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In his essay, “A Case Against Euthanasia,” Daniel Callahan argues against euthanasia by assessing how its legalization would negatively affect society. Callahan claims that euthanasia would add another definition of “acceptable killing” to society's vocabulary, change the role of the physician from life-saver to life-taker, and be extremely difficult to enforce, resulting in abuse and the violation of the fundamental right to life. Of particular concern is Callahan's assertion that euthanasia attracts a certain type of person with a certain set of personal values revolving around the fear of loss of control. He claims that this type of person is not representative of society as a whole, so it would be bad public policy to abandon long-standing traditions and laws in order to “cater to a small minority.” Because the focus of this essay is on voluntary active euthanasia, I will use the term “euthanasia” to refer to when, at the request of the patient, a doctor administers a treatment, with the intent being to terminate the patient's life. While Callahan makes several strong arguments, I have several qualms with some of the foundations upon which he makes his claims. In this paper, I will argue the following: first, there is a need to disentangle suicide and euthanasia in order to fully understand the moral underpinnings of the topic at hand; second, Callahan's notions of “right to life” and “right to freedom and self-determination” are too absolute, but a revision of these ideas will allow us to define circumstances under which euthanasia is morally permissible; third, I will prove that the subjective experience of suffering is more measurable that originally thought, and that the loss of autonomy may be one of the most compromising forms of suffering there is; finally, I will propose some solutions as to how euthanasia may be effectively regulated and address the ever prevalent issue of “killing” versus “letting die.”
Callahan opens his essay by defining euthanasia as a form of suicide, physician-assisted suicide. He describes the common conception of suicide as a desperate, extreme measure that is rarely taken - not even by those who are physically disabled, those who endured insufferable pain in concentration camps, or those confronted with grievous personal tragedies. While proponents of euthanasia often propose it as a choice made by a rational agent who is in significant pain and whose prospects seem hopeless, Callahan denies that any sort of rationality is involved in the decision to opt for the termination of a life. According to Callahan, rationality entails predictability - that is, people under certain, prescribed circumstances will behave in a predictable way. However, it seems that even in the gravest cases of human suffering, it is impossible to predict that people would be more likely to turn to suicide as the preferable solution. If anything, it seems more predictable to assume that people would not opt for suicide over continued, apparently miserable, existence.
Callahan claims that a “common revulsion” against suicide pervades society, which is reflected in how rarely it is utilized. Suicide is seen as a poor solution to life's trials and tribulations, and life is viewed as even more noble when it is daubed with character-building pain and suffering. Furthermore, occurrences of suicide are met with sadness, not relief that the misery of an unhappy life has been alleviated. When one commits suicide, it seems as if some fundamental respect for and commitment to life has been violated. Callahan claims that no amount of relief from suffering can justify the infraction of such a sine qua non right. Thus - deriving his argument from what he claims to be the general consensus regarding suicide (but not specifically patient-assisted suicide) - Callahan claims that euthanasia is discordant with rationality and typical emotional response to death.
While there is a noticeable moral problem regarding suicide, Callahan admits that mere emotional discomfort is not enough to disprove the permissibility of euthanasia. Callahan offers three arguments in favor of euthanasia and goes on to reveal the weaknesses inherent within them. First, proponents of euthanasia often invoke the right of self-determination, the ability to choose one's own actions free from any external compulsions, so long as they do not result in any harm done to others. Perhaps the most fundamental American value is that of freedom, so Callahan agrees that this concept is difficult to reject. However, he provides several reasons as to why we should still regard euthanasia as morally impermissible. Although euthanasia is meant to address the interests of the patient, it impacts others. Thus, euthanasia is not a private act, but a social one that would require strict regulations and profound changes with regards to tradition and the ideas surrounding the practice of medicine.
Until the debate regarding euthanasia arose, the only acceptable circumstances in which one could take the life of another were self-defense, warfare, and capital punishment. Allowing euthanasia would therefore redefine the range of “acceptable killing.” The fear in this is that euthanasia could easily be abused, especially due to doctor-patient confidentiality. There would be no way of knowing whether physicians were obeying regulations or possibly influencing their patients' decisions. Though Callahan does not blatantly claim that all doctors are corrupt, he is wary of entrusting them with the ability to terminate lives. He fears that instances of “private killing” and non-voluntary euthanasia could lead to the corruption of medicine. Furthermore, the role of a doctor has always been to use his skill to save, rather than take, lives. To permit euthanasia would thus oppose the tradition of medicine and the Hippocratic Oath.
