Practical Ethics

Like abortion, providing aid in dying is highly controversial, and the politics of the issue has affected the terms used. In the United States, the discussion has focused on whether, if a patient asks a doctor for help in dying, the doctor ought to be allowed to prescribe something that will, if the patient takes it, end the patient's life swiftly and humanely. This has been legalized in the states of Oregon and Washington following citizen-initiated referenda that were passed by a majority of voters, and the Montana Supreme Court declared in 2009 that it is not contrary to law. It is usually called ‘physician-assisted suicide’ but in the United States, at least, ‘suicide’ has such negative associations that organizations seeking to legalize it prefer to call it ‘death with dignity’ or ‘aid in dying.’ These terms are too vague for philosophical discussions. ‘Death with dignity’ can mean almost anything, depending on what one considers a dignified way to die. ‘Aid in dying’ is barely more specific. It could refer to acts that make a dying person more comfortable, without shortening life, like giving modest amounts of pain relief, or it could refer to giving a patient, on request, a lethal injection. In addition, neither of these expressions says anything about who assists the patient to die. The term ‘physician-assisted dying’ gets closer to what happens, but it still does not emphasize that it is the patient who takes the step of ending her own life. Although it is certainly true that patients who are terminally ill and choose to end their own life to avoid further suffering are making a very different decision from people who kill themselves because they are emotionally disturbed, that does not change the basic fact that all these people are ending their own lives rather than continuing to live for as long as they can. Hence, we should not shy away from the term ‘physician-assisted suicide,’ because that offers the most precise description of what happens when a physician, acting on a request from the patient, provides a prescription for a drug which the patient then takes to end her life. In using this term, we should try to dismiss any negative associations that the term ‘suicide’ may have. Many cultures have considered suicide, in certain circumstances, to be a rational, honourable, and even sometimes a noble act. The Stoic philosopher Seneca wrote that a wise person ‘lives as long as he ought, not as long as he can’. Cato the Younger, a Roman politician renowned for his integrity and refusal to take bribes, committed suicide when he was unable to stop Julius Caesar's overthrow of the Roman republic. According to Plutarch's account, Caesar said ‘Cato, I grudge your death’ – acknowledging that in ending his life, Cato had done something truly noble. So let's use that term, without prejudicing our discussion of whether, in the circumstances we shall be discussing, physician-assisted suicide is justifiable or should be legal.

Physician-assisted suicide can be considered as one form of euthanasia, but the latter term has a wider meaning. According to the dictionary, ‘euthanasia’ refers to ‘a gentle and easy death’, but it is now used to refer to the killing of those who are incurably ill and in great pain or distress, in order to spare them further suffering or distress. Hence, it differs from physician-assisted suicide in that the physician or other person providing euthanasia may do the killing, for example, by giving the patient a lethal injection. Within the usual definition of euthanasia there are three different types, each of which raises distinctive ethical issues. It will help our discussion if we begin by setting out the three forms of euthanasia and place them within the broader framework. We can then assess the justifiability of each form.

It was extraordinarily important to Diane to maintain control of herself and her own dignity during the time remaining to her. When this was no longer possible, she clearly wanted to die. As a former director of a hospice program, I know how to use pain medicines to keep patients comfortable and lessen suffering. I explained the philosophy of comfort care, which I strongly believe in. Although Diane understood and appreciated this, she had known of people lingering in what was called relative comfort, and she wanted no part of it. When the time came, she wanted to take her life in the least painful way possible. Knowing of her desire for independence and her decision to stay in control, I thought this request made perfect sense…In our discussion it became clear that preoccupation with her fear of a lingering death would interfere with Diane's getting the most out of the time she had left until she found a safe way to ensure her death.

