1

Rule-Utilitarianism and Euthanasia

Brad Hooker

1 Introduction Different moral theories will of course ap- proach questions about the moral status of eu- As scientific and technological advances enable thanasia in different ways, though some of these the medical profession to keep people alive theories will end up with the same conclusions. longer, the question arises whether this is This essay considers euthanasia from the per- always a good thing. Should those who could spective of just one moral theory. The theory is prolong life step back under certain conditions rule-utilitarianism. Rule-utilitarianism assesses and allow a very ill person to die? And if possible rules in terms of their expected utility. allowing to die is sometimes right, then what It then tells us to follow the rules with the about actively killing patients when this would greatest expected utility. (Expected utility is be better for the patients than allowing them to calculated by multiplying the utility of each die more slowly and painfully? possible outcome by the probability that it will Such questions are debated under the occur.) heading of euthanasia. The term ``euthanasia'' In the next section, I explain what the term derives from the Greek term for an easy, pain- ``utility'' means. Then I outline another utilitar- less death. However, we often now hear the ian theory ± act-utilitarianism. I do this in order term ``passive euthanasia,'' which refers to pass- to contrast rule-utilitarianism with this perhaps ing up opportunities to save an individual from more familiar theory. I then outline the distinc- death, out of concern for that individual. If tions between different kinds of euthanasia. The passive euthanasia is indeed one kind of eutha- final sections of the paper consider the various nasia, then ``euthanasia'' cannot mean ``killing factors that would go into a rule-utilitarian de- painlessly''; for to pass up an opportunity to cision about euthanasia. save someone, i.e., passive euthanasia, is argu- ably not killing. Furthermore, the death in- volved in passive euthanasia is often painful. 2 Utility So let us take the term ``euthanasia'' to mean ``either killing or passing up opportunities to A moral theory is utilitarian if and only if it save someone, out of concern for that person.'' assesses acts and/or rules in terms of nothing (Note that, on this definition, what the Nazis but their utility. Classical utilitarianism took called ``euthanasia'' was not euthanasia, because ``utility'' to refer to the well-being of sentient it was not done out of concern for the pa- creatures. And classical utilitarianism took the tients.) well-being of sentient creatures to consist in

