The Other Euthanasia Issue

Okay, there’s been some discussion about euthanasia recently.  I know that euthanasia was selected as an example of a thorny issue and Lokee’s article wasn’t intended to be limited to that topic.  That said, however, the consequent discussion (largely at r/philosophy) focussed on the specific rather than the general.

A question that arose in my mind was whether those responding negatively to the idea of legalised euthanasia are also against legalised suicide.

Suicide is has been decriminalised in most nations although it is illegal (and punishable!) in North Korea.  Attempted suicide is punishable in both Singapore and India and, in Russia, it may result in one being taking into psychiatric care.

To make things easy on ourselves, let’s consider only the larger of the western English speaking nations – the US, Canada, the UK and Australia.  In all these nations, suicide is legal while assisted suicide is (perhaps only briefly) legal in only Canada.

In general, it’s not a crime to assist someone do perform an act that is legal.  The legislation of these nations, however, makes a special case for suicide – even in Canada where the current legality of assisted suicide is due to a Supreme Court ruling on the constitutionality of the relevant legislation.

But that’s just the law.  So long as all the necessary boxes are ticked, legislative bodies can make anything illegal – here are a couple of random examples:  (1) In Maryborough, Massachusetts, you may not shoot a Welsh person on Sunday with a longbow in the Cathedral Close (personally, my preference is for a crossbow anyway, so this law is unlikely to affect me), and (2) in Palm Bay Florida, women may not wear pants (one wonders whether there was a deliberate decision to not use the word “trousers”).

Right, let’s get back to the more serious topic of suicide.

As far as I can tell suicide is legal in all the nations being considered, and it's not illegal in any of the countries, states or provinces that make up those nations.  It is vaguely possible that some cities in the US have misdemeanour laws against it.

Before I reach the point I want to make, I need to clarify that I am talking only about successful and seriously intended suicide.  Threatening to commit suicide is a tricky issue, since some people are at risk of following through on the threat, while others who make such threats are little more than a nuisance.  People who threaten to commit suicide should be taken seriously and, preferably, into care.  However, in the rare case that malign intent can be satisfactorily demonstrated, I have no issue with a person who maliciously threatens to commit suicide being punished by the law.  It is reasonable to expect that concern for the well-being of others should not be abused in this way.

Imagine then that a person is serious in their intent to commit suicide.  They make their plans in secret, in order to avoid causing legal problems for any loved ones, and follow those plans through to success – unassisted.  No law has been broken, but what are the consequences?

In an ideal case, the suicide would use a clean method of departure and someone would find the body just after it has gone cold – beyond the point at which resuscitation is possible but before the corpse has begun to decompose.  A thoughtful suicide could even organise the recovery of mortal remains in good time – perhaps via a scheduled email or the delivery of a letter at an appropriate time.

However, this is an ideal case.  There are just so many elements of a plan which may go awry.  Australian Bureau of Statistics figures from 1992 to 2002 tell us that of the 26,500 recorded suicides, poisoning by drugs was only used in about 13% of cases.  Other forms of poisoning, including the use of other more serious poisons, alcohol and car exhaust, accounted for almost 23%.  Hanging and suffocation made up 36%, although this was steadily rising in popularity from 25% in 1992 to 45% in 2002.  Firearms and explosives had a reverse trend, 14% over all, 21% in 1992 and 9% in 2002.  The remaining 14% of suicides were due to drowning, cutting (slit wrists), jumping and “unspecified means”.

About 1000 people die each year on the roads, and it is reasonable to assume that a significant, if not necessarily large, proportion of single vehicle accidents are suicide.  Data for this does not seem to be recorded and it is unclear how many of “unspecified means” were car accidents.  Let’s assume no more than 50 undetected suicides a year over a period of 11 years to total about 27,000 suicides in that period.

Of these, maybe as many as 5,000 were potentially clean drug suicides, in which the body could have been found without an unpleasant mess to deal with.  But there were in the order of 20,000 messy suicides – 2000 a year, all of which had to be dealt with by someone.

And these messy suicides would also almost always have come as a shock.  Someone has to identify the corpse which, already a harrowing task, will be made worse by any visible signs of the suicide method.  Certain methods can result in a period of great uncertainty and suffering for loved ones, for example jumping from a cliff into the surf can result in the body being lost for extended periods, if not forever. A method not overly popular in Australia, but apparently more common in the US, is “suicide by cop” – a method which can potentially lead to suffering on a massive scale if the trigger for the officer-assisted suicide is the shooting of innocent bystanders (such as the Aramoana massacre in New Zealand).

