A Brief Discussion of the Question of Euthanasia

 A Brief Talk on the Issue of Euthanasia

The Basic Definition of Euthanasia

Euthanasia refers to “the act or practice of, out of mercy, killing patients or injured persons who have no hope of recovery by a relatively painless method, or allowing them to die.”[①]

The above is only a dictionary definition, and in academic discussion there are naturally many imprecisions in it. However, I do not intend to offer a new definition. In what follows, I will mainly discuss euthanasia in relation to issues of life and death.

“Euthanasia can be divided into two major categories: passive (or indirect) euthanasia and active (or direct) euthanasia. Active euthanasia can further be divided into active voluntary euthanasia and active non-voluntary euthanasia.”[②]

Passive euthanasia refers to withdrawing treatment or life-sustaining measures and letting the patient die; active euthanasia refers to causing the patient’s premature death by means of medication or other direct measures. Some commentators believe that there is no fundamental difference between passive euthanasia and active euthanasia. For example, James Rachels, by asserting that “from the moral point of view, the distinction between killing and letting die itself makes no difference,”[③] goes on to deny any difference between active euthanasia and passive euthanasia.

Rachels’s argument is superficial. Leaving aside the obvious difference between killing and letting die (perhaps there is no essential difference in logical structure, but in criminal-law terms there is unquestionably a significant distinction), whether euthanasia can be simply lumped together with murder is itself a question. As Bonnie Steinbock says: “It is inaccurate to equate stopping treatment in general with intentionally ending a life. There are at least two cases in which terminating life-prolonging treatment cannot be equated with the intentional ending of a person’s life by another. … The first case involves a patient’s right to refuse treatment. … The second example is when continuing treatment offers little chance of improving the patient’s condition and brings greater discomfort rather than relief.”[④]

The patient’s right to refuse treatment cannot be ignored. After all, a hospital is not a coercive agency like the police or the prison; it has the duty to provide services to citizens, but it has no authority to compel citizens to accept the services it specifies. Citizens certainly have the right to refuse a certain treatment out of a desire to preserve bodily integrity, dissatisfaction with the service, or any other concern. Recognizing a patient’s right to refuse treatment is a respect for the most basic moral principle for researchers and physicians—“the principle of autonomy”[⑤]. Therefore, the distinction between passive euthanasia and active euthanasia is clear. This does not mean, of course, that passive euthanasia is free of controversial ethical issues; nevertheless, in what follows I will focus on active euthanasia (mainly active voluntary euthanasia).

By the way, Rachels also offers an interesting but equally shallow claim: “If after all the relevant factors have been taken into account a person’s death is a good thing, then there is nothing wrong with being the cause of that person’s death. And if his death is not a good thing, then no form of euthanasia is justified.”[⑥]—setting aside whether the cause of a bad thing is necessarily evil and prohibited (in fact, even if one does not evaluate by motive rather than consequence, when faced with a moral dilemma it is very likely that whatever one does will bring about bad consequences). Another important issue here is that whether a person’s death is in fact a good thing or a bad thing is inevitably related to the cause of death. If one is to “take all the relevant factors into account,” one probably cannot avoid first addressing an evaluation of the cause of death. What I want to discuss below is precisely the inquiry into the motive and cause of death in euthanasia.

Is Euthanasia Suicide?

Euthanasia (the term euthanasia as used below specifically refers to active voluntary euthanasia) is also often equated with “physician-assisted suicide.” So, is euthanasia a form of suicide? Or even if it is, how does it differ from ordinary suicide?

From the standpoint of “intentionally causing one’s own death,” euthanasia and suicide are similar. However, it should be noted that not all acts of “intentionally causing one’s own death” are regarded by people as suicide. For example, the revolutionary martyrs who “would rather die than yield” under brutal torture; or self-sacrificing heroes who forget themselves in the act of devotion (Huang Jiguang, Dong Cunrui…); their relinquishing of their own lives is often seen as heroic and not described as “those who take life lightly.”

We might reduce ambiguity by refining the definition of “suicide,” for example by limiting suicide to: “intentionally causing one’s own death, unless one is forced, or dies because of non-arranged factors.” Yet various simple fixes are hard to make satisfactory. For example, acts of righteousness such as Dong Cunrui blowing up a bunker seem more spontaneous than anything else; when he stepped forward, no one was forcing him. But if we broaden the meaning of “forced,” then can those who take their own lives because of tragic circumstances also be said to have been forced?

In short, we seem unable to find an effective way to once and for all distinguish cases like “self-sacrifice” from “suicide,” let alone distinguish euthanasia from suicide.

