Chapter 10 : Care of the Dying

READING:

Daniel Callahan: When Self Determination Runs Amok

Jason Chirichigno

Author: David Callahan

Title: "When Self Determination Runs Amok"

Publication Information: Hastings Center Report (March/April 1992, pp. 52-55).

 

In this article Callahan explores the concepts of euthanasia and physician-assisted suicide, however, for Callahan, these ideas are not simply an ethical debate, rather, they point to fundamental turning points in history. For Callahan, there are three fundamental turning points in relation to these issues: 1)The legitimate conditions under which a person can kill themselves. He claims the emergence of this issue is in stark contrast to many other efforts to curtail the reasons why one person can take another's life. 2)Meaning and limits of self determination. As for self determination, Callahan claims that such a notion simply leads to a "idiosyncratic view of the good life". 3)The claim such issues make upon the institution of medicine. For Callahan, forcing a physician to make his talents and skills available to achieve a patients private vision of the good life is simply wrong. Rather, he believes that a doctor should be availabe to, "promote and preserve human health" (p. 226) Callahan claims that people are confusing suffering, "which comes from life itself, not merely from a sick body" (p. 226). Once Callahan establishes these three concepts he moves on to explore the four ideas that have consistently been used in an attempt to support euthanasia and physician-assisted suicide.

The four ideas repeatedly used to support euthanasia and physician-assisted suicide are: 1)individual self-determination. 2)Moral irrelevance between killing and allowing to die. 3) The supposed paucity of evidence to show likely harmful consequences of legalized euthanasia. 4) The compatability of euthanasia and medical practice. (p.226). Callahan systematically picks apart the four argumants for euthanasia and physician-assisted suicide.

1)Self Determination- For Callahan, there is an important distinction between suicide and euthanasia. Intellectually, he states that individuals might have a self determining right to commit suicide, at least theoretically, however, suicide usually does not involve anyone else's help, euthanasia, clearly involves another person. " Euthanasia is thus no longer a matter of only self-determination, but of a mutual, social decision between two people, the one to be killed, and the one doing the killing" (p. 226). Callahan feels that it is not correct to put so much power into the hands of another human being with regards to your own life, he cites the example of slavery. This leads Callahan into a discussion of the definition of suffering and how difficult it can be to define such an abstract concept. Without a concrete definiton of suffering, Callahan finds it impossible to decide who qualifies for physician-assisted suicide. "Three people can have the same condition, only one will find the suffering unbearable" (p. 227).

2)The difference between killing and allowing to die- It is crucial to Callahan that people make this distinction. He feels that too many individuals think that there is no moral distinction. "It confuses reality and moral judgement to see an ommitted action as having the same casual status as one that directly kills" (p. 227). Callahan talks about removing an individual from life support as it is the underlying disease that kills the individual, not the doctor. For Callahan this is in stark contrast to a physician injecting an individual with a lethal dose of narcotic, even a healthy person would die from such an action. He feels this distinction needs to remain clear and if the distiction does not remian, doctors will always bear the moral burden of the death.

3)Calculating the consequeces of allowing euthanasia and physician assisted-suicide- There are three consequences for Callahan: 1) Ineviability of some abuse of the law. 2) Difficulty in writing and enforcing the law. 3) Slipperiness of the moral reasons for legalizing euthanasia. Callahan then discusses his observations of Holland where he feels doctors are using euthanasia somewhat freely.

4)Euthanasia and Medical Practice- In this section Callahan speaks to the true difficulty in deciphering true "organic" disease and its related suffering from the suffering people tend to feel in reaction to everyday life events. He has a hard time accepting that people should be allowed to take their lives in response to what we should assume to be universal suffering due to the human condition. Callahan states, "It is not medicine's place to lift the burden of that suffering which turns on the meaning we assign to the decay of the body and its eventual death" (p.229).

Callahan concludes that we cannot allow self-determination to run free, rather, doctors should focus on being comforting and palliative (ie reduce pain and anxiety) and that they should practice caring and compassion, instead of death.

 

http://www.cariboo.bc.ca/ae/php/phil/mclaughl/students/phil433/callaha1.htm

http://www.cariboo.bc.ca/ae/php/phil/mclaughl/students/phil433/callaha2.htm

Outline by  Don Berkich,  University of Texas, Corpus Christi (by permission)

The most vigorous debates over euthanasia usually involve Voluntary Active (Other-Administered) Euthanasia, or 'VAE' for short.

Our first author to step forward and debate VAE, Callahan, presents a number of arguments based on the assumption that those who would allow VAE bear the burden of proof (which is equivalent, recall, to the presumption that VAE is morally wrong).

Unlike the presumption that defective infants ought to receive ordinary but necessary medical care, this presumption appears to be the result of religious tradition in medicine. At the very least we can say that there do not seem to be any readily available arguments in favor of this presumption.

Nonetheless, if we grant Callahan this assumption, then it is his task to show that arguments in favor of VAE are unsound. Thus, we consider a series of arguments in favor of VAE in light of Callahan's criticisms and find that, in most cases, Callahan's criticisms are dubious at best.

For example, of the Autonomy Argument, Callahan argues that VAE by definition requires the involvement of another person. Hence even if premise (1)

  • If the Principle of Autonomy is true then every rational agent has the right to be fully self-determining.

is true, it is not at all clear that premise (4) is true:

  • If VAE is morally impermissible then there are rational agents who do not have the right to be fully self-determining.

