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Theoretical Introduction
Lecture #12:
Thomistic Ethics
& Moral Problems
Acts & Omissions
St. Thomas, Can there be voluntariness without any act?
(1a2æ, Q. 6, a. 3)
Double Effect & Acts-Omissions Distinction
• When we do A in order to bring about B we are responsible for B
• What about these two cases?
– When we do A in order to bring about B, knowing that C will also
happen (as a side effect), are we responsible for C?
• e.g., when we use a drug in order to relieve pain, knowing that it
will also hasten the patient’s death, are we responsible for the death
• PDE: yes, but not in the same way for C as for A & B
– When we do not do A, knowing our not doing A will result in B
happening, are we responsible for B?
• e.g., when we do not use a certain procedure, knowing that without
it the patient will die, are we responsible for the death?
• AO distinction: …
• = Is letting someone die different from killing them?
•
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The voluntary is what proceeds from the will.
One thing proceeds from another in two ways.
– directly: when something proceeds from something else because the second thing acts.
– indirectly; when something proceeds from something else because the second thing did not act.
The cause of what follows from inaction
– is the agent as not-acting when
• the agent can act
• and the agent ought to act
– is not the agent when
• the agent cannot act
• and the agent has no obligation to act
Example
– The sinking of a ship is the helmsman’s fault if he just stops steering
– It is not his fault if
• he is unable to steer the ship
• or he is not assigned to be at the helm
Summary: There can be voluntariness [and culpability] without an act
– sometimes without outward act, but with an interior act; for instance, when one wills not to act;
– and sometimes without even an interior act, as when one does not will to act (though one should will to act)
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Background on Euthanasia
Definition of Euthanasia
• Euthanasia (<εὐ good + θάνατος death, so a good death)
– but used to mean “causing a good death” (i.e., killing), not just
“having a good death”
– colloquially, “mercy killing”
• “Euthanasia is the administration of a lethal agent by another person to a
patient for the purpose of relieving the patient’s intolerable and incurable
suffering.”—AMA
• So:
– Immediate action: administration of a lethal agent
– Proximate end: killing a patient (cf. lethal agent)
– More remote end: relieving the patient’s intolerable and incurable
suffering
• In terms of Thomistic analytic vocabulary, composite
– Object: killing a person in a medically bad condition
– End: mercy (for their own benefit)
Definition:
Euthanasia & Other Kinds of Killing
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The Nazi Euthanasia Program
• Different object (& end)
– Japanese Seppuku (
, “hara kiri”)—
• Killing oneself (object)
• to rectify disgrace (end).
– Capital punishment
• Killing a guilty criminal (object)
• To promote civic peace (end).
• Different end
– E.g., the Nazi Aktion T4 program
motivated partly by desire to remove
genetically “defective” people from the
gene pool.
• Killing people with whom something
is genetically wrong (object)
• to improve the health of the next
generation (end).
– But the distinction between these
killings & euthanasia may not be as
sharp as is sometimes imagined.
• Aktion T4 (1939—1941) killed over 100,000 people with mental or
physical disabilities. The reason being “racial hygiene” (eugenics), this
is distinguishable from euthanasia as defined above.
• The magazine cover (right, above) reads: “This person, suffering from
hereditary disease, will cost the community 60,000 DM over the
course of his lifetime. Fellow citizens, this is your money.”
• Blessed Clemens August Graf von Galen (1878—1946), Bishop of
Münster, (right, below) played a particularly important role in
galvanizing opposition to the program in 1941. The Nazi government
put him under house arrest & beheaded three of his priests for
distributing the sermon in which he condemned the program, but his
protest did result in Hitler’s cancellation of the program. Von Galen
was beatified in 2005.
• In 1947, four German doctors & administrators were charged with
crimes against humanity for their participation in this program at the
Nuremberg Military Tribunal. Three were convicted & hanged at
Landsberg Prison on 2 June 1948.
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The Lübeck Martyrs (1943)
The Classical Prohibition Against Euthanasia:
The Hippocratic Oath
• Three Catholic Priests (beatified in 2011):
– Bl. Hermann Lange (left)
– Bl. Eduard Müller (center)
– Bl. Johannes Prassek (right)
• I swear by Apollo, Asclepius, Hygieia, and
Panacea, and I take to witness all the gods, all
the goddesses, to keep according to my ability
and my judgment, the following Oath.
• … never do harm to anyone.
• To please no one will I prescribe a deadly
drug nor give advice which may cause his
death.
• If I keep this oath faithfully, may I enjoy my
life and practice my art, respected by all men
and in all times; but if I swerve from it or
violate it, may the reverse be my lot.
