Peter Singer
The 10th Dasan Memorial Lectures 2007
1. Introduction
The traditional ethic of the sanctity of human life has been central to Jewish and Christian thinking for millenia. I shall argue that the traditional ethic cannot be defended in terms of public reasoning – that is, reasoning that can appeal to people independently of their religious beliefs. I shall begin by looking at the way in which we have, over the last 30 years, changed our understanding of when a human being is dead. I take up this seemingly settled issue in order to show that the change we have made is in fact an illogical one, and one that already represents a significant erosion of the traditional doctrine of the sanctity of human life – and yet one that few of us would wish to undo. Secondly, I shall consider how this question relates to decisions about those who we do not regard as dead, but who have irreversibly lost consciousness. From there I shall discuss the treatment of infants born with severe disabilities, touch upon abortion and the destruction of human embryos to obtain stem cells, and also consider the question of voluntary euthanasia, before concluding with a brief look at some broader issues.
2. Changing Conceptions of Death
In 1968 the legal definition of death, everywhere in the world, was based on the cessation of heartbeat and of the circulation of the blood. Since that year, with surprisingly little controversy, brain death has been accepted as a alternative criterion of death, not only in the United States, but in virtually every country of the world. Of all the developed nations, Japan was the most reluctant to accept this change, and to some extent has remained distinctive from other developed countries in not really accepting the new criterion of death. As we shall see, this scepticism is well-justified, evenif the practical consequences of the change are desirable.
The change in the definition of death was presented and accepted as an improved scientific understanding of the nature of death. It was therefore seen not as an ethical issue at all, but rather as a matter of medical science. This widely-held view is a mistake. The new criterion of death sprang from the suggestion put by Professor Henry Beecher of Harvard University, who was clearly motivated by the need to make organs available in good condition for the then-new procedure of organ transplantation. The Harvard committee that Beecher subsequently chaired did not claim, in its ground-breaking 1968 report, that its new definition of death reflected some scientific discoveries about, or improved scientific understanding of, the nature of death. It was, instead, because the committee saw the status quo as imposing great burdens on various people and institutions affected by it, and as preventing the proper use of the “life-saving potential” of the organs of people in “irreversible coma” that the committee recommended the new definition of death. But the judgment that it is good to avoid these burdens, and to ensure that organs can be used, is an ethical judgment, not a scientific one. To think that this definition was either a new scientific discovery, or merely a matter of clarifying a vagueness introduced by modern methods of intensive care, was a widely shared misconception.’ But it was in no-one’s interest – not that of doctors, hospitals, families of brain-dead patients, or potential organ recipients – to challenge the reassuring idea that accepting the new definition of death was a matter of taking the advice of experts on a technical and scientific matter. This may explain why the new definition has triumphed in a relatively uncontroversial way. But that situation is already unravelling.
Some patients who can be shown to have no brain function are quite evidently still living human organisms. They have been maintained in intensive care units – or even, in one case, at home – for long periods, and in the case of pregnant women, they have even supported fetuses who have grown to term inside them. If a human organism can “survive”, as an organism, for several years after all brain function has ceased, this shows that the brain is not essential for integrated organic functioning. True, the survival of these human beings is dependent on machines, but we do not consider a person on dialysis to be dead because her kidney function has been replaced by a machine. Similarly, we should not think of people whose brains have irreversibly ceased to function as dead because their brain functions have been replaced by machines or other techniques.
Attentive listeners will have noted that the passage I quoted earlier from the Harvard committee’s report refers to “irreversible coma” as the condition that it wishes to define as death. The committee also speaks of “permanent loss of intellect”. “Irreversible coma” is an odd term to use of someone who is dead, and it is by no means identical with the death of the whole brain. Permanent damage to the parts of the brain responsible for consciousness can mean that a patient is in a condition in which the brain stem and the central nervous system continue to function, but consciousness has been irreversibly lost. Patients in a persistent vegetative state are in this situation, although today they would not be said to be in a coma.
Admittedly, the Harvard committee report does go on to say, immediately following the paragraph quoted above: “we are concerned here only with those comatose individuals who have no discernible central nervous system activity.” But the reasons given by the committee for redefining death – the great burden on the patients, their families, the hospitals and the community, as well as the waste of organs needed for transplantation – apply in every respect to all those who are irreversibly comatose, not only to those whose entire brain is dead.
