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The Right to Die
Peter Singer is Professor of Bioethics at Princeton University. His books include Practical Ethics and Rethinking Life and Death. His most recent piece on Webdiary was Pigs, Calves, and American Democracy
by Peter Singer
On December 21, an Italian doctor, Mario Riccio, disconnected a respirator that was keeping Piergiorgio Welby alive. Welby, who suffered from muscular dystrophy and was paralyzed, had battled unsuccessfully in the Italian courts for the right to die. After Riccio gave him a sedative and switched off the respirator, Welby said "thank you" three times to his wife, his friends, and his doctor. Forty-five minutes later, he was dead.
Welby’s request to die was widely publicized in Italy, where it led to heated debate. At the time of writing, it is unclear whether Riccio will be charged with any offense. At least one Italian politician has called for his arrest on a charge of homicide.
Welby’s death raises two questions, which need to be distinguished. One is whether a person has a right to refuse life-sustaining medical treatment. The other is whether voluntary euthanasia is ethically defensible.
A patient’s informed consent should be a prerequisite for all medical treatment, as long as the patient is a competent adult in a position to make a decision. Forcing medical treatment on a competent adult patient who does not want it is tantamount to assault. We may think that the patient is making the wrong decision, but we should respect his or her right to make it. That right is recognized in most countries, but not, apparently, in Italy.
Even the Roman Catholic Church has long held that there is no obligation to use "extraordinary" or "disproportionate" means to prolong life – a view reiterated in the "Declaration on Euthanasia" issued by the Sacred Congregation for the Doctrine of the Faith and approved by Pope John Paul II in 1980. That document states that to refuse a burdensome medical treatment "is not the equivalent of suicide." On the contrary, such a refusal "should be considered an acceptance of the human condition, or a wish to avoid the application of a medical procedure disproportionate to the results that can be expected, or a desire not to impose excessive expense on the family or the community." That description applies well to Welby’s decision. On this view, Riccio was doing what anyone should have been prepared to do for Welby, who was paralyzed and unable to implement his refusal of a burdensome medical treatment.
If the Welby case falls on the right side of the line drawn by Roman Catholic doctrine, the deeper question is whether Church doctrine draws the line in a place that makes sense. If an incurably ill patient can refuse burdensome treatment, knowing that this refusal will mean his or her death, why should an incurably ill patient who is not being kept alive by any medical treatment, but finds that the illness itself makes life burdensome, be unable to seek assistance in escaping that burden?
Defenders of Catholic teaching would answer that in the latter case, the patient intends to end his life, and that is wrong, whereas in the former case, the patient merely intends to avoid the additional burden that treatment brings. Death is, of course, a foreseeable consequence of avoiding that burden, but it is a byproduct that is not directly intended. If the patient could avoid the burden and yet continue to live, that would be his choice. Welby should not have been helped to die, they might argue, because he expressly said that he wanted to die, not that he wanted to avoid a burdensome treatment.
This distinction is dubious. In both cases, the patient knowingly chooses a course of action that will lead to her or his death, rather than an alternative course of action that would have led to a longer but burdensome life. By focusing on the narrower intention to refuse burdensome treatment, rather than the broader implications of the choice, the Roman Catholic Church is able to avoid the inhumane implication that patients must always accept life-prolonging treatment, no matter how painful or costly such treatment may be. But it does so at the cost of rendering incoherent its own vigorous opposition to assisted suicide and voluntary euthanasia.
Many countries recognize a legal right to refuse medical treatment. But only in the Netherlands, Belgium, Switzerland, and the American state of Oregon are physicians permitted to assist a patient in ending his or her life by means other than withdrawing life-sustaining medical treatment.
The Netherlands, in particular, has been subjected to a relentless campaign of vilification. Critics allege that the legalization of voluntary euthanasia has led to a breakdown of trust in the medical profession and all sorts of other dire consequences. But if these allegations are true, no one has told the Dutch. Despite a change of government in the Netherlands since voluntary euthanasia was legalized, no effort has been made to repeal the measure. There is simply no public support for such a move.
