HUM 3710 MOD 4 DB

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Although no moral issue has been as divisive in America as abortion, there have been times when euthanasia has come close. Just consider the uproar over the Terri Schiavo case. In 1989, Schiavo suffered cardiac arrest. Although her life was saved, she remained in a condition known as a “persistent vegetative state,” which means that as far as doctors could tell, she had no cognitive abilities and not even any conscious awareness of her surroundings. In 1998, her husband, Michael Schiavo, petitioned a Florida court to have his wife’s feeding tube removed and allow her to die, saying that his wife would not want to live in her vegetative condition. But Terri Schiavo’s parents demanded that she be kept alive. Legal battles ensued, and controversies made their way as high as the houses of congress. But in spring of 2005, the courts permitted medical personnel to disconnect Terri Schiavo from her life support system at the direction of her husband. She died thirteen days later. The Schiavo case illustrates very well several of the moral issues involved in euthanasia. Under what circumstances should a person be euthanized? In cases where it’s acceptable, how should euthanasia be carried out? And just who gets to make the decision?

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Before proceeding any further, we should clear up a few definitions. Euthanasia is killing someone to relieve her suffering – mercy killing. Active euthanasia means killing the person by doing something – administering a lethal injection, for example. Passive euthanasia, by contrast, is killing the person by doing nothing – such as withholding life support. The distinction between active and passive euthanasia is often addressed in terms of killing vs. letting-die. Another distinction needs to be made as well. Voluntary euthanasia is euthanasia chosen by the person to be euthanized. Involuntary euthanasia is euthanasia chosen by someone else. Voluntary euthanasia is often a provision of sorts in living wills. Involuntary euthanasia is generally carried out – if ever – only when the person to be euthanized is incapacitated to the point that she cannot make her wishes known. Both the active-passive and voluntary-involuntary distinctions will be important for our discussion of the topic.

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There has emerged a broad-based social consensus that euthanasia under at least some circumstances is justified. But under what circumstances? A half dozen or so factors appear to be of great importance: 1) The patient’s condition must cause extreme suffering.2) There is no way to alleviate the patient’s suffering.3) The patient’s diagnosis and prognosis are offered by multiple physicians.4) The patient has explicitly and unambiguously requested euthanasia.5) The patient is of sound mind when making the request.6) The euthanasia is carried out by a physician. The first thing to consider is the patient’s condition. As laid out in the first pair of considerations, the patient must have a very low quality of life. There must be extreme pain with no end in sight. Most people would not want to live the rest of their lives in a state where their capacity to appreciate life was impaired by pain. According to this view, what’s important about life is not just quantity but quality: It’s not enough to live longer, we want to live well. And if our suffering will prevent us from doing so, perhaps it’s better to end our lives. It’s also important to consider the freedom of the person to be euthanized. This is where the fourth and fifth points come into play. If at all possible, the person to be euthanized should make the choice for euthanasia herself, and she must be capable of choosing rationally. We don’t want people choosing death over life because they’re mentally ill. Depression is often treatable, and regardless, people who suffer from mental illnesses tend to make very poor decisions. Given the finality of euthanasia, it is not a decision to be made poorly. It’s also not a decision to be made for someone else except in a limited set of extreme circumstances. The patient must be allowed to make the decision for euthanasia for herself, as a matter of respecting her freedom as an individual. The aforementioned extreme circumstances generally involve situations where the individual’s capacity to express her wishes have been essentially eliminated, as in the case of Terri Schiavo. However, one step that can be taken is the creation of a living will in advance of becoming incapacitated. In a living will, a person can indicate what sorts of treatment she does not wish to receive under a given prognosis. This empowers the individual even when she would otherwise be unable to provide her assent to euthanasia. (And if Terri Schiavo had a living will, rather than simply a series of undocumented conversations with her husband, much of the legal wrangling involved in her case might have been avoided.) Finally, we need to involve medical professionals, as noted in points three and six. They are the ones best able to evaluate the conditions of their patients. But we have to minimize the possibility for error, so there should always be at least a second opinion, if not also a third. And we also don’t want anyone advising euthanasia for a patient when he stands to benefit from the patient’s death, so steps must be taken to ensure the independence of the diagnostic process. It also seems desirable in some ways that physicians carry out the euthanizing process. It is physicians who understand how best to care for patients, even as they die. But the idea that doctors should carry out euthanasia creates some difficulties. They are required, by the Hippocratic Oath that forms the cornerstone of their professional ethics, to “do no harm.” As killing a patient would ordinarily be considered harming her, euthanasia might be a violation of medical professionals’ ethical code.

