This article appears in the November 2006 edition of the Catholic Medical Quarterly

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Autonomy, Dignity and the Legalisation of Euthanasia

Talk to the Bristol/Bath Branches of the Guild of Catholic Doctors 24 May 2006

Luke Gormally

There are various arguments against legalizing euthanasia. Arguments, for example, from the practical effects of doing so: the pressures placed thereby on the vulnerable, and the impossibility of creating an effective regulatory system which would control `abuse' There are arguments about the logic of legalizing voluntary euthanasia: if it is a benefit for die"competent why should the incompetent be deprived of such a benefit? The practice of non-voluntary euthanasia inevitably gets the green light once you legalise voluntary euthanasia, as we can see from Holland. In this talk my focus will be different.

I shall be offering a relatively abstract line of argument. By abstract I mean, in particular, that I shall not refer to concrete clinical cases, which are the natural focus of a doctor's concerns. I will be happy to enter into discussion of the ethical issues raised by concrete cases during the time set aside for discussion. A degree of abstracting from particular cases is justified, however, just to the extent that there are common themes running through concrete cases.

When we think about cases in which patients request assistance in suicide or euthanasia it is plain enough that the idea of patient autonomy is a common theme. The idea of respect for patient autonomy, which is standardly associated with respect for a patient's dignity, is prominent in debates about the legalization of assistance in suicide and euthanasia. So I want to devote this talk to examining the way in which the idea of patient autonomy is associated in the minds of many with the idea of human dignity, and the way these associated ideas may be put to work to justify the legalisation of assistance in suicide and euthanasia, and to offer reasons for thinking that the attempted justification fails.

All existing legislation accommodating euthanasia (as in Holland and Belgium), and all proposals for its legalization in other jurisdictions, stipulate that it is a doctor who is to do the killing. That is why I built into the definition of euthanasia' that it is carried out in the course of medical care, though conveivably it need not be. But since that is what is universally proposed, the key issue on which we have to concentrate is whether there can be justification for the law to make legal provision for doctors to kill their patients for the benefit of the patients.

There are two propositions which govern the argument that follows, though in neither case do I assume the meaning of the proposition to be such as obviously to exclude the reasonableness of legalizing euthanasia. Rather I show that the propositions cannot be interpreted in a sense that would justify the legalization of euthanasia.

The first proposition is that doctors should act for the benefit of their patients. The proposition would be uncontroversial if we could agree what we mean by 'benefit'. But in fact we don't agree. There may have been a time when there was a consensus in the medical profession about the clearly delimited health-related benefits it was entrusted to deliver, but that consensus no longer exists. Health for many has now become a catch-all notion and doctors are expected to secure comprehensive human well-being. Euthanasia can thus appear to be just another human benefit medicine is competent to deliver. As I hope to show, however, those who seek to justify the legalization of euthanasia by reference to patient' autonomy are committed to an indefensible understanding of patient benefit.

The second proposition is that it is never permissible intentionally to kill another human being for reasons incompatible with justice. Since our being alive is the fundamental condition of realising any of the other human goods which are the basic elements of our flourishing as human beings, both morality and the law give a fundamental priority to the protection of human life. Justice has among its most basic requirements restraints designed to protect human life, and in particular restraints on intentional killing. The crucial question raised by the proposal to legalize voluntary euthanasia is whether we can provide a justification for it consistent with the assumptions we need to make if there is to be a just ordering of human relations in society.

We are discussing whether the law can make legal provision for doctors intentionally to kill their patients at the patient's request. The doctor is not some automaton, a mere instrument of the patient's will. It is the doctor who is to do the killing and the doctor who is therefore answerable before the law for what he does. He has to have a reason which the law canregard as an acceptable reason for killing.

