Euthanasia and the Right to Die
By Sam Vaknin
Author of "Malignant Self-love: Narcissism Revisited"
I. Definitions of Types of Euthanasia
Euthanasia, whether in a medical setting (hospital, clinic, hospice) or not (at home) is often erroneously described as "mercy killing". Most forms of euthanasia are, indeed, motivated by (some say: misplaced) mercy. Not so others. In Greek, "eu" means both "well" and "easy" and "Thanatos" is death.
Euthanasia is the intentional premature termination of another person's life either by direct intervention (active euthanasia) or by withholding life-prolonging measures and resources (passive euthanasia), either at the express or implied request of that person (voluntary euthanasia), or in the absence of such approval (non-voluntary euthanasia). Involuntary euthanasia - where the individual wishes to go on living - is an euphemism for murder.
Modern medicine seems to be preoccupied with delusions of omnipotence and the need to avoid the narcissistic injury to the doctor’s ego that death constitutes. This preference of the profession’s image over the patient’s welfare and quality of remaining life is patently unethical. But, to my mind, passive euthanasia is equally immoral. The abrupt withdrawal of medical treatment, feeding, and hydration results in a slow and (potentially) torturous death. It took Terri Schiavo 13 days to die, when her tubes were withdrawn in the last two weeks of March 2005. Since it is impossible to conclusively prove that patients in PVS (Persistent Vegetative State) do not suffer pain, it is morally wrong to subject them to such potential gratuitous suffering. Even animals should be treated better. Moreover, passive euthanasia allows us to evade personal responsibility for the patient's death. In active euthanasia, the relationship between the act (of administering a lethal medication, for instance) and its consequences is direct and unambiguous.
As the philosopher John Finnis notes, to qualify as euthanasia, the termination of life has to be the main and intended aim of the act or omission that lead to it. If the loss of life is incidental (a side effect), the agent is still morally responsible but to describe his actions and omissions as euthanasia would be misleading. Volntariness (accepting the foreseen but unintended consequences of one's actions and omissions) should be distinguished from intention.
Still, this sophistry obscures the main issue:
If the sanctity of life is a supreme and overriding value ("basic good"), it ought to surely preclude and proscribe all acts and omissions which may shorten it, even when the shortening of life is a mere deleterious side effect.
But this is not the case. The sanctity and value of life compete with a host of other equally potent moral demands. Even the most devout pro-life ethicist accepts that certain medical decisions - for instance, to administer strong analgesics - inevitably truncate the patient's life. Yet, this is considered moral because the resulting euthanasia is not the main intention of the pain-relieving doctor.
Moreover, the apparent dilemma between the two values (reduce suffering or preserve life) is non-existent.
There are four possible situations. Imagine a patient writhing with insufferable pain.
1. The patient's life is not at risk if she is not medicated with painkillers (she risks dying if she is medicated)
2. The patient's life is not at risk either way, medicated or not
3. The patient's life is at risk either way, medicated or not
4. The patient's life is at risk if she is not medicated with painkillers
In all four cases, the decisions our doctor has to make are ethically clear cut. He should administer pain-alleviating drugs, except when the patient risks dying (in 1 above). The (possible) shortening of the patient's life (which is guesswork, at best) is immaterial.
It is easy to distinguish euthanasia from all other forms of termination of life. Voluntary active euthanasia is morally defensible, at least in principle (see below). Not so other types of euthanasia.
II. Who is or Should Be Subject to Euthanasia? The Problem of Dualism vs. Reductionism
With the exception of radical animal rights activists, most philosophers and laymen consider people - human beings - to be entitled to "special treatment", to be in possession of unique rights (and commensurate obligations), and to be capable of feats unparalleled in other species.
Thus, opponents of euthanasia universally oppose the killing of "persons". As the (pro-euthanasia) philosopher John Harris puts it:
" ... concern for their welfare, respect for their wishes, respect for the intrinsic value of their lives and respect for their interests."
