Life, liberty and the pursuit of dignity
- Jacques Rousseau
- 17 Jan 2011 08:12 (South Africa)
Professor Sean Davison returned to South Africa in mid-December after the New Zealand high court revised his bail conditions and allowed him back to his family and his job at the University of the Western Cape. He is currently awaiting trial for attempted murder, after giving his mother a lethal dose of morphine four years ago - at her request.
His mother, Patricia, had been terminally ill from a cancer diagnosed in 2004 and thought life no longer worth living. She had tried and failed to starve herself to death and eventually resorted to asking her son to kill her. But voluntary euthanasia is illegal in New Zealand, as it is in South Africa. It’s time for that to change, and Davison will be assisting in setting up Dignity South Africa to have the relevant legislation amended.
The legislation currently applicable is in some disarray, both philosophically (as is quite common in most of the world) and with regard to the legislative status of the draft bill on End of Life Decisions. The South African Law Reform Commission proposed and tabled this bill before Parliament in 1999, but it has yet to be debated.
In the meanwhile, organisations such as Saves (the living will society of South Africa) operate in somewhat of a gray zone where, while South Africans are legally entitled to refuse medical attention even in cases where doing so would hasten death, doing so by so-called “advance directive” might not guarantee the outcome you desire. This is because there is no legislation in place that allows for your advance directive to be established as reliable, or composed under the required state of awareness of the consequences of that directive.
The reason that this situation is philosophically incoherent is that the distinction between passive euthanasia (withholding treatment) and active euthanasia (accelerating death through administering some agent, such as the morphine that Davison gave to his mother) relies on an emotional distinction rather than a morally principled one.
While the distinction between active and passive euthanasia is upheld in law and (officially) in medical practice, it ought to be discarded, as there is no moral difference between killing and letting die in the kind of situations at issue in medical practice. Most doctors seem to accept the idea that it is morally permissible to withdraw or withhold treatment in cases where the patient's imminent death seems certain, but that it is not morally permissible to hasten that same patient's death by measures such as administering a lethal dose of medication.
As an example, let us consider the patient who has terminal cancer and seems certain to die within hours if life-supporting treatment is withdrawn, and probably within days even if treatment is continued. In one possible scenario, Dr X believes there is no hope of the patient's recovery and seeks the permission of the family before withdrawing treatment.
His desire to withdraw treatment is based on factors such as the certainty of the patient's death, minimising the pain of watching somebody linger near death for an extended period, and the cost (financial and in terms of labour-hours) of keeping the patient alive artificially, when those resources could be used in helping patients who do have a chance of recovery. The family gives permission, and treatment is withdrawn.
The patient dies within hours, but it is clear to the doctor and to the family (who gathered around the hospital bed to be with the patient for his final hours) that the patient was enduring excruciating pain during those final hours. Medication was administered to alleviate the pain, but had no effect, as the strength of medication required to alleviate the pain was such that to administer it would have killed the patient, which is something the doctor could not do.
In an alternative scenario, the same patient is being treated by Doctor Z. He is motivated by the same factors as Doctor X, but believes he can do most good and minimise the pain for all concerned by administering a lethal dose of medication to the patient. The patient dies within minutes of injection and it is clear to the doctor and to the patient's family that the patient's last minutes were pain-free.
There is no reason for the death of the patient to be more traumatic for the family in the second scenario and it was certainly less traumatic for the patient. Furthermore, the family were not deprived of valuable time with their loved one, as the patient was not even conscious of their presence due to the amount of drugs he had been administered and the ravages the illness had inflicted on his body and mind.
In this kind of example, it is difficult to see how killing the patient is in any way morally less justifiable than letting him die. It is true, as James Rachels points out, that killing often appears more reprehensible than letting die, but this is often only due to the nature of the killings and what the notion of killing brings to mind. If we read in the newspaper of a gruesome murder, it would obviously seem worse than the newspaper article describing how a doctor turned off the life-support machines of a patient who was irreversibly comatose. But this does not mean that, within the medical context, killing is itself worse than letting die.
One reason for the apparent desirability of passive over active euthanasia is rooted in the acts and omissions doctrine. According to this doctrine (as expressed in the American Medical Association’s policy statement) "the intentional termination of the life of one human being by another" (an act) is forbidden, while the cessation of treatment (an omission) is morally justifiable, as it is not "the intentional termination of the life of one human being by another".
But it should be remembered that to omit to act is also (in this context) an action, as the doctor makes a conscious decision to withdraw or withhold treatment. As Rachels puts it: "What is the cessation of treatment, in these circumstances, if it is not 'the intentional termination of the life of one human being by another'? Of course it is exactly that, and if it were not, there would be no point to it."
