Tuesday, July 18, 2006

Euthanasia (and Katrina).

Had to blog this one. Apparently, the rumours of nurses and doctors euthanizing people stranded in New Orleans hospitals during hurricane Katrina may have been true. The sanctimonious tone taken by some in this article is expected, but morally pathetic.
"We’re not calling this euthanasia. We’re not calling this mercy killings. This is second-degree murder," said Kris Wartelle, a spokeswoman for Attorney General Charles Foti. ... "Euthanasia is repugnant to everything we believe as ethical health care providers, and it violates every precept of ethical behaviour and the law. It is never permissible under any circumstances," [Harry] Anderson [a spokesman for Dallas-based Tenet Healthcare Corp.] said.
I don't think anyone really, seriously opposes all forms of euthanasia. But, let me explore the issue a little.

I'm not terribly familiar with this literature (it is vast), so this is mostly off the top of my head. There's a few distinctions to get on the table first.
  1. Active vs. passive
  2. Voluntary vs. non-voluntary vs. involuntary
  3. Direct vs. indirect
Active vs. passive: Active euthanasia involves doing "something" to cause death. Passive euthanasia involves refraining from doing "something" to cause death. For example, if I were to administer a lethal injection, that would be active euthanasia. If I were to withhold a needed medication, that would be passive.

Voluntary vs. non-voluntary vs. involuntary: Voluntary euthanasia requires the euthanized person's consent. Non-voluntary euthanasia does not require the euthanized person's consent. Involuntary euthanasia is over the person's refusal.

Direct vs. indirect: Direct euthanasia is quite similar to active euthanasia, but requires that whatever is administered (or held back) from the euthanized person is done so knowing that it will directly cause death. Indirect euthanasia requires that whatever is administered (or held back) from the euthanized person is done so knowing that it will indirectly cause death.

So, we can get lots of different combinations of factors here to create a number of different cases. However, I want to collapse the first distinction and the third distinction, which would leave only the second to deal with.

There's a famous argument from James Rachels against the first distinction (which is, incidentally, often glossed as the distinction between "killing" and "letting die"). The argument runs by example. Suppose that I have a nephew who has inherited a lot of money from a mutual relative. If he is to die, however, that money will revert to me. In case A, I enter the bathroom while he is taking a bath and hold his head under water until he drowns. In case B, I enter the same bathroom intending to hold his head under water, but notice that he slips and knocks himself unconscious. I simply stand back while he lies under the water and drowns. Rachels' claim is that case A is not morally different from case B -- my intent in both cases was the same, the consequences were the same, and I'm an equally bad person in each case, so what could make a moral difference?

Whether or not one buys Rachels' line (and many do not), there's a better argument to be made, namely that there is no ontological difference between doing X and refraining from doing Y. (This is a logical point.) If I do X, we can also say that I am refraining from doing not-X. If some arbitrary Y is defined to equal not-X, then refraining from doing not-X is refraining from doing Y. Thus, doing X is refraining from doing Y. On the other hand, if I refrain from doing Y, then we could define some arbitrary X such that I am also refraining from doing not-X. If I am refraining from doing not-X, though, then I am doing X (just eliminating the negatives). Thus, refraining from doing Y is doing X. Therefore, doing X is equivalent to refraining from doing Y. And, since doing X and refraining from doing Y are not ontologically different, they cannot make a moral difference. (The only way this argument will fail is if "refraining" and "doing" are not contradictories, or I cannot define some arbitrary Y as required by the first path, or some arbitrary X as required by the second).

So, there is no difference between active and passive euthanasia.

The direct/indirect thing is a matter of foreseeable consequences and moral responsibility, and the (fairly intuitive) argument runs like this. If I can foresee that my actions (or lack of actions) will have a particular consequence, then, ceteris paribus, I am responsible for that consequence. The ceteris paribus clause covers the fact that, if the consequence is sufficiently distant, then I cannot be held responsible for it. However, I tend to think that these consequences have to be so distant that I did not foresee them. Else, we allow for a moral "escape-hatch". For example, suppose we say that two "steps" removed in a causal chain discharges responsibility. So, I can't kill someone by dropping a piano on their head (zero steps). I can't kill someone by pushing a button that drops a piano on their heads (1 step). I can, however, kill someone by dropping a ball that pushes a button that drops a piano on their heads (2 steps). Indeed, I can construct an infinitely varied Rube Goldberg device to accommodate any distance of "steps" from the foreseen result. So, it seems that either a sufficiently complex Rube Goldberg device excuses moral responsibility -- a bizarre result -- or responsibility is only discharged by (reasonable) ignorance. Or, in other words, if it isn't reasonable to expect me to foresee the consequences, then I can't be held responsible for it.

In the case of euthanasia, though, the euthanizer is only a euthanizer insofar as the consequence (death) is foreseeable. Hence, whether direct or indirect, the euthanizer bears equal moral responsibility.

So, the moral differences, if any, must come on the voluntary vs. nonvoluntary vs. involuntary axis.

Voluntary euthanasia, I think most will accept, can be morally permissible. If I just don't want to live any more and am in horrible pain, people can remonstrate with me not to end my life, but no one can actually prevent me from doing so. (Even if, supposing that I am perfectly healthy and have many goods of life, I am morally prohibited from committing suicide.) If this example is not persuasive, I can jazz it up with more suffering until it becomes so. The point is, after a certain amount of misery, most people will allow that at least I can end my life.

Non-voluntary euthanasia is a little trickier. This is not the case where I've got a living will or some such -- that's voluntary euthanasia, but at a temporal distance. This is a case where I have not made any decision one way or the other, and I have no appointed or morally reasonable representatives to make the decision for me. In that case, I would suggest that the decision has to be made on the basis of medical benefit; but, on the whole, whether non-voluntary euthanasia is permissible will be decided on the basis of how scarce medical resources should be distributed. Should they be distributed to those who cannot be helped? To those who can be helped only a little, but are greatly needy, over those who can be helped a lot, but are not very needy? And so on. It's a difficult topic, and I won't get into it here. Suffice to say, the issue is murky, and sanctimonious hand-waving about the "value of life" does nothing to tell physicians and other health practitioners what they are supposed to do when resources are running out and not everyone can be helped.

Finally, we get to involuntary euthanasia. Involuntary euthanasia is pretty much murder, it seems. But, again, what if resources are sufficiently scarce that not everyone can be helped? Then it seems, again, we need a story about how to distribute scarce medical resources (although, in this case, whatever calculus we come up with will have to consider the fact that depriving the potentially euthanized person of resources is against their will -- that is, the autonomy violation will have to weight the calculus in some way).

On the whole, it seems that the inflexibility of the law fails to see the problems physicians and others face when it comes to medical resources. In ordinary circumstances, medical resources are extremely scarce (particularly, say, organs for transplants). In New Orleans post-Katrina, resources were horrifically scarce -- one might even call them "rare". And there was no indication that any further resources would ever be forthcoming, due to the gross incompetence of the Bush administration. So, the physicians and nurses had to make a horrible decision, for which they had no decision-procedure (due to the bizarre refusal of hospital admins to provide training for these sorts of difficult circumstances). And for this horrible decision, which they are probably still agonizing about, they may face loss of professional licenses and jail. Meanwhile, the Bush admin stooges who deprived them of resources and forced them into the decision they could not handle (and, for that matter, the idiots who refused to deal with the looming possibility of having to euthanize due to lack of resources, and did not provide adequate training in this sort of reasoning) are still walking around free.

As I have said elsewhere on this blog, sometimes, I despair.

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