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James Rachels addresses the difficulties for doctors in his essay on euthanasia. He begins by citing the American Medical Association’s position on the practice: “The intentional termination of the life of one human being by another – mercy killing – is contrary to that for which the medical profession stands and is contrary to the policy of the American Medical Association. The cessation of the employment of extraordinary means to prolong the life of the body when there is irrefutable evidence that biological death is imminent is the decision of the patient and/or his immediate family. The advice and judgment of the physician should be freely available to the patient and/or his immediate family.” (154) The dichotomy here is striking. Doctors may not intentionally terminate the life of their patients – which is generally a very good thing! However, they may cease providing extraordinary treatments to their patients, if that is the wish of the patient or her family – even if the patient will then die. Rachels views the AMA statement through the lens of the distinction between active and passive forms of euthanasia. As he sees it, the AMA is allowing passive euthanasia but forbidding active euthanasia. And this he believes makes no sense: “If one simply withholds treatment, it may take the patient longer to die, and so he may suffer more than he would if more direct action were taken and a lethal injection given. This fact provides strong reason for thinking that, once the initial decision not to prolong his agony has been made, active euthanasia is actually preferable to passive euthanasia, rather than the reverse. To say otherwise is to endorse the option that leads to more suffering rather than less, and is contrary to the humanitarian impulse that prompts the decision not to prolong life in the first place.” (155) In other words, if you’re going to let the patient die to alleviate her suffering, then you should also be willing to kill her directly to alleviate her suffering. That is the more merciful option.

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Rachels’ claim rests upon an important idea, namely that killing someone is no worse than letting them die. Many people believe just the opposite, of course. But leaving aside the fact that in the sort of case already mentioned, suffering is worse when letting the patient die, Rachels wants to examine the matter more closely. He considers a pair of chilling scenarios to make his point (156). Smith and Jones are a pair of rather unscrupulous pair of characters. Each has a young cousin, and each will gain a substantial inheritance if that young cousin should happen to die. One night, Smith drowns his cousin in the bathtub, but makes it look like an accident. Certainly, this is a vile and vicious crime. But things go more easily for Jones. He too intends to drown his cousin in the bathtub one evening. But as he enters, the child slips and falls and drowns of his own accord. Jones doesn’t have to do anything, so he doesn’t. If the child were to emerge gasping for breath, Jones would be willing to hold him under. But he finds that he doesn’t need to do this. Jones simply stands there watching and allows the child to die. Rachels’ question is this. Would you say that in the second scenario, Jones’ conduct was any less immoral Smith’s behavior in the first? Rachels thinks not. In both cases, it is the man’s grotesquely immoral intentions that are the problem. Neither scenario is any better or worse than the other. Killing is morally no worse than letting die. Rachels believes that the same consideration applies to active and passive euthanasia. Here the intention is not grotesque but beautifully humanitarian. And in virtue of having that same moral intent, the killing and the letting die are equivalent as well. Neither is morally worse than the other. In fact, because it leads to less suffering for the patient, active euthanasia is preferable to passive. Once the decision has been made to euthanize, it’s best to do it actively.

