Unit Two: Ethical Issues at the End of Life
One of the ironies of medical care is that many of the issues we now face are due in part to advances in medical care. We can now treat diseases and conditions that would have been considered terminal only a few decades ago. While this is clearly a good thing and counts as progress, it does mean that we now face ethical issues that were not faced in the past. These include the issues relating to euthanasia, a word whose origin means "good death." As the Euthanasia PowerPoint illustrates there are many different types of euthanasia. I have organized these such that the most acceptable practices are listed first and the least acceptable are listed later. The main distinctions are between active and passive euthanasia and voluntary and non-voluntary euthanasia. When combined these give rise to five distinct types of euthanasia.
The articles in this section raise the central question of when, if ever, is it morally acceptable to practice some form of euthanasia. As we consider this issue, notice how closely connected it is with the ideas of informed consent and competence addressed in the previous section. The Cruzan case illustrates this very well and illustrates the problem health care professionals are faced with when there is no clear statement from the patient about their wishes. The Rachels and Brock articles take opposing views on this question. Rachels maintains that the traditional distinction between killing and letting die is not morally significant and in some cases the practice of passive euthanasia should be regarded as morally unacceptable because it leads to more suffering than active euthanasia would. Brock disagrees with the distinctions Rachels makes by attempting to show that the traditional view maintains that what is prohibited is the intentional killing of a patient.
In the Euthanasia PowerPoint I have included a definition from Dr. Wiggins a bioethicist at the University of Louisville. It is interesting to note that in this definition, Wiggins includes the notion of intention. So, euthanasia is the "intentional hastening of a patient's death for the patient's own good." This definition seems to entail that at least some practices of euthanasia are good since they are done to further the patient's own best interest. This no doubt raises a conflict in the minds of many health care professionals who see their job as the prevention of death. How can it be in the patient's own best interest to die? According to many ethicists the answer lies in the distinction between useful treatment and futile treatment. When a treatment will not prolong life significantly or only at the cost of increased suffering then this treatment may not be in the patient's best interest. This point is made in the Brock article. Also in this article he points out the potential good and bad consequences of voluntary active euthanasia as well as the question of whether physicians should be involved in the process.
Callahan summarizes the arguments for euthanasia in his article as follows:
– Individual self-determination and well being
– Moral irrelevance of the difference between killing and allowing to die
– Lack of evidence for harmful consequences of euthanasia
– Compatibility of euthanasia and medical practice
He then proceeds to argue against all of these points. Several interesting points are made in the sections that follow. If the philosophical justification for euthanasia rests on self determination, why should this be restricted to cases where the patient is terminal? Or for that matter why should it be restricted to patients who are competent. This is largely what Callahan means when he says that euthanasia represents a case where "self determination runs amok." If we grant that self determination cannot be restricted without good reason in the case of euthanasia for those who are terminally ill and/or suffering it will be a short step to justifying euthanasia in the name of self determination for those patients who simply want it for whatever reason.
This brings Callahan to the negative consequences of euthanasia. It seems unclear given the evidence (such as that cited by ten Have and Welie) that a clear law can be written that won't be abused. Part of this abuse will be practicing euthanasia on patients who were not originally covered by the law including those who never requested it in the first place. Finally, Callahan argues that "a physician who participates in another person's suicide already abuses medicine." Among other problems, euthanasia forces doctors to make judgments about whether patients' lives are really worth living and this is a judgment, according to Callahan, that doctors are not in any position to make.
Rachels Article
• Active/Passive distinction
• Passive Euthanasia seems to justify more suffering
• "Conventional doctrine leads to decisions concerning life and death made on irrelevant grounds"
• Downs Syndrome case
• Killing is not worse than letting die
• Example of Smith & Jones
Sullivan Article
• Rachels' active/passive distinction is not present in the AMA statement he criticizes.
• The "traditional view" is that "intentional termination of human life is impermissible."
• This is what is ruled out by the statement Rachels criticizes.
Brock Article
• Central argument for voluntary active euthanasia rests on autonomy and patient well-being.
• Good consequences:
• Respect patient autonomy
• Reassure public that this option is available if wanted
• Provides the ability to relieve pain and suffering for terminal patients
• Bad consequences:
• Instill fear of physicians and loss of trust
• "weaken society's commitment to provide optimal care for dying patients"
• Forces patients to justify their decision to continue to live
• "weakens the general legal prohibition of homicide"
• Slippery slope worry
Possible Procedures to Guard Against Abuse of Euthanasia:
• The patient should be provided with all relevant information about his or her medical condition, current prognosis, available alternative treatments, and the prognosis of each.
• Procedures should ensure that the patient's request for euthanasia is stable or enduring and fully voluntary.
• All reasonable alternatives must have been explored for improving the patient's quality of life and relieving any pain or suffering.
• A psychiatric evaluation should ensure that the patient's request is not the result of a treatable psychological impairment such as depression.
Callahan Article
• Arguments in favor of euthanasia:
• Individual self-determination and well being
• Moral irrelevance of the difference between killing and allowing to die
• Lack of evidence for harmful consequences of euthanasia
• Compatibility of euthanasia and medical practice
• Arguments against:
• Euthanasia is not simply a matter of self determination since it involves the help of another
• Confuses causation with moral responsibility
• Negative consequences are likely
• Abuse of the law
• Difficult to write and enforce a precise law
• Slippery slope
• Forces doctors into decisions they are not capable of making
Ten Have & Welie Article
• Summarizes pertinent statistics on euthanasia practice in the Netherlands.
