EuthanasiaEuthanasia

PHL281Y BioethicsPHL281Y BioethicsSummer 2005 University of TorontoSummer 2005 University of Toronto

Prof. Kirstin BorgersonProf. Kirstin BorgersonCourse Website: www.chass.utoronto.ca/~kirstinCourse Website: www.chass.utoronto.ca/~kirstin

OverviewOverview

1.1. Euthanasia – definition and public debateEuthanasia – definition and public debate

2.2. Distinctions Distinctions

3.3. Dax’s CaseDax’s Case

4.4. ‘‘It’s Over Debbie’It’s Over Debbie’

5.5. Rachels’ 3 Arguments (& objections)Rachels’ 3 Arguments (& objections)

6.6. Brock’s Arguments for Active Euthanasia (& objections)Brock’s Arguments for Active Euthanasia (& objections)

7.7. Looking ahead to Physician-Assisted SuicideLooking ahead to Physician-Assisted Suicide

EuthanasiaEuthanasia

““Good death” Good death” ““Euthanasia is the painless killing of a patient Euthanasia is the painless killing of a patient

suffering from a incurable and painful disease” suffering from a incurable and painful disease” ((OEDOED) )

Suicide and Euthanasia have always been topics Suicide and Euthanasia have always been topics of concern for moral philosophers because they of concern for moral philosophers because they raise fundamental questions about the meaning raise fundamental questions about the meaning and value of life and death, and the limits of and value of life and death, and the limits of autonomy and beneficenceautonomy and beneficence

Public AttentionPublic Attention

Why?Why? Health advancements (hygiene, nutrition) and life Health advancements (hygiene, nutrition) and life

expectancyexpectancy Medical technologyMedical technology Social scientific evidence of inadequate pain control Social scientific evidence of inadequate pain control

(SUPPORT study 1995 – USA)(SUPPORT study 1995 – USA) Public demand (high approval rate in Canada)Public demand (high approval rate in Canada) Medicalization of death (4/5 in institutions)Medicalization of death (4/5 in institutions) Underground common practice (‘twilighting’)Underground common practice (‘twilighting’) Shift in cultural values (autonomy – ex/ fertility)Shift in cultural values (autonomy – ex/ fertility) Legal battles and media attentionLegal battles and media attention ……

Recall: Moral/LegalRecall: Moral/Legal

Euthanasia raises debate on a range of Euthanasia raises debate on a range of topics. These tend to fall into two main areas:topics. These tend to fall into two main areas:

Moral – where questions address what is Moral – where questions address what is morally good and justifiablemorally good and justifiable

Legal – where questions address what Legal – where questions address what legislation is most appropriate for a given legislation is most appropriate for a given societysociety

*We are focusing on moral issues raised by *We are focusing on moral issues raised by euthanasiaeuthanasia

DistinctionsDistinctions

Voluntary Euthanasia (VE) – provided at the Voluntary Euthanasia (VE) – provided at the request of a competent individualrequest of a competent individual Example: Sue Rodriguez (Amyotrophic Lateral Sclerosis)Example: Sue Rodriguez (Amyotrophic Lateral Sclerosis)

Nonvoluntary Euthanasia (NE) – provided for an Nonvoluntary Euthanasia (NE) – provided for an incompetent individualincompetent individual Example: Tracy Latimer (Severe Cerebral Palsy)Example: Tracy Latimer (Severe Cerebral Palsy)

Involuntary Euthanasia (IE) – provided without the Involuntary Euthanasia (IE) – provided without the permission of a competent individual (against permission of a competent individual (against his/her will)his/her will) homicidehomicide

Distinctions (continued)Distinctions (continued)

Active Euthanasia (AE) – killingActive Euthanasia (AE) – killing Example: administering a lethal Example: administering a lethal

dose to a patientdose to a patient

Passive Euthanasia (PE) – letting diePassive Euthanasia (PE) – letting die Example: withholding or withdrawing a Example: withholding or withdrawing a

respiratorrespirator

4 Categories4 Categories

1.1. Voluntary Active Euthanasia (VAE)Voluntary Active Euthanasia (VAE) Most attention is hereMost attention is here

2.2. Nonvoluntary Active Euthanasia (NAE)Nonvoluntary Active Euthanasia (NAE)

3.3. Voluntary Passive Euthanasia (VPE)Voluntary Passive Euthanasia (VPE)

4.4. Nonvoluntary Passive Euthanasia (NPE)Nonvoluntary Passive Euthanasia (NPE) Passive forms are relatively widely accepted Passive forms are relatively widely accepted

