Journal of medical ethics, I98I, 7, 74-82

Debate: Extraordinary means and the sanctity of life

Helga Kuhse Department of Philosophy, Monash University, Clayton, Victoria, Australia

Editor's note

Ms Kuhse argues against the doctrine of 'the sanctityof life', against the application of acts and omissionsdoctrine in medical practice, and against the commonassumption that there is a crucial moral differencebetween intentionally discontinuing ordinary medicaltreatment and intentionally discontinuingextra-ordinary medical treatment. Intentional actsor omissions which shorten life are in practice andmust in theory be justified or rejected on the basis ofthe quality of life concerned, she argues. Suchquality of life distinctions are needed in practicebut they are logically incompatible with thedoctrine of the sanctity of life; and the ordinarylextraordinary means distinction cannot circumventthis incompatibility.

Father Hughes in his conmnentary rejects MsKuhse's extretne interpretation of sanctity of lifedoctrine. He argues that the distinction between actsand omissions is relevant to medical practice anddistinguishes between two different senses of'omission' to support this. He finds Ms Kuhse'sreliance on quality of life excessively reductionistand argues that her position seems to commit her todenying any moral difference between intending adeath by withholding extraordinary treatment andintending a death by administering a lethal injection.That there is an important moral distinction here is acrucial intuition which supporters of the traditionalview wish to maintain, even though 'the difficulty ...is to discover a philosophical means to support it'.While sanctity of life doctrines need development,they express 'a healthy presumption in favour oftrying to preserve it'. In a final response Ms Kuhsereplies to her commentator.

Readers' attention is drawn also to the review byProfessor Robin Downie on page 96 of a group of threepapers entitled Prolongation of Life published bythe Roman Catholic Linacre Centre.

Many discussions within medical ethics, explicitlyor implicitly, appeal to and pivot on the 'sanctity-of-life' doctrine. Yet the really critical issues inmedicine are often hidden by 'the hulking darknessof that concept'. Even those who disregard theclearly religious connotations (i) of the conceptoften employ it to argue that wherever there isinnocent human life, nothing must count against it;innocent life must never be taken - especially not by

doctors who have rejected the taking of human lifesince the fifth century BC when physicians first tookthe Oath of Hippocrates and swore to 'give nodeadly medicine to anyone if asked, nor suggest anysuch counsel'. But if a travesty of life has irretriev-ably lost all that seems to make human life valuable,then even the most ardent supporter of the doctrinemay feel that life ought not to be prolonged un-necessarily. Faced with an absolute prohibitionagainst the intentional termination of life, pro-ponents of the 'sanctity-of-life' doctrine argue thatit is then permissible to withhold or withdraw'extraordinary' or 'disproportionate' means of lifesupport. Failure to provide 'ordinary' care isgenerally seen as the intentional termination of life,or passive euthanasia. The cessation of 'extra-ordinary' treatment, on the other hand, isinterpreted differently: it is regarded as the decision'to provide the most appropriate treatment for thatpatient at that time' (2).The rationale underlying the distinction between

ordinary and extraordinary means is thus the ideathat there is a crucial moral difference betweenintentionally discontinuing ordinary treatment andintentionally discontinuing extraordinary treatment.This belief is very common; it is implied by the I973policy statement of the American Medical Associ-ation (3), is supported by the philosopher BonnieSteinbock (4) and has most recently been recon-firmed by Pope John Paul II in the Vatican's'Declaration on Euthanasia' (5). However, I believethat it can be shown to portray either confusedthinking or a point of view unrelated to the interestsof individual patients.

