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In Defense of Voluntary Active Euthanasia and Assisted Suicide by Michael Tooley

In Defense of Voluntary Active Euthanasia and Assisted Suicide by Michael Tooley

In this essay I shall defend the following two claims: first, given appropriate circumstances, neither voluntary active euthanasia nor assisting someone to commit suicide is in any way morally wrong; secondly, there should be no laws prohibiting such actions, in the relevant cases.

The discussion is organized as follows. First, I set out some preliminary concepts and distinctions. Then, in the next two sections, I offer two arguments in support of the thesis that assisted suicide and voluntary active euthanasia are not morally wrong. Finally, I ask whether there is any reason for thinking that, even if, as I have argued, voluntary active euthanasia and assisted suicide are not morally wrong, they should, nevertheless, not be legally permitted – and I argue that this is not the case.

Important Concepts and Distinctions

Writers on this topic define the term “euthanasia” in quite different ways. In the following discussion, I shall use the term “euthanasia” to refer to any action where a person is intentionally killed or allowed to die because it is believed that the individual would be better off dead than alive – or else, as when one is in an irreversible coma, at least no worse off. So understood, under what conditions, if any, is euthanasia morally acceptable, and should it ever be legally permitted?

Two familiar distinctions are important here. First, there is the threefold distinction involving voluntary euthanasia, non-voluntary euthanasia, and involuntary euthanasia. Thus, euthanasia is voluntary if the person who undergoes it has requested it. It is non-voluntary if the person is unable to indicate whether or not he or she wants to undergo euthanasia. (This will include, for example, cases involving infants, and adults who have permanently lost consciousness.) Finally, it is involuntary if the person in question wants to go on living.

The second important distinction is between active euthanasia and passive euthanasia. How this distinction is best drawn is controversial, and there are two slightly different ways of doing so, depending upon how cases involving the withdrawal of life-support systems are classified. Thus, one way of drawing the distinction is in terms of the contrast between acting and doing nothing at all: it is active euthanasia whenever anything at all is done – including the withdrawal of a life-support system – that facilitates the person’s death, and passive euthanasia only if nothing is done that brings about the person’s death.

A different way of drawing the distinction is in terms of whether what might be called the “primary cause” of death is some human action, or, instead, an injury or disease: one has a case of active euthanasia whenever the primary cause of death is human action, and a case of passive euthanasia whenever the primary cause of death is some injury or disease.

Precisely where the line should be drawn between active euthanasia and passive euthanasia is important if one holds, as a significant number of people do, that passive euthanasia is morally permissible, but that active euthanasia is not. Here, however, we can ignore this issue, given that my goal is to argue that voluntary active euthanasia is morally permissible.

Before turning to a defense of assisted suicide and voluntary active euthanasia, it should be noted that some opponents of voluntary active euthanasia and assisted suicide define the term “euthanasia” much more narrowly than I have done – indeed, often very narrowly indeed. This is especially so in the case of writers who are defending the Roman Catholic view on these issues. Thus, for example, Daniel Callahan offers the following definition: “By euthanasia I mean the direct killing of a patient by a doctor, ordinarily by means of a lethal injection” (2005: 189, n.1).

Notice that such a definition is narrower that what I have offered in three ways. First, cases where one allows a person to die do not get classified as euthanasia, even if one’s intention is precisely the same as when one kills a person to enable that person to escape from the suffering that he or she is undergoing. Secondly, cases where, for example, a doctor administers a dose of morphine that it is known will cause death via respiratory failure do not get classified as cases of euthanasia, since it is held that the killing is not “direct”: the doctor’s intention is, it is said, merely to relieve the pain, not to kill, even though the doctor knows that the action will kill the patient. Finally, by incorporating the restriction to terminally ill persons, cases where a person is not terminally ill, but is suffering greatly from pain that cannot be relieved, are being defined as lying outside the scope of euthanasia.

Such a definition of “euthanasia” seems to me ill-advised in the extreme. In the first place, one is deprived of crisp and very useful expressions – such as “passive euthanasia” – for referring to cases where a terminally ill person is allowed to die. Secondly, and more seriously, the person who identifies euthanasia with the direct killing of a terminally ill person typically does so because he or she views the indirect killing of a terminally ill person as morally unproblematic, and similarly for an action of merely allowing a terminally ill person to die. If one holds, however, that such actions are morally permissible, but that the direct killing of a terminally ill person is morally wrong, then among the most crucial issues that one needs to address are, first, why the direct versus indirect distinction has such moral significance, and, secondly, why the same is true in the case of the distinction between killing and letting die. If one defines euthanasia broadly, as I have done, those issues are immediately in front of one. By contrast, a narrow definition of euthanasia makes it very easy to pass over those crucial questions without even any comment, let alone careful discussion and argument.

A Fundamental Defense of Assisted Suicide and Voluntary Active Euthanasia

The argument

A very plausible argument in support of the claim that voluntary active euthanasia and assisted suicide are not morally wrong in themselves is as follows:

(1) If a person is suffering considerable pain due to an incurable illness, then in some cases that person’s death is in his or her own interest.

