When "Right to die" really means "right to kill"
The ethical questions raised about the case of the woman known only as M disguise the human element at the heart of this tragedy.
By Nelson Jones Published 19 July 2011 14:43The Court of Protection is due to consider the case of a woman known only as M, whose family wish for her to be (as the usual terminology has it) "allowed to die". As so often in such cases, the effect of anonymity -- designed to protect both her and her family -- is to turn a real human tragedy into an abstract ethical conundrum. We know, however, that she is 53 and has been severely brain-damaged for the past eight years.
M is in what is described as a "minimally aware" state. This is one step up from a "permanent vegetative state" (PVS), which in turn is one step up from a coma. There is some disagreement among doctors as to what level of awareness she actually possesses, and in the present state of science no conclusive way of determining. Some argue that she is effectively unconconscious, others that she has enough awareness to communicate using a switch. Either way, though, she is not getting any better.
The case of M would break new legal ground. But ever since the case of Tony Bland in 1993, it has become almost routine to withdraw nutrition (water and nourishment) from patients diagnosed with PVS, at least where doctors and the patient's family agree that there is no awareness and no hope of recovery.
The language used in these cases is made up of euphemisms -- "allowed to die", "right to die", "death with dignity", "withdrawal of treatment" -- which disguise (or at least sidestep) what is really going on: the slow death by starvation and dehydration of patients who, to the best of medical knowledge, are not conscious and have no hope of recovery. No pet dog would be treated in such a manner. A dog would be "put to sleep" (another euphemism, of course); in other words, given a lethal injection. That is a quicker death, and a more honest one. For the purpose of withdrawing food and hydration is not a neutral suspension of treatment. It is a positive decision to "allow" someone to die. In fact, to kill them. If as a society we are to do such things, we should at least have the integrity to look them square in the face.
The law makes a clear but I would suggest wholly bogus distinction between "allowing" someone to die and killing them. The latter remains illegal, even in the case of assisted suicide where a person who is fully conscious and in command of their faculties makes a positive decision to end their life.
It would, of course, be open to such a person to refuse food and water and thus to die of dehydration. But such a prolonged and unpleasant death is rarely desired even by someone in the extremes of a terminal illness. This fact ought to concentrate minds on what is really going on when nourishment is withdrawn. The current state of the law rests on a form of moral hypocrisy in which the end is separated from the means: it is acceptable to will the end but not the means.
And so we have reached the morally absurd position in which the law allows someone to be killed without their permission - indeed, in a situation in which it is impossible for them to express an opinion -- whereas someone who desires to die is prevented from acting on that desire. At the same time, the pretence is maintained that in the first case the person is not being killed, merely being allowed to die. The risk of maintaining society's -- and the doctors' -- morally clean hands is borne by the patient, whose consciousness is assumed to be absent though in truth it is impossible to be 100% certain, in every case, that the patient has no awareness.
A patient who was aware of what was going on, who felt the agony of being slowly starved of nourishment, would have no way of making that fact known. A patient who might, given medical advances, one day recover and who might wish to be afforded that slim chance, equally has no way of expressing that preference. (Even today, it is not unknown for a patient to emerge from a diagnosis of PVS.) The court, in allowing the withdrawal of treatment, not only sentences the patient to death, but sentences them to what is potentially a cruel death. And this is viewed as acceptable by many people who would feel outraged if the court went one stage "further" and instead decreed a quick and pain-free termination.
Moreover, while assisted suicide continues to be the subject of fierce public debate, for almost twenty years it has been settled practice to kill (in all but name) patients who have become a burden to their relatives and the health service, who may be unconscious but whose long-term prospects are unknowable. I find this state of affairs distinctly odd.
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31 comments
@David (14:47)
Whilst I fully empathise with the scenario you describe regarding your gran (my father suffered a long debilitating death due to cancer during my teenage years) it is in fact you who is pontificating.