Not all dying patients who wish to die are fortunate enough to have a doctor like Timothy Quill. Betty Rollin has described, in her moving book Last Wish, how her mother developed ovarian cancer that spread to other parts of her body. One morning her mother said to her:

I’ve had a wonderful life, but now it's over, or it should be. I’m not afraid to die, but I am afraid of this illness, what it's doing to me…There's never any relief from it now. Nothing but nausea and this pain…There won't be any more chemotherapy. There's no treatment anymore. So what happens to me now? I know what happens. I’ll die slowly…I don't want that…Who does it benefit if I die slowly? If it benefits my children I’d be willing. But it's not going to do you any good.…There's no point in a slow death, none. I’ve never liked doing things with no point. I’ve got to end this.

Betty Rollin found it very difficult to help her mother to carry out her desire: ‘Physician after physician turned down our pleas for help (How many pills? What kind?).’ After her book about her mother's death was published, she received hundreds of letters, many from people, or close relatives of people, who had tried to die, failed, and suffered even more. Many of these people were denied help from doctors, because although suicide is legal in most jurisdictions, assisted suicide is not.

Dr. Jack Kevorkian, a Michigan pathologist, sought to help people who want to die but cannot get assistance from their own doctor. Initially, he helped people to die with a ‘suicide machine’ consisting of a metal pole with three different bottles attached to a tube of the kind used to provide an intravenous drip. He would insert the tube in the patient's vein, but with the switch set so that only a harmless saline solution can pass through it. The patient could then flip a switch allowing a coma-inducing drug to come through the tube; this was automatically followed by a lethal drug contained in the third bottle. Dr. Kevorkian announced that he was prepared to make the machine available to any terminally ill patient who wished to use it. In June 1990, Janet Adkins, who was suffering from Alzheimer's disease but still competent to make the decision to end her life, contacted Dr. Kevorkian and told him of her wish to die rather than go through the slow and progressive deterioration that the disease involves. Dr. Kevorkian was in attendance while she made use of his machine. He then reported Janet Adkins’ death to the police. He was subsequently charged with murder, but the judge refused to allow the charge to proceed to trial, on the grounds that Janet Adkins had caused her own death. During the next eight years, Dr. Kevorkian assisted many other people to die. He was repeatedly charged with assisting suicide, but no jury convicted him of that offence. When his licence to practise medicine was withdrawn, and he was no longer able to obtain the lethal drug he had been using, he altered the ‘suicide machine’ so that it released carbon monoxide, through a gas mask, to the patient. Finally in 1998, Kevorkian decided to help Thomas Youk, who was dying from ALS, also known as Lou Gehrig's disease, and had asked Kevorkian to end his life. Those suffering from ALS lose control of their muscles, and so as the inevitable end approaches, they are unable to flip switches or take drugs. Kevorkian crossed the line from assisted suicide to voluntary euthanasia by giving Youk a lethal injection. Moreover, in a clear challenge to the legal authorities, he released a video taken while he was giving the injection. This time, a jury convicted him of second-degree homicide, and he served eight years in prison before being released on parole.

Philip Nitschke prefers to work at the edge of the law rather than to challenge it directly. Nitschke was practicing medicine in Australia's Northern Territory when that region legalized voluntary euthanasia. Nitschke helped four terminally ill people end their lives before the law was overturned by the Federal government in 1997. Convinced that people have a right to end their own lives if they choose to do so, he founded Exit International, an organization that runs workshops in Australia, New Zealand, the United Kingdom and the United States advising people on how to end their lives reliably and safely. He has co-authored The Peaceful Pill Handbook to provide the same knowledge to those who cannot attend the workshops. The hard copy version of the book has been banned in Australia, but is available in the United States, and Nitschke has made an electronic version available online (although it is an offense to download it in Australia). Whatever one thinks about the ethics of voluntary euthanasia and physician-assisted suicide, whether such information should be publicly available is itself an ethical question, given the possibility of misuse by those who are not terminally or incurably ill. Many advocates of the legalization of voluntary euthanasia and physician-assisted suicide are themselves against publishing ‘do it yourself’ guides to dying, arguing that laws restricting aid in dying to doctors provide important safeguards. Nitschke might agree that this would be desirable, but consider that because there are still few countries in which either voluntary euthanasia or physician-assisted suicide is legal, the importance of helping those who have good reason to end their lives outweighs the small risk of misuse.

