Transcript File - Applied Ethics

Euthanasia
In this lecture…
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General overview
Arguments for voluntary euthanasia
A right to die?
Arguments against voluntary euthanasia
The slippery-slope argument
Non-voluntary and involuntary
euthanasia
 Active vs. Passive euthanasia
 Physician-assisted suicide
 End-of-life care
General overview
 In earlier periods of human history,
physicians could do little to stave off
death. Today, improvements in public
sanitation, the development of
immunization, the development of
antibiotics, and the many technologies
of modern medicine have combined to
lengthen the human lifespan,
particularly in the developed world.
General overview
 In the developed world, with its
sophisticated healthcare systems, the
majority of the population dies at
comparatively advanced ages of
degenerative diseases –cancer, stroke,
heart disease, etc. – with
characteristically long downhill courses,
marked by a terminal phase of dying.
General overview
 The developments in medical
technology and treatments, which
prolong and sustain life of a patient,
mean that more patients stay alive for
longer.
 However, this extension of life is often
associated with severe pain as well as
intense and burdensome treatments for
the terminally ill patients.
General overview
 At the same time, there has been
progress in the legal acknowledgement
of patients’ rights.
 In many developed nations, patients
have the right to refuse unwanted
treatment or to discontinue it once it
has been started.
General overview
 Euthanasia is the termination of a very
sick person’s life in order to relieve
them of their suffering. The following
are some related terms and definitions:
 Voluntary euthanasia – death is brought
about or hastened at the patient’s
request.
General overview
 Non-voluntary euthanasia – euthanasia
conducted where the explicit consent of
the individual concerned is unavailable.
 Involuntary euthanasia – euthanasia
performed on a person who is able to
provide informed consent, but does not,
either because he or she does not
choose to die, or because he or she was
not asked.
General overview
 Active euthanasia – hastening death by
the use of drugs or other means, with a
doctor’s direct assistance.
 Passive euthanasia – hastening death by
withholding or withdrawing lifesustaining treatment.
 Physician-assisted suicide – the practice
of a doctor providing the means for a
patient to end his own life.
General overview
 Can life become so burdensome, so
filled with pain and suffering, that it
loses all meaning and value?
 Should life be preserved at the cost of
continuous suffering when modern
medicine makes this possible?
General overview
 An accident or illness may bring people
to an extreme of pain, disability,
distress or dependency, so that their
lives become intolerable.
 If there is no reasonable prospect of
substantial improvement, perhaps
hastening the end of life is the only way
to relieve suffering.
General overview
 While most people think unbearable
pain is the main reason people seek
euthanasia, some surveys in the USA
and the Netherlands showed that less
than a third of requests for euthanasia
were because of severe pain.
General overview
 Terminally ill people can have their
quality of life severely damaged by
physical conditions such as
incontinence, nausea and vomiting,
breathlessness, paralysis and difficulty
in swallowing.
General overview
 Psychological factors that cause people
to think of euthanasia include
depression, fearing loss of control or
dignity, feeling a burden, or dislike of
being dependent.
Arguments for voluntary euthanasia
 Three main arguments for voluntary
euthanasia:
1. the argument from autonomy (or selfdetermination)
2. the argument from the relief of pain
and suffering
3. the argument from the right to die
Arguments for voluntary euthanasia
 ‘Autonomy’ or ‘self-determination’
refers to people’s right to making
important decisions about their lives
for themselves according to their own
values or conceptions of a good life,
and the right to be left free to act on
those decisions.
Arguments for voluntary euthanasia
 In exercising autonomy or selfdetermination, people take
responsibility for their lives.
 Since dying is a part of life, choices
about the manner of their dying and
the timing of their death are, for many
people, part of what is involved in
taking responsibility for their lives.
Arguments for voluntary euthanasia
 Proponents of euthanasia argue that
human beings are free and autonomous
and have a right to self-determination in
end-of-life decisions.
 They believe that individuals should
have the right to control the
circumstances of their own death and to
determine how much suffering is too
much.
Arguments for voluntary euthanasia
 Patient autonomy includes the right to
full information concerning the nature
and development of the terminal
illness.
 Any decision about how to die must be
made on the basis of ‘informed consent.’
Arguments for voluntary euthanasia
 Generally speaking, informed consent
exists when patients can understand
what they are agreeing to and
voluntarily choose it.
 People should be informed of their
diagnosis, their prognosis, their
options in responding to their
condition and all other relevant
information.
