Organon F 2019: 1–23 ISSN 2585-7150 (online) DOI (to be assigned) ISSN 1335-0668 (print) * Comenius University  Department of Philosophy and History of Philosophy, Faculty of Arts, Comenius University, Šafárikovo námestie 6, 814 99 Bratislava, Slovak Republic  greif2@uniba.sk © The Author. Journal compilation © The Editorial Board, Organon F. This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International Public License (CC BY-NC 4.0). RESEARCH ARTICLE The Morality of Euthanasia Adam Greif* Received: 22 November 2018 / Accepted: 16 March 2019 Abstract: In this paper, I defend the view that the requested euthanasia of adults is morally permissible and should be legalised; I use an argument from analogy which compares physician-assisted euthanasia with morally less ambiguous and, in my opinion, an acceptable instance of mercy killing. I also respond to several objections that either try to prove that the instance of mercy killing is not acceptable, or that there is a fundamental difference between these two cases of killing. Furthermore, in the remainder of the paper I defend the moral permissibility and legalisation of euthanasia against several objections that appeared in local disputes on this issue, based on the concepts of the limits of freedom, the slippery slope, and the needlessness of euthanasia. Keywords: Legalisation; moral freedom; morality; needlessness of euthanasia; requested euthanasia; sanctity; slippery slope. There are two types of death: we either die at a time and in a manner we do not choose or at a time and in a manner which we do. We can state that most people who have died did not depart at the time or in the manner they would have chosen, as they died either earlier or in a different way than they wanted to. We can assume that, if given the chance, those who 2 Adam Greif Organon F 2019: 1–23 died from illnesses, injuries, advanced age, unfortunate accidents, or by being killed would have preferred to go at a later time as well as in a different and less unpleasant way. In light of this idea, it seems preferable to meet death on our own terms. If medicine and technology have made this possible, we should probably want to allow people to be in charge of the circumstances of their own death. This opinion does not invite controversy when talking about people who wish to live longer, but it becomes controversial once we start discussing those who want to shorten their lives. Granting a longer life to people who desire it does not appear to be an issue, so why does it become one once we start contemplating the rightness of hastening the death of those who request it? Some opine that we would commit a serious mistake by bringing death to those who ask for it, arguing that obeying such a wish is unreasonable. While some claim that wishing to die is unreasonable because every life is worth living, others claim that it is impossible to rationally conclude that our life has ceased to be worth living. Critics of euthanasia thus suggest that rather than complying with a patient's wish to die, we should strive to improve their life. These objections are as important as they are philosophically interesting, and a decent defence of euthanasia should be able to respond to them. Although I share the opinion that we should primarily endeavour to improve the lives of those wishing to die and that a person can sometimes err in thinking their life has ceased to be worth living, I also maintain that in certain circumstances a person's life might become not worth living and that they can rationally arrive at such a conclusion. However, I defended these opinions elsewhere and therefore will simply assume their truth in this paper (see Greif 2018). If they were not assumed true, there would be little need to respond to the second type of objections that question the morality of ending another person's life prematurely, i.e., euthanasia. Euthanasia poses an ethical dilemma. On one hand, there are people who do not consider their lives worth living and express an honest wish to die. I assume we want to empathise with their suffering and show respect for their decision to end their life. On the other hand, a moral doubt remains lingering: "Is it right to end someone's life on their request? Would we not The Morality of Euthanasia 3 Organon F 2019: 1–23 be committing murder or another serious offence?" And we surely do not want to err in such a serious matter. How can it be resolved then? I think there is a solution to this problem. To demonstrate it, I will first present an argument in favour of requested euthanasia being morally unproblematic and permissible.1 I will support the argument by responding to several objections to its premises. Then I will focus on three objections that appeared in a debate in the Czech journal Filosofický časopis in 2010 through 2012. I will try to prove that all these objections can be countered. My defence only focuses on the requested (or voluntary) euthanasia of adults, which I define as "an act when an adult person kills another adult person for the latter's well-being and on the latter's request."2 My main objective is to defend the thesis that "the requested euthanasia of adults is morally permissible." Before commencing my defence of euthanasia, I would like to comment on the nature of my defence. Ethics is a delicate discipline, and ethical questions are notoriously difficult to resolve in a way that everyone would find satisfactory. As a consequence, a certain tension characterises my defence, which I would prefer to disclose at the very beginning. I understand ethics as a kind of rational and secular debate. Therefore, "ethics" deferring to a religious authority or an authority of individuals who claim to possess special moral knowledge is not what I consider to be ethics. I find it crucial that in ethics, whenever possible and necessary, moral assertions should be justified without referring to personal or divine authority. On the other hand, justifying every statement is neither necessary nor possible. Some key statements I cannot or will not justify, hoping that they do not require justification. I am referring to statements that philosophy would call "moral intuitions." My judgement about the trapped lorry driver case, which I will present shortly, provides a rather illustrative example of moral intuition. 