'Heroic' efforts and modern medicaltechnologySophisticated modem medical technology isachieving a continuously increasing control over ourlives, and even if unable ultimately to conquerdeath, it has a lot to say about the conditions andtime of its occurrence. With this, an old question israised with renewed urgency: must human life,regardless of its quality, always be preserved? Is itthe physician's duty to sustain indefinitely the life ofan irreversibly brain-damaged person by way ofartificial respiration and intravenous feeding? Mustthe physician engage in 'heroic' efforts, that is,employ all of modem medicine's devices to add

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Extraordinary means and the sanctity of life 75

another few weeks, days, or even hours to the life ofa terminally ill and suffering cancer victim, or is itpermissible to discontinue treatment ? Must activetreatment be instigated with regard to babies born sodefective that their future promises little more thancontinuous suffering or mere vegetative existence ?These questions are not new but they are, today,

posed with relentless clarity and urgency: Giventhat we can sustain lives such as the above, oughtsuch lives to be sustained - and if not, why not?Most of us would want to hold that there are, orshould be, limits to the physician's duty to prolonglife - but it is difficult to see how such limits can beincorporated within a 'sanctity-of-life' ethic thatabsolutely prohibits the intentional termination oflife and that sees all human life, regardless of itstype or quality, as of infinite and intrinsic worth.Here the 'can' would seem to imply the 'ought'.Given that a human life can be prolonged by medicalintervention, it ought to be prolonged - and it doesnot matter whether the life thus prolonged isconscious, unconscious, painfree or irrelievablyfilled with suffering.When speaking of the 'sanctity-of-life' ethic, I am

not suggesting that the prohibition against thetaking of human life has always been held in anabsolute form, for this would imply total pacifism,exclude capital punishment, sacrificial heroism andkilling in self-defence, practices which are notalways condemned by supporters of the doctrine.But in the realm of medical practice, the 'sanctity-of-life' ethic has ruled supreme for a very longtime (6). Here the intentional termination of life isnot only absolutely prohibited, but the traditionalcomponent of deontological ethics, the acts andomissions doctrine, has no application in thedoctor/patient relationship. Although medicalappiications of the distinction between ordinary andextraordinary means are sometimes misinterpretedas applications of the distinction between acts andomissions (7), it is widely accepted that it is noexcuse for a doctor to say that he did not kill hispatient but 'merely' let him die by withholdinglife-saving treatment. Both medical ethics and thelaw impose a duty on the doctor to care for hispatient, which puts the doctor vis-a-vis his patient ina very different situation from that of an ordinarycitizen who omits to save the life of a stranger.Indeed, the Vatican's Declaration on Euthanasiadefines 'mercy-killing' as 'an act or an omissionwhich of itself or by intention causes death' (8).

This is an extension of the rule 'Do not kill'which, for doctors, now reads: 'Do not kill and donot let die', ie, the absolute prohibition againstshortening the patient's life - even for compassion-ate reasons - applies to both acts and omissions.Letting die, like killing, is absolutely prohibited, for'letting die', as understood here, always implies acounterfactual conditional of the type: If D did Y,then X would not happen. For example, if the

physician were to give a life-prolonging injection,the patient would not die. Both killing and lettingdie thus constitute the 'intentional termination ofthe life of one human being by another - mercykilling' and this is, according to the AmericanMedical Association, 'contrary to that for which themedical profession stands' (3). Euthanasia, whetheractive or passive, is thus absolutely prohibited.

If the 'sanctity-of-life' doctrine as it underlies thepractice ofmedicine is absolute in this sense, there isanother sense in which it is absolute as well: itmakes no distinction between different types orqualities of human life-all life is of equal andintrinsic worth. Chief Rabbi Jakobovits captures thegeneral thrust of the Judaeo-Christian traditionwhen he comments: 'The basic reasoning behindthe firm opposition of Judaism to any form ofeuthanasia proper is the attribution of infinite valueto every human life. Since infinity is, by definition,indivisible, it follows that every fraction of life,however small, remains equally infinite so that itmakes morally no difference whether one shortenslife by seventy years or by only a few hours, orwhether the victim of murder was young and robustor aged and physically or mentally debilitated' (9).

Similarly, the Roman Catholic Church's position:'It is necessary to state firmly one more that nothingand no one can in any way permit the killing of aninnocent human being, whether a foetus or anembryo, an infant or an adult, an old person, or onesuffering from an incurable disease, or a person whois dying' (io).On this view, not only does the distinction between

acts and omissions not apply, but it is also irrelevantwhether or not it is in the patient's interest to havehis life prolonged. As one physician puts it: 'Thepatient entrusts his life to his doctor, and it is thedoctor's duty to sustain it as long as possible. Thereshould be no suggestion that it is possible for thedoctor to do otherwise, even if it were decided thatthe patient were "better off dead" ' (ii).

