Moral dimensions
BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7518.689 (Published 22 September 2005) Cite this as: BMJ 2005;331:689
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I was at a course on teaching medial ethics in Leeds last year, when
one of the philosophy delegates contributed the phrase ‘ethical theories
are a load of cobbled together intuitions’.
I have used that phrase so many times since. Ethical theories are
just theories. Different moral philosophers take different approaches in
analysing ethical issues. Different people take varied approaches in
dealing with the ethical dilemmas of everyday life. Depending on the
approach you take affects where you land up.
What I find interesting about this article is the author’s
acknowledgement of his use of his own intuition. He tells us ‘This view of
euthanasia is too liberal to suit my moral intuitions.’ Intuition can be
explained in many ways. One way is as super-logic, an approach used by
Tony Buzan of Mind Map fame. Another way is as tacit knowledge, as
explored by Donald Schon in his book The Reflective Practitioner.
The beauty of intuition is that it can be explored, and in doing so,
often by use of Socratic dialogue, core value systems can be identified.
In the area of euthanasia the approach taken to analysing the dilemma
seems to fall into two camps. One camp sees that life is of intrinsic
value, and the other camp sees life as of extrinsic value. Intrinsic
value, values you for who you are; extrinsic value, values you for what
you can do.
This author appears to have intuitively chosen an approach that
values life for its extrinsic value. It would be good to see a similar
philosophical article that approaches the same issue from a standpoint
where life is valued for its intrinsic value. Why? Well in the words of
another response to this article ‘human life is of immeasurable worth.’
And that is why I go to work too.
Buzan, T. (1991). The Mind Map Book . New York: Penguin.
Schon, D. 1983. The Reflective Practitioner. New York: Basic Books.
Competing interests:
None declared
Competing interests: No competing interests
The BMJ in the past has specifically praised 'evidence-based
medicine'. I was therefore appalled to find that when selecting articles
to stimulate debate on a topic as important as physician-assisted suicide,
the BMJ does not seem to have applied strict criteria.
I am referring to the second paragraph of Tannsjo's article 'moral
dimensions' when the author quotes statistics which are the result of
unpublished surveys he himself has conducted. We have no idea of the
methodology of these studies, their power or participant selection, and
yet they are used to apparently 'prove' that the 'majority' of people in
three European countries are in favour of legalising lethal injections.
Changes in end of life legislation are surely so important, with such
far-reaching consequences for the way medicine is practised in this
country, that we should not expect to come to reasoned conclusions from
unpublished and unexplained statistics.
Competing interests:
None declared
Competing interests: No competing interests
It is disappointing to see that in this discussion thread and others
relating to the PAS debate knowledge, reason and logic have become
immediate casualties.
The ethicists who have here criticised utilitarian philosophy will (I
hope) have an understanding of how fallacious their own arguments are, as
they are old and oft debated.
For instance, Rob George cites the disorganised tramp as an argument
against utilitarian bioethics(1). The "classic" mind experiment he
describes commits the "real world" fallacy that plagues most such
experiments. It does not consider(a) that such a situation would not
arise in real life and (b) the impact of the consequences of the judgement
outside of the narrow confines of the experiment. The best
consequentialist counter to this argument is that it is hard to imagine a
society with a high degree of utility (happiness) when the old, infirm and
poor are harvested for the benefit of the majority. It is also
interesting that George neglects to mention any of the objections rule-
based utilitarians would have to this argument.
Secondly, there have been comments about Tannsjo‘s dismissal of
deontological theory (2) as the basis for bioethical reasoning. In this I
believe he is entirely correct. There is much scope for debate on which
moral theory we should be using, and to date no ideal theory has been
constructed. However, the religious theories suffer from the essential
problems that they are all mutually exclusive. Would the proponents of
deontology please care to explain which theory is correct, and why?
Judaism? Christianity? Islam? Buddhism?... this list is almost endless.
In the absence of proof for the correctness of a religious viewpoint, the
validity of a religion for constructing an ethical code therefore comes
about from evaluating the ethical beliefs of such a system. This requires
reference to en external set of ethical beliefs and we may therefore
dismiss the religions as an unnecessary abstraction. (Please note however
that this does not mean that the traditions of the world's major religions
has nothing to offer in ethical debate; merely that such religions cannot
be used as the basis of a universal ethical theory).
