Week 11 Euthanasia and Japanese Law
Under existing laws people suffering unrelievable pain or distress from an incurable illness who ask their doctors to end their lives are asking their doctors to become murderers.
Peter Singer Practical Ethics (in White, ed. p.116).
Preliminary Discussion:
Hospital death spurs debate on euthanasia Japan Times April 9th 2006
1). What is the difference between ‘passive’ and ‘active’ euthanasia?
Do you think there is a moral difference between the two?
2). The unnamed chief surgeon in the story has disconnected seven respirators from terminally ill patients, killing them. Why did he do this? And what was his motivation?
a). Was his motivation ethical?
b). Even if it was ethical, was it the correct decision?
3). Masahiro Ishimaru criticizes the “50-year old surgeon” on trial for disconnecting respirators. He reasons: “A doctor’s motivation is rooted in an absolute commitment to saving life- that’s why I don’t feel comfortable with disconnecting respirators.” Do you agree?
4). According to Ishimaru, “liking people” means keeping them alive for as long as possible, no matter what. Is this correct, in all cases?
5). Do you agree with the view that Japanese law is too vague on this issue? If so, how could the law be made more exact?
6). What would the benefits be in making the law more explicit?
16.1 Definition of Voluntary Euthanasia
Robert Young defines euthanasia as follows:
When a person carries out an act of euthanasia, he brings about the death of another person because be believes the latter’s present existence is so bad that she would be better off dead, or believes that unless he intervenes and ends her life, it will become so bad that she would be better off dead. The motive of the person who commits an act of euthanasia is to benefit the one whose death is brought about. (Young Euthanasia: 1)
Voluntary euthanasia is defined as a case where the person who is killed volunteers to be killed. Non- voluntary euthanasia is defined as a case where the person killed does not give consent, because they are either not competent (as the case with very young children) or unable to. Involuntary euthanasia is where a competent person’s life is ended against the explicit wishes of the person killed. (One wonders if the latter is even logically possible, insofar as euthanasia means ‘good death.’)
In these lectures we will only be concerned with voluntary euthanasia, and whether it should be legal (or illegal).
16.2 Necessary Conditions for Candidacy for Voluntary Euthanasia
Advocates of voluntary euthanasia contend that if a person meets the following criteria, voluntary euthanasia should be legally permissible.
1). The person is suffering from a terminal illness
2). The person is unlikely to benefit from the discovery of a cure for that illness during what remains of his or her life expectancy
3). He or she is, as a direct result of their illness, either suffering intolerable pain, or will only have a life that is unacceptably burdensome (because the illness has to be treated in ways that lead to her being unacceptably dependant on others, or on life support machinery)
4). He or she has a strong, enduring and voluntary wish to die (or has already expressed such a wish, but has now lost the capacity to do so),
5). He or she is unable to commit suicide by themselves.
(After Young Euthanasia).
Japanese law tolerates active euthanasia, and has done so for some time. The Japanese Medical Association has approved of euthanasia if the following conditions are met (this follows the Yokohama District Court ruling of a 1995 mercy killing case at Tokai University Hospital). The Japanese Academy of Science and Art has also approved of these rules, so long as the euthanasia is passive euthanasia (defined below, 16.3).
Active euthanasia requires the following conditions to be met:
1). The patient’s death is inevitable and imminent
2). The patient is suffering from unbearable physical pain
3). The doctor has done everything possible to remove the pain
4). The wish of the patient has been made clear. [1]
16.3 Active vs. Passive Euthanasia
Active euthanasia involves a deliberate act which results in the patient’s death, such as giving a lethal injection. Passive euthanasia involves a deliberate omission, such as removing hydration (water), nutrition (food) or machines that maintain airflow. Many medical associations and laws make a moral distinction between the two, suggesting that active euthanasia is morally worse than passive euthanasia. We will discuss this debate in the next lecture.
16.4 Historical Background
Philosophical Discussion on Suicide and Euthanasia
The Classical World: The Greeks and Romans were fairly tolerant of voluntary death, and certainly did not believe that all human life is intrinsically sacred and valuable.
Socrates argues that suicide is always wrong as we are essentially relieving ourselves (that is, our souls) from a ‘guard post’ (that is, our bodies) that the Gods have given us as a punishment.
Plato held that suicide is not immoral in the following circumstances:
a). when one’s mind is morally corrupted
b). When the self- killing is by judicial order (as in the case of Socrates, who was ordered to kill himself)
c). When the self- killing is compelled by extreme and unavoidable personal misfortune
d). When self- killing results from the shame of having done some terrible injustice.
The Stoics and Epicureans thought that simply killing yourself because life is no longer valuable was not morally problematic. Seneca, a Roman philosopher, had this to say: “mere living is not a good, but living well.” He also stated that a wise person “lives as long as he ought, not as long as he can.”
16.5 Early Modern Period:
Euthanasia has been prohibited in Western medicine roughly since the 15th Century, with the introduction of the Hippocratic Oath (an early Greek ethical code for medical practitioners).
In the 16th Century, Thomas More, in his text Utopia, envisaged a community where those with lives that were merely burdensome due to ‘torturing and lingering pain’ could request euthanasia.
16.6 Later Modern Period: Nietzsche
Many die too late, and some die too early. yet strange sounds the precept: “Die at the right time!”
Die at the right time! So teach I, Zarathustra.
…My death, praise I unto you, the voluntary death, which cometh unto me because I want it.
Nietzsche Thus Spake Zarathustra
Discussion: Nietzsche cared for neither deontology nor Utilitarianism, so what is the basis for his apparent advocacy of voluntary death? Is it a good idea, or not?
