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6th November, 2012:  Jim Franklin: Euthanasia   

 

Following on from a discussion earlier this year on the topic "Are we ever allowed to Kill?"  Jim looked at the vexed issue of euthanasia, focussing on the philosophical underpinnings to enable us to make a more informed decision on this complex issue.    The talk ended with a contribution from Irene Franklin,  a medical practioner with more than 30 years experience giving her perspective. 

In addition to the talk given below you can get further information from Jim's book:  Corrupting the Youth. Chapter 16 - given in the link.   http://www.maths.unsw.edu.au/~jim/corruptingtheyouthch16.pdf


  

 

It means you. It may not matter whether you solve the problem of induction or determine the conditions for a just war, but euthanasia is a philosophical issue that most people will confront. Only a minority of deaths are now sudden; most deaths result from chronic conditions and hence need end-of-life decisions.

It would be better to think about it now, before you’re too confused by morphine to think straight. And it is no place for rushing in with simplistic views such as “culture of death” or “whose life is it anyway?” The issues are difficult.

My main point is this: the euthanasia debate is completely confused, with some people passionately “for euthanasia” to relieve terrible suffering, and others passionately “against”, saying life is sacred and it’s wrong to kill the innocent. But when you look closely, you find they actually agree on what should happen. Something has gone wrong with the concepts in the debate. That is a very bad outcome in a debate so important.

First, let us leave side issues aside: slippery slopes, what legislation ought to say, the psychological pressures on old people, the situation in the Netherlands, persistent vegetative states … Those are indeed all very serious issues (I recall the retired judge Barry O’Keefe saying “If you hear people saying ‘Gran wouldn’t want to live like this’, you can be sure they’re the beneficiaries”), but they are not the central issue. Neither is “Who is to decide?” Just as one of the most important distinctions in philosophy is between ontology (what is) and epistemology (how to know it), so it is most important to separate the question of what is right from the question of who should decide on what to do – for example, it may be that responsible adults should be allowed to decide what to eat, but still, self-harm through a bad diet is wrong.

 We can get to those questions later, once we have decided the main issue. That is, Is it all right to up the dose to save pain, knowing it will shorten life?

Let’s start with two extreme views and work our way into the middle.

 

  1. One view begins with autonomy and asks, “Whose life is it anyway?” and says that everyone should have a right to decide for themselves.

We don’t really believe that. If we really thought autonomy trumped other moral goods, we would be happy to allow a temporarily depressed teenager to commit suicide. Indeed, we would hand him the gun. Or if someone old and lonely, or someone feeling undignified in having to ask other people to wash and feed them, wanted to end it all solely for that reason, we would feel it reasonable for them to ask a doctor to euthanase them. But surely a doctor should feel offended by that request and respond that their business is life, not death.

So, our intuition is that there really is a very serious preference for life: life is in itself valuable, or precious, or sacred (in a not necessarily religious sense). It needs a very strong reason to overcome that.

 

  1. At the opposite extreme, one can take a stand on the absolute sanctity of life: on that view, life is instrinsically valuable and the precondition of anything else valuable. So it is always wrong to shorten it, and if it is painful, still, painful life is better than no life at all so it cannot in any circumstances be deliberately shortened.

A few writers believe that, e.g. the former Chief Justice of the High Court Sir Gerard Brennan, and hospitals sometimes find it in Islamic patients. But it is a rare view because it is very harsh, considering the degree of pain possible. It is not the position of the Catholic Church, despite all that the Church says about the sanctity of life, the culture of death and the evils of euthanasia.

 

Now if we don’t agree with either of those two extreme positions, we need some way of drawing the line, between what intervention is allowed in relieving pain and extreme discomfort while foreseeing an earlier death, and what isn’t. There are three plans on how to do it:

 

  1. The first plan relies on the distinction between active vs passive (or natural vs unnatural): the idea is that you might allow nature to take its course (without extreme measures to resuscitate), but may not actively send the patient over the edge.

The distinction between active and passive does make sense, and it’s appealing especially to doctors, who of course prefer not be active in shortening life but are prepared to accept what nature forces on them, and who don’t like excessive resuscitation measures that are hopeless either.

But the trouble is that active vs passive does not draw the line in the right place. It can leave people in very severe pain if nature doesn’t take its course, or is slow in taking its course. Many patients do need something active, like a heavier dose of morphine which will in fact shorten their life, and the active vs passive distinction would prevent them getting what they desperately need. And from the other direction, an omission of action is not necessarily excused just because it’s passive – for example, failing to feed a patient (who should stay alive) and so causing their death is no more morally justified than actively killing them.

 

  1. The second plan on where to draw the line involves the distinction between the intended effects of actions and their side-effects. It’s said that you might increase a dose of painkiller to relieve the pain, while foreseeing that it will shorten life. The purpose of the action is to relieve the pain, and the foreseen death is only an unintended side-effect, so is excusable. That is more or less the position of the Catholic Church.

The distinction between intended effects and side-effects of actions does make sense. For example, collateral damage is a necessary concept in war, where most military actions risk some unintended civilian casualties. The actor has to take responsibility for those casualties, but it isn’t morally the same as deliberately targeting civilians.  And in euthanasia, with a certain amount of common sense and medical judgment, this distinction can be made to give reasonable answers.