Why then did the committee limit its concern to those with no brain activity at all? One reason may be that the committee believed – as many others have believed since – that the bodily functions of people whose whole brain was dead could only be maintained for a day or two. Where the brain stem survives, the body does not need anything more than food, fluids and basic nursing care to keep functioning indefinitely. A second reason could be that in 1968, the only form of “irreversible coma” that could be reliably diagnosed – with no possibility of a patient being declared dead and then “waking up” – was that in which there was no discernible brain activity at all. Another possible reason for the committee redefining death only as far as those with no brain activity at all is that if the respirator is removed from such patients, they stop breathing and so will soon be dead by anyone’s standard. People in a persistent vegetative state, on the other hand, continue to breathe without mechanical assistance. So if the Harvard committee had included in its definition of death people who are in an irreversible coma but still have some brain activity, they would have been suggesting that people could be buried while they are still breathing.
We now know that the bodily functions of those whose brains have entirely ceased to function can be maintained for months or years. So the first possible reason for restricting the definition of death to those whose entire brains have ceased to function is no longer valid. Technology has also eliminated the second reason: although in some cases of patients in a long-term persistent vegetative state, we still lack any completely reliable means of saying when recovery is impossible, in a other cases new forms of brain imaging can establish that the parts of the brain associated with consciousness have ceased to exist, and hence that consciousness cannot return.
Thus of the three reasons for limiting the definition of death to those whose brains have entirely ceased to function, only the last – the problem of declaring patients dead when they are breathing spontaneously – remains.
One solution to the present unsatisfactory state of the definition of death, therefore, is to couple the implications of the reasons given by the Harvard committee for switching to brain death in the first place with our improved diagnostic abilities, and move on to a definition of death in terms of the irreversible loss of consciousness. With the irreversible loss of consciousness, we have lost everything that we value in our own existence, and everything that gives us reason to hope for the survival of someone we love.
The significance of consciousness, and its link with the brain, answers the fundamental question – “why the brain?” – which supporters of the whole brain death criterion have never been able to answer satisfactorily in any other way. The death of the brain is the end of everything that matters about a person’s life. Of course, the death of those parts of the brain required for consciousness, is also the end of everything that matters about a person’s life. So the definition of death in terms of the irreversible loss of consciousness means that the criterion for death is the irreversible cessation of function of what is variously referred to as the cortex, the cerebral hemispheres, or the cerebrum. To avoid the need to define this more precisely, I shall use the expression “the higher brain” to refer to whatever parts of the brain are required for consciousness.
Do we really want to introduce a new concept of death which implies that warm, spontaneously breathing human beings are dead? I doubt that it is wise to attempt such a revisionist redefinition of a term in common use. “Dead” is a term applied much more widely than human beings, or conscious beings. Living things with no brain at all, let alone a higher brain, can be alive, and they can die. Why fiddle with a term that we all understand quite well? Even the much more modest revision proposed by the Harvard committee has yet to be absorbed into the way most people think about death. It is common to read newspaper headlines like “Brain-Dead Woman Gives Birth, then Dies”. If we try to tell relatives that their loved one is dead when he or she is lying on a bed, with no machines in sight, breathing normally, they are simply not going to believe us. And with good reason: for like the proponents of the initial shift to brain death, we would be guilty of trying to disguise an important ethical decision as a matter of scientific fact.
We cannot go back to the traditional definition of death, for then we would lose the chance to obtain many organs that save people’s lives. But equally, we cannot go forward and define death in terms of the irreversible loss of consciousness. But while most people would have difficulty in believing that someone lying on a bed, breathing normally, is dead, they do distinguish between different brain functions, not for the purposes of separating the living from the dead, but because there are some brain functions that we care about, and others that do not matter. If then, we ask which brain functions do matter, I believe that most people would answer that it is, minimally, those associated with consciousness. If it could be shown that vital organs were removed from patients who still retained the capacity for conscious experience, the likelihood of a public outcry would be much greater than if it were reported – as in fact it has been reported – that organs are being taken from patients whose brains continue to secrete hormones, and who thus are not legally dead, in the sense that their brains have not entirely ceased to function.
