Three types of Euthanasia:
-a person asks that his or her life be terminated as an act of mercy. Request could be in living will. Request could be specific ex. That certain life-saving measures are not taken or actively killed by other means.
-Someone may want to make this request because they are in intolerable pain, with no hope of relief. Losing his or her physical or mental abilities, such as MS or Alzheimer’s. Not wanting to undergo other invasive treatments.
Ex. Sue Rodriquez. Diagnosed with ALS
-Assisting someone to commit suicide is a prison term
-family members take their dying loved ones to Switzerland where it is legal to have assisted suicide. Does helping someone get to a clinic in another country mean assisted suicide?
-it is the patients wish
-Patient is suffering, but due to their condition, cannot direct how they should be treated
–in this case family members believe that the person would want euthanasia if they were in a position to make their wishes known
-these situations rise when person is mentally incapacitated, usually from illness, or in a coma
-These cases are difficult because it has to be determined what the patient would want, but without being able to ask them. Not voluntary but not against their wishes
-The third category of euthanasia is the most controversial
-Involuntary euthanasia occurs when the patient does not want to be killed, or might reasonably be expected not to want to be killed if they were to make their wishes known
-In the case of involuntary euthanasia the action is often performed with the intent of relieving the burden of others to make their wishes known
-People are afraid that involuntary euthanasia could become widespread
– People fear this would happen if euthanasia were legalized
-Many are worried there would be a “slippey slope” from voluntary to involuntary euthanasia
Arguments Against Euthanasia
Argument 1: “slippery slope argument”
-If it was legal that there would be a slippery slope between voluntary and involuntary euthanasia
Argument 2: Values argument
-Somerville argues that killing patients goes against medicines fundamental values’ that medicine values life, healing and so on
-She argues we have to be careful of protecting society’s moral values, including the idea of killing. Allowing physicians to kill will erode these values
Argument 3: The sanctity of life argument
-many people argue that euthanasia devalues human life by making it expendable
-If human life is valuable in itself, it is valuable period-not just if the person is living a healthy life. We think killing is almost always wrong life is precious
Argument 4: the errors in medicine argument
-This argument points to the fact that doctors are sometimes wrong in their diagnoses
-What if a person is euthanized, and the cure is found the next day? What if they come out of their comma after?
How do you know if something is valid?
if there is not contradiction with the premises then the argument is valid.
If there is contradiction between the premises then the argument is invalid.
if the argument is invalid it doesn’t mater if the premises are true.=
Three Moral Principles
- Many people think that the way to figure out what is right and what is wrong is to talk about moral principles.
- A moral principle is a moral rule to live by, such as “help others.”
- In an given moral problem, such as euthanasia, if we are to use moral principles, the first step is to figure out which moral principles are relevant.
- The first moral principle relevant to the euthanasia case is the protection of human life principle.
- To protect human life is to do two things:
- One, to avoid taking human life, so to avoid murder and so on.
- Two, to help others who need help in order to survive.
- Many people think this is the right way to approach ethics.
- The second moral principle is the avoidance of suffering principle.
- We could state it as follows: “prevent others from suffering wherever possible.”
- This principle teaches us to help others who are suffering, or to help them avoid it.
- The reason that euthanasia is such an interesting case is that the two principles seem to contradict each other….if the only way to prevent a person’s suffering is to take their life, then what?
- What do we do when principles come into conflict?
- Those who are in favour of euthanasia, however, argue that the protection of life principle does not always have to come first.
- In some cases, where suffering is particularly acute, the avoidance of suffering principle can come first, and euthanasia is justified.
- A big part of moral reasoning is figuring out which principle is going to take precedence in a particular case.
- However, your textbook editors argue that it is even more complicated than this; there is actually a third principle that is relevant to euthanasia.
- The third moral principle is the principle of moral autonomy.
- “Each person has as much freedom to act on his or her own moral beliefs as is compatible with others being able to do the same.”
- In other words, so long as we are not harming others, we should be free to act on our own beliefs and values.
- The trick is figuring out how to follow all three, or whether we even can!
- This is especially hard in cases like euthanasia, where they seem to conflict.