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Bonnie Steinbock criticizes Rachels’ argument. She thinks that he has misconstrued the AMA statement entirely, because it doesn’t allow euthanasia at all, whether active or passive. It allows cessation of treatment, which is not at all the same thing. “The mistake Rachels makes is in identifying the cessation of life-prolonging treatment with passive euthanasia, or intentionally letting die” (159). But won’t the cessation of life-prolonging treatment lead to the death of the patient, you ask? Undoubtedly. The crucial issue has to do with the intent behind ceasing treatment. For while the effect of ceasing treatment may be the death of the patient, that need not be the intent. There are at least two good reasons to cease treatment, neither of which is an intent to end the patient’s life. The first is to respect the patient’s freedom. A patient nearly always has the right to refuse treatment, because it is, after all, her own body that is in question. “In general, a competent adult has the right to refuse treatment, even where such treatment is necessary to prolong life. Indeed, the right to refuse treatment has been upheld even when the patient’s reason for refusing treatment is generally agreed to be inadequate.” (160) While a patient can exercise this right in order to die, that’s not the purpose of respecting it. The purpose is “to protect [the patient] from the unwanted interferences of others.” (160) It’s a matter of individual freedom, first and foremost. The patient should be free to live her life as she sees fit, and that liberty certainly extends to decisions about her medical treatment. In these cases where the patient refuses life-prolonging treatment, the intent of the physician is not to kill her. His intent is simply to respect her liberty. So it’s a mistake to view cessation of treatment as passive euthanasia, even if the effect will be to end her life. The second reason to cease treatment is to discontinue treatments that are ineffective or even counterproductive. This may seem a bit more like euthanasia. For again, ceasing treatment may lead to the patient’s death, and in this case, the physician’s concern is precisely for the quality of the patient’s life. But his concern is for the quality of life brought about by the treatment itself. And in some cases, as the saying goes, the cure is worse than the disease. In such cases, it is probably best to discontinue treatment, unless it really is going to be effective in the long run. If the only result is to increase the patient’s misery for what time she has left, then it should probably be discontinued. In neither situation so far described is the intent to kill the patient. The intent is either to respect the patient’s wishes, or not to give treatments that pointlessly reduce her quality of life. By following through on these intentions, the doctor may well set in motion a chain of events that leads to her natural death. But that’s the effect, not the intent. And it’s the intent that makes his action euthanasia or not. Some may find this to be hair-splitting. Rachels would probably argue that the effect of discontinuing a treatment recognized as “life-prolonging” is easily predictable. The doctor knows that a shortened life will result from his action. Since he knows this, he can hardly be described as somehow “not intending” it. From Rachels’ perspective, Steinbock is playing word-games.

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One issue that reveals itself prominently in Steinbock’s essay is, who decides what is good for the patient? As a matter of rights, this ultimately lies with the patient. And as we saw in addressing the circumstances under which euthanasia may be sought, it is generally agreed that the person to be euthanized ought to consent to the procedure. Voluntary euthanasia is an idea many people are comfortable with. Involuntary euthanasia is an idea that just as many people find disturbing. The issue hits home in situations like the Schiavo case, where the individual to be euthanized cannot participate in the discussion. And it is the distinction between voluntary and involuntary euthanasia that takes center stage in Dan Brock’s discussion. Brock argues that there are two fundamental considerations in determining whether euthanasia is morally acceptable. The first is patient autonomy, or self-determination. As he understands it, self-determination is “people’s interest in making decisions about their lives for themselves according to their own values or conceptions of a good life, and in being free to act on those decisions” (165). Our choices about what is a “good life” are limited by considerations of justice and fairness, such that we allow others to have the same sort of freedom we want for ourselves. But consistent with allowing the same right of self-determination to others, our autonomy is an important good for ourselves. This brings us to the second (and closely related) consideration, namely individual well-being (166). It might seem odd to think of someone’s well-being as served by euthanasia: this means the end of that person’s life, and hence the obliteration of any further well-being! However, Brock argues against the notion, however common and traditional it may well be, that life is good in itself, and always to be preferred to death. When we keep in mind people’s right to determine for themselves what a good life is – as required by recognizing people’s autonomy – then we realize that sometimes, a person may come to believe that the best life now attainable is a life shortened by euthanasia. It is not merely the quantity of life that matters; living for as long as possible is not the only goal. To the contrary, quality of life matters, as well. And when whatever quantity of life remains to one will involved irremediable suffering, it is not hard to see why a person of sound mind might choose less life rather than more. Indeed, if we consider autonomy again, we can see how this might allow a suffering person a so-called “death with dignity.” Choosing to die is not just a way to avoid the painful consequences of continuing to live. It is an affirmative and positive way to express one’s control over one’s own life.

