Lecture #16: Thomistic Ethics

& Moral Problems

Euthanasia;Acts & Omissions

1

Two Topics in this Lecture

• A particular moral problem—euthanasia– along with related problems of suicide & physician-assisted suicide

• A theoretical or conceptual distinction—the relevance of the distinction between acts & omissions to moral evaluation

2

Definition of Euthanasia

• Euthanasia (<εὐ good + θάνατος death, so a good death)– but used to mean “causing a good death” (i.e., killing), not just

“having a good death”– colloquially, “mercy killing”

• The AMA definition (too narrow, but useful for medical contexts)– “Euthanasia is the administration of a lethal agent by another person to

a patient for the purpose of relieving the patient’s intolerable and incurable suffering.”

• In terms of Thomistic analytic vocabulary, composite– Object: killing a person in a medically bad condition– End: mercy (for their own benefit)

3

Definition:Euthanasia & Other Kinds of Killing

• Different object (& end)– Japanese Seppuku (��, “hara kiri”)—

• Killing oneself (object & circumstance)• to rectify disgrace (end).

– Capital punishment• Killing a criminal (object)• By state authority (circumstance)• [in justifiable cases: to secure civic peace

(end)]• Different end

– E.g., the Nazi Aktion T4 program motivated partly by desire to remove people judged to be “genetically defective” from the gene pool.

• Killing people with whom something is (allegedly) genetically wrong (object)

• to improve the health of the next generation (end).

– This program is often called a euthanasia program, but it does not meet the usual definition

– Still, the distinction between these killings & euthanasia as now practised (e.g., in the Netherlands) may not be as sharp as is sometimes imagined.

4

The Nazi Euthanasia Program

• Aktion T4 (1939—1941) killed over 100,000 people with mental or physical disabilities. The reason being “racial hygiene” (like eugenics), this is distinguishable from euthanasia as defined above.

• The magazine cover (right, above) reads: “This person, suffering from hereditary disease, will cost the community 60,000 DM over the course of his lifetime. Fellow citizens, this is your money.”

• Blessed Clemens August Graf von Galen (1878—1946), Bishop of Münster, (right, below) played a particularly important role in galvanizing opposition to the program in 1941. The Nazi government put him under house arrest & beheaded three priests for (among other things) distributing the sermon in which he condemned the program, but his protest did result in Hitler’s cancellation of the program. Von Galen was beatified in 2005.

• In 1947, four German doctors & administrators were charged with crimes against humanity for their participation in this program at the Nuremberg Military Tribunal. Three were convicted & hanged at Landsberg Prison on 2 June 1948.

5

The Lübeck Martyrs (1943)

• Three Catholic Priests (beatified in 2011):– Bl. Hermann Lange (left)– Bl. Eduard Müller (center)– Bl. Johannes Prassek (right)

• One Lutheran Minister– Karl-Friedrich Stellbrink

• See: http://www.luebeckermaertyrer.de/en/index.html

6

The Classical Prohibition Against Euthanasia: The Hippocratic Oath

• I swear by Apollo, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath.

• … never do harm to anyone.• To please no one will I prescribe a deadly

drug nor give advice which may cause his death.

• If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot.

7

Three Conceptual Distinctions

• Voluntary, Non-voluntary, & Involuntary Euthanasia– N.B.: “Voluntariness” is used in a peculiar sense here

• ordinarily, it means that the action comes from the will (voluntas) of the agent• here, it refers to the will of the person who is about to be killed

• Euthanasia & Physician-Assisted Suicide• A Third Distinction, variously made

– Rachels: Active & Passive Euthanasia– Sullivan: Euthanasia (Active & Passive) & Letting Die

8

Voluntariness

• Aristotle on voluntariness in general (Ethics III.1)– Voluntariness requires two things

• knowledge• choice

– Non-voluntariness results when the agent is either … or …• ignorant• under compulsion

– Involuntary acts are those contrary to the will• The distinction & euthanasia

– voluntary euthanasia is death chosen by the patient– non-voluntary euthanasia is death without choice by the patient

• e.g., in the case of infants, who cannot make choices• or in the case of the comatose or others

– involuntary euthanasia is death contrary to the will of the patient• but done for what (in the judgment of others) is in the interest of the person

being killed

9

Distinction II:Euthanasia & Physician-Assisted Suicide

• The distinction– “Euthanasia” refers to acts in which the killing is performed by someone else

• nothing in the definition limits the term to voluntary euthanasia– “Physician-Assisted Suicide” refers to acts in which a physician assists in some

way (e.g., by prescribing lethal drugs) but the actual killing is done by the person himself

• Significance– perhaps not morally significant

• is it not ordinarily permissible to help someone do something that it would not be wrong for them to do?

