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Dying with real dignity

Joseph Campbell

The subject of euthanasia, Greek for 'good death', is once more in the news (see News in Brief, under Canada, Supreme Court #3). As the Latimer court case proved, some people have strange ideas about what a "good death" means. Our contributor from Saskatoon emphasizes dying with real dignity.

Suppose you're suffering terribly with terminal cancer and you allow your doctor to administer a powerful narcotic that kills you. Is this euthanasia? Not necessarily. You and your doctor could have intended to relieve your suffering, not shorten your life. The moral and legal status of medical interventions that risk causing death depends crucially on what the intention is.

Many participants in the euthanasia debate question this. They suggest that, when medical treatment which is foreseeably fatal kills a terminally ill patient, it makes no moral difference whether the intention was to relieve pain or cause death.

Narcotics and potassium
This issue is relevant to charges, since dismissed, that Dr. Nancy Morrison of Halifax was criminally implicated in the death of a terminally ill man. She allegedly gave him potassium chloride and he died.

Potassium chloride and narcotics differ significantly. In this context, potassium chloride has a single effect. At certain levels, it can kill. Narcotics, on the other hand, have two effects. At certain levels, they can relieve pain and kill.

"Why is one OK and the other not OK?" wondered Jocelyn Downie, director of the Health Law Institute at Dalhousie University. "One's simply slower than another," she said in a Southam news report.

To answer her question, we have to examine what we mean by good and evil, right and wrong. Broadly speaking, we can do this on two levels, the existential-physical and the moral-legal. Everyone recognizes that life is existentially and physically good. It is a fundamental human good, in fact. That is to say, it is an end in itself, not just a means, and it is essential to our very personhood.

Death, the negation of life, is therefore existentially and physically evil. It is not just the absence of life, but its destruction. Life, of course, may not always feel good and death may not always seem evil. But in itself life is good; even though the conditions in which we find it may be evil; that is, miserable and degrading. In itself, death is evil, even though it may result in good, that is, an end to physical and mental suffering.

But though death is existentially and physically evil, it is not necessarily morally or legally wrong. People die every day without their deaths being immoral or illegal. Morality and legality are about responsibility. Good and evil on the existential-physical level become right and wrong on the moral, and often the legal level, only when someone is responsible for them.

At the centre of responsibility is intention. We are morally, and often legally, responsible for the evil we intentionally do. But unless we are negligent, we are not morally, nor should we be legally, responsible for the evil we unintentionally do. "I didn't mean to do it" is a legitimate moral and legal defence.

It would seem, therefore, that to avoid doing wrong, morally or legally, we ought to refrain from intentional acts that result in evil. But life is not that simple. Like the medical use of narcotics, which can relieve suffering and cause death, many of our actions have both good and evil consequences. This poses a moral and legal dilemma. If we withhold the drugs, the suffering, itself an existential-physical evil, may continue; if we administer them, the patient may die.

Principle of double effect
The solution lies with a moral norm known as the principle of double effect. This principle recognizes that moral decisions often have a tragic dimension: the good effects we desire from our actions may be inseparably linked to evil effects we deplore. Consequently, to obtain the intended good, we may have no choice but to tolerate the unintended evil. Despite the ambiguity of such actions, we may morally undertake them if there are no reasonable alternatives and the benefits we seek are proportional to the harm we foresee.

The principle of double effect justifies the administration of potentially lethal doses of narcotics, but not of potassium chloride, to the terminally ill. As noted, potassium chloride has a single effect, death. Consequently, to administer it is to intentionally kill the patient. Potassium chloride, in other words, does not relieve suffering. It brings on death, which causes the suffering to end. Its use in this context is a classic case of employing an evil means, killing, to obtain a good end, relief of suffering. This we cannot morally do. The end does not justify the means.

The administration of narcotics is morally different, since it can have two effects, relief of suffering, which is intended, and the hastening of death, which is not. Neither of these effects causes the other. Rather, both result from the use of the drugs. Although one good, a longer life, may be denied in the same act by which another, relief of suffering, is affirmed, the benefit is proportional to the harm. Since the harm is unintended, and there is no reasonable alternative, we may morally consent to the procedure for the sake of the benefit.

But are the benefits and the harm really proportional? It would be dangerous to consider quality of life proportional to life itself. They belong to different orders of reality. The proportion, however, is between quality of life and risk of death. Although foreseeable, the shortening of life that the narcotics may cause is not certain. Since the intention is to relieve suffering, not cause death, the drugs will be administered accordingly, that is to say, carefully and with respect for life.

Narcotics, but not potassium chloride, are OK, in short, because their use can protect both doctor and patient from intentional evil and maintain respect for life generally. The difference is between palliative care, which has built-in moral limits, and voluntary or involuntary euthanasia, which embodies moral laxity. In the Netherlands, laxity has reached the point where each year thousands experience euthanasia involuntarily.

The principle of double effect applies more widely than we perhaps realize. Vaccination, for example, may make us temporarily ill while stimulating the immune system to produce antibodies against disease. Because the immunity is intended, whereas the illness is not, the procedure is morally justified.

So is the damage fire fighters unintentionally do in attempting to save property, as when they hose down buildings adjacent to burning structures. The hosing may prevent the buildings from catching fire but it also could ruin the merchandise they contain. The damage to the merchandise is a foreseen but unintended consequence of an activity aimed at protecting the buildings.

The principle of double effect is more than idle casuistry. It goes to the roots of moral reality.

Joseph Campbell contributes frequently to Catholic Insight on a wide range of issues.

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