It is good to see the start of an ethical debate on this issue, but
it must be done at a serious, thoughtful level.
(1)http://bmj.bmjjournals.com/cgi/eletters/331/7518/689
(2)http://bmj.bmjjournals.com/cgi/content/full/331/7518/689
Competing interests:
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Competing interests: No competing interests
In a general sense one doesn't have to look too far to see innocents
dying for a public interest - Iraq is the current travesty. However, to
give you a couple of philosophers, it was from Nietsche that Hilter
justified his eugenics and most recently John Harris has given us the
classical mind experiment of the 'disorganised tramp'. In this case a
selection of patients in an ITU, all of the same HLA type need organs for
their survival and are, needless to say, both great and good. Since the
tramp, also of the same HLA type, is merely a drain on society, then stict
utilitarianism dictates that he gives up his organs. I think that you will
find this in his book 'The Value of Life'. In case you think this cannot
happen, then reflect on the basis of the decision about the conjoined
twins.
Competing interests:
as per my article
Competing interests: No competing interests
Ignoring, for the sake of brevity, Tannsjo‘s prejudicial
dismissal of deontology and moral rights approaches,
and focussing on his, preferred, utilitarian approach, I
still cannot see that he makes his case. Utilitarianism,
as he describes it, should take heed of the
consequences for all involved in the decision.
However, he limits himself to a passing reference to
relations of the patient. But the true impact of legalising
euthanasia will be felt throughout the whole of society.
An open systems approach to causality teaches us to
look at the feedback loops that can result in our
best-intentioned actions having unforeseen negative
consequences ( a classic example being breeding
diseases which are resistant to antibiotics by
over-reliance on them).
In the case of euthanasia, I would predict one serious
unintended consequence will be that both patients and
the general public will trust doctors less and less. I for
one find it hard to trust a profession allegedly dedicated
to health care which campaigns for the right to kill
patients. Further, I think we should learn from the
abortion experience that predictions of a very small
number of cases are unreliable, and to recognise that if
we take the step of legalising euthanasia, we will be
opening another Pandora’s Box with practically no
possibility of closing it again, however disastrous the
unforeseen consequences.
Anyone interested in learning more about the open
systems approach to understanding change and
unforeseen consequences is welcome to email me:
Andrew Plasom-Scott
Competing interests:
None declared
Competing interests: No competing interests
It is interesting that Prof. Tannsjo does not appropriately highlight
the concept of human dignity in his article.
This is because the belief in the inviolability of life is based on
the belief of human dignity and is, therefore, not a scientific notion.
However, it is also a belief that forms the basis of all human societies.
The argument underpinning the belief in the inviolability of life is
that all human life has worth and therefore it is wrong to take steps to
end a person's life, directly or indirectly, no matter what the quality of
that life. This is in keeping with both traditional codes of medical
ethics and a general perception of what doctors and other healthcare
professionals should do, that is save and preserve life.
For example, the reason why suicide was unlawful in the UK until 1961 was
that it was considered to desecrate the dignity of life enshrined in the
United Nations’ Universal Declaration of Human Rights (1948) and the
Council of Europe’s Convention on Human Rights (1950). Thus, if a person
chooses to kill himself or herself without any attenuating circumstances,
then this action can only be considered as undermining the universal
nature of human dignity which is found in all human persons.
What a person is indeed doing when killing themselves or someone else
without attenuating circumstances is taking the responsibility of the
decision to end a life by indicating that this life is better terminated
than left to exist. In other words, at the specific moment when the
killing takes place the person being killed is no longer endowed of any
value, worth or respect (the defining aspects of human dignity) by the
person doing the killing. But this undermines the whole concept of the
universal and inviolable nature of human dignity. This is reflected in the
fact that as Articles 1 and 3 of the United Nations’ Universal Declaration
of Human Rights indicates, human dignity and the right to life are un-
separable.
This universal nature of human dignity has arisen in order to address
the unacceptable abuses which took place in the past history of humanity.
For example, before the slave trade was abolished or during the Second
World War, many persons believed that specific categories of peoples did
not have the same human dignity as themselves and were, therefore,
considered as second class citizens.