Does the idea of giving everyone access to a ‘peaceful pill’ perhaps give too much weight to individual freedom and autonomy? After all, we do not allow people free choices on matters like, for instance, the taking of heroin. This is a restriction of freedom but, in the view of many, one that can be justified on paternalistic grounds. If preventing people becoming heroin addicts is justifiable paternalism, why isn't preventing people having themselves killed?

The question is a reasonable one, because respect for individual freedom can be carried too far. John Stuart Mill thought that the state should never interfere with the individual except to prevent harm to others. The individual's own good, Mill thought, is not a proper reason for state intervention. But Mill may have had too high an opinion of the rationality of most human beings. It may occasionally be right to prevent people making choices that are obviously not rationally based and which we can be sure they will later regret. The prohibition of voluntary euthanasia cannot be justified on paternalistic grounds, however, for voluntary euthanasia is an act for which good reasons exist. Voluntary euthanasia occurs only when, to the best of medical knowledge, a person is suffering from an incurable and painful or extremely distressing condition. In these circumstances one cannot say that to choose to die quickly is obviously irrational. The strength of the case for voluntary euthanasia lies in this combination of respect for the preferences, or autonomy, of those who decide for euthanasia; and the clear rational basis of the decision itself. When information about ending one's life is made easily available, people may decide to end their lives without such a clear rational basis. Legal, regulated voluntary euthanasia and physician-assisted suicide have far less potential for abuse, and when they are available, there is no need to make it easy for people to find out how to kill themselves.

Involuntary euthanasia resembles voluntary euthanasia in that it involves the killing of those capable of consenting to their own death. It differs in that they do not consent. This difference is crucial, as the argument of the preceding section shows. All the four reasons against killing self-aware beings apply when the person killed does not choose to die.

Something very like involuntary euthanasia appears to have taken place in a hospital in New Orleans during the floods caused by Hurricane Katrina in 2005. Memorial Medical Center, a community hospital that was holding more than 200 patients at the time, was cut off by the rising water. Three days after the hurricane hit, the hospital had no electricity, the water supply had failed, and toilets could no longer be flushed. Some patients who were dependent on ventilators died. In stifling heat, doctors and nurses were hard-pressed to care for surviving patients lying on soiled beds. Adding to the anxiety were fears that law and order had broken down in the city, and the hospital itself might be a target for armed bandits.

Helicopters were called in to evacuate patients. Priority was given to those who were in better health, and could walk. State police arrived and told staff that because of the civil unrest, everybody had to be out of the hospital by 5 P.M.

On the eighth floor, Jannie Burgess, a 79-year-old woman with advanced cancer, was on a morphine drip and close to death. To evacuate her, she would have to be carried down six flights of stairs and would require the attention of nurses who were needed elsewhere. If she were left unattended, however, she might come out of her sedation and be in pain. One of the physicians present instructed the nurse to increase the morphine ‘giving her enough until she goes’. Another physician told nursing staff that several patients on the seventh floor were also too ill to survive. She injected them with morphine and another drug that slowed their breathing until they died.

At least one of the patients injected with this lethal combination of drugs appears to have otherwise been in little danger of imminent death. Emmett Everett was a 61-year-old man who had been paralysed in an accident several years earlier and was in the hospital for surgery to relieve a bowel obstruction. When others from his ward were evacuated, he asked not to be left behind; but he weighed 380 lbs (172 kg), and it would have been extremely difficult to carry him down the stairs and then up again to where the helicopters were landing. He was told the injection he was being given would help with the dizziness from which he suffered.

Whether any of these killings can be justified in these circumstances is debatable, but the killing of Emmett Everett, in my view, cannot be. Significantly, the physicians’ actions were not the result of a slippery slope from the acceptance of voluntary euthanasia or physician-assisted suicide, for those practices have always been illegal in Louisiana. Rather, from what the physicians told Sheri Fink, on whose The New York Times report the previous account is based, the physicians saw what they were doing as an application of the doctrine of double effect, on which physicians commonly draw when giving morphine to relieve pain in a terminally ill patient, though they know it will shorten life. We shall discuss that doctrine shortly.