The Dutch know how voluntary euthanasia is practiced in their country, they know that legal euthanasia has improved, rather than harmed, their medical care, and they want the possibility of assistance in dying, if they should want and need it. Isn’t that a choice that everyone should have?
Copyright: Project Syndicate, 2007.
www.project-syndicate.org
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Life, not as some would know it.
Malcolm, enough legal bullshit mate. You should know better than any of us that laws are temporary. There is no God, so who decides on life or death? Humans who are ignorant and create law to limit us?
Many do need that limiting, but it limits us all, as Bin Laden has so ably demonstrated. No truck with him, but his strategy is working big time. The US has exposed their vulnerability by entering a war they could never "win". Button at the ready, I'm afraid. Let's just hope it's pointed the right way. Being not here.
Democracy cannot be imposed, anywhere. It will fail in I wrack, at least until the three peoples work together. I see a future three countries over there. One or two maybe even democratic, but not imposed. Al Sadr can't wait to rule and wreak revenge. Get out George. JWH will stay and not "cut and run". I wish he would go over and do just that. Avoids euthenasisa, yes?
In a civilized society it must be those who suffer endlessly who choose, as it was briefly in Darwin. Pre Howard's hysterical reaction. Take guns from honest citzens and leave criminals with them. Just brilliant. I'm sure you'd disagree with JWH on that.
If you don't see the relevance of my comments and don't stoop to a response to me, I'll understand. We are mere mortals Malcolm. Unlike yourself apparently. Bait dangled, come on down.
As usual Margo's words are spot on to me. Unless one has felt that endless physical or mental pain, I'd suggest you have no right to continue imposing your silly beliefs on those who have been there.
And still are. Families can influence such decisions but either way it happens, legally or illegally. Why so many road deaths. Suicide is a big part of that in lieu of a peaceful drug induced passing, hurting no innocent driver(s).
Yes there is the risk of the lunatic religions and nasty people misusing such change, but it didn't happen in the NT so I'm happy with it. And, to be frank, there have been many times when I prayed (no response) for an end but didn't have the guts to exit. I know the damage that would cause to my family, their families and so, over generations.
And no doubt some here who also wished I'd done the deed.
A conscious decision though is acceptable as reasons are known, blame and guilt do not continue forever although sorrow does.
Let's leave God where he belongs. In the playground for those who need an imaginary friend.
Jenny, I can only sympathise with your dilemmas. Religious beliefs are tough to beat but we all can do so if we really search and think deeply enough. Who's right? I don't know obviously.
Here's a thought I wrote on another thread for the religious minded.
If such are expecting a messiah to return, how would he or she do so? Tardus? Miracle?
Ask yourself this. Would any know if such a messiah was here today? I'd guess you would all ignore and deride him or her if they did exist. Even if they told you who they were.
Of course there is no such messiah but, again, ask yourself this. Have you ever thoguht you may have met, spoken to or known such a messiah who didn't choose to reveal themselves? Again I'd suggest the answer is NO. but all our beliefs are sacred and should be protected if it gives security or peace. I just don't need that Neanderthal belief anymore as, much as I wanted it to be real, it isn't.
Buddhism is the real go. Personal, spiritual peace for all who seek it. Again, check out the link I gave on the other religious thread.
Fiona, really would like your comments on the MP thread.
Enough 2 Party barracking.
A physician's reply
Fiona: As before,this comment is by a regular who wishes to be anonymous on this one.
If I know my medicine - dimorphine (aka heroin) is prescribable. I have prescribed it.
"hapless cretin destroys not only his own case but his entire livelihood and probably that of his family unto the third generation."
Clearly you have not seen a suffered death.
Life?
I have had an eventful life. I had been near death, or in situations that I ‘was lucky to have survived’ more than a few times before I turned 21.