Similarly, another physician: 'It is not theprivilege of any doctor to decide that he shouldshorten life. The preservation of life must be thesole principle guiding medical practice, includingtreatment of the hopeless cancer patient. Thisprinciple cannot be tampered with or interpretedloosely' (12).

This attitude, whilst it may strike many as crueland impervious to the interests of the patient, isconsistent with the 'sanctity-of-life' principle. It is,however, not in accordance with generally acceptedpractice. Each year, thousands of defective infantsare 'allowed to die' (I3), terminally ill patients donot have their lives prolonged by all possiblemeans (I4), and the life-support of irreversiblycomatose patients is withdrawn in the clearknowledge that death will, in most cases, followwithin minutes (15).But if lives such as these could be prolonged and a

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76 Helga Kuhse

decision is taken against prolonging them, we appearto be confronted with the practice of passiveeuthanasia. However, if these practices are forms ofeuthanasia, then one would want to know how theycan be incorporated in a sanctity-of-life ethic thatabsolutely forbids the intentional 'hastening of thehour of death' (i6). The question is especiallybaffling if, as I have suggested, the acts and omissionsdoctrine is out of place in the doctor/patientrelationship. For then what we have is a practicemorally equivalent to active euthanasia.An answer to this question has traditionally been

given in terms of the distinction between 'ordinary'and 'extraordinary' means of treatment. Whilstfailure to employ 'ordinary' means is generallyidentified with the intentional termination of life,failure to provide 'extraordinary' means is given adifferent status. The Roman Catholic Church seesit as 'a wish to avoid the application of a medicalprocedure disproportionate to the results that canbe expected . . .' (i6).

Judaism, too, supports the distinction betweenordinary and extraordinary or 'artificial' means:

We, too, would make a fundamental distinctionbetween any deliberate hastening of death, whetherwith or without the patient's consent, on the onehand, and the withdrawl of artificial means tosustain a lingering life in its terminal stages on theother, particularly when the recourse to such'heroic' methods would serve only to prolong thepatient's agony. However, the sanction to discon-tinue treatment would not include the withdrawal offood or other necessities of life (I7).

And, in I973, the distinction between ordinary andextraordinary means of life-support moved from thereligious into the secular realm, when it wasemployed in the AMA's policy statement. Afterrejecting the intentional termination of life as'contrary to that for which the medical professionstands,' the statement continues:

The cessation of the employment of extraordinarymeans to prolong the life of the body when there isirrefutable evidence that death is imminent is thedecision of the patient and/or his immediatefamily (3).If the above positions, Roman Catholic, Judaic andmedical, are not to be blatantly self-contradictory,they must hold that the termination of extra-ordinary care is not the intentional or deliberatetermination of life.What, then, constitutes 'extraordinary' treat-

ment ? The language of extraordinary means has along history - especially in the Roman CatholicChurch - where the employment of ordinary meanshas always been seen as obligatory, whereas theemployment of extraordinary means was generally

regarded as optional (i8). As Pope Pius XII phrasedit:

. . . normally one is held to use only ordinarymeans - according to circumstances of persons,places, times and culture - that is to say, means thatdo not involve a grave burden for oneself or another.A more strict obligation would be too burdensomefor most men and women and would render theattainment of the higher, more important good toodifficult ... (I9).

Subsequent to this, the following standard definitionwas adopted:Ordinary means of preserving life are all medicines,treatments, and operations, which offer a reasonablehope of benefit for the patient and which can beobtained and used without excessive expense, pain,or other inconvenience ... Extraordinary means ofpreserving life ... mean all medicines, treatments,and operations, which cannot be obtained withoutexcessive expense, pain or other inconvenience, orwhich, if used, would not offer a reasonable hope ofbenefit (20).

