The Difference between Killing and Allowing to Die

KILLING AND LETTING DIE: WHAT'S THE DIFFERENCE?

Fr Anthony Fisher O.P. to SPUC Conference, Glasgow, 20.3.93

In medical situations there are lots of opportunities to save life - and, sadly, to kill. Medical killing might be divided roughly into two types. The first is where a doctor does something to hasten a patient's death, as when Dr Nigel Cox gave a lethal dose of potassium chloride to a 70-year-old patient who was in severe pain, terminally ill and asked to be killed. Last year he was convicted of attempted murder. But in many places there is considerable lobbying for the legalization of this practice. Holland will soon legalize voluntary active euthanasia by physician. And who knows what the recently appointed House of Lords committee will come up with?

A second kind of medical killing is where a doctor brings about a patient's death by omitting to do something, such as feeding, hydrating, or giving necessary operations and drugs. This is far more common in British hospitals than killing in the more active way. Recentlythe Hillsborough disaster victim, Tony Bland died after the English courts ruled that all food, water and antibiotics could be withdrawn from him. Again, there is considerable lobbying for the legalisation of this second kind of medical killing - by neglect or abandonment - here in Britain.

So a person's death can be intentionally caused, whether actively or passively, by commission or omission. As the judges in Bland's case openly recognized, it makes no difference morally: once you have decided to hasten someone's death (and everyone agreed in both the Cox and Bland cases that that was the doctors' intention), whether one uses active or passive means is simply a question of strategy. A parent who sees her baby drowning in the bath and fails to intervene; a child who fail to feed a starving elderly parent; ancient Greeks or modern doctors who abandon handicapped infants - all engage in passive killing, and all can say 'But I didn't DO anything'. That is precisely the problem: they should have, and someone died as a result.

How, then, can we draw the line between immoral killing (whether active or passive) and morally permissible letting die, and how would we justify the difference? I would suggest that we might consider four basic principles.

The sanctity of human life

The principle of 'the sanctity of human life', was said in the Cox and Bland cases to be deeply embedded in our law and ethics, and strongly felt by people of all religions and none. Human beings are entitled to great and equal respect. Their lives are of such instrinsic importance that no choice intentionally to bring about an (innocent) person's death can be right. Thus the principle has traditionally been worded 'you shall not kill' or 'everyone has (an equal and inalienable) right to life'.

The sanctity of life principle excludes medical killing. It is, however, increasingly common to kill patients in order to relieve burdens to themselves or to others - perhaps more often the latter than the former. We may talk of putting granny out of her misery, but what we really mean is putting granny out of OUR misery. Lord Mustill confessed the hollowness of the notion that discontinuing Tony Bland's treatment was in 'his best interests'. The interests of the family, the medical staff, and the paying community were decisive here. He concluded that 'the distressing truth which must not be shirked is that the proposed conduct is not in the best interests of Tony Bland'.

There are those who would deny the validity of the sanctity of life principle. Some would hold that only human beings with certain qualifications, like consciousness, are entitled to the respect due to persons. Some suggest that respect for life should sometimes be compromised to serve other important values, such as relieving burdens to others. And there are those who argue that some people are simply 'better off dead'. Ultimately these views, clearly underlying the Bland judgments, deny that our mere existence as human beings has value as such, or presume that it can somehow be negated by suffering or degradation. And this directly contradicts the traditional doctrine of the dignity of every human being, whatever his or her condition.

Care for the sick

A second basic principle in this area is the duty to care for others. We may not harm people or treat them negligently or with disrespect. We have 'Good Samaritan' duties to show kindness to others, especially the most needy, and special responsibilities towards dependant persons in our particular care. Certain basic measures such as food, water, shelter, clothing, sanitary and nursing care must be maintained out of respect for the human dignity of every person; anything less is unjust discrimination.