1 I use the expressions "morally unproblematic," "permissible," "permitted," "right," and "moral" interchangeably. Correspondingly, "morally prohibited," "not morally permissible," "wrong," and "immoral" are also interchangeable. 2 I base this definition on the etymology of the word "euthanasia"-εὐθανασία (euthanasía), from εὐ- (eu, "well" or "good") + θάνατος (thanatos; "death")-that is, good death. Since I want to differentiate euthanasia from suicide, I define it as good death caused by another person. 4 Adam Greif Organon F 2019: 1–23 This judgement plays a crucial role in my defence of euthanasia which would not work without it. It is, however, unjustified, and I do not know with certainty if the reasonable majority would accept it. Taking into consideration how much disagreement moral questions tend to generate, it is possible that even what I consider utterly evident might invite harsh criticism. Although I do not know if the reasonable majority would agree with me, I will assume it does. Naturally, in cases like this claims can be made that mostly suit the author's interests instead of reflecting the reasonable majority's opinion; however, this risk is present in every ethical debate and should be accepted by its participants. If we are to arrive at some kind of a resolution, we, the disputing sides, have to establish an initial agreement, even if only by guessing. * * * Let us advance to the argument put forth in favour of the morality of euthanasia. It is based on the famous "trapped lorry driver case," in which a man is killed in a way that I consider permissible and that shares every essential feature with physician-assisted requested euthanasia. The trapped lorry driver case A driver is trapped in a blazing lorry. There is no way in which he can be saved. He will soon burn to death. A friend of the driver is standing by the lorry. This friend has a gun and is a good shot. The driver asks this friend to shoot him dead. It will be less painful for him to be shot than to burn to death. Should the friend shoot the driver dead? (Hope et al. 2008, 185) Premise 1: I can only speak for myself with certainty, but I cannot think of any moral reason why the friend should not comply with the driver's request. Therefore, I believe that the friend should shoot the driver dead. However, before killing the driver, I would have to verify that he truly cannot be helped and that he would suffer tremendously if I did not shoot him. But if I was certain that his situation really was awful and desperate, I hope I could muster enough courage and presence of mind to shoot him dead. I would consider it the right thing to do. In my opinion, emotions tend to get tangled up with morals when discussing euthanasia, which in turn might cloud our judgement. I am sure The Morality of Euthanasia 5 Organon F 2019: 1–23 that shooting the driver dead would not make me happy. I would wish that I did not have to do it and that the lorry driver could live. Because of these feelings of unhappiness and tragedy, I might be tempted to think that I did something wrong. But my reason would clearly tell me that it is not so, as the only possible alternative would have been much worse. If I did not kill him, the trucker would have suffered more and would not have gained anything. So if I were to find myself in such a situation, I would act partially out of empathy, as I would not want the trucker to suffer, and partially out of respect for his free will, because I would want to comply with his wish. I assume that most people would feel and think in a similar-if not the same-way. There are only two options: either the friend shoots the driver dead or he does not do anything. But his not doing anything is clearly worse for the driver, because he will needlessly suffer if he is not shot dead. On the other hand, even though shooting the driver would be tragic, it would still be preferable to letting him burn to death. Therefore, I do not think that any convincing objections can be raised against shooting the lorry driver dead. Consequently, I firmly believe that shooting the driver dead in order to spare him a painful death is permissible. Nevertheless, an anonymous reviewer remarked that the argument I am about to present is unconvincing, since the first premise is unjustified. I have to admit that this is true; I provided no justification for it, as I cannot prove it and cannot support it with any further arguments. But I have so much certainty in it that if someone expressed disagreement or doubt in relation to it, I would have to ask them for an explanation. In other words, what reason could one have to think that shooting the driver dead is not permissible? There are several objections we would normally raise against shooting someone dead. Shooting the driver dead could be wrong because (1) it is against his will; (2) deprives him of all the good things he might have experienced if he lived; (3) harms him; or because (4) it violates his right to life. We can quickly determine that these four initial objections do not apply in the lorry driver's case. First, the lorry driver wanted to die. Second, even though it would be true for the majority of people that their death would deprive them of all the good they could have experienced if they stayed 6 Adam Greif Organon F 2019: 1–23 alive, it is not true for the lorry driver, as nothing good awaited him. Third, it is true that killing a human being harms them in a way, since death typically implies bodily damage of some kind. However, we often choose to endure great bodily harm if it is in our interest. For example, we endure it during a common medical intervention, or, to mention an extreme case, as Aron Ralston endured it when he amputated his forearm with a pocketknife in order to save his life. Fourth, without any doubts, the right to life is one of the most fundamental moral principles we have. Still, we are able to renounce our rights. The lorry driver, just like a patient requesting euthanasia, had a right to life, but he renounced it because it was in his interest. If any objections were raised against the argument I advance, I suspect that the first premise would be more likely to provoke them; therefore, I presume it needs more support. One further objection could be that the friend