Question: discussion of Euthanasia, what is it?
When is it morally appropriate?
Approaching these topics from a philosophical level
Not a dogmatic level, not a talk radio level
What are the facts?
What are the differing positions?
What are the arguments supporting those positions?
Which side has the strongest arguments
Can’t always tell: goal–a more informed discussion leading to a more informed resolution.
Jack Kevorkian Clip: discussed physician assisted suicide and euthanasia
Kevorkian is a proponent of both and willing to go to jail in support of both.
Go into Textbook Readings
Unit: Rights and Liberty: does a person have a right or a liberty to make certain choices about their own lives: a right to die?
What is euthanasia?
Definition: the act or practice of painlessly putting to death persons suffering from incurable conditions or diseases.
EUTHANASIA:--word comes from Greek roots meaning: good death
[remember eudaimonia--good spiritedness, eulogy--speaking well of someone]
Really: euthanasia is either hastening death, not taking actions to prevent death, or actively causing death--in order to prevent a greater suffering--"Mercy killing"
More Terms:
PERSISTENT VEGETATIVE STATE:
all cerebral cortex functions are lost, but the brain stem remains functional
Question: what does this mean?
Higher brain functions are gone: thinking, memory, emotion
but
Lower brain functions: breathing, heart beat control, facial reflexes and muscles, gag and swallowing abilities continue.
Individual in a persistent vegetative state has lost all conscious function: can't feel pain, for example
The individual in this state will never regain consciousness.
However: someone can live in this state for many years.
Going through wake and sleep cycles, opening and closing their eyes.
Unconscious but "awake"
Contrast with someone in a coma: they are unconscious but "asleep"
A person in a coma has a poorly functioning brain stem.
They don't live as long as someone in a persistent vegetative state.
Question: what are some common misconceptions about coma?
ACTIVE AND PASSIVE EUTHANASIA
Passive Euthanasia: Stopping (or not starting) some treatment, which allows the person to dies. The person's condition causes death.
Assisted suicide: otherwise incapacitated person enlists someone else’s help to commit suicide
VOLUNTARY, NONVOLUNTARY (directed), INVOLUNTARY EUTHANASIA
If the person whose life is to be euthanized makes the decision this is voluntary euthanasia
If people other than the person to be euthanized make the decision this is nonvoluntary euthanasia
Involuntary euthanasia--euthanizing someone AGAINST their will.
One problem here is: figuring out what the patient wants or would want
ADVANCE DIRECTIVE also called a LIVING WILL
"Durable power of Attorney" another way of doing this
Make someone a legal representative to make medical decisions.
Turn to Matter of Quinlan 1976
(Also the name of the made for TV movie about Karen Ann Quinlan)
Court Decision in New Jersey
Karen Quinlan–landmark case in discussion of “the right to die”
22 year old woman who stopped breathing for two 15 minute periods
The result of mixing alcohol with Qualudes–a sedative drug drugs
She was put on a respirator
Diagnosed as being in a “chronic persistent vegetative state”
Comment: some people object to the term “vegetative” here
Defined as:
362: subject who remains with the capacity to maintain the vegetative parts of neurological function but who ... no longer has any cognitive function
Problem: removing respirator would not conform to medical practices, standards, conditions
Conclusion: “as nearly as may be determined” .... she can never be restored to cognitive or sapient life.
Question: can medicine make judgments like this: she can never be restored to mental awareness?
Women is debilitated and moribund but stable
Question: what to do about her?
Father wants guardianship turned over to him so he can turn off her respirator and remove her feeding tube.
Raises Constitutional and Legal Issues
1. Right to privacy
Key privacy issue here: does the patient have the right to decide to discontinue treatment?
Question: where does the right to privacy come from–found in the “penumbra” of specific guarantees of the Bill of Rights?
Judge ruled that the only practical way to maintain her right to privacy is to permit her guardian to render the best judgment and remove her from the feeding tube.
The Medical Factor
Key distinction for Euthanasia: ordinary v. extraordinary measures
Question: what is that difference?
What might be ordinary for one patient might be extraordinary for another.
