It is clear enough from the brief descriptions offered above that Warnock's and Dworkin's accounts of which human lives possess worth rest on contrasting what they term the condition of 'simply being alive' or possessing mere 'biological life' with the condition involved in 'having a life' (on which worth depends). Discussing obligations to patients in a persistent vegetative state in his essay 'The Right to Death' Dworkin writes:
'... nothing in the idea that life has intrinsic importance ... can justify a policy of keeping permanently comatose people alive. The worth of their lives - the character of the lives they have led - cannot be improved just by keeping the bodies they used to inhabit technically alive.'16
Here we have a contrast between, on the one hand, a personal life (a life which a person has consciously led, to which value attaches), and, on the other, the ongoing biological life of a body which for some stretch of its existence may be inhabited by a person ('may be', because according to some of these thinkers some human bodies may never have truly 'personal' inhabitants).
This dualism left clear traces in the judgements in Airedale NHS Trust v Bland, in which a distinction was made between Tony Bland himself and his body; e.g. 'his spirit has left him and all that remains is the shell of his body' (Brown P); 'his body is alive, but he has no life.. . He is alive but has no life at all' (Hoffmann LJ, consciously echoing Dworkin).
A dualism 'which thinks of the body as if it were some kind of habitation for and instrument of the real person, is defended by few philosophers... It renders inexplicable the unity in complexity which one experiences in everything one consciously does. It speaks as if there were two things ...: a non-bodily person and a non-personal living body. But neither of these can one recognise as oneself. One's living body is intrinsic, not merely instrumental, to one's personal life. Each of us has a human life (not a vegetable life plus an animal life plus a personal life); when it is flourishing that life includes all one's vital functions including speech, deliberation and choice; when gravely impaired it lacks some of those functions without ceasing to be the life of the person so impaired.'17
Living human beings are organisms. On a non-dualistic view the unified life of the human organism is throughout human. There is not some separable organic substrate, the life of which is 'purely biological', and to which some personal subject, whose life is uniquely manifested in psychological activities, may be attached. The life that is exhibited in thinking is the very same life that is manifested in respiration and heartbeat. To cease to be able to think is to lose an ability, not to lose one's life.'18
The rejection of (anthropological) dualism is important to recovering an appreciation of the inherent dignity of every human life. There is a fundamental conflict between the position of those who acknowledge a value and dignity in human beings given with their humanity and the position of those who think that value and dignity belong to a life only in so far as a person is in control of his life and can give it a valued meaning. The latter position is not reasonable. It fails to acknowledge the value of the radical natural capacity to develop abilities to find meaning in life, and the dignity of the nature in which that radical capacity inheres. And it fails to acknowledge that the developed abilities find their fulfilment not in just any way of life which one can be said to be in control of but in a way of life in which one submits, for example, to the claims of truth and justice. And one is not in control of what counts as true and just. To attach value and dignity exclusively to autonomous control is to have blinded oneself to the true source of the basic value and dignity in a human life.
It is of considerable importance to note one implication of the inseparability of recognising someone's human dignity and recognising his status as a subject of justice. Since denial of the former entails denial of the latter, our practical reasoning should never involve us in judgements which amount to the denial of the inherent worth or dignity of a human being. The basic human dignity of the other is an ineliminable consideration when we deliberate about how we should treat him.
1.1.4 and 1.1.5 have argued for the necessity and reasonableness of attributing a fundamental worth and dignity to every living human being if we are to have a defensible understanding of justice. In so doing we have recovered from contemporary criticism, without benefit of religious premises, the basic truth about human worth and dignity which shapes the content of a sanctity of life ethic.
Anyone who causes the death of another human being with intent to do so (i.e. who intentionally kills by 'act' or omission) acts on the basis that there is some reason for thinking that the person killed should have died. Quite generally what one does intentionally is identified by reference to one's chosen purpose in acting (under that description which makes clear its perceived desirability) and the means which are chosen (under that description which makes clear their perceived relevance to the achievement of one's purpose). Both of these must feature in any adequate statement of why one is acting, i.e. in any adequate statement of one's reasons for doing precisely what one is doing.
