Transcript Document 7157850

Euthanasia and Assisted Suicide
Content
General overview
Arguments for voluntary euthanasia
A right to die?
Arguments against voluntary euthanasia
The slippery-slope argument
Non-voluntary and involuntary euthanasia
Active vs. Passive euthanasia
Physician-assisted suicide
End-of-life care
General overview
In earlier periods of human history, physicians
could do little to stave off death; now,
improvements in public sanitation, the
development of immunization, the
development of antibiotics, and the many
technologies of modern medicine have
combined to lengthen the human lifespan,
particularly in the developed world.
General overview
In the developed world, with its sophisticated
healthcare systems, the majority of the
population dies at comparatively advanced
ages of degenerative diseases – especially
cancer and heart disease – with
characteristically long downhill courses,
marked by a terminal phase of dying.
General overview
The developments in medical technology and
treatments, which prolong and sustain life of
a patient, mean that more patients stay alive
for longer.
However, this extension of life is often
associated with severe pain and intense and
burdensome treatments for the terminally ill
patients.
General overview
At the same time, there has been progress in
the legal acknowledgement of patients’
rights at the end of life.
In many developed nations, patients have the
right to refuse unwanted treatment or to
discontinue it once it has been started.
General overview
Euthanasia is the termination of a very sick
person’s life in order to relieve them of their
suffering. The following are some related
terms and definitions:
Voluntary euthanasia – death is brought about
or hastened at the patient’s request.
General overview
Non-voluntary euthanasia – euthanasia
conducted where the explicit consent of the
individual concerned is unavailable.
Involuntary euthanasia – euthanasia
performed on a person who is able to
provide informed consent, but does not,
either because he or she does not choose to
die, or because he or she was not asked.
General overview
Active euthanasia – hastening death by the
use of drugs or other means, with a doctor’s
direct assistance.
Passive euthanasia – hastening death by
withholding or withdrawing life-sustaining
treatment.
Physician-assisted suicide – the practice of a
physician providing the means for a patient
to end his own life.
General overview
Can life become so burdensome, so filled with
pain and suffering, that it loses all meaning
and value?
Is it ever right to end the life of a terminally ill
patient who is undergoing severe pain and
suffering?
Under what circumstances can euthanasia be
justifiable, if at all?
General overview
Should life be preserved at the cost of pain
when modern medicine makes this possible?
Should life be preserved without hope of
consciousness?
Is there a moral difference between killing
someone and letting them die?
General overview
An accident or illness may bring people to an
extreme of pain, disability, distress or
dependency, so that their lives become
intolerable and there is no reasonable
prospect of substantial improvement.
Some people in such circumstances may wish
for death and consider it cruel to be denied
their release.
General overview
There are circumstances in which hastening
the end of a life seems to be the only way to
relieve suffering.
Mercy killing, as it became known, occur on
battlefields throughout the world. Animals
with painful and fatal injuries would also be
released from their suffering.
General overview
Most people think unbearable pain is the main
reason people seek euthanasia, but some
surveys in the USA and the Netherlands
showed that less than a third of requests for
euthanasia were because of severe pain.
General overview
Terminally ill people can have their quality of
life severely damaged by physical conditions
such as incontinence, nausea and vomiting,
breathlessness, paralysis and difficulty in
swallowing.
General overview
Psychological factors that cause people to
think of euthanasia include depression,
fearing loss of control or dignity, feeling a
burden, or dislike of being dependent.
Arguments for voluntary euthanasia
The main arguments for voluntary euthanasia
are [1] the argument from autonomy (or
self-determination), and [2] the argument
from the relief of pain and suffering.
Arguments for voluntary euthanasia
Autonomy or self-determination refers to
people’s right to making important decisions
about their lives for themselves according to
their own values or conceptions of a good
life, and the right to be left free to act on
those decisions.
Arguments for voluntary euthanasia
Self-determinism pays respect to an
individual’s personal values and enables the
individual to be responsible for his or her
own life.
