1998. Kuhse Why Killing is Not Always Worse

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1998. Kuhse Why Killing is Not Always Worse

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  • Special Section: Euthanasia and Public Policy

    Critical Notice:Why Killing Is Not Always Worse and IsSometimes Better Than Letting Die

    HELGA KUHSE

    The philosophical debate over the moral difference between killing and lettingdie has obvious relevance for the contemporary public debate over voluntaryeuthanasia. Winston Nesbitt claims to have shown that killing someone is,other things being equal, always worse than allowing someone to die.1 But thisconclusion is illegitimate. While Nesbitt is correct when he suggests that killingis sometimes worse than letting die, this is not always the case. In this article, Iargue that there are occasions when it is better to kill than to let die.

    The conventional assumption is that killing a person is worse than allowingher to die. Beginning with James Rachelss famous article Active and PassiveEuthanasia, published in the New England Journal of Medicine in 19752 thisdifference thesis3 has been challenged by producing pairs of cases in whichan agent who lets someone die would generally be judged to be no less rep-rehensible than an agent who kills. Winston Nesbitt argues that these pairs ofcases typically contain a crucial common feature that will indeed make thesecases of letting die the same as killing. Once this crucial feature is removed, heholds, these cases will support, rather than undermine, the difference view.

    Winston Nesbitts argument in support of the difference thesis rests on anumber of contestable assumptions. In briefly retracing his argument, I shallleave these assumptions unchallenged, to then show that even if we accept theseassumptions, Nesbitts conclusion that killing is worse than letting die doesnot follow.

    It will be adequate, for our purposes, to focus on just one of the pairedexamples discussed by Nesbitt: James Rachelss case of the nasty cousins.4

    The first case involves Smith, who will gain a large inheritance should hissix-year-old nephew die. One evening, Smith sneaks into the bathroom wherehis nephew is taking a bath, and drowns him. The second case, that of Jones, isexactly like the first case, except that as Jones is about to drown his nephew, thechild slips, hits his head, and falls, face down and unconscious, into the water.Jones is delighted, and stands by as his nephew drowns.

    In these examples, both men were motivated by personal gain, and bothwere aiming at the childs death. The only relevant difference between the casesis that Smith killed the child, whereas Jones allowed the child to die. But thatdifference, Rachels claims, is not morally relevant in itself, and the differencethesis is false.

    Nesbitt agrees with Rachels that these examples support the common intu-ition that Jones is no less reprehensible than Smith, and that there is, in thesecases, no difference between killing and allowing to die. The reason is, Nesbittholds, that both agents were prepared to kill for the sake of personal gain. After

    Cambridge Quarterly of Healthcare Ethics (1998), 7, 371374. Printed in the USA.Copyright 1998 Cambridge University Press 0963-1801/98 $12.50 371

  • all, Jones was no less prepared to kill than Smith was except that an accident(the child slipping, hitting his head, and falling face-down in the water) obvi-ated the need for Jones to act on his intention. [W]hat determines whethersomeone is reprehensible or not, Nesbitt holds, is not what he in fact doesbut what he is prepared to do, perhaps as revealed by what he in factdoes(p. 104).

    This entails, Nesbitt continues, that Rachelss examples cannot show that thedifference thesis is false. Both cases contain the morally relevant feature thatthe agent was prepared to kill. To test the difference thesis, this common featuremust be removed. We must assume that Jones believes the difference thesis tobe true, and that he was prepared to let his nephew die, but, unlike Smith, wasnot prepared to kill the child. In this case, Nesbitt holds, we might indeed wantto judge Smith more reprehensible than Jones.

    It is this difference, the difference between an agent being prepared to killand an agent merely being prepared to let die, that is, according to Nesbitt,morally significant at least if we accept the widely held view that the raisondetre of morality is to make it possible for people to live together in reasonablepeace and security . . . (p. 105).