(now)(now)

Dax CowartDax Cowart

Donald ‘Dax’ Cowart:Donald ‘Dax’ Cowart: Fighter pilot, high school football heroFighter pilot, high school football hero 25 years old, propane gas explosion killed his 25 years old, propane gas explosion killed his

father and left Dax with burns over 65% of his father and left Dax with burns over 65% of his bodybody

Underwent intensive (and extraordinarily painful) Underwent intensive (and extraordinarily painful) treatments lasting over a year, while consistently treatments lasting over a year, while consistently requesting to die and threatening to kill himselfrequesting to die and threatening to kill himself

Video: ‘Please Let Me Die’ (1974)Video: ‘Please Let Me Die’ (1974) Video: ‘Dax’s Case’ (1984)Video: ‘Dax’s Case’ (1984)

Dax CowartDax Cowart

Right to refuse treatment? Right to refuse treatment?

Should autonomy extend to death?Should autonomy extend to death?

Paternalism/Autonomy debate in Paternalism/Autonomy debate in medicinemedicine

UpdateUpdate

Law degree (1986), Law degree (1986), became a patient became a patient advocateadvocate

Married Married Continues to insist Continues to insist

that his requests to that his requests to discontinue discontinue treatment should treatment should have been respectedhave been respected

‘‘It’s Over Debbie’It’s Over Debbie’

Published in the Published in the Journal of the American Medical Association Journal of the American Medical Association (JAMA) (JAMA) in 1988in 1988

ABSTRACT: “A physician who describes himself or herself ABSTRACT: “A physician who describes himself or herself only as a gynecology resident in a large, private hospital only as a gynecology resident in a large, private hospital writes in writes in JAMAJAMA's "A piece of my mind" column about having 's "A piece of my mind" column about having administered a lethal dose of morphine to a terminally ill administered a lethal dose of morphine to a terminally ill patient. The resident reports that the 20-year-old patient patient. The resident reports that the 20-year-old patient was dying of ovarian cancer, had not eaten or slept in two was dying of ovarian cancer, had not eaten or slept in two days, and was suffering from unrelenting vomiting. The days, and was suffering from unrelenting vomiting. The resident, who had not seen the patient before, also writes resident, who had not seen the patient before, also writes that her [the patient’s] only words at the time were ‘Let's that her [the patient’s] only words at the time were ‘Let's get it over with.’” get it over with.’”

ResponsesResponses

Intuitive response?Intuitive response? Justified killing?Justified killing? JAMA’s positionJAMA’s position

Rachels’ 3 ArgumentsRachels’ 3 Arguments

1.1. The Humanitarian ArgumentThe Humanitarian Argument

2.2. The Irrelevant Reasons ArgumentThe Irrelevant Reasons Argument

3.3. The Main ArgumentThe Main Argument

1. The Humanitarian 1. The Humanitarian ArgumentArgument

Logical structure:Logical structure:

1.1. PE is acceptable on humanitarian PE is acceptable on humanitarian groundsgrounds

2.2. AE is more humane than PEAE is more humane than PE

3.3. Therefore, AE is more acceptable than Therefore, AE is more acceptable than PEPE

ObjectionObjection

It is true that the American Medical It is true that the American Medical Association (AMA) accepts PEAssociation (AMA) accepts PE

Why?Why? What does this mean for the What does this mean for the

argument?argument? Which premise (if any) is problematic?Which premise (if any) is problematic? What about the other premise?What about the other premise?

2. The Irrelevant Reasons 2. The Irrelevant Reasons ArgumentArgument

Logical structure:Logical structure:

1.1. A patient who has a serious medical condition ‘C’ has a A patient who has a serious medical condition ‘C’ has a life that is either worth preserving or not regardless of life that is either worth preserving or not regardless of whether the patient needs a simple operation for whether the patient needs a simple operation for problem ‘P’ which is unrelated to ‘C’, in order to surviveproblem ‘P’ which is unrelated to ‘C’, in order to survive

2.2. Because AE is thought to be wrong, some medical Because AE is thought to be wrong, some medical decisions for those with condition ‘C’ are made on the decisions for those with condition ‘C’ are made on the basis of problem ‘P’basis of problem ‘P’

3.3. Therefore, because AE is thought to be wrong, some Therefore, because AE is thought to be wrong, some medical decisions to save or not to save a patients’ life medical decisions to save or not to save a patients’ life are made on are made on irrelevant grounds irrelevant grounds (grounds which have no (grounds which have no stated moral justification)stated moral justification)

ClarificationClarification

Example: Intestinal blockage and Down’s Example: Intestinal blockage and Down’s SyndromeSyndrome

Basis of decision seems to be an Basis of decision seems to be an assessment what sorts of lives are worth assessment what sorts of lives are worth livingliving

We should ensure We should ensure thesethese decisions are decisions are morally justifiablemorally justifiable

Objections?Objections?