– perhaps this is a legally useful way of helping to ensure that an act of euthanasia is voluntary

10

The Laws

• Voluntary euthanasia– e.g., in the Netherlands, Belgium & Luxembourg; Columbia

• Physician-assisted suicide– (by referendum or legislation) in Oregon, Washington, Vermont, California,

Colorado, & District of Columbia– (imposed by the courts) in Montana

11

Socrates on Suicide

CEBES: Then tell me, Socrates, why is suicide held not to be right? ….SOCRATES: But do your best and the day may come when you  will understand … why, when a man is better dead, he is not permitted to be his own benefactor, but must wait for the hand of another.I admit the appearance of inconsistency but   there may not be any real inconsistency after all in this. There is a doctrine  uttered in secret that man is a prisoner who has no right to open the door  of his prison and run away; this is a great mystery which I do not quite understand. Yet I, too, believe that the gods are our guardians, and that we are a possession of theirs. And if one of your own possessions, an ox or an ass, for example took the liberty of putting himself out of the way when you had given no intimation of your wish that he should die, would you not be angry with him, and would you not punish him if you could? 

12

Jacques-Louis David“The Death of Socrates”

(1787)

St. Thomas Aquinas on Suicide (2a2æ, 64.5)

Article 5. Whether it is lawful to kill oneself?

I answer that, It is altogether unlawful to kill oneself, for three reasons.

First, because everything naturally loves itself, the result being that everything naturally keeps itself in being, and resists corruptions [i.e., ceasing to exist] so far as it can. Wherefore suicide is contrary to the inclination of nature, and to charity whereby every man should love himself. Hence suicide is always a mortal sin, as being contrary to the natural law and to charity.

Secondly, because every part, as such, belongs to the whole. Now every man is part of the community, and so, as such, he belongs to the community. Hence by killing himself he injures the community, as the Philosopher [i.e. Aristotle] declares (Ethic. v, 11).

Thirdly, because life is God’s gift to man, and is subject to His power, Who kills and makes to live. Hence whoever takes his own life, sins against God, even as he who kills another’s slave, sins against that slave’s master, and as he who usurps to himself judgment of a matter not entrusted to him. For it belongs to God alone to pronounce sentence of death and life, according to Deuteronomy 32:39, “I will kill and I will make to live.”

13

St. Thomas Aquinas on Suicide (2a2æ, 64.5)(cont’d.)

Objection 3. Further, it is lawful for a man to suffer spontaneously a lesser danger that he may avoid a greater: thus it is lawful for a man to cut off a decayed limb even from himself, that he may save his whole body. Now sometimes a man, by killing himself, avoids a greater evil, for example an unhappy life, or the shame of sin. Therefore a man may kill himself.

Reply to Objection 3. Man is made master of himself through his free-will: wherefore he can lawfully dispose of himself as to those matters which pertain to this life which is ruled by man’s free-will. But the passage from this life to another and happier one is subject not to man’s free-will but to the power of God. Hence it is not lawful for man to take his own life that he may pass to a happier life, nor that he may escape any unhappiness whatsoever of the present life, because the ultimate and most fearsome evil of this life is death, as the Philosopher [i.e., Aristotle] states (Ethics, III.6). Therefore to bring death upon oneself in order to escape the other afflictions of this life, is to adopt a greater evil in order to avoid a lesser.

14

Adaptation of St. Thomas’ Argument

• Good actions must be good with respect to their end• The end of a human action must be human flourishing• Non-existence is incompatible with human flourishing

– And, even separation of body & soul is incompatible with human flourishing• Suicide is aimed at non-existence (or at least separation of body & soul)• So, it is incompatible with human flourishing

15

Suicide & Euthanasia

• Two possible objections to arguing from the permissibility of suicide to the permissibility of euthanasia– allowing physicians, &c., to practice euthanasia would change the nature of the

medical profession• from its focus on health• to focus on providing whatever a patient wanted

– legally allowing people to kill other people (even with the victim’s permission) is very different from not making it illegal for people to kill themselves

16

Distinction III:Active & Passive Euthanasia

• This distinction is more complex– the terms are controversial– critics object that it obscures more than it clarifies

• A distinction in AMA policy– The intentional termination of the life of one human being by another—mercy killing—is

contrary to that for which the medical profession stands and is contrary to the policy of the American Medical Association.

