Euthanasia I: Ethical Issues

Euthanasia

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

• Sometimes referred to as “mercy killing”

• Some distinctions

– Voluntary/nonvoluntary/involuntary

– Active/passive

Brock

• Focuses on voluntary active euthanasia

• 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 arguments against euthanasia

– One at personal/moral level

– One at policy level

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?”

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

– Euthanasia is ethically permissible but still should not be permitted

Euthanasia is wrong…

• It is the deliberate killing of an innocent person

– Paradigm case of murder vs. euthanasia

• Brock: 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)

Rachels

• Active vs. passive euthanasia – there is no real distinction

• Classic article

– Short! (two journal pages)

– Controversial (because challenges the common view that the distinction is real)

Back to Brock…

• 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

Paradigm cases, again

• Brock: even if both 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

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 (these arguments are not ‘strictly ethical’ because they have both empirical and moral aspects)

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

• All reasonable alternatives must be explained

• There should be a psychiatric evaluation to rule out depression

• 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)

Nonvoluntary euthanasia

• 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

Callaghan

• Euthanasia debate represents “three important turning points in Western thought”

• Legitimate conditions under which one person may kill another

• Meaning and limits of self-determination

• Goal of medicine

Four arguments for euthanasia

• Moral claim – individual self-determination

• Moral irrelevance of distinction between killing and letting die

• Lack of evidence for bad consequences

• Compatibility of euthanasia and medical practice

Euthanasia as a social decision

• Not just self-determination because the physician must also make a decision

– Where does the physician’s moral right to kill come from? Can we waive our right to life?

• In order to be a responsible moral agent, the physician must agree with the patient (i.e. make an independent judgment) that the patient’s life is not worth living

Killing and letting die

• Denying this distinction confuses causality and culpability: stopping treatment is not causing death

– Once it became possible to (in some circumstances) prevent death, society established moral rules governing physician’s obligations in these circumstances

– When a physician stops treatment, the disease is the cause of death “and we have agreed to consider actions like that to be morally licit”