Category Archives: Double Effect

Margaret Somerville/Wanda Morris Debate Assisted Dying on HuffPo. So far, Margaret is Winning!

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Over at the Huffington Post there is a debate between Margaret Somerville, purported ethicist from McGill University in Montreal, and Wanda Morris, Executive Director of Dying with Dignity (Canada), the voice for choice at the end of life in Canada. Somerville, as is her wont, brings out all the usual suspects, none of which are really compelling, and all of which depend on two things, making you afraid of it, and claiming that it’s simply — it’s really that simple folks! — wrong to kill people. She forgets, of course, that people have been killing other people since the dawn of time, and will go on doing it. Certainly, many acts of killing are wrong and to be regretted and condemned, but merely saying that something is a matter of killing another human being is not enough all on its own to make it wrong.

Margaret’s biggest argument — the real big argument so far as Somerville is concerned — is that permitting the act of assisting someone in great suffering to die (she doesn’t like that euphemism, so we’ll come back to it) is changing something fundamental about the way in which we regard human life, and it will bring about untold changes in our society, and may — in fact she is sure that it will — change the way we regard killing others, so that legalising it in the case of those who choose to die in order to end their suffering will set society off on a slippery slope to disaster and depravity. She’s said this numerous times before, and she puts so much weight on it that it really constitutes her main argument against assisted dying (a ”sanitised” form of language that she deplores, but we will come back to that). Margaret’s problem, not to put too fine a point on it, is that she is left asking a vague question about the future: “What long term effects might result from that?” She doesn’t know, but she has this in common with the pope: she believes firmly that this will usher in a “culture of death,” if it hasn’t already arrived, and that there will be much weeping and gnashing of teeth because we didn’t listen to Jeremiahs like her.

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If it is so important to live according to one’s nature: Castrate the lot of them, I say!

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Available in Polish translation here. Thanks again to Malgorzata!

Here’s a picture of the Clown of the Vatican giving Christmas greetings to a room full of celibate fundamentalists who have made a new year’s resolution to oppose gay marriage with all the power supposedly vested in them by the Ruler of the Universe. Indeed, Christmas, for the pope and his henchmen has become the occasion of the most virulent anti-gay campaign ever to emanate from the frowsty halls of the Vatican. Instead of peace and joy, and the sentimentality of cribs and cowsheds and a sacred baby, we have the pope in attack mode. The overly ornate hall is meant to intimidate us, but don’t let the pictures of angels dupe you. These guys know all about realpolitik.

?????

To be quite frank, it now simply makes me angry, that a bunch of celibate men should gather together and tell the rest of the world what sexuality is for, and how people should act with respect to their nature, as though human nature were a fixed datum which cannot be varied or further defined. If the Jesus they pretend to worship were to walk into this hall, they’d have him arrested and sent packing. But the thing is that here is a room full of contradictions, every man jack of them acting contrary to his nature (or at least pretending to do so). And yet they have the unmitigated gall to define how the rest of us are to live. According to a Reuters report, the pope (along with his gang of overdressed “virgins”) is forming a coalition of religions to defend “real” marriage and to oppose the legalisation of gay marriage, and it’s high time we told this geriatric failure of a human being that we don’t think this gathering of men sworn to celibacy has anything to teach the world about sexuality or the family. About love, clearly, they have nothing to teach, the pope’s hateful “Christmas” message having gone out to all the world. You know the pope thinks he’s in trouble when the substitutes gay marriage for the manger and the holy mother and child.

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The Principle of Double Effect, Abortion, Assisted Dying and the Religous idea of the Sanctity of Life. Putting Religion out to Grass

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Under an earlier post, Scott McKenna, who wants, as many of you will know, to continue using the conception of the sanctity of life, though not, he says, in an absolute sense, remarked as follows:

The Church of Scotland states that there are circumstances in which it is permissible to have an abortion, such as when the life of the mother is at risk.   No absolute sanctity here.

The claim, I think, that there is no absolute sanctity here, is questionable. It is possible, in various ways, to work around the notion of absolute sanctity so as to produce justifications for acts in which a death occurs. This is what the Principle of Double Effect (PDE) is all about. Its purpose is to preserve the idea of sanctity while at the same time preventing the sanctity of life from producing counterintuitive consequences.

