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Utilitarian Consequentialism,

Supplemental Notes on (1) Utilitarian Consequentialism, (2) Quality of Life Perspective, (3) Kantian Deontology, and (4) Sanctity of Life Perspective Plus Wrongness of Killing
 
PHL 612, Section One, Winter 2015
 
Topic 1: Utilitarian Consequentialism
 
 
The ethical theory of utilitarianism was initially popularized by Jeremy Bentham (1748-1832) in An Introduction to the Principles of Morals and Legislation (1789) and further refined by John Stuart Mill (1806-1873) in his book titled simply Utilitarianism (1861/ 1998).
 
Classical utilitarians such as Mill and Bentham root their advocacy of the theory in their articulation of the Principle of Utility. That principle is also known as the greatest happiness principle, or the principle of the greatest good for the greatest number. In accordance with the principle of utility, moral agents should strive to generate as much happiness (or positive utility), and as little unhappiness (or negative utility), as possible, for all those affected.
 
James Rachels (1941-2003) emphasizes how radical were the early champions of utilitarianism, who insisted upon moral theory without references to God or to abstract, and often inflexible moral rules “written in the heavens”. [As has been noted previously, utilitarians such as Bentham, and John Austin, were highly critical of natural law theories of morality.] Rachels (2010: 98) stresses that the founders of utilitarianism were committed social reformers as well as philosophers.
 
We begin with an overview of classical utilitarianism, highlighting the following core aspects of that theory:
(1) consequentialism;
(2) hedonism, or subjective accounts of the good;
(3) maximization of positive utility and minimization of negative utility;
(4) aggregation, or “summing across persons”;
(5) universalizability;
(6) agent neutrality; and
(7) impartiality.
After setting out core assumptions and claims, we identify a selection of some of the main shortcomings or weaknesses of those aspects of the theory as identified by critics.
 
Consequentialism: Consequentialists insist that “choices – acts and/ or intentions – are to be morally assessed solely by the states of affairs they bring about” (Alexander and Moore, 2007). The expected consequences of an action are to be assessed in terms of utilities and disutilities, or benefits and disbenefits, for all those affected by the action. This is in direct contrast with nonconsequentialist approaches to morality, such as Kantian deontology, that reject the reliance upon consequences for determination of moral worth. [We discuss Kantian deontology in Topic 3.]
 
Consequentialist theories are sometimes referred to as teleological theories, from the Greek word “telos”, or end. The “telos” or the end, or outcome of moral action, is what determines the content of moral obligation. [The term “teleology” refers to the study of final causes or results; having goals or purposes.] Utilitarianism is characterized as an approach to ethics that is predominantly focused on “conduct” (rather than character).
 
Utilitarians provide an answer to the question: what is the right thing to do?, by referring to what will generate good outcomes. We can know what is the good at which our actions will aim (and the bad which we should avoid) by reflecting upon what creates happiness and unhappiness. As Mill (1861/ 1998) puts it: “The utilitarian doctrine is that happiness is desirable, and the only thing desirable, as an end; all other things being desirable as means to that end”.
 
Hedonism, or Subjective Accounts of the Good and Maximization of Positive Utility and Minimization of Negative Utility: Classical utilitarians rely upon a subjective account of the “good”, conceived in terms of maximization of positive utility – happiness, pleasure, satisfaction, enjoyment and the like – and minimization of negative utility – pain, suffering, unhappiness, displeasure, lack of enjoyment and so on. Happiness and pleasure are the ultimate good, whilst pain and suffering are the ultimate evil. As commentators have observed, the doctrine of hedonism has been around since antiquity, although it has been put to different uses through the ages.
 
The term “hedonic” or “hedonism” comes from the Greek word for delight, sweet or pleasure. In an oft-quoted passage in An Introduction to the Principles of Morals and Legislation (1789, Chapter One, paragraph 1), Bentham wrote:
 
“Nature has placed mankind under the governance of two sovereign masters, pain and pleasure. It is for them alone to point out what we ought to do, as well as to determine what we shall do. On the one hand the standard of right and wrong, on the other the chain of causes and effects, are fastened to their throne. They govern us in all we do, in all we say, in all we think…”
 
Bentham was convinced that “utility” is readily subject to measurement, and moreover, there are many factors that can help us carry out our calculations. These factors include: the intensity of pleasure or pain; the duration; the certainty (or probability that pleasure or pain will occur); the propinquity (or immediacy – the nearness or remoteness of pleasure or pain); the fecundity (or likelihood that a pleasure will lead to other pleasures, or a pain will lead to other pains); purity; and extent, or the number of beings affected by a pleasure or pain. Thus, a pain which is intense or of long duration generates more negative utility than shorter or less intense ones. A pleasure which is longlasting or intense generates more positive utility. A pure pleasure counts for more than one that is mixed with pain.
 
Moral agents, Bentham argues, are to undertake a “hedonic calculus”, by which we figure out who stands to be benefitted, and who stands to be harmed by an action we could take, and by how much each will be harmed. The focus on evaluation of acts has led to Bentham’s particular approach to utilitarianism being branded “act utilitarianism” by contrast with Mill’s “rule utilitarianism”. We discuss the differences between them briefly below.
 
Aggregation, or “summing across persons”: Moral decision makers are required to take into account the impact of each and every potential action on all those who are affected, to the extent that these can be known or predicted.
 
The focus, for Bentham, as just noted, was on individual acts. For each act we might undertake, we are to quantify how much overall net utility it would generate. When we have aggregated, or “added” up, or “summed” all the expected utilities, and subtracted the amount of expected disutilities, of each option, we are morally obligated to choose the option which will have the greatest overall net utility. The option that could generate the largest amount of positive utility and the smallest amount of negative utility is the one that should be selected on this basis.
 
Notice that we are not required to consider the distribution of utilities and disutilities, i.e., whether certain persons or beings will experience great amounts of disutility outweighed by the even greater amounts of positive utility experienced by others. This problem has led critics to charge that classical utilitarianism is “distribution insensitive”.
 
Universalizability, Agent Neutrality and Impartiality:
 
Bentham (1789, Chapter I, paragraph 2) characterized his approach to morality in terms of the principle of utility, by which is meant “that principle which approves or disapproves of every action whatsoever, according to the tendency which is appears to have to augment or diminish the happiness of the party whose interest is in question: or, what is the same thing in other words, to promote or oppose that happiness.”
 
Commentators (for example, Brink, 2007/ 2014) observe that Bentham endorsed a version of psychological egoism, encapsulated in the view that each of us can only aim at our own happiness or pleasure. He combined it with an “other-regarding” moral perspective, reflected in the belief that each of us ought to aim at the general happiness or pleasure.
 
Utilitarian moral theory is contrasted with ethical egoism and altruism, both of which are alternates of consequentialism. Ethical egoism is understood as the position that a moral agent ought to do what is in her own self-interest. By contrast, ethical altruism holds that a moral agent is morally obligated to help others, even potentially to sacrifice her own interests in order to further the interests of others. Thus, the theories of egoism and altruism are said to be agent or subject-focused. Egoism elevates the interests of oneself, whereas altruism downplays or even disregards the interests of oneself.
 
Instead, utilitarianism insists that a moral agent must treat his own interests, desires, or well being, as no more or no less important than that of anyone else. It is characterized as an “agent neutral” approach to morality. A good utilitarian moral reasoner will treat each unit of utility as equal to every other unit of utility, regardless of the potential impacts upon oneself, or upon one’s nearest and dearest.
 
Peter Singer has characterized this strict adherence to impartiality as the “principle of equal consideration of interests”, in the context of his preferred approach, that of preference utilitarianism. As Singer (1993) has articulated, the principle requires us to give equal weight to the like interests of all those affected by our actions, in our moral deliberations.
 
Selected Criticisms and Responses
 
There are objections to utilitarianism which amount to an all out rejection of consequentialism. Some prominent concerns of critics who orient themselves to nonconsequentialist moral perspectives include matters of justice, issues of rights and desert. These will touched on briefly here, but they will be given particular attention in substantial portions of the next topic. Other criticisms arise from a perspective of initial commitment to consequentialism, and target specific aspects of the theory of utilitarianism that can be adapted or modified while still remaining true to the consequentialist cause.
 
Difficulty of Calculating Consequences: An easy criticism of utilitarianism is that we cannot reliably predict the future, and thus there can be great uncertainty about the impacts of our actions. We do not know with certainty what the various possible consequences of our actions will be, especially over the longer term horizon. Numerical probabilities can rarely be assigned to possible future events, so how could moral agents accurately assess the amounts of utility and disutility their actions would generate. In response, utilitarians typically demand that we are to do the best that we can to evaluate expected consequences of our actions. We are obligated, they insist, to work with intuitive weighing of probabilities, along with what we know, and what we can surmise or expect will result from our actions.
 
Objections to Hedonism: It is interesting to note that the concerns about hedonism are shared by those who endorse consequentialism as well as by those who reject it. One contemporary utilitarian, Peter Singer (1993), shifts the focus from “utility” per se to preferences. On Singer’s approach to utilitarianism, the “best” consequences are those that further the “interests” of those affected, i.e., those that satisfy the most preferences or desires. Singer’s view is that preference utilitarianism is to be preferred, because it can avoid the difficulties of quantifying an individual’s mental state (i.e., measuring a specific amount of happiness or unhappiness), and thus overcome a familiar objection to the theory. It is debatable just how far away from classical utilitarianism Singer has moved, since some commentators insist that Bentham and Mill’s account of “pleasure” and “pain” can accommodate the notion that pleasure includes achieving what one desires, and pain includes the non-achievement of what one would wish to avoid.
 
