PAPER Kant on euthanasia and the duty to die: clearing the air Michael Cholbi Correspondence to Dr Michael Cholbi, Department of Philosophy, California State Polytechnic University, Pomona, Pomona, CA 91768, USA; mjcholbi@csupomona.edu Received 23 August 2013 Revised 1 September 2014 Accepted 6 September 2014 To cite: Cholbi M. J Med Ethics Published Online First: [please include Day Month Year] doi:10.1136/ medethics-2013-101781 ABSTRACT Thanks to recent scholarship, Kant is no longer seen as the dogmatic opponent of suicide that he appears to be at first glance. However, some interpreters have recently argued for a Kantian view of the morality of suicide with surprising, even radical, implications. More specifically, they have argued that Kantianism (1) requires that those with dementia or other rationality-eroding conditions end their lives before their condition results in their loss of identity as moral agents and (2) requires subjecting the fully demented or those confronting future dementia to non-voluntary euthanasia. Properly understood, Kant's ethics have neither of these implications (1) wrongly assumes that rational agents' duty of self-preservation entails a duty of self-destruction when they become nonrational, (2) further neglects Kant's distinction between duties to self and duties to others and wrongly assumes that duties can be owed to rational agents only during the time of their existence. Until fairly recently, philosophers treated Kant as the historical standard bearer for an absolute moral prohibition on suicide.1–3 This is not surprising, given the vociferousness of some of Kant's denunciations of suicide. In his Lectures on Ethics, e.g., Kant says that those who commit suicide treat themselves as little better than animals. They are, he says, 'carrion' with no 'inner worth.' Even as we may sympathise with individuals beset with 'grief, worry, and depression', we should, nevertheless, react to suicide with 'revulsion' or 'hate.'4 While Kant allows that suicide may sometimes violate duties to others, the heart of his moral opposition to suicide is the claim that it violates the duties that rational beings owe themselves.5 Rational agents are morally obligated to preserve themselves because they possess a kind of incomparable value, which Kant called 'dignity'. To destroy a rational agent, even oneself, for the sake of one's own well-being is to fail to honour this dignity. Suicide, thus, amounts to treating one's rational agency as a means to one's well-being, when in fact we are required to treat our rational agency as an end in itself.6 Kant, thus, saw suicide as representing a practical contradiction, using one's power of rational choice to destroy the very power of rational choice that gives a person her dignity.5 Indeed, in Kant's eyes, suicide is an attack not simply on our bodies, but on the very source of moral value.7 However, a number of bioethicists and moral philosophers now conclude that Kant's seemingly absolutist stance on the morality of suicide does not follow from these premises.8–11 On their reading of Kant, the duty not to engage in suicide remains a 'narrow' rather than a 'wide' duty . The very act of suicide is at odds with our dignity as rational beings. Thus, unlike a wide duty, such as the duty to develop our talents, which prescribes an end but allows us latitude in how we pursue this end, the duty not to engage in suicide requires not that we adopt some end but that we refrain from self-killing. However, Kant seems to hold that although the duty of self-preservation allows for no exceptions for the sake of 'inclination,' i.e., for the sake of one's own well-being, it may sometimes be over-ridden by other moral duties (e.g., the duty of a contagious person not to expose others to her lethal illness). 'There are,' Kant states, duties 'greater than life and which can be fulfilled only by sacrificing life.'4 Thus, while the duty of selfpreservation is the 'first ... duty of a human being to himself as an animal being,' it is not necessarily the 'principal' such duty and, therefore, the duty of self-preservation does not entail that every suicidal act is morally impermissible.5 However, two writers have argued for the more surprising conclusion that Kantian ethics sometimes morally requires suicide. Dennis Cooley9 has argued that those with diagnosed dementia have a Kantian-based duty to end their lives before their condition results in their loss of identity as moral agents. Robert Sharp,11 appealing to Cooley's argument for a Kantian duty to die, worries that Kant's position, inasmuch as it sees the demented individual as a non-person to whom we have no moral obligations, endorses non-voluntary euthanasia both for the fully demented and for those confronting future dementia. My purpose here is to argue that, properly understood, Kant's ethics has neither of these implications-that those anticipating dementia do not have a duty to die, nor do others have an obligation to non-voluntarily euthanase the demented. Because Sharp's argument appeals to Cooley's conclusions, I first summarise Cooley's conclusions. In Section II, I argue, contra Sharp, that even if those anticipating dementia do have a Kantian-based duty to die, it does not follow either that (1) others are obligated to euthanase those facing future dementia or (2) that others are