22 Rule-Utilitarianism and Euthanasia pleasure and the absence of pain (Bentham, I shall also follow conventional philosophical 1823; Mill, 1863; Sidgwick, 1874). On this view, opinion in supposing that it is possible to be in people's level of well-being is determined solely such a bad condition that death would be a by how much pleasure and pain they experience. welcome release. Severe pain can be unremit- If anything is desirable for its own sake, ting, and indeed so overpowering that the pleasure is. But most utilitarians now think person experiencing it can think of nothing that pleasure, even if construed as widely as else. If the rest of my life would consist of possible, is not the only thing desirable in itself, nothing but excruciating physical pain, then I and pain not the only thing undesirable in itself might be better off dead. Indeed, if the rest of (Moore, 1903, ch. 6; Hare, 1981, 101ff; Parfit, my life would consist wholly of intense psycho- 1984, appendix I; Griffin, 1986, Part One; logical suffering, I'd be better off dead. Of Goodin, 1991, p. 244; Harsanyi, 1993). Utilitar- course, we may argue about where to draw the ians can think that things that are desirable for line between being better off dead and being their own sake include not only pleasure but better off alive (Mitchell, 1995). But it seems also important knowledge, friendship, auton- deeply unreasonable to insist that there are omy, achievement, and so on. Indeed, many never any instances of patients who would be utilitarians now construe utility just as the ful- better off dead. fillment of desire or the satisfaction of prefer- Now, what about divinely bestowed benefits ences, with relatively few restrictions on what and harms? Most utilitarians, and all utilitarian the desires or preferences are for. writers of our era, have written as if there were One reason most utilitarians have moved no rewards or punishments granted by a god or away from a version of utilitarianism that gods. This is not to say that all utilitarians have focuses exclusively on pleasure has to do with been atheists. In fact, many have been religious knowledge. Many of us care about certain believers (perhaps most notably, Bishop Berke- things over and above the pleasure they typic- ley, 1712). Nor would any utilitarians ± theistic ally bring, and one of these things is knowing or agnostic or atheistic ± hold that a person's the important truths (e.g., about the nature of religious beliefs are completely irrelevant to the the universe and about oneself), even if not morality of how he or she is treated. For any knowing the truth would be more pleasant for utilitarian would recognize that people's reli- us. Bliss isn't everything ± for example, if pur- gious beliefs can have an effect on what brings chased at the cost of ignorance. To be sure, them pleasure and on what preferences they knowledge does not always constitute a more form. So utilitarianism will favor, for example, significant addition to well-being than does freedom of religion and even the neutrality of pleasure. But sometimes it does. the state with respect to religion.1 But while People also care about autonomy, by which I utilitarians can think that people's religious mean control over one's own life. Many of us beliefs are often relevant to moral argument would be willing to trade away some pleasure about how these people should be treated, for the sake of an increase in autonomy. Again, modern utilitarians eschew basing any moral this is not to say that even a tiny increase in argument on the truth of any religious belief. autonomy is more important than a great deal of And this prohibition on assuming the truth of pleasure; rather, the point is that pleasure is not any religious belief applies to the belief that always more important to our well-being than there are divinely bestowed benefits and harms. autonomy. Neither value is always more im- That said, we must also note that utilitarian- portant than the other. ism is also often said to assume a god's-eye I agree with such convictions. Knowledge, point of view. The main respect in which this autonomy, and other things can be beneficial is true is that the utilitarian approach prescribes to us, can increase our well-being, over and a totally impartial calculation of well-being. To beyond whatever pleasure they directly or in- be more specific, in the calculation of utility, directly bring us. I shall presuppose this in what benefits or harms to any one person are to count follows. for just as much as the same amount of benefit

23 Euthanasia or harm to anyone else ± that is, count the same way to prevent something much worse. But we without regard to race, religion, gender, social don't think such acts are permissible when the class, or the like. expected and actual utility of such an act would It is a mistake to think that utilitarians hold be only slightly greater than that of complying that what benefits more people is necessarily with the prohibition. better than what benefits fewer. Utilitarians Another problem with act-utilitarianism is focus on the greatest aggregate good. What that it seems unreasonably demanding, requir- results in the greatest aggregate good is some- ing acts of self-sacrifice that seem beyond the times not what benefits the majority. This is call of duty. Think how much a middle-class because the benefits to each of the smaller individual in a relatively affluent country would number may be large and the benefits to each have to give to CARE or Oxfam before further of the greater number small. And large benefits sacrifices on her part would constitute a larger to each of a minority can add up to more than loss to her than the benefit to the starving that small benefits to each of a majority. Thus, utili- CARE or Oxfam would produce with that con- tarians will favor what benefits the minority if tribution. Making sacrifices for strangers up to (but only if ) what benefits the minority results the point that act-utilitarianism requires would in the greatest good overall. be saintly. But morality, most of us think, does On the other hand, many philosophers have not require sainthood. pointed out that utilitarianism gives no intrinsic weight to how equally or fairly benefits are distributed. I myself accept that this is an im- 4 Rule-utilitarianism portant potential problem with utilitarianism. But because I don't think these worries about Rule-utilitarianism differs from act-utilitarian- distribution are relevant to euthanasia, I shall ism in that rule-utilitarianism does not assess ignore them in this paper. each act solely by its utility. Rather, rule-utili- tarianism assesses acts in terms of rules, and rules in terms of their utility. Rule-utilitarian- 3 Act-utilitarianism ism holds that an act is morally permissible if and only if the rules with the greatest expected The most direct and most discussed form of utility would allow it. The expected utility of utilitarianism is act-utilitarianism. There are rules is a matter of the utility of their ``general'' different versions of this theory. One version internalization, i.e., internalization by the over- holds that an act is right if and only if its actual whelming majority. For a code of rules to be consequences would contain at least as much util- internalized is for people to believe these rules ity as those of any other act open to the agent. justified and to be disposed to act and react in Another version claims that an act is right if and accordance with them. Assume I have internal- only if its expected utility is at least as great as ized a rule against killing people against their that of any alternative. will. If this assumption is correct, I will (a) think But there are many familiar counter- this kind of act wrong, (b) be disposed not to examples to both versions of act-utilitarianism. do this kind of act, and (c) be disposed to Some of these counter-examples have to do react negatively to those who I think have with moral prohibitions. For example, both ver- done it. sions of act-utilitarianism imply that killing an To say that rule-utilitarians focus on the con- innocent person, or stealing, or breaking a sequences of the general internalization of rules promise would be morally right if the expected does not mean that they consider only rules that and actual utility of the act would be greater, existing people already accept. Rather, the ques- even if just slightly greater, than that of any tion rule-utilitarians ask about each possible alternative act. We might think that normally code is what the effects on utility would be of prohibited acts could be right in very rare cir- the code's being successfully inculcated in cumstances in which doing such acts is the only people who had no prior moral beliefs or atti-