In the days that I drove fast cars, very fast on what, in this country people would consider ‘very dangerous roads’, my prayer was that if I ever made a mistake I wanted to be dead before those misguided people who would attempt to keep my body ‘warm’, got hold of me. My clear instructions to family were that I was never to be ‘kept alive’ unless there was a real prospect of total recovery.
Both my younger brother and I accepted that as we drove as we did, that it was our responsibility to never involve another vehicle/person. That meant throwing the vehicle off over the side. Yes, I have done so.
I have never had a moments doubt that it is my life, and that I will end it when I no longer feel it is worth living.
Though we were never close, my father at one point, because of his personal circumstances, phoned me to say goodbye, before he shot himself.
I simply said, ‘goodbye’.
Seconds after I had put the phone down, my mother rang to say she had the cops on their way to the farm to get dad. I hung up immediately and phoned dad back and told him that the cops were on their way.
He said, ‘too late, they are here’. From my point of view my father’s life was all down hill from that point on.
If you believe that your life is yours, then you are the sole person with any right to decide what you are going to do with it.
If you do not believe that your life belongs to you, then how can you believe that anything belongs to you?
My body, my life, my decision. I can think of nothing else that is so obvious, so clearly so, so unarguably so!
Physicians View
Margo: This comment is by a regular who wishes to be anonymous on this one.
Defenders of Catholic teaching would answer that in the latter case, the patient intends to end his life, and that is wrong, whereas in the former case, the patient merely intends to avoid the additional burden that treatment brings.
My interpretation is somewhat different to MBD. The pro-life lobby always say words to the effect that palliative care can ease a patient in all cases to a dignified and "natural" death. Not so! Religion (not just catholics) claim that by refusing medical care patients are avoiding the additional burden that treatment brings. What if the patient refuses palliative care because the burden of such care is unbearable? What is the physician to do? Watch as his patient suffers for days and weeks before dying a natural death or offer a level of palliation that will (as someone has already said) bring about a quicker and more dignified death? I know what I would choose and what I have offered.
Moderators - please do not use real name for obvious reasons.
By all means use my name
What is the physician to do anonymous? Do what I have to bloody well do in those gut-renching moments when I put my client in the witness box and watch, virtually helpless, as the hapless cretin destroys not only his own case but his entire livelihood and probably that of his family unto the third generation. Some people just can't be saved. Tough. You just have to grin (or grimace) and bear it.
If, if course, we had a more rational health system where heroin were legalised, the physician's job would be a lot easier. He could just follow his patient's instructions.
Having had half my blood supply replaced a couple of years ago and having my idiot specialist tell my spouse and my mother that I might die, I rather think blood loss is a fairly pleasant way to peg out (maybe the Romans had the right idea after all) but a quick hot shot of heroin also seems a reasonable solution.
Jenny Hume: re Harold
Jenny Hume, re Harold Shipman, it was a joke.
"He (P Singer) is prepared to confront these issues", you say. OK. That's precisely the point I tried to make. I'm too oblique in what I say, aren't I?
At the same time, I come from a time when older people deplored that such as "spastic" children had been allowed to live, and down's syndrome children were left to crawl around the floor and die at an early age. One can't really judge another's quality of life, can one?
It's very odd that the life of such grossly deformed babies is being prolonged in Vietnam. They are obviously not as pragmatic as we are.
Jenny, Christianity is a very broad church, from the dominionists down to such as I; and therefore, in my opinion it is not helpful to raise it in these discussions, unless one chooses to quote from the gospels.
Not oblique really
F Kendall, no, you are not really oblique though one hesitates to take anything said on this issue as anything but serious. It is also not a topic I should try and think about when I am dog tired after a day in the sun.
As far as the mention of Christianity was concerned, that was only to state that having been brought up in the church and all my life taught that the taking of one's own life was a sin, I have never been able to break with that, and I am interested in what arguments those who are not so constrained would make on the issues of suicide and euthanasia. Singer of course is a non believer and we get a reasonable idea of where he stands though he poses a lot of questions with few obvious answers. Those in other faiths are constrained for different reasons. My Buddhist friend would not allow me to do anything that might kill an insect, due to her belief in reincarnation. So Buddhists would have real problems I would think with euthanasia and assisted suicide, though I may be wrong.
