Lecture #11: Euthanasia (Brock, Callahan)

Dan Brock, Voluntary Active Euthanasia

Consider the Quinlan and Cruzan cases; these are landmark cases in which the court has
established a right to die, though only that that extends (apparently) to removal of
life-saving therapy (i.e., passive euthanasia). Also, note the key results of each case:
Quinlan established right to remove lifesaving therapy, but not the right to withhold
food and water, while Cruzan extended this previous finding to allow for the
withholding of food and water as well.1
Before defending VAE, Brock wants to question whether there is really a significant
moral difference between VAE and PAS; he denies that it is really of substantial moral
significance who performs the final act that really leads to death. He admits, however,
that there might be problems with doctors being the ones who actually initiate death
since this might undermine trust in the medical establishment, though this problem is
different than that of mere third-party involvement.
One of Brock's defenses of VAE depends upon the value of self-determination; Brock
thinks that euthanasia should be morally permissible given respect for selfdetermination (i.e., autonomy). It is important to notice that this defense will only work
for voluntary euthanasia since the non-voluntary cannot exercise self-determination or
autonomy. Brock's arguments also depend upon the patient's competence and decision
making ability; absent either one of these, his arguments are substantially undermined.
Brock observes that modern medical technology has made it possible to substantially
extend the lives of patients. Because many of the threats of the past no longer exist
(e.g., hunting accidents and easily preventable childhood diseases) and because of
advances in medicine, it is far more likely that patients will die at advanced ages and be
subject to degenerative conditions.
Because of the deteriorations caused by ages and diseases, deaths often comes only
after enfeeblement. Brock thinks that people have a legitimate interest in avoiding this
process and in having their friends and families remember them as they were, not as the
product of disease and age.
Brock, like Rachels, thinks that VAE can be used to eliminate needless pain and suffering.
Some critics have argued that palliative care can be used to treat the pain and that
death is therefore unnecessary. However, this is most likely not true: there are certain
amounts of pain that cannot be medicated away without other adverse effects upon the
patient (e.g. paralysis). And, even if the pain could be medicated away, the patient
1

If you are not familiar with these cases and would like to learn more about them, the decisions are
worth reading. Quinlan is here and Cruzan is here.
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would be left in such a cognitively altered state that Brock thinks such a life would not
be one of value and that the patient should be able to opt out of it.
So we have seen that both Brock and Rachels think that two different defenses can be
given of VAE: respect for autonomy/self-determination and considerations involving the
well-being of the patient (i.e., avoidance of pain and suffering).
Euthanasia and Public Policy
Brock admits that, though VAE may be morally permissible, there could be substantial
problems with construing a public policy that would allow for it. There are obviously
going to be gray areas and the prospect of abuse, are these reasons alone sufficient to
suggest that VAE should stay illegal (even if not immoral)?
Brock thinks this problem is exacerbated by the following two considerations: first,
there is little empirical data as to exactly what problems would develop; and second,
different people will disagree as to what weightings various positives and negatives
should be given relative to each other. Nevertheless, he thinks that we can at least
observe what the positive and negative features of the legality of euthanasia would be.
(There is, almost twenty years after Brock's paper, extensive data about the "euthanasia
project" in the Netherlands, though the accuracy of the data and its significance remains
unclear. It is especially unclear whether data from the Netherlands is relevant to policy
debates in America; there are different cultural attitudes, the country is both smaller
and more homogenous than ours, etc.)
Good Consequences of Permitting Euthanasia
Brock obviously thinks that the benefits of a euthanasia policy would be that we would
be able to respect the self-determination of individuals and that we could lower the
incidence of pain and suffering (furthermore, while physical pain can be treated, it is
much harder to treat psychological suffering). He also suspects that the number of
people would actually choose euthanasia is relatively small; a big deal is made about a
program that would potentially not affect that many people.
Though there might not be that many people that would actually choose euthanasia,
Brock thinks that a large part of the American public would be consoled by knowing that
they could choose it if they wanted to. Many of us might worry about our ultimate
demise and the prospect of choosing euthanasia is perhaps comforting. Whether we die
suddenly or without a long deterioration, we would have had a more pleasant life
without worries. This would also be of immediate comfort to elderly patients checking
into a hospital.

