Unit 2: Euthanasia
I. Max Bromson Video
general thoughts:
person must be psychologically sound
unlike abortion, there are objective measures to determine whether someone is a fit candidate for assisted suicide, especially since they are a theoretically conscious being
how about say of the family?
II. Rachels: Just About the Distinction
A. Basic Argument
conventional doctrine is that active is always immoral/forbidden, yet passive is sometimes permissible
should be challenged bc:
active oft humaner than passive
leads to objective life vs death decisions being decided on moral grounds
killing vs “letting die”
the most common arguments for it are fake news
says AMA should not endorse this doctrine
B. Points
dif btwn active and passive euthanasia critical for medical ethics (permissible or no??) (is letting die alright to do?)
passive = slow, painful death; active = quick and painless
if the doctor makes the wrong decision and the illness was curable, then decision regrettable anyways
if right, method used doesn’t matter
plain difference btwn kill vs let die isn’t what’s important. It’s the motivation that matters.
assumption: murder = malice, letting die = “more humanitarian”
“letting die” is NOT the same as doing nothing.
nonetheless, “I didn’t do anything” is a popular defense for this
fixing the cause of death = very important legally bc it may determine whether criminal charges brought against doctor
if you’re the reason for someone’s death, that is evil
doctors should not contribute to the argument of active vs passive more than they have to
C. Examples
argument #1
if patient has incurable throat cancer, lots of pain that can’t be alleviated, probably will die soon, even if treatment continued. Begging not to live longer bc pain. If just let die, technically legal, but could be prolonging life and thus prolonging agony.
says strong argument, but is it actually???
babies with congenital defects (e.g. intestinal obstructions) need surgery or they die. By letting die, they die of dehydration instead of having a quick and painless death.
argument #2
take the babies again. Is their life worth preserving?
What if the babies are actually perfectly fine? Can’t
Smith vs Jones: Are either of them really moral?
Smith drowning his baby cousin in the bathroom but makes it look like an accident
kill
Jones plans to drown his baby cousin, but as he goes to do it, his baby cousin accidentally slips and hits his head, so Jones just watches the cousin die.
“lets die”
would not stand up as a reasonable defense in court
D. Iconic Quotes
“Doctors are concerned only with cases in which the patient’s life is of no further use to him, or in which the patient’s life has become or will soon become a terrible burden.”
In Class
AMA is inconsistent because active euthanasia is justified on the same grounds as passive euthanasia
Passive euthanasia: intentional withholding of treatment when death is imminent, including cessation of artificial life support
legal pretty much everywhere
active euthanasia: intentional killing when death is imminent
illegal in US
legal in few countries around the world
physician-assisted suicide: patients are given the means to kill themselves in a controlled medical setting
legal in 10 US states + DC
argues that AE and PE are justified on the same grounds, so both are justified or both are unjustified.
skeleton of the first argument:
1) The justification for PE is that it eases the suffering of the individual when death is imminent.
2) AE also eases the suffering of the individual when death is imminent.
3) Thus, PE and AE are justified (or not justified) on the same grounds. (jointly)
2nd argument:
conventional doctrine: killing is not inherently worse than “letting die”
example: policies surrounding Down Syndrome infants born with intestinal obstruction (even tho it’s a simply surgery, parents could let the child die)
argument: presence or absence of intestinal obstruction is a morally irrelevant reason to decide on life or death
AMA’s position on PE vs AE
The conventional doctrine allows for decisions of life or death to be made on morally irrelevant grounds (as above) which itself is immoral.
