Case B

The following is largely based on a case discussed in James E. White, Problem Cases to Accompany Contemporary Moral Problems, 4th ed, p. 16 and originally reported in the St. Cloud Times, 10/4/89:

Rebecca Mae Ginsmore is blind. She never talks and she has violent seizures. She cries often, particularly when she is moved. Evidently she is in a great deal of pain. Her legs, for instance, are locked together and, over time, her hip bones are being pulled from their sockets.

The cause of Rebecca Mae's deteriorating condition is a terminal genetic disorder called Batten's Disease. Her treatment regimen consists solely of the aggressive treatment of her symptons. Through a tube in her stomach she receives daily doses of pain medications like Percodan and Codeine. To help control her seizures she likewise receives Clonopin and Tegretol. To ameliorate the stress of her existence, she receives Lorazapam and Valium. Finally, she gets doses of Tussionex to help keep her lungs clear. Altogether she takes twelve drugs a day via the tube in her stomach.

Her parents have been told that Rebecca Mae can expect to live for another 7 to 10 years. Rebecca Mae's parents, Peter and Regina Ginsmore, are understandably distraught over their daughter's condition. Regina gently raises the option of euthanasia with Peter. Peter responds by saying that he, too, has been considering the option. Peter and Regina spend a great deal of time discussing all their options. Eventually they raise the issue of Euthanasia with their physician, Dr. Kevin Philmin. They spend some time with Kevin explaining the personal side of Rebecca Mae's disorder. They state that they have concluded that the best option would be for Rebecca Mae's life to be ended. Given his role as Rebecca Mae's physician Peter and Regina ask Kevin to inject her with a lethal drug.

Kevin, appalled at the very idea, refuses. He declares that the Hippocratic Oath forbids his ever harming a patient. More to the point, Kevin adds that his murdering Rebecca Mae (as he calls it) is illegal in the state of Massachusetts.

Peter and Regina drop the issue entirely and never speak of it to Kevin again. Six months later, Rebecca Mae dies at home. Kevin is suspicious, but does not demand an autopsy. Cause of death is listed as respiratory failure.

In fact, Peter and Regina gave Rebecca Mae an overdose of barbituates through the tube in her stomach to kill her.

Two questions:

  1. Was it morally right for Kevin to refuse to end Rebecca Mae's life?
  2. Was it morally right for Peter and Regina to end Rebecca Mae's life?

Theory Applied: Ideal Rule Utilitarianism (IRU)

Conclusion: It was morally impermissible for Kevin to refuse to euthanize Rebecca Mae and it was morally impermissible for Rebecca Mae's parents to euthanize her.

According to IRU, an action x is morally permissible just in case there is a rule R which is an element of a set of (consistent) rules S such that the total consequences of acting in accord with S maximizes utility--i.e., promotes the best interests of the greatest number--at least as well as any alternative set of rules and action x accords with R.

Consider the following rule (R):

Active Other-Administered Non-voluntary Euthanasia should be administered to person X only by their health care professional in cases where

1. X's proxy has requested that X be euthanized.

and

2. X suffers from an incurable and debilitating affliction such that conducting the following thought experiment reveals that X's continued existence is actually an injury to X: Suppose X were lucid and pain-free for ten minutes, suppose X's situation was clearly and carefully explained to X, and X is asked, "knowing that this is your existence, would you prefer to be euthanized?"

Let us suppose that S is a set of rules consisting of as many of the rules we currently adopt as consistently possible and R. Note that R, of course, is not a rule we currently adopt, so S is not identical to the set of rules we currently adopt. Now let us compare two worlds: The Actual World (@) and a Possible World (P) such that S is adopted in P. That is to say, everyone in P acts in accord with the rules in S.

It is a straightforward matter to show that utility is at least as great in P as it is in @--i.e., that u(P) >/= u(@). What is needed to show this is an account of how the total consequences of following R at least as well promote the best interests of the greatest number as the total consequences of not following R.

First, those who presumably suffer enormously from incurable and debilitating afflictions would be released from that suffering in P whereas they are not in @. Release from such suffering is surely in a person's best interests. And if they do not suffer--experience, that is, pain--such as perhaps is the case of the loss of brain function in severe coma, then at the very least they are no worse of than they are now, and the expense, both emotional and financial, to others of caring for them is alleviated in P. Indeed, in either case the emotional and financial hardship of care is removed once the afflicted person is euthanized. Such is not the case, as we have seen, in @. Thus, the total consequences of following R better promote the best interests of the greatest number than not following R. That is to say, utility is maximized in P over @.

But, secondly, it might be argued that R could easily be subject to abuse and this would mitigate the utility in P, perhaps so much as to leave @ a clear winner in the utility game. Perhaps, such an argument might proceed, R would be used as an excuse to get rid of the unwanted ill in society without actually doing anything to help them. It is clear, though, that such is not the case. Obviously there might be some isolated instances of abuse. But R is designed precisely so as to avoid such problems. For example, the proxy is never the one who administers euthanasia. Rather, it is the afflicted person's health care provider--in most instances, their physician. Thus we have a person in authority who is publicly answerable for their actions. Thus a safe-guard is built into the rule R to be sure that there is accountability for those who euthanize. Moreover, it must be the case, as (2) specifies, that NOTHING we know of can be done to help the afflicted person. Of course, there may be unfortunate cases where an afflicted person is euthanized when a cure for their affliction is discovered years later. But such cases can be expected, particular in cases of genetic defect, to be extraordinarily rare and do little to change the balance of utility from P to @. But, most importantly, the problem of a possible cure next year is built into the proposed thought experiment test. Note that X's situation in (2) is clearly and carefully explained to him or her. Part of that explanation must make mention of the fact that a cure MIGHT be discovered at some point in the future. But if we conclude the afflicted person would nonetheless opt for euthanasia in our thought experiment, as in many cases we would surely conclude, then it follows that their continued existence is indeed an injury to them (given what THEY conclude is in their best interests) regardless of whether there is some far-flung cure possible.

On the basis of these arguments I conclude that utility is maximized in P over @ and thus any action which accords with R is morally right.

Now let us consider the case of Rebecca Mae. It is clear from the statement of the case that Rebecca Mae satisfies both conditions (1) and (2) of R. Her parents (proxies) request her euthanasia and her affliction (Batten's disease) is incurable, horribly debilitating, and would surely pass the test of the thought experiment--particularly when one considers all the evidence that Rebecca Mae is often, despite her medication, in horrendous pain.

Thus the case of Rebecca Mae satisfies the necessary conditions on rule R and she should be euthanized by her health care professional. But Kevin, her health care professional, has refused. Thus he acts contrary to R and so his action is morally wrong. But by euthanizing Rebecca Mae themselves, her parents do what is morally wrong since, however good-hearted and laudable their intentions, they also fail to act in accord with rule R.

Were this case to occur in P and not @, Kevin, fulfilling one of his duties as a health care professional, would have humanely and quickly euthanized Rebbeca Mae and all relevant actions would have accorded with R. Such, sadly, is not the case.