euthanasia n phi 2604 n anthony d’ascoli 9/15/2015 anthony d'ascoli 1

Euthanasia

PHI 2604

Anthony D’Ascoli

04/19/23 Anthony D'Ascoli http://www.dascolihum.com

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Introduction

Increasingly, Americans die in medical facilities– 85% of Americans die in some kind

of health-care facility (hospitals, nursing homes, hospices, etc.);

– Of this group, 70% (which is equivalent to almost 60% of the population as a whole) choose to withhold some kind of life-sustaining treatment


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The Changing Medical Situation

Until the 1940’s, medical care was often just comfort care, alleviating pain when possible

During the last 50+ years, medicine has become increasingly capable of postponing death

Increasingly, we are forced to choose whether to allow ourselves to die.


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The Changing Insurance Situation

Initially, the difficult was that physicians often wanted to do more to save the dying than either the dying or their families wanted– The medical challenge– Fear of lawsuits

Now, the difficulty is that insurance companies and managed care may provide financial incentives for doing less for the dying than either they or their families want.

Close to one-third of all Medicare dollars are spent on end-of-life care


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An Increasing Interest inEnd-of-life Issues

The Bill Moyers series on dying; Sept. , 2000.

JAMA issues on End-of-life decisions

New England Journal of Medicine


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What are we striving for?

Euthanasia means “a good death,” “dying well.”

What is a good death?– Peaceful– Painless– Lucid– With loved ones gathered around

Part One.Cases and Laws


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Karen Ann Quinlan

Karen Ann Quinlan


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Karen Ann Quinlan, Web Resources


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Cruzan


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Cruzan, 2


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Cruzan, 3


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Washington v. Glucksburg


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Vacco v. Quill


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Vacco v. Quill. 2


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Terri Schiavo

The Terri Schiavo case is, so far,

the most famous and

notorious end-of-life case of

the twenty-first century.


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Terri Schiavo Timeline, 1 Source: http://www.miami.edu/ethics2/schiavo_project.htm Kathy Cerminara, Nova Southeastern University, Shepard Broad Law Center Kenneth Goodman, University of Miami Ethics Programs

December 3, 1963 -- Theresa (Terri) Marie Schindler born Novermber 10, 1984 Terri Schindler and Michael Schiavo are married at Our Lady of Good Counsel

Church in Southhampton, Pennsylvania. She was 20; he was 21. 1986

The couple move to St. Petersburg, where Ms. Schiavo's parents had retired. February 25, 1990

Ms. Schiavo suffers cardiac arrest, apparently caused by a potassium imbalance and leading to brain damage due to lack of oxygen. She was taken to the Humana Northside Hospital and was later given a percutaneous endoscopic gastrostomy (PEG) to provide nutrition and hydration.

May 12, 1990 Ms. Schiavo is discharged from the hospital and taken to the College Park skilled

care and rehabilitation facility.


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Terri Schiavo Timeline, 2 June 18, 1990 Court appoints Michael Schiavo as guardian; Ms. Schiavo’s parents do not object. June 30, 1990 Ms. Schiavo is transferred to Bayfront Hospital for further rehabilitation efforts. September 1990 Ms. Schiavo’s family brings her home, but three weeks later they return her to the

College Park facility because the family is “overwhelmed by Terri’s care needs.” November 1990 Michael Schiavo takes Ms. Schiavo to California for experimental “brain stimulator”

treatment, an experimental “thalamic stimulator implant” in her brain. January 1991 The Schiavos return to Florida; Ms. Schiavo is moved to the Mediplex Rehabilitation

Center in Brandon where she receives 24-hour care. July 19, 1991 Ms. Schiavo is transferred to Sable Palms skilled care facility where she receives

continuing neurological testing, and regular and aggressive speech/occupational therapy through 1994.

May 1992 Ms. Schiavo’s parents, Robert and Mary Schindler, and Michael Schiavo stop living

together.


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Terri Schiavo Timeline, 3 August 1992 Ms. Schiavo is awarded $250,000 in an out-of-court medical

malpractice settlement with one of her physicians. November 1992 The jury in the medical malpractice trial against another of Ms.

Schiavo's physicians awards more than one million dollars. In the end, after attorneys’ fees and other expenses, Michael Schiavo received about $300,000 and about $750,000 was put in a trust fund specifically for Ms. Schiavo’s medical care.