3rd argument: bare difference argument
Jones merely “let his cousin die”
Smith has to do it by himself. Drowns his cousin. Kills him.
killing is psychologically associated with bad motives, whereas “letting die” is associated with doctors, so there is a more positive connotation w/ positive intentions
III. Gill: Pro-PAS
PAS legal in Oregon since 1998
if resident mentally competent and given <6 months to live, can kick the bucket
2 main arguments:
1) not morally wrong for someone with terminal disease to kill themself
2) not intrinsically wrong for physicians to help someone (w/ terminal disease) kill themself
3rd category of objections (not discussed in article): the claim that legalizing PAS will lead to very bad consequences for the sick, elderly, and other vulnerable elements of the population
A. Main Points
The Person
no one has constitutionally protected right to assisted suicide
tries to support Oregon w/o undermining constitution
bodily autonomy: killing yourself is not the same as selling oneself into self-slavery
“big decisions” vs “little decisions”
big: shape destiny, rest on values as person
little: momentary decisions
so, if person only has little time, then PAS little decision bc only a moment left. Not violate big decision bc no future.
Consider: what if future does not exist in any case?
could learn new things about self, form relationship w/ G!d, or realize profound truths in 6 months left, but that is not the case for all (probably v select few)
Oregon law says it’s not that every terminally ill person must/should kill themself. Killing oneself should be an option for terminally ill people.
opponents think it is wrong for anyone with terminal illness to kill oneself and that moral objections to suicide exist in every situation
may or may not be right for everyone
Physician POV
opponents {Kass, Pellegrino, Callahan} say even if okay to kys, still wrong for physician to help (say “misunderstand the moral foundations of medical practice”)
say inappropriate for physician to make the decision they’re being asked to make bc not an objective decisions (deeming that patient’s life is no longer with living)
HOWEVER, Oregon law really putting 2 tasks on physician:
1) is the patient terminally ill?
2) is the patient mentally competent?
if yes to both, must facilitate patient’s decision
should trying to make a patient healthy again be a physician’s only moral duty? Gill says this thinking leads to problems bc if patient clearly dying and surviving is 100% chance no, then physician has no role to begin with. (new duty becomes reducing suffering)
uses sacrificing one’s own life as a comparison
if you help with sacrifice, this is morally coherent
argues that PAS can also be morally coherent
double effect: allows to fit the withdrawal of life-sustaining treatment into their conception of the moral role of physicians while also excluding PAS (aka having one’s cake and eating it too)
concept NOT unique to medical ethics world
Gill finds concept problematic! Relies on having v clear distinction btwn intentions/goals of physicians who help with PAS and the intentions/goals of physicians who would “let die”
just bc morally defensible does not mean that should be law
to say double effect’s role on PAS is well-established rule of medical ethics is like saying that physicians traditionally have not been allowed to assist w/ suicide
question really should physicians be prohibited from assisting w/ suicide
worst part is when use double effect to defeat Oregon law by saying PAS wrong bc ending life sooner
putting moral value on something that some professions quite literally slap a variable on and measure (delta t); v obj. Meanwhile, double effect is supposed to determine permissibility/morality
too downstream from central justificatory question whether it is bad these patients die
name drops {Miller, Brody, and Quill} as people who believe PAS can be morally consistent w/ integrity of medical professionalism
unless independent point brought up that says morally bad 100% of the time for a competent, terminally ill patient to die sooner, no reason to prohibit PAS
if allowing physicians to withdraw food and water and “let die” not lead to coercion, why would PAS?
B. Others’ Views (some mixed in w/ above)
PAS, Kass argues, inevitably destroys the thing of value that it is intended to promote
Gill disagrees bc argues that Oregon Law meant to promote bodily autonomy bc it expands the number of decisions a person can make
calls Kass simplistic, shallow, and short-sighted
ppl call agreeing w/ PAS self-contradictory bc the autonomy-based justification leads to absurdities (like arguing that it’s completely fine to sell oneself into slavery)
other absurdity: legalization of PAS for healthy/non-terminally ill ppl
autonomy-based justification for PAS implies that the range of self-regarding decisions must be expanded which is simply not true. Thus, can reject.
