This is bioethics bytes with me, David Edmonds and me Nigel Warburton.
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If a patient decides he doesn't want to live any longer, should she be allowed to die?
Should she be allowed to kill herself? If a patient is in no condition to decide, perhaps she's in a coma,
then should somebody else be able to decide for her whether or not she continues to exist?
Who should take on that role? Is there a moral difference between killing and allowing someone to die?
And is the role of the doctor always to prolong life? Peter Singer of Princeton University is one of the world's leading bioethicists.
Peter Singer, welcome to Bioethics Bytes. Thanks, Nigel.
It's good to be with you. We're going to focus on questions about life and death decision making.
You're famous as a utilitarian. How do you approach the issue of deciding medical cases whether someone should live or die?
I think to answer that question, you need to distinguish different cases, although I am a utilitarian.
I think that generally we will bring about better consequences if we allow competent
adults to make their own choices on matters that primarily concern themselves.
This is a principle that John Stuart Mill and Great Utilitarian certainly defended, and I think he was right on this.
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.
So, for instance, if I decide that my life is no longer worth living,
even if other people dispute that I'm fully, morally justified in committing suicide,
I would want to distinguish between saying you're fully,
morally justified in doing it and the question of whether anybody is justified in stopping you doing it.
Firstly, of course, this will only work if you are not only adult but competent in a sound mind.
You've thought about it for a while. So I think people are justified in restraining you to make sure that you have initially.
But if you really have thought about it and you are fully competent,
then I think in the end it's your decision and we should not use the law or coercion to stop you making it.
Now, is it a morally justified decision? Not necessarily.
Because it's possible that because of your death, that will have a harmful effect on others.
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.
So you could have made an unjustifiable decision, but not one.
I think that we would be entitled or ourselves justified in preventing you from making the usual situation.
In medical cases, though, is other people making decision about my life.
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.
These are controversial questions about euthanasia. So how would you approach those?
Well, firstly, I'm not sure if you're factually correct that this is the usual situation,
because obviously there are many other situations that do occur where doctors ask
patients if they want to have further treatment and the patients may say yes or no.
So they're then making their decision.
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.
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,
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.
When we're talking about accepting or refusing life prolonging treatment.
So in other words, when we're talking about what is sometimes called passive euthanasia,
if a patient suffering from cancer says, Doctor, I don't really want to have any more treatment.
I just don't think it's worth it. And I know I only have a couple of months to live.
I think it's time for me to go.
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.
In some other countries in Japan, perhaps that might not happen in that way.
You know, there are different standards, but I think it's important that we promote the idea of patient autonomy in this area.
It's one thing to say don't continue the treatment,
but it doesn't follow that because I want the treatment to continue that it's either medically advisable or even financially possible.
Yes, you're right about that. And sometimes doctors may say, look, we simply have no further treatment that we can offer you.
We can only offer you palliative care at this point. So that may be where it's medically not feasible.
They can also be cases, at least in countries where we have health care provided by the taxpayer,
a national health service or something like that, where doctors might say, this is.
Not something we can provide. We just don't think that the benefits are enough to match the costs.
And I think doctors should be upfront and open about that. They might get some pushback from patients, but sometimes that is the situation.
The other problem has in the past at least been more common,
and that is where doctors believe that their duty is to prolong life and give patients treatment.
Perhaps the patients are not competent.
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,
push treatment on them, holding out hopes that are not very realistic, that the treatment might really help.
The way you said that, you seemed to imply that the doctor's role isn't necessarily to prolong life.
Yes, that is correct.
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.
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,
they're probably the ones who are the best judge of what's their interest.
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?
What is the quality of those extra couple of months going to be?
So we shouldn't just automatically assume that it's right for the doctor to prolong your life.
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.
Is that the kind of choice that a doctor should support?
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.
You know, you might have your own reason. Everyone is different.
You might be expecting the birth of your first grandchild and you want to see that grandchild before you die.
So even though you're going to suffer, you might have a strong reason for wanting to live another month or two.
There can be all sorts of different cases. Now, we've talked about passive euthanasia, but the more controversial case is active euthanasia,
where a doctor or somebody else takes action, which directly leads to death.
Yes, those cases are certainly more controversial, especially at the political level,
because there have been moves to change the law in a number of countries in order to make that possible.
And that obviously has people for and people against.
I think that's something that ought to be permitted.
And I think that in the small number of jurisdictions where it is permitted now in different forms,
it's something that has been shown to work quite well.
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.
And I don't think that there's a really significant moral difference between being able to make a decision that says,
I know that if I refuse this treatment, I will die soon, but I don't want the treatment.
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.
So I want you to give me that injection. There is a difference now from the point of view of the patient,
but from the point of view of the person administering the lethal injection or in the other case of withholding treatment,
because for many people it feels much worse to administer a lethal drug than it does simply not to carry on treatment.
I see that as a psychological difference more than a deep moral difference.