3. The Main Argument3. The Main Argument

Logical structure:Logical structure:

1.1. PE is morally justifiablePE is morally justifiable

2.2. The distinction between killing and letting die The distinction between killing and letting die is not morally significant [from thought is not morally significant [from thought experiment]experiment]

3.3. Therefore, AE is morally justifiable on the Therefore, AE is morally justifiable on the same grounds as PE same grounds as PE

Smith and JonesSmith and Jones

SmithSmith

JonesJones

Killing/Letting DieKilling/Letting Die

Good thought experiment (isolates Good thought experiment (isolates distinction)distinction) Same motivesSame motives Same willingness to killSame willingness to kill Same resultSame result

““Did either man behave better, from a Did either man behave better, from a moral point of view?” (400)moral point of view?” (400)

Was Jones’ behavior less reprehensible Was Jones’ behavior less reprehensible than Smith’s?than Smith’s?

Back to the Main ArgumentBack to the Main Argument

If you are inclined to agree that there is no If you are inclined to agree that there is no moralmoral difference between the behavior of Smith and difference between the behavior of Smith and Jones, then it looks as though Rachels has Jones, then it looks as though Rachels has provided support for his second premise:provided support for his second premise:

2. The distinction between killing and letting die is not 2. The distinction between killing and letting die is not morally significantmorally significant

Note: It may be the case that actual cases of killing are Note: It may be the case that actual cases of killing are usually morally reprehensible (murders, etc.) and cases of usually morally reprehensible (murders, etc.) and cases of letting die usually are not (humanitarian reasons), but then letting die usually are not (humanitarian reasons), but then it is other factors (for example, motive/intention) that it is other factors (for example, motive/intention) that should be the focus of our moral assessmentsshould be the focus of our moral assessments

ObjectionsObjections

?? IntentionsIntentions Rachels - intentions are only relevant Rachels - intentions are only relevant

for assessing character, but are not for assessing character, but are not relevant for assessing the morality of relevant for assessing the morality of an action (note the moral theory in an action (note the moral theory in the background here)the background here)

No act/omission distinctionNo act/omission distinction

RachelsRachels

Wants to eliminate the ‘middle Wants to eliminate the ‘middle ground’ position taken by ground’ position taken by organizations like the American organizations like the American Medical Association (AMA)Medical Association (AMA)

Gives reasons for doubting the moral Gives reasons for doubting the moral relevance of the active/passive relevance of the active/passive distinctiondistinction

BrockBrock

Argues Argues forfor Voluntary Active Euthanasia Voluntary Active Euthanasia (VAE)(VAE)

On the basis of two principles:On the basis of two principles: Autonomy (self-determination)Autonomy (self-determination) Beneficence (well-being)Beneficence (well-being)

Same values that support patient’s rights to Same values that support patient’s rights to decide about life-sustaining treatmentdecide about life-sustaining treatment

BrockBrock

AUTONOMYAUTONOMY Human dignity lies in people’s capacity to direct their Human dignity lies in people’s capacity to direct their

liveslives Individual self-determination extends to death; many Individual self-determination extends to death; many

patients find that quality of life, avoiding suffering, patients find that quality of life, avoiding suffering, maintaining dignity and insuring that others remember maintaining dignity and insuring that others remember us as we wish them to – outweigh merely extending us as we wish them to – outweigh merely extending one’s lifeone’s life

Conception of good life/good death should be respected Conception of good life/good death should be respected (within the bounds of justice and consistent with others (within the bounds of justice and consistent with others doing so as well)doing so as well)

Pluralism suggests that we respect individuals’ right to Pluralism suggests that we respect individuals’ right to control the manner, circumstances and timing of their control the manner, circumstances and timing of their dying and deathdying and death

