Category Archives: Autonomy

Sanctity of Life and its inviolability

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I have to admit that, before Scott McKenna proposed it, it seemed to me that you could not pry the sanctity and inviolability of life apart. As he says, quite clearly:

For me, sanctity of life does not necessarily equate with inviolability.   My argument is that God has given us moral responsibility.   We cannot ever say that God desires intolerable suffering of us and, in ending our life in such circumstances, we, as co-creators with God, are exercising compassion and God-given choice.   There are no ‘disastrous consequences’:  God is bigger than that.  It is precisely because God is compassionate that we have nothing to fear.    We have real moral choice:  we are not ‘sheep’.

This is, it needs to be said, contrary to what is normally meant by the sanctity of life, and, as for moral responsibility, religions have normally seen morality as a function of their belief in and loyalty to God, not something which can be separated from that belief or that commitment.

The Roman Catholic Church puts the point with its wonted bluntness. In its Declaration on Euthanasia it is quite clearly stated:

It is necessary to state firmly once more that nothing and no one can in any way permit the killing of an innocent human being, whether a fetus or an embryo, an infant or an adult, an old person, or one suffering from an incurable disease, or a person who is dying. Furthermore, no one is permitted to ask for this act of killing, either for himself or herself or for another person entrusted to his or her care, nor can he or she consent to it, either explicitly or implicitly. nor can any authority legitimately recommend or permit such an action. For it is a question of the violation of the divine law, an offense against the dignity of the human person, a crime against life, and an attack on humanity. [my italics]

Of course, there is a qualification, bringing the principle of double effect into play, namely, that one may not intentionally bring about the death of an innocent human being. This expedient, however, is simply a band aid where a battle dressing is required. In her book The Sanctity of Life Doctrine in Medicine: A Critique, the Australian philosopher Helga Kuhse defines sanctity of life as follows:

It is absolutely prohibited either intentionally to kill a patient or intentionally to let a patient die, and to base decisions relating to the prolongation or shortening of human life on considerations of its quality or kind. [11; italics in original]

In  the light of these considerations, how can Scott McKenna claim that he supports the principle of the sanctity of life, and yet does not consider this principle absolute?

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The Mindless Idiocy of Religious Morality

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Isn’t it just about time that we told religious moralists to shove it? Really, when you look at the world today, and consider the offences that religions commit against human dignity and justice, for religions to make claims to speak with authority on moral questions is not only laughable, it is plainly obscene. Religious thought is rightly thought to be “other worldly” — it certainly does not belong in this one. Roman Catholic ethicists, like the incredibly doctrinaire Robert P. George, who thinks that only Catholic morality can be justified by reason, and therefore should be made into law, cannot even imagine how it could be possible for anyone to disagree with them, and yet very few moral philosophers do agree with them. They carry on their moral projects in a private room, as though no one else was thinking about ethics at all. No wonder they are so dismayed when people turn them down.

Take Robert P. George’s arguments regarding the immorality of abortion, for example. He thinks that anyone who thinks that abortion, at any stage, is morally justifiable, is simply wrong, and he thinks that this is a position securely grounded in science itself. I will not go into detail, since I do not think the argument deserves this kind of close attention. Just consider this statement and its sequel:

What the zygote needs to function as a self-integrating human organism, a human being, it already possesses.

At no point in embryogenesis, therefore, does the distinct organism that came into being when it was conceived undergo what is technically called “substantial change” (or a change of natures). It is human and will remain human. [71]

Now, let’s stack this claim up against the claim of the woman in whom this zygote has taken up residence.

In the Independent this morning the main headline is:

Woman dies after being refused an abortion in Irish hospital

Here’s part of the story:

Savita Halappanavar, a dentist aged 31, was 17 weeks pregnant when she died after suffering a miscarriage and septicaemia.

The woman’s husband Praveen Halappanavar, 34, claimed she had complained of being in agonising pain while in Galway University Hospital.

He has said that doctors refused to carry out a medical termination because the foetus’s heartbeat was present.

