Euthanasia*

1. Euthanasia* Philosophy 2803 Lecture VIII March 26, 2002 * This replaces the lecture originally labelled lecture VIII

2. Euthanasia • A broad range of activities are sometimes classified as euthanasia • Withholding or withdrawing treatment • Actively ending 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: • it is somehow deemed better that the person we are concerned with dies than that he or she lives and • some course of action or inaction is undertaken with the understanding that it will bring about the death of the person

3. 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 this treatment.

4. What Matters Morally? • The question thus becomes: under what conditions is euthanasia morally acceptable? • Discussion of this issue often turns on the type of euthanasia involved: • Active vs. Passive Euthanasia • Voluntary vs. Non-voluntary Euthanasia • Assisted Suicide

5. Active vs. Passive Euthanasia • Active - roughly, involveskilling 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

6. Two Kinds of Passive Euthanasia • (i) Withholding of Treatment e.g., not performing a needed surgery or not administering a needed drug • (ii) Cessation of Treatment e.g., turning off a respirator • Question:  While i above seems clearly passive, why is cessation 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'?" (375) • Answers to this question tend to rest on claims about ‘naturalness’

7. 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

8. 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, • e.g., the Sue Rodriguez case (pp. 366-372)

9. The Law • Very roughly, the following summarizes the Canadian legal situation re. euthanasia • voluntary passive euthanasia = legal • in fact, required • voluntary active euthanasia = illegal • although see ‘The Doctrine of Double Effect’ • non-voluntary passive euthanasia = legal • under appropriate proxy decision • non-voluntary active euthanasia = illegal • although again see ‘The Doctrine of Double Effect’ • assisted suicide = illegal • see the Sue Rodriguez case (pp. 366-372)

10. Voluntary Passive Euthanasia • As noted, this is the least controversial form of euthanasia • It is now a well established principle that a competent patient has a right to refuse treatment, including lifesaving treatment • But why? • The short answer: because of the central role of informed consent – no consent, no treatment

11. A Longer Answer: The Autonomy/ Dignity Argument for VPE • P1:  A weakened, dying patient has lost control over her life in a significant way. • P2:  Allowing the patient control over how her life ends provides a way of preserving her autonomy and her dignity (as far as is possible). • P3:  Dignity and autonomy are very important values. • C:  In order to preserve the patient's dignity and autonomy, a terminally ill patient should be allowed to choose when treatment will be withheld or withdrawn.

12. Two Questions about the Autonomy/Dignity Argument • Does this argument apply only to terminally ill patients?  If autonomy is so important then why shouldn't the patient's wishes be respected even if she is not terminally ill? • E.g., The anorexic patient who refuses force-feeding • A rational, healthy patient who simply wants to be allowed to starve himself to death. • Because of the stress placed on informed consent, issues of competence are often raised. • Those who think a request for cessation of treatment will be easily agreed to are often mistaken, particularly when the family or medical staff don’t agree

13. Two Questions about the Autonomy/Dignity Argument • Does this argument also support assisted suicide or active euthanasia? • A common response:  ‘No.  There is a morally significant difference between killing and letting die.  While autonomy provides a ground for allowing the person to die.  It provides no grounds for active killing.’ • The American Medical Association (1973):  While "[t]he cessation of the employment of extraordinary means to prolong the life of the body ... is the decision of the patient and/or his immediate family," "mercy killing ... is contrary to that for which the medical profession stands." (372) • James Rachels challenges this view.  He claims the distinction between killing and letting die is morally irrelevant. (372-376)

14. Rachels on Active vs. Passive Euthanasia • "once the initial decision not to prolong his [i.e., a patient with incurable cancer] agony has been made, active euthanasia is actually preferable to passive euthanasia". (373) • Objection: But killing is morally 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 made the mistake of concluding that there is some deep moral difference between killing and letting die.

15. 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?

16. 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?

17. 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?

18. 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?

