Friday, May 4, 2018

Medical and spacecraft ventilators

Some thinking that to turn off a patient’s ventilator would not be to kill but “to let die”. But it seems obvious that to turn off a spacecraft’s ventilation system would be to kill the astronauts through suffocation.

Of course, there are differences between the two cases. One difference is that the medical ventilator is more intimately connected to the patient. This difference, however, would seem to make turning off the ventilator be more of a killing.

A perhaps more promising difference is that when the patient’s ventilator is turned off, the patient dies from a disease that renders unassisted breathing impossible, while the astronauts die from the turning off of the air system. Maybe there is something to this, but I am doubtful. For we can also say that just as the patient would die from a disease, the astronauts would die from the airlessness of space. It is true that one of these is a disease and the other is an environmental condition, but why should that make a difference with respect to what is a killing?

Moreover, if an engineer turns off the ventilation system on the spacecraft before an astronaut reveals that the technician’s doctoral dissertation was plagiarized, that’s murder. And similarly if a doctor turns off a ventilator before the patient reveals that the doctor cheated in medical school, that’s clearly murder, too.

Similarly, if the death penalty is ever permissible, it could in some cases be administered by disconnecting a ventilator—and it would clearly still be an execution, and hence a killing.

But what if the doctor turns off the ventilator for some reason other than to cause the patient’s death, say to prevent an electrical overload to the hospital’s system which would kill many other patients? Changing the intentions with which an act of killing is done can change whether the act is an intentional killing, whether the act is wrong and whether the act is a murder, but I do not think it changes whether the act is a killing. Thus, the doctor who turns off the ventilator for a reason other than to cause death is still killing, but not intentionally.

Nor does it make a difference with respect to killing whether the disconnection is thought of as causing or hastening death. The doctor who turns off the ventilator to prevent the doctor’s medical school cheating from coming to light could think of the activity as hastening death—making the patient die before revealing the secret. But it’s still murder, and hence it’s still killing. Similarly, the plagiarist engineer would be a murderer even if the air system on the spacecraft were failing and the astronauts would die anyway within a week.

Of course, the judgment that turning off the ventilator is killing does not imply that it is murder or even impermissible. But if we grant that it is always murder to intentionally kill the innocent, the turning off a ventilator in order to cause or hasten death is murder.


Christopher Michael said...

Why not say that both are letting die, but that intentional, impermissible instances of letting die are as much murders as are intentional, impermissible killings. Consider the parent who refuses ordinary medical treatment for a curable disease of their child. It's clearly a letting die, but it's also clearly murder. So some murders are instances of letting die.

It would be analogous to how one is guilty of theft who has both the power and responsibility to stop a theft and intentionally fails.

Alexander R Pruss said...

But a murder is an intentional wrongful killing. That murder entails killing seems obvious. (Of course, there are _statutory_ murders that are not killings. But that's a different matter.) Maybe a more promising move along the same lines as you suggest is that intentional, impermissible instances of letting die are morally _on par_ with murder. Similarly, not stopping a theft isn't theft--but it might in some cases be just as bad as theft (or it might be worse).

Note that turning off a ventilator is different from not stopping a theft. Turning off a ventilator is a positive act. A closer analogy to not stopping a theft would be not connecting a ventilator.

It seems that the logical structure in both the spacecraft and medical cases is this: The agent removes something that is preventing death. It seems to me that many cases of removing something that is preventing death are garden variety killings: disabling a parachute, removing insulation from a wire the victim is expected to touch, damaging scuba equipment, draining brake fluid before the victim drives on a windy mountain road, etc.

Christopher Michael said...

Here's another way of looking at it: clearly, there are circumstances in which we could turn off the spacecraft's ventilator. So it's not intrinsically evil. But intentionally killing the innocent is intrinsically evil (modulo explicit and special Divine commands). Therefore, (since we assume the turning off is intentional and the astronauts are innocent) the turning off of the ventilator is not a killing. But absent proportionate good reason to do it, it is as grave as murder. If one wants to distinguish specifically between the malice of murder and the malice of such an act, I wouldn't protest. It seems simpler to call it murder, though.

Alexander R Pruss said...

An act can be intentional and a killing without being an intentional killing, because it need not be intentional under the description "a killing". For instance, in the classic trolley case, redirecting the trolley is a killing (see below) and it is intentional (obvious), but it is not an intentional killing (since then it would be wrong, which it's not). Argument that it is a killing: Suppose that there were *no one* on the right track, and the trolley is redirected to the left track, where there is one person. Then it would be plainly a killing. But the causal connection between the throwing of the switch and the death of the person on the left track is unaffected by how many people are on the right track. So it's still a killing even if there are five people on the right track.