    We are not threatened, Nesbitt concludes his argument, if a person is pre-pared to allow another to die, but is not prepared to kill. Such a person willnot save me if my life should be in danger, but in this he is no more dangerousthan an incapacitated person, or for that matter, a rock or a tree. A person whois prepared to kill, on the other hand, is a threat:

    If such a person should come to believe that she will benefit suffi-ciently from my death, then not only must I expect no help from herif my life happens to be in danger, but I must fear positive attempts onmy life. In that case, given the view mentioned of the point of moral-ity, people prepared to behave as Smith does are clearly of greaterconcern from the moral point of view than those prepared only tobehave as Jones does; which is to say that killing is indeed morallyworse than letting die. (p. 105)

    Let us accept that Nesbitt is correct and that we should indeed be more con-cerned by the presence of Smith-type persons than by Jones-type persons. Butwhat does this show? Does it show, as Nesbitt holds, that killing is indeedmorally worse than letting die, or does it show that it is worse if agents, whoare motivated by personal gain, are not merely content to stand by as naturebestows some good on them, but are also prepared to intervene in the courseof nature, to achieve their ends?

    There is an illegitimate conflation in Winston Nesbitts argument between therightness and wrongness of actions, and the goodness and badness of agents.5

    We might thus agree that it is a bad thing for individuals to be motivated bypersonal gain, rather than by, say, the common good, and that it is worse, otherthings being equal, if such an agent is not only prepared to let death happen,but to make death happen.6 But this is not, of course, the same as showingthat killing is worse than letting die. Killing may be worse than letting die inthese cases, and better than letting die in others.

    Consider the following case, similar to a case that came before the Swedishcourts some years ago:

    Helga Kuhse

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  • A truck driver and his co-driver had an accident on a lonely stretchof road. The truck caught fire and the driver was trapped in thewreckage of the cabin. The co-driver struggled to free him, but couldnot do so. The driver, by now burning, pleaded with his colleague anexperienced shooter to take a rifle, which was stowed in a box on theback of the truck, and shoot him. The co-driver took the rifle and shothis colleague.

    Was what the co-driver did morally reprehensible? Did he act wrongly? Stu-dents who are presented with this case will generally answer both questions inthe negative. The reason for their intuitions is not hard to find. In this case, theagent was not motivated by personal gain, but by compassion. He acted not tobenefit himself, but to benefit another. Should we feel threatened by suchagents? Hardly. We should be comforted by their presence. Conversely, how-ever, we should feel threatened, or at least abandoned, if we were surroundedby agents who believed in the difference thesis and behaved like an incapac-itated person, or . . . a rock or a tree, who would let us die when wesincerely wanted someone to make us die.

    Not only does Nesbitt conflate the distinction between agents and actions, healso implicitly assumes that death is always and everywhere an evil. If thisview is already challenged by the above example, it has been utterly rejected inthe practice of medicine, by patients and doctors alike. Patients and doctors donot believe that life is always a good, and they will, in many cases, deliberatelychoose a shorter life over a longer one. Terminally or incurably ill patientsstandardly refuse life-sustaining treatment, and doctors allow these patients todie, for the patients good. To put it slightly differently, while death is normallyan evil, and to kill a person (or to let her die when we could save her) isharming her, this is not the case when continued life presents an intolerableburden to the person whose life it is. In short, then, doctors who are lettinga patient die, for the patients good, are benefiting rather than harming thepatient they are practicing what is often called passive euthanasia.

    If patients can, however, be benefited by being let die, because death is agood, then they can also be benefited by being killed by the doctor practicingactive euthanasia. Indeed, in some cases, active euthanasia will be preferable,from the patients point of view, to passive euthanasia: being let die mayinvolve unwanted protracted pain and suffering for the patient, and fail to giveher the dignified death she wants. Moreover, there are patients for whom deathwould be a good, but who do not need life support, and whom the doctorcannot let die. This means that a doctor who is merely prepared to let die butnot to make die is, once again, like an incapacitated person, a rock, or a tree,who, while not preventing good to befall some patients, will merely stand byand do nothing to make the good happen for others.7

    If the raison detre of morality is to allow people to live together in relativepeace and security, what kind of motivations would we like doctors to have,and what kinds of actions would we like them to perform? Clearly, we wouldlike them to be motivated to primarily seek our good rather than their own tokeep us alive if this is in our best interests, and to let us die or to make usdie when either one of these actions serves us best. If this is correct, thedifference thesis is false. Killing is not always worse than letting die. Some-times it is morally better.