Ronald Dworkin emphasizes the investments - made by nature, the person involved, and others - which euthanasia wastes. But he also draws attention to the person's "critical interests" - the interests whose satisfaction makes life better to live. The manner of one's own death may be such a critical interest. Hence, one should have the right to choose how one dies because the "right kind" of death (e.g., painless, quick, dignified) reflects on one's entire life, affirms and improves it.
But who is a person? What makes us human? Many things, most of which are irrelevant to our discussion.
Broadly speaking, though, there are two schools of thought:
(i) That we are rendered human by the very event of our conception (egg meets sperm), or, at the latest, our birth; or
(ii) That we are considered human only when we act and think as conscious humans do.
The proponents of the first case (i) claim that merely possessing a human body (or the potential to come to possess such a body) is enough to qualify us as "persons". There is no distinction between mind and abode - thought, feelings, and actions are merely manifestations of one underlying unity. The fact that some of these manifestations have yet to materialize (in the case of an embryo) or are mere potentials (in the case of a comatose patient) does not detract from our essential, incontrovertible, and indivisible humanity. We may be immature or damaged persons - but we are persons all the same (and always will be persons).
Though considered "religious" and "spiritual", this notion is actually a form of reductionism. The mind, "soul", and "spirit" are mere expressions of one unity, grounded in our "hardware" - in our bodies.
Those who argue the second case (ii) postulate that it is possible to have a human body which does not host a person. People in Persistent Vegetative States, for instance - or fetuses, for that matter - are human but also non-persons. This is because they do not yet - or are unable to - exercise their faculties. Personhood is complexity. When the latter ceases, so does the former. Personhood is acquired and is an extensive parameter, a total, defining state of being. One is either awake or asleep, either dead or alive, either in a state of personhood or not
The latter approach involves fine distinctions between potential, capacity, and skill. A human body (or fertilized egg) have the potential to think, write poetry, feel pain, and value life. At the right phase of somatic development, this potential becomes capacity and, once it is competently exercised - it is a skill.
Embryos and comatose people may have the potential to do and think - but, in the absence of capacities and skills, they are not full-fledged persons. Indeed, in all important respects, they are already dead.
Taken to its logical conclusion, this definition of a person also excludes newborn infants, the severely retarded, the hopelessly quadriplegic, and the catatonic. "Who is a person" becomes a matter of culturally-bound and medically-informed judgment which may be influenced by both ignorance and fashion and, thus, be arbitrary and immoral.
Imagine a computer infected by a computer virus which cannot be quarantined, deleted, or fixed. The virus disables the host and renders it "dead". Is it still a computer? If someone broke into my house and stole it, can I file an insurance claim? If a colleague destroys it, can I sue her for the damages? The answer is yes. A computer is a computer for as long as it exists physically and a cure is bound to be found even against the most trenchant virus.
The definition of personhood must rely on objective, determinate and determinable criteria. The anti-euthanasia camp relies on bodily existence as one such criterion. The pro-euthanasia faction has yet to reciprocate.
III. Euthanasia and Suicide
Self-sacrifice, avoidable martyrdom, engaging in life risking activities, refusal to prolong one's life through medical treatment, euthanasia, overdosing, and self-destruction that is the result of coercion - are all closely related to suicide. They all involve a deliberately self-inflicted death.
But while suicide is chiefly intended to terminate a life – the other acts are aimed at perpetuating, strengthening, and defending values or other people. Many - not only religious people - are appalled by the choice implied in suicide - of death over life. They feel that it demeans life and abnegates its meaning.
Life's meaning - the outcome of active selection by the individual - is either external (such as "God's plan") or internal, the outcome of an arbitrary frame of reference, such as having a career goal. Our life is rendered meaningful only by integrating into an eternal thing, process, design, or being. Suicide makes life trivial because the act is not natural - not part of the eternal framework, the undying process, the timeless cycle of birth and death. Suicide is a break with eternity.
