Transcript Lecture 2 – Euthanasia / Physician

Euthanasia
PHL281Y Bioethics
Summer 2005 University of Toronto
Prof. Kirstin Borgerson
Course Website: www.chass.utoronto.ca/~kirstin
Overview
1.
Euthanasia – definition and public debate
2.
Distinctions
3.
Dax’s Case
4.
‘It’s Over Debbie’
5.
Rachels’ 3 Arguments (& objections)
6.
Brock’s Arguments for Active Euthanasia (& objections)
7.
Looking ahead to Physician-Assisted Suicide
Euthanasia
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“Good death”
“Euthanasia is the painless killing of a patient suffering
from a incurable and painful disease” (OED)
Suicide and Euthanasia have always been topics of
concern for moral philosophers because they raise
fundamental questions about the meaning and value of
life and death, and the limits of autonomy and
beneficence
Public Attention
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Why?
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Health advancements (hygiene, nutrition) and life expectancy
Medical technology
Social scientific evidence of inadequate pain control (SUPPORT
study 1995 – USA)
Public demand (high approval rate in Canada)
Medicalization of death (4/5 in institutions)
Underground common practice (‘twilighting’)
Shift in cultural values (autonomy – ex/ fertility)
Legal battles and media attention
…
Recall: Moral/Legal
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Euthanasia raises debate on a range of topics.
These tend to fall into two main areas:
Moral – where questions address what is morally
good and justifiable
Legal – where questions address what legislation
is most appropriate for a given society
*We are focusing on moral issues raised by
euthanasia
Distinctions
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Voluntary Euthanasia (VE) – provided at the request of a
competent individual
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Nonvoluntary Euthanasia (NE) – provided for an
incompetent individual
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Example: Sue Rodriguez (Amyotrophic Lateral Sclerosis)
Example: Tracy Latimer (Severe Cerebral Palsy)
Involuntary Euthanasia (IE) – provided without the
permission of a competent individual (against his/her
will)
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homicide
Distinctions (continued)
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Active Euthanasia (AE) – killing
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Example: administering a lethal
dose to a patient
Passive Euthanasia (PE) – letting die
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Example: withholding or withdrawing a
respirator
4 Categories
Voluntary Active Euthanasia (VAE)
1.
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Most attention is here
2.
Nonvoluntary Active Euthanasia (NAE)
3.
Voluntary Passive Euthanasia (VPE)
4.
Nonvoluntary Passive Euthanasia (NPE)
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Passive forms are relatively widely accepted (now)
Dax Cowart
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Donald ‘Dax’ Cowart:
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Fighter pilot, high school football hero
25 years old, propane gas explosion killed his father
and left Dax with burns over 65% of his body
Underwent intensive (and extraordinarily painful)
treatments lasting over a year, while consistently
requesting to die and threatening to kill himself
Video: ‘Please Let Me Die’ (1974)
Video: ‘Dax’s Case’ (1984)
Dax Cowart
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Right to refuse treatment?
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Should autonomy extend to death?
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Paternalism/Autonomy debate in medicine
Update
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Law degree (1986),
became a patient
advocate
Married
Continues to insist
that his requests to
discontinue treatment
should have been
respected
‘It’s Over Debbie’
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Published in the Journal of the American Medical Association (JAMA)
in 1988
ABSTRACT: “A physician who describes himself or herself only as a
gynecology resident in a large, private hospital writes in JAMA's "A
piece of my mind" column about having administered a lethal dose
of morphine to a terminally ill patient. The resident reports that the
20-year-old patient was dying of ovarian cancer, had not eaten or
slept in two days, and was suffering from unrelenting vomiting. The
resident, who had not seen the patient before, also writes that her
[the patient’s] only words at the time were ‘Let's get it over with.’”
Responses
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Intuitive response?
Justified killing?
JAMA’s position
Rachels’ 3 Arguments
1.
The Humanitarian Argument
2.
The Irrelevant Reasons Argument
3.
The Main Argument
1. The Humanitarian Argument
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Logical structure:
1.
2.
3.
PE is acceptable on humanitarian grounds
AE is more humane than PE
Therefore, AE is more acceptable than PE
Objection
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It is true that the American Medical
Association (AMA) accepts PE
Why?
What does this mean for the argument?
Which premise (if any) is problematic?
What about the other premise?
2. The Irrelevant Reasons
Argument
Logical structure:
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1.
2.
3.
