Extended Examples: Euthanasia

PATERNALISM AND RESPECT FOR AUTONOMY

THE EXAMPLES OF EUTHANASIA AND ASSISTED SUICIDE

 

BASIC CONCEPTS:

Paternalism -- any action or policy in which some person (or group) treats another person the way a parent treats a child; that is, any action that strives to promote the other's good even against the other's wishes. To wit, you constrain someone’s freedom for his/her sake (e.g., drivers are forced to use safety belts because it is good for them).

Autonomy -- self-directed freedom, the governing of one's self according to one's own system of value convictions (in particular, moral convictions) and factual beliefs.

Informed consent -- consent given after full disclosure of risks, benefits, and alternative treatments to any proposed procedure, both in therapy and in medical experimentation.

Law entitles patients to such disclosure, except in emergencies or when the patient is incompetent in which case proxy consent is required.

EUTHANASIA (GOOD DEATH):

In typical (or most paradigm) cases, euthanasia involves the following elements:

(1)  Some person is killed or allowed to die;

(2)  this person is terminally and irreversibly ill and would die soon anyway;

(3)  this person suffers a terrible (physical or mental) pain (his or her conditions are for him/her intolerable);

(4)  this person requests to be killed (or to be allowed to die);

(5)  euthanasia is an act (or omission) of mercy; that is, the reason for killing (letting die) is to spare someone further excruciating suffering, and to provide this person with as "good death" as it is possible under the circumstan­ces.

If an act (omission) is sufficiently similar to the case just described than it is an act of euthanasia (even if it is not a standard, or central, case of euthanasia).

 

FEW DISTINCTIONS AND CLARIFICATIONS

Killing vs. Letting die: Active euthanasia involves deliberate killing. Passive euthanasia involves allowing someone to die.

Voluntary euthanasia: a person actually requests (or did request) to be killed (or to be allowed to die).

Nonvoluntary euthanasia: a person has not requested to be killed (or to be allowed to die) and did not request to be kept alive either.

Involuntary euthanasia: a person has requested to be kept alive. It is plausible to assume that all cases of involuntary euthanasia are morally unjustified, they are cases of unjustified murder.

 

ASSISTED SUICIDE AND EUTHANASIA ARE ALMOST IDENTICAL

Euthanasia: one person kills another (or, allows this person to die). I

Assisted suicide: One person provides another person with the means that allows this person to die; the person who dies kills himself/herself using this means.

 

TYPES OF EUTHANASIA AND THEIR MORAL STATUS

 

LETTING DIE

(ALLOWING)

KILLING

(ACTING)

EXPLICIT REQUEST

(VOLUNTARY)

Morally permissible

???

NO REQUEST

(NON-VOLUNTARY)

Morally permissible

???

REQUEST TO BE KEPT ALIVE (INVOLUNTARY)

Morally wrong

(murder)

Morally wrong

(murder)

A. Most people and organizations allow various forms of passive euthanasia.

B. There is a serious ethical debate about moral permissibility of voluntary and non-voluntary active euthanasia.

C. Most people and organizations assume that involuntary euthanasia is always (or almost always) morally wrong.

This form of euthanasia would cause  lots of suffering and anguish, etc.

It violates the autonomy of individual.

It violates human right; especially, the right to life.

 

THE MAIN ARGUMENT IN SUPPORT OF EUTHANASIA

1.  An Ethical Premise: Any act (or omission) is morally permissible, if it satisfies all of the following conditions:

A. it respects autonomy of everyone who is involved;

B. it violates no one's rights; and

C. It promotes the best interest of everyone concerned.

2.  A factual claim: In typical cases, the acts of euthanasia and assisted suicide are A, B, C.

3.  Therefore, in typical cases the acts of euthanasia and assisted suicide are morally permissible. [from (1) and (2)]

 

AN ARGUMENT FROM CONSISTENCY (in Support of Active Euthanasia)

1.    There is no moral difference between killing someone (per se), and letting someone die (per se). [Other things being equal, killing is just as good/bad as letting someone die.]

