Kant and Mill on Physician-Assisted Suicide
Dr. Timothy Quill made headlines in the fields of patient rights and euthanasia when he published “Death and Dignity” in the New England Journal of Medicine (1991). In the articlce, Quill described his long-term patient, Diane, who had a history of surviving vaginal cancer and regaining control over her life after overcoming alcoholism and depression (Quill, 1991, p. 691-694).
The patient is diagnosed with Leukemia by Dr. Quill and is told that with treatment, she has only a 25% chance of survival and a complication-filled treatment process ahead of her. Without treatment, she only has weeks to months left to live. From her past cancer experiences and her attitude on living life to the fullest, Diane decided to forgo treatment and live out the remainder of her life with whatever strength she had left. In her view this was a dignified choice made with much thought, with her family’s support, and with full mental and emotional faculties.
After discussing all treatment options and the option of suicide, Dr. Quill provided Diane with information regarding the Hemlock Society -- an organization that advocates for a patients’ right to take their own life. She contacted Dr. Quill when cancer-related pain grew too strong, and he prescribed barbiturates, informing her of the dose necessary for sleep assistance and the dose necessary for death. Diane died shortly thereafter by her own hand.
This article discusses the moral implications and influences of the parties involved from the perspectives of utilitarianism and Kantian ethics, and the legitimacy of their conclusions regarding Diane’s and Dr. Quill’s choices.
The story of Diane and her decision to take her own life can be viewed from different perspectives, with differing verdicts on whether or not her chouse was morally 'correct.' The main issues of contention are her choice not to undergo chemotherapy, and more importantly, her decision to cut her life short when she deems it is no longer worth living.
Both of these decisions can be considered a form of suicide as choosing to not undergo treatment is essentially a death sentence. Taking the barbiturates was a way of accelerating the inevitable. A perspective from the utilitarian view of John Stuart Mills would hold that Diane’s decision was morally wrong due to the various “pains” she imposes on the people around her outweighing her own pleasures, as both must be counted equally.
A Kantian perspective, on the other hand, might claim that the moral failure is due to the inability for the maxim Diane follows in her choice to be universalized. While it is likely that both Mills and Kant, as philosophers, would claim that Diane made the wrong choice (although for different reasons), both perspectives fail to adequately address the complexity of human nature, and as such, are not defensible as decision-making structures in this situation.
From a Kantian perspective, as described in Groundwork of the Metaphysics of Morals, the morality of a particular action depends on the fulfillment of duty. Consequences are of no concern, and all that matters in the making of a decision is the intent behind it. For a decision to ascribe to Kant’s categorical imperative, the thinking behind it cannot depend on circumstance: it must have the capability of being universalized without ruining society. As Kant writes,
In Diane’s case, this maxim would be that, “If I suffer in indignity, I should end my own life.” If that were to be adopted, nobody on this earth would remain alive due to the every-day struggles we all face. This is a particularly strong maxim to disobey, as it is considered a perfect duty to oneself, due to the fact that it is without exception, and not influenced by personal inclinations, as imperfect duties may be (Kant, 1964, p. 29). Additionally, Kant has countered the case for suicide by disagreeing that the act of killing oneself can come from self-love. As Kant explains:
As per Kant, love is inherently a life-promoting force, and an act of terminating it does not come from the right intent to be considered moral. Thus, while Diane may be making a decision based on what she considers to be her right to dignity, as per Kant, she is doing a wrong to herself and breaking a critical universal moral rule. Her decision to not undergo chemotherapy is passive as opposed to active, and is an imperfect duty to herself. Nonetheless, Kant would consider it the wrong choice for the same reasons as those relating to an actively perpetrated suicide.
A utilitarian perspective is the foil to a Kantian viewpoint, as intent has no bearing on a decision, while the net outcome is the determining factor for whether something is right or wrong. It is Teleological and focused on maximizing utility, as opposed to the Deontological root of a Kantian philosophy. The ultimate goal is the maximization of pleasure and minimization of pain for the greatest number of people, with the priorities of pleasure ranked in a general order of mental superior to physical: Intellect, moral sentiment, imagination, and feelings followed by sensation (Johnson, 2011, p. 221).
