“When Death Corresponds to the Greater Good”
By Jamie Kouba

If a person is terminally ill or mortally injured, end of life or palliative care may be required to ease that patient’s suffering and make dying as comfortable as possible.  Some people are planners and think ahead.  These people might make a living will or advanced directive to state their wishes should they face a terminal illness or mortal injury.  According to the Mayo Clinic, “advance directives guide choices for doctors and caregivers if you’re terminally ill, seriously injured, in a coma, in the late stages of dementia or near the end of life” (Mayo Clinic Staff).  Advanced directives can include requests for DNR (Do Not Resuscitate), a request for palliative care, and, in states where it is legal, a request for Physician Assisted Suicide (PAS).  Other people might be caught by surprise with a diagnosis of a terminal illness that can leave them in a position where they want to end their suffering. In addition, an unexpected tragedy such as a car accident could leave a loved one brain dead with no hope of regaining cognitive abilities.  In these and other similar circumstances, ethical questions arise about the morality of PAS. Proponents of PAS argue that once a patient has established the need to end life, it should be done with as much efficiency and dignity as possible.  Whereas, those who oppose PAS do so one various grounds including moral, cultural, and religious beliefs, as well as concerns about the Hippocratic Oath and the potential of violating that oath by physicians.
Adding to the complexity of this issue are debates about whether or not there is a moral distinction between active euthanasia and passive euthanasia and how these affect the patient.  There are also the consequences for doctors and loved ones to consider as well.  American physician Leon Kass, who argues that active euthanasia is morally wrong, states that “Ceasing medical intervention, allowing nature to take its course, differs fundamentally from mercy killing; in ceasing treatment the physician does not intend the death of the patient, even when death follows as a result” (475).  Ethical theorists who debate on this topic of active and passive euthanasia arrive at different conclusions depending on the ethical theories that they bring to the debate.  This essay will show that utilitarianism and moral relativism yield jarringly different conclusions on this issue.  Using these theories, I propose that denying yourself life-saving measures (passive euthanasia) is morally equivalent to requesting life-ending measures (active euthanasia).  I will demonstrate through the principles of utilitarianism that there is no difference between active and passive euthanasia morally; and, therefore PAS should be legally available in all states to those who seek it.
Anytime someone is wrestling with a major choice in their life, they often look to their own set of moral principles to guide them to make the “right” choice.  Some people call it their gut instinct; it’s that nudge that you give yourself that says “This is right for me.”  A relativist says there are no moral absolutes and that something is right or wrong for you based on your relative culture and upbringing.  “Moral relativism extends this idea to the area of ethics. Ethical evaluations are made in terms of the context of that act and therefore are relative to the [person’s] culture and values” (Mosser 6.2).  While moral relativism is often placed side by side with other ethical theories, it offers no moral principles or concrete rules to judge what is “right” or “wrong” in any given culture.  Moral relativism does, however, help us to understand why laws on such things as PAS can differ from state to state.
For instance, the federal government of the United States does not have any laws against euthanasia, implying perhaps that the entire culture of the United States has no qualms morally with active or passive euthanasia.  However, according to FindLaw.com, only five states have legalized PAS, implying that a very slim minority of the United States approves of it.  Yet, if we look into the states with proposed legislation on the table for PAS this year, Death with Dignity lists 19 states on their map with support for PAS legislation.  This clearly points out that the United States is a house divided on this issue and that the question of PAS can not be simply answered by appeals to whether or not it’s culturally acceptable (Take Action).
Moral relativism suggests that if the topic is neither right nor wrong, then it ought to be tolerated.  Should that apply to laws however? It must be stated that over the last ten years, there has been a significant turn towards support for PAS and soon the entire country may all be on the same side of this debate. As Edward Rubin points out, “The intense controversy about assisted suicide and the related issue of terminating life support reflects the conflict between two moral systems, one traditional and the other evolving” (766).  Based on the current diversity of views of PAS within the United States, moral relativism is not able to provide a worthwhile conclusion on whether euthanasia is right or wrong. Because of  the failure of moral relativism to provide a clear-cut conclusion, a person seeking answers should look for a different ethical theory to examine the topic of PAS.