However, the difference between euthanasia and suicide in the ordinary sense of “taking one’s life lightly” is also clear. Just as not all “killing” is “murder,” euthanasia should also be distinguished from “taking one’s life lightly.”

Shannon notes: “Although the ethics of suicide are usually discussed in connection with voluntary euthanasia, there are two reasons for distinguishing these discussions. First, suicide is the termination of the life process, especially in non-medical settings; that is, many suicides do not involve suffering from a fatal disease. Second, euthanasia is carried out in a situation where, because of a disease, death is expected in the near term or is inevitable.”[⑦] Some domestic commentators also note: “Although both euthanasia and suicide can lead to the death of the patient, when evaluating the essence and attributes of the act from the standpoint of criminal law, euthanasia and suicide are worlds apart and absolutely cannot be mentioned in the same breath.”[⑧]

That is to say, although euthanasia and suicide in the sense of taking one’s life lightly are hard to draw a clear boundary around in semantic analysis or logical structure, if examined in actual circumstances, the difference is obvious.

So, if self-destructive suicide ought to be restricted, does the special character of euthanasia mean that it can be permitted or even encouraged? Before continuing, it is first necessary to briefly discuss the issue of the right to suicide—if suicide in general and inducement to suicide are permitted, then loosening restrictions on euthanasia would only follow as a matter of course. So, does a person actually have, or in what sense do they have, the so-called “right to choose death”?

Is Suicide a Right?

Many people emphasize that one should be one’s own master, that one should have the freedom to choose death and the manner of death; therefore, one can choose suicide, and this right should not be deprived.

However, these arguments, though they may sound impassioned and can even invoke many great philosophers in support, are still insufficient to prove that the law ought to permit or even encourage suicide. In fact, many commentators confuse two different levels of “rights”:

Shannon points out: “There are also different ways of thinking about rights. One way understands them as moral rights. Moral rights provide a basis for ethical argument and exist prior to and independently of any institutional guarantee. These moral rights often stem from human nature and human dignity, and are therefore understood as universal and inalienable. The second type of rights is legal rights—these rights are specified through law, parliament, or specific national political institutions or political groups. Legal rights are simply those rights granted by the government to citizens; they are aimed at particular cultures and are constrained by society.”[⑨]

It is thus clear that if the “right to choose death” refers to the first sense, the inalienable freedom, then in fact this freedom has never been deprived, nor can it be deprived: a physically healthy person, if firmly resolved, can choose suicide at any time; this kind of “freedom” has not been deprived by anyone. However, even if such freedom is indeed innate, inalienable, and crucial for human beings, this does not mean that it must be supported by law. We may also speak of another class of crucial “freedoms” — do human beings have the freedom to break the law? Do they have the freedom to rebel? In fact, rebellion is important for human beings; without rebels and revolutionaries, history would be hard-pressed to progress. Of course, more often than not, this freedom is only latent, just as those who stress the freedom to commit suicide do: having the freedom to rebel does not mean one actually rebels immediately. The point is that the possibility of rebels also makes any existing regime dare not take things lightly, and instead it must be conscientious and keep improving. So, does such a precious, not-to-be-forgotten “freedom” also need legal support? But it is obvious that to have the law establish a right to violate the law is absurd.

It is therefore clear that when we are talking about legal rights, what is more at issue are specific political institutions and social culture. And the purpose of lawmaking is not to promulgate a dogmatic, exclusive system of values and force all citizens to accept it, but to strive to properly maintain the harmony and stability of a society, which is very likely value-plural, so as to better safeguard citizens’ freedom. Thus, the reason the state prevents the right to suicide may lie in considering various factors concerning the interests of the state as a whole, such as “(1) preventing citizens from offending God and/or good public morality, (2) protecting the state’s interests in the productivity of its citizens, (3) protecting respect for life, because this attitude is conducive to ensuring health care for individuals, (4) reinforcing the duty of individuals to support their children, repay their debts, and fulfill their contracts, and (5) protecting individuals from making improper choices, even if the only person harmed by such choices is themselves.”[⑩]

Therefore, when considering whether euthanasia should receive legal support, what needs greater consideration is not the so-called “right to choose death,” but rather the impact this legislation may have on social harmony and stability as well as on the overall interests of the state.

Life Rights or the Value of Life?

The above discussed the relationship between the so-called “right to death” and euthanasia, and set it aside from the discussion of euthanasia. On the other hand, the so-called “right to life” is what opponents of euthanasia emphasize more. Some commentators believe that the right to life is inalienable and nontransferable. Supporters of euthanasia, by contrast, more strongly emphasize the value or dignity of life, emphasizing the “quality” rather than the “quantity” of life.