February 14, 1993 Michael Schiavo and the Schindlers have a falling-out over the

course of therapy for Ms. Schiavo; Michael Schiavo claims that the Schindlers demand that he share the malpractice money with them.

July 29, 1993 Schindlers attempt to remove Michael Schiavo as Ms. Schiavo’s

guardian; the court later dismisses the suit.


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Terri Schiavo Timeline, 4

March 1, 1994 First guardian ad litem, John H. Pecarek, submits his report. He states that

Michael Schiavo has acted appropriately and attentively toward Ms. Schiavo.

May 1998 Michael Schiavo petitions the court to authorize the removal of Ms.

Schiavo’s PEG tube; the Schindlers oppose, saying that she would want to remain alive. The court appoints Richard Pearse, Esq., to serve as the second guardian ad litem for Ms. Schiavo.

December 20, 1998 The second guardian ad litem, Richard Pearse, Esq., issues his report in

which he concludes that Ms. Schiavo is in a persistent vegetative state with no chance of improvement and that Michael Schiavo’s decision-making may be influenced by the potential to inherit the remainder of Ms. Schiavo’s estate.

February 11, 2000 Judge Greer rules that Ms. Schiavo would have chosen to have the PEG

tube removed, and therefore he orders it removed, which, according to doctors, will cause her death in approximately 7 to 14 days.


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Terri Schiavo Timeline, 5

March 18, 2005

The PEG tube is removed in mid-afternoon. This is the third time the tube has been removed in accordance with court orders.

March 31, 2005Ms. Schiavo dies at 9:05 a.m. Her body is transported to the Pinellas Country Coroners’ Office for an autopsy.

April 15, 2005In response to a motion from the media, Judge Greer orders DCF to release redacted copies of abuse reports regarding Ms. Schiavo. Newspapers report that DCF found no evidence of abuse after investigating the 89 reports filed before February 18, 2005. Thirty allegations are outstanding and still being investigated, but Judge Greer earlier had ruled that those allegations duplicated those previously filed.


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The Schiavo Case: Sources of Uncertainty

For the public, great uncertainty about what the actual facts of the case are—ethical responsibility of the media

For the family, uncertainty and disagreement about whether she was still there or not—ethical responsibility of science—especially neurosciences—to shed light on the connections between brain conditions and personhood. We face two questions in cases such as this:

– Is Terri there?– Is a person there?

• Central to these questions is the issue of how we define personal identity and personhood.

– Is there any hope, or any reasonable hope, for recovery or improvement? For everyone, uncertainty about what Terri’s wishes were. Conflicting

accounts of her wishes. Here we see the importance, not only of advanced directives and durable power of attorney for health care, but also of extensive discussion of these issues among family and friends.

For everyone, uncertainty about the extent of pain and discomfort associated with withdrawal of nutrition and hydration. In this and numerous related questions about the end of life, hospice and palliative care programs can shed light on the process of dying.


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Schiavo Autopsy

The Schiavo autopsy, released June 15 2005, showed severe and irreversible brain damage

Brain half its usual size Damaged in almost all regions,

including that region which controls vision

The Oregon Death with Dignity Act


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http://www.oregon.gov/DHS/ph/pas/index.shtml

Oregon

“The most important reasons for requesting PAD…were – wanting to control the circumstances of death and die at home;

– loss of independence; and

– concerns about future pain, poor quality of life, and inability to care for one’s self.

All physical symptoms (eg, pain, dyspnea, and fatigue) at the time of the interview were rated as unimportant (median score, 1), but concerns about physical symptoms in the future were rated at a median score of 3 or higher.

“Lack of social support and depressed mood were rated as unimportant reasons for requesting PAD. :

Oregonians’ Reasons for Requesting Physician Aid in Dying. Linda Ganzini, MD, MPH; Elizabeth R. Goy, PhD; Steven K. obscha, MD.

ARCH INTERN MED/VOL 169 (NO. 5), MAR 9, 2009


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Part Two.

The Philosophical Issues


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Some Initial Distinctions

Active vs. Passive Euthanasia Voluntary, Non-voluntary, and

Involuntary Euthanasia Assisted vs. Unassisted Euthanasia


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Active vs. Passive Euthanasia

Active euthanasia occurs in those instances in which someone takes active means, such as a lethal injection, to bring about someone’s death;

Passive euthanasia occurs in those instances in which someone simply refuses to intervene in order to prevent someone’s death.