 

Another form of unwitting assistance provided to a suicide arises when someone leaps in front of a train or other vehicle – a method which again can lead to widespread suffering, from the poor person in command of the train (or other vehicle) to those responsible for clearing up afterwards and any witnesses to the death as well as relatives and friends.

So … my question is, if a person is seriously intent on committing suicide, why do we insist that there be a high likelihood that the consequences of that suicide should be messy and devastating for those they leave behind by denying them the option of a better planned, assisted suicide?

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Imagine for a moment, the idea that assisted suicide, euthanasia, was freely available to anyone who wished to avail themselves of it.  Clearly, some form of regulation would be required.  There would be a requirement to ensure that someone petitioning for their own demise should be fully cognisant of their decision (possibly in advance for those suffering comas or intellectual deterioration).

Legislating for regulated euthanasia, I believe, would actually lead to a reduction in the number of suicides.

If I were so inclined, and had the option of a clean, painless, organised suicide in a clinic that was obligated to inform my next of kin at a time of my choosing, I would surely prefer that to the more risky and potentially agonising option of swerving into an on-coming truck, or of jumping from a cliff, or shooting myself.  I would take myself off to the clinic and talk to someone – and it is at this stage that, I believe, a lot of suicides could be averted.

If I had the opportunity to discuss my options with someone properly trained in dealing with potential suicides, I would have to clarify my reasoning not only to that counsellor, but also to myself.  How many people, given the time to stop and think it through properly, would go through with a suicide?  Some, certainly, but quite probably a lot fewer than currently have to screw their courage to the sticking place and do the deed.

Such a regime would not help those who act impulsively, nor those who commit suicide out of shame, but it’s difficult to believe that the option of assisted suicide would not be a far better option for everyone involved.

An Ethical Solution to a Terminal Problem

Lokee here again :)

It seems clear when reading the literature concerning ethics that a consensus, in both the philosophical and scientific spheres as to how our ethics have originated and the degree to which the resulting ethical codes can be captured, normalised and framed, has not yet been reached.

This is understandable given the extent to which the ideas of “right” and “wrong” are woven into our daily lives.  Our actions and beliefs are formed on, and defined according to, an ethical foundation that is laid out when we are children by many external influences including family, friends, teachers, communities, and a variety of texts.  Consequently it is not surprising that the questions, “How do we know what is right and wrong and what principles should guide our ethical decision-making?” plague critical thinkers.  

There is significant evidence to suggest that our ethics have evolved within social groups over time through a process of reciprocal altruism.  In simplistic terms reciprocal altruism can be likened to the process, “If you scratch my back, I’ll scratch yours.”  Or what might be more historically accurate, “If you pick the lice out of my hair, I’ll pick the lice out of yours.”  Thus a system of give and take is initiated for those who live in close proximity to each other, where external actions performed for others are rewarded through reciprocation.  In this scenario, participants swiftly learn to separate those who do cooperate from those who fail to reciprocate, or those who reciprocate, but not to the same level of value, thus establishing structures of justice and fairness.  This form of reciprocal altruism begins within family groups, then progresses to the community and further still to a form of widespread altruism.  Due to unfamiliarity and distance, the latter is less frequent.  As de Waal (1996) states, “Evolution has produced the requisites for morality: a tendency to develop social norms and enforce them, the capacities of empathy and sympathy, mutual aid and a sense of fairness, the mechanisms of conflict resolution, and so on.”

If one accepts, as I do, that our ethics have evolved in a way comparable to what is suggested above, the question then becomes, on what basis should our ethical codes be formed?  If our ethics are an evolved form of reciprocity, that has developed to what we have in modern societies, that is humans valuing those who act and think in a way that benefits others, as well as themselves, what codes should guide our ethical decisions? 

There are a number of well-known ethical codes, which have staunch proponents.  These include utilitarianism, Kant’s Categorical Imperative, virtue ethics and deontology.  In order to understand each of these theories and their effectiveness in solving contemporary ethical problems, I will define each of them and apply them to a controversial ethical debate, that being euthanasia.  