should not shoot the driver dead, because there is always some alternative. In the trapped lorry driver's case, it is only ex hypothesi true that he cannot be saved. But in real life we will not have this certainty and there will always be a chance, however small, that the driver could be saved. Although our intuitions may betray us in some thought experiments, I do not think this is the case now. The original version of the trapped lorry driver case, as described by R.M. Hare (1975) and pointed out by Tomáš Hříbek (2010), illustrates this well. Rather than being a hypothetical case, it describes a situation that actually happened, very similar to the one described above, and which was reported by the press at the time (the lorry driver was probably killed in the end). Instead of pondering on what we would do in a fabricated thought experiment, we can ask ourselves how we would behave if we found ourselves in such a situation, surrounded by all its uncertainties. However small, there is always a chance that the driver can be saved. But if this chance is minimal, it would be more reasonable not to risk the much more obvious possibility of the trucker burning to death coming true. A patient requesting euthanasia is in a similar situation to the driver of the blazing lorry. Although he may not have any epistemic certainty of the accuracy of his prognosis, the evidence at hand and the medical knowledge The Morality of Euthanasia 7 Organon F 2019: 1–23 may yield enough practical certainty for him to make up his mind. (To read more about this type of objection, see Greif 2018). Still another objection might be that shooting the driver dead is wrong because killing an innocent person is always wrong, regardless of the consequences. Given that the driver is innocent, it is wrong to kill him. It is very difficult to deny that killing an innocent person is wrong. After all, it is one of the most fundamental moral convictions. For example, killing a random passer-by is without any doubt a heinous act. In spite of this, I still maintain that killing an innocent person differs from committing a morally prohibited killing, i.e., murder. I think the rule "killing an innocent person is wrong" is usually sufficient for us to understand what makes killing a person wrong; however, I do find it imprecise, as I believe that the trapped lorry driver's case presents a perfect counter-example. Should we refuse to shoot the driver because of his innocence?3 What does the driver's innocence or guiltiness have to do with the moral evaluation of his case? I tried to show that it is morally permissible to shoot the lorry driver dead. If this judgement is right, then the rule that "killing an innocent person is wrong" cannot always be correct, as the lorry driver was also innocent. However, since this a rather intuitive argument, it should be accompanied with an explanation of why the rule is incorrect despite its undeniable appeal. In order to find it, I think we have to think about the purpose of guilt. Why is it sometimes permissible to kill a guilty person but not an innocent one? It seems that the moment an attacker assaults someone, they temporarily lose some of their rights as we stop taking their interests into full consideration. It seems that by endangering someone else's life, for instance, they can lose some of their rights, and their guiltiness gives us a moral right to treat them differently than we normally would. When someone commits a greater crime-say, threatens the life of an adult or a child-it might give us the right to take their life in self-defence. However, a patient requesting euthanasia has not committed any crime. We have no 3 One could even argue that killing the lorry driver is not only morally permissible but also obligatory; if we could comply with the trucker's request but failed to do so, we would allow needless suffering to take place. However, I will not be defending this opinion here. 8 Adam Greif Organon F 2019: 1–23 reason to treat them any differently than anyone else. Therefore, we should neither deny them their rights nor ignore their will. By analysing the purpose of guilt, we can explain why the rule of "killing an innocent person is wrong" should be considered imprecise despite its intuitiveness. In almost every case when an innocent person is killed, we are entitled to think that a morally prohibited killing-that is, murder-occurred. We have a good reason to think so, because the only good argument in favour of the opposite-that the "victim" wanted to die and the killing was merciful-typically does not apply. It is rare that outside of the context of medicine or war perhaps a person was killed because he or she actually wanted to die and being killed was good for them. Finally, some might argue that it is wrong to shoot the driver dead because his life has an intrinsic and impersonal value, that some would call sanctity (Dworkin 1993), and it is wrong to sacrifice it for the quality of one's life or for any other value. Since the value of life itself is impersonal, it is wrong to end driver's life, even though it is no longer valuable for him or anyone else. There is surely much to be said about this view, but I would like to propose a somewhat minimalistic refutation. To start, I think we should ask the following question; "Is the value of life itself absolute?" In other words, does the intrinsic value of life always come before other values or only in some cases? Let us consider both options, one by one. If the intrinsic value of life always comes before other values, then no value can ever be more important. Compared with any other value, the intrinsic value of life would have an absolute worth. If those proclaiming that "every human life is sacred" accepted this option, it would presumably lead to some consequences that would be difficult to accept. Steven Luper illustrated these outcomes by means of the following thought experiments: Two Spells I know how to cast two magical spells. One of them, which Mary wants me to use on her, would ensure that she has a life that is extremely good and far better than the life she otherwise would have had, but the spell will also kill her painlessly in her sleep one day sooner than the day she otherwise would have died of old age. The other spell, which she has forbidden