Transcript Physician-Assisted Suicide

Physician-Assisted Suicide
PHL281Y Bioethics
Summer 2005 University of Toronto
Prof. Kirstin Borgerson
Course Website: www.chass.utoronto.ca/~kirstin
Overview
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Case: Diane
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Defining Physician-Assisted Suicide (PAS)
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Drawing the line at PAS:
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Quill, Cassel and Meier
Wolf
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Slippery Slope Arguments
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Case: Sue Rodriguez
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The Hippocratic Oath
Diane
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“I had come to know, respect, and admire her over the past eight
years” (Quill, 692)
Independent, in control
Diagnosis: acute myelomonocytic leukemia
Odds 25% survival with aggressive treatment
Refused treatment
Overdosed with prescription barbiturates
Physician said she died of ‘acute leukemia’
“I wonder why Diane, who gave so much to so many of us, had to
be alone for the last hour of her life.” (694)
Physician-Assisted Suicide (PAS)
“Suicide carried out with the assistance of a doctor
(whose role is typically to provide a lethal dose of a drug
at the explicit request of the patient)” (OED)
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Distinguished from VAE:
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The final act is solely the patient’s (causal pathway)
Distinguished from VPE:
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Physician provides means to death (prescription for lethal dose)
Quill, Cassel, Meier
VAE ---/--- PAS ------ VPE
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Argued: no essential difference between
physician-assisted suicide and termination of
life-sustaining treatment (passive euthanasia)
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Analogy
Principles and VPE
Why PAS but not VAE?
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Role of Medical Profession
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Risk of Abuse:
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“In assisted suicide, the final act is solely the patient’s, and the risk of
subtle coercion from doctors, family members, institutions, or other
social forces is greatly reduced” (421)
Power and control
In the USA right now, medical care is “too inequitable”; doctor-patient
relationships are “too impersonal” (422)
But: some patients who cannot swallow or move will be unable to
receive PAS
This is thought to be “less than ideal” but necessary in light of risks
of abuse (cost/benefit analysis) (422)
Cost/Benefit Analysis
Objection
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Case of the borrowed gun
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Suggested principle: Providing means for others’
destruction is wrong
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Implications for PAS?
Reply
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Modified principle:
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‘Providing means for others’ destruction is wrong in
cases where the person is in condition x’
Where x = a condition that interferes with
competence
Lesson for PAS: restrictions needed
PAS Criteria Proposed by Q,C,M
Because PAS is extraordinary and irreversible, the
following conditions must be met:
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Incurable condition with severe suffering
Adequate comfort care has been provided
Clear and repeated request to die (no surrogate requests or
advance directive requests, though)
Competence (not depressed, good understanding)
Context of meaningful doctor-patient relationship (note: right
of conscientious refusal by doctor)
Second opinion (consultation)
Clear documentation to support each condition
Justifiable Restrictions?
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Terminally ill?
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Advance directives?
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Missing elements?
Wolf
VAE ------ PAS ---/--- VPE
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Wolf agrees with concerns raised with VAE
Extends these concerns to PAS
Reminds us of the importance of social context
in discussions of ethical issues
Argues: historically/socially vulnerable
populations (gender, race, socio-economic
status) may be differentially affected by
legalization of PAS
Predictive hypotheses (Wolf)
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Possible differential effects of PAS (using the case of
women, but can be extended to other vulnerable
groups):
Higher incidence of women dying by PAS
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In US, women are less likely to have health insurance
Women are over-represented in the ranks of the poor
Women have less access to resources (such as home care)
Women are less likely to receive good attention from physicians
even when insurance is the same
Women are at greater risk for inadequate pain relief
Women are at greater risk for depression
Women more often use attempts at suicide as calls for help or
change
Predictive Hypotheses (Wolf)
2. Women might seek PAS for different (and less acceptable) reasons
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Women are more likely to be moved by a desire not to be burdens on the
family
3. Physicians’ decisions may be affected by gender stereotypes
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Historical and poetic valorization of women’s self-sacrifice (especially
sacrifices by older women)
4. Many people envision women as recipients when discussing PAS and
this may (negatively) influence our reasoning
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Gender issues may influence broad public debate on PAS and euthanasia
Empirical Evidence?
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Wolf tries to use empirical evidence to make her case
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We now have better evidence (from Oregon, for example)
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First predictive hypotheses is not supported – almost exactly 50/50
men/women dying in Oregon
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Second hypothesis is somewhat supported – women choose PAS more
often for reasons such as “being a burden”
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Third hypothesis is somewhat supported (though it is difficult to assess)
– those requesting PAS are more often younger and higher educated
which seems to go against the stereotype of the older, poorer women
who sacrifice themselves for their families
Social Context (Wolf)
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Fourth hypothesis - our reasoning about PAS is affected by:
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Women used in fictional cases (It’s Over Debbie)
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Message – powerful men should relieve suffering of vulnerable women
Women used in actual cases (Dr. Kevorkian)
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First eight subjects women
Why?
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Chance?
Misogynist?
Sexist society and poetic/emotional appeal of women’s suffering and death?
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Evaluation of hypothesis?
Society’s sexism is reflected in these cases and may be influencing the
debate
Lessons from Wolf
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Context matters (reflective equilibrium)
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Good idea to pay attention to differential death rates – is one group
using PAS more often? Could this be a result of social pressures?
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How, in general, do we deal with social pressures in medicine? What
impact does this sort of general social pressure, coercion or
manipulation have on people’s decisions? (We will see this again in
the debate over reproductive technologies)
Justice in health care
Abuse, Safeguards and Legalization
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Opponents of euthanasia frequently warn of the possible negative
consequences of legalizing physician assisted suicide and active
euthanasia (PAS/AE) while ignoring the covert practice of PAS/AE by
doctors and other health professionals.
