Yet another argument against physician assisted suicide

Years ago, I read a clever argument against physician assisted suicide that held that medical procedures need informed consent, and informed consent requires that one be given relevant scientific data on what will happen to one after a procedure. But there is no scientific data on what happens to one after death, so informed consent of the type involved in medical procedures is impossible.

I am not entirely convinced by this argument, but I think it does point to a reason why helping to kill a patient is not an appropriate medical procedure. An appropriate medical procedure is one aiming at producing a medical outcome by scientifically-supported means. In the case of physician assisted suicide, the outcome is presumably something like respite from suffering. Now, we do not have scientific data on whether death causes respite from suffering. Seriously held and defended non-scientific theories about what happens after death include:

1. death is the cessation of existence

2. after death, existence continues in a spiritual way in all cases without pain

3. after death, existence continues in a spiritual way in some cases with severe pain and in other cases without pain

4. after death, existence continues in another body, human or animal.

The sought-after outcome, namely respite from severe pain, is guaranteed in cases (a), (b) and (d). However, first, evidence for preferring these three hypotheses to hypothesis (b) is not scientific but philosophical or theological in nature, and hence should not be relied on by the medical professional as a medical professional in predicting the outcome of the procedure. Second, even on hypotheses (b) and (d), the sought-after outcome is produced by a metaphysical process that goes beyond the natural processes that are the medical professional’s tools of the trade. On those hypotheses, the medical professional’s means for assuring improvement of the patient’s subjective condition relies on, say, a God or some nonphysical reincarnational process.

One might object that the physician does not need to judge between after-life hypotheses like (a)–(d), but can delegate that judgment to the patient. But a medical professional cannot so punt to the patient. If I go to my doctor asking for a prescription of some specific medication, saying that I believe it will help me with some condition, he can only permissibly fulfill my request if he himself has medical evidence that the medication will have the requisite effect. If I say that an angel told me that ivermectin will help me with Covid, the doctor should ignore that. The patient rightly has an input into what outcome is worth seeking (e.g., is relief from pain worth it if it comes at the expense of mental fog) and how to balance risks and benefits, but the doctor cannot perform a medical procedure based on the patient’s evaluation of the medical evidence, except perhaps in the special case where the patient has relevant medical or scientific qualifications.

Or imagine that a patient has a curable fracture. The patient requests physician assisted suicide because the patient has a belief that after death they will be transported to a different planet, immediately given a new, completely fixed body, and will lead a life there that is slightly happier than their life on earth. A readily curable condition like that does not call for physician assisted suicide on anyone’s view. But if there is no absolute moral objection to killing as such and if the physician is to punt to the patient on spiritual questions, why not? On the patient’s views, after all, death will yield an instant cure to the fracture, while standard medical means will take weeks.

Furthermore, the medical professional should not fulfill requests for medical procedures which achieve their ends by non-medical means. If I go to a surgeon asking that my kidney be removed because Apollo told me that if I burn one of my kidneys on his altar my cancer will be cured, the surgeon must refuse. First, as noted in the previous paragraph, the surgeon cannot punt to the patient the question of whether the method will achieve the stated medical goal. Second, as also noted, even if the surgeon shares the patient’s judgment (the surgeon thinks Apollo appeared to her as well), the surgeon is lacking scientific evidence here. Third, and this is what I want to focus on here, while the outcome (no cancer) is medical, the means (sacrificing a kidney) are not medical.

Only in the case of hypothesis (a) can one say that the respite from severe pain is being produced by physical means. But the judgment that hypothesis (a) is true would be highly controversial (a majority of people in the US seem to reject the hypothesis), and as noted is not scientific.

Admittedly, in cases (b)–(d), the medical method as such does likely produce a respite from the particular pain in question. But that a respite from a particular pain is produced is insufficient to make a medical procedure appropriate: one needs information that some other pain won’t show up instead.

Note that this is not an argument against euthanasia in general (which I am also opposed to on other grounds), but specifically an argument against medical professionals aiding killing.

Physician assisted suicide and martyrdom

1. If physician assisted suicide is permissible, then it would have been permissible for early Christians facing being tortured to death by the Romans to kill themselves less painfully.

2. It would not have been permissible for early Christians facing being tortured to death by the Romans to kill themselves less painfully.

3. So, physician assisted suicide is not permissible.

The parity premise (1) is hard to deny. The best case for physician assisted suicide is where the patient strives to escape severe and otherwise unescapable pain while facing imminent death. That’s precisely the case of an early Christian being rounded up by Romans to be tortured to death.

Premise (2) is meant to be based on Christian tradition. The idea of suicide to escape pain could not have failed to occur to early Christians, given the cultural acceptance of suicide “to escape the shame of defeat and surrender” (Griffin 1986). It would have been culturally unsurprising, then, if a Christian were to fall on a sword with the Roman authorities at the door. But as far as I can tell, this did not happen. The best explanation is that the Christian tradition was strongly opposed to such “escape”.

There were, admittedly, cases of suicide to avoid rape (eventually rejected by St. Augustine, with great sensitivity to the tragedy), as well as cases where the martyr cooperated with the executioners (as Socrates is depicted having done).

Medical and spacecraft ventilators

Some thinking that to turn off a patient’s ventilator would not be to kill but “to let die”. But it seems obvious that to turn off a spacecraft’s ventilation system would be to kill the astronauts through suffocation.

Of course, there are differences between the two cases. One difference is that the medical ventilator is more intimately connected to the patient. This difference, however, would seem to make turning off the ventilator be more of a killing.

A perhaps more promising difference is that when the patient’s ventilator is turned off, the patient dies from a disease that renders unassisted breathing impossible, while the astronauts die from the turning off of the air system. Maybe there is something to this, but I am doubtful. For we can also say that just as the patient would die from a disease, the astronauts would die from the airlessness of space. It is true that one of these is a disease and the other is an environmental condition, but why should that make a difference with respect to what is a killing?

Moreover, if an engineer turns off the ventilation system on the spacecraft before an astronaut reveals that the technician’s doctoral dissertation was plagiarized, that’s murder. And similarly if a doctor turns off a ventilator before the patient reveals that the doctor cheated in medical school, that’s clearly murder, too.

Similarly, if the death penalty is ever permissible, it could in some cases be administered by disconnecting a ventilator—and it would clearly still be an execution, and hence a killing.