The Morality of Euthanasia 9 Organon F 2019: 1–23 me to use, would not kill her but would ensure that she has a life that is wretched, and far worse than the life she otherwise would have had. (Luper 2009, 186) The first spell would shorten Mary's life by one day; in exchange, it would ensure that the rest of her life would be extremely good. If we accepted the view that human life has an intrinsic value that can never be sacrificed for any other value, then casting the first spell would be wrong, as Mary's life would be sacrificed for her quality of life. In addition, it would be morally more wrong to apply the first spell than the second one. However, we would probably disagree with these judgements. Besides being beneficial for Mary, the first spell is perfectly moral and in fact more moral than the second one. Therefore, the view that human life has intrinsic value has some hard to accept consequences. Let us now consider Luper's second thought experiment: Unintentional Suicide I have an illness that will kill me within a week if allowed to progress. There is a treatment that will extend my life by one more year, but I will be in pain nearly the entire time. I weigh the extra time against the pain involved and decide to refuse the treatment. I die three days later. (Luper 2009, 187) In this case, I sacrificed a longer life in favour of avoiding pain. If life has absolute intrinsic value, then this would be an immoral act as it is more valuable to live longer than to avoid pain. However, this is not how we think. Refusing treatment is a perfectly rational and moral decision. If we believe that the intrinsic value of life always comes before other values, it leads to certain consequences that we are reluctant to accept. This is why I do not think that we should accept the strong version of the principle that every human life has intrinsic value. Let us consider the second, weaker version of the principle, according to which the intrinsic value of life only comes before other values in some cases. If the intrinsic value of life only comes first in certain situations, then sometimes are other values, such as the quality of life or personal dignity, more important. So when a patient requests euthanasia, how do we know whether these values did not outweigh the value of their life being 10 Adam Greif Organon F 2019: 1–23 intrinsically valuable? Considering the Luper's thought experiments, it seems fairly common that the considerations of quality of one's life or of one's dignity are more important that the intrinsic value of life. Premise 2: If the friend killed the lorry driver, it would be a case of requested euthanasia, as the driver would die for his own good and on his own request. My second premise is that shooting the lorry driver is analogous to physician-assisted requested euthanasia. When calling it euthanasia, it does not matter who performs it; the only fact that counts is that person A kills person B for person B's benefit and on person B's request. These conditions are met in the trapped lorry driver's case. We can furthermore assert that the friend would shoot the driver dead with the intention of helping his friend and complying with his wish rather than taking revenge on him or wanting to put an end to his annoying screams. So when a physician administers the lethal shot to a patient, for the patient's benefit, on the patient's request, and motivated by a good intention, his act is considered right because he does what the friend would do to the trapped lorry driver by shooting him dead. Thus, the argument goes as follows: Argument from analogy P1 Shooting the driver is morally permissible. P2 Shooting the driver is analogous to physician-assisted requested euthanasia (assuming that the physician performs the act with good intention). ---------------------------- C Physician-assisted requested medical euthanasia is presumed to be morally permissible (assuming that the physician performs the act with good intention). Any rejection of the second premise implies that there is a difference between the two instances of killing. This is true; we could surely find plenty of differences between killing the driver of a blazing lorry and killing a particular patient. However, not all of these differences are relevant. For example, in the trapped lorry driver's case, there is the immediate and undeniable danger of terrible suffering. As far as patients are concerned, the majority of cases will probably be different, since the reason why they want to die might not be as immediate or obvious. Despite this, the danger of The Morality of Euthanasia 11 Organon F 2019: 1–23 terrible suffering or loss of dignity, which are neither as immediate nor evident, is not any less real. If we accept this, we should see no significant difference between them. Therefore, we should focus only on the differences that bear a moral relevance. Thus, those criticising the second premise should identify a morally relevant feature, F, which is present in one case but missing from the other. In order to provide support for the second premise, I consider two possible candidates for F; terminal illness or mortal danger and physical suffering. (To get an overview of classic legal conditions for candidacy for euthanasia, see Young 2019.)4 In the case of the blazing lorry, the driver found himself in mortal danger and the likelihood of him having to endure great physical suffering was very high. Should we thus presume that physician-assisted euthanasia is only permissible in cases when the patient's life is in danger (or when they suffer from a terminal illness) and only when their suffering is of a physical nature? I do not think that the morality of euthanasia should depend on whether there is terminal illness, mortal danger, or physical suffering involved. Where terminal illness and mortal danger are concerned, there are patients whose incurable diseases put them through intense agony, and they wish to die even though their illness is not life-threatening. These patients suffer greatly and can reasonably conclude that their lives are not worth living. Why should we consider the fact that they are not terminally ill to be morally relevant? One of the reasons why the insistence on conditions such as terminal illness or mortal danger might seem necessary is