Focus: Uncomfortable endings

Mary Warnock, the eminent moral philosopher and medical ethicist, is standing at the table with cutlery in her hands. What, she asks, is she doing? Is she putting a fork to the left of each table-mat? Is she laying the table? Or is she preparing for a dinner party?

It is, self-evidently, a trick question, for she is doing all three. "Of course, there could be a bomb, the house might blow up, and I might not have a dinner party. But I don't take that possibility into account when I tell you what I'm intentionally doing," she says. We are off on a classic "it depends what you mean by" argument. And Bill "it depends on what the meaning of `is' is" Clinton is nowhere in sight.

The cutlery analogy is one of Baroness Warnock's favourite heuristic devices when it comes to the subject of euthanasia. Is the doctor giving diamorphine to relieve pain? Or to shorten life? And can you meaningfully separate the two, as the present law purports to do with the principle it calls "double effect"?

Euthanasia is one of those subjects in which confusion is endemic, as we discovered again last week with the case of David Moor - the Newcastle GP who escaped a conviction for murder after rowing back in court on his claims to the media that he had helped some 300 of his patients to die over his 30-year career. There are few issues in which those on both sides so routinely mire themselves in the shifting sands of rhetoric and prejudice.

In theory the case for euthanasia is straightforward. Some people suffering from painful, incurable or humiliating illness would prefer to die swiftly and without pain. If their doctors are happy to assist them to suicide, the state should not interfere with the free, informed choices of its citizens in matters that do not cause others harm.

The case against is equally plain. Every life has intrinsic value, irrespective of the individual's mental state or physical condition. Agreeing to clinical homicide in the heart-rending cases would be the start of a "slippery slope" in which today's right to die would become tomorrow's duty to do so.

The trouble is that there is little clarity of thinking in the debate. The principle of "double effect" separates the intention of an act from its consequences. Advocates of "mercy killing" denounce this as a meaningless sophistry, insisting that it is used to cover up the fact that many doctors practise euthanasia without declaring it. Yet the same distinction is used effectively in courts to distinguish between murder and manslaughter. On the other side, those opposed to euthanasia talk about the "sanctity of life" as though it were an absolute which, were it so, would rule out the notion of self-defence and force us all into pacifism.

There is a similar wilfulness when it comes to facing facts. "Those who say double effect is hypocrisy don't really understand symptom control," says Cicely Saunders, the founder of the hospice movement. "Today 96 per cent of cases of pain can be relieved." What about the remaining 4 per cent? "If somebody who is terminally ill is prepared to accept sedation, nobody need die in pain."

Yet medical advances have also brought new considerations on the other side of the argument. It is now understood that the brain stem (which controls the heart and breathing) and the cortex (which thinks, feels and remembers) can die separately. If the brain stem alone perishes, the person is "locked in" to a paralysed body but can survive on a life-support system, and can communicate by blinking. If the stem survives, but the cortex withers, then consciousness disappears but the body maintains a cycle of waking and sleeping, heart and lung rhythms and reflex responses to certain stimuli; this permanent vegetative state (PVS) has been known to last 36 years.

Such distinctions enabled statements to be made about the PVS victim Tony Bland, who died after the courts ruled that food and fluids could be withdrawn from him, that "his spirit had left him, but he was not dead". This is new territory. As was the judges' ruling that nutrition and hydration, when provided by naso-gastric tube rather than through the mouth, were treatment rather than sustenance.

Inevitably advocates of euthanasia, such as Jim Howe, Bland's consultant neurologist, see the ruling as a sanction for pushing further. In Euthanasia, a book by Andrew Dunnett published last month, Dr Howe presses for the extension of the practice to "those with motor neurone disease, who are not in pain, not suffering, who have not got the ravages of vomiting or whatever from cancer, [but]who have decided they don't want the indignity of total helplessness". If such a patient wanted to die next week rather than next year when he's completely helpless, then "killing that person would be a caring thing to do".

More than that, he says: "If an elderly person wants to give all their savings to their grandchildren (rather than spending it on nursing fees) and decides they want to end their life to do that, what's wrong with that?" Bland, he adds, was "not a person ... in an ethical sense. A person is someone who has the capacity to value their life". Chimpanzees and gorillas qualify, he says, but a new-born human baby doesn't.

Such a progression of ideas is not new. Some consequentialist philosophers - like the inventor of animal rights, Peter Singer - have long denied that there is any moral significance between abortion and infanticide, just as they insist that there is no moral difference between killing someone and allowing them to die. And Mary Warnock insists that: "You can kill your cat by shooting it or by neglecting to feed it ... but each is equally morally reprehensible .... In France there's a law against this type of failure to rescue. The English law's built-in concept of cause is exceptionally primitive."

It is small wonder, in the face of this ruthless logic, that opponents of euthanasia talk about slippery slopes and thin ends of wedges. Such metaphors are usually dismissed, yet philosophers distinguish between two kinds of "wedge" arguments: those rooted on moral logic and those based on an analysis of how society actually works.

Moral imperatives are not the only arguments at work today. There is a growing demand for organs for transplant. There are ever-increasing pressures on budgets in the NHS - in which, advocates of euthanasia point out, half of all healthcare spending goes on people in the last six months of their lives. Legalisation of euthanasia must risk abuse and misuse, strains on the relationship of trust between doctor and patient, and self- generated pressure on the elderly "not to be a burden".

In the end logic is not enough. For it plays into other cultural values - about who is valued in our society, about our tendency to place worth on what people have, produce or do - rather than on who and what they are. Baroness Warnock's arguments, like her cutlery, may all point in the same direction. But her analogy is deficient, for the pressures with an issue such as euthanasia come from many directions. Which is why, for all its ambiguity, the present law on the treatment of the dying may be as good as we are likely to get.