It is one of the main pillars of a free and
democratic society that individuals can enjoy
liberty to do what they like as long as they
actions do not harm others.
Arguments for voluntary euthanasia
In exercising autonomy or self-determination,
people take responsibility for their lives.
Since dying is a part of life, choices about the
manner of their dying and the timing of their
death are, for many people, part of what is
involved in taking responsibility for their lives.
Arguments for voluntary euthanasia
Counterargument: Though a patient has a
negative right to be left alone, this does not
translate into a positive right to whatever he
or she wants.
If that were the case, there would be no need
for laws to regulate prescription drugs; a
patient could just buy whatever he or she
felt was appropriate.
Arguments for voluntary euthanasia
Proponents of euthanasia argue that human
beings are free and autonomous and have a
right to self-determination in end-of-life
decisions.
Individuals should have the right to control the
circumstances of their own death and to
determine how much suffering is too much.
Arguments for voluntary euthanasia
Patient autonomy includes the right to full
information concerning the nature and
development of the terminal illness.
Any decision about how to die must be made
on the basis of informed consent.
Arguments for voluntary euthanasia
People should be informed of their diagnosis,
their prognosis, their options in responding
to their condition and all other relevant
information.
Generally speaking, informed consent exists
when patients can understand what they are
agreeing to and voluntarily choose it.
Arguments for voluntary euthanasia
Counterargument: For a decision about death
to be voluntary, the individual must give
explicit consent.
Patients in an indefinite coma or persistent
vegetative state are not candidates for
euthanasia. Nor can euthanasia be justifiably
administered in cases of serious dementia or
clinical depression.
Arguments for voluntary euthanasia
Counterargument: We can never be absolutely
sure that we have voluntary and informed
consent. The pain and drugs may prevent
patients from making a fully rational decision.
Arguments for voluntary euthanasia
Another argument for euthanasia is based
upon compassion, mercy and beneficence.
In cases of intractable suffering and inevitable
death, a spirit of mercy and compassion is
supposed to be the correct response to a
patient’s desire to die.
Arguments for voluntary euthanasia
According to this view, life is devoid of quality
and of meaning to patients subject to severe
and unremitting physical or mental suffering.
These patients should have the option of quick
and painless relief, whether or not the
condition is terminal.
Arguments for voluntary euthanasia
Thus, physicians have an obligation to do
everything within their power to relieve that
suffering, even to the point of hastening
death if there are no realistic alternatives
acceptable to the patients.
Arguments for voluntary euthanasia
Counterargument: Suffering is almost always
relievable without killing the person.
Thanks to techniques of pain management and
better end-of-life care, it is possible to treat
virtually all pain and to relieve all suffering.
A right to die?
Many people think that each person has the
right to control his or her life and so should
be able to determine at what time, in what
way and by whose hand he or she will die.
They believe that human beings should be as
free as possible, and that unnecessary
restraints on human freedom are morally
unjustifiable.
A right to die?
Most countries that put a value on individual
liberty allow competent adults to refuse
medical treatment even if such treatment is
life-saving.
Besides, people have the right to die in the
sense that they can commit suicide –
attempted suicide is decriminalized nearly
everywhere in the world.
A right to die?
Some people, however, invoke the right to life
to justify banning suicide and euthanasia.
According to this view, if we have the right to
life, we owe ourselves the obligation to keep
ourselves alive under any circumstances.
A right to die?
Kantians, in particular, believe that persons
must be treated as ends in themselves and
never merely as means.
To kill oneself because one’s life is no longer
worth living is to treat one’s personhood as a
means and not as an end in itself.
A right to die?
Does the right to life include the right to die?
Do the terminally ill have a right to die?
Does an individual who has no hope of
recovery have the right to decide how and
when to end his or her life?
A right to die?
It can be argued that the right to die is an
integral part of our right to control our own
destinies so long as the rights of others are
not affected.
But euthanasia is not a completely
autonomous act; it requires the assistance of
another person.
