The Needle and the Plug: Is There a Difference Between Killing and Letting Die?

Many people believe there is a significant difference between withdrawing life-sustaining treatment and letting a terminally ill patient die (passive euthanasia) and actively causing a terminal patient’s death by, for instance, delivering a lethal injection (active euthanasia).

Even the American Medical Association (AMA) endorses the distinction. The AMA’s code of medical ethics states that a patient with decision-making capacity “has the right to decline any medical intervention or ask that an intervention be stopped, even when that decision is expected to lead to his or her death and regardless of whether or not the individual is terminally ill.” If a patient doesn’t have decision-making capacity, her surrogate decision maker may, in accordance with her wishes, decline the initiation of life-sustaining treatment or have such treatment stopped if it has already been started.

Active measures to end a patient’s life, however, are forbidden by the code. It says that doctors engaging in active euthanasia “would ultimately cause more harm than good” and that the practice is “fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks.” Another strike against active euthanasia, according to the AMA, is that it “could readily be extended to incompetent and other vulnerable populations” (a rather odd concern given that it could be guarded against by limiting it to when it’s truly voluntary, as is the case for passive euthanasia).

But is active euthanasia morally worse than passive euthanasia if the goal for each is to relieve the patient’s suffering? In his classic 1975 article “Active and Passive Euthanasia,” published in the New England Journal of Medicine, the philosopher James Rachels argued that it isn’t.

In fact, Rachels contended, active euthanasia can be more humane than passive euthanasia. To demonstrate his point, he used the case of a man dying of incurable throat cancer. Even with continued treatment, the man’s going to die eventually. But he’s in excruciating pain, which can’t be successfully relieved, so he doesn’t want the treatment to keep him alive any longer. If he asks the doctor to end treatment, and the doctor obliges, the doctor’s withholding treatment would seem compassionate because the patient is suffering, his disease can’t be cured, and extending his suffering unnecessarily would be wrong.

However, as Rachels pointed out, if treatment were simply withdrawn, it would take longer for the man to die and he would suffer more than he would if he were actively killed by a lethal injection. “This fact,” Rachels argued, “provides strong reason for thinking that, once the initial decision not to prolong his agony has been made active euthanasia is actually preferable to passive euthanasia, rather than the reverse.” Claiming otherwise, he said, “is to endorse the option that leads to more suffering rather than less, and is contrary to the humanitarian impulse that prompts the decision not prolong his life in the first place.”

Rachels also attacked the common belief that killing in itself is morally worse than letting die. He presented two cases that are exactly alike except one involves killing someone and the other involves letting someone die:

In the first, Smith stands to gain a large inheritance if anything 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, 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 4 in his 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.

Rachels argued there is no morally relevant difference between the two cases. “In the first place,” he said, “both men acted from the same motive, personal gain, and both had exactly the same end in view when they acted.”

As for arguments that the Smith and Jones cases are different from cases of euthanasia because they involve nefarious motives and obviously objectionable actions, Rachels said that the point is the same in euthanasia cases – the difference between killing and letting die is not a difference along which moral lines can be drawn:

If a doctor lets a patient die, for humane reasons, he is in the same moral position as if he had given the patient a lethal injection for humane reasons. If his decision was wrong—if, for example, the patient’s illness was in fact curable—the decision would be equally regrettable no matter which method was used to carry it out. And if the doctor’s decision was the right one, the method used is not in itself important.

So, what about arguments declaring that the difference between active and passive euthanasia is that in passive euthanasia the doctor doesn’t do anything to bring about the patient’s death?

It’s incorrect, Rachels argued, to say that in passive euthanasia the doctor doesn’t do anything to bring about the patient’s death. The doctor “does one thing that is very important: he lets the patient die.” Rachels granted that letting someone die is different from other actions in that it’s a kind action that is performed by way of not performing certain other actions, but he maintained that it is nonetheless a type of action.

“The decision to let a patient die,” he said, “is subject is subject to moral appraisal in the same way that a decision to kill him would be subject to moral appraisal: it may be assessed as wise or unwise, compassionate or sadistic, right of wrong.” And if a doctor deliberately let a patient die who had an easily curably disease, the doctor would be just as blameworthy for what he’d done as he would be for needlessly killing a patient.