But what if the doctor turns off the ventilator for some reason other than to cause the patient’s death, say to prevent an electrical overload to the hospital’s system which would kill many other patients? Changing the intentions with which an act of killing is done can change whether the act is an intentional killing, whether the act is wrong and whether the act is a murder, but I do not think it changes whether the act is a killing. Thus, the doctor who turns off the ventilator for a reason other than to cause death is still killing, but not intentionally.

Nor does it make a difference with respect to killing whether the disconnection is thought of as causing or hastening death. The doctor who turns off the ventilator to prevent the doctor’s medical school cheating from coming to light could think of the activity as hastening death—making the patient die before revealing the secret. But it’s still murder, and hence it’s still killing. Similarly, the plagiarist engineer would be a murderer even if the air system on the spacecraft were failing and the astronauts would die anyway within a week.

Of course, the judgment that turning off the ventilator is killing does not imply that it is murder or even impermissible. But if we grant that it is always murder to intentionally kill the innocent, the turning off a ventilator in order to cause or hasten death is murder.

Consent and euthanasia

I once gave an argument against euthanasia where the controversial center of the argument could be summarized as follows:

1. Euthanasia would at most be permissible in cases of valid consent and great suffering.

2. Great suffering is an external threat that removes valid consent.

3. So, euthanasia is never permissible.

But the officer case in my recent post about promises and duress suggests that (2) may be mistaken. In that case, I am an officer captured by an enemy officer. I have knowledge that imperils the other officer’s mission. The officer lets me live, however, on the condition that I promise to stay put for 24 hours, an offer I accept. My promise to stay put seems valid, even though it was made in order to avoid great harm (namely, death). It is difficult to see exactly why my promise is valid, but I argue that the enemy officer is not threatening me in order to elicit a promise from me, but rather I am in dangerous circumstances that I can only get out of by making the promise, a promise that is nonetheless valid, much as the promise to pay a merchant for a drink is valid even if one is dying of thirst.

Now, if a doctor were to torture me in order to get me to consent to being killed by her, any death-welcoming words from me would not constitute valid consent, just as promises elicited by threats made precisely to elicit them are invalid. But euthanasia is not like that: the suffering isn’t even caused by the doctor. It doesn’t seem right to speak of the patient’s suffering as a threat in the sense of “threat” that always invalidates promises and consent.

I could, of course, be mistaken about the officer case. Maybe the promise to stay put under the circumstances really is invalid. If so, then (2) could still be true, and the argument against euthanasia stays.

But suppose I am right about the officer case, and suppose that (2) is false. Can the argument be salvaged? (Of course, even if it can’t, I still think euthanasia is wrong. It is wrong to kill the innocent, regardless of consequences or consent. But that’s a different line of thought.) Well, let me try.

Even if great suffering is not an external threat that removes valid consent, great suffering makes one less than fully responsible for actions made to escape that suffering (we shouldn’t call the person who betrayed her friends under torture a traitor). Now, how fully responsible one needs to be in order for one’s consent to be valid depends on how momentous the potential adverse consequences of the decision are. For instance, if I consent to a painkiller that has little in the way of side-effects, I don’t need to have much responsibility in order for my consent to be valid. On the other hand, suppose that the only way out of suffering would be a pill whose owner is only willing to sell it in exchange for twenty years of servitude. I doubt that one’s suffering-elicited consent to twenty years of servitude is valid. Compare how the Catholic Church grants annulments for marriages when responsibility is significantly reduced. Some of the circumstances where annulments are granted are ones where the agent would have sufficient responsibility in order to make valid promises that are less momentous than marriage vows, and this seems right. In fact, in the officer case, it seems that if the promise I made were more momentous than just staying put for 24 hours, it might not be valid. But it is hard to get more momentous a decision than a decision whether to be killed. So the amount of responsibility needed in order to make that decision is much higher than in the case of more ordinary decisions. And it is very plausible that great suffering (or fear of such) excludes that responsibility, or at the very least that it should make the doctor not have sufficient confidence that valid consent has been given.

If this is right, then we can replace (2) with:

4. Great suffering (or fear thereof) removes valid consent to decisions as momentous as the decision to die.

And the argument still works.

Death, dignity and eternal life

One way to look at the difference between the deaths of humans and brute animals is to say that the death of a human typically deprives the human of goods of rational life that the brute animal is not deprived of. While it is indeed an important part of the evil of typical cases of death in humans that they are deprived of such goods, however, focusing on this leads to a difficulty seeing what is distinctively bad about the death of humans who are not deprived of such goods by death, say elderly humans who have already lost the distinctive goods of rational life.

Sure, one can say that the death of a human is the death of a being that normally has the goods of rational life. But it is unclear why the death of a being that normally has the goods of rational life but actually lacks them is worse than the death of a being that actually and normally lacks the goods of rational life.

(Of course, not everybody shares the normative view that there is something distinctively bad about the death of a human being even when the goods of rational life have already been lost. A significant number of people think that euthanasia in such cases is morally licit. But even among those who think that euthanasia in such cases is morally licit, I think many will still think that there is something particularly morally bad about killing such human beings against their clear prior wishes, and those may find something plausible about what I say below.)

How, then, do we explain the distinctive bad in the death of human beings, even ones that lack the distinctive goods of rational life? In the end, I think I would like to invoke human dignity here, but to a significant degree that’s just giving a name to the problem. Instead of invoking and trying to explain human dignity, I want to explore a different option, one that I think in the end will not succeed, but perhaps there is something in the vicinity that can.

Here is a hypothesis:

• It is the nature of human beings to live forever and never die, but the nature of brute animals is to have a finite life.

If this is true, then death always constitutes a mutilation of the human being. It is what directly deprives the human being of the normative diachronic shape of its life. And killing a human mutilates the human being.

Objection 1: If a murderer didn’t kill her victim, the victim would still have died at some later point.

Response: The murderer is still the proximate cause of the victim’s not living forever. And such proximate causation matters. Suppose that my brother murdered Sally’s brother, and to avenge her brother, in true Hammurabic fashion, Sally seeks to kill me. When she finally comes upon me, I am already falling off a cliff. A moment before I would have hit the ground, Sally shoots and kills me. Sally has murdered me, a grave evil. She is the proximate cause of my death. And that matters, even though it would make little difference to my life if Sally hadn’t killed me.

