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Euthanasia

Euthanasia. PHL281Y Bioethics Summer 2005 University of Toronto Prof. Kirstin Borgerson Course Website: www.chass.utoronto.ca/~kirstin. Overview. Euthanasia – definition and public debate Distinctions Dax’s Case ‘It’s Over Debbie’ Rachels’ 3 Arguments (& objections)

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Euthanasia

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  1. Euthanasia PHL281Y Bioethics Summer 2005 University of Toronto Prof. Kirstin Borgerson Course Website: www.chass.utoronto.ca/~kirstin

  2. Overview • Euthanasia – definition and public debate • Distinctions • Dax’s Case • ‘It’s Over Debbie’ • Rachels’ 3 Arguments (& objections) • Brock’s Arguments for Active Euthanasia (& objections) • Looking ahead to Physician-Assisted Suicide

  3. Euthanasia • “Good death” • “Euthanasia is the painless killing of a patient suffering from a incurable and painful disease” (OED) • Suicide and Euthanasia have always been topics of concern for moral philosophers because they raise fundamental questions about the meaning and value of life and death, and the limits of autonomy and beneficence

  4. Public Attention • Why? • Health advancements (hygiene, nutrition) and life expectancy • Medical technology • Social scientific evidence of inadequate pain control (SUPPORT study 1995 – USA) • Public demand (high approval rate in Canada) • Medicalization of death (4/5 in institutions) • Underground common practice (‘twilighting’) • Shift in cultural values (autonomy – ex/ fertility) • Legal battles and media attention • …

  5. Recall: Moral/Legal • Euthanasia raises debate on a range of topics. These tend to fall into two main areas: • Moral – where questions address what is morally good and justifiable • Legal – where questions address what legislation is most appropriate for a given society *We are focusing on moral issues raised by euthanasia

  6. Distinctions • Voluntary Euthanasia (VE) – provided at the request of a competent individual • Example: Sue Rodriguez (Amyotrophic Lateral Sclerosis) • Nonvoluntary Euthanasia (NE) – provided for an incompetent individual • Example: Tracy Latimer (Severe Cerebral Palsy) • Involuntary Euthanasia (IE) – provided without the permission of a competent individual (against his/her will) • homicide

  7. Distinctions (continued) • Active Euthanasia (AE) – killing • Example: administering a lethal dose to a patient • Passive Euthanasia (PE) – letting die • Example: withholding or withdrawing a respirator

  8. 4 Categories • Voluntary Active Euthanasia (VAE) • Most attention is here • Nonvoluntary Active Euthanasia (NAE) • Voluntary Passive Euthanasia (VPE) • Nonvoluntary Passive Euthanasia (NPE) • Passive forms are relatively widely accepted (now)

  9. Dax Cowart • Donald ‘Dax’ Cowart: • Fighter pilot, high school football hero • 25 years old, propane gas explosion killed his father and left Dax with burns over 65% of his body • Underwent intensive (and extraordinarily painful) treatments lasting over a year, while consistently requesting to die and threatening to kill himself • Video: ‘Please Let Me Die’ (1974) • Video: ‘Dax’s Case’ (1984)

  10. Dax Cowart • Right to refuse treatment? • Should autonomy extend to death? • Paternalism/Autonomy debate in medicine

  11. Update • Law degree (1986), became a patient advocate • Married • Continues to insist that his requests to discontinue treatment should have been respected

  12. ‘It’s Over Debbie’ • Published in the Journal of the American Medical Association (JAMA) in 1988 • ABSTRACT: “A physician who describes himself or herself only as a gynecology resident in a large, private hospital writes in JAMA's "A piece of my mind" column about having administered a lethal dose of morphine to a terminally ill patient. The resident reports that the 20-year-old patient was dying of ovarian cancer, had not eaten or slept in two days, and was suffering from unrelenting vomiting. The resident, who had not seen the patient before, also writes that her [the patient’s] only words at the time were ‘Let's get it over with.’”

  13. Responses • Intuitive response? • Justified killing? • JAMA’s position

  14. Rachels’ 3 Arguments • The Humanitarian Argument • The Irrelevant Reasons Argument • The Main Argument

  15. 1. The Humanitarian Argument • Logical structure: • PE is acceptable on humanitarian grounds • AE is more humane than PE • Therefore, AE is more acceptable than PE

  16. Objection • It is true that the American Medical Association (AMA) accepts PE • Why? • What does this mean for the argument? • Which premise (if any) is problematic? • What about the other premise?