No, it is very difficult to judge another's quality of life other than by measuring it against that which we know and value ourselves. Those who can see cannot imagine what it must be like to live without sight, but many do and quite happily. So measuring from our own experience can be very risky.
Yet we do not have the same difficulty when it comes to our favourite pet when we take it to the vet to have it put out of what we perceive is its misery or lack of quality of life. We make judgements about what the quality of life of that pet should be. As Singer pointed out at the time, many animals could be said to have better quality of life and greater self-awareness than say those grossly deformed children in Vietnam. We do not let a dog live under such circumstances. But legally we must leave a child to do so, our only duty, often sadly neglected in some countries, to carry out a duty of nursing care. I doubt that the ethical boundary we face over this could ever be safely crossed. Give mankind an inch and a mile will inevitably be taken.
All too hard. I'm going to bed.
Jenny Hume: "...the
Jenny Hume: "...the doctor had the discretion to increase doses of morphine to levels well beyond that which is normally recommended."
I do hope that his name was not Harold Shipman.
Is Peter Singer trying here, as with his efforts re disabled babies, to frame a legal construct and guidelines around what doctors may well be doing anyway?
The quick and the dead
F Kendall, I hope the power supply holds here. We've been without for most of last three days and on a generator all day courtesy of Country Energy. The sparkies have had a bad week since the big light show.
Singer, through his book Animal Liberation had an enormous impact on my thinking over the years. But as a Christian I have real problems with some of his views regarding euthanasia, and well remember the furore over disabled babies. Yet he is prepared to confront these issues where other philosophers prefer to walk much safer paths.
Recently I read an article about the state of some babies born in Vietnam from parents affected by agent orange. I was absolutely appalled at their situation. I have never had human beings described as so pitifully afflicted. They lay there in their grossly deformed almost lifeless bodies, some blind, deaf and dumb as well. Yet mankind cannot free them from their hell because it is not legally, morally or ethically right to do so. What a fate, no quality of life whatsoever, no legal right to die and no ability to end life for oneself.
I do not know if you have ever worked in a hospital but if you did I think you might get quite a surprise. Decisions in my day were based on whether the person was suffering pain and some conditions are so painful that the levels of drugs needed to alleviate that pain were more than is normally prescribed. I would be very surprised if things have changed much. It may mean that the patient dies on Monday as opposed to Friday, but I do not think that makes the doctor prescribing the morphine a Harold Shipman by any stretch of the imagination.
Malcolm B Duncan, I would have thought that a patient like the one in Italy considered he had a right to die, and clearly some saw it as their duty to make that possible. And did so.
As regards suicide, as a Christian I cannot agree with it, but I wonder why a non believer would really have any difficulty with it, particularly on the part of an adult who wants to end his or her life. A person committing suicide is exercising what they see as their right to die. And surely if duty comes into it, then it is a duty to allow them to do so, as opposed to a duty to help them bring that about which is different. But yes, moral as opposed to legal duty, one has to know the difference.
If it is no longer an offence to take one's own life, then is that not saying we all have the legal right to die, when and if we so chose, if we are able to make a choice in the matter? And legal duty on the part of anyone else in the matter does not really come into it?
All too difficult for me. And when confronted with the reality of someone wanting my assistance to help them die, I simply freaked out. I just hope when I go, it is quick and easy for me and easy on those who have to bury me. Better go get dinner before the power goes again.
RIGHT TO LIFE?
A right to life without pain and disability and without the immense burden arising from the knowledge of a load on the minds and bodies of others, including loved ones? Sorry, it don’t exist.
There is a limit to the effect of a medical profession which cannot sanction exit, but which cannot relieve all, or even some of this pain.
People in end-stage illness, and their carers, have accordingly no rights to life, nor to exit and death.
It’s all too hard. As is living with the savagery of pain and the body’s endless capacity to linger, to attenuate, and to dwell in discomfort and humiliation.