Objection 2: Even if it is the nature of brute animals to have a finite life, it is not the nature of brute animals to die young. But it is not wrong to kill a brute animal when it is young, even though doing so mutilates the brute animal in much the same way that killing a human mutilates the human by causing her life to be finite if the hypothesis is true.

Response: Agreed: it does mutilate the brute animal to kill it when it is young. But to foreshorten the life of a human being from infinity to a finite amount is much worse—in a sense, infinitely worse—than to foreshorten the life of a brute animal from a longer finite length to a shorter finite length.

Objection 3: Christian faith holds that humans will be resurrected. Thus, killing a human being does not succeed in causing the human being to lose infinite life.

Response: Yes, but according to the hypothesis it is not only the nature of human beings to have an infinite future life but it is also the nature of human beings to have a death-free infinite future life.

Objection 4: Imagine an otherwise unremarkable shrub which has a very special nature: it is supposed to live forever, undying. Destroying this shrub would feel distinctively bad as compared to destroying an ordinary shrub, but still not bad in the same way that killing a human being is. Hence, reference to the normativeness of an infinite future life is not enough to explain the distinctive badness of killing humans.

Response: I think that this objection is decisive. Mere invocation of the normativeness of an infinite deathless life is not enough to solve the problem of the distinctive badness of human death. One still needs something like a story about the special dignity of human beings. But it might be that the hypothesis still helps: it multiplies the synchronic dignity of the human being by something like infinity. So less needs to be accomplished by the dignity part of the account.

An argument against euthanasia

1. (Premise) It is wrong to euthanize a patient who does not give valid consent for euthanasia.
2. (Premise) Valid consent is not the expression of a mental state that constitutes an abnormal mental condition.
3. (Premise) Suicidality is an abnormal mental condition.
4. (Premise) Consent is not valid when it comes from external threats.
5. (Premise) A resolve to die is an instance of suicidality, unless it comes from external threats.
6. (Premise) Consent for euthanasia is the expression of a non-threat-motivated resolve to die, unless it comes from external threats.
7. A patient either consents or does not consent to euthanasia. (Tautology)
8. If a patient consents to euthanasia, the consent is not valid. (2-6)
9. Therefore, no one gives valid consent for euthanasia. (7 and 8)
10. Therefore, it is always wrong to euthanize a patient. (1 and 9)

Presumably, defenders of euthanasia will deny at least one of 3 and 5, thereby denying that all non-threat-motivated resolves to die are abnormal mental conditions.

But now take a paradigmatic case of a suicide. Jones is a disgraced lawyer. She has gambled her clients' money and lost, driving some of her clients to suicide, and has done all sorts of other spectacularly bad things. She now thinks that because of facts about her psychological make-up, she will never again be able to hold up her head in society given how infamous her case is. And so she attempts suicide. We think we should stop her and that she is in an abnormal mental condition. But is Jones' case significantly different from that of Smith who is facing unremitting physical pain and the alleged indignity of medical treatment for the rest of her life? Suppose Jones is right that given her psychological make-up and her social environment, the rest of her life will be full of psychological pain and social indignity (including jail, which is surely more undignified than just about any medical procedure). It seems that that if we think, as we should, that Jones' resolve to die is an abnormal suicidality, we should think the same thing about Smith.

Now, we might say this. Jones is only facing unremitting psychological pain because of an underlying psychological abnormality. Normal people bounce back, and so Jones is not normal. Be that as may be, this abnormal condition of Jones stands to Jones' motivation to die in exactly the same way that Smith's abnormal physical condition stands to Smith's motivation to die. Both of them have a condition that will almost certainly render the rest of their lives miserable. That in the one case the condition is psychological and in the other case it is physical surely makes little difference. Besides, the line between the psychological and physical is hard to draw (though for some purposes a rough-and-ready distinction is helpful). A crucial part of Smith's misery will be pain, and pain is a psychological phenomenon. (And surely it makes no difference whether Smith's pain is normal or abnormal.)

Of course, there is the difference that Smith hadn't done terrible things in the past, while Jones had. But we don't stop Jones from suicide primarily because she had done wicked deeds. We stop her because that's the thing to do when someone is suicidal. And we should likewise stop Smith from killing herself, and a fortiori not help her to do so.

What is the essential harm in murder?

Murder is wrong because it harms the victim in a particularly serious way. But what sort of harm does it impose on the victim? Some will say: takes away consciousness, severs connections with loved ones and interrupts projects. However, that on balance there is such a harm is far from obvious, while it is obvious that murder is wrong. For most people in our culture believe that the dead are conscious, and that many of the dead enjoy a life of bliss that include contact with many loved ones, and the continuation of at least the central project of one's life, namely the relationship with God. The wrongness of killing had better not be based on the controversial—and false!—thesis that there is no afterlife.

Now, one might say: Even if there is an afterlife, death interrupts many projects that involve other living people. Maybe. Yet on some views of the afterlife, the dead contribute at least as significantly to the lives of the living as they did when they were alive, for instance by praying for them. And even if death does interrupt many projects that involve other living people, that can't be central to what makes murder wrong. For consider Joe. He is a nice guy and has below average intelligence. Joe has no close friends, but he does have acquaintances. He lives a decent day-to-day life, but has no significant earthly projects that would be interrupted by death. He longs for heaven, but enjoys his daily life. By nobody's standards is he a candidate for euthanasia. Killing him would be a clear case of murder. But one cannot ground the wrongness of killing Joe in terms of projects involving other living people, because Joe just does not have enough such projects to yield the kind of moral weight that the wrongness of killing him has.

If this is right, then we should not look at the central harm in murder as involving a loss of the goods distinctive of the good human life. Rather the central harm in murder is the loss to a human being of the good of life itself—it is the destruction of the human's living body.  And hence to kill a permanently unconscious human being is wrong for the same central reason as it is wrong to kill a conscious human being.

Objection: But then the central good lost in killing the human is apparently of the same sort as the central good lost in killing a mosquito, and hence it should be just as wrong to kill a mosquito as to kill a human.

Response 1: Who loses a good can be morally relevant, over and beyond the question of what the lost good is.