A second argument made by proponents of euthanasia is that we ought to relieve suffering when we are capable of doing so. While it is the physician's duty to relieve his patients' suffering, this duty has never been absolute (that is, a doctor has never legally been permitted to perform euthanasia without the patient's consent, even if the patient is incapable of providing such consent). Thus, the physician's duty to relieve suffering is trumped by a general moral objection to killing. Callahan also claims that modern palliative care is capable of relieving most pain and suffering, so resorting to the killing of patient is not even necessary in the majority of cases.
A third claim made by supporters of euthanasia is that there is no logical difference between passively letting a patient die through termination of treatment and directly killing a patient via active euthanasia. That is, while one is an omission and the other an action, they are both done with the same intention and end in the same result. Proponents of euthanasia claim that active euthanasia may even be the more humane option of the two, because it would shorten the time spent suffering.
Callahan has three qualms with these arguments. First, he claims that by the time the physician decides to stop treatment, chances are the disease has already taken control, making death inevitable. Thus, the cause of death would be the disease itself, not the physician's action. Second, it cannot be said that the physician hastened the patient's suffering, because it was the physician's treatment that prolonged the patient's life in the first place. Third, in order for withdrawal of treatment to be equivalent to killing, the treatment would have had to be capable of curing the patient. Since at some point life-sustaining treatment can no longer be effective, it cannot be said that the physician's act of omission is responsible for the patient's death.
In my opinion, Callahan's most pressing arguments are those he makes with regards to euthanasia and the law. He again stresses the widespread social implications of euthanasia and the difficulty in regulating laws due to confidentiality. Moreover, the most common reasons given for euthanasia - self-determination and the relief of suffering - cannot easily be defined by the law. Oftentimes, the right of self-determination with regards to euthanasia is limited to terminal cases, but Callahan considers such a requirement to be arbitrary because of other considerable forms of suffering than impending death. Callahan also makes an interesting point in saying that relief of suffering should not necessarily have to require consent; just because someone is not competent of providing consent does not mean their suffering should bear any less weight.
Callahan cites a Netherlands case study in which the difficulty in regulating euthanasia laws becomes startlingly clear. By anonymously interviewing hundreds of physicians, it was discovered that one-third of the euthanasia cases were non-voluntary, 10% of these non-voluntary cases took place with competent patients, and less than 50% of the cases were reported as euthanasia. Euthanasia has recently been legalized in Oregon, and although there has been no evidence of abuse, Callahan claims that it is not that much a stretch to assume that it may be occurring under the radar.
Callahan remarks that the most striking finding from the Oregon study was that main reason people gave when requesting euthanasia was “loss of autonomy and a diminished ability to participate in activities that make life enjoyable” (Callahan 187). Callahan concedes that the loss of autonomy is a form of suffering for those who consider it to be a “grievous affliction,” but he discounts it as insignificant, since it is something we all have to face in old age. Callahan also points out that there is no reliable medical definition of suffering - the difference between bearable and unendurable varies from person to person depending on their individual values. Instead of pain being the motivation for euthanasia, Callahan claims that euthanasia attracts a certain kind of patient with a certain perception of what constitutes a worthwhile quality of life, and that this certain kind of person is a minority. Just as most people would not opt for suicide, most terminally ill people would not choose euthanasia. Thus, euthanasia would be “a legitimization of suicide for those who have a particular conception of the optimum life and its management, one of complete control” (Callahan 188).
Callahan closes “A Case Against Euthanasia” by refuting the “death with dignity” claim made by euthanasia supporters. He asserts that death, even when characterized by loss of control, is never an indignity but rather a fact of human life. Euthanasia does not grant death dignity - it only serves to create the fallacy of dignity for those who wrongly contend that the loss of control is an unsurpassable condition.
While Callahan does provide some strong arguments against permitting euthanasia, there are some fundamental flaws in his reasoning. From the start of his essay, Callahan clearly states that he regards euthanasia as a form of suicide. He thus bases a great deal of his argumentation on beliefs held about suicide as people commonly think of it. I, on the other hand, feel the need to disentangle suicide and euthanasia.
First, suicide and euthanasia take place under entirely different circumstances. Suicide is most frequently committed alone, out of emotional or psychological distress. One may feel compelled to commit suicide for a variety of reasons that generally stem from depression, such as the end of a serious relationship, financial issues, or feelings of failure. Alternatively, euthanasia is only done after thorough, rational consideration and consultation with the expert opinion of a doctor. The decision is made solely on the basis of medical reasons and the quality-of-life-altering consequences of such health issues.
Of the reasons given for suicide, some are understandable whereas others are clearly irrational, thus creating moral unease. Society sees other options as better, and this is why the decision to commit suicide is considered so extreme. Euthanasia, however, would only be permitted under prescribed circumstances with regards to the experience of insufferable physical pain and/or the loss of autonomy. Anyone who values personal integrity and autonomy would at the least be able to relate to the hopelessness experienced under such circumstances. Thus, while it may be difficult to comprehend and justify why Jim might take his life after, say, failing an important exam, it is not so much of a stretch to understand why John might have no motivation to continue living if he had, say, late-stage throat cancer, causing every breath and bite of food to be excruciating, with death in his near future.