according to libertarian view, people should be allowed to have access to whatever decision they want, regardless of whether or not it is moral
internally consistent, so nothing quick can disprove
however, requires full critique of American legal sys., so maybe not going down that route…
libertarian view conflicts w/ Oregon Law bc law does not allow healthy/non-terminally ill ppl to have suicide as an option, but libertarian says should
believe morality plays a part in whether PAS should be allowed or not
however, doesn’t really pertain to the kind of PAS Oregon allows bc if have <6 months to live and kys at 3, would only really have autonomy for 3 more months anyways (and realistically less bc QOL diminishes v quickly w/ disease)
note: CANNOT make decision if incompetent, so you not making the decision doesn’t change anything
{Kass, Callahan, and Pellegrino} believe that patients will easily be manipulated by physicians into killing themselves
Gill calls that a consequentialist argument
consequentialist argument: ethical perspective that judges the morality of an action based on its outcomes or consequences. In this framework, the rightness or wrongness of an action is determined by the amount of goodness or harm it produces. For instance, in discussions surrounding physician-assisted suicide (PAS), some argue that if the outcome leads to a reduction in suffering and respects patient autonomy, then PAS can be considered morally acceptable. This is contrasted with deontological ethics, where actions are considered right or wrong based on rules or duties, regardless of the consequences.
C. Examples
PAS = self-slavery (GILL DISAGREES DAMIT)
difference btwn blowing out a candle still providing light vs. letting candle burn itself out
D. Iconic Quotes
“Something is tragic, Kass tells us, if it is necessarily self-contradictory.” (pg 2)
Gill disagrees w/ Kass!
“First, they can take the hard-line libertarian route, which consists of biting the bullet and embracing the implications that PSS opponents say are absurd.” (pg 3)
“But there is nothing at all incoherent about a person’s preferring a state of affairs in which she is dead to a state of affairs in which she is alive.” (pg 10)
“…not all defensible moral principles ought to be enforced by law.” (pg 12)
In Class
1998, Physician-assisted suicide has been legal in Oregon
if an Oregon resident has <6 months to live AND is mentally …
3 kinds of objection to the laws of passing ^^^
1) It is intrinsically wrong for a person to kill themself.
2) It is wrong for a physician to assist someone in killing herself.
3) Legalizing PAS will lead to bad consequences for the sick, elderly, and other vulnerable populations.
Gill’s argument focuses on these ()
1st pass argument:
1) if a policy increases patient autonomy, we should support said policy.
2) PAS increases patient autonomy.
Thus, we should support PAS.
arguments against it: many anti-PAS theorists have objected to P2. That is, they say it is false (or even incoherent) to say that PAS increases patient autonomy.
IV. Callahan: Anti-PAS
A. Main Points/put
believes PAS movements could be the last step needed to gain full individual self-determination, but claims mistaken
views PAS as a reasonable response to the increased difficulty in dying a peaceful death due to technological, moral, cultural, and medical obstacles now
believes that having control over your own death (PAS perfect option) is blurring the lines btwn killing and letting die
says PAS movement rests on claims:
1) right to self-determination
2)obligation we all owe each other to relieve suffering (but especially physicians!!!)
layman’s terms: if cannot trust disease to kill quickly/peacefully, nor doctors to give appropriate treatment, should be allowed to turn to direct means
Callahan says this is DANGEROUS path for “peaceful death” bc gives illusion you can trust someone enough to give/put your liberty into their hands
expands on modern medicine’s goal of mastering life vs death and thus ideology of control
Callahan claims that PAS has strong basis bc of the failure of modern medicine
scope and death of the moral duty (for doctors, especially) to relieve suffering is absolutely not clear
common answer to how far should one go to relieve suffering:
obliged to relieve suffering when we can do so at no high cost to ourselves and when suffering is unnecessary
kinds of moral/psychological/stressful burdens!!!