Would it ever be possible to justify involuntary euthanasia on paternalistic grounds, to save someone extreme agony? We can imagine a case in which the agony is so great, and so certain, that it overrides all four reasons against killing self-aware beings. Yet to make this decision one would have to be confident that one can judge when a person's life is so bad as to be not worth living – and that one is in a better position to make that judgment than the person herself. But the fact that the other person wishes to go on living is good evidence that her life is worth living. What better evidence could there be?

The only kind of case in which the paternalistic argument is at all plausible is one in which the person to be killed does not realize what agony she will suffer in the future, and if she is not killed now she will have to live through to the very end. On these grounds, one might kill a person who has – though she does not yet realize it – fallen into the hands of homicidal sadists who will torture her to death. These cases are, fortunately, more commonly encountered in fiction than reality.

Here, the distinction between critical and intuitive levels of moral reasoning (see pp. 78–80, Chapter 4) is again relevant. If in real life we are unlikely ever to encounter a case of justifiable involuntary euthanasia, then it may be best to dismiss from our minds the fanciful cases in which one might imagine defending it and treat the rule against involuntary euthanasia as, for all practical purposes, absolute. At the intuitive level, the level of moral reasoning we apply in our daily lives, we can simply say that euthanasia is only justifiable if those killed either:

a. lack the ability to consent to death, because they lack the capacity to understand the choice between their own continued existence or non-existence; or

b. have the capacity to choose between their own continued life and death and have made an informed, voluntary and settled decision to die.

The conclusions we have reached in this chapter violate one of the most fundamental tenets of Western ethics – that killing an innocent human being is always wrong. I have already shown that my conclusions are, at least in the area of disabled infants, a less radical departure from existing practice than one might suppose because of the widespread support for prenatal diagnosis and abortion of a pregnancy that will lead to a disabled child. In this section, I shall argue that there is another area of accepted medical practice that is not intrinsically different from the practices that I advocate. Against this background, the conclusions we have reached may seem less shocking than they otherwise would.

‘Baby Doe’ – a legal pseudonym – was born in Bloomington, Indiana, in 1982, with Down syndrome and some additional problems, including an improperly formed oesophagus – the passage from the mouth to the stomach. This meant that Baby Doe could not receive nourishment by mouth. Surgery to fix the problem was offered, but the parents, after discussing the situation with their obstetrician, refused. Without surgery, Baby Doe would soon die. Baby Doe's father later said that as a schoolteacher he had worked closely with Down syndrome children, and that he and his wife had decided that it was in the best interests of Baby Doe, and of their family as a whole (they had two other children), to refuse consent for the operation. The hospital authorities, uncertain of their legal position, took the matter to court. Both the local county court and the Indiana State Supreme Court upheld the parents’ right to refuse consent to surgery. The case attracted national media attention, and an attempt was made to take it to the United States Supreme Court; but before this could happen, Baby Doe died.

One result of the Baby Doe case was that the United States government, headed at the time by President Ronald Reagan, issued regulations directing that all infants are to be given necessary life-saving treatment, irrespective of disability. But the new regulations were strongly resisted by the American Medical Association and the American Academy of Pediatrics. In court hearings on the regulations, even Dr. C. Everett Koop, Reagan's surgeon general and the driving force behind the attempt to ensure that all infants should be treated, had to admit that there were some cases in which he would not provide life-sustaining treatment. Dr. Koop mentioned three conditions in which, he said, life-sustaining treatment was not appropriate: anencephalic infants (infants born without a brain); infants who had, usually as a result of extreme prematurity, suffered such severe bleeding in the brain that they would never be able to breathe without a respirator and would never be able even to recognize another person; and infants lacking a major part of their digestive tract, who could only be kept alive by means of a drip providing nourishment directly into the bloodstream.