A right to die?
We may have a right to do whatever we like,
including ending our own lives, so long as we
do not unjustly violate other people’s rights.
However, even if we have a right to die, that
does not mean that doctors have a duty to
kill – no doctor can be forced to help
patients who want euthanasia.
A right to die?
Apart from that, the decision to die by
euthanasia will affect other people such as
our family and friends, and we must balance
the consequences for them against our
rights.
Arguments against voluntary euthanasia
The main arguments against voluntary
euthanasia are: [1] the argument from the
intrinsic wrongness of killing, [2] the
argument from the integrity of the medical
profession, and [3] the argument from
potential abuse (i.e. the slippery-slope
argument).
Arguments against voluntary euthanasia
One objection to euthanasia invokes the
‘sanctity of life principle’ which argues that
all killing is morally wrong.
Human life is sacred and valuable intrinsically
because it is a gift from God. Deliberately
shortening life is against God’s will. Only
God should determine the time of death.
Arguments against voluntary euthanasia
According to this view, euthanasia is wrong
because of the sanctity of human life.
The deliberate taking of human life should be
prohibited except in self-defense or the
legitimate defense of others.
Arguments against voluntary euthanasia
Modern medicine has been accused of ‘playing
God’. ‘Thou shalt not kill’ and ‘Man should
not play God’ are typical objections to
euthanasia based on religious faith.
Arguments against voluntary euthanasia
Counterargument: In a free, democratic
society, we do not use the criminal law to
enforce the religious views held by some
people on others who do not share these
views.
A government which respects the right of its
citizens to choose their own religious values
cannot use the criminal law to enforce such
views.
Arguments against voluntary euthanasia
Counterargument: For those who believe that
all matters of life and death must be decided
by God, to use medicine to keep a sick
person from dying is playing God.
If playing God simply means doing what will
affect the chances of life and death, then a
lot of responsible social action does that.
Arguments against voluntary euthanasia
Counterargument: In the euthanasia debate,
the use of the term ‘killing’ should be
avoided because it usually refers to taking a
person’s life against his or her will.
But as far as voluntary euthanasia is
concerned, this is clearly not the case.
Arguments against voluntary euthanasia
Counterargument: The trouble with the
sanctity of life principle is that it implies that
every human being should be kept alive as
long as possible, and that is a proposition
few thoughtful people would accept.
Most would agree, for example, that it is
pointless to keep alive patients in an
irreversible coma or a persistent vegetative
state.
Arguments against voluntary euthanasia
Opponents to euthanasia point out that
depression is very often a contributing factor
in the desire for hastened death.
Clearly, if a patient is depressed or suffering
from a mental disturbance, therapy and
counseling – not euthanasia – should be
recommended.
Arguments against voluntary euthanasia
There is also the justifiable fear that some
elderly patients might be pressured by family,
friends, the government, health care
providers, social workers or by the example
of other terminally ill patients, to choose
euthanasia.
Arguments against voluntary euthanasia
For the elderly, the right to die may become a
duty to die.
The old and ill often feel themselves to be an
unwelcome burden on their children, and if
suicide becomes more widely accepted, the
pressure on the parent to commit suicide
could become hard to resist.
Arguments against voluntary euthanasia
Counterargument: It is a mistake to think that
if euthanasia is strictly prohibited no such
tragedies will occur. The sick will continue
occasionally to attempt suicide in ways which
are neither painless to themselves or others.
Arguments against voluntary euthanasia
Another objection to euthanasia is that there is
always the possibility of an incorrect
diagnosis or the discovery of a treatment
that will permit either survival or recovery.
Allowing euthanasia undermines the
commitment of doctors and nurses to saving
lives and discourage the search for new
cures and treatments for the terminally ill.
Arguments against voluntary euthanasia
Besides, asking doctors to abandon their
obligation to preserve human life could
damage the doctor-patient relationship.
Patients could become distrustful of their
doctors’ efforts and intentions, thinking their
doctors would rather ‘kill them off’ than take
responsibility for them.