A “heartbeat was present”! The woman had suffered a miscarriage, for Christ’s sake! But a heartbeat was present, so, conformable to Robert P. George’s (and the Pope’s) dictum, a human being was present. So, instead of rescuing the woman, she was allowed to die, being told that an abortion was contraindicated because “Ireland is a Catholic country.” The idiocy of this is simply stunning, and yet this is what happened. A life of a woman was forfeited, regardless of her own choices, because there was a heartbeat! It’s enough to make one scream, and to call down execrations on the heads of those “in charge,” and it reminds one that “Mother Teresa” (now Blessed Teresa of Calcutta) declared in accepting the Nobel Peace Prize (of all things!), that abortion was “the greatest destroyer of peace in the world.” (We should all retire to Bedlam!) Neither the woman’s distress nor the husband’s request availed anything, and she was left to die because of the inviolable logic of Roman Catholic ethics. It makes me so angry that I want to wring some prelatical throats.

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Time for the Death with Dignity Movement to Grow Up!

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This post is now available in Polish at Racjonalista — thanks once again to Malgorzata.

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A few days ago, over at the New York Times, a selection of letters in response to Ezekiel Emmanuel’s article on assisted dying, and to Ben Mattlin’s piece on his reasons for opposing the Death with Dignity law that is on the Massachusetts ballot today, were published. I want briefly to address myself to one of these letters, which in my view is particulary powerful. I copy the letter here:

To the Editor:

Dr. Ezekiel J. Emanuel uses a flawed rationale to challenge the legitimacy of assisted suicide. While he seems to agree that it would be acceptable in cases of severe, intractable physical pain, he suggests that it is not legitimate if motivated by emotional pain or depression. The appropriate response in such cases, he maintains, is to provide “counseling and caring.”

As a retired clinical psychologist, I must note that there is a vast difference between the depression of a terminally ill patient, who realistically perceives his situation to be hopeless, and a physically healthy patient suffering from clinical depression.

In the case of a physically healthy patient who is clinically depressed, feelings of worthlessness and hopelessness are the product of inaccurate perceptions of self and circumstances — mental distortions produced by the illness itself. For such patients, treatment can produce marked improvement.

The same cannot be said for terminally ill patients, whose feelings of hopelessness are, sadly, all too realistic and whose depression is often a normal response to a disheartening reality. While the “counseling and caring” Dr. Emanuel recommends can provide comfort to the terminally ill patient, they cannot change the reality of a patient whose quality of life has diminished to the point where each day is another round of frustration and pain, be it physical or emotional.

If I should become terminally ill, I would not want to cede to a third party the right to determine when my life is no longer worth living.

JAMES HAWTHORNE Baltimore, Oct. 29, 2012

I want to shout it from the housetops: Precisely! So much hand-wringing about assisted dying — and all the laws in the United States, unfortunately, get this wrong, and Scotland is about to get it wrong, too, if it passes the bill introduced by Margo MacDonald – is about the fact that people who are dying, or who are suffering from long-drawn-out degenerative conditions like MS and ALS, are depressed. Some will even add “clinically depressed,” just to make the point clear.

However, it has always seemed obvious to me — and it is an obviousness that does not move the opponents of assisted dying — that being in some situations, and finding them to be existentially distressful — what some choose to call clinical depression — is a perfectly reasonable thing to find. As James Hawthorne points out, with great clarity, dying people, and I would add, those suffering from degenerative conditions, or even, I would also add, those who are suffering from conditions or disabilities which they find intolerable (such as Tony Nicklinson or Daniel James), are people

whose feelings of hopelessness are, sadly, all too realistic and whose depression is often a normal response to a disheartening reality.

Why, I wonder, is this not obvious? Why is the distress or depression or existential angst of people who are dying, or who are living in what are to them intolerably painful or undignified or meaningless conditions, not recognised as perfectly natural? To think of these mental states as mental pathologies which bring into question the ability of those who have them to make autonomous decisions is simply perverse. And, I might add, to continue to confine the range of people to whom assisted dying laws apply only to the terminally ill is also perverse, for they are not the only ones for whom it is perfectly natural to have such feelings of existential despair.