Declaratory Relief
Finally, after a few years and many court battles the Judges declared that life-support apparatus could be removed.
Respirator was removed
However Quinlan lived for 10 more years until she finally died of pneumonia
Question: when should we not give ordinary treatment?
J. Gay-Williams
The Wrongfulness of Euthanasia
Gay-Williams arguing against what he sees as the growing acceptance of euthanasia
Claims:
366 I want to show that euthanasia is wrong. It is inherently wrong, but it is also wrong judged from the standpoints of self-interest and of practical effects.
Key in philosophy: know what you’re talking about
➔ Define your terms!
Gay-Williams does this:
He defines euthanasia as intentionally taking the life of a presumably hopeless person.
Turns to the distinction between: Passive v. Active Euthanasia
Gay-Williams argues that passive euthanasia is really not euthanasia
1. Person involved is not killed
2. Death of the person not intended by the withholding of treatment
Passive euthanasia is not euthanasia at all
Question: do you agree with this assessment?
James Rachels
In a different article from the one in our book:
He also says passive v. active euthanasia distinction doesn’t work
Argument by analogy: you stand to gain millions if your nephew dies
Is there a difference between seeing him drowning in the bathtub and letting him drown or actively drowning him in the bathtub.
Gay-Williams gives three philosophical arguments against Euthanasia:
1. The Argument from Nature
A Natural Law Argument:
Gay-Williams says our natural inclination is to stay alive
Our bodies are structured to keep us alive
367 Euthanasia “does violence to this natural goal of survival”
Gay-Williams brings in religious arguments here: violated the commandment to hold life sacred.
Problem with euthanasia: it sets us against our own nature.
Does violence to our dignity
He concludes that
Euthanasia denies our basic human character and requires that we regard ourselves or others as something less than fully human.
Question: possible objections to this view: is being kept alive artificially unnatural?
Natural law would let the person die, perhaps
2. The Argument from Self-Interest
Remember Contract ethics approach: enlightened self-interest
Acting in your own self-interest
Gay-Williams Argument here: death is final.
Once we euthanize someone, we can’t go back and undo it.
Gay-Williams: diagnoses and prognoses are sometimes wrong
Question: what’s the difference between a diagnosis and a prognosis?
Problem: If the prognosis or the diagnosis is wrong, we’ve killed someone needlessly
Case here: if we euthanize we close off all possibilities of a late developing cure
Also: we also rule out all “miraculous” recoveries
Question: objection: can we have safeguards so we only euthanize some one when we’re really sure they’re not going to get better?
3. The Argument from Practical Effects
Makes a “slippery slope” case
Medicine as we have it: doctors and nurses trying to save lives
Practice of euthanasia might alter this.
Could have a corrupting influence on medical practice.
Medical practitioners might decide that certain patients are “better off dead”
Gay-Williams points to a Slippery Slope ➷
➷
Slippery slope: from voluntary euthanasia to “directed euthanasia” to involuntary euthanasia conducted as a part of a social policy
Little problem with slippery slope arguments: they don’t prove anything!
Question: what is the slippery slope here?
Argument by analogy (another type of argument that doesn’t prove anything):
Possibility of diagnosis for mental illness–may just be behavior we disapprove of.
Williams concludes:
368
The dangers of euthanasia are too great to all to run the risk of approving it in any form. The first slippery step may well lead to a serious and harmful fall.
We have a duty to aid the suffering, but euthanasia is not just dying, it is killing.
James Rachels
The Morality of Euthanasia
James Rachels
Rachels is a professor of philosophy at the University of Alabama, Birmingham. Also wrote a very popular Intro. to Ethics textbook.
Rachels is more or less a utilitarian
Defends euthanasia on utilitarian, but not only utilitarian grounds
Article The Morality of Euthanasia
Defending euthanasia
An Absolute Rule?
Quoting Franz Ingelfinger–a little bit like Edmund Burke
We’re in the heyday of the medical ethicist
[possible career in philosophy btw]
Problem with medical ethics: an abstract, idealistic “armchair exercise” untested in the laboratory of experience.