However, a long history does not guarantee clarityand the Catholic Church has noted that even thoughthe extraordinary means criterion 'as a principle stillholds good', a reformulation is indicated 'by reasonofthe imprecision of the term and the rapid progressmade in the treatment of sickness'. 'Thus', therecent Papal statement continues:

... some people prefer to speak of 'proportionateand 'disproportionate' means. In any case, it will bepossible to make a correct judgment as to the meansby studying the type of treatment to be used, itsdegree of complexity or risk, its cost and thepossibilities of using it, and comparing theseelements with the result that can be expected, takinginto account the state of the sick person and his orher physical and moral resources (2I).

In other words, a major factor in determiningwhether a means is optional, ie, extraordinary ordisproportionate, is the 'state of the sick person' and'the result that can be expected'. A means can thusbe either extraordinary or ordinary, depending onthe condition of the patient, and the adjective'optional' ('extraordinary', 'disproportionate','artificial') refers not simply to the treatmentconsidered on its own, but to the treatment con-sidered in relation to the condition ofthe patient. AsBonnie Steinbock puts it: 'The concept is flexible,andwhat mightbe considered "extraordinary" in onesituation might be ordinary in another' (22). Whilethe use of a respirator to sustain a patient through asevere but temporary respiratory ailment would beregarded as ordinary, its 'use to sustain the life of aseverely brain-damaged person in an irreversiblecoma would be considered extraordinary' (22).

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Extraordinary means and the sanctity of life 77

But here the term 'extraordinary' has been so

relativised to the condition of the patient that it isprecisely the condition ofthe patient that changes an

ordinary means into an extraordinary one. Therespirator becomes an extraordinary means becausethe- patient's condition is extraordinary, ie, thepatient's condition is unusual in the sense that inthis particular situation, and contrary to the absolutetenets of the 'sanctity-of-life' doctrine, the pro-

longation of the patient's life has become optional.But if the kind of life that could be prolonged bymedical intervention is allowed to be relevant in thedecision as to whether or not a certain means will beemployed, then we are implicitly moving from a

'sanctity-of-life' ethic to a 'quality-of-life' ethic.Such a move is also implied in Bishop Lawrence

Casey's support for the decision to remove KarenQuinlan from the respirator because she 'has no

reasonable hope of recovery from her comatose stateby the use of any available medical procedures. Thecontinuance of mechanical (cardiorespiratory)supportive measures to sustain continuation of herbody functions and her life constitute extra-ordinary means of treatment' (23). Mechanicalsupportive measures are extraordinary because,while they sustain Karen's life, they sustain it onlyin a comatose state (24). It is the comatose statewhich is determinant, not the inherent 'extra-ordinariness' of the means, nor the fact that Karen'has no reasonable hope of recovery'. If the recovery

criterion were decisive, then also the continued use

of 'iron-lungs' for polio-victims and the continuedinjection of insulin for diabetics would be extra-ordinary and hence optional because they could notlead to recovery from the state of paralysis, nor cure

the diabetic condition.However, all three forms of treatnent have one

thing in common: their continued application willprolong the patient's life. If it is thus permissible todiscontinue treatment in the one case but not in theother two, a defender of this view must point to a

morally relevant difference that distinguishes thesecases. It is not, as we have seen, the distinctionbetween ordinary and extraordinary means, con-

sidered simply as means, and it cannot be thedistinction between the intentional and the non-

intentional termination of life. Because if we accept(as most of us, even non-Catholics, would) that lifecan be terminated intentionally by either 'an actionor an omission which of itself or by intention causesdeath' (25), then withholding of insulin treatment or

'pulling the plug' ofan iron lung would be examplesof the intentional termination of life. But if 'pullingthe plug' of a polio victim's iron lung is the inten-tional termination of life, then - surely - 'pulling theplug' of Karen Quinlan's artificial respirator is too.(Suppose she had died as a result).