(2) If a person’s death is in that person’s own interest, then committing suicide is also in that person’s own interest.

(3) Therefore, if a person is suffering considerable pain due to an incurable illness, then in some cases committing suicide is in that person’s own interest. (From (1) and (2).)

(4) A person’s committing suicide in such circumstances may very well also satisfy the following two conditions:

(a) it neither violates anyone else’s rights, nor wrongs anyone; (b) it does not make the world a worse place.

(5) An action that satisfies conditions (a) and (b), and that is not contrary to one’s own interest, cannot be morally wrong.

(6) Therefore, a person’s committing suicide when all of above conditions obtain would not be morally wrong. (From (3), (4), and (5).)

(7) It could be morally wrong to assist a person in committing suicide only if (i) it was morally wrong for that person to commit suicide, or (ii) committing suicide was contrary to the person’s own interest, or (iii) assisting the person to commit suicide violated an obligation one had to someone else.

(8) Circumstances may very well be such that neither assisting a person to commit suicide nor performing voluntary active euthanasia violates any obligations that one has to others.

(9) Therefore, it would not be wrong to assist a person in committing suicide in the circumstances described above. (From (3), (6), (7), and (8).)

(10) Whenever assisting a person in committing suicide is justified, voluntary active euthanasia is also justified, provided the latter action does not violate any obligation that one has to anyone else.

(11) Therefore, voluntary active euthanasia would not be morally wrong in the circumstances in question. (From (8), (9), and (10).)

This argument, progressing from suicide, through assisted suicide, and on to voluntary active euthanasia, is a very natural one, and the assumptions involved seem quite modest. But is the argument sound? Next, I shall argue that it is.

The soundness of the argument

Anyone who holds that assisted suicide and voluntary active euthanasia are never in themselves morally permissible must hold that the above argument is unsound. Can that contention be sustained? I shall argue that it cannot.

An argument can be unsound in two different ways. First, it may involve fallacious reasoning. Secondly, it may contain one or more false premises. Anyone who wishes to reject the conclusion of the above argument needs to show, therefore, that it is defective in one (or both) of these ways.

As regards the first possible shortcoming, the fundamental way of determining whether an argument contains any fallacious reasoning is to formulate the argument in a logically rigorous way, and then to determine whether each step in the reasoning is in accordance with some truth-preserving rule of inference. But one can also go back to the definition of validity, according to which a given inference is deductively valid if it is logically impossible for the conclusion to be false if all of the premises are true. In setting out the above argument, I have indicated, for each step in the reasoning, what earlier statements the conclusion is supposed to follow from. Readers can therefore ask themselves, in each case, whether the conclusion drawn could possibly be false if the relevant premises were true, and I suggest that, when this is done, it will be seen that the argument is deductively valid.

If this is right, then the argument can only be unsound if at least one of the premises is false. So let us consider whether any good reason can be offered for rejecting any of the premises.

The starting point of the argument is the following claim:

(1) If a person is suffering considerable pain due to an incurable illness, then that person’s death may very well be in his or her own interest.

This claim is, I suggest, very plausible indeed. For one thing, the level of suffering that people undergo in connection with some incurable illnesses is such that they come to hope that death will occur sooner rather than later. In addition, when death does come in such cases, those who loved the individual who has died welcome death, and view it as in the interest of the individual in question. Let us consider, then, the second premise:

(2) If a person’s death is in that person’s own interest, then committing suicide is also in that person’s own interest.

Some would argue that this premise is false. In particular, Roman Catholic philosophers who accept the teachings of their church would argue that even if one is in a situation where one would be better off dead than alive, it is not in one’s interest to bring about one’s own death, since suicide is a mortal sin, and this means that someone who makes a fully informed decision to commit suicide will wind up much worse off, since they will suffer eternal torment in Hell.

A full answer to this question would require a major detour through the philosophy of religion. A brief response, however, is as follows. The Catholic Church holds that many things, beside suicide, are mortal sins – including masturbation, any type of premarital sexual activity, homosexual sex, and the use of contraceptives within marriage. Anyone who wishes to appeal to the authoritative teachings of the Catholic Church in order to object to the second premise needs to be prepared, accordingly, to argue that the Catholic Church is right in holding that the other actions just mentioned also place one at serious risk of spending eternity in Hell. I would suggest that the chances of successfully doing this are not very great. The third premise of my argument was this:

(4) A person’s committing suicide in such circumstances may very well also satisfy the following two conditions:

(a) it neither violates anyone else’s rights, nor wrongs anyone; (b) it does not make the world a worse place.

This premise is, I suggest, very plausible. For while it is true that many people who are thus suffering have obligations to others – especially their husbands or wives, and their children – the obligations in question are typically ones that they could not possibly meet, given that they are in a state of extreme pain. In addition, most obligations are not of such a nature that one is morally obliged regardless of the cost to oneself, so that even if one could meet certain prima facie obligations by soldiering on in the face of extreme pain, it will rarely be the case that one acts wrongly if, in those circumstances, one does not meet the prima facie obligation. Finally, the ending of one’s life, in such circumstances, will not only end one’s own suffering; it will also end the emotional suffering experienced by those who love one. So, in general, the ending of a person’s life in such circumstances will make the world a better place, not a worse one.