– The cessation of the employment of extraordinary means to prolong the life of the body when there is irrefutable evidence that biological death is imminent is the decision of the patient and/or his immediate family.

• Some people (e.g., James Rachels) …– call the first action “active euthanasia”– call the second action “passive euthanasia”– deny that they are morally different

• Others (e.g., Thomas Sullivan)– call the first action “active euthanasia”– call the second action “letting die” (not euthanasia at all)– argue that the AMA is correct in making this moral distinction

17

Rachels’ Two Cases

• Rachels’ Cases– A man about to die of a painful throat cancer– A baby with Down’s Syndrome & intestinal blockage

“A famous test case occurred in 1982 in Indiana, when an infant known as Baby Doe was born with Down syndrome. Children with Down syndrome typically suffer some retardation and other difficulties; while presenting a great challenge to their parents and families, they often live joyful and relatively independent lives. As it happened, Baby Doe also had an improperly formed esophagus, which meant that food put into his mouth could not reach his stomach. Surgery might have remedied this problem, but his parents and physician decided against it, opting for painkillers instead. Within a few days, Baby Doe starved to death.”

Jim Holt, “Euthanasia for Babies?” New York Times Magazine, 10 July 2005

• Question:– What may one do in each case?

• may one let the cancer patient die?• may one decide not to operate on the Down’s-syndrome baby

(i.e., let it die)?

18

Rachels’ Analysis

• Alternative solutions– AMA (according to Rachels; is he right about this?)

• neither may be killed• both may be left to die (in pain)

– Rachels’ solution• (at least) there is no difference between killing them & letting them die• (presumably) each may be killed

• Rachels’ argument– The AMA permits letting the patient die but not killing him– Letting the patient die causes more pain than killing him– So, the distinction permits the more painful solution, but not the less painful– The right solution is to do what causes the least pain– So, the distinction forbids what is right & permits what is wrong

19

AMA Solution

• AMA principles (again)– The intentional termination of the life of one human being by another—mercy

killing—is [wrong]– The cessation of the employment of extraordinary means to prolong the life of the

body when there is irrefutable evidence that biological death is imminent is [permitted at the discretion of the patient or family].

• Application to the cases– Neither patient may be killed (Rachels correctly interprets the AMA here)– May they be left to die?

• Not in pain if pain-killers are available– the hard case is only the extra-ordinary situation when there are no pain-

killers available• Not when an operation is an ordinary means

– possibly effective– not too costly– not too uncomfortable for the patient

– Summary• ordinary means must be used (= letting die not permitted)• extra-ordinary need not be used (= letting die permitted)

20

How to Distinguish the Cases?

• Rachels’ two-point distinction– two kinds of case

• Active euthanasia (actively killing)• Passive euthanasia (all cases letting someone die)

– moral difference between the two cases: none• Sullivan’s three-point distinction

– three kinds of case• Euthanasia

– Active– Passive

• Letting-die– moral significance

• the distinction between active & passive euthanasia is not morally significant– both include the death of an innocent person as an end

• the distinction between euthanasia (active or passive) vs. letting-die is morally significant

– euthanasia is always wrong for the reason just given– letting die may or may not be wrong (depending on circumstances)

21

• The traditional distinction– forbids the intention to cause the death of the patient– does not require use of extraordinary means

• omitting extraordinary means is not necessarily aimed at the death of the patient

• it may be omitted– because it is too expensive– because it is futile– or because using them would be painful

– does require the use of ordinary means• i.e., forbids their malevolent (or negligent) omission

22

James Rachels’ Objection to the AMA Statement

• Rachels’ fundamental concepts: He distinguishes two kinds of euthanasia– Active euthanasia (“killing”)

• doing something (e.g., administering a poison)• to bring about the patient’s death

– Passive euthanasia• omitting to do something (e.g., performing an operation)• because (or perhaps just knowing that) omission will result in the patient’s death

• The problem with his analysis: – if he says “because”, he leaves undiscussed all cases where there is no intention to bring about the

patient’s death– if he says just “knowing that”, he has gone beyond the reasonable definition of euthanasia

• This would include omission of extraordinary means (just letting-die), which is not passive euthanasia.

– All cases of euthanasia include intention of the death of the patient.– Some cases of omitting extraordinary means do not include intention of the death of the patient.

(E.g., the Quinlan case)– So, some cases of omitting extraordinary means are not cases of euthanasia (at all).