Studies in the USA, Netherlands, and Australia suggest that
approximately 4% to 10% of physicians have intentionally assisted a
patient to die (whether PAS or AE).
Are we more or less likely to address issues raised by vulnerable
populations if PAS and AE remain illegal (vs. legal with safeguards)?
Slippery Slope Arguments
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Structure:
If a(1) then a(2), if a(2) then a(3), if a(3) then a(4)… if a(n-1) then a(n). But we
don’t want a(n). Therefore not a(1).
Ex/ If we allow abortion then we will have to allow infanticide; if we allow infanticide,
we will have to allow the murder of ‘undesirable’ types of people. We
don’t want that so we had better not allow abortion.
Ex/ If we allow PAS in cases where the patient has given explicit informed consent,
we will have to allow PAS for those who have left written advance directives. If we
allow PAS on the basis of written advance directives, we will have to allow proxy
decision-makers to decide on PAS for patients who have become incompetent. We
will then have to allow doctors to make decisions about PAS for patients who have no
advance directive or proxy but who ‘would have wanted’ PAS. Next, we will create
some ‘objective’ test for patients (including newborns) whose best interests would be
served by dying, and from there we will make decisions about which infants should
receive NAE. Finally, we will be making decisions about which children and adults
should be euthanized, in spite of their expressed wishes (IAE).
Slippery Slope Arguments
Possible problems with these arguments?
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At each step, we make a prediction. If we multiply the probabilities, the resulting
probability of the chain is reduced. If the probability at each step is 80%, then the
likelihood of a(1) -> a(n) if there are 6 steps is only 33%. The more steps involved,
the less strong the argument.
Slippery slope arguments rest on fuzzy distinctions. If at any point we can make a
clear distinction and ‘draw the line’ we can stop sliding down the slope.
There is no reason to think that the first step must logically lead to the second step
as long as we clearly define and defend the first step and fail to see a similar defense
for the second step.
We are often psychologically compelled to slide down the slope but that does not
mean we are logically compelled.
So…
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Can we make moral distinctions between:
VPE… PAS… VAE… NAE… IAE… Genocide?
Moral Principles in Legal Debates
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We will now look at some of the specific
concerns arising in the legal debate over
AE and PAS
Allows us to pay some attention to moral
issues raised by individual cases (part of
reflective equilibrium)
Facts: Legal Status
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Active Euthanasia:
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Physician-assisted Suicide:
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Netherlands (legalized 2002, permitted since 1984)
Belgium (legalized 2002)
Oregon, USA (legalized 1997)
Switzerland (1941)
76% of surveyed Canadians said they support the ‘right
to die’ – Angus Reid Polls 1993 & 1997 (steady
response)
Canada
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Canada – AE and PAS illegal (though
sometimes not prosecuted)
Criminal Code Section 241
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Every one who
(a)
(b)
counsels a person to commit suicide, or
aids or abets a person to commit suicide whether
suicide ensues or not,
is guilty of an indictable offence and liable to
imprisonment for a term not exceeding 14 years.
Canada
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Original motivation for this legislation was to protect
vulnerable people
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Originally included prohibition on suicide but was
amended in 1974.
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This legislation is broad – prevents all people (not just
physicians) from aiding suicide
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Challenges usually suggest that physicians be written in
as an exception to (b)
Challenges to the Law
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(On six different occasions,
motions or bills have been
proposed by members of
parliament or committees (C203, C-261, C-385, among
others))
Many different challenges to
241(b) in the Supreme Court
Most famous and closest to
success was the Sue Rodriguez
case (1992/3)
We will examine this case, and
take special note of the moral
principles underlying the legal
debate
Sue Rodriguez
Sue Rodriguez Case
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40 year old woman living in B.C.
Amyotrophic Lateral Sclerosis (A.L.S.) ‘Lou Gehrig’s Disease
ALS – mentally competent while body degenerates
In the end, physically unable to swallow, speak, walk or move
without assistance
Requested PAS but illegal
Challenged s.241(b) of the criminal code on the grounds that it
violates ss. 7, 12, & 15 (1) of the Canadian Charter of Rights and
Freedoms
Supreme Court Decision: s.241(b) upheld in 5-4 decision
Sue Rodriguez died in 1994 with the assistance of a physician (who
was never charged)
Charter Rights and Morality
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Charter rights:
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Section 7 – Everyone has the right to life, liberty and security of
the person and the right not to be deprived thereof except in
accordance with the principles of fundamental justice
Section 12 – Everyone has the right not to be subjected to any
cruel and unusual treatment or punishment
Section 15 (1) – Every individual is equal before and under the
law and has the right to the equal protection and equal benefit
of the law without discrimination and, in particular, without
discrimination based on race, national or ethnic origin, colour,
religion, sex, age or mental or physical disability.
Moral Principles Underlying Legal
Debate
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Autonomy?
Beneficence?
Equality/Justice?
Which section of the charter seems most
appropriate from a moral perspective?
Hippocratic Oath
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Wolf, “The principles
bounding medical
practice are not written in
stone. They are subject
to reconsideration and
societal negotiation over
time” (232)
Evaluation of the Oath?
Beyond the Hippocratic Oath
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Next class we begin our exploration of ethical issues
raised by new technological and social developments not
anticipated in the original Hippocratic Oath
Starting with new technology: cochlear implants
Summary
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Case: Diane
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Defining Physician-Assisted Suicide (PAS)
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Drawing the line at PAS:
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Quill, Cassel and Meier
Wolf
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Slippery Slope Arguments
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Case: Sue Rodriguez
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The Hippocratic Oath
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]