16.7 The Current Legal Status of Euthanasia
One Australian state (Northern Territories, 1997) Switzerland, the Netherlands and Belgium have essentially legalized euthanasia. Japan tolerates euthanasia, as mentioned above (the situation in Japan will be discussed more thoroughly in the next lecture). U.S law still considers all euthanasia to be equivalent to murder. (Recall the case of Dr. Anna Pou, charged with murdering patients at Memorial Hospital in New Orleans following Hurricane Katrina). For further details of the history of euthanasia, and the current status of euthanasia laws around the world, see the Stanford article Voluntary Euthanasia by Robert Young.
16.8 Cultural Background: The Buddhist Approach
There is little explicit discussion of the ethics of either suicide or euthanasia, or indeed any bioethical issue, in the Buddhist texts. Most of the secondary literature on this topic is reconstructive or speculative (that is, scholars have to guess or ‘reconstruct’ what the practical implications of Buddhist concepts might be).
Does Buddhism condemn suicide? On the one hand, the Vinaya considers assisting a suicide as a breach of monastic discipline (that is, against the rules that monks must abide by), resulting in expulsion. Yet even in the Pali canon (amongst the oldest Buddhist writings) the suicide of monks, so long as it was done out of the correct motivation, was acceptable. In Japanese Buddhism, even the non-voluntary euthanasia of infants was traditionally accepted.
The Dalai Lama himself has given the following statement:
In the event a person is definitely going to die and he is either in great pain or has virtually become a vegetable, and prolonging his existence is only going to cause difficulties and suffering for others, the termination of his life may be permitted according to Mahayana Buddhist ethics.[2]
16.9 Cultural Background: Buddhism and Shinto in Japan
In Japan, Buddhist and Shinto groups are far more tolerant of euthanasia than are Christian groups. Both Buddhist and Shinto groups advocate “being natural” when medical treatment becomes futile for the terminally ill. (One assumes that this means accepting ‘passive euthanasia’). Some Buddhist groups take prolongation of life using artificial means to be a “disgraceful act against life”; others claim that the patient should cede all control to the doctors, whilst some Shinto groups are accepting of full active euthanasia. In one survey, at least one Zen Buddhist group held that it was up to the patient what the best decision was. In short, the literature on the subject suggests that there is no consensus in Japanese religion as to whether euthanasia should be
permissible. [3]
Question: What are the merits of the principle of ‘being natural?’
16.10 Cultural Background: The Jewish Approach
There are two suicides in the Torah/ Old Testament, and neither is condemned within the text for being a suicide. Suicide is not mentioned in the Ten Commandments as being a specific sin. The first explicit discussion of suicide in Jewish writings appeared in the Semachot, and is a clear condemnation. [4]
However, some Jewish religious experts think that if something hinders the departure of one's soul--for example, if the sound of a woodchopper can be heard close by the house, or if there is salt on the dying person's tongue--it is permitted to remove this noise or the salt. There is also a story in the Talmud (the Jewish law book) that has been interpreted as defending euthanasia. As a rabbi lay dying, his disciples gathered in prayer to prolong his life. Their prayers were unable to restore him to health, sufficing only to keep him alive in great pain and suffering. Seeing this, his maidservant climbed to the upper chamber of the house and tossed a glass vase to the ground. The crashing sound interrupted the praying, and Rabbi died. The Talmud’s authors do not condemn her action, implying approval of it.
16.11 Cultural Background: The Christian Approach
St. Augustine, in the text The City of God (5th Century) condemned suicide. His argument was based on an original reading of the Biblical commandment “thou shalt not kill.” The rest of his arguments were taken from Plato’s Phaedra.
-Many Christians believe in the sanctity of human life; that is, humans are created in the image of God, and that human life itself is the miraculous gift of a divine Creator. Therefore, they argue, they must not kill themselves.
-The standard modern Christian view is that one’s life is the property of God and that to destroy it is to go against God’s wishes. (We’ll discuss David Hume’s counterargument in the next lecture).
The Donatists: Ironically, some early Christians believed that dying as soon as possible was the right thing to do, and would frequently kill themselves or had themselves be killed for the sake of spiritual perfection. (They considered this ‘martyrdom’). The logic is simple enough: This World is corrupt, and the longer one lives, the more opportunity one has to sin. Further, Tertullian, an early Christian, thought that Jesus’s death was a suicide (so, to live the life of Jesus required having someone else kill you, in effect). The Donatist Church, which flourished in the 4th and 5th Centuries in Roman Africa, was such a group. Some have suggested that St. Augustine’s explicit ban on suicide in Christianity was as a result of the Donatist Heresy.
-For the record, many early Christians were famous for doing risky, self- destructive things in the name of their faith, so the condemnation on killing yourself seems a little peculiar, given the reasoning offered (ie. self destruction is against God’s wishes, or that human life is a divine gift, etc). Origen of Alexandria, a major Christian thinker, allegedly castrated himself; medieval penitents were famous for scouring themselves with whips.
General Problems with relying on Religious Traditions for Ethical Guidance:
All of the religious texts cited here- the Buddhist canon, the Torah, Talmud and New Testament- were written thousands of years ago, by people who had no idea of the ethical problems presented by new medical technologies. Even if we assume that the basic ethical principles of these traditions are still tenable, we still need to work out what those principles are, and how to best implement them. Shinto and Japanese Buddhism are extraordinarily vague on bioethical issues; the ethical principles of Judaism and Christianity (like the deontological approach that they inspired) can run into conflict. The more general problem: philosophy begins when we can no longer rely purely on received tradition to make important, sound decisions.
16.12 The Problem of New Technologies; Ordinary vs. Extraordinary Measures
a). The Problem of Progress in Medical Science
Euthanasia has become a much more pressing problem in recent decades because of massive advances in technology used to prolong life. Whereas, until the mid- 20th Century, the chronically ill would simply die, it is now possible to keep chronically ill people alive for years. Consequently, technology can now stretch out physical and intellectual suffering in the very ill to an unprecedented degree.
b). Ordinary vs. Extraordinary Treatment.