The regulations were eventually accepted only in a watered-down form, allowing some flexibility to doctors. Even so, a subsequent survey of American paediatricians specialising in the care of newborn infants showed that 76 percent thought that the regulations were not necessary, 66 percent considered the regulations interfered with parents’ rights to determine what course of action was in the best interests of their children, and 60 percent believed that the regulations did not allow adequate consideration of infants’ suffering.

In a series of British cases, the courts have accepted the view that the quality of a child's life is a relevant consideration in deciding whether life-sustaining treatment should be provided. In a case called In re B, concerning a baby like Baby Doe, with Down syndrome and an intestinal obstruction, the court said that surgery should be carried out, because the infant's life would not be ‘demonstrably awful’. In another case, Re C, where the baby had a poorly formed brain combined with severe physical handicaps, the court authorised the paediatric team to refrain from giving life-prolonging treatment. This was also the course taken in the case of Re Baby J; this infant was born extremely prematurely and was blind, deaf and would probably never have been able to speak.

A survey of European physicians working in neonatal intensive care units in France, Germany, Italy, Luxembourg, the Netherlands, Spain, Sweden and the United Kingdom showed that in all these countries, a majority had set limits to the intensive care given to an infant because it had an incurable condition. They had, for example, withheld resuscitation after a baby's heart had stopped or not put the baby on a respirator. Thus, though many would disagree with Baby Doe's parents’ decision (because people with Down syndrome can live enjoyable lives and are often warm and loving individuals), virtually everyone recognizes that in more severe conditions, allowing an infant to die is the only humane and ethically acceptable course to take. The question is: if it is right to allow infants to die, why is it wrong to kill them?

This question has not escaped the notice of the doctors involved. Frequently, they answer it by invoking a verse by the nineteenth-century poet, Arthur Clough:

Thou shalt not kill; but need'st not strive

Officiously to keep alive.

Unfortunately for those who appeal to Clough's immortal lines as an authoritative ethical pronouncement, they come from a biting satire – ‘The Latest Decalogue’ – the intent of which is to mock the attitudes described. The opening lines, for example, are:

Thou shalt have one god only; who

Would be at the expense of two.

No graven images may be

Worshipped except the currency.

So Clough cannot be numbered on the side of those who think it wrong to kill, but right not to try too hard to keep alive. Is there, nonetheless, something to be said for this idea? The view that there is something to be said for it is often termed ‘the acts and omissions doctrine’. It holds that there is an important moral distinction between performing an act that has certain consequences – say, the death of a disabled child – and omitting to do something that has the same consequences. If this doctrine is correct, the doctor who gives the child a lethal injection does wrong; the doctor who omits to give the child antibiotics, knowing full well that without antibiotics the child will die, does not.

What grounds are there for accepting the acts and omissions doctrine? Few champion the doctrine for its own sake as an important ethical first principle. It is, rather, an implication of one view of ethics, of a view that holds that so long as we do not violate specified moral rules that place determinate moral obligations on us, we do all that morality demands of us. These rules are of the kind made familiar by the Ten Commandments and similar moral codes: ‘Do not kill’, ‘Do not lie’, ‘Do not steal’ and so on. Characteristically they are formulated in the negative, so that to obey them it is necessary only to abstain from the actions they prohibit. Hence, obedience can be demanded of every member of the community.

An ethic consisting of specific duties, prescribed by moral rules that everyone can be expected to obey, must make a sharp moral distinction between acts and omissions. Take, for example, the rule: ‘Do not kill.’ If this rule is interpreted, as it has been in the Western tradition, as prohibiting only the taking of innocent human life, it is not too difficult to avoid overt acts in violation of it. Few of us are murderers. It is not so easy to avoid letting innocent humans die. Many people die because of insufficient food or poor medical facilities. If we could assist some of them but do not do so, we are letting them die. Taking the rule against killing to apply to omissions would make living in accordance with it a mark of saintliness or moral heroism rather than a minimum required of every morally decent person.

