The End of Life 
by James Rachels.
Oxford, 196 pp., £12.95, January 1986, 9780192177469
Show More
Voluntary Euthanasia 
edited by A.B. Downing and Barbara Smoker.
Peter Owen, 303 pp., £14.95, February 1986, 0 7206 0651 9
Show More
Moral Dilemmas in Modern Medicine 
edited by Michael Lockwood.
Oxford, 250 pp., £12.95, January 1986, 0 19 217743 5
Show More
Show More

Most professional philosophers think of themselves primarily as scholars, as hunters and gatherers in the field of understanding with no particular commitment to serve society in any other role. Yet some philosophers have lately found to their delight that they can be useful: indeed that their advice is actually sought by those who have to take decisions of policy or practice. So now in England we have the Warnock Report, while in America philosophers advising hospital ethics committees have been known to carry bleepers to summon them to conferences on matters of life and death. Medical ethics – a subject unheard of only a few decades ago – is lately the main growth area in philosophical publishing, with books, anthologies and journals on subjects such as abortion, euthanasia and medical experimentation tumbling out at a prodigious rate.

Whether these writings on medical ethics are actually influential it is hard to say. It is easy to believe that some of the books and articles most familiar to professors and their students are simply not known in the world outside. For so far as I can gather, philosophers are not generally thought of as sinister characters, and their reputation for insanity seems to be no greater than before. So presumably it is not generally known that the most hair-raising views are being preached by a certain number of philosophers who have made their reputation in ‘practical ethics’. Either this is not known or else it is assumed to be a matter of no practical interest. How otherwise to explain the fact that there was no outcry when the Oxford University Press recently published a book by one Michael Tooley whose theme was a defence of infanticide? How else to explain the lack of public reaction to an article published some time ago in which it was suggested that a handicapped child could be killed and ‘replaced’ with one whose chance of happiness might be greater? Or are we just getting used to these ideas, so that we do not much react when in another Oxford book, The End of Life by James Rachels, it is said that some animals have a better claim to be cared for than a severely retarded child?

It may be argued that it is not of practical importance that these ‘practical’ philosophers say these things, so long as other people keep a modicum of good sense. But it is rash to count on that through all political and social upheavals, and the many philosophers who regard such moral views as ludicrous should surely worry about the fact that they have gained a kind of respectability in the academic world. We should also be interested in the thought processes which have brought pleasant, rather earnest individuals to such extraordinary views.

How have these things come to seem to anyone to be true? Offhand one would expect that it would be the result of theory run riot, and so in a way it is. But with the notable exception of Richard Hare, whose practical philosophy is in any case often modified by his desire to produce a safe morality for fallible human beings rather than ‘archangelic’ moral truth, the philosophers who hold the views I have described are not pioneers in moral theory. They have rather accepted – from Hare and others – one or another kind of utilitarianism, which they may or may not modify to allow respect for the autonomy of choice of well-developed human beings and of higher animals. Indeed, it is rather a lack of theory which has led to the strange phenomenon with which we are concerned. There is, in the first place, a lack of ontological underpinning for the very reasonable and widely-held view that early abortion is not murder whereas late abortion and infanticide are exactly that. It is on account of this lacuna that it has seemed reasonable to think in terms of something called ‘personhood’ which is then supposed to belong to normal children but not to infants or to the severely retarded. Again it is the lack of a philosophical solution to the problem of the special moral significance of specifically human life which has led Michael Tooley, Peter Singer and James Rachels to some of their more bizarre views about the moral equality of the higher animals and some human beings. These are deep theoretical problems, which will not easily be solved. What is remarkable about these philosophers and their followers is not that they cannot solve the fundamental problems, but that they are ready to preach a radical revision of existing moralities on no better ground than the belief that those who advise caution and patience are stuck with outdated moral intuitions.

