Transcript Euthanasia I - Memorial University of Newfoundland

Ethics at the End of Life: Assisted
Death
ISD II
Andrew Latus
June 18, 2003
Outline
 End of Life Issues
 Advance Health Care Directives
 Euthanasia
End of Life Issues
 Discussions of ethics at the end of life
generally focus primarily on the ‘dramatic’
issues of euthanasia and assisted suicide
 Today will be no exception
 However, this leaves out ethical issues you
may encounter more frequently as physicians
Patients’ Perspectives

Singer et al (1999) report the following end
of life issues as being of most concern to a
group of patients surveyed:
1. Receiving Adequate Pain & Symptom
Management


“I wouldn’t want a lot of pain; it’s one of the worst ways
to go”
4 out of 10 dying patients had severe pain most of the
time?
Patients’ Perspectives
2. Avoiding Inappropriate Prolongation of Dying
 “I wouldn’t want life supports if I’m going to die anyway.”
 78% of health care professionals surveyed thought the
treatments they offered were too burdensome?
 Problem of getting info about specific treatments, but not the
big picture
 Role of the physician in giving a ‘realistic’ picture
3. Control Over End of Life Decisions
 “It’s very, very important to me that I can make choices for
myself.”
 More about ‘big picture’ decisions than narrow specific
decisions about treatment?
Patients’ Perspectives
4. Being a Burden on Loved Ones



Making substitute decisions
Witnessing their death
Providing care
5. Involvement of Loved Ones

Considering an advance directive “helped me
get closer to my family … There were so many
times I wanted to get their opinion on certain
things”
Advance Health Care Directives
 See material from Geriatrics session
 Notice that many of the issues mentioned by
the patients could be at least partially dealt
with via an Advance Health Care Directive
 Caution: Don’t overestimate the usefulness of an
AHCD for matters other than identifying a decision
maker. It’s hard to anticipate all eventualities.
Euthanasia
 A broad range of activities are sometimes classified
as euthanasia




Withholding treatment
Withdrawing treatment
Taking action to end someone’s life
Providing someone with the means to end his/her life
 What all of them have in common is that they involve
situations in which:
 Someone, perhaps the patient, deems it better that the
person we are concerned with dies than that efforts to treat
the patient continue and
 Some course of action or inaction is undertaken with the
understanding that it will bring about the death of the person
Is Euthanasia Ever Morally OK?
 If we give the term a broad reading, most people will
answer ‘yes’.
 E.g., Suppose Tom has terminal cancer and that all
conventional treatments have failed.
 Left untreated, he will die in a few days.
 However, there is an experimental drug that has shown
some promise in treating cancers like his, but that also has
some very unpleasant side effects.
 Few would argue that it is immoral if Tom’s doctors accept
his wish to refuse taking part in this experiment.
 The question thus becomes: under what conditions is
euthanasia morally acceptable?
Some Distinctions
 Discussion of particular cases often
turns on the type of euthanasia
involved:
 Assisted Suicide
 Voluntary vs. Non-voluntary Euthanasia
 Active vs. Passive Euthanasia
Assisted Suicide

Not actually euthanasia,
since the 'patient' ultimately
kills himself or herself.

The line between the two
can, however, become very
thin.


e.g., Dr. Jack Kevorkian's
'Mercitron'
Many of the same issues
arise in considering
assisted suicide as in
considering euthanasia

Remaining focus will be on
euthanasia
Voluntary vs. Non-voluntary
Euthanasia
 Voluntary - killing or letting die a competent
person who has expressed a desire for this
(usually over a sustained period of time).
 Non-voluntary - killing or letting die when the
patient is unable to express such a desire
 Note: there is a difference between involuntary
and non-voluntary
 Involuntary euthanasia is not a seriously
considered possibility
Active vs. Passive Euthanasia
 Active - roughly, involves killing a patient
 E.g., administering a fatal dose of morphine to a terminally ill
cancer patient
 This is often what people have in mind when they simply
speak of euthanasia
 Be careful to distinguish killing from murdering (‘wrongful
killing’) – not all killings are murders
 Passive - roughly, involves letting a patient die
 E.g., failing to revive a patient who has signed a DNR order
 Generally, passive euthanasia is looked upon more favorably
than active euthanasia
Forms of Euthanasia
 The distinctions may be combined