It is clear that one can intentionally bring about someone's death by an omission which is intended to bring about death: one can want someone dead and one can bring it about that he dies precisely by choosing to omit to do what one could (and otherwise would) have done to keep him alive. When what one omits with such an intention to terminate life is not merely something one could have done but something one had a duty to do, then the law has rightly regarded such intentional omissions bringing about death as murder.'19 There is no morally significant general distinction to be made between killing and letting die, and any attempt to rely on such a distinction is intellectually perilous.20 One may let a patient die for perfectly sound reasons (see 2.2 below), but one may also 'let a patient die' for unacceptable reasons, including the absolutely unacceptable reason that one wants (however reluctantly) to hasten his death.
Both omissions contrary to duty which intentionally bring about someone's death and actions which intentionally cause death raise two questions which the person responsible should answer:
Distinguishing between acceptable and unacceptable answers to the first question is the most fundamental task in determining what is justifiable killing.
Since it is in virtue of the worth and dignity which attaches to our humanity that we establish to whom justice is owing, recognition of that dignity is the precondition of human beings treating each other properly. That being so, any purported justification of killing must at the very least be consistent with recognising the dignity of every human being. What is absolutely excluded, therefore, is bringing about another's death for reasons incompatible with recognising the dignity of the person killed.
As we have already remarked, at the beginning of this subsection, the relevant reasons are identified in the description of one's intended course of action which identifies the perceived desirability of one's goal/purpose and the perceived relevance to one's goal of one's chosen means.
This general account of which causations of death are absolutely excluded by recognition of the basic worth and dignity of every human life (viz, those intentional causations decided upon for reasons incompatible with the recog nition of human dignity) makes intelligible the moral significance of the distinction between intentional (intended) and (merely) foreseen causation of death. When death is merely foreseen, one's causing it does not feature among the reasons one has for acting, and so is not chosen whether as end or as means (and thus is not intended). Many worthwhile activities, entirely consistent with recognition of human dignity, would be made impossible if all foreseeable causation of death were forbidden (examples would be: high-risk surgery, the giving of opiates for pain control in doses likely to hasten death, high-risk sports).
It is clear that one of the motives of those who seek to show that there is no morally significant difference between intention and foresight is to make a prohibition of the intentional causation of death seem as unreasonable as an absolute prohibition of foreseen causation of death would evidently be. It should now be clear why an absolute prohibition can justifiably cover at least some intentional causations of death, namely all those the reasons for which are incompatible with recognising the basic dignity of the persons to be killed. To allow such killings would be to grant that human beings may be treated as though their dignity were irrelevant to how one chose to act towards them.
In this section it will be argued that the core reason a person proposing to carry out euthanasia would have to identify, to make intelligible what he sees to be the desirability of causing death, is a reason for action incompatible with recognising the dignity of the person to be killed.
It ought to be evident that the killing of a person for advantage or convenience is inconsistent with recognition of that person's dignity, for the person killed is certainly not treated as of equal dignity with those advantaged by his death. Much advocacy of non-voluntary euthanasia is motivated by the thought that it is advantageous to others, in relieving them of the burdens of care for the handicapped and senile.
Purported justifications for voluntary euthanasia, however, as also for much non-voluntary euthanasia, speak of it as a benefit or a good for the patient. If the reason for saying that death is desirable qua benefit to the patient is to be consistent with recognising the basic worth and dignity of the patient's life, then it cannot rest on tacitly assuming (or seeking to show) that no positive value attaches to that life. That assumption would be made if the reason for saying that death would benefit the patient were that it would terminate a condition of negative value, depriving the patient of nothing of positive value. Justifications of that type, if they have any place at all for recognising a value attaching to our humanity (and many do not), in effect treat it as a commensurable and therefore eliminable value in calculating the overall 'worth' of a life. But to treat the basic human dignity of some human beings as an eliminable value is to proceed by denying to those human beings their status as subjects of justice.