Since the doctor is committed to acting for the `benefit' of the patient his reason for killing is going to have to be to the effect that death will be a benefit to the patient. In other words he will have to think that the patient would be better off dead. And a patient can be thought to be better off dead if it is reasonable to think that the patient's life is no longer worth living. This thought does indeed take a hold on patients fora variety of reasons: they may be suffering excessive pain; they may be experiencing intolerable stress; they may find the dependence on others to which they are reduced unacceptable, an intolerable affront to their sense of their dignity; they may be afflicted by a sense of the futility of their existence; or they may simply be tired of life - the reason the Dutch now have in mind to include in the repertoire of reasons for justifying euthanasia. On whatever grounds it may be advanced, an adverse judgement on the continuing worth of a patient's life is central, either explicitly or implicitly, to any justification of euthanasia which claims that it secures a benefit for the patient.

There is an argument about the significance of patient autonomy which seeks to show that doctors can have no alternative but to accept the patient's own valuation of his or her life. Roughly speaking, the claim is that if a patient says his life is no longer worthwhile the doctorcould have no grounds for overriding that judgement since it is down to the patient to determine what counts as the value of his or her life.

What lies behind this claim is a view widespread in the culture, with numbers of proponents among moral and legal philosophers. The view goes roughly as follows. What has value in a human life is the life of the person that has had value conferred upon it by the choices the person makes, and more particularly those choices which futher the interests, successful pursuit of which makes a person feel that his or her life is goingwell. What those interests are is a matter for personal decision. Personal decisions about theinterests one is going to pursue don't have to answer to any general criteria of what counts as a good life. It's more a case of what feels right for me. One gives a coherent sense to one's life by the consistent pursuit of one's chosen interests.

On this account of how a life achieves value, an extensive right to self-determination - an extensive autonomy right - is important precisely because it is through the exercise of choice that one gives the shape one wants to one's life. As Ronald Dworkin puts it, everyone has a "right to a life structured by his own values" because it is autonomy that makes "self-creation"possible.'

Autonomy here means not just giving shape to one's character by the choices one makes in thelight of certain values, but deciding what is to count as valuable, and shaping one's life accordingly. In discussing the legalization of assistance in suicide and euthanasia Dworkin (along with a number of other distinguished philosophers) is fond of quoting a now famous(or infamous) sentence from the joint opinion of Justices O'Connor, Kennedy and Souter in the 1992 United States Supreme Court case of Planned Parenthood v. Casey: "At the heart of liberty is the right to define one's own concept of existence, of meaning, of the universe and of the mystery of human life."Choices based on that 'right', they said, are "central to personal dignity and autonomy".3 The notion that there are some basic moral truths to be recognised in the shaping of one's life has disappeared and been replaced by a radical individualism in determining what is to count as meaningful and valuable.

The significance of this view of the claims of autonomy and of what constitutes human worth or dignity is that it appears to lend a unique authority to a patient's own view of the value of his life. On what basis could a doctor question a patient's judgement that his life is no longer worthwhile if the worth of that life is wholly determined by the patient's idiosyncratic choices? If it is true that the value of a person's life is uniquely determined by the choices that person makes, then, if he or she says that under certain conditions their life would not be worthwhile and they would be better off dead, does that not make out the case for saying that death would be a benefit to the patient? And if a benefit, then surely a doctor is justified in assisting in suicide or executing euthanasia.

In criticising this line of thought I'd like to offer an argumentative response which is serviceable in public policy debates in our pluralistic society about the legalization of euthanasia. It is a line of argument which relies on minimal assumptions.

