Chapter  10: Care of the Dying

Section 3. Presentation of Issues.

VIDEOS:Ending life and Ethics

Woman fights for right to die 

 http://www.blinkx.com/watch-video/woman-fights-for-right-to-die/DVQ9Xj90bkjR141cVsHnzA

End-of-Life Care: Weighing Ethics and Rationing Resources

 http://www.youtube.com/watch?v=RiTp1w48P3E

 LSE Professor Questions Moral Basis for Euthanasia

http://www.youtube.com/watch?v=3DHiSrRF0Ys

Euthanasia
        In order for one to decide the morality of euthanasia, one must first properly define the term.  What is the difference between euthanasia and suicide?  If one is suffering from a fatal illness that is causing intense, prolonged pain with no hope of subsiding, is it euthanasia or suicide for that person to take his or her own life?  Likewise, if one in the same medical situation with the same prognosis secures the help of a physician in ending his or her life, does this action constitute euthanasia or murder?  What are the deciding factors that make the difference? 

        Although the question currently remains unanswered, there have been attempts to clarify, categorically, the different types of euthanasia.  Active and passive are terms that hope to bring some quantification to the quandary.  The difference between the two are relatively simple; active signifies the act of killing (lethal injection, deadly gas inhalation, etc) and passive applies when one has been allowed to die without direct intervention to assist one’s death (withholding medication needed to sustain life).   The active/passive distinction, however, is not been embraced by everyone.  Critics claim this distinction is not enough to provide a guideline to the ethics of such an action.  Many have complained that both version, regardless of the involvement of death strategies, are in effect causing death and therefore immoral.  Additionally, the autonomy of the patient is not addressed in either the passive or the active argument, which brings up another categorical perspective attempting to clarify the morality of the issue. 
        The difference between voluntary and involuntary euthanasia is the next step in distinguishing euthanasia from suicide/murder.  The difference between them is as simple as it seems.  Voluntary is when one opts for death, either by one’s own hand or with the requested assistance of another, and involuntary is when another decides that death is the morally correct course of action, when the person who dies has specifically expressed the desire to live.  There is additionally one final condition to the voluntary/involuntary perspective; nonvoluntary euthanasia is when the patient gives no opinion about life or death and the decision is made by the physician or family and/or friends. 

        With the assistance of combinations of the proposed categories, the styles of euthanasia can be defined as follows:

1.      Self administered
a.      Active
b.      Passive
2.      Other administered
a.      Active and voluntary
b.      Active and involuntary
c.      Active and nonvoluntary
d.      Passive and voluntary
e.      Passive and involuntary
f.      Passive and nonvoluntary (Munson Intervention and Reflection – 204-205)

But how effective are these distinctions in defining euthanasia and do they differentiate when such a death is moral?  Unfortunately, they have not clearly defined the boundaries of such ethical dilemmas.  The morality of assisted death remains in the eye of the individual. 

        Nevertheless, maybe the categorical approach only confuses the reality of one’s motive to act in the best interest of another.  If indeed, active nonvoluntary euthanasia is immoral, what implications does that really embody?  If a person is fatally ill, inevitably facing a future of extremely pain that will, in all probability, linger for an extended period, months or years, does one then have the inherent reasoning to provide an act of mercy for the benefit of he or she who suffers?  When a child comes across a bumblebee, dying in the cold of autumn, and shows compassion for the suffering insect by swiftly crushing it under foot, was that an act of mercy or just the willful murder of a weaker, helpless creature?  If we can agree that the bug’s death was motivated by mercy and compassion in an attempt to end prolonged suffering, why wouldn’t a human being deserve that same mercy and compassion? 

        The fact remains that a bumblebee and a human being are truly very different creatures with no reasonable comparison in inherent value; but then again is the morality of an action embodied in its motive rather than in it’s outcome?  Since the outcome determines the continuation or extinguishing of human life, the matter is of dire concern.  No quick, off-the-cuff decisions will do.  The one main difference between the bug and the human is the ability to communicate an autonomous decision either way.  Since a person is considered reasonable because of his or her ability to communicate his or her desires, level of pain/suffering, feelings of surrender, etc, then that ability could be the deciding factor when one opts to be euthanized regardless of passive or active status of the action.

