A good death: On the curious status of arguments in the debate about euthanasia

Arguments about public policy are funny things. Consider the debate about whether active voluntary or non-voluntary euthanasia ought to be legalised. By voluntary euthanasia I mean euthanasia with the consent of the patient, and by non-voluntary euthanasia I mean euthanasia in cases where the consent of the patient cannot be obtained. Neither of these is to be confused with involuntary euthanasia, which is euthanasia against the wishes of the patient. Active euthanasia is usually considered to involve the active administering of a lethal substance with the purpose of ending life, while passive euthanasia is usually considered to be either the withholding of life preserving treatments, or the provision of medications that decrease suffering but which may also hasten death.

Passive euthanasia, at least in many forms, is legal in most countries. There are, however, only a couple of countries in which active euthanasia is permitted. In my home country of Australia one territory legalised voluntary active euthanasia, only to have the law overturned by the Commonwealth parliament shortly thereafter. In the Netherlands and Belgium active voluntary euthanasia is not a crime so long as the act of euthanizing is undertaken by a doctor, and the circumstances in which the doctor acts meet certain legal criteria. Almost everywhere else, active voluntary euthanasia is criminal.

There are lots of arguments that one might give either in favour of, or against, the criminalisation of active euthanasia. What interests me is the way that some of the arguments about euthanasia tend to be framed, and how that framing is so very different from the ways in which we frame other questions about public policy.

Consider, for example, one of the frequently cited arguments against legalising active euthanasia. According to this argument, legalising active euthanasia is likely to put into place a system in which vulnerable, aged, frail or sick persons may feel either directly or indirectly pressured into terminating their lives. To legalise active euthanasia is, the argument proceeds, to send the message that certain kinds of life are not worth living and have no value to the community. When we send that message we should expect that the people who are leading those lives will themselves come to think that they have no value, and to then think that they are a burden on society and their families, and therefore that they ought to terminate their lives.

Legalising, and thus making easier, the ending of lives does bring with it certain risks. There are the risks that some people will feel unvalued and will end their lives for this reason. There is the risk that unscrupulous doctors or relatives will use such laws for their own purposes to terminate the lives of weak, frail and easily manipulated relatives. There is the danger that older people suffering depression might terminate their lives rather than be appropriately treated. There are not trivial concerns.

But let us take a step back from the debate about euthanasia and think about the argument at a more abstract level. The claim is essentially that if we make certain decisions, in this case about public policy, then we risk certain bad outcomes. Notice that the argument does not suggest that there are not also good outcomes: it does not suggest that allowing people to avoid certain kinds of suffering and indignity is not a good thing. It just suggests that along with any good outcomes there are also potential bad outcomes.

This seems like a good thing to point out. But the fact that a particular decision might have, or indeed could be expected to have, some bad outcomes it not usually, in itself, thought of as a reason to not make that decision, unless the costs of the bad outcomes outweigh all benefits of the good outcomes.

Consider any number of other examples. We all drive cars. This has various benefits that we are all familiar with. But it also has costs – people die and are seriously injured in automobile accidents. What do we do about this? Well, we could criminalise driving. But instead we try to make cars and roads safer in various ways, and we try to find ways to make it more probable that people will survive road traffic accidents. Consider hunting. Whatever you think about the ethics of hunting, it clearly has some costs. People get shot. Hunters get shot, and so do random folk walking through forests. We (by which I mean the US) could ban hunting. But instead people are advised to wear bright clothing when they walk through forested areas during hunting season. We try to mitigate the dangers. I invite you to think about the use of the internet, credit cards, air conditioning, travel by aircraft, travel overseas, the taking of medicines and vaccinations.

These, and so many other activities, are things that most of us think have certain benefits, but also bring certain risks. The taking of aspirin, and the ingestion of alcohol are two pretty obvious cases. Both have certain benefits, and both have very obvious drawbacks. In 2006 7600 people died from taking aspirin (or other NSAIDS) in the US alone, and 85 000 people died in the US of alcohol related injury. Do we criminalise NSAIDS or alcohol? Well no. We do try to minimise their harms in various ways – we try to prevent people drinking and driving, we offer alcohol rehabilitation programs and so forth. Now, if any of these activities had no benefit at all, and had only costs, it seems likely that we would be more inclined to try and prevent them, and might even criminalise them. So if you think that active euthanasia has no benefits at all – that it does not ease suffering and that it does not provide people with choices about how their life will end, at a time in their life when they may not have many choices left (or that if it does, that is not a good thing), then the fact that there are certain risks associated with legalised active euthanasia would be a good reason not to legalise it.

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But it is interesting that arguments such as the one we are considering here, seem to have such power in the domain of public policy regarding euthanasia, where analogous arguments have so little power in analogous public policy decisions. 435 000 people die in the US from tobacco related illnesses every year. But tobacco is legal despite the fact that there are not really so many benefits to be had from it, except of course a love of smoking.

Perhaps it is a individual’s right to choose to smoke or not, and it is society’s duty to try and minimise the damage done: offering nicotine patches, quit lines, and replacement lungs. But if that is so, then why is that not also our attitude to the debate about euthanasia? Perhaps there are some risks related to legalising active euthanasia. That is a good reason to try and find ways to minimise any harm – to find ways to make sure that vulnerable people are not bullied into making decisions they have no desire to make; to make sure that older depressed patients are treated for their depression; to make sure that aged and frail people do not feel that they are not valued or that it would be better for the world if they were not in it. Indeed these, surely, are things we ought to be doing anyway. But why ought the fact that these risks exist be a strong reason to be suspicious of euthanasia, when the fact that 26 000 people die car accidents each year is not a reason to be suspicious of driving?

I think it bears thinking about why we find this peculiar asymmetry in the debate about euthanasia.