September 1985 VII/1
MERCY KILLING AND ALLOWING TO DIE
Roswell Gilbert, 76 years old, is serving a mandatory 25-year sentence at the Avon Park Correctional Institute in Florida for shooting his wife to death on March 4, 1985. Gilbert said he killed his wife of 51 years as "an act of love" to end her suffering from Alzheimer's disease and osteoporosis. Though a jury convicted Gilbert, the Governor of Florida has been asked to grant clemency and thus the case is in the news once again. Our purpose is not to discuss the merits of the jury decision or give the governor advice. Rather, we shall use the case to compare objectively mercy killing with allowing a patient to die. In other words, we shall question why the killing of a suffering comatose person is any different from a death that results when life-support systems, such as tube feeding or a respirator, are removed from a person in the same condition.
Principles
In order to offer an ethical perspective to the question, we must consider the purpose of medicine. Medicine aims at preventing illness and healing disease in order that a person may achieve optimal human functioning in accord with his or her capabilities. But optimal human functioning involves more than physiological function. In order to function humanly, there must be some capacity for cognitive-affective function. If the potential for cognitive-affective function is not present, for example if a person is in an irreversible coma, then applying medical care does not have a purpose. Hence, medical care should be withdrawn once it is determined that it cannot achieve its purpose of improving physiological function so that the cognitive-affective function can be prolonged or restored. The only reason for continuing medical care for a person whose cognitive-affective function has been irreversibly lost is to keep the person comfortable. Even if the family of a person in such a condition asks that aggressive care be continued, the ethical response of the physician would be: "We have done everything possible. It is now time to allow your loved one to die."
If there is no hope that cognitive-affective function will be restored, why not end the person's physiological function and thus terminate life with an injection of air or some other lethal procedure? Why must a family suffer as a loved one slowly and perhaps painfully wends his or her way to a "natural" death? Many ethicians in England and America would opt for this form of treatment maintaining that since the person in question will die anyway, why prolong the suffering? Recall, however, that though the person in an irreversible coma does not have the present or future capability of cognitive-affective function, he or she is still a human being. Though higher human function is impeded the function that remains, namely that of the physiological system, is the function of a human physiological system. Thus there are two persuasive and overriding reasons why such persons should not be put to death, even "to end their suffering:" (1) respect for human life makes us realize that we are stewards of life, not masters of life. People who believe in God will state that God is the author of life and human beings do not have the right to directly cause the end of their own lives nor the life of another innocent person. Human beings have only the right to prolong life and this only when prolongation will help a person fulfill God's plan. Those who do not believe in God realize that each person must be free from direct killing, else society becomes a jungle. If exceptions are made to this moral precept then the strong and the violent dominate and justice and culture are stifled; (2) the second reason for asserting that mercy killing is unethical is more pertinent to health care professionals. If physicians and nurses become associated with killing people, then trust which is the basis of the healing contract will be eroded and slowly disintegrate. If health care professionals offer health care for any primary motivation other than patient benefit, they will soon lose the trust and respect of their patients.
Discussion
Even some who accept the above-mentioned principles would maintain that there is no real difference between allowing a person to die and putting a comatose suffering person to death in order to relieve suffering. Hence they would opt for never removing life-support systems. After all, the argument goes, the outcome is the same in both cases. Moreover if one removes a life-prolonging device or therapy from a dying patient, the patient dies as a result of this action. Thus, they maintain, removing the life-prolonging therapy is. the cause of death just as in mercy killing the cause of death is the direct intervention on the part of the one who performs the injection or act of violence from which death follows. Though the two actions, mercy killing and allowing to die, are similar in result, they are not the same in process nor in proximate motivation.
In the case of allowing to die, it is true that the patient usually dies upon removed of the life-prolonging mechanisms or therapy, but the cause of death is an existing pathology which is now allowed to have its natural effect. For example, the respirator is removed and the patient dies because of pathology in the cardiopulmonary system. The mechanism or therapy which inhibited the life-threatening pathology being removed because it is no longer useful to cognitive-affective function, the pathology is allowed to have its natural effect. Nature is allowed to take its course. In mercy killing the cause of death is a pathology induced by the mercy killer. The pathology may be induced either by the direct intervention with the natural activity of the patient's physiological system or by withholding of some care for that system which should be offered. Thus mercy killing could be accomplished by withholding a needed medicine as well as by a pistol shot. One way or another, then, in mercy killing an act of violence is performed upon the physiology of the person concerned and a pathology is induced. Moreover, at least an implicit motivation for mercy killing is to exercise complete dominion over human life.
Some argue that the ultimate motivation for mercy killing, freeing another from suffering, is enough to justify the action. Thus, they would argue, Roswell Gilbert and others who wish to end suffering should not incur ethical or legal sanctions. Unfortunately, there are many ethicists today who would justify any action as long as the ultimate motivation is good. But this type of thinking abstracts from reality. The actions which lead to fulfilling an ultimate motivation have a motivation of their own which must be justified ethically. For example, though my ultimate motivation may be to raise money to send my children to college, I have no right to obtain this money by robbing widows and orphans.
Conclusion
A final reflection: In determining the objective value or disvalue of any action we realize that the person who performed the action may have been subjectively exonerated from any moral guilt. In the case of Roswell Gilbert and all others in this same situation, we would be more interested in discussing a support system that would have allowed him to bear his sorrow in a more humane manner than in discussing what would be a fitting punishment.
Kevin O'Rourke, OP
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