The Complexity of Non-Voluntary Euthanasia

Dr Howard Martin has been in the news recently for having told the Telegraph that he intentionally shortened the life of a number of his patients.  On the face of it, his actions seem to be fairly straightforward, and to lend some kind of support to the fears of those who think that any easing of the law on assisted dying will put (at least some) patients in danger.  In his interview, he said that he

hastened the final moments of some of his patients.

“I just promised people that they could die free from pain and with dignity[.  ]Most times patients and relatives were of an accord and wanted the patient to be free from pain and have dignity. In that scenario, I would take control by keeping people asleep until they had passed over.

“I twice helped people die, not because they wanted to die but because they had such dreadful suffering. Everyone else wanted to [die] – they could make that choice.”

There is something slightly… oh, I don’t know… not exactly sinister about his words, but… well, somewhere between “sinister” and “iffy” – and, as I said, I can see how they could be taken to lend evidence to the fears of the anti-Assisted Dying (AD) lobby.  Not that I’m accusing Martin of acting in anything but good faith – a couple of shills have already started mentioning Shipman in this case, and we’re a million miles from there.  Nevertheless, people can, in good faith, make all kinds of moral blunders, and there’s part of me that worries that this is what Martin may have done.

I’ve not been exactly reticent on these pages in publicising my views on voluntary euthanasia and assisted dying.  There’s no need to rehearse them here.  Having said that, we should note that Martin’s actions tell us no more about the wisdom of legalising AD than did Shipman’s.  Given that the law plainly didn’t stop either of them doing what they did, altering the law won’t obviously change things for the worse – unless you think, bizarrely, that there’s a cohort of medics out there dying to go on a killing spree if only it weren’t for that pesky illegality.  I don’t believe that there is any such person who exists.

Nor is there really any need to say much about “involuntary euthanasia” – I put that in scare-quotes simply because there’s no such thing: euthanasia implies, at the very least, a killing that is motivated by a concern for the best interests of the person killed – and if a person is saying that, really, they’d really rather not be killed, then that looks pretty much like a deal-breaker.  If they evaluate their life as being worth living, then it is worth living; to kill them is not, in this case, euthanasia.  Bluntly, involuntary euthanasia ought not to attract the attention of ethicists any more than seven-sided triangles ought to attract the attention of mathematicians.

Things are a bit more complicated when it comes to non-voluntary euthanasia (NVE).  For the sake of clarification, this is deliberate and beneficent killing that is neither wholly for nor wholly against the patient’s wishes – perhaps because the patient is not in a position to have any wishes on the matter.

There are times, for example, when killing could be preferable to letting die, and NVE might present itself as a morally desirable option.  Imagine that someone is universally agreed to be irreversibly and severely brain-damaged, and is being kept alive with a ventilator.  There is some evidence of responsiveness to physical stimuli, but no evidence of any higher brain functions, sense of self or anything like that.  Something goes wrong with the machinery, and the ventilation tube has to be withdrawn.  It is apparent that the tube cannot be reinserted without causing great distress – perhaps not without surgery – and reinsertion would be very dangerous anyway; it is also clear that, without it, the patient will die of asphyxiation.

So the medics have an unenviable dilemma: do they attempt to save a life – a life that some would say is merely and irreversibly biological rather than biographical at this stage – for a short time, and in doing so run the risk of causing significant harm, at least some of which will be directly experienced by the patient?  Or do they withhold further intervention?  Current law would allow for the second option.

But it so happens that the medics have nearby a syringe full of a powerful neurotoxin that will kill the patient painlessly within a couple of seconds.  There’s a good number of people who’d argue that they ought to administer it: that there’s something morally perverse about allowing a person to die of asphyxiation but not killing them more quickly.  This would be non-voluntary euthanasia, and plausibly defensible.

Slightly more graphically, we might imagine someone who is trapped in a burning vehicle, and who cannot be cut out before being burned to death – you know this for sure.  It so happens that this person is currently unconscious, though may not remain so, and that you have a loaded pistol.  Here, again, I think that there’d be a good case to be made that you either could or ought to kill the motorist to save him from a worse death.  Again, NVE.

Now, let’s go back to Martin, and the penultimate and peripenultimate sentence of the quotation above.  Here they are again:

I would take control by keeping people asleep until they had passed over.  I twice helped people die, not because they wanted to die but because they had such dreadful suffering.

I’m going to assume that this is a case of NVE.  But it seems different from the examples I just gave.

The first possibility for explaining the difference is that there’s something starkly paternalist about it: the claim seems to be not that Martin couldn’t understand how someone would find such-and-such a life tolerable, but that he took it upon himself to ensure that the patients in question wouldn’t have even to make that kind of judgement.  The moral attention here would be on the usurpation of choice in patients who may or may not have agreed that their life was intolerable, but who never got the chance.

The second possibility goes something like this: there are situations in which the future life to be lived can reasonably be expected to be worse than death.  In those circumstances, I think that NVE might be permissible – that’s why it’s OK to shoot the driver in the burning vehicle.  Of course, we have to be careful with the decision, but the principle stands.  (Moreover, , any indication that the person who stands to die is actually willing to take his chances after all is enough to turn NVE into involuntary “euthanasia”.)

But there are other situations in which we cannot reasonably expect the future life to be worse than counterfactual death – at least, not with any certainty.  In that case, to kill someone non-voluntarily is to deprive them of a future; and I can see how one might mount an argument about the wrongness of this.  It’s tricky, though: the dead don’t know that they no longer have a future, so it looks as though the emphasis has to be on the practitioner – we need to be able to generate an a priori rule with the required normative clout.  I guess that there are versions of deontology and virtue ethics that might be able to provide what’s needed here.  Maybe rule-consequentialism, too, if we can stop it collapsing into non-consequentialism.

Now, the future that patients would otherwise have is likely to be richest in those with more-than-minimal consciousness; and for those with no consciousness and no prospect of it, we could perhaps say that they have no future at all – we might say that there’s not much point to a life that’s all biology and no biography.  But even if there is no point to such a life, it doesn’t follow that there’s a reason to end it.  (I’m leaving aside considerations like resource drain, the strain on families, and so on, for the sake of simplicity.)  If a patient is utterly insensible, there’s no reason to live – but to kill involves a positive intervention, and there’s no reason for that, either.  Hence to kill looks to be arbitrary.  But there’s something morally iffy about arbitrary actions – so we ought not to kill by NVE here.

(Perhaps the reasoning in this case is a bit Kantian – a bit like his argument against cruelty to animals or inanimate nature in The Doctrine of Virtue.  I’ve never been wholly happy with that – it seems a bit slippery-slopey – but there you go…)

Anyway: the point of this rather rambling post is this: NVE is a lot more complex than it seems at first.  It might even be the case that there’re several kinds of NVE, each of which needs independent moral consideration.  It’s only on the basis of such careful consideration that there’s any chance of bringing clarity to the AD debate.

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