As an example, fifty years ago Catholics with any problem of conscience could write to the Australasian Catholic Record to have their doubts answered by Fr Madden, lecturer at St Patrick’s Seminary, Manly. Naturally his answers were always totally orthodox.  He says this in defence of the view that a dose of painkiller might sometimes be increased, even if it is foreseen to shorten life. (In reading this, keep in mind the question: is he for or against euthanasia? The answer is unclear, an indication of the confusion about definitions in this issue):

The suffering [the dying person] has to undergo must be more than he can be expected reasonably to tolerate. While there would be an obligation to bear ordinary pain and discomfort, especially when it is soon to come to an end in death, there is no clear obligation to endure what is morally beyond the limits of human fortitude. It is true that the dying man’s conscious life is shortened, but conscious life is shortened by a narcotic administered at any other time during life, and the shortening of conscious life for the relief of unsupportable pain is justified by the principle of totality. The good of the whole man is the first consideration, and if he is better in a narcotic sleep than suffering excruciating pain, may he not submit to the drug? It is only per accidens [i.e. as a side-effect] that on this occasion he will never awake from it, but the principle which permits the administration of a narcotic applies essentially in the same way for every period of life. This reservation, however, should be made: The last moments of our earthly existence are of the greatest value, and so a more serious cause is required to justify passing into unconsciousness, artificially and deliberately induced, at that crisis than on an occasion when the danger of death does not enter the consideration.

 

But the use of the distinction between deliberate intent and side-effects in the case of euthanasia is conceptually not totally coherent. In particular, it doesn’t fit together with the sanctity of life doctrine that is supposed to balance it. Sanctity of life doesn’t admit of degrees. Once you’ve moved away from the absolute sanctity of life, you don’t know where to stop and the distinction between intended effects and side-effects doesn’t tell you. In itself, in fact, it might well suggest an early intervention – of course the intent of the extra morphine is to relieve pain, not to kill: that is true at any stage, so doesn’t rule out anything in particular.

That is different to the case of war, where a war is only undertaken when an invasion or similar renders a large number of deaths inevitable; sacrificing some innocent civilians in place of others may be forced on one. But in euthanasia, there isn’t anyone else saved by someone’s early death.

So trying to apply the distinction between intended effects and side-effects leaves you balancing the excuse of lack of intention to kill against an attenuated version of the sanctity of life. That’s logically hard to make sense of. It also doesn’t tell you where the balance actually lies.

There is also a fundamental problem about why what is best for a patient should be determined by someone else’s intention. Facts about someone else should not be directly relevant to what is best for a person – that was the complaint about Peter Singer’s making a baby’s right to life dependent on whether it was wanted by its parents. To decide on whether to discontinue aggressive treatment, or increase the dose of painkillers to a level that would hasten death, one must reach the conclusion that death is a more desirable state of affairs than the alternative, in all the circumstances of the case. If it is, how can it be wrong to bring about that state of affairs? Talk about intentions is no help in answering that question. Doubtless, if the victim is beyond the allowed point, the doctor can and should compose his intention so as to have pain relief and not death directly in mind, while if the victim is not yet at that point, the doctor may not so compose his intention. The question about what to do and when is left unresolved.

 

  1. So are there any other plans on where to draw the line between what’s permitted and what’s not?

There is, but you as philosophical people won’t like it. There is a continuum of badness of medical condition (including degree of pain but also severe discomfort like nausea and fits). At some point (or range) on that continuum, life becomes unbearable. This side of the line, the value of life outweighs any wishes of the patient or anyone else that they should be dead. The other side of the line, they deserve relief from unsupportable suffering and have a right to ask for that relief.

Where that point on the continuum lies has then to be decided. Other people’s intentions are irrelevant, and whether other people’s actions are active or passive is also irrelevant. There are no principles left except the degree of suffering. Philosophy, unfortunately, is not much help in deciding points on continuums. It is not that philosophy rules out points on continuums, just that principles expressed in discrete words and concepts are inadequate for the balancing acts required to establish where a point should lie. It’s a matter of degree, not a matter of principles.

 

It is sometimes forgotten that a decision on euthanasia typically involves two people, a patient and a doctor. For a doctor’s perspective, I introduce my wife Irene.

Irene Franklin: My personal understanding of euthanasia: A doctor’s perspective

I’m a medical doctor – mostly in general practice for 33 years.

This is my personal view on euthanasia.

For me euthanasia means the termination of life at the request of a patient. It should be something that both patient and doctor feel comfortable about doing. I respect every individual person’s right to choose in this matter.  My right is to choose to say “no”.

I have only been asked once, by a well patient, and I told them that if that was important to them they should find someone else for that eventuality and build a good relationship with them.

Looking after terminally ill patients whom I’ve known for years beforehand has taught me that no one can be sure of what they will choose when in that position.

The first maxim in medicine is “First do no harm” which includes not attempting to artificially sustain life longer than Nature intended, as well as not to harm or kill.

The second maxim is “Try to do good”.

In the event of severe suffering it is possible to bring relief of physical, psychological and spiritual pain by appropriate means.  In the use of narcotics it must be made clear that these may hasten death in an individual case. Most people were comfortable with that idea. They would rather not suffer the pain.

Each of us is the product of all that has gone before in our lives.

I am a Bible studying, practicing Christian.

I’ve drawn great comfort from walking in the footsteps of people long dead who felt like I do about God and the life we are given.

 In the Jerusalem Bible we read in Psalm 104 v. 29, 30

“You turn Your face away, they suffer,

 You stop their breath, they die and revert to the dust.

 You give breath, fresh life begins,

 You keep renewing the world.”

 

And in Job Ch.12 v.10

“He holds in His power the soul of every living thing,

 And the breath of each man’s body.”

 

 
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