Thursday, December 09, 2004

Universal Voluntary Euthanasia

(The usual disclaimer: the following is to float some ideas; I don't necessarily endorse any of them.)

Death is usually a bad thing, but there are exceptions. A life which promises nothing but suffering makes that 'nothing' look good in comparison. So I take it that euthanasia is justified at least in certain medical cases involving a debilitating terminal illness. This post is intended to build on that assumption (so if you categorically oppose euthanasia, just pretend otherwise for the sake of argument). What I'm wondering is: does this assumption commit us to a much more radical acceptance of state-supported suicide, and if so, is that a bad thing?

The bridging idea here is that terminal illnesses are not the only form of suffering. You don't need to be in a hospital bed to judge that your life is no longer worth living. So if we accept that people have a moral (and legal) right to end their own lives in the one case, wouldn't those same rights also extend to the other?

To clarify: I'm generally no fan of rights talk, but simply use them as a shortcut to utility. The real issue for me, then, is that if we trust the terminally ill to accurately judge when their continued living would create negative utility, why shouldn't we also trust the physically healthy (who may be suffering just as much in other ways)?

One possibility is that the terminally ill are more likely to be correct in their pessimistic judgments. If they are going to die soon anyway, and their physical health is deteriorating, then it may be unlikely that life could surprise them in a positive way. However, otherwise-healthy people contemplating suicide are probably more likely to be irrational in doing so. It would certainly be tragic to throw away one's life because of a temporary bout of depression.

But that doesn't necessarily imply a total ban is best. Perhaps we should simply require that the state be extremely careful in assessing those who declare a desire to end their lives.

There could be some benefit to the State providing a euthanasia service. For one thing, by making counseling a compulsory requirement for applicants, it might help prevent suicides. If someone goes and jumps off a bridge, there's not much we can do to help them (not without some difficulty, at least). But if they go to a state facility, we might be able to get them the help they need.

A second advantage, regarding those few who cannot be dissuaded, is that this way they might at least have a more pleasant end. Suicide is often grisly and painful. If the State can provide a quality service which makes a suffering person's last moments more bearable, then I guess that's some small blessing, right?

Perhaps the biggest problem I can see with this idea, is that the service would probably either be futile or monstrous. Presumably the vast majority of people who (want to) commit suicide are making a mistake. So if the state service accurately assesses that, then it would almost never go through with killing anyone. But if someone really wants to die, and knows the State facility won't grant that wish, then they'd have no reason to go there. They'd just kill themselves the old-fashioned way. So the service would be pointless. Alternatively, if they carry through and kill people who continue to irrationally wish it, then the service is monstrous. (Surely the last thing we want is to encourage more tragic/unnecessary deaths.)

So there might be a problem in finding the right balance here. How paternalistic should we be with regard to the choices of the suicidal? Perhaps some sort of compromise is in order. One might require that the person complete a range of requirements (e.g. extended counseling), but once they finally do so, the ultimate choice is entirely their own. That might be enough to entice the suicidal, while nevertheless making a positive difference by saving people's lives.

Perhaps an even bigger problem would be getting people to use such a service in the first place. If someone really can't bear to live any longer, then they're probably just going to 'off' themselves immediately, rather than trudge over to some government office and get bogged down in bureaucratic requirements (e.g. the counseling) for weeks or months. This is really the same old conflict between 'monstrous' and 'futile'; between the individual's suicidal wishes and the State's interest in saving them.

But at least it might get the attention of those who don't really want to kill themselves, but aren't sure what else to do. The service might be able to help them; but then it would seem no different from the "Lifeline"-style counseling services we already provide.

To be a worthwhile new service, the Universal Voluntary Euthanasia centre would actually have to kill people. And that's not a pleasant thought. What's worse, to be a success we would likely have to market that service to those who would otherwise commit suicide on their own. We'd have to convince people that the UVE service is preferable to a DIY approach. "Leave it to the professionals", or some such message. But can you advocate a suicide provider without (ipso facto) encouraging suicide itself? If not, it looks like we'd end up firmly down the 'monstrous' side of the scale.

I guess from a utilitarian point of view, these practical difficulties are enough to set UVE apart from the more traditional, medical euthanasia. While the latter may be beneficial, we can see why the former would likely do more harm than good.

So, my biggest question is whether anyone can see a way to get the described UVE service to work; a way to balance the twin threats of futility and monstrosity.

A second question is whether one can justify allowing traditional euthanasia, but not UVE, on non-utilitarian grounds.

Your thoughts?