To accept that a person can ever lose his or her dignity would not
only seriously challenge the whole concept of human dignity but would be
an extremely serious precedent in a world that has fought so hard to endow
all persons with the same dignity. In addition, the concept of a person
being able to lose human dignity would dangerously undermine the most
fundamental ideas embodied in the Universal Declaration of Human Rights
which often forms the foundation of our modern societies.
Competing interests:
None declared
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Editor -
Tännsjö has valiantly attempted the probably impossible task of
summarising three complex moral theories in an all too concise space, and
concludes by finding what he sees as a utilitarian justification for
euthanasia. He states, “In utilitarianism, the aim of the act is to
provide maximum benefit”, and further, “Utilitarianism is focussed on the
patient but not only on the patient; it is focussed on everyone affected
by the decision.” These seemingly bland statements conceal difficulties in
defining benefit and determining whose benefit should be paramount.[1]
In utilitarianism, an act is judged as right if it leads to
maximisation of utility, or as Tännsjö puts it, “benefit”, of all parties
involved, no matter how distantly. Within the context of euthanasia, this
therefore includes not only the patient and family, but also friends, the
medical establishment and (tax-paying) society as a whole. Utilitarianism
does not provide a hierarchy of benefit maximisation; it rather demands
that benefit as a whole is maximised. It would be naïve to imagine that
“altruistic or sociable desires invariably outweigh hostile or competitive
desires” when calculating benefit for a group.[2]
It is not difficult to envisage a situation of a highly dependent,
demanding and ill parent with a large care package making excessive and
unfair demands on her four children to the extent that they feel their
quality of life and that of their families is severely compromised.
Utilitarian benefit-maximisation in this scenario could demand non-
voluntary euthanasia of the patient for the benefit of her children,
grandchildren and society as a whole.
Utilitarianism therefore cannot provide a cogent basis for the
legalisation of active voluntary euthanasia without mandating legalisation
of active non-voluntary and active involuntary euthanasia.
Claire Stark Toller
SpR Palliative Care,
Oxford Deanery
1. Tännsjö T. Moral Dimensions. BMJ 2005;331:689-91
2. O. O’Neill, Autonomy, individuality and consent, in O. O’Neill
(ed.) Autonomy and Trust in Bioethics Cambridge University Press 2002
Competing interests:
None declared
Competing interests: No competing interests
This week’s BMJ seems to accept the policy of neutrality towards
Physician Assisted Suicide (PAS), as if what happened at the ARM was fair
and democratic. By all accounts (1) the vote was taken at the very end of
the conference, when most of the delegates had left and only the ‘die
hard’ campaigners for the ‘die easy’ were left! The campaign for
Euthanasia has been constant, like a dripping tap, wearing us out and
acclimatizing us to ideas foreign to our profession.
It seems that the use of autonomy as a basis for a philosophy of life
is intrinsically flawed even if it is naturally, a very central part of
our decision-making processes. Put crudely, it adds up to thinking of
ourselves. “What I want” is all–important, rather than “what can I give or
contribute to this world?” I suppose the word ‘autonomy’ describes self-
centredness very well.
I found the article of Torbjörn Tännsjö (2) , particularly worrying
in this respect. He is arguing for euthanasia, not just PAS. Working back
from a position he wants to adopt, he looks for a suitable framework to
justify his feelings. By contorted and distorted arguments, he turns
common sense on its head. He follows the modern trend to make decisions by
what ‘feels right’ rather by what is objectively right. This seems to be
in complete contradiction to the evidence base requirement of the rest of
medicine.
We are used to being in control and perhaps we suffer from
unrealistic expectations, including that of controlling our death. We have
a right to express our wishes, but we live in a world where, in many
aspects of our life we do not have automatic access to what we want. Even
if we want to plan PAS, we should be prepared for unexpected events… e.g.
an allergy or vomiting up ‘the blue pill’.
The fear that has taken hold of public imagination is that of over
officious and burdensome treatment. Many people would wish not to be
ventilated indefinitely, and this is reasonable. Doctors often have to
make difficult decisions about interventions in collaboration with
expressed wishes.
As a GP I face the daily struggle of explaining to patients that
antibiotics do not cure viral colds. If something is not good or helpful,
it may not be the best solution. We do not have an automatic right to
everything we want.