obligated to euthanase them once demented. Claim (1) overlooks the crucial fact that the duty in question is a duty to oneself and, therefore, not a duty that others may permissibly enforce on a person's behalf. As for claim (2): while Kant's grounding moral status on practical rationality entails that we have no obligations to Cholbi M. J Med Ethics 2014;0:1–4. doi:10.1136/medethics-2013-101781 1 Clinical ethics JME Online First, published on September 22, 2014 as 10.1136/medethics-2013-101781 Copyright Article author (or their employer) 20 . Produced by BMJ Publishing Group Ltd under licence. group.bmj.com on September 23, 2014 Published by jme.bmj.comDownloaded from demented individuals per se, we nevertheless have indirect duties that shape the morally proper responses to demented persons who are no longer rational. Nor are we permitted to disregard the prior advance directives of the demented, for failure to honour such directives can be categorised as a posthumous disregard of the rational agency of the individual who established the directive. Claim (2) is, therefore, mistaken as well. I then return (in Section III) to Cooley's argument for a Kantian duty to die. There I diagnose two shortcomings. First, it does not follow from the duty to preserve rational agents that there exists a duty to annihilate non-rational agents or a duty to annihilate rational agents who anticipate becoming non-rational. Second, in analogising the soon-to-be demented to those who opt to die rather than perform morally despicable acts, Cooley wrongly assimilates the loss of rational agency to the moral misuse of rational agency. COOLEY ON THE DUTY TO DIE Cooley derives a Kantian duty to die on the part of the soon-to-be demented by extrapolating from the exceptions to the duty of self-preservation that Kant himself acknowledged. While Kant was seemingly unwilling to permit exceptions to this duty of self-preservation for the sake of 'self-love,' he allowed that the duty of self-preservation can sometimes be obviated by other compelling moral duties. Cooley notes that Kant seems to argue for such a duty to die for those who confront a dilemma, wherein they are forced either to live under conditions that deny them full moral agency or to die (or allow themselves to be killed). For example, Kant says of a person wrongfully convicted of treason slated for execution that he should opt for execution even if given the option of enslavement instead. To opt for slavery would cost him 'his moral agency' and make him a person lacking in 'human dignity,' according to Cooley.9 He thus has no duty to preserve himself, in this context, and should opt for execution over slavery. Kant expresses similar admiration for the suicide of Cato the Younger, who opted to end his life instead of being Caesar's puppet. Here, Cato opts for the alternative that sustains his 'moral life' over his physical life. As Cooley sees it, suicide is morally obligatory on Kantian grounds when an agent whose moral agency is worthy of preservation is compelled to choose between 'either taking his physical or losing his moral life.'9 i And this is precisely the condition of those facing dementia: As dementia takes root, individuals undergo the slow but permanent loss of the rational capacities that constitute their moral agency and personhood. They will soon lose their moral lives, and so must end their physical lives in anticipation of this loss. As Cooley sees it, the suicides of the soon-to-be demented have a duty to die 'physically before dying morally', thus preserving their moral agency and dignity. As Rosamond Rhodes12 points out, Cooley cannot literally intend that those who anticipate dementia have a duty to end their lives in order to preserve their moral agency and dignity. After all, suicide destroys, rather than preserves, the agency of the person. Hence, Cooley can be more plausibly read as suggesting that such acts of suicide prevent the soon-to-be demented from living in an undignified or demeaning condition wherein their bodies continue to exist, but they live incapable of governing their choices rationally. What suicide avoids, then, is not the end of one's moral life, but the undignified condition of a formerly rational individual living as something less than a moral agent. The soon-to-be demented must (allegedly) end their lives so as to avoid this condition. SHARP ON OUR DUTIES TOWARD THE DEMENTED Sharp contends that Cooley's reasoning represents a 'dangerous trend in bioethics', wherein dementia, or the expectation thereof, opens the door to non-voluntary euthanasia and various forms of abusive behaviour toward the demented. Suppose, for the sake of argument, Cooley is correct that those expecting to be demented have a Kantian-based duty to die before full dementia sets in, and that this duty is justified in order to avoid the indignity that dementia represents. Sharp infers from the claim that 'being dead is better than being demented,' that mercy killing, even if non-voluntary, would be obligatory when the individual with developing dementia is no longer able to end her own life. Euthanasia, even absent the individual's consent, becomes 'acceptable' just when the individual 'has become too demented to fulfil the duty to commit suicide'.11 Unfortunately, Sharp's inference overlooks the crucial fact that the duty Cooley