Response 2: While in some sense for the mouse to breathe and for a human to breathe are the same thing, even the non-instrumental value of the mouse's breathing is not the same as the non-instrumental value of the human's breathing. For the mouse's breathing does not have as its telos the support of distinctively human activity, while the human's breathing does have as its telos the support of distinctively human activity. This value in the human's breathing is present even when, in fact, the human is unable to engage in any distinctively human activity. For there is a value in a striving for an end even when the end is not expected to be achieved, and that value derives from the value the value of the end (this is related to issues in sexual ethics), and the human's breathing strives for the end of distinctively human activity.

The value of unconscious human life

Some think that the life of a human being who has permanently and irreversibly lost consciousness has no value. Here are three arguments against tying human value and human dignity to consciousness.

Argument 1: Leibniz and Freud have taught us that much of our mental life is unconscious. If we just look at a typical person's conscious episodes what we get is a disconnected life, a series of short film clips, rather than the rich story that a typical human life is. It would be strange, then, to make the conscious life be the sole locus of value. This argument is there just to move one's intuitions away from an excessive focus on consciousness. It won't, for instance, be relevant in the case of brain damage so severe that there is good reason to think there are no unconscious mental processes (though in practice it does caution one; we know that medical personnel can be mistaken about whether a patient is conscious, and it seems to be even more difficult to determine whether there are unconscious mental processes).

Argument 2: Some living things, like trees, exhibit metabolic activity. Other living things, like earthworms, exhibit significant movement. Other living things, like geckos (I assume), exhibit conscious awareness. Yet others, like dogs, exhibit significant and flexible problem-solving skills. And others yet, of which the only example we are empirically sure are humans, exhibit the kind of sophisticated intellectual functioning and interaction that is characteristic of persons. But the later entries in this list also exhibit the activities of the earlier ones. Earthworms not only move, but also metabolize. Geckos not only are consciously aware, but also move and metabolize. Dogs not only solve problems, but are conscious, move and metabolize. And humans do all of these—and exhibit sophisticated cognition on top of it. The life of a tree, a worm, a gecko and a dog has value, and the good that is found in each of these is found in the typical life of a human. Not all of these goods require consciousness: the good of metabolism and movement is present in many animals without, as far as we know, consciousness. Thus the life of a human who does not exhibit consciousness nonetheless exhibits a number of other goods. To deny this is basically to deny that humans are animals, or to take the implausible view that the life of a tree or a worm has no value.

Argument 3: Consider the attitude one might have towards someone that one loves who has fallen dreamlessly asleep—say, one's child or one's spouse. One may fondly kiss the beloved's head, recognizing the beloved's present value—fondness always involves an element of taking the beloved to have value. If the value of humans essentially requires consciousness, there is either a mistake here or else the value is entirely constituted by the expected future consciousness. It is implausible to say that a mistake is being made, so let us consider the future-consciousness hypothesis. Suppose that the beloved is going to be executed by a tyrant as soon as she about to regain consciousness. Then there is no future consciousness (except in the afterlife, and I do not think the attitude depends on beliefs about the afterlife). But the tragic absence of a future consciousness does not make one less fond—it does not make one value the person less—but the very opposite. Nor is one's attitude as it is towards a corpse. In the case of the sleeping person who will be executed, one dreads and mourns a future loss; in the case of the corpse, one mourns an already present loss.

Final remarks: The above establishes a weak conclusion: that there is intrinsic value in an unconscious human life. One might think that this weak conclusion avails little. But I think it establishes one thing: It is a mistake to think that one can be bestowing a good on an unconscious patient by killing her. An unconscious patient is not suffering. The evils that have befallen her are evils of privation (maybe the evil of suffering is also an evil of privation, but that is more controversial)—she lacks consciousness, speech, complex two-way interaction, etc. But she still exhibits the kinds of goods that oak trees exhibit. And to kill her is to deprive her even of these goods. (A religious person might say: "It will hasten her happiness in the next life, and that is of value." But rarely do we know that a person's afterlife will be free of suffering. Besides, the hastening is not much of a benefit, because when one is unconscious, one is not waiting. According to her subjective time, she will get the goods of the afterlife just as quickly if she is killed now as when she is allowed to live for another ten years of unconsciousness.)

One might think that it is an indignity for a human to be active only at the level of plants. That, I think, is too high a view of humans. We all begin with a life of purely metabolic activity after conception, and most of us end with a life of purely metabolic activity (if only for a few seconds).

An important question (Trent Dougherty asked me about this today), but one that is not required for my weak conclusions above, is whether the metabolic life is intrinsically more valuable in the human than in the oak tree. The answer is, I think, positive, but it is a hard question. (One argument for a positive answer comes from the hylomorphic view of the human soul—our metabolic life is energized by our rational soul.)

Two kinds of professions

Compare the metalworker and the swordsmith. The metalworker's profession is defined by a particular technique for achieving human ends: the production and modification of items made of metal. The swordsmith's profession, on the other hand, is not defined by any particular technique. It is, instead, defined by an end: the existence of a sword. The two sets of skills may overlap: both a swordsmith and an metalworker can make a sword of metal, and in so doing remain within their professional competency. But a swordsmith can remain within her professional discipline in producing a sword of horn, wood and flint (say, in an emergency when metals are unavailable), while the metalworker who made such a sword would not be working within her profession. On the other hand, the metalworker remains within her professional competency when she makes a metal spoon, while the swordsmith is not working as a swordsmith when she makes a spoon—even though she may be as qualified to produce a spoon as any metalworker, and more so than some.

We can in general distinguish means-defined professions and end-defined ones. Examples of means-defined ones: software engineer, electrical engineer, chemical engineer, metalworker, woodworker, machinist, applied mathematician, lawyer. Examples of end-defined ones: civil engineer, aviation engineer, swordsmith, bowyer, cabinet maker, physicist, pure mathematician, biologist, legislator. There will also be cases of professions defined both by and end means. Some of these result from specializations within a means-defined or an end-defined profession—and sometimes it will be unclear which way is the better way to look at it. Is a biomathematician an applied mathematician (means-defined) who uses mathematical methods for the sake of gaining biological knowledge, or is a biomathematician a biologist (end-defined) who uses mathematical methods to pursue the end distinctive of her biological profession (namely, biological knowledge)?