• So, his claim that the distinction between active & passive euthanasia is not morally significant does not show that the AMA’s distinction between active euthanasia and omission of extraordinary means is not morally significant

23

Thomas Sullivan’s Three-Way Distinction

• Active euthanasia – example: administration of a lethal drug to a patient (cf. Dutch practice)– analysis

• action• aimed at death

• Passive euthanasia– example: not treating a patient in order to cause the patient’s death– analysis

• omission [inaction]• aimed at death

• Letting die– example: Quinlan case– analysis

• omission [inaction]• not aimed at anything,

24

Rachels vs. Sullivan: The Issues

• Is there a moral difference between– killing someone (e.g., by giving poison) to a person about to die (“active euthanasia”)?– stopping a treatment to someone who is about to die (“letting them die”)?

• Rachels – denies that there is a principled difference between letting-die & euthanasia (same

consequences)• & so, calls letting-die “passive euthanasia”

• Sullivan defends the traditional distinction– Euthanasia is morally different from letting-die (different end)– Letting-die

• is sometimes a way of carrying out euthanasia• sometimes is not (but is just letting someone die)• and so is not equivalent to “passive euthanasia”

• This allows defense of the traditional moral judgments (& current law in most states):– That active euthanasia is always wrong– That letting someone die is not always wrong

• though it could be wrong, depending on– ends &– other circumstances

25

Acts & Omissions:

Theoretically & Applied to Euthanasia

26

Evaluating Omissions

• Passive euthanasia & letting-die are both cases of not acting, knowing that death will follow

• Consequentialists— evaluate on the basis of the consequences• Thomists—other considerations are also relevant

27

St. Thomas, Can there be voluntariness without any act? (1a2æ, 6.3)

• The voluntary is what proceeds from the will. • One thing proceeds from another in two ways.

– directly: when something proceeds from something else because the second thing acts. – indirectly; when something proceeds from something else because the second thing did not act.

• The cause of what follows from inaction – is the agent as not-acting when

• the agent can act• and the agent ought to act

– is not the agent when• the agent cannot act• or the agent has no obligation to act

28

Examples

• St. Thomas’ Example– The sinking of a ship is the helmsman’s fault if he just stops steering – It is not his fault if

• the rudder is broken & he is unable to steer the ship • or he is not assigned to be at the helm

• Another example• in some cases, inaction is a kind of action

– when one chooses not to act» The person who decides not to check on the security of a building has done

something in omitting to act.– when one has an obligation to act but does not

» The watchman who negligently fails to check on the security of a building (as he was supposed to do) has done something in omitting to act.

• but not in others– when one has no obligation to act

» The person who does not check on the security of a building has not done something in omitting to act.

» His object & end are whatever else he was doing at the time; the omission does not have consequences that could make the omission bad.

29

Summary

• There can be voluntariness [and culpability] without an act – sometimes without outward act, but with an interior act; for instance, when one wills not to act; – and sometimes without even an interior act, as when one does not will to act (though one should will to act)

30

Euthanasia Cases: Omissions with Bad Consequences:

Cases when Omission would be Wrong

• Is it ever permissible not to provide medical treatment that would save a life?– If one intends the death of the person not treated

• No, omission is not permissible– Such an omission would be a choice not to act

» (See St. Thomas on why there can be voluntariness without any action)– This choice would be bad with respect to the end– So, it would be bad simply.

– If one has an obligation to treat the patient– Such an obligation could be

» contractual (promise to the patient, part of one’s job at a hospital)» professional (the duties of a physician)

• No, omission is not permissible– Such an omission would be bad since

» the circumstances would be bad: not acting (or, doing something else) when you have a (perhaps contractual) obligation to render medical assistance

31

Euthanasia Cases: Omissions with Bad Consequences:

Cases when Omission would not be Wrong

• Is it ever permissible not to provide medical treatment that would save a life?– if the treatment would impose excessive burdens or risks

• Example: respecting a “Do Not Resuscitate” order• Yes, omission is permissible

– This would be a choice not to act– This choice

» (omissions perhaps don’t have objects)» would be good with respect to its end (to avoid the burdens or risks)» would not be bad with respect to its circumstances if the burdens or risks

were great enough relative to the benefits– So, it would not be bad simply

– if the treatment would prevent one from fulfilling other duties• Example: triage, not treating some in order to use the medical resources for others

who had a greater chance of recovery• Yes, omission is permissible

– Such an omission would not be a choice not to act» It would be a choice to do something else

– So, (assuming a good end & the right circumstances) it would not be bad simply

32

The Defense of Euthanasia

• Two approaches– Utilitarian– Autonomist

• Each taken by itself would be too broad– Utilitarianism alone could allow involuntary euthanasia– Autonomy alone could lead to non-medical cases

• Can the two approaches be combined?

33