When a philosopher is seeking to determine whether an act is morally right or wrong, they may look at the consequences of the actions themselves.  In considering those consequences, they are looking to see how much utility, or satisfaction, one gets from the act. This theory of ethics is known as utilitarianism. Utilitarianism is a theory that was first proposed by Jeremy Bentham in 1789.  The principle of utilitarianism seems relatively straightforward; when given a choice between two options, one should choose the option which generates the greatest good, and produces the least amount of suffering.  This means the greatest good or least amount of suffering for a given group, not just for an individual.  Using utilitarianism to decipher the topic at hand, we must first determine what the options are (Mosser 6.1).
Let’s first consider the option of passive euthanasia for a terminally ill patient.  This is usually an option requested in a living-will, or advanced directive.  It generally states that no life sustaining measures are to be taken by the doctors, although they may sedate the patient and keep them comfortable, by applying pain medication.  For most patients, this means no respirators, defibrillators, feeding tubes, or intubations; it is just a matter of trying to achieve a level of comfort while allowing the body to shut down and die on its own.  It can be an agonizing process for the patient, loved ones, and even the doctors to go through; not just physically, but emotionally as well.  The ultimate result is death of the patient.
The second option is active euthanasia, or PAS.  Active euthanasia involves using pills or injections of a lethal dose of medication, given at the patient’s discretion to end life immediately.  Of the five states that allow PAS, each state has different regulations on how, where, and by whom the medication may be administered.  For instance, according to the Washington Death with Dignity Act, once 48 hours have passed since a patient has written their request, they may receive their life ending medication from a pharmacy, and administer the dose themselves.  Some states require that the patient be given a psychiatric evaluation to determine mental competency and to make sure that no one is forcing the patient against their will to choose active euthanasia.  California law requires the medical diagnosis of two doctors to confirm the patient is eligible by law, including psychiatric competency.   After a series of oral and written requests and a 15-day waiting period, which may vary by state, the patient will be prescribed a lethal dose of a barbiturate, usually Seconal or Nembutal.  Upon receiving their medication, the patient is in complete control of the time and place of their death, and who they want around them.  The death is quick and painless, with the patient slipping into a coma and dying in their sleep (The Washington Death; Take Action).
Next, we must use the principles of utilitarianism to determine which is a better option, morally, by deciding which consequences will generate the greatest good and reduce suffering.  If we are applying the principles of utilitarianism to the morality of active versus passive euthanasia, we must look at the consequences of the actions.  In both cases, the patient ends up deceased, therefore the final consequences are the same.  A patient who is terminally ill and suffering will benefit from either passive or active euthanasia because it would produce the greatest good, which would be to eliminate the patient’s suffering.  If the patient is given the right to choose active euthanasia, their death is on their own terms and painless, usually performed in the comfort of their own home and surrounded by loved ones.  Greatest good also applies here to the limiting of the financial strain on the family of the patient, and easing the emotional burden on the family from having to watch a loved one suffer needlessly.  The patients’ needs are not the only ones being served during PAS.  Although the death of a loved one is an obvious source of pain for any person, when a loved one is choosing PAS over suffering, a person can take comfort in the fact that it was a choice made by the deceased to shorten their overall suffering; and, therefore, the loved ones’ final wishes were honored.  The utilitarian would suggest that getting the most good out of a difficult situation is the best option.  With the peace of mind provided to the deceased and their loved ones that PAS provides, despite the loss, it is clearly the right moral choice.