identifies is a duty to oneself. Duties to oneself, as Kant understood them, have a distinctive logic according to which it does not necessarily follow from the fact that some individual has a given duty to herself that others are obligated to act, so that the duty in question is fulfilled. In Kant's taxonomy of duties, duties to self belong to duties of virtue, duties which (unlike duties of right) are not externally enforceable.5 More precisely, duties to self are not duties incumbent on agents in general to make it the case that P. They are, instead, duties incumbent on the person to whom the duty is owed, requiring her to make it the case that P. This is why violations of duties to self are wrongs that only that individual herself can be responsible for. Take, for instance, the central duty that, according to Kant, we have as moral beings, the duty of moral self-perfection. My duty of moral self-perfection is a duty to strive for moral virtue, and this, in turn, implies various subsidiary duties, such as subjecting my moral deliberation to the demands of conscience, developing my talents, cultivating morally desirable dispositions such as sympathy, etc.9 But these are not duties others bear toward me. Others do not fail in their obligations toward me if they fail to develop my talents. Only I can so fail. Applied to the duty to die that Cooley identifies, the duty for a soon-to-be demented individual, S, to end her life is not a duty that is fulfilled however S dies. Rather, it is a duty that can only be fulfilled when S (and no one else) brings about her death. Hence, if there exists a duty to die of the sort Cooley defends, it does not follow that others have a duty to kill those who have such a duty. Sharp is thus incorrect when he writes, 'If the patient is no longer capable of accomplishing this perfectly rational goal [ending her life prior to full dementia], then someone must do it for the patient.'9 And while voluntary euthanasia (or assisted suicide) might be permissible on the grounds that such actions assist a person, with her consent, in the fulfilment of her duty to die, the non-voluntary euthanasia of those with such a duty to die is not a morally proper response. Though they stand on the verge of losing their personhood and have a putative duty to die, it is, nevertheless, a violation of their humanity to non-voluntarily euthanase them. iIt should be noted that Cooley subtly misrepresents Kant's position on Cato's suicide. Kant finds Cato's resolve 'noble' and courageous, but it was not noble for Cato to 'violate himself.' Kant does not conclude that Cato's suicide was morally permissible, and a fortiori, does not conclude, as Cooley states, that Cato had a duty to die. 2 Cholbi M. J Med Ethics 2014;0:1–4. doi:10.1136/medethics-2013-101781 Clinical ethics group.bmj.com on September 23, 2014 Published by jme.bmj.comDownloaded from Sharp also worries about the implications of Cooley's argument for those who are already demented. Cooley's argument seems to imply that though alive, such individuals, being nonrational, would have 'absolutely no moral status whatsoever', and we would be left 'with no reasons for keeping such patients alive,' including no reason to refrain from euthanasing them non-voluntarily. Sharp is certainly correct that the Kantian position on personhood and moral status means that we have no duties to those whose dementia has rendered them non-rational.ii The death of rational agency coincides with the death of the person and the termination of moral status, on a Kantian view. However, Sharp is mistaken in supposing that on such a Kantian view, moral considerations ought not to enter at all into how we treat the demented. Sharp notes that Kant 'would not advocate needlessly killing non-rational beings',9 including the demented. However, Sharp underestimates the extent of the indirect duties we have concerning demented individuals. For one, despite our not having direct duties towards the demented, we may, nevertheless, have direct duties to others concerning the demented. If T promises U that he will provide care to U's mother V when V is later demented, then ceteris paribus, T violates a duty to U concerning V if T fails to provide the promised care to V. Similarly, the grief that friends and relations of a demented individual would experience if he were unexpectedly euthanased would be a strong moral reason against such a decision. Furthermore, we may still have direct duties to a demented individual even if dementia has destroyed the rational person she once was. Sharp contends that since the demented are no longer competent and autonomous, we can ignore advanced directives such individuals made prior to their dementia because 'their wishes, both past and present, no longer carry any weight'.9 However, Sharp's contention rests on the controversial assumption that because the autonomous individual no longer exists, it would not be a wrong to her to disregard the autonomous wishes made in her advanced directive. Kant himself seems to reject this assumption. He argues that slandering the dead and, thereby 'staining' their reputations is 'suspect,' since the dead are unable to defend themselves. Note that although Kant held that we should believe in the immortality of the soul on moral grounds, his argument for the possibility of wronging the dead does