It is often argued that there is a relevant distinction between ‘ordinary’ and ‘extraordinary’ medical treatment. While it is always necessary to use ‘ordinary’ medicine to take care of people, it is morally permissible to remove ‘extraordinary’ treatments. Writes one Christian commentator:
The Church makes a distinction between “ordinary” and “extraordinary” medical treatment. We are required to administer all ordinary treatment because of the dignity of human life and the natural respect owed the person. When death is imminent, we may administer extraordinary treatment according to the wishes of the patient. Extraordinary treatments are those that offer little hope of benefit and are burdensome, such as procedures that are experimental or overly aggressive.
Discussion: Is this a morally relevant distinction? Or is it arbitrary?
16.13 The Utilitarian Argument for Euthanasia: The Argument from Mercy
No human being with a spark of pity would let a living thing suffer so, to no good end.
Stewart Alsop, (in Rachels TRTTD: 176).
According to Utilitarianism, one should maximize pleasure (or whatever absolute good), and minimize pain. Further, Utilitarianism requires that we make the choice with the optimum consequences. When a patient wants to die, due to incurable and unbearable pain, we should assist them. As Rachels puts it, “[t] erminally ill patients sometimes suffer pain so horrible that it is beyond the comprehension of those who have not actually experienced it.” (Rachels “The Morality of Euthanasia,” TRTTD: 175-179, p.175). It is worth reading pp.175-177 of the Rachels essay here just to get a sense of how horrible life may be for the terminally ill.
Rachels gives the following formulation of the Argument from Mercy:
1). Any action or social policy is morally right if it serves to increase the amount of happiness in the world or to decrease the amount of misery. Conversely, an action or social policy is morally wrong if it serves to decrease happiness or to increase misery.
2). The policy of killing, at their own request, hopelessly ill patients who are suffering great pain would decrease the amount of misery in the world.
3). Therefore, such a policy would be morally right. (Rachels TRTTD: 177).
Defenders of euthanasia, against their Christian opponents, make the following point: How could merciful euthanasia oppose the wishes of a benevolent, all- loving, merciful God? (more on this argument in the next lecture).
Note: This argument presupposes Classical Utilitarianism, that is, the reduction of all value down to pleasure- maximization and pain- minimization. Recall the criticisms we’ve already discussed concerning the limits of such a doctrine. Are these criticisms relevant to the Argument from Mercy?
Someone might say: -“Is happiness the only thing to be considered? What about other things, like knowledge, or achievement? Perhaps an unhappy life could still be good because of achievements or knowledge.” (James E. White Contemporary Moral Problems p.99)
-discussion: how is this problem relevant to this case? We are, after all, talking about Voluntary Euthanasia.
The Question of Fear.
Some argue that doctors will become more likely to kill patients without consent if euthanasia is legalized. This will lead, they argue, to fear and insecurity in hospitals.
Singer replies:
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.” (White, ed. p.117).
16.14 Euthanasia and Dignity
Given that the terminally ill may be bedridden, in extreme pain, and incapable of any sort of valuable life, it can be argued that euthanasia may be a more dignified death than merely wasting away. Rachels cites a description of one ‘Jack,’ a terminally ill cancer patient who was reduced to crying like a dog when his painkillers ran out; “always poor Jack’s whimpers and howls would become more loud and frequent until at last the blessed relief [the morphine] came.”
16.15 The Preference Utilitarianism Argument for Euthanasia/
Respect for Autonomy
A Preference Utilitarian may also argue that we should maximize people’s choices, including the choice to die, or to refuse medication. (Recall the standard objection to Preference Maximization: some people may just have incorrect preferences. Is this objection valid here?). This appears to be the view of Singer.
It is […] highly paternalistic to tell dying patients that they are now so well looked after they need not be offered the option of euthanasia. It would be more in keeping with respect with individual freedom and autonomy to legalize euthanasia and let patients decide whether their situation is bearable- let them… have the dignity of choosing their own endings. (in White, ed. p. 119).
Interestingly, the Deontological approach- the respect for autonomy, is very similar to the Preference- Maximization approach. Simply put: we must respect people’s autonomy, in particular their free, rational choice to end their own lives.
Writes Robert Young,
There is no single, objectively correct answer as to when, if at all, life becomes a burden and unwanted. But that simply points up the importance of individuals being able to decide autonomously for themselves whether their own lives retain sufficient quality and dignity to make life worth living. Given that a critically ill person is typically in a severely compromised and debilitated state, it is, other things being equal, the patient’s own judgment of whether continued life is a benefit that must carry the greatest weight… (Young Euthanasia p.3).
16.16 Broader issues: Paternalism vs. Autonomy
One of the more general problems behind this debate is the clash between paternalistic principles, and the principle of respecting autonomy. In simple terms, a paternalistic approach holds that people are simply not capable of deciding for themselves what is best for them, and so they need to be told what to do, or have certain products or choices taken away from them. To respect autonomy, on the other hand, is to accept and facilitate the decisions of the individual. Obviously, a blanket condemnation of voluntary euthanasia will be paternalistic; accepting the choices made by patients (including the decision to die) appears to be unambiguously pro- autonomy.
This issue will reappear when we discuss the drugs debate in Lectures 21 and 22.
WHAT YOU NEED TO KNOW
You need to be able to give a definition of Voluntary Euthanasia
You need to be able to explain the difference between Voluntary Euthanasia and Non- Voluntary Euthanasia
You need to be able to explain the two main arguments in favor of VE: Utilitarianism (both Classical and Preference Utilitarianism) and Deontological (respect for rights).
You need to be able to explain Paternalism and Autonomy
Reading Homework for Lecture 17.
Please try to read the two essays on euthanasia in Rachels The Right Thing to Do, “The Morality of Euthanasia” by James Rachels and “Assisted Suicide: Pro-Choice or Anti-Life?” by Richard Doerflinger.
-Identify and summarize the arguments
-Which arguments are the strongest?
-Which arguments are the weakest? Why are they weak? And how would you respond?