Martin Cooke said...

I guess the point about letting die is that a patient is dying and then aid is given to help the patient to get better, but it is found out that the patient is not getting better, maybe the aid is just making the patient suffer more, so it is withdrawn.

An analogy might be with someone who is on fire, so you put some water on them, but it is not enough, and so they are still burning to death but much more slowly, whereas if you stopped then they would be gone in a flash. It is an interesting question, I think, whether you would be killing them if you turned off a trickle of water that you found to be prolonging their agony. But it does seem to be different if you stop doing something that you yourself started and have found to be making things worse: you would not have been wrong to have not started it.

And the spaceship is totally different. The astronauts are only in it because of the ventilation. The ventilation being on is part of the deal whereby they are there. There is only a superficial similarity with a ventilator, I think.

William said...

It's seemingly assumed in the above that in these scenarios a) the patient gave consent to be on the ventilator and that b) the patient wishes to stay on the ventilator. In many cases, however, b and sometimes also a are false.

Alexander R Pruss said...

Martin and William:

Whether an action is a killing does not depend on such questions of consent and wishes. It does not depend on whether a patient is getting better or worse. It does not depend on whether one should have started an intervention or not.

Such considerations can, of course, affect the question whether the disconnection is an intentional killing, and whether the disconnection is right or wrong. But they don't affect whether the disconnection is a killing.

To make things clearer, bracket all the moral stuff. Replace the disconnecting agent with a monkey that is randomly pressing buttons without any understanding of what the buttons do. The monkey that turns off the spacecraft ventilator kills the astronauts. The monkey that turns off the hospital ventilator kills the patient. The monkey has no intent to kill. The monkey does nothing wrong (or right). But the monkey does kill, and does so in both cases.

Martin Cooke said...

I like that monkey, the two are clearly both killings. The spaceship is not totally different. But it is different enough in an apposite way. When it is a human and not a monkey, and it is a dying patient in pain, not an astronaut, it is not a killing, but a letting die. That is just how "killing" operates, in natural language.

I could make a similar analogy, perhaps. When you shoot someone the bullet kills, but really it is the person pulling the trigger. Similarly when you buy a cheap handbag. It is the foreign gangster who kills, but really it is the person who funds such economic activity. Except, I am wrong. The shooter kills, the buyer does not (except metaphorically: she should think about what she is doing).

If you try to help the guy in the gutter, but you find that you are putting them in agony and only prolonging that agony, as you prolong their life, so that they beg you to stop, to leave them alone, to die, and so you leave them alone; when you leave them alone, to die, you are not killing them. The gangster who put them in the gutter killed them. That is how "killing" operates, in natural language.

Nice monkey though (I went to bed thinking that you were right, and I only checked this morning because experience has taught me that there are no end to the analogies (I will not be surprised when you counter these and I feel again that I was missing the point (-:

Martin Cooke said...

Suppose that a man is dying.
Suppose that a pill could slow what was killing him.
If the dying person rejects that pill, does he kill himself?
Surely not, because he is dying anyway.
He fails to take up an opportunity to lengthen his life.
Perhaps the pill is uncomfortable,
or perhaps it is made in an unethical way,
it hardly matters: do we have to buy
anything that claims to be good for us? No.
So, how does turning off a ventilation machine
amount to a killing?

Alexander R Pruss said...

I think it depends on the details of "rejects".
Version 1: I will be forced to ingest the pill unless I say "No". Then I do think that saying "No" is killing myself. But it need not be an *intentional* killing: as you say, the pill may be uncomfortable or made in an unethical way, and the intention may simply be to avoid the pill rather than to cause death. A killing where one does not intend death can be permissible--the trolley case is the classic example.
Version 2: I will be given the pill only if I say "Yes". And I say nothing. In that case, I am not doing doing anything, and I am not killing myself. (If my reason for not saying anything is so to ensure that I die, then I may be culpable for my intention and for the inaction. It won't be a killing strictly speaking, however.)

I think the language of "letting die" suffers from a confusion between cases of doing something that stops a medical intervention and not starting a medical intervention. People use "letting die" in both kinds of cases. But stopping a medical intervention, say by flipping a ventilator switch to OFF, is a killing. However, this killing will sometimes be permissible when the act it is not intended to be lethal. Not starting a medical intervention isn't a killing, but it can still be wrong when one is intending death.

People try to make too much ride on the question whether there is a killing there or not. There are morally permissible killings and there are plenty of morally impermissible things that aren't killings.

At the same time, there is of course a very strong moral presumption against killing--even killing without intending death--so determining whether an act is a killing moves discussion forward.