In addition to these common humanitarian duties, doctors have some special duties of care. Because of the special vulnerability of patients, it is important that doctors have a clear sense of what they owe their patients by way of action and restraint. A doctor may do no harm to, nor take any undue risks with, a patient, but must seek to promote the patient's good health. This excludes the use of medicine for other purposes such as social engineering, exploitative experimentation, profit maximisation and killing. Killing cures no one, is not nursing care, not therapy. Thus when Dr Cox injected his patient with a lethal drug he was, in the words of the General Medical Council, acting 'wholly outside his duty'.

Respect for patient autonomy

'Autonomy' is an acknowledgment that all human beings are free and equal, and have an inalienable duty to make responsible, rather than forced, arbitrary or whimsical decisions. Thus in law and ethics doctors must respect the directions of their patients, or give those patients who cannot consent only therapy which is in their best interests. Patients, for their part, must exercise this freedom responsibly, in pursuit of their own good health and respect for the good of persons in community.

Autonomy is not licence or whimsy, but carries with it responsibilities. We are not free to do 'whatever we choose'. We have to respect the autonomy of others. We have to consider the implications of our choices for their lives. And we have to take into account the intrinsic morality of our choices and their self-constitutive effects, what they do to us, what they make us and say about us. In Bland's case, however, as so often in public debate, autonomy became a slogan grounding the supposed right of individuals to pursue their own life and death plans whatever they might be. Detached in this way from its proper context, autonomy can become a rationalisation for abandoning and even killing some patients.

Not striving officiously to keep alive

Traditional medical ethics and Christian faith are clear that we need not strive relentlessly to preserve the last vestiges of physical life. Ours is not a survival at any costs ethic. Indeed such an approach can well be due to therapeutic obstinacy, a refusal to face up to the limitations of healthcare and human mortality, a product more of despair than respect for life. Death is always an evil, but for many people it is also a merciful release, the end to a natural term of life, the door to eternal life. Good end-of-life care will only be given if we accept that death is near and that there is little more that human effort can properly do to postpone it. Some treatments will be withheld or withdrawn for good therapeutic reasons. Their continued use may be futile. Or their therapeutic value may be outweighed by the burdens they impose, such as pain, indignity, risk, cost etc.

Intention makes all the difference

When doctors give, withhold or withdraw a treatment, and death results earlier than it might otherwise have done, hurrying up death may or may not be why they chose such a course of action. Encouraging death is often no part of their reason for such chosen conduct. Death may or may not be foreseen, but it is not intended; it belongs neither to the doctor's precise purpose, nor is it the means used to achieve that purpose.

On the other hand, doctors may give or fail to give some treatment because they believe the patient would be 'better off dead', or others would be better off were the patient dead. In this case hurrying up the patient's death is certainly part or the whole of the reason for the chosen conduct.

This, then, is where the difference between killing and letting die lies: not in the difference between acting and omitting to act; not in the quality of the motives, which may be good-willed in both cases; but crucially in the difference between intentionally bringing about a person's death (which is always a harm to both victim and killer, and always wrong) and taking a course of action possibly foreseeing but not intending a person's death (which may harm no-one and be quite right).

In the Bland case the judges have made a radical departure from this traditional ethic - an ethic which the common law has till now more or less taken for granted. Instead of considering only the therapeutic benefits and burdens of Tony Bland's particular proposed treatment (insofar as it was medical treatment at all), as has been the traditional standard, they admitted various 'wider, less tangible' 'quality of life' considerations. These included (in some, though not all, of the judgments): whether the patient is likely to regain consciousness; the pain and indignity suffered as a result of the whole course of care or simply by continuing to live; how the patient would want to be remembered; the prolonged ordeal for relatives and care-givers; the cost to the community of all his care; and whether being alive was in the patient's interests. Lords Browne-Wilkinson and Mustill - the two who were most openly uneasy about the decision - recognized how subjective this kind of quality of life judgment really is, and noted that these judgments are not ones that doctors and jurists have any special skill or expertise to make.