Lecture 17 Euthanasia II: Problems/ The Japanese Context
Lecture 17
Arguments Against Euthanasia/ The Japanese Context
17.1 Objection: The Intrinsic Wrongness of Killing
Richard Doerflinger (in Rachels The Right Thing To Do, hereafter TRTTD, p.180-190, p.180) offers the standard Christian argument against euthanasia: “the deliberate killing of innocent people is always wrong.” Doerflinger goes on to state that this principle is “axiomatic” in both Christianity and Judaism.
Counterarguments:
a). Is the innocence of the people killed relevant? Sometimes a moral argument will be based on a principle that we all agree on (killing innocent people is wrong), but is used in an inappropriate way. I think that Doerflinger uses the notion of “killing the innocent” in such a way. (Recall that we can use a Deontological, Kantian argument to defend euthanasia- and yet Doerflinger himself is using the same moral principles. Is he permitted to do so?)
There is a definitional problem here: the people in question- those who want to die- are defined as “innocents.” This seems to imply that they are not deserving of punishment or death. But why is this an issue, if they are competent adults who have requested to die? That is, why is it relevant that they are innocent?
b). Is it even true that Judaism and Christianity have the axiom of not killing people?
Probably. But, as discussed in the last lecture, this is not as simple as it seems. There are a number of suicides in both Bibles, none of which is accompanied with an explicit condemnation. Judaism emphasizes the importance of this life over the next, unlike Christianity, but both have a more or less Utilitarian ethics of mercy. Further, both Judaism and Christianity traditionally allowed for killing people, for example criminals or enemies in war. Surely people who want to be dead are a special case?
c). Are the ethical axioms of the Jewish and Christian traditions relevant to non- Jews or Christians?
17.2. The Intrinsic Worth of Human Life
Doerflinger, and other Christians, hold that life has intrinsic worth. ‘Intrinsic’ is one of those flashy “philosophy’ words that sounds impressive, but we should think about what this means. It means ‘the essential nature of a thing’ or ‘inherent.’ It comes from the Latin word ‘inward.’ So it means the ‘inner properties.’ That doesn’t really explain much, so here’s an example.
The Hamburger Argument concerning Intrinsic Worth.
So what are the intrinsic properties of a good, tasty hamburger? The shape, the colors, the taste, the smell are all outer, extrinsic properties. So are the properties of making me feel full, or giving me calories. Three questions: how do we know if the burger is a good hamburger? By the intrinsic or the extrinsic properties? Secondly, how could we even know if the burger had any intrinsic properties? (Kant thought about this problem, and concluded that the inner reality of the universe is unknowable). Thirdly, how can the intrinsic properties of a burger have anything to do with whether it is a good hamburger? Is the concept of intrinsic worth even coherent?
If we ask the question “why is property x good?,” any possible answer will concern an extrinsic property. An intrinsic good has no other reason for being good. (Utilitarians think that happiness is an intrinsic good, so the question “why is happiness good?” is meaningless or absurd).
So, is life like a hamburger? That is, is it valuable because of its extrinsic properties (it is fun, it is challenging, it has a goal, etc) or is it valuable because of some strange, secret, metaphysical property independent of any extrinsic good?
Peter Singer: Life has No Intrinsic Worth
Peter Singer thinks that the value of continuing life is not intrinsic but extrinsic. He also thinks that it is not obvious that adequate respect for the sanctity of human life prohibits ending a life. In fact, Singer thinks that suicide/ voluntary euthanasia may be life- affirming if the only alternative is being reduced to a shadow of one’s former self (Cholbi “Kant and the Irrationality of Suicide,” 2002). Perhaps the worth of my life is eradicated as I am forced to watch my own body fall apart around me, and experience my own mind disintegrate.
So, the real statement that Doerflinger should be asserting is “Being Trapped in Hospital in Incredible Unending Pain with No Hope of Recovery and Wishing You Were Dead is Of Intrinsic Worth.”
17.3 Objection: Suicide/ Euthanasia is Contrary to Nature
Recall that Kant had argued that suicide is contrary to the ‘laws of nature,’ meaning the ‘laws of reason,’ as he understood them.
- Socrates had also argued that suicide contradicts the ‘law’ that all living things want to live. This claim would seem to have been disproved by every successful suicide (in any case, self destructive behaviour in animals is not so uncommon; octopuses suicide by eating their own limbs; male spiders and praying mantises suicide, in effect, when they get involved with the females of their kind. For an animal to truly suicide, it would have to understand the concept of death, such as monkeys or elephants). As for the idea that death is contrary to nature, this seems to be contradicted by the fact that all organisms eventually die naturally.
The following argument is from J.Gay-Williams, “The Wrongfulness of Euthanasia,” in White ed. Contemporary Moral Problems Pp.99-102).
Euthanasia does violence to this natural goal of survival. It is literally acting against nature because all the processes of nature are bent towards the end of bodily survival.
When one of our goals is survival, and actions are taken to eliminate that goal, then our natural dignity suffers. (White p.101).
-The Naturalistic fallacy seems to be committed here.
Another variant of naturalism in the euthanasia debate:
J.Gay – Williams: we cannot euthanise people in pain because “suffering is a natural part of life with values for the individual.” (in White p.102).
17.4 Objection: Suicide/ Euthanasia is against Human Dignity
Keep in mind that the dispute here is over Voluntary Euthanasia. The prior question to ask here is “what is dignity?” Christian critics typically refer to our dignity as beings created in God’s image, or some variant of naturalism- it is ‘undignified’ to want to die, as it is natural to want to live (as White argues above). Pro-euthanasia people also refer to dignity. So the debate is really over what this word means.
We may legitimately ask: why is merely being alive more dignified than being dead? We typically prevent prisoners from killing themselves. Why? Because we want them to complete their sentences. We want them to suffer. We don’t want to let them have the dignity of escaping. (Arguably).