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Bad Consequences of Permitting Euthanasia (and Refutations?)

Brock considers whether allowing doctors to perform euthanasia would undermine the
"moral center" of medicine; doctors are supposed to be healers, not killers, and
euthanasia presumably runs contrary to their function. But this might be a bad
argument, just because doctors can perform voluntary euthanasia, patients need not
worry about being subjugated to involuntary euthanasia.
And, Brock suggests, the core ideal of medicine is doing what is best for the patient.
While this usually involves healing, there are times when healing is impossible and,
when this is the case, the values that we hold for doctors suggest that they should help
to minimize pain by assisting in euthanasia. What Brock thinks is highly untenable is to
argue that life has some intrinsic value which physicians should support; clearly there
are some lives that have no value at all.
Another concern Brock considers is whether the availability of euthanasia would
undermine society's commitment to care for the sick; euthanasia might be viewed as a
cheaper alternative and suggested to terminally ill patients. He is skeptical here also:
he thinks there is not necessarily any good reason to think this would happen and,
furthermore, the permissibility of passive euthanasia has not led to more withholdings
of life-sustaining therapies.
Second, VAE will only be administered to a minority of the population (2% of deaths in
Netherlands, e.g.); it will not be so rampant as to underscore entire societal attitudes.
Brock also considers the argument by David Velleman that more choices can actually
make someone worse off; it might be false to think that people only stand to benefit
from the option of euthanasia. (Imagine the clerk at a convenience store who is better
off not knowing the combination to the night safeso long as would-be robbers know
that he doesnt know itbecause then he would be less likely to be robbed.)
If euthanasia is not an option, then people would stay alive by default rather than have
to actively choose life over death. This choice of life would beg for justifications (to self,
to family, etc.) which might be hard to provide. Therefore, turning down euthanasia
might turn out to be quite hard and/or carry with it tremendous psychological pressure.
In the way of response, Brock observes that most Americans want the choice; the
convenience store clerk certainly would not. This approval might show why Velleman's
argument does not work here. Second, if Velleman were right, Brock thinks we should
also withdraw the option of VPE for analogous reasons. Since VPE seems largely
unproblematic, Brock thinks Velleman must be wrong. Finally, a blanket restriction
might be unfair to those who would not be psychologically traumatized by the choice to
stay alive.

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Perhaps if we make VAE morally permissible, then we will undermine general

prohibitions on homicide. Brock thinks that we would just have to reconstrue what
counts as homicide; just as when we build in exceptions for killing that allow for killing in
self-defense, we could build in exceptions to homicide for VAE.
Finally, Brock objects to the argument that allowing VAE would lead down a slippery
slope to unjustified killings, such as IAE or, even worse, some Nazi eugenics program.
However, slippery slopes can be blocked if we can come up with some principled
feature to stop the slide and here we have it: volition! Furthermore, Brock thinks that
there is no good reason to think that any of these negative consequences would actually
obtain.
Policy Guidelines
While Brock has dismissed most of the arguments against VAE, he nevertheless
proposes the following series of safeguards. These are designed to ensure that the
patient's decision is "fully informed, voluntary, and competent":
The patient should be provided with all relevant information about his or her medical
condition, current prognosis, available alternative treatments, and the prognosis of
each.
Procedures should ensure that the patient's request for euthanasia is stable or enduring
(e.g., a brief waiting period could be required) and fully voluntary (e.g., an advocate for
the patient might be appointed to ensure this).
All reasonable alternatives must have been explored for improving the patient's quality
of life and relieving any pain or suffering.
A psychiatric evaluation should ensure that the patient's request is not the result of a
treatable psychological impairment such as depression.