• Do these statistics allow us to draw any conclusions about the possible consequences of legalizing euthanasia in the U.S.?
The articles in this section raise the central question of when, if ever, is it morally acceptable to practice some form of euthanasia. As we consider this issue, notice how closely connected it is with the ideas of informed consent and competence addressed in the previous section. The Cruzan case illustrates this very well and illustrates the problem health care professionals are faced with when there is no clear statement from the patient about their wishes. The Rachels and Brock articles take opposing views on this question. Rachels maintains that the traditional distinction between killing and letting die is not morally significant and in some cases the practice of passive euthanasia should be regarded as morally unacceptable because it leads to more suffering than active euthanasia would. Brock disagrees with the distinctions Rachels makes by attempting to show that the traditional view maintains that what is prohibited is the intentional killing of a patient.
In the Euthanasia PowerPoint I have included a definition from Dr. Wiggins a bioethicist at the University of Louisville. It is interesting to note that in this definition, Wiggins includes the notion of intention. So, euthanasia is the "intentional hastening of a patient's death for the patient's own good." This definition seems to entail that at least some practices of euthanasia are good since they are done to further the patient's own best interest. This no doubt raises a conflict in the minds of many health care professionals who see their job as the prevention of death. How can it be in the patient's own best interest to die? According to many ethicists the answer lies in the distinction between useful treatment and futile treatment. When a treatment will not prolong life significantly or only at the cost of increased suffering then this treatment may not be in the patient's best interest. This point is made in the Brock article. Also in this article he points out the potential good and bad consequences of voluntary active euthanasia as well as the question of whether physicians should be involved in the process.
Callahan summarizes the arguments for euthanasia in his article as follows:
– Individual self-determination and well being
– Moral irrelevance of the difference between killing and allowing to die
– Lack of evidence for harmful consequences of euthanasia
– Compatibility of euthanasia and medical practice
He then proceeds to argue against all of these points. Several interesting points are made in the sections that follow. If the philosophical justification for euthanasia rests on self determination, why should this be restricted to cases where the patient is terminal? Or for that matter why should it be restricted to patients who are competent. This is largely what Callahan means when he says that euthanasia represents a case where "self determination runs amok." If we grant that self determination cannot be restricted without good reason in the case of euthanasia for those who are terminally ill and/or suffering it will be a short step to justifying euthanasia in the name of self determination for those patients who simply want it for whatever reason.
This brings Callahan to the negative consequences of euthanasia. It seems unclear given the evidence (such as that cited by ten Have and Welie) that a clear law can be written that won't be abused. Part of this abuse will be practicing euthanasia on patients who were not originally covered by the law including those who never requested it in the first place. Finally, Callahan argues that "a physician who participates in another person's suicide already abuses medicine." Among other problems, euthanasia forces doctors to make judgments about whether patients' lives are really worth living and this is a judgment, according to Callahan, that doctors are not in any position to make.
Rachels Article
• Active/Passive distinction
• Passive Euthanasia seems to justify more suffering
• "Conventional doctrine leads to decisions concerning life and death made on irrelevant grounds"
• Downs Syndrome case
• Killing is not worse than letting die
• Example of Smith & Jones
Sullivan Article
• Rachels' active/passive distinction is not present in the AMA statement he criticizes.
• The "traditional view" is that "intentional termination of human life is impermissible."
• This is what is ruled out by the statement Rachels criticizes.
Brock Article
• Central argument for voluntary active euthanasia rests on autonomy and patient well-being.
• Good consequences:
• Respect patient autonomy
• Reassure public that this option is available if wanted
• Provides the ability to relieve pain and suffering for terminal patients
• Bad consequences:
• Instill fear of physicians and loss of trust
• "weaken society's commitment to provide optimal care for dying patients"
• Forces patients to justify their decision to continue to live
• "weakens the general legal prohibition of homicide"
• Slippery slope worry
Possible Procedures to Guard Against Abuse of Euthanasia:
• The patient should be provided with all relevant information about his or her medical condition, current prognosis, available alternative treatments, and the prognosis of each.
• Procedures should ensure that the patient's request for euthanasia is stable or enduring and fully voluntary.
• All reasonable alternatives must have been explored for improving the patient's quality of life and relieving any pain or suffering.
• A psychiatric evaluation should ensure that the patient's request is not the result of a treatable psychological impairment such as depression.
Callahan Article
• Arguments in favor of euthanasia:
• Individual self-determination and well being
• Moral irrelevance of the difference between killing and allowing to die
• Lack of evidence for harmful consequences of euthanasia
• Compatibility of euthanasia and medical practice
• Arguments against:
• Euthanasia is not simply a matter of self determination since it involves the help of another
• Confuses causation with moral responsibility
• Negative consequences are likely
• Abuse of the law
• Difficult to write and enforce a precise law
• Slippery slope
• Forces doctors into decisions they are not capable of making
Ten Have & Welie Article
• Summarizes pertinent statistics on euthanasia practice in the Netherlands.
• Do these statistics allow us to draw any conclusions about the possible consequences of legalizing euthanasia in the U.S.?