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Rioclkw lSSN 0269-9702Volurnc 4 Nurnbn 2 1990

EUTHANASIA, ETHICS ANDECONOMICSHETA H A Y R Y AND MATT1 HAYRY

1In reviewing Daniel Callahans book Setting Limits in a recent issueof Bioethics Peter Singer points out an important failure in many recentattempts to tackle the growing financial problems of organized healthcare.2 There are theorists who in the name of economic necessity putforward views arguing that the elderly or the disabled or the poorcan without qualms be denied the benefits of advanced medicine, butwho at the same time firmly refuse every attempt towards legalizingmedical euthanasia. Yet euthanasia would very probably have someeffect at least on the monetary side of the issue, since it would putan end to the waste of many expensive life-prolonging reatments whichare performed at present on terminal and suffering patients againsttheir own wishes.

Although the pros and cons of euthanasia have been thoroughlydiscussed in philosophical and legal debates during the 70s and 80s,the financial aspect has not often been brought to the fore byproponents of permissive p~licies.~his is probably because theiropponents have been busy drawing attention to the alleged similaritiesbetween the Nazi euthanasia programmes and attempts to defendpeoples right to die. Therefore in the eyes of the general public anyimplication of economic considerations has underlined, rather unfairly,the supposed inhumanity of legalizing euthanasia. But there are, in

D. Callahan, Setting Limits: Medical Goals in an Aginf Society (New York: SimonP . Singer, Review essay: Setting Limits, Bioethics 2 (1988): 151-169, pp.As was pointed out to us by one of our referees, an exception to this is M .Tooley, who discusses the cost of maintaining life in his Decisions to terminate lifeand the concept of a person, in J. Ladd (ed.), Ethical ZSSUCSRelated to Lye and Death(Oxford: Oxford University Press, 1979), pp. 72-75.

and Schuster, 1987).167- 169.

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EUTHANASIA, ETHICS AND ECONOMICS 155fact, no good grounds for ignoring the connection between euthanasiaand the urge to save medical resources.

The following account is primarily directed at those who are notfamiliar enough with the debate to believe without demonstration thatthe connection is possible and indeed obvious, and our main purposeis to offer a rough sketch of how ethics and economics may after alllegitimately work side by side in the euthanasia issue.2With the continuing advancement of modern medicine Westernsocieties have, during the last few decades, reached a point whereindividual human beings can be kept alive, at least biologically, longafter they have lost any kind of conscious contact with other humanbeings, or regardlessof whether anybody sees any worth in their living.There are, for example, severely defective infants and children withoutthe slightest positive prospects in their lives, who live a few painfulyears at the most and never become conscious of themselves or othersas persons. There are patients in a persistent vegetative state, victimsof disease or accidents or deep dementia, who have permanently losttouch with the rest of the world. And there are other victims of diseaseand accidents with intolerable pain and suffering, whose only wish,under such circumstances, is to die as quickly and peacefully aspossible.

Modern-day medicine has in many cases made it possible to keepthese human beings alive almost indefinitely. However, the costs ofsuch a life preserving programme are usually very high, both in termsof.money and in terms of futile suffering.

3An economically-minded response to the situation would argue thatsociety can no longer afford to keep everybody alive for as long astechnical possibilities would allow. According to a standard financialargument, expensive high technology or various forms of intensivecare should not be employed on those who cannot be expected tobenefit either themselves or the rest of society to a sufficient degree,For instance, suppose that in an accident two persons are injured:a young medical doctor and an 80-year-old chronic patient. They areboth seriously injured, in fact neither of them can survive withoutrespirator treatment. Now, if only one respirator is available at thetime of the accident, the financial view states that the young medicaldoctor should have priority, on two grounds. Firstly, if saved, he willpersonally benefit more in terms of, say, quality adjusted life years

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156 HETA HAYRY AND MATT1 HAYRYper unit of money spent,4 than the older person, given the probabledifferences in their life expectancies. And secondly, he will most likelyprove more useful to society as a whole than the old chronic.patient.The choice is, the supporters of the view may say, ultimately for thegood of all. (The theory stated by Daniel Callahan in Setting Limitsmight perhaps be employed to back up this line of argument.)

4But there are both practical and theoretical difficulties with the view.Suppose, for example, that the 80-year-old chronic patient happenedto be the president of the country in which the accident took place.Would she be more important to her country than the young doctor?Or suppose that the accident was in fact intentionally caused by theyoung doctor in order to advance his grandmothers death for his owneconomic benefit. Would it be fair to employ straightforward utilitariancriteria under these circumstances?And although the practical difficulties of a particular case couldbe somehow overcome, the large-scale theoretical problems wouldremain. Can the view really be accepted that in matters of life anddeath young people should always be preferred to the old, employedto the unemployed, supporters of the system to dissidents andrevolutionaries? Employing this policy would quite clearly and quiteunethically imply unequal rights to life for different groups of people.