For example, someone cites the ancient Roman philosopher Seneca as saying: “It is not living that is good, but living well. Therefore, the wise person lives as long as he ought to live, not as long as he can live. … He will always consider life according to quality rather than quantity.”[11]

Of course, it is also inadvisable to praise suicide to the extent that Seneca did, but this question is indeed worth pondering: why is life so precious? — We generally believe life is “precious.” The question is whether life deserves pursuit, protection, or promotion because life itself is an unconditional good, or because life is the condition for realizing certain other goods.

First, it is intuitive in many contexts to regard the pursuit of life as unconditional. Moreover, the beauty and wonder of life compel people to hold it in awe. If life had no intrinsic good, why would we revere life so much?

Among the most famous advocates of reverence for life was Albert Schweitzer. Yet Schweitzer’s ethics of reverence for life, as Jardine remarks, is not a normative ethical law but “a kind of return to an older philosophical tradition.” What Schweitzer advocated was a basic attitude toward life in the sense of virtue ethics; he “did not take reverence for life as an ethical law. Reverence for life is an attitude we take toward this world. In this sense, Schweitzer’s ethics is not focused on answering the question ‘How should I act?’ but rather ‘What kind of person should I be?’”[12]

I support the “ethics of reverence for life,” and even support Schweitzer’s ethical “principle” — “Good is to preserve life, to further life, to bring the highest value to fruition in the life capable of development. Evil is to destroy life, to injure life, to suppress the development of life. This is the necessary, universal, absolute ethical principle.”[13] But this is a “principle” in virtue ethics—that is, a general attitude toward life.

The pursuit of life is conditional. Notice that in Schweitzer, although he unconditionally assigned “good” to life, he also said “to bring the highest value to fruition in the life capable of development.” That is to say, in his view, the mere existence of life does not mean the realization of its value; although this “value” is not something external to life, neither is it some fixed thing that “life itself” possesses. Rather than saying that “life itself” has value, it is better to say that the “development” and “realization” of life themselves have value.

Thus, the key to “promoting life” lies in making the “value” inherent in a certain life capable of realization, rather than merely maintaining the phenomenon of life itself. A person who sacrifices his life for a lofty ideal, dignity, or conviction, compared with a “life capable of development” that has lost all vitality and hope and is merely barely sustaining the phenomenon of life in extreme pain, can be said to have more fully realized the value of life. Isn’t that so?

Of course, I am not saying that choosing euthanasia is necessarily a better way of realizing the value of life than tenaciously struggling against illness and pain until the very last moment. In fact, different people may hold different beliefs, and it is also inadvisable to cajole or force terminally ill patients into choosing euthanasia through moral lecturing, public pressure, or similar means.

How Should Euthanasia Be Legislated?

Earlier I mentioned: “The purpose of lawmaking is not to promulgate a dogmatic, exclusive system of values and force all citizens to accept it, but to strive to properly maintain the harmony and stability of a society, which is very likely value-plural, so as to better safeguard citizens’ freedom.” That is to say, in a value-plural society, legal norms and moral evaluations cannot be equated: ethics seeks the good, while law seeks social stability and order.

As Engelhardt says: “The modern hope has been to discover a standard, contentful morality. Such a morality would not only be procedural but should also bind moral strangers—that is, members of different moral communities.”[14] Yet this hope has never succeeded, either in theory or in practice. “Recognizing that one cannot discover a standard, contentful secular morality marks the philosophical predicament of postmodernity.”[15]

The pluralization of values has long since become reality, while the ideal of universalism remains without any prospect—“In a secular pluralistic society, there is a huge problem in trying to find a reasonably justified solution to bioethical dilemmas. The premises people share are insufficient to constitute a concrete understanding of moral life, and rational argumentation itself cannot precisely establish such premises. Therefore, rational people can only establish a common moral structure through mutual agreement. This concrete moral structure must be based on the will to establish a moral viewpoint, rather than on the product of some rational argument.”[16]

In a democratic society of value pluralism, one should adhere to the basic attitude of the “permissibility principle” (namely, that behavior involving others should receive the permission of others), and, through broad communication and consultation, revise laws and norms with the harmony and stability of society as the goal.

