Peter Singer
NOT JUSTIFYING INVOLUNTARY EUTHANASIA
Wed Oct 22 20:59:24 2003
64.140.158.110

TAKING LIFE: HUMANS - by Peter Singer
NOT JUSTIFYING INVOLUNTARY EUTHANASIA
http://www.petersingerlinks.com/taking.htm

Involuntary euthanasia resembles voluntary euthanasia in that it involves the killing of those capable of consenting to their own death. It differs in that they do not consent. This difference is crucial, as the argument of the preceding section shows. All the four reasons against killing self-conscious beings apply when the person killed does not choose to die.

Would it ever be possible to justify involuntary euthanasia on paternalistic grounds, to save someone extreme agony? It might be possible to imagine a case in which the agony was so great, and so certain, that the weight of utilitarian considerations favouring euthanasia override all four reasons against killing self-conscious beings. Yet to make this decision one would have to be confident that one can judge when a person's life is so bad as to be not worth living, better than that person can judge herself it is not clear that we are ever justified in having much confidence in our judgments about whether the life of another person is, to that person, worth living. That the other person wishes to go on living is good evidence that her life is worth living. What better evidence could there be?

The only kind of case in which the paternalistic argument is at all plausible is one in which the person to be killed does not realise what agony she will suffer in future, and if she is not killed now she will have to live through to the very end. On these grounds one might kill a person who has - though she does not yet realise it - fallen into the hands of homicidal sadists who will torture her to death. These cases are, fortunately, more commonly encountered in fiction than reality.

If in real life we are unlikely ever to encounter a case of justifiable involuntary euthanasia, then it may be best to dismiss from our minds the fanciful cases in which one might imagine defending it, and treat the rule against involuntary euthanasia as, for all practical purposes, absolute. Here [R. M.] Hare's distinction between critical and intuitive levels of moral reasoning (see Chapter 4), is again relevant. The case described in the preceding paragraph is one in which, if we were reasoning at the critical level, we might consider involuntary euthanasia justifiable; but at the intuitive level, the level of moral reasoning we apply in our daily lives, we can simply say that euthanasia is only justifiable if those killed either

1. lack the ability to consent to death, because they lack the capacity to understand the choice between their own continued existence or non-existence; or
2. have the capacity to choose between their own continued life or death and to make an informed, voluntary, and settled decision to die.

ACTIVE AND PASSIVE EUTHANASIA

The conclusions we have reached in this chapter will shock a large number of readers, for they violate one of the most fundamental tenets of Western ethics - the wrongness of killing innocent human beings. I have already made one attempt to show that my conclusions are, at least in the area of disabled infants, a less radical departure from existing practice than one might suppose. I pointed out that many societies allow a pregnant woman to Ml a fetus at a late stage of pregnancy if there is a significant risk of it being disabled; and since the line between a developed fetus and a newborn infant is not a crucial moral divide, it is difficult to see why it is worse to kill a newborn infant known to be disabled. In this section I shall argue that there is another area of accepted medical practice that is not intrinsically different from the practices that the arguments of this chapter would allow.

I have already referred to the birth defect known as spina bifida, in which the infant is born with an opening in the back, exposing the spinal cord. Until 1957, most of these infants died young, but in that year doctors began using a new kind of valve, to drain off the excess fluid that otherwise accumulates in the head with this condition. In some hospitals it then became standard practice to make vigorous efforts to save every spina bifida infant. The result was that few such infants died - but of those who survived, many were severely disabled, with gross paralysis, multiple deformities of the legs and spine, and no control of bowel or bladder. Intellectual disabilities were also common. in short, the existence of these children caused great difficulty for their families and was often a misery for the children themselves.

After studying the results of this policy of active treatment a British doctor, John Lorber, proposed that instead of treating all cases of spina bifida, only those who have the defect in a mild form should be selected for treatment. (He proposed that the final decision should be up to the parents, but parents nearly always accept the recommendations of the doctors.) This principle of selective treatment has now been widely accepted in many countries and in Britain has been recognised as legitimate by the Department of Health and Social Security. The result is that fewer spina bifida children survive beyond infancy, but those who do survive are, by and large, the ones whose physical and mental disabilities are relatively minor.

