In response to a recent post — “Double Effect, Choice in Dying and Helga Kuhse” — Loren Amacher makes the following comment:
If I may, I should like to offer a (reasonably) brief tale of ‘double effect’, at least as it might be construed by the RCC, the good bishop of Phoenix, the Conference of Catholic Bishops, even by the ‘holy’ pope himself. It occurred several years ago, during my very active years in neurosurgery when I dealt with a great deal of brain trauma, brain hemorrhage, brain tumors. I have stated in more than one conference that it is not the dead that haunt my dreams, rather the living dead that I have caused to survive.
A vibrant young lad of 17, eager to be the first boy in his recently-immigrated Italian family to go to college, was driving in his old van between his jobs. He worked at least three jobs, to help with anticipated tuition costs. It was a Saturday, and I was on trauma call. In the eastern part of our northeastern city, as he crossed an intersection, a drunk T-boned him, his van disintegrated, and I saw him in the ER. His forehead and face were wide open, brain oozing out, blood crusting his face. Vital signs were good, he was breathing remarkably well, deeply unconscious and it was obvious to any experienced trauma surgeon that he was dreadfully injured. I went to see his relatives, his mother, his older sister, a younger sister, various aunts and cousins. I gave them the picture in all of its bleakness, told them that I could save his life, there would be several ORs required, probably, but that their boy would never, ever, be anything like he was. If I did nothing extensive – beyond cleaning up the gore and closing up his split face – it was most likely that he would not survive more that several days. I left them to their thoughts for an hour, then returned. The older sister said that they appreciated the information that I had given them but they asked me to do everything possible to save his life.
So I did. He got out of hospital after eight weeks or so, went home. He could walk, seemed to understand some things, talked very little, and required constant care. His sister postponed her wedding, then cancelled it when care of her brother took over her life. His father simply wandered off after six months or so, unable to take the daily sight of his ruined boy. His sister brought me a picture at one of his visits. He sat on a sofa, vacuous grin on his face, eye sockets at different heights, a permanent caricature of destroyed life and ruined boy. I keep that photo close by, lest hubris set in at any time.
Now, the point is that I knew what would happen from the outset. I think that the reason I did not claim ‘futility of care’ was that my own 19 year-old boy had died eight months previously in an acute asthmatic attack, and I felt that maybe – just maybe – I could do some good. That was certainly my intention, but the ‘double effect’ here was monstrous. Some people have told me that I had no choice, that doing nothing was tantamount to playing God. To one such fool I said: ‘Better me than the one you are so attached to.’
I’m sure that the collection of moral degenerates listed above would have commended my actions and had some ecclesiastic rule and direction (ERD) to justify it. Say! perhaps I will be eligible for beatification some time in the future!
I have left out the apology for the long post, because the story that Loren tells is so poignant and important that it needs no apology. What is most poignant about the story, I thought, was this remark:
I have stated in more than one conference that it is not the dead that haunt my dreams, rather the living dead that I have caused to survive.
In a comment on Loren’s comment I said the following:
No need to apologise for your long post, Loren. I find the most poignant sentence in the story the one that I have pasted here. We often hear people say that for doctors to help someone die would be, not only to fail in their fiduciary relationship to their patients, but also that it would be entirely contrary to their vocation, implying, I think, that offering such assistance would, in fact, haunt them for the rest of their days.
On the face of it, this is strange. If you know that someone is dying in misery, or living in misery, and would rather die, wouldn’t helping a person to achieve the end they so earnestly desire be more emotionally satisfying than being able to do nothing at all to relieve the distress of the patient? I don’t know about anyone else, but watching helplessly as someone suffers has got to be one of the most ‘soul-destroying’ experiences. Wouldn’t that haunt you more than simply helping someone to die, either by providing the means for them to bring their own lives to an end, or, where this is impossible, actually administering the fatal medicine? Or am I simply missing something about the relationship between doctor and patient that would make this more difficult than providing comfort care, even if this could not relieve the distress and the suffering?