not hinge upon the soul surviving the death of the body. We 'can and must abstract from whether he ceases to be entirely at his death or whether he survives as a person; for in the context of his rights in relation to others,' we 'actually regard every person simply in terms of his humanity', that is, in terms of his rational agency (ref. 9, emphasis added). Kant is thus not appealing to the claim that wrongs done to the dead are harms to the dead. Rather, exercises of rational agency can generate obligations that bind others whether or not the subject of that rational agency continues to exist. Indeed, Kant's position seems to offer a plausible rationale for many of the obligations we suppose we have vis-à-vis the dead (to honour their wills, to inter their bodies with due care, etc.). Their rational agency binds us regardless of whether death destroys them or not (a point Cooley overlooks in his response to commentators13). Kant does not say enough here to resolve the question of precisely at what time postmortem acts wrong agents-whether the wrong is done to the agent when she is dead or when she existed. However, the important point for our purposes is that if we disregard the advanced directive of a person at T2, when the advanced directive was established at T1, and the person at T2 is now demented and non-rational, there is some point in time at which the person is wronged by what we do at T2, irrespective of whether the person exists at T2. Thus, Sharp errs when he supposes that ignoring the prior advanced directive of a demented individual is morally warranted because their 'past wishes ... no longer carry any weight'. The arguments of this section show that even if we concede Cooley's claims concerning a Kantian duty to die, Sharp is mistaken in inferring that the demented, or the soon-to-be demented, are reduced to the moral status of mere things. The next section considers whether the former concession is even warranted. REVISITING COOLEY'S ARGUMENTS As noted above, Cooley's argument for a Kantian duty to die for those expecting to be demented is based on the duty to prevent an individual from living in the condition of indignity that results from losing one's moral or rational agency. Cooley arrives at this duty to die by analysis of Kant's duty of selfpreservation, and the corresponding duty not to commit suicide: We are required to preserve ourselves because our moral agency is a source of dignity or incomparable worth. Cooley infers that because there is a duty to preserve such agency, there is a corresponding duty to annihilate non-rational agents or a duty to annihilate agents who anticipate losing their moral standing as persons thanks to the degeneration of their rational capacities. Hence, on his view, the soon-to-be demented have to end their lives in order to avoid the undignified condition of being alive while lacking moral agency. Cooley infers the duty of suicide on the part of the soon-to-be demented from the claim that if the presence of some property gives someone moral standing that requires the preservation of her life, then the absence (or the anticipated absence) of that same property requires the destruction of her life. Yet it is a faulty inference to suppose that because Wowes a duty to respect or preserve X because X has feature F, that W has the duty to disrespect or destroy any being without feature F (or who expects to lose feature F). Suppose that I discover a long-lost Rembrandt masterpiece in my attic. I understand myself to have a duty to preserve the painting because of Rembrandt's greatness as an artist. But if I also found a kitschy ripoff of Rembrandt, it would not follow that I have a duty to destroy this painting because it lacks Rembrandt's greatness. All that seems to follow is that I do not have a duty to preserve it (or at least no such duty rooted in the reasons that generate the duty to preserve the genuine Rembrandt). After all, the negation of 'I have a duty to preserve X' is not 'I have a duty to destroy X', but 'I have no duty to preserve X'. And so, even if the possession of a particular feature F is the ground of a duty to preserve something, the absence of F is not the ground of a duty to destroy that thing. Nor does the anticipated loss of F entail a duty to destroy that thing either. Hence, it does not follow from Kant's views about obligations concerning self-preservation and suicide that we have any obligation to destroy entities that lack, or will come to lack, the properties that ground these obligations. Cooley may respond that this critique aside, Kant had his reasons for supposing that those anticipating the loss of moral agency, including the soon-to-be demented, have an obligation to end their lives, reasons that parallel those that ground the obligation to end one's life rather than wrong oneself by living in conditions thatiiI qualify this claim later in this section. Cholbi M. J Med Ethics 2014;0:1–4. doi:10.1136/medethics-2013-101781 3 Clinical ethics group.bmj.com on September 23, 2014 Published by jme.bmj.comDownloaded from deny oneself full moral agency. However, Cooley's comparison of those trying to avoid enslaving themselves by committing suicide with those who avoid dementia by committing suicide is puzzling, for they represent very different threats to one's moral agency. The former engage in self-killing