Other philosophers who remain committed to consequentialism recommend that specified “objective” measures of welfare (or illfare) be substituted for the subjective factors of utility and disutility. Thus, for some philosophers, what moral agents should strive to maximize are indicators of well being, such as good health (as seen in increased rates of life expectancy and decreased rates of morbidity and mortality, including infant mortality), high levels of literacy, and so on.
 
Mill’s Modifications: John Stuart Mill (1861) supported Bentham’s advocacy of a consequentialist approach to moral reasoning, and the reliance upon subjective factors, but he insisted on several modifications to the theory, in response to criticisms and objections.
 
Providing a few representative quotes should help to capture the flavour of Mill’s distinctive ways of reasoning about utilitarianism. Mill (1861, Chapter II, paragraph 2) articulated his commitment to utilitarianism in the following terms: “The creed which accepts as the foundation of morals “utility” or the “greatest happiness principle” holds that actions are right in proportion as they tend to promote happiness; wrong as they tend to produce the reverse of happiness. By happiness is intended pleasure and the absence of pain; by unhappiness, pain and the privation of pleasure.”
 
Mill (1861, Chapter II, paragraph 2) argued that: “Pleasure and freedom from pain are the only things desirable as ends; and that all desirable things (which are as numerous in the utilitarian as in any other scheme) are desirable either for pleasure inherent in themselves or as means to the promotion of pleasure and the prevention of pain.”
 
Mill’s simple claim was that happiness is a moral good. With respect to what potential “proof” there could be for the argument Mill is making, he wrote (1861, Chapter IV, paragraphs 2-4):
“… the sole evidence it is possible to produce that anything is desirable is that people do actually desire it … No reason can be given why the general happiness is desirable, except that each person, so far as he believes it to be attainable, desires his own happiness.”
Mill (1861) then connects the inclination of individuals to pursue happiness to a social ethic, as follows:
“…laws and social arrangements should place the happiness, or (as speaking practically it may be called) the interest, of every individual, as nearly as possible in harmony with the interest of the whole . . . so that not only he may be unable to conceive the possibility of happiness to himself, consistently with conduct opposed to the general good, but also that a direct impulse to promote the general good may be in every individual one of the habitual motives of action, and the sentiments connected therewith may fill a large and prominent place in every human being’s sentient existence.”
 
In these and other comparable passages, Mill is interpreted to be presenting the following arguments:

Happiness is a good, desirable in itself.
Every person desires her/ his own Happiness.

Every person comes to recognize the need to promote the happiness of others.

The general happiness is a good to the aggregate of all persons. And, Mill insists that happiness is the one and only thing that is desirable in itself (Mill, 1861, Chapter IV, paragraphs 2-4).

 
Commentators emphasize that although Mill’s detractors assume that he, like Bentham, is a psychological egoist, passages in Mill’s work belie that assumption. For instance, Mill (1861, Ch. IV, para. 4-5) believed that moral agents can develop disinterested concern for virtue, that they can come to care about virtue for its own sake.
 
A very common criticism of utilitarianism is that it is simply too crude. Bentham had insisted that only the amount of utility should be taken into consideration in the hedonic calculus; from his perspective, it made no difference whether one enjoyed “pushpin” (a popular amusement game of Bentham’s time) or enjoyed “poetry”. All that mattered was how much positive utility an activity could generate. Mill made it clear in his writings that in his view the moral evaluation of consequences should take into account “quality” as well as “quantity”.
 
The exclusive focus that Bentham placed on the quantity of utility needed to be balanced, contended Mill, by an appreciation of the importance of the quality of utility, so that a smaller amount of a higher, or high quality, pleasure could be more valuable than a greater amount of a lower, or low quality, pleasure. Mill (1861, Ch. II, para. 6) wrote: “it is better to be a human being dissatisfied than a pig satisfied; better to be Socrates dissatisfied than a fool satisfied”. Mill emphasized the capacity of human beings to appreciate art, music and intellectual endeavours, and to achieve much greater satisfaction from them than from the “lower pleasures”.
 
Philosophers have puzzled over Mill’s discussion of the “higher pleasures”, wondering whether Mill meant that these pleasures are subjective, i.e., mental states, or whether they are objective, actions, activities, or pursuits. Mill’s text is unclear. [For elaboration, see Brink, 2007/ 2014.]
 
Rule Utilitarianism (and Rights)
 
Mill’s other crucial modification to the theory of utilitarianism was the recourse to Rule Utilitarianism as an alternative to Act Utilitarianism. Brink (2007/ 2014: 12) provides the following definitions to differentiate the two:
 
Act Utilitarianism: An act is right insofar as its consequences for the general happiness are at least as good as any alternative available to the agent.
 
Rule Utilitarianism: An act is right insofar as it conforms to a rule whose acceptance value for the general happiness is at least as great as any alternative rule available to the agent.
 
Rule Utilitarianism reflects a commitment to assessing the moral worth of general rules, in order to determine which rules could be expected, over the longer term, to produce the highest amounts of overall net positive utility. Mill was convinced that he could defend the theory against the critic’s assertions that application of utilitarian reasoning led to results that were counterintuitive and contrary to common sense morality.
 
To see how Mill mounted his defence, we need to revisit the construction of act utilitarianism. Jeremy Bentham, it seemed, was wedded to a position that insists that a moral agent is morally obliged to assess each act, and to aspire to achieve the greatest amount of net utility (the greatest good for the greatest number) from each and every act.
 
Critics have pointed out that circumstances could lead to potential justification of lying, since it could be that lying would generate a greater balance of good consequences than bad in a particular instance. The recourse to “white lies” as social glue, and to spare someone’s “feelings”, is usually defended on such grounds. Or, act utilitarianism could seem to support “bearing false witness”, or even the “punishment” of an innocent person. H.J. McCloskey (1965) and other critics have raised objections along these lines with specific scenarios, typically involving a small town experiencing considerable social strife due to commission of a crime. The sheriff of the town knows that by carrying out a quick arrest, the riots and mayhem could be stopped. The sheriff also knows that there is a drifter in town, with no family or friends to suffer distress at his plight. As a utilitarian, surely, the critics charge, the sheriff is morally obligated to bear false witness and to bring about the punishment of an innocent person.
 
Defenders of utilitarian consequentialism have responded in a number of ways. One line of defense is that taken by Stanley Benn and R.S. Peters (1972: 98), in the following passage: “[these criticisms] are based on a misconception of what the utilitarian theory is about… [punishment implies] inflicting suffering under specified conditions, one of which was that it must be for a breach of a rule”. This approach has been referred to as a “definitional stop”. Philosopher John Rawls (1955) coined the term “telishment” to forestall that response. The term, “telishment” refers to an act by officials or authorities of “punishing” a person known to be innocent in order to generate social benefit through deterrence of future wrongdoing. Thus, whether we call it “punishment” or “telishment”, it seems as if utilitarianism is vulnerable to the charge that it could justify an immoral and unjust practice (mistreatment of the innocent) when the aggregate utility would warrant it.
 
Another example is provided by James and Stuart Rachels (2010: 112-113), drawing upon a reported legal case from California: York v. Story (1963). Here is a summary of the case:
“In October, 1958, appeallent [Ms. Angelynn York] went to the police department of Chino for the purpose of filing charges in connection with an assault upon her. Appellee Ron Story, an officer of the police department …. advised appellant that it was necessary to take photographs of her. Story then took appellant to a room in the police station, locked the door, and directed her to undress, which she did. Story then directed appellant to assume various indecent positions. These photographs were not made for any lawful or legitimate purpose. Appellant objected to undressing. She stated to Story that there was no need to take photographs of her in the nude, or in the positions she was directed to take …. Later that month, Story advised appellant that the pictures did not come out and that he had destroyed them. Instead, Story circulated these photographs among the personnel of the Chino police department. In April, 1960, two other officers of that police department, appellee Louis Moreno and defendant Henry Grote …. using police photographic equipment located at the police station, made additional prints of the photographs taken by Story. Moreno and Grote then circulated these prints among the personnel of the Chino police department.”
 
Ultimately, Ms York discovered what the officers had done, and she sued them for an invasion of her privacy. [The legal case ended up being a rather complicated, and technical legal analysis of whether the legal breach was in relation to civil rights, or constitutional rights, and whether there were sufficient legal grounds for further proceedings.]
 
Very troubling for our purposes here is the sense that utilitarianism could support a claim that the actions of the officers were morally justifiable. It could do so on the basis that by comparing the amount of unhappiness caused to York with the amount of happiness experienced by the police officers, the latter could outweigh the former. Before Ms York discovered the infringement of her rights, especially, she does not have knowledge to experience disutility about the rights violation. Even after her discovery, it could be that there are so many officers involved, and that they obtained so much illicit pleasure, that the disutility experienced by the victim is less than the overall positive utility experienced by the officers.
 
Those who are concerned about “rights” are not reassured by Jeremy Bentham’s reported views on rights. Bentham (1792/ 1843: 501) insisted that natural rights are “simple nonsense”, and that “natural and imprescriptible [unalterable, indefeasible] rights” are “rhetorical nonsense, nonsense upon stilts”. Bentham distinguished between moral rights and legal rights in the following passage (1792/ 1843): “Right, the substantive right, is the child of law: from real laws come real rights; but from laws of nature, fancied and invented by poets, rhetoriticians, and dealers in moral and intellectual poisons come imaginary rights, a bastard brood of monsters, gorgons and chimeras dire.” Even for rights that are “real”, Bentham contended that: “There is no right which, when the abolition of it is advantageous to society, should not be abandoned”.
 