To writhe in the body’s own hell of nerve and sinew and mind.
OK for a saint in a cave somewhere, or a monastic tower, but a bit too k’n awful for the average Jack Cale.
First thing, lets give all the ailing lawyers the chop. Lay on Macduff, and let there be no small bier in the kingdom…..
At the bitter end, there’s always buckets of opiates, for them what can take it, and have the veins.
Frère Jihad Jacques OAM née Woodforde
Morals and the Law
Jenny Hume says “There is a right to life, but there is also a right to die…” Now, I’m going to get all legalistic here. In classic legal analysis, any “right” carries with it a concomitant “duty”: no right, no duty; no duty, no right. Typically, one would analyse the “right to life” as imposing a duty on others to assist someone to remain alive in circumstances where a lack of intervention would inevitably result in death although that is limited. For example it is not necessarily the case that one has to go to the aid of someone threatened by a gun wielding felon although in certain circumstances it would be self defence to attack the felon causing his death in order to protect the putative victim.
There is, however, no “right” to die. If there were, it would impose a duty on others to bring that about. I can conceive of no circumstances, legal or moral where that would be the case.
That brings us to the vice inherent in this article. While entitled “The Right to Die”, Singer’s real argument is contained in his conclusion:
Clearly, he is talking about choice, a moral question, not rights, a legal question. Seems reasonable to me that people should have such a choice but, of course, that includes giving them the choice to opt out (i.e. suicide) at any time.
Let me take issue with one further statement of Singer’s that I find questionable in the extreme:
Rather, while I am no apologist for Roman Catholics or other believers in supernatural powers, I suspect the argument in the latter case would be that because god has not seen fit to end the person’s life, the person should wait divine intervention and spend the remaining time reconciling himself to eternity. I find that so bleeding obvious that I really wonder about the nature of some of Singer’s pronouncements generally.
The right to die
I agree with Singer: the distinction referred to is dubious. I cannot see any real difference in a terminally ill person making a decision not to accept further medical treatment, (as some cancer patients do for instance in rejecting further chemotherapy) to a person requesting that artificial means of keeping him or her alive be discontinued. I believe people who are terminally ill, or whose quality of life is so appalling, do have the right to die if they so wish, or at least, not to have their lives prolonged by medical intervention. This man wishes should have been granted with no recriminations for anyone involved.
To switch off life support where the patient cannot indicate their wish in that regard does pose dilemmas, but it can and does happen with the consent of immediate family. Where there is no consensus by the family there can be years of legal argument, the stress of which to all concerned would be terrible.
In the days when I was a nurse I was aware that the doctor had the discretion where pain was severe in a dying patient to increase doses of morphine to levels well beyond that which is normally recommended. When the body is shutting down, high doses of morphine will, I understand from my observations (though this is all a long time ago), bring death on earlier than expected.
But these days people often understandably elect to die at home, and can in fact under palliative care supervision regulate their own pain medication. That dying may take weeks of even months, putting enormous emotional pressure on those closest to them. Probably one of the most distressing experiences in life is to be asked by a dying loved one to actively assist in the ending of that person's life. I was put in that position once, and having to say no nearly put me in my own grave. I would venture to say that such a request often comes without warning and one is never prepared for it. I have lived ever since with the feeling that, in not granting that wish, I failed that person I loved so much. And believe me, it is not an easy thing to live with.
We need as a society to decide where the line in the sand is to be drawn. There is a right to life, but there is also a right to die, and I think we should have more say in that than we have now. My mother made it clear before she died that she was not to be resuscitated if she had a heart attack. We could all start by putting down in writing our instructions under given circumstances on such matters. That at least takes some of the pressure off family members and provides some guidance for our doctors.
Burdens and pressures
Whether or not voluntary euthanasia is defensible is one question.
The extent to which those disabled by illness or age to the extent that they might feel (or be told) that they are a burden to others, and might therefore be pressured to end their lives, is a different but relevant issue.