Arguments against voluntary euthanasia
Counterargument: If euthanasia is restricted to
cases in which it is truly voluntary, then no
patient should fear getting it unless he or
she has voluntarily requested it.
Patients’ trust of their physicians could be
increased, not eroded, by knowledge that
physicians will provide aid in dying only
when patients ask for it.
Arguments against voluntary euthanasia
Opponents to euthanasia also draw attention
to the extraordinary development of
palliative care and pain control in recent
years as a more positive and safer response
to patients’ suffering.
Arguments against voluntary euthanasia
Counterargument: There are indeed drugs
which, if properly administered, can control
pain.
But there are other forms of distress such as
the terror of breathlessness, uncontrollable
vomiting, paralysis, incontinence, inability to
swallow and sheer weakness and
helplessness which cannot always be
adequately controlled.
The slippery-slope argument
The main argument against legalizing
euthanasia is the ‘slippery slope’ argument.
Critics of euthanasia claim that legalizing
voluntary euthanasia will lead to a slippery
slope effect, resulting eventually in nonvoluntary or even involuntary euthanasia.
The slippery-slope argument
Some believe that permitting voluntary
euthanasia would weaken society’s
prohibition of intentional killing, and thereby
undermine the safeguards against nonvoluntary or involuntary euthanasia.
Thus, in order to prevent these undesirable
practices from occurring, we need to resist
taking the first step.
The slippery-slope argument
Slippery slope arguments have been used by
conservatives and traditionalists to oppose all
sorts of social change.
But is there sufficient evidence for the
slippery-slope argument against euthanasia?
The slippery-slope argument
Some people think that euthanasia should not
be allowed because it could be abused and
used as a cover for the murder of innocent
people.
For example, the horrors that characterized
the Nazi regime’s attempt to weed out the
unfit had given euthanasia a bad name.
The slippery-slope argument
The Nazi practice of euthanasia – the killing
about 100,000 disabled people on the
grounds that they had ‘lives not worth
living’ – has been regarded by some as an
example of how the removal of restrictions
against killing can result in mass murder.
The slippery-slope argument
Counterargument: In Nazi German, doctors
took the lives of thousands of their fellow
citizens on orders from the government.
These unfortunates were neither terminally ill
nor in pain. The murder of these people was
thinly disguised as euthanasia.
The slippery-slope argument
Counterargument: The Nazi program of
‘euthanasia’ was neither voluntary nor based
on compassion; it was, rather, motivated by
the desire to preserve the purity of the
German race, and hence was the result of a
vicious and racist ideology.
The slippery-slope argument
For a contemporary example, many scholars
focus their attention on the Netherlands,
where the criteria of legalized euthanasia
had been formalized since the 1980s.
Some of them see the Dutch experience of
conducting euthanasia as evidence for the
slippery slope effect.
The slippery-slope argument
Statistics show that in the Netherlands,
families request euthanasia more often than
patients; and some studies there too show
that some elderly people fear their lives will
be ended without their consent.
The slippery-slope argument
However, more recent studies of the
Netherlands found no evidence that
legalizing voluntary euthanasia will lead us
down the slippery slope to involuntary
euthanasia.
Researchers conclude that, generally speaking,
[1] abuse of the Dutch euthanasia system is
rare, and [2] no slippery slope effect has
occurred.
The slippery-slope argument
Suppose slippery-slope evidence did suggest
that some patients would be abused, how
should this weigh against the freedoms of
other patients to make specific end-of-life
choices?
The slippery-slope argument
Just because a practice can be abused does
not entail that it should not be used at all.
Knives, cars, and drugs can be abused, but
that does not mean they should be
outlawed.
The abuses envisioned in slippery-slope
arguments can be prevented by strict legal
guidelines, like those currently used in the
Netherlands.
