In the last lecture, I introduced consequentialism in terms of cases where you have to decide who lives and who dies, and the issue of what sorts of decisions in those cases are morally permissible. Today, though, we’re going to talk about cases where it’s mainly one person’s life at stake.

The first of these is abortion. You may be used to hearing the abortion debate discussed purely in terms of whether a fetus is a person, but some ethicists have argued that this isn’t the only question that needs to be addressed in the case of abortion. First, I am told that many Catholic ethicists, in articulating a detailed anti-abortion position, have allowed one exception: cases where the mother has cancer and a hysterectomy is necessary to save the mother’s life, but this would result in the death of the fetus. It is argued that this is acceptable based on the doctrine of double effect: the fetus’ death is merely a foreseen side effect of a procedure necessary to save the mother’s life, rather than the means to saving the mothers life. It is important to note that this same rationale entails that if it were necessary to kill the fetus by more direct means in order to save the mother’s life–say, if something goes wrong in child birth, and the only way to get the fetus out is to crush its skull, and the mother will die otherwise–the doctrine of double effect would say that that is not permissible. How many find this distinction plausible? I’ve seen it used in a number of philosophical papers to introduce the problems surrounding consequentialism, and often it’s held up as an example of one of the less plausible distinctions people try to make, but maybe some of you do find it plausible.

However, the philosopher Judith Jarvis Thompson wrote a defense of abortion which uses anti-consequentialist ideas to argue that abortion is permissible in a great range of cases. If you listen to the abortion debate, you will probably pretty quickly run into the claim that it is about women’s right to control their bodies. This sounds odd to a lot of people–it seems to just ignore the important question of whether a fetus is a person. But Thompson argued that, even if the fetus is a person, abortion may be almost guaranteed to kill the fetus and yet be permissible up to the point where the fetus can survive on its own. This is because up to that point abortion will simply be a matter of the woman not allowing her body to be used for the support of another person.

Thompson illustrates her point by this example: imagined you wake up one morning and discover that you have been connected by a series of tubes to a famous violinist. It turns out that the Society of Music Lovers has kidnapped you and turned you into a living life-support machine for a famous violinist. They went through a lot of medical records and determined that you were the only person available who had the right blood type to serve this function. Would it be permissible for you to unplug, even if this results in the death of the violinist? It seems obvious that the answer is “yes.”

It should be clear that the distinction Thompson is arguing for is an anti-consequentialist one. Normally, it’s wrong to kill someone just because their being alive inconveniences us, even if they greatly inconvenience us. However, Thompson argues, you can refuse someone the use of your body to stay alive, even if that guarantees their death. This strategy is a noticable contrast to that of Peter Singer, who has defended abortion in a wide range of cases on consequentialist grounds.

Philippa Foot objected to this argument on the following grounds: the distinction between killing and letting die is really the distinction between initiating a lethal sequence and allowing one to proceed. Here, “lethal sequence” just means a sequence of events that will eventually result in a person’s death. In a sense, this seems plausible. But is this really what’s going on here? When the Society of Music Lovers kidnaps you, they temporarily put a stop the the one fatal sequence of whatever it was that made the famous violinist need a human life support machine. So when you disconnect, is that just restarting a stalled fatal sequence, or could it be starting a new one?

It seems like removing someone’s transplanted kidney certainly would be wrong, though you could use reasoning like Foot’s to say it’s really just restarting a stalled fatal sequence. The act of removing, say, someone’s pacemaker seems similar, at most a teensy bit more ambiguous. The same goes for many cases of disconnecting someone from life support. In these cases, we might say that even if you aren’t really initiating a new fatal sequence, restarting an old one is just as bad as starting a new one. On the other hand, Foot could reply that while there isn’t always a moral difference between creating and restarting fatal sequences, sometimes there is.

That’s a rough outline of how ideas like the doctrine of double effect, and the doing-allowing distinction, come into play in the abortion debate. However, there are also debates about how to treat people past birth. The most obvious one is euthanasia and doctor-assisted suicide. The key point is that no one wants to say that we have to to absolutely whatever it takes to keep people alive as long as possible when they’re sick. Saying this would impose an undue burden on people, in many cases prolong needless suffering, and may be considered an undignified. But there’s a dispute over whether you can ever give someone who is, say, terminally ill and suffering greatly, a lethal injection or even just a overdose of medicine which they can then take orally for themselves. The Netherlands has passed legislation to allow this, and so has, to a lesser extent, the U.S. state of Oregon.

