Euthanasia*
Philosophy 2803
Lecture VIII
March 26, 2002
·
This replaces the lecture originally labelled lecture VIII
Euthanasia
§
A broad range of activities are sometimes classified
as euthanasia
–
Withholding or withdrawing treatment
–
Actively ending someone’s life
–
Providing 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 and
–
some 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 Tom’s 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 Euthanasia
–
Voluntary vs. Non-voluntary Euthanasia
– Assisted Suicide
Active vs. Passive
Euthanasia
§
Active - roughly, involves killing a patient
– E.g., administering
a fatal dose of morphine to a terminally ill cancer patient
–
This is often what people have in mind when they
simply speak of euthanasia
– Be 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 Suicide
§
Not 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 Law
§
Very roughly, the following summarizes the Canadian
legal situation re. euthanasia
•
voluntary passive euthanasia
= legal
•
in fact, required
•
voluntary active euthanasia
= illegal
•
although see ‘The Doctrine
of Double Effect’
•
non-voluntary passive euthanasia
= legal
•
under appropriate proxy
decision
•
non-voluntary active euthanasia
= illegal
•
although again see ‘The
Doctrine of Double Effect’
•
assisted suicide = illegal
•
see the Sue Rodriguez case (pp. 366-372)
Voluntary Passive
Euthanasia
§
As 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 VPE
§
P1: 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 Argument
1. Does
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-feeding
–
A
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 don’t agree
Two
Questions about the Autonomy/Dignity Argument
2. Does
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 Euthanasia
§
Until 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 personhood
§
When the person is ‘gone’, NPE is generally accepted
§
E.g., ‘Harvard Brain Death’ = loss of virtually all brain activity including brain
stem
–
By proxy
§
Under certain conditions, a proxy decision to refuse
or suspend treatment is generally accepted even if the person is still
arguably there
§
But 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)
§
Quinlan’s 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 Cruzan
§
June 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
Cruzan’s 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) made a significant moral
difference
Limits on
Non-Voluntary Euthanasia
§
NAE
is still very controversial
– E.g., the Robert Latimer case
§
The
limits of NPE are also controversial
– E.g., Re. S.D.
– Robert Wendland
(Topic of Groupwork)
A Continuum of Conditions
§
Coma
–
Brain activity, but no
consciousness or wakefulness.
§
Persistent Vegetative State (PVS)
–
Wakefulness, but no awareness
§
Minimally Conscious State (MCS)
–
Wakefulness and minimal awareness
§
Quite Different: Locked-in Syndrome
– Full consciousness,
but extreme paralysis
Minimally Conscious State
§
“a condition of severely
altered consciousness in which minimal, but definite, behavioral evidence of
self or environmental awareness is demonstrated.”
§
May be temporary or permanent
§
Criteria (at least one of):
–
following simple
commands
–
gives yes or no
responses, verbally or with gestures
–
verbalizes intelligibly
–
demonstrates other purposeful
behavior …. in direct relationship to relevant
environmental stimuli
Minimally Conscious State
§
Unlike PVS, those in a MCS can feel pain, etc.
§
“meaningful, good recovery
after 1 year in an MCS is unlikely”
§
“being nonfunctioning and
aware to some degree is worse than being nonfunctioning and unaware”
–
Ronald Cranford
§
“MCS is not a diagnosis; it is a value judgment.”
–
Diane Coleman, president, Not Dead Yet
The Case of Robert Wendland
§
NPE is now generally accepted when a patient is in a
PVS
§
Recently there have been controversies about whether
NPE is appropriate in other sorts of conditions, specifically for patients in a
permanent MCS
– One way of
understanding these controversies is as linked to our conception of personhood
– the more restrictive the conception, the greater range of cases in which NPE
is accepted
Robert Wendland
§
Suffered brain damage in a car accident in 1993
§
Wendland was supposedly in
a permanent Minimally Conscious State (MCS)
§
Could respond to simple
commands.
§
Wife and children claimed he never recognized them
§
Mother claimed he would cry and kiss her hand during
visits
Robert Wendland
§
His
mother opposed the attempt by his wife to have Wendland’s
feeding and hydration tube removed
§
Wendland died in July 2001 of pneumonia before
California Supreme Court could rule
§
California
Supreme Court eventually ruled against his wife
Question
§
Assuming
his wife’s description of Wendland’s condition was accurate, would NPE of Wendland
have been morally acceptable?
§
Why
or why not?
The
Doctrine of Double Effect (DDE)
§
Suppose an action (e.g., giving a terminally ill
cancer patient morphine) has some reasonably foreseeable outcome (e.g.,
quickening the patient’s death) and that it would be unacceptable to perform
this action for the purpose of bringing this outcome about.
§
The DDE claims that it may still be acceptable to
perform this action, provided that the action is not performed for the purpose
of bringing this outcome about.
–
E.g., it may still be acceptable to give the patient
the morphine provided that it is given in order to control his pain.
–
The DDE is commonly, if not explicitly, appealed to in
practice. In this sense, VAE. &
NAE. are quite often practiced.