The moral distinction between killing and letting die in medical cases

In some medical cases there is a moral distinction between killing and letting die, but in others there is not. In this paper I present an original and principled account of the moral distinction between killing and letting die. The account provides both an explanation of the moral distinction and an explanation for why the distinction does not always hold. If these explanations are correct, the moral distinction between killing and letting die must be taken seriously in medical contexts.
Defeasibly, when an agent kills she takes responsibility, but when an agent lets die she does not take responsibility. Therein lies the moral distinction between killing and letting die. The distinction, however, is defeated when an agent is already responsible for the surrounding situation. In such cases, killing does not involve taking any further responsibility and letting die does not avoid taking any responsibility. Medical examples are frequently complicated because patients' autonomous choices impact upon medical practitioners' surrounding responsibility.     

End-of-Life Decisions and Moral Psychology: Killing, Letting Die, Intention and Foresight

In contemplating any life and death moral dilemma, one is often struck by the possible importance of two distinctions; the distinction between killing and “letting die”, and the distinction between an intentional killing and an action aimed at some other outcome that causes death as a foreseen but unintended “side-effect”. Many feel intuitively that these distinctions are morally significant, but attempts to explain why this might be so have been unconvincing. In this paper, I explore the problem from an explicitly consequentialist point of view. I first review and endorse the arguments that the distinctions cannot be drawn with perfect clarity, and that they do not have the kind of fundamental significance required to defend an absolute prohibition on killing. I go on to argue that the distinctions are nonetheless important. A complete consequentialist account of morality must include a consideration of our need and ability to construct and follow rules; our instincts about these rules; and the consequences (to the agent and to others) that might follow if the agent breaks a good general rule, particularly if this involves acting contrary to moral instinct. With this perspective, I suggest that the distinctions between killing and letting die and between intending and foreseeing do have moral relevance, especially for those involved in the care of the sick and dying.     

Killing, letting die and moral perception

There are a number of arguments that purport to show, in general terms, that there is no difference between killing and letting die. These are used to justify active euthanasia on the basis of the reasons given for allowing patients to die. I argue that the general and abstract arguments fail to take account of the complex and particular situations which are found in the care of those with terminal illness. When in such situations, there are perceptions and intuitions available that do not easily find propositional form but lead most of those whose practice is in the care of the dying to resist active euthanasia. I make a plea for their intuitions to be heeded above the sterile voice of abstract premises and arguments by examining the completeness of the outline form of the pro-euthanasia argument. In doing so, I make use of Nussbaum's discussion of moral perception and general claims to be found in the literature of moral particularism.     

Killing, letting die and moral perception: a reply to Grant Gillett

A number of philosophers in recent times have employed arguments to show that there is no morally relevant difference between killing a patient and allowing that patient to die in those circumstances where the outcome is virtually identical and where death is preventable, at least for a significant time. From his perspective as both a philosopher and a clinician, Grant Gillett has rejected such general and abstract arguments in the light of the intuitions and moral perceptions available to clinicians and those who care for the terminally ill. I argue that his strategy fails, is massively question-begging, and that his appeal to the notion of 'moral particularism', far from being an alternative to cogent philosophical argument, actually supports the very position he has attempted to discredit.     

Substance,rights, value,and abortion

Most serious contemporary opposition to abortion is grounded on the belief that human fetuses are members of the same moral category as beings like us, and that the loss of any such life is one of the worst possible losses. Substance view theorists oppose abortion for this reason: in their view beings like us are essentially rational substances with inherent moral worth, and those who perform induced abortion fail to recognize this moral worth. In a recent series of articles, Rob Lovering presents reductio‐style arguments against the substance view, in part arguing that it is inconsistent with our intuitions in rescue and spontaneous abortion cases. In a recent reply, Henrik Friberg‐Fernros argues that the substance view can evade these problematic implications because of a distinction between killing and letting die. According to this argument, the fetus’s right to life is a negative right not to be killed, not a positive right to be rescued, thus the anti‐abortion theorist who lets fetuses die acts acceptably. I argue this stance fails to recognize the inherent moral worth that the substance view contends fetuses possess. One who refrains from saving a person, or doesn’t care how many people she saves, cannot reasonably claim to value life. Furthermore, this stance is at odds with most contemporary anti‐abortion views that oppose induced abortions of both the killing and letting die variety.     