It may be that in all cases of end-defined professions there are some constraints on which means count as part of the distinctive activity of the profession. Thus, it may be argued not be a part of the civil engineer's profession to pray that the bridge not collapse, even though doing so promotes the end that defines her profession. However, it is not clear that this is so. It may be a prejudice to say that the civil engineer does not pray qua engineer.

Nonetheless, despite borderline cases, a basic division into professions primarily defined by a means or set of means, and those defined by an end or set of ends, seems helpful.

Does any of this matter? I think it can. For instance, consider this question: Is it the job of the physician, qua physician, to execute criminals? Assume that the case is one of the rare cases where capital punishment is morally permissible. As has been noted at least since the time of Plato, the physician's professional knowledge makes her the most effective person at both preserving life and taking away life. Moreover, her skills may particularly enable the taking away of life to be reliably painless. If the physicians's profession is primarily defined by means or techniques, then to execute painlessly falls under her profession just as much as to heal. If, on the other hand, her profession is defined in terms of ends, presumably the relevant end is something like the good functioning of the body, and this goal is not promoted by killing. And euthanasia is also not something that falls to the role of a physician.

I think our concept of a physician is a mix. When we talk of the crime of practicing medicine without a license, we are thinking of medicine as in part defined by a particular set of techniques. One does not count as practicing medicine without a license if one suggests to someone that she refrain from eating too many cheeseburgers or if one prays for her health. But only in part. If someone who is not a medical professional intentionally stabs someone else to death with a surgical knife, she would not, I suspect, be charged with practicing medicine without a license in addition to murder, no matter if she had pored anatomy books to figure out how to do the deed.

Still, I think, the primary focus in the medical profession is on the end. Consider that the physician remains within her medical role if the means she recommends to promote end of health involve pharmaceuticals, surgery, physical exercises, psychological exercises, the taking of a placebo, etc. Almost anything that in a morally acceptable way promotes health—with the possible exception of the supernatural—can legitimately fall within the scope of her medical recommendations. She might even diagnose that the patient's headaches are due to financial worries and recommend that the patient come up with a good budget. She would be going beyond her medical competence, I suppose, if she recommended a particular set of safe investments, but that may only be because recommending investments is not a skill that physicians typically have. (A particular practitioner of profession will not have all the skills that can fall under the professional role—the bowyer who cannot work in fiberglass can still be a competent bowyer.)

Moreover, most of the subdivisions within medicine, with the most obvious exception being surgeon, are end-based: the neurologist, the psychiatrist, the gastroenterologist and the pediatrician are each defined by which instances of the goal of health it is their special task to promote.

The pharmacist, on the other hand, is equally defined by means and by end. She does not act within her role if she prepares medication for an execution. It is, after all, her job to take solicitude for the health of the patient, ensure that she is not allergic to the drugs, etc. But she also does not act within her role if she performs surgery.

Euthanasia and the role of the physician

Consider this argument:

1. (Premise) It is not professional for a physician to perform a procedure when there is not sufficient scientific evidence or professional experience about the sequelae of the procedure for the patient.[note 1]
2. (Premise) There is not sufficient scientific evidence or professional experience about the sequelae of euthanasia for the patient.
3. Therefore, it is not professional for a physician to euthanize a patient.

In support of premise (2), note that a crucial thing to have scientific or professional evidence about in the case of a medical procedure is what kinds of things, if any, the patient will be conscious of after the procedure. Now, there is good reason—and perhaps we can consider it "scientific reason"—to think that after the patient is killed, it will no longer be the case that the patient will be conscious of the particular pain, discomfort or indignity that prompted the request for euthanasia. However, there is no scientific evidence or professional experience about whether the patient would or would not have other pains, discomforts or indignities. In fact, there is no scientific evidence or professional experience about whether the patient would or would not have any conscious experiences whatsoever after the procedure.

For an analogy, consider a neurosurgical procedure that could be performed on a suffering patient, which procedure would place the patient in a coma-like state. Suppose further that there was no scientific evidenece or professional experience as to which of the following hypotheses was true:

4. There are no conscious patient experiences following the procedure.
5. The patient is conscious after the procedure, and her conscious states are extremely unpleasant.
6. The patient is conscious after the procedure, and her conscious states are extremely pleasant.
7. The patient is conscious after the procedure, and her conscious states are neither extremely pleasant nor extremely unpleasant.

Surely, the physician who performs the neurosurgical procedure in a responsible way has to have grounds for thinking that (5) isn't the likely outcome for this particular patient. Moreover, for the procedure to be done professionally, those grounds have to be of the sort recognized by the profession—namely, they have to be scientific or based in professional experience.

Observe that the patient's belief as to what the outcome of the procedure would be will not suffice to render a procedure professional. Suppose there is no scientific evidence or medical experience as to whether morphine fights colon cancer. If I request morphine from the physician because I believe, on non-scientific and non-medical grounds, that it fights colon cancer, the physician would not be acting professionally in granting my request. This is true even if my non-scientific and non-medical belief is justified, or even if it is knowledge, say because I know that an angel told me that morphine alleviates colon cancer. It is the physician's professional expectations as to the major sequelae of the procedure that are relevant to whether the physician should perform a procedure or prescribe medication, not the patient's beliefs. Professional medical practice, as it is generally understood in our society, requires both the actual or presumed or proxy informed consent of the patient and the physician's professional judgment.

Could one argue that a physician could kill a patient because she justifiably believes on non-professional grounds that this would be good for the patient? Perhaps the physician justifiably thinks she has an excellent philosophical argument against an after-life or a conclusive theological-cum-empirical argument for the claim that this patient, if killed, would go to heaven. Here, one needs to distinguish three questions:

8. Whether a procedure is or is not professional.
9. Whether a procedure is or is not unprofessional.
10. Whether a procedure is or is not morally permissible.

My argument, I think, does show that killing the patient is not a professional medical procedure. It does not immediately follow from this that it is unprofessional. For instance, reading a fun novel is not (typically) a professional medical procedure, but the physician who reads a fun novel is not behaving unprofessionally (typically). Possibly, however, when we add to (1) that the procedure is "by the physician in her medical role", then we can strengthen the conclusion of (1) to say that the procedure is unprofessional. Nonetheless, there is a further question whether the procedure is morally permissible or not. There might be times when it is morally permissible or even obligatory to violate professional standards (and then perhaps obligatory for any licensing body to take one's license away). Whether euthanasia constitutes such a case is a question I haven't addressed in this post. (Of course, I think euthanasia is always morally wrong, but I think this on grounds other than 1-3: it's wrong because it's an intentional killing of a juridically innocent non-aggressor.)