Death is as natural as life. People have been suffering long, painful deaths like my father's & your gran's since time immemorial, and do so every minute of every day all over the planet. We afford people dignity in life & in death by actually enduring suffering with them; by valuing every last morsel of life they have even when they can't reciprocate it any more; by weeping & mourning with them even. What parent has never wished they could take even the mildest suffering from their children? That is how we know we love them.
Dignity is not an inherent human trait - you do not 'possess' dignity. It is something that is bestowed upon you by others. "Terminating" people (or whatever euphemism we choose) is not bestowing dignity upon them.
You 'pontificate' about how you would like to be treated in various scenarios, but the reality is that you actually have no idea what you might be feeling or thinking during those times. In fact, the anecdotal evidence from those who have survived through some horrific illnesses/suffering is that they often were desperately clinging to life and/or trying to communicate the those around them.
We have to examine our motives too. How much of "S/he wouldn't want to live like this" is actually us saying "I can't bear to see them living like this"?
It is extremely crude to take sexist to mean merely discriminatory. Sexism is negative discrimination against someone on account of their gender- especially when it is irrelevant. So, affirmative action isn't sexist.
I would personally argue that infanticide is justifiable in rare and exceptional cases. However, this is in part down to my vegetarianism. If you look at my first post, I was making a point about society's ethics. If we are to allow the killing of animals on an unprecedented and industrial manner and argue that it is the mother's right to abort her child, it is hypocritical to unreservedly condemn infanticide.
P.S. Not all animals are sentient under your definition and the definition I was using was more philosophical and reffered more to higher emotional reception and basic intellectual ability as found in higher mammals
Herb: Thank you for your considered answers. You said, 'infanticide is justifiable in rare and exceptional cases.'
What are these rare and exceptional cases?
And am I reading you correctly when you say there is negative sexism and positive sexism. So sometimes it is justifiable to discriminate on the basis of sex. This because it can be seen as positive discrimination because it is relevant as opposed to irrelevant.
Can you give some examples of positive discrimination and negative ones?
andyg: 'My belief is that life is sacred and if there's a sign of life then it should be preserved.'
So you are against contraception and abortion?
Surely, we as a society have collectively decided that future prospects of happiness are irrelevant. Instead, what the person (if they are a person, which is debatable (just ask Peter Singer)) is worth depends on their current sentience. If we are to decide to take into account prospects for future development- we would be logically inconsistent if we were to still allow abortion. A foetus isn't a sentient person but will almost certainly grow to become one. If we therefore decide that someone in a condition of PVS shouldn't be killed for fear of potential future developement, we must too decide that abortion is immoral and decide to prohibit that. We have a choice in society and I personally feel that the most progressive and caring choice is to allow both abortion and euthanasia.
Herb: What about infanticide? Would you allow that as well? How progressive are you?
I am a doctor, and to be honest, i find this article repulsive. to say doctors allow people to die to keep their own hands clean, and that allowing people to die is murder is calling doctors murderers. in fact, treatment can only be withdrawn with relatives consent - not many murderers check with their victims nearest and dearest before they pull the trigger. it appears you have no real knowledge of the real world - patients relatives do not like to say to us "please, give relative X a lethal injection". and to be brutally honest, i see no harm in easing their conscience on this topic. as you rightly said, no one has come back from a PVS. not once you say we do not know how much consciousness they have. true. however, we do know they cannot breathe without assistance - hence they have no brain stem function. that makes it impossible - literally, impossible - for pain to be experienced physiologically. the affective component of pain is a mystery, but no one can possibly account for that. grow up, stop commenting about decisions that are all shades of moral gray with eyes suitable only for black and white.
Bart; Well summed up.
Interesting article.
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I suppose the crux of the matter comes down to two choices: Is it better to allow someone to 'live' in a persistent vegetative state (or similar) for years on end, putting that person (potentially) and their family through stress; or is it better that the person dies?
