Well Presumably you would not have invited me to give this lecture unless you had thought I was on your side; and this puts us from the start in a situation of intellectual and moral danger. People are inclined to be very tolerant of arguments that seem to support conclusions they already accept.It is easy to think of this fact as just another symptom of the well-known irrationality of our species, but oddly enough, what appears as irrationality is often a sign of a deeper, underlying rationality. When people are careless about facts, or play fast and loose with logic, this is often because they are trying to make it seem (to themselves as well as others) as though various ideas to which they are strongly committed can be made to fit together. Think, for instance, of someone who refuses to give to a charity, asserting (without any investigation of the matter) that charities waste all the money given to them. Pretty obviously, the invented fact is there to allow the person to reach the desired conclusion (not giving money) without having to make an undesirable admission (not being generous).This is a useful thing to bear in mind in any area where there are strong passions. They are breeding grounds for twisted arguments and invented facts, and identifying these not only clarifies the issues and sharpens political argument; it also offers important indications of what the real motivations are. This applies potentially as much to our own arguments as to our opponents’, and provides a method of real progress in moral enquiry. But here I want to concentrate on arguments against euthanasia.And the first thing to do is to qualify the little I have already said. I have referred tosides and the euthanasia debate, andarguments against euthanasia. But this is just where the trouble starts. A moment’s thought shows that the word “euthanasia” is applied to a wide range of actions; not only the ones counted as voluntary euthanasia, but also such things as turning off life support machines, killing defective babies, and not trying to save the lives of people who are senile or badly damaged in accidents.These are all different, and there is no reason to presume they must be morally identical. Inevitably, however, whenever there is a single word people will tend to think of it as denoting a single thing and this is always dangerous. In particular, people who think of themselves as against whatever it is will often pounce on arguments that seem to work against the most troubling cases, and wave them around as if they were objections to all.The first thing to do, therefore, is to pull the issue out of the impressionistic blur produced by the word “euthanasia,” and make sure that each issue is analyzed in its own right. We must make sure that the clearest cases are not weakened by spurious association with more difficult ones. And of course, the other way round. We must not allow any relatively straightforward cases to disguise the difficulty of others.Since this is a voluntary euthanasia society I shall keep to the range of Issues that come up only under that heading.That will be more than enough to be going on with.THE BASIC ISSUE: MAKING SUICIDE POSSIBLESlippery slopes
Two years ago there occurred the much publicized case of Dr. Cox, who eventually gave in to the pleadings of a patient in desperate, terminal pain,and who wanted to die. This led to the usual rush of public alarm. Euthanasia must not be allowed, it was protested, because if we gave doctors the right to kill we should be off on a slippery slope, turning off life support machines, clearing geriatric wards, and moving inexorably towards Hitlerian extermination camps. Hitler is always the bogey at the bottom of the slope; an awful warning to anyone tempted to set out on it. Dr. Cox was forced, like Galileo, to recant.But the issue brought up by this case has nothing to do with allowing doctors to decide whom to kill. It is, quite differently, that of whether people trapped by disability or institutions should be denied the freedom the rest of us have to commit suicide. Many people are simply not able to kill themselves; and it is, incidentally, a striking fact that the very helplessness which makes suicide impossible does itself provide some of the most rational grounds for wanting to die. The present law [British law], which does not forbid suicide, nevertheless ensures that such people must stay alive, because no one else may help them to do what they cannot do alone.But, say the objectors, at this point it ceases to be suicide and becomes killing; and killing is wrong. But once again, it cannot be presumed that everything describable by a single word must fall into a single moral category.Normally we regard it as charitable and generous when people put their own powers at the disposal of the powerless, to enable them to do what they otherwise could not, and we see this as morally quite different from doing the same things against their will. If your aunt whose fingers are crippled with arthritis cannot put the sugar in her tea, and you do it for her, we do not hesitate to distinguish it from malicious tea sweetening.Why, then, if you get the pills she wants to make her escape from life, or manipulate the syringe because she cannot do it herself, should we put this in the same moral category as doing those things against her will? In any other case such a conflation would scream out its absurdity; and so it should in this one.If assisting the suicide of the helpless is killing~ we must insist that there are different kinds of