Euthanasia

• From Greek: “good death” or “easy death”

• Sometimes referred to as “mercy killing”

• Some distinctions

– Voluntary/nonvoluntary/involuntary

– Active/passive euthanasia/physician-assisted suicide

– Is patient prognosis relevant?

Nancy B. [1992]

• Became ill in June, 1989, diagnosed with Guillain-Barré syndrome

– Rare (1 or 2 per 100,000/year)

– Patients usually recover completely

• Motor paralysis, may include diaphragm

• Nancy B. intubated, placed on respirator

• January 1991, condition declared irreversible (degeneration of muscles)

• Withdrew consent for therapy (respirator)

– Aware of consequences

– Discussed condition with physicians

– Was deemed competent (psychiatric evaluation)

• Sought a court injunction to require hospital/physician to remove the respirator

• Judge ruled that the respirator should be removed

– “The logical corollary of the right to consent is the right not to consent”

– Nancy B. was competent and so deserved to have her autonomy respected

– A person who removed the respirator at Nancy B.’s request (thus, acted as her agent) would not be vulnerable to criminal sanction because s/he would be allowing a natural death rather than assisting the patient to commit suicide

Sue Rodriguez [1993]

• Had been diagnosed with ALS (Lou Gehrig’s disease) in 1991: would lose motor function gradually (including the ability to breathe)

• Did not want to die when she could still enjoy life and so did not want to commit suicide before her condition deteriorated

• Wanted the right to end her life with the help of a physician when she could no longer commit suicide for herself

• Became an activist, trying to change Canadian laws against assisted suicide – case went to the Supreme Court of Canada

– Section 241(b) of Criminal Code – it’s an offense to aid or abet someone in committing suicide

• 1993 – Court refuses to change law, but the decision was close (5-4)

• Majority judgment: section of the Criminal Code prohibiting assisted suicide did impinge upon Rodriguez’s Charter rights, but this was justifiable under another section (1) of the Charter, saying that rights could be infringed upon if I was “demonstrably justified in a free and democratic nation”

• Justice à preserve the sanctity of life

• Sopinka also cited the possibility for abuse if law against assisted suicide were repealed

– Slippery slope argument (if we allow A, then B will occur – where B is clearly unacceptable)

• Dissenting judgments (3): discrimination on the basis of disability, called for a constitutional exemption from law in Rodriguez’s case pending review of issue by Parliament

– But the actual act of ending her life should be committed by Rodriguez herself

Brock

• Focuses on voluntary active euthanasia (and physician assisted suicide)

• Starts by citing an “emerging consensus” that competent patients (or their surrogates) should be able to weigh the benefits and burdens of alternative treatment, including no treatment (passive euthanasia)

Brock’s Primary Aim

• “…to identify confusions in some common arguments [regarding voluntary active euthanasia] and problematic assumptions and claims in others”

Outline

• Clarify terminology

• Overview of main argument for euthanasia

• Two kinds of argument against

– moral

– policy

Voluntary Active Euthanasia and Physician-Assisted Suicide

• The paradigm case of physician-assisted suicide: the physician supplies a lethal drug and the patient uses it to end her life

• The paradigm case of voluntary active euthanasia: The physician administers the lethal dose to the patient

• Brock: there is no substantive moral difference between these two situations

– “what if a physician gave a patient lethal medication knowing that the patient would then administer it to someone else?”

• Since no moral difference, should be no policy difference

Argument for Voluntary Active Euthanasia

• The same two fundamental ethical values that underlie the consensus on a patient’s right to decide about life-sustaining treatment also support the right to euthanasia. These values are:

– Individual self-determination/autonomy

– Individual well-being

Self-determination

• Refers to people’s right to make important decisions about their lives for themselves that accord with their own values or their own conception of a good life. Also the freedom to act on these decisions.

Self-determination regarding death

• People often respond to the thought of death with fear of suffering, desire to retain dignity and control, desire to be remembered in a certain way

• Technology in health care means that for many people, death is/will be preceded by a long period of physical/mental decline

• No single objective point at which this decline makes life a burden: thus need for self-determination

Individual well-being

• Similar to “self-interest” – the assumption that we act in line with our own best interests

• But can it ever be in our best interests to die?