The PDE has its origin in Thomas Aquinas’ defence of killing in self-defence, which is worthwhile quoting in some detail. You can find it in his Summa Theologica, II-II, Question 64, Article 7: “Whether it is Lawful to Kill a Man in Self-defence?” In response to the objections to the claim that it is, Aquinas answers as follows:

I answer that Nothing hinders one act from having two effects, only one of which is intended, while the other is beside the intention. Now moral acts take their species according to what is intended, and not according to what is beside the intention, since this is accidental as explained above. Accordingly the act of self-defence may have two effects, one is the saving of one’s life, the other is the slaying of the aggressor. Therefore this act, since one’s intention is to save one’s own life, is not unlawful, seeing it is natural to everything to keep itself in being, as far as possible. And yet, though proceeding from a good intention, an act may be rendered unlawful, if it be out of proportion to the end. Wherefore if a man, in self-defence, uses more than necessary violence, it will be unlawful: whereas if he repel force with moderation his defence will be lawful, because according to the jurists, “it is lawful to repel force by force, provided one does not exceed the limits of a blameless defence.”

Now, it is clear, I think, that the PDE as thus understood can easily serve its turn in justifying abortion where the woman’s life is in danger. The Roman Catholic Church seems to be under the misapprehension that, if saving the mother involves the “direct” killing of the foetus, the PDE does not apply, as was argued in the case of the woman in Phoenix, when a nun was excommunicated on the strength of this misunderstanding of Aquinas’ argument.

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The Problem with the Sanctity-of-Life Doctrine

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One of the things that having Scott McKenna’s comments have done for me is to force me to focus more attention on assisted dying. Of course, this blog is about that, but it’s also about opposing the interference of the religions in the right-to-die, and sometimes my opposition to religion gets the lion’s share of attention. I don’t regret that, because I do believe not only that religion is one of the biggest obstacles to assisted dying, but that, in other respects, religion is a harmful influence on society, and we would be better off if the religions would take an appropriately marginal place in society, and stop trying to impose their priorities on the rest of us. But I also acknowledge that I have not done as much work on assisted dying as I should have done, so the last few days have taken up the slack a bit, and I have Scott McKenna to thank for it.

I think it is important to note that Scott has received complaints from “head office” about his speaking out in favour of assisted dying, as he mentions in a comment. So, his standing with those who support assisted dying has not been without some cost for him, but, as he says, “head office” isn’t the church. There are people who don’t hew to the party line, and they are part of the church too. Indeed, we know this is true, for, despite the fact that the United States Conference of Catholic Bishops tried very hard in the recent election to convince their members to support Mitt Romney, a majority of them, going by exit polls, did not. So, some Christians are better than their “head office” with their more worldly concerns of power and influence, and it is only fair to point this out, since my temptation sometimes is to tar all Christians, indeed, all religious people, with the same brush, and it is good to remember that many religious people, while remaining, according to their lights, loyal to the best that they see in the message of their religion, do not support the more extreme stands of their leaders.

Of course, one problem with this is that, by remaining in the church, those who oppose the church’s policies give the kind of support, in terms of numbers, that gives weight to church leaders when they speak in public and insist on being taken seriously by politicians and others in charge of public policy. For the churches, remaining relevant, in the sense of maintaining a powerful lobby position with the powers that be, is very important, since once you are truly marginalised, and no one in civil authority is listening to you, the less likely it is that you will be able to help shape laws which reflect the moral preferences of your particular organisation. A lot of people right now are saying that the Church of England has fouled its own nest, and has lost credibility, because, after decades of effort, the bid to enable women to be consecrated bishops has failed. A lot of people will feel that the Church of England is no longer a place for respectable people, because persisting in its rather petulant opposition to women bishops, while allowing women priests, they are showing a kind of selective sexism for which there is no justification. Needless to say, the Roman Catholic Church is worse in this respect, because they won’t allow women to become deacons let alone bishops, and, what with the latest scandal in the form of allowing a woman in Ireland to die, instead of performing a therapeutic abortion (of a miscarrying foetus), the message of the Roman Catholic Church about the value of women has been made rather brutally clear. I’m amazed that people still belong. Hilary Mantel, a few weeks ago, said that the Roman Catholic Church is no longer fit for respectable people, and I’m inclined to agree. If the only way to force change in the church is to refuse to associate with it and its antediluvian beliefs, then disassociation should be the order of the day.