John Stuart Mill, by contrast, was more amenable and respectful of moral “rights” than Bentham, as can be seen in passages from Utilitarianism (1969: 250): “When we call anything a person’s right, we mean that he has a valid claim on society to protect him in the possession of it, either by the force of law, or by that of education and option … To have a right, then … is to have something which society ought to defend me in the possession of. If the objector goes on to ask why it ought, I can give him no other reason than general utility.” Mill is likewise more appreciative of the importance of justice. The following quote (Mill, 1969: 255) is illustrative: “Justice is a name for certain classes of moral rules, which concern the essentials of human well-being more nearly, and are therefore of more absolute obligation than any other rules for the guidance of life; and the notion which we have found to be of the essence of the idea of justice, that of a right residing in an individual, implies and testifies to this more binding obligation.”
 
Yet, as rights-friendly as Mill was, it is still the case that his views reflect an instrumentalist approach to justifying rights (and thus his position is not so far from Bentham’s). This quote is indicative of Mill’s (1977: 258) instrumentalism about rights: “All persons are deemed to have a right to equality of treatment, except when some recognized social expediency requires the reverse”. Rights are important mechanisms, or devices, for protecting valuable interests, but they could be dispensed with, if greater utility could be achieved through other mechanisms. [It should be noted that various portions of Mill’s On Liberty reflect an appreciation of the importance and significance of rights, especially rights pertaining to freedom of conscience and freedom of expression.]
 
Mill insisted that “rule consequentialist” approaches to moral reasoning could address and remedy many of the problems identified by critics. Mill’s approach was to ask which rule would be most optimal from a utilitarian perspective. A rule consequentialist (e.g., rule utilitarian), for instance, would consider the option of choosing between: a rule to “bear false witness against the innocent” and a rule to “never bear false witness against the innocent”, or choosing between a rule to “punish the innocent” and a rule to “never punish the innocent”. Put in those terms, Mill and other defenders of rule utilitarianism believe that it is easy to see that over the longer term, the former rules would generate greater disutility than the latter rules.
 
In the scenario evoked by McCloskey, there is the problem that the real culprit remains at large, and could commit other crimes. There are negative repercussions from the exposure of the injustice, which is likely to be revealed at some point. When that happens it would igniting the fear on the part of any citizen that he or she could be sacrificed next. Ultimately, the disclosure of the deceit could undermine trust in the justice system and the rule of law. Even if one assumes that the deception could be maintained, there would be considerable costs to the officials and the system as a whole in keeping up the façade and preventing disclosure. Likewise, with lying in general, there are negative consequences such as hurt feelings and anger at the discovery of having been the recipient of a lie; these need to be taken into account. A rule in favour of lying or in favour of false promising would lead to undermining of trust in social relations. If one takes into account the wider context and the longer term horizon, then utilitarianism could no longer support “bearing false witness” or “punishment” or “sacrificing” of the innocent as a rule.
 
Using the approach of rule utilitarianism, one could establish the superiority of rules protecting rights (including rights to privacy), rules against breaking one’s promises, and rules against lying. The evaluation of individual acts would be deferred until after the choice of rules has been made. With the optimal rules in place, moral agents should then ask, given that particular rule, is a specific individual act right or wrong in accordance with the rule. Mill apparently believed that by making the shift, he could ensure that utilitarianism would be brought in line with common sense moral intuitions about the imperative of rights, promise keeping and truth telling.
 
Mill wrote favourably about reliance upon secondary principles such as fidelity, veracity, and fair (i.e., secondary to the principle of utility) in moral reasoning. Mill (1861, Ch. II, para. 24-25) recommended that moral agents should rely upon secondary principles when optimal results could be achieved by doing so, or when a moral agent could not know reliably and efficiently in advance, that less than optimal results would be generated from following a secondary principle. Mill’s endorsement was subject to qualification. Secondary principles should, Mill suggested, be set aside in favour of direct appeal to the principle of utility, in situations when following a secondary principle could be expected to lead to clearly “suboptimal” results, or when there are conflicting secondary principles (Brink, 2007/ 2014).
 
Utilitarian theorists are divided on just how feasible rule utilitarianism is, conceptually. What if one evaluates a choice between a rule without exceptions and a rule with exceptions, and it turns out that greater amounts of overall net utility could be generated by a rule allowing for exceptions. For example, as Rachels and Rachels (2010: 119) articulate: “Don’t bear false witness against the innocent, unless doing so would achieve” greater good for a greater number. If the decision is made to allow for exceptions, it seems as if rule utilitarianism risks collapsing back into act utilitarianism (evaluating action on a case by case basis).
 
[For further discussion of the conceptual nuances and complexities of Act versus Rule Utilitarianism, see Hooker, 2003/ 2008, and Sinnott-Armstrong, 2003/ 2011.]
 
Some defenders of utilitarians wish to hold firm to exceptionless rules. By doing so, they risk diluting the theory so that it is a mixed ethical theory, and arguably no longer recognizable as distinctively utilitarian. Others would caution against irrational “rule worship” (as J.J.C. Smart put it in Smart and Williams, 1973: 10), and recommend an unapologetic commitment to consistency. As Smart (Smart and Williams, 1973: 68) articulated:
“Admittedly utilitarianism does have consequences which are incompatible with the common moral consciousness, but I tended to take the view “so much the worse for the common moral consciousness”. That is, I was included to reject the common methodology of testing general ethical principles by seeing how they square with our feelings in particular instances.”
 
A hard-headed (or perhaps hard-hearted) response to McCloskey’s scenario could take the following approach:
“McCloskey says it would be wrong to convict an innocent man because that would be unjust. But what about the other innocent people who will be hurt if the rioting … continue[s]. What about the pain that will be endured by those who are beaten and tormented by the mob. What about the deaths that will occur if the [sheriff] doesn’t lie [or bear false witness]? Children will lose their parents, and parents will lose their children. Of course, we never want to face a situation like this. But if we must choose between securing the conviction of one innocent person and allowing the death of several innocent people, is it so unreasonable to think that the first option is preferable?” (Rachels and Rachels, 2010: 122).
 
Critics who insist that the differences between deliberately and intentionally choosing to lie/ bear false witness/ punish the innocent, and the occurrence of the loss of innocent lives through the actions of others make all the difference. To see why they would say that, it will be necessary to delve into the competing perspective of nonconsequentlialist approaches to ethics.
 
Before we leave the topic of utilitarianism, it is important to acknowledge that the extent to which Mill’s approach reflects a genuine departure from act utilitarianism is continually debated. Passages in Mill’s text lend support to act utilitarianism, yet other passages lend support to rule utilitarianism. Then, there are passages in Mill’s defence of utilitarianism which raise questions about the place of “direct” versus “indirect” approaches to utilitarianism. These are distinguished by Brink (2007/ 2014: 12), as follows:
 
Direct Utilitarianism: “Any object of moral assessment (e.g., action, motive, policy, or institution) should be assessed by and in proportion to the value of its consequences for the general happiness.
 
Indirect Utilitarianism: “Any object of moral assessment should be assessed, not by the value of its consequences for the general happiness, but by its conformity to something else, (e.g., norms or motives) that has (have) good or optimal acceptance value.”
 
In general, those who adhere to direct utilitarianism have faith that people can ensure the realization of maximal utility (i.e., the highest amount of overall net positive utility) by aiming explicitly and expressly at doing so. By contrast, supporters of indirect utilitarianism are much more sceptical about the ability and capacity of moral agents to achieve optimal outcomes directly. Instead, they recommend that moral agents should follow secondary principles, rather than trying to directly generate overall net positive utility. The indirect approach, they contend, is more likely to achieve the desired result. Supporters of both approaches find support in Mill’s work.
 
We turn now to debates over the Quality of Life perspective, which is rooted in Utilitarian Consequentialism.
 
 
Topic 2: Debates Over the Quality of Life Perspective
 
Our focus here is the Quality of Life (Q of L) ethic. As Edward Keyserlingk (1979) stresses, this principle does not have a single, generally accepted meaning; nor as we have seen, does the sanctity of life (discussed just below in Topic 2). Yet, there are interpretations of each of those principles which are commonly defended and which can stand in direct opposition to each other. Thus, it is often said that the quality of life principle is a competing principle to the sanctity of life.
 
Assessing and Evaluating Quality of Life
 
The Q of L ethic has applications in many non-medical contexts, and those other applications tend to be less controversial. For instance, it is widely accepted that it is morally obligatory for governments to strive to improve and enhance the air quality, water quality, working conditions, literacy rates, and other aspects of the daily lives of their citizens. In this sense, factors that increase the quality of human life can be seen to be objective. There are connections drawn between objective indicators of quality of life and human needs, such as those set out by Abraham Maslow (1943; 1954: 35-47) in his oft cited “hierarchy”: physiological (food, water, sleep, etc.); safety and security (including health, employment and property); love and belonging (family, friendship and sexual intimacy); self esteem (confidence, achievement, respect of others); and self-actualization (morality, creativity, spontaneity), the latter at the top of the pyramid.
 
Social scientists and policy analysts have found that characterizations and indicators of quality of life can be of considerable use for determining “an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns” (WHOQOL, 1998). The World Health Organization, for instance, emphasizes the importance for ensuring basic human rights, of aiming towards the realization of at least adequate “quality of care”, comprising access to medical care, rehabilitation, and support services, particularly in relation to persons with disabilities or recognized health conditions.
 
There is substantial debate over the impact of “disability” – defined by the World Health Organization (2001) simply as “physical impairments, activity limitations, and participatory restrictions caused by a health condition” – on people’s perceptions of the quality of their lives. [It should be emphasized that there is a substantial literature in disability studies problematizing medical models of “disability”, and persistent disagreements about the extent to which the notion of disability is socially constructed.] How a person with “disabilities” (however that term is understood) responds to their life circumstances can have a lot to do with their social context, including the types and amounts of economic, emotional and psychological supports they have access to. The views and attitudes of one’s fellow citizens may also have a lot to do with how “disabilities” influence one’s perception of quality of life. [The application of the quality of life principle, and utilitarianism more generally, to issues relating to disabilities, can be very vexed, as we elaborate on below.]
 