At the outset I readily acknowledge that there is indeed a type of goodness or value, and therefore a type of dignity, which a life may acquire in virtue of the kind of choices an individual makes in giving shape to his or her character. One could usefully call it existential dignity. Existential dignity is indeed typically exhibited in the character people acquire in virtue of the way they live their lives. But we are not inclined to recognise goodness and dignity in just any kind of character, however deliberately acquired. This alone suggests that what is to count as a valuable or worthwhile life cannot be determined by an individual without reference to shared understanding of what is worthwhile. That being so, it is not obvious that a person's estimate of the value of his or her life should have a unique authority in the eyes of a physician simply in virtue of the patient's say-so. The belief that it does possess unique authority has to assume that there is no body of shared values which enjoys the authority of being objective. It is quite implausible to hold this to be the case about the moral value of a range of dispositions of character. Do we not think that all human beings need, for example, a degree of courage in the conduct of their lives? So a physician may well think that there are common criteria for assessing existential dignity which stand in the way of accepting the patient's own judgement that his life in certain circumstances would no longer be worthwhile. Nonetheless, the existence of objective criteria for assessing existential dignity would not necessarily exclude the possibility of a doctor agreeing with a patient's belief that on balance his life was no longer worth living.

There is something more fundamentally wrong with holding that a ,patient's belief that his life is no longer worth living and that he would be better off dead can justify a doctor in acceding to a request for euthanasia. This view assumes not only a mistaken view of existential dignity, but, more importantly, fails to recognise a more basic dignity without recognition of which we cannot ground a defensible account of justice in human relationships.

It is clear that many deny there is any such thing as the basic human dignity to which I refer. So why propose that we cannot do without the assumption that human beings possess a common basic dignity prior to any existential dignity they may possess?

Consider what would be the case it if were true that there is no account to be given of the value of a life independently of the value the person whose life it is determines it has. To be able to confer value on one's life a person must have adequately developed abilities for understanding, judgement and choice, abilities which will be characteristically exercised in thinking of various things, projects and activities as valuable and investing one's life with value through one's engagement in certain projects and activities. How well developed must the relevant abilities be to be adequately developed? There is no single rationally compelling answer to this question so that it is inevitable that it becomes a matter of choice where one draws the line between those deemed to have adequately developed psychological abilities and those who have not yet reached the requisite developmental stage. But if where one draws the line in this regard is necessarily a matter of choice then the line-drawing is arbitrary. A certain arbitrariness in determining the membership of many bodies is unavoidable, but it is hardly admissible in determining who belong to the community of those who are to be treated justly. Since what we are discussing here are the features in virtue of which a human being is deemed to have the kind of value which entitles him or her to just treatment, it is obviously unacceptable that the features which are held to be relevant should be based on an arbitrary choice. The obviousness follows from the fact that one of our most basic intuitions about justice is that it excludes arbitrariness about who is to be treated justly. The need for a non-arbitrary understanding of who are to be treated justly requires that we assume that it is the simple fact of being human which establishes one's entitlement, so that all human beings are deemed to be equal in basic worth and dignity.

Can such an understanding find a grounding outside some framework of religious belief? Or does it have to be a groundless assumption for the secularist thinker, who in consequence may be tempted to think it a fiction arising from the desire to retain a hold on the concept of justice? If that is all that could be said for it, it might well be concluded that the concept of justice should be jettisoned. It would then appear that for secularism our dealings with each other depended on who had the power to determine who should command a certain respect and who, on the other hand, would be dealt with as convenience dictated.

Even within the emaciated resources of what passes for public reason in our society it is possible to offer intellectual resistance to such a descent into barbarism. We might reflect that the abilities to understand, judge and choose, which everyone rightly prizes, and in exercising which we may come to live well as human beings, are abilities we develop in virtue of a fundamental capacity inherent in our nature. They do not supervene in our lives in virtue of something extrinsic to our nature, even though their development depends on a facilitating environment. So if we recognise a worth and dignity which can be exhibited in the exercise of the abilities for understanding, judgement and choice, we should recognise aneven more fundamental worth and dignity in the human nature in virtue of which we are capable of developing those abilities.