24 Rule-Utilitarianism and Euthanasia tudes. At least in principle, the code of rules are more intuitively acceptable than those of best from a utilitarian point of view might be act-utilitarianism (Brandt, 1963; 1967). very different from those now accepted in any given society. (For developments of this sort of theory, see Brandt, 1963, 1967, 1979, part two; 5 Kinds of Euthanasia 1988; Harsanyi, 1982; Johnson, 1991; Barrow, 1991; Hooker, 1995, 2000.) We need to distinguish three different kinds of The intuitive attractions of rule-utilitarianism euthanasia, or rather three different ways eutha- become clear as we notice the ways in which this nasia can be related to the will of the person theory seems superior to act-utilitarianism. For killed. Suppose I ask you to either kill me or let unlike act-utilitarianism, rule-utilitarianism me die should my medical condition get so bad agrees with common conviction that individual that I am delirious and won't recover. If you acts of murder, torture, promise-breaking, and then comply with my request, we have what is so on can be wrong even when they produce commonly called voluntary euthanasia. It is vol- somewhat more good than their omission untary because the person killed asked that this would produce. For the general internalization be done. of rules prohibiting murder, torture, promise- Now suppose that I slip into an irreversible breaking, and the like would clearly result in coma without ever telling anyone whether I more good than the general internalization of wanted to be killed in such circumstances. If rules that did not prohibit such acts. Thus, on I am then killed or let die, we have what is the rule-utilitarian criterion of moral permissi- commonly called non-voluntary euthanasia. The bility, acts of murder, torture, and so on, can be distinguishing characteristic of non-voluntary impermissible even in rare cases where they euthanasia is that it is euthanasia on some- really would produce better consequences than one who did not express a desire on the any alternative act. matter. Likewise, rule-utilitarianism will not require But what if I do express a desire not to be the level of self-sacrifice act-utilitarianism re- killed no matter how bad my condition gets? quires. For, crudely, rule-utilitarianism ap- Then killing me would constitute what is called proaches this problem by asking how much involuntary euthanasia. Quite apart from its each relatively well-off person would have to moral status, involuntary euthanasia can seem contribute in order for there to be enough to puzzling. To be euthanasia, it must be done for overcome world hunger and severe poverty. If the good of the person killed. Yet if the person the overwhelming majority of the world's relatively concerned expresses a desire that it not be done, well-off made regular contributions to the most how can it be done for this person's own good? efficient famine relief organizations, no one Well, involuntary euthanasia may be morally would have to make severe self-sacrifices. wrong (we will discuss why in a moment), but Thus, rule-utilitarianism is not excessively we must start by acknowledging that people are demanding (Hooker, 1991, 2000; cf. Carson, not always in the best position to know what is 1991). best for themselves. Someone could be mistaken The advantages of rule-utilitarianism over even about whether he or she would be better off act-utilitarianism are often construed as utilitar- dead than alive in a certain state. And other ian advantages. In other words, some philoso- people could think that the person in front of phers have argued that rule-utilitarianism will in them had made just this kind of mistake. If they fact produce more utility than act-utilitarianism not only thought this but also were motivated to (Brandt, 1979, pp. 271±7; Harsanyi, 1982, pp. do what was best for this person, they might con- 56±61; and Johnson, 1991, especially chs. 3, 4, 9; template euthanasia. What they would then be Haslett, 1994, p. 21; but compare Hooker, 1995, contemplating would be involuntary euthanasia. section III). I am not running that argument. Another important distinction is the distinc- Instead, I am merely pointing out that rule- tion between active and passive euthanasia. utilitarianism seems to have implications that Active euthanasia involves actively killing some-