Euthanasia, patient autonomy and the physician's task

In this post, I am not going to distinguish between a doctor's "helping" a patient kill herself and the doctor's killing the patient herself, since in both cases the doctor kills, in the former case in concert with the patient and the latter alone. To help an assassin pull the trigger or aim the gun is to be a co-assassin. There are two different kinds of reasons given for allowing doctors to kill suffering terminally ill patients: care and autonomy. Those who focus on care base their argument on the patient's suffering and the physician's task in relieving that suffering. One difficulty with justing the euthanasia on such grounds is that once one sees euthanasia as a part of the physician's task of relieving the suffering, then it would become the physician's job to euthanize an incompetent patient (an eight-year-old?) who is suffering, terminally ill and yet begs to live, but where either no proxy is available or the proxy consents, just as it would be the physician's job to do life-saving surgery on an incompetent patient who resists the surgery. But even a lot of supporters of physician-assisted suicide will say that this is going too far.

Suppose instead that we base the killing of the patient on autonomy considerations: the patient chooses to be killed. Here, it is not clear what role in the justification is played by the fact that the patient is terminally ill and suffering, except maybe an epistemic role in providing evidence that the patient is not insane to request killing. After all, if the point is that people have the right to make deep decisions about life and death matters, then it seems that it would be equally the right of a patient who is quite well physically and mentally but who wishes to avoid creditors to request being killed by a physician, whereas surely this is not a request a doctor should accede to.

Now, a defender of euthanasia might object that a limiting condition on a physician's following of patient instructions is the good of the patient, and the person seeking to escape creditors would do better to declare bankrupcy than to be killed. Thus, just as on the first view, euthanasia was justified by care with consent being a limiting condition, on this view euthanasia is justified by consent with care being a limiting condition. However, this is problematic in a different way: It misunderstands the doctor's role. While those who took the first view were wrong in thinking that care calls for killing, they were right that care is the doctor's task.

Consider a surgeon who removes a malignant tumor. It would surely be very strange to say: "In order to honor the patient's choice to determine what is and what is not a part of his body, Dr. Magrodska removed Mr. Jones' tumor." Surely the right thing to say is that Dr. Magrodska removed the tumor because it was malignant, with Mr. Jones' consent being a mere necessary condition (and one that could be satisfied in other ways were Mr. Jones to be incompetent). Professionals are not servants of their clients' wishes, and physicians are professionals par excellance.

Now, there may be things that only a physician is qualified to do and which are done primarily as a response to the patient's wishes. Certain kinds of elective cosmetic surgery are such. But I think it is correct to say that in such a case the physician is not acting as a physician. Rather, she is acting as a medically-trained beautician. And even there she risks losing her status as a professional altogether if she does not act from a belief that the surgery makes the patient more beautiful. That a task requires medical training does not make the task a medical one (not that killing people painlessly requires medical training—see my previous post). Someone with medical training may be needed as consultant for a film set in a hospital—but such consulting is not a medical task.

There is thus a tension between the aspects of care and autonomy in the justification of killing terminal patients. If one focuses on care, then consent becomes a mere limiting condition and one arrives at abhorrent conclusions about killing vociferously protesting children. But if one focuses on autonomy, then physician-assisted suicide ceases to be a medical task.

Physician-Assisted Suicide

Derek Humphry wrote, as part of a defense of Physician-Assisted Suicide (PAS):

The help of a physician [in PAS] is imperative, because loved ones and family members untrained in the medical profession are rarely able to help a loved one to die [...].

This idea seems a standard part of the arguments for PAS.[note 1]

But there are four ways of reading "able" in "able to help": morally, legally, technically or psychologically, as well as combinations of these. Hymphry is presumably not claiming that family members are morally unable to help, that it is wrong for them to "help", since it would be really weird to suppose that medical training somehow gives one permission to kill when before the killing would be immoral. Nor is he claiming that unlike physicians they are legally unable to kill, for instance because they would be charged with murder, since the legality of PAS is precisely what is at issue, and if PAS is illegal, then physicians are also legally unable to "help".

Probably the best reading is "technically able to help", given the mention of training. But on that reading, the claim is false. There are many highly reliable methods of basically instaneously killing a person, at least if the killer has a normal amount of dexterity and physical strength. At the expense of some gruesomeness, let's briefly mention shotguns and large axes. One might object that in those cases, it is not a matter of helping but a matter of doing the whole job oneself. But it is easy to give the victim a role, say having the victim pull the trigger with a string.

Perhaps, then, we should read "able to help" as "psychologically able to help". On this reading, medical training makes it psychologically possible to kill. This is scary in that it makes medical training be akin to military training, a regime that makes one into someone who is not merely technically but psychologically capable of killing, overcoming our innate resistance to killing (on the latter topic, see this fascinating book by Rachel MacNair). Besides, if psychological resistance is the issue, one doesn't need a physician, just an able-bodied psychopath.

Maybe the best reading of the quote from Humphry is to combine the technical and psychological. The technical skills of the ordinary person, just much as those of the physician, make possible multiple relatively painless methods of killing, but these methods are messy, and are likely to be traumatic for the perpetrator. The methods available to the physician are neater. I think, though, there is a more perspicuous way of putting the difference: The methods available to the ordinary person make it look like the family member has killed a person, while the methods available to the physician make it look like a medical procedure has been performed. But once we formulate it in this way, it seems that the main "advantage" of the methods available to the physician is that they hide what has happened—the destruction of a human body. And that, in turn, is no advantage at all, since it hides from the moral imagination the truth of the situation, thereby skewing the decision.

Objection 1: Humphry could simply be worried about cleaning up after a killing committed with an axe or a gun.

Response: That seems unlikely. Besides, if mess is the issue, someone formerly in the special forces could surely be hired to do a neat and instantaneous job. Physicians are not the only people with technical skills for killing.

Objection 2: Being killed medically is more dignified than being killed with a gun.