Daniel Callahan, Physician-Assisted Dying: Self-Determination Run Amok

Callahan thinks that the euthanasia debate is emblematic of three significant turning
points in Western thought and, for this reason, is especially important:
It represents a potential turning point in the legitimate conditions under which one
person may kill another. VAE, if permissible, will authorize consensual adult killing; it
gives one adult the right to kill and it gives another adult the right to be killed. This
seems like a serious transition that should not be lightly regarded.
It would also counter a wide-spread practice in Western society to limit the conditions
under which people may legitimately be killed; we can no longer kill for theft,
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insubordination, etc., and capital punishment also seems to be on the way out. Callahan
thinks that adding another category of murder is questionable given this trend to
remove permissible categories of murder.
It also represents a turning point in the meaning and limits of self-determination. By
granting individuals the right to exercise their self-determination in a way that has, until
now, been disallowed places a tremendously high value on autonomous choice.
Callahan thinks that this newfound priority for autonomy can sacrifice other societal
goalssuch as trust in the medical professionand that it is striking that one would
endorse it so baldly.
The third turning point comes from the demands that a policy of euthanasia would place
upon medical institutions and medical practitioners. If individuals have a moral and
legal right to euthanasia, then these practitioners and institutions obviously must
accommodate that right, potentially to their own detriment. For example, institutional
goals might be forced to reconcile the apparent incompatibility between preserving life
and condoning death, and doctors may be psychologically fragmented by the different
services that they will now be expected to provide.
Callahan thinks that, on each of these issues, a legalized practice of euthanasia would
push us in the wrong direction. He observes that arguments for euthanasia typically
take one of four forms, which he will address in order:
1.
2.
3.
4.

Moral considerations of self-determination and patient well-being (cf., Rachels

and Brock);
Moral irrelevance of the distinction between killing and letting die: philosophers
think that the permissibility of VPE entails the permissibility of VAE (cf., Rachels);
Lack of evidence to suggest that there would be harmful effects of legalized
euthanasia (cf., Brock); and
Compatibility of euthanasia and the medical practice (cf., Brock).

Self-Determination
Callahan argues that many arguments for euthanasia revolve around the centrality of
self-determination: people are presumed to have an interest in deciding for
themselves, according to their own beliefs, about what makes life good, [and] how they
will conduct their lives.2 While Callahan grants that self-determination is certainly an
important value, he wonders how it can unquestionably be extended to grant a right to
die and, more poignantly, how it could grant some third party (i.e., a doctor) the right to
kill.
While Callahan might be willing to grant patients the right to kill themselves, he thinks
that a good justification has not been offered as to what makes it permissible for
2

Callahan (1992), p. 52.

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doctors to kill. Is it merely that the patient competently and autonomously rejects life?
Callahan thinks that the right to life is not something that can merely be waived or
forfeited like the right to an apple.
Why? Selling oneself into slavery and practices of dueling have both been outlawed,
despite the infringements that these laws place upon self-determination. It might be
the case that these practices show insufficient respect for the dignity of life and that
euthanasia could be banned by similar considerations. Regardless, given the stakes,
Callahan argues that the burden should be on the euthanasia proponent to show why
the right to life can be forfeited and the right to kill can be conferred; he claims that
neither has been established.
He also argues that doctors cannot be morally compelled to kill; the most that we could
get is that it is permissible for them to kill. Any doctor who does not want to participate
in euthanasia should, on Callahans view, be exonerated from any duties.
Killing and Allowing to Die
Callahan observes that many defenses of VAE consist in denying the distinction between
killing and letting die and, given this denial, the permissibility of VAE follows from the
permissibility of VPE.
Callahan, however, thinks that there certainly is a difference between killing and letting
die, and that those who deny it confuse causation and culpability. (Callahans discussion
here is quite unclear, lets try to help him out.) For example, return to Rachels thought
experiment from the previous lecture, which purports to deny the distinction. Rachelss
reaction is that the uncles act equally bad in either case, which is to say that he is
equally morally culpable whether he actively drowns his nephew or whether he merely
watches the nephew drown.
Though the culpability is the same in both cases, it does not follow that there was no
difference between them. In fact, there was an important moral difference between
them: in the first, the uncle caused the death and, in the second, he did not. Thus
Rachelss example only shows that the two cases are identical in regard to the moral
culpability of the uncle, not that there is no important moral difference between them
since there are important moral categories other than culpability.