Arguments for voluntary euthanasia
 Counterargument [1]: For a decision
about death to be voluntary, the
individual must give explicit consent.
Patients in an indefinite coma or
persistent vegetative state are not
candidates for euthanasia. Nor can
euthanasia be justifiably administered
in cases of serious dementia or clinical
depression.
Arguments for voluntary euthanasia
 Counterargument [2]: We can never be
absolutely sure that we have voluntary
and informed consent. The pain and
drugs may prevent patients from
making a fully rational decision.
Arguments for voluntary euthanasia
 Another argument for euthanasia is
based upon compassion, mercy and
beneficence.
 In cases of intractable suffering and
inevitable death, a spirit of mercy and
compassion is supposed to be the
correct response to a patient’s desire to
die.
Arguments for voluntary euthanasia
 According to this view, life is devoid of
quality and of meaning to patients
subject to severe and unremitting
physical or mental suffering.
 These patients should have the option
of a quick and painless relief.
Arguments for voluntary euthanasia
 Thus, doctors have a duty to do
everything within their power to relieve
that suffering, even to the point of
hastening death if there are no realistic
alternatives acceptable to the patients.
Arguments for voluntary euthanasia
 Counterargument: Suffering is almost
always relievable without killing the
person. Thanks to techniques of pain
management and better end-of-life care,
it is possible to treat virtually all pain
and to relieve all suffering.
A right to die?
 Many people think that each person has
the right to control his or her life and
so should be able to determine at what
time, in what way and by whose hand
he or she will die.
 They believe that human beings should
be as free as possible, and that
unnecessary restraints on human
freedom are morally unjustifiable.
A right to die?
 Most countries that put a value on
individual liberty allow competent
adults to refuse medical treatment even
if such treatment is life-saving.
 Besides, people have the right to die in
the sense that they can commit suicide
– attempted suicide is decriminalized
nearly everywhere in the world.
A right to die?
 Some people, however, invoke the right
to life to justify banning suicide and
euthanasia.
 According to this view, if we have the
right to life, we owe ourselves the duty
to keep ourselves alive under any
circumstances.
A right to die?
 Kantians, in particular, believe that
persons must be treated as ends in
themselves and never merely as means.
 Suicide, in Kant’s view, uses oneself
merely as a means (by giving up one’s
own life) to avoid pain and suffering.
This, in his view, debases one’s
humanity.
A right to die?
 Do you think that the terminally ill
should have a right to die? Do you think
that an individual who has no hope of
recovery should have the right to
decide how and when to end his or her
life?
A right to die?
 It can be argued that the right to die is
an integral part of our right to control
our own lives.
 However, euthanasia is not a
completely autonomous act or personal
decision; it requires the assistance of
another person.
A right to die?
 We may have a right to do whatever we
like, including ending our own lives.
 However, even if we have a right to die,
it does not mean that doctors have a
duty to kill us (or help us to commit
suicide) – no doctors can be forced to
help patients who want euthanasia.
A right to die?
 Apart from that, the decision to die by
euthanasia will affect other people such
as our family and friends, and we must
balance the consequences for them
against our rights.
Arguments against voluntary euthanasia
 The main arguments against voluntary
euthanasia are:
1. the argument from the intrinsic
wrongness of killing
2. the argument from the integrity of the
medical profession
3. the argument from potential abuse
(i.e. the slippery-slope argument)
Arguments against voluntary euthanasia
 One objection to euthanasia invokes
the ‘sanctity of life’ principle which
argues that all killing is morally wrong.
 Human life is sacred and valuable
intrinsically because it is a gift from
God. Deliberately shortening life is
against God’s will. Only God should
determine the time of death.
Arguments against voluntary euthanasia
 The deliberate taking of human life
should be prohibited except in selfdefense or the legitimate defense of
others.
 ‘Thou shalt not kill’ and ‘Man should
not play God’ are typical objections to
euthanasia based on religious faith.
Arguments against voluntary euthanasia
 Counterargument [1]: In a free,
democratic society, we do not use the
law to enforce the religious views held
by some people on others who do not
share these views. A government which
respects the right of its citizens to
choose their own religious values
cannot use the law to enforce such
views.
Arguments against voluntary euthanasia
 Counterargument [2]: For those who
believe that all matters of life and death
must be decided by God, to use
medicine to keep a sick person from
dying is playing God. If playing God
simply means doing what will affect the
chances of life and death, then a lot of
responsible social action does exactly
that (e.g. giving aid to starving children).