• One Lutheran Minister
– Karl-Friedrich Stellbrink
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Distinctions
• Euthanasia
– Voluntary, Non-voluntary, & Involuntary
– Active & Passive
• Physician-Assisted Suicide
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The New Laws
• Voluntary euthanasia
– e.g., in the Netherlands, Belgium & Luxembourg
• Physician-assisted suicide
– e.g., in Oregon, Washington, & Vermont
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AMA policy
• The intentional termination of the life of one human being by another mercy killing - is contrary to that for which the medical profession stands
and is contrary to the policy of the American Medical Association.
• The cessation of the employment of extraordinary means to prolong the
life of the body when there is irrefutable evidence that biological death is
imminent is the decision of the patient and/or his immediate family.
Rachels
Rachels vs. Sullivan
on
the AMA Policy
Rachels’ Initial Cases & First Argument
• The Cases
– A man about to die of a painful throat cancer
– A baby with Down’s Syndrome & intestinal blockage
• Rachel’s argument
– The distinction authorizes letting the patient die but not killing him
– Letting the patient die causes more pain than killing him
– So, the distinction authorizes the more painful solution
– The right thing to do is to do what causes the least pain.
– So, the distinction authorizes what is wrong.
• Questions:
– Does the AMA statement justify
• letting the cancer patient die?
• deciding not to operate on the Down’s-syndrome baby (= letting it
die)?
– What would St. Thomas say? Are the decision-makers responsible for
the patient’s death?
Rachels’ Second Argument
• “the conventional doctrine leads to decisions concerning life and death
made on irrelevant grounds”
– Down’s-syndrome children needing an operation are allowed to die
– Down’s-syndrome children not needing an operation are allowed to
live
• “The reason why such operations are not performed in these cases is,
clearly, that the child has Down's syndrome and the parents and doctor
judge that because of that fact it is better for the child to die.”
– What does the AMA allow here?
– What would St. Thomas say about this decision: Are the decisionmakers responsible for the child’s death?
A Possible Defense of the Distinction
• The argument
– Killing is worse than letting die
– So, active euthanasia is worse than letting someone die
• Rachels’ reply
– The cousin-drowner (in his story) killed his cousin
– The other cousin (who watched his cousin drown) just let his cousin
die
– The two acts (drowning and watching-drown) are equally bad
– So, killing is not worse than letting die
•
Rachels’ Summary
• “I have argued that killing is not in itself any worse than letting die; if my
contention is right, it follows that active euthanasia is not any worse than
passive euthanasia.”
– killing is not in itself any worse than letting die
• (the stories were supposed to show that)
– if my contention is right, it follows that active euthanasia is not any
worse than passive euthanasia
– so, active euthanasia is not any worse than passive euthanasia
• “it is not exactly correct to say that in passive euthanasia the doctor does
nothing, for he does do one thing that is very important: he lets the
patient die.”
• When, according to St. Thomas, would it be correct to say that the
physician not doing something makes him responsible for the patient’s
death?
– Not if he could not have done anything
• but only if he could have done something did he let the patient die
– Also not if he had no obligation to do something
• physicians do have an obligation to use ordinary means desired by
the patient
• but not to use extraordinary means
• and not to treat an unwilling patient
Sullivan
• “what is the cessation of treatment, in these circumstances, if it is not ‘the
intentional termination of the life of one human being by another’? Of
course it is exactly that, and if it were not, there would be no point to it.”
What Rachels’ Seems to Think
• There is no morally relevant distinction between active euthanasia &
letting die
• So, the two acts are alike
• Letting the patient die (out of mercy) is morally permissible
• So, killing them is morally permissible
Sullivan on the Cousins
• The Cousins
– One cousin is guilty of murder
– The other is guilty of malicious omission
– There is not much difference between active murder and malicious
omission
– So the cousins are morally alike
• Extension of the insight
– The doctor who allows the Down’s-syndrome baby to die is like the
cousin who watches his cousin die
Rachels & the AMA
• Rachels rejects the distinction between
– active euthanasia
– passive euthanasia
• The AMA distinguishes
– “The intentional termination of the life of one human being by another
—mercy killing”—forbidden
– “The cessation of the employment of extraordinary means to prolong
the life of the body when there is irrefutable evidence that biological
death is imminent”—permitted
• The traditional distinction
– forbids the intention to cause the death of the patient
– does not require use of extraordinary means
• omitting extraordinary means is not necessarily aimed at the death
of the patient
• it may be omitted
– because it is futile
– or because using them would be painful
– does require the use of ordinary means
• i.e., forbids their malevolent omission
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Another Version of Rachels vs. Sullivan
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Rachels vs. Sullivan
• Two approaches to the analysis of these cases
– Rachels
• a two-concept distinction
– Active euthanasia
– Passive euthanasia or letting-die
• denial of the moral significance of this distinction
– Sullivan
• a three-concept distinction
– Active vs. passive euthanasia
– Euthanasia (active or passive) vs. letting-die
• moral significance
– the distinction between active vs. passive euthanasia may not be
significant
– the distinction between euthanasia (active or passive) vs.