Stressing the importance of consciousness may suggest that we should move to a higher brain conception of death; but this is not the only possible conclusion to draw. To claim that human beings die when they have irreversibly lost the capacity for consciousness is too paradoxical. Instead we could accept the traditional conception of death, but reject the ethical view that it is always wrong intentionally to end the life of an innocent human being. We could then regard it as ethically acceptable (subject to the appropriate consent being given) to discontinue life support, or to remove organs for transplantation, when there has been an irreversible loss of consciousness. We would thus achieve the same practical outcome as we would achieve by redefining death in terms of the irreversible loss of consciousness. We would, in the terms used by the Harvard committee, have relieved the burden on families, hospitals and those in need of hospital beds, placed by the need to care for those who can never return to consciousness. We would have relieved this burden, not only when it arises from those whose whole brain has ceased to function, but also when it arises from those whose brain stem continues to operate. We would have done this without having to declare dead – in any sense – those who breathe unaided. Last but by no means least, we would have made our ethical judgments transparent, thus advancing public understanding of the issues involved rather than hindering it.
The only serious objection I can see to this proposal is the claim that, no matter how logically compelling it may be, it is so out of touch with reality that it stands no chance of success. After all, it is a head-on challenge to the traditional doctrine of the sanctity of all human life. Better, some will say, to do our best to push back the extent of that doctrine’s reach, by extending the definition of death to cover those who have irreversibly lost consciousness, than to hurl ourselves vainly against the doctrine’s citadel. Better, in other words, to maintain the fiction that brain death really is death, and indeed to try to spread this fiction even wider.
I would not deny that there are occasions when a fiction serves a useful purpose and is better not disturbed. But this does not seem to be one of them. For one thing, the fiction is coming apart anyway; and on the other, the traditional sanctity of life doctrine is increasingly being abandoned by both medical practice and the law, if not yet in the United States, then in other countries like The Netherlands, Belgium, and Great Britain. Truth is generally a better basis for ethics than fiction.
3. Life and death decision-making for embryos fetuses and infants.
I have shown that even those who want to hold fast to a traditional view of the sanctity of all human life must face difficult problems in relation to humans whose brains have irreversibly ceased to function. To reach a coherent and consistent solution to these problems, we need to dig deeper, and question something that we ordinarily take for granted, the idea that it is always wrong to take the life of an innocent human being. This is, to many people, a shocking suggestion, for the sanctity of human life is something that we scarcely dare question. Yet philosophers ought to question just those beliefs that we routinely take for granted, including this one, and I hope I have now shown that the questions are already raised even by something that is a matter of broad consensus, namely the shift to a definition of death in terms of the irreversible cessation of brain function. So here is one way to make progress with this problem. Ask yourself: “Is it worse to kill a human being than it is to kill, say, a chicken?” Unless you are a vegetarian, you are certainly going to say yes, it is. And even if you are a vegetarian – as I am – you are very likely going to think – as I do – that when someone kills people randomly in the street or in a school, that is a greater tragedy than what happens daily at a slaughterhouse. But why? Unless we take refuge in religious teachings, which not all of us share, the answer has to be because of some difference between humans and animals. That difference, however, cannot merely be the fact that we belong to one species and chickens, for instance, belong to another. To think that mere species membership alone could make such a crucial moral difference would be a kind of species-racism – more briefly, speciesism. Suppose there were intelligent Martians, very like us, and entirely peacable and friendly to us, but of a different species. Would it be acceptable to kill them, just because they are not members of our species? Surely not.
So if it is worse to kill human beings at random than to kill nonhuman animals, the difference must have something to do with the kinds of beings that humans are. And I would suggest, more specifically, that it must have something to do with the higher mental capacities that humans have – capacities that nonhuman animals do not have. This cannot be merely the capacity to feel pleasure or pain, or to suffer from the severing of a relationship like that between mother and child, for all mammals have these capacities. To give us a reason for thinking it much worse to kill typical humans than it is to kill beings of other species, the capacities must go beyond these – they might include, not merely awareness, but self-awareness, or possibly the capacity for making plans for the future. Here we have, I believe, a reason for distinguishing between the wrongness of killing beings that is based on something that is clearly morally relevant. The fact that a being is capable of understanding that it has “a life” does make it worse, other things being equal, to end that life. Then, and only then, are we ending the life of a being that knows it is alive, and can see itself as existing over time. Then, and only then, does the being have any conception of what it might lose by being killed, or have any capacity to have desires for the future that are thwarted by being killed.
But at this point it will become obvious that while typical humans – the humans who get killed when a suicide bomber blows himself up in a public square – have these capacities, and have them to a degree that a nonhuman animal does not, some humans do not have them. Newborn infants, for example, do not have them. And, while you might immediately object that a newborn infant has the potential to become a being with intellectual capacities far superior to those of any nonhuman animal, if this is supposed to be the reason why it is as bad to kill a newborn infant as an older human being, we shall have to acknowledge that the human fetus also has a very similar potential to that of the infant, and hence the same reason would make it very seriously wrong to kill a human fetus.