Arguments against voluntary euthanasia
 Counterargument [3]: In the euthanasia
debate, the use of the term ‘killing’
should be avoided because it usually
refers to taking a person’s life against
his or her will. But as far as voluntary
euthanasia is concerned, this is clearly
not the case.
Arguments against voluntary euthanasia
 Counterargument [4]: The trouble with
the sanctity of life principle is that it
implies that every human being should
be kept alive as long as possible, and
that is a proposition few thoughtful
people would accept. Most would agree,
for example, that it is pointless to keep
alive patients in an irreversible coma or
a persistent vegetative state.
Arguments against voluntary euthanasia
 Opponents to euthanasia point out that
depression is very often a contributing
factor in the desire for hastened death.
 Clearly, if a patient is depressed or
suffering from a mental disturbance,
therapy and counseling – not
euthanasia – should be recommended.
Arguments against voluntary euthanasia
 There is also the justifiable fear that
some elderly patients might be
pressured by family, friends,
government, health care providers,
social workers or by the example of
other terminally ill patients, to choose
euthanasia.
Arguments against voluntary euthanasia
 For the elderly, the right to die may
become a duty to die.
 The old and ill often feel themselves to
be an unwelcome burden on their
children. If euthanasia has become a
widely accepted option, they may feel
under pressure to ask for it.
Arguments against voluntary euthanasia
 Counterargument: It is a mistake to
think that if euthanasia is strictly
prohibited no such tragedies will occur.
The sick will continue occasionally to
attempt suicide in ways which are
neither painless to themselves or
others.
Arguments against voluntary euthanasia
 Another objection to euthanasia is that
there is always the possibility of an
incorrect diagnosis or the discovery of a
treatment that will permit either
survival or recovery.
Arguments against voluntary euthanasia
 Allowing euthanasia undermines the
commitment of doctors and nurses to
saving lives and discourage the search
for new cures and treatments for the
terminally ill.
Arguments against voluntary euthanasia
 Besides, asking doctors to abandon
their duty to preserve human life could
damage the doctor-patient relationship.
 Patients could become distrustful of
their doctors’ efforts and intentions,
thinking their doctors would rather
‘kill them off’ than take responsibility
for them.
Arguments against voluntary euthanasia
 Counterargument: If euthanasia is
restricted to cases in which it is truly
voluntary, then no patient should fear
getting it unless he or she has
voluntarily requested it. Patients’ trust
of their physicians could be increased,
not eroded, by knowledge that
physicians will provide aid in dying
only when they ask for it.
Arguments against voluntary euthanasia
 Opponents to euthanasia also draw
attention to the extraordinary
development of palliative care and pain
control in recent years as a more
positive and safer response to patients’
suffering.
Arguments against voluntary euthanasia
 Counterargument: There are indeed
drugs which, if properly administered,
can control pain. But there are other
forms of distress such as the terror of
breathlessness, uncontrollable
vomiting, paralysis, incontinence,
inability to swallow and sheer weakness
and helplessness which cannot always
be adequately controlled.
The slippery-slope argument
 One of the main arguments against
legalizing euthanasia is the ‘slippery
slope’ argument.
 Critics of euthanasia claim that
legalizing voluntary euthanasia will
lead to a slippery slope effect, resulting
eventually in non-voluntary or even
involuntary euthanasia.
The slippery-slope argument
 They argue that if we allow voluntary
euthanasia, then we will be authorizing
doctors and nurses to sometimes kill
their patients.
 Once medical professionals are making
decisions about whose life is worth
living and whose life is not, then over
time our commitment to protecting
innocent life will inevitably weaken.
The slippery-slope argument
 In other words, permitting voluntary
euthanasia would weaken society’s
prohibition of intentional killing, and
thereby undermine the safeguards
against non-voluntary or involuntary
euthanasia.
 Thus, in order to prevent these
undesirable practices from occurring,
we need to resist taking the first step.
The slippery-slope argument
 Slippery slope arguments have been
used by conservatives and
traditionalists to oppose all sorts of
social change.
 But is there sufficient evidence for the
slippery-slope argument against
euthanasia?
The slippery-slope argument
 Some people think that euthanasia
should not be allowed because it could
be abused and used as a cover for the
murder of innocent people.
 For example, the horrors that
characterized the Nazi regime’s attempt
to weed out the unfit had given
euthanasia a bad name.