This is the chief thesis of James Rachels’s book on euthanasia: that we should dare to be revisionists, and realise above all that ‘we overestimate how bad it is to kill.’ Not that Rachels thinks there is nothing wrong with killing, when killing harms some being by depriving him of ‘a biographical life’. However, a ‘biographical life’ which has to do with ‘desires and aspirations’ belongs, we are told, to chimpanzees but not to severely subnormal human beings, whom we are therefore at liberty to kill. (Presumably we can also kill those who are very senile, though Rachels’s nerve may have failed him at this point, and dictated his preference for examples having to do with Quinlan-type cases of irreversible coma.)

Rachels insists, as he originally did in a widely-read contribution to the New England Journal of Medicine, that we cannot make a moral distinction between killing someone and allowing him to die. Apart from differences of motive or of side-effect the two are simply morally equivalent. This Rachels thinks he can show by his favourite example of a baby who is either deliberately drowned in the bath or else deliberately allowed to die. (In both cases by a villain who wants him dead.) From the fact that one action seems as bad as the other Rachels concludes that there is no ‘intrinsic’ difference between killing and allowing to die. What he has failed to notice is that we can construct another example in which again we hold motive and outcome constant but where it is permissible to allow the child to die but not to push him underwater. We only have to imagine that the lives of other children are at stake to see that while we could indeed leave one to drown while hurrying to save the others, we would very properly be had up for murder if we held him under the water as part of a plan to save them. Rachels and others like him who insist on the moral irrelevance of the distinction between killing and letting die do so partly because they do not discuss the right distinction, which should be seen as separating not act and omission as such but rather the origination of harm from the failure to bring aid. The deeper root of the mistake lies, however, in the belief that a decent moral code can be constructed without bringing in the concept of rights at an early stage. All sorts of absurdities follow from the failure to recognise that the right human beings have not to be interfered with carries much further than their right to be rescued from trouble. It would be unfair, however, to suggest that Rachels’s book has nothing in it but nonsense. For what he is chiefly concerned with is voluntary euthanasia, where it may be supposed that the right not to be killed has been given up by the patient seeking death. Rachels’s thesis is that voluntary ‘active’ euthanasia is as unobjectionable as voluntary ‘passive’ euthanasia, and in this he may be right. Some do, of course, argue that even voluntary euthanasia is illicit because it involves a disregard for the possible value of the remaining part of a life. But to most of us, as to Rachels, it seems that if a dying person has got to the stage at which we hope for his sake for a speedy end, then we would want to be able to listen to his demand that we help him to die soon. What stops some of us from supporting ‘active’ euthanasia is the terrible thought that no safeguards could prevent abuse of such an institution, and that we might quickly find ourselves on a slippery slope.

In this context we shall be looking with great interest at what happens in Holland where the practice of ‘active’ euthanasia is already to some extent in place. An all too brief account of the Dutch situation is given in an updated edition of Voluntary Euthanasia, issued to commemorate the Golden Jubilee in Britain of the Voluntary Euthanasia Society. There Pieter Admiraal writes:

  In our hospital at Delft every patient knows that he can always freely discuss with us the option of euthanasia if he wants to. If he opts for it, the decision of the team to perform euthanasia will be discussed in advance with all the nurses in the department involved. We never make a secret of it. Moreover, recent jurisprudence has made clear that a team discussion is one of the prerequisites for avoiding legal prosecution in the Netherlands. Euthanasia as an act of respect to an incurable patient in such a patient’s interest and on his request is regarded in our hospital as a dignified last act of medical care for a patient in his terminal phase.

This is a useful volume, which includes an interesting attack on voluntary euthanasia from within the Catholic tradition by Luke Gormally, Director of the Linacre Centre in London. One doubts, however, whether he will persuade many people to adopt the belief that last hours or days may always ‘be worthwhile’, however much the person whose life it is begs to be released from his suffering.