If there is a morally relevant difference betweensuch cases, it must lie elsewhere. And so it does. Itlies in the different qualities or types of life preserved

by continued medical support. But quality-of-lifecriteria cannot be incorporated into a 'sanctity-of-life' ethic that regards all human life, irrespective ofits type or quality, as of the same intrinsic worth.According to the 'sanctity-of-life' doctrine, coma-tose human life has the same 'sanctity' as the life ofa conscious or self-conscious human being. Hencethis doctrine is incompatible with the way thedistinction between ordinary and extraordinarymeans is drawn by Bishop Lawrence Casey and as itis presupposed by the recent Papal Declaration onEuthanasia.The undefined use of the term 'human life' avoids

a necessary task: it does not say what it is that givesvalue to human life; it does not say what principlesshould serve as possible justification for the termin-ation or continuation ofhuman life. While I have noway of refuting someone who holds that beingphysiologically alive, even though unconscious, isintrinsically valuable, I can refute all those who wantto combine this position with a limited duty of life-preservation in 'extraordinary' cases. The twopositions are incompatible because the moralrelevance ofthe adjective 'extraordinary', in this andmany other cases, must rest on quality-of-life con-siderations, the moral relevance of which is beingdenied by the 'sanctity-of-life' doctrine.The important point is this: we are faced not

merely with a theoretical confusion, of interest onlyto philosophers and moral theologians, but with amisleading doctrine that has indefensible conse-quences in practice as well. Much of the currentmedical literature shows that there has been animplicit shift to quality-of-life standards (26), andsociological studies indicate how certain qualitativefactors enter into medical decision-making in lifeand death cases (27). But from an ethical perspectivethe quality-of-life question is not adequately treateduntil and unless one gives morally relevant reasonsas to why a certain quality or qualities should bedecisive in terminating or continuing life-pro-longing treatment (28). In practice this means thatthe medical profession is, in the absence of suchstandards, faced with an anarchy of values andmeaning.Thus doctors have applied (29), but - according

to Steinbock - misinterpreted (30), the 'extra-ordinary means' criterion in situations like thefamous Johns Hopkins case, where a Down'ssyndrome child requiring routine surgery for anintestinal obstruction was 'allowed to die' bydehydration and starvation over a Is-day period onthe grounds that surgery would have been an'extraordinary' procedure. In cases like this, surgerycan be withheld not because the treatment is, in anyway, 'extraordinary'. but because the concept'extraordinary' is 'extremely flexible'. If a child notafflicted with Down's syndrome is born with anintestinal obstruction, surgery to remove theobstruction is an 'ordinary' procedure. When a

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78 Helga Kuhse

mongoloid child has such an obstruction, surgerybecomes an 'extraordinary' procedure. Why? Notbecause the nature of the operation has changed, butbecause the child is a mongoloid. A mongoloidchild's life is given a different value from that of anormal infant. The 'extraordinary means' criterionthus masks a quality-of-life judgment which maywell require - but does not receive - furtherjustification (why is it in a mongoloid infant'sinterest to die ?) (3I). Furthermore, if euthanasia formongoloid infants can be justified, why then onlyfor those with an intestional obstruction requiring asimple operation? The answer is that in the lattercase, but not in the former, the 'extraordinary means'criterion can be invoked to mask a quality-of-lifedecision that is incommensurable with a 'sanctity-of-life' ethic.By presenting quality-of-life decisions as an

almost technical question, namely as one concerning'means' which may or may not be optional, sub-stantive moral issues are evaded. One of these is thequestion of what it is that we value when makingquality-of-life decisions. If we decide that 'certainheroic intervention is not worthwhile' (32), ie thatthe value of an individual's life is insufficient towarrant continuation of life-prolonging efforts, thisrequires a clear assessment of the locus of that valueand if it derives from different sources, their relativeweights. As long as such substantive criteria are notmade explicit in medical decision-making, as long aswe rely on the extreme flexibility of the concept of'extraordinary means' to make a sanctity-of-life ethicsuperficially credible, we will engage in muddledpractice. Doctors will let infants die by withholding'extraordinary' or 'disproportionate' treatment onthe basis 'that prognosis for meaningful life [is]extremely poor. . .' (33), without, however, being ableto provide substantive criteria as to what,constitutesa 'meaningful life'; they will also resuscitate sixtimes the 68-year-old doctor suffering fromterminal cancer (34) on the basis that resuscitation isnow an 'ordinary' procedure in the modern hospitalsetting. They will do so without being able to saywhat value or values they are trying to serve, otherthan to act in accordance with a 'sanctity-of-life'ethic that is impervious to the interests ofthe patient.The point is that in our age of sophisticated

medical technology death is often not 'imminent inspite of the means used' (35). Death can often, quiteliterally, be kept waiting by the bed or the machine.It is only when supportive measures are discontinuedthat death becomes imminent. Discontinuing suchmeasures is, unavoidably, a 'hastening ofthe hour ofdeath' (35). It also, unavoidably, requires theshouldering of moral responsibility for the death ofthe patient.