Active and Passive Euthanasia
- Margaret Somerville, in Tuesday’s reading, and James Rachels, in today’s reading, both talk about the difference between active and passive euthanasia.
- It is a difference that many people think is very important, and in fact many forms of passive euthanasia are perfectly legal.
- Active euthanasia occurs when a physician performs an action to bring about the death of his or her patient.
- An example this would be giving a lethal injection of morphine.
- Passive euthanasia also brings about the death of a patient, but it happens when a physician fails to act. In this case not doing something is what brings about the patient’s death.
- Examples here would be withholding food or water, not performing CPR, or not performing necessary surgery.
- Some cases are borderline, however:
- Unplugging a person’s ventilator
- Unplugging a person’s feeding tube and feeding them by mouth, knowing they can’t absorb much by mouth
- It’s not always clear what counts as active and what counts as passive
- James Rachels gives an extended argument to the effect that the distinction doesn’t make a moral difference.
- In other words, if one is okay, the other is fine too, and if one isn’t okay, then neither is the other.
- Either both are right or both are wrong.
- Rachel’s uses a straightforward pair of cases to make his point.
- First, you’ve got Smith, who stands to gain a huge inheritance if his six-year old cousin dies. To get the money, he drowns his cousin in the bathtub, and then arranges it so it looks like an accident.–>active
- Second, there is Jones, who also stands to gain from a cousin’s death. He goes up to the bathroom intended to drown him, but notices that the child has bumped his head and is drowning anyway. Standing back, he marvels at his good fortune.–> passive (not doing what is necessary)
- Rachel’s argues that there is no relevant difference between the two cases.
- Both did something that was terribly morally wrong, and both are equally culpable.–> same in euthanasia case
- Is there a moral difference between giving them a lethal injection, and withholding treatment such as CPR?–: Rachels would say no difference
- Some, instead of drawing the distinction between active and passive euthanasia, draw the distinction between “ordinary” and “extraordinary” treatment.
- According to this, it is wrong to withhold ordinary treatment like food and water, but not extraordinary treatment like surgery.
Arguments for Euthanasia
The first argument is if a person has the right to do what they want with their body, they have the right to ask someone else to do it for them.
The second argument stems from the principle of avoiding suffering.
It is the claim that if the only thing that can prevent a person’s further suffering is taking their life, then that can be permitted if that is what the person wants.
Third, Nowell-Smith argues that if we have a right to life (which surely we do), then we have a right to let go of our life.–> moral autonomy
He argues that a right to life does not imply a duty to stay alive.
Fourth, the best interests argument. Nowell-Smith argues that if a person is choosing to die, then they have decided that for them, dying is better than staying alive.–>what they have decided is the choice for them
He argues that the person best able to know what is in their own best interests is the person themselves, and so they should decide.
These are the four main arguments in favour of euthanasia:
First, control over one’s own body
Second, avoiding suffering
Third, the right to life implies a right to end one’s life > Nowell-Smith
Fourth, the best interests argument: the person affected is best able to know what’s in his or her best interests Nowell-Smith
Fifth, the fairness argument.
An able-bodied person can commit suicide without any help, and it is legal.
It is unfair to deny a person who is not able to commit suicide on their own the same right.
Physician-assisted suicide (PAS) is the provision of medication for the purpose of bringing about death. Throughout history, physicians have secretly practiced PAS and euthanasia, in which doctors directly administer lethal drugs. In the United States, ethical and legal debates over PAS sprung into prominence in 1990 when Jack Kevorkian brought the topic to the public’s attention. Kevorkian, nicknamed Dr. Death, advocated its legalization and, until his death, had conducted over 130 assisted suicides (1). In June 1997, the U.S. Supreme Court ruled that individuals do not have a constitutional right to PAS. But the court did not prohibit the practice either. Rather, it allowed the states to decide for themselves. As of early 2013, Oregon, Washington, and Montana are the only three states that have legalized PAS, having done so in 1997, 2008, and 2009, respectively (2). Whether the option of PAS is a constitutional right, an act of compassion, or a violation of the traditional principles underlying medicine, the concerns surrounding PAS continue to carry implications for patients near the end of life.
