Is the Case “Against” Euthanasia Really Just a Case for Better Policy?

February 24, 2011 at 00:20 (Bioethics, Great Quotes, Politics)

Lately, one of the topics I’ve had occasion to think about quite a bit is the culture-war-tinged set of issues swirling around physician-assisted suicide and euthanasia. A couple of months ago, a dear family friend of mine succumbed to lymphoma, and while the specific question of assisted suicide didn’t come into the picture there, end-of-life care inevitably forces everyone to consider what might happen along those lines. In particular, that episode prompted me to revisit the powerful Nietzsche quote I keep on my Facebook profile: “One should die proudly when it is no longer possible to live proudly.”

Fast forward to a few weeks ago, when I happened to sit in on a lecture by one Dr. Margaret Cottle, whose unexpectedly polemical presentation really jarred me into revisiting the euthanasia debate with some of the perspective I have gained from my own area of research. For the sake of background, here is an article that quotes Dr. Cottle quite a bit (though I must apologize that I couldn’t find an article from a less upsetting and nasty website). Interestingly, though, the talk that I heard her give didn’t really focus on what one might take to be the deep, in-principle reasons to oppose physician-assisted suicide. Instead, it was largely a broadside on how permissive euthanasia policies have played out where they have been implemented. In Dr. Cottle’s estimation, the impact of such policies has, in every case, been an unmitigated disaster.

Why did her talk give me such pause? Well, because it highlighted an important feature in the topography of this, and other similar, debates.

Namely this: Dr. Cottle argued in such a way that my basic, deep-down feeling about the moral status of euthanasia never really had a chance to come into play. Her approach was such that, if all of the presented facts could be taken at face value (which they can’t due to issues of framing, about which more in a second), no further debate would be necessary: if I had only her words to go on, and I were calling the shots, I’d repeal every pro-right-to-die policy ever implemented anywhere, notwithstanding my basic intuition that some cases exist for which there is absolutely no defensible ethical objection against hastening a suffering patient’s dying process. Luckily, I don’t have only her words to go on – but let’s take a closer look at what I mean here.

A Pyrrhic Victory for a Good Cause Is Still Bad

The possibility I want to focus on is this: there may be certain morally worthwhile goals that we humans just happen to be really bad at making worthwhile progress towards – so bad, in some cases, that the reasonable thing to do is to go back to the drawing board and figure out a better way to make that progress without giving rise to unpalatable amounts of moral collateral damage. In other words and by way of example, the following could be the case:

a) it is fundamentally morally worthwhile for our legal and medical systems to shore up the right-to-die  for appropriately terminally ill and suffering patients – whatever sort of thing a Very Good Thing is, this is one of them

b) a particular policy has been enacted that moves us toward this goal, but it has led to numerous outcomes that most people on both sides of the debate can agree are undesirable: for example, it has led to many patients being euthanized without proper consideration given to their consent in the matter, and it has led to patients being pressured to choose suicide for the sake of healthcare resource-efficiency, and it has led to a decrease in the availability and quality of palliative care


c) even though the policy was a step in the right direction conceptually or philosophically, it ought to be repealed

and a further possibility:

d) it could be that we humans are so hopelessly bad at implementing, e.g., good euthanasia policy that we should never try to do it even though it would be morally best if we could somehow get it right. (One might have a reasonable chance at successfully arguing that eugenics is an example of this sort.)

Of course, Dr. Cottle’s further stance is that a) is also not quite correct, to put it mildly. I found it telling that even Dr. Cottle, for all her concern about “clear-cutting the cultural old-growth forest” of strict Hippocratic refusal to engage in compassionate killing, was ultimately staking out her opposition to a very carefully defined type of case. She distanced herself from any interpretation of her position that would infringe on patients’ right to refuse treatment, instead focusing on the distinction between allowing death to come quicker as a result of symptom management versus intentionally hastening death in order to reduce the need for increasingly intensive symptom management. (Whether that is a philosophically tenable position is, I need hardly say, a jam-packed can of worms all its own.) One impression I have come away with is that the number of cases that actually fall into that “sweet spot” – that region of overlap in which, after carefully considering all the facts, an anti-euthanasia doctor would make a different call than a pro-euthanasia doctor – is really vanishingly small. So much of the time, the deep conflict isn’t even laid bare; the right choice is obvious to even the most committed partisans. You don’t have to be a sanctity-of-life zealot to see that the twentysomething ballet dancer who develops arthritis in her feet and suddenly feels she has nothing to live for oughtn’t be a candidate for physician-assisted suicide. And you don’t have to be Jack friggin’ Kevorkian to understand that the ninetysomething facing down a third round of debilitating chemo might just want to forego it and opt for symptom management while cancer takes its course, and that’s an okay decision. This seems like a trivial point, but the inclination to dismiss it as such is exactly what I’m taking aim at.