An ethic that judges acts according to whether they do or do not violate specific moral rules must, therefore, place moral weight on the distinction between acts and omissions. An ethic that judges acts by their consequences will not do so, for the consequences of an act and an omission will often be, in all significant respects, indistinguishable. For instance, deciding not to put a premature infant who cannot breathe unaided on a respirator has consequences just as fatal as giving the child a lethal injection.

The acts and omissions issue poses the choice between these two basic approaches in an unusually clear and direct way. What we need to do is imagine two parallel situations differing only in that in one a person performs an act resulting in the death of another human being, whereas in the other she omits to do something, with the same result. Here is a description of a relatively common situation, taken from an essay by Sir Gustav Nossal, an eminent Australian medical researcher:

An old lady of 83 has been admitted [to a nursing home for the aged] because her increasing degree of mental confusion has made it impossible for her to stay in her own home, and there is no one willing and able to look after her. Over three years, her condition deteriorates. She loses the ability to speak, requires to be fed, and becomes incontinent. Finally, she cannot sit in an armchair any longer, and is confined permanently to bed. One day, she contracts pneumonia.

In a patient who was enjoying a reasonable quality of life, pneumonia would be routinely treated with antibiotics. Should this patient be given antibiotics? Nossal continues:

The relatives are contacted, and the matron of the nursing home tells them that she and the doctor she uses most frequently have worked out a loose arrangement for cases of this type. With advanced senile dementia, they treat the first three infections with antibiotics, and after that, mindful of the adage that ‘pneumonia is the old person's friend’, they let nature take its course. The matron emphasises that if the relatives desire, all infections can be vigorously treated. The relatives agree with the rule of thumb. The patient dies of a urinary tract infection six months later.

This patient died when she did as a result of a deliberate omission. Many people would think that this omission was well-justified. They might question whether it would not have been better to omit treatment even for the initial occurrence of pneumonia. There is, after all, no moral magic about the number three. Would it also have been justifiable, at the time when a decision not to give an antibiotic was taken, to give an injection that would bring about the patient's death in a peaceful way?

Comparing these two possible ways of bringing about a patient's death at a particular time, is it reasonable to hold that the doctor who gives the injection is a murderer who deserves to go to jail, whereas the doctor who decides not to administer antibiotics is practising good and compassionate medicine? That may be what courts of law would say, but surely it is an untenable distinction. In both cases, the outcome is the death of the patient. In both cases, the doctor knows that this will be the result and decides what she will do on the basis of this knowledge, because she judges this result to be better than the alternative. In both cases, the doctor must take responsibility for her decision – it would not be correct for the doctor who decided not to provide antibiotics to say that she was not responsible for the patient's death because she did nothing. Doing nothing in this situation is itself a deliberate choice, and one cannot escape responsibility for its consequences.

One might say, of course, that the doctor who withholds antibiotics does not kill the patient, she merely allows the patient to die; but one must then answer the further question why killing is always wrong and letting die is sometimes right. The answer that most advocates of the distinction give is simply that there is a moral rule against killing innocent human beings and none against allowing them to die. This answer treats a conventionally accepted moral rule as if it were beyond questioning; it does not go on to ask whether we should have a moral rule against killing (but not against allowing to die). We have already seen that the conventionally accepted principle of the sanctity of human life is untenable. The moral rules that prohibit killing but accept ‘letting die’ cannot be taken for granted either.

Reflecting on these cases leads us to the conclusion that there is no intrinsic moral difference between killing and allowing to die. That is, there is no difference which depends solely on the distinction between an act and an omission. (This does not mean that all cases of allowing to die are morally equivalent to killing. Other factors – extrinsic factors – will sometimes be relevant. This will be discussed further in the next chapter.) Allowing to die – sometimes called ‘passive euthanasia’ – is already accepted as a humane and proper course of action in certain cases. If there is no intrinsic moral difference between killing and allowing to die, active euthanasia should also be accepted as humane and proper in certain circumstances.

