VOLUNTARY EUTHANASIA SOCIETY OF SCOTLAND NEWSLETTER / JANUARY 1998
Making ideas reality
An exclusive interview with
philosopher Helga Kuhse
Helga Kuhse is Associate Professor at Monash University and Director of the Centre for Human Bioethics. Her books include “The Sanctity-of-Life-Doctrine in Medicine - a Critique” (OUP, 1987), “Should the Baby Live - The Problem of Handicapped Infants" (with Peter Singer) (OUP, 1985), the collection ”Willing to Listen - Wanting to Die" (Penguin 1994), and “Caring: Nurses, Women and Ethics” (Blackwell, 1997). Professor Kuhse is editor of ‘Monash Bioethics Review’ and Co-editor (with Peter Singer) of ‘Bioethics’. She is a member of a number of ethics committees and has been an expert witness to the Northern Territory Government on the Rights of the Terminally Ill Act, and to the Australian Senate’s inquiry into the Euthanasia Laws Bill.
You have been credited by many, including the politician Marshall Perron, as the inspiration behind the Rights of the Terminally Ill Bill. (The world’s first, if short lived, euthanasia law.1) To influence politicians successfully is a goal for every voluntary euthanasia society. What is the essence of an effective argument?
Helga Kuhse: The first requirement for a successful argument is that it be sound. That’s true for a philosophical argument and ultimately also, I believe, for an argument that has any hope of convincing politicians. Ideally such an argument must also ‘touch a nerve’. Sometimes that will just be a political nerve, where the politician can see that it’s in her or his political self-interest to take up that issue; sometimes, however, it will also be something like ‘the justice nerve’, where a politician is catapulted into action simply by realizing that preventable injustices are being done. In the case of Marshall Perron, it was certainly not the political nerve that led him into action. Rather, it was a matter of realizing that the existing situation regarding medical end-of-life decisions was arbitrary and unjust. Australian patients, like British and American patients, can lawfully refuse life-sustaining treatment, and doctors can administer life-shortening palliative care, but are not allowed to provide direct help to dying patients who need and want it. Having reached the conclusion that there were no good reasons for the restriction on patients’ end-of-life decisions, and that this restriction harmed suffering, dying people, Marshall Perron decided to do what he could to remedy the situation. As he put it in his first reading speech: “The focus of this legislation is to give those who suffer, the right to choose a death with dignity, to bring to an end the torture many endure on their death-bed... Society has, through the laws in place today, made an assessment for all of us - that our quality of life, no matter how wretched, miserable and painful is never so bad that any of us will be allowed to put an end to it. I am not prepared to allow society to make that decision for me or those I love.
Not that long ago, it would be unheard of for a philosopher to “come out” on such an important issue and take sides.2 What has changed that you, as a philosopher, are now able to take such a stance?
In the first half of this century and beyond philosophers generally took the view that ethics was concerned largely with an analysis of the meaning of words, such as ‘good’ or ‘right’, and that practical questions were not their concern. In the 1970s this had begun to change and philosophers focused on practical questions - such as the moral rights and wrongs of abortion, the Vietnam war, and the question of euthanasia. In this they returned to a much older tradition that has always seen moral philosophy or ethics as practical, that is, as being concerned with what to do, rather than with knowledge, or what is the case.
I have always seen moral philosophical as practical in that sense. After all, if your moral reflection tells you that a particular action or policy is unfair and unjust, and that traditional modes of thinking about it are deeply flawed, how can you remain silent and do nothing?
How did you first become so passionately interested in the “right to die”?
It was a matter of thinking about the ethical issues involved, about the moral principles and policies that we have the best reasons to adopt when it comes to end-of-life decisions. A central issue in the so-called right to die debate is the distinction between actions and omissions and between killing and allowing to die. Under many legal systems, and certainly under Australian legislation, doctors are permitted by law to ‘allow their patients to die.’ But they are not permitted to actively or directly end a patient’s life. When I found no morally relevant reason that could support that distinction, I argued against it - and for the moral right of dying patients to request direct help in dying from their doctors. Because there are no morally relevant reasons to support that distinction, this meant that our public policy system that upheld the distinction was unfair and unjust. It allowed some patients - those who were ‘fortunate’ enough to require life support, which they can legally refuse - to die with the help of their doctor; other patients who were suffering just as much were denied that right - for no other reason than the arbitrary reason that they did not need life support. That is extremely unfair and unjust - and such injustices have always stirred my passions.
Annie Lindsell3 recently gained judicial approval for what many consider an incremental approach - assurance of drugs for personal dignity under the doctrine of double-effect. Australia and the U.S. have sought directive legislation to allow euthanasia within certain pre-defined rules. Scotland’s Sheila McLean, on the other hand, has suggested “permissive” legislation4 which, by contrast, keeps voluntary euthanasia illegal but with exceptions to the rule. Do you have any thoughts about these different lines of attack?
I think an approach that allows voluntary euthanasia by stealth under the principle of double effect will not do us much good in the long run. Mind you, I think it is good that it accommodated Annie Lindsell dying at a time of her choosing, with the help of her doctor. But as a matter of public policy the principle of double effect will not do. The reason is simple. The principle of double effect focuses on the doctors’ intentions - whether a doctor directly intends the patient’s death or merely foresees it. But why should the doctor’s intention be the primary right-making feature of the end-of-life decision? There are no good reasons for this. Firstly, it’s the patient’s life . This means the primary-rightmaking feature ought to be the patient’s consent - rather than the doctor’s intention. The second reason is that intention is ultimately an internal state of mind. Often only the person herself can say what she intends to do when she does what she does. The principle of double effect has its basis in religion. In that context it may have made some sense. After all, if god can look into people’s hearts and minds, he or she will be able to know whether a person’s intentions are ‘pure’, or whether the person intends something that it is impermissible to intend. An example from Christian religion is of course the prohibition of the intentional termination of innocent human life, which includes euthanasia.
