According to Kant, dignity signifies the inner worth of a person who has the capacity to exercise her rational faculties according to the moral laws. This articulation of dignity allows us to build two distinct moral perspectives on euthanasia.
Firstly: Since dignity has an absolute value—and as rational beings we have a duty to respect the dignity inherent in us—it follows that no amount of pain or suffering can morally legitimize any act which leads to the termination of dignity. Therefore, euthanasia to the extent it entails killing of oneself to ease one’s own pain and suffering would be, in Kantian terms, an immoral act. Secondly: individuals who do not have the capacity to exercise their rational functions lack dignity (in the sense Kant understood it).Footnote 36 Life in such cases becomes a mere biological unit lacking any rational or moral capacity. Since such individuals can no longer be regarded as persons (in Kantian terms), it could be argued, that Kantian prohibition against suicide would not apply to such individuals. By extension, it could also be argued, that the prohibition would not apply to such cases where an individual commits suicide on a justified likelihood that she would lose control of her rational faculty.
There isn’t much to be said about the first perspective except that there is a strong moral support for euthanasia outside the moral universe of Kant; hence it would not be taken up for any further discussion. As regards the second situation, and despite the relative simplicity of the perspective we have generated, there are inherent difficulties that borders on issues of complex moral concerns like the duty to die and matters of capacity and consent. While some of the issues can be subjected to a philosophical extrapolation, for example moral issues like the debate on “dying with dignity”, there are others that cannot be answered without subjecting it to a full empirical treatment.Footnote 37
Existing literature on euthanasia suggests that a Kantian prohibition on suicide can be eschewed in respect of persons suffering from dementia.Footnote 38 Since dementia involves the loss of cognitive functioning—a key feature of the Kantian notion of humanity—it is argued that individuals in such state exist simply as physical beings.Footnote 39 The emphasis on physical beings, serves as a deliberate contrast to the idea of a moral being, as someone who still has control of her rational faculties. It also reinforces a key concept of the mind–body paradigm: that the body’s moral status is conditional to serving as a conduit for rational functions.Footnote 40 Under such circumstances, it is argued, Kant cannot have a moral objection to euthanasia.
Taking this hypothesis as a starting point, Cooley observes that “in the case of those who will be demented, it is a rational duty to die physically before dying morally” adding further that this is a duty which the individual “owes to herself as a moral agent”.Footnote 41 Cooley grounds the duty to die from his reading of Kant’s duty of self-preservation, which as explained by Kant could be eschewed only in the face of higher moral duties. Cooley extrapolates this argument to suggest that an individual who is anticipating dementia has a moral duty to commit suicide before dementia set roots and deprives her of her rational capacity. Thus, Cooley argues that in the face of a certain possibility that one may be deprived of one’s rational faculties (as in the case of dementia), it is better to commit suicide and preserve one’s moral and rational agency, than settle for a less moral existence.
It is noteworthy that Cooley does not extend the same duty to those already in a state of dementia. He observes that the loss of rational agency, which comes with dementia, deprives a person of her moral status and dignity, thereby rendering her incapable of any duty.Footnote 42 This point is taken further by Sharpe, who argues that patients suffering from dementia are like objects, hence, they should be treated in a manner that is ethically best suited to the interest of others.Footnote 43 Arguing from a Kantian perspective of beneficence, Sharp argues that a demented person is a burden—both financially and emotionally—to all those near him; hence it would be in the best interest of others to euthanize her.Footnote 44 For most part, while Sharp disagrees with Cooley’s interpretation of the Kantian duty to die—and by extension with the claim that person anticipating dementia has a duty to die—he agrees with Cooley that a person suffering from dementia has no dignity. Unlike Cooley however, he argues that if such persons do not commit suicide before the onset of dementia, the onus would fall on others to do it for her once dementia sets in.
Critics have questioned whether a Kantian duty to die could be applied to patients suffering from dementia. While Sharp shares Cooley’s premise that a demented person lacks dignity, he is doubtful whether the same premise could be used to justify a duty to die on the part of patients anticipating dementia. Sharp also argues that Cooley’s reliance on the Kantian analogy of the madman wouldn’t do much to further his claim as both apply to different situations. He observes that Kant’s justification for suicide by the madman are based on considerations that are unique to the madman’s own position—for example he may pose a danger to others or his own person—which may not be compatible to the position that demented patients find themselves.Footnote 45 Cooley’s work has also been criticised as being based on an incorrect interpretation of Kantian ethics. Cholbi, for example, argues that Kantian ethics allows no scope for a duty to die, at least in respect of situations that are unique to individuals anticipating dementia.Footnote 46 Cholbi observes that Cooley’s reference to a Kantian duty to die applies only to those situations where an individual has to choose between surrendering his dignity and living an undignified life or sacrificing himself and saving his honour in the process.Footnote 47 Cholbi is sceptical that a soon-to-be demented person warrants the same consideration regarding dignity as someone staring at a life full of indignity. In the former case, he argues, the question of indignity would never arise because a demented person being a “non-person” is neither capable of dignity nor indignity.Footnote 48 Moreover, Cholbi believes that Cooley completely misunderstands the different “threats to moral agency” that necessitates suicide in both the cases.Footnote 49 In the case of a person staring at a life full of servitude, suicide is necessary so that his moral agency is not misused for immoral purposes, whereas in the case of person avoiding dementia suicide is an option so that he does not lose that agency.Footnote 50
According to Cholbi, Cooley follows a line of reasoning that does not logically justify the conclusion he is seeking to achieve. Cholbi, for example, points out that the reasoning Cooley’s argument goes like this: that if the moral standing of a person is by reason of her possessing a certain property, which also requires her to preserve it, then it follows that if the property is lost (or will be lost) she should kill herself. Cholbi argues that this conclusion is logically flawed, in that, it does not follow from the premise Cooley has adopted. By way of an analogy Cholbi explains that if an object has certain value because of a certain property it possesses which also requires it to be preserved, it does not follow that the loss of the property (or possible loss of the property) entails the destruction of the object. All that follows, observes Cholbi, is that “I do not have a duty to preserve it”.Footnote 51
But Can a Kantian duty of self-preservation, which basically is a duty to oneself, be exercised on behalf of the duty-holder? Sharp, for example, suggests that if the patient is no longer capable of ending her life (prior to full onset of dementia), then someone must do it for her.Footnote 52 It is doubtful, given the personal nature of the duties to the self, whether this suggestion can hold ground.Footnote 53 It should be noted that what Kant envisages as duties to the self consists of some exclusive category of duties, which by their very nature could only be performed by the duty-holder. Since these duties are aimed at the moral perfection of individuals, its full worth can only be realised if the duty-holder performs the task herself. Hence, Cholbi argues that Sharp’s proposal of euthanizing a demented patient is based on an incorrect reading of Kantian philosophy.