Henry Sidgwick said that only conscious (i.e., intelligent) beings can appreciate values and meanings. So, life is significant to conscious, intelligent, though finite, beings - because it is a part of some eternal goal, plan, process, thing, design, or being. Suicide flies in the face of Sidgwick's dictum. It is a statement by an intelligent and conscious being about the meaninglessness of life.
If suicide is a statement, than society, in this case, is against the freedom of expression. In the case of suicide, free speech dissonantly clashes with the sanctity of a meaningful life. To rid itself of the anxiety brought on by this conflict, society cast suicide as a depraved or even criminal act and its perpetrators are much castigated.
The suicide violates not only the social contract but, many will add, covenants with God or nature. St. Thomas Aquinas wrote in the "Summa Theologiae" that - since organisms strive to survive - suicide is an unnatural act. Moreover, it adversely affects the community and violates the property rights of God, the imputed owner of one's spirit. Christianity regards the immortal soul as a gift and, in Jewish writings, it is a deposit. Suicide amounts to the abuse or misuse of God's possessions, temporarily lodged in a corporeal mansion.
This paternalism was propagated, centuries later, by Sir William Blackstone, the codifier of British Law. Suicide - being self-murder - is a grave felony, which the state has a right to prevent and to punish for. In certain countries this still is the case. In Israel, for instance, a soldier is considered to be "military property" and an attempted suicide is severely punished as "the corruption of an army chattel".
Paternalism, a malignant mutation of benevolence, is about objectifying people and treating them as possessions. Even fully-informed and consenting adults are not granted full, unmitigated autonomy, freedom, and privacy. This tends to breed "victimless crimes". The "culprits" - gamblers, homosexuals, communists, suicides, drug addicts, alcoholics, prostitutes – are "protected from themselves" by an intrusive nanny state.
The possession of a right by a person imposes on others a corresponding obligation not to act to frustrate its exercise. Suicide is often the choice of a mentally and legally competent adult. Life is such a basic and deep set phenomenon that even the incompetents - the mentally retarded or mentally insane or minors - can fully gauge its significance and make "informed" decisions, in my view.
The paternalists claim counterfactually that no competent adult "in his right mind" will ever decide to commit suicide. They cite the cases of suicides who survived and felt very happy that they have - as a compelling reason to intervene. But we all make irreversible decisions for which, sometimes, we are sorry. It gives no one the right to interfere.
Paternalism is a slippery slope. Should the state be allowed to prevent the birth of a genetically defective child or forbid his parents to marry in the first place? Should unhealthy adults be forced to abstain from smoking, or steer clear from alcohol? Should they be coerced to exercise?
Suicide is subject to a double moral standard. People are permitted - nay, encouraged - to sacrifice their life only in certain, socially sanctioned, ways. To die on the battlefield or in defense of one's religion is commendable. This hypocrisy reveals how power structures - the state, institutional religion, political parties, national movements - aim to monopolize the lives of citizens and adherents to do with as they see fit. Suicide threatens this monopoly. Hence the taboo.
Does one have a right to take one's life?
The answer is: it depends. Certain cultures and societies encourage suicide. Both Japanese kamikaze and Jewish martyrs were extolled for their suicidal actions. Certain professions are knowingly life-threatening - soldiers, firemen, policemen. Certain industries - like the manufacture of armaments, cigarettes, and alcohol - boost overall mortality rates.
In general, suicide is commended when it serves social ends, enhances the cohesion of the group, upholds its values, multiplies its wealth, or defends it from external and internal threats. Social structures and human collectives - empires, countries, firms, bands, institutions - often commit suicide. This is considered to be a healthy process.
More about suicide, the meaning of life, and related considerations - HERE.
Back to our central dilemma:
Is it morally justified to commit suicide in order to avoid certain, forthcoming, unavoidable, and unrelenting torture, pain, or coma?