Some opponents of euthanasia would object, however, that although suicide may very well not violate the rights of other humans, it does not follow that condition (4a) is satisfied. Moreover, that condition, they would contend, is in fact never satisfied, since all lives belong to God, and so the destruction of anyone’s life – including destruction by the person in question – violates God’s right of ownership.

This ‘divine ownership’ objection is unsound for at least three reasons. First, it can be shown that many bad things that are present in the world, such as undeserved suffering, make it very unlikely that God, understood as an all-powerful, all-knowing, and perfectly good being, exists. Secondly, persons cannot be the property of others, since autonomy is a right that persons possess by virtue of their nature as beings capable of conscious experience, thought, and rational choice. Thirdly, consider sentient beings that are not persons. Such beings can be owned, but ownership does not make it permissible to compel such beings to suffer. Similarly, if, contrary to the second point, persons could be owned by others, that would still not render it permissible to prohibit persons from committing suicide when that was in their rational self-interest, and not morally wrong.

The fourth premise of the argument was this:

(5) An action that satisfies conditions (a) and (b), and that is not contrary to one’s own interest, cannot be morally wrong.

The claim that this premise is plausible can be supported as follows. First of all, it initially seems plausible that for an action to be wrong, there must be some individual – either a person, or a sentient being that is not a person – who is wronged by the action. But if condition (a) is satisfied, then no one else is wronged, and so the only possibility is that in ending one’s own life, one is wronging oneself. We are considering, however, a case where suicide is, by hypothesis, in one’s own interest. But if an action is in one’s own interest, how can one do wrong to oneself by performing that action? Surely one cannot. If so, then the upshot is that no one – either oneself or anyone else – is wronged by the action.

So far, so good. However, reflections concerning future generations have convinced many philosophers that an action may be wrong even if it wrongs no one (Parfit, 1984: 357–61). For consider two actions, one of which will lead to future generations that enjoy an extremely high quality of life, and the other of which will result in future generations that have lives worth living, but only barely so. Other things being equal, would not the second action be morally wrong? But notice that there may be no one who is worse off if the second action is performed, since it may be that none of the people who have lives worth living, but only barely so, when the second action is performed, would have existed if the first action had been performed, while the people who would have enjoyed lives of very high quality if the second action had been performed are not worse off, since they never exist. So it would seem that no one is wronged if the second action is performed, since no one is worse off.

What is true, however, is that the world is a worse place given the second action than it would have been if the first action had been performed. So if, as is generally thought, the second action is wrong, then a natural conclusion is that actions can be wrong if, even though they wrong no one, they make the world a worse place than it would otherwise be.

The reason for including condition (b) in statement (5), accordingly, is to address this possibility. This having been done, it would seem, then, that the fourth premise, thus formulated, is very plausible.

The fifth premise of my argument was this:

Here, the supporting line of thought is this. Suppose that someone is considering performing an action that is not morally wrong. How could it be wrong to help them to perform that action? Two possibilities come to mind. First, it could be that while it was not morally wrong for the other person to perform the action, it was an action that was very seriously contrary to that person’s own best interests, and that, because of this, it would be wrong for one to provide the person with assistance in performing the action. Secondly, it could be that one has obligations to someone else that one would violate if one helped the person to perform the action in question. One might, for example, belong to a religious group where it is a condition of membership that one does not provide assistance to someone in committing suicide.

In the absence of either of these circumstances, however, is there any way in which it could be wrong to help a person to commit suicide? It is, I suggest, very hard to see any other possibility here. It would certainly seem, then, that the fifth premise is justified.

The sixth premise was this:

(8) Circumstances may very well be such that neither assisting a person to commit suicide nor performing voluntary active euthanasia violates any obligations that one has to others.

The ground for accepting this premise is simply that, while one might have obligations to others that would make it wrong for one to assist someone to commit suicide, or for one to perform voluntary active euthanasia – obligations that arose, for example, from membership in some religious group, or professional union, that prohibited such actions – it will not in general be true that one has such obligations. Finally, the concluding premise of my argument was this:

(11) Whenever assisting a person in committing suicide is justified, voluntary active euthanasia is also justified, provided the latter action does not violate any obligation that one has to anyone else.

Here the thought is simply this. Provided that one does not have any obligations to others that would make it wrong for one to provide someone with voluntary active euthanasia, then the difference between helping someone to end his or her life, and doing it for that person, cannot be morally significant. So the final assumption in the argument is justified.

Voluntary Passive Euthanasia versus Voluntary Active Euthanasia

The argument

My second argument in support of the thesis that voluntary active euthanasia and assisted suicide are not morally wrong in themselves focuses upon the relationship between active and passive euthanasia. To arrive at that argument, consider the following closely related, well-known argument:

(1) Voluntary passive euthanasia is not morally wrong in itself.

(2) Intentionally killing a person and intentionally letting a person die are, in themselves, morally on a par.