in order not to misuse that agency for immoral purposes. The latter engage in selfkilling not to lose that agency. And Kant's argument for suicide being justifiable in the former case seems to turn on the notion that our physical lives matter less than our moral honour. After all, Cato, and the man wrongfully convicted of treason, will not become non-agents if they opt to live. They will fail to show adequate respect for morality and for their own rational agency, but they will still be rational agents. But where is the moral dishonour in losing one's moral agency to the mental deterioration of dementia? The individual who ends her life in order to avoid grievously wronging herself thus destroys her rational agency in order to avoid a violation of her dignity-and it is this 'indignity' that warrants her suicide. But that is not the story with a person anticipating dementia. For she will no longer have dignity at all. There is no prospect of her living in the morally undignified condition Kant takes to justify suicide. Thus, the feature that Cooley takes to warrant a duty to die in the case of those who opt to act immorally rather than die is not present in the case of those anticipating dementia. The former will be bad persons if they do not choose suicide. The latter will be non-persons if they do not choose suicide. Cooley's analysis of Kant's view of suicide is thus too coarse. The condition of those who engage in moral wrongdoing is 'undignified,' whereas the condition of the demented is more accurately described as neither dignified nor undignified. Perhaps non-dignified captures their condition better: a condition in which they lack the very capacities that are respected (or disrespected) in individuals with dignity. CONCLUSION In the end, then, Cooley's argument for a Kantian duty to die for those who anticipate dementia rests on a category mistake that conflates two distinct aspects of agency or dignity and wrongly assumes that the absence of those features that ground the obligation not to commit suicide entails an obligation to commit suicide. Thus, Cooley's framework, to which Sharp appeals, is suspect, and even if it were plausible, it does not imply that individuals facing dementia have a duty to engage in suicide, as Sharp alleges. The revival of interest in Kant's thinking about suicide and self-preservation has been salutary. But in jettisoning the interpretation of Kant as an absolute opponent of suicide, some philosophers have been too hasty in trying to identify instances where Kant (or a properly Kantian view) would see suicide as morally obligatory. I suspect that the best Kantian position will likely be a moderate one instead, wherein suicide is often wrong, rarely obligatory and occasionally optional. My discussion here at least provides evidence in support of the former two points. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed. REFERENCES 1 Brandt R. The morality and rationality of suicide. In: Perlin S, ed. Handbook for the study of suicide. Oxford: Oxford University Press, 1975:61–75. 2 Latham SR. Kant condemned all suicide. Am J Bioeth 2007;7:49–51. 3 Perry C. Suicide fails to pass the categorical imperative. Am J Bioeth 2007;7:51–3. 4 Kant I. Collins lecture notes. In: Schneewind, JB, Heath P, eds. and trans. Lectures on ethics. Cambridge: Cambridge University Press, 1997:37–222. 5 Kant I. Metaphysics of Morals (1797). In: Gregor M, ed. and trans. Practical philosophy. Cambridge: Cambridge University Press, 1996:353–604. 6 Kant I. Groundwork of the Metaphysics of Morals (1785). In: Gregor M, ed. and trans. Practical philosophy. Cambridge: Cambridge University Press, 1996:43–108. 7 Cholbi M. Kant and the irrationality of suicide. Hist Philos Q 2000;17:159–76. 8 Cholbi M. Suicide intervention and non-ideal Kantian theory. J Appl Philos 2002;19:245–59. 9 Cooley D. A Kantian moral duty for the soon-to-be demented to commit suicide. Am J Bioeth 2007;7:37–44. 10 Altman M. Kant and applied ethics: the uses and limits of Kant's practical philosophy. Malden, Massachusetts: Wiley-Blackwell, 2011. 11 Sharp R. The dangers of euthanasia and dementia: how Kantian thinking might be used to support non-voluntary euthanasia in cases of extreme dementia. Bioethics 2012;26:231–5. 12 Rhodes R. A Kantian duty to commit suicide and its implications for bioethics. Am J Bioeth 2007;7:45–7. 13 Cooley D. Response to open peer commentaries on "A Kantian Moral Duty for the Soon to Be Demented to Commit Suicide". Am J Bioet 2007;7:1–3. 4 Cholbi M. J Med Ethics 2014;0:1–4. doi:10.1136/medethics-2013-101781 Clinical ethics group.bmj.com on September 23, 2014 Published by jme.bmj.comDownloaded from doi: 10.1136/medethics-2013-101781 published online September 22, 2014J Med Ethics Michael Cholbi clearing the air Kant on euthanasia and the duty to die: http://jme.bmj.com/content/early/2014/09/22/medethics-2013-101781.full.html Updated information and services can be found at: These include: References http://jme.bmj.com/content/early/2014/09/22/medethics-2013-101781.full.html#ref-list-1 This article cites 8 articles P<P Published online September 22, 2014 in advance of the print journal. service Email alerting the box at the top right corner of the online article. Receive free email alerts when new articles cite this article. 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