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This is bioethics bytes with me, David Edmonds and me Nigel Warburton.

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Bioethics Bytes is made in association with Vox, which we here are Centre for Practical Ethics and made possible by a grant from the Wellcome Trust.

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For more information about bioethics bytes go to WW W Docs Practical Ethics dot oecs docs ac dot UK or to i-Tunes u.

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If a patient decides he doesn't want to live any longer, should she be allowed to die?

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Should she be allowed to kill herself? If a patient is in no condition to decide, perhaps she's in a coma,

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then should somebody else be able to decide for her whether or not she continues to exist?

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Who should take on that role? Is there a moral difference between killing and allowing someone to die?

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And is the role of the doctor always to prolong life? Peter Singer of Princeton University is one of the world's leading bioethicists.

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Peter Singer, welcome to Bioethics Bytes. Thanks, Nigel.

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It's good to be with you. We're going to focus on questions about life and death decision making.

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You're famous as a utilitarian. How do you approach the issue of deciding medical cases whether someone should live or die?

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I think to answer that question, you need to distinguish different cases, although I am a utilitarian.

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I think that generally we will bring about better consequences if we allow competent

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adults to make their own choices on matters that primarily concern themselves.

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This is a principle that John Stuart Mill and Great Utilitarian certainly defended, and I think he was right on this.

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So if we're talking about a common an adult, then I think in pretty much all circumstances you can imagine that decision ought to be up to him or her.

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So, for instance, if I decide that my life is no longer worth living,

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even if other people dispute that I'm fully, morally justified in committing suicide,

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I would want to distinguish between saying you're fully,

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morally justified in doing it and the question of whether anybody is justified in stopping you doing it.

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Firstly, of course, this will only work if you are not only adult but competent in a sound mind.

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You've thought about it for a while. So I think people are justified in restraining you to make sure that you have initially.

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But if you really have thought about it and you are fully competent,

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then I think in the end it's your decision and we should not use the law or coercion to stop you making it.

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Now, is it a morally justified decision? Not necessarily.

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Because it's possible that because of your death, that will have a harmful effect on others.

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And it's possible that you made the wrong decision in that basis because you didn't give sufficient weight to the interests of others.

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So you could have made an unjustifiable decision, but not one.

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I think that we would be entitled or ourselves justified in preventing you from making the usual situation.

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In medical cases, though, is other people making decision about my life.

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They decide because I'm in a coma or they decide because I'm not actually coherent enough to bear to think through what my life chances are anymore.

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These are controversial questions about euthanasia. So how would you approach those?

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Well, firstly, I'm not sure if you're factually correct that this is the usual situation,

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because obviously there are many other situations that do occur where doctors ask

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patients if they want to have further treatment and the patients may say yes or no.

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So they're then making their decision.

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Secondly, if in fact, you're right, and this is not the standard way that things happen, then I think that's something that needs to change.

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And in my experience, I've been involved in bioethics since the late 1960s or early 1970s, and my experience there has been a very significant shift,

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at least in the Western world, in that recognition of the autonomy of the patient and the right of the patient to make those decisions.

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When we're talking about accepting or refusing life prolonging treatment.

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So in other words, when we're talking about what is sometimes called passive euthanasia,

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if a patient suffering from cancer says, Doctor, I don't really want to have any more treatment.

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I just don't think it's worth it. And I know I only have a couple of months to live.

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I think it's time for me to go.

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In Britain and the United States and Canada and Australia and most countries that I know best, most doctors would say, okay, that's your decision.

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In some other countries in Japan, perhaps that might not happen in that way.

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You know, there are different standards, but I think it's important that we promote the idea of patient autonomy in this area.

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It's one thing to say don't continue the treatment,

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but it doesn't follow that because I want the treatment to continue that it's either medically advisable or even financially possible.

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Yes, you're right about that. And sometimes doctors may say, look, we simply have no further treatment that we can offer you.

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We can only offer you palliative care at this point. So that may be where it's medically not feasible.

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They can also be cases, at least in countries where we have health care provided by the taxpayer,

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a national health service or something like that, where doctors might say, this is.

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Not something we can provide. We just don't think that the benefits are enough to match the costs.

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And I think doctors should be upfront and open about that. They might get some pushback from patients, but sometimes that is the situation.

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The other problem has in the past at least been more common,

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and that is where doctors believe that their duty is to prolong life and give patients treatment.

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Perhaps the patients are not competent.