killing, and that this kind bears no moral resemblance at all to murder, or even to justifiable forms of killing without consent.When the matter is put this way, it provides an indication of what really lies behind the objections. When do we say that it is wrong to help other people to do what they want to do, but cannot? Only, surely, when what they want is itself wrong. You would not feel that kindness to your arthritic aunt should extend to pulling poison on her behalf into her neighbor’s tea. Surely, therefore, anyone who thinks it wrong to assist the suicide of the helpless must think suicide itself wrong. Conversely, if the law does not forbid suicide, it has no justification for its seeing the assisting of suicide as different from the assisting of anything else.So we can start the clarification of the issues by resolutely detaching “this most fundamental case–the desperate situation of people who want to die but cannot kill themselves–from anything else to which the label of euthanasia may have become attached. And when this is done, and (obviously most important) proper safeguards are in place to make sure that what is going on really is assisted suicide and not murder, the slippery-slope idea stands exposed for the irrelevance it is. There is no slope. Suicide is not a thing there is any danger of anyone’s getting into a habit of.Making life worth livingNeedless to say, however, that will not be the end of the argument, even when it is clear that the issue is the limited one of freedom to commit suicide. One of the commonest symptoms of deeply rooted attitudes, held not because of the arguments offered in their defense but for other, unstated, reasons, is the speed with which refuted arguments are replaced by others.
The next familiar line of argument is that euthanasia of this sort should not be necessary; that we should instead be making people’s lives worth living, by controlling their pain and making them feel valued. And this argument is a good piece of strategy, because no one is going to rush in and deny that we should be doing these things. It also tends todivert supporters of euthanasia into arguments about the extent to which it is possible to control pain, when what they should really be doing is exposing this maneuver as a fudge of the first order, and a particularly dangerous one. To see this, all that is needed is a steady eye for the point at issue. It is claimed that we should make life worth living for the suffering, andimpliedthat this is a reason for not allowing help with suicide. But how can a claim that something should not be needed be regarded as a reason for saying it should be forbidden? You might just as well say that because all children should learn to read at school, we should prohibit adult literacy classes.If we could reliably make everyone’s life worth living, no one would wantto die, and laws preventing assistance would have no purpose. Conversely, to the extent that they have a purpose,preciselywhat they achieve is to force continuing life on people whose sufferings we have not managed to prevent. The claim that we should prevent suffering is being used to defend a law whose main effect is to perpetuate it.This is a clear case of an argument so outrageously bad that it could not possibly be thought to work by anyone not already convinced of the conclusion on quite other grounds. It seems obvious, once again, that its proponents really disapprove of suicide altogether, but are unwilling to face the fact that this may mean forcing people to remain alive in agony.To put the matter even more starkly, the prevention of suicide achieves nothing for the sufferers, but it does mean the rest of us can I avoid having forced on our attention the knowledge of how many people there are who would rather be dead, and can more easily forget them. I do not think for a moment that that is themotive of the people who argue in this way, but it is the effect. Anyone who really wants to make people’s lives worth living should be glad to allow suicide, as a reminder of the extent of failure.The dangers of coercionThe final objection I want to consider against allowing assistance with suicide is increasingly common, and widely accepted as conclusive. It is that if euthanasia were allowed, we could never be sure it was truly voluntary. Relatives and doctors might make people feel unwanted, or even (though I have not actually heard this suggested) leave them in more pain than necessary to coerce them into choosing death. And even if this did not happen, people might still feel burdensome and under an obligation to choose to go. We must therefore keepthe option closed.This issue is more complicated than the previous two, and there is no quick answer on the euthanasia side. But what can be shown is that the other side is even less entitled to its own quick answer.It is necessary to get the form of the problem clear. We should not be thinking about wards full of old people and wondering what their relations would do if we decided to institute voluntary euthanasia. Rather the question is, for everyone in a democracy, about the kinds of institutions weshould prefer to live by. Would we, individually, choose to live in a society which forbade voluntary euthanasia altogether, to protect ourselves from the risk of being put under pressure to choose it?It is certainly true that making things impossible isone way to prevent our being coerced into doing them. This is a well understood maneuver. On the other hand, it is not one to be adopted lightly. Usually it is absurd to give up an option completely in order to avoid the chance of being put under pressure to use it in a particular way; you would hardly think of giving up the freedom to choose whom to marry in order to avoid the danger of being put under pressure to make the wrong choice. Such decisions can be made only through careful risk analysis, involving estimates of how bad the various possible outcomes are, and how likely they are to come about. How likely is it that our relatives would start putting
