Spring, 2004
The words and concepts we use make intellectual discourse possible; but language is not simply an inert enabler; it can resonate emotionally charged implications, and not only facilitate discourse, but also influence it. In his discussion of the total artificial heart (TAH), Veatch engages two high voltage concepts, "killing" and "death." ("The total artificial heart: Is paying for it immoral and stopping it murder?" Lahey Clinic Medical Ethics, Winter 2004, {www.lahey.org/ethics/}.) He would alter the definition of death to avoid the direct "killing" that would follow stopping or removing the TAH and seems more comfortable if those acts could be conceptualized as merely permitting "the dying process to continue." These linguistic maneuvers raise interesting questions.
According to Veatch, stopping mechanical ventilation or dialysis may allow death to "proceed unabated" but these maneuvers do not directly cause death. However, the functioning of the artificial heart "actually is the basis for saying life continues." According to the cardiac definition of death, one dies when heart function ceases irreversibly; therefore, terminating an artificial heart kills directly and immediately, "as certainly as injecting potassium into the ventricle."
Veatch proposes changing the definition of death to "one relying only on brain function loss." Stopping the TAH would then no longer be the immediate cause of death and would "turn out to be no different from stopping any other life-supporting treatment." Veatch, it seems, would agree with stopping or removing a TAH if that intervention was "deemed disproportionately burdensome" but he is intent on avoiding the accusation of direct intended killing.
Before consigning "killing" to the trash can of immoral acts, the concept warrants further exploration. Although Veatch mentions "liberals" for whom direct killing may under certain circumstances be morally justified, he has done a disservice by implying in his title that killing is equivalent to "murder." "Killing" is a more complex phenomenon with a spectrum that includes: genocide, mass murder, first degree murder, second degree murder, manslaughter, second degree manslaughter, the execution of criminals, euthanasia and killing in battle and selfdefense. Could the termination of life supports be more honestly construed as yet another form of "killing" but one that under appropriate circumstances might be justified?
The removal of a mechanical ventilator, stopping dialysis and stopping an artificial heart all lead to death. There is a cause and effect relationship. When you remove a mechanical ventilator from a person with terminal cancer, they don't die of cancer, they die because they stop breathing. When you stop dialysis in a demented man, he doesn't die of dementia, he dies of renal failure. Cancer and dementia may be the initiating factors, the root problems that ultimately lead to death, but they are not the immediate mechanism of death.
Veatch's desire to avoid direct killing also warrants examination. Whether an act causes instantaneous direct death, as when stopping a TAH, or delayed death, as after removing a ventilator or stopping dialysis, may not be morally significant. If a man is pushed off the roof of a high-rise building he doesn't die directly and instantaneously; nonetheless, we don't allow that the push merely enabled him to die of gravity.
It is not uncommon for surrogate decision makers to express the feeling that removing life-supports is tantamount to killing their relative. We use convoluted language to convince them of the importance of their good intentions and that they are simply allowing the patient to die of some underlying disease. Perhaps we should acknowledge the truth in their intuitions. If the removal of burdensome therapy is construed as a justified form of killing, it should not meet automatic public disapproval precisely because the absolute rejection of killing is not a widespread belief.
Intention is important, but the use of intention to exculpate a bad effect that can be foreseen is problematic. In double effect whether an act is moral or immoral can depend on the psychological predisposition of the actor. The same act may be judged differently depending on the actor's state of mind. Intentions can be murky, complex and difficult to decipher. Should the intention to relieve pain become suspect if it briefly crosses the actor's mind that the patient might be better off dead?
If the heir to his uncle's fortune surreptitiously disconnected his uncle from a mechanical ventilator, most people would consider that killing; but if the ventilator is disconnected by a nurse or physician, Veatch might call it enabling death from another cause. That the identical act can be considered both killing and not killing is a troubling inconsistency. Let's for the moment confront reality bluntly and label the removal of life-sustaining treatment "killing" and see where that leads us.
I first propose a new category of life, "medically contingent life." This concept defines people who are alive only because of an active medical intervention. The removal of that intervention will directly and in a short time lead to death. This would place people dependent on ventilators, on dialysis and on a TAH in the same category. The concept might require further elaboration, but by defining life differently among a specific group of people, the boundary of any permissible killing is drawn and restricted. A form of "killing" - let's tentatively call it "termanasia" - would be defined as that which consisted of the removal of life-supporting treatment from people whose lives are "medically contingent." Just as killing in selfdefense may be justified, killing by the removal of life-supports from people living "medically contingent lives" might also be justified as long as defined appropriate rules are followed.
Veatch and I seem to have reached the same conclusion; we both agree a TAH can be stopped or removed when that is appropriate. Veatch would arrive at that conclusion by altering the definition of death so that removal cannot be considered intended direct killing. I would arrive at the same conclusion by allowing that removal is a specific form of killing, albeit justified killing. I have also downplayed the moral significance of direct versus indirect killing and expressed some reservations concerning the exculpatory power of intention.
It might be argued, in another testament to the power of language, that to justify killing in one sphere facilitates its justification under other circumstances. It's important to refrain from drawing conclusions that go beyond what is actually stated in an argument. If the removal of life-supports under appropriate conditions from people leading "medically contingent lives" is acknowledged as justified killing, it does not follow that killing under other circumstances is also being justified.