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Calculating the Consequences

When the consequences of public policy endorsement of euthanasia are considered, its
defenders often argue that there is no reason for pessimism and that many of the
concerns are wildly unfounded. Given data from the Netherlands, and given some
thought, Callahan thinks that the following adverse consequences are virtually certain:
1.
2.
3.

There will inevitably be some abuse of the law;

It will be indescribably difficult to construct helpful and precisely written
legislation, and enforcement will also be a logistical hazard; and
Such permissibility will allow for slippery slopes.

Why will there be abuse? Callahan thinks that laws regarding difficult moral issues are
always subject to infractions, particularly insofar as various medical practitioners will
have different interpretations of the law and/or exercise their own moral judgments
rather than blindly following some law.
Furthermore, data from the Netherlands convincingly demonstrates that many Dutch
doctors violate the laws, particularly by illegally practicing non-voluntary euthanasia (by
either not receiving patient consent or by euthanizing non-cognitive patients; the latter
is not provided for by Dutch law). Callahan also observes indifference to the abuse,
which he finds discouraging. He sees no reason to think that these transgressions would
not exist in America.
Why will there be logistical difficulties? Euthanasia law must necessarily make use of
subjective terms, such as terminal illness or unbearable pain. What do these mean?
It is almost impossible to define these terms and, even if it were, their interpretation
would always fall into the hands of different and fallible physicians. Suggestions for
independent review or decision by committee do not redress these problems.
The enforcement would also be tremendously difficult. In the Netherlands, for example,
only 10% of doctors report their applications of euthanasia. These acts take place in
private medical establishments, not in the public eye; physicians are consequently
afforded tremendous latitude in their practices. (Callahan might be overly pessimistic
here; if we have stiff penalties, autopsies, and external reviews, we might be able to
make some progress and discourage unjustified euthanizing.)

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As for slippery slopes, remember the two strongest justifications for euthanasia:
respect for self-determination and considerations of welfare. If we are going to allow
VAE on either of these grounds, then Callahan thinks that more groups will be eligible
for death:
1.

If self-determination is the ultimate value, then we do not need terminal disease,

tremendous suffering, or anything else to authorize the right to die; anyone
could choose death and demand it out of respect for self-determination. So
allowing VAE on this ground will ensure the moral permissibility of all requests
for death by competent individuals and not just restrict those requests to
euthanasia (i.e., the good deaths). And;

2.

If relief of suffering is the ultimate value, then the permissibility of VAE would
suggest the permissibility of NAE; why should those without volition be forced to
suffer? Callahan thinks that this is quite bad, drawing the line at volition might
be desirable but cannot be done on considerations of avoidance of suffering.

Euthanasia and Medical Practice

Finally, Callahan takes issue with the position that euthanasia does not run contrary to
the goals and functions of modern medicine. Doctors are most properly conceived of as
healers and the addition of killer to their job description would have tremendous
effects. At a minimum, it would change how the public viewed the medical
establishment and most likely lead to distrust. Imagine an elderly woman who was
considering going to the hospital but realized that given the permissibility of VAE and
the potential for either abuses or a slide to NAE, she might be euthanized. This would
certainly affect her decision to seek treatment for her ailments. And, whether this is
rational or not, it would undoubtedly happen.
Also, performing euthanasia would undoubtedly affect doctors own self-images.
Without the permissibility of euthanasia, they get to conceive of themselves wholly as
healers; this is positive and inspiring. If choosing death were an option, perhaps they
would take healing less seriously or fail to pursue aggressive therapies with customary
zeal. Death is depressing and participating in it could end up depressing doctors who
would consequently not serve their patients as well. Doctors are, of course, people and
the effects on them should be taken seriously; it is not only the patients that are
affected by policies regarding euthanasia.

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