pressure on us? Is it a severe enough danger to justify the sacrifice of the freedom to opt out if we are in terrible pain?There is no algorithm for calculations of this sort, but a few comments may help to put the matter in perspective.First, although this line of argument does not seem to be motivated by a straightforward opposition to suicide, I think in fact it must be. Anyone who can see the anti-euthanasia conclusion as immediate and obvious, rather than as difficult and to be reached only after much agonizing, is willing to give up the suicide option to avoid any risk at all that anyone will be put under pressure to take it. No one who thought the option intrinsically valuable could give it up so quickly. And for anyone who would like to keep it, the case for giving it up need seem nothing like as strong.For one thing, it is not at all obvious that allowing suicide will make it more likely that people are put under pressure to take that option. It could work quite the other way: Relatives and hospitals might become so afraid of being accused of driving anyone to euthanasia that they become assiduous in their attempts to prevent it. Until we try, we shall not know.Furthermore, there is no reason to think of these probabilities, whatever they are, as fixed. We could try to influence them in various ways. Perhaps hospitals might deliberately develop a culture in which euthanasia was regarded as a failure, and patients were persuaded not to choose it. (Though that would, of course, create pressures the other way.)And, finally, a most important point. If different people might have different preferences in this context, we should consider whether it might be possible to let people choose their own risks. Even if suicide were allowed, I do not see why people who did not want the risk of pressure could not (say) sign an anti-suicide pledge, and join societies and churches committed to the repudiation of this option.That kind of possibility does, indeed, seem to me to settle the issue. But even if it does not, it still seems clear that we need not be bullied by what is widely regarded as a knock-down argument against euthanasia, but which, without the hidden presupposition that suicide is never morally acceptable, is nothing of the sort.SECOND ISSUE: EASING DEATHSo far I have discussed only one part of the voluntary euthanasia issue, that of making death possible for people who cannot choose to die, and considered three common arguments against it. But of course there are other issues, and a closely related one is that of making death pleasant. For many people suicide is not actually impossible, but can be achieved only by painful or distressing means. Many of us think everyone should have access to the means of dying painlessly.The usual objection is that this makes suicide too easy, and people will do away with themselves during passing bouts of depression. That, however, confuses ease and pleasantness. Most of us probably think there should be a waiting time, perhaps longer for young people than old, and other safeguards. But that is quite compatible with making death painless for anyone who can show they really want it.But still it will be said, to make death less unpleasant is to make it more attractive, and more people will choose it than otherwise would have done. Surely we should keep death unattractive in order to discourage suicide?If this sounds plausible, consider it in more detail. Think of life as measured against a scale of satisfaction, and each person as fixing a point on that scale at which life becomes not worth living. If we
want to prevent people choosing suicide when they reach that point, there are two ways of doing it. One is to make life better, so that it rises again above the crisis point. The other is to make death so unpleasant that things have to get even worse before death becomes an attractive option. Either of these, therefore, would prevent suicides.But why, exactly, do we want to prevent suicide? What is bad about it? Some people think it bad in itself, and probably as sinful; others think the ground for regret is that anyone’s life should be not worth living. If you want to prevent suicide for this second reason, only the first way of proceeding–improving people’s lives–makes any sense. Preventing suicide by making death unpleasant does not make anyone’s life one scrap more worth living; it just gives them a reason to live with more misery.In other words, the now-familiar background assumption appears again, in yet another disguise. To oppose allowing people the means of painless suicide is to regard suicide as bad in itself, and to be discouraged whether life is worth living or not.THIRD ISSUE: ADVANCE DIRECTIVESFinally, many of us would like to be able to specify that if we became so ill or damaged that we could not make any wishes known, we should be actively killed. This is quite different from saying thateveryone in a coma or irreversibly damaged by a stroke should be done away with; that is related, but it needs a separate argument. Here the