This brings me to my second point: the extra-ordinary means criterion hides this responsibilityunder the mantle of its means-related language.While it may well be true that the doctor has, in

certain circumstances, 'no reason to reproach him-self with failing to help the person in danger' (35),substantive criteria must be provided to tell us whatthese circumstances are. In all those cases wheredeath is not immIinent in spite of the means used, thephysician is responsible for the death of the patientwhen he decides not to operate, to discontinuetreatment, or to turn off the artificial respirator. AsRobert S Morison puts it:

Squirm as we may to avoid the inevitable, it seemstime to admit to ourselves that there is simply nohiding place and that we must shoulder the re-sponsibility of deciding to act in such a way as tohasten the declining trajectories of some lives, whiledoing our best to slow down the decline of others.And we have to do this on the basis ofsome judgmenton the quality of lives in question (36).

When the Nuer, an East African tribe, saw a needto do away with defective infants, they did it byclassifying these defective infants as 'hippopota-musses', mistakenly born to human parents. Theseinfants were put into the river - their naturalhabitat. This was not killing Nuer infants, it wasdoing what was appropriate for young hippopota-musses; and Nuer morality, prohibiting the takingof tribal life, could emerge unscathed (37).When we allow defective infants to die by

classifying as 'extraordinary' the means used to keepthem alive, we are resorting to an equally spuriousdevice in order to preserve unscathed our sanctity-of-life ethic. If we want to go beyond definitionalploys, we must accept responsibility for our life-and-death decisions, we must drop the traditionalsanctity-of-life ethic and embrace a quality-of-lifeethic instead.

AcknowledgmentI wish to thank Professor Peter Singer of MonashUniversity for his encouragement and for his manyhelpful comments and criticisms of an initial versionof this paper.

References and notes(i) Caouser K D. The 'sanctity of life': an analysis of a

concept. Amnals of internal medicine 1973; 78: 124.(2) Steinbock B. The intentional termination of life. In:

Steinbock B, ed. Killing and letting die. New Jersey:Englewood Cliffs, I980; 74: first published inEthics in science and medicine I979; 6/i: 59-64.

(3) Proceedings, AMA House of Delegates. December1973. Cited by Steinbock B. The intentionaltemiination of life. See reference (2): 70.

(4) See reference (2): 69.(5) Sacred Congregation for the Doctrine of the Faith.

Declaration on euthanasia May 5. Vatican City:Polyglot Press, I980.

(6) See Fletcher J. The rights to live and to die. In:Kohl M, ed. Beneficient euthanasia. Buffalo, NewYork: Prometheus, I979; 47.

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(7) See, for example Rachels J. Active and passiveeuthanasia. The New England journal of medicineI975 January 9; 292: 78-80, and critique bySteinbock B. The intentional termination of life.See reference (2): 69-77.

(8) See reference (5): 6.(g) ChiefRabbi Jakobovits I, as cited by John, Cardinal

Heenan, Archbishop of Westminster. A fascinatingstory. In: Lack S, Lamerton R, Chapman G, eds.The hour of our death: a record of the conference onthe care of the dying held in London I973. London,1974; 7.

(io) Declaration on euthanasia. See reference (5): 7.(ii) Karnofsky D A. Why prolong the life of a patient

with advanced cancer? Cancer journalfor cliniciansI960 Jan-Feb, X: 9, as cited by Wilson J B. Deathby decision. Philadelphia: The Westminster Press,1975; ii8.

(I2) Cameron C S The truth about cancer. Prentice Hall,1976: 115-I i6, as cited by Wilson J B. See reference(I I).

(13) See New York Times I974 June i6: Part IV: 7, ascited by Singer P. Practical ethics. Cambridge:Cambridge University Press, 1979; 149 and 229.

