Physician-assisted suicide, the doctrine of double effect, and the ground of value

Ethics

Volumn 109, Issue 3, 1999, Pages 586-605

  Kamm, F M ^a  

^a NONE

Author keywords

[No Author keywords available]

Indexed keywords

DRUG; HYPNOTIC SEDATIVE AGENT;

ANALYTICAL APPROACH; ARTICLE; ASSISTED SUICIDE; BEHAVIOR; DEATH; DEATH AND EUTHANASIA; DEMENTIA; ETHICS; HUMAN; MEDICAL ETHICS; MORALITY; MOTIVATION; PAIN; PALLIATIVE THERAPY; PASSIVE EUTHANASIA; PHILOSOPHICAL APPROACH; PHYSICIAN; SOCIAL BEHAVIOR; SOCIAL PSYCHOLOGY; TERMINAL CARE;

ANALYTICAL APPROACH; DEATH AND EUTHANASIA; PHILOSOPHICAL APPROACH;

DEATH; DEMENTIA; DOUBLE EFFECT; ETHICS; EUTHANASIA, PASSIVE; HUMANS; HYPNOTICS AND SEDATIVES; INTENTION; MORAL OBLIGATIONS; MOTIVATION; PAIN; PALLIATIVE CARE; PHARMACEUTICAL PREPARATIONS; PHYSICIANS; SOCIAL RESPONSIBILITY; SOCIAL VALUES; SUICIDE, ASSISTED; TERMINAL CARE;

EID: 0033106466     PISSN: 00141704     EISSN: None     Source Type: Journal    
DOI: 10.1086/233923     Document Type: Article

References (35)