Some people, particularly in the United States, will endorse this conclusion. But in my view it is misguided, both for fetuses and for embryos. The world population is more than six billion, and is heading for somewhere around 9 or 10 billion – a figure that will strain our planet’s resources to the limits of their capacity, especially the ability of the atmosphere to absorb our carbon dioxide emissions = a topic I will discuss in my next lecture. We do not think it obligatory, or even desirable, for fertile couples to bring as many human beings as possible into existence, even though each one of them would, in all probability, become a unique, rational, self-aware human being. And on the same grounds, I do not think that the fact that a human fetus would, in all probability, become a unique, rational, self-aware being is a reason against having an abortion.
Since research into the use of stem cells has been widely discussed in Korea, I shall add that what I have said about fetuses applies even more clearly to the early human embryo that is destroyed in order to obtain human embryonic stem cells. Again, the fact that these embryos are human in the sense of being a member of the species Homo sapiens is, for the reasons given in my first Dasan lecture, and also above, not a ground for thinking that they have a right to life. We should not favor our own species merely because it is our own. And the embryo, when it is in vitro, cannot even develop further without assistance, both from scientists and from a woman who will accept it into her body. Obviously, the embryo at this early stage has no capacity for feeling pain or pleasure, or for having any conscious experiences at all. If, as I have argued, its potentiality is not a sound basis for attributing a right to life to it, then there is no ethical objection to destroying it, as long as we have the consent of the people from whom the egg and sperm came. If stem cells really hold the promise of cures for major diseases that afflict millions, and the best source for these stem cells is a human embryo, then we could argue that there is even an ethical obligation to obtain stem cells in that way.
4. The treatment of infants with severe disabilities.
I can now begin to explain my views on the issue of life-and-death decision making for infants with disabilities. For the reason I have just quickly sketched, I do not think that killing any newborn infant is morally equivalent to killing a rational and self-conscious being. This does not mean, of course, that killing infants is a matter of moral indifference. On the contrary, to kill an infant is normally very wrong indeed, but normally it is wrong primarily because of the harm it does to the parents, who have conceived the child, and already love it and wish to nurture it. The death of a newborn infant is generally a tragedy for the parents, not for the infant who has not even glimpsed the prospects of the life that might have been in store for it.
What difference, then, does disability make to our life-and-death decision-making for newborn infants? I became interested in the treatment of severely disabled newborn infants in the late 1970s when I learned that it is common practice for doctors to deal with such cases by “letting nature take its course.” This means that no operations are performed, or no antibiotics given, and the babies die slowly over many days, weeks, or even months. Parents are often not consulted, but simply told that there is nothing that can be done for their child. This seems to me an evasion of moral responsibility, and often grossly inhumane. Yet on investigating the prospects for some of the more severely disabled infants, I had to accept that it was not always good to prolong life, no matter what its prospects might be. But who should make this difficult decision? The infant, of course, cannot.
The parents are, in normal circumstances, the people most affected by whether their infant lives or dies, and they should, on the basis of the fullest possible information, have the principal say in the decision whether or not the resources of modern medicine should be used to keep their child alive. I accept that doctors may have an unduly negative view of life with a particular disability. I therefore urge parents in doubt over such a decision not to rely only on information from their doctors, but to contact groups representing those with the particular disability, or their parents or carers, to broaden their sources of information.
Nevertheless, parents will still sometimes decide, on reasonable grounds, that it is better that the child should not live. What should happen then? Around the time I took up my appointment at Princeton, when the controversy about my views on this topic was given a lot of publicity, I received a phone call from a doctor who directs a neonatal intensive care unit, and deals with such cases every day. He told me that, after consulting with parents, if they agree that it is better that their child should not be kept alive, he will turn off respirators, and even withdraw the tubes that supply the baby with food and fluids. But he will not give the baby a lethal injection. He said that he sees an important moral distinction there, but he could not explain to me in what it lay. I told him that I can understand why, psychologically, he perceives the two as different, but that I can see no important moral distinction between allowing death to occur by the deliberate withholding of available medical treatment and actively intervening to hasten death and ensure that it comes swiftly and humanely. In fact, I think the latter course, precisely because it does involve less suffering, is often the morally better one to take.