It is a very sensitive issue, but I know that if I was in a similar situation, I would want those close to me would have the courage to know I would not wish to lie motionless in hospital for years and to allow me to die. If you want to describe that as killing me, so be it. Those around me would be exposed to undue suffering because of my medical condition (recovery from which is infinitesimally unlikely) , and I do not want that to occur. Dying would be far more dignified than potentially outliving my family and friends thanks to being kept alive by doctors and nurses.
Similarly, if I am diagnosed with a degenerative or terminal illness which will eventually kill me, I would rather have the power to choose when my time to go would be. I don't know if the author has watched a loved one's slow decline to death from, for example, terminal cancer. I did and it was one of the most horrendous experiences of my life. My gran was a nurse in her younger days. She was a very spirited and feisty woman before she became ill. She died at home with her family around her, but by then she was basically being kept alive by morphine and had been unconscious for days, her lungs gradually filling with fluid as her body shut down. Would she have wanted to go that way? I doubt it very much.
It is easy for a journalist to pontificate and moralise from an ivory tower. But when their words take no account of reality, they ring hollow.
Hypothetical situation.
A baby is found to have a severe mental handicap. They will never develop full cognition but always remain at this level. Lets say they are the equivalent of a cat (I know this is very unscientific). It is also found that they suffer from extreme pain. Is it not humane to kill them rather than make them suffer?
I did give you an example of positive discrimination- affirmative action
What sort of doctor are you Joseph? One who doesn't know how to use the shift key?
Running away from the hard questions Hans. Perhaps you're trying to find an animal that doesn't have any senses?
@ Mr. Divine
Actually, I would.
Before recoiling into Daily Mail style shock, i beg of you to hear me out. Now we permit mothers to kill a foetus since the foetus has no ability to feel pain. Emotionally and intellectually, they are closer to a fruit fly than a developed human. They therefore have no ability to suffer and in my opinion, are as significant as a non-human animal. To argue otherwise would be speciesist since it would rely on their mere species to define their moral value. As a progressive, I see racism, sexism, homophobia etc as ignorant and wrong. It would therefore be hypocritical for me to be speciesist. Now, do are infants sentient? Some are- particularly older ones. However, those who are not shouldn't have the same rights as a developed human. So, under certain circumstances, it is justifiable.
P.S. read Peter Singer to gage a better form of this argument
"The language used in these cases is made up of euphemisms -- "allowed to die", "right to die", "death with dignity", "withdrawal of treatment" -- which disguise (or at least sidestep) what is really going on"
This is nonsense. If this person was not being deliberately kept alive they would have died a long time ago. "Allowed to die" seems a perfectly reasonable term for such a situation and hardly a side-stepping euphemism.
Excellent piece and I fear too close to the nerve for many.
Interesting the reactions of "you don't know what you are talking about, so shut up" from Chris Yapp.
Sorry for your loss Chris, but the similarity with the "just shut up, OK" remarks from supporters of abortion is striking.
Can anyone doubt that we are moving towards executing the old and infirm for convenience and to put an end to our own distress at their condition?
And that is the positive interpretation of people's motives.
My point was this:it is justifiable in certain situations to commit infanticide, just like abortion. Moreover, it is hypocritical for society to condemn infanticide but permit abortion and the killing of sentient animals (incase you hadn't guessed, i'm a vegetarian). And I don't believe infanticide is permissible on a large scale for such trivial and ignorant reasons such as your example. http://www.homeappliancesguide.org/
I have thought the same thing myself. I would be happy to die though an opiate overdose or maybe cocaine. The other painless way is breathing pure nitrogen. I would not want to be dehydrated to death. Should not happen.
Herb: So you in favour of infanticide but against sexism.
What if a woman has a female baby but she wanted a male one. As a result she kills the male one. She's being sexist. But you said infanticide is OK.
You have taken my argument and exaggerated it in attempt to show its flaws but instead have shown the flaws of your position by doing so.
But anyway, of course I don't agree with that action and of course not only on the grounds of feminism.