Is it morally justified to ask others to help you to commit suicide (for instance, if you are incapacitated)?
Imagine a society that venerates life-with-dignity by making euthanasia mandatory (Trollope's Britannula in "The Fixed Period") - would it then and there be morally justified to refuse to commit suicide or to help in it?
Though legal in many countries, suicide is still frowned upon, except when it amounts to socially-sanctioned self-sacrifice.
Assisted suicide is both condemned and illegal in most parts of the world. This is logically inconsistent but reflects society's fear of a "slippery slope" which may lead from assisted suicide to murder.
IV. Euthanasia and Murder
Imagine killing someone before we have ascertained her preferences as to the manner of her death and whether she wants to die at all. This constitutes murder even if, after the fact, we can prove conclusively that the victim wanted to die.
Is murder, therefore, merely the act of taking life, regardless of circumstances - or is it the nature of the interpersonal interaction that counts? If the latter, the victim's will counts - if the former, it is irrelevant.
V. Euthanasia, the Value of Life, and the Right to Life
Few philosophers, legislators, and laymen support non-voluntary or involuntary euthanasia. These types of "mercy" killing are associated with the most heinous crimes against humanity committed by the Nazi regime on both its own people and other nations. They are and were also an integral part of every program of active eugenics.
The arguments against killing someone who hasn't expressed a wish to die (let alone someone who has expressed a desire to go on living) revolve around the right to life. People are assumed to value their life, cherish it, and protect it. Euthanasia - especially the non-voluntary forms - amounts to depriving someone (as well as their nearest and dearest) of something they value.
The right to life - at least as far as human beings are concerned - is a rarely questioned fundamental moral principle. In Western cultures, it is assumed to be inalienable and indivisible (i.e., monolithic). Yet, it is neither. Even if we accept the axiomatic - and therefore arbitrary - source of this right, we are still faced with intractable dilemmas. All said, the right to life may be nothing more than a cultural construct, dependent on social mores, historical contexts, and exegetic systems.
Rights - whether moral or legal - impose obligations or duties on third parties towards the right-holder. One has a right AGAINST other people and thus can prescribe to them certain obligatory behaviors and proscribe certain acts or omissions. Rights and duties are two sides of the same Janus-like ethical coin.
This duality confuses people. They often erroneously identify rights with their attendant duties or obligations, with the morally decent, or even with the morally permissible. One's rights inform other people how they MUST behave towards one - not how they SHOULD or OUGHT to act morally. Moral behavior is not dependent on the existence of a right. Obligations are.
To complicate matters further, many apparently simple and straightforward rights are amalgams of more basic moral or legal principles. To treat such rights as unities is to mistreat them.
Take the right to life. It is a compendium of no less than eight distinct rights: the right to be brought to life, the right to be born, the right to have one's life maintained, the right not to be killed, the right to have one's life saved, the right to save one's life (wrongly reduced to the right to self-defence), the right to terminate one's life, and the right to have one's life terminated.
None of these rights is self-evident, or unambiguous, or universal, or immutable, or automatically applicable. It is safe to say, therefore, that these rights are not primary as hitherto believed - but derivative.
Go HERE to learn more about the Right to Life.
Of the eight strands comprising the right to life, we are concerned with a mere two.
The Right to Have One's Life Maintained
This leads to a more general quandary. To what extent can one use other people's bodies, their property, their time, their resources and to deprive them of pleasure, comfort, material possessions, income, or any other thing - in order to maintain one's life?
Even if it were possible in reality, it is indefensible to maintain that I have a right to sustain, improve, or prolong my life at another's expense. I cannot demand - though I can morally expect - even a trivial and minimal sacrifice from another in order to prolong my life. I have no right to do so.
Of course, the existence of an implicit, let alone explicit, contract between myself and another party would change the picture. The right to demand sacrifices commensurate with the provisions of the contract would then crystallize and create corresponding duties and obligations.