The slippery-slope argument
The legal guidelines for euthanasia in the
Netherlands include:
[1] The patient must face a future of
unbearable, interminable suffering;
[2] The request to die must be voluntary and
well-considered;
The slippery-slope argument
[3] The doctor and patient must be convinced
there is no other solution; and
[4] A second medical opinion must be obtained
and life must be ended in a medically
appropriated way.
The slippery-slope argument
Another widely discussed example is the state
of Oregon of the United States.
Since 1994, euthanasia has been legalized in
Oregon under limited conditions for
terminally ill patients who experience
unacceptable suffering.
The slippery-slope argument
Data collected by the Oregon Health
Department show that the practice is stable
and relatively rare, accounting for
approximately one in 1,000 deaths.
We also know that pain management has
improved in Oregon, and hospice utilization
is among the highest in the nation.
Non-voluntary and involuntary euthanasia
A non-voluntary decision about death refers to
cases in which the decision is not made by
the person who is to die.
Such cases would include situations where,
because of age, mental impairment, or
unconsciousness, patients are not competent
to give informed consent to life-or-death
decisions and where others make the
decision for them.
Non-voluntary and involuntary euthanasia
In those instances where the patient is not
able to communicate wishes, medical staff
and family are faced with a dilemma.
For example, this may happen when an
otherwise healthy person has entered a
persistent vegetative state without having
expressed their wishes or intentions
concerning end-of-life treatment.
Non-voluntary and involuntary euthanasia
The family may seek to exercise ‘substituted
judgment’ and, on the basis of statements
the dying person made in the past, request
the withdrawal of life support.
Otherwise, such a person may be kept alive by
medications and gastric tube feeding for
many years.
Non-voluntary and involuntary euthanasia
In these cases, family members or relatives try
to make a decision for the patient according
to what the patient would choose or in the
best interests of the patient.
Some hospitals have established ‘ethics
committees’ to provide guidance.
Non-voluntary and involuntary euthanasia
Involuntary euthanasia occurs when patients
are killed against their will or without their
consent.
This kind of euthanasia is almost always
considered wrong and is rarely debated.
Non-voluntary and involuntary euthanasia
Most people tend to equate involuntary
euthanasia with murder, but it is possible to
conceive of cases where the killing would
count as being for the benefit of the person
who dies.
Active vs. passive euthanasia
In active euthanasia, death is brought about
by a physician’s act, for example, when a
person is killed by a lethal injection.
In passive euthanasia, death is the result of
withholding or withdrawal of treatment.
Active vs. passive euthanasia
In active euthanasia, the proximate cause of
death is the physician’s act. But in passive
euthanasia, the proximate cause of death is
the patient’s disease, not the physician.
Some regard the difference as one between
killing as an act of commission, and letting
die as an act of omission.
Active vs. passive euthanasia
The distinction between active and passive
euthanasia is consequential because some
people who reject active euthanasia do
accept passive euthanasia as a practice that
provides benefits to the dying person
without violating ethical standards and
religious values.
Active vs. passive euthanasia
Opponents to active euthanasia deem this
action wrong because they believe that
taking an innocent person’s life in all
circumstances is morally impermissible.
On the other hand, it is believed that no one
has to take direct responsibility for a
person’s death in the case of passive
euthanasia.
Active vs. passive euthanasia
James Rachels, however, argues that there is
no moral distinction between active and
passive euthanasia.
He uses the example of Smith and Jones to
prove this point.
Active vs. passive euthanasia
Smith stands to gain a large inheritance if
anything should happen to his 6-year-old
cousin. One evening while the child is taking
his bath, Smith sneaks into the bathroom
and drowns the child, and then arranges
things so that it will look like an accident.
Active vs. passive euthanasia
Jones also stands to gain if anything should
happen to his 6-year-old cousin. Like Smith,
Jones sneaks in planning to drown the child
in his bath. But as he enters the bathroom
Jones sees the child slip, hit his head, and
fall face-down in the water. Jones watches
all this happen without doing anything, and
the child drowns all by himself accidentally.