25 Euthanasia one out of a concern for that person's own good. With respect to euthanasia, rule-utilitarian- Passive euthanasia involves passing up oppor- ism is especially likely to take the same line on tunities to prevent the death of someone out of law as it does on morality. That is, if rule- concern for that person's own good. utilitarians think that people's being allowed in The distinction between active and passive certain circumstances to kill or let die would euthanasia cuts across the distinction between have generally good consequences, then they voluntary, non-voluntary, and involuntary eu- will think such acts are morally allowed in the thanasia. In other words, either with my con- specified circumstances. They will also think sent, or without knowing what my wishes are or the law should allow them in the specified con- were, or against my wishes, you might kill me. ditions. And if they think the consequences Likewise, either with my consent, or without would be generally bad, then they will think knowing what my wishes are or were, or against morality does, and the law should, prohibit the my wishes, you might pass up an opportunity to acts in question. keep me from dying. Thus we have: Thus, in the following discussion of the rule- utilitarian approach to euthanasia, I will focus Active Voluntary Euthanasia on just one realm and assume that the other Active Non-voluntary Euthanasia follows suit. The realm on which I shall focus Active Involuntary Euthanasia is the law. The question, then, is: what kinds of Passive Voluntary Euthanasia euthanasia (if any) should the law allow? Passive Non-voluntary Euthanasia Passive Involuntary Euthanasia 7 The Potential Benefits of Euthanasia

6 Law and Morality Perhaps the most obvious potential benefit of permitting euthanasia is that it could be used to We also need to distinguish between questions prevent the unnecessary elongation of the suf- about law and questions about moral rightness, fering experienced by many terminally ill permissibility, and wrongness. Utilitarians, as people and their families. What about painkill- well as moral philosophers of many other stripes, ing drugs? Some kinds of pain cannot be elim- can think that there may be some moral require- inated with drugs, or at least not with drugs that ments that the law should not try to enforce. A leave the patient conscious and mentally coher- relatively uncontroversial example concerns the ent. And in addition to physical agony, there is moral requirement forbidding breaking verbal often overwhelming emotional suffering for the promises to your spouse. There may be good patient, and derivatively for friends and family utilitarian reasons for not bothering the law in attendance. All this could be shortened if with such matters ± to police the give and take euthanasia were allowed. of such relationships might be too difficult and To the extent that the point is speedy ter- too invasive. This isn't to deny that breaking mination of physical and emotional suffering, verbal promises to spouses is usually morally active rather than passive euthanasia can seem wrong, only that the law shouldn't poke its desirable. For passive euthanasia would often nose into this matter. involve a slow and painful death, whereas active So, initially at least, there is the potential for euthanasia could end the patient's suffering im- divergence in what the rule-utilitarian says mediately. There may, however, be especially about the law and about morality. There is less large costs associated with allowing active eu- scope for this on rule-utilitarianism, however, thanasia. I shall consider these later. than there is on some other theories. For both in Another advantage of permitting euthanasia ± the case of law and in the case of morality, the and again the advantage is even more pro- first thing rule-utilitarianism considers is the nounced in the case of permitting active eutha- consequences of our collective compliance with nasia ± concerns resource allocation. The rules. (See Mill, 1863, ch. 5.) resources, both economic and human, that are