I am not sufficiently familiar with Sheila Mclean’s proposal to venture much of a comment. Generally speaking, however, I think that decriminalization is best in practice. Sheila’s proposal and the decriminalization of voluntary euthanasia (which would after all be an exception to the general prohibition of intentional killings) may, of course, come to much the same thing.
With the hindsight of the Northern Territory’s (sadly) rather short-lived Act, do you think legislators and campaigners could, or should, try a different approach? How do you see things developing in Australia?
It’s difficult to know what is likely to be the most effective approach. I am still hopeful that the Premier of the Australian state of Victoria, Jeff Kennett, will bring in such legislation. He has spoken out strongly in favour of voluntary euthanasia, but seems to lack the political will to bring in legislation. The reason may, of course, not just be a lack of will. It could also be his shrewd political assessment that the present parliament is not likely to support him on that issue.
Oregon voters have won the day again on their physician assisted suicide act. How do you see this working?
Yes, it’s a great victory for Oregon and ultimately for the world. It will help to rekindle enthusiasm and political will in other parts of the United States and in other countries. How will it work? Well, we have to wait and see. There are still a lot of unresolved issues that need to be worked out. One of these is, of course, that the legislation allows only medically assisted suicide, not voluntary euthanasia. This may mean that some patients will not be able to end their lives - they might be too sick or too ill to swallow pills, for example - and in some cases attempted suicides will fail. Both scenarios raise questions about the proper role of doctors, and of course about the limits of the law.
For many lay people, the value of bioethics often seems peripheral to the main objectives. You are often involved “at the coal face” trying to convince people about various issues. Is this an increasingly important role for ethicists? What other arguments are there to convince our readers of the need for philosophy at a time when governments are seeking to trim university budgets?
I think bioethicists - those who are ready to challenge and are unencumbered by particular allegiances that would prevent them from going where their arguments lead them - have an important role to play in public debates of practical moral problems. They are trained in the analysis of moral arguments, have specialized in a field that is complex and diverse (think of genetics and the various ethical issues raised by the mapping of the human genome alone), they are familiar with the different moral theories, their strengths and weaknesses, and have developed a good nose for bad arguments. Their input into the public (and of course also into the specialist) debate is hence of the utmost importance. They should not, of course be seen as dispensers of ultimate moral truths, but as articulators of ethical arguments and positions. And they do have another important role to play in public life. They will often, and quite appropriately, take on the role of Socratic gadfly: that is, question hallowed traditional assumption. It is especially at a time when economic rationalism reigns supreme, in university as elsewhere, that we need philosopher gadflies. I might be able to convince your readers that we need them, but will I also be able to convince the economic rationalists who fund universities of their important role? I think Socratic gadflies may be too much of an irritant for them and their political masters. Life, they may decide, is easier if education is restricted to the imparting of technical or vocational skills...
What public figures have been your greatest inspirations in life?
Oh, there were a great many of them. My first hero - I must have been 10 around the time - was Hans Hass, a famous deep sea diver who took wonderful photographs of marine life. I think he appealed to me not only because he seemed very brave and adventurous, but also and especially because he made visible a new and unknown world, the world of intricate sea anemones, of sponges, and corals, and of the most beautiful and the most monstrous underwater creatures. After that, I was deeply impressed by various social reformers, people such as Martin Luther King, by various women involved in the Women’s Liberation Movement, and so on. More recently still, it has been my colleague and friend Peter Singer who has been a great inspiration to me. He has put the Animal Liberation Movement on the map and his book on the subject did, at the time, turn me into a life-long vegetarian. His clear-headed approach and his determination to uncover and fight injustices and irrationalities exemplifies the best in a public philosopher.
Your arguments about end of life in other areas (e.g. Should the Baby Live?) Have provoked controversy world-wide. Is there a different type of responsibility when you become a controversial figure rather than the rather blander academic archetype who merely analyses arguments for and against an issue? Have you “stepped out of the ivory tower”?
I’m not sure that I ever was in the ivory tower. When Peter Singer and I wrote the book Should the Baby Live?, I was just finishing my Ph.D., and that book catapulted me straight into the public arena. I see myself as always having two responsibilities - one academic, that is, to carefully examine philosophical arguments, and one practical: to make these arguments accessible to a wider public. The first is necessary to be as sure as one can be of one’s philosophical and ethical base; the second is necessary if one believes, as I do, that good philosophy must ultimately be practical.
What do you most like about EXIT Newsletter?
Its wide coverage of national and international issues, and the fact that it allows space for the more extended coverage of particular issues by particular people, relevant to voluntary euthanasia and medical end-of-life decisions in general.
1. The Rights of the Terminally Ill Bill allowed voluntary euthanasia in Australia’s Northern Territory for a brief six months before it was overturned by the Federal Government. Marshall Perron, the NT Governor who successfully pushed the Bill through parliament, publicly credited Professor Kuhse when he spoke at the public forum of the WFRTDS Conference in Sydney in 1996. He told delegates how it was one of her conference papers on euthanasia that had convinced him of the importance of the issue and inspired him to push an appropriate bill through parliament. (See EXIT Newsletter July 1995 for his address to parliament).
2. Many academics find this role inappropriate.
3. See our tribute to Annie Lindsell elsewhere in this issue.
4. Reprinted elsewhere in this issue. Further analysis of some of the different legal approaches can be found in Colin Gavaghan’s article on Oregon, this issue, and in Chris Docker’s chapter “The Way Forward” in Death, Dying and the Law, Dartmouth Press.
Helga Kuhse was interviewed by Chris Docker