A patient who has a serious medical condition ‘C’ has a life
that is either worth preserving or not regardless of whether
the patient needs a simple operation for problem ‘P’ which is
unrelated to ‘C’, in order to survive
Because AE is thought to be wrong, some medical decisions
for those with condition ‘C’ are made on the basis of problem
‘P’
Therefore, because AE is thought to be wrong, some medical
decisions to save or not to save a patients’ life are made on
irrelevant grounds (grounds which have no stated moral
justification)
Clarification
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Example: Intestinal blockage and Down’s
Syndrome
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Basis of decision seems to be an assessment
what sorts of lives are worth living
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We should ensure these decisions are morally
justifiable
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Objections?
3. The Main Argument
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Logical structure:
1.
2.
3.
PE is morally justifiable
The distinction between killing and letting die is not
morally significant [from thought experiment]
Therefore, AE is morally justifiable on the same
grounds as PE
Smith and Jones
Smith
Jones
Killing/Letting Die
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Good thought experiment (isolates distinction)
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Same motives
Same willingness to kill
Same result
“Did either man behave better, from a moral
point of view?” (400)
Was Jones’ behavior less reprehensible than
Smith’s?
Back to the Main Argument
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If you are inclined to agree that there is no moral
difference between the behavior of Smith and Jones,
then it looks as though Rachels has provided support for
his second premise:
2. The distinction between killing and letting die is not morally
significant
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Note: It may be the case that actual cases of killing are usually
morally reprehensible (murders, etc.) and cases of letting die usually
are not (humanitarian reasons), but then it is other factors (for
example, motive/intention) that should be the focus of our moral
assessments
Objections
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?
Intentions
Rachels - intentions are only relevant for
assessing character, but are not relevant
for assessing the morality of an action
(note the moral theory in the background
here)
No act/omission distinction
Rachels
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Wants to eliminate the ‘middle ground’
position taken by organizations like the
American Medical Association (AMA)
Gives reasons for doubting the moral
relevance of the active/passive distinction
Brock
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Argues for Voluntary Active Euthanasia (VAE)
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On the basis of two principles:
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Autonomy (self-determination)
Beneficence (well-being)
Same values that support patient’s rights to decide
about life-sustaining treatment
Brock
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AUTONOMY
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Human dignity lies in people’s capacity to direct their lives
Individual self-determination extends to death; many patients
find that quality of life, avoiding suffering, maintaining dignity
and insuring that others remember us as we wish them to –
outweigh merely extending one’s life
Conception of good life/good death should be respected (within
the bounds of justice and consistent with others doing so as
well)
Pluralism suggests that we respect individuals’ right to control
the manner, circumstances and timing of their dying and death
Brock
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BENEFICENCE
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It looks like respect for autonomy and beneficence conflict in cases of
euthanasia because life is usually highly valued as a good
But in cases where euthanasia is requested, the benefits and burdens of
life have shifted and the only person who can assess the balance is the
individual
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It may be the case that further life is a harm/burden and so we act
beneficently when we allow for VAE
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Of course we have to watch out for depression and dementia just as we
would with all treatment decisions (i.e. the person must be competent)
Objections
1.
The practice of medicine is in jeopardy
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The “very soul of medicine” is on trial (406)
2 distinct concerns:
A. Consequentialist Concern - undermines trust
(doctors as killers as well as healers)
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Reply: voluntary only & could increase trust
Objections
B. Contrary to the Central Aims of Medicine undermines ‘moral center’ of medicine
Reply: what should be the moral center? If
autonomy and beneficence, then VAE
 “What should not be at the moral center is a
commitment to preserving patients’ lives as such,
without regard to whether those patients want
their lives preserved or judge their preservation a
benefit to them” (407)
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General Objections
2. Limits of respect for autonomy
 We draw the line in other cases:
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Example: Intervening in cases of anorexia
Example: Refusing to provide ‘elective amputation’ for
Body Integrity Identity Disorder (BIID)?
So why not draw the line at choosing death?
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Possible Reply: Liberty principle and Mill
But then… (above cases)
General Objections
3. Slippery Slope
4. Risks of Abuse
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More detail on these later
Very common arguments
Further Support for VAE
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Animals
Biology is (not) destiny – we interfere in
all sorts of ways with life and death
(fertility treatments, surgery,
pharmaceutical drugs)
Shared Arguments
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Autonomy
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Beneficence and Preventing Suffering
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Integrity of the Medical Profession
Summary
1.
Euthanasia – definition and public debate
2.
Distinctions
3.
Dax’s Case (Passive Euthanasia)
4.
‘It’s Over Debbie’ (Active Euthanasia)
5.
Rachels’ 3 Arguments (& objections)
6.
Brock’s Arguments for Active Euthanasia (& objections)
Looking ahead…
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Next class: Physician-assisted suicide
Contact
Prof. Kirstin Borgerson
Room 359S Munk Centre
Office Hours: Tuesday 3-5pm and by appointment
Course Website: www.chass.utoronto.ca/~kirstin
Email: [email protected]