Singer: Justifying Voluntary Euthanasia

JUSTIFYING VOLUNTARY EUTHANASIA
Under existing laws in most countries, people suffering unrelievable pain or distress from an incurable illness who beg their doctors to end their lives are asking their doctors to risk a murder charge. Although juries are extremely reluctant to convict in cases of this kind the law is clear that neither the request, nor the degree of suffering, nor the incurable condition of the person killed, is a defence to a charge of murder. Advocates of voluntary euthanasia propose that this law be changed so that a doctor could legally act on a patient's desire to die without further suffering. Doctors have been able to do this quite openly in the Netherlands, as a result of a series of court decisions during the 1980s, as long as they comply with certain conditions. In Ger- many, doctors may provide a patient with the means to end her life, but they may not administer the substance to her.
The case for voluntary euthanasia has some common ground with the case for non-voluntary euthanasia, in that death is a benefit for the one killed. The two kinds of euthanasia differ, however, in that voluntary euthanasia involves the killing of a person, a rational and self-conscious being and not a merely conscious being. (To be strictly accurate it must be said that this is not always so, because although only rational and self-conscious beings can consent to their own deaths, they may not be rational and self-conscious at the time euthanasia is contemplated - the doctor may, for instance, be acting on a prior written request for euthanasia if, through accident or illness, one's rational faculties should be irretrievably lost. For simplicity we shall, henceforth, disregard this complication.)
We have seen that it is possible to justify ending the life of a human being who lacks the capacity to consent. We must now ask in what way the ethical issues are different when the being is capable of consenting, and does in fact consent.
Let us return to the general principles about killing proposed in Chapter 4. 1 argued there that killing a self-conscious being is a more serious matter than killing a merely conscious being. I gave four distinct grounds on which this could be argued:
1. The classical utilitarian claim that since self-conscious beings are capable of fearing their own death, killing them has worse effects on others.
2. The preference utilitarian calculation that counts the thwarting of the victim's desire to go on living as an important reason against killing.
3. A theory of rights according to which to have a right one must have the ability to desire that to which one has a right, so that to have a right to life one must be able to desire one's own continued existence.
4. Respect for the autonomous decisions of rational agents.
Now suppose we have a situation in which a person suffering from a painful and incurable disease wishes to die. if the individual were not a person - not rational or self-conscious - euthanasia would, as I have said, be justifiable. Do any of the four grounds for holding that it is normally worse to kill a person provide reasons against killing when the individual is a person who wants to die?
The classical utilitarian objection does not apply to killing that takes place only with the genuine consent of the person killed. That people are killed under these conditions would have no tendency to spread fear or insecurity, since we have no cause to be fearful of being killed with our own genuine consent. If we do not wish to be killed, we simply do not consent. In fact, the argument from fear points in favour of voluntary euthanasia, for if voluntary euthanasia is not permitted we may, with good cause, be fearful that our deaths will be unnecessarily drawn out and distressing. In the Netherlands, a nationwide study commissioned by the government found that 'Many patients want an assurance that their doctor will assist them to die should suffering become unbearable.' Often, having received this assurance, no persistent request for euthanasia eventuated. The availability of euthanasia brought comfort without euthanasia having to be provided.
Preference utilitarianism also points in favour of, not against, voluntary euthanasia. Just as preference utilitarianism must count a desire to go on living as a reason against killing, so it must count a desire to die as a reason for killing.
Next, according to the theory of rights we have considered, it is an essential feature of a right that one can waive one's rights if one so chooses. I may have a right to privacy; but I can, if I wish, film every detail of my daily life and invite the neighbours to my home movies. Neighbours sufficiently intrigued to accept my invitation could do so without violating my right to privacy, since the right has on this occasion been waived. Similarly, to say that I have a right to life is not to say that it would be wrong for my doctor to end my life, if she does so at my request. In making this request I waive my right to life.
Lastly, the principle of respect for autonomy tells us to allow rational agents to live their own lives according to their own autonomous decisions, free from coercion or interference; but if rational agents should autonomously choose to die, then respect for autonomy will lead us to assist them to do as they choose.