Polls which suggest that people will support assisted dying for the terminally ill, but would not do so for those whose suffering is not terminal within a specified period, are not, I suspect, asking the right questions. The public response to Tony Nicklinson’s case suggests this, for it seems clear that a majority of people would have supported Nicklinson in his legal campaign to receive legal permission to receive help to die. And it is not, as so many people seem to think, that people like Tony Nicklinson want to die. They do not. But they know that death is the only way out of situations in life that have become intolerable and burdensome to them. Elizabeth might have lived for many years more in the complete paralysis which was soon to be her misfortune, and yet those years would have been years of torment that she did not want to experience. Her torment was already great enough, and she just wished that she could die.

To confine assisted dying to the terminally ill is not enough, and it should be seen to be not enough, and so confining it reflects such a lack of understanding of the reasons why people elect to die that those who support limited assisted dying of this sort need to have a short sharp shock to bring them to a recognition of the realities. They may be working within what are the political realities as polling numbers seem to reveal them to be, but they do not reflect the reality of people’s lives, and their reasons for choosing to die. It is high time that the death with dignity movement grew up, and stopped pandering to the religious forces of unreason which, at a stretch, can be brought to see that those who are already dying may be helped to hasten death, but who cannot be brought to see that other lives may be even more intolerable, because their torment will go on sometimes for years without remission. It is time that those who support assisted dying began to think beyond the narrow confines of their prison houses, where they have been locked away because of religious opposition to assisted dying, and to come to recognise that there are many other reasons, besides the imminence of death itself, why people may reasonably wish that they were dead.

The duty allotted by nature

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Many arguments regarding abortion or euthanasia (or assisted dying more generally) are based on supposed “laws of nature.” The status of such natural laws is not clear, but we are assured that they are, notwithstanding their nature as facts about the world, morally binding upon those to whom they apply. We saw this in action not so long ago when I addressed myself to Edward Feser’s book The Last Superstition. One of the things that struck me with such force about that book, and the response to my criticism of it — and here it is important to remember that the entire milieu of contemporary scholastic philosophy, basing itself on Aristotle and Aquinas, is related as like to unlike when it is used in philosophical discussion itself — is that there is a sense in which, for the modern scholastic, the arguments are already made and the conclusions are already reached, well before we begin, and there is nothing, beyond simple agreement, that can be accepted as the rational response to scholastic argumentation.

This is particularly clear in Robert George’s book, The Clash of Orthodoxies. When he is discussing Rawls’ theory of justice, he takes it for granted that the idea of justice as fairness is all very well where we do not know the truth, but where we do know it – as, he claims, we would know it if we accepted his argumentation, for this argumentation produces truth of such power and validity that it cannot be reasonably questioned by a rational person — any settlement made behind the “veil of ignorance” (or, as Rawls alternatively says, in the “original position”) is immediately called into question by any rational demonstration of the truth. George believes himself to have established, beyond reasonable doubt, that abortion, infanticide and euthanasia or assisted suicide (assisted dying) are contrary to the natural law, and therefore irrational and immoral. This, it would seem, immediately upsets the possibility of establishing an “original position” (even as a philosophical hermeneutic) from which political arrangements can be made which will assure the just (=fair) disposition of rights and privileges, wealth and opportunity that is consistent with the greatest benefit to the least well off person in society. For if justice, established in this way, must be subject to the truth (as understood by a subsection of the citizenry), any such contractual arrangements would be immediately called into question by the rational demonstration that something believed, behind the veil of ignorance, to be a matter of individual choice and determination, is, in actuality, not open to reasonable question.

The important point to notice here is that Rawls’ theory of justice was intended to overcome the ideological differences between different members of society, so that, for those, like George, who believe that their position is the only rational one, in terms of providing conclusive argument for the truth of its conclusions, there would be no hindrance to their believing themselves to have achieved truth, and to act in accordance with it, without at the same time requiring others to subordinate their own lives or reasoning to the conclusions reached by George and his fellow believers. When Rawls speaks of comprehensive world views existing side-by-side in the same society on the basis of contractual agreement not to impose views peculiar to themselves on others — thus preserving both peace and justice in society — he has in mind claims like those made by George, that their arguments offer conclusive demonstrations of the truth of their beliefs. In the kind of secular society for which Rawls’ theory of justice was intended as a means of achieving social peace and concord, as well as providing the greatest liberty for each citizen compatible with equal liberty for all, the move that George is making is simply illegitimate, for it is claiming moral certainty in a world where no such certainty exists.