The slippery-slope argument
 The Nazi practice of ‘euthanasia’ – the
killing about 100,000 disabled people
on the grounds that they had ‘lives not
worth living’ – has been regarded by
some as an example of how the removal
of restrictions against killing can result
in mass murder.
The slippery-slope argument
 Counterargument [1]: In Nazi German,
doctors took the lives of tens of
thousands of their fellow citizens on
orders from the government. These
unfortunate people were neither
terminally ill nor in pain. The murder
of these people was thinly disguised as
‘euthanasia’.
The slippery-slope argument
 Counterargument [2]: The Nazi
program of ‘euthanasia’ was neither
voluntary nor based on compassion; it
was, rather, motivated by the desire to
preserve the purity of the German race,
and hence was the result of a vicious
and racist ideology.
The slippery-slope argument
 For a contemporary example, many
scholars focus their attention on the
Netherlands, where the criteria of
legalized euthanasia had been
formalized since the 1980s.
 Some of them see the Dutch experience
as evidence for the slippery slope effect.
The slippery-slope argument
 Statistics showed that in the
Netherlands, families requested
euthanasia more often than patients;
and some studies there too showed that
some elderly people feared their lives
would be ended without their consent.
The slippery-slope argument
 However, more recent studies in the
Netherlands found no evidence that
legalizing voluntary euthanasia has had
any serious bad consequences.
 Researchers conclude that, generally
speaking, [1] abuse of the Dutch
euthanasia system is rare, and [2] no
slippery slope effect has occurred.
The slippery-slope argument
 Suppose slippery-slope evidence did
suggest that some patients would be
abused, how should this weigh against
the freedoms of other patients to make
specific end-of-life choices?
The slippery-slope argument
 Just because a practice can be abused
does not entail that it should not be
used at all. Knives, cars, and drugs can
be abused, but that does not mean they
should be outlawed.
 The abuses envisioned in slippery-slope
arguments can be prevented by strict
legal guidelines, like those currently
used in the Netherlands.
The slippery-slope argument
 The legal guidelines for euthanasia in
the Netherlands include:
1. The patient must face a future of
unbearable, interminable suffering.
2. The request to die must be voluntary
and well-considered.
The slippery-slope argument
3. The doctor and patient must be
convinced there is no other solution.
4. A second medical opinion must be
obtained and life must be ended in a
medically appropriated way.
Non-voluntary and involuntary euthanasia
 A non-voluntary decision about death
refers to cases in which the decision is
not made by the person who is to die.
Such cases would include situations
where, because of age, mental
impairment, or unconsciousness,
patients are not competent to give
informed consent to life-or-death
decisions and where others make the
decision for them.
Non-voluntary and involuntary euthanasia
 In those instances where the patient is
not able to communicate wishes,
medical staff and family are faced with
a dilemma.
 For example, this may happen when a
patient has entered a persistent
vegetative state without having
expressed their intentions concerning
end-of-life treatment.
Non-voluntary and involuntary euthanasia
 The family may seek to exercise
‘substituted judgment’ and, on the
basis of statements the dying person
made in the past, request the
withdrawal of life support.
 Otherwise, such a person may be kept
alive by medications and gastric tube
feeding for many years.
Non-voluntary and involuntary euthanasia
 In these cases, family members or
relatives try to make a decision for the
patient according to what the patient
would choose or in the best interest of
the patient.
 Some hospitals have established ‘ethics
committees’ to provide guidance on
such matters.
Non-voluntary and involuntary euthanasia
 Involuntary euthanasia occurs when
patients are killed against their will or
without their consent.
 This kind of euthanasia is almost
always considered wrong and is rarely
debated.
Non-voluntary and involuntary euthanasia
 Most people tend to equate involuntary
euthanasia with murder, but is it
possible to conceive of cases where the
killing would count as being for the
benefit of the person who dies?
Active vs. passive euthanasia
 In active euthanasia, death is brought
about by a physician’s act, for example,
when a person is killed by a lethal
injection.
 In passive euthanasia, death is the
result of withholding or withdrawal of
treatment.
Active vs. passive euthanasia
 In active euthanasia, the proximate
cause of death is the physician’s act. But
in passive euthanasia, the proximate
cause of death is the patient’s disease,
not the physician’s act.
 Some regard the difference as one
between killing as an act of commission,
and letting die as an act of omission.
Active vs. passive euthanasia
 The distinction between active and
passive euthanasia is an important one
because some people who reject active
euthanasia do accept passive
euthanasia as a practice that provides
benefits to the dying person without
violating ethical standards or religious
values.