We do not have reason to think that those who have lost the abilities to which they attach their own sense of their dignity as human beings - in particular the incompetent - are not in fact human beings, and as such bearers of a worth and dignity more fundamental than any existential dignity that may have characterised their lives. This more basic dignity is reason not to accept those self-valuations which inspire requests for assistance in suicide, including suicidal advance directives, and requests for euthanasia. What recognition of this more basic dignity blocks is the judgement that a person has not got a worthwhile life, and thereby blocks the inference that that person would be better off dead.

It is sometimes objected to this claim that it relies on collapsing a distinction which should be maintained between the thought that the continued living of a life is no longer worthwhile and the thought that the person, whose life it is, lacks value. You can continue to think, it is said, that a person has value while thinking that that person's continued existence is no longer worthwhile. But this contention relies on what is surely an indefensible dualism of person, on the one hand, and personal existence on the other. If you talk about the value of a person you are talking about something which holds good of the actuality of that person. To say that something has positivevalue though its actual existence has negative value is nonsense. The being of a human person is not distinct from his or her ongoing life. A human person just is a living human body, and the life of a person is the life of that body. Hence to say that the ongoing life of a particular living human being is not worthwhile is to deny value to the person whose life it is.

The reality of a shared basic human dignity leaves no room for the claim that a patient's own judgement on the value of his ongoing life constitutes the sole basis on which a physician can judge the value of the patient's life. It is not open to a physician to judge that a person's life lacks worth and for that reason he would be better off dead. And no such judgement should be accommodated by the law as a reason for killing patients or assisting their suicide, for any such judgment would subvert what is most fundamental to just legal arrangements in society, namely recognition of the equality in basic (connatural) dignity of all human beings.

That is the line of reasoning which I have found serviceable in public policy debates about the legalization of euthanasia. It proved influential, for example, in the deliberations of the 1993-1994 House of Lords Select Committee on Medical Ethics which voted unanimously against the legalization of active voluntary euthanasia.

I'd like to close by briefly sketching an important theme in the Christian understanding of human dignity which contrasts so radically with the understanding of human dignity which sees it as wholly a function of an individual's choices.

In his essay `Goodness beyond virtue" the Australian philosopher Raimond Gaita recounts an experience he had as a 17 year-old which has been decisive for his philosophical outlook. He was working as a ward assistant in a psychiatric hospital with severely demented patients, who were treated by most staff as one would treat brute animals and who were wholly abandoned by their families. There was a small group of younger psychiatrists who, speaking of the `inalienable dignity' of these patients, sought to improve their conditions. The young Gaita greatly admired these psychiatrists, but their senior colleagues thought them fools and some of the nurses vehemently despised them.

For the purposes of this talk you can take those patients to stand for all those human being who are perceived - by ethers, or by themselves - as lacking or having lost any dignity they may have possessed. Talk of `inalienable human dignity', Gaita reflects, has a hard job carrying conviction in the face of human beings as sorely afflicted as the psychiatric patients he knew. What seriously convinced him was the following experience:

One day a nun came to the ward. In her middle years, only her vivacity made an impression on me until she talked to the patients. Then everything in her demeanour towards them - the way she spoke to them, her facial expressions, the inflexions of her body - contrasted with and showed up the behaviour of those noble psychiatrists. She showed that they were, despite their best efforts, condescending, as I too had been. She thereby revealed that even such patients were, as the psychiatrists and I had sincerely and generously professed, the equals of those who wanted to help them; but she also revealed that in our hearts we did not believe this.'

Gaita acknowledges the role that the nun's own religious beliefs is likely to have played in explaining her behaviour - her belief, for example, that these poor people are children of God, loved by God. But for Gaita, who is agnostic about the reality of God, what she revealed by her attitude requires no independent justification.

Seeing her I felt irresistibly that her behaviour was directly shaped by the reality which it revealed. I wondered at her, but not at anything about her except that her behaviour should have, so wondrously, this power of revelation... her behaviour was striking not for the virtues it expressed, or even for the good it achieved, but for its power to reveal the full humanity of those whose affliction had made their humanity invisible. Love is the name we give to such behaviour.'