Euthanasia, after one makes their way past the customary catch cries scrawled on placards, familiar media sound-bites and spurious generalisations, is a complex issue and reveals no short cuts to easy answers.  There are six forms of euthanasia, based upon the following two distinctions, passive and active, and voluntary, involuntary and non-voluntary (Benn, 1993).  Of these the form that is deemed by the majority to be the most acceptable, or “easy to swallow” is passive and voluntary, where the patient has given consent for treatment to be stopped.  The next acceptable but seemingly less popular is active and voluntary, where the patient has given consent to be assisted to end their life through the administering of a lethal injection.  Put simply, passive and active voluntary euthanasia is the painless killing of a consenting terminally ill patient or a person in an irreversible coma, in the latter case by the activation of a living will.  A number of governments have legalized passive or active voluntary euthanasia, but for the most part, it remains to be considered murder.  For the purposes of this writing, I am going to apply ethical codes to the concept of passive or active voluntary euthanasia, as these forms of euthanasia tend to be considered by more people to be justified and necessary.  

Currently in Australia, the Euthanasia Laws Act 1997 states that the freedom of the states to make laws “does not extend to the making of laws which permit or have the effect of permitting (whether subject to conditions or not) the form of intentional killing of another called euthanasia (which includes mercy killing) or the assisting of a person to terminate his or her life.”

Utilitarianism, as promoted by Jeremy Bentham and John Stuart Mill, purports that the right decision is identified by that which creates the greatest good (happiness) for the greatest number of people.  Applying this ethical code to the quandary of euthanasia throws the decision-maker right into a murky grey area.  If one were to change the law to permit passive and active voluntary euthanasia, is the greatest good being created for the greatest number of people?  If identifying how many people would be made happy by the legalization of passive and active voluntary euthanasia were as easy as taking an opinion poll of the population to calculate if the majority of people agreed with the legalisation, then in Australia, according to the Utilitarian code of ethics, passive and active voluntary euthanasia should be permitted (80-85% of Australians overwhelmingly support legalizing these forms of euthanasia). 

As mentioned previously, unfortunately the euthanasia debate is not as simple as taking an opinion poll, for when one reflects, a number of clear arguments against euthanasia become apparent and the “greatest good for the greatest number” starts to lessen notably.   There are a number of objections made against the legalization of euthanasia, not objections against the practice itself, but against what may come to pass as a result.  For example, the elderly and chronically sick who may feel pressure, from such a change in the law, to unburden their family and the healthcare system of their duty of care.  Even worse than this, the greedy or uncaring relatives that place pressure on doctors and medical staff, or even emotionally manipulate the patients themselves, to identify their life as being hopeless.  In addition there is the valid argument that it is not fair to unflinchingly place the responsibility of being involved in the decision to take a human being’s life on others, and in this case, family members.  While some may be able to more easily reason that the termination of life is a necessary choice, others may struggle with the moral burden. 

                                                                      

Also by opening one door, are we then opening others, leading to involuntary euthanasia and increases in unnecessary or preventable deaths?  As once some forms of euthanasia become acceptable or accessible, one looks onwards to other forms.  In addition, with the rapid pace at which new treatments and cures are being made in the medical sphere, it is logical to assume that if voluntary euthanasia were permitted, many might end their life in instances where if they had have remained, a cure or treatment may have become available.  Which leads me to this conclusion, utilitarianism while idealistic, is far too vague in its espousing to be an effective ethical code, when making ethical decisions. 

Consequentialism advocates that the ways in which you act are justified if the results of your actions are positive.  Do the ends justify the means?  In respect to passive and active voluntary euthanasia, if performed to relieve a consenting terminally ill patient from suffering, then the consequences, a desired end to their pain, would indeed justify the cessation of their life.  Being that utilitarianism is a strand of consequentialism, it comes as no surprise that when the theory is applied directly to the simplistic view of the problem, a decision is easily reached. However, just as with utilitarianism, once a person digs beneath the top layer of this multi-layered quandary, the objections previously mentioned surface, and the consequentialist perspective becomes unworkable as a way of addressing the objections that arise from the introduction of the practice of euthanasia.  For the objections that are raised come not from the direct consequence, but from the ripples that follow after.   

Virtue ethics tells us that the decision a person should make is determined by how it will reflect on their moral character.  In fact, “A right act is the action a virtuous person would do in the same circumstances” (BBC, 2013).  Consequently, virtue ethics is not concerned with individual actions, but with the sum value of a person’s actions throughout their life.  Also, virtue ethics is not framed by any set of rules or moral duties, but its sole aim is to guide a person towards achieving character traits and enacting the behaviours of a virtuous person.  Throughout history the minimum standard of virtues have changed, and many philosophers fail to agree on which virtues are of priority, although there seems to be some consensus along the lines of prudence, fidelity and justice (BBC, 2013). 

Virtue ethics is a personalized theory that does not lend itself to individual scenarios.  As a guide for how a person should strive to live, its benefits are apparent, but with no clear rules for a person to follow, when faced with a dilemma, and no encompassing agreement on what virtues a “good” person should possess, it leaves a person to their own devices when faced with complex ethical decisions.  Thus when it comes to addressing an ethical decision that affects an entire nation and has potential ripple effects globally, virtue ethics renders itself impractical.