because there is a possibility that the patient's condition might improve in the future-for instance, with the invention of a new revolutionary cure or as a consequence of unexpected remission. I believe that in particular cases, these factors should be taken into account when evaluating the rationality of euthanasia. However, they should not be regarded as an obstacle to performing euthanasia on non-terminally ill patients or people not finding themselves in mortal danger. The reason behind this is that if a patient is neither terminally ill 4 Naturally, someone might always point out a morally relevant feature that differentiates requested euthanasia from the trapped lorry driver's case. If an important difference has escaped my attention, I would like to be informed about it. 12 Adam Greif Organon F 2019: 1–23 nor in mortal danger, but their life is still not worth living, more suffering could be avoided with euthanasia, since without it they are likely to live longer and suffer even more. If we imagined, per impossibile, that the lorry driver would not be burning alive for several minutes but for days, months, or even years, we would have all the more reason to spare him this suffering. Nevertheless, if we or our patient had a good reason to believe that there is a realistic chance of improving his or her situation, I do not think we should comply with his or her request for euthanasia. However, we can come to understand with a reasonable amount of certainty that some patients do not have a realistic chance. The next condition relates to intolerable physical pain, which is put in direct contrast with mental or psychological pain. As far as I can see, we should not differentiate between these types of suffering where euthanasia is concerned, as psychological suffering is not any less real or unpleasant than physical one. Despite this, I maintain that when patients suffering from psychological pain rather than physical pain request euthanasia, we should deliberate their petition with much more care. I suppose that the insistence on the condition of physical pain is similar to the previous one. It is more difficult to assess whether a patient's life has ceased or will cease to be worth living if they suffer from psychological pain than if they experienced physical pain; the former is much more elusive. I find this to be a good reason for regulating euthanasia more strictly when it comes to patients afflicted with psychological pain; however, this does not mean that euthanasia should be denied to them. Some people suffer from incurable and unbearable psychological pain and their psychological condition renders their lives not worth living. If we cannot help them in any way and we have no reason to believe that we will be able to help them in the future, we might consider complying with their request. I do not mean to suggest that patients should be given euthanasia without trying to help them first. On the contrary; everyone requesting euthanasia should be offered help, whether in the form of psychiatric therapy, palliative care, or some kind of experimental treatment. What I am suggesting is that those not in mortal danger or whose suffering is mainly of a psychological nature should be presented with stricter legal conditions when requesting euthanasia. The Morality of Euthanasia 13 Organon F 2019: 1–23 Although I consider these arguments convincing, others might not. It is also likely that some of my claims might prove to be untrue or unacceptable. If I am mistaken, I would like to be informed on the fallacies in my thinking, which I presume there will be; even in our provenience many objections have been raised against the position I am trying to defend. In the next part of this study, I will try to explain why my opinion on euthanasia has not been changed by them. * * * Objection 1: The right to die is beyond the limits of the freedom of an individual. Death is something humans have no moral right to decide about. Since euthanasia involves one person killing another, it is not permissible. Response: Saying that one's right to die violates the (moral) limits of personal freedom does not seem right, since our society does not object when someone voluntarily puts their life in danger. We do not denounce people who risk their lives by becoming soldiers, police officers, fire-fighters, or stunt performers, nor do we condemn those putting their health in jeopardy with their lifestyle choices-say, by damaging their lungs by smoking or by pursuing extreme sports. This means that while a person is free to put their life at risk and lose it in the case of an accident, or consciously shorten and endanger it with the lifestyle they lead, they are not free to end it directly. Would those who raise this objection morally condemn all activities whose pursuit puts a person's life at risk or shortens it? Our society accepts such behaviour, and there are even instances when a person voluntarily taking their life is thought to be highly commendable. For example, a soldier throwing himself on a grenade and saving his friends is not committing a morally deplorable act but a laudable one! The perception of a mother dying for her child is similar. An opponent of euthanasia might suggest that when someone requests the termination of their life, they do not sacrifice themselves to save another person's life-they do so for their own well-being. However, I do not find this objection convincing enough. We could assume that the soldier's sacrifice did not save his friends' lives but "merely" spared them years of terrible torture. We could similarly imagine that the mother did not sacrifice herself to save her child's life but to stop it from being brutally tormented. I suppose 14 Adam Greif Organon F 2019: 1–23 most of us would not accuse these people of doing anything wrong. If we were to morally evaluate their sacrifice, we would be more likely to consider it laudable. Jakub Jirsa (2011, 587) wrote in his paper that "my life is something I do not have right to do with as I see fit,"5 hence ending a life prematurely is morally problematic. I assume Jirsa is talking about a moral right rather than a legal one. I will furthermore assume that breaking a moral right means doing something wrong. If that is so, then Jirsa's sentence suggests that ending or