In contemplating any life and death moral dilemma, one is often struck by the possible importance of two distinctions; the distinction between killing and “letting die”, and the distinction between an intentional killing and an action aimed at some other outcome that causes death as a foreseen but unintended “side-effect”. Many feel intuitively that these distinctions are morally significant, but attempts to explain why this might be so have been unconvincing. In this paper, I explore the problem from an explicitly consequentialist point of view. I first review and endorse the arguments that the distinctions cannot be drawn with perfect clarity, and that they do not have the kind of fundamental significance required to defend an absolute prohibition on killing. I go on to argue that the distinctions are nonetheless important. A complete consequentialist account of morality must include a consideration of our need and ability to construct and follow rules; our instincts about these rules; and the consequences (to the agent and to others) that might follow if the agent breaks a good general rule, particularly if this involves acting contrary to moral instinct. With this perspective, I suggest that the distinctions between killing and letting die and between intending and foreseeing do have moral relevance, especially for those involved in the care of the sick and dying.
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It is often implied that death may be a very likely or even inevitable consequence of the administration of analgesics and sedatives to terminally ill patients (see for example Kuhse 1987, 86). There is a widespread consensus in modern palliative care circles that this is rarely the case (Ashby 1997; Fohr 1998; Sykes and Thorns 2003a). On the other hand, it is conceded that sometimes palliative treatment does indeed hasten death (Sykes and Thorns 2003b, 343), which clearly leaves a question to be answered by the absolutist.
As pointed out in note 1 above, such a situation is exceedingly rare. The claim of certainty is generally unrealistic and is only made here in order to maintain some symmetry between the pairs; as is argued in the main text, differences in certainty are in reality an important part of the distinction between intending and foreseeing.
In this light, a flaw in Rachels’ intuition test is apparent: Jones sets out to kill his cousin. Only luck intervenes, but if it had not, Jones would have proceeded to try to kill his cousin, and would most likely have succeeded. Jones’ ultimate action may be an “allowing”, but in some sense it is an attempted killing, and it naturally affects our intuitions in a similar way to a killing.
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I would like to thank Associate Professor Ian Kerridge and Associate Professor Rachel Ankeny for extensive comments on the ideas in this paper and reviews of the draft manuscript.
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Douglas, C. End-of-Life Decisions and Moral Psychology: Killing, Letting Die, Intention and Foresight. Bioethical Inquiry 6, 337–347 (2009). https://doi.org/10.1007/s11673-009-9173-2
- Double effect principle
- Withholding treatment
- Terminal care