Who holds the keys of death? The logic of assisted dying

The ethical principle of double effect.

Tom Dove

Tom is a physician and completing a theology doctorate.

white pills form an angle on a blue background

Hal Gatewood on Unsplash.

Healthcare hinges on the principle of double effect. This ethical principle makes the vital distinction between intent and effect. That is, one’s intent does not always result in a single intended effect, whether foreseen or not. In taking a patient’s blood, for example, my intent is to acquire information to aid treatment. An additional effect of this process is that—almost inevitably—this patient will experience pain, albeit minor. This principle of single intent and multiple effects applies throughout the practice of caring for human bodies, in all those instances where caring for those bodies involves physical interference, from prescribing medications to surgical procedures. And, in some instances, identifying and treating symptoms (such as terminal breathlessness) involves the use of medications that, as an unintended effect, result in death.

In the case of assisted dying, the distinction is important. The intent of assisted dying is to end pain and suffering by ending life. The ending of life is the treatment used to relieve pain and suffering. The intent is not to isolate and treat particular symptoms associated with a condition. The intent is to bring the condition itself to an end—which requires bringing the patient’s life to an end. This is not to make any judgment whatsoever about whether such a course is “right” or “wrong”, but rather to draw out the simple observation that this course involves an unprecedented change in medical practice. Assisted dying involves the categorical adoption of ending life as a possible treatment for a condition.

This is not quite the same as the slippery slope argument; it is about the logic of assisted dying. The point I am making is this: once ending life is introduced as a treatment, the key ethical step has already been taken. Applying that treatment in other instances of “suffering” (be they mental illness or ageing, for example) does not involve any new ethical steps. It simply involves the further application of a principle that has already been adopted. Despite the considered safeguards of the bill, therefore, the moral-ethical arguments against applying this treatment more widely will, at best, stand on shaky ground. For who could be so bold as to insist on what constitutes “suffering” for an individual?

Should the bill hold out the keys of death in this way? I can only think of One who is strong enough to wield those…

Article

Community

Creed

Sin

13 November 2024

3 min read

In the city of broken windows

Our fractures become fractal, breaking bigger and bigger windows.

Jamie Mulvaney

Jamie is Associate Minister at Holy Trinity Clapham, London.

a multi-paned window mural shows people while amid it are broken window panes.

A broken window mural, Ellis Island Immigrant Hospital.

Rhododendrites, CC BY-SA 4.0, Wikimedia Commons.

We weren't expecting a knock on the door from our next-door neighbour on New Year's Day. It was pouring with rain, and said rain was pouring into the boot of our car, with the window smashed. Thanks for letting us know. Annoying, inconvenient and expensive. But just how expensive is a smashed window?

The 'broken windows theory', that visible signs of crime, antisocial behaviour and civil disorder begets more serious crimes, was introduced American sociologists James Q. Wilson and George Kelling:

'Social psychologists and police officers tend to agree that if a window in a building is broken and is left unrepaired, all the rest of the windows will soon be broken. This is as true in nice neighborhoods as in rundown ones. Window-breaking does not necessarily occur on a large scale because some areas are inhabited by determined window-breakers whereas others are populated by window-lovers; rather, one un-repaired broken window is a signal that no one cares, and so breaking more windows costs nothing. (It has always been fun.)'

This is not an academic theory. Where I live in London, i took the local council 1,315 days to replace a local resident's broken window. The sense of decay extends beyond borders, with fewer than half the residents thinking they live on clean streets, with rubbish and weeds gone unchecked. It is also one of the worst boroughs in London for varying types of crime, and over the past few years often being the worst. It's hard not to think the little things and the big things are linked. In other news, the now-resigned CEO of the council has pleaded guilty to drink-driving, failing to stop after a car crash and driving without insurance, and not guilty to possession of cocaine.

Our problems in society all found their greenhouses somewhere inside of us.

Crime is on the move. As homes have become more difficult to burgle, crime has been pushed out onto the streets with shoplifting and bike theft. The Economist recently reported that 'stolen bikes and e-bikes have also become the getaway vehicle of choice for thieves, according to the Merseyside police. In one way or another, some 80 per cent of acquisitive crime in Liverpool involves a nicked bike.' It's going to be fascinating to see the wider impact, but simply by stopping suspicious riders and marking thousands of bikes across Liverpool, reported thefts have fallen by 46 per cent between July 2023 and July 2024 compared with the previous year.

These problems can't be solved by overstretched police or the council. Everyone's responsible so no one's to blame. Practical implementations of the broken windows theory have not been without controversy. But for those of us who live in urban environments, to look out from our homes is to see a city of broken windows. The impact is more than weeds 'uprooting' pavements: it's an uprooted society. Correlation and causation might be blurred, but that's the point. In Christianity, sin is understood as having a polluting effect. Just as fossil fuels in China will pollute the atmosphere for someone in Scotland, sin is not hermetically sealed. Our problems in society all found their greenhouses somewhere inside of us.

Jesus said 'what comes out of you is what makes you 'unclean'. For from within, out of your hearts, come evil thoughts, sexual immorality, theft, murder, adultery, greed, malice, deceit, lewdness, envy, slander, arrogance and folly. All these evils come from inside and they make you 'unclean'.' They pollute our lives. And they pollute the world around us.

The Christian church, much like many institutions, is reckoning with prioritising competency at the expense of character. Little sins are not so little when they permeate and promote a culture where certain sins are permissible. Our fractures become fractal, breaking bigger and bigger windows.

All this sounds pretty bleak and Dickensian when of course there's always another city to see: full of life, vibrancy and joy. But we'd be wilfully ignorant to ignore the disorder of broken windows and broken lives all around us. It might overwhelm us, or our eyes might glaze over as we see those broken windows. But we'd do well not to ignore the broken windows within us too. For our sake, and the sake of our streets.