A second, more subtle point contingent upon the first is that the motives behind suicide and euthanasia have different underpinnings. While both result from hopelessness, only euthanasia is done to benefit the person whose death is brought about. It may be argued that suicide provides relief to the victim and is therefore beneficial to him. However, most of the time, the reasons behind committing suicide are not nearly as morally significant or unchangeable as those behind the desire for euthanasia. After failing his exam, Jim may choose to drop the course, retake it, or study especially hard for the next test so as to make up for his poor grade. John, on the other hand, cannot be cured of throat cancer, nor can he make his pain medications more effective. Thus, while there may be better alternatives to suicide, in many cases there are none for euthanasia.
Third, although suicide and euthanasia both result in the termination of a life, the ending of this life can be seen in two completely different respects. Suicide can be viewed as the “extinguishing” of a life, tragically cut short by irrational decision-making. Euthanasia, on the other hand, may be seen as the acceleration of natural death, a process that has already commenced due to disease or disability. While suicide is the termination of the trajectory of a human life, euthanasia is the speeding up of already inevitable death.
In making these three points, I do not intend to assert that suicide and euthanasia are entirely unrelated concepts; instead, I claim that - while suicide and euthanasia exist on the same spectrum - there are distinctions between them that must be made. I place the cases of those rationally seeking euthanasia at one extreme and the cases of those irrationally resorting to suicide at the other. Thus, only the most extreme cases of suicide - those in which the reasons given for the choice made would be rational, understandable, easily definable, and insurmountable - could be considered to be on the same level as euthanasia. That is, only in cases where the suffering is so severe and other better alternatives do not exist would the unease surrounding suicide disappear, because the reasons for wanting death over continued existence would be morally justifiable. However, I contend that only a very small minority of suicides meet these characteristics, so in general terms, a distinction between suicide and euthanasia ought to be made. Patients seeking euthanasia, on the other hand, meet all of these demands, so Callahan cannot rightly apply the moral unease surrounding the typical case of an irrational suicide to the typical case of rational euthanasia.
A second weakness in Callahan's argument is that he fails to prove that euthanasia is a violation of the right to life. The crux of Callahan's mistake lies in his absolute use of the terms “right to self-determination/freedom” and “right to life.” To relinquish one's absolute right to freedom would essentially entail slavery. However, it is possible to come up with a number of examples in which the relinquishing of portions of the right to freedom does not result in the relinquishing of the absolute right to freedom. For instance, take the social, political, and legal constructs of society. In joining a society, individuals recognize that, by giving up certain freedoms, they are allowing themselves to pursue other goals (such as giving up the ability to take another person's life in order reside in a safe community where your life is protected, becoming a citizen of the United States knowing that you might be drafted, etc.). The relinquishing of some freedoms for the pursuit of personal interest is not seen as inherently wrong. This same understanding can be applied to the right to life: if it is morally permissible for a rational agent to decide under what circumstances he wants to give up a portion of his freedom, so should it be morally permissible for him to decide under what circumstances he wants to give up a portion of his right to life.
Some might argue that the right to life cannot be transferred from one person to another (in this case, from patient to physician). However, it seems there are instances in which people can relinquish at least portions of fundamental rights to others, as is seen with the case of right to freedom. This position does not impose that euthanasia is morally permissible, but it does seem to recognize self-determination as justification for the relinquishing of at least a portion of one's right to life. An interesting way to rephrase this question is, if we have a fundamental right to life and the right to self-determination holds that we ought to be able to choose our own actions with regards to this life, does it not follow that we ought to have a “right to death”? If the interest in determining how we spend our lives is protected by the right to self-determination, why should this right not extend right up until the very end of our lives?
A third problem I have with Callahan's essay is his interchangeable use of the terms “pain” and “suffering.” Callahan speaks of pain as a physical experience, and notes inadequate pain relief as the primary reason euthanasia laws are passed. Although pain and suffering are frequently used synonymously, suffering can be understood as a much more individualized, subjective, and complex experience. Despite a universal understanding of suffering, it is highly personal in that its perception varies from person to person and is dependent on personal interpretation. Suffering is complex in that it is composed of physical, emotional, cognitive, social, and even spiritual elements. Thus, suffering may be accompanied by, but is certainly not limited to, physical pain.