It’s hard to argue that Rachels was wrong. In cases of both active and passive euthanasia, the motive, to relieve a terminally ill patient’s suffering, and the result, are the same. The method by which the result is brought doesn’t seem to matter. Though Rachels thought there was no morally relevant distinction between active and passive euthanasia, he never went so far as to say explicitly that to let someone die is to kill her.

The medical ethicist Dan Brock, on the other hand, argued just that with this case in his 1992 article “Voluntary Active Euthanasia,” published in the Hastings Center Report:

Consider the case of a patient terminally ill with ALS disease. She is completely respirator dependent with no hope of ever being weaned. She is unquestionably competent but finds her condition intolerable and persistently requests to be removed from the respirator and allowed to die. Most people and physicians would agree that the patient’s physician should respect the patient’s wishes and remove her from the respirator, though this will certainly cause the patient’s death. The common understanding is that the physician thereby allows the patient to die. But is that correct?

Suppose the patient has a greedy and hostile son who mistakenly believes that his mother will never decide to stop her life-sustaining treatment and that even if she did her physician would not remove her from the respirator. Afraid that his inheritance will be dissipated by a long and expensive hospitalization, he enters his mother’s room while she is sedated, extubates her, and she dies. Shortly thereafter the medical staff discovers what he has done and confronts the son. He replies, “I didn’t kill her, I merely allowed her to die. It was her ALS disease that caused her death.” I think this would rightly be dismissed as transparent sophistry-the son went into his mother’s room and deliberately killed her. But, of course, the son performed just the same physical actions, did just the same thing, that the physician would have done. If that is so, then doesn’t the physician also kill the patient when he extubates her?

Brock noted the important moral differences between the doctor’s behavior and that of the son: the doctor acted with the woman’s consent and the son didn’t; the doctor had good motives and the son didn’t; and the doctor occupied a role in which he was authorized to fulfill the woman’s wishes and the son didn’t.

So, the doctor’s act was justified, and the son’s act wasn’t. Yet in both cases, the woman is killed.

Whether you agree with Rachels and Brock or not, you have to admit that the conceptual and moral distinctions between active and passive euthanasia aren’t very sharp. In cases in which passive euthanasia is justified, it’s hard to come up with good reasons why active euthanasia is not also justified – whether compassion is delivered through a needle or the pulling of a plug doesn’t matter all that much.

John Christman’s Content-Neutral Version of Positive Liberty

This is a post is a follow-up to a previous post discussing Isaiah Berlin’s distinction between positive and negative liberty.

In his essay “Two Concepts of Liberty,” the political philosopher Isaiah Berlin warned that the logic of positive liberty could lead to authoritarian corruption. Deemed the “inversion thesis” by George Crowder, Berlin’s argument was that by purporting to be more consistent with liberty than an individual’s actual wishes, the notion of positive liberty can be used to justify coercion against individual’s expressed wishes, thereby inverting the concept of liberty into its very opposite.

In “Liberalism and Individual Positive Freedom,” philosopher John Christman attempts a positive conception of freedom that is not subject to the dangers that concerned Berlin.

Whereas Berlin emphasized the historical notions of positive liberty that opened the door for coercion because the coerced desires or actions supposedly conformed with reason more so than the individual’s own, Christman argues that positive liberty need not rely on such strict conditions. It is not the content of the individual’s desires, he argues, but the procedures by which his desires are formed that constitute positive liberty. According to Christman, a person P is positively free with regard to some desire D if:

  1. P was in a position to reflect upon the processes involved in the development of D;

  2. P did not resist the development of D when attending to this process of development, or P would not have resisted that development had P attended to the process;

  3. The lack of resistance to the development of D did not take place (or would not have) under the influence of factors that inhibit self-reflection (unless exposure to such factors was autonomously chosen, in which case that choice had to be made without such factors); and

  4. The judgments involved in this self-reflection, plus the desire set that results, are minimally rational for P.

Christman spends quite a bit of time elaborating on the fourth condition and its requirement of minimal rationality. Traditional accounts of positive liberty, he argues, are laden with declarations connecting “true” liberty with the demands of reason. The question, he maintains, is to what extent must the judgments involved in the self-reflection demanded by positive liberty be rational, or in what sense must they be rational?