2.    In typical cases, the only difference between active euthanasia (AE) and passive euthanasia (PE) is this: AE involves killing while PE involves letting someone die.

3.    If (1) and (2), then in typical cases there is no moral difference between AE and PA. [That is, if (1) and (2), then... AE is just as good/bad as PE.]

______________

4.     Therefore, in typical cases, there is no moral difference between AE and PA. [That is, AE is just as good/bad as PE.] [from (1), (2), and (3)]

5.     In typical cases, passive euthanasia is morally permissible. [This premise is granted by AMA and various religious organizations.]

______________

6.     Therefore, in typical cases, active euthanasia is morally permissible. [from (4) and (5)]

 

TWO CASES IN SUPPORT OF Premise (1): Based J. Rachels, "Active and Passive Euthanasia", The New England Journal of Medicine 282 [1975], pp. 78-80):

CASE I (Killing): Smith stand to gain a large inheritance if anything should happen to his six-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.

CASE II (Letting die): Jones also stands to gain if anything should happen to his six-year-old cousin. Like Smith, Jones sneaks in planning to drown the child in his bath. However, just as he enters the bathroom Jones sees the child slip and hit his head, and fall face down in the water. Jones is delighted; he stands by, ready to push the child's head back under if it is necessary, but it is not necessary. With only a little thrashing about the child drowns all by himself, "accidentally", as Jones watches and does nothing.

An Argument In Support of Premise (1):

A.            If there moral difference between killing someone (per se) and letting someone die (per se), then there is moral difference between what Smith did and what Jones did.

B.            But there is no difference between what Smith did and what Jones is did.

__________

Therefore, premise (1) is true; that is, there is no moral difference between killing someone (per se) and letting someone die (per se).

 

TWO CONCEPTS OF EXTRAORDINARY MEANS

THE FIRST PURELY DESCRIPTIVE CONCEPT OF ORDINARY MEANS:

Ordinary means of treatment are all medicines, treatments, and operations, which are common, easily administered, and cheap (e.g., insulin and antibiotic). 

  • "For the physician, ordinary means of preserving health are standard, recognized, or established medicines or procedures of the time period one is acting in, at the level of prevailing medical practice, and within the limits of availability."
  • For the physician, extraordinary means for preserving life would be medicaments or procedures that are fanciful, bizarre, experimental, incompletely established, unorthodox, or not recognized. (The Catholic Bishops of Florida, AThe Pastoral Letter on Death ... (See also: http://www.culturalcatholic.com/CatholicLivingWill.htm)

A PROBLEM:

This is a purely descriptive concept/distinction. This is not the distinction proposed by ethicists and moral theologians (including the American Medical association) as morallyrelevant. In particular, virtually all ethicists and moral theologians agree that it is sometimes permissible to discontinue antibiotics or insuline (if they do not offer any reasonable chances of benefits). So, anti-biotics and insuline would count, in some contexts, as extra-ordinary means of treatment. 

THE SECOND NORMATIVE CONCEPT OF ORDINARY MEANS OF TREATMENT

  • From the viewpoint of the theologian, ordinary means for preserving life include "all medicines, treatments, and operations which offer a reasonable hope of benefit for the patient and which can be obtained and used without excessive expense, pain, or other inconvenience." For the theologian, extraordinary means for preserving life are "all medicines, treatments, and operations which cannot be obtained or used without excessive expense, pain, or other inconvenience for the patient or for others or which, if used, would not offer reasonable hope or benefit for the patient. (The same letter)
  • Ordinary means of preserving life are all medicines, treatments, and operations, which offer a reasonable hope of benefit for the patient and which can be obtained and used without excessive expense, pain, and other inconveniences. Extra-ordinary means of preserving life are all those medicines, treatments, and operations which cannot be obtained without excessive expense, pain, and other inconveniences, or which, if used, would not offer a reasonable hope of benefit (Paul Ramsey, Patient as a Person...)