Response: I simply do not see this. Why should being poisoned by an injection administered by someone in a white coat be more dignified than being shot dead? After all, we think of soldiers in wartime as dying with honor and dignity when they are shot by the enemy. I think the issue is not that being killed medically is more dignified, but that being killed medically hides the truth about what is happening. And dying in such a sneaky way is, if anything, less dignified.

Final comment: If I am right, then a major reason for PAS is a desire to make killing look less like a killing. And that desire is illegitimate if PAS is morally permissible. At the same time, I think the presence of that desire reflects something good: it reflects a revulsion at killing. But to kill the patient in a way that hides the destruction of the body is not the right way to respond to that revulsion. The right way to respond to that revulsion is to recognize the dignity of human life, and to care for rather than kill the patient.

Consensual killing

In an earlier post this week, I argued that if one accepts the Interest Thesis (IT) that what makes a killing of an innocent person wrong is that it goes against the victim's interests, one needs to hold that it is never in the interests of a person to be killed. Hence, if IT holds, the justification of euthanasia in terms of the interests of the patient/victim fails. I ended the post by mentioning an account on which a person's consent is what makes it acceptable to kill the person, without settling the question whether that would be a good account. I will now try to settle this in the negative.

Why would x's consent make it permissible to kill x? Consent (and I use the term to mean "valid consent", consent satisfying whatever kinds of freedom and knowledge conditions are needed) is tied to autonomy. Generally speaking, when consent makes it permissible to do something which is impermissible without the consent, that is because doing the action without the consent is a violation of the person's integrity. Is killing a person without her consent a violation of the person's integrity? That claim seems to have a lot of plausibility.

But why does non-consensual killing violate a person's integrity? Here, we have to be careful. It won't do to say that such killing makes it impossible for the person to fulfill her life's autonomous projects. For it might be that the person's life is in such a miserable state that she has no projects that are interrupted by the death. She may want death, but still not consent to death. It need not even be an autonomous project of hers to continue living, just a morally driven determination not to consent to death.

Perhaps we want to say that non-consensual killing violates a person's autonomy because death is always a very serious harm and we should not intentionally impose very serious harms on innocent people without their permission. But I think we can simplify this principle to just say: "We should not intentionally impose very serious harms on innocent people", and then all intentional killing of the innocent is forbidden. Moreover, even if we don't go for this simplification, if we think death is a very serious harm, then we are apt to think that someone requesting death is irrational or constrained by circumstances, both of which endanger the validity of the consent. At this point it will be really implausible that it is the lack of consent that makes murder be wrong—for the serious badness of death is entering into the story.

Or maybe, in line with the element of formalism in Kantian ethics, we will say that the reason it is wrong to kill someone without her consent is that it is wrong to significantly change a person's life without her consent.

But this change principle is inapplicable and/or false. First of all, it's not clear that terminating a life counts as "changing a life". Moreover, if it counts, then so does beginning a life. But a couple does not need consent from their future child to conceive that child. Second, there are many significant life changes that it is permissible to impose on a person. It would not be impermissible for me to offer you a billion dollars, if I had it and if I had no morally obligatory alternatives for my largesse. But the offer would significantly change your life, and it would do so without your consent. For either you would accept the offer, in which case your life would significantly change (assuming you're not already very rich), or you would reject the offer, in which case your life would also significantly change, for instance because for the rest of your life you would from time to time be reflecting on your decision and wondering if it was the best one. Nor would I need to ask a person her permission before offering her a life-changing argument. Granted, she would have to consent to the change of life, but if the argument were powerful, her life would be forced to change: either she would have to act in accordance with the argument or else she would have to become the sort of person to whom arguments do not matter. Examples like this can be multiplied.

Killing, the victim's interests, and euthanasia

This post is based on the argument of the previous. I am going to argue for the following (material) conditional:

1. If killing an innocent person is wrong because it goes against the victim's interests, then killing an innocent person always goes against the victim's interests.

The Interests Thesis (IT) is that killing an innocent person is wrong because it goes against her interests. The Bad Life Thesis (BLT) is the thesis that it is possible for an innocent person to have such miserable prospects that it is not against her interests to be killed. The conditional (1) can be seen either as providing a reductio of IT or else an argument against BLT. I suspect there are philosophers who accept IT and BLT, for instance accepting IT as a way of countering Marquis-type arguments against abortion and accepting BLT in defense of euthanasia. I think that even if one rejects euthanasia, as I do, BLT has some plausibility (I recall the story about some saint praying for death when very ill—it's wrong to kill the innocent, but perhaps not irrational to pray for death), so overall one might take this argument to provide evidence against IT.

My argument for (1) is very simple:

2. If x is an innocent person who does not consent to being killed, then it is wrong to kill x even if it were in x's best interest to be killed. (Premise)
3. If IT, then it isn't wrong (barring special circumstances such as promises) to kill someone when it is not against her interests to be killed. (Premise)
4. If BLT, then it is possible to have an innocent person such that it is not in her interest to be killed and the "special circumstances" clause in (3) does not apply. (Premise)
5. Therefore, if IT, then not BLT.

There is something tricky in (4), but if one thinks that the special circumstances in (3) involve the existence of additional positive features of the situation that make a killing be wrong (one might say that those are features that make the killing wrong—say, as the breaking of a promise—but don't make the killing murder), I think (4) will be plausible. Could lack of consent be such a special feature? But I don't think it would be a special feature: it would mean that we are gutting IT, and replacing it with the view that what makes killing wrong is that it goes against the person's consent.

Now, the standard justifications of euthanasia involve the claim that euthanasia can be in the interests of the victim/patient. But if BLT is false, then these justifications fail. If there is no other kind of justification, then euthanasia is wrong.

One might try to justify euthanasia by saying that killing someone who validly consents to being killed is not wrong. But this is not a justification of euthanasia as such, but a justification of helping anybody who validly consents to being helped in suicide, whether the suicide is a case of euthanasia or not. I take it to be an essential feature of euthanasia that it be a killing construed to be in the best interests of the innocent victim/patient.

Objection: We need to ask the patient whether she consents to being euthanized because we cannot presume to judge for her whether death is in her interest. Her opinion has a merely epistemic role here.

