Wednesday, August 16, 2017

Consent and euthanasia

I once gave an argument against euthanasia where the controversial center of the argument could be summarized as follows:

  1. Euthanasia would at most be permissible in cases of valid consent and great suffering.

  2. Great suffering is an external threat that removes valid consent.

  3. So, euthanasia is never permissible.

But the officer case in my recent post about promises and duress suggests that (2) may be mistaken. In that case, I am an officer captured by an enemy officer. I have knowledge that imperils the other officer’s mission. The officer lets me live, however, on the condition that I promise to stay put for 24 hours, an offer I accept. My promise to stay put seems valid, even though it was made in order to avoid great harm (namely, death). It is difficult to see exactly why my promise is valid, but I argue that the enemy officer is not threatening me in order to elicit a promise from me, but rather I am in dangerous circumstances that I can only get out of by making the promise, a promise that is nonetheless valid, much as the promise to pay a merchant for a drink is valid even if one is dying of thirst.

Now, if a doctor were to torture me in order to get me to consent to being killed by her, any death-welcoming words from me would not constitute valid consent, just as promises elicited by threats made precisely to elicit them are invalid. But euthanasia is not like that: the suffering isn’t even caused by the doctor. It doesn’t seem right to speak of the patient’s suffering as a threat in the sense of “threat” that always invalidates promises and consent.

I could, of course, be mistaken about the officer case. Maybe the promise to stay put under the circumstances really is invalid. If so, then (2) could still be true, and the argument against euthanasia stays.

But suppose I am right about the officer case, and suppose that (2) is false. Can the argument be salvaged? (Of course, even if it can’t, I still think euthanasia is wrong. It is wrong to kill the innocent, regardless of consequences or consent. But that’s a different line of thought.) Well, let me try.

Even if great suffering is not an external threat that removes valid consent, great suffering makes one less than fully responsible for actions made to escape that suffering (we shouldn’t call the person who betrayed her friends under torture a traitor). Now, how fully responsible one needs to be in order for one’s consent to be valid depends on how momentous the potential adverse consequences of the decision are. For instance, if I consent to a painkiller that has little in the way of side-effects, I don’t need to have much responsibility in order for my consent to be valid. On the other hand, suppose that the only way out of suffering would be a pill whose owner is only willing to sell it in exchange for twenty years of servitude. I doubt that one’s suffering-elicited consent to twenty years of servitude is valid. Compare how the Catholic Church grants annulments for marriages when responsibility is significantly reduced. Some of the circumstances where annulments are granted are ones where the agent would have sufficient responsibility in order to make valid promises that are less momentous than marriage vows, and this seems right. In fact, in the officer case, it seems that if the promise I made were more momentous than just staying put for 24 hours, it might not be valid. But it is hard to get more momentous a decision than a decision whether to be killed. So the amount of responsibility needed in order to make that decision is much higher than in the case of more ordinary decisions. And it is very plausible that great suffering (or fear of such) excludes that responsibility, or at the very least that it should make the doctor not have sufficient confidence that valid consent has been given.

If this is right, then we can replace (2) with:

  1. Great suffering (or fear thereof) removes valid consent to decisions as momentous as the decision to die.

And the argument still works.

25 comments:

Angra Mainyu said...

Hi Alex,

I'd like to raise a couple of objections:

a. Consent is not required. For example, if a dog is suffering horribly, it's permissible to kill it in order to spare it the suffering. That would be a humane action. Dying would be the lesser evil for the dog, compared with the alternative. What if a human being is incapable of expressing consent or denying it (e.g., the parts of the brain required for that are destroyed and/or not yet developed), but suffers also great pain? It seems it would be the lesser evil also to kill them.
What seems generally impermissible (though not metaphysically necessarily impermissible) would be to engage in euthanasia against a person's will, or when the person doing the killing has not taken reasonable measures to ask the other person what she prefers.

b. Imagine a person is conscious and capable of speaking. She's also suffering greatly, and a machine is keeping her alive. But she request that the machine be disconnected. Now, if your premise 2. is true, then valid consent has been removed. Moreover, if (2) is false but (4) is true, then also valid consent has been removed, since that is a decision to die. It would be generally a mistaken psychological assessment to say it's a decision to not having any more procedures done on them. An informed person who chooses to be disconnected is choosing to die over the suffering the procedures entail, which is also what the person who chooses euthanasia is choosing.