– Quality of life

– Life as burden, not benefit

– Again, no objective standard

Two caveats

• Problem of clinically depressed patients (and illness, especially terminal illness, may cause or worsen depression)

• Does not compel physicians to act contrary to their own values à there are limits on what a patient can ask a physician to do

Opponents to Euthanasia

• Two kinds of argument

– Euthanasia is ethically wrong (moral argument)

– Euthanasia is ethically permissible but still should not be permitted (policy argument)

1. Euthanasia is wrong…

• It is the deliberate killing of an innocent person

• Brock’s reply: euthanasia is killing, but is morally permissible

Doctors don’t kill

• “In the context of medicine, the ethical prohibition against deliberately killing the innocent derives some of its plausibility from the belief that nothing in the currently accepted practice of medicine is deliberate killing.”

– “Killing” vs. “letting die” (active/passive)

The Greedy Son

• There are important ethical differences between the doctor’s actions and those of the greedy son:

• Patient’s consent

• Different motives

• Socially-sanctioned role: doctor is authorized to carry out patient’s wishes

Rachels

• Brock’s example: it’s not the “passive” in passive euthanasia that makes it morally acceptable

– No difference between active and passive euthanasia

• Rachels – also argues that there is no moral difference between active and passive euthanasia

Killing vs. Letting Die

• Why do people want to make this distinction?

– Killing as “unjustified” causing of death. Withdrawing of life-sustaining treatment is justified in a medical context

• Psychological discomfort with the idea that doctors kill (shifts responsibility to the disease)

Paradigm cases, again

• Brock: even if euthanasia is killing, it could still be morally permissible:

– It differs from the paradigm case of killing in another important way

– In the paradigm case, killing takes something of value (life) away from the victim – this is a large part of why killing is wrong

– In euthanasia, the “victim” no longer values her life

2. Policy arguments

• Even if euthanasia is morally permissible, there are good legal and policy reasons not to permit it

– Brock: these arguments are stronger than the strictly ethical ones

• Different types of policy argument may disagree about:

– What consequences might follow permitting euthanasia

– The relative moral importance of these consequences

Good consequences of allowing euthanasia

• Respects the self-determination of competent patients (but we need to consider the importance/weight we should give to this good consequence; this also requires that we look at alternatives to euthanasia)

• Provides reassurance to those who feel they might someday want the option of euthanasia

• “Argument from mercy”

• Applies to those whose dying would otherwise be filled with pain and suffering (physical or psychological)

Potential Bad Consequences

• Performing euthanasia is incompatible with physicians’ role as healer – allowing euthanasia will change the way we see physicians

• Would weaken society’s resolve to provide care to the dying ($)

• Would threaten the right to refuse life-saving treatment (increased involvement of courts)

• Need for they dying to justify their continued existence (“the existence of the option [of euthanasia] becomes a subtle pressure to request it”)

• Will weaken the general prohibition against homicide

• The slippery slope argument

- voluntary euthanasia is morally permissible, but if we allow it, then it’s only a matter of time before we allow nonvoluntary euthanasia, involuntary euthanasia

Brock re the slippery slope

• This scenario is possible, but is it likely?

– No evidence (speculation)

– Also, can put safeguards in place to prevent descent down the slippery slope

Brock’s recommended safeguards

• Patient should be given all relevant information

• There should be a waiting period (to make sure that the request is stable) – and should also make sure it is truly voluntary (not due to pressure from others)

• All reasonable alternatives must be explored for pain relief, increasing QOL, etc.

• There should be a psychiatric evaluation to rule out depression

Nonvoluntary euthanasia

• Brock also suggests that, in some cases, nonvoluntary euthanasia might be morally permissible

• In the case of incompetent individuals, surrogates make their medical decisions – this might well extend to the request for euthanasia

• In some cases, the surrogate expresses the wishes the patient had when competent

• In other cases, the patient’s wishes are unknown – this raises the possibility of abuse

• Brock – should put better safeguards in place for all end-of-life decision-making, not just euthanasia