6 comments:

  1. Having seen state-supported housing, I don't think I would trust a state-supported suicide counseling service. It would be cheaper just to kill them all, and when the budget runs low... well... 

    Posted by Jason Kuznicki

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  2. Problem is that you might end up killing huge numbers of teenagers and young adults. These indivuduals would probably have changed their minds about hteir worthlessness as they grew older but given the opportunity at any particular moment might decide to kill themselves.
    From a social utility point of view their personal decision is likely to hve a very large negitive effect on the rest of the country/society (as opposed to a choice by a 90 year old), their lack of internaliztion of their future self and society's wishes would result in net negitive utility probably.
    Thus society presumably should make such a choice difficult to such a degree as to balance such problems.
    Also from a pragmatic point of view the massive reduction in trained but not yet working age population would be harmful to the economy thus reducing ones ability to provide social services in other areas. 

    Posted by geniusNZ

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  3. Euthanasia relates to "rational suicides", Most suicides ae irrational and probably not affected by any structure we might set up. We would normally take the view today that suicide was irrational for a healthy person and so euthanasia arises only for the seriously ill or debilitated. This necessarily involves a dialogue between the patient (the only person who ultimately knows what he wants) and health professional(s) who know (best) what will (or may) happen if particular options are followed.

    There are at least 4 situations

    1. Patient can be kept alive only by heroic intervention that cannot be justified on current funding priorities.

    2. Extreme suffering which cannot be alleviated or can be alleviated only by heroic measures that cannot be justified on curretn funding priorities.

    3. Suffering which canot be alleviated without risk to the patient.

    4. Severe debilitation leading to severely diminished future quality of life and little prospect of improvement.


    The first situation will result in the patient dying (unless reources are diverted which simply transfers the problem to another patient). The patient has no choice - this is just a limit of the health service (or of current medical technology).

    The second situation is the one that usually results in animals being put down - it's probably possible to keep a horse with a broken leg alive and comfortable it's just that no one's going to pay to do it. It's unusual with humans as we're normally willing to spend quite significant sums on alleviating pain even when the final prognosis is hopeless.

    The third case is probably the most common with human terminal care. Pain is managed with (eg) opiates but eventually doses are likely to prove fatal. Adoption of this regime would normally require the patient's consent.

    The fourth case is typified by Alzheimer's or other neurological complaints. The patient may not be suffering but has no prospect of much quality of life. Some patients may want to hang on to whatever is left others may find the frustrations intolerable. These decisions may be complicated by teh fact that the patient may reach a stage where they are not competent to decide their future or are unable to communicate their decision. Presumably they need to delegate this decision to someone else through a power of attorney (or otherwise).

    It's important that a patient can choose to "die with dignity" when the time comes. A patient who fears being stuck in a body which will not die while unable to communicate a choice to die may sign "Do not resuscitate" orders or forgo life-saving medical treatment at an earlier time simply to escape that future fear. 

    Posted by Greyshade

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  4. I had a conversation about this with a friend, and ended up contented with the view that our current system is best. Rather than legitimising it in law, which would be to open the system up for legal challenge and rorting for inheritances, it should be dealt with through leniency. That is drug overdose 'errors' being overlooked, etc. Apparently when someone is right on the edge, it's not too hard to push them over making it look like an accident. Leaving the system as it is lets us prevent people from bullying people into accepting euthanasia, and allows us to look the other way when a little bit of mercy is shown towards those on the brink. 

    Posted by Tennessee Leeuwenburg

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  5. It's interesting to compare the comments from Genius and Greyshade. Genius worries that the extra opportunity might lead many more people to kill themselves (what I described as the "monstrous" scenario). Greyshade, by contrast, suggests no-one would use the service as suicidal people would "probably not [be] affected by any structure we might set up" (i.e. my "futile" scenario).

    Of course, they can't both be right.

    So does anyone think an appropriate balance might possibly be found (at least in theory if not in practice)?

    Jason - ha, rather cynical! But what if it were run by a private charity group? I don't know the details of how Lifeline works here in N.Z. - I think it's a volunteer/charity sort of organization, but I don't know where their funding comes from (state or private donations?). But they seem to do a good job, anyway, from what I've heard. 

    Posted by Richard

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  6. In relation to your main point here - Lifeline seems to work on the principle that you can convince someone to want somthing (eg to live) and then deliver it and that amounts to added utility. rather like coke adds a huge amount of utility to the earth (in a sense) by creating demand for itself.
    My question is - "is this a valid comparison?" if not why not?
    Under what situations should such "convincing be considered appropriate and at what point is it antisocial?

     

    Posted by GeniusNZ

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