According to Callahan, the moral and subsequent legal prohibition of VAE is a legitimate constraint on self-determination.

To disarm Callahan's Criticism, it suffices to point out that premise (4) is false only if at least one of the restrictions on Autonomy covers VAE. A review of the possible restrictions, however, quickly reveals that none of them cover VAE:

The Harm Principle: Autonomy should be restricted if, by doing so, we act to prevent harm to others.

Clearly the Harm Principle does not apply, since only the patient himself is to be euthanized.

Weak Paternalism: An individual's autonomy should be restricted if, by doing so, we act to prevent the individual from doing harm to him or herself.

Weak Paternalism might apply if we can make the case that euthanasia is a harm to the person. But as we have seen, in many cases it is continued existence which is the actual harm.

Strong Paternalism: An individual's autonomy should be restricted if, by doing so, we act to benefit the individual.

Much the same reasoning applies to Strong Paternalism as to Weak Paternalism.

The Principle of Legal Moralism: Autonomy should be restricted if necessary for the observance of laws which, presumably, reflect moral standards.

Perhaps this is the principle Callahan has in mind. But if so, then he is seriously begging the question against the Autonomy Argument. For what the Autonomy Argument seeks to show is precisely that VAE is morally permissible. Any disagreement with current law is irrelevant if the Autonomy Argument is sound.

The Welfare Principle: Autonomy should be restricted if it is done so with the expectation of a substantial benefit to others.

It is hard to see how this principle would apply at all; precisely what substantial benefit could be obtained for others from forcing, say, a terminally ill patient in great pain to stay alive?

Since no principled restriction on autonomy covers VAE, we may safely reject Callahan's criticisms of the Autonomy Argument.

Although Callahan is to be congratulated for giving such a spirited defense of the presumption that VAE is morally impermissible, analysis of Callahan's criticisms shows that they all have serious shortcomings.

You should be able to give similar analyses of Callahan's criticisms of the remaining three arguments.

The Autonomy Argument:


 


 


 


 

 


 

1

If the Principle of Autonomy is true then every rational agent has the right to be fully self-determining.
 

 

2

The Principle of Autonomy is true.
 

Therefore

3

Every rational agent has the right to be fully self-determining.

1&2


 

4

If VAE is morally impermissible then there are rational agents who do not have the right to be fully self-determining.
 

Therefore

5

VAE is morally permissible.

3&4

Callahan's Criticisms:

  1. VAE by definition requires the involvement of another person. Hence even if premise (1) is true, it is not at all clear that premise (4) is true. The moral and subsequent legal prohibition of VAE is a legitimate constraint on self-determination. Recall the four constraints on the Principle of Autonomy.
  2. If VAE were morally permissible we would be requiring physicians to make judgments about the value of another person's life. But this is an impossible position in which to put a physician.

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The Active/Passive Argument:


 


 


 


 

 


 

1

If killing is morally worse than letting die, then for any two cases C1 and C2, where C1 and C2 are exactly alike in all respects except that in C1 there is a killing while in C2 there is a letting die, C1 is morally worse than C2.
 

 

2

It is not the case that for any two cases C1 and C2, where C1 and C2 are exactly alike in all respects except that in C1 there is a killing while in C2 there is a letting die, C1 is morally worse than C2.
 

Therefore

3

It is not the case that killing is morally worse than letting die.

1&2


 

4

If it is not the case that killing is morally worse than letting die, then there is no moral difference between VAE and voluntary passive euthanasia (VPE).
 

Therefore

5

There is no moral difference between VAE and VPE.

3&4


 

6

If there is no moral difference between VAE and VPE, then ,if VPE is morally permissible, then VAE is morally permissible.
 

Therefore

7

If VPE is morally permissible then VAE is morally permissible.

5&6


 

8

VPE is morally permissible.
 

Therefore

9

VAE is morally permissible.

7&8

Callahan's Criticisms:

  1. If sub-conclusion (3) is true, then physicians cause the death of an injured or ill patient by not successfully treating the patient. But that is absurd.
  2. Sub-conclusion (3) is false because it rests on the confusion of causality with culpability.

      The physician may be morally responsible for failing to treat but is not causally responsible for the death.

      Moral responsibility changes with technology and knowledge, causal responsibility does not.

      Causal responsibility and Moral responsibility coincide only for cases of Active killing. They diverge in cases of Passive killing.

*******************************\

The Utilitarian Argument:


 


 


 


 

 


 

1

If VAE maximizes utility then VAE is morally permissible.
 

 

2

VAE maximizes utility.
 

Therefore

3

VAE is morally permissible.

1&2

Callahan's Criticisms:

    Premise (2) is false, since

    1. There would be an inevitable abuse of any laws permitting VAE.
    2. No laws permitting VAE could be written carefully enough to succeed in maximizing utility.
    3. Laws permitting VAE would inevitably lead to non-voluntary and perhaps even involuntary active euthanasia.

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VAE and the Aims of Medicine

The Medical Argument:


 


 


 


 

 


 

1

If VAE is consistent with the aims of medicine, then VAE is morally permissible.
 

 

2

VAE is consistent with the aims of medicine.
 

Therefore

3

VAE is morally permissible.

1&2

Callahan's Criticisms:

    Premise (2) is false, since it implies that the aim of medicine is to promote the good life and make judgments about the value of a life whereas the true aim of medicine is simply to heal the sick or injured.

 

 

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