At this point readers might legitimately ask whether I believe what I have written. Have I concocted this discussion merely to illustrate that the legitimacy of an act can be a function of how we use language? As a physician who struggles against death, do I want to endorse a form of killing? And do I want to be in a position where I have to tell a woman whose husband is hopelessly ill with metastatic cancer that she ought to kill him by allowing the removal of his ventilator? My answer to both of these questions is no. I feel conflicted because I believe we have an obligation to use language as precisely and accurately as possible. When we alter and distort language to facilitate an ulterior motive, the line that separates honest discussion from manipulation and propaganda begins to blur; but honesty can be brutal.
I think we more closely approximate moral reality when we consider the removal of burdensome life-sustaining medical interventions as its own category. We can call it a category of killing but should judge it on its own terms rather than describing it as analogous to something else, such as other forms of killing or enabling the dying process. The interventions that sustain medically contingent life should from their initiation themselves be considered to be morally contingent on their benefits outweighing their burdens. Veatch has argued elsewhere in favor of a higher brain definition of death. 1 I have bypassed that argument and only mean to say that justification for stopping or removing a TAH should not be the reason to alter the definition of death.
David Steinberg, MD
Chief, Section of Medical Ethics Lahey Clinic Medical Center, Burlington, MA
Footnotes
1 Veatch RM. Transplantation Ethics. Georgetown University Press, 2000:70.
Response: David Steinberg has challenged my approach to stopping an implanted total artificial heart (TAH). Since death is traditionally understood as irreversible heart stoppage, deactivating TAHs could plausibly be understood as direct, active killing. I pointed out that, with a proper understanding of the definition of death, stopping TAHs could still be classified as only an indirect killing.
Steinberg points out that there is an alternative: confronting the traditional active killing forgoing distinction directly. We could simply accept that some patients might actively end their own lives by authorizing TAH stoppage and that some surrogates might instruct physicians to actively kill their loved ones. If active killing were potentially morally acceptable, we could admit these patients were killed when their machines were turned off, but deny this was wrong.
My analysis was not as antithetical to Steinberg's position as he thought. I stated that there were three options: We could follow the "liberals" accepting that direct, active killing can be justified. We could follow the "conservatives" and acknowledge that turning off TAHs is morally unacceptable active killing. I proposed a third option: limiting death to brain death so that stopping the TAH becomes indirect killing, a forgoing of life support that would indirectly lead to death when (and only when) brain function ceases irreversibly. This does not require adopting a higher-brain definition; merely acknowledging that heart-stoppage alone doesn't count as death. Our multiple-option definition has always been wrong. Now we have a reason to acknowledge it.
Steinberg assumes I reject options one and two in favor of option three. But I didn't quite say that. It is true that option three is only needed in the TAH context if one wants to retain the possibility of stopping the TAH without directly causing death, but I have for the last decade been perplexed over the question of whether the traditional active-killing/ forgoing distinction can be sustained. I put forward the third option for those who end up supporting the traditional formulations, but still believe stopping the TAH can be moral.
While I am open to Steinberg's liberal alternative of legitimizing active, direct killings, for both practical and theoretical reasons I remain skeptical. First, as a practical matter, the active-killing/forgoing distinction is remarkably robust. It has withstood political attacks for at least a century and in the US no jurisdiction has yet overturned it. While Oregon has legalized active self killing, no other state has followed suit and Oregon militantly retains a prohibition on merciful homicides. Even the Netherlands continues to prohibit merciful homicides of those who do not persistently and voluntarily request to be killed. Hence, in the case of an incompetent patient, in no place in the world would stopping a TAH be legal if it is conceptualized as an active, direct killing.
Of course, Steinberg can argue that this does not make the distinction valid. In order to make his case, Steinberg needs to defend more than merely active, direct killing by TAH stoppage. Imagine someone with a TAH who has made a competent, adequately informed decision to stop the machine and has authorized a physician to do what is necessary to get it stopped.
There is another problem with Steinberg's solution. Physicians can be forced by patients or valid surrogates to stop lifesupport, but surely cannot be forced to kill their patients. My proposal serves the interests of a patient whose physician was unwilling to kill, but would be obliged to withdraw lifesupport by turning off a TAH.
The underlying problem is that something remains very troublesome about killing another human being. Some of us have even gone to the extreme of rejecting (at least prima facie) all human killing and have become pacifists. Of course, if killings by omission are conceptualized as being included in this prohibition, the norm would be impossible to follow. (We all omit lifesupport for starving people throughout the world every day.) Hence, we have trumped up an active-killing/forgoing distinction that provides a more-or-less bright line that sorts into two group behaviors leading to death.
For those who have not chosen pacifism, the active killing of unjust aggressors is sometimes added as another qualification, but the prohibition on the active, direct killing of the innocent is remarkably stable, in spite of its logical ambiguities.
In claiming that stopping TAHs is forgoing rather than active, direct killing, I speak to the substantial majority who retain these bright lines, but still see stopping a TAH as acceptable. I am willing to continue conversing with the minority preferring my first option, but the evidence is that that position is not selling. Even if it does sell, it opens the door to a much broader range of active killings than I was addressing. I am yet to be convinced that legalizing active merciful homicide is the way to go.
Robert M. Veatch, PhD
Professor of Medical Ethics The Kennedy Institute of Ethics Georgetown University, Washington, DC
in collaboration with
Dartmouth-Hitchcock Medical Center
The opinions expressed in the journal, Lahey Clinic Medical Ethics,
belong to the individual contributors and do not represent the institutional position
of Lahey Clinic on any subject matters discussed.