In another useful volume of essays Michael Lockwood has collected together nine talks originally given at a seminar sponsored by the Oxford University Department of External Studies, and these are in general notable for their moderation and good sense. Some are on standard subjects such as abortion, experiments on children, or autonomy and consent, but there are others which either break new ground or are of special topical interest. Bernard Williams, for instance, has contributed an unusual and illuminating piece about the ‘slippery slope’ argument, suggesting that it may often be reasonable to make a sharp normative distinction even where our concepts do not tell us just where it should be.

We lay down a maximum length of pregnancy for abortion, a number of days during which experiments on a fertilised ovum are permitted, a minimum age for admission to certain sorts of films, and so on.

  Is drawing a line in this way reasonable? Can it be effective? The answer to both these questions seems to me evidently to be ‘Yes, sometimes,’ and as that unexciting reply suggests, there is not a great deal to be brought to deciding them beyond good sense and relevant information. It may be said that a line of this kind cannot possibly be reasonable since it has to be drawn between two adjacent cases in the range – that is to say, between two cases that were not different enough to distinguish. The answer is that they are indeed not different enough to distinguish, if that means that their characteristics, unsupported by anything else, would have led one to draw a line there.

Nevertheless, says Williams, it is reasonable to draw a sharp line if that is necessary to distinguish acceptable from unacceptable practices. It is no objection to drawing the line in the place that we do draw it that it would have been no worse to draw it somewhere else.

Two other pieces must also be singled out for special praise. Ian Kennedy, Reith Lecturer for 1980, has contributed an essay on the ethical and legal implications of prescribing oral contraceptives to girls below the age of consent without their parents’ permission, discussing this highly topical and controversial subject with extraordinary clarity and acumen. And in another piece Mary Warnock expresses her own opinions on subjects covered by the Warnock Report, or closely related to it, in a way that makes one aware once more of the excellence of the choice which put her in charge of the Committee of Inquiry. In the present essay she makes some remarks about the supposed distinction between professional medical ethics and the doctor’s own morality, and suggests that individual doctors should have neither the burden nor the privilege of deciding which services should be available to their patients – as in the case of those who wish to be ‘parents’ outside the context of orthodox family life:

the homosexual, for example, or the single woman, or the lesbian couple, any of whom may, increasingly, come to demand a child as of right, a child to be born by surrogacy or AID. Such persons are no in way sick. They are not infertile, as far as the doctor may know. They simply want the service available to the infertile to be available to them. They regard it as a right, either to father a child whom they can bring up, or to bear a child whom they can bring up. Is the doctor to provide the service?

Mary Warnock’s own objection to commercial surrogacy is here reaffirmed, but she is quite ready to listen to doubts about the overriding value to children of ‘normal’ family life. As to the burden of deciding what services should be available to whom, she supports the setting-up of licensed centres where they should be available, thus taking part of the decision off the shoulders of individual doctors faced with their own patients’ demands.

Whether right or wrong there is a robust common sense involved in the Warnock Report, and in its chairman’s contribution to this volume. What Williams, Kennedy and Warnock all make evident is the value of a philosophical or a legal training in making it possible for those who are determined to do so precisely to hold on to common sense. In this connection one might invent, without the least intention of rudeness, the concept of a jobbing philosopher. A jobbing philosopher is one who takes time off from the even more fascinating contemplation of fundamental theory to do a job of work in the world which he is (or should be) particularly fitted to do. Just as a plumber is called in when there is trouble with the plumbing, so a philosopher should be called in where conceptual issues show signs of getting out of hand. Philosophers do, after all, have a lot of experience in dealing with tricky arguments in which inoffensive-seeming premises lead by apparently inexorable logic to clearly ridiculous conclusions. To vary the metaphor, they are like trained singers able to hold a line against interference, which is why they are often able, in the end, to defend common sense.