As is observed by Peter Suber (no date), proponents of the Quality of Life perspective vary considerably in their approach to determining what makes a life worth living. Some focus on the presence of positive features, or elements, or dimensions, such as autonomy, dignity and rationality. [Those are concerns that are first and foremost for many proponents of the Sanctity of Life principle, as we will see below in the next topic.] Others focus on the absence of negativity, i.e., the lack of “extreme pain, hopeless deterioration, and irreversible incapacity” (Suber, n.d.). And still others combine both.
 
Utilitarian consequentialism lends support to the Q of L perspective. The ethical theory of utilitarianism was initially popularized by Jeremy Bentham in An Introduction to the Principles of Morals and Legislation (1789/ 1961) and further refined by John Stuart Mill in his book titled simply Utilitarianism (1861/ 1998). [Jeremy Bentham’s life and work are discussed in the Introduction to Module 2, and John Stuart Mill’s life and work are discussed in the Introduction to Module 5.] The assumptions, claims, and criticisms of, classical utilitarian moral theory are discussed in Module 6, Topic 4.
 
Debates in Bioethics
 
The contested aspects of the Quality of Life principle in the context of bioethics come to light from several directions. One is the focus on subjective indicators and comparisons of the relative values of different lives. The other is the connection between cognitive capacities and sentience, and the wrongness of killing. Philosophers such as James Rachels and Peter Singer have developed arguments based on the position that active, voluntary euthanasia can be morally justified. They have also argued that nonvoluntary euthanasia can potentially be justified, depending on the circumstances. Philosophers do not try to argue that involuntary euthanasia can ever be morally justified.
 
Recall that for classical utilitarianism, it is subjective factors that contribute to lesser or greater quality of life, including psychological states of perceived happiness. A contemporary version of utilitarianism, characterized as “preference utilitarianism”, has been developed by R.M. Hare, and defended by Peter Singer, and other philosophers. This approach to moral reasoning requires moral agents to choose actions that can be expected to fulfill the greatest number, or amount, of the interests, or preferences, of the greatest number of beings affected.
 
There are cognitive capacities that a person has that contribute to that person’s experience of positive utility. These include abilities: to engage in relationships, to form and recollect memories, to make plans and set goals and achieve them. As Peter Singer (1963: 133-134) has written: “A self-conscious being is aware of itself as a distinct entity, with a past and a future… A being aware of itself in this way will be capable of having desires about its own future….” A person has “interests” in continuing to exist in order to experience fulfillment through the satisfaction of wants, desires, or preferences. [Peter Singer’s use of the term “being” is intended to be inclusive of all sentient beings, including many nonhuman animals. The topic of the moral status and treatment of animals is well outside the scope of our discussion.]
 
On this approach, it can make sense to quantify the impacts of factors that can make lives go better or worse for those who live those lives. Some of us may feel comfortable making assessments about different stages or phases or time periods of our own lives, adjudging that one particular stage or phase or time period was more replete with happiness, enjoyment, pleasure or satisfaction than another. Classical utilitarians then contend that it can make sense to compare the “relative” amounts of overall quality (the net positive utility once the disutilty has been accounted for, or factored into the equation) of the lives of different persons. Preference utilitarians focus on comparison between lives which have higher, or greater, amounts of preference satisfaction and those which have lower, or lesser, amounts. Doing so leads to judgments about the “relative” value of different lives, and generates considerable controversies.
 
The relative valuation of lives that can be derived from the Q of L principle has been defended as the the basis for decision making as to whether to treat someone, whether to continue treatment, or whether to discontinue treatment. It is well recognized that any competent patient has the right to refuse treatment, as Edward Keyserlingk (1979: 59) emphasizes “on any grounds at all, whether they seem reasonable or foolish to others”. Thus, a patient with decision making capacity is well within her rights to say that the quality of her own life, as she experiences it, is not of sufficient quality, for her to wish to continue living past a certain point. That is the initial basis for Sue Rodriguez’s assertion of her right to self determination. Her view is that death, when she is ready for it, will be of benefit to her, an improvement over her condition of life.
 
Sue Rodriguez’s position goes even further, however. She is arguing that her judgment about the quality of her own life should be respected the extent of providing her with assistance in coming to the end on her own terms, at her own chosen time, and in her own way. This was implied in her questions: “If I cannot give consent to my own death, Whose body is this? Who owns my life?” It is the extension that is rejected by the majority of the BC Court of Appeal and the Supreme Court, and it should be emphasized, by Canadian legislators to date.
 
Utilitarians can, and do, argue that on the basis of the logic of their arguments, what makes it wrong to take the life of a person with high levels of cognitive capacities, without consent, is that the person’s desires for the future would be thwarted by doing so. However, the contrary logic holds. When a person desires the end of life, and requests assistance in dying, that person has no wish to go on living that would be thwarted by killing her. Instead, helping that person to die will help to satisfy her preference, i.e., to achieve her goal of determining when and how her life will end. If a person is lacking in cognitive capacities, such that the person does not have (or could not have) desires for the future, the loss of the remainder of life would not be as great. [There are numerous complexities when one tries to take account of the “potential” for future preference satisfaction, for a fetus or newborn.]
 
Problematizing the Moral Distinction Between Active and Passive Euthanasia
 
Philosophers such as James Rachels insist that the moral distinction between “letting die”, or passive euthanasia and “mercy killing”, or active euthanasia, may not be iron clad. Actively killing, it is argued, can be as morally justifiable, as letting die. In some cases, it may even be morally preferable to kill someone than to let that person die.
 
Rachels (1986: 133) insists that the “bare difference” between killing and letting die does not determine whether either or both are morally justifiable. Thus, the mere fact that Act X consists of killing, whereas Act Y is comprised of letting die, does not make Y acceptable and X unacceptable. Another way of putting it is that there is not an intrinsic moral difference between the two types of acts, in terms of causation and intention (or motivation) (Singer and Kuhse, 1993: 169). What could make either or both morally wrong, for Rachels (1986: 140) is the “loss” of life. If it is a loss for Person Z to lose his life, then it is equally a loss, whether death occurs by being killed by another, or by another “letting him die”. The consequence is the same.
 
Philosopher James Rachels (1975) has argued that:
(1) Allowing to die, or passive euthanasia is sometimes morally legitimate;
(2) Allowing to die is morally equivalent to killing, or active euthanasia;
(3) Therefore, killing can sometimes be morally acceptable.
 
Rachels (1986: 112) presents the following scenario to defend his position:
 
Smith has a six-year old cousin. Smith will inherit a lot of money if the cousin dies. One evening Smith enters the bathroom and drowns the child. Jones also has a six-year old cousin and will also inherit a lot of money if the cousin dies. Like Smith, Jones plans to kill the child. Just as he enters the bathroom, he observes the child slip, hit his head and fall into the water. Jones just stands by, watching the child die.
 
Rachels relies upon that example to argue that the “letting die” on the part of Jones is as morally wrong as the “killing” on the part of Smith.
 
Critics of Rachels have specifically argued that the Smith and Jones scenario does not adequately capture the context in which the issue of euthanasia arises (Pauer-Studer, 1993: 146). There is, they insist, a difference that makes a moral difference between respecting the expressed wishes of a competent patient (or, although this is more contested, a request made on behalf of a patient by a proxy decision maker) and failing to help prevent a death by one’s omission (as in the Jones situation).
 
Applications of Q of L Perspective Contested
 
The application of the Q of L principle, in association with utilitarian moral philosophy, in the context of medical decision making is most contested, when it is applied to patients who lack decision making capacity. For patients who do not have sufficient autonomy, or competence, to make decisions for themselves, due to their conditions (being a newborn, being unconscious, being in a persistent vegetative state, or being comatose), others must make decisions on their behalf. Those others are labelled as proxy, or substitute, or surrogate decision makers. [Who can perform that role, and their obligations is governed by provincial legislation in the Canadian context.]
 
An argument could be made, from the perspective of utilitarianism, that an infant with severe and significant disabilities, including profound cognitive impairments, does not have well-formed or well-developed “wishes” to continue living (and arguably, could not be expected to develop those through the aging process). If, in addition, it is determined that the infant may be expected to experience considerable pain and suffering from continued life, a utilitarian analysis could support a decision that the infant would be “better off” dead.
 
A decision to refuse consent to medical treatment for a life-threatening condition which was reversible, on behalf of a child with Down’s syndrome was made by the parents of “Baby Doe”, in Bloomington, Indiana, in 1982. The case of Baby Doe is discussed by Helga Kuhse and Peter Singer (1988: 1-11), in their book titled: Should the Baby Live?: The Problem of Handicapped Infants. Once the parents made the decision for non-treatment, the baby was left to die, given only water and painkillers. Kuhse and Singer, as well as Rachels, argued that it would have been more “humane” to give Baby Doe a lethal injection, in order to spare the infant the pain and suffering of a protracted death. On the assumption that the decision of the parents for non-treatment would be left to stand, they argue that “killing” would be preferable to “letting die” in such a situation.
 
Kuhse and Singer have generated considerable controversy with their discussion of the case. They have insisted that their analysis did not assume that the original choice for non-treatment was either justified or not justified. Their focus was on the issue of the defensibility of the “method” of death (Kuhse and Singer, 1993: 170). It should be added that Helga Kuhse and Peter Singer (1993: 170) do acknowledge that there may be extrinsic reasons for morally differentiating between killing and letting die. Such extrinsic reasons would include the impact upon the preferences of other affected persons (such as parents, and others).
 
Commentators on the Baby Doe case have insisted that it was not morally justifiable for the parents to decide as they did, for non-treatment. Both options being debated – either letting die or killing – were morally wrong.
 