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Is the human foetus a human person?

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The real question to ask is whether that is even the right question. In the last few days there has been a rash of media articles pertaining to abortion.  I’m not sure where it began or who began it, but suddenly the issue started making media waves in both Canada and Britain at about the same time. The new British Minister for Women (who also holds the portfolio for culture and sport) made the suggestion that the limit for abortion be lowered from 24 to 20 weeks, since new advances suggest that viability begins at around 20 weeks gestation. It actually doesn’t. There has been very little change in this respect over the last few years, and life-expectancy at 20 weeks is still very low and the risks correspondingly high, even with all the modern bells and whistles of post-natal care. According to the Independent newspaper yesterday (4th October 2012):

A spokesman for the British Medical Association said yesterday: “The BMA does not believe there is any scientific justification to reduce the abortion limit from 24 to 20 weeks. We will not be lobbying for any reduction.”

Predictably, the so-called ”pro-life” forces have immediately jumped on the minister’s bandwagon, since, of course, they want to see abortion prohibited absolutely, so anything heading in that direction will win their support, whether justified by the medical facts or not. After all, they don’t think these things are even relevant to the discussion. But it came as a bit of a surprise that the Minister for Women and Equalities should make the suggestion as a “modern feminist.” It’s a bit unclear why she thinks this is a feminist position. The idea is, apparently, that late abortions have a more destructive emotional impact on women, but this misses the point, for, even though it is often very difficult for a woman to make a decision for a late term abortion, the reason almost always is correspondingly serious, often the discovery that the foetus is discovered to have a serious abnormality, which means that the birth will be either of  a dead baby or one that is serious compromised at birth. Almost all abortions are early. “Pro-lifers” may find all abortions disturbing, but that is only because they find the thought of abortion itself disturbing, not because it is.

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Further progress in the “right-to-die” movement

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A lot of things have been happening lately in the right-to-die movement, and they are worth recording here. Perhaps the most powerful statement so far made was made by Tony Nicklinson, who, after losing his High Court case for the right to die, lost hear, refused to eat, and died a few days later, finally free of the burden of a life which was becoming increasingly intolerable for him. That the courts would not set a precedent — and there is no obvious reason why they could not — because this is a matter for a Parliament which has shown scant interest in the issue for years, was a great disappointment, not only to Tony, but to many other people who are seeking relief from intolerable conditions of life.

A lot of commentators have remarked that the court could not have acted, for to have acceded to Tony Nicklinson’s request would have been, effectively, to legalise euthanasia, and there seem to be a lot of people who are unwilling to take that extra step, including many in the right-to-die movement. That they are completely wrong about this doesn’t seem to dawn on them. It may be that the preferred way is to provide the means for assisted suicide, so that the person who is suffering is the one who actually has to do the deed, but this excludes, by definition, all those who cannot do the deed, like Tony Nicklinson, and others who have lost the use of their bodies. Many people with MS and ALS end up in this state, and the limitation of assisted dying to assisted suicide means that these people will be forced to make the decision to die earlier than they otherwise might have done, because they would know that, once trapped in their bodies, they are trapped forever, unless they wish to starve themselves to death. But what people who was assistance in dying want is to be in full possession of their faculties when they die, and those who starve themselves to death eventually pass into a comatose state, and then they die. Why they cannot be helped simply makes no sense. It is significant that those who have fought this in court are those who are or who were likely to be in a state where assisted suicide would have been of no use to them. Tony Nicklinson, Diane Purdy, and Diane Pretty: all except Ms. Purdy were unable, at the time of their court challenges, were unable to die by receiving assistance in suicide. And still, unfortunately, the right-to-die organisation in Britain, Dignity in Dying, has not got the point.