Voluntary passive euthanasia (VPE)
Voluntary active euthanasia (VAE)
Non-voluntary passive euthanasia (NPE)
Non-voluntary active euthanasia (NAE)
 VPE is the least controversial form of
euthanasia
 a competent patient has a right to refuse treatment
Forms of Euthanasia
 NPE is now broadly accepted in at least some
situations (e.g., a neonate with almost
certainly fatal birth defects)
 There are limits, however, e.g., in the Stephen
Dawson case, S.D.’s parents were not allowed to
refuse lifesaving treatment even though they felt
S.D. would be better off dead
 Any form of active euthanasia is much more
controversial, so we will examine the
active/passive distinction more closely
Two Kinds of Passive Euthanasia
 (i) Withholding of Treatment e.g., not performing a
needed surgery or not administering a needed drug
 (ii) Withdrawing of Treatment e.g., turning off a
respirator
 Question: While i above seems clearly passive, why
is withdrawing of treatment passive?
 Rachels: "what is the cessation of treatment ... if it is not 'the
intentional termination of the life of one human being by
another'?" (pp. 79-80)
Karen Quinlan
 1975 - Quinlan goes into a drug induced coma
 Suffers anoxia causing irreversible brain damage
 Required a ventilator to live
 Not brain dead, but in a persistent vegetative state
 Quinlan’s sister - "If Karen could ever see herself like this, it
would be the worst thing in the world for her."
 Hospital - '1 in a million' chance of recovery
 Family sought to have her removed from the respirator, doctors
& hospital refused
Why Was the Cruzan Case Controversial?
 AMA Declaration (1973)
 “The intentional termination of the life of one human being by
another … is contrary to that for which the medical profession
stands…
 … The cessation of the employment of extraordinary means to
prolong the life of the body when there is irrefutable evidence that
biological death is imminent is the decision of the patient and/or his
immediate family.” (Rachels, 78)
 Note the word ‘extraordinary’
 In 1975, the AMA did not draw a clear distinction between
withdrawing treatment and active euthanasia
 In 1986, the AMA adopted a policy which clearly drew this
distinction
 CMA Code: “17. Ascertain wherever possible and recognize your
patient’s wishes about the initiation, continuation and cessation of
life-sustaining treatment.”
The Outcome
 1976 - N.J. Supreme Court overturns a lower court decision and rules
in favour of the Quinlans.
 Doctors 'weaned' her off the respirator in a successful attempt to keep
her alive.
 Died of pneumonia - June 13, 1986
 This case reminds us that standards regarding ethical matters can
change very quickly.
 The Karen Quinlan case would be much less controversial today.
 Is the lesson of the case that the line between active and passive
euthanasia is uninteresting morally speaking?
Rachels on Active vs. Passive
Euthanasia
 Rachels: Active euthanasia is not necessarily worse
than passive euthanasia
 Objection: Killing is worse than letting die!
 Response: Rachels claims that we have been
misled by the fact that most actual cases of killing are
morally worse than most actual cases of letting die
 Because of this, we have mistakenly concluded there
is some deep moral difference between killing &
letting die.
Cases
 (i) A unconscious patient will almost certainly die
unless paced on a respirator. His family explain he
has expressed a clear desire not to be placed on
one. He is treated according to those wishes and
dies.
 (ii) Case i, but the man is placed on the respirator
before his family arrive. After his wishes are
explained, he is removed from the respirator and
dies.
 Are these cases of killing or letting die?
 Are these cases morally different?
Cases
 (1) A man drowns his young cousin so that he
won't have to split an inheritance with him.
 (2) Case #1, except, before he can kill him,
the cousin slips and falls face down in the
bathtub. The man just has to watch his cousin
drown.
 Are these cases of killing or letting die?
 Are these cases morally different?
Cases
 (a) In accordance with an ALS patient's
wishes the doctors remove her from her
respirator. She dies.
 (b) A greedy son removes an ALS patient
from her respirator because he wants to
collect his inheritance. She dies.
 Are these cases of killing or letting die?
 Are these cases morally different?
Is Rachels Right?
 Do the cases make a convincing
argument that the difference between
active and passive euthanasia is
morally irrelevant?
 If so, then what is morally relevant?
The Law
 Very roughly, the following summarizes the Canadian
legal situation re. euthanasia
• voluntary passive euthanasia = legal
• in fact, required – no consent, no treatment
• voluntary active euthanasia = illegal
• although see ‘The Doctrine of Double Effect’
• not true in all countries (e.g., Netherlands since 2001)
• non-voluntary passive euthanasia = legal
• under appropriate proxy decision only
• non-voluntary active euthanasia = illegal
• although again see ‘The Doctrine of Double Effect’
• assisted suicide = illegal
 not true in all countries, e.g., Oregon’s Death with Dignity Act
A Closing Issue: The Doctrine of
Double Effect (DDE)
 Suppose an action (e.g., giving a terminally ill cancer patient
morphine) has some reasonably foreseeable result (e.g.,
quickening the patient’s death) and that it would be
unacceptable to perform this action for the purpose of bringing
this result about.
 The DDE claims that it may still be acceptable to perform this
action, provided that the action is not performed for the purpose
of bringing this result about.
 E.g., it may still be acceptable to give the patient the morphine
provided that it is given in order to control his pain, not to hasten
the patient’s death
 The DDE is commonly, if not explicitly, appealed to in practice.
 As a result, VAE & NAE may sometimes be practiced.
The DDE in Practice
 “Doctors should feel comfortable giving as
much pain medication as it takes to ease
suffering, even if it hastens death … The key
is a doctor’s intent when giving drugs.”
 (CBC story on consensus guidelines re. palliative
care and analgesia, 2002)
 Does the DDE make theoretical sense?
 Does the DDE make practical sense?