To begin seeing what makes these issues so difficult, we may as well start with the trouble about the meaning of the word “euthanasia.” Breaking it down into its Greek roots won’t help us much–”eu” is “good,” “thanatos” is “death,” so we have “euthanasia” as meaning “good death,” but plenty of people deny that the things we call euthanasia are good, and no one would use it to refer to say, dying heroically in battle, even people who think that’s a really good way to go.

Everyone agrees that active killing of the sick is included in euthanasia. But some people use the word “euthanasia” also to include withdrawal of medical care. In that case, you get a distinction between active and passive euthanasia. There was a vivid demonstration of this in 2005, with the Terri Schaivo case, where the question was whether to remove a feeding tube of a woman who had suffered severe brain damage as a result of cardiac and respiratory failure, and who could no longer feed herself. This got a lot of public attention, and opinion was divided; even though trying to save Schaivo become known as mainly a cause of the religious right, the controversy didn’t break down strictly on religious lines.

One thing that came up in the Schaivo case was that the Catholic church had made an official declaration that, while extreme measures need not be taken to save a dying person, food and water never count as extreme measures, even when given by feeding tube. Whatever you think of feeding tubes, we clearly think this is right most of the time. Removing basic necessities is killing, not letting die. I assume you all know the story of Oedipus. The story goes that the Oracle said he would grow up to kill his father and marry his mother, and his parents decided to try to stop this. But all they did was have him placed on a mountainside, rather than running him through with a sword. He was found by a childless couple and raised as their own. Then, not realizing who his real parents were, he killed his father and married his mother.

Most people would say, in this case, that Oedipus’ parents tried to kill him, rather than trying to let him die. As it happens, when you hear about infanticide in the ancient world–when you hear about Plato advocating infanticide, or 20th century eugenicists taking inspiration from infanticide in ancient Sparta–often what’s actually being talked about is leaving an infant to die. But we still think of it as killing. Or, some Eskimo groups had a practice of senilicide, killing of the old. This simply meant that those who were too old to contribute were expected to go out into the cold to die, but we would describe that as a form of suicide or killing, not merely letting die by withdrawing heat and shelter. Many people would have the same reaction to a culture I learned about from an Asian studies professor as an undergrad, where the old are expected to at some point announce that they will stop eating, and slowly starve to death as a result.

In the modern world, we often face questions about what to do with severely disabled infants. Consider some real examples from Peter Singer’s /Rethinking Life and Death/: In the United States, a baby is born prematurely, so much so that he will have severe disabilities if he survives at all, and the parents ask that no heroic measures be taken to save him. They are gotten to consent to treatment with the threat of being taken to court. In another U.S. case, a baby born with Down’s Syndrome and a deformed esophagus. The deformed esophagus could have been fixed by surgery, but the parents and doctors decide not to. In the aftermath, the Regan administration goes into action to prevent such things don’t happen again, but Regan’s pro-life surgeon general admits he would not advocate prolonging the life of a child born without an intestine, a condition that is harder to fix, though such infants can be kept alive in the short term by IV. Again, in Britain, there was a court case where an infant with Down’s syndrome was given only water and painkiller, no food. The doctor was taken to court first for murder, then when that charge could not be made to stick, attempted murder. But he wasn’t found guilty even of that.

One last case, that I learned about in an undergraduate biology class at the University of Wisconsin-Madison: a local boy has a genetic illness that makes his skin extraordinarily vulnerable to blistering–it comes from a defect in connective proteins. Even eating turned out to be painful for him. He agreed to have food and water withheld, and died. I learned about this case from a biology teacher who I knew to be an Evangelical Christian, and who I’ve been told has taken a strongly pro-life stance in other cases. But from the way he presented that case in class, I don’t think he thought it was wrong of that boy to refuse food and water.

I’ve given quite a few more real-life cases in this lecture than in the last, because this is an issue where the real life cases are so much starker. In real-life cases of choosing to harm one to save others, there’s usually great uncertainty. Consider torture of terror suspects: is the intelligence about the threat really good? Does the suspect really know anything? Will he really be honest under torture? Even if the answer to all those three is “yes,” will the information ultimately make a difference, or will it come too late? But in many of these medical cases, it’s clear that if the doctor does one thing, there will be one outcome, and if the doctor does another thing, there will be another. We get clear-cut questions about how to formulate a consistent set of moral judgments.

The consequentialist position is that there can’t really be a killing/letting die distinction. This horrifies a lot of people. For advocating it, Peter Singer has been called the “Architect of the Culture of Death,” “Professor Death,” etc. But in these cases, I think there are two main considerations that might push people towards a more consequentialist answer: first, and most central, is the gut reaction, in looking at some medical cases, of saying “I wouldn’t want to live like that.” After that comes a worry that improvements in medical technology are making the distinction between killing and letting die increasingly vague.