Houdini said...
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Houdini said...

I was thinking the exact thing with regards to your second point (b). Also Dr. Pruss, I would like to see you defend this statement because it lies at the root of the issue:

"It is wrong to kill the innocent, regardless of consequences or consent."

Walter Van den Acker said...

"Great suffering (or fear thereof) removes valid consent to decisions as momentous as the decision to die."

This is very speculative. There is no evidence that this is the case in every case or even in most cases. There is, however, evidence that sometimes people are "forced" to suffer. In those cases, there is no patient consent to continu suffering.

"It is wrong to kill the innocent, regardless of consequences or consent" is, in the case of euthanasia or even suicide, contradictory. A person who consents to being killed is not innocent, because he has, according to Catholic doctrine, made a morally wrong choice.
So you'd have to rephrase your claim to "It is wrong to kill anyone, regardless of consequences or consent", but that would entail radical pacifism and rejection of capital punishment, which is not offical Catholic doctrine.

Dagmara Lizlovs said...

Humans are not dogs.

Angra Mainyu said...

Dagmara Lizlovs, humans are not dogs, and in my assessment, dogs are generally treated much better in these sorts of situations.

If we were talking about a dog, a lot of people would not hesitate to be merciful and take a humane action, namely to kill the dog suffering horribly. That's what best for the dog.
But if it's a human being, many of the same people would fail to do so, even if the human being in question does not have the ability to make choices, does not have the ability to think, and has essentially no mental life other than constant pain - no joy, no virtue, no vice, nothing but pain until death. They fail to realize that a painless death is what's best for that human being (yes, of course, you disagree. This is one of those examples of vast moral disagreements that will not go away for the foreseeable future, as nearly everyone will keep their current views unchanged.

Charlie Gard is a recent example, I think. Many people talked about "death panels" and were sincerely outraged because the decision was made not to continue trying to extend his life, whereas many others said that not allowing further attempts to extend his life was the best thing for him, and were also sincerely outraged because the parents, the Pope and others were pushing for more life-extension measures.
Some of us, on the other hand, believe that the no further treatment was not as bad as what the parents wanted to do, but still pretty bad overall, given what was known about his condition: Maybe he was no longer capable of feeling anything, in which case it was pretty much all the same. But the assessment of the doctors treating him was that he probably was in considerable pain. If that was so, his life was one of just pain - no ability to have any sort of happiness, social relations, moral life, etc.: just pain and more pain. No longer trying to extending his life with the available means, in my assessment, wasn't in his best interest at all. Killing him painlessly would have been so. A dog would have received such mercy. But it's illegal for a human. I think the law is seriously misguided.

But we live in a world of vast moral disagreements on many issues (even if there is a bigger background of agreement that tends to go unnoticed), and I don't think a significant number of people on any of the sides of that sort of debate will ever change their view regardless of argumentation. So, I offered a different objection to the argument against euthanasia, by pointing to other situations in which consent is generally regarded as valid, even though there is great suffering or the threat of great suffering.

Also, what if there is no imminent threat?
Today, there are people who carry a "do not resuscitate" card. That is generally considered valid.
Also, generally, they give their consent in situations in which there is no imminent threat to their lives. If people also carried "please kill painlessly in such-and-such dire situations" card, there would be no issue of consent under great suffering or fear thereof, unless perhaps one counts the fear that it just might happen. But then, that kind of worry about what might happen is also present in the cases of "do not resuscitate" cards.

Alexander R Pruss said...

If the decision to disconnect is a decision to die, then I'd say something very similar to the euthanasia case.

Alexander R Pruss said...

Houdini:

Arguments against killing the innocent in general are not something I've worked on much. I do think that these two standard ones have a lot going for them.

Thomism: It is always wrong to act directly against a fundamental good. The life of the innocent is one of the fundamental goods.

Plato: Our life belongs to our creator. As far as we can tell, we have no permission from the creator to destroy that life apart from cases where justice requires it.

Dagmara Lizlovs said...

Only God decides the length of our lives.

Angra Mainyu said...