No embryo has a right to sustain its life, maintain, or prolong it at its mother's expense. This is true regardless of how insignificant the sacrifice required of her is.
Yet, by knowingly and intentionally conceiving the embryo, the mother can be said to have signed a contract with it. The contract causes the right of the embryo to demand such sacrifices from his mother to crystallize. It also creates corresponding duties and obligations of the mother towards her embryo.
We often find ourselves in a situation where we do not have a given right against other individuals - but we do possess this very same right against society. Society owes us what no constituent-individual does.
Thus, we all have a right to sustain our lives, maintain, prolong, or even improve them at society's expense - no matter how major and significant the resources required. Public hospitals, state pension schemes, and police forces may be needed in order to fulfill society's obligations to prolong, maintain, and improve our lives - but fulfill them it must.
Still, each one of us can sign a contract with society - implicitly or explicitly - and abrogate this right. One can volunteer to join the army. Such an act constitutes a contract in which the individual assumes the duty or obligation to give up his or her life.
The Right not to be Killed
It is commonly agreed that every person has the right not to be killed unjustly. Admittedly, what is just and what is unjust is determined by an ethical calculus or a social contract - both constantly in flux.
Still, even if we assume an Archimedean immutable point of moral reference - does A's right not to be killed mean that third parties are to refrain from enforcing the rights of other people against A? What if the only way to right wrongs committed by A against others - was to kill A? The moral obligation to right wrongs is about restoring the rights of the wronged.
If the continued existence of A is predicated on the repeated and continuous violation of the rights of others - and these other people object to it - then A must be killed if that is the only way to right the wrong and re-assert the rights of A's victims.
The Right to have One's Life Saved
There is no such right because there is no moral obligation or duty to save a life. That people believe otherwise demonstrates the muddle between the morally commendable, desirable, and decent ("ought", "should") and the morally obligatory, the result of other people's rights ("must"). In some countries, the obligation to save a life is codified in the law of the land. But legal rights and obligations do not always correspond to moral rights and obligations, or give rise to them.
VI. Euthanasia and Personal Autonomy
The right to have one's life terminated at will (euthanasia), is subject to social, ethical, and legal strictures. In some countries - such as the Netherlands - it is legal (and socially acceptable) to have one's life terminated with the help of third parties given a sufficient deterioration in the quality of life and given the imminence of death. One has to be of sound mind and will one's death knowingly, intentionally, repeatedly, and forcefully.
Should we have a right to die (given hopeless medical circumstances)? When our wish to end it all conflicts with society's (admittedly, paternalistic) judgment of what is right and what is good for us and for others - what should prevail?
One the one hand, as Patrick Henry put it, "give me liberty or give me death". A life without personal autonomy and without the freedom to make unpopular and non-conformist decisions is, arguably, not worth living at all!
As Dworkin states:
"Making someone die in a way that others approve, but he believes a horrifying contradiction of his life, is a devastating, odious form of tyranny".
Still, even the victim's express wishes may prove to be transient and circumstantial (due to depression, misinformation, or clouded judgment). Can we regard them as immutable and invariable? Moreover, what if the circumstances prove everyone - the victim included - wrong? What if a cure to the victim's disease is found ten minutes after the euthanasia?
Personal autonomy is an important value in conflict with other, equally important values. Hence the debate about euthanasia. The problem is intractable and insoluble. No moral calculus (itself based implicitly or explicitly on a hierarchy of values) can tell us which value overrides another and what are the true basic goods.
VII. Euthanasia and Society
It is commonly accepted that where two equally potent values clash, society steps in as an arbiter. The right to material welfare (food, shelter, basic possessions) often conflicts with the right to own private property and to benefit from it. Society strikes a fine balance by, on the one hand, taking from the rich and giving to the poor (through redistributive taxation) and, on the other hand, prohibiting and punishing theft and looting.