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Criticisms of the Active/Passive Distinction in Euthanasia

Conceptual Clarity– Vague dividing line between active and

passive, depending on notion of “normal care”

– Principle of double effect Moral Significance

– Does passive euthanasia sometimes cause more suffering?


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Active Euthanasia

Typical case for active euthanasia– there is no doubt that the patient will die

soon– the option of passive euthanasia causes

significantly more pain for the patient (and often the family as well) than active euthanasia and does nothing to enhance the remaining life of the patient, and

– passive measures will not bring about the death of the patient.


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Voluntary, Non-voluntary, and Involuntary Euthanasia

Voluntary: patient chooses to be put to death

Non-voluntary: patient is unable to make a choice at all

Involuntary: patient chooses not to be put to death, but is anyway


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Assisted vs. Unassisted Euthanasia

Many patients who want to die are unable to do so without assistance

Some who are able to assist themselves commit suicide with guns, etc.--ways that are much harder and difficult for those who are left behind.


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Overview of Distinctions

Passive Active:Not Assisted

Active:Assisted

Voluntary Currently legal;often contained inliving wills

Equivalent tosuicide for thepatient

Equivalent to suicidefor the patient;Possibly equivalent tomurder for theassistant, except inOregon

Nonnvoluntary:Patient Not

Able to Choose

Sometimes legal,but only with courtpermission

Not possible Equivalent to eithersuicide or beingmurdered for thepatient;Legally equivalent tomurder for theassistant

Involuntary:Against

Patient’sWishes

Not Legal Not possible Equivalent to beingmurdered for thepatient;Equivalent to murderfor assistant


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Compassion for Suffering

The larger question in many of these situations is: how do we respond to suffering?– Hospice and palliative care– Aggressive pain-killing medications– Sitting with the dying– Euthanasia


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The Sanctity of Life

Life is a gift from God Respect for life is a “seamless

garment” Importance of ministering to the sick

and dying See life as “priceless” (Kant)


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The Right to Die

Do we have a right to die?– Negative right (others may not interfere)– Positive right (others must help)

Do we own our own bodies and our lives? If we do own our own bodies, does that give us the right to do whatever we want with them?

Isn’t it cruel to let people suffer pointlessly?


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The Slippery Slope

Worrisome examples from history:– Nazi eugenics program

• California eugenics program– Chinese orphanages

Special danger to undervalued groups in our society– The elderly– Minorities– Persons with disabilities– Groups that are typically discriminated against


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Two Models

A utilitarian model, which emphasizes consequences

A Kantian model, which emphasizes autonomy, rights, and respect


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The Utilitarian Model

Goes back at least to John Stuart Mill (1806-73)

The greatest good for the greatest number


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Main Tenets

Morality is a matter of consequences We must count the consequences for

everyone Everyone’s suffering counts equally We must always act in a way that

produces the greatest overall good consequences and least overall bad consequences.


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The Calculus Morality becomes a

matter of mathematics, calculating and weighing consequences

Key insight: consequences matter

The dream: bring certainty to ethics


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How much care should be given at the end of life?

Health care providers are increasingly concerned, not just about how much money is spent on patients, but about how effectively it is spent.

Disproportionate amount of money spent in final months of life.• 40 percent of Medicare dollars cover care

for people in the last month.• Nearly one third of terminally ill patients

with insurance used up most or all of their savings to cover uninsured medical expenses such as home care.

Concept of medical futility is utilitarian in character.


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What is a good death?

Jeremy Bentham.Hedonistic utilitarians:

a good death is a painless death.

Eudaimonistic utilitarians: a good death is a happy death.

John Stuart Mill


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Understanding Bizarre Suggestions

All of the following make sense if we think of end-of-life decisions solely in terms of reducing painful consequences:

Passive euthanasia sometimes worse than active euthanasia—James Rachels

“It’s over, Debbie”—just end the suffering A duty to die


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The Kantian Model

Central insight: people cannot be treated like mere things.

Key notions:– Autonomy &

Dignity– Respect– Rights


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Autonomy & Respect

Kant felt that human beings were distinctive: they have the ability to reason and the ability to decide on the basis of that reasoning.– Autonomy = freedom + reason– Autonomy for Kant is the ability to

impose reason freely on oneself.