Christian tradition does not share Gaita's agnosticism about what grounds the truth about human beings which warrants such love.

"Dignity", St. Thomas Aquinas said, "signifies something's goodness on account of what it is in itself."' There is a goodness to human nature which consists centrally in the radical orientation of our being to union with the goodness which is God. Each person is made for fulfilment in union with God. We come into existence for that fulfilment - we each of us exist for our own good, and that is why we are lovable for our own sake.' In the course of human development we can progress, under divine grace, towards this fulfilment through understanding and judgment and choice and growth in virtue. But this human good is already the good of those who have not yet acquired the dispositions and abilities necessary to existential dignity, and it remains the good of those who prove incapable of development or who have lost the abilities through exercise of which human existential dignity is exhibited.

In being the good of each of us it is our common good. And we reach this common good through a common life. We need others - in different ways, depending on our capacities and condition - to reach our common good. We need persons who love in us that common good as our good. We therefore need friends. But it is precisely because we have a common good that we can have friends - that we can be loved for our own sake and that our friends can know what will count as loving behaviour towards us. For if there are no grounds for a shared understanding of what makes for our fulfilment, how can others know what is required truly to love us? It is the fundamental orientation of our nature to a common good which grounds a shared understanding of what makes for our fulfilment.

Those who have come to think their lives are no longer worthwhile, in fact share with the rest of us a common good and a common dignity, and they need human friendship, and, minimally, respect for their dignity. It is no expression of respect or act of friendship to help implement suicidal advance directives, or assist the competent to commit suicide or execute euthanasia. It is subversive of the conditions of the common life we all need if we have to live within a legal regime which accommodates any of these practices.

We should be clear in our minds about the deeply destructive character of the ideological position of those like Dworkin who locate the value of a human life solely in the autonomously determined value with which a person is said to invest his or her life. Since that autonomous determination is carried out without reference to any common criteria of what counts as the human good, what each individual counts as his or her `good' may have no claim to being recognised by others. This means that we cannot know what it is to love others; the necessary good of friendship cannot get any purchase within such an outlook.' Society fragments into groups with shared preferences in the absence of a common good. And in this atomistic state of affairs the immature, the severely mentally impaired, the senile, and those who think their lives lacking in continued worth, are no longer seen as lovable for their own sakes, but are rather candidates for expulsion from society.

In charity, St. Thomas says, we love others as "companions in the sharing of beatitude"The beatific vision is, God willing, our vision, not [just your vision or my vision]. And so we [can] love one another as lifelong companions along the way. `This is most clear', St. Thomas writes in his Commentary on Aristotle's Nicomachean Ethics, `where the path is uncertain, for everyone calls back even an unknown and foreign stranger from going the wrong way, as if every man is naturally an acquaintance and a friend of every other man."10 That thought is central to the Christian understanding of human dignity.

End Notes

  1. A list of definitions of terms was distributed on the occasion of the talk.
  2. Ronald Dworkin, Life's Domination (London: Harper Collins Publishers, 1993), p.214
  3. 505 V.5 833 (1992) at 851
  4. In Raimond Gaita, A Common Humanity (London & New York: Rortledge, paperback edition 2002), pp.17-27.
  5. Gaita: 18-19
  6. Gaita: 19-20
  7. St. Thomas Aquinans, HI Sent. d.35, q.1,a.4,
  8. See on this truth Stephen Brock, `Crosby and Aquinas on Personal Dignity', The Thomist 69 (2005): 173-201.
  9. See David M Gallagher, `Person and Ethics in Thomas Aquinas', Acta Philosophica 4(1995) : 51-71.
  10. St. Thomas Aquinas, In Eth. Nic. 1155 a 21-23. This quotation and the text in which it is nested are from John O'Callaghan, `Creation, Human Dignity and the virtues' Nova et Vetera (English Edition) 1 (2003): 109-140, at p.128