Looking at Diane’s choice, it is seen that her motivations are moral sentiment, as she wants to preserve her dignity, imagination, as she does not want to think of herself wasting away, and sensation, as she will not have to suffer the excruciating pain or chemotherapy. However, the problem with Diane’s approach from Mill’s perspective is that it is primarily oriented to maximize her happiness, and does not consider the happiness of those around her. When approaching a moral issue from Mill’s perspective, all parties involved must be considered evenly without regard for emotional sentiment.
For one, her doctor is put into the very uncomfortable position of deciding whether or not he should participate in what society may consider to be murder; a direct confrontation with her physician’s moral sentiment. Whether or not he comes to believe that he did the right thing, much of the current societal system would label him a criminal. Laws may be unfair, but this situation has outcomes that affect people other than Diane negatively. Her family is also not factored in, as she is giving up the small, but still possible chance of successful treatment that they wished she would take (Quill, 1991, p. 691-694). She makes it mandatory that her son will not have his mother beside him, and that she will not live a life with her husband. Thus, if all people are weighed equally, as Mill describes, Diane has done the wrong thing.
Unlike Kant’s perspective, however, there is a slight difference between the two aspects of Diane’s decision; the refusal to undergo chemotherapy, and the decision to cut her life short. The decision to not undergo chemotherapy is actually not a moral issue for the doctor, as it is a viable patient choice when the patient is fully informed, as Diane is. It is the second choice, physician assisted suicide, which presents the moral quandary.
In today’s legal system, it would be considered illegal, and thus, has ramifications such as potential jail time and the loss of a medical license if the physician’s actions are discovered (Assisted Suicide Laws in the United States). As a result, the moral stance Mills would have in this case is not clear. However, since Diane’s overall decision necessarily involved the ingestion of barbiturates, it can be interpreted that the decision is not acceptable from a Utilitarian perspective.
One of Kant’s assumptions is that suicide is wrong due to the fact that self-love can never be tied to death.
Both Kantian and Utilitarian philosophies aim to provide a structure for making the right decisions under any circumstances. However, due to a variety of reasons, they both fail to lead to an adequate moral choice in regards to Diane’s very personal situation, and neither is truly defensible. One of Kant’s assumptions is that suicide is wrong due to the fact that self-love can never be tied to death. From what we know of Diane, prolonging her life would have nothing to do with love to herself; instead, it would be betraying her very nature as a strong woman who has felt suffering, and does not want to go through it again.
This is presented as a universal statement, as if it must apply to every individual, no matter how much pain and suffering they might be experiencing. An essential flaw in the Utilitarian perspective is that it requires one to make a prediction about the future to weigh outcomes for events that have not yet occurred. For example, what if Diane’s family would have felt more pain in seeing her suffer through treatment than as opposed to knowing that she died in dignity before her existence grew too painful to bear? In that case, Diane has done the right thing in regard to her family.
Perhaps the most questionable aspect of both Kant’s and Mill’s philosophies is the complete lack of regard to an individual’s personal and emotional stance on a situation. Both believed that a person’s personal feelings should have no bearing on a personal decision. Mills even claims that if a decision goes against what a person desires, the moral satisfaction from doing the right thing should overcome any other hurt sentiments, such as feeling and emotion that occurred as a result of the action. As is stated in Ethics: Selections From Classical and Contemporary Writers:
This is not reflective of the nature of humanity, since we are living, breathing, and feeling creatures that develop attachments and we have a right to honor those personal attachments in favor of those to people who we do not know. More fundamentally, the issue with these two philosophies, one being deontological and the other teleological, is that each covers what the other does not.
To have a more legitimate outline for moral action, both the consequences and the intent must be considered in the process of making a decision. This may make it more difficult to come up with answer as to what the 'moral choice' is for any particular situation, but at least the decision-making process will not be missing a critical half of what is normally part of the day-to-day reasoning process. A balanced approach creates a more defensible ethical philosophy.
Assisted Suicide Laws in the United States. (n.d.). Retrieved June 12, 2015, from http://www.patientsrightscouncil.org/site/assisted-suicide-state-laws/
Kant, I. (2008). On the metaphysics of morals and ethics. Radford, VA: A & DPub.
Quill, T. (1991). Death and Dignity. New England Journal of Medicine N Engl J Med, 691-694.
Johnson, O. (2011). Ethics: Selections from classical and contemporary writers (11th ed). Boston, MA: Wadsworth Cengage Learning.