Several interesting philosophical questions arise in this area of human activity but they generally centre on how to deal with the life of a person. They include the questions of when human life begins and when it ends; whether certain lives have greater value than others; whether demands for full good health are justifiable; how to decide on the distribution of medical resources. They are usually of immediate general interest since questions of whether such things as contraception, abortion, infanticide, euthanasia, cloning, genetic engineering, IVF treatment, spending of money on smokers versus a cure for malaria, affect us all and, given that we cannot all agree about them, attract a lot of controversy.
Perhaps the most fruitful question to ask at the outset is why it is wrong to kill someone? Some will claim that it is always wrong to kill someone, no matter what. Often, this will be articulated as everyone having a ‘right to life’. Notice that this is claimed as a moral right (not a legal one – if a government decided to change the law and allow some group of its citizens to be killed this would not make killing them right). However, it is not good enough just to say that ‘every person has a right to life’ and leave it at that. It must be justified in some way otherwise there is no answer to someone who says that ‘no-one has a right to life’.
Taking the absolutist stance and saying that it is always wrong to kill is quite a hard position to sustain if someone is pointing a gun at you and you have a gun which will shoot them dead. Given your views, you must not shoot but, in that case, you will die. (And being dead you will not even have the satisfaction of knowing you were right and your killer was wrong.) Another example would be of a dictator who has hideous tortures inflicted on hundreds of people every day and who can only be stopped by assassination: is the dictator’s ‘right to life’ worth respecting? If you say ‘yes’ then we can crank up the thought-experiment until the dictator has world-power and the means to torture everyone in the world except himself (or herself, of course) for all of their lives and for all future people. At this point, perhaps everyone will concede that such a monster could be killed which then concedes the point that absolutism on the killing question is unsustainable.
In such cases of self-defence, in wars, vile torturers, perhaps even when it comes to capital punishment, most of us will allow that killing is acceptable. We might go so far as to permit the killing of a patient with irreparable brain damage, in a coma and suffering pain, by thinking that the death is preferable to the life of that patient. In other words, apart from extreme pacifists, there is nothing ‘sacred’ about human life to the majority of people. What really counts is not so much having a life, but having a worthwhile life.
That, however, is usually not quite the end of the matter. At first glance we might think, yes, we ought not to kill (or to allow to die) someone who has a worthwhile life all other things being equal (this rules out circumstances like the horrible torturer etc.). But what if the cost of keeping one person with a worthwhile life alive means that we have to sacrifice the well-being of masses of other people? If it meant that the money spent on non-essential things like, say, anaesthetics had to be diverted to keep alive one person would we think this the right thing to do? Most of us would probably say that this is going too far – that having a worthwhile life is not an absolute proscription against killing (or allowing to die). In other words, in some circumstances, a life can be sacrificed. (Again, some people do not concede this. They are usually Believers who maintain that only God has the right to end a life no matter what the circumstances. We will look at this standpoint later on.)
We can now turn to the question of who is to decide what a worthwhile life is. Imagine that a family-less, friendless, life-sentenced prisoner has incurable cancer from which he will die in 12 months. You know that the pain from the cancer will get unbearable. In short, let us say that you know that he will not have a life worth living. The prisoner, however, says that he wants to carry on living right to the very end. Should the prisoner be killed? On the one hand, this would be an act of mercy – we would have nothing to gain from it, it is done in the person’s best interests. On the other hand, we are going against the individual’s wishes. I guess that, like me, you will want to say that the prisoner is the best person to decide and that he should be allowed to live out his life. You reject the paternalist approach (that some authority ‘knows best’) and emphasise the autonomy of the individual.
Nothing is ever easy, however. What if the prisoner is mentally unstable and incapable of reasoning? What if he is capable of reasoning but is (and will remain until death) in a permanent coma? In these cases we might decide that we could ignore the wishes of the individual.