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Now, if we switch to those sorts of cases, give patients treatment that really is not in the patient's interests or if they are competent,

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push treatment on them, holding out hopes that are not very realistic, that the treatment might really help.

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The way you said that, you seemed to imply that the doctor's role isn't necessarily to prolong life.

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Yes, that is correct.

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I don't think the doctor's role is necessarily to prolong life, because you have to ask the question is prolong life in the patient's best interests.

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I think the doctor's role is to do what is in the patient's best interests with the qualification that if the patient is autonomous,

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they're probably the ones who are the best judge of what's their interest.

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But if you're going to die in a couple of months and the doctor can prolong that by another month or two, the real question is, do you want that?

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What is the quality of those extra couple of months going to be?

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So we shouldn't just automatically assume that it's right for the doctor to prolong your life.

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But if I choose to have a longer life of inferior quality going into pain and so on, I'd rather live in suffering even if it's acute.

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Is that the kind of choice that a doctor should support?

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Yes, I think if that's what you want and if it's within the cost benefit ratio that the health care system works under, I do think that's your choice.

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You know, you might have your own reason. Everyone is different.

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You might be expecting the birth of your first grandchild and you want to see that grandchild before you die.

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So even though you're going to suffer, you might have a strong reason for wanting to live another month or two.

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There can be all sorts of different cases. Now, we've talked about passive euthanasia, but the more controversial case is active euthanasia,

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where a doctor or somebody else takes action, which directly leads to death.

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Yes, those cases are certainly more controversial, especially at the political level,

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because there have been moves to change the law in a number of countries in order to make that possible.

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And that obviously has people for and people against.

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I think that's something that ought to be permitted.

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And I think that in the small number of jurisdictions where it is permitted now in different forms,

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it's something that has been shown to work quite well.

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So I see it as an extension of what we've been talking about, that the patient is the one who ought to make the decision, the competent patient.

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And I don't think that there's a really significant moral difference between being able to make a decision that says,

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I know that if I refuse this treatment, I will die soon, but I don't want the treatment.

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And on the other hand, saying, I know that if you give me a lethal injection, I will die soon, but I don't want to live.

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So I want you to give me that injection. There is a difference now from the point of view of the patient,

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but from the point of view of the person administering the lethal injection or in the other case of withholding treatment,

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because for many people it feels much worse to administer a lethal drug than it does simply not to carry on treatment.

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I see that as a psychological difference more than a deep moral difference.

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I would respect the psychology of doctors who feel that there is this important

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difference and who are willing to withdraw treatment or not carry on further treatment,

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but are not willing to give a lethal injection.

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But on the other hand, say in the Netherlands, where voluntary euthanasia has been openly practised for probably about 30 years now,

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many doctors don't regard those two ways of ending life as being so significantly different, and they are prepared to give a lethal injection.

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So if they're comfortable with that and it's what the patient wants, then I don't see a problem.

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Now, when you've expressed this kind of view before, some people have caricatured your view as on the slippery slope towards Nazi so-called

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euthanasia programs where people were given lethal injections against their will.

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How do you stop going down that slippery slope? You're right that that criticism has been flung at me.

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But I'm glad you said Nazi so-called euthanasia programs, because although they did use the term,

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those programs were really directed towards preserving the purity of the Aryan folk and getting rid of useless mouths.

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They were not in the interests of the people who were killed, some of whom were intellectually disabled but enjoying good lives.

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So I think what's important is that the decisions should not be made by the state,

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but that the decision should be made either by the individual or in the case of those who are not competent,

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such as perhaps infants or people with very severe intellectual disability by the parents or guardians.

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So that it should be a decision that is in the best interests of the individuals and the family,

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perhaps, and not simply something that's done according to rules that the state lays down.

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Isn't the difficulty there that once you pass the response of.

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To the family.

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They may be heavily burdened, as I would say, by the care of somebody whose life is actually worth living from the individual's perspective.

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It puts them in a terribly difficult situation. It does put them in a difficult situation.

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But I find it hard to see a better way of deciding this than to allow the parents to make that decision.

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And they may be influenced by the burden that is imposed on them, but I don't think that is unreasonable.

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If you imagine a situation where, let's say parents already have a child or children and they feel that the care of the disabled

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child is so demanding that they can't pay the attention to their other children that they want to.

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Plus, they feel that the quality of life of the disabled child is marginally desirable.

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Maybe it is desirable, maybe it's not, but it's very barely so.

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Plus, let's assume that the state is not helping them out with the care or doesn't have the resources or the capacities to do that.

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And there's no one else who would look after that child then.