In many ethical dilemmas we are forced to make a distinction between sentient beings and persons. Sentient beings are capable of experiencing physical pain, but to experience complex suffering - something that compromises one's integrity to the point that life is no longer considered valuable - is an entirely different concept. Because not just the feeling but the meaning of suffering is so important, capacities such as self-consciousness, a sense of oneself as a distinct entity with a past and future, a sense of goals and values, and the notion of integrity are necessary for a being to experience suffering. In this sense, it seems the concept of personhood is an antecedent to suffering, and I contend that if we are to place a special, intrinsic value on human life and personhood, we in turn ought to pay special attention to human suffering. Thus, I find it counterintuitive of Callahan to claim that the loss of autonomy only constitutes suffering “for those for whom `the loss of autonomy' is a grievous affliction” (Callahan 187). By nature of being human and possessing personhood, it seems we would innately have an interest in our own autonomy, and since autonomy and self-determination are such fundamental components of integrity, the loss of autonomy constitutes significant suffering. One may even go so far as to say the loss of autonomy is the worst suffering of all.
Callahan makes a good point in noting that the subjective nature of suffering makes it extremely difficult to measure or define, thus making the determination of morally permissible euthanasia problematic. Indeed, if we were to define morally permissible euthanasia based off of personal values, this could easily turn into a messy situation. However, this statement can be disproved with a few simple premises:
Now that we have jumped this hurdle, the next step is to define under what circumstances euthanasia would be morally permissible. I agree with Callahan that individual personal values cannot be the basis for defining morally permissible euthanasia, but I hold that one personal value can be: autonomy. The following premises prove that the loss of autonomy is a sufficient reason for morally permissible euthanasia:
Callahan claims that the loss of control is not the popular reason why patients request euthanasia, so we should not uproot tradition just to “cater to a small minority.” However, the Oregon study revealed that the primary reason for requesting euthanasia for 80% of patients was the loss of autonomy. Before Callahan can make such a statement, I think it is necessary that more investigation be done with regards to the frequency of motives behind euthanasia. Callahan also claims that modern palliative care can relieve most suffering, so it is not even necessary to resort to euthanasia. While he acknowledges that in some cases palliative care is not enough, he does not propose a solution for those patients who fall outside the boundaries of modern pain management. Furthermore, in making this statement, Callahan completely disregards the non-physical components of suffering which greatly affect one's perceived quality of life and sense of integrity. By permitting euthanasia, I argue that we would be taking a more holistic approach to modern medicine - an approach that would encompass not just the physical, but the psychological, emotional, and existential components of the patient's experience.
As Callahan mentions, the legalization of euthanasia would raise concerns about the possibility of abuse. If we were to adopt conservative regulatory procedures, however, abuse could be greatly minimized or even eliminated. For example, permission for euthanasia would require a persistent request from a rational patient, consultation with his primary doctor, a second consultation with another doctor so as to ensure the primary doctor is not influencing his decision, and a third consultation with a psychiatrist to ensure the patient is in a rational mental state. Upon deciding to go through with euthanasia, the patient and all doctors involved would sign a consent form in the presence of a notary. During the actual process of euthanasia, an authorized third party would have to be present. Another solution could be the requirement that everybody have a living will. The living will could be incorporated into the paperwork filled out when a child is born; the parents would make the calls until the child turned eighteen, upon which time he could make whatever revisions he pleased. I acknowledge that it would be virtually impossible to obtain a living will from all currently living citizens. Therefore, in the cases remaining where the patient has no living will, the default would be to provide life-sustaining treatment. The only remaining problem I foresee in these solutions is the exclusion of already living patients that are not competent of giving consent. I do not intend to disregard the suffering of these patients, but at the same time I cannot support non-voluntary euthanasia under any circumstances. Thus, I advocate that a policy regarding euthanasia be adopted as soon as possible so as to allow patients who may be incompetent in the future the ability to have their interests carried out.
One final matter I would like to address is the debate over the distinction between “killing” and “letting die.” For those like Callahan who contend there is a moral difference between the two, the rationality, good intentions, and relief associated with euthanasia are no matter - killing is still killing. While I do not agree with this claim (and may even go so far as to say the act of omission may be an action in and of itself), I will, for a moment, give Callahan the benefit of the doubt and say that euthanasia is equivalent to killing. Even if this were so, Callahan's arguments only go so far as to say that legalizing euthanasia would “open the door” to forms of acceptable killing. But is this necessarily a bad thing? A great amount of ethical discussion has gone into the decisions about self-defense, warfare, and capital punishment. The fact that so much consideration has gone into the debate surrounding euthanasia serves as proof that we are approaching this situation cautiously. Finally, even if we were to concede that euthanasia is a form of killing, the arguments presented in this paper suggest that, under certain circumstances, it would be morally justifiable. Certainly, we do not want to welcome forms of killing into our society, but to admit acceptable killing is an entirely different matter.