(3) The only intrinsic difference between voluntary active euthanasia and voluntary passive euthanasia is that the former is a case of killing, and the latter a case of letting die.

(4) Therefore, voluntary active euthanasia is not morally wrong in itself. (From (1), (2), and (3).)

Given that (3) is true by definition, and that few think that (1) is mistaken, the crucial premise in the argument appears to be (2). Is it true, then, that killing and letting die are morally on a par? The answer is not entirely clear. On the one hand, a number of philosophers have argued that intentionally killing and intentionally letting die have precisely the same moral status (Oddie, 1997, 1998; Rachels, 1975; Tooley, 1980). One very interesting way of attempting to establish this conclusion, for example, is by means of a “Bare Difference Argument,” where the basic idea is to focus upon two cases, each involving a person’s death, that differ only in that one is a case of killing, and the other a case of letting die, and where there does not appear to be any morally significant difference between the two cases. (See, for example, Rachels, 1975: 79.) If there are such cases, must it not follow that there is no intrinsic moral difference between killing and letting die?

The status of Bare Difference Arguments has been disputed, with many philosophers holding that this form of argument is sound (Malm, 1992; Oddie, 1997; Rachels, 1979), and others holding that it is not sound (Beauchamp, 1977; Foot, 1977: 101–2; Kagan, 1988). On the face of it, the argument certainly appears sound. The problem, however, is that there are cases where the intuitions of most non-consequentialists are that killing and letting die are not morally equivalent. One of the most famous cases, discussed at length by Harris (1975), involves the possibility of killing a healthy person in order to use that person’s organs to save two people who need transplants if they are to survive. If killing and letting die are morally on a par, shouldn’t killing one person to save two be not only permissible, but also commendable, and perhaps obligatory? Many people, however, feel that that is not so.

I think it can be shown that the Bare Difference Argument is sound. What I shall do here, however, is argue instead that one can avoid this controversial question by shifting from the above argument to a slightly different one.

To see how this can be done, consider the following, asymmetry principle:

(A) Both the property of killing a person and the property of allowing a person to die arewrong-making properties of actions, but the former is a weightier wrong-making property than the latter.

If this principle were correct, then statement (2) in the argument above would be false, and the argument itself would fail. But principle (A) is not sound. The reason is that, as David Boonin (2000: 160–1) has contended, any grounds for holding that there is a moral difference between killing and letting die must also be grounds for holding that a certain much more general principle is correct – the principle, namely, that intentionally causing a given harm is intrinsically more wrong than intentionally allowing that harm to occur. Or, to put it in terms of wrong-making properties:

(B) Both the property of intentionally causing a harm, and the property of intentionally allowing a harm to occur, are wrong-making properties of actions, but the former is a weightier wrong-making property than the latter.

But if this is right, then to the extent that the killing versus letting die distinction is morally significant, it is so precisely because it is just an instance of the more general distinction between intentionally causing harm and intentionally allowing harm to happen. But then the original asymmetry principle stated above cannot be an accurate formulation of what may be true in the killing versus letting die case, since it fails to distinguish between cases where killing and letting die are harms and cases where they are benefits. What is needed, then, is not (A), but the following, modified asymmetry principle:

(C) Both the property of killing a person, when the killing harms the person, and the property of allowing a person to die, when allowing the person to die harms the person, are wrong-making properties of actions, but the former is a weightier wrong-making property than the latter.

Next, given (B), the question naturally arises as to whether there is a corresponding principle dealing with benefits, and, in response, I would suggest that if (B) is plausible, then the following principle must also be plausible:

(D) Both the property of intentionally causing a benefit, and the property of intentionally allowing a benefit to occur, are right-making properties of actions, but the former is a weightier right-making property than the latter.

Or, at the very least, if (B) is plausible, then surely the following more modest variant on (D) must also be plausible:

(E) Both the property of intentionally causing a benefit, and the property of intentionallyallowing a benefit to occur, are right-making properties of actions, but the former is at least as weighty a right-making property as the latter.

But then, finally, if (E) is plausible, then surely the following principle must also be acceptable:

(F) Both the property of killing a person, when the killing benefits the person, and the property of allowing a person to die, when allowing the person to die benefits the person, are right-making properties of actions, and the former is at least as weighty a rightmaking property as the latter.

Given principle (F), the argument that I want to advance is then as follows:

(1) Voluntary passive euthanasia is not morally wrong in itself.

(2) Both the property of killing a person, when the killing benefits the person, and the property of allowing a person to die, when allowing the person to die benefits the person, are right-making properties of actions, and the former is at least as weighty a right-making property as the latter.

(3) The only intrinsic difference between voluntary active euthanasia and voluntary passive euthanasia is that the former is a case of killing, and the latter a case of letting die.

(4) Therefore, voluntary active euthanasia cannot be morally worse in itself than voluntary passive euthanasia. (From (2) and (3).)

(5) Therefore, voluntary active euthanasia is not morally wrong in itself. (From (1) and (4).)

An evaluation of the second argument

The argument just set out starts from the following premise:

(1) Voluntary passive euthanasia is not morally wrong in itself.