Although there will be some room for argument at the margins, from the above we can isolate two principles which should be taken into account with regard to killing. The first is that it is wrong to take a worthwhile life. The second is that the autonomy of the individual is to be taken into consideration. When these two principles clash (as in the case of the deranged cancerous prisoner) one principle will not necessarily trump the other.
At this point it might be worth pointing out that these principles appear to stem from two different ethical systems. The ‘worthwhile life’ one seems to be utilitarian with its analysis of ‘greatest good’; the ‘autonomy’ one has a duty-based derivation – a respect for individuals. A virtue ethicist would beg to differ and indicate that questions of killing involve the exercise of justice, prudence, courage, compassion, and so on (and the avoidance of callousness, indifference, self-interest, cruelty, and so on). That said, we can now turn to some specific medical questions to see how moral philosophy can be applied to help us towards solutions. We will look at the first one at some length to get a fuller appreciation of the philosophical method in this regard.
Having examined why it is wrong to kill, we discovered two major principles. In looking at abortion, one of them doesn’t come into play: the fetus has no say in the matter and so cannot establish autonomy. The other principle (having a ‘worthwhile life’) is one that is open to question: is a fetus an entity to which this concept even applies?
So, is it wrong to kill a fetus? A lot of people will say that it is and we will look at some of their justifications for saying it.
One argument is that the fetus is a human being and given that all human beings have moral status, then it is as wrong to kill a fetus as kill any other human being. This is not a strong argument. It consists of a major assertion which needs further justification. Who is to say what is, or is not, a human being? I might say that the fetus is not a human being and then the argument has to shift. Where it has to shift will be explored later.
A second argument which seems more promising is to say that the fetus is a potential person and that it is wrong to intervene and stop potential persons from becoming persons. Persons are more than simply members of the species Homo sapiens. A person is conscious, capable of a degree of reflective thought, capable of forming relationships, has some kind of emotional responses, has a sense of their own identity, and perhaps other attributes. Persons are to be respected and valued. Therefore, potential persons also are to be respected and valued.
This argument is unsatisfactory on two counts. The first is that we are not valuing the fetus for what it is in itself but what it will become. This seems to miss the mark. Imagine a mother who loves her baby simply because she knows she will be a successful pop star in the future rather than loving her for what she is now. We would not see her as a good mother. In the same way, a fetus ought to be valued as a fetus rather than valuing it for what it will become.
The second count is that the argument can be extended to include contraception as being wrong. Any (reproductively healthy) male and female could produce more persons. One can imagine a vast number of ‘potential people’ who are denied the actuality of life by various contraceptive methods. If killing a fetus is wrong because it could become an actual person, then using contraception is equally wrong. This seems absurd even to those people (such as Roman Catholics) who claim that contraception is wrong. Killing a fetus is seen as more wrong than wearing a condom to prevent an egg being fertilized. If it is more wrong, then it must involve something more than the ‘prevention of potential’ argument.
A reply to this is to say that it is because a fetus is closer to becoming a person than sperm and egg being kept separate and this makes up the difference. But again, this will not do. This still misses the valuing of the fetus in itself, and it seems too weak as a justification. If you have ordered a birthday cake for 3 o’clock and the bakery rings up to tell you that you are not going to get one, then it makes no difference if it were the ingredients for the cake that were stolen at 10 o’clock, or the cake itself were stolen as it was taken out of the oven at 12 o’clock, or the finished, iced cake stolen at 2 o’clock. In short, it does not matter how close the cake is to becoming what you want (your cake) if that is all you value. In the same way, if what you value is the person, when it is prevented from becoming one, whether preconception (the mere ingredients), as a zygote, an embryo, or as a fetus, cannot make a difference. And yet it ought. Thus, we need something better than the ‘prevention of potential’ argument.
What we want is an argument that confers moral status on the fetus as a person in its own right (and not a ‘human being’ or a ‘potential person’).
