by Joe Miller,
Director of Development
Way back in the late 1990s, I took a class called “Death, Dying and the Law” as part of my PhD program.
The class was taught by two UVA professors—John Arras, a philosopher who specialized in bioethics, and Richard Bonnie, a law professor who specialized in law and medicine.
We read articles with titles like “Killing and Letting Die,” which—as you might expect from the title—asks whether there is a moral difference between actively killing someone and passively allowing someone to die.
At first glance, the answer seems pretty obvious. You can’t kill people. But we let people die all the time. For example, thousands of children die every single day from malnutrition. That’s horrible. But no one reading this article is morally responsible for failing to prevent those deaths.
And yet, that simple answer isn’t quite right.
After all, some cases of killing are permissible. Self-defense and war are obvious examples.
And some cases of letting die are wrong. A first responder who refuses to give aid has done something wrong. Or imagine you’re walking past a shallow pond and see a small child drowning in waist-deep water. Most of us would agree that anyone who failed to rescue the child is a pretty lousy person.
If some cases of killing are okay and some cases of letting die are wrong, then we’re left with the messy task of trying to figure out which kinds of things fall into which category. That is, when faced with a particular kind of life-or-death problem, we have to ask ourselves: is this one of those cases where killing is permissible? Or, conversely, is this one of those cases where letting someone die would be wrong?
These kinds of questions come up fairly regularly in medicine.
For example, the most unforgettable part of my “Death, Dying and the Law” class was a documentary about the life of Dax Cowart. Cowart was burned horrifically in a propane explosion. He was then forcibly treated for 14 months, despite his frequent refusals to accept treatment.
It’s a harrowing film—one that changed some of the ways that medicine is practiced.
The medical profession now takes a patient’s consent as a necessary condition for beginning treatment.
There are still tricky cases—what happens when a patient cannot give consent (because, say, they are unconscious or not competent)? Many big hospitals now have an ethicist on staff to help out with these tough cases. (Arras was the staff ethicist at the UVA hospital at the time of my course.)
End of life decisions are some of the trickiest of those ethical problems.
If a fully competent patient refuses care, then physicians must comply—even in cases where the physician believes the patient could survive if treated. That ethical requirement extends to withdrawing care—for example, a patient can demand a feeding tube be withdrawn or a life support machine be unplugged. Here, too, physicians must comply with the patient’s wishes.
But the killing vs letting die distinction gets blurry in some of these cases. After all, unplugging a machine or withdrawing a feeding tube is an action, one that the physician knows will result in the patient’s death.
There are similarly tricky questions around pain relief. Physicians are permitted to administer pain relief to patients who have refused other treatment. The line between a dose of painkiller sufficient to relieve pain and a dose that proves lethal can be quite small.
How much difference is there between a physician who removes a feeding tube with the intention of complying with a patient’s wishes while knowing that the act will result in the patient’s death and one who administers a large dose of painkiller with the intention of relieving pain while knowing that the dose will be lethal?
This fall, West Virginians will have to answer that question.
We’ll be voting on Amendment 1, which would prohibit physicians and health care providers from participation “in the practice of medically-assisted suicide, euthanasia, or mercy killing.” If the amendment passes, it would be enshrined in the state constitution.
There are no easy answers on this one.
I spent years studying ethics, and I honestly don’t know which lever to pull.
Health professionals shouldn’t kill their patients. But I can still hear Cowart’s screams as he begged to die, and I don’t think I could vote to convict a health professional who slipped him a lethal dose of morphine.
I don’t know what I will decide, but I do know that this is an issue that deserves careful thought and a lot more background and nuance than this column contains. I also know that there is a lot of thoughtful, nuanced work on this topic, work that is based on a variety of philosophical, religious and legal perspectives.
And I know that our libraries—and our librarians—can help you find some of those things to read before you have to walk into the ballot box in November.