All standard justifications of voluntary euthanasia, in so far as they represent it as a benefit to the patient killed, do so in a way which is inconsistent with recognition of the basic dignity of every human being. Here are four standard patterns of justification:
It will be said that the above argument against euthanasia, both voluntary and non-voluntary, is narrow-minded in basing itself exclusively on a doctrine of equal human dignity. It will be argued that at least in respect of voluntary euthanasia there is a case to be answered in its favour based on a right to personal autonomy. As already noted, there is much talk of 'conflicting moral principles of the sanctity of life and the right to personal autonomy'24, and of the need to balance their differing claims. A reasoned assessment of such talk must depend on what kind of claims in the name of autonomy are well-grounded, and more particularly on whether 'a right to personal autonomy' ever reasonably overrides what is required by recognition of human dignity. Something, therefore, needs to be said in general terms about autonomy and a 'right to personal autonomy', and about its relation to the normative constraints on killing imposed by recognition of human dignity.
The words 'autonomy' and 'autonomous' are used in respect of a capacity, a condition and a right.
To be autonomous, as the word implies, is to be self-governed or self-directed or self-determining in the conduct of one's life; that is the condition. 'Autonomy' is used of the capacity to be self-directed in the conduct of one's life. 'Respect for autonomy' involves respect at least for this capacity. 'A right to autonomy' must be a right to at least some exercise of the capacity for self-direction in one's life. But what exercise of that capacity? The answer we give to that question must surely depend on the understanding we have of the value of autonomy.
Some semi-popular talk about autonomy and the right to have one's autonomy respected seems to suggest that what people value is doing what they want (in the sense of acting on the wants, wishes and desires they happen to have) as distinct from having to do what someone else wants. But it seems fairly clear that the ability to do what one happens to want to do is not sufficient for self-government in the conduct of one's life. Someone whose condition is one of wanton self-indulgence does what he happens to want to do. What is valued in the capacity for self-government is at the very least our ability to evaluate our desires and to act selectively in accordance with our evaluations.
But will action in accordance with any kind of evaluation count as an exercise of autonomy? Our answer to this question will depend on what we think the point of self-government or self-direction is.
The capacity for self-government is properly exercised and developed with a view to the flourishing or well-being of the person who possesses it, and of the communities to which that person properly belongs in friendship and justice. If so exercised it is indeed an aspect of that flourishing. In what way is it an aspect?
Human happiness or well-being is not left to be wholly a matter of luck, or of grace which does not require willing cooperation; what we make of ourselves (our character) makes an important difference to whether or not we flourish as human beings. And our characters are decisively shaped by our chosen actions: these do not merely bring about effects external to us, they also serve to form our dispositions. A person's exercise of choice will in this way inescapably make for well-being or misery in his life.
So there is a clear case for valuing human choice, and hence for valuing the exercise of autonomy, precisely in so far as it serves to form in us those dispositions which are conducive to human flourishing.
People differ in their views on how wide an exercise of the capacity for self-direction should be respected. One very important factor in determining those differing views is whether or not one believes there is human knowledge of moral truths, that is, knowledge of the objective requirements we need to meet if we are to flourish as human beings.
If there is such knowledge, then it is clear why we should value the exercise of choice in conformity with that knowledge: for evidently that would be an exercise of autonomy which makes for human flourishing. But it would not be obvious why we should value exercises of autonomy at variance with the objective requirements of human flourishing.
Still, if there is to be choice one has to allow not just for the possibility but also for the reality of erroneous choices. So, necessarily, respect for autonomy must leave scope for some erroneous choices. But it does not follow that any and every exercise of choice is to be respected. We need to bear in mind why this capacity is to be valued; and if our choices seriously undermine in us the capacity to flourish as human beings, and a fortiori if they aim to damage aspects of this capacity in others, there is no reason of moral principle why those choices should be respected.
Can a right to autonomy be invoked to justify voluntary euthanasia? It is important to recognise how limited a role in justification the actual request to be killed can play. Certainly the mere fact of a request in itself provides little reason for a doctor to kill a patient. Can we envisage a doctor thinking it justifiable to kill a patient just because the patient has asked to be killed? Hardly. Indeed, we can envisage many circumstances in which doctors who are not opposed in principle to euthanasia would refuse requests; as when they think the request is prompted by an erroneous view of the prognosis, or by some relievable depression, or by circumstances which can be readily changed. Any doctor who feels that a given patient still has a worthwhile life to live will not accede to a request for euthanasia from that patient. By contrast, it is precisely the judgement that a patient no longer has a worthwhile life which will seem to justify euthanasia. The role of this judgement in justifying euthanasia is not altered by the different grounds a doctor may have for arriving at it. Sometimes it will seem true on the basis of evidence which the doctor can independently take stock of: pain, degeneration, depression, wretched circumstances. At other times the judgement will be clinched in the doctor's mind only by what the patient asserts: that his life is no longer worth living.
