Transcript Euthanasia I - Memorial University of Newfoundland

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.