole argument, with an argument map, at the end. Here we go.

3. Stage One: Suicide can sometimes be in a person’s interest
The first stage of argument proposes that a person’s committing suicide is — under certain circumstances — in that person’s interest. It looks like this:

  • (1) If a person is suffering considerable pain due to an incurable illness, then in some cases that person’s death is in his or her own interest.
  • (2) If a person’s death is in his or her own interest, then committing suicide is also in that person’s own interest.
  • (3) Therefore, if a person is suffering considerable pain due to an incurable illness, then committing suicide is in that person’s own interest.

This argument is logically valid (“If A then B” + “If B then C” → “If A then C”). It is also relatively innocuous: It says nothing, yet, about whether suicide is morally permissible. It only says that it can be in a person’s interest. Still, some people might object to its premises and we must see what can be said in their favour.

As regards premise (1), Tooley makes two supporting observations. First, he notes that many people who suffer from painful and incurable diseases come to welcome their own deaths. Since people are generally assumed to be good judges of what is in their interest, this implies that their deaths are (likely) in their own interests. Second, he notes that the family members of those who suffer from such diseases also welcome their deaths. We will add these two supporting observations into the completed argument map as (1.1) and (1.2) respectively.

As regards premise (2), Tooley notes that some religious believers are likely to reject this premise. For instance, Catholics who believe that suicide is a sin, and that anyone who commits it is destined for Hell, are likely to reject it. We’ll give this objection the number (2.1) There are a couple of ways to respond to this. One would involve a major detour into the philosophy of religion and might end up arguing that a good God is unlikely to send people to Hell for eternity. An alternative response — the one Tooley endorses in the interests of time — is to point out that Catholics think that many things (homosexual acts, premarital sex, contraception and masturbation) are sins. So anyone persuaded by Catholic doctrine on suicide must adopt a similar attitude towards these acts. The suggestion is that most people are unlikely to do this and so this objection to premise (2) fails. These points will be added to the argument map as (2.2) and (2.3).

4. Stage Two: Suicide is not (always) morally wrong
We now move on to the next stage of the argument. This stage focuses on the transition from “in a person’s interest” to “not morally wrong”. As follows (note: (3) serves as the first premise of this argument, but I’m not going to write it out again):

  • (4) A person’s committing suicide in such circumstances may very well also satisfy the following two conditions: (a) it neither violates anyone else’s rights, nor wrongs anyone; and (b) it does not make the world a worse off place.
  • (5) An action that satisfies conditions (a) and (b), and that (c) is not contrary to one’s own interest, cannot be morally wrong.
  • (6) Therefore, a person’s committing suicide when that act does not violate conditions (a), (b) and (c) is not morally wrong.

There are a couple of things going on here. On the one hand, premise (5) is setting down certain conditions for moral rightness. On the other hand, premises (4) and (3) are saying that those conditions are met in certain cases of suicide. Let’s look at the conditions first and then consider whether they actually are met in certain cases of suicide.

Conditions (a) and (c) appeal to the idea that to be morally wrong an act must wrong some sentient being by violating their rights or undermining their interests (on certain conceptions of rights these are one and the same thing). By themselves these conditions would seem uncontroversial. The major objection to them is that they do not exhaust the conditions of moral wrongness. Derek Parfit, for instance, has a famous thought experiment in which you are asked to choose between two actions. The first of which will lead to future generations enjoying an extremely high quality of life, and the second of which will lead to future generations having lives that are not worth living.

The typical reaction to this thought experiment is that to perform the second action would be to do something morally wrong. But this reaction is difficult to explain if (a) and (c) exhaust the conditions of moral wrongness. After all, the future generations who are harmed by the second action are not yet alive and so cannot be wronged by your actions in the present. This suggests that there is more to wrongness than just harming the rights and interests of sentient beings (other thought experiments can be used to reach similar conclusions). And this possibility is exactly what condition (b) is designed to cover.

So the conditions of moral wrongness seem to be sound, now we must ask whether they will be met in certain cases of suicide. We have already seen in stage one how condition (c) can be met when the person is enduring considerable pain due to an incurable illness. So we focus here on (a) and (b).

Tooley argues that in the same circumstances condition (a) can be met. How so? Well, although it is true that those contemplating suicide in such cases will have obligations to others, they are unlikely to be able to meet those obligations due to the pain they are suffering (4.1). Furthermore, obligations usually allow for some level of cost-benefit analysis to determine whether they need to be fulfilled — if the personal cost of fulfilling the obligation is exceptionally high, as it might be in cases of incurable illness, then the obligations may be relaxed (4.2).