26 Rule-Utilitarianism and Euthanasia now devoted to keeping alive people who have people against their wishes is, as Hobbes (1651) incurable and debilitating diseases could often insisted, the bedrock of social existence. With- more cost-effectively be devoted to curing out communal acceptance of that prohibition, people of curable diseases, or to funding pre- life would be precarious and insecure. No law ventive medicine, or even just to feeding the should be passed which genuinely threatens to starving. What I mean by saying that the change undermine people's commitment to the general in resource allocation would be more cost ef- prohibition on killing the innocent against their fective is that this would increase average life- wishes. expectancy and quality of life. At this point someone might say, ``Ah, but For utilitarians who count personal auton- we can distinguish between killing innocent omy as a value over and above whatever feelings people against their wishes but for their own of satisfaction it brings and frustration it pre- good, and killing them for some other reason.'' vents, there is an additional consideration. It is True, we can make that distinction. But is it a that voluntary euthanasia must increase personal distinction whose enshrinement in law would be autonomy, in that it gives people some control felicitous? No, again because people would not over when their lives end. And if active volun- feel secure in a society where they might be, tary euthanasia were allowed, this would give against their wishes, killed for their own good. people some control over how their lives end. These points about insecurity add up to a Concern for people's autonomy obviously very persuasive rule-utilitarian argument counts only in favor of voluntary euthanasia. against permitting active involuntary eutha- It is irrelevant to the discussion of non-volun- nasia. But do they count against passive involun- tary euthanasia of any kind, and opposes invol- tary euthanasia? In the case of passive untary euthanasia of any kind. euthanasia, there isn't such a risk that people will stay away from doctors and hospitals for fear of being made worse off than they are 8 The Potential Harms of Allowing already. Suppose you had a serious illness and Involuntary Euthanasia found yourself in a society where active invol- untary euthanasia was neither permitted nor A law permitting active involuntary euthanasia is practiced, but passive involuntary euthanasia likely to be strongly opposed by rule-utilitarians was permitted and practiced. Then, you would for other reasons as well. One such reason is that not need fear that going to the hospital would many people would be scared away from hos- get you killed against your wishes. But you pitals and doctors if they thought that they might might worry that the doctors or hospital be killed against their wishes. I cannot imagine would, against your wishes, pass up opportun- how allowing involuntary euthanasia could gen- ities to prolong your life. Yet you probably erate benefits large enough even to begin to offset wouldn't live longer if you stayed out of the this loss. The last thing a public policy should do hospitals. Indeed, if you were under the care is scare people away from trained medical of a doctor, you would probably suffer less. experts. A related point is that allowing involun- Thus, you have less to lose by going into the tary euthanasia would terrify many people taken hospital in a society where passive involuntary to a hospital while unconscious. Imagine waking euthanasia is permitted than you do in a society up to find that you had been taken to a hospital where active involuntary euthanasia is permit- where people can, against your wishes, kill you, as ted. If passive involuntary euthanasia only were long as they (claim to) think this would be best legally and morally permitted, the consequence for you. would not be that everyone who thought they Furthermore, to allow the killing of innocent had or might have a fatal disease would avoid people against their wishes would be difficult to doctors. So the disadvantages of allowing pas- square with other moral prohibitions of su- sive involuntary euthanasia are clearly less than preme importance. In particular, the general the disadvantages of allowing active involuntary feeling of abhorrence for the killing of innocent euthanasia.