trying to end one's life is not permissible. If he were right, it would mean that neither suicide and physician-assisted suicide nor requested euthanasia were permissible, since they involve either ending one's life or an attempt to do so. In my interpretation, Jirsa offers two different arguments to support his claim about the limits of a person's moral freedom. Let us start by considering the first one, which is based on the assumption that "I am permitted to do what I see fit only with what is (or could theoretically be) entirely within my control" (Jirsa 2011, 588). The author complements this contention by saying that one's own life is not something one entirely controls. Thus: Jirsa's first argument P1 My life is not and theoretically could not be entirely within my control. P2 I am morally permitted to do as I see fit only with what is or theoretically could be within my full control. ---------------------------- C Therefore, I am not morally permitted to do with my own life as I see fit. Let us look at the premises. What justifies the first premise? To support it, Jirsa is citing Galen Strawson, who argues that we cannot prove to be truly morally responsible for our actions. For the sake of concision, I rephrased Strawson's argument as follows: 5 All translations from Czech are my own. The Morality of Euthanasia 15 Organon F 2019: 1–23 Strawson's argument P1 "You do what you do because of the way you are." P2 "To be truly morally responsible for what you do you must be truly responsible for the way you are-at least in certain crucial mental respects." P3 "You cannot be truly responsible for the way you are, so you cannot be truly responsible for what you do." P4 "To be truly responsible for the way you are, you must have intentionally brought it about that you are the way you are, and this is impossible." (Strawson 1994, 13–14) P5 It is impossible to intentionally bring about who you are, because you must have existed before beginning to exist. ---------------------------- C Thus, you are not morally responsible for what you do. Strawson's argument denies the existence of moral responsibility. If we accepted his contention, we would have to believe that it is not possible to be morally responsible for anything. Strawson himself clearly does not take this conclusion seriously; he presents it as a philosophical puzzle. His aim is to provoke a defensive reaction in philosophers so that they present a satisfactory explanation for the nature of moral responsibility without resorting to such absurdities, as there is no moral responsibility. Jirsa's first premise most likely seeks support in premises of Strawson's argument. The way I am defines how I behave and decide. But since I have not intentionally brought about the way I am-as it is impossible-I cannot have any control over the way I am, and as a result I cannot have any control over what is defined by my nature-i.e., my behaviour and decisionmaking. However, if this is the reasoning behind Jirsa's first premise, it means that we have no control over anything. No decision or act would be free. For the sake of argument, let us assume that Jirsa's first premise is true. Let us take a look at the justification the second premise depends upon. Jirsa claims (Jirsa 2011, 588) it to be his assumption. For the sake of argument, let us now presume it true. If we recognised this statement, we would not be morally permitted to do as we see fit with anything. Because by accepting the justification Jirsa provides for his first premise, we would also 16 Adam Greif Organon F 2019: 1–23 have to acknowledge that we do not have full control over anything. But, as the second premise suggests, if having full control over X is the precondition for doing with X as we see fit, then we do not have the moral permission to do as we see fit with anything. I would like to contradict this by saying that I am morally permitted to do as I see fit with my choice of words in this sentence. I find the implication that moral permission is impossible to be unacceptable. We should rather refuse Jirsa's line of reasoning than accept such an implication. Nevertheless, if we carried on analysing Strawson's puzzle, we would stray too far from our discussion on euthanasia. Jirsa's second argument is based on Wittgenstein's thesis from his Tractatus Logico-Philosophicus, declaring that "[d]eath is not an event in life but is the end of life" (qtd. in Jirsa 2011, 588). Jirsa's conclusion was that ending or trying to end one's life is not permissible. However, the claim that death is not an event in life but is the end of life does not imply that ending or trying to end one's life is morally wrong. We thus need to complement it with an additional premise. I am not sure which one Jirsa would prefer, since he did not express it explicitly. I will assume that since Jirsa believes that death is not an event in life, and that therefore it is wrong to bring it about, than it is wrong to bring about everything that is not an event in life. Based on this premise, we can construct the following argument: Jirsa's second argument P1 If X is not an event in life, then it is wrong to bring about X. P2 Death is not an event in life, it is the end of life. ---------------------------- C Therefore, it is wrong to bring about death. If this is Jirsa's second argument, then I do not find it convincing. If a person cannot decide on the death of another person because death is not an event in the life of the person to be killed but is the end of it, then, for the same reason, they cannot decide about the beginning of life. Conception is also not an event in the life of the conceived-it is the beginning of it. Physicians would thus not be permitted to provide assistance not only in death, but in birth as well. The Morality of Euthanasia 17 Organon F 2019: 1–23 My last objection against Jirsa's position is independent of the argument provided for its support. If the position was true or acceptable, then shooting the trapped lorry driver, together with the soldier's and mother's sacrifice, would be wrong. Should we accept this conclusion? I do not think so. This is why I believe Jirsa's arguments should not be accepted. However, it is possible that I misinterpreted or misunderstood his resoning. Objection 2: Euthanasia should be prohibited