The ethics of ex utero research on spare 'non-viable' IVF human embryos

In this paper, the focus is not on some particular developmental feature of the human embryo, but rather on the embryo's potential for development tout court. To this end, the moral relevance of the difference between human embryos that have the potential for continued human growth and development and human embryos that do not have this potential is explored and a distinction between viable and non-viable IVF human embryos is introduced. This is followed by a discussion of what is morally wrong with killing to show that none of the concerns associated with the act of killing apply to the destruction of non-viable IVF human embryos. On this basis, it is argued that scientifically and ethically sound research on spare non-viable IVF human embryos may proceed.     

Omissions, Causation, and Responsibility

In this paper I discuss a recent exchange of articles between Hugh McLachlan and John Coggon on the relationship between omissions, causation, and moral responsibility. My aim is to contribute to their debate by isolating a presupposition I believe they both share and by questioning that presupposition. The presupposition is that, at any given moment, there are countless things that I am omitting to do. This leads both McLachlan and Coggon to give a distorted account of the relationship between causation and moral or (as the case may be) legal responsibility and, in the case of Coggon, to claim that the law??s conception of causation is a fiction based on policy. Once it is seen that this presupposition is faulty, we can attain a more accurate view of the logical relationship between causation and moral responsibility in the case of omissions. This is important because it will enable us, in turn, to understand why the law continues to regard omissions as different, both logically and morally, from acts, and why the law seeks to track that logical and moral difference in the legal distinction it draws between withholding life-sustaining measures and euthanasia.     

Acting to Let Someone Die

This paper examines the recent prominent view in medical ethics that withdrawing life‐sustaining treatment (LST) is an act of killing. I trace this view to the rejection of the traditional claim that withdrawing LST is an omission rather than an act. Although that traditional claim is not as problematic as this recent prominent view suggests, my main claim is that even if we accepted that withdrawing LST should be classified as an act rather than as an omission, it could still be classified as letting die rather than killing. Even though omissions are contrasted with acts, letting die need not be, for one can let die by means of acts. The remainder of the paper is devoted to establishing this claim and addresses certain objections to it.     

The Meta‐Nudge – A Response to the Claim That the Use of Nudges During the Informed Consent Process is Unavoidable

Richard Thaler and Cass Sunstein, in Nudge: Improving Decisions About Health, Wealth, and Happiness, assert that rejecting the use nudges is ‘pointless’ because ‘[i]n many cases, some kind of nudge is inevitable’. Schlomo Cohen makes a similar claim. He asserts that in certain situations surgeons cannot avoid nudging patients either toward or away from consenting to surgical interventions. Cohen concludes that in these situations (assuming surgeons believe that surgery is the best option for their patients), nudging patients toward consenting to surgical interventions is (at the very least) uncriticizable or morally permissible. I call this argument: The Unavoidability Argument. In this essay, I will respond to Cohen's use of the unavoidability argument in support of using nudges during the process of informed consent. Specifically, I argue that many so‐called ‘unavoidable nudges’ are, in fact, avoidable. Although my argument is directed toward Cohen's use of the unavoidability argument, it is applicable to the unavoidability argument more generally.     

Euthanasia and the active-passive distinction

The author examines various claimed differences between active and passive euthanasia and, if there are differences, whether they are morally significant. He refutes arguments based on acting vs. not acting, intention, double effect, cause of death, and natural law theory. Reichenbach proposes that the most helpful distinction is the one between intentional killing (active euthanasia) and appropriate treatment for the dying or terminally ill (passive euthanasia). Significant moral difference, however, rests on the contention that intentional killing is always wrong and that, all else being equal, dying by natural means is intrinsically good, whereas dying by unnatural means is not.     