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Treating People as Mere Means

The Tuskegee Syphilis Experiments– More than four hundred

African American men infected with syphilis went untreated for four decades in a project the government called the Tuskegee Study of Untreated Syphilis in the Negro Male.

– Continued until 1972


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Protecting Autonomy

Advanced Directives are designed to protect the autonomy of patients They derive directly from a Kantian view of what is morally important.


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Autonomy: Who Decides

Kantians emphasize the importance of a patient’s right to decide

Utilitarians look only at consequences

In cases such as the Siamese twins, they see radically different worlds.


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From Autonomy to Rights

Because human beings have the ability to make up their own minds in accord with the dictates of reason, they have certain rights.

If someone has a right, we have a correlatively duty to respect that right.

Rights Duties


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Types of Rights Two types of rights

– Negative: imposes duties of non-interference on others

– Positive: imposes duties of assistance on others

Health care (including end-of-life care) as a right:– Negative right. Widespread

agreement on this.– Positive right. Much

disagreement. Do people have a right to health care even when they can’t pay? On whose shoulders does the duty fall?


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Conclusion

Many of the ethical disagreements about end-of-life decisions can be seen as resulting from differing ethical frameworks, esp. Kantian vs. utilitarian.

Use these models to understand where you stand, where your patients stand, and where your organization stands in regard to end-of-life issues.

Lawrence M. HinmanSend E-mail to Larry Hinman

University of San Diego


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The Interdisciplinary Characterof Moral Problems:

End-of-life Decisions


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Disciplines Considering End-of-Life Issues

Philosophy Religious Studies

& Theology Literature Psychology Sociology Biology

Economics Political Science Media Studies Medicine Art Theater


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Euthanasia

The word “euthanasia” comes from the Greek words for death (thanatos) and “good” or “well” (eu-). Although it is often taken in a narrow sense as referring to assisted suicide, its original sense is of more interest to us here:

how can we die well?


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End-of-Life Decisions

Until recently, end-of-life decisions for most people were easy: You tried to stay alive as long as you could, and then you just died.

Today, we are lucky if we are able to “just die.” In most cases, difficult decisions have to be made about when to stop medical treatment.


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The Biology of Aging and Dying

Biologists and researchers in related fields are continually probing into questions central to our understanding of the biological dimensions of aging and dying, including:– Can the aging process be

slowed down?– On the biology of dying, see

Sherwin Nuland’s How We Die.


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Psychology

The psychological dimensions of end-of-life decisions

Classic source: Elizabeth Kübler-Ross, On Death and Dying

• Stage 1- Shock and denial

• Stage 2- Anger

• Stage 3- Bargaining

• Stage 4- Depression

• Stage 5- Acceptance

• Typically no clear demarcation b/w stages and some may occur in different order


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Art

Throughout the ages, we have sought to understand death through art.


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Art

Throughout the ages, we have sought to understand death through art.

Dürer, “The Four Horsemen of the Apocalypse”


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Art--2Jack Kevorkian

Nearer My God to Thee


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Music

Whether through requiems or ragas, we have always expressed our feelings about death and end-of-life decisions through music.Mahler’s Kindestotenlieder


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Literature

Leo Tolstoy, “The Death of Ivan Illych”

See The Oxford Book of Deathby D. J. Enright


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Theology & Religious Studies

Consider the various ways in which different religious traditions provide us with guidance in making difficult decisions at the end of life.– Christian– Jewish– Buddhist– Muslim– Native American


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Economics

Consider economic factors that have had an impact on end-of-life issues:

Increasing cost of health care Greater social mobility Percentage of health care dollars

spent in last few months of life


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Sociology

Study of different social aspects of dying, such as varying mortality rates for various groups in various nations, percentage of accidental deaths, etc.

See Michael Kearl’s Guide to Sociological Thanatalogy: http://www.trinity.edu/~mkearl/death.html


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Anthropology Anthropologists

have long been concerned with death and the rituals surrounding it.

Celebrations of Death: The Anthropology of Mortuary Rituals.Edited by by Peter Metcalf, Richard Huntington

euthanasia n phi 2604 n anthony d’ascoli 9/15/2015 anthony d'ascoli 1

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