 

The deontological perspective suggests that a person is obligated to meet their duties by following prescribed moral rules, when making an ethical decision, irrespective of the consequences that may follow.  That is to say, certain actions are deemed right or wrong, and therefore despite what consequences may come from adhering to such rules, one must abide by them. Deontological ethics is often linked to Christianity, or theism in general, as in its description deontology is extremely prescriptive, thus the moral rules are viewed as coming from, or being in themselves, a moral authority, and the person who follows the rules is merely the agent.  As many of the moral “laws” people claim to follow are found in the Christian doctrine, as read in the Ten Commandments, it is easy to see why, the deontological perspective is easily adapted into the Christian way of life. 

When addressing the question of euthanasia in public debates, the deontological perspective is often brought to the forefront.  This being due to the popularised moral law, “Thou shall not kill.”  Also aligned with the deontological argument is the religious-based contention that life is sacred, and therefore it is immoral to take ones own life.  In fact, life is not ones own, but belongs to God, and thus He is the only being who has the power or right to end a person’s life.  If a person strongly believes in such moral laws, then they cannot agree to the practice of euthanasia, irrespective of any valid points, proponents may have. Consequently the deontological perspective quickly impedes any further investigation of the issue.  As deontology states, one cannot look to the consequences, one must only be guided by their own moral duties. 

Another moral theory considered a deontological perspective as it is directly linked to moral duty and defined by a person’s actions, rather than the consequences of their actions, is Kant’s Categorical Imperative.  Kant’s theory states one should, “Act only according to that maxim whereby you can, at the same time, will that it should become a universal law.”  His ethical code can be aligned to the Golden Rule, “Do unto others, as you have them do unto you,” although it is far more prescriptive, as once a rule is applied universally, all decisions a person makes must come from this identified reasoning.  That is to say that the moral value of an action is judged according to reason-based identified moral principles.  In my opinion, Kant’s Categorical Imperative is a method of reason that is rightly espoused by many as a reminder to think objectively about the individual decisions a person makes, and the effect it may have on those around them.  In this way, it is a useful tool in our daily social interactions, however its restrictions are not appropriate when addressing complex ethical decisions as it impedes looking in-depth at their multi-faceted nature.  Also in my opinion, to ignore the consequences of ones actions or in fact not perform an action that would have a positive consequence, simply because it does not fit within ones reasoned moral principles, is narrow-minded.  Complex decisions are not well solved by constrained methods of reasoning. 

What is clear to me, after summarising the above ethical theories, and applying them to the complex issue of passive and active voluntary euthanasia, is that no one theory can systematically guide a person to an ethical decision.  Simple or prescriptive theories are for simple problems, and the entire concept of ethics rests on the fact that many dilemmas are not black and white.  However, this is not to say that some ideas from the aforementioned theories should not be put into practice.  Ethical codes provide worthwhile suggestions, as to how to attack an ethical dilemma that if one were to carefully pick and choose, an array of useful tools will be at the ready, when faced with an ethical problem.  Therefore, it is my contention that all one can really hope for, when faced with a complex ethical dilemma, is to do just that.  Analyse a decision objectively (Kant), both the process and consequence, be guided by ones personal moral values and ideals (deontology and virtue ethics), and think not only of oneself but all those that may be affected by the outcome (utilitarianism and The Golden Rule).  Through such reasoning, the best possible decision will hopefully be made.  

List of References

BBC.  (2013).  BBC – Ethics: Introduction to Virtue Ethics.  http://www.bbc.co.uk/ethics/introduction/virtue.shtml

BBC.  (2013).  Euthanasia and physician assisted suicide.  http://www.bbc.co.uk/ethics/euthanasia/

Benn, Piers.  (1993).  The Gentle and Easy Death.  http://philosophynow.org/issues/6/The_Gentle_and_Easy_Death

de Waal, Frans. (1996).  Good Nature: The Origins of Right and Wrong in Humans and Other Animals.  Cambridge: Harvard University Press.    

Frost’s Scottish Anatomy.  The Ethics of Euthanasia.  http://www.martinfrost.ws/htmlfiles/scottish_anatomy/euthanasia_ethics.html

Singer, Peter.  (1993).  Practical Ethics.  Cambridge:  Cambridge University Press. 

Wikipedia.  Euthanasia.  http://en.wikipedia.org/wiki/Euthanasia