1. The arguments I present would also apply to passive PAS (e.g., when a patient refuses treatment, intending to die, and has a doctor stop sedation so that he can take a lethal drug) and to euthanasia (E). (For discussion of why this is "passive," see my "Physician-Assisted Suicide, Euthanasia, and Intending Death" [hereafter cited as "PAS, E, and ID"], in Physician Assisted Suicide: Expanding the Debate, ed. Margaret P. Battin, Rosamond Rhodes, and Anita Silvers [New York: Routledge, 1998], pp. 26-49.) Passive E can also be distinguished from passive PAS: in the former, the doctor either does not start, or else he stops, life-saving treatment. In the latter, he stops, or does not start, non-life-saving aid, and this enables the patient to end his life either actively or passively. Active voluntary E can be distinguished from PAS by the fact that in E (a) the doctor does the act which finally causes death, and (b) the doctor must intend death. In PAS, the doctor only may intend death, while the patient must intend death for it to be a suicide. Some would say this is so in PAS because the doctor may only wish to give the patient a choice whether to die. But I think that a doctor who gives a patient a lethal drug for his use is only assisting suicide at all if she gives it once the patient has formed the intention to commit suicide himself. Hence, the doctor is not merely making possible a choice, since the choice has been made. Still, she may only wish to facilitate the patient's doing whatever he chooses and not herself intend that the patient die. (For more on this, see "PAS, E, and ID.") This analysis disagrees with that presented by the majority of U.S. Supreme Court justices in Vacco et al. v. Quill et al. and State of Washington et al. v. Glucksberg et al., where they claim that a physician who assists in suicide necessarily intends the death of the patient, whereas one who terminates treatment may only possibly intend the death. (See the Court's decisions reprinted in Battin, Rhodes, and Silvers, eds.)
2. On this distinction, see my Morality, Mortality (New York: Oxford University Press, 1993), vol. 1.
3. For more on death as a benefit, see my "PAS, E, and ID."
4. Ronald Dworkin seems to take this view in Life's Dominion (New York: Simon & Schuster, 1993).
5. I discuss the so-called Texas Burn Victim Case in this way in my Morality, Mortality (New York: Oxford University Press, 1996), vol. 2.
6. I assume that death is not only a lesser evil, but the least evil of the alternatives to pain in the circumstances. I thank Seana Shiffrin for this point. Ordinarily, doctors give the painkiller themselves, but we might also imagine a case of "assisted pain relief," in which the doctor provides the morphine and the patient takes it.
7. Again, here we might also imagine a case in which a doctor gives the patient the means of causing the lesser evil of pain and the patient intentionally causes it.
8. I thank Michael Otsuka for suggesting that I bring out this suppressed premise in the Three-Step Argument presented in my "A Right to Choose Death?" Boston Review 22 (1997): 21-23, and "PAS, E, and ID."
9. Ronald Dworkin, Thomas Nagel, Robert Nozick, John Rawls, Thomas Scanlon, and Judith Thomson in "Assisted Suicide: The Philosophers' Brief," New York Review of Books 44 (March 27, 1997): 41-47 (hereafter cited as "Philosophers' Brief").
10. Henceforth, for convenience, I will speak only of death being in the patient's best interests, but I should be understood to include the possibility that it instead prevents an event one could reasonably wish to avoid regardless of future good.
11. The three four-step arguments and criticism of the "Philosophers' Brief" presented here build on my previous discussions in "A Right to Choose Death?" and "PAS, E, and ID."
12. Philippa Foot, "Euthanasia," Philosophy and Public Affairs 6 (1977): 85-112.
13. See Warren Quinn, "Actions, Intentions and Consequences: The Doctrine of Double Effect," in his Morality and Action (Cambridge: Cambridge University Press, 1993).
14. This test is rough because there are special cases where failure to get the first step does not indicate we may not do PAS. The exceptions are not inconsistent with the spirit of the four-step arguments. On this, see my "PAS, E, and ID."
15. See their separate concurring opinions.
16. This is how I understand Thomas Hill, Jr.'s version of the Kantian objection to suicide in his "Self-Regarding Suicide," in his Autonomy and Self-Respect (Cambridge: Cambridge University Press, 1991).
17. It is a problem with the account of Kantian objections to suicide given by Hill in "Self-Regarding Suicide" that none of the objections really aim at suicide per se; i.e., they do not distinguish between intending death and doing what we foresee leads to death.
18. On the distinction, see Thomas Hill, Jr., "The Formula of the End-in-Itself," in his Dignity and Practical Person (Ithaca, N.Y.: Cornell University Press, 1993). I thank Richard Arneson for calling this discussion to my attention.
19. Kamm, "A Right to Choose Death?" p. 21.
20. J. David Velleman, "A Right of Self-Termination?" in this issue, pp. 606-28; Velleman criticizes the position I took in "A Right to Choose Death?" I am grateful to him and to the editors of Ethics for allowing me to read his article.
21. My aim in that earlier article, as in Sec. II of this one, was to show that if MPR is permissible, PAS would be, and if PAS were impermissible, MPR would be.
22. Velleman speaks of unconditional value, but I believe he means incomparable value to the extent these differ. See above, note 18.
23. If my remarks do not accurately represent Velleman's view, I believe the arguments I present are intrinsically worth considering in any case.
24. He agrees that death might be in a person's best interest on occasion, even if seeking what is in his best interest is disrespectful of him as a person.
25. It is not entirely clear to me that in a Kantian view, if a property Z makes it important that X have things that are good for it, Z also makes it important that X have things that are good for it in ways other than as a specifically Z-bearing entity. For example, if the capacity for rational autonomy gives a creature (X) incomparable value, what is good for fostering its rational autonomy will have value. If pain did not interfere with X's rational autonomy, X's being out of pain might be a good for X that it is not important that X have. If this were true, it would also affect Velleman's basic argument that the importance of people makes it important that they not be in pain. I shall simply assume that what makes people important gives them an importance that makes it important that they not be in pain.
26. See Joel Feinberg, "Voluntary Euthanasia and the Inalienable Right to Life," Philosophy and Public Affairs 7 (1978): 93-123.
27. Though Kant might disagree, as he attributes no intrinsic worth to animals.
28. Perhaps, it might be said, because more pain in the world is an intrinsic evil, even if it happens to what doesn't matter. But could a Kantian argue this additional pain is a moral evil?
29. I owe this example to Franklin Bruno.
30. I owe this point to Franklin Bruno.
31. As David Sanson emphasized to me.
32. I owe this point to Janos Kis. He suggests that, in most cases, in aiming at destroying the person, we really aim only at destroying her body which is in pain. If dualism were true, we would be quite happy to have the disembodied mind continue on. But would we specifically eliminate the mind to get rid of mental pain?
33. I thank Barbara Herman for raising this possibility.
34. I owe this case to David Kaplan.
35. Feinberg makes this distinction in "Voluntary Euthanasia and the Inalienable Right to Life."