He argues that Deontology does not suit his ethic as its rigidity
‘condemns murder, euthanasia, suicide and abortion’. This is why he opts
for the utilitarian relativism, which is ultra-bendable and adaptable and
thereby is incapable of giving us humans any gold standard. I have yet to
meet anyone who finds abortion a good thing. Some consider it a necessary
evil, but government policy has always been directed at lowering abortion
rates.
A person’s rights impact on the duties of others, i.e., a doctor is
being asked to hand his patient the means to kill himself. Just because
suicide is not a criminal offence, it does not make it something we should
assist people with. This is against our human instincts and the training
and practice of many doctors who spend many surgery hours ‘persuading
people to step down from the window-ledge’. PAS proposes is that we give
them a hand-up so they can jump comfortably. Surely we should look for
and treat depression, search for the real reasons for the unhappiness and
try to combat the problems one by one.
I have patients who have suffered recurrent or continuous depression
for many years, despite the best treatment. Most pass through phases of
blackness only to get better, some do not improve dramatically and
continue to play with the idea of suicide as they see no other way out.
Would the fact that they develop a cancer, or some other terminal disease,
automatically mean we should give up struggling to improve their life and
succumb to their wishes? I do not see the logic in that, or where you
would suggest we draw the line? The NHS is rationed and the resources may
not always be available. As he suggested, it would be cheaper and better
for highly dependant patients to die. This could lead to euthanasia on
demand, which is what we have witnessed to happen with abortion. The
temptation to give the ‘blue pill’ to all depressed patients who ask for
it would certainly lighten my workload by about 50%.
However in the long term this would not make economic sense, as human
richness would also be lost. Suffering can increase the insight and beauty
of life. Some of the best artists and poets have been depressed and we
would never have had the Goons without Spike.
The decisions and actions of one person can have far reaching
implications because we live in a society. Suicide can be devastating to
a family; it is a real tragedy. People can spend their lives coming to
terms with the suicide of a loved one. Not only does it give them an
irremediable feeling of failure: “Perhaps I did not love enough! What did
I do or say? Why did I not visit that night? Etc.” In addition, suicide
in the family can increase the risk of suicide in other members of that
family. I have spent many hours listening to the relatives, especially
spouses and offspring. We have to consider the effect of PAS on the
families and society in general. It is very difficult to judge an
individual’s state of mind or their motives, but I often understand from
the relatives that the act of suicide is a very selfish act.
I would propose that you leaving the ‘physician’ out PAS and use the
term ‘euthanologists’, (as someone called this new breed of henchmen) for
two reasons.
1) This would not endanger or destroy the doctor patient relationship
2) The funding would not come from an already tight health-care budget.
Anne Williams
GP Glasgow
(1) BMA News Opinion Saturday July 23 2005
(2) Torbjörn Tännsjö Taking the final step: changing the law on euthanasia
and physician assisted suicide: Moral dimensions BMJ 2005;331:689-691,
http://bmj.bmjjournals.com/cgi/content/extract/331/7518/689
Competing interests:
None declared
Competing interests: No competing interests
Whilst discussing the moral arguments that lie behind the doctrine of
double effect, Tannsjo states that there is frequent use of this doctrine
in clinical practice in Western countries. He argues that the deaths of
patients are hastened by the administration of large doses of analgesics
(with the intention of relieving pain).
This is certainly not the case in specialist palliative care practice
in the UK. Careful and appropriate titration of analgesics is not only the
most effective way of achieving pain control, but will actually reduce the
incidence of unwanted side effects (including hastening death). Every
patient will have a last dose of analgesia in the same way that they will
have a last cup of tea. This does not mean that the analgesics (or the
tea) shortened their life, merely that they were dying already.
Problems with the understanding of the doctrine of double effect and
the issue of whether it is frequently used in clinical practice were
considered by the House of Lords Select Committee on the Assisted Dying
for the Terminally Ill Bill, as well as having been highlighted by the
House of Lords Select Committee on Medical Ethics in 1994. In the presence
of these repeated warnings that misunderstandings about the doctrine of
double effect will cloud the debate on assisted dying, it is unfortunate
that Tannsjo has failed to understand the reality of clinical practice in
palliative care.