claim is only that we should be allowed to decide for ourselves. What reason could anyone offer for saying that weshould not?The usual line of argument here is that we can never be sure. We cannot be sure that the coma will not be emerged from, or that a new treatment will not be found. Furthermore, we cannot be sure about the state of mind of someone unable to communicate, and who may have undergone a change of mind since writing the directive.All these arguments, however, make the same presuppositions. They all presuppose that in case of doubt we should err on the side of caution, and that caution means not killing unless we are absolutely certain. Since we can never be certain, we should never risk killing.But this is another case where risk analysis is needed, and many of us would assess the situation in quite the opposite way. The worst imaginable outcome is not being killed when we might (conceivably) have changed our minds but be unable to say so; far worse than that would be theunutterable horrorof being trapped for years in a dreadful, degrading existence, unable even to communicate a wish to escape. The same applies to the risk of dying when a cure might be found, as compared with that of being kept alive and its not being found.This seems to me so clear that it seems also relevant to the involuntary euthanasia issue: Surely in any case of doubt it would be better to risk killing quickly someone who might not want to die than to leave in such an appalling existence someone who might want to. But the voluntary case seems quite unanswerable, because this is not a matter that needs to be settled for everybody or nobody. It is something that people can choose for themselves, and it seems quite outrageous that they should not be allowed to.Once again, the opposition to this kind of euthanasia clearly has nothing to do with respect for choices and fears about mistakes. It must arise from a general conviction that no one should be able to choose to die; or at least, to have anyone else’s assistance in doing so.So it seems to me that all the standard arguments against the different forms of voluntary euthanasiaare not only seriously mistaken, but mistaken in ways that could not deceive anyone in neutral contexts. The situation seems to be the one I described at the outset. Deep feelings that these things are wrong accompany a wish to justify them (at least in public) in terms that seem more humane and
enlightened than a simple opposition to suicide, and the arguments are a valiant attempt to reconcile the irreconcilable. If this were better understood, I think it might be much easier to overcome the continuing resistance to voluntary euthanasia.DOCTORS AND DYINGFinally, one note on a rather different matter. Advocates of euthanasia often seem to take for granted the idea that it can be justified only by terminal illness and intolerable pain. But this is odd,because there could be innumerable good reasons for wanting to die. Hopeless disability, simple old age that made impossible all the things that gave life purpose, or just not wanting to waste on a nursing home the money you hoped to leave to your children or VESS (Voluntary Euthanasia Society of Scotland) , I might make it perfectly rational to wish to die. Why should we think some reasons, but not others, adequate for euthanasia?My suspicion is that the idea of confining voluntary euthanasia to cases ofterminal illness arises partly from political realism, but even more from assumptions about where doctors fit into all this.A common line of argument against euthanasia is that doctors should be committed to preserving life. Other people say that their duty of care should be understood more broadly than this, and that there is a duty to end suffering, even by death, when life is declining and has nothing more to offer. But even these people rarely go so far as to say that doctors should help anyone who simply wants to die.Obviously any society needs to decide the use its doctors may make of their powers. However, there is no reason why their role, whatever it is, should define the boundaries of euthanasia. There are two aspects to being a doctor: technical knowledge, and a set of commitments about the use that may be made of it. But these two are separable; and even though we might agree that there were certain things doctors should not do, that would not be a reason for saying that no one else should do it either. The means of suicide could be available elsewhere.If this possibility is widely overlooked, that may be another consequence of the way the euthanasia issue has been seen as the question of what doctors should be allowed to do to people. Voluntary euthanasia is anyway not about allowing doctors to decide when anyone shall die, but about the permissibility of providing technical help for people who are not adequately equipped themselves. But if technical help is the issue, it need not come from doctors at all and voluntary euthanasia need not be limited to cases of pain and imminent death.We can see the issue for what it is: the idea that an essential element of a good life is the freedom to leave it in peace and with dignity.*Janet Radcliffe Richards is alecturerin philosophy in England on the central faculty of the Open University, where she specializes in ethics, philosophy of science, and applied philosophy. The essay reprinted here was published in theNewsletter of the Voluntary Euthanasia Society of Scotlandin September 1994. This essay was originally delivered as a lecture directed toward a live audience.