Abstract
The chapter focuses on cases of assisted suicide and voluntary euthanasia in relation to the rarely discussed notion of indirect paternalism. Indirect paternalism involves not just a paternalistic intervener and a person whose welfare is supposed to be protected, but also another party, whom I call “assistant.” Indirect paternalism interferes with an assistant in order to prevent harm to another person. I will introduce a strategy that paternalists can pursue to justify indirect paternalism. It specifically targets an element of assistance cases, namely the fact that people do not necessarily have a justified claim or entitlement to demand such assistance. To prevent people from providing assistance seems normatively different from preventing a person to do something to herself by her own means. I critically discuss arguments from the goals of medicine and from the conscientious objection. These aspects are not deemed decisive when considering the case of indirect paternalistic intervention. Finally, I argue against the rationale of indirect paternalism by showing that there are at least two situations where it does not succeed. One such situation that undermines the justification of indirect paternalism is present when the offered service is itself harmless, another pertinent situation consists of a person necessarily requiring assistance to be really free. At least in some cases, these very conditions are given when contemplating assistance to die.
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Notes
- 1.
- 2.
Though at least theoretically there might be multiple-party cases of paternalism that are not forms of indirect paternalism, see Feinberg ( 1986, 9). Feinberg used the term “two-party cases”, but this might be confusing as there are more than two parties involved in the practice of indirect paternalism. He obviously meant that two parties are the target of a paternalistic interference, where one party is interfered with and the other benefits.
- 3.
Because B seems to harm A one might think that these cases were already banned by the Millian harm principle. Yet it should be obvious that the voluntary consent changes the normative status of the same action here and, as we will see, it is even slightly misleading to say that B harms A.
- 4.
We could also say that impersonal harm is harm for a person, but only personal harm is harm to a person.
- 5.
Note that it is even possible to accept that impersonal harm is intrinsically bad, and still allow for other considerations, which have to do with personal interests, to outweigh this kind of harm and to conclude that there is no personal harm present where a person has an interest in an impersonal harm. A person may reasonably choose what is intrinsically bad, as long at it is not only intrinsically bad.
- 6.
It is indeed arguable whether soft paternalism should be called “paternalism” at all (see Feinberg 1986, 12). But even if intervention into non-voluntary choices were not paternalism after all, this would of course still allow us to regard the cases we now refer to under the umbrella term “soft paternalism” as unjustified.
- 7.
Obviously it is an important issue what kind of undue influences there might be, which consequently undermine consent to (impersonal) harm. I cannot discuss this question here, but see, for instance, Kleinig ( 2010, 13 ff.).
- 8.
In these cases we might also want to use the notion “autonomous choice”. I disregard the relation between autonomy and voluntariness for the purposes of this essay.
- 9.
There is an important debate regarding the possible coerciveness of inducements that I will ignore for the purposes of this chapter (see, for instance, Radcliffe 2010).
- 10.
- 11.
Surely one may want to insist that the consent given by a person to the service of the assistant is normatively sufficient to justify providing assistance. Indeed, this seems to follow from the logic of the volenti principle. But one aspect of my chapter is to show why assuming a normatively different status of indirect paternalism is plausible and that the volenti principle cannot be an absolute principle.
- 12.
I take ‘claim’ to be a moral notion here. It can be seen as a moral right, but I avoid the terminology to prevent confusion with legal rights. A person might have a legal entitlement to all kinds of morally dubious services, but these contracts are not my concern here, rather whether those contracts should be allowed. I also take ‘claim’ as to imply a duty of others to refrain from interference, so it is not just a ‘liberty’, in the Hohfeldian sense (Hohfeld 1923), where a person has permission to do something and hence is not doing something wrong. A justified claim, or entitlement, as such, does not include a duty of others to provide necessary means to pursue a goal, but I want to consider later how far such provision might indeed be morally required.
- 13.
Though we might want to introduce bans on, say, the aggressive marketing of sweets.
- 14.
In contrast, Hill (2014, 277), in a recent contribution to a companion asserts: “Thus if suicide is not immoral in certain cases, then it will be permissible for others to assist unless there are further arguments against this.” (Emphasis in original.) It might be worth stressing that I do not want to argue that an assistant’s help to kill a person might be itself morally wrong, but that the case for an entitlement to such service needs to be made.
- 15.
Some people might want to say that I am conceding far too much to the paternalist, as anti-paternalists would maintain that service users always have a claim right, if not to the provision of services, but to purchase services on a free market. In addition they might want to say that service providers have the right to sell their services, as long as these are neither immoral nor illegal. But this argument relies (a) on the ideology of the free market, a topic I would like to avoid, and (b) on a liberal reading of what might be regarded as immoral—namely only services that cause personal harm to others. My aim here is to scrutinize the paternalist strategy in relation to indirect paternalism without begging the question in favor of a strongly liberal, or even libertarian, point of view, although I have of course already hinted at certain aspects of a liberal viewpoint that seem to me unavoidable.
- 16.
This difference might not be significant in practice, after all, in case of assistance to die, as it is normally not discussed or in reality offered as a paid service. If indeed those services would only be affordable for rich people, this might lead to injustice. I disregard the issue of payments in this chapter.
- 17.
- 18.
I prefer the term “real liberty”, because it has been used in related discussions, especially in Philippe van Parijs’s book Real Freedom for All (1995). Occasionally “positive liberty” is also used in the debate, but it might cause some confusion with another notion of positive liberty that was discussed in a famous essay by Isaiah Berlin (2002).
- 19.
This formulation is less complicated than it should be. We might want to add that people should only be at liberty to do what they want to do when sufficiently informed, when no coercing influences are present, and so on.
- 20.
Thanks to Michael Cholbi for raising this issue.
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Schramme, T. (2015). Preventing Assistance to Die: Assessing Indirect Paternalism Regarding Voluntary Active Euthanasia and Assisted Suicide. In: Cholbi, M., Varelius, J. (eds) New Directions in the Ethics of Assisted Suicide and Euthanasia. International Library of Ethics, Law, and the New Medicine, vol 64. Springer, Cham. https://doi.org/10.1007/978-3-319-22050-5_3
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