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die. That is, there is no difference which depends solely on the |
distinction between an act and an omission. (This does not mean |
that all cases of allowing to die are morally equivalent to killing. |
Other factors - extrinsic factors - will sometimes be relevant. |
This will be discussed further in Chapter 8.) Allowing to die - |
sometimes called 'passive euthanasia' - is already accepted as |
a humane and proper course of action in certain cases. If there |
is no intrinsic moral difference between killing and allowing to |
die, active euthanasia should also be accepted as humane and |
proper in certain circumstances. |
Others have suggested that the difference between withholding |
treatment necessary to prolong life, and giving a lethal injection, |
lies in the intention with which the two are done. Those |
who take this view resort to the 'doctrine of double effect', a |
doctrine widely held among Roman Catholic moral theologians |
and moral philosophers, to argue that one action (for example, |
refraining from life-sustaining treatment) may have two effects |
(in this case, not causing additional suffering to the patient, and |
209 |
Practical Ethics |
shortening the patient's life). They then argue that as long as |
the directly intended effect is the beneficial one that does not |
violate an absolute moral rule, the action is permissible. Though |
we foresee that our action (or omission) will result in the death |
of the patient, this is merely an unwanted side-effect. But the |
distinction between directly intended effect and side-effect is a |
contrived one. We cannot avoid responsibility simply by directing |
our intention to one effect rather than another. If we |
foresee both effects, we must take responsibility for the foreseen |
effects of what we do. We often want to do something, but |
cannot do it because of its other, unwanted consequences. For |
example, a chemical company might want to get rid of toxic |
waste in the most economical manner, by dumping it in the |
nearest river. Would we allow the executives of the company |
to say that all they directly intended was to improve the efficiency |
of the factory, thus promoting employment and keeping |
down the cost of living? Would we regard the pollution as |
excusable because it is merely an unwanted side-effect of furthering |
these worthy objectives? |
Obviously the defenders of the doctrine of double effect would |
not accept such an excuse. In rejecting it, however, they would |
have to rely upon a judgment that the cost - the polluted river |
- is disproportionate to the gains. Here a consequentialist judgment |
lurks behind the doctrine of double effect. The same is |
true when the doctrine is used in medical care. Normally, saving |
life takes precedence over relieving pain. If in the case of a |
particular patient it does not, this can only be because we have |
judged that the patient's prospects for a future life of acceptable |
quality are so poor that in this case relieving suffering can take |
precedence. This is, in other words, not a decision based on |
acceptance of the sanctity of human life, but a decision based |
on a disguised quality of life judgment. |
Equally unsatisfactory is the common appeal to a distinction |
between 'ordinary' and 'extraordinary' means of treatment, |
coupled with the belief that it is not obligatory to provide ex- |
210 |
Taking Life: Humans |
traordinary means. Together with my colleague, Helga Kuhse, |
I carried out a survey of paediatricians and obstetricians in Australia |
and found that they had remarkable ideas about what |
constituted 'ordinary' and what 'extraordinary' means. Some |
even thought that the use of antibiotics - the cheapest, simplest, |
and most common medical procedure - could be extraordinary. |
The reason for this range of views is easy to find. When one |
looks at the justifications given by moral theologians and philosophers |
for the distinction, it turns out that what is 'ordinary' |
in one situation can become 'extraordinary' in another. For |
example, in the famous case of Karen Ann Quinlan, the young |
New Jersey woman who was in a coma for ten years before |
she died, a Roman Catholic bishop testified that the use of a |
respirator was 'extraordinary' and hence optional because Quinlan |
had no hope of recovery from the coma. Obviously, if doctors |
had thought that Quinlan was likely to recover, the use of the |
respirator would not have been optional, and would have been |
declared 'ordinary'. Again, it is the quality of life of the patient |
(and where resources are limited and could be used more effectively |
to save lives elsewhere, the cost of the treatment) that |
is determining whether a given form of treatment is ordinary |
or extraordinary, and therefore is to be provided or not. Those |
who appeal to this distinction are cloaking their consequentialist |
views in the robe of an absolutist ethic; but the robe is worn |
out, and the disguise is now transparent. |
So it is not possible to appeal to either the doctrine of double |
effect or the distinction between ordinary and extraordinary |
means in order to show that allowing a patient to die is morally |
different from actively helping a patient to die. Indeed, because |
of extrinsic differences - especially differences in the time it |
takes for death to occur - active euthanasia may be the only |
humane and morally proper course. Passive euthanasia can be |
a slow process. In an article in the British Medical Journal, John |
Lorber has charted the fate of twenty-five infants born with |
spina bifida on whom it had been decided, in view of the poor |
211 |
Practical Ethics |
prospects for a worthwhile life, not to operate. It will be recalled |
that Lorber freely grants that the object of not treating infants |
is that they should die soon and painlessly. Yet of the twentyfive |
untreated infants, fourteen were still alive after one month, |
and seven after three months. In Lorber's sample, all the infants |
died within nine months, but this cannot be guaranteed, or at |
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