My point was this:it is justifiable in certain situations to commit infanticide, just like abortion. Moreover, it is hypocritical for society to condemn infanticide but permit abortion and the killing of sentient animals (incase you hadn't guessed, i'm a vegetarian). And I don't believe infanticide is permissible on a large scale for such trivial and ignorant reasons such as your example.
Great piece.
Before making any judgement regarding a person's life it would be much more beneficial to the above commentators if they were made aware of what kind of life M had, what she would have said had this story been about someone else.
M would have been a baby, a toddler, a school pupil, a young lady with dreams about her future. She would have laughed, cried, mourned, and gone through all the other experiences of life. I sometimes shudder when the question of 'assisted suicide' is brought up because there are so many ethical and moral decisions to be considered. I am also concerned that as Human beings we continue to take that next step forward. My belief is that life is sacred and if there's a sign of life then it should be preserved. This is a slippery slope for the future of health care and I can see those with personal self interest never far away from ill gotten gains of what is now a difficult subject to discuss.
So under what circumstances is it justifiable to kill new born babies?
Aren't all animals sentient, for all of them have senses.
And don't you think that under some circumstances it is justifiable to be sexist, to discriminate on the basis of sex?
The mother of my children died recently after 8 years and 7 months in borderline PVS/minimally aware. the health professionals throughout did their best. It is however, not what she would ahve wanted and you should really stick to writing about something you know about. Your pontifications are about a different planet than the one we lived in those years
An outstanding piece.
One question. You state that "for twenty years it has been practice to kill in all but name, patients who have become a burden to their relatives and to the NHS...whose long term prospects are unknowable."
I would be interested to learn the types of cases to which you refer. If this is true it is horrifying.
Palliative care will often give a dose of opiates whichnis entirely necessary to ease the pain and suffering of a patient, death being the side effect, using the ethical principle of double effect, however this is entirely appropriate as are many situations where no attempt will be made to ressucitate.
The Liverpool Care Plan is particularly inhumane and the fact that the others may be able to kill you in the name of compassion is an issue that should concern us all.
I see the comments are full of people missing the point.
This article was not about it being morally wrong to bring about the end of a life, in a situation where they needed constant attention and machines to remain alive.
The point was that once we have made the decision that we consider it acceptable to cause by inaction, the death of a person, that allowing them starve to death and so on is repugnant. We don't do it to animals and the people who wish a choice to choose their own death don't want to have to starve themselves to death either.
We have the capability to give people a quick death but due to our moral qualms about taking positive action we cause people unnecessary suffering.
If we are to allow for situations where people make a choice that a sick person be allowed to die, then we need the honesty to bring that event about with the absolute minimum of suffering, by direct action, not by inaction that allows us to pretend it is natural.
It is not natural for humans to allow loved ones to starve to death.
It's the old expression
"They shoot horses, don't they?"
Herb: Thanks for that. I agree with you that infanticide in that circumstance is alright.
When you talk about negative sexual discrimination being irrelevant how do you decide if it is irrelevant? And who can decide the relevancy?
This is a really interesting, thoughtful article.
The use of euphemisms to avoid speaking about death is, I suppose, understandable. Although there are verbs that can be used for the death of an other, (‘kill’, ‘murder’, and ‘execute’) there is no verb that easily can be used to describe my willing of my own death. Suicide was used in the 19C as a verb but I’ve never heard anyone use it that way. I think it tends to be ‘commit suicide’ which also seems to borrow the verb ‘commit’ to avoid the verbal action of suicide. It seems then that the use of euphemism or metaphor sometimes needs to stand in for an absence of language.
I’m not sure agree that give a lethal injection is more honest a description of the event because it seems to place the action on the giving of the injection rather than the receiving a lethal injection.
Mary Warnock considers the argument about capital punishment to be settled but I’m not so sure that the principle of the state authorizing the death of its citizens doesn’t have the potential to reintroduce that argument by the backdoor. Once you concede that the state can, on principle, terminate the life of its citizens (which of course it does but likes to pretend it doesn’t) then the similarities of language from one arena might well bleed into the other.
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