17.5 Objection: Suicide/ Euthanasia is Contrary to God’s Will
This is simply the view that God does not want us to kill ourselves.
One objection that has not been addressed in the literature that I have read: God is going to kill us all anyway. So why should he care if we do it ourselves?
These arguments are from David Hume, and are taken from Michael Cholbi’s Stanford Encyclopedia article “Suicide”.
1). If by ‘divine order’ is meant the causal (that is, scientific) laws created by God, then it would always be wrong to contravene these laws for our own happiness. But we always
act to protect ourselves from disease or some other misfortune. So why would God allow us to disturb nature in some circumstances and not in others?
(Simple example: I look up and see a brick falling down towards me. If I step out of its way, I am contravening God’s decision to kill me).
2). What does ‘divine order’ mean?
a). Discerned by reason, or b). such that adherence will produce our happiness (or absence of sadness), then why should suicide not be consistent with such orders? (Recall Bentham: a benevolent God would simply accept voluntary euthanasia).
3). If God placed us on Earth as a ‘sentinel,’ surely God gives us consent to quit if he allows us to go through with the act of self- destruction.
Other Traditional Christian Arguments: Life is God’s Gift/ We are God’s Property
If we are God’s property, we are a very strange sort of property, as we were apparently also given free will. If we are free and rational beings, how can we be dominated in such a way?
-The argument presupposes that God does not wish his property to be destroyed (or rather, destroy itself). But how could our death harm an all- good, all powerful Creator? And how could such a deity be all- Loving? If something exists that causes me harm or extreme pain (such as my life), am I not justified in destroying it?
Michael Cholbi: If life is God’s gift, how is a painful life, lived out to the bitter end, a ‘gift’?
17.6 Objection: Suicide/ Euthanasia is a violation of one’s obligation to the
Community
Paul Henri Baron d’Holbach (1723- 1789) gives the following argument (note the combination of Utilitarianism and Social Contact theory here: we join the Contract for our happiness; if the Contract cannot make us happy, the contract is void.).
If the covenant which unites man to society be considered, it will be obvious that every contract is conditional, must be reciprocal; that is to say, supposes mutual advantages between the contacting parties, the citizens cannot be bound to his country, to his associates, but by the bounds of happiness. Are these bonds cut asunder? He is restored to liberty: Society, or those who represent it, do they use him with harshness, do they treat him with injustice, do they render his existence painful? Chagrin, remorse, melancholy, despair, have they disfigured to him the spectacle of the Universe? In short, whatever cause it may be, if he is not able to support his evils, let him quit a world which from henceforth is for him only a frightful desert. (my italics) (d’Holbach 1970: 136-137, in Cholbi p.11).
In plain English: Our obligation to the community is a reciprocal obligation, that is, a contract: if life is no longer worth living, the deal is off.
17.7 Objection: VE is not necessary; palliative and hospice care are sufficient
Robert Young: Neither palliative care not hospice care is a panacea (perfect cure). Young notes that even high- quality palliative care can involve side effects such as vomiting, nausea, incontinence, loss of awareness due to semi-permanent drowsiness, and so on.
The ‘rosy picture’ painted of hospice and palliative care is misleading, he argues: “for those who prefer to die on their own terms and in their own time, neither option may be attractive. For many dying patients, the major source of distress is having their autonomous wishes frustrated.” Young p.4
17.8 Objection: Competence Problem (The Rationality of Suicide)
a). The Incoherence Argument
Richard Doerflinger argues that suicide is always irrational, and that the “right to suicide” is the “ultimate contradiction.” He reasons as follows: a “free act that by destroying life, destroys all the individual’s future earthly freedom.” Hence, “society best serves freedom by discouraging rather than assisting self-destruction.” (Doerflinger TRTTD:182).
Is this really a contradiction?
b). Depression and Rationality
How do we know that the patient’s wish to die is truly “competent, enduring and genuinely voluntary” (in the wording of Euthanasia regulations)?
Cholbi: depression can “primitivize [make simple and basic] one’s intellectual processes,” leading to errors in estimating probabilities. Depressed people can focus on present agonies in an irrational way. So perhaps their decision to die is not sound (Cholbi p.12).
Replies: a). This does not concern every case (unless we bite the bullet and declare all
people who want to die to be ‘irrationally’ suicidal)
b). People could write a ‘living will’ beforehand.
17.9 Objection: Active vs. Passive Euthanasia
In both Japan and the USA, passive euthanasia is considered acceptable in some cases, but not active euthanasia, which is classified as murder.
Young argues that this distinction is morally arbitrary: “There is a widespread belief that passive (voluntary) euthanasia, in which life sustaining or life prolonging measures are withdrawn or withheld, is morally acceptable because steps are simply not taken which would preserve or prolong life (and so a patient is allowed to die), whereas active (voluntary) euthanasia is not, because it requires an act of killing.
Recall Aya Okubo’s objection from lecture 16: a) the doctor is supposed to intervene to help people, so it is not as if the doctor is morally innocent if he or she simply does nothing; b). the doctor has made a conscious decision to ‘do nothing.’
Young: The passive/ active distinction is more a matter of pragmatics than morality.
-The distinction is vague- what is the moral difference between pulling the plug on a machine, or neglecting to replace the oxygen tanks or the battery? Or walking slowly to a room after a request for urgent assistance? Are these acts or omissions? Passive euthanasia or active euthanasia? In any case, the intention is the same- to end the life of the patient.
Rachels: Cousin in the Bath Thought – Experiment
Rachels uses the following thought- experiment to illustrate what he things is the arbitrary distinction between passive and active euthanasia.
In the first [case], Smith stands to gain a large inheritance if anything [fatal] should happen to his six- year old cousin. One evening while the child is taking his bath, Smith sneaks into the bathroom and drowns the child, and then arranges things so that it will look like an accident.