Another case that arose in the United States involved a “Baby Jane Doe”, an infant with severe brain damage and a condition requiring surgery, whose parents decided to opt for nontreatment, in New York City, in 1983. In the case of Baby Jane Doe, the medical experts expected that surgery would prolong the infant’s life, but that her underlying conditions were predicted to cause continuing challenges with paralysis and epilepsy. A Vermont lawyer, Lawrence Washburn, undertook litigation to require a court to order that the surgery should be performed. The argument was made that the denial of surgery was discrimination against Baby Jane Doe on the basis of her medical conditions and disabilities.
 
As a result of the wide publicity that the Baby Doe and Baby Jane Doe cases attracted, there was legal reform in 1985. The Baby Doe Amendment law extended laws against child abuse, to specify that withholding fluids, food, and medically indicated treatment from children with disabilities would constitute child abuse.
 
Edward Keyserlingk (1979: 59) recommends that whenever decisions are being made on behalf of a non-competent, or incompetent patient, factors such as social utility, social worth, social status, or subjective factors for quality of life, be excluded from consideration. This would limit the potential range and scope of the application of the quality of life principle.
 
Slippery Slope Considerations
 
Critics of the Q of L perspective have insisted that there are good reasons for maintaining the criminal prohibition against active, voluntary euthanasia, or assisted suicide, even if it is difficult to conclusively establish the moral basis for doing so. The wedge, or the slippery slope argument, is one of the most frequently raised concerns.
 
A characterization of the slippery slope, or wedge, type of argument is provided by Edward Keyserlingk, author of the Law Reform Commission Report titled Sanctity of Life or Quality of Life. Keyserlingk articulates the slippery slope or wedge argument in these terms (1979: 22): “once some form of killing or letting die … is legitimated in a particular instance, though it may be compassionate, sometimes morally justifiable or at worst a minor evil in itself, if allowed and applied generally, it will, despite goodwill and the best available safeguards, lead to wrongs of ever increasing magnitude.” It is typically argued that a relatively small first step will lead to a chain of events that will inevitably and irreversibly culminate in some horrible or terrible outcome.
 
The assumption being made is that decriminalizing active, voluntary euthanasia will ultimately lead to loosening of moral restrictions. Eventually, permissive and lax attitudes will result in active, nonvoluntary euthanasia being practiced, and even on some accounts, lead to involuntary euthanasia. At the very least, critics of reform insist that it would generate unforeseen and undesired consequences, including the problem that people with severe disabilities or terminal conditions may feel pressured to request assistance in dying sooner, in order to avoid being a burden on their families and loved ones. They would, it is suggested, come to feel that active, voluntary euthanasia was not just accepted, but that it was “expected”. Another worry flagged by critics is that the legalisation of assisted suicide could lead to reductions in funding for palliative treatments, or even potential cures. Despite such arguments being flagged as potential fallacies in informal logic (if they are without sufficient warrant), slippery slope objections are very popular in bioethics, in relation to topics such as cloning, genetic engineering, and reproductive technology as well as euthanasia.
 
Focus on Safeguards
 
Those who advocate for decriminalization are well aware of the need to address the fears and concerns of those who reject proposals for legal reform. They can produce specific recommendations for criteria and conditions to act as safeguards (as do several of the dissenting judges who ruled in the case of Sue Rodriguez). Increasingly, advocates of reform will draw upon empirical evidence about the jurisdictions where euthanasia has been decriminalized and/ or legalized, and express confidence that the challenges can be met. However, critics of reform rely upon empirical evidence about those same jurisdictions to draw support for their expectations of dire consequences that would ensue from decriminalization.
 
To sum up, the Q of L perspective reflects the view that not all lives have equal value. The value of life is contingent, and lives can have relative value. It is the presence or absence of qualities (positive or negative) that makes lives have more or less value. There are conditions under which a particular life may be deemed to be no longer worth living (by the person whose life it is or by others). The notion of lives being worthwhile or not worthwhile can be of help for medical decision making, for determining which patients should be given which treatments, and which should not. The conceptual framework of Quality of Life could also be adopted and adapted to deciding whether, and if so, when and how, it might be morally justifiable to kill, as well as to “let” someone die.
 
Many critics of extensions of the quality of life perspective, in association with utilitarian moral philosophy, resist the idea that the lives of different persons can be commensurable (or evaluated by a common standard). They resist making value judgements about the relative value of other people’s lives. They especially reject attempts to contrast or compare the life of one person who is able-bodied and in the prime of health with another person who has substantial health challenges or disabilities, and then pronounce the life of the latter to be relatively less valuable than the former overall. And, they are particularly outraged by the view that it could ever be considered to be morally justifiable to intentionally and deliberately kill a human being, for any reason other than in self-defence.
 
We now turn to consideration of Kantian Deontology (in Topic 3), before delving into debates over the competing principle, Sanctity of Life (in Topic 4).
 
 
Topic 3: Kantian Deontology (Nonconsequentialism)
 
Numerous philosophers have developed a variety of nonconsequentialist alternatives to utilitarian moral theory. Here we are going to focus on the most familiar form of nonconsequentialism, which is deontology, and on the work of just one of those philosophers, Immanuel Kant. [See Alexander and Moore (2007/ 2012) for further discussion.] The term deontology is a Greek word meaning “theory of duty or obligation”. As Alexander and Moore (2007/ 2012) articulate: “Roughly speaking, deontologists of all stripes hold that some [moral] choices cannot be justified by their effects. For deontologists, what makes a choice right is its conformity with a moral norm.” Deontological theories of ethics typically emphasize the crucial importance of motive and intention in the determination of the moral worth of action.
The inscription found on Immanuel Kant’s tomb nicely captures the spirit of his philosophy. It is an excerpt from the Critique of Practical Reason: “Two things fill the mind with ever new and increasing admiration and awe, the more often and steadily we reflect upon them – the starry heavens above me and the moral law within me.” On the Kantian conception of morality, all human beings, whatever their beliefs about the source of authority for moral norms, have a moral conscience, a common sense grasp of morality, and a firm conviction of our moral responsibility (Rohlf, 2010: 31). The belief that morality applies to each and every one of us, and that we are morally accountable for our actions, does not need to be proven by deduction, insists Kant (1785).
 
It can be a considerable challenge to try to summarize what is a dense, complex, and highly nuanced theory. To some extent, it is requisite to making sense of Kant’s moral philosophy to recognize its place in his broader philosophy. For ease of articulation, and in the aim of brevity, we will set out a series of questions and responses, in order to highlight the crucial concerns, and distinctive contributions of Immanuel Kant to moral theorizing.
 
Question: What is Kant’s underlying conception of humanity?
Response: In Kant’s conception of humanity, we are all autonomous, capable of acting and choosing freely. The concept of autonomy refers to the capacity to be self-governing, self-determining, to be one’s own person. Kant contrasts autonomy with heteronomy, a term used to refer to action in accordance with inclination or desire that is not self-chosen. (Johnson, 2004/ 2008; Rohlf, 2010)
 
Human beings inhabit two realms. One is the realm of necessity, the sensible world, in which actions are determined by laws of nature and regularities of cause and effect. Laws of nature are the products or constructs of human understanding, arising from the application of human intuition to the world of experience. Theoretical philosophy, for Kant, is concerned with how the world is. The other realm is that of freedom, the intelligible world that is independent of the laws of nature. In that other realm, practical philosophy is concerned with how the world ought to be, and human reason generates the moral law (see below). Kant insists that human beings are much more than mere physical creatures with appetites, more than mere objects of experience. We are also subjects of experience, beings who can act freely in accordance with self-chosen moral norms. (Johnson, 2004/ 2008; Rohlf, 2010)
 
Q: What is Kant’s notion of freedom?
R: For Kant, human freedom is the opposite of natural necessity. In the Groundwork, Kant (1785) writes: “Everything in nature works in accordance with laws. Only a rational being has the power to act in accordance with his idea of laws – that is, in accordance with principles.” The human capacity for freedom is exemplified in the ability for a moral agent to act autonomously, to act in accordance with a moral law that is chosen by the agent.
 
Q: What makes human life special, and persons of equal worth?
R: Kant (1785) wrote: “Beings… without reason, have only a relative worth, as means, and are therefore called things, whereas rational beings are called persons because their nature .. marks them out as an end in itself ….” (translation by Gregor, 1997: 37). Commentator Robert Johnson (2004/ 2008: 1) elaborates: “… it is the presence of self governing reason in each person that Kant thought offered decisive grounds for viewing each as possessed of equal worth and deserving of equal respect…” We return to the links between these ideas and Kant’s conception of morality below. It is the capacity to act freely that gives human life its special dignity, its inherent worth, its intrinsic value. Something which has intrinsic value has value “in itself”, “for its own sake”, or “in its own right”. By contrast, something which has extrinsic value is valuable for the sake of something else, as a means to the end of some other valuable thing.
 
Q: What is the good will?
R: Kant defines “will” as a power to determine oneself to action. A good will is the supreme good to which all other values are subordinate. This oft-quoted passage from the Groundwork reflects Kant’s (1785) thinking: “A good will isn’t good because of what it effects or accomplishes, it is good in itself. Even if by utmost effect the good will accomplishes nothing it would still shine like a jewel for its own sake as something which has full value in itself.” It is only the good will that can be good in itself, good without qualification. Acting from duty evidences a good will. (Glasgow, 2012)
 
Q: What is it to act from duty, or to act on the basis of duty?
R: Acting from duty, insists Kant, may mean that we choose to act, in effect, against our desires or inclinations. Dutiful action is differentiated from action that is motivated by self-interest, or self-preservation, or happiness, or sympathy. When we act on the basis of duty, we may find that we constrain ourselves to act in ways that we do not “want”, or in ways that do not satisfy our “desires” or our “preferences”. Yet, the duties that we recognize as moral agents are ones that reflect the contingencies of human life (Rohlf, 2010).
 