The criteria for rationality vary, he notes, and they can range from the requirement of consistency between beliefs and desires, to requiring the choice of the most effective means to achieve one’s ends, to having sufficient evidence for the beliefs upon which one’s desires depend. All accounts of rationality, however, can be put into one of two categories: “internalist” or “subjective” accounts and “externalist” or “objective accounts.”

For an internalist account, the criterion by which an action is considered rational is dependent only on those beliefs and desires that are “internal” to the person. The relation of those beliefs and desires to the external world (i.e., their accuracy) is not considered. It is usually demanded, Christman maintains, that the internal beliefs (upon which the conditional desires are based) are consistent and the desires are consistent.

By contrast, the externalist account of rationality requires that the person have adequate objective evidence to justify his beliefs, and that his desires be based on these beliefs. An even more stringent version of the externalist condition is one that requires the person to conform his desires to the correct values as well as to factual external evidence.

Christman summarizes the distinction between internalist and externalist accounts of rationality in the following way: “the internalist would only demand that a person acts for reasons (perhaps ones which meet some requirement of consistency), while the externalist demands that the free agent must act in accordance with reason, where that includes knowledge of the truth, both about the world as well as morality.”

Christman defends the minimal, internalist account of rationality for the development of the desires of a positively free, autonomous person. This means that individuals whose actions are based on inconsistent beliefs or inconsistent desires are positively unfree. Christman does note that probably no one has completely consistent beliefs and desires, so the requirement is actually that there be a lack of manifest inconsistencies. He doesn’t offer a point at which beliefs or desires should be considered manifestly inconsistent, but I suppose a line could be drawn, at least in theory. There is no requirement, however, that the beliefs in question fit the external (objective) facts, and there is, similarly, no requirement that the brute desires be appraised on the basis of their rationality.

This conception of positive liberty, Christman argues, answers Berlin’s critique that proponents of positive liberty can justify interference with others’ actions by claiming the coercion is consistent with liberty. No one, he argues, will be in an epistemic position to justify interference on the basis of failed rationality of the internalist type. To do so, the interferer would have to know more than the agent about the internal structure of the agent’s desires and beliefs, and judge them to be inconsistent. Chirstman thinks this is practically impossible.

Christman even argues that requiring an external evidence condition for one’s beliefs would only allow for interference in a narrow range of cases. The cases would include, for instance, those in which the interferer has access to more factual information than the agent and where the information is indisputable and the agent had reasonable access to it. Interfering with an agent’s actions under such circumstances is justifiable, Christman says, because “to act unwittingly is not to act freely. And if I interfere with your unwitting actions I do not disrupt your self-government in any meaningful way.” Further, he continues, “most writers in the liberal tradition accept this as neither paradoxical nor pernicious.”

If these less stringent conditions of positive freedom are accepted, and the notion that freedom requires adherence to the correct values is rejected, then what results is a content-neutral, autonomy-based conception of positive freedom. Christman defends this content-neutral conception as follows:

There are good theoretical reasons for a content neutral conception. For any desire, no matter how evil, self-sacrificing, or slavish it might be, we can imagine cases where, given the conditions faced, an agent would have good reason to have such a desire. That is, there may be many cases where I freely pursue a strategy of action that involves constraining my choices and manipulating my values. But if this is part of an autonomous pursuit of a goal, it is implausible to claim that the resulting actions or values do not reflect my autonomy. So since we can imagine any such preference as being autonomously formed, given a fantastic enough situation, then it cannot be the content of the preference that determines its autonomy. It is always the origin of desires that matters in judgments about autonomy.

On this view, Christman argues, as long as an individual’s desires and values are generated in accordance with the procedural conditions of autonomous preference formation, then the actions that stem from them will be positively free, regardless of the content of those desires and values.

This post was adapted from my bioethics master’s thesis: “The Moral Significance of Non-Autonomous Refusals of Medical Treatment.”

