Editorials

When doctors might kill their patients

Following the acquittal of an English doctor, Dr David Moor, who had given a dying patient a lethal dose of diamorphine, we invited two ethicists to debate the issue at the centre of the case: that of giving a drug with the intention of relieving suffering even though it may hasten death. Professor Raanan Gillon argues that the difference between intending and foreseeing is all important, while Professor Len Doyal argues that the effect of this is to raise the moral character of a clinician above the best interests of his or her patients

Foreseeing is not necessarily the same as intending

And the difference is crucial for patients and their doctors 

Like many other general practitioners I breathed a sigh of relief when Dr David Moor was acquitted of murder earlier this month.¹ Like him and many other doctors, I too have given a patient intravenous heroin intending to relieve his distress but foreseeing that my action might hasten death. Yet some argueoften passionatelythat there is no difference between (a) my foreseeing that my action may kill my patient and my patient then dying and (b) my intending my action to kill my patient and my patient then dying. If the court believed that there was no difference then I, as well as Dr Moor and countless other doctors, would be murderers. I argue that a and b are different logically, experientially, conceptually, legally, and morally. Moreover, if people, especially doctors and lawyers, begin to believe the mistaken idea that they are not different very bad consequences will follow for dying patients. Furthermore, all this is true whether or not voluntary euthanasia is legalised, for voluntary euthanasia is a different issue.

Different intentions, different actionsIt is a logical (analytic) truth that any two actions, the same in all respects including their outcomes but differing in the agent's intentions, are two different actions. Foreseeing but not intending deathais logically a different action from foreseeing and intending death as in b.

Experientially differentI've never intentionally killed anyone, but from time to time I have killed severely wounded animals. My experiences of intentionally killing (which I still find repulsive even though I think I was right so to act) are totally different from my experiences of giving potentially lethal doses of heroin to relieve suffering.

Conceptually different, with a practical test of the differenceForeseeing and intending are two different conceptsthat is, they mean different things. The most important difference is that if you intend to do something you necessarily aim to make it happen, but that is not necessarily true if you merely foresee it happening. In our context there is a vital practical test of the difference. If having relieved the patient's pain and distress one ceases to give, for example, the diamorphine until and unless the pain or distress recur one's intention has clearly not been to kill the patient. If, despite relieving the pain and distress, one goes on giving more heroin until the patient does die (or gives much larger doses of heroin than one thinks necessary to relieve pain and distress) then equally clearly one not only foresees the patient's deathone intends it.

Legally differentIn the United Kingdom, as in many other countries, doctors may give as much pain relief as is necessary to relieve the patient's pain and suffering where this is judged to be in the patient's interests and has not been refused by the patient, even though the doctor knows that the patient's life may be shortened as a result. But intentionally shortening another's life is a serious crime. While there are several legal defences, such as self defence, that may justify homicide, euthanasia is not one of them in most countries.

Morally differentMany people believe that intentional shortening of another's life, no matter how benign the intention or how willing the other, is fundamentally morally wrong, at least if the other is not an aggressor. But to treat a person's pain and suffering despite foreseeing that the patient's life may thus be shortened need not be wrong given various conditions (in Roman Catholic theology these conditions are known as the doctrine of "double effect"). I do not personally share the view that euthanasia is always absolutely morally wrong. But there is another way in which it is prima facie morally wrong. In countries where laws can be changed by democratic methods everyone has a prima facie moral obligation to obey the law, and the more serious the offence the stronger the obligation. Thus in the United Kingdom we all have a prima facie moral obligation not to intend our patients' deaths. From this perspective it remains morally desirable to treat the patient's pain, for the patient's benefit and in the absence of the patient's rejection of such treatment, despite foreseeing that the treatment may shorten life.

Changing the law is a separate issueMany people, including many doctors, would like the law of murder to be changed to permit voluntary euthanasia. I do not argue this issue here (though I personally have changed my mind and now suspect that legalising euthanasia may overall do more harm than good). But the important point is that this is an entirely separate issue. Dr Moor was acquitted because the judge and jury accepted that he did not intend to kill his patientwhich would have been murderbut merely intended to prevent his patient from suffering. Clearly they believed that Dr Moor's previously reported statements about helping many of his patients to die did not show that he intended to kill them.

Disastrous consequences if the difference is rejectedIf patients are to continue to be helped to peaceful and gentle deaths (the literal meaning of euthanasia) doctors must continue to be allowed to give sufficient treatment to achieve this, even when they foresee that the treatment may accelerate the patient's death. If the difference between foreseeing and intending is rejected doctors will no longer be able to give adequate pain relief to their dying patientsand we are all potentially dying patients.

The law and the public should continue to trust doctors to provide pain relief in a legally acceptable way, no matter how hard it sometimes is to be certain what another person's intentions were when he or she acted. Those who wish to change the law on euthanasia should work through the normal democratic processes. Meanwhile the medical professionwith our awesome and to some terrifying powers over life and deathmust continue to earn that public trust by being absolutely clear that with the law as it stands we must never treat our patients with the intention of accelerating their deaths.

Raanan Gillon, Professor of medical ethics. 

Imperial College School of Medicine at St Mary's, London W2 1PG