I would respect the psychology of doctors who feel that there is this important
difference and who are willing to withdraw treatment or not carry on further treatment,
but are not willing to give a lethal injection.
But on the other hand, say in the Netherlands, where voluntary euthanasia has been openly practised for probably about 30 years now,
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.
So if they're comfortable with that and it's what the patient wants, then I don't see a problem.
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
euthanasia programs where people were given lethal injections against their will.
How do you stop going down that slippery slope? You're right that that criticism has been flung at me.
But I'm glad you said Nazi so-called euthanasia programs, because although they did use the term,
those programs were really directed towards preserving the purity of the Aryan folk and getting rid of useless mouths.
They were not in the interests of the people who were killed, some of whom were intellectually disabled but enjoying good lives.
So I think what's important is that the decisions should not be made by the state,
but that the decision should be made either by the individual or in the case of those who are not competent,
such as perhaps infants or people with very severe intellectual disability by the parents or guardians.
So that it should be a decision that is in the best interests of the individuals and the family,
perhaps, and not simply something that's done according to rules that the state lays down.
Isn't the difficulty there that once you pass the response of.
To the family.
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.
It puts them in a terribly difficult situation. It does put them in a difficult situation.
But I find it hard to see a better way of deciding this than to allow the parents to make that decision.
And they may be influenced by the burden that is imposed on them, but I don't think that is unreasonable.
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
child is so demanding that they can't pay the attention to their other children that they want to.
Plus, they feel that the quality of life of the disabled child is marginally desirable.
Maybe it is desirable, maybe it's not, but it's very barely so.
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.
And there's no one else who would look after that child then.
I think that's a very difficult situation. But if the family are in that situation,
I think they should be allowed to make the decision that they see as best for themselves and the family as a whole.
Some people believe that if a foetus is shown to be severely disabled, that is sufficient justification for terminating that potential child's life.
Would you agree with that? Yes, I do.
Sufficient justification, assuming that that is what the couple or perhaps the pregnant woman feel that they want to do.
But I do think that they should be able to make that decision. And if they make that decision,
some disability groups feel that is a decision that makes them somehow lesser people in the world
because society is prepared to tolerate the termination of people with this particular disability.
Well, what society is prepared to tolerate is the termination of a pregnancy of a
foetus that will develop into a child that will have this particular disability.
So I think it's important that the termination of the pregnancy or even since we were talking about euthanasia,
ending the life of the newborn infant, that that is not a person who is capable of expressing a view on it yet.
It's a decision to end a life before it's fully begun.
And I can understand that some disability groups do feel that in some way this is
a judgement that their lives are less worth living than than those of others.
But after all, that judgement is not really one we can fully avoid.
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.
So you go to the hospital and you say, I wouldn't have to say it. It would just be assumed, right?
Can you please repair my leg so I can walk again?
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,
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.
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.
Of course it's not that I don't want to give you equal respect.
It's not that I don't want the state to put resources into making your life as good as it possibly can be.
But I do think other things being equal, it's better to be able to walk and not to be in a wheelchair.
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,
some people might within a particular society prefer to have a preponderance of male children.
Cumulatively, a lot of people making that decision could have a disastrous effect for the society,
even though individual families it's not really going to make a massive difference to.
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?
I agree that there are particular cases of which I think the sex selection one is
a good example where there are clearly going to be adverse social consequences,
at least in some societies, because of the choices people make.
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.
That is not going to lead to that effect.
For example, you might allow it where there are sex linked genetic diseases, you might allow it for family balance,
where parents want to have at least one child of either sex and they already have a couple of the same sex.
And you would hope that that would balance itself out,
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.
So in those cases, there would not be the adverse social consequences.
But if it was simply, let's say, a preference for boys, I think the state is justified in saying,
you know, that's not something that we're going to allow.
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.
You take what you're given, as it were. Well, religious people may feel like that.
I mean, I can only say that I'm not one of them. I don't think there is a god.
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.
I think we're in this world by ourselves and we have to make the best decisions by our own lives.
And if there is a god. Then it seems like he allows us to have our choices on these matters.
I mean, he certainly hasn't sent down thunderbolts to destroy people who are trying to have their choices.
He hasn't even sort of put up messages in the sky saying, this is contrary to my will, don't do it.
You mentioned that you've been thinking about moral decision making in the area of life and death since the sixties.
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.
Firstly, physicians are more respectful of patient autonomy than they were then, and that's been a big shift.
Also, when I became interested in this,
there was no jurisdiction anywhere in the world where either voluntary euthanasia or physician assisted suicide was legal.
The Netherlands, Belgium and Luxembourg have fully legalised both physician assisted suicide and voluntary euthanasia.
Physician assisted suicide is now legal in Oregon, Washington and Montana.
So there has been significant legal change. And I think as these jurisdictions become better known and better studied,
more of them will join it because people will see that this is something that works and is something that they want.
Peter Singer, thank you very much. Thanks, Nigel. It's been good to be with you again.
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