Q: What gives an action moral worth?
R: According to Kant, what makes an act morally worthy is not the consequences that flow from it, but instead it is the motive, or the intention behind the act. The motive for an action confers moral worth on that action. The good will gives an action its moral worth. For Kant, what is crucial is doing the right thing for the right reason. (Glasgow, 2012)
 
An example may be helpful (from Glasgow, 2012). Imagine that two people standing on the shore observe someone in the water drowning. Person X attempts to save the drowning person out of desire for a potential monetary reward, and/ or for the publicity, fame and renown, and is successful. Person Y, by contrast, wants to save the victim only out of genuine altruism, but is unsuccessful in the effort. According to Kant, despite the lack of success, it is only Person Y whose action can be considered morally worthy. Person Y is a person of good will.
 
Q: How do, or should, moral agents make moral decisions?
R: A moral agent should reason through the use of maxims. A maxim is an abstract description of the action that one intends to perform. It is a rule or principle for action. Since humans are rational beings, our action will always aim at an end or goal. Our ends or goals are represented in our maxims. A maxim states what you should do (your action), and why you should do it (your goal or your end). Kant (1785) provides the following as an example of a maxim: “to let no insult pass unavenged”.
 
Maxims can be complex. They can contain descriptions of a physical act (A), descriptions of circumstances (C), as well as the purpose or end of action (E). Maxims can take the form: I will do Act A in circumstances C to achieve end E (Glasgow, 2012). Note that “ends” are distinguishable from motives. One’s end is what one is hoping to achieve, whereas one’s motive is why one wants to achieve that end.
 
Q: How are human reason and maxims related?
R: Human reason is the power to choose independent of the dictates of nature, inclination or circumstance. It is through the exercise of reason that a moral agent selects potential maxims to guide action.
 
Q: What is the moral law?
R: The moral law consists of commands that one gives to oneself, dictates of how we ought to act in specific situations. The moral law takes the form of categorical imperatives.
 
Now we can shift to setting out the core conceptual framework of Kant’s distinctive approach to moral reasoning, making use of Kant’s own examples, and then follow up with some prominent and sustained criticisms his work has inspired.
 
Hypothetical and Categorical Imperatives
 
An imperative is an authoritative command; moral agents use their reason to discover which imperatives should guide their conduct. A hypothetical imperative is a “principle of rationality that says that I should act in a certain way if I choose to satisfy some desire” (Rohlf, 2010: 33). Such an imperative takes the form of “If, then”. This form of reasoning takes a familiar pattern: “we have a certain desire (to become a better chess player, to go [university]; we recognize that a certain course of action will help us get what we want [i.e., practicing our game, taking an admissions test and filling out an application]; and so we follow the indicated plan” (Rachels and Rachels, 2010: 127-128). The bindingness of the “ought” is dependent upon us having the relevant desire.
 
A categorical imperative is an imperative that is general, one that applies as an absolute rule, unconditionally, and without reference to, or independent of any further purpose. Kant’s (1785) own articulation of the distinction reads as follows: “If the action would be good solely as a means to something else, the imperative is hypothetical, if the action is presented as good in itself and therefore as necessary …. for a will which of itself accords with reason, then the imperative is categorical.” The typical form of a categorical imperative is this: “you ought to do Z”, full stop, period. No ifs, ands of buts. Some philosophers, such as James Rachels (2010: 128) have lamented that categorical imperatives are “mysterious”. It should be helpful to bring in Kant’s own examples to dispel some of the mystery.
 
Kant discussed the example of a shopkeeper who asked himself whether he ought to cheat his customers to illustrate the difference. The shopkeeper might consider a maxim of this construction: “If I want to benefit from repeat business, I need to maintain a reputation as an honest businessman, and thus, I should not cheat my customers.” It is for the sake of holding on to customers that the businessman would choose a maxim of honest business practices. However, the shopkeeper is choosing honesty for its instrumental value, and through the incantation of a hypothetical imperative. The shopkeeper’s moral choice is tethered to his desire to benefit materially from a good reputation. It is the desire for wealth that determined the maxim. For Kant, the shopkeeper’s reasoning process was flawed, and he failed to properly exercise his capacity for autonomy. The alternative maxim would be more abstract and more general: “Always be honest”. Such a maxim would apply to all moral agents, in any circumstances, and regardless of their desires or inclinations. It would be, in effect, a “universal law”.
 
First Formulation of the Categorical Imperative: Universal Law
 
To animate his articulation of the categorical imperative, Kant (1785) described the situation of a man facing financial hard times thusly:
“A man finds himself forced by need to borrow money. He well knows that he will not be able to repay it, but he also sees that nothing will be lent him if he does not firmly promise to repay it at a certain time. He desires to make such a promise, but he has enough conscience to ask himself whether it is not improper and opposed to duty to relieve his distress in such a way…. He considers: Is it not unlawful and inconsistent with duty to get out of a difficulty in this way?”
The man, knowing that he could not repay the loan, asks himself: Should I make a false promise (i.e., to repay the loan)? If I choose that maxim, how would it be if that maxim became a universal law?
 
Kant insisted that such a maxim would be inconsistent:
“Now, assuming he does decide to do so, the maxim of his action would be as follows: When I believe myself to be in need of money, I will borrow money and promise to repay it, although I know I shall never be able to do so. Now this principle of self-love or of one’s own advantage may perhaps be consistent with my whole future welfare; but the question now is, Is it right? I change then the suggestion of self-love into a universal law, and state the question thus: How would it be if my maxim were a universal law? Then I see at once that it could never hold as a universal law of nature, but would necessarily contradict itself. For supposing it to be a universal law that everyone when he thinks himself in a difficulty would be able to promise whatever he pleases, with the purpose of not keeping his promise, the promise itself would become impossible, as well as the end that one might have in view in it, since no one would consider that anything was promised to him, but would ridicule all such statements as vain pretences.”
 
The choice of a maxim based on false promising would be self-defeating. If adopted by all persons, everywhere, at all times, as a universal law, people could no longer believe any promises made to them, and that would completely undermine the social practice of promising.
The discussion thus far corresponds to what is known as the first formulation of the categorical imperative, variously articulated in these terms:

Act only on that maxim whereby thou canst at the same time will that it should become a universal law;
Act in such a way that the general rule behind your action could consistently be willed to be a universal law;
I ought never to act except in such a way that I can also will that my maxim should become a universal law”.

 
Second Formulation of the Categorical Imperative: Respect for Persons
 
Kant (1785) then provides another articulation of the categorical imperative, using that same example of the man needing a loan in the following passage:
“… he who is thinking of making a lying promise to others will see at once that he would be using another man merely as a means …. For he whom I propose by such a promise to use for my own purposes cannot reasonably assent to my mode of acting towards him, and therefore cannot himself contain the end of this action. This violation of the principle of humanity in other men is more obvious if we take in examples of attacks on the freedom and property of others. For then it is clear that he who transgresses the rights of men, intends to use the person of others merely as means, without considering that as rational beings they ought always to be esteemed also as ends, that is, as beings who must be capable of containing in themselves the end of the very same action.”
 
Another example relied upon by Kant (1785) is the scenario of a man considering suicide:
“A man reduced to despair by a series of misfortunes [and evils] feels wearied of life, but is still in possession of his reason sufficiently to ask whether it would not be contrary to his duty to himself to take his own life. Now he inquires whether the maxim of his action could become a universal law of nature. His maxim is: From self-love I adopt it as a principle to shorten my life when its longer duration is likely to bring more evil than satisfaction. It is asked then simply whether this principle founded on self-love can become a universal law of nature. Now we see at once that a system of nature which it should be a law to destroy life by means of the very feeling whose special nature it is to impel to the improvement of life would contradict itself, and therefore could not exist as a system of nature; hence that maxim cannot possibly exist as a universal law of nature, and consequently would be wholly inconsistent with the supreme principle of all duty.”
 
A proposed maxim to commit suicide to avoid misery, or pain and suffering, could not, Kant insists, be consistently willed as a universal law.
 
Continuing on with the example of the man considering suicide, Kant (1785) then frames the discussion in terms of respect for persons:
“He who contemplates suicide should ask himself whether his action can be consistent with the idea of humanity as an end in itself. If he destroys himself in order to escape from painful circumstances, he uses a person merely as a means to maintain a tolerable condition up to the end of life. But a man is not a thing, that is to say, something which can be used merely as a means, but must in all his actions be always considered as an end in himself. I cannot, therefore, dispose in any way of a man in my own person so as to mutilate him, to damage or kill him.”
 
Kant elaborates on what is known as the second formulation as follows:
“If there is a supreme practical principle or, in respect of the human will, a categorical imperative, it must be one which, being drawn from the conception of that which is necessarily an end for everyone because it is an end in itself, constitutes an objective principle of will, and can therefore serve as a universal practical law. The foundation of this principle is: rational nature exists as an end in itself. Man necessarily conceives of his own existence as being so: so far then this is a subjective principle of human action. But every other rational being regards its existence similarly, just on the same rational principle that holds for me: so that it is at the same time an objective principle from which as a supreme practical law all laws of the will must be capable of being deduced.”
 
As we noted above, human beings, or persons, have dignity, intrinsic value and inherent worth. Suicide would be wrong, writes Kant, because it would be a violation of the dignity in one’s own person. To choose a maxim to commit suicide would be treating the cessation of a person’s life as a means to the alleviation of misery or suffering. Instead, Kant insists, a rational moral agent should recognize and affirm a moral duty not to kill oneself out of a duty of respect for persons.
 
