2.3: Euthanasia, or Mercy Killing (Nathan Nobis)

9 Euthanasia, or Mercy Killing
Nathan Nobis²⁴

1. Introduction

Sadly, there are people in very bad medical conditions who want to die. They are in pain, they are suffering, and they no longer find their quality of life to be at an acceptable level anymore. Given all that, they want their lives to end: they want to be out of their misery. Some of these people are kept alive by machines or other medical treatments. If these machines were turned off or the medical interventions stopped, these people would die.

Can it be morally permissible, or not wrong, to turn off these machines or stop treatment and so let someone die, in circumstances like these? Many people think it can be. They believe that, morally, we do not have to do everything we can to keep someone alive, no matter their quality of life or what they want. Indeed, sometimes keeping someone alive, when they could be allowed to die, would be wrong: we really should just let them die.

Here I develop an argument for this view, that what’s usually called “passive euthanasia” can be morally permissible. More interestingly though, I explain how the reasons in favor of passive euthanasia suggest and support thinking that in some circumstances “active euthanasia” is justified, so it can be OK to actively kill some patients, for example, by giving them an overdose of drugs that will painlessly end their lives. So, I argue that if you think it can sometimes be OK and appropriate to let some patients die, then you should also think it can sometimes be OK and appropriate to actively kill some patients.

2. Definitions

Let’s begin with some definitions to better understand the issues.

First, our topic is euthanasia, which is sometimes called “mercy killing.” The word euthanasia relates to the idea of a “good death.” People typically seek euthanasia to avoid a very bad death full of agony, pain, and suffering and all that results from that: for example, people wracked with horrific pain might not be able to meaningfully experience their final days or weeks with loved ones, due to the constant agony: when you are in terrible pain, it’s hard to talk, and listen, and share.

The most common type of euthanasia involves someone euthanizing someone else. Another type involves someone performing euthanasia on themselves, or euthanizing themselves: this is a type of suicide.

Euthanasia is usually classified as three types: voluntary, non-voluntary and involuntary:

• These three types of euthanasia can further be classified as “passive” and “active”:
  • We will soon see that these common ways of distinguishing active and passive euthanasia aren’t entirely clear.

    Here we will only discuss arguments about voluntary euthanasia, but readers can thoughtfully extend that discussion to the unique circumstances of non-voluntary euthanasia. Since involuntary euthanasia, passive or active, is generally wrong, it won’t be discussed further.

    3. An Argument for Passive Euthanasia

    it be morally permissible to let someone die, or perform voluntary passive euthanasia? The options are ‘yes’ and ‘no.’

    ‘No’ suggests that we must always do everything we can to keep someone alive, even if they are miserable, want to die, and say so. To many, that’s just cruel. If a dog or cat were in a similar condition, we would do the merciful and humane thing and put them out of their misery: this is perhaps the one way that animals are often treated better than humans.

    The judgment that ‘yes, it can be OK to let someone die’ can be supported by both consequentialist (or utilitarian) and Kant-inspired moral reasoning. What Kant himself argued about these issues might be different from what’s argued here: Kant sometimes applied his own moral principles to practical issues in unconvincing ways.

    For the consequentialist, the person being out of their misery is a better consequence for them, and overall, than their staying alive: killing them decreases the net unhappiness, pain, and badness in the world. For the Kantian, letting them die respects their autonomy (or personal self-governance): we should respect people’s decisions about profound issues in their own lives. Given their reasonable desires, respecting their wishes treats them as “end in themselves,” but forcing them to live in their unwanted condition treats them as a “mere means” toward our own ends, not their own.

    ‘Yes’ can also be supported by spelling out conditions in which it can be OK to let someone die. We begin with an ‘if’ and develop a moral principle:

    If…

    • someone is dying, and
    • is in horrible pain and suffering, and
    • that pain and suffering cannot be relieved, and
    • that person wants to die and clearly says so, and
    • informed, thoughtful and caring people agree that the person would be better off no longer living…,

    then it can be permissible to let that person die.

    To many people, a principle like this seems plausible. And it justifies passive euthanasia in many circumstances.

    The details of a principle like this, however, take us to harder questions about euthanasia, harder than those that arise in most circumstances: for examples, what if someone wants to die now but isn’t currently in horrible pain and suffering, or is expecting to die, but many years later after a very slow decline? Should anyone else have “say” over your own life or judge whether some pain and suffering is “horrible enough” for you to reasonably wish to die? If so, who? What if someone isn’t dying and doesn’t even have a bad medical condition but just finds their life not worth living and so wants to die (and so, say, plans to starve themselves to death or do other things that will result in their death)? These harder questions, and others, would need to be addressed for a complete defense of this or similar principles and any arguments based on them.

