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.     

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.     

Killing, letting die and the bare difference argument

I believe that there is no intrinsic moral difference between killing and letting die. That is, there is no difference that depends solely on the distinction between an act and an omission. I also believe that we can reasonably establish this thesis by appeal to the Bare Difference Argument. The form of this argument involves considering two imaginary cases in which there are no morally relevant differences present, save the bare difference that one is a case of killing and one a case of letting die. But in the pair of cases under consideration this bare difference makes no moral difference. Hence it cannot be that the bare difference between killing and letting die is in itself a morally important difference.
Winston Nesbitt has recently argued that the Bare Difference Argument fails because "the examples produced typically possess a feature which makes their use in this context illegitimate, and that when modified to remove this feature, they provide support for the view which they were designed to undermine". I argue that Nesbitt misunderstands the logic of the Bare Difference Argument and that accordingly his objections are mistaken.     

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.     

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.     

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 Kantian ethics approach to moral bioenhancement

It seems, at first glance, that a Kantian ethics approach to moral enhancement would tend towards the position that there could be no place for emotional modulation in any understanding of the endeavour, owing to the typically understood view that Kantian ethics does not allow any role for emotion in morality as a whole. It seems then that any account of moral bioenhancement which places emotion at its centre would therefore be rejected. This article argues, however, that this assumption is incorrect. Given later writings by Kant on the role of sympathy, and taking into account other concerns in Kantian ethics (such as bodily integrity), it may in fact be the case that Kantian ethics would allow for an account of moral bioenhancement through emotional modulation, and that in some (rare) cases such an intervention might even be considered to be a duty.     

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.     

Why Gametes are not Like Enriched Uranium

According to Rivka Weinberg, gametes are like enriched uranium: both are hazardous materials. Exposing human beings to enriched uranium can result in radioactivity and decreased life expectancy, while exposing sperm and ova to each other can result in the creation of needy innocent persons with full moral status. Weinberg argues that when we engage in activities that put our gametes at risk of joining with others and growing into persons, we assume the costs of that risky activity. She calls this the Hazmat Theory of parental responsibility. The theory is novel and important, and has far‐reaching consequences for the ethics of procreation, parenting, and population, implying among other things that that the only way to avoid acquiring parental responsibilities may be to “abstain from sexual intercourse or surgically interfere with our gamete‐release system.” For these reasons the theory merits careful scrutiny. In this article I criticize the theory's account of how parental responsibility is acquired and its treatment of the standard of care expected of gamete possessors, and argue that it fails to properly account for a distinction between procreative costs and parental responsibility. Even if gametes are hazardous, it does not follow that parental responsibility in Weinberg's sense is acquired whenever one brings new persons into existence.     

ONTOLOGY OR PHENOMENOLOGY? HOW THE LVAD CHALLENGES THE EUTHANASIA DEBATE

This article deals with the euthanasia debate in light of new life‐sustaining technologies such as the left ventricular assist device (LVAD). The question arises: does the switching off of a LVAD by a doctor upon the request of a patient amount to active or passive euthanasia, i.e. to ‘killing’ or to ‘letting die’? The answer hinges on whether the device is to be regarded as a proper part of the patient's body or as something external. We usually regard the switching off of an internal device as killing, whereas the deactivation of an external device is seen as ‘letting die’. The case is notoriously difficult to decide for hybrid devices such as LVADs, which are partly inside and partly outside the patient's body. Additionally, on a methodological level, I will argue that the ‘ontological’ arguments from analogy given for both sides are problematic. Given the impasse facing the ontological arguments, complementary phenomenological arguments deserve closer inspection. In particular, we should consider whether phenomenologically the LVAD is perceived as a body part or as an external device. I will support the thesis that the deactivation of a LVAD is to be regarded as passive euthanasia if the device is not perceived by the patient as a part of the body proper.     

End‐of‐Life Decisions and the Reinvented Rule of Double Effect: A Critical Analysis

The Rule of Double Effect (RDE) holds that it may be permissible to harm an individual while acting for the sake of a proportionate good, given that the harm is not an intended means to the good but merely a foreseen side‐effect. Although frequently used in medical ethical reasoning, the rule has been repeatedly questioned in the past few decades. However, Daniel Sulmasy, a proponent who has done a lot of work lately defending the RDE, has recently presented a reformulated and more detailed version of the rule. Thanks to its greater precision, this reinvented RDE avoids several problems thought to plague the traditional RDE. Although an improvement compared with the traditional version, we argue that Sulmasy's reinvented RDE will not stand closer scrutiny. Not only has the range of proper applicability narrowed significantly, but, more importantly, Sulmasy fails to establish that there is a morally relevant distinction between intended and foreseen effects. In particular, he fails to establish that there is any distinction that can account for the alleged moral difference between sedation therapy and euthanasia.     