Under ideal circumstances, no doctor and no person would want to be the cause of a patient's death – especially perhaps the death of one’s parent, as in Davison’s case. It is sometimes felt that if the doctor opts for passive euthanasia, he could argue that he was not the cause of death in the way he would be if he opted for active euthanasia. But choosing to withdraw or withhold treatment is an action subject to moral appraisal in the same way as choosing to administer a lethal dose, as long as the motivations are the same in both cases.
In active and passive euthanasia, the patient dies from the illness itself – whether the doctor or son hastens that death does not appear to be morally relevant, at least not in cases where a person expresses a desire to die. It’s certainly true that not all cases are this simple. We could construct scenarios where a son insists that his parent wants to die, but there are plausible suspicions that an imminent inheritance, rather than the parent’s suffering, is the real motivating force for his desire to facilitate her death.
So, as with many such tricky cases in medical and other areas of ethics, we would need to develop rules around active euthanasia that would not encourage fears of a slippery slope, whereby we eventually find that all “undesirable” or even “unworthy” life is placed in jeopardy. And in practice, doctors regularly make these judgements and apply rules of this sort (whether entrenched in law or not) in cases of passive euthanasia.
And once it has been decided that the patient's life should not be prolonged, what moral difference does it make if the patient dies through active or passive euthanasia? The fact that active euthanasia is at present forbidden by law seems to be the only reason that the distinction is currently relevant in medical practice. As Rachels says, "Whereas doctors may have to discriminate between active and passive euthanasia to satisfy the law, they should not do any more than that. In particular, they should not give the distinction any added authority and weight by writing it into official statements of medical ethics."
Furthermore, we should also work towards eliminating the distinction in law, at least for uncontroversial cases such as the Davison case, where there is evidence that an acceleration of death was requested by a compos mentis family member or friend. In doing so, we could still require that doctors or other agents need the permission of the patient, family or a surrogate decision-maker before allowing active euthanasia. This would eliminate abuses of the practice, at least to the same extent as similar safeguards do in place for passive euthanasia.
Some objections to active euthanasia appeal to a possible erosion of our respect for human life as a reason to forbid it. However, while our Constitution affords us a right to life, it does not confer on us a duty to live. This is entrenched in law via the freedom we have to refuse treatment. If refusing treatment would lead to our death, and we are aware of this, it seems a gross disrespect of the life we have left to refuse us the choice to hasten that death and to die in a manner of our choosing.
It is not at all clear that there are good reasons for maintaining a moral difference between killing and letting die, at least in situations encountered in medical practice. Rachels is correct in saying the only difference between killing and letting die is the bare difference, and the bare difference does not make a moral difference. It’s about time the draft bill on End of Life Decisions was debated in Parliament, and about time people like Davison no longer need fear legal repercussions for valuing a mother’s liberty. DM
- Identity politics, authority and freedom of speech
- Homophobia and the politics of outrage
- Please look after the place while I’m gone.
- Parliament – where dead sheep savage one another
- ‘Catholic’ and ‘Muslim’ South Africa
- Free speech doesn’t guarantee an audience
- So atheists are people too?
- A culture of dying
- Deciding when to die
- Minds are what brains do
- So what are universities for?
- Mantashe wants to help you 'Know your DA'
- Hey, teacher, leave them kids alone!
- UCT, race, and the seductive moral outrage machine
- The sound and fury of sanctimony
- Burn the witch!
- Not even Madiba can turn anecdotes into data
- Pornography is coming to eat your children
- Do you know what’s good for you?
- #We Say Enough
- Talking about risk-mitigation is not (always) victim blaming
- Can Frankensalmon triumph over uninformed ad-hoc opinions?
- You can leave your hat on
- If performance-enhancing drugs are bad, let's ban high-fibre cereal too.
- Blood deferrals: Too important to take personally
- The world according to Zuma - and the trouble with 'culture'
- A free market in false choices
- I, for one, welcome our robot overlords
- Debate is the key
- Been there? Got the T-shirt? Think carefully before you wear it...
- You are what you tweet
- Body language: Freedom confronts respect in Body Worlds human forms
- Choose wisely: Mourdock, rape and targeted outrage
- Birds of a feather...philosophise together?
- So who owns oppression, really?
- Help, not demonisation, will stem child abuse
- More about trolls
- Please do not feed the trolls
- Affirmative action: Equity does not come with voting rights alone
- SAA's cadet programme: The sky isn't falling
- South Africa: Why do you make me hate you?
- SA & religion: Eyes wide shut
- Freedom of speech & freedom of abuse
- Is free speech fried in Chick-fil-A debate?
- Colorado killings: there's no comfort in the absurd
- Let's try to avoid drive-by charity on Mandela Day
- First do no harm
- The cutting edge of religion
- Public holidays: positive discrimination?