BrockBrock

BENEFICENCEBENEFICENCE

It looks like respect for autonomy and beneficence conflict in It looks like respect for autonomy and beneficence conflict in cases of euthanasia because life is usually highly valued as a cases of euthanasia because life is usually highly valued as a goodgood

But in cases where euthanasia is requested, the benefits and But in cases where euthanasia is requested, the benefits and burdens of life have shifted and the only person who can burdens of life have shifted and the only person who can assess the balance is the individualassess the balance is the individual

It may be the case that further life is a harm/burden and so we It may be the case that further life is a harm/burden and so we act beneficently when we allow for VAEact beneficently when we allow for VAE

Of course we have to watch out for depression and dementia Of course we have to watch out for depression and dementia just as we would with all treatment decisions (i.e. the person just as we would with all treatment decisions (i.e. the person must be competent)must be competent)

ObjectionsObjections

1.1. The practice of medicine is in jeopardyThe practice of medicine is in jeopardy

The “very soul of medicine” is on trial The “very soul of medicine” is on trial (406)(406)

2 distinct concerns:2 distinct concerns:

A. Consequentialist Concern - undermines A. Consequentialist Concern - undermines trust (doctors as killers as well as healers)trust (doctors as killers as well as healers)

Reply: voluntary only & could increase trustReply: voluntary only & could increase trust

ObjectionsObjections

B. Contrary to the Central Aims of B. Contrary to the Central Aims of Medicine - undermines ‘moral center’ of Medicine - undermines ‘moral center’ of medicinemedicine

Reply: what should be the moral center? If Reply: what should be the moral center? If autonomy and beneficence, then VAEautonomy and beneficence, then VAE

““What should not be at the moral center is a What should not be at the moral center is a commitment to preserving patients’ lives as commitment to preserving patients’ lives as such, without regard to whether those such, without regard to whether those patients want their lives preserved or judge patients want their lives preserved or judge their preservation a benefit to them” (407)their preservation a benefit to them” (407)

General ObjectionsGeneral Objections

2. Limits of respect for autonomy2. Limits of respect for autonomy We draw the line in other cases:We draw the line in other cases:

Example: Intervening in cases of anorexia Example: Intervening in cases of anorexia Example: Refusing to provide ‘elective Example: Refusing to provide ‘elective

amputation’ for Body Integrity Identity Disorder amputation’ for Body Integrity Identity Disorder (BIID)?(BIID)?

So why not draw the line at choosing death?So why not draw the line at choosing death? Possible Reply: Liberty principle and MillPossible Reply: Liberty principle and Mill But then… (above cases)But then… (above cases)

General ObjectionsGeneral Objections

3. Slippery Slope3. Slippery Slope

4. Risks of Abuse4. Risks of Abuse

More detail on these laterMore detail on these later Very common argumentsVery common arguments

Further Support for VAEFurther Support for VAE

AnimalsAnimals Biology is (not) destiny – we interfere Biology is (not) destiny – we interfere

in all sorts of ways with life and in all sorts of ways with life and death (fertility treatments, surgery, death (fertility treatments, surgery, pharmaceutical drugs)pharmaceutical drugs)

Shared ArgumentsShared Arguments

AutonomyAutonomy

Beneficence and Preventing SufferingBeneficence and Preventing Suffering

Integrity of the Medical ProfessionIntegrity of the Medical Profession

SummarySummary

1.1. Euthanasia – definition and public debateEuthanasia – definition and public debate

2.2. Distinctions Distinctions

3.3. Dax’s Case (Passive Euthanasia)Dax’s Case (Passive Euthanasia)

4.4. ‘‘It’s Over Debbie’ (Active Euthanasia)It’s Over Debbie’ (Active Euthanasia)

5.5. Rachels’ 3 Arguments (& objections)Rachels’ 3 Arguments (& objections)

6.6. Brock’s Arguments for Active Euthanasia (& Brock’s Arguments for Active Euthanasia (& objections)objections)

Looking ahead…Looking ahead…

Next class: Physician-assisted suicideNext class: Physician-assisted suicide

ContactContactProf. Kirstin BorgersonProf. Kirstin Borgerson

Room Room 359S359S Munk Centre Munk CentreOffice Hours: Tuesday 3-5pm and by Office Hours: Tuesday 3-5pm and by

appointmentappointmentCourse Website: www.chass.utoronto.ca/~kirstinCourse Website: www.chass.utoronto.ca/~kirstin

Email: kirstin@chass.utoronto.caEmail: kirstin@chass.utoronto.ca