5According to another, only indirectly financial, line of argument -the one Singer is presumably referring to in his review of Callahansbook- edical means should not, as a rule, be used to keep a patientalive, if death, from the patients own viewpoint, is a better alternative.No outsider evaluation of the patients life expectancy or worth tosociety is needed in this model, since the only explicit considerationis the good of the patient as experienced by her or himself.

The point of this suggested policy can best be seen in the contextof the following definition:

Euthanasia means both(i) the easy death of a person for whom death is a better alternativethan life; and(ii) the conscious inducement of such a death by other persons,

O n quality adjusted life yea rs, or QALYs, see , e .g . ,J . Harris, QALYfyingthe value of life,JoumalofMedicul EthicJ 13 (1987): 117-123; A. Williams, Response:QALYfying the value of life, Journal ofMedical Ethics 13 (1987): 123.

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EUTHANASIA, ETHICS AND ECONOMICS 157either by acting or omitting to act, either directly orindirectly.

It is easy to see that if cases of euthanasia in sense (i) exist and if medicalassistance to death in sense (ii) can be morally defended, then manydifficult allocation problems in modern medicine could be avoidedwithout having to pay any direct attention to the financial side of theissue. Voluntary withdrawals b y the patients themselves or theirproxies would surely release considerable resources to be used for otherconsumers of health care services.

6

However, several objections can be- nd have been- aised againstthis kind of policy. The most important of these are:( 1 ) That genuine cases of euthanasia in sense (i) do not, in fact,

exist, since life is always and for everybody a better alternativethan death.(2) That euthanasia in sense (ii) is not justifiable, since it isimpossible in real life to know with certainty whether or notfor the patient death is a better alternative than life.(3 ) That active direct euthanasia in sense (ii) is not justifiable, sincedirectly killing human beings is wrong.(4) That active direct euthanasia in sense (ii) is not justifiable, sincethe task of killing patients cannot legitimately be given eitherto family or friends, or to medical personnel.

Let us see briefly how these objections could be met.

7

To begin with, is life always and for everybody a better alternativethan a quick and easy death? A look at the most eligible candidatesfor medical euthanasia certainly tends to suggest otherwise. Take,for instance, newborn infants with severe spina bifida malformations:what life has to offer to them is a few weeks or months of painfulexistence, and a certain death before life has really even begun. O rtake patients with fully developed AIDS: their prospects involve anunavoidable regression into pre-senile dementia, loss of personal

The terms direct and indirect refer to the Roman Catholic distinctionbetween intentional and unintentional evildoing. The sense in which we use theconcepts here is more fully explained in our Utilitarianism, human rights andthe redistributionofhealth through preventive medical measures,Journnl OfAppliedPhilosophy 6 (1989): 43-51, pp 45-47.

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158 HETA HAYRY A N D M A T TI HAYRYdignity, and increasing anguish and suffering, which culminates indeath within a year. Or take the case of terminal cancer patients: whatcan they expect but constant physical pain or, alternatively, nauseacaused by painkillers, and an inevitable progression towards prematuredeath.

Now, if a group of AIDS or cancer patients themselves say thattheir lives are not worth living any more, and express a wish to bemedically euthanatized, it seems unreasonable to maintain either thatthey are wrong concerning the value of their own lives, or that otherpeople cannot know with certainty whether their lives are in factworthless to them.6 The case of newborn infants with spina bifidaproblems is more difficult in this respect, since. these patients cannotmake choices for themselves, and proxy decisions are thereforerequired. But while an agnostic view regarding the mental abilitiesof very small children may be justifiable in general, it does not followthat visible suffering could be ignored on this account. It is not verylikely, for instance, that an infant starving slowly to death wouldactually prefer this to a quick and easy end.

8As for the remaining two objections, the distinctions between activeand passive euthanasia on the one hand, and direct and indirecteuthanasia on the other, have been thoroughly discussed during thelast few decades, and we shall not even attempt to reproduce therichness of the debate here. We shall simply assume two points thatare well established in the literature. The first is that passive euthanasiais ethically unproblematic: it is not the medical personnels duty orright to subject terminal patients to life-preserving treatment whichthe patients themselves refuse. The second is that the distinctionsbetween active and passive, direct and indirect, do not bear enoughmoral relevance to constitute conclusive counterarguments againstactive direct e~thanasia.~

But even if the legitimacy of intentional killing is taken for granted,the question concerning the legitimate killer remains. It has beenargued that if the task of performing active euthanasia is given to close

We assume here that if a persons continued life is worthless to herself, thenit is worthless, period. As one of our referees noted, there may be instrumental ortheological considerationsthat tend to suggest otherwise either generally or in a givensituation. But we take the view that in the euthanasia issue at least the person herself,if competent, is the best - nd sole relevant- udge as regards the value of herown life. See, e.g., H . Kuhse, The Sanc!iQ-of-LifeDmtnne in Medicine: A Critique (Oxford:Clarendon Press, 1987).