In the second [case], Jones also stands to gain if anything should happen to his six- year old cousin. Like Smith, Jones sneaks in planning to drown the child in the bath. However, just as he enters the bathroom, Jones sees the child slip and hit his head, and fall face down in the water. Jones is delighted; he stands by, ready to push the child’s head back under if it is necessary, but it is not necessary. With only a little thrashing about, the child drowns all by himself, “accidentally,” as Jones watches and does nothing.
(In White p. 105).
Rachels continues: “if a doctor deliberately let a patient die who was suffering from a routinely curable illness, the doctor would certainly be to blame for what he had done…it would not be a defense at all for him to insist that he “didn’t do anything.” (in White p. 106).
Reply : Tom L. Beauchamp
Beauchamp uses a Utilitarian argument in favour of keeping the active/ passive distinction, for two reasons:
1). Patients wrongly diagnosed as hopeless, and who will survive even if a treatment is ceased (in order to allow a natural death),
2). Patients wrongly diagnosed as hopeless, and who will survive only if he treatment is not
ceased (in order to allow a natural death). (Beachamp, in White p.113).
Discussion: Are these arguments compelling? Or are the problems with maintaining the distinction (if it is indeed morally arbitrary) serious enough to override these considerations? What are the costs of maintaining the distinction?
17.10 Objection: The Doctrine of Double Effect
J.Gay-Williams argues that ‘passive euthanasia’ does not exist. If the life- saving treatment is ended, he argues, the patient is not killed:
“nor is the death of the person intended by the withholding of additional treatment…the aim may be to spare the person additional and unjustifiable pain, to save him from the indignities of hopeless manipulations…” (in White p.100).
Reply: Young:
..giving massive doses of morphine far beyond what is needed to control pain, or removing a respirator from a sufferer from motor neurone disease would seem… to amount to the intentional brining about of the death of the person being cared for… it is highly stilted to claim, as some doctors do, that the intention is anything other than the intention to bring about death” (Young p.6).
17.11 Objection: “pro-choice” arguments for euthanasia are not, in fact, pro- choice (Richard Doerflinger).
Deontologists who support voluntary euthanasia appeal to the Deontological principle to respect the choices of others. But Doerflinger argues that this is contradictory (the argument here is continuous with the ‘contradiction’ argument above).
He argues that the choice to die is analogous to the choice to sell oneself into slavery, as it negates the possibility of choosing. (Note the Kantian language here: the choice to die is a denial of one’s free, rational nature, as, once you’re dead, you are no longer free and rational).
“pro- choice” is not really “pro- choice” because a living patient is still capable of freedom of choice. Pro- voluntary euthanasia people are in fact inconsistent as they both respect and do not respect choices, Doerflinger argues, because ‘corpses do not have choices.’ “On this view, suicide is not the ultimate exercise of freedom but its ultimate self- contradiction: A free act that by destroying life, destroys all the individual’s future freedom.” (TRTTD:182).
A dying person capable of making a choice of that kind is also capable of making less monumental free choices regarding the assessment of his or her own past life and the resolution of his relationships with family and friends. (TRTTD:183)
What are we to make of this? How is the choice to have chicken instead of ham for lunch, or any other decision that the terminally ill may make, as significant as the wish to die? Keep in mind Doerflinger’s claim: that he, not the pro-Euthanasia people, truly respects people’s choices.
It appears that Doerflinger’s commitment to respect people’s decisions is in fact the commitment to respect people’s decisions that agree with his own Catholic Orthodoxy.
17.12 Objection: Pragmatic argument (some last-minute discovery may be made).
One of the requirements of the VE guidelines is that no last- minute discovery is likely to come about. In any case, it is not a compelling argument for all cases: a last- minute discovery is going to either be in the development or the experimental stage for a long time after its discovery.
17.13 Slippery Slope Argument
Doerflinger gives a number of clustered arguments which are essentially a slippery slope argument. That is, accepting euthanasia will lead to a corruption of society’s prohibition on murder.
“removing the taboo against assisted suicide will lead to destructive expansion of the right to kill the innocent.” (Rachels TRTTD: 181).
The Coercion Problem: “older people will feel like ‘useless burdens.’
Official acceptance of the rationality of death may lead to the belief amongst old people that they are just eccentric or selfish for wanting to stay alive.
The Will to Power Argument - Doctors will develop a ‘taste for killing’
Definition Shift: The definition of ‘terminally ill’ will become broader.
A similar argument, given by
Gay-Williams:
…euthanasia as a policy is a slippery slope. A person apparently hopelessly ill may be allowed to take his own life. Then he may be permitted to deputize others to do it for him should he no longer be able to act. The judgment of others then becomes the ruling factor. Already at this point euthanasia is not personal and voluntary, for others are acting “on behalf of” the patient as they see fit…it is only a short step to ….involuntary euthanasia conducted as part of a social policy….The category of the “hopelessly ill” provides the possibility of even worse abuse. Embedded in a social policy, it would give society or its representatives the authority to eliminate all those who might be considered too “ill” to function normally any longer. (in White p.102).
hence, accepting VE would lead to a Nazi- like mass murder. The same argument is offered by Doerflinger:
Robert jay Lifton has perceived differences between the German “mercy killings” of the 1930’s and the later campaign to annihilate the Jews of Europe [some 6 million innocent and for the most part healthy people] yet still says that “at the heart of the Nazi enterprise…is the destruction of the boundary between healing and killing.” (In Rachels TRTTD: 187).
And again, in Beauchamp:
…once killing is allowed, a firm line between justified and unjustified killing cannot be securely drawn. …it is…a matter of historical record that this is precisely what happened [during the ]Nazi era, where euthanasia began with the best intentions for horribly ill, non-Jewish Germans and gradually spread to anyone deemed an enemy of the people. (in White p.111).
The implication here is that allowing VE will lead inexorably (inevitably) to mass murder of innocent people who are perfectly healthy. This is bad history, bad logic and bad psychology.
