Abstract
When it is considered to be in their best interests, withholding and withdrawing life-supporting treatment from non-competent physically ill or injured patients – non-voluntary passive euthanasia, as it has been called – is generally accepted. A central reason in support of the procedures relates to the perceived manner of death they involve: in non-voluntary passive euthanasia death is seen to come about naturally. When a non-competent psychiatric patient attempts to kill herself, the mental health care providers treating her are obligated to try to stop her. Yet it has been suggested that death by suicide can be a part of the natural course of a severe mental illness. Accordingly, if the perceived naturalness of the deaths occurring in connection with non-voluntary passive euthanasia speaks for their moral permissibility, it could be taken that a similar reason can support the moral acceptability of the suicidal deaths of non-competent psychiatric patients. In this article, I consider whether the suicidal death of a non-competent psychiatric patient would necessarily be less natural than those of physically ill or injured patients who die as a result of non-voluntary passive euthanasia. I argue that it would not.
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Notes
While prognoses of patients suffering from severe mental illnesses are currently often less pessimistic than they were earlier, it would unfortunately still be exaggerated to maintain that all severe mental illnesses are curable, cf., e.g., Clemmensen et al. (2012)); Jobe and Harrow (2010); and Slade (2009).
Callahan, Ryan, & Kerridge maintain that coercive suicide-preventing treatment is acceptable in the cases of non-competent patients. While Szasz argues against suicide-prevention, he also thinks that physician-assisted suicide is not acceptable medical practice. The Royal Dutch Association of Medicine, in its turn, allows that physical illnesses and injuries can provide grounds for physician-assisted dying and maintains that suicide based on psychiatric reasons should not be treated differently from assisted suicide in medicine generally. In Belgium, also, suffering unrelated to physical illness or injury is acknowledged in law as a valid basis for physician-assisted dying (cf. Royal Dutch Association of Medicine 2011 and, e.g., Naudts et al. 2006).
Some understandings of naturalness, including the one employed here, allow that naturalness comes in degrees. I take it that, in this context, a death is natural enough when it is as natural as the deaths occurring in connection with non-voluntary passive euthanasia.
It is possible for one to reject active euthanasia and endorse passive euthanasia and think that only the death occurring in connection with the former is natural without believing that its naturalness speaks for its moral acceptability. But then it is unclear what is meant by bringing up the issue of naturalness here and, as proposed, precisely why only passive euthanasia should be deemed morally acceptable. I am not saying that there could not be convincing answers to these questions but that it remains unclear what they would be.
It has been proposed that ‘unresponsive wakefulness syndrome’ would be a more adequate name than ‘vegetative state’ for the condition in question (Laureys et al. 2010). Yet as the older terminology still appears to be more prevalent and, accordingly, less likely to cause confusion, I here use it, but without any intention of endorsing any pejorative connotations that might attach to it. For characterizations of the central features of the chronic disorders of consciousness see, e.g., Fine (2005).
As the above usage of terminology suggests, in cases like that of Mary the question would commonly be taken to be about suicide. Accordingly, the expression ‘psychiatric non-voluntary passive euthanasia’ could be considered misleading, if not question begging. The considerations presented below provide reasons for putting this concern aside.
The forms of euthanasia in which a patient is killed against her will, variations of involuntary euthanasia, are commonly morally condemned and legally prohibited.
As suggested, referring to the division between killing and letting die or to that between intending and foreseeing death are not the only possible ways of arguing that active and passive euthanasia are morally different from each other (and the latter division has also been used in defending active euthanasia). It could instead be maintained that in passive euthanasia a harm is only permitted but in active euthanasia it is caused, that passive euthanasia does not take away anything a patient would have had without outside help whereas active euthanasia does, etc. Yet the divisions between killing and letting die and intending and foreseeing death would appear to be the most popular ones in this connection. And the other distinctions would seem to face similar problems as those two divisions: precisely why would a permitted harm be morally better than a caused one? Etc.
The just characterized one is the main sense in which personal autonomy is understood in current medical ethics (see, e.g., Beauchamp and Childress 2008, Ch. 4). Yet it is not universally endorsed in the context (cf., e.g., Taylor 2009) and, as is also well-known, beyond the sphere of medical ethics a still wider variety of conceptions of autonomy can be found (see, e.g., Dworkin 1988; Garnett 2014; Kekes 2011). For further elucidation of the notion of personal autonomy employed above and defense of it against central rival conceptions of autonomy see, e.g., Beauchamp & Childress (2008, Ch. 4) and Beauchamp and Wobber (2014).
According to some understandings of the notion, naturalness is centrally about absence of human involvement.
I here understand ‘treatment’ in a wide sense in which it encompasses, among other things, all of the means by which the mental health care providers taking care of Mary try to prevent her from killing herself.
The other patients are, of course, suffering in the sense that they have a severe medical condition. But in that respect they and Mary are similar to each other.
Some recent studies suggest that patients with chronic disorders of consciousness may have feelings free of cognitive awareness, so that they may be in distress (see, e.g., J. Panksepp et al. 2007). Given that voluntary euthanasia is commonly taken to presuppose that a patient makes an autonomous request to die, the category of non-voluntary passive euthanasia would seem to encompass also patients who are known to suffer, but who are not autonomous. Accordingly, it would seem to be possible that some patients deemed eligible for non-voluntary passive euthanasia are in distress.
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I thank an anonymous reviewer of this journal for comments and the Kone Foundation for generous financial support.
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Varelius, J. Mental Illness, Natural Death, and Non-Voluntary Passive Euthanasia. Ethic Theory Moral Prac 19, 635–648 (2016). https://doi.org/10.1007/s10677-015-9664-7
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DOI: https://doi.org/10.1007/s10677-015-9664-7