Not all doctors, of course, are as ready as this doctor was to consult with parents and withdraw treatment, even when the prospects for a baby are very poor. Around the same time that I spoke to the doctor, I received an email from a woman I will call Mrs B:
My son, John [not his real name], was born almost 2 1/2 years ago 11 weeks premature and weighing only 1 lb 14oz. They assured me that because he was already 29 weeks and had no intracrainial hemorrhages that he would be fine; he would just need to catch up with other kids his birth age. That is not the case. John has spastic diplegia cerebral palsy with underlying right hemiplegia…, has sensory problems, and has speech delays. We don’t know what his level of intellectual functioning will be, although people tell me he will probably be of “normal” intelligence with perhaps numerous learning disabilities. He is certainly more functional than some children with CP and has at least a small chance at a reasonably “normal” life, but that is not the issue.
My husband and I love our son (middle of three), but had someone told me, “Mrs. B. your son will have numerous disabilities down the road. Do you still want us to intubate him?”, my answer would have been no. It would have been a gut wrenching decision, but it would have been for the best. It would have been in the best interest for John, for us, and for our other children. I am saddened beyond words to think of all he will have to cope with as he grows older.
This is not the only letter of this kind I have received, and I do not think that Mrs B is an atypical mother. Many parents of children with severe disabilities judge the lives of their children to be such that it would have been better if they had died at or soon after birth. Others, of course, take a very different view.
Mrs B goes on to make another point that is also relevant to the question of how most of us would act when faced with the option to choose whether to have a child with a serious disability:
This is definitely not the life I would have chosen for myself either. My husband and I have never made it a secret that we were not cut out to be parents of a severely handicapped child, and had always said that if we were to find out we were having one, we would abort. I felt I was not a special enough person to deal with having that kind of a child.
This is, evidently, a common view. Prenatal diagnosis is routinely recommended for women who become pregnant over the age of 35, and the overwhelming majority of women of that age act on the recommendation. If the tests show that the fetus is affected by a condition such as Down syndrome, or spina bifida, almost all women will terminate the pregnancy. Their motivation may be mixed. In part, like Mrs B, they may not see themselves as cut out to be the mother of a child with a severe disability. But, wanting the best for “their child”, they may also think that it is better to terminate a life that has started badly, and perhaps try again.
In thinking about these issues, we should not forget that most couples today, at least in the developed world, plan their families. They will have perhaps two or three children. The decision to abort a fetus that has, say, Down syndrome, is not a decision that is “anti-children”, still less “anti-life”. It is a decision that says: “Since I will only have two children, I want them to have the best possible prospects for a full and rich life. And if, at the outset, those prospects are seriously clouded, I would rather start again.”
This is surely a reasonable view to take. Does it reflect a prejudice against the idea that life with a disability can be worth living? If that is a prejudice, it is one that is very widely held. Most people believe that, other things being equal, it is better to have children without disabilities. Otherwise, why would be spend money on research to find ways of overcoming conditions like paraplegia?
It is curious that many of us seem to accept such reasoning when it comes to preventing the births of children with disabilities, sometimes even when this involves ending a life during pregnancy, and yet we are shocked by exactly the same reasoning as soon as the baby has been born. I am not sure why. If there is one thing that the opponents of abortion are right about, it is surely that birth does not mark any decisive change in the nature of the being itself. The development of the fetus into infant is a gradual one. Perhaps the most significant difference that birth makes is that the infant can more easily be given up for adoption. That is why, where the disability is not a very serious one, if there are couples keen to adopt a child, that is a better outcome than ending its life.
Apart from that distinction between the late fetus and the newborn, I can see no reason for drawing the line at birth – unless it is the need to have some non-arbitrary line that compels us to take our stand with birth. I have suggested that the real moral dividing line occurs later, when self-awareness begins. But here too there is no sharp line to be drawn. That is why, at one point, my colleague Helga Kuhse and I proposed that a breathing space of 28 days should be allowed after birth, in which parents and doctors together should have discretion to make life and death decisions about a newborn child. But I now think this is too arbitrary to work – so I will merely say that these decisions should be made as soon after birth as the accurate diagnosis of the infant’s condition, and the parents’ need for due consideration, permits.