This is a claim that few would challenge, as the view that voluntary passive euthanasia is, in general, morally permissible is very widely accepted indeed. But it is not really a claim that should be taken for granted, especially given that many arguments offered against voluntary active euthanasia are in fact arguments against voluntary passive euthanasia as well (Tooley, 1995).

How, then, should one defend this premise? My own approach would be to defend this by the same line of argument that I used earlier to defend the view that suicide is not morally wrong, at least in certain circumstances. Those who hold that suicide is morally wrong would need, of course, to argue along different lines, but that is not something that we need to consider here.

The second premise of the argument is this:

(2) Both the property of killing a person, when the killing benefits the person, and the property of allowing a person to die, when allowing the person to die benefits the person, are right-making properties of actions, and the former is at least as weighty a right-making property as the latter.

How might this premise be challenged? The only challenge, I think, that deserves serious consideration is one that argues that the property of killing a person, when the killing benefits the person, cannot be a right-making property of actions, since the direct killing of an innocent person is always wrong in itself.

The proper response to this challenge to the second premise is, I suggest, to ask what basis can be offered for the claim that the direct killing of innocent persons is always morally wrong in itself. One possibility would be an axiological underpinning, according to which the existence of innocent persons is valuable, in the sense of making the world a better place. But this way of attempting to explain the principle in question is open to two serious objections. The first is that if this explanation of the wrongness of killing innocent persons were correct, then intentionally refraining from bringing innocent persons into existence would also be morally wrong, and to the very same degree, since the failure to create an object that would have a certain value makes precisely the same difference with regard to the overall value of the world as the destruction of an already existing object of the same sort, other things being equal. But the failure to bring an innocent person into existence is not morally on a par with destroying an innocent person who already exists. So the principle that the direct killing of innocent persons is always wrong in itself cannot be explained axiologically.

The second objection is this. Consider an innocent person who is suffering terribly from an incurable illness, and who would prefer to be killed, rather than to go on living. If one holds that killing such a person would be wrong because one would thereby be destroying something of value, then one should also hold that one would make the world a better place by creating an additional innocent person who one knew would suffer to the same degree as a result of the same incurable disease. But the latter, surely, is very implausible.

A second way of attempting to defend the claim that the direct killing of an innocent person is always wrong in itself is by appealing to the idea of rights, and by holding that such an action is wrong because an innocent person has a right to life. But this account is also open to at least two objections. The first is that people can, in general, waive their rights. Thus, for example, the fact that one has a right to some object does not mean that one does something wrong if one destroys it, or gives it to someone. Why, then, should the situation be any different with regard to the right to life? Why shouldn’t it be permissible, for example, to commit suicide? Why should the right to life not be a right that, like other rights, one can waive?

A second, and deeper objection involves asking how rights function. A plausible view, I suggest, is that rights function in two ways. First, they function to protect an individual’s interests. Secondly, they function to provide individuals with the freedom to make decisions concerning what they will do with their lives. But if this is correct, then when a person wants to die, helping her to do so will further that person’s autonomy, while if it is in the person’s interest to be dead, killing that person will further that person’s interests. So if rights function to protect interests and autonomy, then, when both the relevant conditions are satisfied, so that it is in the person’s interest to be killed, and the person asks to be killed, granting that request will not be contrary to either of the things that rights function to protect. Accordingly, the claim that the direct killing of an innocent person is always wrong in itself cannot be defended by appealing to the idea of rights. The conclusion that will be supported by an appeal to the idea of a right to life will be, at most, the much more limited one that the killing of an innocent person is wrong in itself if that action is either contrary to what the person really wants, or contrary to the person’s interest.

The third and final premise of the second argument is this:

(3) The only intrinsic difference between voluntary active euthanasia and voluntary passive euthanasia is that the former is a case of killing, and the latter a case of letting die.

But this is unproblematic, since it follows from the relevant definitions.

In conclusion, then, the second argument also appears to provide a sound justification for the claim that voluntary active euthanasia is morally acceptable. It is then a straightforward matter to argue that the same is true of assisting a person to commit suicide, in the appropriate circumstances.

Should Assisted Suicide and Voluntary Active Euthanasia Be Legal?

If assisted suicide and voluntary active euthanasia are morally permissible, what should their legal status be? Certainly, the fact that an action is not morally wrong constitutes strong prima facie grounds for concluding that it should not be illegal. It is possible, however, for actions that are not morally wrong nevertheless to be such as should be prohibited, on the ground that allowing the actions in question would give rise to other actions that would harm individuals, or violate their rights. Further consideration is therefore necessary, and so, in this final section, I shall consider three important objections to the legalization of assisted suicide and voluntary active euthanasia.

The first argument, put forward by Yale Kamisar (1958), focuses upon possible harm to those who choose to undergo euthanasia. The thrust of Kamisar’s argument is that if voluntary active euthanasia is available, some people will choose to be killed in circumstances where being killed is contrary to their interest.

