Who holds the keys of death? The logic of assisted dying

The ethical principle of double effect.

Tom Dove

Tom is a physician and completing a theology doctorate.

white pills form an angle on a blue background

Hal Gatewood on Unsplash.

Healthcare hinges on the principle of double effect. This ethical principle makes the vital distinction between intent and effect. That is, one’s intent does not always result in a single intended effect, whether foreseen or not. In taking a patient’s blood, for example, my intent is to acquire information to aid treatment. An additional effect of this process is that—almost inevitably—this patient will experience pain, albeit minor. This principle of single intent and multiple effects applies throughout the practice of caring for human bodies, in all those instances where caring for those bodies involves physical interference, from prescribing medications to surgical procedures. And, in some instances, identifying and treating symptoms (such as terminal breathlessness) involves the use of medications that, as an unintended effect, result in death.

In the case of assisted dying, the distinction is important. The intent of assisted dying is to end pain and suffering by ending life. The ending of life is the treatment used to relieve pain and suffering. The intent is not to isolate and treat particular symptoms associated with a condition. The intent is to bring the condition itself to an end—which requires bringing the patient’s life to an end. This is not to make any judgment whatsoever about whether such a course is “right” or “wrong”, but rather to draw out the simple observation that this course involves an unprecedented change in medical practice. Assisted dying involves the categorical adoption of ending life as a possible treatment for a condition.

This is not quite the same as the slippery slope argument; it is about the logic of assisted dying. The point I am making is this: once ending life is introduced as a treatment, the key ethical step has already been taken. Applying that treatment in other instances of “suffering” (be they mental illness or ageing, for example) does not involve any new ethical steps. It simply involves the further application of a principle that has already been adopted. Despite the considered safeguards of the bill, therefore, the moral-ethical arguments against applying this treatment more widely will, at best, stand on shaky ground. For who could be so bold as to insist on what constitutes “suffering” for an individual?

Should the bill hold out the keys of death in this way? I can only think of One who is strong enough to wield those…

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War & peace

21 July 2023

7 min read

How to disagree agreeably

How do we converse passionately about controversial topics without falling out or falling into war? Jörg Friedrichs shares his insights after a difficult conversation with a colleague.

Jörg Friedrichs

Jörg Friedrichs is Associate Professor at Oxford University's Department of International Development and Official Fellow of St Cross College, Oxford.

Two 1950's men un suits sit at a table dominated by a large hanging microphone. One points a raise hand and finger into the air. The other listens.

A 1951 BBC debate between Iorwerth Thomas MP and Gwynfor Evans Teitl.

Llyfrgell Genedlaethol Cymru / The National Library of Wales, vis Unsplash.

Last year in spring, I bumped into an academic colleague whom I had not seen for a long time. I mean, we had talked over screens but not seen each other in person. He is a valued colleague, yet we ended up having a difficult conversation about the Ukraine war where we could have easily fallen out. It was close but, fortunately, did not happen, so let me share how we had a productive discussion instead. Of course, we did not end up agreeing on everything, but we did let one another finish. Avoiding an escalation was not easy then and is never easy in situations of this kind, but it is worth trying because relationships are more important than asserting personal viewpoints.

Differences of opinion escalate easily in so many situations, especially in war-like ones. We see this with the war in Ukraine, but also in the context of the so-called culture wars. How do we disagree agreeably when people hold strong and principled views about controversial issues? Gender and lifestyle? Religion and race? How do we express a nuanced view that might question strongly held opinions, without either being labelled as something nefarious - “racist”, “woke”. Or thus labelling somebody else? What I am going to share is applicable to many situations, from the culture wars to marital disputes, from conversations over football to a post-mortem between parents when their kids have had a meltdown in the playground.

Difficult conversations

There is no question that conflict generates false moral certainties, and it is often good to question them. Just because Russia attacked Ukraine, is anything to punish Russia justified? Conversely, just because Ukraine has suffered an attack, is it a victim nation deserving unlimited and unconditional support regardless of its own actions? Is the West, because it supports Ukraine, unquestionably in the right? Is any support of Russia, or even an attitude of neutrality, totally objectionable?

In a war situation, people tend to look at things in a black-and-white fashion, and even-handed views are unpopular. Expressing them requires courage because partisan observers will attack us when we fail to roundly condemn one side while exonerating the other.

How are we going to react when they do so? We will certainly feel put on the spot, but this does not disqualify their arguments. We therefore must consider their accusations with humility.

In my conversation with the colleague, he accused me of spreading “Kremlin propaganda” when I suggested that the West should be more sensitive to the concerns expressed by Russia as a humiliated great power. Spreading Kremlin propaganda is not a minor accusation these days, and I did not feel I deserved it. I therefore found that, in a situation like this, keeping one’s patience is challenging. I was tempted to counterattack, perhaps accusing the colleague of being prejudiced. Instead, I had to take a deep breath and explain to him, as calmly as I could, that my aim was not to side with Russia but to suggest something that might have enabled, and might still enable, diplomatic negotiations and peaceful change rather than replicating a conflict that is so hugely damaging.