Alex:

The decision to not resuscitate is generally a decision to die not because death is a goal, but because the person reckons that under certain circumstances, it would be better than the available alternatives. But the same would happen with a "kill painlessly" decision - which hypothetically can also be made in advance, when there is no threat. In both cases, death is not the end, but it's a means to an end.
Do you think there is a relevant difference, with regard to the validity of consent? If so, I'd like to ask why.

Also, the decision to discontinue treatment when the person is lucid, capable of communicating, etc., is regarded as valid even if there was no previous decision (i.e., even if the person had not made the decision earlier, when she was not undergoing great suffering). Do you think the decision not to continue treatment should be banned? Or do you think they should be allowed even if they're morally impermissible?

Alexander R Pruss said...
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Alexander R Pruss said...

1. The decision ahead of time seems problematic in respect of validity in that one does not know what the pain will be like under the specific circumstances in question. I would think that in this respect, death would be a bit like sex if euthanasia were ever permissible, in that valid consent would need to be given at the time rather than earlier.

2. She who intends the end intends the means.

3. The discontinuation of treatment case does worry me, and I think it may damage my argument. The specific case that worries me is one where the patient asks that the treatment be discontinued not in order to die -- such a decision would be wrong -- but one where the patient asks for discontinuation because the treatment itself is too grave a burden. The worry that I have is that even if the patient isn't seeking relief from treatment-independent sufferings, the treatment-independent sufferings can bias the patient's thinking in favor of discontinuation. I.e., even if the patient does not deliberately seek to die, she may have a bias in favor of dying which can color her decision-making. Yet it doesn't seem to be wrong to accept the patient's decision to discontinue treatment.

4. Maybe the thing to say is this. The default position is that we are not allowed to invade the bodies of others, and so treatment normally requires what we might call "strong consent" (the sort of thing is not had by children, or when inebriated, etc.) Withdrawal of consent, however, does not need quite the same strength of consent.

We require stronger consent in the case of treatment than in the case of non-treatment, and it shouldn't be super-hard to withdraw consent from treatment.

Active euthanasia is a maximally invasive form of treatment, in that it affects the whole body by killing it. It would require super strong consent.

But termination of treatment, especially of invasive treatment, does not require that much in the way of strength of consent. (Compare: While a person needs to be sober to validly consent to sex, a person does not need to be sober to withdraw consent from sex. But the analogy is imperfect, because I am not sure a drunken patient's withdrawal of consent for treatment would be valid.)

5. It is logically consistent to say both (a) it would be wrong for x to terminate consent for treatment in some case and (b) others would have a duty to terminate the treatment in C if consent were terminated.

Dagmara Lizlovs said...

Please explain all this to her. Sbe obvously didn't get it:

http://www.mirror.co.uk/news/world-news/euthanasia-patient-fought-back-doctor-9707709

Houdini said...

Dr. Pruss:

Do you know a good book, article, or paper that deals with the Thomistic argument you mentioned?

Angra Mainyu said...

Alex:

1. I don't see why that would be problematic. There are choices and then they remain valid even when one is unable to revoke them. For example, consent to perform surgery is like that - the patient will not be conscious then, but allows the doctors to do the surgery by giving them consent when she is conscious. In some cases, the person suffers serious harm as a result, and not necessarily in order to get fix some other ailment they have (e.g., organ donation).
At any rate, I would say that in this regard, the case of euthanasia is relevantly analogous to the "do not resuscitate" case.

As for sex, I don't know why that would be analogous (why do you think so?), or that consent in advance is never valid. For example:
a. A and B are in a relationship (married, or whatever), and they agree to allow each other to initiate sex and wake them up in that manner, in the morning. Is that always rape or generally some kind of sexual assault, due to a lack of valid consent?
b. C and D decide are sober, and they decide to drink and then have sex, so they do that. Let's say they're equally drunk. Is that mutual sexual assault due to a lack of consent?

2. Okay, then the case seems similar to euthanasia in that regard - which is what I'm arguing on the matter.

4. I don't know whether I would put it in terms of "strength of consent". I do think usually, one is not allowed to invade the bodies of others. But consent is not always needed - not strong, and not even weak.
One example is the case of young children who need surgery but oppose it.
Another example: doctors do not need consent to perform surgery on patients who are unconscious as a result of an accident (and have not left instructions for such cases), even though sometimes they have to inflict serious harm on the patient, including cutting through her muscle, bones, etc., or even amputate a limb, remove an organ, and so on. They're doing it as a means of preventing something even worse for the patient. But then, I would say that sometimes, killing a patient is also done as a means of preventing something worse for the patient (and from the perspective of objectives at least, that's how often it's done - becase it is done, even if illegally).