Active vs. passive euthanasia
 Opponents to active euthanasia think
that the practice is wrong because they
believe that taking a person’s life under
all circumstances is morally
impermissible.
 On the other hand, it is believed that
no one has to take direct responsibility
for a person’s death in the case of
passive euthanasia.
Active vs. passive euthanasia
 James Rachels, however, argues that
there is no moral difference between
active and passive euthanasia.
 He uses the example of Smith and Jones
to prove this point.
Active vs. passive euthanasia
 Smith stands to gain a large inheritance
if anything should happen to his 6-yearold 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.
Active vs. passive euthanasia
 Jones also stands to gain if anything
should happen to his 6-year-old cousin.
Like Smith, Jones sneaks in planning to
drown the child in his bath. But as he
enters the bathroom Jones sees the
child slip, hit his head, and fall facedown in the water. Jones watches all
this happen without doing anything,
and the child drowns all by himself
accidentally.
Active vs. passive euthanasia
 Is Jones’ behavior, Rachels asks, any
less reprehensible than Smith’s?
 If the answer is ‘no’, then we must
conclude that the difference between
killing and letting die does not really
make a moral difference.
Active vs. passive euthanasia
 Rachels: “If one simply withholds
treatment, it may take the patient
longer to die, and so he may suffer
more than he would if more direct
action were taken and a lethal injection
given.”
Active vs. passive euthanasia
 “…once the initial decision not to
prolong his agony has been made,
active euthanasia is actually preferable
to passive euthanasia, rather than the
reverse… the process of being ‘allow to
die’ can be relatively slow and painful,
whereas being given a lethal injection is
relatively quick and painless.”
Active vs. passive euthanasia
 If death is the inevitable outcome,
there are no morally relevant
differences between not providing the
treatment and taking active steps to
end life.
 Taking active steps to end a patient’s
life in a quick and painless manner may
be the morally right thing to do because
unnecessary suffering can be avoided.
Active vs. passive euthanasia
 The reason why killing is normally a
great wrong is that dying is normally a
great harm. But if it is in the best
interest of a patient to die now rather
than suffer a prolonged and painful
dying process, then killing is no longer
a wrong.
Physician-assisted suicide
 Assisted suicide usually refers to cases
where people who want to die need
help to kill themselves and ask for it.
 In physician-assisted suicide, the
physician does not directly cause the
patient’s death but enables the patient
to choose the time and circumstances
of his or her own death, usually by
prescribing a lethal dose of drugs.
Physician-assisted suicide
 The main difference between physicianassisted suicide and euthanasia lies in
who performs the last causal act
leading to death.
 In the case of physician-assisted suicide
it is the patient; in the case of
euthanasia it is the physician.
Physician-assisted suicide
 Without the assistance of their doctors,
patients can choose to die by refusing
food and water. They will die more
slowly than with physician-assisted
suicide but die they will.
 Advocates of physician-assisted suicide
argue that alternatives should be
provided so that patients need not
choose this unpleasant way of dying.
Physician-assisted suicide
 Arguments against physician-assisted
suicide include considerations such as
the possibility of discovery of cures, the
dangers of mistaken diagnosis, the
difficulties of knowing whether the
patient asking for it is rational, the
dangers of patients being coerced by
others, and so on.
Physician-assisted suicide
 Is it morally wrong to help another
person commit suicide?
End-of-life care
 We are getting better at providing
effective palliative care, and hospice
care is more widely available.
 Because of advances in palliative care
and mental health treatment, there is
no reason any person should ever feel
they are suffering intolerably, whether
it is physical or mental suffering or
both.
End-of-life care
 Palliative care is physical, emotional
and spiritual care for a dying person
when cure is not possible. It provides
relief from pain and suffering and
thereby offers an alternative to
euthanasia.
 Good palliative or hospice care has the
goal of helping the patient to live each
day as well as possible.
End-of-life care
 Advocates of palliative and hospice care
emphasize the importance of reducing
human suffering.
 Palliative management of suffering is
believed to substantially decrease the
number of requests for both euthanasia
and physician-assisted suicide.
End-of-life care
 According to this view, palliative and
hospice care – including excellent pain
and symptom management and
psychosocial support for patients and
families – should be part of the
standard of care for all severely ill
patients.
End-of-life care
 A major study in cancer patients found
that people who receive early palliative
care choose less chemotherapy, spend
less time in hospital, and start hospice
care earlier.
 As a result, they have less suffering,
lower cost, and they live 25 percent
longer on average.