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  • James Rachels devised the case of the nasty cousins to demonstrate thatthere is no intrinsic moral difference between killing and letting die, or activeand passive euthanasia. Now, if Nesbitt is right, Rachelss example of thenasty cousins fails to show that the difference thesis is false. If I am right,however, Nesbitt in turn fails to establish the truth of the difference thesis.While he has shown that killing is sometimes worse than letting die, I haveshown that killing is sometimes better than letting die.

    This has clear implications for the public debate over (voluntary) euthanasia.Nesbitt accepts that the truth or falsity of the difference thesis may ultimatelydepend on the truth of the moral theory that underpins it. But, he says, wecannot wait for a demonstration of the correct moral theory before we attemptto make decisions on pressing moral questions, such as active or passiveeuthanasia (or killing a patient and letting her die). Rather, answers to practicalpublic policy questions are rarely derived from first ethical principles, but are,quite properly, based on common intuitions.8

    Acceptance of Nesbitts common intuition view would lead one to ques-tion the contemporary blanket public policy distinction between active andpassive euthanasia: while doctors are typically permitted, by law, to let patientsdie, at the patients request, they are almost everywhere prohibited from mak-ing them die. In countries like Australia, Britain, and the United States, rec-ognition of peoples common intuitions would, however, lead one to the viewthat not only passive, but also active voluntary euthanasia should be allowed.9

    Far from establishing the truth of the difference thesis, Winston Nesbitt hasundermined the very thesis he set out to support. Not only is active euthanasiano worse than passive euthanasia, and sometimes morally better, his argumentalso lends support to the view that public policies should allow some forms ofactive euthanasia.

    Notes

    1. Nesbitt W. Is killing no worse than letting die? Journal of Applied Philosophy 1995;12(1):1016.2. Rachels J. Active and passive euthanasia. New England Journal of Medicine 1975;7880.3. See note 1, Nesbitt 1995:101.4. See note 2, Rachels 1975, p. 79.5. Kuhse H. The Sanctity of Life Doctrine in Medicine A Critique. Oxford: Clarendon Press, 1987:88-

    90, 142, 148, 15863. See also Frankena W. McCormick and the traditional distinction. In: McCor-mick R, Ramsey P, eds. Doing Evil to Achieve Good. Chicago: Loyola University Press, 1978.

    6. Walton D. On Defining Death. Montreal: McGill-Queens University Press, 1979:11820; see note 5,Kuhse 1987:7981.

    7. Here it is, of course, important to not confuse the distinction between killing and letting die, orbetween making happen and letting happen, with the distinction between actions andomissions. In distinction from a tree or a rock, an agent may act to let happen for example,by telling the nurse not to attach the patient to a respirator, or by turning the respirator off. Seenote 10, Kuhse 1967:chapters 2, 3.

    8. See note 1, Nesbitt 1995:101, n.2.9. Opinion polls in these countries have consistently shown strong public support for active

    voluntary euthanasia. For the opinions of some groups of healthcare professionals, see, forexample, Heilig S. The SFMS Euthanasia Survey: results and analyses. San Francisco Medicine1988;May:246, 34; Ward BJ. Attitudes among NHS doctors to requests for euthanasia. BritishMedical Journal 1995;308:13324; Baume P, OMalley E. Euthanasia: attitudes and practices ofmedical practitioners. Medical Journal of Australia 1994;161:13744; Kuhse H, Singer P. Voluntaryeuthanasia and the nurse: an Australian survey. International Journal of Nursing Studies 1993;30(4):31122.

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