1) demand on us to act and relieve suffering (e.g. time, money, etc.)
can be heavy demands
2) need to discern when suffering cannot be fully overcome and just accept the situation as is
subtler
if make highest goal in life to reduce suffering, miss out on human purposes and experience
to accept PAS is to accept a life that is not worth living if one cannot have self-mastery and self-determination
2 levels of suffering:
1): fear, uncertainty, anguish of sick person coping w/ illness (psychological penumbra)
physician should do everyting they can to reduce this 1st level
2) meaning of suffering for meaning of life itself
when patient says life has no meaning, this problem cannot be solved by medicine, he says
says purpose of medicine to relieve problems of human mortality
physician’s technical power to help death along must not be matched to/by any moral or legal code bc it’ll lead to corruption
PAS makes a previously solo task a now non-solo task
3 previous socially agreed circumstances where it’s okay to kill someone:
1) self-defense
2) killing in a just war
3) killing in the capital punishment
says PAS movement nothing more than an attempt to add a 4th occasion
calls the joining of “mental competency” and “terminality” arbitrary
suicide is not a private act
B. Examples
C. Iconic Quotes
“Claiming the right to control our bodies and our lives is characteristically American.” (pg 1)
“Physical pain and psychological suffering among those who are critically ill and dying are great evils. The attempt to relieve them by the introduction of euthanasia and assisted suicide is an even greater evil.” (pg 17)
Class: October 22nd, 2024 - {Callahan}
assumption of others: all suffering ought to be relieved
Callahan disagrees
burden #1: duty to relieve suffering:
human impulse deeply engrained
burden #2: need to discern when suffering cannot (or should not) be wholly overcome
some moral duties that we support after the fact (antecedently endorse) often entail some degree of suffering
not always the case that our moral duties involve the minimization of suffering
refining our moral duties to one another: Callahan concludes our highest moral duty is NOT to relieve suffering but to enhance one another’s good and welfare (and the relief will be a step in achieving that)
unnecessary suffering: suffering that serves no further purpose
Callahan rejects to this phrase bc of “ambiguity” (in this case, failing to discern a difference btwn…) and that people don’t mean unnecessary, they really mean unavoidable necessary suffering
{Call.} claims that labeling end-of-life suffering unnecessary is making a value judgement that life is only worth living when it’s marked by self-determination
claims goes against many current/historical cases of people who have had heroic lives or those who lived in oppressive regimes
2 levels of suffering:
1) psychological penumbra (shadow) of illness
2) deeper philosophical/spiritual level (meaning of life itself)
views PAS as permanent solution for a temporary/varying thing
making the assumption that psych. suffering is less valid
argues we must not lose sight of the fact that we have traditionally put measures in place to prevent individuals from committing suicide. He thinks PAS would cause society to move backwards.
says his opponents blend together too many arguments
Rachels: relief from suffering
Gill: autonomy self-determination argument
in order to proceed, have to fully trust in patient’s self-report
you don’t know what they’re experiencing first hand
Class: Oct 29th (MAiD discussion)
arguments in favor of PAS
discrimination against individuals based on the type of disorder they are suffering from
against mental illness inclusion in MAiD is medical paternalism
ppl w/ mental disorders are not automatically incompetent
complex nature of phys. + mental pain
complex nature of co-occuring mental and phys. illness
ultimate duty to reduce suffering, honor personal autonomy, etc.
suicidality = symptom of severe mental disorder
Are we just listening to their depression if we allow them to die?
Are they mentally competent enough (do they have the capacity?) to make the decision?
already take away people’s decision making ability for 72 hrs if attempted to kill themselves (psychiatric hold)
most severe choice you will ever make
Part 1:
intrinsic concerns regarding MAiD for mental illness
Part 2:
mental + chronic illness + disability
relation to societal issues
poor ppl more likely to seek death via made
looking awfully similar to eugenics…
4.1% deaths in Canada bc MAiD
Adam Maier-Clayton a video case
Class: Oct 31 (Paternalism, Disagreements, and the Moral Difference)
autonomy vs paternalism
giving people the best care possible
Groll’s proposal:
considering relative severity of proposed instance of paternalism
Katie vs Julian: moral facie between the two
K believes people will drive safer around her if she doesn’t wear a helmet
J doesn’t wear a helmet bc he loves the thrill
paternalism ~ “X acts paternalistically towards Y by doing (omitting) Z if:
1) Z (or its omission) interferes with the liberty or autonomy of Y
2) X does so without the consent of Y
3) X does so only bc X believes if Z will improve the welfare of Y
means are actions you select to get towards your ends