Reasons for Requesting PAS
Investigators have conducted studies on patient rationale for requesting assisted suicide. Results indicate that uncontrollable pain is not the most important factor among patients interested in PAS. Instead, patients more frequently cite depression, hopelessness, and psychological distress as reasons for PAS (3). Other motivations include loss of autonomy, dignity, and fatigue at the end of life, which may result from an inability to participate in once-enjoyable activities (4,5). A 2005 investigation of the Oregon health care system demonstrated that patients requesting assisted suicide are more likely to be younger, unmarried, and have a higher degree of education. Patients with a college education are almost eight times more likely to use PAS than those without a high school education. The most frequent conditions suffered by PAS-seeking individuals include amyotrophic lateral sclerosis, HIV/AIDS, and malignant cancer (4). In particular, cancer patients made 31 of the first 43 requests for assisted suicide (3).
Arguments Supporting PAS Legalization
Supporters of PAS argue that physicians have a responsibility to relieve suffering and to respect patient autonomy. Forms of suffering not only include physical and psychological issues but also interpersonal and existential matters; for example, a patient may consider himself a burden to his family and incapable of enjoying life. Despite available counseling and technology, medical interventions may not alleviate patient suffering. In such cases, supporters indicate that having the option of assisted suicide is an act of compassion that respects patient autonomy (5). Proponents argue that it is wrong to leave patients in a state of unbearable pain, and that uncertainty over whether the physician will honor the patient’s desires may cause a rift in the patient-physician relationship (6). Pointing out the fact that patients have the legal right to refuse treatment, which may hasten death, proponents also claim that individuals should have the right to request medical interventions that can directly result in death (7). Some patients nearing the end of life may simply prefer assisted suicide to heavy sedation or withdrawal from life support. Furthermore, the decision to undergo PAS, contrary to the decision to end life-sustaining treatment, is always an active one made by the patient him or herself (6). Lastly, supporters point out that the choice between life and death is a personal matter that should not be regulated by the government (5).
Arguments Against PAS Legalization
Opponents of PAS argue that the practice undermines the Hippocratic principles that have governed medicine for thousands of years. Dating back to the fifth century B.C., the Hippocratic Oath states that one “will neither give a deadly drug to anybody who asked for it, nor […] make a suggestion to this effect” (8). Not granting a patient’s choice to undergo assisted suicide does not directly imply that the physician has acted without compassion and abandoned the individual. The term “compassion,” which means to suffer with, indicates that the physician is obligated to remain with the patient throughout the struggle. Opponents argue that in cases of physical or psychological suffering, the physician should take whatever measures possible to end the pain. However, when dealing with interpersonal or spiritual problems that extend beyond medicinal treatment, health professionals should recruit the necessary individuals to provide the patient comfort and peace; these may include the clergy, family, or friends. Such practices, critics claim, outline the quintessential role of the physician in a patient-physician relationship. Legalizing PAS would effectively compromise the patient-physician relationship and demoralize the physician’s role as a healer (5). Furthermore, the legalization of PAS may hinder progress that has been made in palliative care (7).
Opponents also claim that legalizing PAS will widen possibilities for misuse and abuse. For instance, if PAS becomes socially and legally acceptable, the practice could be further extended to include patients with non-terminal illnesses and to those without the capacity to make autonomous decisions. In addition, society may begin viewing the disabled, the elderly, and the sick, among others, as appropriate candidates for PAS. As a result, these vulnerable subgroups may be discriminated against and be coerced into opting for assisted suicide (5).
Map of the United States highlighting states that have legalized physician-assisted suicide.
Criticism of the Current Regulations on PAS
There are a number of guidelines surrounding PAS. For example, Oregon law requires the patient to make two oral requests and one written request. In particular, there must be a 15-day waiting period between oral requests and a two-day lapse between making the written request and receiving medication (2). Oregon law also requires physicians to offer palliative care as an alternative option (9). Aside from these procedural steps, there are several other regulations that are subject to personal opinion. For example, patients must be diagnosed with less than six months to live and be cleared of impaired judgment (2). Whether or not an individual meets these criteria depends upon the health professionals making the assessments. It is difficult to accurately determine how long a patient has left to live and to understand an individual’s motivations and state of mind concerning assisted suicide (5).