27 Euthanasia

The disadvantages of allowing passive invol- But closely associated with the point that untary euthanasia may nevertheless be enough doctors sometimes misdiagnose someone's con- to convince rule-utilitarians to oppose it. Utili- dition is the point that doctors are sometimes tarians have long argued that their doctrine is wrong about what will happen to someone generally anti-paternalistic (Mill, 1859). Grown- whose condition is correctly diagnosed. Sup- up human beings are generally the ones who pose the doctors rightly believe that there is know which of the ways their lives might unfold now no treatment known to prevent the disease would be best for themselves, because they are some people have from bringing acute pain generally the ones who know best their own followed by a painful death. But a cure or aspirations, tastes, talents, sensitivities, vulner- more effective pain block might soon be dis- abilities, etc. Of course there are general excep- covered. If people are killed or allowed to die tions ± e.g., people with permanent or temporary today and the medical breakthrough comes to- mental impairments. But, by and large, people morrow, euthanasia will have amounted to are the best guardians of their own well-being. giving up on those people too soon ± with As noted at the very end of the previous obviously tragic results. section, rule-utilitarians can have another reason However, again restrictions could be put in for opposing involuntary euthanasia, passive place to prevent the losses envisaged. One re- just as much as active. This reason comes from striction could specify that euthanasia is com- the idea that autonomy is an important compon- pletely out of the question until someone is fairly ent of well-being. Indeed, this seems to be the near the final stages of a disease, where new cures strongest rule-utilitarian reason for disallowing or treatments are very unlikely to be able to passive involuntary euthanasia. change the fatal path of the disease. (And one way of approximating this restriction would be to allow passive but not active euthanasia. But this 9 The Potential Harms of Allowing seems an unnecessarily crude way of ensuring Voluntary and Non-voluntary that people aren't killed before they could be Euthanasia cured.) Another restriction could specify that euthanasia be out of the question until after a Turn now to the harms that voluntary and non- thorough and disinterested investigation into the voluntary euthanasia might involve. Suppose state of research on cures and treatments. When the doctors tell Jones he has disease X. This this investigation shows that the development of disease almost immediately produces excruciat- a cure or new treatment is a realistic possibility ing pain, dementia, and then death. Jones asks during the life of the patient, euthanasia would to be killed, or at least allowed to die, before the again be prohibited. pain gets too severe. The doctors comply with From a rule-utilitarian perspective, the Jones's wishes. Later, however, a post-mortem points about mistaken diagnoses and future reveals that he didn't have disease X at all, but cures seem to mandate restrictions on when instead some curable condition. As this story euthanasia would be considered, but they illustrates, euthanasia can inappropriately take don't preclude euthanasia altogether ± even a life after a mistaken diagnosis. active euthanasia. Something else, however, And yet how often do medical experts mis- does threaten to add up to a conclusive case diagnose a condition as a terminal illness when against allowing any kind of euthanasia, espe- it isn't? And how wise is it now to go against cially active euthanasia. This is the danger of expert medical opinion? And are there ways of intentional abuse. minimizing the risk of doctors acting on mis- Think of the people who might be in a hurry diagnoses? Euthanasia could be restricted to for some ill person's death. Some of these might cases where three independent medical experts be people who have to care for the ill person, or ± and I mean real experts ± make the same pay for the care and medicine the person re- diagnosis. With such a restriction, the worry ceives. Another group, often overlapping with about misdiagnoses seems overblown. the first, is made up of the person's heirs. The