From my point of view, the colleague had accused me unjustly, and so I found it difficult to render justice to what he was saying. Yet, while spreading Kremlin propaganda was not my aim, I had to recognise that part of what I had said overlapped with what a Kremlin propagandist might say. It was uncomfortable to accept that, perhaps, my colleague had put his finger on a vulnerable spot and I should take greater care to distance myself. To make things worse for myself, my colleague also pointed me to a factual inaccuracy regarding a historical detail. In all honesty, I found it challenging to accept any form of criticism from someone who had just accused me of spreading Kremlin propaganda. Yet, the intellectual virtue of docility demanded me to concede the inaccuracy of this particular historical claim and stand corrected. I had to remember that, ultimately, what unites us is a search for truth, and that the truth can only reveal itself in a discursive spirit of give-and-take.

Disagreeing agreeably

We then had a productive discussion where I was able to point out that, during the crisis preceding the attack, Russia had made it very clear that the casus belli (cause of the war) had been a dispute over whether Ukraine was entitled to join a military alliance perceived as hostile by Russia. The USA and its allies insisted that this was not negotiable. Was that, and is that, worth a conflict that is killing countless people and has dire consequences for global energy and food systems? Has everything been done to avoid the war, and is everything being done to end it? While it is easy to see that Putin’s Russia is wrong, are we sure that “we” are right?

Since the end of the Cold War, “we” (that is, Washington and its allies) have been involved in a significant number of military interventions, from Kosovo to Afghanistan and from Iraq to Libya. By comparison, Moscow has hardly been involved in any out-of-area interventions. Where Russia has invaded an adjacent country or region, as in Crimea and South Ossetia, the trigger was always the fear of a neighbouring country turning hostile. While attacking a neighbouring country is unacceptable, it seems fair to ask if the USA would stand by idly if a hostile power were extending its reach into its own regional neighbourhood (Cuba, Nicaragua, Granada). While a US attack on a country in its regional neighbourhood seems unlikely under present circumstances, there is a need to understand Russia beyond condemning the invasion of Ukraine.

Unfortunately, propaganda from both sides has become so intense that it is becoming difficult to gain an even-handed understanding. There has even been open debate about using nuclear weapons. 35 years ago, the Cold War ended with a consensus that a nuclear war cannot be won and must never be fought. Indeed, fear of a nuclear holocaust was one of the reasons why the Cold War remained, largely, “cold.” There was communication with Moscow even under Brezhnev. Today, some would see a dialogue with Putin as treason. How can fundamental lessons of diplomacy and deterrence be unlearned so quickly?

We must value and recognize not only those whom we find it easy to empathize with, such as the Ukrainian and Russian people, but also those whom we dread and whom we fear.

While my colleague stood his ground and reminded me, repeatedly, that “we” must punish or even humiliate Putin’s Russia for its attack on a sovereign country, we were able to have a calm debate where he listened to my arguments as much as I listened to his.

This was only possible because I had stuck, as best I could, to a series of intellectual virtues, highlighted above in bold: courage; humility; patience; justice; docility; and search for truth. The list goes back to Nigel Biggar, a moral theologian who has adapted Christian virtues for intellectual needs. Professing such virtues is easy in principle, but hard in the heat of a real encounter. In the exchange with my colleague, I passed the test by the skin of my teeth. At other times, I fall short.

Now, for those familiar with the lore of Christian virtues, you will know that 'six' is a weird number. Everything should come in 'sevens'. So Nigel Bigger gives us a final, seventh intellectual virtue. Charity. Quite possibly the most important.

If only we could become like brothers and sisters who are able to carry out our disagreements in love, giving each other the benefit of the doubt in having sincere intentions and reasoning to the best of our abilities.

Of course, virtue sounds like a very grand word. Perhaps there are saintly figures who “possess” virtues as personal qualities. For the rest of us, virtues are aims to which we should strive, however much we struggle to reach them. Centuries ago, even a child would have been able to enumerate the seven virtues of Christian morality. Today, some of us may still remember the three theological virtues (love, faith and hope), but what were again the four natural or cardinal virtues? Well, never mind.

In a twist that encapsulates the best of the Christian tradition, the virtues are not about being virtuous in a self-righteous way. Contrary to the pagan tradition where virtue is something heroic, Christian virtues are about valuing and recognizing others while humbling and decentring ourselves. We must value and recognize not only those whom we find it easy to empathize with, such as the Ukrainian and Russian people, but also those whom we dread and whom we fear. Christian virtues equip us for the arduous task of entering a dialogue with Putin’s Russia, with the view to seeking peace. Having negotiated with everyone from Stalin to the Vietcong, from Gaddafi to the Taliban, we hear today that the idea of negotiating with Putin’s Russia is naïve at best and misguided at worst. Yes, it is going to be fiendishly difficult. Yet, it is necessary. Equipped with intellectual virtues, nothing should stop us from trying. Neither should we stop trying to have conversations across the trenches, even those of the culture wars.

Note: this post uses material from an earlier post by the same author.