Tannsjo T. 'Moral dimensions' BMJ 2005; 331: 689-691
House of Lords Select Committee on Medical Ethics 'Report of the Select
Committee on medical ethics 1994, HL Paper 21. London: HMSO, 1994
House of Lords Select Committee on the Assisted Dying for the Terminally
Ill Bill 'Assisted Dying for the Terminally Ill Bill [HL], Volume II, HL
Paper 86-II. London: HMSO, 2005
Competing interests:
None declared
Competing interests: No competing interests
A utilitarian argument against euthanasia
Tannsjo is correct to observe that the same philosophical starting
points can be used to arrive at very different outlooks. For example, I
can use utilitarianism to oppose euthanasia.
Utilitarianism is an ethical approach that attempts to maximise
happiness for society or humanity. Its founder, Jeremy Bentham, claimed
that “nature has placed mankind under the governance of two sovereign
masters, pain and pleasure. It is for them alone to point out what we
ought to do, as well as to determine what we shall do. On the one hand the
standard of right and wrong, on the other the chain of causes and effects,
are fastened to their throne. They govern us in all we do, in all we say,
in all we think.” (1) He deveolped the proposition thus: “it is the
greatest happiness of the greatest number that is the measure of right and
wrong.” However, his subsequent reflection that “it is vain to talk of the
interest of the community without understanding what is the interest of
the individual” supposedly threw his model into confusion. Which had
become more important to him: the individual or the greatest number?
I believe he still favoured community happiness over individual
happiness. After all, he believed that the role of law was to delimit
autonomy, and that the creation of rights destroyed all notion of liberty.
For example, in Anarchial Fallacies (2) he wrote: “The great enemies of
public peace are the selfish and dissocial passions, necessary as they
are, the one to the very existence of each individual, the other to his
security. On the part of these affections, a deficiency in point of
strength is never to be apprehended: all that is to be apprehended in
respect of them, is to be apprehended on the side of their excess. Society
is held together only by the sacrifices that men can be induced to make of
the gratifications they demand: to obtain these sacrifices is the great
difficulty, the great task of government. What has been the object, the
perpetual and palpable object, of this declaration of pretended rights? To
add as much force as possible to these passions, already but too strong, -
- to burst the cords that hold them in, -- to say to the selfish passions,
there - everywhere -- is your prey! -- to the angry passions, there -
everywhere -- is your enemy.”
How might Bentham have applied these ideas to the legalisation of
euthanasia? Firstly, euthanasia might eliminate physical and existential
pain in the person wishing to be euthanased. It might also provide some
comfort to anyone who believed that the person would be better off dead,
although this sense of comfort would presumably be counterbalanced by the
grief of bereavement. It would actually create emotional pain in those
opposed to euthanasia, either through intimate involvement with a
particular case or through a general objection to the whole principle.
Secondly, a euthanased person cannot be confidently described as being in
a state of pleasure. Even third parties who thought that death was the
best option could hardly be described as pleased after the death: unless
malicious, they would probably express regret that euthanasia seemed the
most appropriate choice. Those opposed to the act from the outset would
definitely be displeased. Therefore, I suggest that a chain of causes and
effect that both eliminates and creates pain whilst pleasing nobody is
unlikely to measure up favourably to the utilitarian standard of right and
wrong as understood by Bentham. Euthanasia would not have featured as part
of his delimited autonomy, and he rejected the notion of rights.
Philosophy often has a superficial softness to it, but I often find
it very harsh for the simple reason that its objectivity can trivialise
something very important: human feeling. For example, Bentham once said:
“The question is not, "Can they reason?" nor, "Can they talk?" but rather,
"Can they suffer?"” I suspect that he was not afraid of answering in the
affirmative, particularly when rights, which in his eyes were misconceived
notions, potentially threatened the greatest happiness of the greatest
number. Whatever the outcome of the parliamentary debate on assisted
dying, there will still be pain and there will still be pleasure. We must
only hope that the whole process will help generate the greatest happiness
of the greatest number.
(1) Bentham J. The Principles of Morals and Legislation, 1781
(2) Bentham J. Critique of the Doctrine of Inalienable, Natural
Rights. From Jeremy Bentham, Anarchical Fallacies, vol. 2 of Bowring
(ed.), Works, 1843.
Competing interests:
Hospice doctor
Competing interests: No competing interests