19. Non-voluntary Euthanasia • Until relatively recently, NPE & NAE were largely looked upon as morally unacceptable • Two ways in which NPE has become somewhat accepted • By appeal to standards of personhood • When the person is ‘gone’, NPE is generally accepted • E.g., ‘Harvard Brain Death’ = loss of virtually all brain activity including brain stem • By proxy • Under certain conditions, a proxy decision to refuse or suspend treatment is generally accepted even if the person is still arguably there • But recall Re. S.D. from lecture on consent, there are limitations on these decisions

20. The Case of Karen Quinlan • 1975 - Quinlan goes into a drug induced coma • Suffers anoxia (loss of oxygen to the brain) causing irreversible brain damage • Required a ventilator/respirator to live • Not brain dead, but in a persistent vegetative state (unconscious) • 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. • 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

21. The Case of Nancy Cruzan • June 11, 1983 - Cruzan, 24, suffers anoxia as a result of a car crash, enters a p.v.s. • Kept alive by a feeding tube • Parents sought permission to disconnect their daughter's feeding tube • June, 1990 - U.S. Supreme Court rules that in the absence of 'clear and compelling' evidence of Cruzan’s wishes, it may not be disconnected. • Publicity brings new witnesses (who knew her as Nancy Davis, her married name).  • In a new trial, a lower court rules the 'clear and compelling' standard has now been met. • Dec. 14, 1990 - N.C. is disconnected & subsequently dies • Many commentators thought that the fact that Cruzan required only a feeding tube (not a respirator) made a significant moral difference

22. Limits on Non-Voluntary Euthanasia • NAE is still very controversial • E.g., the Robert Latimer case • The limits of NPE are also controversial • E.g., Re. S.D. • Robert Wendland (Topic of Groupwork)

23. A Continuum of Conditions • Coma • Brain activity, but no consciousness or wakefulness. • Persistent Vegetative State (PVS) • Wakefulness, but no awareness • Minimally Conscious State (MCS) • Wakefulness and minimal awareness • Quite Different: Locked-in Syndrome • Full consciousness, but extreme paralysis

24. Minimally Conscious State • “a condition of severely altered consciousness in which minimal, but definite, behavioral evidence of self or environmental awareness is demonstrated.” • May be temporary or permanent • Criteria (at least one of): • following simple commands • gives yes or no responses, verbally or with gestures • verbalizes intelligibly • demonstrates other purposeful behavior …. in direct relationship to relevant environmental stimuli

25. Minimally Conscious State • Unlike PVS, those in a MCS can feel pain, etc. • “meaningful, good recovery after 1 year in an MCS is unlikely” • “being nonfunctioning and aware to some degree is worse than being nonfunctioning and unaware” • Ronald Cranford • “MCS is not a diagnosis; it is a value judgment.” • Diane Coleman, president, Not Dead Yet

26. The Case of Robert Wendland • NPE is now generally accepted when a patient is in a PVS • Recently there have been controversies about whether NPE is appropriate in other sorts of conditions, specifically for patients in a permanent MCS • One way of understanding these controversies is as linked to our conception of personhood – the more restrictive the conception, the greater range of cases in which NPE is accepted

27. Robert Wendland • Suffered brain damage in a car accident in 1993 • Wendland was supposedly in a permanent Minimally Conscious State (MCS) • Could respond to simple commands. • Wife and children claimed he never recognized them • Mother claimed he would cry and kiss her hand during visits

28. Robert Wendland • His mother opposed the attempt by his wife to have Wendland’s feeding and hydration tube removed • Wendland died in July 2001 of pneumonia before California Supreme Court could rule • California Supreme Court eventually ruled against his wife

29. Question • Assuming his wife’s description of Wendland’s condition was accurate, would NPE of Wendland have been morally acceptable? • Why or why not?

30. The Doctrine of Double Effect (DDE) • Suppose an action (e.g., giving a terminally ill cancer patient morphine) has some reasonably foreseeable outcome (e.g., quickening the patient’s death) and that it would be unacceptable to perform this action for the purpose of bringing this outcome 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 outcome 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. • The DDE is commonly, if not explicitly, appealed to in practice. In this sense, VAE. & NAE. are quite often practiced.