However, in passive euthanasia, the patient is more likely to suffer more, and for longer periods of time.  Although the patient is ultimately terminal, the death does not always come quickly.  Sometimes “terminal sedation” is required where the patient is kept in a coma-like state, under sedation while they starve to death, as the body’s organs shut down one at a time.  It can be a grueling process for the family and the medical staff to have to endure, as well as the patient.  Then there is the added expense of health care for extended periods of time which loved ones are sometimes left to deal with.  Also, the patient’s life often ends in a hospital or nursing home.  The very act of letting nature take its course may seem like that “right” thing to do, but if the process extends the pain, misery, and grief for all the participants involved, it can hardly be considered as serving the greater good.
The right of a terminally ill individual to end his or her life is a serious matter, and they should be given options that will bring them comfort in their final moments.  Someone planning a living-will has a number of priorities in mind; these “include being free of pain and psychological stress, having control over decisions about their care, avoiding treatments that prolong their deaths, and not burdening their families” (Alfonso 43). These priorities do not change when someone is at the end of their life, but has not planned ahead.  Having the option of PAS will help to ease the patient’s mind that their death can be on their terms.
As mentioned earlier, Kass argues that active euthanasia is morally wrong because it involves the physician intending the death of a patient.  However, two notable philosophers offer compelling arguments against this position. James Rachels argues that “active euthanasia is in many cases more humane than passive euthanasia” (78).  t is much more compassionate to give the patient what they want, and let them choose their own death.  We as pet owners feel that the compassionate thing to do is euthanize our four-legged friends when we can no longer help them medically. Why is it that Grandma should be treated with less compassion than we give Lassie?  Especially, if it is a choice that Grandma is making herself. The utilitarian philosopher Peter Singer asserts that “if beings are capable of making choices, we should, other things being equal, allow them to decide whether or not their lives are worth living” (529). Given the above facts and considerations, a utilitarian must conclude since both cases end in death that the only option would be to choose the more humane of the two options.  This is active euthanasia since it ends the patient’s life sooner and with less suffering, which corresponds to the greater good.
Having drawn this initial conclusion, it is still necessary to consider whether there are any significant moral distinctions between active and passive euthanasia; so now we turn to the side of the doctors and their perspectives.  Advanced directives require that a doctor stop life-saving measures, but it does not require the doctor to stop trying to heal the patient.  As Rachels points out, the current doctrine regarding end of life care for patients is this, “The idea is that it is permissible, at least in some cases, to withhold treatment and allow a patient to die, but it is never permissible to take any direct action designed to kill the patient” (78).  A utilitarian may look at this issue from the doctor’s perspective and say that being forced to “kill” a patient is detrimental to the doctor’s mental health and emotional state, and therefore the consequences for the doctor do not outweigh the benefits for the patient.  The idea is that these doctors are being forced to live with the negative consequences of their actions long after the patient’s suffering has ended.  Dr. Stevens, in his paper “Emotional and Psychological effect of Physician-Assisted Suicide and Euthanasia on Participating Physicians,” came to the conclusion that “many doctors who have participated in euthanasia and/or PAS are adversely affected emotionally and psychologically by their experiences” (187).   Opponents to PAS argue that the death affects more people than just the patient or the doctor.  This may include other caregivers, friends, and family.  They say those person’s emotional states should also be taken into account when weighing the consequences.  A caregiver or loved one will suffer when a person dies, but opponents of PAS argue that knowing ahead of time when and how your loved one is going to die makes the grief worse.  It is obvious that a topic such as death garners a lot of attention from both sides of the debate, however ultimately the dying person should have the final say in their own death because it is their body, and the greatest good will apply to them.