The policy of selection, then, appears to be a desirable one: but what happens to those disabled infants not selected for treatment? Lorber does not disguise the fact that in these cases the hope is that the infant will die soon and without suffering. it is to achieve this objective that surgical operations and other forms of active treatment are not undertaken, although pain and discomfort are as far as possible relieved. If the infant happens to get an infection, the kind of infection that in a normal infant would be swiftly cleared up with antibiotics, no antibiotics are given. Since the survival of the infant is not desired, no steps are taken to prevent a condition, easily curable by ordinary medical techniques, proving fatal.

All this is, as I have said, accepted medical practice. in articles in medical journals, doctors have described cases in which they have allowed infants to die. These cases are not limited to spina bifida, but include, for instance, babies born with Down's syndome and other complications. In 1982, the 'Baby Doe' case brought this practice to the attention of the American public. 'Baby Doe' was the legal pseudonym of a baby born in Bloomington, Indiana, with Down's syndrome and some additional problems. The most serious of these was that the passage from the mouth to the stomach - the oesophagus - was not property formed. This meant that Baby Doe could not receive nourishment by mouth. The problem could have been repaired by surgery - but in this case the parents, after discussing the situation with their obstetrician, refused permission for surgery. Without surgery, Baby Doe would soon die. Baby Doe's father later said that as a schoolteacher he had worked closely with Down syndrome children, and that he and his wife had decided that it was in the best interests of Baby Doe, and of their family a whole (they had two other children), to refuse consent f the operation. The hospital authorities, uncertain of their leg position, took the matter to court. Both the local county court and the Indiana State Supreme Court upheld the parents' rig] to refuse consent to surgery. The case attracted national made attention, and an attempt was made to take it to the U.S. Supreme Court, but before this could happen, Baby Doe died.

One result of the Baby Doe case was that the U.S. government headed at the time by President Ronald Reagan, who had come, to power with the backing of the right-wing religious 'Moral Majority', issued a regulation directing that all infants are to be given necessary life-saving treatment, irrespective of disability. But the new regulations were strongly resisted by the American Medical Association and the American Academy of Pediatrics. In court hearings on the regulations, even Dr C. Everett Koop, Reagan's surgeon-general and the driving force behind the attempt to ensure that all infants should be treated, had to admit that there were some cases in which he would not provide life sustaining treatment. Dr Koop mentioned three conditions in which, he said, life-sustaining treatment was not appropriate anencephalic infants (infants born without a brain); infants who had, usually as a result of extreme prematurity, suffered such severe bleeding in the brain that they would never be able to breathe without a respirator and would never be able even to recognise another person; and infants lacking a major part of their digestive tract, who could only be kept alive by means o a drip providing nourishment directly into the bloodstream.

The regulations were eventually accepted only in a watered down form, allowing some flexibility to doctors. Even so, a subsequent survey of American paediatricians specialising in the care of newborn infants showed that 76 percent thought that the regulations were not necessary, 66 percent considered the regulations interfered with parents' right to determine what course of action was in the best interests of their children, and 60 percent believed that the regulations did not allow adequate consideration of infants' suffering.

In a series of British cases, the courts have accepted the view that the quality of a child's life is a relevant consideration in deciding whether life-sustaining treatment should be provided. In a case called In re B, concerning a baby like Baby Doe, with Down's syndrome and an intestinal obstruction, the court said that surgery should be carried out, because the infant's life would not be 'demonstrably awful'. in another case, Re C, where the baby had a poorly formed brain combined with severe physical handicaps, the court authorised the paediatric team to refrain from giving life-prolonging treatment. This was also the course taken in the case of Re Baby J: this infant was born extremely prematurely, and was blind and deaf and would probably never have been able to speak.

Thus, though many would disagree with Baby Doe's parents about allowing a Down's syndrome infant to die (because people with Down's syndrome can live enjoyable lives and be warm and loving individuals), virtually everyone recognises that in more severe conditions, allowing an infant to die is the only humane and ethically acceptable course to take. The question is: if it is right to allow infants to die, why is it wrong to kill them?