- The new discrimination – against men
- Censorship: The chilling effect
- Health Warning: You may not smoke, but you can eat yourself to death
- 'I see a red door and I want it painted black'
- Freedom of speech; oh, perish the thought
- Homophobia trending among traditional leaders
- How to meat friends and influence people
- How to meat friends and influence people
- Still hunting, still gathering
- Dogmatix isn't only a canine in the Asterix comic books
- Exactly Whose Humanity is Vanishing?
- Tim Noakes on carbohydrates - fad or fact?
- Mind over matter – and knowing the difference
- Don't PIN your freedoms to Icasa's apron strings
- Killing the messenger never silences the message
- The unbearable rightness of maybe being wrong
- The worrisome worth of foregone conclusions
- The tyranny of labels
- Staring into the abyss of ‘special privileges’
- Twitter censorship, the Streisand Effect and three fingers pointing back
- Free speech is good - but not in my back yard
- Abortion - the great conceptual conundrum
- Killing live animals to talk to dead people is bull
- Stalking votes with over-the-counter vetoes
- Always look on the One side of life
- Get Tested: Get off the entitlement horses and give it a chance
- The Lotters, Harry Potter and SA's judicial system
- The haunting of Helen Zille
- The Great T-Shirt Debate that went horribly wrong
- M&M & the media – playing the ball or the men?
- Twitter - fast food for ever-fattening egos
- How Occupy Wall Street became Pick a Protest
- Steve Jobs was just a man
- What are you?
- Who did ET really call? Woo-woo fest at Wits might have the answer
- How to strut like a slut and itch like a bitch
- The world according to reader feedback
- To judge or not to judge; that is the Mogoeng
- 'A Boy Named Sue' and a victim named 'slut'
- How to bake the perfect humble pie
- How to win friends and influence the irrational
- See what I mean? Or maybe you don't...
- Separating sense from nonsense
- Racial nationalism - the silliest disease of them all
- Sticks and stones may break my bones, but words can rip my soul
- Just catch the next feminist wave
- That's right - tertiary education is a privilege, not a right
- The conundrum of university - level remedial education - where do we start?
- The immense value of the egghead
- If ridicule be the right remedy, mock on
- Racism, put on your ballot-proof vest
- It was the lizard on the grassy knoll
- Of unenclosed toilets and enclosed ballot booths
- Our responsibility to build a better 'Bill'
- It's the Singer, not the Song
- Trapped in an abusive relationship? Dial 0800-VOTE
- Hate speech and hateful words - there is a difference
- Why the Bill of Responsibilities doesn't make the grade
- Natural selection and principled prejudice
- The Orwellian horror of a world without grammar
- Beware the Jabberwock
- Ya don’t learn nuffink by shutting others up
- U2, Brute!
- Unfollowing the defriended is like delisting the unlikeable
- There's something fishy about Kenny and his critics
- Astrology - the gullible's travails are written in the stars
- Dr Woo and the Silicon Snake-oil Bangle Sellers
- Life, liberty and the pursuit of dignity
- Who wants to be African anyway?
- The Beatles warned you, Mr President
- Annelie Botes, racism, moralistic awards 'n all
- The silence of the racists
- The proof of the pudding
- Freedom is a fragile thing
- The conditionality of morality
- Of guillotines, smoking, kissing children and scientific proof
- Why moral absolutism hasn't done so well
- The moral arrogance of relativism
- The dilemma of being special in a world of special people
- Of burning closets and closed minds
- Is Internet making us stoopid commenters?
- To be, or not to be serious
- Stepping into greyer shades of grey
- Books and beliefs and other burning issues
- Talking of Hawking and thinking of God
- ‘You may be wrong for all I know, but you may be right’
- The unbearable triteness of best-selling BS
- The struggle for true freedom is with us more than ever
- It’s silly to take a penknife to a gunfight
- Tell me lies, tell me sweet little morally questionable falsehoods
- I think therefore I am … at least I think so
- First, do no harm
- All rights are equal – or should be
- Beauty and the beastly behaviour
- Afrighana versus United States of North America – a continental dilemma
- Of shoes and ships and sealing wax – the multiple tasks of multi-tasking
- Blow the vuvuzela and blow the cultural argument
- Roll up! Roll up! Welcome to the World Cup!
- Thought police, never a good thing
- The redemptive nature of offence
- Potholes or profits – the modern dilemma of corporate social responsibility
- Too many cows, too few tuna and too big an appetite
- Press freedom’s value is in our capacity to take part
- Of uncertainty and the opinions it spawns
- Just another brick in the wall
- Playing the authenticity card
- The dangers of tolerance
- ‘Twas Easter and the slithey toves did gyre and gimble on the roads
- Julius is The Man
- Beware the orthorexics as you chomp down on your boerie-roll
- Freedom of (Multi)choice
- Let's talk about our moral code