(Note however that this is a weak version of the Slippery Slope argument).
17.14 Replies to the Slippery Slope Argument against VE
a). Rachels: Slippery Slope arguments are difficult to prove
“Because such arguments involve speculations about the future, they are notoriously hard to evaluate.” (Rachels EMP: 10). Rachels notes that, in 1978, when the first ‘test-tube’ baby was born, there were very dire predictions of all sorts of disasters that this technology would cause. The technology has since become routine.
b). The logic of the connection between VE and mass murder of handicapped people is implausible.
Firstly, consider Doerflinger’s argument that allowing VE will lead to doctors just killing handicapped people without consent. How are the arguments for allowing the terminally ill, in extreme pain, to die with professional assistance, if they want to die, in any way relevant to the issue of the rights of handicapped people to not be murdered?
Recall that the basic argument for VE is the argument from mercy. So how do we go from this decision:
Voluntary Euthanasia: value judgment: pain is bad
to this type of decision?
Involuntary ‘euthanasia’ of handicapped people who don’t want to
be dead: value judgment: people who are handicapped are useless
and should be killed.
Doerflinger thinks that the first decision will lead to people accepting the second. Is this plausible?
Young:
It is …difficult to see the alleged psychological inevitability of moving from voluntary to non- voluntary euthanasia. Why should it be supposed that those who value the autonomy of the individual and so support provision for voluntary euthanasia will, as a result, find it psychologically easier to kill patients who are not able competently to request assistance with dying? What reason is there to believe that they will, as a result of their support for voluntary euthanasia, be psychologically driven to practice non- voluntary euthanasia? (Young pp.6, 7)
c). Arguments based on Nazi policy are grossly inaccurate.
Young again:
There never was a policy in favor of, or a legal practice of, voluntary euthanasia in Germany in the 1920’s or 1940’s…There was, prior to Hitler coming to power, a clear practice of killing some disabled persons; but the justification was never suggested to be that their being killed was in their best interests…Hitler’s later revival of the practice and its widening to take in other groups such as Jews and Gypsies was part of a program of eugenics, not euthanasia. (Young p.7).
Concerning the idea that euthanasia will be more common if it is legalized, a). this argument presupposes that it is a bad thing, and b). there is no evidence (as in the Netherlands) that the rate will in fact increase. Young also notes that euthanasia is already practiced; so long as it is kept illegal, euthanasia will be secret and hence unregulated. Legalization will be better monitored if it is legal. (Young p.7).
17.15 The Relevance of Medical Costs
It has been argued that the costs of life- sustaining treatment is simply irrelevant to moral decision making. David Seedhouse, an avowed Kantian, has argued this.
This strikes me as naïve. If the treatment of a terminally ill person who wants to die is costing as much as the life- saving vaccination of thousands of young children, we have to consider the lives saved by ending the (futile) treatment of the terminally ill. As the costs of medical care for the terminally ill soar, and resources are limited, we may be forced into a life-raft situation.
17.16 The Situation in Japan
Several factors specific to the medical profession in Japan complicate the euthanasia debate. These are:
a). Legal and moral vagueness
b). A reluctance to openly discuss the issue
c). socioeconomic pressure to self-sacrifice
d). Paternalism within the Japanese health system
e). Inadequacy of nursing care in the Japanese health system
f). Underdeveloped hospice care.
a). Legal and Moral Vagueness
Misao Shirai, of the Japanese Society for Dying with Dignity, notes that there is no official standard or procedure to oversee euthanasia. As noted in Lecture 16, the guidelines in Japan were set in court, not by the Health Department itself. A related problem is the tradition of Ishin-Denshin, that is, of oral agreements concerning death and dying, rather than having anything official written down. Such arrangements as ‘living wills’ and multiple doctor and psychiatrist reports approving of euthanasia would be impossible without paperwork.
b). A reluctance to openly discuss the issue
Shirai adds: “We [Japanese] often shun or loathe death, and people don’t consider death as their own problem. I think that goes a long way to explain people’s attitude towards euthanasia.” Noritoshi Tanida, a doctor at the Yamaguchi University School of Medicine, notes that in 1996, during the Keihoku Hospital case, there was a public pretence that euthanasia in Japan did not exist and that nobody asked for it. Yet between 40 and 70 per cent of people surveyed the same year stated that they would be in favor of euthanasia.
Tanida notes: In a recent survey, it was found that only 15% of terminally ill patients’ requests for euthanasia were honored. Most were forced artificial nutrition until they died. If an unconscious, bedridden person get pneumonia, they are given antibiotics. Why? So that the doctor in question is not condemned as being a murderer (Tanida p.7). Tanida points to a Japanese tendency to scapegoat people, rather than deal with the real issues.
Reference: Shane Mcleod “Japanese doctor sparks euthanasia debate.” The World Today (Australian Broadcasting Company http://ww.abc.net.au/worldtoday/content/2006/s1605759.html).
c). Socio-Economic Pressure to Self- Sacrifice
Kenzo Hamano, a philosopher at Kwansei Gakuin University, notes that defending euthanasia in the name of autonomy is not so simple here. “In Japan, the concepts of self- determination and autonomy tend to be used to cover up the explicit and implicit socio- economic and political pressures upon individual’s decision making processes. With the actors pretending [that] these pressures do not exist; people’s decisions are then treated as if they are in fact free and autonomous ones” (Hamano p.2).
…”Not all seemingly autonomous decisions are in fact authentically autonomous; there are many features of contemporary pressures upon an individual to make a particular choice. In other words, these external pressures tend to make the other alternatives [appear] unrealistic or unacceptable.” He adds that the traditional “virtue of self- sacrifice” is not really a tradition at all, and is a consciously invented tradition dating from the Meiji period. He adds that it is not a virtue to will one’s own death in the name of the community but a “manifestation of the low quality of the Japanese attitude towards life.”
d). Paternalism
According to Rihito Kimura, there is a tradition of not explaining to terminally ill people the true nature of their condition, on the grounds that this is the most appropriate way to proceed. Yet a Yomiuri Shinbun newspaper poll in 1991 showed that 65% of people said that they would prefer to be given full diagnostic information even if they were terminally ill. Patients frequently do not have access to the information necessary to make their health care wishes known.