In reality: there are “few absolutes at the bedside”
Rachels talks about Doctor’s prohibition of “mercy killing”
Rachels supports euthanasia
How does he define his terms:
The Standard Case: active euthanasia
369 Suffering terminal patient who, while rational, requests to be killed as an alternative to a slow lingering death.
Question: are acts of such killing morally wrong?
Remember: What is moral and what is legal are two separate things.
Supporting Arguments:
The Argument from Mercy
Argument from mercy
Question: what is the argument from mercy?
“Mercy” as a justification for “mercy killing”
Rachels looks at two examples: Jonathan Swift’s painful death in 1745
Stewart Alsop’s description of a 28 year old man, Jack, dying in 1975
Mercy killing: this is what you’d do with a dog?
Why not do the same for a human?
Alsop: “No human being with a spark of pity could let a living thing suffer so, to no good end.”
Rachels wants to know what is right in cases where mercy-killing is the only alternative to extreme suffering.
Sometimes better pain medication will help
Question: what do you think?
Utilitarianism
Rachels is basically a utilitarian
Looking at utilitarian arguments for euthanasia–basically a logically rigorous way of laying out the argument from mercy
Classic Utilitarianism:
371
1. An action is morally right or wrong if it increases the amount of net happiness in the world
2. Killing a hopelessly ill patient who is suffering great pain, at his own request, would decrease the amount of misery in the world
3. Therefore, such an action would be morally right.
Question: what do you think of this argument?
Before Rachels defends his argument, he attacks it.
Problems with Premise 1:
seems like there is something more needed than just pleasure and pain.
Second Problem: what if the person leading the miserable life does not want to die?
Should we kill him anyway, on utilitarian grounds?
Rachel’s response defending a utilitarian view:
Promotion of happiness and avoidance of misery are not the only things morally valuable, but they are still morally important.
Rachels defends Mill and Bentham’s utilitarian consequentialism
What it amounts to:
1. emphasis on consequences: right actions are the ones with the best results
2. pain and pleasure determine which results are best
3. idea of equality: everyone’s pain and pleasure are equal
Rachels points to: Contemporary Utilitarianism:
Replaces happiness with interests and welfare
Happiness hard to judge, your interests and your welfare are easier to determine
Question: what is in your interest
What is your welfare?
New approach yields the argument:
1. If an action promotes the best interests of everyone concerned, then that action is morally acceptable
2. In at least some cases, euthanasia promotes the best interests of everyone concerned.
3. Therefore, in at least some cases, euthanasia is morally acceptable
Question: what do you think of this argument?
Rachels says the above would apply to Jack’s case
Though would also apply to cases where a person is suffering but a cure is available–
In those cases euthanasia is ruled out.
The Argument from the Golden Rule
Golden rule: do unto others as you’d have them do unto you.
Bad for a sexual pervert, good for everyone else
Rachels: Kant’s theory of the Categorical Imperative; a sophisticated version of the Golden Rule
Rachels’ question: does it support euthanasia?
Talks about a Gospel parable: the man who throws his debtor into prison and then asks the king to forgive his own debt.
Clear violation of the Golden Rule or Categorical Imperative
Rachels finds an obvious application to Euthanasia:
We’re all going to die someday
Would we rather die at 80, from a fatal injection
or die at 80 plus a few weeks in extreme pain and misery
Question: What would you prefer?
So: If you wouldn’t want something to happen to you, why impose it on others?
Cites R.M. Hare’s example of the Petrol Lorry driver who asks someone to kill him before he’s burned up in the fire.
Question: what’s a petrol lorry?
Rachels notest that Kant was personally opposed to mercy killing
However, Rachels claims that the Categorical Imperative seems to sanction it
Question: do you agree?
The Possibility of Unexpected Cures
Gay-Williams raises this possibility: If you kill someone, that person’s life is over for all time
You can’t go back
Rachels agrees
What if a doctor makes a mistake? Makes a mis-diagnosis?
Response: just because this sometimes happens doesn’t mean doctors can never know for sure if a case is hopeless.
Analogy: just because someone could confuse a Rolls-Royce with a Mercedes doesn’t mean there is noone could tell the difference between the two.