Euthanasia involves a few such finely-balanced values: the sanctity of life vs. personal autonomy, the welfare of the many vs. the welfare of the individual, the relief of pain vs. the prolongation and preservation of life.
Why can't society step in as arbiter in these cases as well?
Moreover, what if a person is rendered incapable of expressing his preferences with regards to the manner and timing of his death - should society step in (through the agency of his family or through the courts or legislature) and make the decision for him?
In a variety of legal situations, parents, court-appointed guardians, custodians, and conservators act for, on behalf of, and in lieu of underage children, the physically and mentally challenged and the disabled. Why not here?
We must distinguish between four situations:
1. The patient foresaw the circumstances and provided an advance directive (living will), asking explicitly for his life to be terminated when certain conditions are met.
2. The patient did not provide an advanced directive but expressed his preference clearly before he was incapacitated. The risk here is that self-interested family members may lie.
3. The patient did not provide an advance directive and did not express his preference aloud - but the decision to terminate his life is commensurate with both his character and with other decisions he made.
4. There is no indication, however indirect, that the patient wishes or would have wished to die had he been capable of expression but the patient is no longer a "person" and, therefore, has no interests to respect, observe, and protect. Moreover, the patient is a burden to himself, to his nearest and dearest, and to society at large. Euthanasia is the right, just, and most efficient thing to do.
Society can (and often does) legalize euthanasia in the first case and, subject to rigorous fact checking, in the second and third cases. To prevent economically-motivated murder disguised as euthanasia, non-voluntary and involuntary euthanasia (as set in the forth case above) should be banned outright.
VIII. Slippery Slope Arguments
Issues in the Calculus of Rights - The Hierarchy of Rights
The right to life supersedes - in Western moral and legal systems - all other rights. It overrules the right to one's body, to comfort, to the avoidance of pain, or to ownership of property. Given such lack of equivocation, the amount of dilemmas and controversies surrounding the right to life is, therefore, surprising.
When there is a clash between equally potent rights - for instance, the conflicting rights to life of two people - we can decide among them randomly (by flipping a coin, or casting dice). Alternatively, we can add and subtract rights in a somewhat macabre arithmetic.
Thus, if the continued life of an embryo or a fetus threatens the mother's life - that is, assuming, controversially, that both of them have an equal right to life - we can decide to kill the fetus. By adding to the mother's right to life her right to her own body we outweigh the fetus' right to life.
The Difference between Killing and Letting Die
Counterintuitively, there is a moral gulf between killing (taking a life) and letting die (not saving a life). The right not to be killed is undisputed. There is no right to have one's own life saved. Where there is a right - and only where there is one - there is an obligation. Thus, while there is an obligation not to kill - there is no obligation to save a life.
Anti-euthanasia ethicists fear that allowing one kind of euthanasia - even under the strictest and explicit conditions - will open the floodgates. The value of life will be depreciated and made subordinate to considerations of economic efficacy and personal convenience. Murders, disguised as acts of euthanasia, will proliferate and none of us will be safe once we reach old age or become disabled.
Years of legally-sanctioned euthanasia in the Netherlands, parts of Australia, and a state or two in the United States (living wills have been accepted and complied with throughout the Western world for a well over a decade now) tend to fly in the face of such fears. Doctors did not regard these shifts in public opinion and legislative climate as a blanket license to kill their charges. Family members proved to be far less bloodthirsty and avaricious than feared.
As long as non-voluntary and involuntary types of euthanasia are treated as felonies, it seems safe to allow patients to exercise their personal autonomy and grant them the right to die. Legalizing the institution of "advance directive" will go a long way towards regulating the field - as would a new code of medical ethics that will recognize and embrace reality: doctors, patients, and family members collude in their millions to commit numerous acts and omissions of euthanasia every day. It is their way of restoring dignity to the shattered lives and bodies of loved ones.