The architect and the bee: some reflections on postmortem pregnancy

Do physicians have a duty to sustain the pregnancies of women who die during the first or second trimester? Physicians cannot simply assume that the woman would have wished the pregnancy to continue, nor (in the U. S., at any rate) is it clear that the state has any interest in fetal life before viability. The conditions for beneficence-based duties of fetal rescue will often be unmet, both because sustaining the pregnancy is not always a clear gain to the born child and because it may impose a substantial burden on the benefactor. And duties of special relationship cannot readily be applied in these cases, as it is difficult to see how the relationship between someone who no longer exists and someone who does not yet exist can breed special duties. Further, to draw on Marx's distinction between the architect, who builds purposefully, and the bee, who cannot help what she is doing, I argue that human pregnancy is in a number of respects purposeful, creative, and deliberate, and that postmortem pregnancy, which follows the model of the bee, is a destructive icon that undercuts women's agency.     

The choice between people: 'common sense' morality, and doctors

Kamm is concerned with explaining how "common sense" morality might be used in deciding about the distribution of scarce medical resources. Drawing an analogy between redirection of possible harms or threats and the allocation of health resources, she first explores how an ordinary moral agent, not a physician, might act. Using what Kamm calls the principle of irrelevant utilities (PIU), a moral agent might decide between contestants for a particular good based on "sobjectivism" (Sob), the author's term for a combination of the objective and subjective points of view. Kamm explores decision making using three versions of Sob that weigh interests and rights, equivalences, and aggregation of costs (losses). She concludes that, while ordinary moral agents functioning as social agents may act according to objective aggregated costs, physicians should be concerned with equivalents and individuals when allocating resources.     

When good organs go to bad people

A number of philosophers have argued that alcoholics should receive lower priority for liver transplantations because they are morally responsible for their medical conditions. In this paper, I argue that this conclusion is false. Moral responsibility should not be used as a criterion for the allocation of medical resources. The reason I advance goes further than the technical problem of assessing moral responsibility. The deeper problem is that using moral responsibility as an allocation criterion undermines the functioning of medicine.     

Autonomy is a Right,Not a Feat: How Theoretical Misconceptions have Muddled the Debate on Dynamic Consent to Biobank Research

Should people be involved as active participants in longitudinal medical research, as opposed to remaining passive providers of data and material? We argue in this article that misconceptions of ‘autonomy’ as a kind of feat rather than a right are to blame for much of the confusion surrounding the debate of dynamic versus broad consent. Keeping in mind two foundational facts of human life, freedom and dignity, we elaborate three moral principles – those of autonomy, integrity and authority – to better see what is at stake. Respect for autonomy is to recognize the other's right to decide in matters that are important to them. Respect for integrity is to meet, in one's relationship with the other, their need to navigate the intersection between private and social life. Respect for authority is to empower the other – to help them to cultivate their responsibility as citizens. On our account, to force information onto someone who does not want it is not to respect that person's autonomy, but to violate integrity in the name of empowerment. Empowerment, not respect for autonomy, is the aim that sets patient‐centred initiatives employing a dynamic consent model apart from other consent models. Whether this is ultimately morally justified depends on whether empowerment ought to be a goal of medical research, which is questionable.     

RISK AND MID‐LEVEL MORAL PRINCIPLES

We discuss ethical aspects of risk‐taking with special focus on principlism and mid‐level moral principles. A new distinction between the strength of an obligation and the degree to which it is valid is proposed. We then use this distinction for arguing that, in cases where mid‐level moral principles come into conflict, the moral status of the act under consideration may be indeterminate, in a sense rendered precise in the paper. We apply this thought to issues related to pandemic influenza vaccines. The main conclusion of the paper is that on a principlist approach some acts may be neither right nor wrong (or neither permissible nor impermissible), and we claim that this has important implications for how we ought to make decisions under risk.     

MORAL FICTIONS AND MEDICAL ETHICS

Conventional medical ethics and the law draw a bright line distinguishing the permitted practice of withdrawing life‐sustaining treatment from the forbidden practice of active euthanasia by means of a lethal injection. When clinicians justifiably withdraw life‐sustaining treatment, they allow patients to die but do not cause, intend, or have moral responsibility for, the patient's death. In contrast, physicians unjustifiably kill patients whenever they intentionally administer a lethal dose of medication. We argue that the differential moral assessment of these two practices is based on a series of moral fictions – motivated false beliefs that erroneously characterize withdrawing life‐sustaining treatment in order to bring accepted end‐of‐life practices in line with the prevailing moral norm that doctors must never kill patients. When these moral fictions are exposed, it becomes apparent that conventional medical ethics relating to end‐of‐life decisions is radically mistaken.     

VIRTUE ETHICS AND THE SELECTION OF CHILDREN WITH IMPAIRMENTS: A REPLY TO ROSALIND MCDOUGALL

In ‘Parental Virtues: A New Way of Thinking about the Morality of Reproductive Actions’ Rosalind McDougall proposes a virtue‐based framework to assess the morality of child selection. Applying the virtue‐based account to the selection of children with impairments does not lead, according to McDougall, to an unequivocal answer to the morality of selecting impaired children. In ‘Impairment, Flourishing, and the Moral Nature of Parenthood,’ she also applies the virtue‐based account to the discussion of child selection, and claims that couples with an impairment are morally justified in selecting a child with the same impairment. This claim, she maintains, reveals that the flourishing of a child should be understood as requiring environment‐specific characteristics. I argue that McDougall's argument begs the question. More importantly, it does not do justice to virtue ethics. I also question to what extent a virtue ethics framework can be successfully applied to discussions about the moral permissibility of reproductive actions.     

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.