Despite the legal requirements listed above, critics claim that these safeguards can be easily circumvented. For example, though physicians must present palliative care as another option, they may be uninformed about methods of relieving patient suffering, thereby hindering their ability to offer credible and practical solutions (9). Meanwhile, the law does not require physicians to direct patients to palliative care specialists. In Oregon, physicians referred only 13 percent of the first 142 patients requesting PAS to palliative care consultants. The current situation effectively encourages physicians to offer the option of palliative care for the purpose of meeting legal requirements, rather than for the purpose of relieving patient distress (9).
Critics also pointed out issues with the current legal statutes surrounding psychiatric problems. In particular, Oregon law requires physicians to refer patients to a psychiatrist or psychologist only when the physician believes that an individual suffers from impaired judgment. However, previous studies suggest that physicians are not adequately equipped to diagnose patients with depression or impaired judgment (9). Such a diagnosis would require health professionals to examine the patient’s previous experiences with death and to be aware of suicide-associated risk factors, including alcoholism and past episodes of depression. Though the Oregon University Center for Ethics recommends that all PAS cases undergo psychiatric evaluation, physicians have referred patients to psychiatrists at a low and decreasing rate. By 2006, only four percent of PAS cases in Oregon underwent proper evaluation. In addition to determining whether a patient is capable of making an informed decision, such evaluation may provide mental relief and take away the individual’s desire to die. Critics point out that having a professional capable of understanding and relieving a patient’s desperation is necessary for the individual to make an informed decision about PAS (9).
Another criticism of the legal system is the lack of safeguards against coercion. Though Oregon law requires patients to have the capacity to voluntarily request assisted suicide, the possibility of coercion still remains, especially among older individuals who are more dependent on their family members. Consider the case of Kate Cheney, an 85-year-old widow diagnosed with terminal stomach cancer. Due to fear of experiencing unbearable pain and of losing bodily control, she looked into the option of PAS and proceeded with the necessary evaluations with the assistance of her daughter Erika. She ultimately received the lethal drugs upon being deemed competent, despite the fact that one psychologist had noted memory defects and possible coercion by her daughter. Cheney decided to take the medication shortly after being placed into a nursing home by her family. Cases like this highlight the coercion that may result from caretaker and financial burdens, among other considerations (9).
Debates concerning assisted suicide continue today. Is PAS ethically and legally justified? Should the principles underlying hospice care be altered to accommodate PAS? Whatever position one takes, it is safe to say that it is critical to improve palliative care and the regulations surrounding health care. To protect patient rights and enable individuals to make informed decisions, the health care system must provide better access to specialists equipped with the necessary tools and understanding and to prevent safeguards surrounding PAS from being circumvented.
Contact Danny Wong at
1. H. Chua-Eoan, The Life and Deaths of Jack Kevorkian (2011). Available at http://www.time.com/time/nation/article/0,8599,2075644,00.html (03 January 2013).
2. V. Lachman, MEDSURGNursing19, 121-125 (2010).
3. E. J. Emanuel, J. Am. Med. Assoc. Intern. Med. 162, 142-152 (2002).
4. K. Darr, J. Health Law40, 29-63 (2007).
5. L. Snyder, J. D., D. P. Sulmasy, Ann. Int. Med.135, 209-216 (2001).
6. M. Angell, New Engl. J. Med. 336, 50-53 (1997).
7. R. D. Orr, Is Physician-Assisted Suicide Ever Justified? (2006). Available at http://www.the-hospitalist.org/details/article/255671/Is_Physician-Assisted_Suicide_Ever_Justified_.html (03 January 2013).
8. P. Tyson, The Hippocratic Oath Today (2001). Available at http://www.pbs.org/wgbh/nova/body/hippocratic-oath-today.html (03 January 2013).
9. H. Hendin, K. Foley, Mich. Law Rev.106, 1613-1639 (2008).
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