Remissions of cancer: generally come in the early stages.
No doubt about the Jack example.
What about the “miracle cure” that might be discovered “tomorrow”?
Rachels: this is a naive view of medical progress
Really a process of slow and painstaking investigation.
Is any possibility of a cure on the horizon?
How long can the patient hold out?
Is the patient past the stage where a “cure” would work?
It may be dishonest to tell patients there is hope when there isn’t.
Rachels concludes: we want to be careful about declaring a patient “hopeless” when there really is a chance of recovery.
Euthanasia shouldn’t be considered when there is the slightest doubt.
However: we may not conclude that doctors never know that a case is hopeless
Closes 374
Sadly, we know that in some cases there is no hope, and in those cases the possibility of an unexpected cure cannot be offered as an objection to euthanasia.
Looking at legal issues in Physician Assisted Suicide
Question: what’s the difference between a legal issue and a moral issue?
In March 1996, the Ninth Circuit Court of Appeals concluded in Compassion in Dying v. State of Washington (now titled State of Washington v. Glucksberg) that there is a constitutionally protected liberty interest in determining the time and manner of one's own death.
It then ruled that a Washington state law prohibiting physicians from prescribing life-ending medication for use by terminally ill, competent adults violates this fourteenth amendment due process right.
In 1997 the U.S. Supreme Court reversed court of appeals decisions invalidating laws this law and a similar one in New York (in Quill v. Vacco).
Ronald Dworkin, Thomas Nagel, Robert Nozick, John Rawls, Thomas Scanlon, and Judith Jarvis Thomson
The Brief of the Amici Curiae (1997)
Question: what is an amicus curiae?
“Friend of the Court”: a party uninvolved in particular litigation but allow3ed to advise the court on a matter of law concerning the litigation.
Dworkin–a law professor as well as philosopher
The others: specialists in philosophy of law as well as ethical philosophy
Basic argument of the brief:
They start out with a
1. Legal Argument: a liberty interest protected by the Equal Protection clause of the 14th Amendment.
Key claim here: there are certain decisions, for example, decisions about religious faith, political and moral allegiance, marriage, procreation, and death.
These decisions are deeply personal and “pose controversial questions about how and why human life has value.”
The philosophers conclude: In a free society, individuals must be allowed to make those decisions for themselves.
So: they point to certain fundamental right and liberty in a free society
Question: how important is it that we be able to make such critical decisions for ourselves? What if we make the wrong decisions? Shouldn’t someone make these decisions for us?
Focus on death: call it (377)
This is the final act in life’s drama
Philosophers’ Goal: the last act should reflect the convictions we have tried to live by, not the convictions of others forced upon us.
Looking at pluralistic American Society:
The philosophers give examples of many different attitudes toward the meaning of death held by different people.
None, they say, can be dismissed as irrational.
Also, key claim: none should be imposed from the outside.
They use a parallel argument to defend their claim:
377 It is intolerable for government to dictate that doctors never be permitted to try to keep someone alive as long as possible, when that is what the patient wishes,
By parallel argumentative force:
So it is intolerable for government to dictate that doctors may never, under any circumstances, help someone to die who believes that further life means only degradation.
Question: Question of paternalism here: what is the limit of government to dictate to us on important issues?
The make a Second Point:
They claim that state interests do not justify a categorical prohibition on all assisted suicide
This is a Counter-argument to the Solicitor General.
The Solicitor General argues that the state have the right to “override” certain liberties because they might endanger the lives of other patients who might ask for death when it is plainly not in their interests to die or when their consent has been improperly obtained.
Question: not in someone’s interest to die, when is that?
The philosophers present 3 reasons why state interest doesn’t overrule private interest:
1. Courts have already ruled against the idea of overriding state interest in similar cases
They claims that: The inherent dangers of abuse of physician assisted suicide could be addressed through legislation
For example: Nevada ruling about euthanasia:
Competent adult patients who seek to refuse medical treatment be examined by two non-attending physicians
If the patient is ruled competent and has less than six months to live, their right of self-determination overrides state interest
If they have more than six months to live, they must bring the case before a trial judge
2. The philosophers claim the Solicitor General overlooks the fact that an adequate system of rules could reduce the risk of mistakes.