But I have digressed. What’s interesting is that she didn’t really make too big a deal of why she begs to differ on the “sweet spot” cases. The form of the argument was, rather, “This idea you all really like a lot hasn’t worked out so well. I think we can all agree (based on my presentation of the data about how badly it has worked out) that we should reconsider.”

I emphasize this point in large part because it doesn’t get enough emphasis in our polarized culture of climactic moral showdowns. We’re so eager to shoehorn every debate into a clash of the philosophical titans that so much of the bread and butter of ethics – thoughtfully working through the nature and consequences of our practices and decisions in order to promote desiderata upon which the vast majority of reasonable people can easily agree – is forgotten.

Overblown Debate Is (Mostly) Avoidable

In the research I’ve been pursing on the ethics of cognitive enhancement, I have for a while been trying to work through the distinction between pragmatic lines of argument on the one hand, and deep, in-principle, philosophical objections on the other hand. It seems to me that this is a distinction worth paying attention to, and getting clear on when debating issues of this sort. When we consider ethical concerns over such hot-button issues, regardless of whether we want to attack or defend a particular line of argument, it is important to figure out whether the concern is ultimately amenable to practical solutions. In other words, one needs to ask the objector in the euthanasia debate (even if that entails asking the question of oneself): is it possible in principle for euthanasia to be so well-implemented that my objection is satisfied? Or is that a conceptual impossibility? A similar dynamic is probably also at work in the controversy over abortion: those who are pro-choice can only gain so much ground by explaining that they want abortion to be as safe and as rare as possible, because for their opponents, it is simply impossible for abortion to be sufficiently safe and sufficiently rare. Of course, in all of these cases, it tends to be the case that the pragmatic problems are pressed into service for the in-principle objections – witness how the grisly details of the Kermit Gosnell case a couple of weeks ago were mobilized not only by pro-choice groups as an example of why abortion needs to be safe, legal, and rare, but also by the other guys as evidence that it shouldn’t be legal because it is sometimes neither safe nor rare.

As I mentioned a few paragraphs ago, I don’t have only Dr. Cottle’s presentation to go on in figuring out whether premise b) is a reasonable thing to believe in this case. Recently I was fortunate enough to have a chat with Dr. Gary Johanson, a palliative care specialist based in my old hometown. I won’t put words in his mouth by going into a ton of my own editorialized detail, but suffice it to say that he is well acquainted with the facts about how euthanasia policy has played out, and he sees things very differently. The lesson, of course, is that so much depends on how you frame the evidence – and this, of course, is where the real nitty-gritty of the political debate must actually play out. For all its towering import to culture-warriors, the question of whether physician-assisted suicide is deep-down intrinsically always-and-forever no-matter what Wrong And Evil And Forbidden or not is not really gonna be on the table for a while. Not until we can figure out how to implement the policy in a way that thoughtful, ethically conscious, non-zealot right-to-die proponents are actually satisfied with. Maybe then we can sit down and take a hard look at a reasonably-close-to-best-case scenario, and get clear on where the further wrong is.

Of course, that’s all rather wishful thinking. The pragmatics are of course important to me, but it’s the deep in-principle stance that ultimately motivates my interest in the debate, too. That’s how people are. For me, I can’t touch upon this issue and not think of the unabridged version of Nietzsche’s words in Twilight of the Idols:

“To die proudly when it is no longer possible to live proudly.  Death of one’s own free choice, death at the proper time, with a clear head and with joyfulness, consummated in the midst of children and witnesses: so that an actual leave-taking is possible while he who is leaving is still there.”

Isn’t that a beautiful image? Granted, not every person can have this luxury … but oughtn’t we strive to hew as close to it as we can?



  1. Kathy Lollock said,

    Nietzsche’s words are indeed a beautiful image, Roland. I can’t help but think about Mom in that statement. She had the luxury of what we call “comfort care.” Perhaps, the Christian Right would look at that as “euthanasia.” However, it is far from it, being done regularly in Catholic Hospitals and by Catholic Hospices. I have to think, If only Ed were given this opportunity. Mom was dying, her heart barely functioning; and she was in congestive heart failure thereby breathing with extreme difficulty. How does one become comfortable and at peace with no suffering during those last hours? The answer is morphine. It is the only thing that allowed Mom to breathe again, be at rest, and talk and say goodbye to her loved ones. And again it is that good old principle of double effect, the bottom line being INTENT. Mom didn’t want to speed up her death to die and leave her loved ones. That was a secondary effect of morphine. She wanted quality during her last hours, and she was blessed. How comforting for us to see her pass so peacefully!

  2. Roland Nadler said,

    Thanks for sharing, Kathy :) for me, it’s encouraging to imagine (and I don’t think it’s too remote a possibility, given what I’ve said above) that almost all the reasonable voices in this debate, including those on the other side, can agree that your mother’s case unfolded in a humane and unobjectionable manner. I really do think that the fringe positions are advocated by small vocal minorities in this case.

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