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End-of-Life Decisions and Moral Psychology: Killing, Letting Die, Intention and Foresight

Abstract

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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Notes

  1. 1.

    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.

  2. 2.

    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.

  3. 3.

    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.

References

  1. Anscombe, E. 2001. Medalist’s address: Action, intention, and ’double effect’. In The doctrine of double effect: Philosophers debate a controversial moral principle, ed. P. A. Woodward. Notre Dame: University of Notre Dame Press. Originally published in Proceedings of the American Catholic Philosophical Association 56, 1982.

  2. Ashby, M. 1997. The fallacies of death causation in palliative care. Medical Journal of Australia 166: 176.

    PubMed  CAS  Google Scholar 

  3. Bennett, J. 1981. Morality and consequences. The Tanner Lectures on Human Values, II. Salt Lake City: University of Utah.

    Google Scholar 

  4. Bennett, J. 1998. The act itself. Oxford: Oxford University Press.

    Book  Google Scholar 

  5. Delaney, N.F. 2008. Two cheers for “closeness”: Terror, targeting and double effect. Philosophical Studies 137(3): 335–367.

    Article  Google Scholar 

  6. Douglas, C., I. Kerridge, and R. Ankeny. 2008. Managing intentions: The end-of-life administration of analgesics and sedatives, and the possibility of slow euthanasia. Bioethics 22(7): 388–396.

    PubMed  Article  Google Scholar 

  7. Fohr, S.A. 1998. The double effect of pain medication: Separating myth from reality. Journal of Palliative Medicine 1(4): 315–328.

    PubMed  Article  CAS  Google Scholar 

  8. Foot, P. 2001. The problem of abortion and the doctrine of double effect. In The doctrine of double effect: Philosophers debate a controversial moral principle, ed. P. A. Woodward. Notre Dame: University of Notre Dame Press. Originally published in Virtues and Vices and Other Essays in Moral Philosophy, 1978, University of California Press.

  9. Gillett, G. 1994. Killing, letting die and moral perception. Bioethics 8(4): 312–328.

    PubMed  Article  Google Scholar 

  10. Greene, J. 2005. Cognitive neuroscience and the structure of the moral mind. In The innate mind, ed. P. Carruthers, S. Laurence, and S. Stich. Oxford: Oxford University Press.

    Google Scholar 

  11. Hare, R. M. 1993. Medical ethics: Can the moral philosopher help? In Essays on bioethics. Oxford: Oxford University Press. Originally published in 1977. Philosophical Medical Ethics: Its Nature and Significance, ed. S. Spicker and H.T. Engelhardt Jr: 49–96. Reidel/Kluwer.

  12. Hauser, M. 2006. Moral minds. New York: HarperCollins Publishers.

    Google Scholar 

  13. Holland, R. F. 1975. Suicide. In Moral problems : A collection of philosophical essays ed J. Rachels. New York: Harper & Row. Originally published in Talk of God (Royal Institute of Philosophy Lectures Volume 2, 1967–8).

  14. Howard-Snyder, F. 2002. Doing vs allowing harm. In Stanford Encyclopedia of Philosophy Fall 2008 Edition, ed. E. N. Zalta. http://plato.stanford.edu/entries/doing-allowing/. Accessed 1 June 2009.

  15. Kuhse, H. 1987. The sanctity-of-life doctrine in medicine: A critique. Oxford: Clarendon Press.

    Google Scholar 

  16. Mackie, J.L. 1977. Ethics: Inventing right and wrong. London: Penguin.

    Google Scholar 

  17. Magnusson, R.S. 2006. The devil’s choice: Re-thinking law, ethics, and symptom relief in palliative care. The Journal of Law, Medicine & Ethics 34(3): 559–569.

    Article  Google Scholar 

  18. McIntyre, A. 2006. Doctrine of double effect. In The Stanford Encyclopedia of Philosophy Summer 2006 Edition, ed. E. N. Zalta. http://plato.stanford.edu/archives/sum2006/entries/double-effect. Accessed 1 June 2009.

  19. McMahon, J. 1994. Killing, letting die, and withdrawing aid. In Killing and letting die, ed. B. Steinbock and A. Norcross: 250–279. New York: Fordham University Press. Originally published in Ethics 103: 250–279.

  20. Nagel, T. 2001. Agent-relative morality. In The doctrine of double effect: Philosophers debate a controversial moral principle, ed. P. A. Woodward. Notre Dame: University of Notre Dame Press. Originally published in “The Limits of Objectivity,” The Tanner Lectures on Human Values, 1980, University of Utah Press.

  21. O’Keeffe, T.M. 1984. Sucide and self-starvation. Philosophy 59(229): 349–363.

    Article  Google Scholar 

  22. Quill, T.E. 1993. The ambiguity of clinical intentions. New England Journal of Medicine 329(14): 1039–1040.

    PubMed  Article  CAS  Google Scholar 

  23. Quinn, W. S. 1994. Actions, intentions and consequences: The doctrine of doing and allowing. In Killing and letting die, ed. B. Steinbock and A. Norcross New York: Fordham University Press. Originally published in Philosophical Review, 98.

  24. Quinn, W. S. 2001. Actions, intentions, and consequences: The doctrine of double effect. In The doctrine of double effect: Philosophers debate a controversial moral principle, ed. P. A. Woodward. Notre Dame: University of Notre Dame Press. Originally published in Philosophy and Public Affairs, 18, 334–351.

  25. Rachels, J. 1994. Active and passive euthanasia. In Killing and letting die, ed. B. Steinbock and A. Norcross: 112–119. New York: Fordham University Press. Originally published in N Engl J Med, 292, 78–80.

  26. Scanlon, T.M. 2008. Moral dimensions. Cambridge: Belknap Press of Harvard University Press.

    Google Scholar 

  27. Simpson, J. 1989. Touching the void. New York: Harper and Row.

    Google Scholar 

  28. Steinbock, B. 1994. The intentional termination of life. In Killing and letting die, ed. B. Steinbock and A. Norcross. New York: Fordham University Press. Originally published in Ethics in Science and Medicine, 6.

  29. Sykes, N. and A. Thorns. 2003a. The use of opioids and sedatives at the end of life. The Lancet Oncology 4(5):312–318.

    PubMed  Article  Google Scholar 

  30. Sykes, N. and A. Thorns. 2003b. Sedative use in the last week of life and the implications for end-of-life decision making. Archives of Internal Medicine 163(3):341–344.

    PubMed  Article  Google Scholar 

  31. Thomson, J.J. 1999. Physician-assisted suicide: Two moral arguments. Ethics 109(3): 497.

    PubMed  Article  Google Scholar 

  32. Tooley, M. 1994. An irrelevant consideration: Killing versus letting die. In Killing and letting die, ed. B. Steinbock and A. Norcross, 103–111. New York: Fordham University Press.

    Google Scholar 

  33. Trammell, R. 1994. Saving life and taking life. In Killing and letting die, ed. B. Steinbock and A. Norcross, 290–297. New York: Fordham University Press. Originally published in Journal of Philosophy, LXXII, 131–137.

  34. van der Maas, P.J., J.J. van Delden, L. Pijnenborg, and C.W. Looman. 1991. Euthanasia and other medical decisions concerning the end of life. Lancet 338(8768): 669–74.

    Article  Google Scholar 

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Acknowledgements

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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Correspondence to Charles Douglas.

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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

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Keywords

  • Intention
  • Double effect principle
  • Euthanasia
  • Withholding treatment
  • Terminal care