Daniel Sulmasy

One major argument against prohibiting euthanasia and physician-assisted suicide (PAS) is that there is no rational basis for distinguishing between killing and allowing to die: if we permit patients to die by forgoing life-sustaining treatments, then we also ought to permit euthanasia and PAS. In this paper, the author argues, contra this claim, that it is in fact coherent to differentiate between killing and allowing to die. To develop this argument, the author provides an analysis of Saint Augustine’s distinction between martyrdom and suicide, highlighting the relevance of intention in the assessment of an agent’s actions. As a general matter of ethics, the intentions of agents, not just the outcomes of their actions, matter enormously for drawing distinctions between what is permissible and what is impermissible. Constructing an Augustinian account of this distinction between killing and allowing to die, the author argues that it is coherent to hold that assisted suicide is wrong, while also accepting that it is permissible to withhold or withdraw life-sustaining treatments.

New Natural Law Theory and the Catholic medico-moral tradition often lead to similar conclusions in hard cases regarding end-of-life care. Considering the provision of artificial nutrition and hydration to patients suffering from post-coma unresponsive wakefulness, however, brings to light subtle ways in which NNL differs from the centuries-old natural law tradition. In this essay, I formalize the methodology embedded within the casuistry of the medico-moral tradition and show how it differs from NNL with respect to the role played by double-effect reasoning and the perspective for analyzing cases regarding care for those who cannot speak for themselves. Importantly, the ordinary/extraordinary means distinction has never historically been understood as an application of double effect and logically cannot be so understood. Given the outsized role that double effect plays in NNL, the theory leads to conclusions that deviate from the Catholic medico-moral tradition and creates additional burdens and duties for the sick.

Dear Norm,Thank you for sharing such a personal and heartfelt essay. I have been asked by the editors to comment. Reading it inspires me to do so in a similarly heartfelt way. Although I don't know you well, I thought I'd write to you as if you were my patient.I share your sense that Alzheimer disease is a terrible scourge. I've seen much of this disease over a lifetime of practice, and I deeply understand its ravages and the debility and suffering it causes. But what you propose is not a good solution for the problems that Alzheimer disease poses for patients, families, and society. It will ultimately do far more harm than good. Please let me try to explain.

Towards the end of the last century, bioethics underwent an “empirical turn,” characterized by an increasing number of empirical studies about issues of bioethical concern. Taking a cue from the evidence-based medicine movement, some heralded this as a turn toward evidence-based ethics. However, it has never been clear what this means, and the strategies and goals of evidence-based ethics remain ambiguous. In this article, the author explores what the potential aims of this movement might be, ultimately arguing that, while the development of good empirical research can and should aid in ethical deliberation, one ought to avoid assuming or suggesting that empirical studies themselves determine normative prescriptions and proscriptions. The limits of the use of empirical studies in bioethics are explored in detail, and 10 potential ways that such studies can soundly contribute to bioethics are described. Good ethics depends upon sound facts, but ethics cannot be based on evidence alone.

This is the third republication of Jonas’s original, first published in 1966, and previously republished in 1979 and 1982. The prestige of repeated republication generally designates a classic, and this book, while still known by too few, deserves such acclaim. As a general rule, philosophers of science concern themselves either with explaining what scientists do or with prescribing what scientists ought to do. Jonas has a different aim. He examines the fundamental underlying presuppositions of modern science, particularly biology, locates these presuppositions within the history of ideas, and critiques them. The result is a rich feast of fascinating observations and ideas. While these eleven essays were not initially conceived of as a unified whole, they fit together nicely. Even the very brief transition chapter and epilogue serve as far more than filler. Both are illuminating and contribute substantially to the overall coherence of the book.

In this dissertation, I defend the view that the distinction between killing and allowing to die is coherent and morally important. ;I first review the history of the distinction from Hippocrates to the early 20th century. I next show that contemporary accounts of the distinction do not reflect the intuitions of those who employ it. I dismiss accounts based on acts and omissions, causing and allowing, harming and benefitting, double effect, the movements of agents, social expectations, and causal responsibility. ;Because of the confusing ways in which the words 'killing' and 'allowing to die' are used, I introduce neologisms. Gribbing is an act in which an agent creates a new, non-therapeutic, lethal pathophysiological state intending that a human being should die by way of that act. Alting is an act in which an agent removes or refrains from initiating an intervention that stops or delays the natural history of an underlying lethal state, either intending that a human being should die by way of that act, or not so intending. The form of the distinction I defend is that all Gribbing is wrong, except in cases of self-defense or rescue. Some Alting is wrong, and some is not. ;I then present a theory of intention to support the thesis that what all Gribbing has in common with the bad cases of Alting is the agent's intention that a human being should die by way of the agent's act. This gives the distinction practical moral importance, since the burden of proof is upon the Gribber to show that death was not the intention. ;Finally, I apply this formulation in a variety of cases, showing that it leads to judgments that generally coincide with those of people who employ the unexamined distinction. If what one means by 'the distinction between killing and allowing to die' is a distinction between Gribbing and Alting, then the distinction is coherent and morally meaningful. The remaining task is to justify the premise that acting with the intention that a human being should die by way of one's act is always morally wrong