DOES JUSTICE REQUIRE THAT WE BE AGEIST?

This paper restates some of the principal arguments against an automatic preference for the young as advocated by Kappel and Sandøe, arguments many of which have been extant for over a decade but which Kappel and Sandøe largely ignore. It then goes on to demonstrate that Kappel and Sandøe's "indifference test" fails to do the work required of it because it can be met by unacceptable conceptions of justice. The paper develops a number of new arguments against what I have called "ageist" preferences for the young or for those with long life expectancy. Finally I show that Kappel and Sandøe must believe that murdering older people is less morally wrong than murdering the young and that people relying on arguments such as theirs will have to accept the moral respectability of killing the innocent in order to maximise units of lifetime.     

Moral Philosophy,Moral Expertise,and the Argument from Disagreement

Several recent articles have weighed in on the question of whether moral philosophers can be counted as moral experts. One argument denying this has been rejected by both sides of the debate. According to this argument, the extent of disagreement in modern moral philosophy prevents moral philosophers from being classified as moral experts. Call this the Argument From Disagreement (AD). In this article, I defend a version of AD. Insofar as practical issues in moral philosophy are characterized by disagreement between moral philosophers who are more or less equally well credentialed on the issue, non‐philosophers have no good reasons to defer to their views.     

MORAL FICTION OR MORAL FACT? THE DISTINCTION BETWEEN DOING AND ALLOWING IN MEDICAL ETHICS

Opponents of physician‐assisted suicide (PAS) maintain that physician withdrawal‐of‐life‐sustaining‐treatment cannot be morally equated to voluntary active euthanasia. PAS opponents generally distinguish these two kinds of act by positing a possible moral distinction between killing and allowing‐to‐die, ceteris paribus. While that distinction continues to be widely accepted in the public discourse, it has been more controversial among philosophers. Some ethicist PAS advocates are so certain that the distinction is invalid that they describe PAS opponents who hold to the distinction as in the grip of ‘moral fictions’. The author contends that such a diagnosis is too hasty. The possibility of a moral distinction between active euthanasia and allowing‐to‐die has not been closed off by the argumentative strategies employed by these PAS advocates, including the contrasting cases strategy and the assimilation of doing and allowing to a common sense notion of causation. The philosophical debate over the doing/allowing distinction remains inconclusive, but physicians and others who rely upon that distinction in thinking about the ethics of end‐of‐life care need not give up on it in response to these arguments.     

A moral argument for frozen human embryo adoption

Some people (e.g., Drs. Paul and Susan Lim) and, with them, organizations (e.g., the National Embryo Donation Center) believe that, morally speaking, the death of a frozen human embryo is a very bad thing. With such people and organizations in mind, the question to be addressed here is as follows: if one believes that the death of a frozen embryo is a very bad thing, ought, morally speaking, one prevent the death of at least one frozen embryo via embryo adoption? By way of a three-premise argument, one of which is a moral principle first introduced by Peter Singer, my answer to this question is: at least some of those who believe this ought to. (Just who the “some” are is identified in the paper.) If this is correct, then, for said people, preventing the death of a frozen embryo via embryo adoption is not a morally neutral matter; it is, instead, a morally laden one. Specifically, their intentional refusal to prevent the death of a frozen embryo via embryo adoption is, at a minimum, morally criticizable and, arguably, morally forbidden. Either way, it is, to one extent or another, a moral failing.     

