1 Euthanasia (CPHL509, 2011) Paul Raymont The word euthanasia is derived from an ancient Greek phrase that means

good death. Today, we apply this term to cases in which death is a good thing for the one who dies. While there is not universal agreement on how to use these terms, many authors use passive euthanasia in reference to cases in which we allow someone to die for her own sake, and active euthanasia in reference to cases in which we actively participate in causing someones death for his own sake. Passive euthanasia is thus supposed to involve the withholding or withdrawal of life-sustaining treatment. Active euthanasia may involve mercy killing or physician-assisted suicide. We should also distinguish between voluntary and nonvoluntary euthanasia. In voluntary euthanasia, treatment is withheld (if its passive) or one is killed (if its voluntary) at the request of the one who dies. That is, voluntary euthanasia is euthanasia that accords with the expressed wishes of the person who dies. By contrast, nonvoluntary euthanasia is carried out without the consent of the individual. Typically, this is because the person in question is not competent to formulate or express her wishes (e.g., because she is an infant, or because he is in a persistent vegetative state and has left no living will). Some authors introduce a third term, involuntary euthanasia, to cover those cases in which the euthanasia is against the expressed will of the one who dies. It can be argued, though, that such cases are not true examples of euthanasia, since it is hard to see how death can be hastened for the sake of the one who dies if that person doesnt want to die. In Canada, passive euthanasia is legal while active euthanasia is not. E.g., in 1992 the Superior Court of Quebec determined that Nancy B. had the right to be taken off a respirator even though she would die as a result. The Court said that complying with her wishes would not constitute homicide or assisted suicide, but would instead simply be a matter or respecting her right to refuse treatment. This right is an extension of her right to self-determination. Indeed, forcing any unwanted treatment on her, even life-sustaining treatment, would amount to battery. By contrast, mercy killing and assisted suicide are illegal. With regard to assisted suicide, Section 241 of the Criminal Code prohibits advising someone to commit suicide and aiding or abetting a suicide. It has long been unclear just how we are to interpret this last phrase. The matter was clarified in the recent trial of Evelyn Martens (2004) in British Columbia. In that case, Justice Davies advised the jury that one aids or abets a suicide if one helps in an active way someone to commit suicide. Here, helping in an active way involves physically assisting in the dying. For example, it would be illegal to provide someone with the equipment or drugs for the purpose of suicide, or to help someone use the equipment or drugs for that purpose. It would even be illegal to agree to stand by while someone attempted suicide with the expressed intention of intervening to cause death if the suicide failed. Some people argue that the main reasons for allowing passive euthanasia (namely, mercy and respect for autonomy) also support allowing active euthanasia. Moreover, they contend, we already tolerate some forms of active euthanasia (specifically, mercy killing)

2 even though we dont label them as such. E.g., some people are given morphine to ease their pain. In order for the morphine to work, the dose must be continually increased. It is generally agreed that in some cases, the amount of morphine administered actually causes the patient to die sooner than he otherwise would have. Isnt this a case where a doctor knowingly causes someone to die, and isnt it therefore an example of mercy killing? Perhaps, although opponents of any change in our laws reply that there is a crucial moral difference between this morphine example and genuine cases of active euthanasia. In developing this reply, they distinguish between (on the one hand) the directly intended consequences of an action and (on the other hand) the merely foreseen consequences of an action. The directly intended consequence of using morphine (in other words, the main reason why we use it) is to alleviate the patients pain. Granted, we can foresee that the patient may well die sooner because of the morphine, but that isnt the reason why we administer it its given as a pain killer, not a patient killer. By contrast, if I give someone a lethal injection (an example of active euthanasia), then the direct intention, or main reason, behind my act is to cause death; death here is not merely foreseen but is in fact directly intended. On the basis of this intended-foreseen distinction, one might then say that its wrong to aim at death or, in other words, to do something with the direct intention of producing death, and that this is why active euthanasia (e.g., giving a lethal injection) is wrong. But its okay to use morphine because the death of the patient is there merely foreseen and not directly intended. I wrapped up this section of the debate about euthanasia by noting that in fact, many of us have conflicting intuitions about whether killing is better or worse than letting die. Sometimes, we say killing is worse. However, in other cases we say that killing can be better than letting die. E.g., in the case where the Swedish truck driver asked his co-driver to shoot him in order to prevent him from burning to death in the truck wreckage, most of us thought that killing was morally better than letting the driver die in the flames. Perhaps we can account for these apparently conflicting intuitions in the following way: if an outcome is bad, we regard the quicker and more efficient means to that outcome as being morally worse than slower, less efficient alternatives; but if an outcome is good, we regard the quicker, more efficient means to that result as being morally better than slower, less efficient alternatives; killing is a quicker and more efficient means of producing death than merely letting someone die; so, if death is thought to be bad, we see killing as being worse than letting die; but if death is thought to be good (in comparison to the available alternatives), we will see killing as being better than letting die (as in the example of the Swedish truck driver). If we adopt this approach, then we can argue that active euthanasia is actually better, in many cases, than passive euthanasia, for cases of active euthanasia are situations in which death is taken to be a good thing (relative to the alternatives). I considered some examples of places that currently allow some forms of active euthanasia. Most other western democracies have laws similar to Canadas they, too, allow some forms of passive euthanasia but not mercy killing or assisted suicide. Exceptions include the Netherlands, Belgium and three US states (Oregon, Washington and Montana).

