Is it really morally wrong to kill someone? That question, strange enough on its own, is downright bizarre when it's asked in the Journal of Medical Ethics. In "What makes killing wrong?", a paper in the Journal's January issue, Walter Sinnott-Armstrong, a philosopher at Duke, and Franklin Miller, a bioethicist at the National Institutes of Health, argue that there isn't, fundamentally, anything wrong with killing another person. Killing is only incidentally bad because of one of its consequences: "total disability." Such a revision of our ethical code, the authors suggest, would help shed light on many of the thorniest issues in medical ethics, including the ethics of organ transplantation.
The Hippocratic oath in the form of a cross, from a twelfth-century Byzantine manuscript.
Sinnott-Armstrong and Miller start, as philosophers often do, with a thought experiment:
Imagine that Abe robs Betty and shoots her in the head so that she will not testify against him if he is caught. As a result, Betty dies. It is clearly immoral for Abe to shoot Betty. Why?
For most of history, they point out, there's been only one answer to this question: Abe's action was wrong because killing -- unless it's justified by certain very special circumstances, like war -- is always wrong. But in fact, they write, Abe does more than just kill Betty when he pulls the trigger. "Abe's act causes at least two effects on Betty. One is death -- the loss of life. The other effect, which is less often noticed, is total disability. Shooting Betty makes her unable to do anything, including walking, talking, and even thinking and feeling."
When you really think it through, they argue, it's this second effect which bears most of the moral weight. Imagine, they suggest, what would happen if Abe totally disabled Betty without killing her. Although such an outcome would have been inconceivable for most of human history, it's possible, even common, today, because of the advanced medical technologies available in our intensive care units. It's now possible for doctors to save Betty's life, even while her injuries still totally disable her, causing "irreversible brain damage that makes her unable to walk, talk and even think and feel." She could continue to live in such a totally disabled state for a lengthy period of time in an I.C.U.
Suppose, Sinnott-Armstrong and Miller write, that total disability, but not death, were the result of Abe's shooting Betty. Betty is alive, but totally disabled, in an I.C.U. Now, we must ask "whether death or total disability provides the best explanation of why Abe's act of shooting is immoral." Is what Abe did to Betty less wrong than it would have been if he had also killed her? Or, from another perspective, in what sense would Betty's situation be worse if she were not just totally disabled, but also dead? Is death, in some basic sense, worse than total disability? Or, when you get right down to it, is it total disability which makes death so terrible? Ultimately, Sinnott-Armstrong and Miller conclude, "We see nothing to make Betty's death worse than her total disability."
What's the benefit of thinking about killing in this new way? Well, for one thing, the authors argue, it clarifies some of the thorniest issues in medical ethics. If we share the conclusion that "killing by itself is not morally wrong, although it is still morally wrong to cause total disability," then we will have a clearer sense of how to make judgments at the periphery of life and death. Take organ transplation:
The established legal and ethical prerequisite for vital organ donation is known as ‘the dead donor rule’: vital organs, such as the heart, both lungs and both kidneys, cannot legitimately be procured from a donor unless the donor is already dead. The dead donor rule fundamentally reflects the application of the norm that doctors must not kill. In actual practice, however, donors of vital organs are not dead—or not known to be dead—at the time when organs are procured.
In real, confusing, contradictory life, many life-saving organs come from still-living patients who have been diagnosed with "brain death"; others come from barely alive, neurologically damaged patients who couldn't survive without life-support equipment. These procedures make sense for practical and humanitarian reasons. But they are hard to justify, both legally and philosophically, and that lack of justification has made doctors, patients, and voters confused and uncertain.
Understanding that it's total disability, not death itself, which makes killing so bad clarifies the ethics of organ transplantation. "Once we recognise that the prohibition of killing has no moral force independent of disability," Sinnott-Armstrong and Miller conclude, "we can focus on the ethically relevant question: When is it morally justifiable to procure vital organs?" Ultimately, "it is not ethically necessary for vital organ donors to be dead. It suffices for them to be totally disabled, with no prospect of recovery of any human abilities or experience." And, "according to this standard, our current practices of vital organ transplantation are ethically justified."
Unconvinced? Make sure to read the full article, which takes on all sorts of objections. Sinnott-Armstrong and Miller are very aware that they are suggesting a "radical departure from traditional morality and medical ethics." But, they argue, the burden of proof is now on their opponents to prove that Betty would be worse-off dead than totally disabled.
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