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Brown Bumbling Beyond Believable Bounds

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I pilloried Andrew Brown in a recent post, and it might be thought unkind to follow up so soon with another excoriating tribute to the Guardian’s favourite dunce. However, this morning I decided to do a search through the archives of the Guardian and the Times (London), to see what had been said on the subject of assisted dying over the years. I downloaded over 70 articles from those two newspapers alone, and amongst them I happened very early on one of Andrew Brown’s, and this one was so obviously simply ridiculous — did I comment on it back in January? — I don’t remember — that I simply had to take up the poison pen once again. The article is entitled “Assisted suicide is never an autonomous choice.” Now, I know that Brown is challenged in the area of making rational choices, but it does not follow that everyone is handicapped in quite the way that he seems to be, so his claim deserves closer attention.

Now, while he doesn’t refer to Onora O’Neill, the British philosopher who also makes a similar claim, though on what some might consider more carefully considered grounds, it seems that Brown’s attempt owes at least something to Dr. O’Neill, whose 2001 Gifford Lectures formed the foundation for her book Autonomy and Trust in Bioethics. O’Neill has a very rigorous understanding of what constitutes autonomy, based on Kant’s theory of the categorical imperative, which in one of its forms — the Formula of the Law of Nature – states that one should

Act as if the maxim of your action were to become through your will a universal law of nature. [Groundwork, Paton's translation, 84; italics in original]

Accordingly, O’Neill defines what Kantian autonomy would look like in the following way:

Autonomy in action is no more — but also no less — than the attempt to act on principles on which all others could act. [Autonomy and Trust in Bioethics, 94]

In other words, autonomy is lawlike rather than lawless, in principle intelligible by others, and also refutable by others. It must be able to give an account of itself.

This is essentially the stand which O’Neill herself took in her submission to the Falconer Commission, where she said:

I do not believe that it is possible to draft adequate safeguards without invoking misleading and unrealisable fantasies about individual autonomy.

This comes from notes that I took of her testimony, although I cannot now find those submissions online. The Falconer Commission, in its report, does not quote O’Neill, so perhaps her point of view didn’t have much effect, but it is still, I believe, unreasonable. It is unreasonable to have such high standards for autonomy in respect of decisions to receive help in dying, while having no standards at all in respect of decisions to refuse treatment or to have treatment withdrawn, for it is generally held that a patient may refuse treatment or request that it be withdrawn without giving any reason at all, let alone a rational one. To raise the bar so high when it comes to assisted dying is simply discordant with what is being done in most areas of medicine where the perspective of the patient is considered to be the decisive factor in decision-making.

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Andrew Brown gets it wrong again?! What do you call someone who gets it wrong more often than he gets it right?

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I was thinking of writing something this morning on assisted dying and changing values — because a new British poll has come up with some surprising results — and then I came upon Andrew Brown’s take on assisted dying, and my decision was made for me (which will please Sam Harris and Jerry Coyne immensely!). Everytime Andrew Brown takes aim at something he’s almost sure to get it wrong — though once in awhile, as if by accident, he seems to make sense – but this time the goes so far over the edge that one has to wonder whether he wasn’t under the influence of some mind-altering drug. Perhaps it was just his usual hubris, but, if so, he was feeling particularly expansive when he wrote this piece in the Guardian: Assisted dying: who’s to decide when a life is not worth living? I could give him the answer to his question in a few words, but experience shows that people like Brown just won’t listen. They’ve already made up their minds. They know the score. And we should only listen to them, apparently, because they certainly don’t listen to anyone else.

That’s what’s so galling about this issue. People are not listening. Brown didn’t listen to Tony Nicklinson, who he thinks was “relatively healthy.” Listen:

In conjunction with other recent surveys, it shows that more people are in favour of the law allowing the killing of relatively healthy patients like Tony Nicklinson than of those who are terminally ill.

What does “relatively healthy” mean, I wonder? If this man was relatively healthy, then what does one have to do to be counted sick? This is the picture accompanying Brown’s article:

I don’t ask the question in a way that suggests that there is an obvious answer to the question whether Tony Nicklinson is sick enough to be permitted to receive help in dying. Because that decision belonged to none other than Tony Nicklinson himself. And he made it!! I’m asking the question in such a way as to put the question to Brown: How miserable does someone have to be before they should be allowed to ask for such help? We know Tony Nicklinson’s answer. Why doesn’t Brown see that Tony Nicklinson was not only making a perfectly reasonable decision; but that it is an intolerably cruel thing to force someone like Tony Nicklinson to go on living when life has become for them a burden to great to bear? Why doesn’t Brown’s humanity kick in?