By this definition, insulin and antibiotics are ordinary means of preserving life only if they offer a reasonable hope of benefit. If the situation is hopeless, the insulin and the antibiotics are extraordinary.

IMPLICATIONS OF THE SECOND CONCEPT OF ORDINARY MEANS

  • The concept of a reasonable hope of benefits must be explained. What do we mean, exactly, by this concept?
  • Almost always, the doctors may extend or prolong someone's life. Yet, the quotes and examples offered above imply that, sometimes, a doctor is not obligated to use such medicines as anti-biotics or insuline. So, they assume that it is not always obligatory to prolong someone's life. 
  • That is, to use this normative definition, we must assume that, at least sometimes, it is not overall good (beneficial) for a person to stay alive. That's why we can withold or withdrew a medical treatment.

Questions for review:

1) Suppose that a terminally ill patient with highly progressed AIDS has developed pneumonia. Doctors can cure pneumonia but they do not do it. A patient dies. Arguably, it’s a case of

A) active euthanasia;

B) passive euthanasia; 

C) suicide;

D) none of the above.

2) The same example. The doctors reason as follows, “We could cure this patient pneumonia using antibiotics. Such treatment is readily available and inexpensive. But, it would not offer this person any reasonable chances of benefit for he will soon die no matter what. Thus, there is no obligation to treat pneumonia.” (Paul Ramsey offers this sort of argument; see the handout on euthanasia and the outline posted on the class web site.) This reasoning assumes that, in this case, the treatment of pneumonia would involve

A) extraordinary (i.e. heroic) means of treatment;

B) ordinary means of treatment;

C) both;

D) neither.

3) Stef argued that the concept of extraordinary means of treatment proposed by AMA, Roman Catholic Church, Paul Ramsey, and many other professional and religious organizations  requires us to assume that  merely being or staying alive

A) is always beneficial to a person;

B) is not always beneficial for a person (sometimes, it is not beneficial for a person);

C) is morally irrelevant;

D) none of the above.

4)  According to Stef, one of the main difference between passive euthanasia (PE) and active euthanasia (AE) is this:

A) PE involves allowing while AE involves doing;

B) PE is permissible while AE is wrong;

C) PE is voluntary while AE is not;

D) none of the above.

5) According to arguments presented in class, involuntary euthanasia is wrong because of

A) consequentialist considerations (overall, it’s not the best alternative);

B) deontological considerations (it violates autonomy of individuals and their rights);

C) both A) and B;

D) none of the above.

6) If a dying person requests death, is not treated, and dies, it is a case of

A) active voluntary euthanasia;

B) passive voluntary euthanasia;

C) passive involuntary euthanasia;

D) passive nonvoluntary euthanasia;

E) none of the above.

7) Same case. Assume that his treatment is extremely expensive and she does not have any reasonable chances of benefit. If the doctors did not treat her, they would have withhold

A) ordinary means of treatment;

B) extraordinary means of treatment;

C) neither of the above.

8) Stef argued in class that, in typical cases, both passive and active euthanasia may be permissible because

A) each may best for all involved (it maximizes social utility);

B) neither violates autonomy or human rights;

C) both A) and B);

D) none of the above

9) For legal purposes (e.g., according to the Oregon laws permitting some forms of assisted suicide), a person is terminally ill if, according to the medical prognosis, he or she will die within

A) 3 months;

B) 6 months;

C) 1 year;  

D) 2 years;  

E) 3 years.

10) In the US, people have a constitutional right

A) to commit a suicide;

B) to have an active euthanasia;

C) both A) and B);

D) none of the above, so it is up to the states to regulate these issues.

11) Kevorkian employs some constraints on when assisted suicide is permissible. These constraints are

A) much weaker than those used in the Oregon’s law permitting assisted suicide (e.g., Kevorkian does not require any significant waiting period, does not make sure that a person is competent, etc.)

B) about as strong as those used in the Oregon’s law permitting assisted suicide;

C) much stronger than those used in the Oregon’s law permitting assisted suicide.