  17. 2. The Irrelevant Reasons Argument • Logical structure: • A patient who has a serious medical condition ‘C’ has a life that is either worth preserving or not regardless of whether the patient needs a simple operation for problem ‘P’ which is unrelated to ‘C’, in order to survive • Because AE is thought to be wrong, some medical decisions for those with condition ‘C’ are made on the basis of problem ‘P’ • Therefore, because AE is thought to be wrong, some medical decisions to save or not to save a patients’ life are made on irrelevant grounds (grounds which have no stated moral justification)

  18. Clarification • Example: Intestinal blockage and Down’s Syndrome • Basis of decision seems to be an assessment what sorts of lives are worth living • We should ensure these decisions are morally justifiable • Objections?

  19. 3. The Main Argument • Logical structure: • PE is morally justifiable • The distinction between killing and letting die is not morally significant [from thought experiment] • Therefore, AE is morally justifiable on the same grounds as PE

  20. Smith and Jones

  21. Smith

  22. Jones

  23. Killing/Letting Die • Good thought experiment (isolates distinction) • Same motives • Same willingness to kill • Same result • “Did either man behave better, from a moral point of view?” (400) • Was Jones’ behavior less reprehensible than Smith’s?

  24. Back to the Main Argument • If you are inclined to agree that there is no moral difference between the behavior of Smith and Jones, then it looks as though Rachels has provided support for his second premise: 2. The distinction between killing and letting die is not morally significant • Note: It may be the case that actual cases of killing are usually morally reprehensible (murders, etc.) and cases of letting die usually are not (humanitarian reasons), but then it is other factors (for example, motive/intention) that should be the focus of our moral assessments

  25. Objections • ? • Intentions • Rachels - intentions are only relevant for assessing character, but are not relevant for assessing the morality of an action (note the moral theory in the background here) • No act/omission distinction

  26. Rachels • Wants to eliminate the ‘middle ground’ position taken by organizations like the American Medical Association (AMA) • Gives reasons for doubting the moral relevance of the active/passive distinction

  27. Brock • Argues for Voluntary Active Euthanasia (VAE) • On the basis of two principles: • Autonomy (self-determination) • Beneficence (well-being) • Same values that support patient’s rights to decide about life-sustaining treatment

  28. Brock • AUTONOMY • Human dignity lies in people’s capacity to direct their lives • Individual self-determination extends to death; many patients find that quality of life, avoiding suffering, maintaining dignity and insuring that others remember us as we wish them to – outweigh merely extending one’s life • Conception of good life/good death should be respected (within the bounds of justice and consistent with others doing so as well) • Pluralism suggests that we respect individuals’ right to control the manner, circumstances and timing of their dying and death

  29. Brock • BENEFICENCE • It looks like respect for autonomy and beneficence conflict in cases of euthanasia because life is usually highly valued as a good • But in cases where euthanasia is requested, the benefits and burdens of life have shifted and the only person who can assess the balance is the individual • It may be the case that further life is a harm/burden and so we act beneficently when we allow for VAE • Of course we have to watch out for depression and dementia just as we would with all treatment decisions (i.e. the person must be competent)

  30. Objections • The practice of medicine is in jeopardy • The “very soul of medicine” is on trial (406) • 2 distinct concerns: A. Consequentialist Concern - undermines trust (doctors as killers as well as healers) • Reply: voluntary only & could increase trust

  31. Objections B. Contrary to the Central Aims of Medicine - undermines ‘moral center’ of medicine • Reply: what should be the moral center? If autonomy and beneficence, then VAE • “What should not be at the moral center is a commitment to preserving patients’ lives as such, without regard to whether those patients want their lives preserved or judge their preservation a benefit to them” (407)

  32. General Objections 2. Limits of respect for autonomy • We draw the line in other cases: • Example: Intervening in cases of anorexia • Example: Refusing to provide ‘elective amputation’ for Body Integrity Identity Disorder (BIID)? • So why not draw the line at choosing death? • Possible Reply: Liberty principle and Mill • But then… (above cases)

  33. General Objections 3. Slippery Slope 4. Risks of Abuse • More detail on these later • Very common arguments

  34. Further Support for VAE • Animals • Biology is (not) destiny – we interfere in all sorts of ways with life and death (fertility treatments, surgery, pharmaceutical drugs)

  35. Shared Arguments • Autonomy • Beneficence and Preventing Suffering • Integrity of the Medical Profession

  36. Summary • Euthanasia – definition and public debate • Distinctions • Dax’s Case (Passive Euthanasia) • ‘It’s Over Debbie’ (Active Euthanasia) • Rachels’ 3 Arguments (& objections) • Brock’s Arguments for Active Euthanasia (& objections)

  37. Looking ahead… • Next class: Physician-assisted suicide

  38. Contact Prof. Kirstin Borgerson Room 359S Munk Centre Office Hours: Tuesday 3-5pm and by appointment Course Website: www.chass.utoronto.ca/~kirstin Email: kirstin@chass.utoronto.ca

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