This question has not escaped the notice of the doctors involved. Frequently they answer it by a pious reference to the nineteenth-century poet, Arthur Clough, who wrote:

Thou shalt not kill; but need'st not strive Officiously to keep alive.

Unfortunately for those who appeal to Clough's immortal lines as an authoritative ethical pronouncement, they come from a biting satire - 'The Latest Decalogue' - the intent of which is to mock the attitudes described. The opening lines, for example, are:

Thou shalt have one god only; who Would be at the expense of two. No graven images may be Worshipped except the currency.

So Clough cannot be numbered on the side of those who think it wrong to kill, but right not to try too hard to keep alive. is there, nonetheless, something to be said for this idea? The view that there is something to be said for it is often termed 'the acts and omissions doctrine'. It holds that there is an important moral distinction between performing an act that has certain consequences - say , the death of a disabled child - and omitting to do something that has the same consequences. if this doctrine is correct, the doctor who gives the child a lethal injection does wrong; the doctor who omits to give the child antibiotics, knowing full well that without antibiotics the child will die, does not.

What grounds are there for accepting the acts and omissions doctrine? Few champion the doctrine for its own sake, as an important ethical first principle. It is, rather, an implication of one view of ethics, of a view that holds that as long as we do not violate specified moral rules that place determinate moral obligations upon us, we do all that morality demands of us. These rules are of the kind made familiar by the Ten Commandments and similar moral codes: Do not kill, Do not lie, Do not steal, and so on. Characteristically they are formulated in the negative, so that to obey them it is necessary only to abstain from the actions they prohibit. Hence obedience can be demanded of every member of the community.

An ethic consisting of specific duties, prescribed by moral rules that everyone can be expected to obey, must make a sharp moral distinction between acts and omissions. Take, for example, the rule: 'Do not kill.' If this rule is interpreted, as it has been in the Western tradition, as prohibiting only the taking of innocent human life, it is not too difficult to avoid overt acts in violation of it. Few of us are murderers. It is not so easy to avoid letting innocent humans die. Many people die because of insufficient food, or poor medical facilities. If we could assist some of them, but do not do so, we are letting them die. Taking the rule against killing to apply to omissions would make living in accordance with it a mark of saintliness or moral heroism, rather than a minimum required of every morally decent person.

An ethic that judges acts according to whether they do or do not violate specific moral rules must, therefore, place moral weight on the distinction between acts and omissions. An ethic that judges acts by their consequences will not do so, for the consequences of an act and an emission will often be, in all significant respects, indistinguishable. For instance, emitting to give antibiotics to a child with pneumonia may have consequences no less fatal than giving the child a lethal injection.
Which approach is right? I have argued for a consequentialist approach to ethics. The acts/omissions issue poses the choice between these two basic approaches in an unusually clear and direct way. What we need to do is imagine two parallel situations differing only in that in one a person performs an act resulting in the death of another human being, while in the other she omits to do something, with the same result. Here is a description of a relatively common situation, taken from an essay by Sir Gustav Nossal, an eminent Australian medical researcher:

An old lady of 83 has been admitted [to a nursing home for the aged] because her increasing degree of mental confusion has made it impossible for her to stay in her own home, and there is no one willing and able to look after her. Over three years, her condition deteriorates. She loses the ability to speak, requires to be fed, and becomes incontinent. Finally, she cannot sit in an armchair any longer, and is confined permanently to bed. One day, she contracts pneumonia.

In a patient who was enjoying a reasonable quality of life, pneumonia would be routinely treated with antibiotics. Should this patient be given antibiotics? Nossal continues:

The relatives are contacted, and the matron of the nursing home tells them that she and the doctor she uses most frequently have worked out a loose arrangement for cases of this type. With advanced senile dementia, they treat the first three infections with antibiotics, and after that, mindful of the adage that 'pneumonia is the old person's friend', they let nature take its course. The matron emphasises that if the relatives desire, all infections can be vigorously treated. The relatives agree with the rule of thumb. The patient dies of a urinary tract infection six months later.

This patient died when she did as a result of a deliberate omission. Many people would think that this omission was well- justified. They might question whether it would not have been better to omit treatment even for the initial occurrence of pneumonia. There is, after all, no moral magic about the number three. Would it also have been justifiable, at the time of the omi