        The problem then becomes the person’s clarity of reasoning.  Does pain, and/or depression, symptoms that commonly accompany fatal illness or injury, interfere with one’s ability to make an autonomous decision?  If so, who then who is deputized to make such decisions concerning future existence for the person who suffers?  A new problem may then arise; a patient may find themselves at the mercy of an unauthorized guardian, making decisions by proxy.  Herein lies the next aspect of consideration, advanced directives. 

        Cases like Terry Schiavo, Nancy Cruzan and Karen Quinlan all emphasize the need for advanced directives.  While clear-minded and healthy, one could decide what kind of treatment would be desirable and at what stage of injury or illness, at what condition of existence that treatment would preferably be denied. Although there is no guarantee that physicians and family members would follow such directives, it would leave no doubt as to one’s will should a catastrophe occur.  Unfortunately, even when physician’s are willing to respect the predestined instructions of a patient, in many cases where the patient is unable to communicate, the physicians will ignore the directives pre-ordained by the patient and follow the instruction of his or her family.  The simple truth of the matter is, “Families never sue because of the overtreatment of a patient, but they do sue because of withholding or discontinuing treatment.” (Munson Intervention and Reflection– 194)              

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DEFINING DEATH

Traditional Heart Lung Criteria

Whole Brain Criteria- No Consciousness, No Brain Stem Activity, IRREVERSIBLE COMA

Uniform Determination of Death Act - Adopted by > 35 states not by New York

Higher Brain - Coma with brain stem activity

Personhood- neo cortex- loss of what is essential and characteristic

The Problem of Death : When is a person dead?

  • The Traditional View: A person is dead when there is a permanent cessation of breathing and blood flow.
  • The Whole-Brain View: A person is dead when there is a complete and irreversible cessation of all brain functions.
  • The Higher-Brain View: A person is dead when there is a complete and irreversible cessation of all consciousness.
  • The Personhood View: A person is dead when the features essential to meeting either the criteria for personal identity or the criteria for personhood are lost.

A definition of Irreversible Coma was presented in (JAMA Aug. 1968 ) and the committee of the Harvard Medical School that set it set the medical standard for complete and irreversible loss of all brain activity. There should be no doctor of medicine that does not know the four criteria set out by that report.

Since the appearance of that report the criteria set out by the Harvard Committee has set the standard in the USA and over 100 countries in the world.

Missouri was not in the first growing of states that enacted laws based on the new criteria but it was in the third wave.

Irreversible coma = medical diagnosis and prognosis

Irreversible coma = complete and irreversible loss of all brain activity

In 49 states the legal authority set out laws that recognize a "medical standard " to determine an irreversible cessation of all functions of the entire brain.

Irreversible coma is the "medical standard " to determine an irreversible cessation of all functions of the entire brain.

There are over four different definitions of "brain death" in the world of medicine.

"Brain death " is a highly ambiguous phrase.

Doctors can be very, very loose with that phrase. It ranges in their use from partial brain destruction to whole brain loss of activity.

There have been many cases of people declared "brain dead" who recovered consciousness.

There are no cases of anyone declared to be in an irreversible coma having recovered any brain activity at all.

Far better to inquire and investigate to insure that irreversible coma has occurred and then in 49 states that person is legally dead.

In NY the person in irreversible coma may be declared dead but does not need to be.

In NY people are being trained to check for irreversible coma and then say a person is brain dead.

http://www.health.state.ny.us/nysdoh/bsd/guidelin.htm

In the NY document :

An individual who has sustained either:

Irreversible cessation of circulatory and respiratory functions; or

Irreversible cessation of all functions of the entire brain, including the brain stem, is dead.

A determination of death must be made in accordance with accepted medical standards.