Kamisar’s argument is problematic in two ways. In the first place, if a person were tempted to choose euthanasia in a situation where that was contrary to that person’s own interest, and where the person was not emotionally disturbed, it is hard to see why, if the person were presented with the reasons why it would be better to go on living, he or she would be unable to appreciate the force of those reasons.

In the second place, it can be shown (Tooley, 1995) that the possibilities for irrational choice that Kamisar proposes, whatever weight they have, generally have precisely as much weight in the case of voluntary passive euthanasia. So one cannot, as Kamisar does, hold that such possibilities constitute grounds for not legalizing active euthanasia without equally holding that they are also grounds for not allowing passive euthanasia.

The other two arguments against legalization deserve more careful consideration. First, there are what are often referred to as “wedge” or “slippery slope” arguments against voluntary active euthanasia. These come in two forms. Both maintain that legalizing active euthanasia would be a mistake because doing so would be likely to lead to undesirable consequences involving the legalization of other things. According to one version of the argument, these consequences would follow by virtue of a logical relation: if one legalizes voluntary active euthanasia, then logical consistency requires that one also legalize, for example, involuntary euthanasia (Sullivan, 1975: 24). The second version of the wedge argument, by contrast, maintains that the undesirable consequences would follow simply due to certain facts about human psychology.

The problem with the “logical consistency” version of the argument will be clear from the discussion in the previous section. For the present argument can be seen to rest upon the assumption that the relevant basic moral principle involved here is something along the lines of

(1) The direct killing of an innocent person (or, alternatively, an innocent human being) is always wrong in itself.

But as we in effect saw earlier, such a principle is not correct. It needs to be replaced, instead, by a principle such as

(2) Innocent persons have a right to life.

But then the point is that, while (2) does support a claim such as

(3) It is prima facie wrong to kill an innocent person if it is in that person’s interest to go on living, or if the person has not given permission to have his or her life terminated.

It does not support a claim such as

(4) It is prima facie wrong to kill an innocent person who has a fixed and rational desire to be dead, and who has given permission to have his or her life terminated.

Thus, once the unsound claim that the direct killing of an innocent person is always wrong in itself is replaced by the sound principle that innocent persons have a right to life, the present argument collapses, since one can consistently hold both that voluntary active euthanasia is morally permissible and that involuntary euthanasia is not.

The second form of the wedge argument, by contrast, need not involve any unsound assumption about the relevant moral principles. For here it is granted, at least for the sake of argument, that voluntary active euthanasia is not wrong in itself. It is then argued, however, that acceptance of voluntary active euthanasia may lead to the acceptance of actions that are wrong in themselves – such as involuntary active euthanasia.

But what reasons are there for thinking that this will take place? Kamisar, in advancing this version of the wedge argument, offers three reasons. First, he claims that advocates of the legalization of voluntary active euthanasia often seem to hold that the case for legalizing certain types of non-voluntary euthanasia is at least as compelling as legalizing voluntary active euthanasia (1958: 1027–8). Secondly, he cites a poll that measured the amount of public support for, on the one hand, euthanasia for defective infants and, on the other hand, euthanasia for incurably and painfully ill adults, and where the result was that more people approved of the former than of the latter (45 percent versus 37.3 percent) (1958: 1029). Finally, Kamisar appeals (1958: 1031–2) to what happened under the Nazis, citing the description offered by Leo Alexander (1949; emphasis in original):

The beginnings at first were merely a subtle shift in emphasis in the basic attitude of the physicians. It started with the acceptance of the attitude, basic in the euthanasia movement, that there is such a thing as life not worthy to be lived. This attitude in its early stages concerned itself merely with the severely and chronically sick. Gradually the sphere of those to be included in this category was enlarged to encompass the socially unproductive, the ideologically unwanted, the racially unwanted and finally all non-Germans.

But it is important to realize that the infinitely small wedged-in lever from which this entire trend of mind received its impetus was the attitude toward the non-rehabilitable sick.

How strong are the considerations offered by Kamisar? The problem with the first two types of support that he offers is that they concern attitudes toward nonvoluntary euthanasia, and so they are not relevant to the claim that one is in danger of sliding down a slope that leads from voluntary active euthanasia to things that are morally wrong unless one holds that non-voluntary euthanasia – as contrasted with involuntary euthanasia – is morally wrong. But, in the first place, this is a deeply controversial claim, as is shown by one of the very facts that Kamisar cites – namely, that more Americans in the poll that he referred to approved of euthanasia in the case of “defective infants” than in the case of “incurably and painfully ill adults.” Secondly, there are strong arguments that can be offered in support of the moral acceptability of euthanasia in the case of severely defective infants – arguments that Kamisar does not even address.