Political Life Contra Salvation

The seclusion of the church has become a tool that has dulled the political acumen and the weapon for the oppressed. There was a time when churches were the harbingers of social justice. Now they often prefer tax exempt status over empowering their congregants. To provide clarity, there was a time that churches fought loudly for the political favor in the black community. Leaders like MLK and Malcolm X stemmed from very politically active churches (*Nation of Islam is a quasi-church in my mind and now bears some strange resemblances to prosperity gospel groups). Their harm was inextricably linked with their ability to lift up others with them. Now, we get souls who laud themselves and their money. Prosperity gospel, that prayer and God chooses who should be rich, generates an inwardness that was not a mainstream approach to religion until the rise of televangelism. Now it haunts the religious community around every corner. Even to the point that yoga isn’t safe. Bikram yoga is an excruciating practice where you engage in yogic practice in a 100+ degrees Fahrenheit room. It spread like wildfire and though many are there for the exercise portion it also carries a religious engagement similar to prayer. Its founder is now on the lam from the law for sexual assault and tax evasion. He believed his own hype and had some outlandish words and beliefs.

Joel Osteen, the sole weasel to escape from Roger Rabbit’s world, has established an elaborate series of machinations to funnel money into his own pockets. His narrow skull filled with gleaning teeth can be seen at Wal-Marts across the US. Preaching an independence that suggests an inward and isolationist approach is his “shtick”. Essentially saying your problems are just God testing you, go further inward and you will work your own way out. Oh, and most importantly, give money to me because God wants me to thrive. The gall. The shamelessness. Yet, people give. Osteen has a net worth of about 40-60 million. He claims that there is no need to be ashamed about being rich. I guess when you are that rich, you can swallow the pride. Not someone who brings good into the world. Certainly not to the public at large. And, easy as it would be to criticize so many other elements, including his time working under Judge Doom, we must admonish him for the looking inward instead of engaging the injustices of this world. Not even willing to open his vast megachurch in Houston to help those suffering immediately after Hurricane Harvey ravaged the city. Yet, the power of shame can only sway Joel so much. He opened after the internet barraged him with criticism but he persisted on making excuses.

If I were to say what these congregations are good for, it would seemingly be only in their ability to further fleece the government for tax purposes.  Perhaps the inward turn from the churches at large was because they were simply afraid to lose their tax exempt status. If that is the case, then money has triumphed over salvation.

 

 

The Knobe Effect and the Intentionality of Side Effects

Imagine that the chairman of a company decides to implement an initiative that will reap profits for his company but will also have a particular side effect. The chairman knows the side effect will occur, but he couldn’t care less. Making money is his only reason for making his decision.

The chairman goes forward with the initiative, his company makes a lot of money, and the side effect occurs as anticipated.

Did the chairman bring about the side effect intentionally? Don’t answer yet.

In a famous 2003 experiment, the philosopher Joshua Knobe showed that people’s judgments about whether a side effect is intentional or not depend on what the side effect is. He randomly assigned subjects to read one of two scenarios, which were the same as the one above, except the actual side effects of the chairman’s decision were presented. In the first scenario, the initiative harms the environment. In the second, it helps the environment.

Of the subjects who read the scenario in which the initiative harmed the environment, 82% said the chairman intentionally brought about the harm. Subjects made the opposite judgment in the other condition. Asked whether the chairman intentionally helped the environment by undertaking the initiative, 77% said that he didn’t.

So, there is an asymmetry in the way we ascribe intentionality to side effects – now known as the “Knobe Effect” or the “Side Effect Effect” – and this study suggests that it stems from our moral evaluations of those side effects. As Knobe concluded in the 2003 study, people “seem considerably more willing to say that a side-effect was brought about intentionally when they regard that side-effect as bad than when they regard it as good.”

But subsequent research by Knobe and others has shown that it’s not that simple. Sometimes people judge good side effects, such as when an action violates an unjust Nazi law, as intentional and bad side effects, like complying with the Nazi law, as not intentional. Richard Holton argues that it is whether a norm is knowingly violated, and not necessarily whether a side effect is morally good or bad, that influences people’s judgments of intentionality.

You probably would’ve struggled to say whether the chairman intended the “particular side effect” because there was nothing to guide your intuitions. If there were, though, you likely would’ve exemplified the Knobe Effect.