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).

Logically complex intentions

In a paper that was very important to me when I wrote it, I argue that the Principle of Double Effect should deal with accomplishment rather than intention. In particular, I consider cases of logically complex intentions: “I am a peanut farmer and I hate people with severe peanut allergies…. I secretly slip peanuts into Jones’ food in order that she should die if she has a severe peanut allergies. I do not intend Jones’ death—I only intend the logically complex state of Jones dying if she has a severe peanut allergy.” I then say that what is wrong with this action is that if Jones has an allergy, then I have accomplished her death, though I did not intend her death. What was wrong with my action is that my plan of action was open to a possibility that included my accomplishing her death.

But now consider a different case. A killer robot is loose in the building and all the doors are locked. The robot will stop precisely when it kills someone: it has a gun with practically unlimited ammunition and a kill detector that turns it off when it kills someone. It’s heading for Bob’s office, and Alice bravely runs in front of it to save his life. And my intuition is that Alice did not commit suicide. Yet it seems that Alice intended her death as a means to saving Bob’s life.

But perhaps it is not right to say that you intended your death at all. Instead, it seems plausible that Alice intention is:

1. If the robot will kill someone, it will kill Alice.

An additional reason to think that (1) is a better interpretation of Alice’s intentions than just her unconditionally intending to die is that if the robot breaks down before killing Alice, we wouldn’t say that Alice’s action failed. Rather, we would say that it was made moot.

But according to what I say in the accomplishment paper, if in fact the robot does not break down, then Alice accomplishes her own death. And that’s wrong. (I take it that suicide is wrong.)

Perhaps what we want to say is this. In conditional intention cases, when one intends:

2. If p, then q

and p happens and one’s action is successful, then what one has contrastively accomplished is:

3. its being the case that p and q rather than p and not q.

To contrastively accomplish A rather than B is not the same as to accomplish A simply. And there is nothing evil about contrastively accomplishing its being the case that the robot kills someone and kills Alice rather than the robot killing someone and not killing Alice. On the other hand, if we apply this analysis to the peanut allergy case, what the crazy peanut farmer contrastively accomplishes is:

4. Jones having a peanut allergy and dying rather than having a peanut allergy and not dying.

And this is an evil thing to contrastively accomplish. Roughly, it is evil to accomplish A rather than B just in case A is not insignificantly more evil than B.

But what about a variant case? The robot is so programmed that it stops as soon as someone in the building dies. The robot is heading for Bob and it’s too late for Alice to jump in front of it. So instead Alice shoots herself. Can’t we say that she shot herself rather than have Bob die, and the contrastive accomplishment of her death rather than Bob’s is laudable? I don’t think so. For her contrastive accomplishment was accomplished by simply accomplishing her death, which while in a sense brave, was a suicide and hence wrong.

A difficult but important task someone should do: Work out the logic of accomplishment and contrastive accomplishment for logically complex intentions.

From suicide to slavery

I've been thinking about an argument with this logical form:

1. If suicide is permissible, then slavery is permissible.
2. Slavery is not permissible.
3. So, suicide is not permissible.

Of course, the most controversial premise is (1), though I could also imagine a defender of suicide denying (2) in the case of voluntary enslavement. One reason to accept (1) is something like this:

4. If suicide is permissible, then we have ultimate authority over our own lives.
5. If we have ultimate authority over our own lives, then it is permissible and valid for us to sell ourselves into slavery.
6. If it is permissible and valid for us to sell ourselves into slavery, then slavery is permissible.
7. So, if suicide is permissible, then slavery is permissible.

By "valid", I mean that the sale would actually work: that authority over our lives would be transferred to another. The notion of "ultimate authority" is rather foggy and I think (4) and (5) can be questioned. But I still think it's an argument worth developing, as all three premises (4)-(6) have some plausibility.

Another line of thought in favor of (1) is:

8. If suicide is permissible, it is permissible and valid to deputize another to unconditionally kill one.
9. If it is permissible and valid to deputize another to unconditionally kill one, it is permissible and valid to deputize another to kill one at will.
10. If it is permissible and valid to deputize another to kill one at will, then it is permissible and valid to sell oneself into slavery.
11. If it is permissible and valid to sell oneself into slavery, then slavery is permissible.

Here, valid deputization is a deputization that actually succeeds in giving the other the requisite authority. The thought behind (10) is that if one give life-and-death authority over oneself to another, one can a fortiori give the other kinds of authority that define the master-slave relationship.

Suicide can be murder

Joe thinks chess is an evil game and creates a killer robot tasked with killing the greatest chess player on earth, whoever it might be. The robot succeeds with the task. Joe is clearly a murderer, not merely an attempted murderer. But suppose Joe is the greatest chess player on earth, though he had no suspicion of this fact. Then Joe has committed suicide. And is a murderer. Hence a suicide can be a kind of murder.

(I actually think suicide is generally murder. But that's a stronger claim.)

Murder and injustice

Not every kind of killing is a murder. Only an intentional killing is a murder. And not every intentional killing is a murder--just killing in a just war isn't murder. Only a wrongful intentional killing is a murder.

But not every kind of wrongful intentional killing is a murder. Jim takes a vow of non-violence, is drafted into the military notwithstanding the vow and intentionally kills in a just war in a way that is wrong due to violation of the vow (in some cases it might be that the needs of defending the innocent could override the vow, but stipulate that this isn't one of those cases). This intentional killing is a vow-breaking rather than a murder. Samantha is a police officer who shoots down a terrorist shooter who is on a rampage. However (and Samantha knew this), this terrorist is a crazy scientist who has just discovered a cure for a medical condition that kills millions, a cure that he was going to share after murdering ten people. Killing the scientist is wrong, but it's not a murder. Frederick is an executioner executing a duly convicted person who clearly deserves death, but this is a case the death penalty is impermissible for reasons other than justice (say, because there is a less violent way to protect society, which according to Evangelium Vitae implies that the death penalty is wrong). Martha intentionally kills an unjust aggressor in a war where her side meets some but not all the conditions of a just war: there is just cause, but the condition of reasonable expectation of success is not met.

In the above cases, the intentional killing is wrong but for reasons other than justice to the person killed. Indeed, in at least the cases of Jim and Samantha, the person being killed isn't being wronged at all.

I hypothesize that an intentional killing is a murder only if it is wrong as an injustice to the person killed. But this condition is still not sufficient. Suppose Jim instead of taking a vow of non-violence promised Patricia that he would never do anything to physically harm her, unless it was his moral duty to do so. And now Jim faces Patricia in a just war, under circumstances such that apart from the promise it would be permissible but not obligatory for him to kill her, and with the promise it is impermissible for him to kill her. Killing Patricia would be unjust to her, but the injustice is that of breaking a promise to her, rather than that of murder.

It's looking to me that murder is an intentional killing that is wrong due to a particular kind of injustice to the person being killed. It is difficult to specify the particular kind of injustice in a non-circular way, though.

Corollary: If suicide is a form of murder, then it is possible to be unjust to oneself.

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.

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.)

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.