28 Rule-Utilitarianism and Euthanasia heirs might even include the hospital in which be non-voluntary euthanasia. Rule-utilitarians the person lies. With so much to gain from an might well think that a cost±benefit analysis of early death of the ill person, these people might this sort of euthanasia would end up supporting easily convince themselves that the ill person it ± given that the law is designed so as to ensure would be better off dead. If it were left up to that the people making the final decision are these people, many ill people might unnecessar- experts with nothing but the best interests of ily be killed or allowed to die. A system which the patient in mind. allowed this would both result in unnecessary But what about patients who were once ra- deaths and terrify the ill. tional enough to consent or withhold consent Even without these points about intentional but never made their wishes known and now abuse, rule-utilitarians have enough reason to are incapable of prolonged rationality? Rule- disallow involuntary euthanasia. But do the utilitarians can think that to allow euthanasia points about intentional abuse add up to a com- would be best here too. A more important ques- pelling rule-utilitarian argument against volun- tion, however, might be whether the law should tary euthanasia? Certainly they necessitate require adults now in possession of their faculties severe restrictions at the very least. to indicate formally whether they want eutha- One sensible restriction would be that, with a nasia if they become terminally ill and are single exception, the people given authority in plagued by acute pain which can be mollified the decision about euthanasia must be people only by severely mind-altering drugs. It might with nothing to gain directly or indirectly from actually increase autonomy to get people to their decision. The single exception is of course decide whether they would want euthanasia for the patient himself or herself. But heirs and themselves before they are unable to make such those who stand to benefit from heirs could be decisions. Obviously, the system for doing this denied any authoritative say in the matter. Thus would have to involve informing people what if a hospital is itself an heir, its doctors could be they were being asked to decide about. It would precluded from having any role, including that also need to be designed so as to make sure of making or confirming the diagnosis. The law people's decisions are their own, i.e., not the could be designed to ensure that the decision to result of some sort of coercion. Furthermore, perform euthanasia on a patient is made by ideally the system would annually ask for con- people focusing on the wishes and best interests firmation that people haven't changed their of the patient. Of course the patient may ask minds (there could be a box to check on annual loved and trusted others, including heirs, what tax returns). they think. But the law could insist that doctors Some people will think that, no matter how with nothing to gain certify that the patient clever rule-utilitarians are in adding safeguards really would be, at the time of the euthanasia, to a law allowing euthanasia, there will be at least better off dead. And the law could insist that the a few people who manage to subvert it, and so patient be asked on a number of occasions abuses will occur. Rule-utilitarians may grant whether he or she really does want euthanasia. this, but then ask how many such abuses there Patients will need the law to protect them would be. Would there be so many abuses as to against coercive pressures by family and other terrify the general population? These questions heirs (not that the law can ever entirely protect are ones of sociology and social psychology. If us from our families). the answers to them are that the abuses would be Focus now on non-voluntary euthanasia ± extremely rare and the general population would euthanasia performed on people who have not not become paranoid over them, then a rule- indicated whether or not they want their lives to utilitarian might be willing to accept that, if be prolonged. Some patients have never been in some abuse is inevitable, this cost of a few abuses a position to give or withhold consent. This is would be worth the benefits of allowing eutha- true of individuals who never developed suffi- nasia. cient rationality to be capable of consenting. There is one more potential harm associated Any euthanasia performed on such people will with allowing voluntary and non-voluntary