There is now only a gradual change from the traditional view that accept without question the decisions of their doctors.
e). Inadequate Care
Japanese doctors use less morphine (a standard opiate painkiller) than those of any other developed country. Japan uses 12.9 grams of morphine per person per day, compared to:
Australia 101.9g
Canada 92.8g
USA 64.2g
If doctors simply do not care about the welfare or happiness of the patients (which is a standard complaint by Japanese medical ethics experts), it is likely that patients are more likely to want to die. Euthanasia guidelines require that everything must be done to minimize the patient’s pain. Until the health system does this as a matter of course, discussion of legalizing euthanasia are premature.
The quality of nursing care in Japan is also inadequate. Nursing care work is underpaid, stressful, physically and mentally exhausting. There are no accurate figures on exactly how stressful it is, which itself suggests official negligence. The situation is so bad that there have been a number of murder- suicides- a nurse kills a patient (perhaps in euthanasia? Hamano is not clear), and then kills herself (or himself). Hence, the term “nursing- care hell” (kaigo-jigoku) is a common phrase in Japanese.
Hospice care is also inadequate. A hospice is basically a facility for caring for the terminally ill, expected to live about six more months, as comfortably as possible. There are about 126 million people in Japan, and each year, there are about 250,000 Japanese who are dying from cancer. In the whole country there are around 60 hospices and 1000 beds between them. Further, according to Hamano, most doctors do not understand the purpose of hospices.
Conclusion: A complete overhaul of the entire health system is required before the issue of euthanasia can be dealt with.
YOU NEED TO KNOW
You need to be able to explain the three STRONGEST objections to the legalization or (as in Japan) tolerance of Voluntary Euthanasia.
You should be able to explain the difference between Active and Passive Euthanasia
You should know what the Slippery Slope argument is.
You should know how the situation in Japan complicates the Euthanasia debate.
References
Frances Howard-Snyder “Doing vs. Allowing Harm,” in Stanford Encyclopedia of Philosophy,
http://plato.stanford.edu/entries/doing-allowing/
Robert Young “Voluntary Euthanasia” in Stanford Encyclopedia of Philosophy, http://plato.stanford.edu/entries/euthanasia-voluntary/
Rihito Kimura “Death and Dying in Japan,” Kennedy Institute of Ethics Journal, Vol. 6
No.4, 1996 http://www.bioethics.jp/licht_biodying.html
Kenzo Hamano “Should Euthanasia be Legalized in Japan? The Importance of the
Attitude Towards Life” in Asian Bioethics in the 21st Century. Eubios Ethics Institute
(CD and online resource) 2006http://www2.unescobbk.org/eubios/ABC4/abc4110.htm
Norito Tanida “Implications of Japanese religious views towards life and death in
medicine”, in Asian Bioethics in the 21st Century. Eubios Ethics Institute (CD and
online resource) http://www2.unescobkk.org/eubios/ABC4/abc4288.htm.
Michael Hoffman “Hospital death spurs debate on euthanasia,” Japan Times April 9th
2006
Roy W. Perrett “Buddhism, euthanasia and the sanctity of life,” Journal of Medical
Ethics, Vol.22 No.5 October 1996
Michael Cholbi “Suicide” in The Stanford Encyclopedia of Philosophy May 2004
http://plato.stanford.edu/entries/suicide/
Ze'ev W. Falk “Jewish Perspectives on Assisted Suicide and Euthanasia” Journal of Law and Religion, Vol. 13, No. 2 (1998 - 1999), pp. 379-384
The following texts are in the Lakeland Shinjuku library:
William Dudley, ed. Death and Dying: Opposing Viewpoints (San Diego: Greenhaven
Press, 1992)
Lisa Yount, ed. Euthanasia (San Diego: Greenhaven Press, 2002).
Tom Beauchamp, ed. Intending Death: The Ethics of Assisted Suicide and Euthanasia
(Upper Saddle River: Prentice Hall, 1996).
James E. White, ed. Contemporary Moral Problems 3rd Ed. (St. Paul, MN: West Publishing
Company, 1991)
The White text contains the following essays:
J.Gay-Williams “The Wrongfulness of Euthanasia” in James E. White, ed. Contemporary Moral
Problems 3rd Ed. (St. Paul, MN: West Publishing Company, 1991):99-103
James Rachels “Active and Passive Euthanasia” in James E. White, ed. Contemporary Moral
Problems 3rd Ed. (St. Paul, MN: West Publishing Company, 1991):103- 107
Tom L. Beauchamp “A Reply to Rachels on Active and Passive Euthanasia,” in James E. White, ed.
Contemporary Moral Problems 3rd Ed. (St. Paul, MN: West Publishing Company, 1991):107-
115
Peter Singer “Justifying Voluntary Euthanasia,” in James E. White, ed. Contemporary Moral Problems 3rd Ed. (St. Paul, MN: West Publishing Company, 1991): 115-120
[1]Rihito Kimura “ Should Euthanasia be legalized in Japan?” p.4
[2] The Dalai Lama, “Letter to the Editor,” Asiaweek 1985 Nov 1: issue 73.
[3] Noritoshi Tameda “Implications of Japanese religious views towards life and death in medicine,” Ebios Ethics Institute http://www2.unescobkk.org/eubios/ABC4/abc4288.htm. Email: tanida@cilas.net
[4] Ze'ev W. Falk “Jewish Perspectives on Assisted Suicide and Euthanasia” Journal of Law and Religion, Vol. 13, No. 2 (1998 - 1999), pp. 379-384doi: 10.2307/1051471