So, although there are reasons for thinking that killing a self-conscious being is normally worse than killing any other kind of being, in the special case of voluntary euthanasia most of these reasons count for euthanasia rather than against. Surprising as this result might at first seem, it really does no more than reflect the fact that what is special about self-conscious beings is that they can know that they exist over time and will, unless they die, continue to exist. Normally this continued existence is fervently desired; when the foreseeable continued existence is dreaded rather than desired however, the desire to die may take the place of the normal desire to live, reversing the reasons against killing based on the desire to live. Thus the case for voluntary euthanasia is arguably much stronger than the case for non-voluntary euthanasia.
Some opponents of the legalisation of voluntary euthanasia might concede that all this follows, if we have a genuinely free and rational decision to die: but, they add, we can never be sure that a request to be killed is the result of a free and rational decision. Will not the sick and elderly be pressured by their relatives to end their lives quickly? Will it not be possible to commit outright murder by pretending that a person has requested euthanasia? And even if there is no pressure of falsification, can anyone who is ill, suffering pain, and very probably in a drugged and confused state of mind, make a rational decision about whether to live or die?
These questions raise technical difficulties for the legalisation of voluntary euthanasia, rather than objections to the under- lying ethical principles; but they are serious difficulties nonetheless. The guidelines developed by the courts in the Netherlands have sought to meet them by proposing that euthanasia is acceptable only if
• It is carried out by a physician.
• The patient has explicitly requested euthanasia in a manner that leaves no doubt of the patient's desire to die.
• The patient's decision is well-informed, free, and durable.
• The patient has an irreversible condition causing protracted physical or mental suffering that the patients finds unbearable.
• There is no reasonable alternative (reasonable from the patient's point of view) to alleviate the patient's suffering.
• The doctor has consulted another independent professional who agrees with his or her judgment.
Euthanasia in these circumstances is strongly supported by the Royal Dutch Medical Association, and by the general public in the Netherlands. The guidelines make murder in the guise of euthanasia rather far-fetched, and there is no evidence of an increase in the murder rate in the Netherlands.
It is often said, in debates about euthanasia, that doctors can be mistaken. In rare instances patients diagnosed by two competent doctors as suffering from an incurable condition have survived and enjoyed years of good health. Possibly the legalisation of voluntary euthanasia would, over the years, mean the deaths of a few people who would otherwise have recovered from their immediate illness and lived for some extra years. This is not, however, the knockdown argument against euthanasia that some imagine it to be. Against a very small number of unnecessary deaths that might occur if euthanasia is legalised we must place the very large amount of pain and distress that will be suffered if euthanasia is not legalised, by patients who really are terminally ill. Longer life is not such a supreme good that it outweighs all other considerations. (if it were, there would be many more effective ways of saving life - such as a ban on smoking, or a reduction of speed limits to 40 kilometres per hour - than prohibiting voluntary euthanasia.) The possibility that two doctors may make a mistake means that the person who opts for euthanasia is deciding on the balance of probabilities and giving up a very slight chance of survival in order to avoid suffering that will almost certainly end in death. This may be a perfectly rational choice. Probability is the guide of life, and of death, too. Against this, some will reply that improved care for the terminally ill has eliminated pain and made voluntary euthanasia unnecessary. Elisabeth Kubler-Ross, whose On Death and Dying is perhaps the best-known book on care for the dying, has claimed that none of her patients request euthanasia. Given personal attention an the right medication, she says, people come to accept their deaths and die peacefully without pain.
Kubler-Ross may be right. It may be possible, now, to eliminate pain. In almost all cases, it may even be possible to do it in a way that leaves patients in possession of their rational faculties and free from vomiting, nausea, or other distressing side-effects. Unfortunately only a minority of dying patients now receive this kind of care. Nor is physical pain the only problem. There can also be other distressing conditions, like bones so fragile they fracture at sudden movements, uncontrollable nausea and vomiting, slow starvation due to a cancerous growth, inability to control one's bowels or bladder, difficulty in breathing, and so on.