letting-die is
James Rachels’ Objection
to the AMA Statement
•
Rachels’ fundamental concepts: He distinguishes two kinds of euthanasia
– Active euthanasia (“killing”)
• doing something (e.g., administering a poison)
• to bring about the patient’s death
– Passive euthanasia
• omitting to do something (e.g., performing an operation)
• because (or perhaps just knowing that) omission will result in the patient’s death
•
The problem with his analysis:
– if he says “because”, he leaves undiscussed all cases where there is no intention to bring
about the patient’s death
– if he says just “knowing that”, he has gone beyond the reasonable definition of euthanasia
• This would include omission of extraordinary means (just letting-die), which is not
passive euthanasia.
– All cases of euthanasia include intention of the death of the patient.
– Some cases of omitting extraordinary means do not include intention of the death
of the patient. (E.g., the Quinlan case)
– So, some cases of omitting extraordinary means are not cases of euthanasia (at
all).
•
So, his claim that the distinction between active & passive euthanasia is not morally
significant does not show that the AMA’s distinction between active euthanasia and omission
of extraordinary means is not morally significant
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Thomas Sullivan’s Three-Way Distinction
• Active euthanasia
– example: administration of a lethal drug to a patient (cf. Dutch practice)
– analysis
• action
• aimed at death
• Passive euthanasia
– example: not treating a patient in order to cause the patient’s death
– analysis
• omission [inaction]
• aimed at death
• Letting die
– example: Quinlan case
– analysis
• omission [inaction]
• not aimed at anything,
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Rachels vs. Sullivan:
The Issues
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Another Version of the Theoretical Issues
• Is there a moral difference between
– killing someone (e.g., by giving poison) to a person about to die (“active euthanasia”)?
– stopping a treatment to someone who is about to die (“letting them die”)?
• Rachels
– denies that there is a principled difference between letting-die & euthanasia (same
consequences)
• & so, calls letting-die “passive euthanasia”
• Sullivan defends the traditional distinction
– Euthanasia is morally different from letting-die (different end)
– Letting-die
• is sometimes a way of carrying out euthanasia
• sometimes is not (but is just letting someone die)
• and so is not equivalent to “passive euthanasia”
• This allows defense of the traditional moral judgments (& current law in most states):
– That active euthanasia is always wrong
– That letting someone die is not always wrong
• though it could be wrong, depending on
– ends &
– other circumstances
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General Principles on Acts & Omissions
• St. Thomas’ principles are designed for the evaluation of human actions.
– Is not an omission an inaction & hence not subject to moral evaluation?
– St. Thomas argues that,
• in some cases, inaction is a kind of action
– when one chooses not to act
» The person who decides not to check on the security of a building has
done something in omitting to act.
– when one has an obligation to act but does not
» The watchman who negligently fails to check on the security of a building
(as he was supposed to do) has done something in omitting to act.
• but not in others
– when one has no obligation to act
» The person who does not check on the security of a building has not done
something in omitting to act.
» His object & end are whatever else he was doing at the time; the omission
does not have consequences that could make the omission bad.
Omissions with Bad Consequences:
Cases when Omission would not be Wrong
• Is it ever permissible not to provide medical treatment that would save a life?
– if the treatment would impose excessive burdens or risks
• Example: respecting a “Do Not Resuscitate” order
• Yes, omission is permissible
– This would be a choice not to act
– This choice
» (omissions perhaps don’t have objects)
» would be good with respect to its end (to avoid the burdens or risks)
» would not be bad with respect to its circumstances if the burdens or risks
were great enough relative to the benefits
– So, it would not be bad simply
– if the treatment would prevent one from fulfilling other duties
• Example: triage, not treating some in order to use the medical resources for others
who had a greater chance of recovery
• Yes, omission is permissible
– Such an omission would not be a choice not to act
» It would be a choice to do something else
– So, (assuming a good end & the right circumstances) it would not be bad
simply
Omissions with Bad Consequences:
Cases when Omission would be Wrong
• Is it ever permissible not to provide medical treatment that would save a life?
– If one intends the death of the person not treated
• No, omission is not permissible
– Such an omission would be a choice not to act
» (See St. Thomas on why there can be voluntariness without any action)
– This choice would be bad with respect to the end
– So, it would be bad simply.
– If one has an obligation to treat the patient
• Such an obligation could be
– contractual (promise to the patient, part of one’s job at a hospital)
– professional (the duties of a physician)
• No, omission is not permissible
– Such an omission would be bad since
» the circumstances would be bad: not acting (or, doing something else)
when you have a (perhaps contractual) obligation to render medical
assistance
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