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EUTHANASIA, ETHICS AN D ECONOMICS 159relatives and friends, they may develop doubts and anxietiesafterwards. And if ordinary medical practitioners are nominated tothe task, the result may be that, in addition to the possible trauma,their disposition towards saving lives may be adversely affected. Inresponse to these shortcomings, Roger Crisp has suggested that neitherrelatives, friends, nor ordinary medical practitioners should be theones to bring about patients death at their own request, but that,instead, a specialist professional group of what Crisp calls telostriciansshould be trained for the purpose.

9It is easy to see that Crisps proposal could indeed be helpful in findingthe right persons to bring about a good death. O n the other hand,it is also easy to see how opponents of active euthanasia could usehis point as well as the rest of the foregoing argument in defence oftheir own views. The argumentation thus far might be interpretedto imply three things: first, that human life is sometimes worthlessto an extent where death can be seen as the preferable solution; second,that direct killing is not necessarily worse than withdrawals of treatmentwhen such worthless lives are at stake; and third, that special trainingprogrammes should be organized for killer doctors, partly if notentirely designed to weaken the psychological barriers such doctorsshare with every decent person against taking the lives of innocenthuman beings. Within this interpretation it is only logical to state,as Callahan states in his book, that legal euthanasia would come tohave a frightening symbolic value for the disabled and the elderly.

But what is overlooked by Callahan and other traditionalists is therelevance of what people themselves actually want. As far as voluntaryeuthanasia is concerned, its rejection in favour of economic orpragmatic calculations gives rise to a re-interpretation of the threepoints just mentioned. First, while proponents of euthanasia interpreta worthless life to mean one which a person her or himself judgesas worthless, according to the economic models the lives of all oldand disabled citizens are worthless. Second, if patients suffer andtherefore wish their death to be hastened, proponents of euthanasiaaim at relieving the suffering, whereas opponents seem to aim atprolonging pointless pain. And third, as far as training telostriciansis concerned, it is not at all clear to us how the finance-orientedsolutions could genuinely be considered a superior solution. Insteadof having specialists to fulfil the wishes of terminal patients, is it reallybetter to force through financial pressures all medical practitioners

* R.Crisp, Good death: Who best to bring it?, Bioethics 1 (1987): 74-79.

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160 HETA HAYRY A N D MATT1 HAYRYto turn their backs on their poor, old and disabled patients? Thesymbolic value of the economic kind of approach would surely be atleast as frightening as that of legalizing voluntary euthanasia.

10Since nonvoluntary euthanasia in its turn involves proxy decisions, andis therefore problematic, voluntary choices, where they are an option,clearly ought to be preferred. On the practical level this implies thatpeople should be asked at an early age how they would like to be treatedin case of an accident or senility leading to an irreversible state ofincompetence. There might, for instance, be systematic collectionsof life and death wills, in which persons could name their choicesin such situations. And the wills should then be respected incontemplating medical euthanasia in real life situations.

The problem of infanticide remains even after these considerations:newborn babies with, say, spina bifida malformations cannot be askedwhether they would like to live or die - r rather, in their case, todie slowly or die quickly. This is an important aspect of the issue,but it can be ignored here because the practice of infanticide, no matterhow it is arranged, cannot have any direct frightening symbolic valueeither to infants, who are not aware of the situation, or to older childrenor adults, who will never be infants again.

11In conclusion, it seems to us that voluntary and- n obvious casesat least - onvoluntary medical euthanasia can be and should beaccepted forthwith. The ethical inferiority of any economic solutionis evident, especially as f a r as voluntary euthanasia goes. When peopleare capable of making decisions and forming judgements concerningtheir own life and death, it would be a violation of their moralautonomy not to act according to their considered wishes. In addition,if somebody wishes to live, or has expressed a wish to be kept alive,it would be a direct attack against his right to life to let financialconsiderations override these wishes. And all this is true with regardto an individuals clearly expressed previous statements as well.

As for the financial side of the issue, respecting peoples moralautonomy and rights in this way would most probably reduce theurgency of economic life and death decisions in the foreseeable future.The universal acceptance (and legalization) of voluntary andnonvoluntary medical euthanasia would very likely release considerablemedical resources for those patients who really want to live. And if,

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E U T H A N A S IA , E T H I C S AND E C O N O M I C S 161in addition, a wide collection of living wills were organized, in a fewdecades the situation could look even better.

But the real beauty of this scheme cannot be measured by simplycounting the money that will be saved for other purposes. What makesthe legalization of medical euthanasia such an attractive solution, andpreferable to the policies Daniel Callahan and other traditionalistshave in mind, is that all the benefits, including monetary savings,would be gained without actually losing anything- specially, withoutviolating any basic and justifiable moral principles.

ACKNOWLEDGEMENTSOur thanks are due to the editors and two anonymous referees of theBioethics for critical comments, and to Mark Shackleton, Lecturer inEnglish, University of Helsinki, for revising the language of the paper.Department of Philosophy,University of Helsinki