as it would lead to a slippery slope. If we started practising it, it would eventually result in involuntary euthanasia or even medical murder. Response: The slippery slope objection fundamentally differs from the previously proposed arguments. Although it claims that we should not be practising euthanasia, it does not say that euthanasia itself is wrong. What it deems morally wrong are the side effects of practising and legalising euthanasia. Euthanasia is thus indirectly wrong. Those against the legalisation of euthanasia maintain that we would find ourselves on a slippery slope that would eventually lead to involuntary euthanasia and medical murder. These critics worry that by legalising requested euthanasia, sooner or later we would due to sociological, psychological, or even logical reasons end up emulating practices of Nazi Germany. They worry that if euthanasia became an option, it would eventually turn into an expectation or even a requirement. I presume that we would not like to live in a society that required or even forced some of its members to undergo premature and unwanted death; I know I would not. How then can I advocate for the legalisation of requested euthanasia?6 Marta Munzarová (2012, 416) described the situation in the Netherlands in the following way: "Killing patients without their request is still happening, but the reporting must be different (since it is not euthanasia, which is defined by Dutch law as killing 'on the patient's request'). Can we imagine a more illustrative example of a slippery slope?" I support the legalisation of euthanasia because I do not believe it would lead us down a slippery slope. Firstly, advocating for requested euthanasia 6 I support the right to euthanasia in the sense that a patient should have the option to receive euthanasia, but I do not support it in the sense that a physician should be obliged to administer it to them. 18 Adam Greif Organon F 2019: 1–23 and rejecting involuntary euthanasia is not contradictory. The distinction between them is clear. The cases Munzarová mentions show how patients' lives were terminated without their explicit request. The authors of the study claim that these were predominantly patients who were unable to express their will because, for instance, they were in a coma. These were instances of so-called non-voluntary euthanasia,7 usually performed on patients who were incapable of giving voice to their decisions; thus, these patients did not die against their will. I suppose Munzarová is trying to point out that the medical records relating to the termination of lives contain a category of patients who did not explicitly consent to being killed. This fact in itself does not prove that there is a slippery slope; only long-term statistics could confirm that, as one-year data do not adequately illustrate how many cases of euthanasia without the explicit consent of the patient were performed in previous years. We should compare records of several years and see if they indicate a growth in deaths we consider wrong. Moreover, we also do not know how many instances recorded in the category of "a patient's life ended without their explicit consent" occurred in countries that still see euthanasia as murder but find terminal sedation acceptable (like Slovakia, for example), since we do not keep a record of them. As a result, we do not know if a system that has legalised euthanasia is better or worse in this aspect than a system where it is illegal. But let us get back to the key question. Is there any evidence to support the contention that in the Netherlands, instances of unacceptable-or less acceptable-forms of ending lives are on the rise? A Dutch study conducted in 2010 (Onwuteaka-Philipsen et al. 2012, 912) indicated a decline in the frequency of cases where lives were terminated without the explicit consent of the patient, while a meta-analysis of Dutch studies (Rietjens et al. 2009, 279) concluded that "the legalization of euthanasia in the Netherlands did not result in a slippery slope for medical end-of-life practices." Therefore, 7 There is a difference between involuntary and non-voluntary euthanasia. In the case of involuntary euthanasia, the patient does not want to die, or they can express their will but it is being ignored. In the case of non-voluntary euthanasia, the patient is unable to communicate what they want. The Morality of Euthanasia 19 Organon F 2019: 1–23 there is no evidence to support the claim that the Dutch euthanasia practices are on a slippery slope. In addition, I would not like to brush off Munzarová's suggestion that non-voluntary euthanasia is inherently morally wrong-if that is indeed what she suggests. I believe that there are situations-especially those involving people who will never regain consciousness-where non-voluntary euthanasia should be permitted. However, I will have to defend that thesis on another occasion. Finally, if we eventually found out that in spite of what current records indicate, the legalisation of euthanasia would lead our society to a slippery slope, we can always change the law and reinstate the former system. So even if legalising euthanasia proved to be a mistake, we would not be obliged to continue with it forever. Therefore, I do not think there is a reason for us to worry about finding ourselves on a slippery slope. There is, however, one additional argument, somewhat close to the slippery slope idea. One could argue that legalising euthanasia would be harmful even if no one was forced to undergo it, because it would necessarily present the population with an uncomfortable choice. The mere fact that one is presented with a choice between continued life and euthanasia could exert, in some segments of the population, a measure of psychological pressure and therefore cause suffering. I believe this reasoning is close to Jirsa's line of argument, since he has voiced his opinion that legalising euthanasia would exert pressure on patients that are the most vulnerable and disadvantaged (Jirsa 2011, 589). In response, I would like to say, somewhat vaguely, that it is far from clear that the value gained by avoiding suffering caused by the pressure of choice is greater than the value gained by avoiding suffering of euthanasia applicants. I personally doubt it is. Although I have no evidence for this claim, I presume that the proponents of this argument would agree with me that this argument, just like the slippery slope argument, should be based on empirical evidence. Objection 3: Euthanasia should not be practised as there is no need for it. What renders it needless is the efficiency of palliative and hospice care, along with the fact that patients may refuse nutrition and hydration and will thus die without any assistance. 