Others have suggested that the difference between withholding treatment necessary to prolong life and giving a lethal injection lies in the intention with which the two are done. Those who take this view resort to the ‘doctrine of double effect’, a doctrine widely held among Roman Catholic moral theologians and moral philosophers, to argue that one action (for example, refraining from life-sustaining treatment) may have two effects (in this case, not causing additional suffering to the patient and shortening the patient's life). They then argue that as long as the directly intended effect is the beneficial one that does not violate an absolute moral rule, the action is permissible. Though we foresee that our action (or omission) will result in the death of the patient, this is merely an unwanted side effect. But the distinction between directly intended effect and side effect is a contrived one, and the doctrine can easily be misused, as we have seen in the case of Memorial Medical Center in New Orleans after Hurricane Katrina. We cannot avoid responsibility simply by directing our intention to one effect rather than another. If we foresee both effects, we must take responsibility for the foreseen effects of what we do. We often want to do something but cannot do it because of its other, unwanted consequences. For example, a chemical company might want to get rid of toxic waste in the most economical manner, by dumping it in the nearest river. Would we allow the executives of the company to say that all they directly intended was to improve the efficiency of the factory, thus promoting employment and keeping down the cost of living? Would we regard the pollution as excusable because it is merely an unwanted side effect of furthering these worthy objectives? Obviously, the defenders of the doctrine of double effect would not accept such an excuse. In rejecting it, however, they would have to rely on a judgment that the cost – the polluted river – is disproportionate to the gains. Here, a consequentialist judgment lurks behind the doctrine of double effect. The same is true when the doctrine is used in medical care. Normally, saving life takes precedence over relieving pain. If in the case of a particular patient it does not, this can only be because we have judged that the patient's prospects for a future life of acceptable quality are so poor that in this case relieving suffering can take precedence. This is, in other words, not a decision based on acceptance of the sanctity of human life, but a decision based on a disguised quality of life judgment.

Equally unsatisfactory is the common appeal to a distinction between ‘ordinary’ and ‘extraordinary’ means of treatment, coupled with the belief that it is not obligatory to provide extraordinary means. Together with my colleague, Helga Kuhse, I carried out a survey of paediatricians and obstetricians in Australia and found that they had remarkable ideas about what constituted ‘ordinary’ and ‘extraordinary’ means. Some even thought that the use of antibiotics – the cheapest, simplest and most common medical procedure – could be extraordinary. The reason for this range of views is easy to find. When one looks at the justifications given by moral theologians and philosophers for the distinction, it turns out that what is ‘ordinary’ in one situation can become ‘extraordinary’ in another. For example, in the landmark case of Karen Ann Quinlan, a young New Jersey woman who was in a coma, breathing with the aid of a respirator and considered to have no prospect of recovery, a Roman Catholic bishop testified that the use of a respirator was ‘extraordinary’ and hence optional because Quinlan had no hope of recovery from the coma. Obviously, if doctors had thought that Quinlan was likely to recover, the use of the respirator would not have been optional and would have been declared ‘ordinary’. On the other hand, when the respirator was removed and Quinlan, to most people's surprise, continued to breathe on her own, her parents, who were Roman Catholics, did not seek the removal of her feeding tube. Quinlan survived for another nine years but never recovered from her coma.

In 2004, during the controversy over Terri Schiavo, Pope John Paul II stated firmly that a feeding tube must not be withdrawn from people in a vegetative state, saying that ‘the administration of water and food, even when provided by artificial means, always represents a natural means of preserving life, not a medical act’. It is hard to see how the use of a feeding tube is not a medical act – inserting one is not something that people without health care training can do. Is there really a significant moral difference between withdrawing a respirator and withdrawing a feeding tube? The patient's prospects of at least a minimal quality of life (and, where resources are limited and could be used more effectively to save lives elsewhere, the cost of the treatment) should determine whether a given form of treatment is to be provided or not.