Philosophers can, therefore, be useful. It is right that doctors, who are themselves busy with other things, often want professional philosophers on hospital ethics committees. But this usefulness depends on the ability of philosophers to recognise, in Socratic fashion, what they do not know. It is reasonable to see modern moral philosophy as a relatively backward part of the discipline. We do not yet have a satisfactory fundamental moral theory, or even very much really good modern work at a fundamental level, and only humility will save us from well-deserved opprobrium. If philosophers are going to be useful they will have to keep their feet on the ground.

Send Letters To:

The Editor
London Review of Books,
28 Little Russell Street
London, WC1A 2HN

Please include name, address, and a telephone number.


Vol. 8 No. 17 · 9 October 1986

SIR: If Philippa Foote’s incredulous astonishment at the suggestion that severely retarded children be killed is genuine (LRB, 7 August), and not merely the hysteria that often accompanies moral outrage in women (itself unsuitable in a serious critic), she seems too naive to be reviewing serious books at all. Or perhaps it is a means of discrediting by ridicule the serious and quite sane people who recommend it. A reader waits vainly for some mention of the viable alternative that her vehemence suggests she has in mind. We do not expect her to provide a solution to the problem, but we do expect her to acknowledge that it is one. In discussing voluntary euthanasia, about which her views seem rational and calm, she writes: ‘to most of us … it seems that if a dying person has got to the stage at which we hope for his sake for a speedy end, then we would want to be able to listen to his demand that we help him to die soon.’ A severely brain-damaged child is a dying person (when he is a person) all his life, but Professor Foote would seemingly be willing to force the ‘right to live’ upon him without finding it at all necessary to ‘hope for his sake for a speedy end’, an end that, owing to the frightful efficiency of medical science, is likely to be far from speedy. It seldom occurs to champions of the ‘right’ to live that this implies the ‘right’ to die: if it does not, living is not a right but a tyranny. A severely retarded infant, who will with average ill-luck grow up to be a severely retarded adult, has rights only in a metaphorical sense, since his real rights are usurped for ever by his next of kin. Only a human being with a functioning brain, capable, according to expectation, of eventually taking over his life from the adults who are his regents, can have rights if the word is to have any meaning at all. A human being without it is a person only by courtesy of the unhappy adults who must somehow reconcile themselves to living with him.

Vera Liebert
Rhinebeck, New York

SIR: Philippa Foot is amazed by the likes of Michael Tooley and James Rachels, and she has amazed me in turn. The moral conclusions drawn by these gentlemen do not suit her, but instead of looking to their arguments to see where they went wrong, or entertaining the notion that they might be correct, she responds like a vigorous pathologist who has spotted disease. Soon enough she unearths the microbe of utility at work and prescribes a stiff dose of rights as cure.

Utilitarianism is a troublesome doctrine, but so is the theory of rights, as demonstrated by tough-minded philosophers a generation ago, who were preceded by an earlier generation of critics at work before the Second World War. The issues of medical ethnics, as Foot acknowledges, remain extremely troublesome, too troublesome to be met by quick gestures and comfortable presumptions.

Gerard Elfstrom
Atlanta, Georgia

Vol. 8 No. 18 · 23 October 1986

SIR: Two correspondents in the last number of your paper take issue with me. We should ask the first, Vera Liebert, if we are to kill severely retarded children for their sakes, or for ours? And is it all right to kill the senile as well, provided they are senile enough?

Gerard Elfstrom seems to have missed the long central paragraph of my review in which I single out for reasoned criticism the mistake that James Rachels and others have made in denying moral relevance to the distinction between allowing something to happen and bringing it about. It is a grave charge against utilitarianism that it cannot accommodate this part of our everyday morality.

Philippa Foot
University of California, Los Angeles

send letters to

The Editor
London Review of Books
28 Little Russell Street
London, WC1A 2HN

Please include name, address and a telephone number

Read anywhere with the London Review of Books app, available now from the App Store for Apple devices, Google Play for Android devices and Amazon for your Kindle Fire.

Sign up to our newsletter

For highlights from the latest issue, our archive and the blog, as well as news, events and exclusive promotions.

Newsletter Preferences