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The need to resolve the issues of euthanasia and physician assisted suicide will become more acute in the developed world over the next few decades. There are at least two main causes for this. On the one hand, medical technology has increased tremendously, and we are now faced with the prospect of keeping some patients alive almost indefinitely regardless of their quality of life, and irrespective of the incredible costs of continued treatment. On the other hand, patients, and their proxies, see autonomous choice as their right, whether this be the right to end their lives (or have their lives ended for them) at the time of their choosing or, alternatively, to receive continued medical treatment that is deemed 'futile' by health care professionals.
In most of the developed world passive euthanasia in the form of withholding or withdrawing life sustaining treatment is thought to be morally acceptable and is hence legally allowable, under certain conditions. Although a case passive euthanasia occasionally finds it way into the public spotlight -- as it did a couple of years ago with the case of Terri Schiavo -- most of these cases now pass unnoticed. In part, this has been because both the medical profession and the public have, by and large, accepted the concept of medical futility, despite how troublesome the concept may actually be, as Young details in Chapter 3.
In contrast, however, there are very few places in the world where it is legally allowable to engage in active euthanasia (e.g., by lethal injection) or physician assisted suicide (PAS). Indeed, The Netherlands, Belgium, Switzerland, and the states of Oregon and Washington constitute the entire lot of them. Many who favor the legalization of active euthanasia and PAS, like Robert Young, find this situation odd. As he, and others before him, has argued, many of the arguments that support passive euthanasia also support active euthanasia and PAS. For example, if one supports voluntary passive euthanasia on the basis that we ought to respect the wishes of competent, autonomous adults, then, on the face of it, those same concerns for autonomy should apply equally to active forms of euthanasia and PAS. The same should apply if our arguments focused primarily on mercy, beneficence, or compassion. In fact, one can easily imagine cases where being compassionate toward a dying patient suffering from uncontrollable pain would lead one to active rather than passive euthanasia.
Of course, those opposed to active euthanasia and PAS have offered many arguments why only passive euthanasia is justifiable. The bulk of Medically Assisted Death considers these arguments and, ultimately, rejects them as flawed. One of those arguments is that there is a fundamental difference between acts and omissions such that "all other things being equal, those instances of harming that result from an agent doing something are morally worse than those that result from an agent allowing something similarly harmful to occur" (84). A variant of this argument is the doctrine of the double effect, which maintains that one can act in such a way as to knowingly (or at least foreseeably) cause the death of one's patient so long as one doesn't intend the death. This would typically happen when one increases pain medication to such an extent that one causes the death of the patient: but, so the argument goes, one's intent was to relieve pain, not cause death, and so one is not guilty of active euthanasia. Young does a nice job in refuting both these arguments by reviewing a host of relevant literature. In brief, Young argues first that context makes all the difference here, not the action-omission distinction per se. We can easily imagine cases, he says, where not doing anything to save someone's life would be as morally bad as actively killing them and, conversely, we can imagine cases where actively killing is preferable to letting die. Regarding the doctrine of the double effect, Young argues first that distinguishing between what an agent intends to do and what he foresees cannot withstand the moral weight placed upon it by defenders of the doctrine of the double effect. Second, the doctrine fails to establish an absolute prohibition on causing another's death, And, finally, the doctrine will be irrelevant in cases where a competent patient voluntarily requests active euthanasia or PAS (112). Indeed, Young argues that one of the oddities of defenders of this doctrine and of passive over active euthanasia and PAS is that they often don't take the wishes of the patient seriously enough and hence engage in non-voluntary euthanasia, albeit passively so.
In other chapters of Medically Assisted Death, Young considers arguments regarding the sanctity of human life, professional integrity and medically assisted death, competence, advance directives, and slippery slope arguments. I have always found the slippery slope arguments on this issue particularly fascinating, in part because we now have a wealth of empirical data, primarily from The Netherlands, regarding what has happened when laws have changed to allow voluntary active euthanasia and/or PAS. Despite claims from a whole host of opponents to active euthanasia and PAS, the data does not support the claim that we have slid down a slippery slope. Indeed, numbers seeking active euthanasia or PAS have remained relatively constant over the years and it continues to be the case that very few deaths are the result of active euthanasia or PAS, and in fact, it continues to be the case that the vast number of requests for them in Holland are either turned down or, even when approved, do not eventuate in PAS or active euthanasia. This is not to say that the Dutch have got it perfectly right. There are still problems there including the continued underreporting of cases (though this has improved dramatically) and the fact that some cases of non-voluntary euthanasia occur in violation of the law (albeit only in cases where a terminal person is in the last moments of her life). But the data simply do not support the call to arms that we have received from opponents of the Dutch law: indeed, some critics of it seem to display a flagrant disregard of the actual data.
In discussing euthanasia and PAS, Young is very comprehensive, even if he says nothing particularly new about it. This isn't completely unexpected, however, since the area of medically assisted death is now well traversed terrain. However, Young does make "reference more frequently than is common in philosophical works to relevant medical and legal matters because ... credible work in bioethics needs to be in contact with the medical and legal realities" (12). He is to be congratulated for this, since paying insufficient attention to these details can result in one's philosophical musing to be of little use to those people working on the ground. This is true even if one must be careful here, because the medical and legal issues are notoriously slippery and can change not only over time but also from place to place, and so one must be able to keep philosophical principles clearly in mind amidst all this confusion.
My only real complaint about Medically Assisted Death is that Young doesn't come completely clean about his position on active euthanasia and PAS until the end of the book. In the Introduction, he says that his "central thesis is that there is a strong case for legalizing physician-assisted suicide and voluntary euthanasia but that this is neither justifiable nor necessary to do so for non-voluntary euthanasia" (1). It seems, however, that Young is actually not opposed to some cases of non-voluntary euthanasia, as he makes clear in Chapter 11. That he waited until the end of his book to tell us this is purely pragmatic and political. That is, he says, he didn't want to give his opponents ammunition at this time against his position on voluntary and active euthanasia. Whether or not he is correct in his pragmatic point, I would have preferred that let us know his actual position from the very outset.
© 2009 Robert Scott Stewart
Robert Scott Stewart, Ph.D., Professor of Philosophy, Cape Breton University