Articulations of what is known as the second formulation of the categorical imperative include:

“Act in such a way that you always treat humanity whether in your own person or in the person of any other, never simply as a means, but always at the same time as an end”.
Rational beings all stand under the law that each of them should treat himself and all others, never merely as a means, but always at the same time as an end in himself.
Always treat persons (including yourself) as ends, never as means only, always treat persons with respect.”

 
Kant, in his various articulations of the categorical imperative, stipulated the following about maxims: (i) each maxim should be chosen as though they would hold as a universal law; and (ii) every human being must chose maxims in accordance with respect for persons as ends in themselves. [There is also a third formulation of the categorical imperative, known as the “Kingdom of Ends”. It is not as directly germane for our purposes here.]
 
Kant on the Case of the Inquiring Murderer
 
To ready ourselves to examine some of the familiar criticisms and objections that Kant’s theory has provoked, we need to bring in one more hypothetical example discussed by Kant, known as the case of the inquiring murderer.
 
The example was conjured up by some contemporaries of Kant to discover just how far would he take his theory, in its rejection of consequences as the determinant of moral worth. The case is summarized in Rachels and Rachels (2010: 130):
Imagine that someone is fleeing from a murderer and tells you he is going home to hide. Then the would-be murderer comes, playing innocent, and asks where the first man went. You believe that if you tell the truth, the murderer will find the man and kill him. Furthermore, suppose the murderer is already headed in the right direction, and you believe that if you simply remain silent, the would-be murderer will find the man and kill him.
Kant was asked what the man should do, and he responded in an essay titled “On A Supposed Right to Lie from Altruistic Motives”.
 
Kant’s response is layered, but the gist of it is that Kant insists the categorical imperative entails a prohibition against lying. Kant’s explication was along the following lines (Rachels and Rachels, 2010: 130-131, citing Kant, 1949: 348):
After you have honestly answered the murderer’s question as to whether his intended victim is at home, it may be that he has slipped out so that he does not come in the way of the murderer, and thus the murder may not be committed. But if you had lied and said that he was not at home when he really had gone out without your knowing it, and if the murderer had then met him as he went away and murdered him, you might justly be accused as the cause of his death. For if you had told the truth as far as you knew it, perhaps the murderer might have been apprehended by the neighbours while he searched the house and thus the deed might have been prevented. Therefore, whoever tells a lie, however well intentioned he might be, must answer for the consequences, however unforeseeable they were, and pay the penalty for them… To be truthful (honest) in all deliberations is therefore a sacred and absolutely commanding decree of reason, limited by no expediency.
 
Kant (1949: 138) believed so strongly in the categorical imperative against lying that he considered it to be “the obliteration of one’s dignity as a human being”.
 
It should now be a good time to turn to the critical responses to Kantian deontology.
 
Selected Criticisms
 
Formalism and Abstraction: John Stuart Mill and many others have objected that Kant’s articulation of the Categorical Imperative leaves it empty, or trivial, unable to do any productive work in moral decision making. The level of abstraction inherent in Kant’s account ensures that any ethical principles it could generate would be incapable of being action-guiding. Defenders of Kant’s work, such as Onora O’Neill (2012), have responded by arguing that the line of criticism misrepresents how Kant’s theory ought to function. Morality should be based on abstract principles, and then moral agents need to follow through on adapting and applying those principles in ways that would be action-guiding.
 
Neglect of Inclinations or Empirical Dimensions: Kant’s approach is criticized for seeming to endorse the view that only by ignoring or disregarding our inclinations could we be sure that we were acting out of duty. Another variant charges that Kantian ethics neglects or ignores the empirical dimensions of morality. In response, Marcia Baron (1997) observes that while the categorical imperative is free of empirical facts, it is still the case that empirical facts can enter into the process of applying the categorical imperative. Contemporary philosophers committed to deontology have dedicated themselves to providing more empirically sensitive theorizing.
 
Exceptions Are Excluded: To the complaint that Kant’s approach excludes a place for exceptions, defenders of Kantian ethics insist that exceptions are not ruled out by fiat, but that any exceptions to be considered have to be morally justified (Baron, 1997).
Rigorism: Kant’s articulation of deontological ethics is seen to be fraught with rigorism. In response, Onora O’Neill (2012) remarks that Kantian ethics can be made more flexible, and can incorporate differentiated applications.
 
Conflicting Grounds of Moral Obligation: As is so graphically and dramatically illustrated by Kant’s response to the Case of the Inquiring Murderer, Kant’s theory does not provide a procedure for dealing with moral conflicts. Remarkably, it seems that Kant did not envisage that a moral agent could find themselves to be facing conflicting grounds of moral obligation.
 
A moral agent could be obligated not to do A, since it is morally wrong, or obligated not to do B, which is also morally wrong, and be unable to avoid choosing one of those actions, as in the Inquiring Murderer situation. James Rachels presented a real world example that depicts the same challenge:
During the Second World War, Danish and Dutch fishermen smuggled Jewish refugees to England in their boats. Those fishing boats with refugees in the hold would sometimes be stopped by Nazi patrol boats. The Nazi Captain would call out and ask the Dutch captain where he was bound for, and who was on board, and so on. The fishermen would lie, and be allowed to pass. Now it is clear that the fishermen had two alternatives: Either to Lie (violating a moral obligation not to lie) or to Allow People to be Killed (contrary to moral obligation).
 
Elizabeth Anscombe, otherwise sympathetic to nonconsequentialism in ethics, was critical of Kant’s way of framing the argument. The claim that if one were to lie in such situations, one would be following the rule that “it is acceptable to lie” is overly simplistic. Perhaps in situations such as that of the inquiring murderer, one should adopt a maxim along these lines: “I will lie when doing so would save someone’s life” (Rachels and Rachels, 2010: 130, citing Anscombe, 1958). That characterization of the maxim could be consistently willed as a universal law.
 
Smuggled in Consideration of Consequences:
 
We began with one of John Stuart Mill’s criticisms of Kant’s ethics, and we will end with another one. Mill charged that Kant seemed to smuggle in consideration of consequences. For instance, when Kant wrote of universalizing the maxim of false promising, he appealed to the outcome, or consequences of everyone adopting a maxim of false promising, to argue for its rejection.
 
Kant’s defenders (Baron, O’Neill and others) insist that the categorical imperative should be understood as a test to ensure that you, as the moral agent, are not privileging your own needs, and desires. Even if consequences can be invoked in the process of moral reasoning, at some level, it is not the case that the categorical imperative thereby becomes a “test of the consequences” of one’s actions.
 
 
 
Topic 4: Debates Over the Sanctity of Life Perspective
It can be challenging to provide a definitive account of the Sanctity of Life principle, since there are numerous variants, and many qualifications have been introduced and defended by its proponents. At its most simple, the S of L perspective insists that “lives have sanctity regardless of the degree or kind of suffering, deterioration, dependency, or development that they manifest” (Suber, n.d.: 2). And in its most familiar form, the S of L perspective decisively rejects the view that “the value of a life may depend on its quality, or condition, or circumstances” (Suber, n.d.: 2).
 
Conceptualizing Sanctity of Life
 
The Sanctity of Life perspective can be conceptualized in terms of Classical Natural Law theory of morality, which is distinctively teleological, although it can contain elements of categorical reasoning (as in Aquinas’s formulation). [The work of Saint Thomas Aquinas is representative of Natural Law theory of morality, as well as Natural Law theory of law.] Or alternatively, the Sanctity of Life perspective can be understood through contemporary, non-consequentialist approaches to moral reasoning.
 
The most familiar form of non-consequentialist moral theory is that of Deontology (a Greek word meaning theory of duty or obligation), an approach most commonly identified with the work of Immanuel Kant.
 
The Sanctity of Life ethic is a principle with roots in Biblical morality, but it has secular incarnations as well. Its core assumptions are articulated by Leonard Weber (1976: 41-42) as follows: “The sanctity of life ethic defends two propositions: (1) That human life is sacred by the very fact of its existence; its value does not depend upon a certain condition … of that life. (2) That, therefore, all human lives are of equal value; all have the same right to life.” Helga Kuhse (1987) has characterized the two core claims of the Sanctity of Life principle in these terms: (1) The Inviolability Condition; [Inviolability refers the condition of something that must be kept sacred, that must not, or cannot be dishonoured or transgressed.] (2) The Equality Condition – No single life deserves priority over any other life.
 
The first claim, also referred to as the “ultimity” claim (i.e., that life has ultimate value), has been subjected to differing interpretations. It might mean that life is of absolute value, in which case no other value could ever outweigh or override the value of life, except perhaps more life (Suber, n.d.: 4). Or it might mean that life is of infinite value, although this has implications that some commentators find conceptually perplexing. Or, on another interpretation, it might mean that life is of maximum, albeit finite value (Suber, n.d.: 4). Other interpretations focus on the intrinsic value, or inherent worth of life. The latter three interpretations are most compatible with a secular orientation.
The Meaning and Value of Life
 
The Sanctity of Life perspective is understood to provide answers to some crucial questions about life. What gives life meaning and wherein lies the value of life?
 
Some variants are religious in their orientation; for these, it is the givenness of life, i.e., that life is a “gift” from the Creator, that gives it immeasurable value. Other variants, especially secular ones, find the value of life to reside in mere existence. The principle, so formulated, seems to be suggesting that it is “biological vitality, perhaps with a spiritual glow” (but not necessarily), or the bio-electrical and chemical activity of organisms that gives life its unique and special value (Suber, n.d.). Such accounts seem to be equivalent to vitalism, and not all adherents of the sanctity of life principle endorse that perspective. [See, for instance, the discussion in Keyserlingk, 1979: Chapter 2.] On other accounts, it is the notion of human dignity that is at the heart of the sanctity of life. The value of human life, on this decidedly secular approach, resides in the capacity of human beings for living self-conscious, autonomous moral lives (Bayertz, 1996: 226).
 