Indeed, because of extrinsic differences – especially differences in the time it takes for death to occur – active euthanasia may be the more humane course. In the 1970s, Dr. John Lorber, a British physician, recommended that infants born with the most severe form of spina bifida – then a relatively common birth defect in which the baby has a wound on the back exposing the nerves – should be allowed to die, because he considered that their prospects of a worthwhile life were poor. Lorber openly acknowledged that the object of not treating these infants is that they should die soon and painlessly. Yet when he charted the fate of twenty-five infants born with spina bifida on whom it had been decided not to operate, he found that fourteen were still alive after one month and seven after three months. An Australian clinic following Lorber's approach to spina bifida found that of seventy-nine untreated infants, five survived for more than two years. For both the infants, and their families, this must have been a long, drawn-out ordeal. It is also (although in a society with a reasonable level of affluence this should not be the primary consideration) a considerable burden on the hospital staff and the community's medical resources. (Today, far fewer babies are born with spina bifida, partly because of the discovery that taking folic acid early in pregnancy reduces the incidence of the condition and partly because spina bifida can now be detected during pregnancy and most fetuses with the condition are aborted.)

Consider, to take another example, infants born with Down syndrome and a blockage in the digestive system which, if not removed, will make it impossible for the baby to eat. Like ‘Baby Doe’, these infants may be allowed to die. Yet the blockage can be removed and has nothing to do with the degree of intellectual disability the child will have. Moreover, the death resulting from the failure to operate in these circumstances is, though sure, neither swift nor painless. The infant dies from dehydration or hunger. Baby Doe took about five days to die, and in other recorded instances of this practice, it has taken up to two weeks for death to come.

It is interesting, in this context, to think again of our earlier argument that membership of the species Homo sapiens does not entitle a being to better treatment than a being at a similar mental level who is a member of a different species. We could also have said – except that it seemed too obvious to need saying – that membership of the species Homo sapiens is not a reason for giving a being worse treatment than a member of a different species. Yet in respect of euthanasia, this needs to be said. If your dog is ill and in pain with no chance of recovery, the humane thing to do is take her to the vet, who will end her suffering swiftly with a lethal injection. To ‘allow nature to take its course’, withholding treatment while your dog dies slowly and in distress over days, weeks or months, would obviously be wrong. It is only our misplaced respect for the doctrine of the sanctity of human life that prevents us from seeing that what it is obviously wrong to do to a dog, it is equally wrong to do to a human being who has never been able to express a view about such matters.

To summarize: passive ways of ending life result in a drawn-out death. They introduce irrelevant factors (a blockage in the intestine or the presence of an easily curable infection) into the selection of those who shall die. If we are able to admit that our objective is a swift and painless death, we should not leave it up to chance to determine whether this objective is achieved. Having chosen death, we should ensure that it comes in the best possible way.

Before we leave this topic, we must consider an objection that looms so large in the anti-euthanasia literature that it merits a section to itself. It is, for instance, the reason why Dr. John Lorber rejected active euthanasia. He wrote:

I wholly disagree with euthanasia. Though it is fully logical, and in expert and conscientious hands it could be the most humane way of dealing with such a situation, legalizing euthanasia would be a most dangerous weapon in the hands of the State or ignorant or unscrupulous individuals. One does not have to go far back in history to know what crimes can be committed if euthanasia were legalized.

Would euthanasia be the first step down a slippery slope? In the absence of prominent moral footholds to check our descent, would we slide all the way down into the abyss of state terror and mass murder? The experience of Nazism, to which Lorber no doubt is referring, has often been invoked as a spectre to warn us against euthanasia. Here is a more specific example, from an article by another doctor, Leo Alexander:

Whatever proportions [Nazi] crimes finally assumed, it became evident to all who investigated them that they had started from small beginnings. The beginnings at first were merely a subtle shift in emphasis in the basic attitude of the physicians. It started with the acceptance of the attitude, basic in the euthanasia movement, that there is such a thing as life not worthy to be lived. This attitude in its early stages concerned itself merely with the severely and chronically sick. Gradually the sphere of those to be included in the category was enlarged to encompass the socially unproductive, the ideologically unwanted, the racially unwanted and finally all non-Germans. But it is important to realize that the infinitely small wedged-in lever from which this entire trend of mind received its impetus was the attitude toward the nonrehabilitable sick.