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The possibility of a death with dignity is of key importance in John Hardwig’s essay on the duty to die. It is, perhaps, a strange turn of phrase “duty to die.” But Hardwig believes there are circumstances in which individuals are morally obligated to die, even when their lives are not under imminent threat from illness. The fundamental issue at bottom of this seemingly bizarre obligation is the perfectly ordinary fact that our lives are connected to the lives of others. We are woven into the fabric of the lives of our parents and our children, our siblings and our friends. “We are not,” as Hardwig says, “a race of hermits” (180). For this reason, there is simply no such thing as an “exclusively self-regarding decision,” a decision that affects no one but the one making it. Every decision we make has consequences for everyone around us, and in some cases those consequences can be very significant. This is clearly the case when it comes to decisions made late in life considering how much more life to pursue. I have an obligation, Hardwig thinks, not to wreck the lives of my family and friends for the long term just so that I may live a little longer in the short term. Sadly, this sort of thing happens all the time. Consider the case described on page 183: A terminally ill, 87-year-old woman would rather have her 55-year-old daughter lose her savings, her home, and her job so that she could have a 50 percent chance of living another six months. Is that really a morally decent way to treat one’s child? It is perfectly understandable that the daughter would be willing to do this for her mother – what loving child wouldn’t? But Hardwig’s point is, the mother shouldn’t be putting her daughter in that position in the first place. Note that Hardwig isn’t saying that she should be legally required to commit suicide; his argument is moral not legal. And he isn’t saying that anyone else should make a moral demand of her that she kill herself. But in terms of moral obligations, the woman has a duty to die, for the benefit of those who would be adversely affected if she chose to keep living.

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Some may say that Brock and Hardwig’s views of euthanasia are utterly repugnant to the value of life. Brock’s endorsement of voluntary euthanasia, if widely followed or made the basis of policy, would make involuntary euthanasia possible, as well. And Hardwig’s even stronger notion of a moral obligation to die treats human beings as nothing more than financial burdens. In both cases, critics might say that these views of euthanasia display callous indifference to life itself. But both men would have ready responses to their critics on this score. As Brock points out, the idea of a slippery slope from allowing voluntary to allowing involuntary euthanasia is nothing more than speculation. It is possible that we might become inured to ending people’s lives involuntarily – but is there evidence that this would happen? None has yet been provided (175), and as evidence from countries like the Netherlands or states like Oregon seems to show, it is possible for voluntary euthanasia to be practiced without involuntary euthanasia gaining any traction And Hardwig thinks that far from diminishing the value of human life, recognition of the duty to die helps us appreciate that value even more strongly. We fear death, because too often death is left without meaning; it just “happens.” And frequently it happens at the end of a protracted process of trying in vain to prevent it from happening. A death in fulfillment of the duty to die, however, is a meaningful death. It connects us with our loved ones, for whose benefit we have chosen to die. In choosing to fulfill our duty to die, we recognize that life is not just a value for ourselves, but a value for our loved ones, too. This sort of selflessness would be a noble way to pass on – a death with dignity. Still, as Hardwig’s example makes clear, there remains a fine line to walk between euthanasia and simply suicide. Where to draw that line is a decision for each of us. And I look forward to seeing your thoughts on that distinction and more on the discussion board.

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