20 Adam Greif Organon F 2019: 1–23 Response: Some claim that there is no need for euthanasia because palliative and hospice care have improved so much that they can significantly reduce the patients' suffering. Marek Vácha (2010, 273) maintains that "palliative care has advanced so much that when a patient has been suffering from unbearable physical pain for a long time, he is most likely receiving the wrong treatment." Jirsa seconds this opinion, as does Munzarová (Jirsa 2011, 581; Munzarová 2012, 416). This objection differs from the previous two as it refrains from calling euthanasia directly or indirectly wrong and merely attempts to prove its needlessness;8 therefore, it does not challenge my thesis about requested euthanasia being morally permissible. Despite this, I would still like to address this objection, as it has been presented by several authors. I do not mean to imply that there is anything wrong about palliative or hospice care. I do believe that it is important for people whose quality of life is expected to decline to avail themselves of such avenues of treatment if they want to. We should fully support those who make use of such treatments rather than wishing to die, as every potentially helpful option should be examined and tried. This is why I would prefer it if palliative care received wider recognition. However, it is up to the patient to ultimately decide if they find palliative care useful; they can judge for themselves whether it makes their life worth living or not. After all, it might not; contrary to Vácha's view, nothing guarantees that palliative care will render their lives more liveable (unless my opponents can prove that it is 100% effective). Even if palliative care could relieve a patient of their pain, it might come at a higher cost than the patient is willing to pay. By the time the physician successfully identifies a pain management method that would suit a particular patient's needs, it is possible that the patient will have had to suffer through a lengthy period of trial and error during which their pain will not be alleviated and their quality of life will not improve. And even if the physician found a suitable treatment, the patient might spend the rest of their life experiencing nausea, incontinence, frequent losses of consciousness or other 8 This objection is more pertinent to debates disputing the rationality of euthanasia rather than its morality; however, I decided to include it, as it is normally presented as a moral reproach. The Morality of Euthanasia 21 Organon F 2019: 1–23 distressing symptoms. If a patient decides that they do not want to receive palliative care at such a cost and refuses to spend their remaining days with such poor quality of life, they might want to die with medical assistance. This is supported by studies of patients who have been presented with a choice between high standard palliative care and a physician-hastened death and who preferred or would prefer the latter (Wilson et al. 2007; Quill et al. 2008). This objection differs from the others in one further aspect. Rather than attacking the permissibility of euthanasia, it challenges its legalisation. I do not mean to claim that if something is morally permissible then it must also be legal. However, I do think that if an act is morally permitted then the most fundamental objection against its legalisation loses its ground. Those opposing the legalisation of euthanasia carry the burden of proof in showing that as a society, we should legally prohibit something that is morally permitted. I believe that Jirsa's remaining objections could be solved if euthanasia was properly regulated, as no supporter of sound mind would want to legalise euthanasia without taking proper regulatory measures. Legalisation and morality are two different things and I fully agree with Jirsa (2011, 586) that we should not lose sight of what sets them apart. I think that in some countries, legalising euthanasia might cause more harm than good. Similarly to Jirsa and several other participants of the euthanasia discussion in Slovakia, I worry that legalising euthanasia under the circumstances that currently prevail in the country would be rather harmful, although I do not know it with certainty. I do not know if legalising euthanasia would ultimately have a negative impact on our society, as scientific evidence is needed to get a well-founded answer to this question.9 To the best of my knowledge, there is no evidence for any of these sides, which is why I refuse to take a stand in this discussion. But even if we accepted that 9 If I may venture a speculation, the experience so far suggests that physicianassisted death and euthanasia are generally being implemented by developed countries with high healthcare standards (Physician-assisted death: Switzerland, Oregon, Washington, Montana, Vermont, Canada, and soon Australia; Euthanasia: The Netherlands, Belgium, Luxembourg, and Colombia). This might signify that implementing such end-of-life practices in countries with less developed health care systems could lead to adverse consequences. 22 Adam Greif Organon F 2019: 1–23 in the current state of affairs euthanasia would be harmful, conditions might improve in the future, which might present the right circumstances for legalising euthanasia. Besides, if we believe that euthanasia is morally permitted and should be legally accessible, we should take active means to bring about such a future. * * * Summa summarum, I think that from a moral point of view, the requested euthanasia of adults is permissible, because I accept the argument from analogy, and because I am not aware of any good objection against its permissibility. Where the legal aspect is concerned, I differentiate between immediate legalisation and legalisation when the time is right. 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