Of course, your example is of a situation in which non-voluntary euthanasia would be required, since the person, in this case, could not give informed consent. But he couldn’t give informed consent to being patched up either. Where does non-voluntary euthanasia appear on your scale of what it is appropriate or inappropriate to do for someone at the end of life?
Opponents of assisted dying often point to the number of cases of non-voluntary euthanasia in places like the Netherlands or Belgium, that is, cases where someone is killed or put out of their misery who is not in a position either to object to or accept such assistance, and therefore cannot be supposed to have given informed consent to what is done. Often, it seems, non-voluntary euthanasia comes into question most frequently at a point very close to death, when the person involved seems obviously to be going through a period of great distress, and is not able to give informed consent. In Belgium, the average estimated time that life is shortened for those receiving non-voluntary euthanasia is only a few hours, and in almost all cases it is done because it is known to have been the patient’s wish, or because the patient’s loved ones ask for great suffering to be relieved.
Such situations seem, on the face of it, to justify the use of non-voluntary euthanasia, but many people are concerned that this will lead, in the end, to a slippery slope, and soon we will be approving involuntary euthanasia, such as was practiced by the Nazis. That is, people capable of giving informed consent are not consulted, and their lives are terminated because of a judgement that their lives are no longer worth living. I am not convinced that this is a danger, but if it were, it would be possible to rule out non-voluntary euthanasia entirely. However, this would mean that cases such as the one described by Dr. Amacher would also remain unaddressed.
Very often the concern is expressed that disabled people, quite able to make their own judgements about the worthwhileness of their lives would be put at risk if non-voluntary euthanasia were to be legalised. I think this is not the case. So long as a person is able to value their life, there seems to be no question about their right to life. But are there situations where euthanasia is appropriate and should be legalised? My own sense is that choice must be the norm, and that, so long as the issue of choice is central, we do not need to fear slippery slopes.
But Loren’s example gives one pause, and the interesting thing about it is that it stands the idea of double effect on its head. Normally, the intentional action is one that, it is supposed, is without question good. It may, for instance, be relieving pain. The secondary (double) effect is, it is supposed, without question bad, but since it is not intended, and is only the consequence of acting on a good intention, it is not involved in the moral calculus in considering the goodness of the action. But what if the apparent good intention, that is, saving a person’s life (the primary effect), has a such a very destructive effect all round (the secondary effect), that it is impossible to intend the first without also intending the latter? It is hard enough to keep the effects separate in any event, and seems a bit like shell game at the best of times. But what if it is simply impossible not to intend both effects, because the primary and secondary effects are so entangled and bring about such destructive consequences?
It’s a bit like dropping the atomic bomb on Hiroshima or Nagasaki. Those who planned the mission must have known what the effect would be. The intention was to bring a swift end to the war with Japan, which was the good intention. But how did the planners keep the horrific secondary effect out of their minds while they carried out this good intention? After all, they could still have defeated Japan using conventional weaponry. Could saving the lives of Allied (mainly American) soldiers who would have had to invade, at great cost, Japan’s home islands, be used to justify the enormous destruction of civilian lives and property that must have been known to have been the likely consequence of dropping nuclear devices on two of Japan’s large cities (one of which, curiously enough, had, as I understand it, the largest concentration of Christians in Japan)? The same thing applies, as A.C. Grayling has pointed out, with the carpet bombing of German cities, at enormous cost in human life, including women and children.
These are important questions, and need to be answered. I have called my web site Choice in Dying, because that seems to me the least problematic of all the proposals for assistance in dying or euthanasia. I think that restricting assistance in dying only to those who have a diagnosis of 6 months left to live leaves out too large a number of people for whom it would be reasonable to choose to die. But the questions that are raised by Loren Amacher’s comment, and by the Groningen Protocol regarding the euthanasia of newborns and infants, also need to be answered, for suffering does not end with those who are competent to make choices, and our moral concern cannot end there either.