As for euthanasia decided by the patient, I don't see why consent would be invalidated because of the (fear of) great suffering. If - say - the patient instead chose also a very invasive procedure in order to take the shot at staying alive (due to fear of death, for example), would that fear invalidate consent? What if they give consent to have an organ removed and transplanted to their child, parent, etc., out of fear for the life of the other person? You could say that that's less invasive. But it's also vastly invasive. And the decision can validly be made, even under fear of dire consequences if it's not made. So, why would consent to be killed be invalid, but consent to suffer other very serious harms would not be? (and it's consistent to draw a line at death, but it's also consistent not to do so, so consistency is not going to settle the issue).

5. Yes; I was asking what your position on the matter is.

Dagmara Lizlovs said...

How do we value life? Is it a gift? How do we value people? As made in the image and likeness of God or only when they are of use and do not require too much from us?

A problem with euthanasia and pbysician assisted suicide, once they become established as medical practice is cost effectiveness. It can be more cost effective from a financial point to use euthanasia or assisted suicide than to provide treatment. This does not apply to the hard cases only, it is moving into the less hard cases. Take for instance a severely depressed person, termination of life could be more cost effective than providing hospitalization, medication and long term therapy. This also can apply to cancer treatments. A case in point was a woman on Oregon several years back who had lung cancer. Oregon had recently legalized physician assisted suicide. Her insurance company was willing to pay for the drugs to terminate her life but not to treat her cancer. She fought it in court and eventually won; however by this time the cancer had progressed into terminal stages.

Dagmara Lizlovs said...

Here is the link:

http://abcnews.go.com/Health/story?id=5517492&page=1

Dagmara Lizlovs said...

Here is an article on physician assisted suicide and mental illness:

http://www.medscape.com/viewarticle/848910

Yeah the old life not worthy of life business.

Dagmara Lizlovs said...

M√ľnster's Bishop Clemens von Galen courageous sermon in Nazi Germany against euthanasia:

http://www.priestsforlife.org/preaching/vongalen41-08-03.htm

steve said...

Alex,

You said: "She who intends the end intends the means."

That certainly seems logical. But how would you relate that to the double effect principle, which is typically formulated so that the ends cannot justify the means?

Dagmara Lizlovs said...

Here is another article. Shows how really twisted things have gotten:

http://www.christianpost.com/news/pope-francis-orders-catholic-group-to-stop-offering-euthanasia-at-belgian-hospitals-195434/

Dagmara Lizlovs said...

Another article. Although this one id on physician assisted suicide. Euthanasia and physician assisted suicide corrupt medical practice and the healing arts.

http://dailysignal.com/2015/10/28/new-study-shows-legalizing-physician-assisted-suicide-increases-suicide-rates/

Walter Van den Acker said...

Dagmara

I am Belgian, so maybe I can give you some background information on what is going on here.
Euthanasia has been legal in Belgium onder specific circumstances since 2002. Euthanasia is "offered" in virtually every Belgian hospital, including Catholic hospitals. There really isn't much controversy about euthanasia in the case of severe irreversible suffering in terminally ill patients.
With regards to metal suffering, the case is more complex, but in March 2017, the Belgian board of directors of the Brothers of Charity psychiatric hospitals decided to institutionalize the practice of euthanasia in certain well-defined cases, in which the patient's condition is considered to be irrevesrible and offering no hope of recovery, provided there is a well-considered existential choice by a patient capable of giving consent.
I say "intitutionalized" because euthanasia has already been possible in many of the hospitals run by the Brothers of Charity for years. the only thing that happened this year was that the board decided to be open about it.





Alexander R Pruss said...

steve:
This principle is at the heart of Double Effect. She who intends the end intends the means, but she need not intend the side-effects.

Angra:
These are all good questions. I am not sure I have good answers to all of them. As I tried to make clear in the post, I am no longer that confident in the consent-based argument, and your objections make me less confident in it.

Dagmara Lizlovs said...

Here's this from Canada:

https://www.firstthings.com/web-exclusives/2017/08/its-a-culture-war-stupid