29 Euthanasia active euthanasia. To allow them might seem to ment stopped the practice after it led to a few be a step onto a slippery slope to a very undesir- deaths, and the courts upheld that freedom of able position. As I have already noted, the pro- religion did not extend to persuading people to hibition on killing the innocent against their will submit to lethal dangers during worship. These is an immensely valuable, indeed essential, pro- decisions could well be supported on utilitarian grounds. hibition. Would people slide away from a firm commitment to that prohibition if they came to accept the permissibility of voluntary and non- References voluntary active euthanasia? This question, like the question of whether Barrow, R., Utilitarianism (London: Edward Elgar, the level of intentional abuse would be un- 1991). acceptably high, is really one for social scien- Bentham, J., An Introduction to the Principles of tists. Any answers to such questions have to be Morals and Legislation (1823). partly speculative. We ought to know by now Berkeley, G., Passive Obedience, or the Christian Doc- that large social, economic, or legal changes trine of Not Resisting the Supreme Power, Proved and often have unexpected results. We cannot be Vindicated upon the Principles of the Law of Nature certain what the results of allowing voluntary (1712). Brandt, R. B., ``Toward a Credible Form of Utilitar- and non-voluntary active euthanasia would be. ianism,'' Morality and the Language of Conduct, ed. Rule-utilitarians have to make a judgment based H.-N. CastanÄeda and G. Nakhnikian (Detroit: on what they think the probabilities are. And Wayne State University Press, 1963), pp. 107±43. with respect to the sorts of changes under dis- ÐÐ , ``Some Merits of One Form of Rule- cussion here, reasonable people can disagree Utilitarianism,'' University of Colorado Studies in about the probabilities. Thus, reasonable rule- Philosophy (1967), pp. 39±65. Reprinted in Brandt, utilitarians can come down on different sides 1992, pp. 111±36. about the permissibility of voluntary and non- ÐÐ , A Theory of the Good and the Right (Oxford: voluntary active euthanasia. Clarendon Press, 1979). But even where there is reasonable disagree- ÐÐ , ``Fairness to Indirect Optimific Theories in ment, there can be a right answer. The success Ethics,'' Ethics 98 (1988): 341±60. Reprinted in Brandt, 1992, pp. 137±57. of voluntary active euthanasia in Holland sug- ÐÐ , Morality, Utilitarianism, and Rights (New gests that the worries about abuse and slippery York: Cambridge University Press, 1992). slopes can be answered. Of course any law Carson, T., ``A Note on Hooker's `Rule Consequen- allowing euthanasia (especially, active eutha- tialism','' Mind 100 (1991): 117±21. nasia) would need to be very carefully drafted. Goodin, R., ``Utility and the Good,'' A Companion to And the law would have to be rigorously policed, Ethics, ed. P. Singer (Oxford: Blackwell, 1991), pp. to prevent abuse. Though not certain, I am con- 241±8. fident these things could be done. And, undeni- Griffin, J., Well-Being: Its Meaning, Measurement and ably, the benefits, mainly in terms of the decrease Moral Importance (Oxford: Clarendon Press, 1986). of suffering and the increase in autonomy, are Hare, R. M., Moral Thinking (Oxford: Clarendon Press, 1981). potentially enormous. Harsanyi, J., ``Morality and the Theory of Rational Behaviour,'' Utilitarianism and Beyond, ed. A. Sen and B. Williams (Cambridge: Cambridge Univer- Notes sity Press, 1982), pp. 39±62. ÐÐ , ``Expectation Effects, Individual Utilities, and Thanks to John Cottingham, Hugh LaFollette, and Rational Desires,'' in Hooker, 1993, pp. 115±26. Andrew Leggett for helpful comments on an earlier Haslett, D. W., Capitalism with Morality (Oxford: draft of this chapter. Clarendon Press, 1994). 1 Though utilitarians may also favor some restric- Hobbes, T., Leviathan (1651). tions on this. I remember that in Tennessee in the Hooker, B., ``Rule-Consequentialism and Demand- 1960s there was a Christian sect using rattlesnakes ingness: Reply to Carson,'' Mind 100 (1991): in church services. As I remember, the govern- 270±6.

30 Rule-Utilitarianism and Euthanasia

ÐÐ (ed.), Rationality, Rules, and Utility: New Essays Mill, J. S., On Liberty (1859). on the Moral Philosophy of Richard Brandt (Boulder, ÐÐ , Utilitarianism (1863). CO: Westview Press, 1993). Mitchell, D., ``The Importance of Being Important: ÐÐ , ``Rule-Consequentialism, Incoherence, Fair- Euthanasia and Critical Interests in Dworkin's ness,'' Proceedings of the Aristotelian Society 95 Life's Dominion,'' Utilitas 7 (1995): 301±14. (1995): 19±35. Moore, G. E., Principia Ethica (Cambridge: Cam- ÐÐ , Ideal Code, Real World: A Rule-Consequentialist bridge University Press, 1903). Theory of Morality (Oxford: Oxford University Parfit, D., Reasons and Persons (Oxford: Clarendon Press, 2000). Press, 1984). Johnson, C., Moral Legislation (New York: Cam- Sidgwick, H., The Methods of Ethics (London: Mac- bridge University Press, 1991). millan, 1874; 7th edition, 1907).

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