I want to conclude this section of my lecture by emphasising that what I have been discussing is in the context of infants, and parents’ decisions about infants. None of it has any direct application to older children or adults with disabilities. The fact that a person is in a wheelchair, or blind, has nothing at all to do with his or her status as a “person”, and therefore is in no way relevant to the seriousness of ending that person’s life against his or her will. It is, I admit, true that I would allow parents to end the lives of children who would later grow up to be in wheelchairs, or blind. So people might say to me – as some have – that if my views had been widely followed, they would not be alive today. But that is also true in many cases in respect of abortion, and it might also be true in some cases because of prenatal counselling, since parents may have been advised to, for example, obtain donor semen to avoid a genetic disability. Does anyone see this as a reason to stop prenatal counselling? And no doubt there are many people alive today who would not be alive if their parents had not been able to have an abortion, because then their parents would not have had another child.
Finally, I would like to say again, as I have said many times before, that I believe that people with disabilities should be given the fullest possible support from the community in integrating into the community, and being enabled to receive an education, and to live and work as normally as they possibly can.
5. Voluntary Euthanasia and Physician Assisted Suicide.
Another challenge to the traditional ethic comes from the increasing emphasis on the rights of patients to make their own decisions about medical care. In a free society, those with one ideological position about the wrongness of killing are not entitled be in a position to prevent an informed, competent terminally ill patient and a willing doctor from making and acting on the patient’s own judgment about when his or her life is no longer worth living. It is therefore odd that those who have claimed to be defenders of individual rights and freedoms have not all come to the support of the legalisation of voluntary euthanasia. How can anyone who thinks that the Government ought not to intrude unnecessarily in the private lives of its citizens hold that the Government should interfere in the private decisions of terminally ill patients and their doctors about when it is time to die?
The great irony of the work of the right-to-life advocates who sought, in vain, to prolong the life of Terri Schiavo, the Florida woman whose husband and parents had a bitter court battle over whether her feeding tube should be withdrawn, is that the outcome of all the publicity about the case was a surge in the number of people in the United States completing advance declarations making it clear that they do not wish to continue to live in circumstances like those in which she was living for the fifteen years before her death. Thus the fight over the removal of Schiavo’s feeding tube is likely to significantly increase the removal of feeding tubes. More broadly, the case has revived interested in the full range of right-to-die questions, including issues like active voluntary euthanasia and physician-assisted suicide that, because they require a patient to be competent to make decisions, raise ethical questions very different from those at issue in the Schiavo case itself.
The nineteenth century philosopher John Stuart Mill argued that individuals are, ultimately, the best judges and guardians of their own interests. So, in a famous example, he said that if you see people about to cross a bridge you know to be unsafe, you may forcibly stop them in order to inform them of the risk that the bridge may collapse under them, but if they decide to continue, you must stand aside and let them cross, for only they know the importance to them of crossing, and only they know how to balance that against the possible loss of their lives. Mill’s example presupposes, of course, that we are dealing with beings who are capable of taking in information, reflecting and choosing. Anyone who values individual liberty should agree with Mill that the person whose life it is, should be the one to decide if that life is worth continuing. If a person with unimpaired capacities for judgment comes to the conclusion that his or her future is so clouded that it would be better to die than to continue to live, the usual reason against killing – that it deprives the being killed of the goods that live will bring – is turned into its opposite, a reason for acceding to that person’s request.
Voluntary euthanasia will be morally unacceptable to some members of our society. Their views are, however, implicitly respected in the very idea of voluntary euthanasia – it is an option (like palliative care and the withholding of treatment) available to those who want it, and is not a mode of dying that must be taken up by everyone. Palliative care and non-treatment will remain the preferred option for many people. The fact, however, that palliative care can give many people the kind of dignified death they want does not mean that it is appropriate for everyone.
So it is scarcely relevant to argue, as many do, that there are few terminally ill patients who cannot be helped by palliative care. The figure may be as low as 5%. The fundamental point would still stand even if the percentage were only 0.05%: no patient should be made to die in ways that, while meeting the moral or religious precepts of some, are anathema to their own.
6. Letting Die
There is a further, broader, implication of the position I have defended about life and death. Just as we should be critical of the distinction between allowing to die and intentional killing in the case of the medical treatment of a severely disabled newborn, so too we should question this distinction when it comes to our failure to do enough to save the lives of people in absolute poverty in the world’s least developed countries. Here we are “allowing to die” by withholding aid, in order to have more to spend on ourselves. While this may not be exactly the same as killing, it is uncomfortably close in its outcome, and it is relevant to an estimated 18 million deaths from poverty-related causes every year. But this is a large topic and I will leave it for the next lecture.