Sharp also, it seems, mistakenly conflates two distinct ethical systems and uses the precepts of one ethical system to justify a claim made under the other. For example, his position on the moral status of demented persons (and the consequent need to euthanize them) follows unequivocally from the Kantian notions of dignity and personhood. Yet he is equally considerate of the emotional and financial consequences of keeping a demented person alive, something he uses as a justification for euthanizing a demented person. These are at best utilitarian considerations, something which Kant himself would never have approved. While Sharp could still argue that as non-moral entities, patients of dementia are not amenable to Kant’s ethical precepts since it applies only to rational persons. But such a stance only begs the question whether Kantian ethics are inapplicable to non-rational persons? As Cholbi points out in his work, it would be a fallacy to presume that Kantian ethics are not applicable to demented individuals. For one, Cholbi observes “we may have indirect duties to others concerning the demented’, which in this case would involve not causing unnecessary pain to the families and friends of the demented person by our actions.Footnote 54
Is Cooley justified in assuming that there is a Kantian duty to die? While Kant believes that it is morally permissible for a person to sacrifice herself if it could preserve her honour, it is not clear whether he considers it morally obligatory as well. Cholbi himself claims that such a conclusion is not possible from Kant’s own example in this regard.Footnote 55 Yet there are aspects of Cholbi’s criticism against Cooley that needs to be reconsidered in the light of Kantian notion of “honour”. The argument here is not to create a Kantian duty to die but to understand whether “honour” in the sense that Kant understood it could be reconciled with Cholbi’s suggestion that it is not dishonourable to be demented.
To start with, Cholbi is correct in assuming that suicide necessitated by the threat to one’s rational agency cannot be compared with suicide necessitated by the fear of losing one’s rational agency. The stress on killing however is overemphasised. It should be the consequences of being alive that should guide our discussion on this matter rather than the act of killing oneself. For Kant, suicide is morally permissible only when staying alive would lead to the moral agency being used in contradiction to the objectives of rational existence. Cholbi refers to such situation as the “misuse” of rational agency. But what does misuse mean in this context? Cholbi refers to misuse in a Kantian sense of the term, which in the context of autonomy implies using our rational agency for purposes that are not warranted by the moral law. In a state of perpetual slavery, a person is governed not by the action she wills in accordance with the moral law, but by the dictates of her master. Slavery, in this sense is dishonourable for Kant because it effectively curbs the capacity to exercise one’s rational faculties in accordance with the autonomy of the will.
Is it dishonourable to be demented? Cholbi answers in the negative; and going by the literal meaning of the word, there is indeed nothing dishonourable about being demented. However, in Kantian terms dishonoured existence has implications that are deeply rooted in one’s capacity to live a moral life. It implies a condition in which an individual is no longer in a position to honour the dignity of her autonomy. Rachel Bayefsky points to a Kantian quality called the “love of honour”, which, she suggests, implies an attitude to live up to the “dictates of autonomous reason, and not on the opinion of others”.Footnote 56 She further claims that “honour for Kant, then, is not simply an external appendage or an inimical passion, but can actually play a role in discharging a duty to respect the dignity of humanity”.Footnote 57 If honourable existence means an attitude to live up to the dictates of autonomous reason, then it follows that only a person who possesses the faculty of rational agency can live with that attitude. Dementia impairs all those faculties that Kant considered necessary for moral existence; thus, taking it beyond the scope of the demented individual to honour her dignity. Based on this perspective, there is no reason to doubt that it is indeed dishonourable to be demented. Of course, not being able to exercise one’s rational faculties by reason of some medical condition is one thing, and wrongfully exercising it under coercion is another thing. But the goal here is not to compare the reasons why an individual is incapable of exercising her rational agencies. The inquiry, instead, should concern with the consequences that ensue if a person does not kill herself even in the likelihood of losing her rational agency. In other words, it is the likelihood of being in a position which compromises her ability to lead a moral life that justifies suicide and not the reason why she is in that situation. Based on the above points it seems that under a Kantian ethical framework it would be morally permissible for a person anticipating dementia to euthanize herself.