There is an obvious objection to this. Some might argue — contra the above — that ending one’s own life violates God’s right of ownership over us (4.3). Tooley detects three flaws with this response. First, it assumes that God exists when this is unlikely to be the case (4.4). Second, and more importantly, even if there is a God such a right of ownership is highly implausible since it conflicts with moral autonomy, which is generally thought to be a great good (4.5). Third, even if there is some right of ownership over non-autonomous beings — as there might be in the case of pets and their owners — this does not give the owner the right to compel the being to suffer needlessly (4.6). Tooley’s approach here is a bit too kitchen-sinky for my taste. I tend to think that in ethical debates of this sort one should either grant the most complex premises (like the existence of God) for the sake of argument, or else one should engage with them more fully. I don’t like the “this is unlikely” approach taken in (4.4).

Anyway, turning to condition (b), Tooley again thinks it highly likely that this condition will be met in the case of incurable illness with considerable pain. He does so on the grounds that death in these cases (i) ends the suffering to the individual, (ii) is likely to ease the emotional suffering of the friends and families of the individual, and (iii) is unlikely to generate any outweighing suffering due to loss of a loved one (4.7).

In sum, stage two of the argument seems well-supported.

5. Stage Three: Assisting Suicide is not morally wrong
Stage three of the argument makes the all-important leap from cases in which the individual takes their own life (suicide) to cases in which another person assists the individual in the taking of their own life. It says (again, (6) is an unwritten premise here):

  • (7) It would be morally wrong for a person (call them “A”) to assist another in committing suicide (call them “B”) if and only if: (i) it was morally wrong for B to commit suicide; or (ii) committing suicide was contrary to A’s own interests; or (iii) A’s assisting B to commit suicide violated an obligation that A owed to a third party C.
  • (8) Circumstances may well be such that A’s assisting B to commit suicide was neither (i) morally wrong for B; or (ii) contrary to A’s interests; or (iii) in violation of A’s obligations to any third party C.
  • (9) Therefore, it may not be morally wrong to assist another in committing suicide.

This stage of the argument follows a similar pattern to the previous one. It sets some conditions for morally wrongful assistance and then it says those conditions are met in certain cases of assisted suicide.

Let’s look to the conditions of morally wrongful assistance first. Here, I must admit, I’ve hit upon a snag. Although conditions (i) and (iii) seem relatively straightforward, condition (ii) seems less so. The problem has to do with the ambiguity of Tooley’s original formulation of premise (7). Whereas I try to make it clear who is being referred to by introducing the characters A and B, Tooley does not and refers simply to “the person”. Unfortunately, this makes it unclear whose interests are being referred to in condition (ii). I’ve interpreted it above as referring A’s interests ( i.e. the interests of the assister) and I think this makes sense: it would seem imprudent (and likely a condition of wrongness) for A to assist another in undermining his interests. That said, it could be that Tooley is referring to B’s interests and drawing a distinction between objective and subject interests. In other words, the idea is that while B might subjectively think that a particular action (in this case suicide) is in their interests, they might be wrong about this when their interests are assessed from the third-person perspective. So if you, as an outside observer, think that the action is not in B’s interests, you should not assist them in performing it. Again, this seems plausible, but it also expresses a thought more complex than Tooley’s original formulation allowed for.

However the ambiguity gets sorted out, it seems like premise (8) will hold. We have already seen how suicide is not necessarily morally wrong for the person committing it, hence condition (i) can be avoided. Furthermore, there would seem to be circumstances in which either interpretation of (ii) fails to hold. Tooley acknowledges that some people may be members of organisations (religious or professional) which impose an obligation on them not to assist in the suicide of another (8.1). For those people, condition (iii) will be met. But Tooley responds by noting that this obligation will not, in general, be present and so, once again, there are circumstances in which (iii) will not be met (8.2).

6. Stage Four: From Assisted Suicide to Voluntary Active Euthanasia
The last stage of the argument is the easiest. It simply suggests that if assisted suicide is morally permissible, then so too is voluntary active euthanasia. The only difference between the two is that, in the former, the individual plays an active role in bringing about their own demise, whereas, in the latter, a third party does all the work. Tooley contends that this difference cannot be morally significant. So we get:

  • (10) Wherever assisting a person in committing suicide is permissible, voluntary active euthanasia is also justified, provided the latter does not violate any obligation that one has to anyone else.
  • (11) Therefore, voluntary active euthanasia can, in certain circumstances, be morally permissible.

The completed argument map is below.

Okay, that’s all for this post. In the next part, we’ll consider the distinction between passive and active voluntary euthanasia, and we’ll also look at the legalisation of euthanasia.

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