Lecture8 euthanasia

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  • Euthanasia*Philosophy 2803Lecture VIIIMarch 26, 2002

    * This replaces the lecture originally labelled lecture VIII

  • EuthanasiaA broad range of activities are sometimes classified as euthanasia

    Withholding or withdrawing treatmentActively ending someones lifeProviding someone with the means to end his/her life

    What all of them have in common is that they involve situations in which:

    it is somehow deemed better that the person we are concerned with dies than that he or she lives andsome course of action or inaction is undertaken with the understanding that it will bring about the death of the person

  • Is Euthanasia Ever Morally OK?If we give the term a broad reading, most people will answer yes.

    E.g., Suppose Tom has terminal cancer and that all conventional treatments have failed. Left untreated, he will die in a few days. However, there is an experimental drug that has shown some promise in treating cancers like his, but that also has some very unpleasant side effects.Few would argue that it is immoral if Toms doctors accept his wish to refuse this treatment.

  • What Matters Morally?The question thus becomes: under what conditions is euthanasia morally acceptable?

    Discussion of this issue often turns on the type of euthanasia involved:

    Active vs. Passive EuthanasiaVoluntary vs. Non-voluntary EuthanasiaAssisted Suicide

  • Active vs. Passive EuthanasiaActive - roughly, involves killing a patient

    E.g., administering a fatal dose of morphine to a terminally ill cancer patientThis is often what people have in mind when they simply speak of euthanasiaBe careful to distinguish killing from murdering (wrongful killing) not all killings are murders

    Passive - roughly, involves letting a patient die

    E.g., failing to revive a patient who has signed a DNR order

  • Two Kinds of Passive Euthanasia(i) Withholding of Treatment e.g., not performing a needed surgery or not administering a needed drug

    (ii) Cessation of Treatment e.g., turning off a respirator

    Question: While i above seems clearly passive, why is cessation of treatment passive?

    Rachels: "what is the cessation of treatment ... if it is not 'the intentional termination of the life of one human being by another'?" (375) Answers to this question tend to rest on claims about naturalness

  • Voluntary vs. Non-voluntary Euthanasia Voluntary - killing or letting die a competent person who has expressed a desire for this (usually over a sustained period of time).

    Non-voluntary - killing or letting die when the patient is unable to express such a desire

    Note: there is a difference between involuntary and non-voluntary Involuntary euthanasia is not a seriously considered possibility

  • Assisted SuicideNot actually euthanasia, since the 'patient' ultimately kills himself or herself.

    The line between the two can, however, become very thin. e.g., Dr. Jack Kevorkian's 'Mercitron'

    Many of the same issues arise in considering assisted suicide as in considering euthanasia,

    e.g., the Sue Rodriguez case (pp. 366-372)

  • The LawVery roughly, the following summarizes the Canadian legal situation re. euthanasia

    voluntary passive euthanasia = legal in fact, required

    voluntary active euthanasia = illegalalthough see The Doctrine of Double Effect

    non-voluntary passive euthanasia = legal under appropriate proxy decision

    non-voluntary active euthanasia = illegalalthough again see The Doctrine of Double Effect

    assisted suicide = illegalsee the Sue Rodriguez case (pp. 366-372)

  • Voluntary Passive EuthanasiaAs noted, this is the least controversial form of euthanasia It is now a well established principle that a competent patient has a right to refuse treatment, including lifesaving treatment

    But why?

    The short answer: because of the central role of informed consent no consent, no treatment

  • A Longer Answer: The Autonomy/ Dignity Argument for VPEP1: A weakened, dying patient has lost control over her life in a significant way. P2: Allowing the patient control over how her life ends provides a way of preserving her autonomy and her dignity (as far as is possible). P3: Dignity and autonomy are very important values. C: In order to preserve the patient's dignity and autonomy, a terminally ill patient should be allowed to choose when treatment will be withheld or withdrawn.

  • Two Questions about the Autonomy/Dignity ArgumentDoes this argument apply only to terminally ill patients? If autonomy is so important then why shouldn't the patient's wishes be respected even if she is not terminally ill?

    E.g., The anorexic patient who refuses force-feedingA rational, healthy patient who simply wants to be allowed to starve himself to death.