Hard cases

We should have great concern for patients in hard cases like Cox and Bland and seek by whatever means are morally and practically available to ease their suffering and respect their dignity. We should have tremendous sympathy for the family and healthcare workers surrounding such patients: when people take a long time to die, those who must accompany them often suffer the most. Perhaps we could do a lot more to support them.

In hard cases like these, sympathy and compassion also tempt us to compromise our basic norms and fudge our laws. The temptation is to think that we can allow just one, or a few, exceptions; we can still hold the line 'as a general rule'. But rational reflection and human experience suggest that the implications of such exceptions go far wider than the relief of hard cases.

Apart from the intrinsic evil of killing people, medical killing changes us individually and as a society. The doctor's character will inevitably be very significantly shaped by killing a patient, however well-meaningly. It will change the doctor's attitudes, habits, dispositions, taboos. Ethically, psychologically and sociologically, it invites further extension of the killing principle, and discourages alternative approaches to suffering, such as research into cures and the provision of good palliative care and pain management.

There are other problems with medical killing too. There are the pressures, subtle and overt, conscious and unconscious, which would be put on patients, families and healthcare workers to seek euthanasia: pressures all the harder to resist when one is very vulnerable, one's freedom very limited, one's self-esteem very low. Licence for medical killing would quickly become a duty to take part in it. There is the problem of the effects on the doctor- patient relationship, and family relationships, poisoning the atmosphere with suspicion and guilt. And there is the spectre of the economic argument, in a rapidly-aging society in which healthcare costs are escalating, to keep extending the occasions for medical killing.

Where next?

The conduct of the Bland case raises many more questions. Why, for instance, were lawyers and judges so eager to rule that 'advance directives' or 'living wills' are legal, when this issue had no bearing on the present case? Counsel for the Attorney-General appeared with the self-styled brief to be an 'independent and impartial' friend of the court: why was he the strongest proponent of withdrawing Tony Bland's tube-feeding, legalizing this kind of passive euthanasia, and recognizing living wills? Did cost-cutting play a part in the attitude of the Government? Press estimates put the total cost of caring for PVS patients at somewhere between £40 to £150 million a year; were some or all of them 'allowed to die with dignity', there would be significant savings. The parties to the case were unwilling to raise the money matter; but counsel for the Attorney-General did so, and the judges followed the lead. But how can a society as affluent as Britain, even in recession, justify abandoning the severely handicapped on financial grounds?

Medical killing is so often presented as the compassionate or merciful way to treat those in severe pain or incurable incompetence. But compassion is not the same as giving people whatever they say they want, or we think they want: it is having empathy with them in their suffering and seeking their genuine good. Nor is mercy the strategy of curing misery by killing the miserable: it entails staying by their side and offering the best care we can.

The Bland case confronts us with to the question of why it is that we care for people with PVS, coma, profound intellectual handicap, Alzheimer's Disease, and so on. If we hope that some will regain consciousness and independence, we know others will not. By supporting them we affirm our respect for their humanity, express our love for them, and maintain our human solidarity with them. This is a kind of respecting and loving which no one should pretend is easy.

But for all the polemics about 'dignified death' used by the euthanasia movement and now by the courts, we can forget that dignity is not recognised by telling the old, infirm or comatose how undignified their condition is, or that they would be better off dead. It is not recognised by standing by and watching someone die of thirst and hunger. Dignity in old age, handicap, unconsciousness, and suffering are above all a matter of knowing you are respected and loved. Surely we can find more creative ways of demonstrating love and respect than by homicide.

Fr A Fisher OP

Fr Anthony Fisher OP is an Australian currently undertaking a Phd at Oxford University. His Thesis concerns Bio-ethics. Fr Anthony can be contacted at Compuserve ID 76711,1340.

Anthony Fisher, O.P. for The Catholic Herald - page 4