Active vs. passive euthanasia
Is Jones’s behavior, Rachels asks, any less
reprehensible than Smith’s?
If the answer is ‘no’, then we must conclude
that the difference between killing and
letting die does not really make a moral
difference.
Active vs. passive euthanasia
Rachels: “If one simply withholds treatment, it
may take the patient longer to die, and so he
may suffer more than he would if more
direct action were taken and a lethal
injection given.”
Active vs. passive euthanasia
“…once the initial decision not prolong his
agony has been made, active euthanasia is
actually preferable to passive euthanasia,
rather than the reverse… the process of
being ‘allow to die’ can be relatively slow and
painful, whereas being given a lethal
injection is relatively quick and painless.”
Active vs. passive euthanasia
If death is the inevitable outcome, there are
no morally relevant differences between not
providing the treatment and taking active
steps to end life.
Active steps to end a patient’s life in a quick
and painless manner may be the morally
right thing to do because unnecessary
suffering can be avoided.
Active vs. passive euthanasia
The reason why killing is normally a great
wrong is that dying is normally a great harm.
But if it is in the best interests of a patient to
die now rather than suffer a prolonged and
painful dying, then killing is no longer a
wrong.
Physician-assisted suicide
Assisted suicide usually refers to cases where
people who want to die need help to kill
themselves and ask for it.
It may be something as simple as getting
drugs for them and putting those drugs
within their reach.
Physician-assisted suicide
In physician-assisted suicide, the physician
does not directly cause the patient’s death
but enables the patient to choose the time
and circumstances of his or her own death,
usually by prescribing a lethal dose of drugs.
Physician-assisted suicide
The main difference between physicianassisted suicide and euthanasia lies in who
performs the last causal act leading to death.
In the case of physician-assisted suicide it is
the patient; in the case of euthanasia it is
the physician.
Physician-assisted suicide
Without the assistance of their doctors,
patients can choose to die by refusing food
and water. They will die more slowly than
with physician-assisted suicide but die they
will.
Advocates of physician-assisted suicide argue
that alternatives should be provided so that
patients need not choose this unpleasant
way of dying.
Physician-assisted suicide
Arguments against physician-assisted suicide
include considerations such as the possibility
of discovery of cures, the dangers of
mistaken diagnosis, the difficulties of
knowing when requesters are rational, the
dangers of patients being coerced by others,
and so on.
Physician-assisted suicide
Is it morally wrong to help another person
commit suicide?
If a patient asks to be withdrawn from a
respirator, would it make a moral difference
if the patient, rather than the doctor, pulled
the plug?
End-of-life care
We are getting better at providing effective
palliative care, and hospice care is more
widely available.
Because of advances in palliative care and
mental health treatment, there is no reason
any person should ever feel they are
suffering intolerably, whether it is physical or
mental suffering or both.
End-of-life care
Palliative care is physical, emotional and
spiritual care for a dying person when cure is
not possible. It provides relief from pain and
suffering and thereby offers an alternative to
euthanasia.
Good palliative or hospice care has the goal of
helping the patient to live each day as well
as possible.
End-of-life care
Advocates of palliative and hospice care
emphasize the importance of reducing
human suffering.
Palliative management of suffering is trusted
to substantially decrease the number of
requests for both euthanasia and physicianassisted suicide.
End-of-life care
According to this view, palliative and hospice
care – including excellent pain and symptom
management and psychosocial support for
patients and families – should be part of the
standard of care for all severely ill patients.
End-of-life care
Some of the practices used in end-of-life care,
however, have been likened to euthanasia.
For example, there is the practice of making a
‘Do Not Resuscitate’ (DNR) order, where
patients request that no treatment be given
to them if their hearts stop beating or they
stop breathing.
End-of-life care
Another controversial practice is known as
‘palliative sedation’. When a person
experiencing extreme suffering, for which
there is no effective treatment, he or she
may be put to sleep using sedative
medication.
For example, palliative sedation is often used
to treat burns victims who are expected to
die.