3 With regard to the Netherlands, beginning in 1981 some forms of active euthanasia were technically illegal but tolerated, where this meant that the Dutch government declared an intention not to prosecute doctors who participated in active euthanasia as long as they complied with the governments guidelines (which required that the individual experience unbearable suffering). In 1986, a Dutch court interpreted unbearable suffering to include non-physical pain. Thus, in 1993 a Dutch physician assisted the suicide of a physically healthy but depressed woman. As a result of a new law (which went into effect at the beginning of 2002), active euthanasia is no longer even technically illegal in the Netherlands. Under the new Dutch law, some forms of active euthanasia are to be permitted if there is a voluntary and wellconsidered request from the patient, unbearable suffering and no prospect of improvement. There is no requirement that ones suffering be physical, and no requirement that ones illness be terminal. Reflection on the Dutch experience gives rise to an objection to active euthanasia. Specifically, some worry that any legalization of active euthanasia will put us on a slippery slope. The concern is that while some uses of active euthanasia may well be morally justified, any legal measures that permit active euthanasia will inevitably lead us eventually to tolerate more objectionable forms of it (e.g., for people with nonphysical forms of suffering). Its not clear, though, that a slippery slope is inevitable. E.g., there is no evidence of one thus far in Oregon. Perhaps the most forceful objection to active euthanasia is the fear that it will lead our legislators unwittingly to stigmatize some disabled or handicapped people. This is because if we permit active euthanasia at all, we surely will not allow its use for just any person who requests it. Instead, we will require that only people who are deemed to suffer from a sufficiently low quality of life will have the option of being actively euthanised. However, in specifying what sorts of people have a low enough quality of life, wont we end up implying that all of the people who fall into the specified categories are inferior to the rest of us? E.g., if we permit active euthanasia for quadriplegics, wont we thereby imply that all quadriplegics (including those who want to live) lead lives of inferior value to the rest of us? For our lives, after all, cannot be deliberately ended, but their lives can be. In the required reading for this topic, Brock, Miller, and Truog (BMT) defended the idea that we should permit some form of active euthanasia. They claimed that we already permit a kind of mercy killing by allowing the discontinuation (or withdrawal) of life-sustaining treatment, but that we trick ourselves into thinking that this practice is merely passive euthanasia (and not really mercy killing). BMT consider an objection to this line of thinking, one that derives from Daniel Callahan. According to this objection, if we disconnect a respirator, we dont thereby kill the patient but, instead, merely allow something else, an illness, to kill the patient. To support this claim, BMT (following Callahan) note that if we disconnect a respirator from someone

4 who did not require it in the first place, she wont die as a result. Therefore, disconnecting the respirator is not itself sufficient to produce death; so it isnt a way of causing death and therefore isnt a form of killing. By contrast, if we give someone a lethal injection, hell die regardless of whether he was sick or healthy. Therefore, the lethal injection is sufficient to produce death; hence it is a way of causing death, and to cause death is to kill. BMT respond to this objection. They say that if an evil son got rid his ailing mother by disconnecting her respirator, we wouldnt have any difficulty in saying that the son had killed her. We certainly wouldnt find it plausible to say that the son had merely allowed the disease to kill her. This is because what the son did caused his mothers death. It follows that if the doctor had done the very same thing (disconnecting the respirator), she too would thereby have caused the mothers death and so would have killed her. I argued in favour of BMT in this dispute. I objected that the critic (who gives Callahans objection) relies on an implausible conception of causation; for the critic assumes that A causes B only if A is by itself sufficient to produce B. Against this conception, I argued that A causes B only if its true that if (contrary to fact) A had not occurred at that moment, B would not have occurred at the time at which it occurred. Heres the example I used to bolster this: if I cut the hose on the scuba tank of someone whos under water, I cause his death; and this is true even though cutting the hose on the scuba tank would not have made the guy die if hed still been up on the boat that is, cutting the hose under water caused the guy to die even though it was not all by itself sufficient to make him die (all that water also had to be present). But note that its true that if (contrary to fact) I hadnt cut the hose on the tank when the guy was under water, he would not have died just then. This is why its true that my act caused his death even though it wasnt all by itself sufficient to make him die. So, BMT may still argue that although our system currently classifies the withdrawing, or discontinuing, of life-sustaining treatment as passive euthanasia, it is not really distinct from killing. One can then infer, as BMT do, that since we already allow some activities that are in fact forms of active euthanasia, we ought to permit other, more obvious forms of active euthanasia, too.