Voltaire said: “I do not agree with what you say, but I will defend to the death your right to speak.” This sentence shows that subjective value judgments and rights are not necessarily always identical. Engelhardt also notes that in a value-plural society, “there will often be this conflict: X has the right to do A, but A is extremely wrong.”[17]

Even in the case of freedom of speech, if it is excessively exercised and thereby becomes defamation or deception of others, thus infringing upon their rights and interests, it still has to be constrained by law. But if a person’s speech does not constitute harm to others or to society, then even if we think he is mistaken, we should not deprive him of freedom of speech. Here, whether to restrict his speech is not a judgment about what is right or wrong in value terms, but a consideration of the harm it poses to others. Similarly, if a person’s actions do not pose a threat to others—or if X’s actions harm only Y, but Y shares the same values as X and therefore regards X as legitimate—then as outsiders, we have no need to force him, under our values, to accept restraints. What ought to be legally constrained are those actions that cause harm to others or to society as a whole.

That is to say, even if the law recognizes euthanasia as a legitimate right, this does not mean that everyone must unanimously agree with euthanasia.

In China as it stands today, people already have a fairly high degree of acceptance of euthanasia—the approval rates for euthanasia shown in various opinion polls are all around 70% or higher[18]. It can be seen that the legalization of euthanasia already has a considerable social foundation. However, I still remain cautious about this—the problem is that China’s current legal system, on the whole, is not constructed under some pluralist ideal, and China’s laws at present still carry a fairly strong sense of moral guidance. Once euthanasia is legalized, it will inevitably bring along a certain direction of value. Add to this the fact that China’s current judicial system, medical system, and public-opinion system are all quite imperfect, and it is not advisable to rush headlong into euthanasia legislation.

Compared with legislation on euthanasia, improving the legal system and the medical system is perhaps more urgent and important. In particular, it is worth making a concerted effort to build a more完善 social welfare system and more psychological services and hospice institutions. Compared with euthanasia, sound welfare guarantees and warm hospice care are more helpful in alleviating the physical and mental suffering of the dying.

Main Works Consulted:

[U.S.] H.T. Engelhardt: Foundations of Bioethics (Second Edition), trans. Fan Ruiping, Peking University Press, 2006

[U.S.] Thomas A. Shannon: Introduction to Bioethics, trans. Xiao Wei, Heilongjiang People’s Publishing House, 2005

[U.S.] James P. Sterba: Morality in Practice, trans. Cheng Lian et al., Peking University Press, 2006

Gao Chongming, Zhang Aiqin: Fifteen Lectures on Bioethics, Peking University Press, 2004

Wang Xiaohui: On Euthanasia, Jilin People’s Publishing House, 2004

Zhai Xiaomei: The Dignity of Death, Capital Normal University Press, 2002

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[①] From Webster’s University Dictionary, quoted in Zhai Xiaomei, The Dignity of Death, Capital Normal University Press, 2002, p. 47

[②] Gao Chongming, Zhang Aiqin: Fifteen Lectures on Bioethics, Peking University Press, 2004, p. 204

[③] [U.S.] James P. Sterba: Morality in Practice, trans. Cheng Lian et al., Peking University Press, 2006, p. 183

[④] Ibid., pp. 192–193

[⑤] See Gao Chongming, Zhang Aiqin: Fifteen Lectures on Bioethics, Peking University Press, 2004, p. 232

[⑥] [U.S.] James P. Sterba: Morality in Practice, trans. Cheng Lian et al., Peking University Press, 2006, p. 184

[⑦] [U.S.] Thomas A. Shannon: Introduction to Bioethics, trans. Xiao Wei, Heilongjiang People’s Publishing House, 2005, p. 98

[⑧] Wang Xiaohui: On Euthanasia, Jilin People’s Publishing House, 2004, p. 12

[⑨] [U.S.] Thomas A. Shannon: Introduction to Bioethics, trans. Xiao Wei, Heilongjiang People’s Publishing House, 2005, p. 34

[⑩] [U.S.] H.T. Engelhardt: Foundations of Bioethics (Second Edition), trans. Fan Ruiping, Peking University Press, 2006, p. 347

[11] Ibid., p. 352

[12] [U.S.] Des Jardins: Environmental Ethics, trans. Lin Guanming, Yang Aimin, Peking University Press, 2002, p. 155

[13] [French] Albert Schweitzer: Reverence for Life, trans. Chen Zehuan, Shanghai Academy of Social Sciences Press, 2003, p. 9

[14] [U.S.] H.T. Engelhardt: Foundations of Bioethics (Second Edition), trans. Fan Ruiping, Peking University Press, 2006, p. 1

[15] Ibid., p. 1

[16] Ibid., p. 104

[17] Ibid., p. 103

[18] See Zhai Xiaomei: The Dignity of Death, Capital Normal University Press, 2002, p. 116

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