Constraints and heroes

A story, perhaps apocryphal, is told about the United States surgical team which pioneered the first artificial heart procedure. It is said that the team received a number of telephone calls from people around the country who, worried about the ailing heart recipient, offered to donate to him their own hearts. When the surgical team, justifiably curious, sent psychiatrists to examine these donors, they found to their surprise that many of the donors were rational, competent, sincere, and fully aware that as a consequence of donating their hearts they would die.... My concerns here will be threefold. First, I want to add some substance to the widely-held intuition that there is something morally objectionable about a physician participating in procedures which put even a willing subject at risk. In so doing, I want to explore the larger question of why such a puzzle arises -- why physicians, and many others, find it morally objectionable to help someone do something which all agree to be heroic. Finally, I will start by examining some ways of framing the issue, widely employed in medical ethics, which I believe are simply wrong. This sort of puzzle is much more interesting than proponents of these standard arguments would have us believe, and it illustrates some larger points about morality which are often overlooked.     

The conjoined twins and the limits of rationality in applied ethics

In this article I consider the case of the surgical separation of conjoined twins resulting in the immediate and predictable death of the weaker one. The case was submitted to English law by the hospital, and the operation permitted against the parents' wishes. I consider the relationship between the legal decision and the moral reasons adduced in its support, reasons gaining their force against the framework of much mainstream normative ethical theory. I argue that in a few morally dilemmatic situations, such a legalistic–theoretical approach cannot plausibly accommodate certain irreducible and ineliminable features of the ethical experience of any concrete individual implicated in the situation, and that this failure partly undermines its self–appointed role of guiding such an individual's conduct. For example, the problem as experienced by the judge and by the parents might not be the same problem at all, and some of their respective reasons may be mutually unintelligible or impotent. I certainly do not argue for a rejection of law or of moral theory; I merely challenge their implicit claim to comprehensiveness and their fixation with an idealised and putatively universal rationality modelled on converging scientific enquiry. Finally, I claim that at least in the twins' case there may be insufficient normative robustness to the conclusions reached, or indeed reachable, by the court in a situation where intuitions and moral reasons pull in fundamentally incommensurable directions; as such, there may be room for an acknowledgement of the spiritual, through a humble abstention from making a decision – which is not to be confused with deciding to do nothing.     

Being human: Why and in what sense it is morally relevant

The debate on the question of the moral status of human beings and the boundaries of the moral community has long been dominated by the antagonism between personism and speciesism: either certain mental properties or membership of the human species is considered morally crucial. In this article, I argue that both schools of thought are equally implausible in major respects, and that these shortcomings arise from the same reason in both cases: a biological notion of being human. By contrast, I show to what extent being human is morally relevant in a non-biological sense. I establish the living human form as the essential criterion for belonging to the moral community, and defend it against a number of possible objections. This new morphological approach is capable of capturing essential elements of personism and speciesism without sharing their faults, and of reconstructing widespread moral intuitions.     

Moral Enhancement and Those Left Behind

Opponents to genetic or biomedical human enhancement often claim that the availability of these technologies would have negative consequences for those who either choose not to utilize these resources or lack access to them. However, Thomas Douglas has argued that this objection has no force against the use of technologies that aim to bring about morally desirable character traits, as the unenhanced would benefit from being surrounded by such people. I will argue that things are not as straightforward as Douglas makes out. The widespread use of moral enhancement would raise the standards for praise and blame worthiness, making it much harder for the unenhanced to perform praiseworthy actions or avoid performing blameworthy actions. This shows that supporters of moral enhancement cannot avoid this challenge in the way that Douglas suggests.     

Compulsory moral bioenhancement should be covert

Some theorists argue that moral bioenhancement ought to be compulsory. I take this argument one step further, arguing that if moral bioenhancement ought to be compulsory, then its administration ought to be covert rather than overt. This is to say that it is morally preferable for compulsory moral bioenhancement to be administered without the recipients knowing that they are receiving the enhancement. My argument for this is that if moral bioenhancement ought to be compulsory, then its administration is a matter of public health, and for this reason should be governed by public health ethics. I argue that the covert administration of a compulsory moral bioenhancement program better conforms to public health ethics than does an overt compulsory program. In particular, a covert compulsory program promotes values such as liberty, utility, equality, and autonomy better than an overt program does. Thus, a covert compulsory moral bioenhancement program is morally preferable to an overt moral bioenhancement program.