    Because of the stress placed on informed consent, issues of competence are often raised.

    Those who think a request for cessation of treatment will be easily agreed to are often mistaken, particularly when the family or medical staff dont agree

  • Two Questions about the Autonomy/Dignity ArgumentDoes this argument also support assisted suicide or active euthanasia? A common response: No. There is a morally significant difference between killing and letting die. While autonomy provides a ground for allowing the person to die. It provides no grounds for active killing. The American Medical Association (1973): While "[t]he cessation of the employment of extraordinary means to prolong the life of the body ... is the decision of the patient and/or his immediate family," "mercy killing ... is contrary to that for which the medical profession stands." (372)

    James Rachels challenges this view. He claims the distinction between killing and letting die is morally irrelevant.(372-376)

  • Rachels on Active vs. Passive Euthanasia

    "once the initial decision not to prolong his [i.e., a patient with incurable cancer] agony has been made, active euthanasia is actually preferable to passive euthanasia". (373)

    Objection: But killing is morally worse than letting die!

    Response: Rachels claims that we have been misled by the fact that most actual cases of killing are morally worse than most actual cases of letting die

    Because of this, we have made the mistake of concluding that there is some deep moral difference between killing and letting die.

  • Cases (i) A unconscious patient will almost certainly die unless paced on a respirator. His family explain he has expressed a clear desire not to be placed on one. He is treated according to those wishes and dies.

    (ii) Case i, but the man is placed on the respirator before his family arrive. After his wishes are explained, he is removed from the respirator and dies. Are these cases of killing or letting die? Are these cases morally different?

  • Cases(1) A man drowns his young cousin so that he won't have to split an inheritance with him.

    (2) Case #1, except, before he can kill him, the cousin slips and falls face down in the bathtub. The man just has to watch his cousin drown. Are these cases of killing or letting die? Are these cases morally different?

  • Cases(a) In accordance with an ALS patient's wishes the doctors remove her from her respirator. She dies.

    (b) A greedy son removes an ALS patient from her respirator because he wants to collect his inheritance. She dies.

    Are these cases of killing or letting die? Are these cases morally different?

  • Is Rachels Right?Do the cases make a convincing argument that the difference between active and passive euthanasia is morally irrelevant?

    If so, then what is morally relevant?

  • Non-voluntary EuthanasiaUntil relatively recently, NPE & NAE were largely looked upon as morally unacceptable

    Two ways in which NPE has become somewhat accepted

    By appeal to standards of personhoodWhen the person is gone, NPE is generally acceptedE.g., Harvard Brain Death = loss of virtually all brain activity including brain stem

    By proxyUnder certain conditions, a proxy decision to refuse or suspend treatment is generally accepted even if the person is still arguably thereBut recall Re. S.D. from lecture on consent, there are limitations on these decisions

  • The Case of Karen Quinlan

    1975 - Quinlan goes into a drug induced coma Suffers anoxia (loss of oxygen to the brain) causing irreversible brain damage Required a ventilator/respirator to live Not brain dead, but in a persistent vegetative state (unconscious) Quinlans sister - "If Karen could ever see herself like this, it would be the worst thing in the world for her." Hospital - '1 in a million' chance of recovery Family sought to have her removed from the respirator, doctors & hospital refused. 1976 - N.J. Supreme Court overturns a lower court decision and rules in favour of the Quinlans. Doctors 'weaned' her off the respirator in a successful attempt to keep her alive. Died of pneumonia - June 13, 1986

  • The Case of Nancy CruzanJune 11, 1983 - Cruzan, 24, suffers anoxia as a result of a car crash, enters a p.v.s.

    Kept alive by a feeding tube

    Parents sought permission to disconnect their daughter's feeding tube

    June, 1990 - U.S. Supreme Court rules that in the absence of 'clear and compelling' evidence of Cruzans wishes, it may not be disconnected.

    Publicity brings new witnesses (who knew her as Nancy Davis, her married name).

    In a new trial, a lower court rules the 'clear and compelling' standard has now been met.

    Dec. 14, 1990 - N.C. is disconnected & subsequently dies

    Many commentators thought that the fact that Cruzan required only a feeding tube (not a respirator) m