A doctor, minded to think that at bottom a human life can have value only if the person whose life it is consciously finds value in it, may well accept, in the presence of some corroborative evidence,a patient's judgement that his life has irrevocably lost value and dignity. But that fact about the doctor's background reasoning is not a ground for thinking that the doctor is not himself responsible for the judgement that this patient no longer has a worthwhile life. For it is this judgement which will make it appear to him that a choice to bring about the patient's death is a beneficent choice.
Notwithstanding, then, that the killing which carries out voluntary euthanasia is requested, the justification of that killing rests centrally on the contention that the patient no longer has a worthwhile life. But precisely that contention is inconsistent with recognising the continuing worth and dignity of the patient's life.
In any apparent conflict between, on the one hand, the requirement that we do not deny equal human dignity and respect for the sanctity of human life and, on the other, the putative claims of respect for autonomy, the principle of the sanctity of human life must always trump those claims. For recognition of equal human dignity is fundamental to recognition of all human beings as subjects of justice.
There is no authentic conflict between rightly respecting the sanctity of human life and rightly respecting autonomy. The exercise of human autonomy in giving shape, direction and character to a human life is not a source of value and dignity which is properly at odds with the fundamental source of human worth and dignity in human nature itself. For, as we saw (1.1.4), what makes it reasonable to recognise human nature as the source of our basic worth and dignity as human beings is the fact that our nature in its development is intrinsically directed to human fulfilment and human good. And what best makes sense of the ideal of respect for autonomy is the role played by free choice in the achievement of that fulfilment to which our nature is directed; for self-determining choice is integral to that achievement. But if the moral significance of autonomy is to be understood in that way, then the value of autonomy is derivative from, and reflective of, that which gives value to our humanity. So it should be clear that the claims of autonomy cannot properly extend to choices which are inconsistent with recognising the basic worth and dignity of every human being.
It is sometimes said25 that debility, degeneration and dependency experienced by those who have become permanently incompetent, or the undignified way in which (sometimes unavoidably) they are treated, are inconsistent with the meaning and character they had given to their lives while competent. It is then claimed, or insinuated, that this meaning and character have been the exclusive source of dignity in the lives of many such people so that their present condition should be recognised as completely depriving them of dignity. For this reason, therefore, it would be beneficent to put an end to their lives.
Sufficient has already been said to show that such a line of reasoning provides no defensible ground for euthanasia of the incompetent who were formerly competent. As many of those nurses and others who care for such persons know, and testify to by their dispositions and acts of solidarity, communion or friendship with them, these people, though sadly weakened or wounded and scarcely or no longer able to exercise their autonomy, remain the very same persons they always were. Their state is in a sense undignified, but it is not an indignity (of the kind inflicted upon people by demeaning actions). Right down to their deaths they continue to share in the radical equality-in-dignity of all human beings.
The teaching of Christian tradition about the sanctity of life can be recast in secular terms as a doctrine of equal basic worth and dignity. This doctrine has to be assumed if there is to be a non-arbitrary understanding of who are the subjects of justice, but the intrinsic reasonableness of the assumption can be defended.
Since we must hold all human beings to possess an ineliminable worth and dignity if they are to be recognised as subjects of justice, any justification for killing incompatible with recognising that worth and dignity is inadmissible.
Justifications of voluntary and non-voluntary euthanasia as beneficent rely essentially on the judgement that, overall, the present life of the person to be killed is of negative value (not worthwhile). But such a judgement is incompatible with recognising the ineliminable worth and dignity of the person to be killed. Hence intentional killing (by act or omission) for euthanasiast reasons falls under the absolute prohibition of intentional killing of the innocent (itself the core requirement of respect for the sanctity of life).
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2. The Duties of Doctors:Duties of Treatment and Duties of Care
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