A straightforward solution is to say that personhood begins at conception because it is at this point that the genetic ingredients are brought together to produce a distinct individual entity. Though a simple solution, for most people it is overly simplistic. Calling a zygote a person is stretching the limits of what counts as a person too far. We would not call an acorn an oak tree, or a caterpillar a butterfly, or a collection of the right ingredients a cake, although all of them, like a zygote, in the right conditions, will one day become an oak, a butterfly, a cake or a person.
A second straightforward solution is to say that personhood begins at birth – when the baby is named, welcomed, appreciated by other human beings. This seems a good boundary line for demarcation. But is it a clear distinction between the unborn baby and the baby? Imagine if it were the case that women had transparent wombs and abdomens and that it were possible to see the fetus growing inside the mother-to-be. Here it is easy to imagine the fetus/unborn baby being appreciated in pretty much exactly the same way that a newborn baby would be. Thus, this apparent boundary line could easily be blurred.
A third straightforward solution is to claim that personhood begins when the fetus becomes capable of surviving independently from its mother. This runs into two difficulties. The first is that, for completeness, we would have to say that a human ‘plugged in’ to another person who, say, cleaned their blood for them while a donor liver was waited for, was not a person. On these grounds the argument runs into absurd consequences. The second is that the capacity to survive independently is a moving boundary: earlier and earlier premature babies are surviving. Again, absurdity raises its head if we have to say that becoming a person depends on whether the hospital has the latest incubator or not. We might also consider a third difficulty. In the future it may become possible to not only fuse sperm and egg outside the body, but to grow the zygote in an ‘artificial womb’ until ready for delivery to the parents. Here the dependency on the mother is nil and so the argument collapses back to the ‘conception’ position above.
As we have seen, trying to identify an exact point at which personhood begins, and hence when killing becomes an issue, is doomed to failure. There are two reasons for this. The first is that personhood is itself not a clearly defined thing. Rather, it is a cluster of characteristics each of which can vary in extent. The second is that human life is not a series of abrupt transitions. Even though stages are identifiable, there are no sharp boundaries that can be drawn: embryo – fetus – baby are identifiable stages but so are child – youth – middle aged – old aged. No-one can confidently point to a moment when one stage becomes the next.
This leaves us with the view that personhood has to be regarded as a variable, that a fertilized egg is less of a person than a fetus which is less of a person than a baby. With this it follows that it is less wrong to kill a fetus than a baby, less wrong to kill a fertilized egg than a fetus.
This has got us a little further forward, perhaps, but by focusing on the personhood of the fetus we have been totally discounting the personhood of the mother.
One view might be that this should be discounted, that what is at issue is the life of the unborn child irrespective of the mother-to-be’s views. Certainly, one can care for the mother but she should have no privileged say about whether the fetus lives or is killed. Are there any good arguments for saying that this is wrong and that the mother does have the privilege?
One such argument is that a woman has a right to what goes on with her own body and therefore the right to decide whether to allow a fetus to grow in it or not. In this argument there is one of two assumptions. One is that the fetus is not a person in any way (a position which we have already rejected). The other is that the moral status of the fetus as a person is less than that of the mother. In what circumstances might one justify putting one life ahead of another?
What if the birth of the baby would certainly cause the death of the mother? Surely the mother can abort the baby to save her own life? This seems to be a simple matter of self-defence and most people would see it as justifiable to kill another person who was about to kill them. (This needs some qualification to be wholly palatable. It would not be justifiable to kill an attacker if lesser measures were possible – knocking them unconscious, say, rather than knocking their head off. Nor would it be justifiable to pre-empt the killer – if you knew a contract killer was planning to shoot you tomorrow, you should not poison him today. For the pregnant woman these sorts of considerations don’t apply.) This gives an adequate justification for killing a fetus if the mother’s life is at stake, but not otherwise. If abortion in circumstances other than these is to be defended, another argument is required.