Question: what sort of rules would work here?
Considers the Dutch practices here:
The guidelines say that the person who is going to die:
must completely understand what will happen;
must know about all other kinds of treatment;
must freely repeat their wish to die over a period of time;
must be suffering from something that will not stop or go away.
In addition: A second doctor, (not the doctor who will perform the euthanasia) must agree that euthanasia is acceptable in that particular case.
After the patient has died, the doctor who performed the euthanasia must complete a long questionnaire.
When the patient is dead, a coroner must look at the body and check the facts of the case.
Finally, after all this has been done, the Ministry of Justice can decide to prosecute, if it is not satisfied
Question: would those rules lead to abuse? Would they work in the U.S.?
3. The philosophers argue that the Solicitor General is overestimating the risks.
Question: what kind of risks are here?
Risk of Medical Mistake–mis diagnosis or prognosis
Risk of Undue influence–pressure from others
Question: how might the risk work in practice?
The philosophers argue that these risks can be dealt with in practice
Also: there are plenty of risks associated with what we have now.
Conclusion: each individual has the right to make “the most intimate and personal choices central to personal dignity and autonomy.” 380
Further their argument by giving examples of people requesting assisted suicide
Jane Doe, Jane Roe, John Doe, James Poe, etc.
People in extreme pain, etc.
Question: do these people have a right to say what treatment they get?
Chief Justice William Rehnquist
Majority Opinion in Washington, et al. v. Glucksberg et al. (1997)
Here we have the Legal opinion of Chief Justice of the Supreme Court William Rehnquist
Question: why is this called an opinion? Is this just a Supreme Court justices’ “opinion”?
Majority opinion rejects the argument that the state statutes outlawing assisted suicide infringe any fundamental right
Rehnquist concludes that, because all competent persons are entitled to refuse lifesaving medical treatment and no one is permitted to assist a suicide, that there is no different treatment of similarly situated persons to trigger the Equal Protection Clause.
All nine justices agreed with the result.
All, including Rehnquist recommend that the debate about assisted suicide continue.
A majority of the justices made it clear that, after public debate and legislative consideration have run a reasonable course, they might rule differently in a different case at a later time.
How does Rehnquist make his argument?
He appeals to American traditions and the tradition of common law.
First: Long standing objections and prohibitions to suicide and assisted suicide dating back to the 13th century.
Early American colonies adopted the common-law approach.
In recent years many States’ assisted suicide bans have been reexamined and affirmed
Even today when most people die in institutions
Voters and legislators continue to reaffirm their states’ prohibitions on assisting suicide.
Question: is this a good argument? This is what the tradition of legal precedence says.
This is also, apparently, what the majority of the people want?
What if the majority of people wanted something different (as in the Netherlands) would this change what was right?
Part II: Rehnquist takes on the key claim the Washington and New York laws are unconstitutional
Rehnquist argues that the 14th amendment’s Due Process clause does not extend to assisted suicide
Also concludes that physician assisted suicide is “fundamentally incompatible with the physician’s role as a healer.
Gets to the Netherlands case:
Cites statistics:
2,300 cases of voluntary euthanasia
400 cases of assisted suicide
1000 cases of euthanasia without an explicit request.
But also 4941 cases where physicians administered lethal morphine overdoses without the patients’ explicit consent.
Question: what is the problem here?
Rehnquist makes key claim against declaring the laws unconstitutional:
Pg. 386
This study suggests that, despite the existence of various reporting procedures, euthanasia in the Netherlands has not been limited to competent, terminally ill adults who are enduring physical suffering and that regulation of the practice may not have prevented abuses in cases involving vulnerable persons, including severely disabled neonates and elderly persons suffering from dementia.
Question: slippery slope and abuse problems? How bad are they?
Rehnquist concludes saying that this ruling permits the debate about physician-assisted suicide to continue.
Question: what do you think of this counter-objection?
Should we allow people to make their own decisions about their own deaths?
Or does saying we allow this open the doors to wide ranging abuse?
