Book Review: Euthanasia Examined

Also known as the Walton Report. Excerpts of this report comprise Chapter 9 of Euthanasia Examined, ed. Keown John See also When Death is Sought: Assisted Suicide and Euthanasia in the Medical Context, New York State Task Force on Life and the Law (1994) and Euthanasia, Aiding Suicide and Cessation of Treatment, the Law Reform Commission of Canada, Report 20.

The propositions, as opposed to commentary on some of them, will be set in bold face.

See Euthanasia Examined, p.98. Hereafter page references to this volume will be found in parenthesis in the text.

See note 14 below.

Gormally is citing Airedale NHS Trust v. Bland [1993] Appeal Case 789.

Stuart Hornett gives an ethical and legal analysis of advance directives in Chapter 17 of Euthanasia Examined. Common law, he claims, recognizes, in principle, the two basic concepts underlying advance directives, viz., that such a patient may refuse life-sustaining treatment even if it results in death and that such a decision may take an anticipatory form and will bind a patient's doctor in the same way as any other competent decision. The courts seem to have accepted that a decision made by a competent patient is sacrosanct and may not be impugned for being unethical, v.g., by being suicidal or by abdicating responsibility for dependent third parties. Hornett is in favor of having directives inform but not bind the doctor. His reasons are the potential clinical problems occasioned by advance directives, the questionable premises upon which anticipatory decisions are given effect and the danger of ill-informed refusals being made by individuals.

In Chapter 13 of Euthanasia Examined Joseph Boyle seeks to refute those who argue that it is always morally obligatory/permissible to withdraw tube feeding from patients in PVS because such treatment provides no benefit or because the burdens of treatment are always disproportionate to the benefits. It does not follow that it is never permissible to withdraw tube feeding. There are situations where one can withdraw treatment without intending the death of the patient and without considering the patient to be a nobody. Circumstances of the particular case will be the decisive moral consideration in arriving at the moral judgement about the level of care to be provided to any patient in PVS. “The condition itself and the essential requirements for caring for people who suffer from it are not sufficient to show either that withdrawing food and water is permissible or required or that continuing to provide them is required”. (198) The relevant moral rule is that “we must do what we can to care for patients in PVS, and to maintain the human ties with them which show our respect for their human dignity”. This means that “a level of care which can be provided compatibly with other responsibilities is morally required”. Needless to say, Boyle comes out of a framework of moral and anthropological thinking that is foreign to Jennett. We shall have much to say about this later.

Chapters 8, 9, and 10 of Euthanasia Examined speak to how the law ought to address the specific moral issue of euthanasia. Gormally's chapter (10) is the most philosophically grounded of these essays. It contains a sketch and defense of the moral principle that ought to inform the law on euthanasia (and other human life issues).

Harris makes no distinction between an organically whole living human body with its vital functions and functioning and a body that has ceased to function as an organic whole but which nonetheless contains parts which function in isolation often only with the help of a machine.

Harris does not explain how euthanasia is compatible with respect for the valuing self given that when the evaluated life is destroyed the valuing self is destroyed as well. How is deliberate destruction of what is of “intrinsic, cosmic importance” (16) compatible with respect for it?

What if I should decide to de-value the lives of other human beings? Harris does not appear to be able to exclude murder in that situation. He might perhaps counter that what counts is not my valuation of other peoples’ lives but their own autonomous valuing. But why should I and my autonomous will respect the autonomous valuing of others? Harris does not explain why I, who am ex hypothesi the creator of values, should value positively the value projects of others. Harris plays down the implications for others of his view that “[p]ersons who do not want to live are not on this account wronged by having this wish granted, through voluntary euthanasia for example”. (9) To be sure, it is consistent with Harris's understanding of personhood and value that “[n]on-persons or potential persons [v.g. fetuses, infants, patient in PVS] cannot be wronged in this way because death does not deprive them of anything they can value. If they cannot have that wish to live, they cannot have that wish frustrated by being killed”. (9) But do people whom even Harris would consider genuine persons (viz. those who can wish or not to live) escape the logic of his position? In other words, can Harris's view rule out non-voluntary and even involuntary euthanasia? The considerations above suggest that he cannot.

This argument goes beyond the “empirical” slippery slope argument (of which more later) in terms of what is likely to happen if we approve ethically or legally assisted suicide or voluntary euthanasia.

See note 5.

Hopefully Davies will read the carefully researched article of John Keown, the editor of Euthanasia Examined, on Dutch euthanasia practice. He finds “ample evidence from the Dutch experience to substantiate the relevance of the ‘slippery slope’ argument in both its forms.” (263) The logical form of the argument runs that the acceptance of voluntary euthanasia leads to acceptance of at least nonvoluntary euthanasia because the former rests on the judgement that some lives are not “worth” living, which judgement can logically be made even if the patient is incapable of requesting euthanasia. If a doctor can make this judgement in relation to an autonomous patient he can, logically, make it in relation to an incompetent patient. And if death is a “benefit” for a competent patient suffering certain conditions, why should it be denied incompetent patients suffering from similar conditions? Keown shows that there were far more cases of nonvoluntary euthanasia in Holland in 1990 than of voluntary euthanasia partly because “the underlying justification for euthanasia in Holland appears not to be patient self-determination, but rather acceptance of the principle that certain lives are not ‘worth’ living and that it is right to terminate them.” (287) The empirical form of the argument runs that even if a line can in principle be drawn between voluntary and nonvoluntary euthanasia, a slide will occur in practice because the safeguards to prevent it cannot be made effective. In the Dutch case “…the Guidelines are simply incapable, because of their vagueness and the fact that they entrust the decision-making to the individual practitioner, of ensuring that euthanasia is carried out only in accordance with the criteria they [the courts and The Royal Dutch Association] specify.” (266) The Survey done for the Remmelink Commission shows that doctors intended to accelerate death in far more that the 2,700 cases classified by the Commission as “euthanasia” and assisted suicide. “This total ignores the 1000 cases of intentional killing without request and in addition, three further categories where there is said to have been some intention to shorten life: first, the 8,100…cases of increasing the dosage of palliative drugs; secondly, the 8,750 cases of withholding or withdrawing treatment without request and finally, the 5,800…cases of withholding or withdrawing treatment on request. Adding these 23, 650 cases to the 2,700 produces a total of 26, 350 cases in which the Survey states that doctors intended, by act or omission, to shorten life. This raises the incidence of euthanasia from around 2% to over 20% of all deaths in Holland.” (217) And let it be noted that 15,258 or 57.9% of these deaths were nonvoluntary. The Commission seeks to defend the 1,000 cases of nonvoluntary euthanasia it admits by stating that “active intervention” was usually “inevitable” because of the patient's “death agony”. (276) As Keown notes, this attempted ethical justification amounts to little more than a bare assertion that killing without request is morally acceptable.

See Chapter 10 - Walton , Davies, Boyd and the legalization of euthanasia.

Dieter Giesen's article in Chapter 14, “Dilemmas at Life's End: A Comparative Legal Perspective”, is useful for its legal scholarship. However, he does not appear up to the ethical status quaestionis. Here he appears eclectic rather than systematic and analytic in his approach.