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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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Misunderstanding Assisted Dying

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Almost everyone does — misunderstand assisted dying, that is. This is particularly evident in several recent articles, both in Canada in the UK. I’ll just discuss Derek Miedema’s “My right to life trumps your right to die“, and Matt Gurney’s “Euthanasia’s foes, out of arguments, settle for fear-mongering” in this post. The first one, obviously, opposes assisted dying, the latter supports it; both are misunderstandings.

The main problem lies in the fact that Miedema makes a number of claims about the danger of assisted dying, and Gurney accepts that these are genuine dangers, but insists that they can be overcome by careful legislation. But he needn’t have taken Miedema’s arguments at face value in the first place, and by doing so, distorts both the nature and the purpose of assisted dying. This distortion is present in almost all the polls that have been done in order to gauge the level of support for assisted dying in most jurisdictions, and is based on the idea that the only reason for assisted dying is serious and uncontrollable pain at the end of life. This is a misunderstanding of what people who are demanding that their right to assistance in dying be recognised are saying, and allowing for assistance in dying only for those who are terminally ill and in great pain is not an adequate response to those demands.

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To answer my own question …

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Of course the pro-life movement is not pro-life!

The term ‘pro-life’ is a euphemism for religious oppression. The catholic church is at the centre of the “pro-life” movement, but it is not alone in taking a supposedly pro-life stance. Evangelical Christians, fundamentalists of most religions, Muslims and others are also “pro-life” in this euphemistic sense. There are some atheists, like Christopher Hitchens, who are also anti-abortion, and a few, like Nat Hentoff, who are opposed to assisted dying, but their number is few and the ground on which they stand is shaky. Wikipedia’s entry under ”Pro-Life” includes one reference — in the footnotes — to the Athiest and Agnostic Pro-Life League, but its numbers are small, and, having read a few of the “articles” in its Library section, the reasons they give are weak, and are almost word for word a mirror image of the arguments of the religious, whose culture they share. 

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Fleeced! The Fragility of Human Dignity

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All we, like sheep, have gone astray; we have turned, each one, to his own way; and the Lord has shorn us of the last vestiges of dignity, herded like sheep

I was convinced of one thing, after studying the United States Conference of Catholic Bishops’ ERDs, namely, that the idea of human dignity can be terribly misapplied and misused. I was struck by how fragile human dignity really is. Some people think that the idea of dignity cannot demarcate a genuine priority in moral discourse. Udo Shuklenk, for example, borrowing from A.J. Ayer, speaks of dignity, in a eponymously named paper, as a matter of woolly uplift, a mere matter of emotional gesturing.

In this short paper (or editorial), he says this:

Recent empirical research focuses on the importance and meaning of dignity to terminally ill patients. Dignity here, however is little other than an umbrella term for various patient needs being satisfied. This place-holder function offers us nothing by way of addressing the crucial normative questions that usually give rise to the deployment of ‘dignity’ in bioethics and biopolicy, such as for instance the moral permissibility or otherwise of assisted dying.

My own experience is quite different. Dignity was of profound concern to Elizabeth as MS took a more and more firm grip on her life. And dying with dignity became one of her central, critical concerns. Was she merely emoting, gesturing vaguely to something that could be accounted for in other terms? I don’t think so. Her concern for dignity was her concern for a number of things, including autonomy, respectful self-regard, and equality in her encounters with medical professionals. It had nothing to do with her needs being satisfied. It had to do with the way others regarded her, and how she regarded herself. This was completely independent of her various needs being satisfied. Indeed, in having some of her needs satisfied she felt a definite degradation of dignity, because increasing dependence for some of her needs became humiliating and existentially threatening. The boundaries between herself and others were breaking down.

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A Special Case of Double Effect

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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:

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