The philosopher Judith Jarvis Thomson has argued that a woman does not have a moral duty to the fetus to keep it alive. She has an ingenious analogy to illustrate her case. You are under general anaesthetic having a minor operation. A man is brought into the hospital with two collapsed kidneys. There are no dialysis machines available and he is on the point of death due to blood poisoning. Coincidentally, you and he are compatible such that he can be ‘plugged in’ to you so that you clean his blood for him. There is no time to lose so the doctors go ahead and plug you in. When you come round, they explain what has happened to you and ask you to go on being connected to the man until a machine or a new kidney is available: a matter of months. Do you have a moral duty to stay connected to the man or can you opt for freedom from the connection and leave him unplugged and dead? Thomson says that you do not have a moral duty, that consenting to being plugged in is an act of charity rather than duty: we only have moral duties towards those to whom we have a special responsibility. The parallel is obvious: the pregnant woman does not have a moral duty to the fetus and can, if she wishes, be ‘uncharitable’ and have an abortion without doing wrong to the fetus, just as you do no wrong by choosing not to give money to a beggar.
What is attractive about this argument is that charitableness is on a sliding scale rather like the circumstances for abortion are on a sliding scale whereas our moral duty does not have the same elasticity. Most of us would say that of course it is right that a raped and traumatised 12-year-old who is three-months pregnant should be allowed to have an abortion should she wish, and that of course it is wrong for a career woman who is six-months pregnant and has just been invited on a fantastic skiing trip to have an abortion because the bump gets in the way. Circumstances make the difference here just as circumstances make the difference when it comes to being charitable. Of course it is right to give food to the starving if you have more than you need; of course it is wrong to give money to the rich while allowing your own children to go without.
The problem with Thomson’s argument is with her assumption that we can readily distinguish between those to whom we have moral duties and those to whom we are charitable. If the man with collapsed kidneys were your father you should stay plugged in. But what if he were an uncle, or a second cousin, or a tenth cousin? A fetus might well be regarded as something more than a stranger, something which a mother may well have a moral duty towards rather than charity.
Having considered the fetus and the mother, it is worth pointing out that there are many side-effects which also matter. Calling them side-effects is not to minimize their importance, it merely addresses the fact that they are not central to the issue of killing – we could eliminate all side-effects and the killing would still matter. In the case of abortion the side-effects would include the psychological, physiological, sociological effects which will all have an influence on the final decision. Thus, for instance, a mother will be more affected psychologically by a late rather than an early abortion; the effect of a long pregnancy on her body will be greater the longer it progresses; would ‘abortion on demand’ weaken our social structure, would unwanted babies be better off adopted? Should doctors and nurses not have to suffer the distress of assisting with late abortions? All of these side-effects to the question of killing a fetus are weighty. Indeed, if we adopt the utilitarian position, they must be taken into consideration when deciding whether an abortion will lead to the ‘greatest good’.
Before leaving this issue, we ought to consider the opposite case: is it ever wrong not to have an abortion? There are some distressing syndromes which result in the death of a fetus at some stage before it will be born, or the baby is born but will only have a very short life and one that is painful. Here one could appeal to the principle of a worthwhile life and conclude that, just like the older person incapacitated and in pain on a life-support machine with no prospect of improvement, death is preferable.
Inadequate though it is, perhaps the best approach is to try to imagine ourselves in the position of the fetus (or the person on the life-support machine) and then decide between life and death. When such syndromes are identified, it may well be wrong not to have an abortion. What might make a difference are the side-effects. So, for example, if the mother believes abortion is a mortal sin and believes her soul will be forever damned if she consents to it, then this may be justification enough to let the baby suffer such a life.
Conclusions to be drawn from this discussion on abortion are that what is in question is: what is the status of personhood of the fetus rather than when human life begins? What grounds can justify the setting of one person’s worthwhile life above another? By isolating these problems we can at least move the debate away from the often-emotional responses to the problem of abortion and onto ground where reasoned examination is called for. The latter has proved more fruitful in the past in terms of uncovering what is best.