(I4) See Rachels J. Euthanasia, killing and letting die.In: Ethical issues relating to life and death. New Yorkand Oxford: Oxford University Press, 1979; 150, onthe practice of 'no coding'.

(I5) See Melbourne Herald I979 November 29, reportingon the death of a squash champion who hadsuffered severe brain damage following cardiacarrests. 'The machine, in the Royal AdelaideHospital's intensive care unit, was switched off justafter midnight and Torsam Khan, 27, was deadwithin I0 minutes'.

(i6) See reference (5): II.(17) See reference (9): 6 - italics in original.(i8) Beauchamp T L, Childress J F. Principles in

biomedical ethics. New York: Oxford UniversityPress, I979; 117-I26.

(I9) Pius XII, AAS 49. I957; I031-I032.(20) Kelly S J G. Medico-moral problems. St Louis, The

Catholic Hospital Association, 1958; 129.(21) See reference (5): 10.(22) See reference (2): 72.(23) In the matter of Karen Quinlan. Opinion in the

Supreme Court of New Jersey 1976 March 31.355 A. 2d 647, p 659.

(24) McCormick R. The quality of life, the sanctity oflife. Hastings Center Report 1978; 8/i: 30.

(25) See reference (5): 6.(26) See for example Shaw A. Dilemmas of 'informed

consent' in children. The New England journal ofmedicine 1973; 289: 885-890. Also Duff R S,Campbell A G M. Moral and ethical dilemmas inthe special care nursery. The New England journalofmedicine I973; 289: 890-894.

(27) Crane D. The sanctity of social life: physicians'treatment of critically ill patients. New York:Russell Sage Foundation, I975.

(28) See also ReichWT. Qualityof life. In: Encyclopaediaof Bioethics Volume 2 New York and London:MacMillan and The Free Press, 1978; 831.

(29) McCormick R A. See reference (24): 35.(30) See reference (2): 73-74.

(3I) See for example, Gustafson J M. Mongolism,parental desires and the right to life. Perspectives inbiology and medicine I973; I6: 529-557.

(32) Colen B D. Karen Ann Quinlan: living and dying inthe age of eternal life. Los Angeles: Nash, I976; II5,as cited by Steinbock B. See reference (2); 73.

(33) Duff R S, Campbell A G M. Moral and ethicaldilemmas in the special care nursery. See reference(26): 890 (italics added).

(34) Case study 14. In: Beauchamp T L, Childress J F.Principles of biomedical ethics. See reference (i8):263-264.

(35) See reference (5): II.(36) Morison R S. Death- process or event ? Science I97I

August 2o; I73: 697.(37) I owe this example to Beauchamp T L, Childress

J F. See reference (I8): I2I.

CommentaryGerard Hughes SJ Heythrop College, University ofLondon

It would be difficult to read Helga Kuhse's paperand remain convinced that all was well with thearguments in medical ethics about the preservationof life, or that the guidelines for medical practicewere perfectly clear. Her case for saying that thereare both philosophical difficulties and practicaluncertainties is surely unanswerable. Upon closerinspection, however, it becomes less obviousprecisely which points she has established, which amore traditional moralist would be concerned todispute. Ms Kuhse makes several points: one is thatthere is a serious inconsistency in the traditionalview of the sanctity of life; the second is that thedistinction between actions and omissions has noapplication in the traditional view; and the thirdconcerns a more positive proposal to replace thetraditional doctrine about the sanctity of life by afully explicit appeal to the quality of life. I shouldlike to reply, as it were on behalf of the traditionalposition, on each of these points, and to make someremarks on precisely how they are connected to oneanother.

Helga Kuhse argues that it is inconsistent to holdboth the 'sanctity of life doctrine' and the view thatthere is an important distinction to be drawnbetween ordinary and extraordinary means ofpreserving life. Now, it certainly is inconsistent tohold both:

a) that one must never intentionally kill, shorten life,or allow someone to die, andb) that one is not obliged to take extraordinary meansto preserve someone's life,c) just if it is also held that the prohibition on allowingsomeone to die obliges one to take all possible meansto keep him alive.

The charge of inconsistency crucially depends onshowing that the 'sanctity of life doctrine' must

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