The assertion that Physician Assisted Suicide is morally permissible does not mean that doctors who are opposed to PAS must be forced to participate in it.  If a doctor does not feel comfortable providing a life-ending medication to a terminally-ill patient, then that doctor should not be forced to do so; however, they should be able to provide the patient with the name of a doctor who will.  As Rubin points out, “suicide is an appropriate response when there is no further possibility of living a fulfilling life” (780). If a loved one wants to help a person who is seeking PAS, yet they personally do not believe it is the right thing to do, there are other options that do not include active participation such as perhaps just being there for the final moments.  A person doesn’t always need to stand in someone else’s way to stand up for what they believe is right.  A pacifist wouldn’t start a physical fight to demonstrate his position against war; a person who is against PAS can still support a patient seeking PAS without breaking their own moral code.   A doctor or loved one could put their personal feelings aside and help the patient get the care they request and deserve.  A patient who chooses to end their life is making a very personal decision, and they should be surrounded by people who are on their side.  They are already fighting their body and they shouldn’t have to fight someone else’s moral code as well in order to serve the greater good and end their suffering.
Death is hardest on the living.  That is probably why the topic of active versus passive euthanasia is such a hotly debated topic.  However, looking at it through the lens of a utilitarian’s perspective, it can be argued that there is no moral difference between active and passive euthanasia.  “If patients can rationally opt for an earlier death by refusing life-supporting treatment or by accepting life-shortening palliative care, they must also be [considered] rational enough to opt for an earlier death by physician-assisted suicide or voluntary euthanasia” (Singer 538).  Despite any objection from those who seek to muddy the waters with semantics over the difference between “allowing nature to take its course” and “mercy killing,” a terminally ill patient should legally have access to PAS, and be able to choose their own death because it leads to the greatest good and allows the suffering to be over for them, their loved ones, their caregivers, and their health care workers.  If we choose the haphazard approach of moral relativism and leave the decision to eventually legalize PAS up to individual states, we are leaving countless patients needlessly suffering undignified deaths, while their loved ones and caregivers suffer the fate of watching them waste away.  We should as a country, make PAS legally available to those in need of it; it is the morally right choice.

Works Cited

Alfonso, Heather.  “The Importance of Living Wills and Advanced Directives.”  Journal of Gerontological Nursing.  35.1 (2009) 42-45. 14 March 2016. Web.
FindLaw.  “Death with Dignity Laws by State.”  FindLaw, 2006. 8 August 2016. Web.
“The Washington Death with Dignity Act: An Overview for Patients and Families.”  End of Life Washington.  2016. www.endoflifewa.org.  15 March 2016. Web.
“Take Action: Death with Dignity Around the U.S.” Death with Dignity. www.deathwithdignity.org. 21 March 2016.
Kass, Leon R.  “Why Doctors Must Not Kill.” Public Interest.  94 (1989): 25-46. 20 March 2016. Web.
Mayo Clinic Staff.  “Living Wills and Advanced Directives for Medical Decisions”. Mayo Clinic, 11 November 2014.  www.mayoclinic.org. 16 March 2016. Web.
Mosser, Kurt.  Understanding philosophy. San Diego: Bridgepoint, Inc. 2013.  [Electronic version]. 14 March 2016. Print.
Rachels, James.  “Active and Passive Euthanasia.”  The New England Journal of Medicine. 292.1 (1975): 78-80. 18 March 2016. Web.
Rubin, Edward.  “Assisted Suicide, Morality, and Law: Why Prohibiting Assisted Suicide Violates the Establishment Clause.” Vanderbilt Law Review.  63.3 (2010): 761-811.EBSCOhost. 16 March 2016. Web.
Singer, Peter. “Voluntary euthanasia: A Utilitarian perspective.” Bioethics.  17.5/6 (2003):526-541. EBSCOhost. 16 March 2016. Web.
Stevens, Kenneth R.  “Emotional and Psychological Effects of Physician-Assisted Suicide and Euthanasia on Participating Physicians.”  Law & Medicine.  21/3.  (2006): 187-200. 18 March 2016. Web.

Jamie Kouba is a third year student at Ashford University, working on a double Bachelor’s Degree in English and Cultural Anthropology. She is a member of Alpha Sigma Lambda, and hopes to pursue her Master’s Degree in Anthropology after graduation. She is married, with one daughter, and spends most of her free time outdoors.