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I think that's a very difficult situation. But if the family are in that situation,

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I think they should be allowed to make the decision that they see as best for themselves and the family as a whole.

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Some people believe that if a foetus is shown to be severely disabled, that is sufficient justification for terminating that potential child's life.

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Would you agree with that? Yes, I do.

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Sufficient justification, assuming that that is what the couple or perhaps the pregnant woman feel that they want to do.

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But I do think that they should be able to make that decision. And if they make that decision,

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some disability groups feel that is a decision that makes them somehow lesser people in the world

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because society is prepared to tolerate the termination of people with this particular disability.

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Well, what society is prepared to tolerate is the termination of a pregnancy of a

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foetus that will develop into a child that will have this particular disability.

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So I think it's important that the termination of the pregnancy or even since we were talking about euthanasia,

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ending the life of the newborn infant, that that is not a person who is capable of expressing a view on it yet.

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It's a decision to end a life before it's fully begun.

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And I can understand that some disability groups do feel that in some way this is

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a judgement that their lives are less worth living than than those of others.

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But after all, that judgement is not really one we can fully avoid.

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It's as if somebody said, Suppose that you're hit by a car as you leave the building now and you break both legs.

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So you go to the hospital and you say, I wouldn't have to say it. It would just be assumed, right?

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Can you please repair my leg so I can walk again?

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Now you imagine somebody who's in a wheelchair and is has a condition that they'll never be able to walk again, saying, Hey,

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you just made a judgement that my life is less worth living than yours because you don't want to be in a wheelchair that the rest of your life.

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I think I'd have to say yes. That is a judgement I make. It's not that I don't think you should go on living.

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Of course it's not that I don't want to give you equal respect.

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It's not that I don't want the state to put resources into making your life as good as it possibly can be.

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But I do think other things being equal, it's better to be able to walk and not to be in a wheelchair.

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Isn't there potentially a conflict here? Because if we put all the decision making in the hands of parents in the area of sex selection, for instance,

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some people might within a particular society prefer to have a preponderance of male children.

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Cumulatively, a lot of people making that decision could have a disastrous effect for the society,

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even though individual families it's not really going to make a massive difference to.

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Wouldn't it be better to have some kind of overseeing committee that decides what you can do rather than to put it all in the hands of the parents?

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I agree that there are particular cases of which I think the sex selection one is

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a good example where there are clearly going to be adverse social consequences,

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at least in some societies, because of the choices people make.

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So I think it's reasonable there for the state to say you can only do sex selection if you have some particular reason for it.

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That is not going to lead to that effect.

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For example, you might allow it where there are sex linked genetic diseases, you might allow it for family balance,

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where parents want to have at least one child of either sex and they already have a couple of the same sex.

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And you would hope that that would balance itself out,

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because there would be just as many families who have boys and want to have a girl as there would be families who have girls and want to have a boy.

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So in those cases, there would not be the adverse social consequences.

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But if it was simply, let's say, a preference for boys, I think the state is justified in saying,

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you know, that's not something that we're going to allow.

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I know a lot of people listening to this will think the kinds of policies that you're advocating a tantamount to playing God for religious people.

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You take what you're given, as it were. Well, religious people may feel like that.

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I mean, I can only say that I'm not one of them. I don't think there is a god.

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So I think the question of playing God doesn't really arise, because that suggests that somehow we usurping a role that is already being played.

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I think we're in this world by ourselves and we have to make the best decisions by our own lives.

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And if there is a god. Then it seems like he allows us to have our choices on these matters.

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I mean, he certainly hasn't sent down thunderbolts to destroy people who are trying to have their choices.

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He hasn't even sort of put up messages in the sky saying, this is contrary to my will, don't do it.

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You mentioned that you've been thinking about moral decision making in the area of life and death since the sixties.

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Is there any progress or are we more or less where we were then? Oh, I definitely think there's been progress in two ways.

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Firstly, physicians are more respectful of patient autonomy than they were then, and that's been a big shift.

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Also, when I became interested in this,

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there was no jurisdiction anywhere in the world where either voluntary euthanasia or physician assisted suicide was legal.

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The Netherlands, Belgium and Luxembourg have fully legalised both physician assisted suicide and voluntary euthanasia.

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Physician assisted suicide is now legal in Oregon, Washington and Montana.

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So there has been significant legal change. And I think as these jurisdictions become better known and better studied,

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more of them will join it because people will see that this is something that works and is something that they want.

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Peter Singer, thank you very much. Thanks, Nigel. It's been good to be with you again.

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