This leaves Kamisar’s appeal to the case of Nazi Germany. Here there are at least two questions that need to be asked. The first is whether the claim that is advanced in the above passage is in fact correct. For some writers – such as Marvin Kohl (1975) and Joseph Fletcher (1973) – have argued that the Nazi mass murders, rather than growing out of attitudes toward the non-rehabitable sick, were based upon the idea of the protection and purification of the Aryan stock, and upon an intense anti-Semitism – and one that was long established in Europe (Hay, 1951). Moreover, if one examines Hitler’s Mein Kampf, there appears to be very strong evidence for that view, and against Leo Alexander’s claim. Consider, for example, the following passages:

What we must fight for is to safeguard the existence and reproduction of our race and our people, the sustenance of our children and the purity of our blood, the freedom and independence of the fatherland, so that our people may mature for the fulfillment of the mission, allotted it by the creator of the universe. (Hitler, 1971: 214)

The Jewish doctrine of Marxism . . . withdraws from humanity the premise of its existence and culture. As a foundation of the universe, this doctrine would bring about the end of any order intellectually conceivable to man. And as, in this greatest of all recognizable organisms [humans], the result of an application of such a law could only be chaos, on earth it could only be destruction for the inhabitants of this planet.

If, with the help of his Marxist creed, the Jew is victorious over the other peoples of the world, his crown will be the funeral wreath of humanity and this planet will, as it did thousands of years ago, move through the ether devoid of men. (Hitler, 1971: 65)

In the light of passages such as these, Leo Alexander’s claim that the starting point of the holocaust was “with the acceptance of the attitude, basic in the euthanasia movement, that there is such a thing as life not worthy to be lived” seems clearly untenable.

Secondly, even if Leo Alexander were right, one would still need to go on to ask to what extent the Nazi experience, which occurred in a dictatorship, is a good indicator of what is likely to happen in a democratic society such as the United States.

The answer, surely, is that it is not: if someone in the United States were to advocate such a program, the opposition would be overwhelming.

Finally, it is also possible to offer empirical evidence against the wedge argument, as is done, for example, by Rachels (1993: 62). He argues that there is “historical and anthropological evidence that approval of killing in one context does not necessarily lead to killing in different circumstances,” and cites, as illustrations, the killing of defective infants in various societies, and the killing of people in self-defense in our own society. So there is good reason for thinking that people are perfectly capable of drawing clear and firm moral lines, and therefore are not in danger of sliding down what are claimed to be slippery slopes.

In addition, however, one can now offer empirical evidence of a very direct sort, since there is a society where voluntary active euthanasia has, for the past few years, been permitted – namely, the Netherlands. For while some who oppose legalization of voluntary active euthanasia have claimed that the Dutch experiment provides support for the slippery slope argument – on the grounds that there have been cases of involuntary euthanasia in the Netherlands – in fact the opposite is the case, as emerges if one compares the situation in the Netherlands with what obtains in societies where voluntary active euthanasia is not permitted. In particular, if one compares the results of surveys carried out in the Netherlands in 1990 and 1995, and in Australia in 1995–6, the following facts emerge. First, in the Netherlands, the percentage of active terminations without the patient’s explicit consent fell from 0.8 percent to 0.7 percent over the period from 1990 to 1995, whereas, in Australia, the percentage of such cases in 1995–6 was 3.5 percent – that is, five times higher than in the Netherlands. Secondly, in the Netherlands, in 1995, 13.5 percent of all deaths involved a decision to withhold or withdraw treatment, whereas in Australia in 1995–6, this occurred in 30.5 percent of cases. Moreover, in Australia, in 22.5 percent of the cases, the decision to withhold or withdraw treatment was done without the patient’s explicit consent (Kuhse et al., 1997; Oddie, 1998). The conclusion, accordingly, is that the rights of individuals are more likely to be violated when voluntary active euthanasia is illegal, than when it is permitted.

This brings me to the final objection that I shall consider to the legalization of voluntary active euthanasia. The thrust of this objection is that there are serious problems about how to implement the legalization of euthanasia. Should there be no laws at all concerning voluntary active euthanasia? That surely would lead to significant abuse. But if laws are needed, what form should they take? If the laws introduced complex and stringent procedures, then relatively few people who would benefit from voluntary active euthanasia might wind up being able to do so. On the other hand, if the procedures were very relaxed ones, wouldn’t the likelihood of abuses re-emerge?

In response to this problem, Rachels (1993: 63–5) has suggested that one can bypass the problem of writing difficult and detailed legislation dealing with when voluntary active euthanasia is permissible by instead introducing a rule to the effect that, just as the fact that a killing has been done in self-defense may serve as a defense against a charge of homicide, so the fact that a killing was one of voluntary euthanasia could function in the same way – that is, as a satisfactory defense against a charge of homicide.

Rachels’s proposal is an interesting one, and it would certainly appear to be a desirable change. It is unclear, however, how much access people would have to voluntary active euthanasia as a result. But perhaps one could combine Rachels’s suggestion with the introduction of rather conservative legislation that would prescribe procedures under which voluntary active euthanasia, in certain clear-cut types of case, would be legally permissible. The combination of these two approaches might then both provide access to voluntary active euthanasia for those in need, while at the same time minimizing the likelihood of abuse, since anyone committing euthanasia in a borderline case would need to be prepared to prove that it was indeed a case of voluntary euthanasia.