    In sum, a basic case for passive euthanasia can be supported by utilitarian, Kantian and common-sense moral thinking. Let’s consider two objections before moving on to the case for active euthanasia.

    3.1. First, some claim that pain can always be controlled, and patients always kept comfortable, so there is never a need to let anyone die (or, of course, actively kill them).

    In reply, medical professionals try their best to control pain and make patients comfortable and they often are effective. But the insistence that pain can always be made bearable for everyone is, unfortunately, not true: some patients’ pains cannot be controlled to their own satisfaction.

    3.2. Second, some argue that “miracles” are always possible, so there’s always a chance that someone gets better and even survives, and so we shouldn’t let patients die.

    These hopes are understandable, but there are conditions that nobody has ever recovered from, and so the chances are very slim. And we don’t usually make important decisions based on very unlikely chances: for example, you could be in an unlikely car accident where a seatbelt harms you, rather than helps you: nevertheless, wearing a seatbelt is the smart choice.

    Also, no type of euthanasia, passive or active, would prevent a miracle, especially a genuine miracle involving divine intervention: turning off the machines could be the occasion for a miraculous recovery, and an overdose of painkillers could be miraculously transformed into life-saving medications. People hoping for a miracle shouldn’t forget what miracles really could be.

    4. An Argument for Active Euthanasia

    The basic argument for active euthanasia, that is, for intentionally killing people who, due to their medical conditions, wish to be killed and say so is fairly simple.

    We begin by reflecting on the basic reasons why passive euthanasia can be OK: it gets people out their misery and respects what they want for their own lives. “Letting people die” is a means toward those ends or goals. However, these goals can be pursued more directly and immediately by actively killing patients who wish to die. Letting people die often takes a long time, and that time will often be filled with pain and suffering, which the patient wants to avoid. Killing people, when they want to be killed, achieves the goals that they want, that is, to be out of their misery, more quickly and with less pain. And that is what they want, so they get what they want, quicker.

    So, the basic assumptions that less unwanted pain and suffering is typically better than more and people’s desires about profound matters affecting their own lives and deaths usually should be fulfilled sooner than later, and the fact that killing someone is often a more effective means towards those ends, justifies active euthanasia, at least in some circumstances.

    5. Objections: Potentially Relevant Differences Between Active and Passive Euthanasia

    There are many objections to this type of reasoning, all intended to explain why active euthanasia is wrong but passive euthanasia can be permissible. Let’s consider some of the most common.

    5.1. First, some claim that it’s always wrong to intentionally kill someone, so passive euthanasia can be OK but active euthanasia is wrong.

    In reply, while we should agree that it’s, at least, nearly always wrong to intentionally kill someone, we should observe that most people want to live and do not currently have lives full of pain, suffering, and misery. So, the rule against killing is good in general, but we can argue that there are justifiable exceptions to this rule and that euthanasia is one of them.

    5.2. Second, some argue that allowing active euthanasia puts us on a “slippery slope” to murdering patients, and people in general, who are not in challenging medical circumstances or do not want to die. That’s wrong, so we shouldn’t allow euthanasia, which might lead to that.

    In reply, we can rightly wonder why that would happen, since arguments for euthanasia are very specific on the conditions where it might be permissible. They are especially clear that if someone wants to live, they should not be euthanized.

    Here we have no good reason to think this bad thing would happen or that it must happen or that nothing can be done to likely prevent it. We can, would and do implement safeguards to prevent or lessen any bad results that are unlikely but might happen from any acceptance of euthanasia, just as we do with many other things that might lead to bad results if misused or abused.

    5.3. Third, some argue there is always an important (moral) difference between “allowing” something to happen and “doing” something, and so passive euthanasia is OK but active is not.

    We might wonder if there is a clear distinction here. Consider this example:

    You see that someone is about to unknowingly walk and fall into a deep pit in the ground. You could easily warn them of the pit, but you keep quiet and they fall in and are seriously injured. You tell yourself that if you had pushed them into the pit, you’d be blameworthy, but since you have “done nothing” you are completely blameless.

    Many would find this judgment unbelievable: you did do something: what you did was stay silent and not warn them of the pit. “Inaction” is itself an action: doing nothing is doing something. Furthermore, what you did (in “doing nothing”) was wrong. It would often be worse for you to push the person into the pit yourself (or maybe not?), but your letting them fall in was wrong: you partially caused their injury: had you acted differently, they wouldn’t have gotten hurt.