Response: This confuses consent with opinion, a performative with an assertion. It can be perfectly rational to say: "I know that having A done to me is in my best interest, but I do not consent to having A done to me." And if someone tells us that being killed would be in her best interest but nonetheless does not consent to being killed, it is uncontroversially wrong to kill her. Why would someone think that A is in her best interest but not consent to A? Well, she might think it's immoral to consent to A. Or she might have made a promise to someone never to consent to A, without making any promise to avoid A.

An argument concerning abortion

Note: Portions of the argument below sound like I accept consensual euthanasia. I don't: intentionally killing juridically innocent persons, whether they consent or not, is wrong. But I don't make use of this belief in the argument, and my argument is in large part aimed at people who do not share this belief of mine on euthanasia.

This post is divided into three sections, the first giving a standard argument against abortion, the second giving a standard response, and the third arguing that the standard response is unsatisfactory, at least if one allows that one can rationally desire to die, a thesis that I am not sure of, but that few people who are not already pro-life will deny.

Part I: A standard argument against abortion: This takes two steps. First, one shows that a typical fetus would have a future of the same sort that we do were she not killed. This may involve metaphysical arguments to establish that the future is indeed the fetus's future in the sense that the fetus is identical with the adult human being. (I argue like this here.) The second step is to show that at least one of the reasons that it is wrong to kill you or me is that it would undeservedly deprive you or me of this sort of future, so that it is wrong to kill a typical fetus for exactly the same reason.

Part II: One standard response: Grant, at least for the sake of discussion, the claim that the fetus would have a future like ours, but deny that the undeserved deprivation of a future life like ours makes the killing wrong. Instead, what makes it wrong to kill someone is that doing so goes against the person's interests, which are defined in terms of the desires that the person has (on a crude version of the response) or would have in ideal mental circumstances (on a less crude version of the response), desires whose fulfillment requires the continuation of life. The reason for going for the "ideal desire" view is some version of the example of the suicidal teenager: it is wrong to kill the suicidal teenager even if the teenager lacks all future-directed desires. But, one argues, in ideal mental circumstances, the teenager would want to live, so a better story is the ideal desire one.

Part III: A response to the response: It is not the case that what makes it wrong to kill x is that x actually or ideally has desires that require the continuation of life. For suppose George does not actually or ideally desire the continuation of life. He is miserable, abandoned by all friends, no longer capable of engaging in any of his past projects, in the grip of a painful terminal illness. It seems not that implausible to suppose that George could rationally desire to die, so that he not only actually but also ideally has the desire to die. We may also suppose that he has no fulfillable ideal desires incompatible with the desire to die. Now some strongly pro-life people will deny the idea that one can rationally desire to die, but I suspect there are very, very few pro-choice philosophers who will dispute this. Moreover, even someone completely opposed to euthanasia can hold that it is rational to have the desire to die as long as one adds that it is wrong to act on that desire (other than maybe by praying for death).

So, to recap, we suppose, and few pro-choicers will deny us this assumption, that George rationally, consistently and ideally desire to die. By the response in Part II, what makes it wrong to kill people is actual or ideal desires that require future existence. But George doesn't have such desires, and hence it follows that is not wrong to kill him. But this is absurd.

A reader might say: "So, you've shown that if you accept Part II, you accept the permissibility of euthanasia. Almost everybody who is pro-choice already accepts the permissibility of euthanasia, so this is no reductio." But that would be a mistake. For I did not say that George consents to being killed. All I said is he desires death. It is one thing to desire something and another to consent to it (see this post). And I suspect that most pro-choice folks will agree that it is wrong to kill a non-consenting innocent adult, even if that adult desires to be killed. For it is the consent rather than the desire that matters here. Why would George not consent? Here, a myriad of possibilities is available, including religious views, views about the sanctity of life, views about the way that killing him would dehumanize the killer, etc.

So it is not enough to establish the lack of actual or ideal desires presupposing future life to show that a killing is permissible. Step II fails.

Could we say that the fetus consents to being killed, so that we could say that it is permissible to kill someone lacking actual or ideal desires presupposing future life if the victim consents to being killed? No: the fetus plainly does not consent. Could we say that the fetus would consent if it could be asked? We have no reason to suppose that. In the typical case, the fetus would be asked to give up a future like ours with no compensating benefit to the fetus, and there is no reason to suppose a positive answer to a deal like that. Alternately, perhaps, we could handle the consent question in the way we handle it in practice: appoint a proxy. But note that a proxy cannot have a potential conflict of interest, and in the case of abortion, the mother does have a potential conflict of interest—if she's considering abortion, this is not unlikely to be the case because she takes the pregnancy to conflict with her interests or the interests of her significant other or of her other children. Rather, the proxy has to be one who considers primarily what is good for the individual that she is a proxy. I suspect that, given "future like ours" considerations, in typical cases such a proxy will not agree to abortion.

Could we instead say that the fetus does not dissent from being killed, and it's permissible to kill someone who (a) lacks actual or ideal desires presupposing future life, and (b) does not dissent from being killed? That requirement seems too weak. It would be wrong to shoot George without positive consent from him (if he's capable of giving it) or presumed consent or proxy consent, I think.

A final option (Frank Beckwith suggested something like this): Perhaps the pro-choice opponent can say that having (actually or ideally) desires, or desires of a certain sort, is part of what makes one a person, and so it is not the case that killing someone who has the desire for life is wrong because it goes against that desire, but what makes it wrong to kill is that it is a person who is non-consensually killed. If one takes this view, then it seems one gets a completely different account of the wrongness of killing from that given in Part II. It is not the having of desires presupposing future life that makes it wrong for one to be killed (at least if innocent), but, simply what makes it wrong to kill x is that x is a non-consenting person. Her desires are beside the point: only the consent matters here. However, this account of what is wrong with killing is inferior to the Marquis account in Part I. For it fails to show how killing someone is different from doing other things that the person does not consent to, such as patting on the shoulder. Patting on the shoulder may be wrong without consent (though probably not always wrong), but is clearly much less of an evil than killing someone. Nor is it that the victim actually or ideally has ideally a stronger desire not to be killed than not to be patted, or that she more strongly dissents from being killed than from not being patted, since neither of these might be true, at least if we assume that one can rationally desire to be dead.

So it seems to me that it is hard to rescue Part II, and hence the Marquis argument's claim that if a fetus has a future like ours then it is wrong to abort the fetus survives.