One final important issue is this. It is usually assumed that if voluntary active euthanasia or assisted suicide were to be legalized, then such actions would be carried out by doctors. This assumption has led to strong opposition to legalization on the part of the American Medical Association, which has held that, in view of the basic orientation of the practice of medicine toward the saving of lives, doctors should not perform active euthanasia. Advocates of legalization have tended to respond by challenging the latter view – arguing, for example, that assisted suicide and voluntary active euthanasia are not really contrary to the Hippocratic Oath. But, even if this is so, one might very well ask whether it might not in fact be better if doctors were not involved, and if, instead, both the relevant counseling, and the carrying out of the actions in question, were in the hands of other trained professionals. For, in the first place, it may very well be psychologically difficult, for many people, to shift from attempting to do everything that can be done to save a person’s life, to doing something to end that person’s life. In the second place, would it not be better for euthanasia and assisted suicide to be carried out by people who have been specially trained to do this, people who are willing to step in when doctors have done all that they can, who are knowledgeable about the needs and the psychology of those who are dying, and who are therefore better able to provide the support and comfort that is needed at such a time?

References

Alexander, Leo (1949). “Medical science under dictatorship.” New England Journal of Medicine, 241: 39–47.

Beauchamp, Tom L. (1977). “A reply to Rachels on active and passive euthanasia.” In Thomas Mappes and Jane Zembaty (eds.), Social Ethics: Morality and Social Policy (pp. 67–76). New York: McGraw-Hill.

Boonin, David (2000). “How to argue against active euthanasia.” Journal of Applied Philosophy, 17/2: 157–68.

Callahan, Daniel (2005). “A case against euthanasia.” In Andrew I. Cohen and Christopher Heath Wellman (eds.), Contemporary Debates in Applied Ethics (pp. 179–90). Oxford: Blackwell.

Foot, Philippa (1977). “Euthanasia.” Philosophy & Public Affairs, 6/2: 85–112.

Fletcher, Joseph (1973). “Ethics and euthanasia.” In Robert H. Williams (ed.), To Live and to Die (pp. 113–22). New York: Springer Verlag. (Reprinted in Joseph Fletcher, Humankind: Essays in Biomedical Ethics (pp. 149–58). Buffalo, MA: Prometheus Books, 1979.) Harris, John (1975). “The survival lottery.” Philosophy, 50: 81–7.

Hay, Malcolm (1951). The Foot of Pride. Boston: Beacon Press. (Reprinted in 1960 as Europe and the Jews. Boston, NJ: Beacon Press.)

Hitler, Adolf (1971[1925–7]). Mein Kampf, trans. Ralph Manheim. Boston, MA: Houghton Mifflin Company.

Kagan, Shelly (1988). “The additive fallacy.” Ethics, 99: 5–31.

Kamisar, Yale (1958). “Some nonreligious views against proposed ‘mercy-killing’ legislation.” Minnesota Law Review, 42/6: 969–1042.

Kohl, Marvin (1975). “Voluntary beneficent euthanasia.” In Marvin Kohl (Ed). Beneficent euthanasia (pp. 130-41). Buffalo, NY: Prometheus Books.

Kuhse, Helga, Singer, Peter, Baume, Peter, Clark, Malcolm, and Rickard, Maurice (1997). “Endof-life decisions in Australian medical practice.” Medical Journal of Australia, 166: 191–6.

Malm, Heidi (1992). “In defense of the contrast strategy.” In John Martin Fischer and Mark Ravizza (eds.), Ethics: Problems and Principles (pp. 272–7). New York: Harcourt Brace Jovanovich.

Oddie, Graham (1997). “Killing and letting-die: from bare differences to clear differences.” Philosophical Studies, 88: 267–87.

Oddie, Graham (1998). “The moral case for the legalization of voluntary euthanasia.” Victoria University of Wellington Law Review, 28: 207–24.

Parfit, Derek (1984). Reasons and Persons. Oxford: Oxford University Press.

Rachels, James (1975). “Active and passive euthanasia.” The New England Journal of Medicine, 292/2: 78–80.

Rachels, James (1979). “Euthanasia, killing, and letting die.” In John Ladd (ed.), Ethical Issues Relating to Life and Death (pp. 146–63). Oxford: Oxford University Press.

Rachels, James (1993). “Euthanasia.” In Tom Regan (ed.), Matters of Life and Death, 3rd edn. (pp. 30–68). New York: McGraw Hill.

Sullivan, Joseph V. (1975). “The immorality of euthanasia.” In Marvin Kohl (ed.), Beneficent Euthanasia (pp. 12-33). Buffalo, NY: Prometheus Books.

Tooley, Michael (1980) “An irrelevant consideration: killing versus letting die.” In Bonnie Steinbock (ed.), Killing and Letting Die (pp. 56–62). Englewood Cliffs, NJ: Prentice-Hall.

Tooley, Michael (1995). “Voluntary euthanasia: active versus passive, and the question of consistency.” Revue Internationale de Philosophie, 49/3: 305–22.

In Defense of Voluntary Active Euthanasia and Assisted Suicide by Michael Tooley

Important Concepts and Distinctions

The argument

The soundness of the argument

The argument

An evaluation of the second argument

References

Further reading

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