Although we have spent a good deal of time on the question on abortion, it is easy to see how the same principles and method apply to other ethical questions in the field of medicine – especially those involving the life or death of persons such as in euthanasia, infanticide and suicide. Hence we can turn from any more specifics and look at a couple of other philosophical principles that attract attention: acts and omissions; and ‘playing God’.
In America a few years ago a passer-by was put in an appalling moral dilemma. A truck had been in an accident and was on fire. The driver was hopelessly trapped with both legs pinned. The fire was spreading in the cab. The driver handed the passer-by a gun and pleaded with him to shoot him in the head to spare him the agony of being burnt to death. The passer-by shot him dead. Would you have?
A very similar moral dilemma is one which faces doctors routinely: which is worse, acting to shorten the life of a terminally-ill patient by administering a painless overdose, or omitting to act and leaving the patient to die in agony?
The utilitarian has a simple solution: it doesn’t matter what you do – whether you act or omit to act – all that needs concern you is whether the outcome is better in terms of greater happiness or lesser suffering. However, this does not square with what is regarded as a doctor’s duty: to intervene to save life rather than hasten its end.
There certainly seems to be a big difference between failing to act knowing that this will result in death and acting such that death will result – even though the outcome is the same in both cases. Failing to send money to the starving in Africa such that ten of them die is not the same as sending them ten poisoned meals.
Many philosophers, however, reject what seems to be a clear distinction between acting and omitting to act. They say that acting or not acting both depend on a decision that a person makes. Since the decision is mental, the action (or lack of it) which follows is merely the implementation of that decision: the agent is still responsible for the decision that has been made. Thus, in the example above, if I know full well that the money I fail to give will certainly result in ten deaths, then this is just as bad as sending ten poisoned meals. On this analysis, the reasons for the decision are crucial rather than the outcome. In this way, a duty-based ethics will differ from the utilitarian one.
It might be worth noting here that, in Britain at least, doctors are not allowed by law to act to kill patients. This includes those patients which the courts have decided can be allowed to die (such as those in a persistent vegetative state whose next of kin have expressed a wish for the death). In such cases the patient has feeding tubes removed such that they die of dehydration/starvation usually over a period of several days. Doctors are not allowed to administer an overdose to bring about a speedy, painless death instead. The reasoning is that ‘allowing to die’ in this way is not the same as ‘acting to kill’. Many find this distinction unreasonable. It is often puzzling to consider the apparent inconsistency in this respect when one considers animals in pain with no chance of recovery. Here the law demands that they be given a quick and painless death rather than just standing by and waiting for their death by letting them starve.
One reason for this reluctance to allow doctors to kill their patients (when the patient wishes this to be done and is incapable of suicide) is the very understandable one that any of us would feel of not wishing to be the arbiter of the moment of another person’s death. In the past, the moment of the creation of a life, as well as the decision about when it would end, was seen as being in God’s hands and hence the reluctance is often expressed as not wishing to ‘play God’.
This is not a coherent argument for some people. In the case of the creation of a human life, many of us are content to circumvent God’s natural processes by practising contraception. In life we are generally also content to go against God’s will – we put up umbrellas thus going against his will that our heads get wet from the rain; we are vaccinated against getting diseases; we take medicines, have operations, to extend our lives; we jump out of the way of falling rocks. In many ways, we choose a lifestyle that will determine our longevity – taking more or less exercise, eating more or less of certain types of food, and so on. In all of these ways, we are exercising autonomy: it is our decision about how long our life extends and, nowadays, we are free to end it (by suicide) if we wish.
All that said, there still remains a very human reluctance to choose between, say, which of two patients is going to get the kidney machine and live, and which is not and will die. Even if we adopt a simple utilitarian approach, who are we to judge which of the two patients will have greater utility than the other? This ‘very human reluctance’ may just be a lack of courage, or it may reflect a deep sympathy with human life. In any event pure reasoning does not seem adequate to eliminate it from the minds of most of us, doctors or otherwise.