So the accepted medical standard is in the second clause that of the criteria for IRREVERSIBLE COMA, which is actually not a coma at all but conveying the appearance of continuing unconsciousness due to artificial support systems.

Advanced Directives:

Do Not Resuscitate Orders- DNR's

Living Wills

Proxy Appointments-Legal Agents--click on link for PROXY FORM for New York State

The Right of Self Determination:

1. Children- guardians make decisions and may not refuse imperative (life saving) procedures

2. Adults

A. Incompetent - court appointed guardian makes decisions and may not refuse imperative 9life saving) procedures

B. Competent- may refuse any and all treatments:

Exceptions: prisoners and those with dependents may not refuse imperative treatments

C. Formerly Competent and now incapacitated

OPTIONS:

Doctor Decides

Committee of Doctors

Advanced Directives

Document: Living Will

Surrogate: Durable power of Attorney: PROXY

Next of Kin

Court

===========================================================

ETHICAL THEORIES

Natural Law:

No direct termination of a life. Indirect is allowed. Pain relief even unto respiratory failure is permitted. No moral obligation to treat the hopeless cases. Allowing to die is permitted allowing nature or God's Will to take their courses.

UTILITARIAN:

Action or inaction that leads to death is correct when it alleviates suffering and promotes the general welfare and better feelings (utility).

Kant:

Rational agents have the duty to preserve their lives if possible. No deliberate suicide. When agent is no longer capable of rational thought then there is no longer a duty to preserve that life. Allowing to die is thus permitted and compatible with Kant's principle even if not required as a perfect duty.

Ross:

Duty to fulfill promise and a duty to act in a person's best interests.

Rawls:

Maximize Liberty and allow for self determination. Minimizing the disadvantages allows for terminating treatments and hastening the death of the hopelessly ill and suffering.

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The classification scheme is somewhat artificial, but it gives us a way to conceptualize various morally relevant aspects of euthanasia. For example, was the euthanasia voluntary, involuntary, or nonvoluntary? Was it self- or other-administered? Was it active or passive?

To be sure, there are likely to be some cases of euthanasia which are hard to classify. There may also be classifications for which there are no cases. For instance, at the close of class an astute student suggested that perhaps there is no such thing as active self-administered nonvoluntary euthanasia.

Here is a worksheet of sorts. The first table draws distinctions between the different kinds of Euthanasia. It is useful to write in examples of each kind of Euthanasia in the table. For instance, a common example of Active Involuntary Other-Administered Euthanasia is murder.

Distinctions Among Cases

Self Administered

Other Administered



 

Active


 

Voluntary



 


 


 

Involuntary



 


 


 

Nonvoluntary



 


 


 



 

Passive


 

Voluntary



 


 


 

Involuntary



 


 


 

Nonvoluntary



 


 


 

Let's now consider the implications of some of our theories for each of the kinds of Euthanasia. For example, it should be clear that the second formulation of the Categorical Imperative implies that Active Involuntary Other-Administered Euthanasia is morally wrong.

NLT

Self Administered

Other Administered



 

Active


 

Voluntary


 

 

Involuntary


 

 

Nonvoluntary


 

 



 

Passive


 

Voluntary


 

 

Involuntary


 

 

Nonvoluntary


 

 

KET

Self Administered

Other Administered



 

Active


 

Voluntary


 

 

Involuntary


 

 

Nonvoluntary


 

 



 

Passive


 

Voluntary


 

 

Involuntary


 

 

Nonvoluntary


 

 

SCT

Self Administered

Other Administered



 

Active


 

Voluntary


 

 

Involuntary


 

 

Nonvoluntary


 

 



 

Passive


 

Voluntary


 

 

Involuntary


 

 

Nonvoluntary


 

 

 

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© Copyright Philip A. Pecorino 2002. All Rights reserved.

Web Surfer's Caveat: These are class notes, intended to comment on readings and amplify class discussion. They should be read as such. They are not intended for publication or general distribution.

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