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Giles Fraser, circumcision, liberalism and identity

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Let’s get this straight to start with. Giles Fraser is a priest in the Church of England. Born a Jew, and circumcised according to Jewish custom when he was 8 days old, he relented when his wife objected to circumcision, and did not have his son Felix circumcised according to the custom of his people. All this is recorded in his Guardian article, “This German circumcision ban is an affront to Jewish and Muslim identity.”

What started the ball rolling was a decision in a Cologne court where a judge ruled that circumcision is against the best interests of the child, and accordingly instituted a legal ban. The German Chancellor, Angela Merkel, said that she “did not want Germany to be the only country in the world in which Jews cannot practice their rights.” An interesting sidelight on this statement, which Fraser tells us beggars belief, is that the original case concerned a Muslim boy, and complications arising from his circumcision.

I have already expressed myself in support of the judgement of the court in Cologne. The problem as I saw it then — and I have not changed my mind — is that the belief that the common good of the community can be achieved independently of individual autonomy is not obvious. This would have to be shown, and, I suggest, it cannot be. If community can exist only by suppressing the autonomy of individuals, has the common good been achieved, or is there still something wanting — namely, the personal fulfilment of individuals? It is so easy to talk about the priority of community, as Fraser does, without recognising its cost to individuals. This does not mean, of course, that we do not have to balance the demands of community against the demands of individual autonomy. It may not be to the good of individuals, as well as the community, if autonomy always trumps community, but simply claiming that community should precede and trump autonomy is equally unsatisfactory.

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Let’s get some perspective, shall we?!

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My last few posts have been about assisted dying — which should come as no surprise to anyone, since this is the ostensible subject of this blog. As I say in the masthead: “Arguing for the right to die and against the religious obstruction of that right.” One thing that annoys me almost as much as religious opponents of assisted dying are those secularists/humanists/atheists who simply seem unable to get it right. These are the people who are not dependent upon religious doctrine to tell them what is right and wrong; these are also people who, in general, are supposed to check and double-check their sources and their arguments, because when you haven’t got doctrine to reassure you, you really do have a responsibility to think a bit more closely about the things that concern you. You may not always get it right, of course — that’s a danger we all face — but we should get it right more often than not, if we really have taken the trouble to think about something, try our best to discover the best evidence or reasoning for what we believe, and then take care, when speaking or writing about it, that we avoid the worst effects of self-deception, emotional loading, and special pleading.

Now, just to be clear about this, if there were conclusive evidence that legalising assisted dying would be impossible without resulting in massive risk to the so-called vulnerable, the mentally and physically challenged who live amongst us, whether because of accident of birth, illness, mishap or age, then I would be the first to say that legalising assisted dying is something we should not undertake for fear of the inevitable consequences of doing so. The trouble is, there is no evidence that this is the case, despite the best efforts of those who have no respect for evidence at all to show us that it is. Recently, José Pereira, in the journal Current Oncology (accessible here), argued in detail that the laws in Belgium and the Netherlands are simply unable to protect the most vulnerable in those countries, and that thousands of people are being killed there involuntarily every year. I was faced with the fact of this paper’s existence in an interview I did for CTV’s W5 programme last year. Victor Malarek gave it to me cold, and, since I hadn’t seen the paper, and did not know how cogent the arguments being used were, I had very little to say about it, though I did point out that opponents of assisted dying regularly make such claims and that so far they have been shown to be entirely bogus, so that I would not myself lend much credence to them without a very serious background check. (The producers chose to edit these comments out, so that no expression of doubt was permitted to dampen the force of Pereira’s claims.) After the interview I located the paper, and wrote a more serious assessment, though it still had no effect on the outcome; and, in the end, no objections to Pereira’s claims were voiced in the programme, and the result, though it appeared to give more time to supporters of assisted dying, gave Pereira and his fears the last word, and represented them as “expert testimony” in such a way as to constitute bad journalism if not out and out prevarication.

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