    Examples like these suggest that there are not clear moral or conceptual differences between doing something and allowing something to happen. The objection above mistakenly assumes there are.

    5.4. There’s an important (moral) difference between killing and letting die, and so passive euthanasia is OK but active is not.

    This final objection is similar to the previous. James Rachels famously responds with an example like this:

    An evil aunt will inherit lots of money if her five-year-old nephew dies. She plans to drown him in the bathtub and make it look like an accident. She will get away with it. He just started his bath and she’s on her way to the bathroom to drown him. She opens the bathroom door and is delighted to see that he has slipped in the bathtub and is drowning. She watches, ready to push him under if he steadies himself and is able to save his own life. But, as her luck would have it, he doesn’t and so he drowns. She never touches him throughout the ordeal and inherits the cash, never telling a soul what happened.

    What an awful story. What an awful aunt. Her motives were awful and what she did was wrong. If she explained that she didn’t “do anything,” that she didn’t do anything wrong, that, at best, she merely “let someone die” – it’s not like she killed anyone! – she is profoundly mistaken: letting someone die can be just as bad (or nearly as bad) as killing someone. We might even say that a way to kill someone is to let them die.

    The objection here depends on a clear moral distinction between killing and letting die. There is no such distinction.

    5.5. Mistakes are possible, so we shouldn’t allow euthanasia.

    A final objection is not to the ethics of euthanasia per se, but whether, as a social or legal policy, it should be allowed: it’s possible that we could think an action is, or can be, morally permissible, but that for various reasons, as society we shouldn’t allow it.

    The concern is that where active euthanasia is allowed, some people who should not be killed could be killed. This is true: this is a possibility. It’s also true that where passive euthanasia is allowed, some people could be let die who should be kept alive. The argument is that since mistakes and wrongdoing regarding euthanasia are always possible, we should not allow it as a society. (This is consistent with thinking that euthanasia is sometimes morally permissible).

    In reply, we cannot ignore the opposing truth that if euthanasia is not allowed, that would result in mistakes and wrongdoing also: people would be wrongly kept alive, and wrongly forced to endure more suffering than they can bear and their deepest desires for their own lives disrespected.

    These possible mistakes, unlike the possible mistakes in allowing euthanasia, however, cannot be corrected or addressed by any safeguards or precautions, if euthanasia is not allowed. The wisest strategy then is to allow euthanasia, with limits and safeguards, and work to ensure that any mistakes and wrongdoing are minimized, and hopefully prevented completely.

    6. Conclusions

    There are, of course, more objections to these arguments, and other important arguments and concerns to discuss, and factual information to review, to have genuinely responsible views about these matters: this essay is just a start.

    These issues of this essay are important and not just for people currently facing difficulties where euthanasia might be part of the response. These issues are important to all of us since we have no idea what will happen to us, and our loved ones, years down the road, tomorrow, or even later today: an accident or illness might befall us that forces us to ask and answer hard questions about whether our lives are still worth living. While we hope these questions aren’t forced on us, we should ask them now and work on answering them now, together and as individuals. Part of a good death is that it is an end of a good life, and an opportunity to begin a better life is always now.

    Reference

    James Rachels, “Active and Passive Euthanasia,” New England Journal of Medicine 1975; 292: 78-80.

    For Further Reading

    Young, Robert, “Voluntary Euthanasia”, The Stanford Encyclopedia of Philosophy (Spring 2019 Edition), Edward N. Zalta (ed.), forthcoming URL = <https://plato.stanford.edu/archives/spr2019/entries/euthanasia-voluntary/>.

    Cholbi, Michael, “Suicide”, The Stanford Encyclopedia of Philosophy (Fall 2017 Edition), Edward N. Zalta (ed.), URL = <https://plato.stanford.edu/archives/fall2017/entries/suicide/>.

    Woollard, Fiona and Howard-Snyder, Frances, “Doing vs. Allowing Harm”, The Stanford Encyclopedia of Philosophy (Winter 2016 Edition), Edward N. Zalta (ed.), URL = <https://plato.stanford.edu/archives/win2016/entries/doing-allowing/>.

    For Review and Discussion

    1. What are the reasons someone might their life to end? Are those reasons strong enough to support their ending their life? Why or why not?

    2. We regularly euthanize non-human animals, but euthanizing people is limited to certain countries (most notably The Netherlands). Is there a major difference between non-human animals and people that justifies our different use of euthanasia? Why or why not?

    3. What is the strongest argument opposed to allowing active euthanasia? Is this argument stronger than the arguments in favor of active euthanasia? Why or why not?