The S of L position is frequently characterized by the rejection of the view that it is the qualities or features or aspects of existence (such as health, happiness, enjoyment, and so on) which give life value. The S of L perspective, as its defenders insist, is not immune to appreciation of the wonders of the “higher” qualities of life, such as self-consciousness, friendship, community, self-worth, rationality, capacity for autonomous decision-making, and more. However, the position resists making value judgments about lives; its adherents would not accept that some lives are of more value than others, because of the presence of “higher” qualities (or greater amounts of those qualities).
 
It is a challenge for the advocates of the S of L perspective to work out what might be the parameters of the lives that are of sacred value. On the broadest, and some would argue, the most consistent position, it would be all lives, human and non-human alike, that would be of value. Theologian and medical doctor (and Nobel Peace Prize winner) Albert Schweitzer (1865-1975) endorsed and promoted the view of “reverence for life”. Peter Suber (n.d.: 16) points out complexities that arise: “Since organic life survives only by eating organic life, it makes life itself immoral or tragic.” This is especially the case if the theory is construed so as to rule out killing of any kind for any reason. Even if the theory can encompass some killing in order to save life (such as by eating to stay alive), it would seem to be impermissible to consider sacrificing “lower” life forms for the good of “higher” life forms, if all forms of life are equally valuable. [Thus, a fulsome S of L position may go far beyond not just vegetarianism, but even veganism.]
 
The S of L perspective could insist that it is only human life that has sanctity. As Edward Keyserlingk (1979: 18) articulates: “[h]uman life is precious, even mysterious, and is worthy of respect and protection”. This approach, while vulnerable to the charge of speciesism, tends to be more common amongst those who endorse the S of L perspective. Then, the question is whether the value resides in all of human life, simply by virtue of being human, or whether value is connected to particular qualities or features of human beings.
 
Critics of the perspective contend that by moving away from valuation of life per se, would-be supporters of Sanctity of Life seem to be shifting towards a Quality of Life approach of some sort. Peter Suber (n.d.: 17) makes an argument along these lines. Suber insists that the “humans are special” version of Sanctity of Life is virtually indistinguishable from a “threshold” Quality of Life position. Suber (n.d.: 13) characterizes a threshold Q of L approach in terms of the belief that “there is a certain, comparatively low threshold of quality above which all lives should be treated as possessing equal and ultimate value”. It is a position that ascribes ultimity and equality to lives on the basis of certain qualities.
 
[It is interesting to note that Peter Suber (n.d.: 14) suggests that Immanuel Kant is proposing a version of what Suber identifies as “threshold Q of L”, rather than a strict Q of L approach. This is because Kant, famously, had a threshold of ultimate value, namely rationality. Kant ultimately did not “limit his valuation to human beings or organic lives” (Suber, n.d.: 14).]
 
If the S of L proponents insist that it is mere existence, but only human existence, that is of ultimate value and worth, their critics have further concerns. Suber is especially concerned about the need for moral principles to help us with the difficult and often tragic choices that must be made due to the impact of technological innovations in modern medicine, and in the face of inevitable scarcities of resources. As Suber (n.d.: 16) puts it, the S of L perspective “commands us to have no favourites, no preferences, no priorities. That is the effect of the equality condition in the position. The ultimity condition in the position requires us to divert all our resources from uses that do not save or preserve life to life-saving purposes.” It seems, contends Suber, that all our resources should be devoted to the primary task of preserving and extending life (and postponing death), diverting us from all the other tasks and uses of resources that could be dedicated to improving and enhancing quality of life. In what the defenders of S of L would regard as a caricature of their position, Suber (n.d.: 7) expresses the worry that far too many and too much of society’s scarce resources will be marshalled in the service of keeping alive for as long as possible even those who may no longer “wish” to do so, or those who can no longer “appreciate” their lives.
 
Suber assumes that there is no escaping the need to “choose among lives” in the context of contemporary medicine. The S of L principle is not at all helpful, charges Suber (n.d. 20): “Its equality condition paralyzes choice; al the contenders must be valued equally, even some are otherwise fit and happy and others are unborn, vegetative, suicidal, or brain-dead”. As Suber (n.d.: 7) laments, the S of L perspective “does not make triage unnecessary just because it makes choice impossible”.
 
Wrongness of Killing
 
Another principle that can be inferred from the sanctity of life principle, is that of the Wrongness of Killing (W of K), which in turn has several distinct interpretations. Whether killing can ever be justifiable is another key issue that divides the Sanctity of Life supporters amongst themselves, and separates them from their Quality of Life-oriented critics.
 
Many of those who endorse the S of L perspective insist that the taking of human life, or the failure to provide support for the continuation of life, is a form of “playing God”. The following quote illustrates this view: “The prerogative of giving life belongs to God; nor may the prerogative be usurped… the prerogative of taking life … is God’s and God’s alone” (Kluge, 1975: 137). Other interpretations can be founded on a secular basis, such as those that focus on the non-interference in nature, and avoidance of unacceptable interference with nature. Thus, some argue that euthanasia is morally unacceptable, because it amounts to interfering with the course of nature, as to when and how death will occur.
 
The “interfering with nature” argument is typically countered with the objection that virtually all of medicine amounts to interference with nature, and the insistence that we should concentrate on distinguishing between morally allowable ways of doing so, and those that are not.
 
The rationales for a general prohibition against the taking of human life without adequate justification can take several forms. On one interpretation, it is wrong to take any human life for any reason. Such a strict interpretation of the Wrongness of Killing (W of K) principle would rule out killing in war, and capital punishment, along with abortion (on the assumption that the fetus is a human being, either from the moment of conception or from the time of viability), suicide, and euthanasia. Some defenders the strictest interpretation of W of K would argue that it is not morally acceptable to kill, even in cases of self-defence. Yet, other supporters of even the strict version of W of K would allow for the exception of killing in self-defence; that would be morally permissible, although not obligatory.
 
One popular modification of the W of K principle would stipulate that it is only wrong to take an innocent human life. On this interpretation, it is easy to see that killing in self-defense is distinguished from murder; taking the life of a noninnocent person (such as one who threatens your life) is morally distinct from taking the life of an innocent person. On the modified approach, abortion and euthanasia are still morally prohibited, but capital punishment could be morally justifiable for the crime of murder (the murderer is clearly not innocent), as could the killing of combatants in wartime (although the killing of civilians, who are innocent, would not be acceptable). And another interpretation of W of K can be derived from a focus on harm: “one ought not to kill a human being whose existence or actions neither have caused nor will cause imminent harm” (Keyserlingk, 1979: 29).
 
As Peter Suber (n.d.: 6) has stressed, the proponents of S of L can be “stymied by the question whether one life may be sacrificed to save many”. Some advocates of S of L will support some kinds of killing, assuming that more lives might be saved by doing so. These would be instances of “preventive killing”. This rationale could be applied to killing in wartime, or perhaps the use of the death penalty for its deterrent effect. [There is, it should be noted, a substantial amount of empirical research calling into question the effectiveness of the death penalty for deterrence.] But S of L and W of K supporters would resist making the kinds of generalizations that Q of L supporters would make, about the general permissibility of sacrificing a lesser number of lives in order to save a greater number of lives.
 
Issues of Trust
 
There is one more concern that should be briefly mentioned, a concern voiced by those who reject the calls for the reform of laws concerning euthanasia – although it is not an argument grounded in the S-of-L perspective per se. It is the issue of trust between health care providers and the recipients of that care.
 
The concern is that allowing medical professionals to kill their patients, even with the consent of that patient, would be a radical transformation, one that threatens to “seriously compromise the expectation of moral limits and boundaries on which patient trust is based” (Keyserlingk, 1979: 128). The Hippocratic Oath for health care providers stipulates that “I will give no deadly medicine to any one if asked, nor suggest any such counsel”. It is argued that legally allowing for physician-assisted suicide, in particular, would jeopardize the relationship between a patient and her health care provider. If bringing about the premature death of a patient becomes part of regular medical practice, the worry is that health care providers could lose their compassion, and that patients may become suspicious and distrustful of them.
 
Health care providers, as suggested by opinion polls and other research, are deeply divided over proposals to decriminalize assisted suicide. Note that the objection has particular traction against proposals for physician-assisted suicide, but not all proposals for reform focus on the role of health care providers. In Switzerland, for instance, assisted suicide is legally permitted, and there is no requirement for a physician to be involved. [As a point of interest, there is no requirement that the recipient of assistance in dying has to be a Swiss citizen, a situation that has led to what some have called “suicide tourism”.] These issues, while important, are beyond the scope of our present purposes.
 
It can be a daunting task to try to sum up a principle which resists easy summation. Some progress can be made by emphasizing that for the Sanctity of Life perspective, life is of intrinsic worth, and absolute value. Human lives have equal value regardless of the condition of those lives. On some accounts, it is mere existence which gives life value. Respect for autonomy entails that a mentally competent adult can request cessation or withdrawal of treatment, for reasons that may or may not reflect her evaluation about the quality of her life. There may be very narrowly circumscribed and carefully delineated criteria for when killing could be morally permissible (such as in situations of self-defence), but it could never be morally justifiable to kill a person (or even to assist in the suicide of a person), on the basis that the person’s life was of insufficient quality, or that it was not a “life worth living”. In general, the sanctity of life principle can be relied upon to support a resistance to decriminalization of active, voluntary euthanasia, including physician-assisted suicide, on moral grounds. Arguments drawing upon sanctity of life will benefit from association with other principles, such as the wrongness of killing, and the need to protection vulnerable persons from risks of harm, including abuse of trust.
 
 
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