Dr Timothy Quill, a doctor from Rochester, New York, has described how he prescribed barbiturate sleeping pills for 'Diane', a patient with a severe form of leukaemia, knowing that she wanted the tablets in order to be able to end her life. Dr Quill had known Diane for many years, and admired her courage in dealing with previous serious illnesses. in an article in the New England Journal of Medicine, Dr Quill wrote:
It was extraordinarily important to Diane to maintain control of herself and her own dignity during the time remaining to her. When this was no longer possible, she clearly wanted to die. As a former director of a hospice program, I know how to use pain medicines to keep patients comfortable and lessen suffering. I explained the philosophy of comfort care, which I strongly believe in. Although Diane understood and appreciated this, she had known of people lingering in what was called relative com- fort, and she wanted no part of it. When the time came, she wanted to take her life in the least painful way possible. Knowing of her desire for independence and her decision to stay in control, I thought this request made perfect sense.... In our discussion it became clear that preoccupation with her fear of a lingering death would interfere with Diane's getting the most out of the time she had left until she found a safe way to ensure her death.
Not all dying patients who wish to die are fortunate enough to have a doctor like Timothy Quill. Betty Rollin has described, in her moving book Last Wish, how her mother developed ovarian cancer that spread to other parts of her body. One morning her mother said to her:
I've had a wonderful life, but now it's over, or it should be. I'm not afraid to die, but I am afraid of this illness, what it's doing to me.... There's never any relief from it now. Nothing but nausea and this pain.... There won't be any more chemotherapy. There's no treatment anymore. So what happens to me now? I know what happens. I'll die slowly .... I don't want that .... Who does it benefit if I die slowly? if it benefits my children I'd be willing. But it's not going to do you any good .... There's no point in a slow death, none. I've never liked doing things with no point. I've got to end this.
Betty Rollin found it very difficult to help her mother to carry out her desire: 'Physician after physician turned down our pleas for help (How many pills? What kind?).' After her book about her mother's death was published, she received hundreds of letters, many from people, or close relatives of people, who had tried to die, failed, and suffered even more. Many of these people were denied help from doctors, because although suicide is legal in most jurisdictions, assisted suicide is not.
Perhaps one day it will be possible to treat all terminally ill and incurable patients in such a way that no one requests euthanasia and the subject becomes a non-issue; but this is now just a utopian ideal, and no reason at all to deny euthanasia to those who must live and die in far less comfortable conditions. It is, in any case, highly paternalistic to tell dying patients that they are now so well looked after that they need not be offered the option of euthanasia. It would be more in keeping with respect for individual freedom and autonomy to legalise euthanasia and let patients decide whether their situation is bearable.
Do these arguments for voluntary euthanasia perhaps give too much weight to individual freedom and autonomy? After all, we do not allow people free choices on matters like, for instance, the taking of heroin. This is a restriction of freedom but, in the view of many, one that can be justified on paternalistic grounds. If preventing people from becoming heroin addicts is justifiable paternalism, why isn't preventing people from having themselves killed?
The question is a reasonable one, because respect for individual freedom can be carded too far. John Stuart Mill thought that the state should never interfere with the individual except to prevent harm to others. The individual's own good, Mill thought, is not a proper reason for state intervention. But Mill may have had too high an opinion of the rationality of a human being. It may occasionally be right to prevent people from making choices that are obviously not rationally based and that we can be sure they will later regret. The prohibition of voluntary euthanasia cannot be justified on paternalistic grounds, how- ever, for voluntary euthanasia is an act for which good reasons exist. Voluntary euthanasia occurs only when, to the best of medical knowledge, a person is suffering from an incurable and painful or extremely distressing condition. In these circumstances one cannot say that to choose to die quickly is obviously irrational. The strength of the case for voluntary euthanasia lies in this combination of respect for the preferences, or autonomy, of those who decide for euthanasia; and the clear rational basis of the decision itself.