Killing or Letting Die, a series on decision-making when death is at the table:
Part 1 - Intending or Pretending?
Part 3 - Causation or Conflation?
Part 4 - The Priority of Authority?
Part 5 - Conclusion
We’ve trekked over a series of four parts exploring the differences between killing and letting die. Where does that leave us?
First, I want to point to a few general thoughts that the specific project helped to cultivate:
Moral evaluation is a multifaceted, multilayered, iterative process. The facets of moral evaluation might include things like intention, duty, causation, and authority (as we explored here), and other things. The layers of moral evaluation might reveal themselves as we dive into any one of these areas. You may have felt, as I certainly did, that we were swimming over deep waters. We didn’t begin to plumb their depths, but maybe we got a sense of some of the currents and wildlife underneath us. There are very few actions that you can evaluate on one criterion alone. But this makes the moral evaluation more complicated because you need some way of weighing among these different factors to reach a conclusion. Moral evaluation is also iterative. I’m sure I could circle back around to repeat this series and say more than I did, and say it differently, reflecting on what’s been explored in other areas. And I could do it again, and again. Sometimes people do that, always hemming and hawing, never concluding. That needn’t be the case, but it sometimes is when all you’re left to conclude is, “I don’t know. But I know that I don’t know better now.”
Words are tools for exploring relationships. The raw humanity of situations in which we consider this problem, the terrible suffering that shoves us to this threshold of death, puts practical considerations immediately before us: what really is the difference between killing and letting someone die? I tried to turn over some of the rocks in that field. If we wander away from all that for a bit, though, we see that these concepts, “killing” and “letting die,” are tools for asking questions. By using these concepts as tools, what can we learn about clinicians and their relationship with patients? What can we learn about the sick and suffering and their relationship with the world? What is medicine for? Thinking of the concepts in this way can help to uncover presuppositions on all sides and make disagreement more productive. I tried, in the course of this series of essays, to peek over the ridge into this territory without becoming overly pedantic. We can’t forget that eventually we need to sit the tools down to behold again the humanity of those who are living amidst this fraught landscape. Hopefully we return them with more clarity about what we can and should do.
There’s always more. Wendell Berry wrote, “Telling a story is like reaching into a granary full of wheat and drawing out a handful. There is always more to tell than can be told.” I feel like that’s the case with these thorny issues. You might feel like you have a pretty good command of the relevant literature, but there’s always a new thing to consider. In this case, we haven’t considered, say, existential and phenomenological features of the question. Do they matter? They might! We also didn’t dive deeply into the legal history. If we did, we’d also need to consider into which country’s history we’d dive. Personal narratives also provide their own insights. All this contributes to the iterative nature of moral evaluation. That doesn’t mean you can never draw a conclusion or make a decision, but I’m humbled to consider the expanse upon which I only glance, even as others dedicate their entire careers to mining corners of it. I haven’t offered this series claiming it’s comprehensive or even systematic, but only to work out my thinking in public view. I hope whatever scrutiny it receives sharpens my mind and softens my heart.
Honesty matters. I appreciate that James Rachels drew something hidden out into the open about how some people would decide to treat infants with easily correctable surgical problems depending on whether or not they had Down syndrome. Consistency is important. If I discover an inconsistency in my own reasoning, I should try to reconcile that. That’s what I’ve attempted to do here: Rachels provoked me to consider why I think “killing” and “letting die” are (usually) different. For some, though, tolerating the discomfort inherent in working out these inconsistencies may be too much and, frankly, not a priority. Consistency is important, but we’re not perfect. The beans might burn while we’re pondering conceptual distinctions. Concepts might remain indistinct while you enjoy some beans with your family.
Sometimes opinions change, sometimes they’re deepened and strengthened. In this particular instance, I reached a conclusion close to what I imagine I would have before I set out (recognizing that this series is a mile marker in a journey that pre-dates its writing by many years). While this may be an example of Jonathan Haidt’s elephant of intuition leading the rational rider (i.e., providing post hoc reasoning for something I felt was right anyway), I think it may (also) be an example of using reasoning to gain greater insight into one’s moral evaluations. For some people, moral evaluation starts and ends with intuition. Developing that into something more articulate can help you and others, if only to have a more productive disagreement.
And here are a few thoughts on the specific matter at hand:
A clinician shouldn’t kill their patients, or help them kill themselves. I tried to make the case for this when I wrote about death as a goal of care. I feel like this exploration has reinforced my opinion on the matter. There’s nothing in what I’ve read that would lead me to even suspect it’s a good idea for a clinician to kill their patient, or to help them kill themselves. Good idea or bad, though, my heart breaks for a world in which people are faced with this choice: terrible suffering or a quick death. My heart breaks for these people. And how tempting it is to have a means within one’s grasp that is guaranteed to end that suffering. But I say no because it will hurt people. Not only that, but it will so deform the practice of medicine that, like termite-infested joists under a home, its foundations will be unable to support the weight of the moral work that seeks to care for people at their most vulnerable. Like termites, some of the reasoning that attempts to support killing patients is insidious (e.g., assuming there’s such a thing as a “life worth living”).
Sometimes letting someone die is wrong, sometimes it isn’t. Rather than likening “letting die” to “killing,” I find it more straightforward to evaluate the act of “letting die” on its own terms. When we do that, we find that in some cases, it’s permissible, and in other cases, it isn’t. That doesn’t mean we can take our reasoning for “letting die” and translate it immediately to “killing,” a separate idea.
The worst cases of letting someone die rise to the level of murder. This is so extreme we wouldn’t even call it “letting die.” Consider a visiting family member who turns off a patient’s ventilator. As we discussed, someone must have the capacity and authority to act otherwise in order to reasonably be said to have allowed something to occur. This family member, while they had the capacity to turn off the ventilator, didn’t have the authority, and therefore didn’t “let die.” They killed; indeed, they murdered. The same can’t be said of a clinician who turns off the ventilator with the patient’s consent with the intention of removing an intrusive medical intervention that is no longer benefitting the patient.
Clinicians need to adopt practices to keep them oriented as they care for dying patients. Some clinicians will never encounter this dilemma. Others, like me, will encounter it nearly every day. Without clarity of mind about what one is doing, one’s intuitions may rub a blister into the conscience. Sometimes this is called moral distress. Working through one’s own thoughts on the matter can be helpful in bringing such intuitions to light and using them to direct study about morally salient matters like these. Space and time for reflection are critical. It’s hard to do because some days you’re just running around with your hair on fire. Still, reflection (a more complex process than merely venting or pausing to consider something) is just as necessary as learning the right doses for the right medications or the right surgical technique. Without it, clinicians literally become de-moralized.
I hope you’ve found this series helpful. I have. I’ve appreciated hearing from some of you. Please share your thoughts in the comments on any of the essays to continue the conversation.