I’ve been thinking harder about what might be called a “combined” account for justifying killing: it is permissible for A to kill B if the harm A inflicts on B is negligible, and B gives valid consent to being killed by A. Problem: what counts as a harm and who decides whether or not it is “negligible?” One might think that A cannot be harmed if A’s preferences are satisfied, which just collapses harm into the logic of preference satisfaction making the combined account redundant — consent is all that is needed. Still others think that the harm must be construed as something lost in terms of a “worthwhile life” (Glover, 1977), or “biographical life” (Rachels, 1986), or “a future of value” (Marquis, 1989) or some ability “to act or do things” (Sinnott-Armstrong and Miller, 2013). It is thought that there is little if not nothing left to lose near the end of life if these things constitute what would be lost in act of harmful killing. But who decides whether there is little if not nothing left to lose? Is it the patient? The doctor? Both? If it is the patient, then once again, the combined account is redundant, for harm just collapses into the logic of preference satisfaction, which can be explained in terms of respect for autonomy.
One reason we might think the “combined account” is attractive is because it seems to rule out killing an otherwise healthy person who might have a death wish (let’s call her ‘Susan’). This assumes that people other than Susan are in a position to determine that an unacceptable harm would be caused if Susan’s death wish were to be honored. Thus, we privilege Susan’s wishes only when others have judged her life not to be worth living. In any case, Susan’s self-determination is profoundly limited because she is only empowered to give up her life when she is in a diminished state. The problem with this, however, is that Susan’s choice to go on living requires some sort of justification if she is to be counted as rational. Since we expect human beings to provide reasons for their choices, Susan is required to justify her continued existence under the pain of irrationality in a way that healthy people are not (Velleman, 1992). This wretched inequality is entirely contingent upon one’s health status, and therefore places an intolerable burden on the vulnerable so that they might enjoy one of the most basic rights that should be guaranteed by any just society, the right not be killed. Indeed, the sort of “autonomy” — if could be called that — given to the dying in the combined account masks a form of paternalism more insidious than the kind the bioethics movement rejected in the 1970s, and should therefore be rejected if autonomy is to have the sort of value it is assumed to have.
Some of these thoughts are echoed in Daniel Callahan’s book The Troubled Dream of Life:
Recall that there are two classical arguments in favor of euthanasia and assisted suicide: our right of self determination, and our claim upon the mercy of others, especially doctors, to relieve our suffering if they can do so. These two arguments are typically spliced together and presented as a single contention. Yet if they are considered independently—and there is no inherent reason why they must be linked—they display serious problems. Consider, first, the argument for our right of self determination. It is said that a competent adult person ought to have a right to euthanasia for the relief of suffering. But why must the person be suffering? Does not that stipulation already compromise the right of self determination? How can self determination have any limits? Why are not the person’s desires or motives, whatever they be, sufficient? How can we justify this arbitrary limitation of self determination? The standard arguments for euthanasia offer no answers to those questions.
Consider next the person who is suffering but not competent, perhaps demented or mentally retarded. The standard argument would deny euthanasia to that person. But why? It would seem grossly unfair to deny such a person relief simply because he lacked competence. Are the incompetent less entitled to relief from suffering than the competent? Will it only be affluent middle class people, mentally fit and able, who can qualify? Will those who are incompetent but suffering be denied what those who are intellectually and emotionally better off can have? Would that be fair? Do they suffer less for being incompetent? The standard argument about our duty to relieve suffering offers no response to those questions either.
Is it, however, fair to euthanasia advocates to do what I have done, to separate, and treat individually, the two customary arguments in favor of a legal right to euthanasia? The implicit reason for joining them is no doubt the desire to avoid abuse. The aim of requiring a demonstration of suffering and terminal illness is to exclude perfectly healthy people from demanding that, in the name of self determination and for their own private reasons, another person be called upon to kill them. The aim of requiring a show of mental competence to effect self determination is to exclude the nonvoluntary or involuntary killing of the depressed, the retarded, and the demented.
My contention is that the joining of those two requirements is perfectly arbitrary, a jerry-rigged combination if ever there was one. Each has its own logic, and each could be used to justify euthanasia. But, in the nature of the case, that logic, it seems evident, offers little resistance to denying any competent person the right to be killed, sick or not; and little resistance to killing the incompetent, as long as there is good reason to believe they are suffering. There is no principled reason to reject such logic, and no reason to think it could long remain suppressed by the expedient of an arbitrary legal stipulation that both features, suffering and competence, be present (1993, pp. 107-109).